Dossier n. 212/2011 [Abstract] Regional report on maternal mortality and morbility in Emilia-Romagna. 2001-2007

Maternal death is a sentinel event that reflects the quality of prenatal and perinatal care and that represents an important indicator of health system performance.

The definition of maternal death as in the tenth revision of the International Classification of Diseases (ICD-10) is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. ICD-10 also provides a definition for late maternal death: the death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy.

Worldwide less than 1% of maternal deaths happen in developed countries. Maternal mortality ratio (MMR), defined as the number of maternal deaths per 100.000 livebirths in a specific time period, decreased during the last decades (in Italy, according to ISTAT data, MMR was 13,1 per 100.000 in 1980 and decreased to 3 per 100.000 in the more recent estimate referred to the years between 1998-2007).

Enhanced surveillance systems or ad hoc surveys specific investigations have shown, in several countries, that up to 200% of maternal deaths are underestimated when current information flows are used.

Emilia-Romagna Region, in collaboration with 5 other Italian regions, has taken part to a record linkage study coordinated by Istituto superiore di sanità, to quantify maternal mortality underestimation and to identify main causes of maternal mortality and morbidity. Methods and results are described in the first section of the report.

The linkage process involved the regional register of deaths (ReM) that contains information from ISTAT death certificates, and the regional database of hospital discharge (SDO) that contains records of all patients admitted to hospital. Data linkage allowed the selection of all resident women in reproductive-aged who died during the period 2001-2007 and that were admitted to hospital within 365 days before death, due to pregnancy, childbirth and puerperium complications.

Records of the identified cases were reviewed to classify maternal deaths according to causes and timing (ICD-10 classification); MMR was calculated and classified as direct, indirect, within 42 days or late maternal mortality. Specific MMR by age, nationality and mode of delivery was also considered.
Regional MMR for resident women irrespective of place of death was 7.6 deaths per 100.000 livebirths, resulting in an underestimation of the MMR of 70% respect to official statistics based on death certificates.

The ratio differs by age group (<35 years or ≥35 years) and nationality (Italian or not Italian), but differences are not statistically significant, probably due to the small numbers involved.

Caesarean section was associated to an increased relative risk of maternal death of almost 5 respect to spontaneous delivery, but this result should be interpreted with caution, considering that maternal complications leading to deaths are more frequent among women that undergoes caesarean section.

Using the criterion of admission to intensive care unit, the query of the regional hospital discharge register allowed the estimation of severe maternal morbidity (near-miss cases study), that corresponds to 2.8 per 1000 deliveries.


The second section of the report describes the work performed by the regional working group on maternal mortality of the Commissione consultiva tecnico-scientifica sul percorso nascita and the results obtained.

Following the study conducted with the ISS and other regions, the Emilia-Romagna Region established a multidisciplinary working group to realize a clinical audit based on the integration of the information obtained through record-linkage with those obtained from clinical documentation. The objectives were to assess the accuracy of the method of record-linkage in detecting maternal death cases and their main causes, and to identify, through a qualitative analysis of the identified cases, critical areas of perinatal care for the realization of a structured audit.

To reach these objectives the region asked to the local health services an hard copy of the medical records of cases identified by record-linkage. The analysis covered all deaths with at least one admission for pregnancy in the previous 365 days, occurring in the years 2001-2007 in the region, irrespective of the woman’s place of residence. It was possible to retrieve the documentation of 86 cases. The report describes in detail the cases, dividing them according to the causes of death identified in the review process. Record-linkage method has shown to be an accurate method for detecting maternal deaths, showing an excellent level of agreement with the audit results. The audit process verified the classification of maternal deaths by causes, allowing a partial redistribution of the identified cases.

Unsatisfactory collection and transfer of information on women’s clinical risk factors and socio-psychological context emerges as one of the problems within the care pathways, and it can be interpreted as a marker of cultural and organizational difficulties within the multidisciplinary approach that should characterize perinatal care. Other problems relates to little use of the autopsy and to insufficient attention to cancer prevention during pregnancy.