Maternal Mortality in Japan
Abstract & Commentary
Synopsis: Preventable material deaths in Japan could be reduced if the obstetrician had the assistance of another clinician.
Source: Nagaya K, et al. JAMA 2000;283:2661-2667.
To determine the causes of maternal mortality in Japan, Nagaya and colleagues conducted a cross-sectional study of maternal deaths between Jan. 1, 1991, and Dec. 31, 1992. Maternal death was defined using the International Classification of Diseases, 9th revision (ICD-9), as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration of pregnancy or its management, but not from accidental or incidental causes." Death certificates and case records were examined by a 42-member panel of medical specialists to determine if the deaths were preventable. The resources available for patient care and staffing patterns of the facilities where the deaths occurred were characterized. Of 230 maternal deaths, 197 occurred in a hospital, 22 outside a medical facility and, in 11 cases, medical records were not available. The overall maternal mortality rate was 9.5/100,000 births. A total of 86 out of 219 maternal deaths (39%) were due to hemorrhage, making it the most common cause of maternal mortality. Of the 197 deaths that occurred in a hospital, 74 (38%) were due to hemorrhage including uterine rupture (n = 14), atony (n = 11), and placental abruption (n = 10), followed by intracranial hemorrhage (n = 27; 14%), hypertensive disorders of pregnancy (n = 17; 9%), pulmonary embolism (n = 17; 9%), and amniotic fluid embolism (n = 7; 4%). A total of 72 of 197 deaths (37%) occurring in medical facilities were thought to be preventable with another 32 (16%) possibly preventable. The greatest number of preventable deaths were observed in facilities with only one obstetrician, and 49 of the 72 preventable deaths resulted when a single physician was functioning as both the obstetrician and the anesthesiologist. These facilities were also characterized by limited obstetric coverage at night, on weekends and holidays, and limited laboratory support. Smaller facilities that transferred complicated patients to larger centers had a 14-fold higher preventable maternal death rate.
Nagaya et al note that 40% of Japan’s deliveries occur in clinics with 19 or fewer beds where staffing is provided by a single physician who sees all outpatients, all inpatients, and performs deliveries. They propose that preventable maternal deaths, particularly those due to hemorrhage, could be reduced if the obstetrician had the assistance of another clinician. They recommend that regional partnerships be established with smaller medical facilities providing ambulatory care and designated regional medical centers providing delivery services.
Comment by Steven G. Gabbe, md
Japan has one of the lowest infant mortality rates in the world (3.6/1000). Yet its maternal mortality rate in 1990 was 8.6/100,000, higher than the rates in the United States, the United Kingdom, and Canada. This paper by Nagaya et al and an accompanying editorial by Ikegami and Yoshimura1 provide important insights into obstetric care in Japan and propose strategies to reduce maternal mortality. In Japan, approximately 11,000 medical facilities provide ambulatory or inpatient obstetric care, but there are only 14,000 obstetricians, including residents. Most facilities have only one physician who serves as both an obstetrician and an anesthesiologist. Family physicians do not provide obstetric care in Japan, and only about 1% of nurse midwives perform deliveries. The fee for obstetrical care is not regulated by the national fee schedule that applies to most healthcare, making obstetric practice profitable. A physician may own his or her local clinic or small hospital and provide obstetric care in this setting. Furthermore, few hospitals have a quality assurance and improvement program, and recertification is not required by any of the specialty boards. As documented by Nagaya et al, this pattern of practice may contribute to maternal mortality when obstetric emergencies such as hemorrhage occur and the obstetrician must manage the patient alone without adequate anesthetic or laboratory support. The proposal to centralize deliveries in facilities with adequate staffing and ancillary support makes good sense.
Reference
1. Ikegami N, Yoshimura Y. JAMA 2000;283:2712-2714.
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