title: Understanding regional differences in maternal mortality: a national case-control study in France.
abstract: OBJECTIVE
  To assess the risk of postpartum maternal death associated with region, and to examine whether the quality of care received by the women who died differed by region.
  
  
  METHODS
  A national case-control study.
  
  
  METHODS
  France.
  
  
  METHODS
  Selected from recent nationwide surveys, 328 postpartum maternal deaths from 2001 through 2006 as cases; and a representative sample (n = 14 878) of women who gave birth in 2003 as controls.
  
  
  METHODS
  Crude and adjusted odds ratios (aOR) of maternal death associated with region were calculated with logistic regression, and the quality of care for women who died was compared according to region with chi-square tests or Fisher's exact tests.
  
  
  METHODS
  Risk of postpartum maternal death associated with region, and quality of care.
  
  
  RESULTS
  After adjustment for maternal age and nationality, the risk of maternal death was higher in the Ile-de-France region (aOR 1.6, 95% CI 1.2-2.0) and the overseas districts (aOR 3.5, 95% CI 2.4-5.0) than in the group for the rest of continental France. In both regions, the excess risk of death from haemorrhage, amniotic fluid embolism and hypertensive disorders was significant. In continental France, after further controlling for women's obstetric characteristics, the risk of maternal death in Ile-de-France remained higher (aOR 1.8. 95% CI 1.3-2.6). The women in the cases groups received suboptimal care more frequently in Ile-de-France than in the other continental regions (64% versus 43%, P = 0.01).
  
  
  CONCLUSIONS
  These results suggest that quality of care and organisation of health services may play a role in the differential risk of maternal mortality between regions in France. Research on severe maternal morbidity and its determinants is needed to clarify the mechanisms involved.
authors.affiliation: INSERM, UMR S953, Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, UPMC University, Paris, France. Monica.saucedo@inserm.fr
authors.forename: M
authors.initials: M
authors.lastname: Saucedo
authors.forename: C
authors.initials: C
authors.lastname: Deneux-Tharaux
authors.forename: M-H
authors.initials: MH
authors.lastname: Bouvier-Colle
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D002423:Cause of Death; D005260:Female; D005602:France / Q000453:epidemiology; D006801:Humans; D008423:Maternal Age; D008427:Maternal Health Services / Q000592:standards; D008428:Maternal Mortality; D011247:Pregnancy; D011644:Puerperal Disorders / Q000401:mortality*; D011787:Quality of Health Care; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D012307:Risk Factors; D055815:Young Adult