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Maternal Mortality in Sweden: Classification, Country of Birth, and Quality of Care
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).ORCID iD: 0000-0001-5545-1413
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 [en]
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: urn:nbn:se:uu:diva-216781ISBN: 978-91-554-8863-5 (print)OAI: oai:DiVA.org:uu-216781DiVA: diva2:690761
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
List of papers
1. Excess mortality in women of reproductive age from low-income countries: a Swedish national register study
Open this publication in new window or tab >>Excess mortality in women of reproductive age from low-income countries: a Swedish national register study
2013 (English)In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 23, no 2, 274-279 p.Article in journal (Refereed) Published
Abstract [en]

Background: Cause-of-death statistics is widely used to monitor the health of a population. African immigrants have, in several European studies, shown to be at an increased risk of maternal death, but few studies have investigated cause-specific mortality rates in female immigrants. Methods: In this national study, based on the Swedish Cause of Death Register, we studied 27 957 women of reproductive age (aged 15-49 years) who died between 1988 and 2007. Age-standardized mortality rates per 100 000 person years and relative risks for death and underlying causes of death, grouped according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, were calculated and compared between women born in Sweden and in low-, middle- and high-income countries. Results: The total age-standardized mortality rate per 100 000 person years was significantly higher for women born in low-income (84.4) and high-income countries (83.7), but lower for women born in middle-income countries (57.5), as compared with Swedish-born women (68.1). The relative risk of dying from infectious disease was 15.0 (95% confidence interval 10.8-20.7) and 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. Conclusions: Women born in low-income countries are at the highest risk of dying during reproductive age in Sweden, with the largest discrepancy in mortality rates seen for infectious diseases and diseases related to pregnancy, a cause of death pattern similar to the one in their countries of birth. The World Bank classification of economies may be a useful tool in migration research.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-180473 (URN)10.1093/eurpub/cks101 (DOI)000317425100022 ()22850186 (PubMedID)
Available from: 2012-09-07 Created: 2012-09-07 Last updated: 2017-12-07Bibliographically approved
2. Maternal mortality in Sweden 1988-2007: more deaths than officially reported
Open this publication in new window or tab >>Maternal mortality in Sweden 1988-2007: more deaths than officially reported
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.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-187061 (URN)10.1111/aogs.12037 (DOI)000313714500006 ()23157437 (PubMedID)
Available from: 2012-12-03 Created: 2012-12-03 Last updated: 2017-12-07Bibliographically approved
3. Suboptimal care and maternal mortality among foreign-born women in Sweden: Maternal death audit with application of the 'migration three delays' model
Open this publication in new window or tab >>Suboptimal care and maternal mortality among foreign-born women in Sweden: Maternal death audit with application of the 'migration three delays' model
Show others...
2014 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, 141- p.Article in journal (Other academic) Published
Abstract [en]

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.

National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-216634 (URN)10.1186/1471-2393-14-141 (DOI)000334948500002 ()
Available from: 2014-01-24 Created: 2014-01-24 Last updated: 2017-12-06Bibliographically approved
4. Suicides during pregnancy and one year postpartum in Sweden, 1980–2007
Open this publication in new window or tab >>Suicides during pregnancy and one year postpartum in Sweden, 1980–2007
Show others...
2016 (English)In: British Journal of Psychiatry, ISSN 0007-1250, E-ISSN 1472-1465, Vol. 208, no 5, 462-469 p.Article in journal (Refereed) Published
Abstract [en]

Background

Although the incidence of suicide among women who havegiven birth during the past 12 months is lower than that ofwomen who have not given birth, suicide remains one of themost common causes of death during the year followingdelivery in high-income countries, such as Sweden.

Aims

To characterise women who died by suicide duringpregnancy and postpartum from a maternal careperspective.

Method

We traced deaths (n = 103) through linkage of the SwedishCause of Death Register with the Medical Birth and NationalPatient Registers. We analysed register data and obstetricmedical records.

Results

The maternal suicide ratio was 3.7 per 100 000 live births forthe period 1980–2007, with small magnitude variation overtime. The suicide ratio was higher in women born inlow-income countries (odds ratio 3.1 (95% CI 1.3–7.7)).Violent suicide methods were common, especially during thefirst 6 months postpartum. In all, 77 women had receivedpsychiatric care at some point, but 26 women had nodocumented psychiatric care. Antenatal documentationof psychiatric history was inconsistent. At postpartumdischarge, only 20 women had a plan for psychiatricfollow-up.

Conclusions

Suicide prevention calls for increased clinical awareness andcross-disciplinary maternal care approaches to identify and support women at risk.

National Category
Obstetrics, Gynecology and Reproductive Medicine Psychiatry
Identifiers
urn:nbn:se:uu:diva-216779 (URN)10.1192/bjp.bp.114.161711 (DOI)000375515700013 ()26494874 (PubMedID)
External cooperation:
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, FAS 2007-2026
Available from: 2014-01-24 Created: 2014-01-24 Last updated: 2017-12-06Bibliographically approved

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