2015—2016年四川省孕产妇死亡评审情况分析

Analysis of maternal mortality in Sichuan province from 2015 to 2016

目的通过对2015-2016年四川省孕产妇死亡评审情况进行分析,以期为卫生计生行政部门、医疗保健机构采取措施减少孕产妇死亡,进一步降低孕产妇死亡率提供参考。方法死亡评审专家组依据WHO的"十二格法"对四川省2015-2016年163例孕产妇死亡资料进行评审,本研究对评审结果进行描述性分析。结果省级已完成163例孕产妇死亡评审,产科出血、妊娠期高血压疾病、静脉血栓形成及肺栓塞症、心脏病、羊水栓塞是四川省孕产妇死亡的前5位主要原因。163例已评审的死亡病例中,可避免死亡124例,占76.07%,不可避免死亡39例,占23.93%。124例可避免死亡病案中,按首位影响因素分析,医务人员知识技能因素67例,占54.03%,居第1位,其中县、乡级医务人员知识技能因素分别占37.90%和5.65%;个人家庭因素57例,占45.97%。结论加强高危孕妇规范化管理工作,保障边远地区血源供应及时,加强产科医务人员急救知识培训成为四川省减少孕产妇死亡的重要措施。

Objective To analyze the maternal mortality in Sichuan province from 2015 to 2016 for the purpose of providing reference for the department of health and family planning,medical and health care institutions to take measures to reduce maternal mortality.Methods The death assessment panel reviewed 163 cases of maternal mortality data in Sichuan province from 2015 to2016 in accordance with ＂twelve grid method＂ of the World Health Organization（WHO）.The findings were descriptively analyzed.Results Provincial level had completed 163 cases of maternal death review,and it suggested that obstetric hemorrhage,pregnancy induced hypertension,venous thrombosis and pulmonary embolism,heart disease,amniotic fluid embolism were the five leading causes of maternal mortality in Sichuan province.Among the 163 evaluated death cases,death could be avoided in 124 cases（76.07%）and death was unavoidable in 39 cases（23.93%）.According to the first influencing factors,among 124 cases of avoidable deaths in medical records,the death of 67 cases（54.03%）was caused by medical staff knowledge and skills,ranking first,including the county（37.90%）and township（5.65%）;the death of 57 cases was caused by the personal family,accounting for 45.97%.Conclusion It′s important for the reduction of maternal mortality in Sichuan province to strengthen standardized management of high-risk pregnant women,ensure the timely supply of blood resources in remote areas,and enhance the training of emergency medical knowledge for obstetric medical personnel.