Severe maternal morbidity surveillance, temporal trends and regional variation: A population‐based cohort study

Abstract

ObjectiveTo quantify temporal trends and regional variation in severe maternal morbidity (SMM) in Sweden.DesignCohort study.PopulationLive birth and stillbirth deliveries in Sweden, 1999–2019.MethodsTypes and subtypes of SMM were identified, based on a standard list (modified for Swedish clinical setting after considering the frequency and validity of each indicator) using diagnoses and procedure codes, among all deliveries at ≥22 weeks of gestation (including complications within 42 days of delivery). Contrasts between regions were quantified using rate ratios (RRs) and 95% confidence intervals (95% CIs). Temporal changes in SMM types and subtypes were described.Main outcome measuresTypes and subtypes of SMM.ResultsThere were 59 789 SMM cases among 2 212 576 deliveries, corresponding to 270.2 (95% CI 268.1–272.4) per 10 000 deliveries. Composite SMM rates increased from 236.6 per 10 000 deliveries in 1999 to 307.3 per 10 000 deliveries in 2006, before declining to 253.8 per 10 000 deliveries in 2019. Changes in composite SMM corresponded with temporal changes in severe haemorrhage rates, which increased from 94.9 per 10 000 deliveries in 1999 to 169.3 per 10 000 deliveries in 2006, before declining to 111.2 per 10 000 deliveries in 2019. Severe pre‐eclampsia, eclampsia and HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome (103.8 per 10 000 deliveries), severe haemorrhage (133.7 per 10 000 deliveries), sepsis, embolism, disseminated intravascular coagulation, shock and severe mental health disorders were the most common SMM types. Rates of embolism, disseminated intravascular coagulation and shock, acute renal failure, cardiac complications, sepsis and assisted ventilation increased, whereas rates of surgical complications, severe uterine rupture and anaesthesia complications declined.ConclusionsThe observed spatiotemporal variations in composite SMM and SMM types provide substantive insights and highlight regional priorities for improving maternal health.

Risk of Perinatal and Maternal Morbidity and Mortality Among Pregnant Women With Epilepsy

“…Severe maternal morbidity conditions were identified based on a comprehensive list of indicators (eTable 4 in Supplement 1), previously developed by the Canadian Perinatal Surveillance System 28 and the US Centers for Disease Control and Prevention US, 29,30 and recently modified and validated for use with the Nordic health register. 31 In this study, we excluded conditions that are more prevalent among individuals with epilepsy, such as status epilepticus (G41) and shock (R57), to accurately capture severe maternal morbidity conditions and prevent over ascertainment. Severe maternal morbidity was categorized into specific groups including: (1) eclampsia or severe preeclampsia, (2) severe hemorrhage, (3) surgical complications, eg, disruption or hematoma of obstetric wound, (4) sepsis, eg, major puerperal infection, septicemia during labor, (5) obstetric shock, (6) cardiac complications, eg, acute myocardial infarction, heart failure, (7) kidney failure, (8) cerebrovascular morbidity, eg, cerebral venous thromboembolism, intracranial hemorrhage, (9) complications of anesthesia and obstetric interventions, including cardiac and pulmonary complications, and (10) severe mental health conditions, ie, suicide attempts, and any hospitalization for psychiatric disorder as a primary diagnosis (eTable 4 in Supplement 1).…”