Rise in maternal mortality in the Netherlands

Schutte, Joke M.; Steegers, E.A.P.; Schuitemaker, Nico; Santema, Job G.; Boer, Karin; Pel, Maria; Vermeulen, Guus M.; Visser, Willy; Roosmalen, Jos van

doi:10.1111/j.1471-0528.2009.02382.x

Cited by 225 publications

(117 citation statements)

References 13 publications

(21 reference statements)

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“…2,101,156,176,177 This study shows that medical comorbidities are also important factors associated with deaths arising from obstetric causes (direct deaths) in the UK; almost 50% of the populationattributable risk is associated with the presence of medical comorbidities. This highlights the importance of optimal care for women with pre-existing medical problems in pregnancy.…”

Section: Conclusion and Implications For Policy And Practicementioning

confidence: 99%

“…2,[99][100][101] Sepsis is estimated to cause 9.7% of maternal deaths in Africa, 11.6% in Asia and 7.7% in Latin America and the Caribbean combined. 102 In 2006-8, the UK maternal mortality rate from genital tract sepsis was 1.13/100,000 maternities, a rate not seen since the early 1970s, 100,103 and in 2009-12, one-quarter of all maternal deaths were due to infectious causes.…”

Section: Introductionmentioning

confidence: 99%

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Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight

Acosta

Brocklehurst

et al. 2016

Programme Grants Appl Res

101

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BackgroundStudies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision.ObjectivesTo (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts.MethodsMixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group.SettingMaternity units in all four countries of the UK.ParticipantsWomen with near-miss maternal morbidities, their partners and comparison women without severe morbidity.Main outcome measuresThe incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches.ResultsWomen and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services.LimitationsThis programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded.ConclusionsImplementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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Section: Conclusion and Implications For Policy And Practicementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight

Acosta

Brocklehurst

et al. 2016

Programme Grants Appl Res

101

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“…Although only a small proportion of deaths occur in high income settings, maternal mortality is an increasing concern because of an increase in risk factors such as obesity,3 advanced maternal age4 and births among migrants 5. These factors have been reflected in the increase in maternal deaths in the United States of America (USA) and in the Netherlands 6, 7…”

Section: Introductionmentioning

confidence: 99%

Factors associated with maternal mortality at advanced maternal age: a population‐based case–control study

McCall

Nair

Knight

2016

BJOG

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ObjectiveThis study aimed to examine the factors associated with maternal mortality among women aged ≥35 years.DesignUnmatched population based case–control study.SettingUnited Kingdom.PopulationBetween 2009 and 2012, 105 cases of maternal deaths aged ≥35 years were extracted from the surveillance database of the MBRRACE‐UK confidential enquiries into maternal deaths in the UK. In addition, 766 controls aged ≥35 years were identified from the UK Obstetric Surveillance System (2005–2012).MethodsRisk factors known to be associated with maternal mortality and morbidity and for which data were available were examined for their association with maternal mortality among women ≥35 years using logistic regression analysis.Main outcome measuresOdds ratios and 95% confidence intervals associated with maternal death.ResultsFive factors were found to be significantly associated with increased odds of death among women aged ≥35 years: smoking during pregnancy (adjusted odds ratio (aOR) 2.06, 95% CI 1.13–3.75), inadequate use of antenatal care (aOR 23.62, 95% CI 8.79–63.45), medical co‐morbidities (aOR 5.92, 95% CI 3.56–9.86) and previous pregnancy problems (aOR 2.06, 95% CI 1.23–3.45). The odds associated with death increased by 12% per year increase in age (aOR 1.12, 95% CI 1.02–1.22).ConclusionAge was associated with maternal mortality even after adjusting for other known risk factors. Importantly, this study showed an association between maternal mortality and smoking among women aged 35 years or older. It emphasises the importance of public health action to reduce smoking levels and address trends in rising maternal age.Tweetable abstractSmoking is a risk factor for maternal death for those aged over 35 years.

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“…Maternal deaths also tend to be more and more the result of rare complications, whereas regular lifethreatening complications such as major obstetric haemorrhage (MOH) are relatively underexposed as they less frequently lead to death nowadays. 2,3 The most important and difficult issue, however, is the definition of severe maternal morbidity. Different research groups have already addressed this issue, and the World Health Organization is in the process of integrating these efforts into internationally accepted criteria for severe maternal morbidity.…”

Section: Introductionmentioning

confidence: 99%

“…[1][2][3][4] The most important reason is the extremely low maternal mortality rate in Western countries, so that it takes years to collect the numbers needed to be able to draw valid conclusions from analysing cases of maternal mortality. Maternal deaths also tend to be more and more the result of rare complications, whereas regular lifethreatening complications such as major obstetric haemorrhage (MOH) are relatively underexposed as they less frequently lead to death nowadays.…”

Section: Introductionmentioning

confidence: 99%

Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population‐based study of 371 000 pregnancies

Zwart

Richters

Öry³

et al. 2008

BJOG

Self Cite

316

163

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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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Rise in maternal mortality in the Netherlands

Cited by 225 publications

References 13 publications

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Factors associated with maternal mortality at advanced maternal age: a population‐based case–control study

Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population‐based study of 371 000 pregnancies

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