Experiences with facility-based maternal death reviews in northern Nigeria

Objective

To evaluate the effectiveness of the maternal death review (MDR) system and process in improving quality of maternal and newborn health care in northern Nigeria.

Methods

A combination of quantitative and qualitative methods was used, including review of MDR forms and of health management information system data on maternal deaths (MDs), as well as semi-structured interviews with members of 11 MDR committees.

Results

Facility-based MDRs were initiated in 75 emergency obstetric and newborn care facilities in northern Nigeria and were initially conducted in the 33 hospitals; however, the process stopped after some time and had to be revitalized. Main reasons were transfer of key members of MDR committees, lack of supportive supervision, and shortage of staff. Ninety-three (12.1%) of 768 identified MDs were recorded on MDR forms and 52 (6.7%) had been reviewed. MDRs resulted in improved quality of care, including mobilization of additional resources. Challenges were fear of blame, shortage of staff, transfer of MDR team members, inadequate supportive supervision, and poor record keeping.

Conclusion

MDR requires teamwork, commitment, and champions at health facility level to spearhead the process. MDR needs to be institutionalized in the Ministry of Health, which provides oversight, policy guidance, and support, including supportive supervision.     

Estimating maternal mortality and causes in South Africa: National and provincial levels

Objectives

maternal mortality estimates for South Africa have methodological weaknesses. This study uses the Growth Balance Method to adjust reported household female deaths and pregnancy-related deaths and the relational Gompertz model to adjust reported number of live births and estimate maternal mortality in South Africa at national and provincial level; examines the potential impact of HIV/AIDS prevalence; and investigates the recorded direct causes of maternal mortality.

Design

data from the 2001 Census, 2007 Community Survey and death registrations were utilised. Information on household deaths, including pregnancy-related deaths was collected from the aforementioned census and survey.

Setting

enumerated households in the 2001 Census and a nationally representative sample of 250,348 households in the 2007 Community Survey.

Participants

information about members of households who died in the preceding 12 months was collected, and of these deaths whether there were women aged 15–49 who died while pregnant or within 42 days after childbirth.

Findings

maternal mortality ratio of 764 per 100,000 live births in 2007, ranging from 102 per 100,000 live births in the Western Cape province to 1639 in the Eastern Cape. Maternal infections and parasitic diseases as well as other maternal diseases complicating pregnancy, childbirth and the puerperium are the major causes. The study found a weak correlation between provincial HIVprevalence and maternal mortality ratio.

Conclusion

despite strategies to improve maternal and child health, maternal mortality remains high in South Africa and it is unlikely that the Millennnium Developmemnt Goal of reducing maternal will be achieved.     

Maternal death from stroke: a thirty year national retrospective review

Objective

In the United Kingdom (UK), the maternal mortality rate from stroke is reported at 0.3/100,000 deliveries, but only antenatal data have previously been reviewed. We hypothesise that the true rate is much higher due to a propensity for stroke occurring in the post-partum period, and that the rate will rise in parallel with trends of increasing maternal age and medical co-morbidities. Our objectives are to investigate the UK stroke mortality rate in pregnancy and the puerperium, and to examine temporal changes in fatal maternal strokes over a 30 year period.

Study design

Retrospective review of stroke-related maternal deaths reported to the UK confidential enquiries into maternal death between 1979 and 2008, encompassing 21,514,457 maternities. In accordance with the ICD.10 classification, cases were divided into direct or indirect deaths. Late and coincidental deaths were not included in analyses. Lessons from sub-standard care associated with maternal death from stroke were collated.

Results

In 1979–2008 there were 347 maternal deaths from stroke: 139 cases were direct deaths, i.e. the fatal stroke was a direct result of pregnancy. The incidence of fatal stroke is relatively constant at 1.61/100,000 maternities, with a 13.9% (95% CI 12.6–15.3) proportional mortality rate. Intracranial haemorrhage was the single greatest cause of maternal death from stroke.

Conclusion

This is the largest UK study examining the incidence of fatal maternal stroke in pregnancy and the puerperium. Our results highlight the high proportion of women who die from stroke in the puerperium. Sub-standard care featured especially in regard to management of dangerously high systolic blood pressure levels. These deaths highlight the importance of education in managing rapid-onset hypertension and superimposed coagulopathies.     

Maternal education and breastfeeding practices in China: A systematic review and meta-analysis

Objectiveto examine the association between maternal education and breastfeeding prevalence in China.Methodsa systematic review and meta-analysis was conducted based on the literature of observational studies retrieved from electronic databases of CNKI, Medline, Embase, CINHAL, ProQuest and Science Direct. Maternal education was recoded into two binary categorical variables using different cut-off points. Both fixed and random effect models were used to estimate the pooled association between maternal education and breastfeeding prevalence in China. Visual inspection of Galbraith plot for heterogeneity detection, sensitivity analysis and publication bias test were performed.Findingsa total of 31 studies were included in the systematic review, and 15 and 26 studies were suitable for meta-analysis in terms of two different cutoff points of maternal education respectively. In the group using 6-year education cut-off (Group 1), the odds of breastfeeding was 10% (pooled OR=0.90, 95% CI: 0.83, 0.97) lower in mothers who had been educated for 'more than 6 years' compared to mothers with '6 years or less' education.In the group using 12-year education cut-off (Group 2), the odds of breastfeeding was 9% (pooled OR=0.91, 95% CI: 0.86, 0.96) lower in mothers who had 'more than 12 years' education compared to mothers who attained '12 years or less' education. There was substantial heterogeneity across the studies in both groups. Through meta-regression analysis, sample size of studies was detected contributing to the heterogeneity in Group 1; however none of study level factors were found to be a source of heterogeneity in Group 2.Conclusionin the Chinese culture and employment environment, mothers who have attained a higher level of education are less likely to breastfeed their babies compared to mothers with lower education levels.     

Maternal mortality in southern israel

Summary Between 1969 and 1991 there were 166,410 births in Southern Israel with 13 maternal deaths (7.8/100,000). In the Jewish population there were 119,130 deliveries with 7 maternal deaths (5.9/100,000), and the Bedouins had 47,280 deliveries with 6 maternal deaths (12.7/100,000). Prenatal care was an important preventive factor. 7 maternal deaths occurred among 151,088 women who had received prenatal care (4.6/100,000), whereas 6 such deaths occurred among 15,322 without prenatal care (39.1/100,000) (P value 0.0005). Ten of the 13 women who died were over 24 years old. Eight of the 13 patients were multiparous. Live births occurred in 6 patients and stillbirths in 5 patients. Hemorrhage, preeclampsiaeclampsia and pulmonary embolism were the leading causes of maternal death.     

Maternal death associated with hydatidiform molar pregnancy

Three maternal deaths with hydatidiform molar pregnancies associated with severe hemorrhage and coagulopathy are described. Symptoms of coagulation abnormalities are few in mild degrees of intravascular coagulation. This paper addresses the importance of anticipating a coagulopathy in hydatidiform molar pregnancy even before evacuation of the abnormal conceptus since evacuation aggravates fibrinolytic activity and therefore increases hemorrhage in these conditions.     

上海市20年剖宫产产妇死亡原因分析

目的 了解剖宫产产妇死亡原因及剖宫产潜在危险性,以降低剖宫产产妇死亡率。方法 对上海市１９７８～１９９７年间剖宫产产妇死亡病例资料进行回顾性分析。结果 （１）１９７８～１９８７年的剖宫产率为１５．５５％（２５８１５８／１６５９８９２）,显著低于１９８８～１９９７年的２９．３９％（３６５３７６／１２４３３３７）,两者比较,差异有极显著性（Ｐ〈０．０１）。（２）２０年间产妇死亡４３０例,其中剖宫产产妇     

全国孕产妇死亡监测结果分析

目的 了解我国各地区孕产妇死亡率、死亡原因及影响因素,提出降低孕产妇死亡率的对策与措施。方法 根据全国及各省的人口数进行分层整群抽样,形成覆盖全国１．０亿人口的２４７个监测点,对监测资料进行分析。结果 监测地区７年内活产总数为８７０９２２０例,孕产妇死亡率７年平均为７７．４／１０万,其中城市为４５．５／１０万,农村为９５．４／１０万;全国不同地区孕产妇死亡率为２６．０／１０万￣３０８．０／１０万不     

Maternal and Perinatal Death Inquiry and Response Project Implementation Review in India

Purpose

Profile of maternal deaths in selected districts of four Indian states was studied to examine the regional differences in non-biological causal factors (socioeconomic and sociocultural) in maternal mortality and to examine the method and completeness of implementation of Maternal and Perinatal Death Inquiry and Response (MAPEDIR) process.

Methods

An integrated qualitative and quantitative method was used to study the MAPEDIR process in selected districts of four states in India, through the use of standardized questionnaire for key informant interviews, participant observation checklist, analysis of verbal autopsy questionnaire, and maternal death reports.

Results

A comparison of Profile’s maternal deaths investigated showed that women died between 25 and 27 years of age. Half of the women died at home because of inability to afford transport (Delay II) and treatment costs. One third of the deaths had occurred in a health facility (Delay III) because of lack of specialists, equipments or blood. Two thirds of the delays (Delay I) were in seeking medical care. Review of the implementation process of MAPEDIR highlighted that the social audit review model is a unique field based collaborative initiative comprising of stakeholders from various sector in order to improve maternal health programming by reducing maternal mortality.

Conclusions

MAPEDIR has been able to identify socio-cultural, economic and health care systems related determinants of maternal deaths. Standardization the mechanism for information data sharing at district, sub-district and village level can maximize the use of available evidence for advocacy and policy shifts by developing policies and interventions suited to local needs.     

Maternal mortality in Greece, 1996-2006

Objective

To present retrospective data for maternal deaths in Greece from 1996 to 2006.

Methods

Demographic information and information on the causes of death was provided by the Hellenic Statistical Authority. Maternal deaths were assessed by cause of death, maternal age, and place of residence. The maternal mortality ratio (MMR) was estimated and expressed as the number of deaths per 100 000 live births.

Results

From 1996 to 2006, 29 deaths were attributed to pregnancy and childbirth, yielding a total MMR of 2.63. The leading cause of direct deaths was hemorrhage and that of indirect deaths was cardiac disease. There was a borderline significant decline in the MMR during the study period. The MMR was significantly higher at the extremes of the reproductive age range.

Conclusion

Maternal mortality in Greece is low; however, no formal data have been published since 1996. Knowledge of the causes of maternal death can lead to the prevention of maternal deaths and safer motherhood.     

Maternal death caused by midgut volvulus after bariatric surgery

A 31-year-old woman with a history of laparoscopic Roux-en-Y gastric bypass surgery presented at 25 6/7 weeks' gestation with complaints of abdominal pain. Maternal death followed midgut volvulus, perforation, and septic shock.     

Assessment of maternal near-miss and quality of care in a hospital-based study in Accra,Ghana

Objective

To assess the baseline incidence of maternal near-miss, process indicators related to facility access, and quality of care at a tertiary care facility in urban Ghana.

Methods

A prospective observational study of all women delivering at the facility, including those with pregnancy-related complications, was conducted between October 2010 and March 2011. Quality of maternal health care was assessed via a newly developed WHO instrument based on near-miss criteria and criterion-based clinical audit methodology.

Results

Among 3438 women, 516 had potentially life-threatening conditions and 131 had severe maternal outcomes (94 near-miss cases and 37 maternal deaths). More than half (64.4%) of the women had been referred to the facility. The incidence of maternal near-miss was 28.6 cases per 1000 live births. Anemia contributed to most cases with a severe maternal outcome. More than half of all women with severe maternal outcomes developed organ dysfunction or died within the first 12 hours of hospital admission. Although preventive measures were prevalent, treatment-related indicators showed mixed results.

Conclusion

The WHO near-miss approach was found to represent a feasible strategy in low-resource countries. Improving referral systems, effective use of critical care, and evidence-based interventions can potentially reduce severe maternal outcomes.     

高龄妊娠宫内死胎原因分析

目的探讨高龄妊娠孕妇发生宫内死胎的原因。 方法本研究采用回顾性研究方法对2009年1月1日至2014年12月31日因宫内死胎(单胎)在广州医科大学附属第三医院妇产科住院治疗的339例患者临床资料进行分析,根据孕妇分娩年龄分为高龄组(≥35岁)和非高龄组(20～34岁),比较两组孕妇宫内死胎的原因。采用独立样本t检验、χ²检验或Fisher精确概率法对数据进行统计学分析。 结果高龄妊娠宫内死胎率为1.66%(61/3 670)比非高龄组1.10%(278/25 227)高,χ²＝8.670,P＝0.003;两组宫内死胎各种病因发生率的比较,差异均无统计学意义(P均>0.05);高龄组不明原因宫内死胎发生率27.87%(17/61)明显比非高龄组7.55%(21/278)高,χ²＝20.74,P＝0.000)。 结论高龄妊娠孕妇发生宫内死胎风险比非高龄者高,需加强对高龄妊娠人群孕期母胎监测。     

Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa

Objective

To assess the association between cesarean delivery rates and pregnancy outcomes in African health facilities.

Methods

Data were obtained from all births over 2-3 months in 131 facilities. Outcomes included maternal deaths, severe maternal morbidity, fresh stillbirths, and neonatal deaths and morbidity.

Results

Median cesarean delivery rate was 8.8% among 83 439 births. Cesarean deliveries were performed in only 95 (73%) facilities. Facility-specific cesarean delivery rates were influenced by previous cesarean, pre-eclampsia, induced labor, referral status, and higher health facility classification scores. Pre-eclampsia increased the risks of maternal death, fresh stillbirths, and severe neonatal morbidity. Adjusted emergency cesarean delivery rate was associated with more fresh stillbirths, neonatal deaths, and severe neonatal morbidity—probably related to prolonged labor, asphyxia, and sepsis. Adjusted elective cesarean delivery rate was associated with fewer perinatal deaths.

Conclusion

Use of cesarean delivery is limited in the African health facilities surveyed. Emergency cesareans, when performed, are often too late to reduce perinatal deaths.