Every year more than 5 million women give birth in the EU.
Another 2 million women have failed pregnancies, spontaneous and induced
abortions as well as ectopic pregnancies. Although a very rare event, maternal
mortality is considered a major marker of health system performance because
many maternal deaths are associated with sub-standard care and are potentially
avoidable. Maternal mortality results from several much more frequent obstetric
complications and diseases. Maternal morbidity is not, however, measured well,
mainly because there is no international agreement about its definition and
thus about the methods for estimating its prevalence.
220.127.116.11. Data sources
Data sources relevant for maternal health have been
presented in Chapter 18.104.22.168.
presentation and analysis
The EURO-PERISTAT indicator list includes one core
indicator for monitoring maternal health, the maternal mortality ratio, as well
as two recommended indicators, maternal deaths by cause and the prevalence of
severe maternal morbidity (Alexander et al, 2003). The causes of maternal death
can be separated into those directly attributed to pregnancy, which include
thrombo-embolism, amniotic fluid embolism, haemorrhage, hypertension,
infections/sepsis, obstetrical complications, and ‘indirect’ causes, such as
cardiac and other maternal conditions that are aggravated by pregnancy.
Committees that audit maternal deaths regularly report that 40-60% of them are
associated with substandard care (London: Stationary Office, 2001;
Bouvier-Colle et al, 1995; Schuitmaker, 1998).
The main definition of what constitutes a maternal death
in European statistics is early obstetrical death, both direct (the pregnancy
directly caused the death) and indirect (death is due to a cause which preceded
but was complicated by the pregnancy). The time period covered is from
conception to 42 days after the outcome of the pregnancy. This means that
so-called “fortuitous” or coincidental (not causally related to pregnancy) and
“late” (between 43 and 365 days after the outcome of pregnancy) deaths are
excluded. The maternal mortality ratio is a complex fraction in which the
numerator is maternal deaths and the denominator is live born children. This
denominator is a surrogate for a more desirable but more difficult to assess
denominator: pregnant women, the full population at risk for maternal death.
Accurate MMRs require the inclusion of a sufficiently large number of births,
certainly no fewer than 100 000. For smaller countries, this requires a span of
Data quality for maternal deaths must be considered on two
levels: ascertainment (completeness of registration) and case description.
Improvement of ascertainment has been studied thoroughly and includes all of
the following: record linkage (births, deaths, induced abortions, antenatal
surveillance program data), a pregnancy check box on the death certificate, and
an informant network (Atrash et al, 1995). Nonetheless, problems remain, even
where all these methods are used. In some European countries, for example, a maternal
death of a woman who is an illegal resident or an asylum seeker would not be
counted. Audits of maternal deaths exist in many countries and are important
for obtaining good quality data. The Confidential Enquiry on Maternal Deaths in
the UK, which began more than half a century ago, is often considered to be the
model for this procedure (more information about the history, methods, reports
and other publications from this enquiry can by found at the following website:
http://www.cemach.org.uk). Other European countries have now adopted similar
procedures for undertaking systematic reviews of deaths as for example in
France (Philibert et al, 2006) or the Netherlands (van Roosmalen et al, 2002).
As shown in Figure 22.214.171.124. the maternal mortality ratio in
the European Union has declined from about 20 maternal deaths per 100 000 live
births in the early 1980s to 7 deaths per 100 000. The most significant decline
has been observed in Romania, which had the highest ratio in Europe, between
140 and 160 per 100 000 in the 1980s. After the liberalisation of abortion act,
the ratio declined to 26 per 100 000 in 2002-2004, still the highest among the
EU Member States. The three Baltic countries also had relatively high ratios in
the 1990s, but their ratios have declined, especially in Latvia and Lithuania.
126.96.36.199. Evolution of the maternal mortality ratio in selected EUGLOREH
As shown in Figure 188.8.131.52., which gives the maternal
mortality ratios for the two-year period 2003 and 2004, there is a substantial
variation in Europe. In many cases, especially for small Countries,, MMR are
generated using a small number of events and total births, whilst observed
differences are not statistically significant.
Maternal mortality ratio in selected EUGLOREH countries in 2004-2006
For a few countries - Denmark, Iceland, Finland, the
Netherlands, Slovenia, Spain and Switzerland - the most recent data show the
same or even higher maternal mortality ratios after the year 2000 than in the
early 1990s. Improved quality of maternal mortality statistics may explain this
negative trend, but the deterioration can also be explained by increased risk
factors among pregnant women (such as advanced maternal age, the increased
proportion of women with migrant origin, the more common prevalence of chronic
diseases and maternal conditions, the higher multiple birth rates caused by
more common use of procedures to manage subfertility) and the increased use of
medical technology in delivery (such as invasive pain relief and Caesarean
Previous work to establish the level of maternal morbidity
within different countries of Europe has produced estimates ranging from 1.0 to
10.1 per 1 000 deliveries, but there are no widely accepted definitions or
inclusion criteria. The prevalence of “severe” maternal morbidity, which is
most often defined by severe haemorrhage, sepsis and hypertensive disorders of
pregnancy, ranges from 0.07-8.23% with a case-fatality ratio ranging from
Severe maternal morbidity is a EURO-PERISTAT recommended
indicator, but this indicator is still being developed since it requires a
consensus on conditions to include and a common methodology for identifying
cases. The EURO-PERISTAT group is currently testing the feasibility and quality
of an indicator based on a set of conditions and medical interventions that
have a clear definition and can be identified using hospital discharge data.
This indicator is determined by the number of women experiencing any
combination of the following conditions or procedures as a proportion of all
women delivering live and still-born babies: (1) eclamptic seizures, (2)
surgery (other than tubal ligation or caesarean section) or embolisation (3)
blood transfusion (4) hospitalization in an ICU for more than 24 hours.
In order to monitor perinatal health trends - including
those of pregnant women and their babies - and understand the differences
observed between countries, it is necessary to have information about the
characteristics of childbearing women and the risk factors associated with poor
outcomes. For a synthesis of available knowledge see Table 9.1a.
The EURO-PERISTAT indicator set specified several key
demographic and socioeconomic indicators that should be monitored, including
the multiple birth rate, maternal age, parity, smoking and maternal education.
The mother’s country of origin was also targeted as an indicator for further
development in EURO-PERISTAT, since many countries have documented poorer
perinatal health outcomes for migrant women. Of these proposed indicators,
however, data are only currently available on maternal age and parity in
existing routine databases. We also present data on smoking among women of
reproductive age (Table 9.1a) using data from EUROSTAT, with data from 2000 on
smoking among pregnant women collected by EURO-PERISTAT in its feasibility
study (Breart et al, 2003). More recent data, collected more recently by the EURO-PERISTAT project,
are being analyzed and will be published expectedly in early 2009.
during pregnancy, delivery and the postpartum
The EUROPERISTAT project includes a series of indicators
for monitoring healthcare provided to pregnant women and newborns. Medical technologies
associated with the perinatal period continue to advance quickly, particularly
those related to the management of sub-fertility and the care of preterm
infants. Describing variations in the use and success of these medical
technologies is an important task of health monitoring in the European Union.
Describing how clinicians support women and babies through the process of
healthy pregnancy and birth also enhances our understanding and comparisons of
health in the perinatal period at European level. Descriptions of healthcare
services must measure interventions implemented to prevent death and morbidity,
but must also incorporate aspects of healthcare quality, as assessed by mothers
European countries can learn by sharing their experiences
in healthcare provision. There is a large variability in the approaches to
healthcare and these may have an effect on outcomes (Alran et al, 2002; Langer
et al, 1997; Stephenson et al, 1993). For example, some countries have higher
rates of obstetrical interventions, such as indicated caesarean sections for
twins or induced deliveries for post-term pregnancies, which in turn have an
impact on the rates of pre-term and post-term births (Blondel et al, 2006;
Zeitlin et al, 2007). Similarly, there is a large variability in the
organization of care for very preterm babies which may also have an impact on
their health (Van Reempts, 2007).
A key challenge is the identification of meaningful
indicators that perform similarly across different healthcare systems. Many
indicators useful at national level cannot be transposed for comparisons
between Member States because they reflect different realities in the different
models of care present in Europe.
Few of the indicators recommended by EURO-PERISTAT are
available in international databases. These indicators nonetheless provide an
indication of the variability that exists between countries in Europe with
respect to the care provided to pregnant women and newborns. We also present
data below on the length of postpartum stay. These indicators were not selected
for the EURO-PERISTAT set because their interpretation requires more
information on other services provided to pregnant women in terms of home
visits after discharge. However, they are useful for illustrating the different
Figure 184.108.40.206. shows an increasing trend towards higher
rates of caesarean section for all countries in Europe. These data also
illustrate the large variation between European countries in the use of
caesarean sections, with ranges from about 150 per 1000 live births to 300 per
1000 live births. This practice has been shown in studies to be affected by
maternal characteristics such as age, parity and previous caesarean section,
and also by health system characteristics including the size of obstetric units
and their status as public or private institutions (Bertollini et al, 1992;
Gould et al, 1989; Lin and Xirasagar, 2004). Caesarean delivery is associated
to increased morbidity among mothers and requires longer and more costly
lengths of hospital stay.
220.127.116.11. Caesarean section rate per 1 000 live births from 1990 to 2005
Length of Hospital Stay
The length of hospital stay has been decreasing over time
all across Europe as illustrated in Figure 18.104.22.168. However, as these data also
show, this decrease has been more dramatic in some countries than in others,
and is illustrative of wide differences in the European approaches towards
perinatal care. Some countries, such as the UK, provide regular home visits
after early discharge. To assess the health impact of these trends towards
shorter hospital stays it is therefore necessary to have additional information
on home care and routine follow-up services.
22.214.171.124. Evolution of length of stay in hospital after
spontaneous singleton deliveries in European MS from 1990 to 2005
Infertility and treatment of infertility
Advances in medical technology have improved the
possibilities to help couples with infertility problems. In 2004, up to 3-4% of
newborns in Denmark and Slovenia were born after in vitro fertilisation (IVF)
or other method where the egg cell is fertilised outside the woman's body. This
percentage was high also in other Nordic countries and Belgium (2-3%), while between 1-2% in the largest old EU Member States (Germany, France and United Kingdom). For most of the Member States entering EU in 2004, the percentage is even
lower. Legislation, financing (public/private insurance/couples themselves),
demand and supply of infertility services explain the large differences between
EU Member States.
Percentage of babies born after assisted reproductive technology
There are wide variations in maternal mortality ratios in
Europe. It is difficult to interpret their meaning, because some of the higher
mortality countries may just be doing a better job finding and counting
maternal deaths. A priority for the surveillance of the health of pregnant
women is thus to achieve complete ascertainment of maternal deaths. It is also
essential to standardise coding of the causes of death. Instituting audits of
maternal deaths are a well proven method for improving reporting and for
identifying areas for health service improvement. Finally, we must go beyond
mortality and develop methods for using routine databases such as hospital
discharge data and medical birth registers to measure severe maternal morbidity.
The great variety of approaches to care during pregnancy,
delivery and the postpartum in Europe raise questions about the appropriate
levels of intervention and the use of evidence based medicine for determining
medical practices in the perinatal period. All countries face questions about
the best ways to use new medical techniques which have contributed to the large
improvements in health outcomes for mothers and their babies. Many of these
techniques are not risk-free and raise ethical issues that require continuous
evaluation. In many countries, babies born alive at 25 and 26 weeks of
gestation now have a 50% chance of survival (Effer et al, 2002; Draper et al,
1999), but these extremely preterm babies have a much higher rate of disabling
impairments than babies born at term (Wood et al, 2000; Doyle, 2001).
Developments in the management of sub-fertility now mean that infertile couples
can conceive, but these treatments increase multiple births – which have higher
mortality and morbidity – and are associated to preterm birth and congenital
anomalies (Hansen et al, 2002; Jackson et al, 2004). Improved antenatal
screening techniques bring up the difficult issue of when to terminate a
pregnancy. A key challenge for the care of pregnant women and newborns is to
use and benefit from new medical technology without over-medicalising pregnancy
and childbirth and thus generating higher levels of parental anxiety,
unnecessary medical interventions and poor use of valuable healthcare
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IVF In-Vitro Fertilisation