[Analysis of maternal mortality in the Czech Republic in 2000]

Analysis of maternal mortality in the Czech Republic in 2000.

Retrospective statistical and clinical analysis.

Department of Obstetrics and Gynecology of the 1st Medical School of Charles University and General University Hospital, Prague 2, Institute for the Care of Mother and Child, Prague.

We present an annual analysis of maternal mortality in the Czech Republic, organized into two parts: 1) international statistical part, and 2) clinical part in Czech only with abbreviated anonymous analysis of individual cases of maternal death. We are aware that follow-up analysis cannot fully express dramatic situations around all cases or reproduce in details all their aspects. We though believe that this form will help to our gynecologists to learn about courses of the deaths, particularly when the frequency of such cases is low and circumstances are unusual. Individual analyses include also conclusions of expert committees or analyses performed by the Czech Medical Chamber. Comments and notes however are not for forensic purposes and are used only for medical ones.

We used a database of 10 cases of maternal deaths in the Czech Republic in 2000. We analyzed their causes, clinical courses, especially in connection to obstetrical surgery, and adequacy of provided care.

There were 10 reported maternal deaths in connection to pregnancy, labor and delivery or within 42 days after delivery in the Czech Republic in 2000. There were 90,910 live-born babies and total, gross maternal mortality (A + B + C) was 0.11 per 1000, i.e. 11 deaths per 100,000 live-born babies. This is only 0.02 per 1000 better than results in 1999 (Table 3 shows data on maternal mortality for last 10 years). In 2000, there was one maternal death unrelated to gestation--category C, therefore maternal mortality in connection to gestation (A + B) was 0.099 per 1000 i.e. 9.9 deaths per 100,000 live-born babies compared to 10.1 deaths in 1999. The causes of deaths were different. Only two women were within group A (specific risk--direct maternal mortality), therefore direct maternal mortality was 2.2 per 100,000 live-born babies. Seven maternal deaths were in the group B (non-specific risk--indirect maternal mortality) and indirect maternal mortality was unusually high, 7.7 per 100,000 live-born babies. It is difficult to judge the difference due to possible error of small numbers. The demographic part of the report has been sent to the Office of Health Statistics and Information and detailed report to the Department of Health Care of the Ministry of Health of the Czech Republic.

Since 1994, when we introduced nationwide organization measures to identify risk groups of pregnant women and use of micro-heparinization among those, we have succeeded to lower the frequency of thrombolism, till then leading cause of maternal deaths, especially in links to operative deliveries and in smaller extent among high-risk women during pregnancy. The decrease of maternal mortality was substantial, by 50%, however only temporary, followed by a partial increase to about 10 maternal deaths per 100,000 live-born babies. This increase was to increased frequency of coagulopathies, HELLP syndrome, and, in 2000, due to non-specific cardiovascular causes and some neurologic complications. The majority of these cases and especially those with non-adequate obstetrical care will be anonymously analyzed together with responsible chiefs of ob/gyn departments during perinatology conference in 2002 and results will be consequently published. Increase of non-specific causes of maternal deaths in 2000, especially of those with cardiovascular complications, indicate a necessity to be careful especially with older parturients, diabetic women, obese women and "dangerous" multiparae, where the possibility of cardiovascular complications might require need concentrated medical diagnosis. Primary attention, though, should be aimed at impaired coagulation of blood. The cases of complications of DIC persistently show insufficient diagnostic and therapeutic measures especially in small facilities with limited laboratory compartments, outdated and wrong therapeutic measures and almost missing potential for consultancy. In spite of this it is particularly necessary to concentrate on prevention among cases with higher risk for DIC. We have concentrated on publications in collaboration with hematologists and anesthesiologists in this field, although some measures are lacking the universal consent, especially some therapeutic means. It is very important to us that chiefs of ob/gyn departments are open for professional discussions, although some situations are prone to forensic evaluation. We believe that our approach of anonymous analyses with two-year delay is sufficient for necessary audit of maternal mortality.