The contribution of suicide to maternal mortality: A nationwide population-based cohort study.

OBJECTIVE: To identify the incidence and characteristics of maternal suicide. DESIGN: Nationwide population-based cohort study. SETTING: The Netherlands, 2006-2020. POPULATION: Women who died during pregnancy or within 1 year postpartum, and a reference population of women aged 25-45 years. METHODS: The Cause of Death Register and Medical Birth Register were linked to identify women who died within 1 year postpartum. Data were combined with deaths reported to the Audit Committee for Maternal Mortality and Morbidity (ACMMM), which performs confidential enquiries. Maternal suicides were compared with a previous period (1996-2005). Risk factors were obtained by combining vital statistics databases. MAIN OUTCOME MEASURES: Comparison of incidence and proportion of maternal suicides among all maternal deaths over time, sociodemographic and patient-related risk factors and underreporting of postpartum suicides. RESULTS: The maternal suicide rate remained stable with 68 deaths: 2.6 per 100 000 live births in 2006-2020 versus 2.5 per 100 000 in 1996-2005. The proportion of suicides among all maternal deaths increased from 18% to 28%. Most suicides occurred throughout the first year postpartum (64/68); 34 (53%) of the women who died by suicide postpartum were primiparous. Compared with mid-level, low educational level was a risk factor (odds ratio 4.2, 95% confidence interval 2.3-7.9). Of 20 women reported to the ACMMM, 11 (55%) had a psychiatric history and 13 (65%) were in psychiatric treatment at the time of death. Underreporting to ACMMM was 78%. CONCLUSIONS: Although the overall maternal mortality ratio declined, maternal suicides did not and are now the leading cause of maternal mortality if late deaths up to 1 year postpartum are included. Data collection and analysis of suicides must improve.

Nationwide confidential enquiries into maternal deaths because of obstetric hemorrhage in the Netherlands between 2006 and 2019.

INTRODUCTION: Obstetric hemorrhage-related deaths are rare in high income countries. Yet, with increasing incidences of obstetric hemorrhage in these countries, it is of utmost importance to learn lessons from each obstetric hemorrhage-related death to improve maternity care. Our objective was to calculate the obstetric hemorrhage-related maternal mortality ratio (MMR), assess causes of obstetric hemorrhage-related deaths, and identify lessons learned. MATERIAL AND METHODS: Nationwide mixed-methods prospective case-series with confidential enquiries into maternal deaths due to obstetric hemorrhage in the Netherlands from January 1, 2006 to December 31, 2019. RESULTS: The obstetric hemorrhage-related MMR in the Netherlands in 2006-2019 was 0.7 per 100 000 livebirths and was not statistically significantly different compared with the previous MMR of 1.0 per 100 000 livebirths in 1993-2005 (odds ratio 0.70, 95% confidence interval 0.38-1.30). Leading underlying cause of hemorrhage was retained placenta. Early recognition of persistent bleeding, prompt involvement of a senior clinician and timely management tailored to the cause of hemorrhage with attention to coagulopathy were prominent lessons learned. Also, timely recourse to surgical interventions, including hysterectomy, in case other management options fail to stop bleeding came up as an important lesson in several obstetric hemorrhage-related deaths. CONCLUSIONS: The obstetric hemorrhage-related MMR in the Netherlands in 2006-2019 has not substantially changed compared to the MMR of the previous enquiry in 1993-2005. Although obstetric hemorrhage is commonly encountered by maternity care professionals, it is important to remain vigilant for possible adverse maternal outcomes and act upon an ongoing bleeding following birth in a more timely and adequate manner. Our confidential enquiries still led to important lessons learned with clinical advice to professionals as how to improve maternity care and avoid maternal deaths. Drawing lessons from maternal deaths should remain a qualitative and moral imperative.

Confidential enquiry into maternal deaths in the Netherlands, 2006-2018.

INTRODUCTION: To calculate the maternal mortality ratio (MMR) for 2006-2018 in the Netherlands and compare this with 1993-2005, and to describe women's characteristics, causes of death and improvable factors. MATERIAL AND METHODS: We performed a nationwide, cohort study of all maternal deaths between January 1, 2006 and December 31, 2018 reported to the Audit Committee Maternal Mortality and Morbidity. Main outcome measures were the national MMR and causes of death. RESULTS: Overall MMR was 6.2 per 100 000 live births, a decrease from 12.1 in 1993-2005 (risk ratio [RR] 0.5). Women with a non-western ethnic background had an increased MMR compared with Dutch women (MMR 6.5 vs. 5.0, RR 1.3). The MMR was increased among women with a background from Surinam/Dutch Antilles (MMR 14.7, RR 2.9). Half of all women had an uncomplicated medical history (79/161, 49.1%). Of 171 pregnancy-related deaths within 1 year postpartum, 102 (60%) had a direct and 69 (40%) an indirect cause of death. Leading causes within 42 days postpartum were cardiac disease (n = 21, 14.9%), hypertensive disorders (n = 20, 14.2%) and thrombosis (n = 19, 13.5%). Up to 1 year postpartum, the most common cause of death was cardiac disease (n = 32, 18.7%). Improvable care factors were identified in 76 (47.5%) of all deaths. CONCLUSIONS: Maternal mortality halved in 2006-2018 compared with 1993-2005. Cardiac disease became the main cause. In almost half of all deaths, improvable factors were identified and women with a background from Surinam/Dutch Antilles had a threefold increased risk of death compared with Dutch women without a background of migration.

Giving birth after caesarean: Identifying shared preferences among pregnant women using Q methodology.

BACKGROUND: Caesarean rates are rising worldwide, the main contributor being the elective repeat caesarean. During the past decades, rates of vaginal birth after caesarean dropped considerably. This requires insight in women's preferences regarding giving birth following a previous caesarean. AIM: To gain a better understanding of women's values and preferences regarding the upcoming birth following a previous caesarean. Using Q methodology, this study systematically explores and categorises their preferences. METHODS: Q methodology is an innovative research approach to explore and compare a variety of viewpoints on a certain subject. Thirty-one statements on birth after caesarean were developed based on the health belief model. Thirty-six purposively sampled pregnant women with a history of caesarean ranked these statements from least to most important. By-person factor analysis was used to identify patterns which, supplemented with interview data, were interpreted as preferences. FINDINGS: Three distinct preferences for giving birth after a caesarean were found; (a) "Minimise the risks for me and my child", giving priority to professional advice and risk of adverse events, (b) "Seek the benefits of normal birth", desiring to give birth as normal as possible for both emotional and practical reasons, (c) "Opt for repeat caesarean", expressing the belief that a planned caesarean brings comfort. CONCLUSIONS: Preferences for birth after caesarean vary considerably among pregnant women. The findings help to understand the different types of information valued by women who need to decide on their mode of birth after a first caesarean.

Women with a Preterm Cesarean Have High Rates of Successful Trial of Labor in a Subsequent Term Pregnancy.

OBJECTIVE: The rate of cesareans has increased worldwide. Therefore, an increasing number of women has to decide how to deliver in a subsequent pregnancy. Individualized information on risks and success chances is helpful. This study investigates the effect of a preterm cesarean on success of subsequent term trial of labor. STUDY DESIGN: Ten-year Dutch cohort (2000-2009) of women with one previous cesarean and a subsequent term trial of labor. Subgroups were made based on gestational age at first cesarean delivery (25-28, 28-30, 30-32 and 32-34 weeks) and stratified based the way in which second delivery started. Rates of vaginal deliveries, maternal, and neonatal outcomes were compared with women who had a first-term cesarean (37-43 weeks). RESULTS: Four thousand three-hundred forty-two women delivered by preterm cesarean in the first pregnancy. These women had high rates of successful trial of labor, both after spontaneous onset (86.2-96.2%) and induction (72.8-75.4%). Rates of adverse outcomes were low and similar compared with women with a previous term cesarean. CONCLUSION: In this 10-year nationwide cohort, women with a preterm first cesarean who opted for trial of labor in a subsequent pregnancy had high rates of successful trial of labor.

Decision-making during trial of labour after caesarean; a qualitative study with gynaecologists.

OBJECTIVE: The attempt of a woman to deliver vaginally after having had a caesarean in a previous pregnancy is increasingly common in current obstetric practice. During a trial of labour after caesarean, gynaecologists consider whether continuing vaginal birth is safe or, alternately, whether a repeat caesarean is advised. There is large variation in the success rates of women with comparable medical risk factors, requiring better insight in how this assessment is made. As a window of opportunity to intervene in this unexplained variation in practice in specific, and in the globally rising caesarean rate in general, our aim was to increase understanding of gynaecologists' decision-making during trial of labour. STUDY DESIGN: We conducted a constructivist grounded theory study, interviewing Dutch gynaecologists. Data collection and analysis were performed concurrently. Initial convenience sampling shifted to theoretical sampling as the study progressed. Data collection continued until theoretical sufficiency was reached. We applied open and axial codes to transcripts of the interviews, and then assembled the axial codes into themes that built up to an emerging theoretical framework. RESULTS: Nine gynaecologists were interviewed. Data indicated they continuously weighed the chance of a successful outcome of trial of labour against the likelihood of adversities. Patients' opinions, aspects of progress of labour and gynaecologists' personal stances regarding trial of labour played a role in the decision-making process; these factors are influenced by organisational affordances and culture. Variation in the assessment of individuals' chances of success and variable thresholds for a repeat caesarean added to the complexity of the decision-making. CONCLUSION: This study pieced together patient-, delivery-, physician- and society-related factors that result in vitally important decisions during trial of labour after caesarean; it reveals the complexity as well as the repetitive patterns involved in this process. Exposing these factors offers opportunities to incorporate the decision-making process in targeted educational interventions, with the aim of modifying the underlying assumptions and concepts in order to reduce practice variation.