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Ahmed SMA, Cresswell JA, Say L. Incompleteness and misclassification of maternal death recording: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2023; 23:794. [PMID: 37968585 PMCID: PMC10647144 DOI: 10.1186/s12884-023-06077-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 10/18/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVE To quantify the extent of incompleteness and misclassification of maternal and pregnancy related deaths, and to identify general and context-specific factors associated with incompleteness and/or misclassification of maternal death data. METHODS We conducted a systematic review of incompleteness and/or misclassification of maternal and pregnancy-related deaths. We conducted a narrative synthesis to identify methods used to capture and classify maternal deaths, as well as general and context specific factors affecting the completeness and misclassification of maternal death recording. We conducted a meta-analysis of proportions to obtain estimates of incompleteness and misclassification of maternal death recording, overall and disaggregated by income and surveillance system types. FINDINGS Of 2872 title-abstracts identified, 29 were eligible for inclusions in the qualitative synthesis, and 20 in the meta-analysis. Included studies relied principally on record linkage and review for identifying deaths, and on review of medical records and verbal autopsies to correctly classify cause of death. Deaths to women towards the extremes of the reproductive age range, those not classified by a medical examiner or a coroner, and those from minority ethnic groups in their setting were more likely misclassified or unrecorded. In the meta-analysis, we found maternal death recording to be incomplete by 34% (95% CI: 28-48), with 60% sensitivity (95% CI: 31-81.). Overall, we found maternal mortality was under-estimated by 39% (95% CI: 30-48) due to incompleteness and/or misclassification. Reporting of deaths away from the intrapartum, due to indirect causes or occurring at home were less complete than their counterparts. There was substantial between and within group variability across most results. CONCLUSION Maternal deaths were under-estimated in almost all contexts, but the extent varied across settings. Countries should aim towards establishing Civil Registration and Vital Statistics systems where they are not instituted. Efforts to improve the completeness and accuracy of maternal cause of death recording, such as Confidential Enquiries into Maternal Deaths, are needed even where CRVS is considered to be well-functioning.
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Affiliation(s)
- Sahar M A Ahmed
- Department of Sexual and Reproductive Health Research, World Health Organization, Geneva, Switzerland.
| | - Jenny A Cresswell
- Department of Sexual and Reproductive Health Research, World Health Organization, Geneva, Switzerland
| | - Lale Say
- Department of Sexual and Reproductive Health Research, World Health Organization, Geneva, Switzerland
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Diguisto C, Saucedo M, Kallianidis A, Bloemenkamp K, Bødker B, Buoncristiano M, Donati S, Gissler M, Johansen M, Knight M, Korbel M, Kristufkova A, Nyflot LT, Deneux-Tharaux C. Maternal mortality in eight European countries with enhanced surveillance systems: descriptive population based study. BMJ 2022; 379:e070621. [PMID: 36384872 PMCID: PMC9667469 DOI: 10.1136/bmj-2022-070621] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare maternal mortality in eight countries with enhanced surveillance systems. DESIGN Descriptive multicountry population based study. SETTING Eight countries with permanent surveillance systems using enhanced methods to identify, document, and review maternal deaths. The most recent available aggregated maternal mortality data were collected for three year periods for France, Italy, and the UK and for five year periods for Denmark, Finland, the Netherlands, Norway, and Slovakia. POPULATION 297 835 live births in Denmark (2013-17), 301 169 in Finland (2008-12), 2 435 583 in France (2013-15), 1 281 986 in Italy (2013-15), 856 572 in the Netherlands (2014-18), 292 315 in Norway (2014-18), 283 930 in Slovakia (2014-18), and 2 261 090 in the UK (2016-18). OUTCOME MEASURES Maternal mortality ratios from enhanced systems were calculated and compared with those obtained from each country's office of vital statistics. Age specific maternal mortality ratios; maternal mortality ratios according to women's origin, citizenship, or ethnicity; and cause specific maternal mortality ratios were also calculated. RESULTS Methods for identifying and classifying maternal deaths up to 42 days were very similar across countries (except for the Netherlands). Maternal mortality ratios up to 42 days after end of pregnancy varied by a multiplicative factor of four from 2.7 and 3.4 per 100 000 live births in Norway and Denmark to 9.6 in the UK and 10.9 in Slovakia. Vital statistics offices underestimated maternal mortality by 36% or more everywhere but Denmark. Age specific maternal mortality ratios were higher for the youngest and oldest mothers (pooled relative risk 2.17 (95% confidence interval 1.38 to 3.34) for women aged <20 years, 2.10 (1.54 to 2.86) for those aged 35-39, and 3.95 (3.01 to 5.19) for those aged ≥40, compared with women aged 20-29 years). Except in Norway, maternal mortality ratios were ≥50% higher in women born abroad or of minoritised ethnicity, defined variously in different countries. Cardiovascular diseases and suicides were leading causes of maternal deaths in each country. Some other conditions were also major contributors to maternal mortality in only one or two countries: venous thromboembolism in the UK and the Netherlands, hypertensive disorders in the Netherlands, amniotic fluid embolism in France, haemorrhage in Italy, and stroke in Slovakia. Only two countries, France and the UK, had enhanced methods for studying late maternal deaths, those occurring between 43 and 365 days after the end of pregnancy. CONCLUSIONS Variations in maternal mortality ratios exist between high income European countries with enhanced surveillance systems. In-depth analyses of differences in the quality of care and health system performance at national levels are needed to reduce maternal mortality further by learning from best practices and each other. Cardiovascular diseases and mental health in women during and after pregnancy must be prioritised in all countries.
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Affiliation(s)
- Caroline Diguisto
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
- Université Paris Cité, CRESS UMR 1153, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Paris, France
- Pôle de gynécologie obstétrique, médecine fœtale, médecine et biologie de la reproduction, centre Olympe de Gouges, CHRU de Tours, 37 044 Tours, France; Université de Tours, 37032 Tours, France
| | - Monica Saucedo
- Université Paris Cité, CRESS UMR 1153, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Paris, France
| | - Athanasios Kallianidis
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Netherlands
| | - Kitty Bloemenkamp
- Department of Obstetrics, Division Women and Baby, Birth Centre Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | | | - Marta Buoncristiano
- National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanità - Italian National Institute of Health, Rome, Italy
| | - Serena Donati
- National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanità - Italian National Institute of Health, Rome, Italy
| | - Mika Gissler
- Department of Knowledge Brokers, THL Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
| | - Marianne Johansen
- Department of Obstetrics, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Miroslav Korbel
- 1st Department of Obstetrics and Gynaecology, Faculty of Medicine, Comenius University in Bratislava, Slovak Republic
| | - Alexandra Kristufkova
- 1st Department of Obstetrics and Gynaecology, Faculty of Medicine, Comenius University in Bratislava, Slovak Republic
| | - Lill T Nyflot
- Norwegian Research Centre for Women's Health, Oslo University Hospital, Oslo, Norway
- Department of Obstetrics, Drammen Hospital, Drammen, Norway
| | - Catherine Deneux-Tharaux
- Université Paris Cité, CRESS UMR 1153, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Paris, France
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Berdzuli N, Lomia N, Staff AC, Lazdane G, Pestvenidze E, Jacobsen AF. Audit of Early and Late Maternal Deaths in Georgia: Potential for Improving Substandard Obstetric Care. Int J Womens Health 2021; 13:205-219. [PMID: 33628061 PMCID: PMC7899038 DOI: 10.2147/ijwh.s288763] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/09/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Quality of care is an important factor in reducing preventable maternal deaths, yet it is a significant challenge in many countries. Substandard and poor quality of care is the leading factor in two-thirds of maternal deaths in European countries. Our study investigated the deaths of all women of reproductive age in 2012 in Georgia. The aim was to define the underlying causes of maternal deaths and to identify the factors in women’s care which contributed to the fatal outcomes. Methods A national Reproductive Age Mortality Survey was conducted in Georgia in 2014–15. Data from multiple sources was triangulated to identify all deaths of women of reproductive age. This was followed by verbal autopsy diagnoses. Each case of early and late maternal death was investigated through interviews and medical record reviews at the last medical facility providing care for the deceased woman. A specialist panel reviewed and assigned underlying causes of death, assessed the management of each woman’s condition, and identified elements of suboptimal care. Results We identified a total of 23 maternal deaths, including 15 (65%) early and eight (35%) late deaths. The maternal mortality ratio was 26.3 per 100 000 live births. The four leading causes of early maternal deaths were: sepsis, hemorrhage, embolism, and pregnancy-induced hypertension. Embolism and sepsis were the direct causes of the eight late maternal deaths. Cancer, tuberculosis, and postpartum suicide constituted the indirect causes of death. Improvements in care which would have made a difference to the outcomes were identified in 87% of early maternal deaths and 67% of late maternal deaths due to direct obstetric causes. Discussion Delayed recognition and inappropriate management of maternal complications were common across almost all cases studied. The findings from Georgia highlight the conclusion that most maternal deaths were preventable and that improvement in obstetric care is urgently required.
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Affiliation(s)
- Nino Berdzuli
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nino Lomia
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anne Cathrine Staff
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Gunta Lazdane
- Department of Obstetrics and Gynaecology, Riga Stradins University, Riga, Latvia
| | - Ekaterine Pestvenidze
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anne Flem Jacobsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
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