2024-04-09 11:09:08
According to the joint report from Inserm and Santé Publique France published on April 3 on maternal deaths in France, suicide is the leading cause of maternal mortality considered up to one year after the end of the pregnancy.
Between 2016 and 2018, 272 maternal deaths were recorded in France, i.e. one maternal death every 4 days and a maternal mortality ratio considered up to one year from the end of the pregnancy of 11.8 deaths per 100,000 live births. , with no decrease compared to previous periods.
With around 90 deaths per year, or 11.8 deaths per 100,000 births, “ France is in the average of European countries »note the authors of the survey.
Suicide: 45 deaths out of the 272 recorded between 2016 and 2018
Suicide becomes the leading cause of maternal mortality considered up to one year after the end of pregnancy, and the cardiovascular illnesses are the leading cause of maternal mortality considered up to forty-two days. This profile reminds us that the health of pregnant women goes beyond the strictly obstetrical sphere. Thus suicide caused 45 deaths out of the 272 recorded between 2016 and 2018, or 17% of the total with a Maternal Mortality Ratio (MMR) of 1.9/100,000 live births, or approximately one maternal death from psychiatric causes every 3 weeks in France
The authors specify that the peak occurs around four to five months after giving birth. Regarding the profile, these are often women in their first pregnancy and women who have already had proven psychiatric history or eating disorders.
There are socio-demographic inequalities in maternal mortality:
– the risk of maternal mortality increases markedly with the age of women from the age of 35;
– the mortality of migrant women is twice that of women born in France;
– socially vulnerable women are 1.5 times more represented among deceased women.
“Territorially, the overseas departments and regions (DROM) are distinguished by a level of mortality equivalent to twice that of France. LWomen born in sub-Saharan Africa and overseas migrants present a risk 3.1 and 2 times higher than those born in France.
Prevention, screening and coordinated care
Analysis of the journey of deceased women shows that improvement is possible, because more than half of maternal deaths are considered probably or possibly avoidable and in two thirds of cases, the care provided was not optimal. The preventability factors identified emphasize the importance of prevention, screening, and coordinated and multidisciplinary care from the preconception period to the months after delivery, in all areas of health. of the woman. The qualitative analysis of maternal deaths allowed the committee of experts to identify 30 key messages targeting the elements of care and its organization to be improved, in particular for better consideration of mental health and cardiovascular in supporting pregnant women and those who have given birth.
According to Inserm and Santé Publique France, “ 60% of maternal deaths are probably or possibly preventable ».
30 key messages to boost avoidability
These 30 key messages concern various aspects of the care pathway for women before, during and after their pregnancy. They illustrate the observation that the prevention of these severe maternal complications is everyone’s business, caregivers in maternity or community obstetrics, caregivers in other specialties, general practitioners, social action professionals, health policy makers, user associations, women themselves and those around them.
– During pregnancy and postpartum, the level of risk for a woman, in the 3 somatic dimensions, psychiatric and social, is evolving. Its evaluation must therefore be repeated throughout this period.
– During prenatal follow-up, information on the social context, living conditions and history of violence must be collected in detail, in the same way as traditional medical history.
– The measures which make it possible to establish or re-establish social security coverage during pregnancy are deployed from the first contact with the healthcare system.
– The exchange of information and coordination of care between the maternity team and other healthcare providers is a major factor in preventing death among women with somatic or psychiatric pathology pre-existing or discovered during pregnancy. They ideally begin preconception and continue several months after delivery.
– The state of pregnancy, postpartum and breastfeeding do not modify the management according to the usual recommendations of good clinical practice, unless there is a specific justified reason.
– The diagnostic criteria as well as cardiopulmonary resuscitation for cardiopulmonary arrest in pregnant women are the same as outside pregnancy. Beyond 20 weeks of amenorrhea, or if the uterus is palpable above the umbilicus, it is recommended to perform uterine latero-deviation to the left and, intra-hospital, to perform a cesarean section. maternal rescue in the absence of recovery after 5 minutes of well-conducted resuscitation.
– Two specific areas of training could improve risk management in maternity:
• bedside ultrasound (POCUS): cardiac ultrasound for the diagnosis of heart failure in cases of dyspnea and hemodynamic failure, and abdominal ultrasound to look for intraperitoneal effusion in the event of signs of hypovolemia post-operatively. ‐cesarean section;
• team simulation for life-threatening emergency situations.
– In the event of a vital maternal emergency, every minute counts. It is up to each maternity ward to establish an organizational procedure for maternal vital emergencies immediately accessible to all, including the procedures for requesting human reinforcements as well as those for resorting to extracorporeal membrane oxygenation (ECMO).
– Some patients require continuous monitoring during pregnancy or postpartum, which is not possible in a conventional service. It is up to each maternity ward to organize access to critical maternal care.
– Post‐mortem examinations should be systematically considered in cases of maternal death without obvious cause: • in a context of unexpected and sudden death, signing the death certificate with medico‐legal obstacle opens the possibility of a medico‐legal autopsy ;
• if it is impossible to perform the autopsy or while waiting for it, a whole body scan, carried out quickly, will make it possible to identify certain causes of death, in particular a hemorrhagic stroke or fluid effusion;
• the autopsy allows the diagnosis of rare pathologies sometimes pre-existing in pregnancy, or even familial.
According to Inserm and Santé Publique France, “60% of maternal deaths are probably or possibly preventable.”
• Maternal mortality in France: better understanding for better prevention. Maternal deaths in France 2016-2018 – 7th report of the Confidential National Inquiry into Maternal Deaths (ENCMM) 2016-2018, Public Health France, April 2024.
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