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Obstetric patients treated in intensive care units and maternal mortality
European Journal of Obstetrics Jc Gynecology
ELSEVIER
and Reproductive Biology 65 (1996) 121-125
Plenary Session 8 -
Critical obstetric problems
Chairpersons: N. Patel, L. Lamp6
Obstetric patients treated in intensive care units and maternal mortality Marie-HClbne Bouvier-Colle*, Benoit Salanave, Pierre-Yves Ancel, Noelle Varnoux, He& Fernandezb, @mile Papiernik’, Gerard B&art” and the Regional teams for the Survey: D. Benhamoub, P. Boutroy’, I. Caillier’, M. Dumoulin2, P. Foumet2, M. Elhassani’, F. Puech2, C. Poutot ’ %sMut National de la SantPet de la Recherche Mdicale, U149 Recherches &pid&miologiques SW la .Yant&des Femmes et des Enfants. 123, bd de Port-Royal F-75014, France bService de ~y~eo~ogie ~bst~tr~, ~opital Antoine B&I&e, Ckmart, France ‘Service d’Obst&rique. Port-Royal, Par& France AhStSWt Objective: To ascertain the frequency of serious diseases in pregnant women. Study design: A population based survey was performed in France. The cases were all the women admitted for treatment in intensive care unit (KU). The severity of the cases was measured with the simplified acute physiology score (SAPS) the lethality and the rate of still bii. Reds: 435 obstetric patients were included. The estimated frequency of severe diseases was 310 S.D. 36 per 100 000 live births. The most frequent diagnose that motived admission in KU was hypertensive diseases. The lethality rates diffe’eredgreatly between specific disorders. The lethality rate was lower when scheduled maternity was located in a teaching hospital. Conclusion: Regarding these results it appears that the majority of obstetric patients with severe diseases are referred to suitable care, but a small proportion of women who had to change their type of care registered a significant higher lethality. Keywords: Maternal deaths; Intensive care; Obstetric patients
1. Introduction Maternal mortality rates appear to be higher in France than in most other European countries. These differences may result from variations in the registration of causes of death and coding; they may be the consequence of inequality in health care; and they may be due to differences in the frequencies of pregnancy-related disorders. The first explanation requires investigation at the European level and will not be considered here. The second hypothesis has received support from recent confidential enquiries showing a high proportion (66%) of maternal deaths that are associated with subs~ndard care in our country [l], versus 50% in the Netherlands and in the United Kingdom [2,3]. Important questions still remain: what is the actual frequency of serious dis-
* Corresponding author. Tel.: +33 142 345572;fax: +33 143 268979. ’ Mater& rtgionaie, Nancy. 2 Matemit&rcgionale, Lille.
orders? What sort of risk factors - individu~ or related to the perinatal care system - might explain the ins&Xcient quality of prenatal care? We have previously observed that the majority of patients who died of obstetric causes had been admitted to medical intensive care units (ICUs) [4]. At that time, we did not know the actual frequency of serious morbidity in the total popu-
lation of pregnantwomen[5],since
there has been such scant study of critical or serious illnesses during preg-
nancy (including the postpartum period). There are a few studies that present data about obstetric patients treated in the ICUs of university hospitals or with specific diseases such as eclampsia or HELLP, but the general size of the problem has not been evaluated (6-91. Our survey therefore had two principal aims: to ascertain the current frequency of serious diseases in pregnant women in France; and to discover whether individual or health care factors related to serious &orbidity might explain the differences in ihe lethality of different maternal diagnoses. We present here the iesults
0 1996 Elsevier Science Ireland Ltd. All rights I.eserved SSDI 0301-2115(95)02317-Z
0301-21W96615.00
122
M.-H. Bouvier-Coile et al. /European
Journal of Obstetrics & Gynecology and Reproductive Biology 6S (19%)
of the survey related to the frequency of women treated in the intensive care units and the pathologies leading to admission to ICV.
121-125
Table 1 Principal causes of admission to Intensive care unit Diagnoses
Cases
Deaths
Hypertensive diseases HTA Eclampsia, HELLP Vascular cerebral ACC Haemorrhages Prepartum Postpartum Uterine rupture Blood clot Embolisms Phlebitis Postoperative disorders Purperal infections Other related pregnancy diseasesa Complications of anaesthesia Obstetric trauma All obstetric direct
II4 61 52 I 87 I6 67 4 54 29 25 21 I9 7 6 4 312
6 0 5 I 5 0 4 I 2 I I 2 I I 0 0 I7
23 I3 IO IO I6 72
0 2 0 0 2 4
27 22 2 51 435
0 I 0 I 22
2. Survey De@ A population based survey was carried out in two French administrative regions, Nord-Pas de Calais, and Lorraine, looking at the population of obstetric patients, including women who were pregnant or delivered within 42 days. This delay was retained according to the definition of maternal death by the International Classification of Diseases [lo]. The cases were defined as all obstetric patients admitted for treatment or surveillance to an ICU or the closest equivalent surgical and medical resuscitation or critical care unit in the region. Abortion, and ectopic pregnancies were included. The live births data of the two regions were obtained from the National Institute of Statistics. The same questionnaire was retrospectively completed for all the cases. Questions probed the women’s characteristics, their medical, socio-demographic obstetric, and surgical histories, the monitoring of the current pregnancy, including problems, hospital and ICU admissions, and the procedures and treatment(s) carried our at each of these stages. The severity of the cases was measured by the simplified acute physiology score (SAPS), which was calculated 24 h after the patient had entered the ICU [Ill. The rate of still births was defined as the ratio of still births to the total number of births in the survey. The lethality rate, which was defined as the ratio of maternal deaths to cases. 3. Results The analysis included 435 obstetric patients who were treated in ICU. Defining critical illness in pregnancy and delivery by admission to an intensive care unit, we estimated its frequency at 308 in Nord-Pas de Calais and 312 in Lorraine, and mean at 310 S.D. 36 per 100 000 live births. There were 22 maternal deaths among the 435 cases, for an overall lethality rate of 5.1%. Table 1 presents the principal diagnoses that motivated admission to the ICU. The most frequent were hypertensive diseases (114/435, or 26.2%), followed by 87 haemorrhages (20%) and 54 embolisms (12.4%). The lethality rates did not differ between the direct (5.4%) and the indirect obstetric causes (5.6%), but important discrepancies were found between specific disorders. The lethality was highest for cardio-vascular diseases (15.4%) and for obstetric complications (14.3%); it was lowest for external causes, such as attempted suicide, Table 2. It is worth noting that the maternal lethality rates for the main disorders involved in
Respiratory diseases Cardio-vascular diseases Digestive diseases Preexisting disorders Other causes All obstetric indirect
Suicide attempts Poisoning Other externally caused deaths All external All causes
sHepatum Steatosis, renal insufftciency, premature delivery included.
maternal deaths - hypertensive diseases, haemorrhages, and embolisms - are significantly lower than with the other disorders. Inversly the stillbirth rates are highest with puerperal infections, hypertensive diseases, and haemorrhages. There were significant differences in the mean values of maternal age, SAPS, and number of days in the ICU, according to diagnosis. The age was lowest for external causes such as suicide and accidental poisoning and higher for obstetric trauma, haemorrhages, and infectious diseases. The SAPS was highest for infectious diseases, cardiac disorders, and haemorrhages. The longest ICU stays were observed for anaesthesia complications; the shortest, for suicide attempts. No significant association was observed between the SAPS and either the number of days in the ICU or the lethality rate; the SAPS was, however, significantly associated with the patient’s age. Another factor that we examined to see if it was related to the lethality rate was the category of hospital in which the women received prenatal care or gave birth, or both. It is well known that complicated or high-risk
M.-H. Bouvier-Colle et al. /European Journal of Obstetrics di Gynecology and Reproductive Biology 65 (19%) 121-125
123
Table 2 Severity of the diseases according to the principal cause of admission to ICU Mean age in years
SARY
cases 114 87 54 21 19 7 6 4 312
28.3 29.7 28.4 28.5 29.1 28.3 27.7 31.5 28.9
5.8 6.4 3.0 5.5 8.1 5.0 2.8 6.5 5.6
Numberof
CauSeS
Hypertensive dii Haemorrhages Blood clot Pospoperative disorders Puerperal infections Other related pregnaucy diseases Complications of anaesthesia obstetric trauma All direct
Stay duration in days 4.7 2.8 6.5 2.8 4.5 3.4 9.7 2.0 4.3
Still birth in %
Lethality in %
24.6 17.3 7.3 5.0 33.3 17.3
-5.3 5.7 3.7 9.5 5.3 14.3 0 0 5.5
Respiratory diseases Cardio-vascular dimases Digestive diseases Preexisting disorders Other indirect causes Ail indirect
23
29.0
4.0
3.7
-
0
13 10 10 16 72
29.2 28.8 29.2 29.1 29.1
6.7 1.0 1.2 6.1 4.3
10.3 1.1 3.4 5.2 5.6
-
15.4 0 0 12.5 5.6
Suicide attempts Poisoning Other external causes All external
21 22 2 51
23.5 25.3 22.0 24.2
2.0 0.2 1.2
1.9 1.1 4.5 1.6
2.9
0 4.5 0 2.0
435
28.3
4,8
4.2
13.3
5.1
AI1 causes
7.1
sSimplified acute physiology scorn.
pregnancies are best treated in teaching hospitals or in very active maternity wards. We found lethality to be highest among women who were scheduled to give birth in private or small public hospitals, but no difference existed according to the type of hospital in which they actually gave birth, Table 3. These seemingly discordant results are explained by the change in the type of prenatal care between registration and delivery. In fact the pregnancy of 53 of these women ended during the first trimester by abortion or ectopic pregnancy, Table 4. Fifty-six women changed type of facility and 326 others were treated in the same category of hospital throughout their pregnancy. The lethality rate varied widely among
these three groups: it increased d~ati~y which the type of obstetric care changed.
in cases in
4. connnents Our survey revealed two main points. First, we discovered the high frequency of obstetric patients who require care in intensive care units. Second, we noted that the majority of women who suffered serious complications during their pregnancy were treated in hospitals providing a high level of care. The frequency of women who needed intensive care in our study was different from that observed in those too-
Table 3 Lethality according to hospital scheduled and actual delivery Number of cases
Ikaths
Lethality in %
Test P value
OR [Cfl’
Scheduled hospital - Others - Teaching hospital
277 116
18
6.5 0.9
0.02
I
7.9 11.1~60.61 1
Delivery hospital - others - Teaching hospital
260 161
15 7
5.8 4.3
NS
ad-ratio
and confidence interval.
124
M.-H. Bouvier-Colle et al. /European Journal of Obstetrics & Gynecology and Reproductive Biology 65 (19%)
IZl-125
Table 4 Distribution and lethality of women according to type of hospital
Women who changed type hospital - Yes - No Pregnancies ended at the 1st trimester
Number of cases
Deaths
Lethality in %
Test P Value
CR [CIla
56 326
9 10
16.1 3.1
0.00
6.1[2.3-15.71 I
53
3
5.7
I.9 10.5-7.31
POdd-ratio and confidence interval.
rare studies of the subject; large discrepancies also exist within these surveys. Graham reports a rate of 105 per 100 000 pregnancies extending beyond 20 weeks gestational age, in a teaching hospital in Nottingham [6], whereas Mabie found a rate of 883 per 100 000 deliveries [7] in Memphis. Intermediate frequencies reported include: 228 per 100 000 deliveries, in a survey by Monaco taking deaths into account until two weeks post partum; 205, at the ICU of the public hospital of Brisbane [4]; and 400 per 100 000 deliveries at the ICU of the University of California at San Francisco [9], according to Kilpatrick. These numbers depend partly on the organisation of health services, which varies in different countries. Furthermore, each of those surveys involved one tertiary referral hospital and not an administrative area containing a variety of types of hospitals, as our survey did. Nevertheless our patients’, mean number of days in the ICU was quite similar to those reported elsewhere, which varied from 2.5 to 5.4 days per patient. The lethality rate observed in our survey is lower than those published in older surveys, which range from the 20% observed by Collop to the 8.7% Graham reports; our results were quite similar to the most recent findings by Lewinsohn, 7% [13]. We found that lethality was lower for women who were treated from the beginning to the end of their pregnancy in teaching hospitals, but no difference in lethality was seen based on the level of care in the hospital where the pregnancy ended. We have not yet seen similar types of results elsewhere. We agree with Graham that the interpretation of the frequencies is complicated by the variety of policies for intensive management of obstetric emergencies [5]. It is.important to note that, even in this context, many deaths, especially those related to haemorrhages and hypertensive diseases, appear to have been avoidable.-Progress in the quality of care for these frequent disorders might improve maternal mortality substantially. One element, though, might prevent such progress: the increasingly high maternal age at birth. The increase in maternal age at birth, in our opinion, will lead to an increase in maternal mortality rates in both France and Great Britain through 2005 [15]. We also found an im-
portant proportion of women with serious medical histories in the population of obstetric cases requiring intensive care; in addition, a higher frequency of indirect obstetric causes was at the origin of complications such as cardiac diseases, in which lethality rates were quite elevated. These results raise the question of the organisation of care in obstetric emergencies, which often require the management expertise of several subspecialists [5]. In conclusion, it appears that the majority of women with complicated pregnancies are referred to hospitals that can provide them with suitable care. Nonetheless, a small proportion of women had to change their type of care. It can be presumed that their mortality would have been lower if they had been treated sooner in more appropriate hospitals. Efforts should be made to diminish the number of these women and thus decrease maternal mortality in France. Acknowledgements This research received the financial support of the Caisse Nationale d’Assurance Maladie des Travailleurs Salaries, and of the Delegation a la Recherche Clinique of Assistance Publique de Paris. The authors are very grateful to the regional teams who performed the data collection: Drs I Caillier and C Poutot in Lorraine, Drs M Dumoulin and M El Hassani in Nord-Pas-de-Calais, Pr Femandez in Hauts-de-Seine. References 111Bouvier-Colle MH, Vamoux N, Breart G, Medical Expert Committee. Maternal deaths and substandard care: the results of a confidential survey in France. Eur J Obstet Gynec Reprod Biol 1995; 58: 3-7. I21 Schuitmaker NWE, Bennebroek-Gravenhorst J, Van Geijn HP, Dekker GA, Van Dongen PWJ. Maternal mortality and its prevention. Eur J Obstet Reprod Biol 1991; 42: 531-535. [31 Department of Health. Report on confidential enquiries into maternal deaths in the United Kingdom 1988-1990. HMSO, London, 1994. [41 Bouvier-Colle MH, Vamoux N, Costes Ph. Hatton F. Reasons for the underreporting of maternal mortality in France as indicated by a survey of all deaths among women of childbearing age. Int J Epidem 1991; 20 885-891.
M.-H. Bouvier-Colle et al. /European
Journal of Obstetrics & Gynecology and Reproductive
[5] Collop NA, Sahn SA. Critical illness in Pregnancy. An analysis of 20 patients admitted to a Medical intensive care unit. Chest 1993; 103 1548-1552. [6] Graham SG, Luxton MC. The requirement for intensive carer support for the pregnant population. Anaesthesia 1989; 44: 581-584. [7] Mabie WC, Sibai BM. Treatment in an obstetric intensive care unit. Am J Obstet Gynecol 1990; 162: 1-4. [8] Monaco TJ, Spiehnan FJ, Katz V. Utilization of intensive care resources by obstetric patients. Abstract, Society Obstet Anaesth Perinat, Boston may 1991. [9] Rilpatrick SJ, Matthay MA. Obstetrics patients requiring critical care. A five year review. Chest 1992; 101: 1407-1412. [IO] World Health Organization. Manual of the International classification of diseases. Geneva. 1997.
Biology 65 (19%)
121-125
125
[l I] Le Gall J-R, Loirat P, Alperovitch A, Glaser P, Granthil C, Mathieu D, Mercier P, Thomas R, Villers D. A simplified acute physiology score for ICU patients. Crit Care Med 1984; 12: 975-977. 112) Stephens ID. KU admission from an obstetrical hospital. Can J Anaesth 1991; 38: 677-681. [13] Lewinsohn G, Herman A, Leonov Y, Khnowski E. Critically ill obstetrical patients: Outcome and predictability. Crit Care Med 1994; 22: 1412-1414. 114) Bouvier-Colle MH, Vamoux N, Breart G. Les morts matemelles en France. Ed INSERM, Paris 1994. [ 151 Salanave B, Bouvier-Colle M-H. Maternal mortality: a probable increase. Submitted for publication to Paed Perinat Epidemiology.
ELSEVIER
and Reproductive Biology 65 (1996) 121-125
Plenary Session 8 -
Critical obstetric problems
Chairpersons: N. Patel, L. Lamp6
Obstetric patients treated in intensive care units and maternal mortality Marie-HClbne Bouvier-Colle*, Benoit Salanave, Pierre-Yves Ancel, Noelle Varnoux, He& Fernandezb, @mile Papiernik’, Gerard B&art” and the Regional teams for the Survey: D. Benhamoub, P. Boutroy’, I. Caillier’, M. Dumoulin2, P. Foumet2, M. Elhassani’, F. Puech2, C. Poutot ’ %sMut National de la SantPet de la Recherche Mdicale, U149 Recherches &pid&miologiques SW la .Yant&des Femmes et des Enfants. 123, bd de Port-Royal F-75014, France bService de ~y~eo~ogie ~bst~tr~, ~opital Antoine B&I&e, Ckmart, France ‘Service d’Obst&rique. Port-Royal, Par& France AhStSWt Objective: To ascertain the frequency of serious diseases in pregnant women. Study design: A population based survey was performed in France. The cases were all the women admitted for treatment in intensive care unit (KU). The severity of the cases was measured with the simplified acute physiology score (SAPS) the lethality and the rate of still bii. Reds: 435 obstetric patients were included. The estimated frequency of severe diseases was 310 S.D. 36 per 100 000 live births. The most frequent diagnose that motived admission in KU was hypertensive diseases. The lethality rates diffe’eredgreatly between specific disorders. The lethality rate was lower when scheduled maternity was located in a teaching hospital. Conclusion: Regarding these results it appears that the majority of obstetric patients with severe diseases are referred to suitable care, but a small proportion of women who had to change their type of care registered a significant higher lethality. Keywords: Maternal deaths; Intensive care; Obstetric patients
1. Introduction Maternal mortality rates appear to be higher in France than in most other European countries. These differences may result from variations in the registration of causes of death and coding; they may be the consequence of inequality in health care; and they may be due to differences in the frequencies of pregnancy-related disorders. The first explanation requires investigation at the European level and will not be considered here. The second hypothesis has received support from recent confidential enquiries showing a high proportion (66%) of maternal deaths that are associated with subs~ndard care in our country [l], versus 50% in the Netherlands and in the United Kingdom [2,3]. Important questions still remain: what is the actual frequency of serious dis-
* Corresponding author. Tel.: +33 142 345572;fax: +33 143 268979. ’ Mater& rtgionaie, Nancy. 2 Matemit&rcgionale, Lille.
orders? What sort of risk factors - individu~ or related to the perinatal care system - might explain the ins&Xcient quality of prenatal care? We have previously observed that the majority of patients who died of obstetric causes had been admitted to medical intensive care units (ICUs) [4]. At that time, we did not know the actual frequency of serious morbidity in the total popu-
lation of pregnantwomen[5],since
there has been such scant study of critical or serious illnesses during preg-
nancy (including the postpartum period). There are a few studies that present data about obstetric patients treated in the ICUs of university hospitals or with specific diseases such as eclampsia or HELLP, but the general size of the problem has not been evaluated (6-91. Our survey therefore had two principal aims: to ascertain the current frequency of serious diseases in pregnant women in France; and to discover whether individual or health care factors related to serious &orbidity might explain the differences in ihe lethality of different maternal diagnoses. We present here the iesults
0 1996 Elsevier Science Ireland Ltd. All rights I.eserved SSDI 0301-2115(95)02317-Z
0301-21W96615.00
122
M.-H. Bouvier-Coile et al. /European
Journal of Obstetrics & Gynecology and Reproductive Biology 6S (19%)
of the survey related to the frequency of women treated in the intensive care units and the pathologies leading to admission to ICV.
121-125
Table 1 Principal causes of admission to Intensive care unit Diagnoses
Cases
Deaths
Hypertensive diseases HTA Eclampsia, HELLP Vascular cerebral ACC Haemorrhages Prepartum Postpartum Uterine rupture Blood clot Embolisms Phlebitis Postoperative disorders Purperal infections Other related pregnancy diseasesa Complications of anaesthesia Obstetric trauma All obstetric direct
II4 61 52 I 87 I6 67 4 54 29 25 21 I9 7 6 4 312
6 0 5 I 5 0 4 I 2 I I 2 I I 0 0 I7
23 I3 IO IO I6 72
0 2 0 0 2 4
27 22 2 51 435
0 I 0 I 22
2. Survey De@ A population based survey was carried out in two French administrative regions, Nord-Pas de Calais, and Lorraine, looking at the population of obstetric patients, including women who were pregnant or delivered within 42 days. This delay was retained according to the definition of maternal death by the International Classification of Diseases [lo]. The cases were defined as all obstetric patients admitted for treatment or surveillance to an ICU or the closest equivalent surgical and medical resuscitation or critical care unit in the region. Abortion, and ectopic pregnancies were included. The live births data of the two regions were obtained from the National Institute of Statistics. The same questionnaire was retrospectively completed for all the cases. Questions probed the women’s characteristics, their medical, socio-demographic obstetric, and surgical histories, the monitoring of the current pregnancy, including problems, hospital and ICU admissions, and the procedures and treatment(s) carried our at each of these stages. The severity of the cases was measured by the simplified acute physiology score (SAPS), which was calculated 24 h after the patient had entered the ICU [Ill. The rate of still births was defined as the ratio of still births to the total number of births in the survey. The lethality rate, which was defined as the ratio of maternal deaths to cases. 3. Results The analysis included 435 obstetric patients who were treated in ICU. Defining critical illness in pregnancy and delivery by admission to an intensive care unit, we estimated its frequency at 308 in Nord-Pas de Calais and 312 in Lorraine, and mean at 310 S.D. 36 per 100 000 live births. There were 22 maternal deaths among the 435 cases, for an overall lethality rate of 5.1%. Table 1 presents the principal diagnoses that motivated admission to the ICU. The most frequent were hypertensive diseases (114/435, or 26.2%), followed by 87 haemorrhages (20%) and 54 embolisms (12.4%). The lethality rates did not differ between the direct (5.4%) and the indirect obstetric causes (5.6%), but important discrepancies were found between specific disorders. The lethality was highest for cardio-vascular diseases (15.4%) and for obstetric complications (14.3%); it was lowest for external causes, such as attempted suicide, Table 2. It is worth noting that the maternal lethality rates for the main disorders involved in
Respiratory diseases Cardio-vascular diseases Digestive diseases Preexisting disorders Other causes All obstetric indirect
Suicide attempts Poisoning Other externally caused deaths All external All causes
sHepatum Steatosis, renal insufftciency, premature delivery included.
maternal deaths - hypertensive diseases, haemorrhages, and embolisms - are significantly lower than with the other disorders. Inversly the stillbirth rates are highest with puerperal infections, hypertensive diseases, and haemorrhages. There were significant differences in the mean values of maternal age, SAPS, and number of days in the ICU, according to diagnosis. The age was lowest for external causes such as suicide and accidental poisoning and higher for obstetric trauma, haemorrhages, and infectious diseases. The SAPS was highest for infectious diseases, cardiac disorders, and haemorrhages. The longest ICU stays were observed for anaesthesia complications; the shortest, for suicide attempts. No significant association was observed between the SAPS and either the number of days in the ICU or the lethality rate; the SAPS was, however, significantly associated with the patient’s age. Another factor that we examined to see if it was related to the lethality rate was the category of hospital in which the women received prenatal care or gave birth, or both. It is well known that complicated or high-risk
M.-H. Bouvier-Colle et al. /European Journal of Obstetrics di Gynecology and Reproductive Biology 65 (19%) 121-125
123
Table 2 Severity of the diseases according to the principal cause of admission to ICU Mean age in years
SARY
cases 114 87 54 21 19 7 6 4 312
28.3 29.7 28.4 28.5 29.1 28.3 27.7 31.5 28.9
5.8 6.4 3.0 5.5 8.1 5.0 2.8 6.5 5.6
Numberof
CauSeS
Hypertensive dii Haemorrhages Blood clot Pospoperative disorders Puerperal infections Other related pregnaucy diseases Complications of anaesthesia obstetric trauma All direct
Stay duration in days 4.7 2.8 6.5 2.8 4.5 3.4 9.7 2.0 4.3
Still birth in %
Lethality in %
24.6 17.3 7.3 5.0 33.3 17.3
-5.3 5.7 3.7 9.5 5.3 14.3 0 0 5.5
Respiratory diseases Cardio-vascular dimases Digestive diseases Preexisting disorders Other indirect causes Ail indirect
23
29.0
4.0
3.7
-
0
13 10 10 16 72
29.2 28.8 29.2 29.1 29.1
6.7 1.0 1.2 6.1 4.3
10.3 1.1 3.4 5.2 5.6
-
15.4 0 0 12.5 5.6
Suicide attempts Poisoning Other external causes All external
21 22 2 51
23.5 25.3 22.0 24.2
2.0 0.2 1.2
1.9 1.1 4.5 1.6
2.9
0 4.5 0 2.0
435
28.3
4,8
4.2
13.3
5.1
AI1 causes
7.1
sSimplified acute physiology scorn.
pregnancies are best treated in teaching hospitals or in very active maternity wards. We found lethality to be highest among women who were scheduled to give birth in private or small public hospitals, but no difference existed according to the type of hospital in which they actually gave birth, Table 3. These seemingly discordant results are explained by the change in the type of prenatal care between registration and delivery. In fact the pregnancy of 53 of these women ended during the first trimester by abortion or ectopic pregnancy, Table 4. Fifty-six women changed type of facility and 326 others were treated in the same category of hospital throughout their pregnancy. The lethality rate varied widely among
these three groups: it increased d~ati~y which the type of obstetric care changed.
in cases in
4. connnents Our survey revealed two main points. First, we discovered the high frequency of obstetric patients who require care in intensive care units. Second, we noted that the majority of women who suffered serious complications during their pregnancy were treated in hospitals providing a high level of care. The frequency of women who needed intensive care in our study was different from that observed in those too-
Table 3 Lethality according to hospital scheduled and actual delivery Number of cases
Ikaths
Lethality in %
Test P value
OR [Cfl’
Scheduled hospital - Others - Teaching hospital
277 116
18
6.5 0.9
0.02
I
7.9 11.1~60.61 1
Delivery hospital - others - Teaching hospital
260 161
15 7
5.8 4.3
NS
ad-ratio
and confidence interval.
124
M.-H. Bouvier-Colle et al. /European Journal of Obstetrics & Gynecology and Reproductive Biology 65 (19%)
IZl-125
Table 4 Distribution and lethality of women according to type of hospital
Women who changed type hospital - Yes - No Pregnancies ended at the 1st trimester
Number of cases
Deaths
Lethality in %
Test P Value
CR [CIla
56 326
9 10
16.1 3.1
0.00
6.1[2.3-15.71 I
53
3
5.7
I.9 10.5-7.31
POdd-ratio and confidence interval.
rare studies of the subject; large discrepancies also exist within these surveys. Graham reports a rate of 105 per 100 000 pregnancies extending beyond 20 weeks gestational age, in a teaching hospital in Nottingham [6], whereas Mabie found a rate of 883 per 100 000 deliveries [7] in Memphis. Intermediate frequencies reported include: 228 per 100 000 deliveries, in a survey by Monaco taking deaths into account until two weeks post partum; 205, at the ICU of the public hospital of Brisbane [4]; and 400 per 100 000 deliveries at the ICU of the University of California at San Francisco [9], according to Kilpatrick. These numbers depend partly on the organisation of health services, which varies in different countries. Furthermore, each of those surveys involved one tertiary referral hospital and not an administrative area containing a variety of types of hospitals, as our survey did. Nevertheless our patients’, mean number of days in the ICU was quite similar to those reported elsewhere, which varied from 2.5 to 5.4 days per patient. The lethality rate observed in our survey is lower than those published in older surveys, which range from the 20% observed by Collop to the 8.7% Graham reports; our results were quite similar to the most recent findings by Lewinsohn, 7% [13]. We found that lethality was lower for women who were treated from the beginning to the end of their pregnancy in teaching hospitals, but no difference in lethality was seen based on the level of care in the hospital where the pregnancy ended. We have not yet seen similar types of results elsewhere. We agree with Graham that the interpretation of the frequencies is complicated by the variety of policies for intensive management of obstetric emergencies [5]. It is.important to note that, even in this context, many deaths, especially those related to haemorrhages and hypertensive diseases, appear to have been avoidable.-Progress in the quality of care for these frequent disorders might improve maternal mortality substantially. One element, though, might prevent such progress: the increasingly high maternal age at birth. The increase in maternal age at birth, in our opinion, will lead to an increase in maternal mortality rates in both France and Great Britain through 2005 [15]. We also found an im-
portant proportion of women with serious medical histories in the population of obstetric cases requiring intensive care; in addition, a higher frequency of indirect obstetric causes was at the origin of complications such as cardiac diseases, in which lethality rates were quite elevated. These results raise the question of the organisation of care in obstetric emergencies, which often require the management expertise of several subspecialists [5]. In conclusion, it appears that the majority of women with complicated pregnancies are referred to hospitals that can provide them with suitable care. Nonetheless, a small proportion of women had to change their type of care. It can be presumed that their mortality would have been lower if they had been treated sooner in more appropriate hospitals. Efforts should be made to diminish the number of these women and thus decrease maternal mortality in France. Acknowledgements This research received the financial support of the Caisse Nationale d’Assurance Maladie des Travailleurs Salaries, and of the Delegation a la Recherche Clinique of Assistance Publique de Paris. The authors are very grateful to the regional teams who performed the data collection: Drs I Caillier and C Poutot in Lorraine, Drs M Dumoulin and M El Hassani in Nord-Pas-de-Calais, Pr Femandez in Hauts-de-Seine. References 111Bouvier-Colle MH, Vamoux N, Breart G, Medical Expert Committee. Maternal deaths and substandard care: the results of a confidential survey in France. Eur J Obstet Gynec Reprod Biol 1995; 58: 3-7. I21 Schuitmaker NWE, Bennebroek-Gravenhorst J, Van Geijn HP, Dekker GA, Van Dongen PWJ. Maternal mortality and its prevention. Eur J Obstet Reprod Biol 1991; 42: 531-535. [31 Department of Health. Report on confidential enquiries into maternal deaths in the United Kingdom 1988-1990. HMSO, London, 1994. [41 Bouvier-Colle MH, Vamoux N, Costes Ph. Hatton F. Reasons for the underreporting of maternal mortality in France as indicated by a survey of all deaths among women of childbearing age. Int J Epidem 1991; 20 885-891.
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