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Maternal mortality in Sweden 1988-2007: more deaths than officially reported
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell kvinno- och mödrahälsovård och migration/Essén)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology. (Obstetrisk forskning/Högberg)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology. (Obstetrisk forskning/Högberg)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell kvinno- och mödrahälsovård och migration/Essén)
2013 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 92, no 1, 40-46 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE:

To obtain more accurate calculations of maternal and pregnancy-related mortality ratios in Sweden from 1988 to 2007 by using information from national registers and death certificates.

DESIGN:

A national register-based study, supplemented by a review of death certificates.

SETTING:

Sweden, 1988 to 2007.

POPULATION:

The deaths of 27 957 women of reproductive age (15 to 49 years).

METHODS:

The Swedish Cause of Death Register, Medical Birth Register, and National Patient Register were linked. All women with a diagnosis related to pregnancy in at least one of these registers within one year prior to death were identified. Death certificates were reviewed to ascertain maternal deaths. Maternal mortality ratio, the number of maternal deaths/100 000 live births (excluding and including suicides); and pregnancy-related mortality ratio (number of deaths within 42 days after termination of pregnancy, irrespective of cause of death/100 000 live births) were calculated.

MAIN OUTCOME MEASURES:

Direct and indirect maternal deaths and pregnancy-related deaths.

RESULTS:

The maternal mortality ratio in Sweden, based on the current method of identifying maternal deaths, was 3.6. After linking registers and reviewing death certificates, we identified 64% more maternal deaths, resulting in a ratio of 6.0 (or 6.5 if suicides are included). The pregnancy-related mortality ratio was 7.3. A total of 478 women died within a year after being recorded with a diagnosis related to pregnancy.

CONCLUSIONS:

By including the 123 cases of maternal death identified in this study, the mean maternal mortality ratio from 1988-2007 was 64% higher than reported to the World Health Organization.

Place, publisher, year, edition, pages
2013. Vol. 92, no 1, 40-46 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-187061DOI: 10.1111/aogs.12037ISI: 000313714500006PubMedID: 23157437OAI: oai:DiVA.org:uu-187061DiVA: diva2:573678
Available from: 2012-12-03 Created: 2012-12-03 Last updated: 2017-12-07Bibliographically approved
In thesis
1. Maternal Mortality in Sweden: Classification, Country of Birth, and Quality of Care
Open this publication in new window or tab >>Maternal Mortality in Sweden: Classification, Country of Birth, and Quality of Care
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

After decades of decrease, maternal mortality rates have shown a slight increase in Europe. Immigrants, especially Africans, have shown to be at higher risk than native women. This could not be explained solely by well-known obstetric and socio-economic risk factors. The aim of this thesis was to study incidence, classification and quality of care of maternal deaths in Sweden, with focus on the foreign-born population. The study population was identified through linkage of the Cause of Death Register, Medical Birth Register, and National Patient Register, and medical records obtained from hospitals. Data from registers, death certificates, and medical records were reviewed. Suboptimal care was studied by structured implicit review of medical records. Differences between foreign- and Swedish-born women were analysed by relative risks, Chi2- and Fisher’s exact test.

Underreporting of maternal mortality was shown to be substantial: as compared to the official statistics, 64% more maternal deaths were identified. Women born in low-income countries were identified as being at highest risk of dying during reproductive age in Sweden. The relative risk of dying from diseases related to pregnancy was 6.6 (95% confidence interval 2.6–16.5) for women born in low-income countries, as compared to Swedish-born women. Major and minor suboptimal factors related to care-seeking, accessibility, and quality of care were found to be associated with a majority of maternal deaths and significantly more often to foreign-born women. Suboptimal factors identified included non-compliance, communication barriers, and inadequate care. The rate of suicides during pregnancy or within one year after delivery did not change during the last three decades, and was higher for foreign-born women. A majority of women who committed suicide had been under psychiatric care, but such documentation at antenatal care was inconsistent, and planning for follow-up postpartum was generally lacking.

The conclusion of this thesis is that foreign-born women are a high-risk group for maternal death and morbidity that calls for clinical awareness with respect to their somatic and psychiatric history, care-seeking behaviour, and communication barriers. Cross-disciplinary care is necessary, both in obstetric emergencies and in cases of maternal psychiatric illness, to avert maternal death and suicide.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2014. 69 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 970
Keyword
underreporting, foreign-born, immigrants, low-income countries, suboptimal care, audit, suicide, reproductive age, maternal death, maternal care
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-216781 (URN)978-91-554-8863-5 (ISBN)
Public defence
2014-03-13, Rosénsalen, Akademiska sjukhuset ingång 95/96, Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2014-02-19 Created: 2014-01-24 Last updated: 2014-04-29

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Esscher, AnnikaHögberg, UlfHaglund, BengtEssén, Birgitta

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