Underreporting of maternal mortality in The Netherlands
Objective
To establish the actual number of maternal deaths in The Netherlands by determining the degree of underreporting.
Methods
We conducted a nationwide, retrospective crosscheck of the three available maternal mortality registration systems and issued a questionnaire to senior obstetricians in all hospitals during the years 1983–1992.
Results
The officially reported maternal mortality rate during the study period was 7.1 per 100,000 live births (133 maternal deaths per 1,862,985 live births). After completion of the study, our data indicate that the rate should be at least 9.7 per 100,000 live births (180 maternal deaths). Early pregnancy and indirect deaths were more likely to be underreported than direct deaths during labor and the puerperium. Failure to register the recent pregnancy on the death certificate was a frequent problem. Misclassification was particularly evident for cerebrovascular disorders, cardiovascular disorders, and eclampsia.
Conclusion
The level of underreporting of maternal mortality in The Netherlands was estimated at 26%. The pregnancy status of women should be registered on death certificates. Officially reported maternal mortality rates are unreliable and international comparisons using these data thus are less meaningful.
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Cited by (71)
Secular Increases in Spontaneous Subarachnoid Hemorrhage during Pregnancy: A Nationwide Sample Analysis
2019, Journal of Stroke and Cerebrovascular DiseasesCitation Excerpt :The reported frequency of sSAH in pregnant women ranges from 8 to 31/100,000 deliveries.3 It is estimated that sSAH causes up to 1 in 10 of all maternal deaths.4-7 Some studies suggest that the risk of sSAH during pregnancy is higher than other time periods.8,9
Importance: Understanding of the epidemiology, outcomes, and management of spontaneous subarachnoid hemorrhage (sSAH) during pregnancy is limited. Small, single center series suggest a slight increase in morbidity and mortality. Objective: To determine if incidence of sSAH in pregnancy is increasing nationally and also to study the outcomes for this patient population. Design, Setting, and Participants: A retrospective analysis was performed utilizing the Nationwide Inpatient Sample (NIS) and Healthcare Cost and Utilization Project for the years 2002-2014 for sSAH hospitalizations. The NIS is a large administrative database designed to produce nationally weighted estimates. Female patients age 15-49 with sSAH were identified using the International Classification of Diseases, 9th Revision, Clinical Modification code 430. Pregnancy and maternal diagnosis were identified using pregnancy related ICD codes validated by previous studies. The Cochran-Armitage trend test and parametric tests were utilized to analyze temporal trends and group comparisons. Main Outcomes and Measures: National trend for incidence of sSAH in pregnancy, age, and race/ethnicity as well as associated risk factors and outcomes. Results: During the time period, there were 73,692 admissions for sSAH in women age 15-49 years, of which 3978 (5.4%) occurred during pregnancy. The proportion of sSAH during pregnancy hospitalizations increased from 4.16 % to 6.33% (P-Trend < .001) during the 12 years of the study. African-American women (8.19%) and Hispanic (7.11%) had higher rates of sSAH during pregnancy than whites (3.83%). In the NIS data, the incidence of sSAH increased from 5.4/100,000 deliveries (2002) to 8.5/100,000 deliveries (2014; P-Trend < .0001). The greatest increase in sSAH was noted to be among pregnant African-American women from (13.4 [2002]) to (16.39 [2014]/100,000 births). Mortality was lower in pregnant women (7.69% versus 17.37%, P < .0001). Pregnant women had a higher likelihood of being discharged to home (69.78% versus 53.66%, P < .0001) and lower likelihood of discharge to long term facility (22.4% versus 28.7%, P < .0001) than nonpregnant women after sSAH hospitalization. Conclusions and Relevance: There is an upward trend in the incidence of sSAH occurring during pregnancy. There was disproportionate increase in incidence of sSAH in the African American and younger mothers. Outcomes were better for both pregnant and nonpregnant women treated at teaching hospitals and in pregnant women in general as compared to nonpregnant women.
Underreporting of maternal mortality in Taiwan: A data linkage study
2015, Taiwanese Journal of Obstetrics and GynecologyThis study examined the extent to which maternal mortality in Taiwan is underreported in officially published mortality statistics.
We used National Health Insurance claims data collected from two million samples, which were linked with the officially published mortality data, to identify women aged 15–49 years, who were admitted to a hospital with pregnancy-related diagnoses during 2000–2009 and died during the pregnancy or within 42 days after the termination of pregnancy.
Based on these linked data, we identified 26 maternal deaths, only nine of which were reported in the original officially published mortality data; thus, the rate of underreporting was 65% [(26 − 9)/26]. The revised maternal mortality ratio was 14.1 deaths per 100,000 live births (95% confidence interval: 8.7–19.5), which was approximately three times higher than the official reported ratio of 4.9 (95% confidence interval: 1.7–8.1). The most common cause of maternal deaths was amniotic fluid embolism (n = 10), followed by eclampsia and preeclampsia (n = 4).
Approximately two-thirds of the maternal deaths in Taiwan were unreported in the officially published mortality data. Hence, routine nationwide data linkage is essential to monitor maternal mortality in Taiwan accurately.
Global causes of maternal death: A WHO systematic analysis
2014, The Lancet Global HealthData for the causes of maternal deaths are needed to inform policies to improve maternal health. We developed and analysed global, regional, and subregional estimates of the causes of maternal death during 2003–09, with a novel method, updating the previous WHO systematic review.
We searched specialised and general bibliographic databases for articles published between between Jan 1, 2003, and Dec 31, 2012, for research data, with no language restrictions, and the WHO mortality database for vital registration data. On the basis of prespecified inclusion criteria, we analysed causes of maternal death from datasets. We aggregated country level estimates to report estimates of causes of death by Millennium Development Goal regions and worldwide, for main and subcauses of death categories with a Bayesian hierarchical model.
We identified 23 eligible studies (published 2003–12). We included 417 datasets from 115 countries comprising 60 799 deaths in the analysis. About 73% (1 771 000 of 2 443 000) of all maternal deaths between 2003 and 2009 were due to direct obstetric causes and deaths due to indirect causes accounted for 27·5% (672 000, 95% UI 19·7–37·5) of all deaths. Haemorrhage accounted for 27·1% (661 000, 19·9–36·2), hypertensive disorders 14·0% (343 000, 11·1–17·4), and sepsis 10·7% (261 000, 5·9–18·6) of maternal deaths. The rest of deaths were due to abortion (7·9% [193 000], 4·7–13·2), embolism (3·2% [78 000], 1·8–5·5), and all other direct causes of death (9·6% [235 000], 6·5–14·3). Regional estimates varied substantially.
Between 2003 and 2009, haemorrhage, hypertensive disorders, and sepsis were responsible for more than half of maternal deaths worldwide. More than a quarter of deaths were attributable to indirect causes. These analyses should inform the prioritisation of health policies, programmes, and funding to reduce maternal deaths at regional and global levels. Further efforts are needed to improve the availability and quality of data related to maternal mortality.
USAID, the US Fund for UNICEF through a grant from the Bill & Melinda Gates Foundation to CHERG, and The UNDP/UNFPA/UNICEF/WHO/The World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research.
Maternal cardiac arrest and perimortem caesarean delivery: Evidence or expert-based?
2012, ResuscitationTo examine the outcomes of maternal cardiac arrest and the evidence for the 4-min time frame from arrest to perimortem caesarean delivery (PMCD) recommended in current resuscitation and obstetric guidelines.
Review and data extraction from all reported maternal cardiac arrests occurring prior to delivery (1980–2010). Cases were included if they provided details regarding both the event and outcomes. Outcomes of arrest were assessed using survival, Cerebral Performance Category (CPC) and maternal/neonatal harm/benefit from PMCD. Outcome measures were maternal and neonatal survival.
Of 1594 manuscripts screened, 156 underwent full review. Data extracted from 80 relevant papers yielded 94 included cases. Maternal outcome: 54.3% (51/94) of mothers survived to hospital discharge, 78.4% (40/51) with a CPC of 1/2. PMCD was determined to have been beneficial to the mother in 31.7% of cases and was not harmful in any case. In-hospital arrest and PMCD within 10 min of arrest were associated with better maternal outcomes (ORs 5.17 and 7.42 respectively, p < 0.05 both). Neonatal outcome: mean times from arrest to delivery were 14 ± 11 min and 22 ± 13 min in survivors and non-survivors respectively (receiver operating area under the curve 0.729). Neonatal survival was only associated with in-hospital maternal arrest (OR 13.0, p < 0.001).
Treatment recommendations should include a low admission threshold to a highly monitored area for pregnant women with cardiorespiratory decompensation, good overall performance of resuscitation and delivery within 10 min of arrest. Cognitive dissonance may delay both situation recognition and the response to maternal collapse.
Death by suicide during the perinatal period has been understudied in Canada. We examined the epidemiology of and health service use related to suicides during pregnancy and the first postpartum year.
In this retrospective, population-based cohort study, we linked health administrative databases with coroner death records (1994–2008) for Ontario, Canada. We compared sociodemographic characteristics, clinical features and health service use in the 30 days and 1 year before death between women who died by suicide perinatally, women who died by suicide outside of the perinatal period and living perinatal women.
The perinatal suicide rate was 2.58 per 100 000 live births, with suicide accounting for 51 (5.3%) of 966 perinatal deaths. Most suicides occurred during the final quarter of the first postpartum year, with highest rates in rural and remote regions. Perinatal women were more likely to die from hanging (33.3% [17/51]) or jumping or falling (19.6% [10/51]) than women who died by suicide non-perinatally (p = 0.04). Only 39.2% (20/51) had mental health contact within the 30 days before death, similar to the rate among those who died by suicide non-perinatally (47.7% [762/1597]; odds ratio [OR] 0.71, 95% confidence interval [CI] 0.40–1.25). Compared with living perinatal women matched by pregnancy or postpartum status at date of suicide, perinatal women who died by suicide had similar likelihood of non–mental health primary care and obstetric care before the index date but had a lower likelihood of pediatric contact (64.5% [20/31] v. 88.4% [137/155] at 30 days; OR 0.24, 95% CI 0.10–0.58).
The perinatal suicide rate for Ontario during the period 1994–2008 was comparable to international estimates and represents a substantial component of Canadian perinatal mortality. Given that deaths by suicide occur throughout the perinatal period, all health care providers must be collectively vigilant in assessing risk.
Characteristics and outcomes of pregnant women hospitalized with severe maternal outcomes in eastern Ethiopia: Results from the Ethiopian Obstetric Surveillance System study
2024, International Journal of Gynecology and Obstetrics