Maternal death has become a rare occurrence in high-income countries. Nevertheless, the maternal mortality ratio—the ratio of the number of women who die from direct or indirect obstetric causes during pregnancy or within 42 days of delivery to the number of live births—remains an important indicator of maternal health and the performance of the healthcare system in these countries.

Since maternal mortality statistics derived from death certificates are limited in their ability to capture the full scope of the problem—including underestimation of maternal deaths and a biased characterization of the profile of women at risk—an “ad hoc” system for studying maternal mortality has been proposed.
Since 1996, the Confidential National Survey on Maternal Deaths (ENCMM) has been conducted in France under the scientific leadership of Inserm Unit 1153 – the EPOPé team. To date, the ENCMM has recorded 1,300 maternal deaths throughout France between 1996 and 2012.

Objectives of the ENCMM

The ENCMM studies all maternal deaths in France with two objectives: to characterize the epidemiology of maternal mortality and its trends using a quantitative approach, and to analyze the circumstances surrounding the onset and management of the adverse event and the fatal outcome, in order to identify areas for improvement, using a primarily qualitative approach.

It is the role and mission of the National Committee of Experts on Maternal Mortality (CNEMM) to analyze all maternal deaths at the national level, with a view to identifying areas for improvement. This Committee is composed of obstetrician-gynecologists, anesthesiologists, midwives, and epidemiologists, and has been under the supervision of Santé publique France since 2014.

Confidential Survey Method

To ensure that study data is collected comprehensively and confidentially, the ENCMM has developed a three-step procedure approved by the French Data Protection Authority (CNIL):

Step 1: Identification of “pregnancy-related” deaths

All deaths occurring during pregnancy or up to one year after its end, regardless of the cause and mode of termination, are included. Three sources of identification are used:

1. death certificates, with the participation of the Center for Epidemiology of Medical Causes of Death (CépiDc),

2. the INSEE’s national database of birth and death records, which allows for the identification of women who died within one year of giving birth,

3. the national PMSI database (Program for the Medicalization of the Information System) identifies hospital deaths of women in an obstetric context.

At the same time, all Perinatal Health Networks participate in direct reporting in the event of a possible maternal death occurring in a facility within their territory.

Step 2: Documentation of deaths

After obtaining the consent of the physician involved in the case, the EPOPé team notifies a pair of assessors, who will be responsible for gathering information (the woman’s medical history, the course of her pregnancy, the circumstances surrounding the event leading to the death, and the care provided). This pair consists of volunteer clinicians and includes an obstetrician or midwife and an anesthesiologist-intensivist. The files are centralized by the EPOPé team and anonymized before being reviewed by the expert committee.

Step 3: Review and Classification of Deaths

This is the specific mission of the CNEMM. In plenary meetings, each death case that has been investigated is discussed collectively, based on all available information. Following the collective discussion, the committee reaches a consensus judgment on:

1. the cause of death—whether it is a maternal death (causal link to pregnancy) or a non-maternal death (temporal but not causal link),

2. the adequacy of the care provided: care is classified as optimal or non-optimal, and

3. the preventability of the death, classified as “unpreventable,” “possibly preventable,” or “certainly preventable,” depending on the existence of circumstances whose correction could have prevented the fatal outcome.

The results of this survey are published in triennial reports and articles in scientific journals. The institutions involved are: Inserm 1153-EPOPé Team, Santé publique France, and CépiDC