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. 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. 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. 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.

/pdf/suboptimal-care-and-maternal-mortality-among-foreign-born-2ln6mopxo3.pdf

Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model

Objective To investigate the effect of in situ simulation (ISS) versus off-site simulation (OSS) on knowledge, patient safety attitude, stress, motivation, perceptions of simulation, team performance and organisational impact. Design Investigator-initiated single-centre randomised superiority educational trial. Setting Obstetrics and anaesthesiology departments, Rigshospitalet, University of Copenhagen, Denmark. Participants 100 participants in teams of 10, comprising midwives, specialised midwives, auxiliary nurses, nurse anaesthetists, operating theatre nurses, and consultant doctors and trainees in obstetrics and anaesthesiology. Interventions Two multiprofessional simulations (clinical management of an emergency caesarean section and a postpartum haemorrhage scenario) were conducted in teams of 10 in the ISS versus the OSS setting. Primary outcome Knowledge assessed by a multiple choice question test. Exploratory outcomes Individual outcomes: scores on the Safety Attitudes Questionnaire, stress measurements (State-Trait Anxiety Inventory, cognitive appraisal and salivary cortisol), Intrinsic Motivation Inventory and perceptions of simulations. Team outcome: video assessment of team performance. Organisational impact: suggestions for organisational changes. Results The trial was conducted from April to June 2013. No differences between the two groups were found for the multiple choice question test, patient safety attitude, stress measurements, motivation or the evaluation of the simulations. The participants in the ISS group scored the authenticity of the simulation significantly higher than did the participants in the OSS group. Expert video assessment of team performance showed no differences between the ISS versus the OSS group. The ISS group provided more ideas and suggestions for changes at the organisational level. Conclusions In this randomised trial, no significant differences were found regarding knowledge, patient safety attitude, motivation or stress measurements when comparing ISS versus OSS. Although participant perception of the authenticity of ISS versus OSS differed significantly, there were no differences in other outcomes between the groups except that the ISS group generated more suggestions for organisational changes. Trial registration number NCT01792674.

https://bmjopen.bmj.com/content/bmjopen/5/10/e008344.full.pdf

Simulation-based multiprofessional obstetric anaesthesia training conducted in situ versus off-site leads to similar individual and team outcomes: a randomised educational trial

Venous thromboembolism (VTE) is the leading cause of maternal death in the Western world, and the risk increases during pregnancy and puerperal period. It was the objective of the present study to estimate the absolute and the relative risk of VTE at different weeks of gestation and in the postnatal period as compared to non-pregnant women. This was a historical controlled national cohort study. The National Registry of Patients identified relevant diagnoses. These data were linked to The National Registry of Medical Products Statistics for information about current use of oral contraceptives. Danish women 15 to 49 years old during the period January 1995 through December 2005 were included in the study. In total 819,751 pregnant women were identified of whom 727 had a diagnosis of VTE. The absolute risk of VTE per 10,000 pregnancy-years increased from 4.1 (95% CI, 3.2 to 5.2) during week 1–11 up to 59.0 (95% CI: 46.1 to 76.4) in week 40 and decreased in the puerperal period from 60.0 (95% CI:47.2–76.4) during the first week after birth to 2.1 (95% CI:1.1 to 4.2) during week 9–12 after birth. Compared with non-pregnant women, the incidence rate ratio rose from 1.5 (95% CI:1.1 to1.9) in week 1–11, to 21.0 (95%CI16.7 to 27.4) in week 40 and 21.5 (95% CI:16.8 to 27.6) in the first week after delivery, declining to 3.8 (95% CI:2.5 to 5.8) 5–6 weeks after delivery. In conclusion, the risk of VTE increases almost exponentially through pregnancy and reaches maximum just after delivery and is no longer significantly increased six weeks after delivery.

Venous thromboembolism in pregnant and puerperal women in Denmark 1995-2005. A national cohort study.

Objective
To quantify risk factors for venous thromboembolism during pregnancy and the puerperal period.

/pdf/risk-factors-for-venous-thromboembolism-in-1-3-million-1m2o3x2vwd.pdf

Risk Factors for Venous Thromboembolism in 1.3 Million Pregnancies: A Nationwide Prospective Cohort

Objective. To determine the prevalence of suicidal thoughts and attempts and to identify demographic variables and mental health correlates such as anxiety/depression and domestic violence among pregnant women in an urban community in Pakistan. Design. Cross-sectional data from a prospective cohort study are presented. Setting. Women enrolled in an antenatal care clinic and followed to delivery in an urban area of Pakistan. Population. Cohort of pregnant women in Pakistan. Methods. A total of 1,369 pregnant women were enrolled and interviewed regarding various maternal characteristics and pregnancy outcomes, and were asked specific questions about suicidal thoughts and attempts and administered the Aga Khan University Anxiety Depression Scale at 20–26 weeks of gestation. Main outcome measures. Suicidal thoughts and attempts, verbal, sexual or physical abuse. Results. Overall, 148 of the 1,369 (11%) women studied had considered suicide. Of these, 148 women, 67 (45%) had attempted suicide. In all, ...

/pdf/prevalence-of-suicidal-thoughts-and-attempts-among-pregnant-2j6ql62swb.pdf

Prevalence of suicidal thoughts and attempts among pregnant Pakistani women

Objective. To describe a method for identification, classification and assessment of maternal deaths in Denmark and to identify substandard care. Design. Register study and case audit based on data from the Registers of the Danish Medical Health Board, death certificates and hospital records. Setting. Denmark 2002–2006. Population. Women who died during a pregnancy or within 42 days after a pregnancy. Methods. Maternal deaths were identified by notification from maternity wards and data from the Danish National Board of Health. A national audit committee assessed hospital records of direct and indirect deaths. Main outcome measures. Maternal mortality ratio, causes of death and suboptimal care. Results. In the study period, 26 women died during pregnancy or within 42 days from direct or indirect causes, leading to a maternal mortality ratio of 8.0/100,000 live births. Causes of death were cardiac disease, thromboembolism, hypertensive disorders of pregnancy, Streptococcus A infections, suicide, amniotic f...

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1080/00016340902897992

Maternal deaths in Denmark 2002-2006.

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Maternal deaths in Denmark 2002-2006.