{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T07:42:35Z","timestamp":1793173355387,"version":"4.5.0"},"reference-count":38,"publisher":"BMJ","license":[{"start":{"date-parts":[[2022,11,16]],"date-time":"2022-11-16T00:00:00Z","timestamp":1668556800000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ"],"accepted":{"date-parts":[[2022,9,28]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To compare maternal mortality in eight countries with enhanced surveillance systems.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Descriptive multicountry population based study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Eight countries with permanent surveillance systems using enhanced methods to identify, document, and review maternal deaths. The most recent available aggregated maternal mortality data were collected for three year periods for France, Italy, and the UK and for five year periods for Denmark, Finland, the Netherlands, Norway, and Slovakia.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Population<\/jats:title>\n                    <jats:p>297\u2009835 live births in Denmark (2013-17), 301\u2009169 in Finland (2008-12), 2\u2009435\u2009583 in France (2013-15), 1\u2009281\u2009986 in Italy (2013-15), 856\u2009572 in the Netherlands (2014-18), 292\u2009315 in Norway (2014-18), 283\u2009930 in Slovakia (2014-18), and 2\u2009261\u2009090 in the UK (2016-18).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Outcome measures<\/jats:title>\n                    <jats:p>Maternal mortality ratios from enhanced systems were calculated and compared with those obtained from each country\u2019s office of vital statistics. Age specific maternal mortality ratios; maternal mortality ratios according to women\u2019s origin, citizenship, or ethnicity; and cause specific maternal mortality ratios were also calculated.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Methods for identifying and classifying maternal deaths up to 42 days were very similar across countries (except for the Netherlands). Maternal mortality ratios up to 42 days after end of pregnancy varied by a multiplicative factor of four from 2.7 and 3.4 per 100\u2009000 live births in Norway and Denmark to 9.6 in the UK and 10.9 in Slovakia. Vital statistics offices underestimated maternal mortality by 36% or more everywhere but Denmark. Age specific maternal mortality ratios were higher for the youngest and oldest mothers (pooled relative risk 2.17 (95% confidence interval 1.38 to 3.34) for women aged &lt;20 years, 2.10 (1.54 to 2.86) for those aged 35-39, and 3.95 (3.01 to 5.19) for those aged \u226540, compared with women aged 20-29 years). Except in Norway, maternal mortality ratios were \u226550% higher in women born abroad or of minoritised ethnicity, defined variously in different countries. Cardiovascular diseases and suicides were leading causes of maternal deaths in each country. Some other conditions were also major contributors to maternal mortality in only one or two countries: venous thromboembolism in the UK and the Netherlands, hypertensive disorders in the Netherlands, amniotic fluid embolism in France, haemorrhage in Italy, and stroke in Slovakia. Only two countries, France and the UK, had enhanced methods for studying late maternal deaths, those occurring between 43 and 365 days after the end of pregnancy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Variations in maternal mortality ratios exist between high income European countries with enhanced surveillance systems. In-depth analyses of differences in the quality of care and health system performance at national levels are needed to reduce maternal mortality further by learning from best practices and each other. Cardiovascular diseases and mental health in women during and after pregnancy must be prioritised in all countries.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmj-2022-070621","type":"journal-article","created":{"date-parts":[[2022,11,16]],"date-time":"2022-11-16T20:05:40Z","timestamp":1668629140000},"page":"e070621","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":126,"title":["Maternal mortality in eight European countries with enhanced surveillance systems: descriptive population based study"],"prefix":"10.1136","volume":"379","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1176-0991","authenticated-orcid":false,"given":"Caroline","family":"Diguisto","sequence":"first","affiliation":[{"name":"National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK"},{"name":"Universit\u00e9 Paris Cit\u00e9, CRESS UMR 1153, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOP\u00e9, INSERM, INRAE, Paris, France"},{"name":"P\u00f4le de gyn\u00e9cologie obst\u00e9trique, m\u00e9decine f\u0153tale, m\u00e9decine et biologie de la reproduction, centre Olympe de Gouges, CHRU de Tours, 37 044 Tours, France; Universit\u00e9 de Tours, 37032 Tours, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1213-5693","authenticated-orcid":false,"given":"Monica","family":"Saucedo","sequence":"additional","affiliation":[{"name":"Universit\u00e9 Paris Cit\u00e9, CRESS UMR 1153, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOP\u00e9, INSERM, INRAE, Paris, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6078-1185","authenticated-orcid":false,"given":"Athanasios","family":"Kallianidis","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1377-4625","authenticated-orcid":false,"given":"Kitty","family":"Bloemenkamp","sequence":"additional","affiliation":[{"name":"Department of Obstetrics, Division Women and Baby, Birth Centre Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Birgit","family":"B\u00f8dker","sequence":"additional","affiliation":[{"name":"Nordsj\u00e6llands Hospital, Hiller\u00f8d, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marta","family":"Buoncristiano","sequence":"additional","affiliation":[{"name":"National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanit\u00e0 - Italian National Institute of Health, Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4607-2072","authenticated-orcid":false,"given":"Serena","family":"Donati","sequence":"additional","affiliation":[{"name":"National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanit\u00e0 - Italian National Institute of Health, Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8254-7525","authenticated-orcid":false,"given":"Mika","family":"Gissler","sequence":"additional","affiliation":[{"name":"Department of Knowledge Brokers, THL Finnish Institute for Health and Welfare, Helsinki, Finland"},{"name":"Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden"},{"name":"Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marianne","family":"Johansen","sequence":"additional","affiliation":[{"name":"Department of Obstetrics, Rigshospitalet University Hospital, Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1984-4575","authenticated-orcid":false,"given":"Marian","family":"Knight","sequence":"additional","affiliation":[{"name":"National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miroslav","family":"Korbel","sequence":"additional","affiliation":[{"name":"1st Department of Obstetrics and Gynaecology, Faculty of Medicine, Comenius University in Bratislava, Slovak Republic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1216-0824","authenticated-orcid":false,"given":"Alexandra","family":"Kristufkova","sequence":"additional","affiliation":[{"name":"1st Department of Obstetrics and Gynaecology, Faculty of Medicine, Comenius University in Bratislava, Slovak Republic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8979-1563","authenticated-orcid":false,"given":"Lill T","family":"Nyflot","sequence":"additional","affiliation":[{"name":"Norwegian Research Centre for Women's Health, Oslo University Hospital, Oslo, Norway"},{"name":"Department of Obstetrics, Drammen Hospital, Drammen, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6561-3321","authenticated-orcid":false,"given":"Catherine","family":"Deneux-Tharaux","sequence":"additional","affiliation":[{"name":"Universit\u00e9 Paris Cit\u00e9, CRESS UMR 1153, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOP\u00e9, INSERM, INRAE, Paris, France"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2022,11,16]]},"reference":[{"key":"2025110101572061000_379.nov16_7.e070621.1","unstructured":"World Health Organization, UNICEF, UNFPA, World Bank Group, United Nations. 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