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The Italian Obstetric Surveillance System (ItOSS), a programme coordinated and managed by Italy’s National Institute of Health (ISS, Istituto Superiore di Sanità), has updated its online platform to include key reference literature and publications. Among these, a recently published article in Scientific Reports presents maternal mortality estimates in Italy for the period 2011-2019.

The maternal mortality ratio (MMR), defined as the number of maternal deaths per 100,000 live births, was reported at 8.4, showing a significant downward trend. This figure aligns with maternal mortality rates observed in other European countries, such as France and the United Kingdom.

This estimate was obtained using an innovative methodology, made possible through the active surveillance system promoted and coordinated by ItOSS.

“The problem of estimating maternal mortality is well known,” said Alice Maraschini, statistician at ISS and the study’s lead author, in an interview with Univadis Italy, a Medscape Network platform.

“It has been demonstrated that, if we rely only on death registers, there is an underestimation of the phenomenon because we cannot intercept deaths that do not have a real obstetric cause but in which the fact of being pregnant or having given birth may have played a role,” she continued.

She further explained, “When the WHO published the general data on maternal mortality, Italy had the lowest maternal mortality rate in the world. However, it was seen that it depended more on a lack of information in the death registers rather than on reality. Even today, the coding is often imprecise, and it can happen that a cause of death, such as cardiac arrest, is attributed to a woman who, if you go to check, died from another cause, even obstetric.”

The WHO has since revised its estimates for countries with national maternal mortality surveillance systems, and in many cases, these estimates have increased. In less developed countries, where a higher proportion of maternal deaths are directly due to obstetric causes, the extent of underestimation is generally lower.

“Our surveillance system uses two approaches,” Maraschini explained. “A retrospective one, in which we evaluate the current data flows and therefore the death certificates linked to the hospital discharge certificates, and a prospective one, based on a confidential reporting and investigation system,” she added.

By combining data sources, the researchers were able to accurately estimate maternal mortality, defined as deaths occurring during pregnancy or within 42 days of pregnancy outcome, including spontaneous or induced abortion, ectopic pregnancy, or childbirth.

Causes of Maternal Death

Maternal deaths were classified as direct, caused by obstetric complications, medical interventions, omissions, or mistreatment, and indirect, resulting from pre-existing or pregnancy-related diseases worsened by pregnancy.

Between 2011 and 2019, 368 maternal deaths were recorded, of which 60.1% were classified as direct deaths. The leading causes were:

• Obstetric haemorrhage (MMR: 1.74)
• Sepsis (MMR: 1.12)
• Cardiac disease (MMR: 0.91)
• Thromboembolism (MMR: 0.74)
• Hypertensive disorders of pregnancy (MMR: 0.62)

The ItOSS team also analysed late maternal deaths, defined as deaths occurring 43-365 days after pregnancy. Of the 308 cases, the most common causes were:

• Suicide (29.9%)
• Cancer (28.6%)
• Cardiovascular disease (11.7%)

“The topic of mental health is important. Until recently, deaths by suicide were considered accidental, but it has since been understood that the perinatal and postnatal periods have a significant impact on a woman's mental health. Some studies have shown that almost 60% of women who committed suicide had mental health problems. This must be considered by doctors who assist pregnant women, including general practitioners: a fragile woman, who may have already had symptoms of psychological distress, must be given special attention,” Maraschini said.

Active Surveillance

Reliable data are the foundation for reducing maternal mortality, said Serena Donati, scientific director of ItOSS.

“Maternal mortality surveillance in Italy began in 2008 with the analysis of healthcare records, but active surveillance was introduced in 2013. Today, we have involved nearly all regions, covering 99% of births,” she told Univadis Italy.

She highlighted that “before the ISS, in collaboration with the regions, began this work, 6 out of 10 maternal deaths were not recorded.”

On an international scale, Italy’s surveillance system is now classified as advanced, a designation achieved by only eight countries in Europe.

“We have a clinical representative in every health facility where a maternal death can occur — not only in maternity wards but also in intensive care units, stroke units, coronary care units, ensuring a broad and integrated approach,” Donati said.

Creating and maintaining this network requires significant dedication and perseverance.

“Today, Italian doctors and midwives are aware that participating in ItOSS provides valuable insights and offers the opportunity to participate in research projects on serious maternal morbidity while also benefiting from continuing professional development,” she noted.

By identifying the most frequent causes of maternal mortality, ItOSS coordinates research projects enrolling women who experience life-threatening pregnancy or childbirth complications (near-miss cases). These studies aim to identify risk factors, improve healthcare practices and organisational structures, and assess the training needs of healthcare professionals.

“Since we started active surveillance, we have systematically coordinated research activity and supported it with the development of guidelines, recommendations for best practices, and distance-learning courses,” Donati reported. Given that the leading cause of direct maternal death in Italy was and remains obstetric haemorrhage, we developed the first national evidence-based guideline on postpartum haemorrhage, which was assessed as the best among those available internationally.

Improving Care

Tracking MMR trends helps to measure the impact of improvements in maternal care. The MMR for obstetric haemorrhage has dropped significantly.

“Every time a maternal death occurs, the hospital administration and the contact person within the designated facility report the case to the regional operational unit and to us,” said Donati.

She added that from January 1, 2025, reporting would transition to a secure web platform, improving data security and efficiency over the previous paper-based method.

Once a case is reported, the facility contact conducts an internal audit, and the healthcare team reviews the case and documents the details using a dedicated form. An anonymised copy of the clinical records is then uploaded to the platform for review by a regional multidisciplinary committee. The review process remains strictly confidential, with professionals bound by medical secrecy and required to disclose any potential conflicts of interest prior to the review.

"The investigation concludes with the attribution of the cause of death and the evaluation of the quality of care, and the experts distinguish avoidable cases from unavoidable ones and, among these, also define which could have had better care," Donati explained. The conclusions of the regional committee are then reviewed at the national level through confidential surveys.

Each year, leading clinicians from across the country meet to discuss complex or disputed cases and reach a consensus on cause attribution and preventability. To ensure confidentiality, the ISS knows which regions report maternal deaths but not the specific facilities that are involved.

This system operates independently from judicial investigations, which are often initiated by family members in such cases. “The judicial authority seeks responsibility; we seek aspects susceptible to improvement. If there had been even the slightest mix-up, we would never have obtained the trust of the professionals,” Donati explained.

How many maternal deaths are preventable? “They fluctuate between 40% and 45%, as in all other advanced developing countries. Unfortunately, we know that we will never eliminate maternal deaths because some are not avoidable despite excellent care. However, we know that four to five out of every ten maternal deaths could be prevented,” Donati concluded.

This story was translated, with slight adaptation, from Univadis Italy using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.