Maternal mortality due to obstetric hemorrhage by surgical injury during cesarean section: A nationwide study.

INTRODUCTION: Obstetric hemorrhage remains a largely preventable cause of maternal mortality globally. The contribution of uterine atony to hemorrhage-related maternal mortality has decreased in France, while the contribution of other causes of obstetric hemorrhage such as surgical injury during cesarean has been reported to increase. However, little evidence exists regarding the risk factors and care processes of women who died from this cause of hemorrhage. Therefore, we aimed to describe the clinical profile, underlying mechanisms, and preventability factors among women who died from obstetric hemorrhage by surgical injury during cesarean section. MATERIAL AND METHODS: Nationwide analysis of all hemorrhage-related maternal deaths by surgical injury during cesarean in France identified by the nationwide permanent enhanced maternal mortality surveillance system (ENCMM) between 2007 and 2018. We described the characteristics of the women, delivery hospitals, circumstances of hemorrhage, features of obstetric and resuscitation/transfusion care, and main preventability factors. RESULTS: Between 2007 and 2018, hemorrhage-related maternal mortality in France decreased from 1.6/100 000 live births (95% CI 1.1-2.2) (39/2 472 650) in 2007-2009 to 0.8/100 000 live births (95% CI 0.5-1.3) (19/2 311 783) in 2016-2018. Hemorrhage-related maternal mortality ratio due to surgical injury during cesarean increased from 0.08 (95% CI 0.01-0.3) (2/2 472 650) to 0.2 (95% CI 0.07-0.5) (5/2 311 783) per 100 000 live births. Among the 18 women who died from surgical injury during cesarean over the 12-year study period, we report a high prevalence of obesity (67%, 12/18), previous cesarean (72%, 13/18), and second-stage cesareans (56%, 10/18). In 22% (4/18), cesarean section was performed in a hospital providing <1000 births annually, with no blood bank (39%, 7/18) or no adult intensive care (44%, 8/18) on-site. Overall preventability of deaths was 94% (17/18). Main preventability factors were related to delay in hemorrhage diagnosis (77%, 14/18) due to late recognition of abnormal parameters (33%, 6/18) and late bedside ultrasound (56%, 10/18), and delay in management due to insufficient surgical skills (56%, 10/18). CONCLUSIONS: In France, surgical injury during cesarean section is an increasing, largely preventable contributor to hemorrhage-related maternal mortality, as other causes of fatal hemorrhage have become less frequent. The profile of these women showed a high prevalence of obesity, previous cesarean, second-stage cesarean, and delivery in hospitals with limited medical and surgical resources, which suggests explanatory mechanisms for the fatal outcome and opportunities for prevention.

Trends in Maternal Mortality From Obstetric Hemorrhage in France: 15 Years of Confidential Enquiry Into Maternal Deaths.

BACKGROUND: The aim of this study was to assess temporal trends in incidence and underlying causes of maternal deaths from obstetric hemorrhage in France and to describe clinical care before and after implementation of the first national guidelines published in 2004 and updated in 2014. METHODS: Data from all hemorrhage-related maternal deaths between 2001 and 2015 were extracted from the French Confidential Enquiry into Maternal Deaths. We compared the maternal mortality ratio (MMR), cause of obstetric hemorrhage, and death preventability by triennium. Critical care, transfusion, and obstetric management among women who died were described for 2001 to 2003 and 2013 to 2015. RESULTS: The MMR from obstetric hemorrhage significantly decreased over time from 2.3 of 100,000 livebirths (54 of 2,391,551) in 2001 to 2003 to 0.8 of 100,000 livebirths (19 of 2,412,720) in 2013 to 2015. In 2001 to 2003, uterine atony accounted for 50% (27 of 54) of maternal deaths vs 21% (4 of 19) in 2013 to 2015. As compared to 2001 to 2003, an increased proportion of women had hemodynamic continuous monitoring in 2013 to 2015 (30%, 9 of 30, vs 47%, 8 of 18) and received vasopressor infusion therapy (57%, 17 of 30, vs 72%, 13 of 18), and a smaller proportion was extubated during active hemorrhage (17%, 5 of 30, vs 0 of 18). Transfusion therapy was initiated more frequently and earlier in 2013 to 2015 (71 vs 58 minutes). In 2013 to 2015, 88% of maternal deaths due to hemorrhage remained preventable. The main identified improvable care factors were related to delays in diagnosis and surgical management, particularly after cesarean delivery. CONCLUSIONS: Maternal mortality by obstetric hemorrhage decreased dramatically in France between 2001 and 2015, particularly mortality due to uterine atony. Among women who died, we detected fewer instances of substandard transfusion management or critical care. Nevertheless, opportunities for improvement were observed in most of the recent cases.

[Maternal mortality in France, 2016-2018, frequency, causes and women's profile]. / Mortalité maternelle en France, 2016­2018, fréquence, causes et profil des femmes.

OBJECTIVE: To describe, for the 2016-2018 period, the frequency, causes and risk factors of maternal deaths in France. METHOD: Data from the National Confidential Enquiry into Maternal Deaths for 2016-2018. RESULTS: For 2016-2018, 272 maternal deaths occurred in France up to 1 year after the end of pregnancy, i.e a maternal mortality ratio of 11.8 per 100,000 live births (95 % CI 10.4-13.3), and 8.5 (IC 95 % 7.4-9.8) for maternal mortality up to 42 days. Compared to women aged 20-24, the risk of maternal death is multiplied by 2.6 for women aged 35-39, by 5 for women aged 40 and over. Obese women are twice as frequent among maternal deaths (26 %) than in the general population of parturients (11 %). There are territorial disparities -the maternal mortality ratio in the French overseas departments is 2 times higher than in metropolitan France (significant difference but smaller than in 2013-2015)-, and social disparities -the mortality of migrant women remains higher than that of women born in France, particularly for women born in sub-Saharan Africa whose risk is 3 times higher than that of native women. One in three women who died (34 %) had socio-economic vulnerability versus 22 % in the overall population of parturients. Among causes of maternal deaths, the predominant role of psychiatric conditions (mostly suicides) is confirmed for the period 2016-2018, leading cause of maternal mortality considered up to 1 year (17 %), MMR of 1.9/100,000 NV. i.e. approximately one death from psychiatric causes every 3 weeks. Cardiovascular diseases are the second leading cause of maternal mortality up to one year (14 %) and the leading cause up to 42 days (16 %), with 1.3 deaths per 100,000 NV. Amniotic fluid embolism ranks as the third cause (8 %) (2nd cause, 11 %, for MM limited to 42 days), i.e. MMR of 0.9 per 100,000 NV. After a regular decline over the last decade, maternal mortality from obstetric hemorrhage is at a stable level compared to the previous triennium 2013-2015, MMR of 0.9/100,000 NV, i.e 5th cause of MM up to one year (7 %) and 4th cause of MM up to 42 days. CONCLUSION: The overall national maternal mortality ratio does not show a downward trend, even with constant surveillance method. Territorial inequalities persist but change in their magnitude and in the regions concerned. The profile of the causes of maternal mortality up to one year of the pregnancy end shows the leading role of suicides and cardiovascular diseases, which illustrates that the health of pregnant women or those who have recently given birth is not limited to the obstetric domain, and highlights the importance of multidisciplinarity in the management and organization of care for women in this period.

[National confidential enquiry into maternal deaths in France, a 25-year enhanced surveillance system, essential for the reliable characterization of maternal deaths]. / Enquête Nationale Confidentielle sur les Morts Maternelles en France, un système de surveillance améliorée depuis 25 ans, indispensable pour la caractérisation fiable des décès maternels.

Although maternal mortality is rare in wealthy countries, it remains a fundamental indicator of maternal health. It is considered to be a "sentinel event", the occurrence of which indicates dysfunctions, often cumulative, in the healthcare system. In addition to the classic epidemiological surveillance findings - number of deaths, maternal mortality ratio, distribution of medical causes, sub-groups of women at risk - its study, through a precise analysis of the history of each woman who died, enables to highlight areas for improvement in the content or organisation of care, the correction of which will make it possible to prevent not only deaths but also upstream morbid events involving the same mechanisms. To achieve this dual epidemiological and clinical audit objective, an ad hoc "enhanced" system is needed. France has had such a system since 1996, the Enquête Nationale Confidentielle sur la Mortalité Maternelle (ENCMM), under the joint supervision of Santé Publique France and Inserm. The ENCMM method aims to identify maternal deaths exhaustively and reliably up to 1 year after the end of pregnancy, and to document each death as fully as possible. The 1st step is the multi-source identification (direct declaration, death certificates, linkage with birth certificates, hospital stay database) of women who died during pregnancy or in the year following its end. The 2nd step is the collection of detailed information for each death by a pair of clinical assessors. The 3rd step is the review of these anonymised documents by the National Expert Committee on Maternal Mortality, which establishes the maternal nature of the death (causal link with pregnancy) and, with a stated aim of improvement rather than judgement, assesses the adequacy of care and the preventability of the death. The summary of the information gathered for maternal deaths in the 2016-2018 period is presented in the other articles of this special issue.

[Maternal mortality, adequation of care and preventability, France 2016-2018]. / Mortalité maternelle, adéquation des soins et évitabilité, France 2016­2018.

OBJECTIVE: To describe, for the 2016-2018 period, the adequacy of care provided to women who died of maternal death in France, as well as the possible preventability of these deaths. METHOD: National data from the Enquête Nationale Confidentielle sur les Morts Maternelles for 2016-2018. For each maternal death identified, the National Expert Committee on Maternal Mortality (CNEMM) assesses the adequacy of the care provided and whether the death was probably, possibly or not preventable. RESULTS: For 2016-2018, 272 maternal deaths (considered up to 1 year after the end of pregnancy) occurred in France. Of these, 265 had sufficient information collected by the confidential survey and could be assessed by the CNEMM. In total, care was judged to be "sub-optimal" for 66% of deaths assessed for all causes, a proportion similar to that for previous periods. In addition to the obstetric and anaesthetic care provided at the time of the acute complication, which was judged to be sub-optimal for 45% (obstetric care) and 38% (anaesthetic care) of maternal deaths, this report highlights the scope for improvement in other types of care, more related to prevention and screening: "sub-optimal" preconception care for 51% of the women who died for whom it was justified, particularly notable for deaths linked to a preexisting condition (52%) and for suicides (67%); prenatal surveillance judged to be "sub-optimal" in 30% of cases, a sub-optimality also more frequent among deaths linked to a preexisting condition (35%) and suicides (34%). In all, 59.7% of maternal deaths assessed were judged to be "probably" (17%) or "possibly" (42.7%) preventable, a profile that remained stable. Suicide and other psychiatric causes, the leading cause of maternal death, were considered to be potentially preventable in 79% of cases. Deaths from haemorrhage remained largely preventable (95%, the highest proportion by cause). The factor most often implicated was inadequate care, and preventability linked to this factor was identified in 53% of deaths, all causes combined. Gap in organization of care was a preventability factor identified in 24% of deaths, and poor interaction between the woman and the healthcare system in 22% of deaths. CONCLUSION: This proportion of more than half of potentially preventable maternal deaths shows that a reduction in maternal mortality in France is still possible and must be achieved, the objective being to prevent all preventable deaths. Analysis of the factors involved, overall and by cause of death, suggests areas for improvement.

Timing and Preventability of Cardiovascular-Related Maternal Death.

OBJECTIVE: To describe the clinical profile, management, and potential preventability of maternal cardiovascular deaths. METHODS: We conducted a retrospective, descriptive study of all maternal deaths resulting from a cardiovascular disease during pregnancy or up to 1 year after the end of pregnancy in France from 2007 to 2015. Deaths were identified through the nationwide permanent enhanced maternal mortality surveillance system (ENCMM [Enquête Nationale Confidentielle sur les Morts Maternelles]). Women were classified into four groups based on the assessment of the national experts committee: those who died of a cardiac condition and those who died of a vascular condition and, within these two groups, whether the condition was known before the acute event. Maternal characteristics, clinical features and components of suboptimal care, and preventability factors, which were assessed with a standard evaluation form, were described among those four groups. RESULTS: During the 9-year period, 103 women died of cardiac or vascular disease, which corresponds to a maternal mortality ratio from these conditions of 1.4 per 100,000 live births (95% CI 1.1-1.7). Analyses were conducted on 93 maternal deaths resulting from cardiac (n=70) and vascular (n=23) disease with available data from confidential inquiry. More than two thirds of these deaths occurred in women with no known pre-existing cardiac or vascular condition. Among the 70 deaths resulting from a cardiac condition, 60.7% were preventable, and the main preventability factor was a lack of multidisciplinary prepregnancy and prenatal care for women with a known cardiac disease. For those with no known pre-existing cardiac condition, preventability factors were related mostly to inadequate prehospital care of the acute event, in particular an underestimation of the severity and inadequate investigation of the dyspnea. Among the 23 women who died of a vascular disease, three had previously known conditions. For women with no previously known vascular condition, 47.4% of deaths were preventable, and preventability factors were related mostly to wrong or delayed diagnosis and management of acute intense chest or abdominal pain in a pregnant woman. CONCLUSION: Most maternal deaths attributable to cardiac or vascular diseases were potentially preventable. The preventability factors varied according to the cardiac or vascular site and whether the condition was known before pregnancy. A more granular understanding of the cause and related risk factors for maternal mortality is crucial to identify relevant opportunities for improving care and training health care professionals.

Maternal mortality in eight European countries with enhanced surveillance systems: descriptive population based study.

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.

Maternal mortality in women with pre-viable premature rupture of membranes: An analysis from the French confidential enquiry into maternal deaths.

INTRODUCTION: Pre-viable premature rupture of membranes (pre-viable PROM) is a rare event occurring in less than 1% of pregnancies. Nevertheless, it can be responsible for severe maternal complications, the risk of which needs to be balanced with the possibility to prolong the pregnancy up to viable gestational age. Maternal sepsis was reported in 1%-5% of women who received conservative management and prophylactic antibiotics, but information on maternal mortality is lacking. Our objective was to identify maternal deaths in women who had pre-viable PROM, describe the characteristics of the women, explore preventability factors within the care they received, and estimate the lethality of pre-viable PROM. MATERIAL AND METHODS: We identified all maternal deaths associated with pre-viable PROM from the 2001-2015 French National Confidential Enquiry into Maternal Deaths (NCMM). Data on women's characteristics and the care they received were extracted from the ENCMM database. The lethality was determined after estimating the total number of pregnant women with pre-viable PROM from the national hospital discharge database. RESULTS: Between 2001 and 2015, we identified seven maternal deaths associated with pre-viable PROM, representing 0.6% of all maternal deaths over this period (ie, maternal mortality ratio 0.06/100 000 live births). Six maternal deaths were attributed to sepsis after genital infection by Gram-negative bacilli and one to postpartum hemorrhage due to placenta accreta. Four of these seven cases were considered preventable. The main preventability factors were delayed diagnosis, delayed fetal extraction, and inappropriate antibiotic treatment. The estimated lethality was 4.5/10 000 women with pre-viable PROM. CONCLUSIONS: Maternal death associated with pre-viable PROM is rare but possible. Most of these deaths seem preventable, with areas for improvement related to earlier diagnosis and better treatment of uterine infections, which can evolve rapidly.

Understanding maternal mortality in women with obesity and the role of care they receive: a national case-control study.

OBJECTIVE: Obesity has significant implications for the health of pregnant women. However, few studies have quantified its association with maternal mortality or examined the relevant underlying causes and the role of care, although this remains the most severe maternal outcome. Our objectives were to quantify the risk of maternal death by prepregnancy body mass index and to determine whether obesity affected the quality of care of the women who died. DESING: This is a national population-based case-control study in France. Cases were 364 maternal deaths from the 2007-2012 National Confidential Enquiry. Controls were 14,681 parturients from the nationally representative 2010 perinatal survey. We studied the association between categories of prepregnancy BMI and maternal death by multivariable logistic regression, estimating adjusted odds ratios and 95% confidence intervals, overall and by specific causes of death. Individual case reviews assessed the quality of care provided to the women who died, by obesity status. RESULTS: Compared with women with normal BMI, underweight women (<18.5 kg/m2) had an adjusted OR of death of 0.75 (95% CI, 0.42-1.33), overweight women (25-29.9 kg/m2) 1.65 (95% CI, 1.24-2.19), women with class 1 obesity (30-34.9 kg/m2) 2.22 (95% CI, 1.55-3.19) and those with class 2-3 obesity (≥35 kg/m2) 3.40 (95% CI, 2.17-5.33). Analysis by cause showed significant excess risk of maternal death due to cardiovascular diseases, venous thromboembolism, hypertensive complications and stroke in women with obesity. Suboptimal care was as frequent among women with (35/62, 57%) as without obesity (136/244, 56%), but this inadequate management was directly related to obesity among 14/35 (40%) obese women with suboptimal care. Several opportunities for improvement were identified. CONCLUSIONS: The risk of maternal death increases with BMI; it multiplied by 1.6 in overweight women and more than tripled in pregnant women with severe obesity. Training clinicians in the specificities of care for pregnant women with obesity could improve their outcomes.

Delivery Hospital Characteristics and Postpartum Maternal Mortality: A National Case-Control Study in France.

BACKGROUND: The variability in resources for managing critical events among maternity hospitals may impact maternal safety. Our main objective was to assess the risk of postpartum maternal death according to hospitals' organizational characteristics. A secondary objective aimed to assess the specific risk of death due to postpartum hemorrhage (PPH). METHODS: This national population-based case-control study included all 2007-2009 postpartum maternal deaths from the national confidential enquiry (n = 147 cases) and a 2010 national representative sample of parturients (n = 14,639 controls). To adjust for referral bias, cases were classified by time when the condition/complication responsible for the death occurred: postpartum maternal deaths due to conditions present before delivery (n = 66) or during or after delivery (n = 81). Characteristics of delivery hospitals included 24/7 on-site availability of an anesthesiologist and an obstetrician, level of perinatal care, number of deliveries annually, and their teaching and profit status. In teaching and other nonprofit hospitals in France, obstetric care is organized on the principle of collective team-based management, while in for-profit hospitals, this organization is based mostly on that of "one woman-one doctor." Logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for postpartum maternal death. RESULTS: The risk of maternal death from prepartum conditions was lower for women who gave birth in for-profit compared with teaching hospitals (aOR, 0.3; 95% CI, 0.1-0.8; P = .02) and in hospitals with <1500 vs ≥1500 annual deliveries (aOR, 0.4; 95% CI, 0.1-0.9; P = .02). Conversely, the risk of postpartum maternal death from complications occurring during or after delivery was higher for women who delivered in for-profit compared with teaching hospitals (aOR, 2.8; 95% CI, 1.3-6.0; P = .009), as was the risk of death from PPH in for-profit versus nonprofit hospitals (aOR, 2.8; 95% CI, 1.2-6.5; P = .019). CONCLUSIONS: After adjustment for the referral bias related to prepartum morbidity, the risk of postpartum maternal mortality in France differs according to the hospital's organizational characteristics.

Maternal Death Due to Amniotic Fluid Embolism: A National Study in France.

BACKGROUND: A structured definition of amniotic fluid embolism (AFE) based on 4 criteria was recently proposed for use in research by the Society for Maternal-Fetal Medicine (SMFM) and the Amniotic Fluid Embolism Foundation. The main objective of this study was to review all AFE-related maternal deaths in France during 2007-2011 according to the presence or not of all these 4 diagnostic criteria. METHODS: Maternal deaths due to AFE were identified by the national experts committee of the French Confidential Enquiry into Maternal Deaths during 2007-2011 (n = 39). The maternal mortality ratio for AFE was calculated. We applied the structured definition proposed by the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation to AFE-related maternal deaths identified by the national experts committee. Characteristics of women, pregnancies and deliveries; clinical and biological features of AFE; and specific laboratory tests used were described by the presence or not of all 4 diagnostic criteria. Management of obstetric hemorrhage and quality of care according to the experts were also described. RESULTS: The maternal mortality ratio from AFE was 0.95/100,000 live births (95% confidence interval, 0.67-1.3). Detailed clinical data were collected for 36 women who died from AFE: 21 (58%) had all 4 proposed diagnostic criteria and 15 (42%) had 1 or more missing criterion. Documented early disseminated intravascular coagulopathy was missing for 14 women, and 2 women exhibited more than 1 missing criterion. Ten of the 15 women with missing criteria had clinical coagulopathy, with standard hemostasis tests performed in only 3. Specific diagnostic examinations for AFE were performed in similar proportions by the presence or not of all diagnostic criteria. Opportunities to improve care included timely performance of indicated hysterectomy (n = 13) and improved transfusion practices (n = 9). In the context of maternal cardiac arrest, for 5 of 13 women, fetal extraction was performed within 5 minutes. CONCLUSIONS: The structured definition of AFE for research studies would exclude more than one-third of AFE-related maternal deaths identified by the national experts committee. Inclusion of clinical coagulopathy as a diagnostic criterion for AFE would reduce this proportion to 14%. There is still room for improvement in the management of obstetric hemorrhage and timely fetal extraction in the context of maternal cardiac arrest, frequently observed in AFE-related maternal death.

Caesarean Delivery and Postpartum Maternal Mortality: A Population-Based Case Control Study in Brazil.

BACKGROUND: Cesarean delivery rates continue to increase worldwide and reached 57% in Brazil in 2014. Although the safety of this surgery has improved in the last decades, this trend is a concern because it carries potential risks to women's health and may be a modifiable risk factor of maternal mortality. This paper aims to investigate the risk of postpartum maternal death directly associated with cesarean delivery in comparison to vaginal delivery in Brazil. METHODS: This was a population-based case-control study performed in eight Brazilian states. To control for indication bias, deaths due to antenatal morbidity were excluded. We included 73 cases of postpartum maternal deaths from 2009-2012. Controls were selected from the Birth in Brazil Study, a 2011 nationwide survey including 9,221 postpartum women. We examined the association of cesarean section and postpartum maternal death by multivariate logistic regression, adjusting for confounders. RESULTS: After controlling for indication bias and confounders, the risk of postpartum maternal death was almost three-fold higher with cesarean than vaginal delivery (OR 2.87, 95% CI 1.63-5.06), mainly due to deaths from postpartum hemorrhage and complications of anesthesia. CONCLUSION: Cesarean delivery is an independent risk factor of postpartum maternal death. Clinicians and patients should consider this fact in balancing the benefits and risks of the procedure.

Pitfalls of national routine death statistics for maternal mortality study.

BACKGROUND: The lessons learned from the study of maternal deaths depend on the accuracy of data. Our objective was to assess time trends in the underestimation of maternal mortality (MM) in the national routine death statistics in France and to evaluate their current accuracy for the selection and causes of maternal deaths. METHODS: National data obtained by enhanced methods in 1989, 1999, and 2007-09 were used as the gold standard to assess time trends in the underestimation of MM ratios (MMRs) in death statistics. Enhanced data and death statistics for 2007-09 were further compared by characterising false negatives (FNs) and false positives (FPs). The distribution of cause-specific MMRs, as assessed by each system, was described. RESULTS: Underestimation of MM in death statistics decreased from 55.6% in 1989 to 11.4% in 2007-09 (P < 0.001). In 2007-09, of 787 pregnancy-associated deaths, 254 were classified as maternal by the enhanced system and 211 by the death statistics; 34% of maternal deaths in the enhanced system were FNs in the death statistics, and 20% of maternal deaths in the death statistics were FPs. The hierarchy of causes of MM differed between the two systems. The discordances were mainly explained by the lack of precision in the drafting of death certificates by clinicians. CONCLUSION: Although the underestimation of MM in routine death statistics has decreased substantially over time, one third of maternal deaths remain unidentified, and the main causes of death are incorrectly identified in these data. Defining relevant priorities in maternal health requires the use of enhanced methods for MM study.

Ten years of confidential inquiries into maternal deaths in France, 1998-2007.

OBJECTIVE: To assess trends in the maternal mortality ratio over a 10-year period in France and the causes, risk factors, quality of care, and avoidability of maternal deaths. METHODS: Maternal deaths up to 1 year after the end of the pregnancy from 1998 to 2007 were identified and studied through the French Confidential Enquiry Into Maternal Deaths system. Time trends were analyzed by comparing the two 5-year periods for maternal mortality ratios, both overall and by women's characteristics, causes of death, existence of suboptimal care, and avoidability. RESULTS: For the 10-year period, 660 maternal deaths were identified. The maternal mortality ratio was similar in the two 5-year periods, 8.8 per 100,000 live births (95% confidence interval [CI] 7.8-9.8) for 1998-2002 and 8.4 per 100,000 live births (95% CI 7.6-9.4) for 2003-2007. The distributions of maternal age, nationality, and of causes of death did not change. Overall, hemorrhage was the leading cause of death, responsible for 18% of maternal deaths, followed by amniotic fluid embolism, thromboembolism, hypertensive disorders, and cardiovascular conditions, each of which contributed to 10-12% of deaths. Suboptimal care decreased from 70% in 1998-2002 to 60% in 2003-2007 (P<.03). Half of all deaths were considered avoidable and this proportion did not change. The most frequent contributory factor was inadequate management. CONCLUSION: The ratio and profile of maternal mortality in France remained unchanged from 1998 to 2007. Half of all maternal deaths are still considered avoidable, which indicates that improvement remains possible. LEVEL OF EVIDENCE: : III.

Measurement of nuchal translucency and the prenatal diagnosis of Down syndrome.

OBJECTIVES: To estimate the sensitivity of nuchal-translucency measurement and compare it with that of second-trimester serum screening using population-based data and to evaluate the effect of nuchal-translucency measurement on the gestational age at prenatal diagnosis of Down syndrome and pregnancy termination. METHODS: We used The Paris Registry of Congenital Malformation data on 594 cases of Down syndrome (live births, fetal deaths, and pregnancy terminations) from 2001-2006. Analyses were done separately for women younger than 38 years and women aged 38 years or older. Analyses included binomial regression and fractional polynomials to model time trends in gestational age at diagnosis and at pregnancy termination. RESULTS: Ninety percent of the fetuses had undergone nuchal-translucency measurement as compared with only 22% that underwent second-trimester serum screening. This was principally because half of the pregnant women were given a diagnosis of Down syndrome during the first trimester after an abnormal result of nuchal-translucency measurement. Second-trimester serum screening had a higher sensitivity than did nuchal-translucency measurement (72% compared with 56%). The increasing use of nuchal-translucency measurement led to an increase in early diagnosis of Down syndrome in women younger than 38 years of age; diagnosis before 15 weeks of gestation increased from 21.7% in 2001 to 51.6% in 2006 (P=.016). Pregnancy termination before 15 weeks also increased from 18.8% in 2001 to 47.5% in 2006 (P=.02). CONCLUSION: The main effect of the increased use of nuchal-translucency measurement was a substantial increase in the early detection of Down syndrome, principally in younger women. This is an important advantage because several studies have shown that women prefer early diagnosis of Down syndrome. LEVEL OF EVIDENCE: III.