Confidential enquiry into maternal deaths in the Netherlands, 2006-2018

Introduction To calculate the maternal mortality ratio (MMR) for 2006-2018 in the Netherlands and compare this with 1993-2005, and to describe women's characteristics, causes of death and improvable factors. Material and Methods We performed a nationwide, cohort study of all maternal deaths between January 1, 2006 and December 31, 2018 reported to the Audit Committee Maternal Mortality and Morbidity. Main outcome measures were the national MMR and causes of death. Results Overall MMR was 6.2 per 100 000 live births, a decrease from 12.1 in 1993-2005 (risk ratio [RR] 0.5). Women with a non-western ethnic background had an increased MMR compared with Dutch women (MMR 6.5 vs. 5.0, RR 1.3). The MMR was increased among women with a background from Surinam/Dutch Antilles (MMR 14.7, RR 2.9). Half of all women had an uncomplicated medical history (79/161, 49.1%). Of 171 pregnancy-related deaths within 1 year postpartum, 102 (60%) had a direct and 69 (40%) an indirect cause of death. Leading causes within 42 days postpartum were cardiac disease (n = 21, 14.9%), hypertensive disorders (n = 20, 14.2%) and thrombosis (n = 19, 13.5%). Up to 1 year postpartum, the most common cause of death was cardiac disease (n = 32, 18.7%). Improvable care factors were identified in 76 (47.5%) of all deaths. Conclusions Maternal mortality halved in 2006-2018 compared with 1993-2005. Cardiac disease became the main cause. In almost half of all deaths, improvable factors were identified and women with a background from Surinam/Dutch Antilles had a threefold increased risk of death compared with Dutch women without a background of migration

Nationwide confidential enquiries into maternal deaths because of obstetric hemorrhage in the Netherlands between 2006 and 2019

Introduction: Obstetric hemorrhage-related deaths are rare in high income countries. Yet, with increasing incidences of obstetric hemorrhage in these countries, it is of utmost importance to learn lessons from each obstetric hemorrhage-related death to improve maternity care. Our objective was to calculate the obstetric hemorrhage-related maternal mortality ratio (MMR), assess causes of obstetric hemorrhage-related deaths, and identify lessons learned. Material and methods: Nationwide mixed-methods prospective case-series with confidential enquiries into maternal deaths due to obstetric hemorrhage in the Netherlands from January 1, 2006 to December 31, 2019. Results: The obstetric hemorrhage-related MMR in the Netherlands in 2006–2019 was 0.7 per 100 000 livebirths and was not statistically significantly different compared with the previous MMR of 1.0 per 100 000 livebirths in 1993–2005 (odds ratio 0.70, 95% confidence interval 0.38–1.30). Leading underlying cause of hemorrhage was retained placenta. Early recognition of persistent bleeding, prompt involvement of a senior clinician and timely management tailored to the cause of hemorrhage with attention to coagulopathy were prominent lessons learned. Also, timely recourse to surgical interventions, including hysterectomy, in case other management options fail to stop bleeding came up as an important lesson in several obstetric hemorrhage-related deaths. Conclusions: The obstetric hemorrhage-related MMR in the Netherlands in 2006–2019 has not substantially changed compared to the MMR of the previous enquiry in 1993–2005. Although obstetric hemorrhage is commonly encountered by maternity care professionals, it is important to remain vigilant for possible adverse maternal outcomes and act upon an ongoing bleeding following birth in a more timely and adequate manner. Our confidential enquiries still led to important lessons learned with clinical advice to professionals as how to improve maternity care and avoid maternal deaths. Drawing lessons from maternal deaths should remain a qualitative and moral imperative

Exploring the applicability of the pregnancy and childbirth outcome set: A mixed methods study

Objective: The International Consortium for Health Outcomes Measurement developed the Pregnancy and Childbirth (PCB) outcome set to improve value-based perinatal care. This set contains clinician-reported outcomes and patient-reported outcomes. We validated the set for use in the Netherlands by exploring its applicability among all end-users prior to implementation. Methods: A mixed-methods design was applied. A survey was performed to assess patients (n = 142), professionals (n = 134) and administrators (n = 35) views on the PCB set. To further explore applicability, separate focus groups were held with representatives of each of these groups. Results: The majority of survey participants agreed that the PCB set contains the most important outcomes. Patient-reported experience measures were considered relevant by the majority of participants. Perceived relevance of patient-reported outcome measures varied. Main themes from the focus groups were content of the set, data collection timing, implementation (also IT and transparency), and quality-based governance. Conclusion: This study supports suitability of the PCB outcome set for implementation, evaluation of quality of care and shared decision making in perinatal care. Practice Implications: Implementation of the PCB set may change existing care pathways of perinatal care. Focus on transparency of outcomes is required in order to achieve quality-based governance with proper IT solutions

Lessons learned from the perinatal audit of uterine rupture in the Netherlands: A mixed‐method study

Abstract Background and Aims To analyze outcomes of nationwide local audits of uterine rupture to draw lessons for clinical care. Methods Descriptive cohort study. Critical incident audit sessions within all local perinatal cooperation groups in the Netherlands. Women who sustained uterine rupture between January 1st, 2017 and December 31st, 2019. Main Outcome Measures Improvable factors, recommendations, and lessons learned for clinical care. Women's case histories were discussed in multidisciplinary perinatal audit sessions. Participants evaluated care against national and local clinical guidelines and common professional standards to identify improvable factors. Cases and outcomes were registered in a nationwide database. Results One hundred and fourteen women who sustained uterine rupture were discussed in local perinatal audit sessions by 40–60 participants on average: A total of 111 (97%) were multiparous of whom 107 (94%) had given birth by cesarean section in a previous pregnancy. The audit revealed 178 improvable factors and 200 recommendations. Six percent (N = 11) of the improvable factors were identified as very likely and 18% (N = 32) as likely to have a relationship with the outcome or occurrence of uterine rupture. Improvable factors were related to inadequate communication, absent, or unclear documentation, delay in diagnosing the rupture, and suboptimal management of labor. Speak up in case a suspicion arises, escalating care by involving specialist obstetricians, addressing the importance of accurate documentation, and improving training related to fetal monitoring were the most frequent recommendations and should be topics for team (skills and drills) training. Conclusions Through a nationwide incident audit of uterine rupture, we identified improvable factors related to communication, documentation, and organization of care. Lessons learned include “speaking up,” improving the transfer of information and team training are crucial to reduce the incidence of uterine rupture

A national surveillance approach to monitor incidence of eclampsia: The Netherlands Obstetric Surveillance System

Introduction: There have been many efforts in the last decade to decrease the incidence of eclampsia and its related complications in the Netherlands, such as lowering thresholds for treatment of hypertension and mandatory professional training. To determine the impact of these policy changes on incidence and outcomes, we performed a nationwide registration of eclampsia, 10 years after the previous registration. Material and methods: Cases of eclampsia were prospectively collected using the Netherlands Obstetric Surveillance System (NethOSS; 2013-2016) in all hospitals with a maternity unit in the Netherlands. Complete case file copies were obtained for comparative analysis of individual level data with the previous cohort (2004-2006). Primary outcome measure was incidence of eclampsia; main secondary outcomes were antihypertensive and magnesium sulfate use, and maternal and perinatal mortality. Results: NethOSS identified 88 women with eclampsia. The incidence decreased from 6.2/10 000 in 2004-2006 to 1.8/10 000 births (relative risk [RR] 0.28, 95% confidence interval [CI] 0.22-0.36). Increases in the use of antihypertensive medication (61/82 vs 35/216; RR 18.4, 95% CI 9.74-34.70) and magnesium sulfate treatment (82/82 vs 201/216; RR 1.08, 95% CI 1.04-1.12) were observed. There was one intrauterine death following termination of pregnancy. No cases of neonatal mortality were reported in NethOSS compared with 11 in the LEMMoN. Maternal death occurred in one woman compared vs three in the previous registration. Conclusions: There has been a strong reduction of eclampsia and associated perinatal mortality in the Netherlands over the last decade. Management changes and increased awareness may have contributed to this reduction

Maternal cardiac arrest in the Netherlands: A nationwide surveillance study

Background: Maternal cardiac arrest is a complex and demanding clinical situation requiring a well-attuned team effort of healthcare workers of multiple disciplines. A recent report on maternal cardiac arrest in the United Kingdom reported a rise in incidence over a span of 10 years, while maternal mortality increased in the United States between 2000 and 2014. However, reported causes of maternal cardiac arrest differed between both countries. Objective(s): To determine the incidence, causes and management of maternal cardiac arrest in the Netherlands and compare incidence with previous estimates in the Netherlands and the United Kingdom. Study design: Using the Netherlands Obstetric Surveillance System, all Dutch cases of maternal cardiac arrest during a three-year period (2013–2016) were prospectively collected. Complete casefile copies were obtained for analysis. Main outcome measures were incidence of maternal cardiac arrest and cardiac arrest in pregnancy, use of perimortem caesarean section if appropriate and maternal death. Results: The monthly card return rate was 97%; 18 women with cardiac arrest during pregnancy and 20 postpartum met the inclusion criteria. Incidence of maternal cardiac arrest was 7.6 per 100,000 pregnancies and 3.6 per 100,000 pregnancies excluding postpartum maternal cardiac arrest. Main causes were pulmonary embolism (n = 9), major obstetric hemorrhage (n = 7) and amniotic fluid embolism (n = 6). Aortocaval compression relief and perimortem caesarean section were performed in 9/14 (29%) and 11/14 (79%) respectively in pregnancies 20 weeks gestational age onwards. Twenty-two women died, representing a case fatality rate of 58% (95% CI 42–72%). Conclusion(s): There is a higher incidence of cardiac arrest in pregnancy compared to both previous estimates in the Netherlands and recently established figures in the United Kingdom. Main causes of maternal cardiac arrest are potentially preventable and/or treatable complications of pregnancy. Insufficient use of critical elements of obstetric resuscitation identifies the need for enhanced obstetric emergency training for obstetric and non-obstetric first responders

Risk factors, management, and outcomes of amniotic fluid embolism: A multicountry, population-based cohort and nested case- control study

International audienceBACKGROUND:Amniotic fluid embolism (AFE) remains one of the principal reported causes of direct maternal mortality in high-income countries. However, obtaining robust information about the condition is challenging because of its rarity and its difficulty to diagnose. This study aimed to pool data from multiple countries in order to describe risk factors, management, and outcomes of AFE and to explore the impact on the findings of considering United Kingdom, international, and United States AFE case definitions.METHODS AND FINDINGS:A population-based cohort and nested case-control study was conducted using the International Network of Obstetric Survey Systems (INOSS). Secondary data on women with AFE (n = 99-218, depending on case definition) collected prospectively in population-based studies conducted in Australia, France, the Netherlands, Slovakia, and the UK were pooled along with secondary data on a sample of control women (n = 4,938) collected in Australia and the UK. Risk factors for AFE were investigated by comparing the women with AFE in Australia and the UK with the control women identified in these countries using logistic regression. Factors associated with poor maternal outcomes (fatality and composite of fatality or permanent neurological injury) amongst women with AFE from each of the countries were investigated using logistic regression or Wilcoxon rank-sum test. The estimated incidence of AFE ranged from 0.8-1.8 per 100,000 maternities, and the proportion of women with AFE who died or had permanent neurological injury ranged from 30%-41%, depending on the case definition. However, applying different case definitions did not materially alter findings regarding risk factors for AFE and factors associated with poor maternal outcomes amongst women with AFE. Using the most liberal case definition (UK) and adjusting for the severity of presentation when appropriate, women who died were more likely than those who survived to present with cardiac arrest (89% versus 40%, adjusted odds ratio [aOR] 10.58, 95% confidence interval [CI] 3.93-28.48, p < 0.001) and less likely to have a source of concentrated fibrinogen (40% versus 56%, aOR 0.44, 95% CI 0.21-0.92, p = 0.029) or platelets given (24% versus 49%, aOR 0.23, 95% CI 0.10-0.52, p < 0.001). They also had a lower dose of tranexamic acid (median dose 0.7 g versus 2 g, p = 0.035) and were less likely to have had an obstetrician and/or anaesthetist present at the time of the AFE (61% versus 75%, aOR 0.38, 95% CI 0.16-0.90, p = 0.027). Limitations of the study include limited statistical power to examine factors associated with poor maternal outcome and the potential for residual confounding or confounding by indication.CONCLUSIONS:The findings of our study suggest that when an AFE is suspected, initial supportive obstetric care is important, but having an obstetrician and/or anaesthetist present at the time of the AFE event and use of interventions to correct coagulopathy, including the administration of an adequate dose of tranexamic acid, may be important to improve maternal outcome. Future research should focus on early detection of the coagulation deficiencies seen in AFE alongside the role of tranexamic acid and other coagulopathy management strategies