Can excess maternal mortality among women of foreign nationality be explained by suboptimal obstetric care?

Abstract

Objectives To test the hypothesis that the risk of postpartum maternal death in France remains significantly higher for women of foreign nationality after individual characteristics are taken into account and to examine whether the quality of care received by the women who died differs according to nationality.Design A national case-control study. Setting Metropolitan France.Population A total of 267 women who died of maternal death from 1996 to 2001 as cases and a representative sample (n = 13 186) of women who gave birth in 1998 as controls.Methods Crude and adjusted odd ratios were calculated with multivariate logistic regression, and the quality of care for cases was compared according to nationality with chi-square tests or Fisher's exact tests.Main outcome measures Odd ratio for postpartum maternal death associated with nationality and quality of care.Results After taking individual characteristics into account, the risk of postpartum maternal death was twice as high for foreign women. The odds ratio was 5.5 (95% CI: 3.3-9.0) for women from sub-Saharan Africa and 3.3 (95% CI: 1.7-6.5) for those from Asia, North and South America. There was no significant excess risk of postpartum maternal death for the other European and North Africa women. The risk of dying from hypertensive disorder or infection was four times higher for foreign women. Among women who died, care was more often considered not optimal for foreign women (78 versus 57%).Conclusions The excess risk of postpartum maternal death persisted for foreign women after individual characteristics were taken into account and was especially important for some nationalities and for some causes of death, primarily hypertensive disorders. These results point to an immediate need to pay special attention to early enrolment in prenatal care, screening and prenatal management of hypertension, especially in women of sub-Saharan African nationality.Keywords Maternal mortality, nationality, quality of care.Please cite this paper as: Philibert M, Deneux-Tharaux C, Bouvier-Colle M. Can excess maternal mortality among women of foreign nationality be explained by suboptimal obstetric care?

Understanding regional differences in maternal mortality: a national case–control study in France

“…Nonetheless two important known risk factors-age, which is a primordial factor in terms of risk of death, and nationality-could be considered for all the women. [8][9][10]16 The clinical characteristics (parity, hospitalisation during pregnancy and emergency caesarean) are not especially refined, but they can be considered as a proxy for the mother's health status, during pregnancy and, to some extent, at delivery. Residual confounding cannot be excluded, in particular educational level, income, 17 obesity, 18 or inadequacy of prenatal care.…”

“…Results in several countries show an association between some individual characteristics, such as advanced age or foreign nationality or geographic origin, and a higher risk of maternal death. [8][9][10] The implications of these findings in terms of prevention nonetheless remain unclear.…”

Les parturientes « africaines » en France et la césarienne

“…Ainsi, l'étude nationale confidentielle sur la mortalité maternelle qui s'intéresse pour la première fois en 2008 au risque de décéder d'une grossesse ou d'un accouchement par nationalité révèle que ce risque est deux fois plus élevé pour les femmes de nationalité étrangère, et cinq fois plus pour celles originaires de l'Afrique subsaharienne (Philibert et al 2008) 2 . De plus, toutes femmes étrangères confondues, les décès sont associés à une qualité de soins « non optimale » dans 78 % des cas (vs 56 % pour les Françaises), la mauvaise observance des recommandations médicales n'étant retenue que pour 3 % des décès.…”

Maternal mortality in the context of political free health care on pregnancy and birth to the treichville teaching hospital, Abidjan-Cote d'Ivoire

“…The circumstances of these transfers are identical in countries with high rates of maternal mortality. 11 The poor quality discharge is one of the factors on which action must be taken if we want to reduce significantly the maternal death rates in poor countries. Especially since these patients arrive late and sometimes in dramatic situations.…”