Improving Maternity Care in the Netherlands: Why Not to Miss Maternal Near Miss

Abstract

This thesis examines maternal near miss (MNM) in the Netherlands and evaluates the surveillance of maternal deaths and MNM through the NethOSS audit cycle to improve maternity care. Maternal mortality surveillance and confidential enquiries aim to reduce maternal mortality and improve the quality of care. In high-income countries, where maternal deaths have become rare, surveillance of MNM provides additional opportunities to further improve maternity care. In the Netherlands, the Audit Committee Maternal Mortality and Morbidity (AMSM) and the Netherlands Obstetric Surveillance System (NethOSS) register and analyse maternal deaths and MNM through a continuous obstetric surveillance audit cycle consisting of data collection, analysis and audit, implementation of actions, and outcome validation. Part I focuses on three types of maternal near miss: uterine rupture, spontaneous hemoperitoneum in pregnancy (SHiP), and maternal cardiac arrest. For uterine rupture, several risk factors were identified, including a previous caesarean section, advanced maternal age, preterm gestational age, labour augmentation, and origin from Sub-Saharan Africa or Asia. Warning symptoms during labour, such as abdominal pain and CTG abnormalities, require rapid intervention to prevent severe maternal and perinatal outcomes. SHiP is shown to be a rare but potentially life-threatening condition with high perinatal mortality, in which early recognition and appropriate imaging are essential. In addition, a higher incidence of maternal cardiac arrest was found than previously reported, underlining the importance of targeted multidisciplinary training in obstetric resuscitation. Part II investigates health disparities between ethnic groups in relation to maternal outcomes. Among women with uterine rupture, a longer time to intervention was observed in women classified as non-Western, with a trend towards less favourable perinatal outcomes. Qualitative analyses suggest that stereotypes about pain perception and expression may influence clinical decision-making, while awareness of such implicit bias is often limited. This may contribute to inequalities in care and highlights the importance of increasing awareness. Finally, in part III, the role of NethOSS during the COVID-19 pandemic is described. Pregnant women were found to have an increased risk of severe disease, hospital admission, and intensive care unit admission, particularly in the presence of additional risk factors such as obesity and non-European origin. International comparisons showed variation in admission criteria and treatment strategies, with indications of underuse of COVID-19-specific therapies during the early phase of the pandemic. Infection with the Delta variant was associated with more severe maternal and perinatal complications, whereas vaccination significantly reduced the risk of severe outcomes. Overall, this thesis demonstrates that systematic surveillance and audit of maternal mortality and MNM are essential for continuous quality improvement, identifying high-risk groups, and promoting equitable access to safe obstetric care.