Slovenian Maternal Mortality Surveillance System

The Slovenian maternal mortality surveillance System is coordinated by the Slovenian National Institute for Public Health (https://nijz.si/). It involves all 14 Slovenian maternity hospitals. Its primary objective is to collect and disseminate crucial data on maternal mortality. The overarching aim of the maternal mortality surveillance in Slovenia is to ameliorate the country's standard of ante, intra and postnatal care.

Mission statement

To provide estimates on maternal mortality, identify key factors contributing to maternal deaths, and promote targeted public health interventions to improve the quality of care during childbirth and prevent avoidable adverse outcomes.

Aims

Aligned with our mission, the objectives of the Slovenian maternal mortality surveillance System encompass the following:

• Estimating the maternal mortality ratio (MMR) using multiple methods described below
• Identifying the main causes of maternal mortality
• Identifying critical clinical-care and organizational challenges susceptible to improvement
• Formulating evidence-based recommendations for clinical practice
• Provide ongoing training to healthcare professionals on the leading causes of maternal mortality and severe morbidity

Monitoring maternal mortality in Slovenia

In Slovenia, we use multiple methods to identify maternal deaths and avoid case misclassification and underestimation of maternal mortality. Identification of pregnancy-associated deaths is based on the manual revision of death certificates (I.) and the computer-based linkage of available databases (II.):

I. Death certificates of all women in reproductive age are manually reviewed and on the basis of data written on death certificates (i.e. disease or condition directly leading to death / antecedent cause of death / underlying cause of death / contributing conditions and other circumstances of death) three types of cases are selected for further investigation:

1. Deaths with underlying cause of death coded within the ICD-10 obstetric chapter;
2. Deaths with any mention of pregnancy, birth or puerperium or related conditions (usually misclassified cases);
3. Deaths with “suspicious” diagnoses (e.g. pulmonary embolism, unspecified hemorrhagic shock, unspecified sepsis etc.).

To determine whether deaths in the third group were pregnancy-related, additional information is gathered, usually from autopsy reports.

II. The second method of case identification is computer-based record linkage of Mortality Database with National Perinatal Informational System (NPIS) where all births are recorded (birth register) and Information System on Fetal Deaths (ISFD) where extra uterine pregnancies, spontaneous and legal abortion are registered (fetal deaths register). This method identifies women who died within one year after the termination of pregnancy resulting in birth or fetal death.

Subsequently, a multidisciplinary working group analyzes all identified pregnancy-associated deaths. Systematic investigation includes gathering medical documentation from all health care providers of deceased women. The working group then analyzes all the circumstances of each death, assigns the cause of death and assesses preventability. Based on the findings, a report is prepared every three years including recommendations for health sector and community actions.

Identification of pregnancy-associated deaths based on the manual revision of death certificates is used since the mid Nineteen-Nineties. The computer-based record linkage started as a pilot phase in the period 2000 – 2002 and is routinely used since year 2003. It has proved to be a highly efficient method of additional case identification.

Using both this methods we believe that our data on maternal mortality (presented in a table 1) from year 2000 and especially from year 2003 on do not need further adjustment for completeness.