Maternal mortality as an indicator of obstetric care in Europe

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Abstract
Objective  This analysis considers the usefulness of maternal mortality ratio (MMR) as an indicator of obstetric care in the context of low overall maternal mortality. We explore whether variation in the level of MMR among European countries reflects differences in obstetric care.Design  The data presented in this article were collected as part of the European Concerted Action on Mothers' Mortality and Severe morbidity (MOMS). In this study, a panel of experts followed a protocol to determine cause of death and whether it was pregnancy‐related. This analysis uses the expert panel's confirmation of cause of death and obstetric attribution.Setting  All maternal deaths within 11 European countries.Population  Two hundred and ninety obstetric deaths occuring between 1992 and 1995.Methods  We present the results of a multivariable analysis that controls for cause of death, moment of death, place of death, pregnancy outcome, women's age and nationality.Main outcome measures  We test the hypothesis that countries with higher MMR would have proportionally more cases of direct obstetric death due to thromboembolism, hypertension, haemorrhage or infection compared with other countries in the study. We examine timing of death and maternal age to measure whether there are differences between country groups for older mothers.Results  We find distinct patterns in cause and timing of death and age‐specific mortality ratios between countries with different levels of MMR.Conclusions  Despite low rates of maternal mortality in Europe, between‐country differences follow patterns with respect to cause and timing of death and maternal age. In addition to representing an important indicator of health status in a country, differences in MMR among European countries provide insight to where obstetric care plays a role maternal deaths.