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.

Neonatal complications and neurophysiological development in twins - a long-term follow-up study.

OBJECTIVES: To investigate the association between neonatal complications and neurophysiological development in twins at 18 and 48-60 months of age. METHODS: This was a secondary analysis of 841 Danish mono- and dichorionic diamniotic twins from a randomized controlled trial (PREDICT study), which included an assessment of the twin's neurophysiological development using the Ages and Stages Questionnaire (ASQ) that had been filled out by the parents at 18 and 48 or 60 months. The correlation within twin pairs was accounted for by the method of generalized estimating equation. Models were adjusted for maternal educational score and gestational age at delivery. RESULTS: ASQ data were available for 823 children at 18 months and 425 children at 48 or 60 months. Low maternal educational score and preterm delivery <34 weeks were associated with a lower ASQ score at 48-60 months (-15.4 points (95%CI -26.4; -4.5) and -13.2 points (95%CI -23.8; -2.5), respectively). Neonatal sepsis and a compound of intraventricular hemorrhage, retinopathy of prematurity and necrotizing enterocolitis (IVH/ROP/NEC) were associated with lower ASQ score at 18 months (-15.3 points (95%CI -28.1; -2.5) and -30.8 points (95%CI -59.5; -2.1), respectively). Children with IVH/ROP/NEC had a lower ASQ score at 48-60 months (-34.2 points (95%CI -67.9; -0.6)). The associations were not specific to only one ASQ domain. CONCLUSION: Several neonatal complications are associated with poorer neurophysiological development in twins during childhood, even after adjustment for gestational age at delivery.

An audit of 70 maternal deaths.

INTRODUCTION: Although women rarely die during pregnancy and childbirth in Denmark, keeping track of the maternal mortality rate and causes of death is vital in identifying learning points for future management of critical illness among obstetric patients and in pinpointing risk factors. METHODS: We identified maternal deaths between 2002 and 2017 by linking four Danish national health registers, using death certificates and reports from hospitals. An audit group then categorised each case by cause of death before identifying any suboptimal care and learning points, which may serve as a foundation for national guidelines and educational strategies. RESULTS: Seventy women died during pregnancy or within six weeks of a pregnancy in the study period. The most frequent causes of death were cardiovascular disease (n = 14), hypertensive disorder (n = 10), suicide (n = 10) and thromboembolism (n = 7). Suboptimal care was identified in 30 of the 70 cases. CONCLUSIONS: Mortality from some of the most important causes of death decreased during the study period. No deaths from preeclampsia or thrombosis, two of the leading causes of death, were identified after 2011. In 2015-2017, suicide was the main cause of maternal death, which indicates that a stronger focus on vulnerability in pregnancy and childbirth is essential. Among the 70 deaths, 34% were potentially avoidable, indicating that it is essential continuously to focus on how to reduce severe maternal morbidity and mortality. FUNDING: none TRIAL REGISTRATION. not relevant.

Reduction in maternal mortality in Denmark over three decades.

INTRODUCTION: Women very rarely die during pregnancy and childbirth in Denmark. Although maternal deaths are registered worldwide, various studies indicate that underreporting does occur. This paper presents validated Danish register data for two periods between 1985 and 2017. METHODS: Maternal deaths were identified from 1985 to 1994 and from 2002 to 2017 by linking four national health registers, death certificates and notifications from maternity wards. A group of obstetricians categorised and assessed all medical records, classifying each case by cause of death. RESULTS: Linkage of four registers yielded valid data, leading to the identification of 143 maternal deaths in the abovementioned periods. From 1985-1994 there were 73 deaths and 618,021 live births, resulting in a maternal mortality rate of 11.8 per 100,000 live births with a non-significant 2% annual increase (95% confidence interval (CI): -6.0-11.0%). From 2002 to 2017 there were 70 maternal deaths and 999,206 live births, resulting in a maternal mortality rate of 7.0 per 100,000 live births (95% CI: 5.5-8.9) with a significant 9% annual decrease (95% CI: 4.0-14.0%). CONCLUSIONS: Overall maternal mortality decreased in the course of the two periods (n = 33 years), with a significant decrease during the last period. This is suggested to be a result of multiple clinical and organisational improvements as discussed in the paper. FUNDING: none. TRIAL REGISTRATION: not relevant.

The impact of cardiovascular diseases on maternal deaths in the Nordic countries.

INTRODUCTION: Cardiovascular diseases have become increasingly important as a cause of maternal death in the Nordic countries. This is likely to be associated with a rising incidence of pregnant women with congenital and acquired cardiac diseases. Through audits, we aim to prevent future maternal deaths by identifying causes of death and suboptimal factors in the clinical management. MATERIAL AND METHODS: Maternal deaths in the Nordic countries from 2005 to 2017 were identified through linked registers. The national audit groups performed case assessments based on hospital records, classified the cause of death, and evaluated the standards of clinical care provided. Key messages were prepared to improve treatment. RESULTS: We identified 227 maternal deaths, giving a maternal mortality rate of 5.98 deaths per 100 000 live births. The most common cause of death was cardiovascular disease (n = 36 deaths). Aortic dissection/rupture, myocardial disease, and ischemic heart disease were the most common diagnoses. In nearly 60% of the cases, the disease was not recognized before death. In more than half of the deaths, substandard care was identified (59%). In 11 deaths (31%), improvements to care that may have made a difference to the outcome were identified. CONCLUSIONS: Between 2005 and 2017, cardiovascular diseases were the most common causes of maternal deaths in the Nordic countries. There appears to be a clear potential for a further reduction in these maternal deaths. Increased awareness of cardiac symptoms in pregnant women seems warranted.

Induction of labor with high- or low-dosage oral misoprostol-A Danish descriptive retrospective cohort study 2015-16.

INTRODUCTION: In Denmark, the rate of induced labor from 37 gestational weeks has increased by 108% from 12.4% in 2000 to 25.1% in 2012, and today more than 1 in 4 deliveries are induced. Standard procedure at North Zealand Hospital changed in 2016 from a dosage of 50 µg oral misoprostol 2-3 times daily, to 25 µg up to 8 times daily. Also, since 2016 healthy women with uncomplicated pregnancies (primiparous and multiparous) have been offered induction as an outpatient procedure. This study aimed to compare the current low-dosage procedure (25 µg) with the former high-dosage procedure (50 µg) in terms of induction to delivery time, maternal and fetal outcomes, and risk of uterine hyperstimulation. MATERIAL AND METHODS: Data from June 2015 to October 2016 were included. Comparable baseline, demographic, and obstetric data for women induced according to high-dosage or low-dosage protocols were retrieved from local medical files. Descriptive statistics, Pearson's chi-squared tests, Kaplan-Meier survival estimates, and logistic regression analyses were performed. RESULTS: The study included 816 induced deliveries. The high- and low-dosage groups differed in rates of plurality and place of induction. Induction to delivery times lasting longer than 72 hours were significantly decreased in the low-dosage group (adjusted odds ratio [aOR] 0.48, 95% confidence interval [95% CI] 0.27 to 0.86). Women in the low-dosage group also less often needed additional induction (P = 0.02), and the rate of uterine hyperstimulation was low irrespective of protocol (1% vs 3%, P = 0.16). There were no cases of uterine rupture in either group. The probability of vaginal delivery in the low-dosage group increased (adjusted hazard ratio 1.27, 95% CI 1.08 to 1.49), as did the risk of delivery with vacuum extraction (aOR 2.27, 95% CI 1.24 to 4.15), whereas delivery by cesarean section slightly decreased (aOR 0.89, 95% CI 0.59 to 1.33). The risk of meconium-stained liquor was nonsignificantly decreased (aOR 0.82, 95% CI 0.55 to 1.23). CONCLUSIONS: The low-dosage induction protocol was associated with favorable obstetric outcomes in terms of increased probability of vaginal delivery, but with higher risk of vacuum extraction. Protracted inductions and additional nonmedical interventions were reduced. There were no cases of uterine rupture. Statistically nonsignificant, the risk of uterine hyperstimulation was increased whereas the risk of meconium-stained liquor and of cesarean section was slightly decreased.

Maternal deaths in the Nordic countries.

INTRODUCTION: Despite the seriousness of the event, maternal deaths are substantially underreported. There is often a missed opportunity to learn from such tragedies. The aim of the study was to identify maternal deaths in the five Nordic countries, to classify causes of death based on internationally acknowledged criteria, and to identify areas that would benefit from further teaching, training or research to possibly reduce the number of maternal deaths. MATERIAL AND METHODS: We present data for the years 2005-2013. National audit groups collected data by linkage of registers and direct reporting from hospitals. Each case was then assessed to determine the cause of death, and level of care provided. Potential improvements to care were evaluated. RESULTS: We registered 168 maternal deaths, 90 direct and 78 indirect cases. The maternal mortality ratio was 7.2/100 000 live births ranging from 6.8 to 8.1 between the countries. Cardiac disease (n = 29) was the most frequent cause of death, followed by preeclampsia (n = 24), thromboembolism (n = 20) and suicide (n = 20). Improvements to care which could potentially have made a difference to the outcome were identified in one-third of the deaths, i.e. in as many as 60% of preeclamptic, 45% of thromboembolic, and 32% of the deaths from cardiac disease. CONCLUSION: Direct deaths exceeded indirect maternal deaths in the Nordic countries. To reduce maternal deaths, increased efforts to better implement existing clinical guidelines seem warranted, particularly for preeclampsia, thromboembolism and cardiac disease. More knowledge is also needed about what contributes to suicidal maternal deaths.

Short- and long-term perinatal outcome in twin pregnancies affected by weight discordance.

INTRODUCTION: The objective was to investigate the association between chorionicity-specific intertwin birthweight discordance and adverse outcomes including long-term follow up at 6, 18, and 48-60 months after term via Ages and Stages Questionnaire. MATERIAL AND METHODS: In this secondary analysis of a cohort study (Oldenburg et al., n = 1688) and a randomized controlled trial (PREDICT study, n = 1045) twin pairs were divided into three groups according to chorionicity-specific birthweight discordance: <75th percentile, 75th-90th percentile and >90th percentile. Information on infant mortality, admittance to neonatal intensive care units, and gestational age at delivery was available for all pairs. Detailed neonatal outcomes were available for 656 pairs from PREDICT, of which 567 pairs had at least one Ages and Stages Questionnair follow-up. Logistic regression models were used for dichotomous outcomes. Ages and Stages Questionnair scores were compared using the method of generalized estimating equation to account for the correlation within twins. RESULTS: The 75th and 90th percentiles for birthweight discordance were 14.8 and 21.4% for monochorionic and 16.0 and 23.8% for dichorionic twins. After adjustment for small for gestational age and gender, birthweight discordance >75th and >90th percentile was associated with induced delivery <34 weeks [odds ratio 1.71 (95% confidence interval 1.11-2.65) and odds ratio 2.83 (95% confidence interval 1.73-4.64), respectively]. Discordance >75th-percentile was associated with an increased risk of infant mortality after 28 days [odds ratio 4.69 (95% confidence interval 1.07-20.45)] but not with major neonatal complications or with low mean Ages and Stages Questionnair scores at 6, 18, and 48-60 months after term. CONCLUSION: Chorionicity-specific intertwin birthweight discordance is a risk factor for induced preterm delivery and infant mortality, but not for lower scores for neurophysiological development at 6, 18, and 48-60 months.

Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the 'migration three delays' model.

BACKGROUND: Several European countries report differences in risk of maternal mortality between immigrants from low- and middle-income countries and host country women. The present study identified suboptimal factors related to care-seeking, accessibility, and quality of care for maternal deaths that occurred in Sweden from 1988-2010. METHODS: A subset of maternal death records (n = 75) among foreign-born women from low- and middle-income countries and Swedish-born women were audited using structured implicit review. One case of foreign-born maternal death was matched with two native born Swedish cases of maternal death. An assessment protocol was developed that applied both the 'migration three delays' framework and a modified version of the Confidential Enquiry from the United Kingdom. The main outcomes were major and minor suboptimal factors associated with maternal death in this high-income, low-maternal mortality context. RESULTS: Major and minor suboptimal factors were associated with a majority of maternal deaths and significantly more often to foreign-born women (p = 0.01). The main delays to care-seeking were non-compliance among foreign-born women and communication barriers, such as incongruent language and suboptimal interpreter system or usage. Inadequate care occurred more often among the foreign-born (p = 0.04), whereas delays in consultation/referral and miscommunication between health care providers where equally common between the two groups. CONCLUSIONS: Suboptimal care factors, major and minor, were present in more than 2/3 of maternal deaths in this high-income setting. Those related to migration were associated to miscommunication, lack of professional interpreters, and limited knowledge about rare diseases and pregnancy complications. Increased insight into a migration perspective is advocated for maternity clinicians who provide care to foreign-born women.

[Diagnosis and treatment of acute colonic pseudo-obstruction]. / Diagnostik og behandling af akut colonpseudoobstruktion.

Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie's syndrome, is a clinical condition with acute dilatation of the colon without a provable mechanical cause. Early recognition and treatment of the condition is important in order to improve the outcome. The diagnosis is based on clinical and radiographic findings. Supportive therapy should be the initial management. If no improvement occurs after 24 hours, medical treatment with neostigmine administered i.v. is instituted and repeated if necessary. Colonoscopic decompression is the next step, but if ischaemia or perforation appear surgery should be performed.

Cytokines and the risk of preterm delivery in twin pregnancies.

OBJECTIVE: To estimate the association between cytokine levels in twin pregnancies and risk of spontaneous preterm delivery, including the effect of progesterone treatment. METHODS: This secondary analysis of a randomized placebo-controlled trial investigating the effect of progesterone treatment on preterm delivery in twin pregnancies included 523 women with available dried blood spot samples collected before treatment with progesterone (n=258) or placebo (n=265) and after 4-8 weeks of treatment. Samples were analyzed for cytokines using a sandwich immunoassay. Cytokine levels in spontaneous preterm delivery at 34-37 weeks of gestation and spontaneous preterm delivery before 34 weeks of gestation were compared with delivery at 37 weeks of gestation or more for placebo-treated women. The association between interleukin (IL)-8 and risk of spontaneous preterm delivery before 34 weeks of gestation was estimated further, including comparison according to treatment. Statistical analyses included Kruskal-Wallis test, Mann-Whitney U test, linear regression, and Cox regression analysis. RESULTS: We found a statistically significant association between IL-8 and spontaneous preterm delivery. At 23-33 weeks of gestation, the median IL-8 level was 52 pg/mL (interquartile range 39-71, range 19-1,061) for term deliveries compared with 65 pg/mL (interquartile range 43-88, range 14-584) for spontaneous preterm delivery at 34-37 weeks of gestation and 75 pg/mL (interquartile range 57-102, range 22-1,715) for spontaneous preterm delivery before 34 weeks of gestation (P<.001). Risk of spontaneous preterm delivery was associated with a large weekly increase in IL-8 (hazard ratio 2.0, 95% confidence interval [CI] 1.2-3.3). There was no effect of progesterone treatment on IL-8 levels. Levels of IL-8 at 18-24 weeks of gestation were associated with a cervix less than 30 mm (odds ratio 1.8, 95% CI 1.2-2.7). CONCLUSION: Risk of spontaneous preterm delivery before 34 weeks of gestation is increased in women with high IL-8 levels. Progesterone treatment does not affect IL-8 levels.

The FIB-PPH trial: fibrinogen concentrate as initial treatment for postpartum haemorrhage: study protocol for a randomised controlled trial.

BACKGROUND: Postpartum haemorrhage (PPH) remains a leading cause of maternal mortality worldwide. In Denmark 2% of parturients receive blood transfusion. During the course of bleeding fibrinogen (coagulation factor I) may be depleted and fall to critically low levels, impairing haemostasis and thus worsening the ongoing bleeding. A plasma level of fibrinogen below 2 g/L in the early phase of postpartum haemorrhage is associated with subsequent development of severe haemorrhage. Use of fibrinogen concentrate allows high-dose substitution without the need for blood type crossmatch. So far no publications of randomised controlled trials involving acutely bleeding patients in the obstetrical setting have been published. This trial aims to investigate if early treatment with fibrinogen concentrate reduces the need for blood transfusion in women suffering severe PPH. METHODS/DESIGN: In this randomised placebo-controlled double-blind multicentre trial, parturients with primary PPH are eligible following vaginal delivery in case of: manual removal of placenta (blood loss ≥ 500 ml) or manual exploration of the uterus after the birth of placenta (blood loss ≥ 1000 ml). Caesarean sections are also eligible in case of perioperative blood loss ≥ 1000 ml. The exclusion criteria are known inherited haemostatic deficiencies, prepartum treatment with antithrombotics, pre-pregnancy weight <45 kg or refusal to receive blood transfusion. Following informed consent, patients are randomly allocated to either early treatment with 2 g fibrinogen concentrate or 100 ml isotonic saline (placebo). Haemostatic monitoring with standard laboratory coagulation tests and thromboelastography (TEG, functional fibrinogen and Rapid TEG) is performed during the initial 24 hours.Primary outcome is the need for blood transfusion. To investigate a 33% reduction in the need for blood transfusion, a total of 245 patients will be included. Four university-affiliated public tertiary care hospitals will include patients during a two-year period. Adverse events including thrombosis are assessed in accordance with International Conference on Harmonisation (ICH) good clinical practice (GCP). DISCUSSION: A widespread belief in the benefits of early fibrinogen substitution in cases of PPH has led to increased off-label use. The FIB-PPH trial is investigator-initiated and aims to provide an evidence-based platform for the recommendations of the early use of fibrinogen concentrate in PPH. TRIAL REGISTRATION: ClincialTrials.gov NCT01359878.

Maternal deaths in Denmark 2002-2006.

OBJECTIVE: To describe a method for identification, classification and assessment of maternal deaths in Denmark and to identify substandard care. DESIGN: Register study and case audit based on data from the Registers of the Danish Medical Health Board, death certificates and hospital records. SETTING: Denmark 2002-2006. POPULATION: Women who died during a pregnancy or within 42 days after a pregnancy. METHODS: Maternal deaths were identified by notification from maternity wards and data from the Danish National Board of Health. A national audit committee assessed hospital records of direct and indirect deaths. MAIN OUTCOME MEASURES: Maternal mortality ratio, causes of death and suboptimal care. RESULTS: In the study period, 26 women died during pregnancy or within 42 days from direct or indirect causes, leading to a maternal mortality ratio of 8.0/100,000 live births. Causes of death were cardiac disease, thromboembolism, hypertensive disorders of pregnancy, Streptococcus A infections, suicide, amniotic fluid embolism, cerebrovascular hemorrhage, asthma and diabetes. CONCLUSION: Our method proved valid and can be used for future research. Causes of death could be identified and learning points from the assessments could form the basis of focused education and guidelines. Future complementary 'near miss' studies and cooperation with other countries with comparable health systems are expected to improve the benefits of the enquiries, contributing to improved management of life-threatening conditions in pregnancy and childbirth.

Maternal mortality in Denmark, 1985-1994.

OBJECTIVES: In Denmark, maternal mortality has been reported over the last century, both locally through hospital reports and in national registries. The purpose of this study was to analyze data from national medical registries of pregnancy-related deaths in Denmark 1985-1994 and to classify them according to the UK Confidential Enquiry into Maternal Deaths (CEMD). STUDY DESIGN: All deaths of women with a registered pregnancy within 12 months prior to the death were identified by comparing the Danish medical registries, death certificates, and relevant codes according to International Classification of Diseases (ICD-10). All cases were classified using the UK CEMD classification. Cases of maternal death were further evaluated by an audit group. RESULTS: 311 cases were classified. 92 deaths (29.6%) occurred 42 days), 1 woman died from a direct obstetric cause, 46 from indirect causes, and 172 from fortuitous causes. Hypertensive disorders of pregnancy were the major cause of direct maternal deaths. The rate of maternal deaths constituted 9.8/100,000 maternities (i.e. the number of women delivering registrable live births at any gestation or stillbirths at 24 weeks of gestation or later). CONCLUSION: This is the first systematic report on deaths in Denmark based on data from national registries. The maternal mortality rate in Denmark is comparable to the rates in other developed countries. Fortunately, statistics are low, but each case represents potential learning. Obstetric care has changed and classification methods differ between countries. Prospective registration and registry linkage seem to be a way to ensure completion. This retrospective study has provided the background for a prospective study on registration and evaluation of maternal mortality in Denmark.

Use of recombinant activated factor VII in primary postpartum hemorrhage: the Northern European registry 2000-2004.

OBJECTIVE: To collect data from nine European countries for cases of obstetric hemorrhage between 2000 and 2004 in which recombinant activated factor VII (rFVIIa) was used. METHODS: The cases were identified through national surveys. Standardized case report forms included sociodemographic details, past medical and obstetric history, and details of the progress and management of labor in which the postpartum hemorrhage occurred. Clinicians were asked to describe subjectively the effect of rFVIIa administration using two mutually exclusive categories: 1) bleeding reduced or 2) bleeding unchanged or worse. RESULTS: A total of 113 forms were returned (88%) with 97 (86%) classified as treatment, and 16 (14%) as "secondary prophylaxis." Clinicians noted improvements after a single dose for 80% of women in the treatment group, and for 75% in the secondary "prophylaxis" group. However, rFVIIa failed in 15 cases (13.8%). Few serious adverse events were noted related to rFVIIa administration; there were four cases of thromboembolism, one myocardial infarction, and one skin rash. CONCLUSION: Clinical reports and hematologic data suggest improvement for more than 80% of women after rFVIIa administration and few adverse effects. LEVEL OF EVIDENCE: II.

Is there an association between female circumcision and perinatal death?

OBJECTIVE: In Sweden, a country with high standards of obstetric care, the high rate of perinatal mortality among children of immigrant women from the Horn of Africa raises the question of whether there is an association between female circumcision and perinatal death. METHOD: To investigate this, we examined a cohort of 63 perinatal deaths of infants born in Sweden over the period 1990-96 to circumcised women. FINDINGS: We found no evidence that female circumcision was related to perinatal death. Obstructed or prolonged labour, caused by scar tissue from circumcision, was not found to have any impact on the number of perinatal deaths. CONCLUSION: The results do not support previous conclusions that genital circumcision is related to perinatal death, regardless of other circumstances, and suggest that other, suboptimal factors contribute to perinatal death among circumcised migrant women.

Introducing qualitative perinatal audit in a tertiary hospital in Sudan.

In a 3-month period, May to August 2000, the perinatal mortality rate at Omdurman Maternity Hospital (OMH), Sudan, was 8.2%. Two groups of perinatal deaths, intrapartum deaths of non-malformed infants and neonatal deaths of mature infants above 34 weeks, both considered to be potentially avoidable by improved care, were in excess when compared with other regions. It was therefore decided to perform in-depth assessment of cases in these two groups. An interdisciplinary internal audit was designed in collaboration with two external obstetricians. The audit activity was preceded by a 2-day workshop at the hospital. Individual assessments based on 43 detailed narratives were followed by regular consensus meetings. This structure seemed useful for interdisciplinary discussions, and the audit process resulted in several specific suggestions for quality improvement in data collection, interdisciplinary collaboration, and obstetric and neonatal care. The present audit activity is not very resource demanding and therefore a good starting point for quality assurance in a developing country. However, since adverse outcome audit only focuses on selected cases and may encourage interventions without considering the full impact on the population, it should not stand alone. Audit of perinatal deaths should be combined with other quantitative and qualitative quality assessment activities for improvement of perinatal care.

Are some perinatal deaths in immigrant groups linked to suboptimal perinatal care services?

OBJECTIVE: To test the hypothesis that suboptimal factors in perinatal care services resulting in perinatal deaths were more common among immigrant mothers from the Horn of Africa, when compared with Swedish mothers. DESIGN: A perinatal audit, comparing cases of perinatal deaths among children of African immigrants residing in Sweden, with a stratified sample of cases among native Swedish women. POPULATION AND SETTING: Sixty-three cases of perinatal deaths among immigrant east African women delivered in Swedish hospitals in 1990-1996, and 126 cases of perinatal deaths among native Swedish women. Time of death and type of hospital were stratified. MAIN OUTCOME MEASURES: Suboptimal factors in perinatal care services, categorised as maternal, medical care and communication. RESULTS: The rate of suboptimal factors likely to result in potentially avoidable perinatal death was significantly higher among African immigrants. In the group of antenatal deaths, the odds ratio (OR) was 6.2 (95% CI 1.9-20); the OR for intrapartal deaths was 13 (95% CI 1.1-166); and the OR for neonatal deaths was 18 (95% CI 3.3-100), when compared with Swedish mothers. The most common factors were delay in seeking health care, mothers refusing caesarean sections, insufficient surveillance of intrauterine growth restriction (IUGR), inadequate medication, misinterpretation of cardiotocography (CTG) and interpersonal miscommunication. CONCLUSIONS: Suboptimal factors in perinatal care likely to result in perinatal death were significantly more common among east African than native Swedish mothers, affording insight into socio-cultural differences in pregnancy strategies, but also the suboptimal performance of certain health care routines in the Swedish perinatal care system.