PSF 2024 – French maternal mortality: how to improve the French results?

PSF 2024 – French maternal mortality: how to improve the French results?
PSF 2024 – French maternal mortality: how to improve the French results?

France is in the European average for maternal mortality, with a rate of 8.5/100,000 live births, according to the latest triennial ENCMM survey 2016-2018. However, this figure has increased slightly compared to previous surveys: over the period up to one year after the end of pregnancy, which seems to better reflect the impact of pregnancy on women’s health, this figure was 11.8/100,000 between 2016 and 2018, while it had been between 10.3 and 10.8 since 2007. A session of the congress Paris Women’s Health (June 12-14, 2024, Paris) recalled the main findings: half of these deaths occur during pregnancy and a quarter during the peripartum period and up to the 6the postpartum day. Those most at risk are women aged 35 and over, those who are obese, those who are socially vulnerable, those living in overseas departments and regions or those from immigrant backgrounds. However, two major factors are particularly highlighted by this new survey.

Most deaths would be preventable

It is estimated, after analysis of medical records, that 17% of cases of maternal mortality are probably avoidable and that 43% are possibly avoidable. In one case out of two, they are explained by the inadequacy of care and they are then divided equally between defects in the organization of care or the interaction of the patient with the care system. If these figures are down compared to the previous period, they encourage us to repeat some messages of good practice, such as the importance of exchanging information and coordinating care between the maternity team and other care providers, particularly when the woman has a pre-existing pathology or one discovered during pregnancy. In retrospect, ” analysis of the files reveals flaws in the organization of care, a lack of communication, insufficient teams, inadequate care locations or lack of transfer…”, reported Dr. Jean-Michel Dreyfus (gynecologist, Lyon). It is therefore also crucial ” to consider repeating follow-up or monitoring examinations depending on the women’s risk level. Some conditions may worsen during pregnancy and it is important to identify them in order to adjust management “. Attention in particular to women suffering from depression, epilepsy, breast cancer or cardiovascular diseases. Thus, neither pregnancy nor the months following childbirth should modify the management of these comorbidities. For women affected by certain diseases (psychiatry, pre-eclampsia, diabetes or postpartum sepsis), monitoring must be continuous, which is often not feasible in a conventional service. Which implies for maternity wards ” to organize access to critical maternal care”.

Suicide: vulnerable women in complex medical and socio-economic situations

Another alarming figure: that of deaths by suicide, which represent 17% of cases over the period 2016-2018, making it the leading cause of maternal mortality ahead of cardiovascular causes (15%) or amniotic embolisms (8%). Half of them concern women without a psychiatric history, commented Dr. Marie-Noëlle Vacheron (neuropsychiatrist, Paris). And, for those who had some [dépression, bipolarité, antécédents de tentative de suicide…]half had never spoken about it to the caregivers involved in monitoring their pregnancy. “This should raise awareness of the importance of informing all pregnant women, their partners, those close to them and, more broadly, the general public.” that pregnancy is a vulnerable period “These events occurred within a median time of 4 to 5 months postpartum, all through violent modes of suicide and in women in predominantly vulnerable socio-economic situations. Three out of four cases could have been avoided, she regretted. Also, all health professionals must be made aware of the subject. »

It is essential to collect personal and family history, including that concerning different consumptions, sleep disorders, withdrawal, anxiety, frequent visits to the emergency room, etc. all should serve as warning signs for greater vigilance “The temporality of the events confirms that maternal mortality monitoring must be sufficient throughout the first postpartum year. However, the specialist acknowledged: ” These are women who often refuse care, are non-compliant with treatments… They have a complex background and are difficult to support.” There is therefore a challenge in maintaining a link while women gradually no longer have close contact with the healthcare system after a few weeks.

Guiding public policy priorities

« Maternal mortality is a sentinel event that should constitute an alert for health professionals and public authorities “, explained Dr. Marie Bruyère, anesthesiologist-resuscitator, Bicêtre hospital, Le Kremlin-Bicêtre. Indeed, ” These events illustrate the performance of the healthcare system, make it possible to identify groups that are victims of inequalities in care and help guide the actions to be taken. ” However, France also has rates of amniotic fluid embolism and mortality from hemorrhage that are higher than European figures. In order to reduce these figures, the report recommends several avenues: ” Knowing how to evoke an amniotic embolism must be a reflex in maternity. The precocity of the diagnosis and the intensity of the treatment are crucial and hysterectomy must be considered without delay. » in case of suspicion.

In order to reduce the consequences of hemorrhage, the place of delivery of high-risk women should depend on the available resources, with a multidisciplinary procedure established in the antenatal period. Postoperative monitoring should be ensured regularly in the first hours following a cesarean section and early intervention is required in the event of any suggestive hemodynamic disorder.

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