UK and Slovakia record high maternal deaths

Mothers in Slovakia and the UK are up to four times more likely to die during pregnancy or soon after than mothers in Norway and Denmark, according to an analysis of eight European countries published today.

The youngest and oldest mothers have the highest risk, as well as those from minority ethnic backgrounds and those born abroad.

Writing in today’s edition of *The BMJ*, the research team say their findings demonstrate the need to introduce enhanced methods of identifying, documenting and reviewing maternal deaths.

The findings from this observational study follow research published last week that showed the number of women dying during pregnancy or shortly after has risen sharply in the UK and Ireland, from 8.79 women per 100,000 giving birth in 2017-19 to 10.9 per 100,000 in 2018-2020, with increases steepest in the most deprived areas.

While maternal mortality is at historic lows in high income countries, it remains an important indicator of quality of care, health system performance and maternal care.

Previous studies comparing countries’ maternal mortality rates have been based on government death certificate data, and the research team says this underestimates maternal deaths and gives inaccurate information about cause of death.

Researchers compared data from eight high income countries with enhanced surveillance systems – Denmark, Finland, France, Italy, the Netherlands, Norway, Slovakia, and the UK – and data were taken from the International Network of Obstetric Survey Systems (INOSS).

Data from 2013 and after were collected for a three-year period for France, Italy and the UK, and a five-year period for Denmark, Finland, the Netherlands, Norway, and Slovakia, to account for the varying number of births in each country. Data from Finland were collected from 2008 to 2012.

They included in the analysis deaths at any time during pregnancy and up to one year after the end of pregnancy.

A maternal mortality ratio (MMR) was calculated as the number of maternal deaths per 100,000 live births up to 42 days after the end of pregnancy, while deaths occurring between 43 days and one year after the end of pregnancy were defined as late deaths.

A fourfold difference in MMR was found between countries with the highest (Slovakia, 10.9) and lowest (Norway, 2.7) rates and when looking at all eight countries, the UK had the second highest MMR after Slovakia, with 9.6 deaths per 100,000.

In France and the UK, the two countries that record late maternal deaths, there were 10.8 and 19.1 late deaths per 100,000 live births, respectively. These late death figures account for 25% of total maternal mortality in France, and 50% in the UK.

In all countries but Norway, the maternal mortality rate was at least 50% higher for women born abroad or with a minority ethnic background.

A pooled analysis of the data by age showed maternal death rates were highest for both the youngest and the oldest mothers in all countries except the Netherlands, with women under 20 at twice the risk of death compared with women aged 20-29, while those aged 40 years or over were at almost four times the risk of death.

And cardiovascular diseases and suicide were found to be the leading causes of maternal deaths in most countries.

Although this is an observational study, with some limitations that may have influenced their results, the team say they are confident in the data, saying differences in maternal mortality profiles between countries “are not at all or very little related to measurement variations.”

They write: “Variations in maternal mortality ratios exist between high income European countries with enhanced surveillance systems.”

The researchers say in-depth analyses of differences in quality of care and health system performance at national levels are needed to further reduce maternal mortality and they add that cardiovascular diseases and mental health in women during and after pregnancy need to be prioritised in all countries.

Diguisto C, Saucedo M, Kallianidis A et al. Maternal mortality in eight European countries with enhanced surveillance systems: descriptive population based study. *BMJ* 17 November 2022; doi: 10.1136/bmj-2022-070621


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