Objective To assess incidence of uterine rupture in scarred and unscarred uteri and its maternal and fetal complications in a nationwide design.Design Population-based cohort study.Setting All 98 maternity units in the Netherlands. Methods Women with uterine rupture were prospectively collected using a web-based notification system. Data from all pregnant women in the Netherlands during the study period were obtained from Dutch population-based registers. Results were stratified by uterine scar.Main outcome measures Population-based incidences, severe maternal and neonatal morbidity and mortality, relative and absolute risk estimates.Results There were 210 cases of uterine rupture (5.9 per 10 000 pregnancies). Of these women, 183 (87.1%) had a uterine scar, incidences being 5.1 and 0.8 per 10 000 in women with and without uterine scar. No maternal deaths and 18 cases of perinatal death (8.7%) occurred. The overall absolute risk of uterine rupture was 1 in 1709. In univariate analysis, women with a prior caesarean, epidural anaesthesia, induction of labour (irrespective of agents used), pre-or post-term pregnancy, overweight, non-Western ethnic background and advanced age had an elevated risk of uterine rupture. The overall relative risk of induction of labour was 3.6 (95% confidence interval 2.7-4.8). ConclusionThe population-based incidence of uterine rupture in the Netherlands is comparable with other Western countries. Although much attention is paid to scar rupture associated with uterotonic agents, 13% of ruptures occurred in unscarred uteri and 72% occurred during spontaneous labour.

Objective To assess incidence, case fatality rate, risk factors and substandard care in severe maternal morbidity in the Netherlands.Design Prospective population-based cohort study.Setting All 98 maternity units in the Netherlands.Population All pregnant women in the Netherlands.Methods Cases of severe maternal morbidity were collected during a 2-year period. All pregnant women in the Netherlands in the same period acted as reference cohort (n = 371 021). As immigrant women are disproportionately represented in Dutch maternal mortality statistics, special attention was paid to the ethnic background. In a subset of 2.5% of women, substandard care was assessed through clinical audit.Main outcome measures Incidence, case fatality rates, possible risk factors and substandard care.Results Severe maternal morbidity was reported in 2552 women, giving an overall incidence of 7.1 per 1000 deliveries. Intensive care unit admission was reported in 847 women (incidence 2.4 per 1000), uterine rupture in 218 women (incidence 6.1/10 000), eclampsia in 222 women (incidence 6.2/10 000) and major obstetric haemorrhage in 1606 women (incidence 4.5 per 1000). Non-Western immigrant women had a 1.3-fold increased risk of severe maternal morbidity (95% CI 1.2-1.5) when compared with Western women. Overall case fatality rate was 1 in 53. Substandard care was found in 39 of a subset of 63 women (62%) through clinical audit.Conclusions Severe maternal morbidity complicates at least 0.71% of all pregnancies in the Netherlands, immigrant women experiencing an increased risk. Since substandard care was found in the majority of assessed cases, reduction of severe maternal morbidity seems a mandatory challenge.Keywords Ethnicity, incidence, maternal mortality, nationwide, risk factors, severe maternal morbidity, substandard care.Please cite this paper as: Zwart J, Richters J, Ö ry F, de Vries J, Bloemenkamp K, van Roosmalen J. Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study of 371 000 pregnancies. BJOG 2008;115:842-850.

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