Department of Obstetrics and Gynecology, Academic Hospital Paramaribo (AZP), Paramaribo, Suriname.
Division Women and Baby, Department of Obstetrics, Wilhelmina's Children Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
Reprod Health. 2021 Feb 19;18(1):46. doi: 10.1186/s12978-020-01051-1.
The World Health Organization (WHO) provides a framework (ICD-MM) to classify pregnancy-related deaths systematically, which enables global comparison among countries. We compared the classification of pregnancy-related deaths in Suriname by the attending physician and by the national maternal death review (MDR) committee and among the MDR committees of Suriname, Jamaica and the Netherlands. There were 89 possible pregnancy-related deaths in Suriname between 2010 and 2014. Nearly half (47%) were classified differently by the Surinamese MDR committee as compared to the classification of the attending physicians. All three MDR committees agreed that 18% (n = 16/89) of the cases were no maternal deaths. Out of the remaining 73 cases, there was disagreement regarding whether 15% (n = 11) were maternal deaths. The Surinamese and Jamaican MDR committees achieved greater consensus in classification than the Surinamese and the Netherlands MDR committees. The Netherlands MDR committee classified more deaths as unspecified than Surinamese and the Jamaican MDR committees. Underlying causes that achieved a high level of agreement among the three committees were abortive outcomes and obstetric hemorrhage, while little agreement was reported for unspecified and other direct causes. The issues encountered during maternal death classification using the ICD-MM guidelines included classification of suicide during early pregnancy; when to assume pregnancy without objective evidence; how to count maternal deaths occurring outside the country of residence; the relevance of direct or indirect cause attribution; and how to select the underlying cause when direct and indirect conditions or multiple comorbidities co-occur. Addressing these classification barriers in future revisions of the ICD-MM guidelines could enhance the feasibility of maternal death classification and facilitate global comparison.
Insight into the underlying causes of pregnancy-related deaths is essential to develop policies to avert preventable deaths. The WHO International Classification of Diseases-Maternal Mortality (ICD-MM) guidelines provide a framework to standardize maternal death classifications and enable comparison in and among countries over time. However, despite the implementation of these guidelines, differences in classification remain. We evaluated consensus on maternal death classification using the ICD-MM guidelines.
The classification of pregnancy-related deaths in Suriname during 2010-2014 was compared in the country (between the attending physician and the national maternal death review (MDR) committee), and among the MDR committees from Suriname, Jamaica and the Netherlands. All reviewers applied the ICD-MM guidelines. The inter-rater reliability (Fleiss kappa [κ]) was used to measure agreement.
Out of the 89 cases certified by attending physicians, 47% (n = 42) were classified differently by the Surinamese MDR committee. The three MDR committees agreed that 18% (n = 16/89) of these cases were no maternal deaths, and, therefore, excluded from further analyses. However, opinions differed whether 15% (n = 11) of the remaining 73 cases were maternal deaths. The MDR committees achieved moderate agreement classifying the deaths into type (direct, indirect and unspecified) (κ = 0.53) and underlying cause group (κ = 0.52). The Netherlands MDR committee classified more maternal deaths as unspecified (19%), than the Jamaican (7%) and Surinamese (4%) committees did. The mutual agreement between the Surinamese and Jamaican MDR committees (κ = 0.69 vs κ = 0.63) was better than between the Surinamese and the Netherlands MDR committees (κ = 0.48 vs κ = 0.49) for classification into type and underlying cause group, respectively. Agreement on the underlying cause category was excellent for abortive outcomes (κ = 0.85) and obstetric hemorrhage (κ = 0.74) and fair for unspecified (κ = 0.29) and other direct causes (κ = 0.32).
Maternal death classification differs in Suriname and among MDR committees from different countries, despite using the ICD-MM guidelines on similar cases. Specific challenges in applying these guidelines included attribution of underlying cause when comorbidities occurred, the inclusion of deaths from suicides, and maternal deaths that occurred outside the country of residence.
世界卫生组织（WHO）提供了一个框架（ICD-MM），用于系统地对妊娠相关死亡进行分类，这使得各国之间可以进行全球比较。我们比较了苏里南的主治医生和国家孕产妇死亡审查（MDR）委员会对妊娠相关死亡的分类，以及苏里南、牙买加和荷兰的 MDR 委员会之间的分类。2010 年至 2014 年期间，苏里南共有 89 例可能的妊娠相关死亡。尽管使用了 ICD-MM 指南，但苏里南的 MDR 委员会对近一半（47%）的病例的分类与主治医生的分类不同。在这三个 MDR 委员会中，所有三个委员会都同意，18%（n=16/89）的病例不是孕产妇死亡。在剩下的 73 例中，对于是否有 15%（n=11）是孕产妇死亡，存在分歧。苏里南和牙买加的 MDR 委员会在分类方面达成了比苏里南和荷兰的 MDR 委员会更大的共识。荷兰的 MDR 委员会将更多的死亡归类为未指明原因，而苏里南和牙买加的 MDR 委员会则没有。在三个委员会中，具有高度一致性的根本原因是流产结局和产科出血，而对于未指明原因和其他直接原因，则报告的一致性较低。在使用 ICD-MM 指南对孕产妇死亡进行分类时遇到的问题包括对早期妊娠自杀的分类；在没有客观证据的情况下假设怀孕的时间；如何计算在居住地以外发生的孕产妇死亡；直接或间接病因归因的相关性；以及当直接和间接情况或多种合并症同时发生时，如何选择根本原因。在 ICD-MM 指南的未来修订中解决这些分类障碍，可以提高孕产妇死亡分类的可行性，并促进全球比较。
了解妊娠相关死亡的根本原因对于制定政策以避免可预防的死亡至关重要。世界卫生组织的《国际疾病分类-孕产妇死亡率》（ICD-MM）指南提供了一个框架，用于规范孕产妇死亡分类，并使各国之间能够随着时间的推移进行比较。然而，尽管实施了这些指南，分类仍然存在差异。我们评估了使用 ICD-MM 指南对孕产妇死亡分类的共识。
比较了 2010-2014 年期间苏里南的妊娠相关死亡在该国（主治医生和国家孕产妇死亡审查（MDR）委员会之间）的分类，以及苏里南、牙买加和荷兰的 MDR 委员会之间的分类。所有评审员均应用 ICD-MM 指南。使用 Fleiss kappa（κ）来衡量一致性。
在由主治医生认证的 89 例病例中，47%（n=42）由苏里南的 MDR 委员会进行了不同的分类。这三个 MDR 委员会一致认为，这些病例中有 18%（n=16/89）不是孕产妇死亡，因此不包括在进一步的分析中。然而，对于剩下的 73 例病例中是否有 15%（n=11）是孕产妇死亡存在分歧。MDR 委员会将死亡归类为直接、间接和未指明原因的类型（κ=0.53）和根本原因组（κ=0.52）的一致性中等。荷兰的 MDR 委员会将更多的孕产妇死亡归类为未指明原因（19%），而牙买加（7%）和苏里南（4%）的 MDR 委员会则没有。苏里南和牙买加的 MDR 委员会之间的相互一致性（κ=0.69 对 κ=0.63）优于苏里南和荷兰的 MDR 委员会之间的相互一致性（κ=0.48 对 κ=0.49），分别为类型和根本原因组。流产结局（κ=0.85）和产科出血（κ=0.74）的根本原因类别之间的一致性极好，未指明原因（κ=0.29）和其他直接原因（κ=0.32）的一致性良好。
尽管在类似的情况下使用了 ICD-MM 指南，但苏里南和来自不同国家的 MDR 委员会在孕产妇死亡分类方面存在差异。在应用这些指南时存在具体挑战，包括当合并症发生时确定根本原因，包括自杀死亡，以及发生在居住地以外的孕产妇死亡。
