EUGLOREH project




9.3. Adults

9.3.2. Maternal health

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9.3.2. Maternal health Introduction


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. Data sources

Data sources relevant for maternal health have been presented in Chapter Data 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 ‘indirectcauses, 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-calledfortuitous” 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 the inclusion of a sufficiently large number of births, certainly no fewer than 100 000. For smaller countries, this requires a span of several years.


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: 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 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.


Figure Evolution of the maternal mortality ratio in selected EUGLOREH countries


As shown in Figure, 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.


Figure 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 section).




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 “severematernal 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 0.02-37%.


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. Risk factors


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. Care 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 themselves.


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 European approaches.


Caesarean Delivery

Figure 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.


Figure 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 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.


Figure 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.


Table Percentage of babies born after assisted reproductive technology Future developments


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 resources. References



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IVF      In-Vitro Fertilisation