Maternal near miss approach to evaluate quality of care in Alborz province,Iran

Objectivethe maternal near miss approach has been developed by World Health Organization for assessing and improving the quality of care. This study aimed to examine the incidence, characteristics, and features of the care provided for maternal near-miss cases in public and private hospitals in Alborz province, Iran.Methodsa cross sectional, facility-based study was conducted in all 13 public and private hospitals of Alborz province between April 2012 and December 2012. The World Health Organization near miss criteria were applied to gather and analyse the data, and indicators related to maternal near miss, access to and quality of maternal care.Findings38,715 deliveries were assessed. There were 38,663 live births, 419 (1.08%) had potentially life-threatening conditions and 199 had severe maternal outcomes (SMO) (192 near miss cases and 7 maternal deaths). The maternal near-miss ratio was 4.97 cases per 1000 live births. The incidence of severe maternal outcome was 5.15 cases per 1000 live births. Severe mortality outcomes index within 12 hours of hospital stay from admission (SMO12) was 3.52%. The proportion of SMO12 cases from the total SMO cases was 99.5%. The Intensive Care Unit (ICU) admission rate among women with SMO was 72.7%, while the overall admission rate was 0.7%. Overall, hypertensive disorder was the most frequent condition among women with potentially life-threatening conditions and maternal near-miss cases. Cardiovascular dysfunction and respiratory dysfunction were the most prevalent dysfunctions among maternal near miss (MNM) cases and maternal death cases respectively.Key conclusions and implications for practicethe WHO maternal near miss criteria help to identify issues that may lead to life threatening conditions and can be used to monitor and improve the quality of care in maternity settings. Hypertensive disorders related to near miss conditions need more attention to prevent maternal severe outcomes in Alborz province. Most of the process indicators were not satisfactory. The WHO tool enables health managers to improve maternal health care.     

Evaluation of Obstetric Near Miss and Maternal Deaths in a Tertiary Care Hospital in North India: Shifting Focus from Mortality to Morbidity

Objective

Near miss audit improves understanding of determinants of maternal morbidity and mortality and identifies areas of substandard care. It helps health professionals to revise obstetric policies and practices.

Methods

A retrospective review of obstetric case records was performed to assess frequency ad nature of maternal near miss (MNM) cases as per WHO criteria. For each case, primary obstetric complication leading to maternal morbidity was evaluated. Obstetric complications were analyzed to calculate prevalence ratio, case fatality ratio, and mortality index.

Results

There were 6,357 deliveries, 5,273 live births, 247 maternal deaths, and 633 MNM cases. As per WHO criteria for Near miss, shock, bilirubin >6 mg%, and use of vasoactive drugs were the commonest clinical, laboratory, and management parameters. Hemorrhage and hypertensive disorders of pregnancy were leading cause of MNM (45.7 and 24.2 %) and maternal deaths (28.7 and 21.5 %). Highest prevalence rate, case fatality ratio, and mortality index were found in hemorrhage (0.53), respiratory diseases (0.46), and liver disorders (51.9 %), respectively.

Conclusion

Developing countries carry a high burden of maternal mortality and morbidity which may be attributed to improper management of obstetric emergencies at referring hospitals, poor referral practices, and poor access/utilization of health care services.     

Emergency obstetric care as the priority intervention to reduce maternal mortality in Uganda.

PURPOSE: We conducted a survey to determine availability of emergency obstetric care (EmOC) to provide baseline data for monitoring provision of obstetric care services in Uganda. METHODS: The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions. Following this, performance improvement process was implemented in 20 district hospitals to scale-up EmOC services. FINDINGS: A maternal mortality ratio (MMR) of 671/100,000 live births was recorded. Hemorrhage, 42.2%, was the leading direct cause of maternal deaths, and malaria accounted for 65.5% of the indirect causes. Among the obstetric complications, abortion accounted for 38.9% of direct and malaria 87.4% of indirect causes. Removal of retained products (OR 3.3, P<0.002), assisted vaginal delivery (OR 3.3, P<0.001) and blood transfusion (OR 13.7, P<0.001) were the missing signal functions contributing to maternal deaths. Most health facilities expected to offer basic EmOC, 349 (97.2%) were not offering them. Using the performance improvement process, availability of EmOC in the 20 hospitals improved significantly. CONCLUSION: An integrated programming approach aiming at increasing access to EmOC, malaria treatment and prevention services could reduce maternal mortality in Uganda.     

Geographic accessibility to obstetric care and maternal mortality in a large metropolitan area of Brazil

Objective

To assess maternal mortality and its association with accessibility to obstetric care in the metropolitan region of Rio de Janeiro, Brazil.

Methods

Maternal mortality was assessed from 2 national databases, one administrative and the other designed for epidemiologic purposes. Distances traveled from residence to hospital via the transit network were calculated using a specialized information system. Deaths were grouped by area of residence, and maternal mortality ratios (number of deaths per 100,000 live births) as well as death incidence ratios (deaths/live births in 2 regions or hospital types) were calculated for these areas.

Results

We identified 236 deaths and estimated under-reporting at 30%. The most common causes of death were hypertension-related disorders, “other obstetric conditions,” and complications from abortion; the longest traveled distance was 66.43 km (mean, 13.65 km); and maternal mortality ratios varied between 25.54% and 56.45%, the highest values being for areas with the lowest municipal human development index. The highest death incidence ratios were found at general hospitals without specialized obstetric care.

Conclusion

Maternal mortality is still a serious problem in the studied region. The wide variations among areas of different socioeconomic conditions suggest the need for a better allocation of health care resources.     

Mortalidad materna en España en el período 1995–1997: resultados de una encuesta hospitalaria

ObjectiveThe Spanish Society of Obstetrics and Gynecology (SSOG) was informed of the need for more exact determination of the maternal mortality rate and its causes in SpainSubjects and methodsA survey in accordance with the European Certificate of maternal death was sent to the Spanish hospitals (SSOG Directory, 1995), to investigate the maternal mortality rate and its causes from 1995?–1997ResultsReplies were received from 69 hospitals, with 363,589 live births from 1995–1997. There were 26 maternal deaths; consequently, the mortality rate was 7.15/100,000 live births. A direct obstetric cause was found in 50% of the deaths and an indirect obstetric cause was found in 42%. Only 7.6% were classified as unknown. According to the data of the National Institute of Statistics, the rate was 2.74/100,000ConclusionsOfficial figures may underestimate the maternal mortality rate by 38%. Death certificates should be modified and a National Committee should be established to study maternal death in collaboration with the National Institute of Statistics     

Improving maternal mortality at a university teaching hospital in Nnewi, Nigeria

ObjectiveTo evaluate the impact of the introduction of the Service Compact with all Nigerians (SERVICOM) contract on maternal health at Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria.MethodsA retrospective and comparative study of maternal deaths between 2004 and 2010 was carried out. The main outcome measures were yearly maternal mortality ratio (MMR), relative risk (RR) of maternal mortality, and presentation–intervention interval. The yearly MMR and the RR of maternal mortality were compared with the figures from 2004, which represented the pre-SERVICOM era.ResultsThere were 4916 live births and 54 maternal deaths during the study period, giving an MMR of 1098 per 100 000 live births. Pre-eclampsia/eclampsia was the most common direct cause (25.0%), followed by hemorrhage (18.8%) and sepsis (8.3%). Anemia (12.5%) was the most common indirect cause. There was a progressive reduction in MMR and RR of maternal mortality, with a corresponding increase in live births. The presentation–intervention interval improved significantly from 2006.ConclusionA positive change in the attitude of health workers and the elimination of fee-for-service in emergency obstetric care would reduce type 3 delays in public health facilities, and consequently reduce maternal mortality.     

Maternal mortality in health institutions with emergency obstetric care facilities in Enugu State, Nigeria.

In order to assess the current level of maternal mortality in health institutions with comprehensive emergency obstetric care in Enugu State, South Eastern Nigeria, a retrospective analysis of maternal deaths for the years 1999-2003 was carried out to establish the maternal mortality ratios in the eligible health institutions. Each maternal death was studied in detail to establish the socio-demographic characteristics of the women who died; their referral sources, type of delay (if any), medical causes of death and their preventability. In-depth interviews of the service providers were carried out to throw more light on the maternal mortality situation in the state. Five out of seven eligible health institutions were studied. Within the 5-year period (1999-2003), there were 141 maternal deaths and 18,257 live births giving a maternal mortality ratio of 772 maternal deaths per 100,000. The folders of 89 out of the 141 women who died were retrieved. Of these 89 maternal deaths, 51.7% of them were unemployed, 52.4% were referred from private hospitals; type 3 delay was the commonest type of delay encountered in the care of the women. Referral delay was the main cause of delay accounting for 46.4% of all cases of type 3 delay. The leading causes of maternal deaths among the women were obstetric haemorrhage (19.1%), sepsis (18.0%), prolonged obstructed labour/ruptured uterus (16.9%) and pre-eclampsia/eclampsia (16.9%). The in-depth interviews corroborated the high maternal mortality ratio recorded and the type 3 delays in tackling obstetric emergencies. It also showed some discrepancies between reality and the health providers' perception of the magnitude of maternal mortality situation in the state. It was concluded that in health institutions in Enugu State with comprehensive emergency obstetric care facilities, the maternal mortality ratio remains high due to type 3 delays. Most of the referrals come from private hospitals, hence the need to retrain the private practitioners in emergency obstetric care.     

Feto-maternal outcomes in obstetric patients with near miss morbidity: an audit of obstetric high dependency unit

Aim: To evaluate and compare the feto-maternal outcomes of pregnant women with potentially life-threatening complications (PLTC) and near miss events admitted to the obstetric high dependency units (OHDU).

Methods: Pregnant women with PLTC admitted to the OHDU were enrolled. Feto-maternal outcomes, need for NICU admission and neonatal mortality, were compared between women without near miss events (controls) and those with near miss events.

Results: Of the 1505 admissions to the obstetric department during the study period, 1127 delivered at our hospital. Among the deliveries 125 (11%) women were admitted to the OHDU and 19 (15%) of them were referred to the intensive care unit (ICU) of the hospital. The incidence of near miss morbidity (n?=?46) was 37% among the mothers admitted to OHDU and 4.1% among the deliveries. The outcomes were similar in both groups for mean birth weight (among live births), neonatal death and still birth or intra-uterine deaths. The mean duration of ICU stay, proportion of ICU admission, and the mean duration of hospital stay were significantly higher for women with near miss events.

Conclusion: In the presence of standardized OHDU and an ICU, the feto-maternal outcomes of women with PLTC and near miss event are similar to those without near miss events.     

Changing patterns of emergency obstetric care at a Nigerian University hospital.

OBJECTIVE: To analyze the changing patterns of critical obstetric care over two consecutive 3-year periods and identify the factors responsible for the trend through combined audits of near miss and maternal mortality at a Nigerian University hospital. METHODS: Retrospective audit and comparison of "near misses" and maternal deaths recorded in 1999-2001 and 2002-2004 at a tertiary care center in southwest Nigeria. The definition of near miss morbidity was based on validated disease-specific criteria. For each near miss and maternal death, the local audit committee compared the actual management with local treatment protocols and explored avoidable factors. Case fatality rate was calculated for "critically ill obstetric patients" (CIOP-CFR) for both periods. The cause-specific case fatality rate (CFR) was used to assess the trend in standards of care for life-threatening obstetric conditions. Data were compared using the chi(2) or Fisher's exact test. P<0.05 was considered statistically significant. RESULTS: There were 175 near misses and 27 maternal deaths in 1999-2001 and 211 near misses and 44 maternal deaths in 2002-2004. The CIOP-CFRs for the two periods showed a declining (but non-significant) trend in the standard of emergency obstetric care for life-threatening conditions (13.4% to 17.3%, P=0.250). The CIOP-CFR for postpartum hemorrhage significantly increased from 3.1% to 21.1% in the 2nd period (P=0.033), reflecting a decline in the standard of care. Lack of blood for transfusion became a more significant administrative problem in the 2nd period occurring in 17.8% of all critically ill patients managed in 2002-2004. There was a notable though statistically insignificant increase in the non-adherence to treatment protocol among cases of maternal death in 2002-2004 compared with 1999-2001. CONCLUSIONS: The standard of critical obstetric care in this center is suboptimal with no evident improvement over the 6-year period. This audit supports the feasibility of including near miss reviews in maternal death audits to provide insights into the trend in the quality of emergency services for severe maternal complications while highlighting factors associated with deficiency or improvement in care for specific maternal conditions.     

Disease burden due to pre-eclampsia/eclampsia and the Ethiopian health system's response

Objective

To assess the maternal disease burden due to pre-eclampsia/eclampsia in Ethiopia and the national health system's readiness to respond to the needs of women with pre-eclampsia/eclampsia.

Methods

The national emergency obstetric and newborn care (EmONC) assessment entailed collecting information from 112 hospitals and 685 health centers in Ethiopia, focusing on their infrastructure, the services they provided, human resources, equipment and supplies, case load, and mortality due to pre-eclampsia/eclampsia.

Results

Pre-eclampsia/eclampsia complicated 1.2% of all institutional deliveries. Given the low institutional delivery rate and an expected incidence of 2%-8% of all deliveries, this implies that only a small fraction (3.8%) of all women with pre-eclampsia/eclampsia received care at health facilities. 11% of all maternal deaths and 16% of direct maternal deaths were due to this obstetric complication. The cause-specific case fatality rate was high (3.6%). Availability of urine test strips, anticonvulsants, antihypertensives, and actual service provision to treat these diseases was limited, especially at health centers.

Conclusion

The salutary effects of the national EmONC assessment were immediate, as evidenced by how quickly the release of the Ethiopian report led to important national efforts to improve maternal and newborn health. Expansion of health services should be augmented with periodic assessments of logistics and quality-related issues to assure functioning facilities for women accessing obstetric services.     

The outcome of pregnancy in an immigrant Ethiopian population in Israel

To study the assumption that obstetric risk factors would change over time in an immigrant Ethiopian population, a retrospective study of the records of singleton births among the Ethiopian immigrants between 1981–88 was undertaken and compared to a similar study of the general population. The Ethiopian immigrants were characterized by pregnancies at age extremes, a greater incidence of preeclampsia and premature deliveries, and a lower incidence of premature rupture of membranes. There was over time an increase in maternal weight gain among the Ethiopians as well as an increase in the incidence of preeclampsia and perinatal mortality.     

The outcome of pregnancy in an immigrant Ethiopian population in Israel

To study the assumption that obstetric risk factors would change over time in an immigrant Ethiopian population, a retrospective study of the records of singleton births among the Ethiopian immigrants between 1981–88 was undertaken and compared to a similar study of the general population. The Ethiopian immigrants were characterized by pregnancies at age extremes, a greater incidence of preeclampsia and premature deliveries, and a lower incidence of premature rupture of membranes. There was over time an increase in maternal weight gain among the Ethiopians as well as an increase in the incidence of preeclampsia and perinatal mortality.     

National data system on near miss and maternal death: shifting from maternal risk to public health impact in Nigeria

Background

The lack of reliable and up-to-date statistics on maternal deaths and disabilities remains a major challenge to the implementation of Nigeria's Road Map to Accelerate the Millennium Development Goal related to Maternal Health (MDG-5). There are currently no functioning national data sources on maternal deaths and disabilities that could serve as reference points for programme managers, health advocates and policy makers. While awaiting the success of efforts targeted at overcoming the barriers facing establishment of population-based data systems, referral institutions in Nigeria can contribute their quota in the quest towards MDG-5 by providing good quality and reliable information on maternal deaths and disabilities on a continuous basis. This project represents the first opportunity to initiate a scientifically sound and reliable quantitative system of data gathering on maternal health profile in Nigeria.

Objective

The primary objective is to create a national data system on maternal near miss (MNM) and maternal mortality in Nigerian public tertiary institutions. This system will conduct periodically, both regionally and at country level, a review of the magnitude of MNM and maternal deaths, nature of events responsible for MNM and maternal deaths, indices for the quality of care for direct obstetric complications and the health service events surrounding these complications, in an attempt to collectively define and monitor the standard of comprehensive emergency obstetric care in the country.

Methods

This will be a nationwide cohort study of all women who experience MNM and those who die from pregnancy, childbirth and puerperal complications using uniform criteria among women admitted in tertiary healthcare facilities in the six geopolitical zones in Nigeria. This will be accomplished by establishing a network of all public tertiary obstetric referral institutions that will prospectively collect specific information on potentially fatal maternal complications. For every woman enrolled, the health service events (care pathways) within the facility will be evaluated to identify areas of substandard care/avoidable factors through clinical audit by the local research team. A summary estimate of the frequencies of MNM and maternal deaths will be determined at intervals and indicators of quality of care (case fatality rate, both total and cause-specific and mortality index) will be evaluated at facility, regional and country levels.

Management

Overall project management will be from the Centre for Research in Reproductive Health (CRRH), Sagamu, Nigeria. There will be at least two meetings and site visits for efficient coordination of the project by regional coordinators and central coordinating staff. Data will be transferred electronically by hospital and regional coordinators and managed at the Data Management Unit of CRRH, Sagamu, Nigeria.

Expected outcomes

The outcome of the study would provide useful information to the health practitioners, policy-makers and international partners on the strengths and weaknesses of the infrastructures provided for comprehensive emergency obstetric care in Nigeria. The successful implementation of this project will pave way for the long-awaited Confidential Enquiries into Maternal Deaths that would guide the formulation and or revision of obstetric policies and practices in Nigeria. Lessons learnt from the establishment of this data system can also be used to set up similar structures at lower levels of healthcare delivery in Nigeria.     

Audit of severe maternal morbidity in Uganda--implications for quality of obstetric care

BACKGROUND: For every maternal death, there are probably 100 or more morbidities, but the quality of health care for these women who survive has rarely been an issue. The purpose of this study is to explore audit of severe obstetric morbidity and the concept of near miss in four referral hospitals in Uganda. METHODS: This was an exploratory systematic enquiry into the care of a subset of women with severe morbidity designated as near miss cases by organ failure or dysfunction. Patient factors and environmental factors were also explored. Data were abstracted from clinical records and from interviews with patients, relatives, and health workers. RESULTS: Records of 685 women with severe maternal morbidity were examined and 229 cases fulfilled the criteria for near miss cases. Obstetric hemorrhage, rupture of the uterus, puerperal sepsis, and abortion complications were the major conditions leading to the near miss state in more than three quarters of the patients. Nearly half the cases were at home when the events occurred. More than half the cases delayed to seek care, because the patients were unwilling, or relatives were not helpful. Similar proportion also experienced substandard care in the hospitals. CONCLUSIONS: A systemic analysis found substandard care and records, and patient-related factors in more than half the cases of severe maternal morbidity. Audit of near miss cases might offer a non-threatening stimulus for improving the quality of obstetric care.     

Near miss audit in obstetrics

PURPOSE OF REVIEW: Over the past decade, there has been increasing interest internationally in studying maternal near misses, or severe morbidity, to complement traditional audit of maternal mortality. This review summarizes studies in this field published during 2005-2006. RECENT FINDINGS: There is wide variation among published studies in terms of definitions of near miss, sources of data, and assessment of quality of care. Some investigators focus on single categories of near miss (e.g. postpartum haemorrhage, obstetric hysterectomy, intensive care unit admission), whereas others include multiple categories (ranging from two to 14). Some groups identify cases from routinely collected administrative data; whereas others search hospital registers and individual case records. Many investigators make no attempt to assess quality of care or preventability, but restrict their studies to the reporting of rates of severe morbidity. Others assess care by means of interviews with survivors or case note review, but study only a sample of cases and cannot report incidence rates. A minority of investigators both report incidence rates and assess quality of care. SUMMARY: Near miss audit is increasingly used to complement maternal mortality review. Standardization of inclusion criteria and of methods for case assessment would facilitate comparisons over time and among countries.     

The Turkey National Maternal Mortality Study

Objective Complications during pregnancy, delivery and puerperium are the most widespread causes of death and disability among women of reproductive age in developing countries. In most of these, reliable estimates of maternal mortality are lacking. This paper aims to report Turkey's basic maternal mortality indicators derived from the National Maternal Mortality Study (NMMS).

Methods The data originate from NMMS which was an implementation of a Reproductive Age Mortality Study (RAMOS) data-collection strategy. Maternal mortality rates and ratios were estimated, and information was gathered for improving the existing recording and reporting systems. Burial data by age and sex were collected prospectively over a 12 month period. Interviews with household members, health care providers, and reviews of facility records were then used to classify the deaths as pregnancy-related or maternal or otherwise.

Results A national pregnancy-related mortality ratio of 38 (± 2.8) and a maternal mortality ratio of 29 (± 2.5) per 100,000 live births were found. The NMMS shows that 59% of all pregnant women died from direct maternal causes, 16% from indirect causes and 23% from co-incidental causes.

Conclusion Maternal mortality is highest in regions with a poorer network of good roads, harsher winter conditions and longer distances to the next secondary level health facility which provides comprehensive obstetric emergency care services.     

Trends in maternal mortality in resident vs. migrant women in Shanghai, China, 2000-2009: a register-based analysis

Although Shanghai has good maternal health indicators, it also has a large in-migrating population, which has made control of maternal mortality a major challenge. This study analyzed maternal mortality and causes of death in pregnant women in Shanghai in the ten years from 2000 to 2009, comparing resident and migrant women. All live births were registered and every maternal death audited. The number of live births rose from 84,898 in 2000 to 187,335 in 2009. The number of migrants increased 4.6 times, while the proportion of live births to migrant women increased from 27% to 55%. There were 262 maternal deaths, 55 in Shanghai residents and 207 in migrant women (78.9% of the total). Most deaths in migrant women were due to illegal delivery. Three policy changes focusing on maternal health greatly reduced deaths: low-cost delivery services were established for migrant women in maternity hospitals, five obstetric emergency care and referral centres were created in general hospitals, and training for health professionals and health education for women were instituted. Maternal mortality in Shanghai decreased steadily from 2000 to 2009, reaching 10 per 100,000 live births in 2009. Among Shanghai permanent residents the ratio was below ten in most of those years, while among migrant women it declined sharply from 58 to 12 per 100,000 live births.     

The tremendous cost of seeking hospital obstetric care in Bangladesh

In Bangladesh, maternal mortality is estimated to be 320 per 100,000 live births, among the highest in the world, and most deliveries in rural areas occur at home. Women with obstetric complications fear to seek hospital care for various reasons; one of which is the tremendous cost. This paper shows how cost impedes rural, poor women's access to emergency obstetric care. The data are from a larger ethnographic study of childbirth practices in 2000--01 in Apurbabari village, the adjacent sub-district health complex and more distant tertiary hospitals at district level. Families had to spend what for them added up to a fortune for a caesarean section and other surgery, medicines, laboratory investigations, blood transfusion, food, travel and other expenses. Corruption in the form of demands for under-the-table payments to obtain these aspects of essential care is rife. Adequate resources should be allocated to the different health facilities, including for emergency obstetric treatment. Thana health complexes (sub-district hospitals) should be upgraded to provide comprehensive obstetric care. The system for prescribing drugs should be reformed and the causes of corruption investigated and addressed. Hospital care should not be allowed to further impoverish the poor. Addressing these issues will help to encourage rural, poor women to seek skilled delivery and post-partum care, particularly in emergency situations.     

Maternal mortality in a rural referral hospital in the Niger Delta, Nigeria.

Almost two decades after the safe motherhood initiative, maternal mortality figures remain very high in Nigeria. Very few studies are available on the features of maternal mortality in rural Nigeria. The objective of this study was to determine the incidence and causes of maternal mortality in a rural referral hospital in the Niger Delta, Nigeria. An audit of 115 consecutive maternal mortalities over a 10-year period at a rural-based tertiary hospital was undertaken. There were 5,153 deliveries and 115 maternal deaths during the study period, with a maternal mortality ratio of 2,232/100,000 live births. The most common causes of maternal mortalities were puerperal sepsis, abortion complications, pre-eclampsia/eclampsia, prolonged obstructed labour, haemorrhage accounting for 33%, 22.6%, 17.4%, 13.0% and 7.8%, respectively. The percentage mortality for unbooked was 10 times that for booked patients. Unbooked status is a risk factor for maternal mortality as this was statistically significant p < 0.0001. Traditional birth attendants were involved in the initial management of at least two-fifths (38.2%) of the non-abortion mortalities while half had been managed in private hospitals and maternities. Maternal mortality will continue to increase unless appropriate steps are taken to improve the use of antenatal care, thereby reducing unbooked emergencies. Hospitals need to be equipped with facilities for emergency obstetric care. Continuous programmes that will integrate TBAs and orthodox practices should be put in place as this will reduce delays and improve referral systems.