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.     

Antenatal screening for Group B Streptococcus: A diagnostic cohort study

Background

Information on the extent of postpartum maternal morbidity in developing countries is extremely limited. In many settings, data from hospital-based studies is hard to interpret because of the small proportion of women that have access to medical care. However, in those areas with good uptake of health care, the measurement of the type and incidence of complications severe enough to require hospitalisation may provide useful baseline information on the acute and severe morbidity that women experience in the early weeks following childbirth. An analysis of health services data from Lusaka, Zambia, is presented.

Methods

Six-month retrospective review of hospital registers and 4-week cross-sectional study with prospective identification of postpartum admissions.

Results

Both parts of the study identified puerperal sepsis and malaria as, respectively, the leading direct and indirect causes of postpartum morbidity requiring hospital admission. Puerperal sepsis accounted for 34.8% of 365 postpartum admissions in the 6-month period. Malaria and pneumonia together accounted for one-fifth of all postpartum admissions (14.5% & 6% respectively). At least 1.7% of the postpartum population in Lusaka will require hospital-level care for a maternal morbidity.

Conclusions

In developing country urban settings with high public health care usage, meticulous review of hospital registers can provide baseline information on the burden of moderate-to-severe postpartum morbidity.     

Review of Twin Pregnancies with Single Fetal Death: Management,Maternal and Fetal Outcome

Aim

To study management and maternal and fetal outcome in single fetal death in twin pregnancies.

Materials and Methods

We studied 64 (1.37 %) twin deliveries out of a total of 4,655 deliveries in GMC, Haldwani (Uttrakhand). Out of them, 5 (7.81 %) were complicated with single fetal death in the second or third trimester. These cases were managed conservatively with regular monitoring of maternal coagulation profile along with intensive fetal surveillance for the surviving twin. The cases were studied for antenatal complications and placental chorionicity with placental histopathology and postmortem of the dead fetus. Neonatal and maternal outcome in the postpartum period was also studied.

Results

No antenatal complications were present in four out of five cases with one having PIH. Three out of five pregnancies could be extended to term and had no maternal complications. The other fetus could be salvaged in three and all of them had a normal neonatal period. One pregnancy ended in preterm labor with delivery of a preterm baby which could not be saved. One resulted in death of the other fetus also where pregnancy was remote from term.

Conclusions

Although our study was small, it indicates that in case of twin pregnancy with single fetal death with good surveillance, the live fetus can be salvaged.     

Evaluation of Severe Maternal Outcomes to Assess Quality of Maternal Health Care at a Tertiary Center

Background

Maternal mortality and near-miss index reflect the quality of care provided by a health facility. The World Health Organization recently published near-miss approach where strict near- miss criteria based on markers of organ dysfunction are defined.

Objectives

The aim of the study was to determine the frequency of severe maternal complications, maternal near-miss cases and maternal deaths, to analyze causes of near-miss and maternal mortality and to determine the values of maternal near-miss indicators.

Methods

This was a prospective observational study conducted at a tertiary care centre in North India from January 2012 – March 2013. WHO's near-miss approach was implemented for evaluation of severe maternal outcomes and to assess the quality of maternal health care.

Results

The number of women attending our facility with severe maternal complications was low (205 in 6,767 live births); as a result maternal near-miss ratio (MNMR) was low; 3.98/1,000 live births; Overall Maternal near-miss mortality ratio (MNM:1MD) was also low, 3.37:1, because of strict criterion of labeling near-miss and delay in referral to the hospital. Hypertensive disorder (37.5 %) was the commonest underlying cause for maternal mortality.

Conclusion

Basic implementation of WHO near-miss approach helped in the systematic identification and evidence-based management of severe maternal complications thereby improving the quality of maternal health in a developing country.

     

Rationale for a Long-term Evaluation of the Consequences of Potentially Life-threatening Maternal Conditions and Maternal “Near-miss” Incidents Using a Multidimensional Approach

Recent advances in health care mean that women survive severe conditions and events related to pregnancy that would previously have resulted in death. Therefore, a greater number of women will experience significant maternal morbidity with significant consequences. Little is known, however, about these long-term consequences. Some investigators have evaluated the repercussions of severe biological or traumatic events, and have reported that survivors are at an increased risk of death in the five years after the event. In addition, they continue to experience both organic and emotional problems such as clinical, cardiac, respiratory, and neurological complications, as well as anxiety and depression, following discharge from hospital. Following a maternal “near-miss” incident, various life domains may be affected (organic, mental, cognitive, and social function), and these must be evaluated in addition to the related economic issues and quality of life. However, because of the diversity of methods and instruments used to evaluate possible repercussions, comparisons between the few studies available on the subject are difficult. An in-depth debate should be initiated to discuss the methodological aspects of such investigation. We propose a conceptual and methodological discussion on the long-term repercussions of severe maternal morbidity based on the evaluation of the following variables: reproductive health, quality of life, posttraumatic stress syndrome, sexual function, postpartum depression, daily functioning, and the physical, neurological, and psychomotor development of the children born after a complicated pregnancy.     

A cluster randomized controlled trial to evaluate the effectiveness of the clinically integrated RHL evidence -based medicine course

Objective

to develop and validate a questionnaire on severe maternal morbidity and to evaluate the maternal recall of complications related to pregnancy and childbirth. Design: validity of a questionnaire as diagnostic instrument. Setting: a third level referral maternity in Campinas, Brazil. Population: 386 survivors of severe maternal complications and 123 women that delivered without major complications between 2002 and 2007.

Methods

eligible women were traced and interviewed by telephone on the occurrence of obstetric complications and events related to their treatment. Their answers were compared with their medical records as gold standard. Sensitivity, specificity and likelihood ratios plus their correspondent 95% confidence intervals were used as main estimators of accuracy. Main outcomes: diagnosis of severe maternal morbidity associated with past pregnancies, including hemorrhage, eclampsia, infections, jaundice and related procedures (hysterectomy, admission to ICU, blood transfusion, laparotomy, inter-hospital transfer, mechanical ventilation and post partum stay above seven days).

Results

Women did not recall accurately the occurrence of obstetric complications, especially hemorrhage and infection. The likelihood ratios were < 5 for hemorrhage and infection, while for eclampsia it almost reached 10. The information recalled by women regarding hysterectomy, intensive care unit admission and blood transfusion were found to be highly correlated with finding evidence of the event in the medical records (likelihood ratios ranging from 12.7-240). The higher length of time between delivery and interview was associated with poor recall.

Conclusion

Process indicators are better recalled by women than obstetric complication and should be considered when applying a questionnaire on severe maternal morbidity.     

Cerebrovascular Complications in Pregnancy and Puerperium

Objectives

The aim of this study was to analyze the incidence, possible etiological factors, pathology, clinical manifestations, brain CT scan features, treatment, and prognosis of cerebrovascular complications occurring in pregnancy and puerperium.

Methodology

This is a prospective analytical study conducted at the Govt. Hospital for women and children, Chennai, from January 2006 to February 2008. During the above period, 26 women were diagnosed with various cerebrovascular complications. In these patients, the clinical data, risk factors, neurological features, investigations, results, and neuroimaging reports were analyzed.

Results

The incidence of cerebrovascular complications in this study was 66 per 100,000 deliveries. None had prior history of diabetes, hypertension, renal disease, or seizure disorder. Two women were suffering from cardiac disease. PET and eclampsia were seen in 19/26 (73 %) cases. Seven women were suffering from anemia and one with severe sepsis. The neurological complications manifested predominantly in the postpartum period. Cases presented with hemiplegia/facial palsy and aphasia. CT scan imaging showed intracerebral hemorrhage in four cases, cerebral infarcts in five cases, and cortical vein thrombosis in 16 cases. There were five maternal deaths in this study.

Conclusion

Stroke occurring in pregnancy, though rare, is a serious complication which can lead to maternal death. In this study, hypertension has emerged as an important risk factor; therefore, attention should be focussed on maintaining normotension in the peripartum period.     

Prevalence of violence against pregnant women and associated maternal and neonatal complications in Leon, Mexico

Objectives

to determine the prevalence of violence against women and associated maternal and neonatal complications in a developing country setting.

Design

cross-sectional study using a face-to-face questionnaire.

Setting

postpartum area at a tertiary care referral hospital in Leon, Mexico.

Participants

1623 postpartum women.

Data collection

women were recruited at 24–72 h post partum. The diagnosis and severity of violence were assessed using a modified questionnaire based on the Index of Spouse Abuse and Severity of Violence against Women Scale.

Findings

of 1623 women, 711 (43.8%) were diagnosed with violence during pregnancy; 563 (79.1%) experienced mild violence and 148 (20.9%) experienced severe violence. Of the women who experienced violence, 72.9% experienced psychological violence, 15.8% experienced physical violence and 11.3% experienced sexual violence. Maternal complications were higher in women who experienced violence (30.2% vs 23.6%, p=0.004). Women who experienced sexual violence had more maternal complications (43.2%), and women who experienced psychological violence had more neonatal complications (54.2%).

Key conclusions

violence during pregnancy is quite common in the study setting. Maternal complications are higher in women who experience violence during pregnancy. The type of violence has different effects on maternal and neonatal health.

Implications for practice

it is recommended that pregnant women who are experiencing violence should be identified during antenatal care to avoid maternal or neonatal complications.     

Maternal Complications Associated with Severe Preeclampsia

Objective

Hypertension disorders are associated with higher rates of maternal, fetal, and infant mortality, and severe morbidity, especially in cases of severe preeclampsia, eclampsia, and HELLP syndrome. The aim of the study was to determine maternal outcomes in pregnant women with severe preeclampsia.

Data Source

The data source consisted of 349 cases with severe preeclampsia.

Design

A cross-sectional study was undertaken on 349 cases of severe preeclampsia in pregnancy.

Setting/Period

The patients selected for this study were from those who presented at Kermanshah University of Medical Sciences, Department of Obstetrics and Gynecology during 2007–2009.

Materials and Methods

Statistical analysis was performed using SPSS 16 software and conducting Chi square and independent sample t tests. Demographic data involving age, parity, gestational age, clinical, and laboratory findings were recorded from the medical files. In addition, delivery route, indications of cesarean delivery, and maternal complications were determined.

Results

Of the 349 severely preeclampsia cases, among the 22 cases (6.3 %) who had suffered from eclamptic seizers, 17 cases (77.3 %) were in the age group of 18–35 years (P = 0.351) and 13 cases (59.1 %) in the gestational age group of 28–37 weeks (P = 0.112). One case (0.3 %) was demonstrated to have HELLP syndrome. Placental abruption was obstetric complication in 7.7 % (27 cases). Delivery route was vaginal in 120 cases (34.4 %), while 229 cases (65.6 %) underwent cesarean delivery. The most frequent maternal complication (37 cases) reported was coagulopathy (10.6 %).

Conclusions

We concluded that severe preeclampsia and eclampsia are associated with higher rates of maternal severe morbidity and that these two factors still remain the major contributors to maternal morbidity in Iran.     

Prepregnancy obesity and the risk of gestational diabetes mellitus

Background

Investigation of maternal near-miss is a useful complement to the investigation of maternal mortality with the aim of meeting the United Nations' fifth Millennium Development Goal. The present study was conducted to investigate the frequency of near-miss events, to calculate the mortality index for each event and to compare the socio-demographic and obstetrical data (age, parity, gestational age, education and antenatal care) of the near-miss cases with maternal deaths.

Methods

Near-miss cases and events (hemorrhage, infection, hypertensive disorders, anemia and dystocia), maternal deaths and their causes were retrospectively reviewed and the mortality index for each event was calculated in Kassala Hospital, eastern Sudan over a 2-year period, from January 2008 to December 2010. Disease-specific criteria were applied for these events.

Results

There were 9578 deliveries, 205 near-miss cases, 228 near-miss events and 40 maternal deaths. Maternal near-miss and maternal mortality ratio were 22.1/1000 live births and 432/100 000 live births, respectively. Hemorrhage accounted for the most common event (40.8%), followed by infection (21.5%), hypertensive disorders (18.0%), anemia (11.8%) and dystocia (7.9%). The mortality index were 22.2%, 10.0%, 10.0%, 8.8% and 2.4% for infection, dystocia, anemia, hemorrhage and hypertensive disorders, respectively.

Conclusion

There is a high frequency of maternal morbidity and mortality at the level of this facility. Therefore maternal health policy needs to be concerned not only with averting the loss of life, but also with preventing or ameliorating maternal-near miss events (hemorrhage, infections, hypertension and anemia) at all care levels including primary level.     

Priorities in emergency obstetric care in Bolivia––maternal mortality and near-miss morbidity in metropolitan La Paz

Objective  To document the frequency and causes of maternal mortality and severe (near-miss) morbidity in metropolitan La Paz, Bolivia.
Design  Facility-based cross-sectional study.
Setting  Four maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government-subsidised programme.
Population  All maternal deaths and women with near-miss morbidity.
Methods  Inclusion of near-miss using clinical and management-based criteria.
Main outcome measures  Maternal mortality ratio (MMR), severe morbidity ratio (SMR), mortality indices and proportion of near-miss cases at hospital admission.
Results  MMR was 187/100 000 live births and SMR was 50/1000 live births, with a relatively low mortality index of 3.6%. Severe haemorrhage and severe hypertensive disorders were the main causes of near-miss, with 26% of severe haemorrhages occurring in early pregnancy. Sepsis was the most common cause of death. The majority of near-miss cases (74%) were in critical condition at hospital admission and differed from those fulfilling the criteria after admission as to diagnostic categories and socio-demographic variables.
Conclusions  Pre-hospital barriers remain to be of great importance in a setting of this type, where there is wide availability of free maternal health care. Such barriers, together with haemorrhage in early pregnancy, pre-eclampsia detection and referral patterns, should be priority areas for future research and interventions to improve maternal health. Near-miss upon arrival and near-miss after arrival at hospital should be analysed separately as that provides additional information about factors that contribute to maternal ill-health.     

Diagnosis and treatment of iron-deficiency anaemia during pregnancy and postpartum

Introduction  

Iron-deficiency anaemia during pregnancy and postpartum occurs frequently and may lead to severe maternal and foetal complications. New treatment regimens include intravenous iron administration in particular clinical situations. The aim of the study was to determine optimal diagnostic and therapeutic approaches to iron-deficiency anaemia during pregnancy and postpartum.     

Hypnosis Antenatal Training for Childbirth (HATCh): a randomised controlled trial [NCT00282204]

Background

In the first year after childbirth, 94% of women experience one or more major health problems (urinary incontinence, faecal incontinence, perineal pain, back pain). Difficulties in intimate partner relationships and changes affecting sexual health are also common. The aim of this study is to investigate changes in women's health from early pregnancy until four years after the birth of a first child.

Methods/design

The Maternal Health Study is a longitudinal study designed to fill in some of the gaps in current research evidence regarding women's physical and psychological health and recovery after childbirth. A prospective pregnancy cohort of >1500 nulliparous women has been recruited in early pregnancy at six metropolitan public hospitals in Melbourne, Australia between April 2003 and December 2005. In the first phase of the study participants are being followed up at 30–32 weeks gestation in pregnancy, and at three, six, nine, 12 and 18 months postpartum using a combination of self-administered questionnaires and telephone interviews. Women consenting to extended follow-up (phase 2) will be followed up six and 12 months after any subsequent births and when their first child is four years old. Study instruments incorporate assessment of the frequency and severity of urinary and bowel symptoms, sexual health issues, perineal and abdominal pain, depression and intimate partner violence. Pregnancy and birth outcome data will be obtained by review of hospital case notes.

Discussion

Features of the study which distinguish it from prior research include: the capacity to identify incident cases of morbidity and clustering of health problems; a large enough sample to detect clinically important differences in maternal health outcomes associated with the method of birth; careful exposure measurement involving manual abstraction of data from medical records in order to explore mediating factors and possible causal pathways; and use of a variety of strategies to improve ascertainment of health outcomes.     

"Near-miss" obstetric events and maternal deaths in Sagamu,Nigeria: a retrospective study

Aim  

To determine the frequency of near-miss (severe acute maternal morbidity) and the nature of near-miss events, and comparatively analysed near-miss morbidities and maternal deaths among pregnant women managed over a 3-year period in a Nigerian tertiary centre.     

Prevalence of liver disease in pregnancy and its outcome with emphasis on obstetric cholestasis: An Indian scenario

Objective

To determine the prevalence of liver disease in pregnant Indian women and the risk of adverse pregnancy outcomes resulting from intrahepatic cholestasis.

Methods

We analyzed 5947 pregnant women, A total of 79(1.32%) patients had abnormal liver tests. 47 (0.79%) women who gave birth at Sant Parmanand Hospital from January 1997 to August 2008 had pregnancy complicated by cholestasis. Fisher’s exact 2-Tail p-value analysis was used to compare pregnancy characterstics of this group with those of the general obstetric population (n = 5300).

Results

Obstetric cholestasis started at a mean ± SD of 31 ± 4 weeks’ gestation, with pruritus as the leading symptom.. Affected pregnant women had meconium stained liquor significantly more often (40.4%) than the general obstetric population (18.86%). Intrahepatic cholestasis increased the low basic risk of preterm delivery, thereby increasing the need for neonatal care in the general population. Increased incidence of postpartum hemorrhage was also significant(29.78%) p<0.0004.

Conclusion

Intrahepatic cholestasis of pregnancy has an adverse effect on maternal and fetal prognosis, and affected pregnancies merit closer surveillance.     

Near-miss o casi pérdida en un hospital de referencia

Objectives

To analyze maternal health from direct mortality and the concept of near-miss at La Fe University Hospital in Valencia (Spain) from 1991 to 2007.

Material and methods

We calculated the direct maternal mortality ratio (DMMR) from 1971-2007 and the severe obstetric morbility-mortality ratio from 1991-2007, and analyzed their causes.

Results

A significant DMMR decrease (rho = - 1), with a significant reduction in mortality due to cardiovascular disease was found. When analyzing severe maternal morbidity, we observed an increase of placenta previa (OR = 1.79), abruptio placentae (OR = 1.35), uterine rupture (OR = 2.48) and anesthetic complications (OR = 6.20), with a significant decrease of postpartum hemorrhage (OR = 0.63) and severe puerperal infection (OR = 0.32).The prevalence of hypertensive disorders of pregnancy, thromboembolic disease, intrauterine fetal death and severe morbidity/mortality ratio remained stable during the study period.

Conclusions

Estimating the severe obstetric morbidity-mortality ratio due to different near-miss definitions in the literature is difficult. The DMMR decreased, while the morbidity/mortality ratio remained stable.     

Pregnancy outcome in women with pulmonary arterial hypertension: single-center experience from India

Background

A retrospective analysis of the records of all the patients of pulmonary arterial hypertension with pregnancy at AIIMS, New Delhi, India, to study maternal and perinatal outcome and to compare outcome between severe and mild pulmonary arterial hypertension.

Materials and methods

A retrospective analysis was carried out of 30 pregnancies in women with pulmonary arterial hypertension (PAH) who delivered at ≥28 weeks of gestation from July 2006 through July 2012 at a tertiary care center in India. Pulmonary artery blood pressure (PABP) during the first trimester of pregnancy or before pregnancy was considered to define PABP as severe or mild, with severe cases having systolic PABP >50 mmHg on echocardiography.

Results

Out of 30 patients, 14 patients had severe PAH and 16 patients had mild PAH. Women with severe PAH had a significantly higher incidence of preterm delivery (11 vs. 3, P < 0.05), small for gestational age infants (10 vs. 2, P < 0.05) and cardiac complications (6 vs. 1, P < 0.05) compared to women with mild PAH. There was maternal mortality in a patient with Eisenmenger syndrome. In women with severe PAH and mild PAH, PABP increased in later pregnancy from 63.14 ± 7.6 to 71.57 ± 7.9 mmHg (P < 0.05) and from 40.37 ± 3.6 to 41.69 ± 4.1 mmHg (P < 0.05), respectively.

Conclusions

Pregnancy in women with severe PAH is associated with higher maternal morbidity and adverse fetal outcome compared to pregnancy in women with mild PAH.     

Membrane stripping to prevent post-term pregnancy in Enugu, Nigeria: a randomized controlled trial

Objectives

This study aimed at evaluating the effectiveness and safety of membrane stripping at 40–41 weeks of gestation as a means of preventing post-term pregnancy and the need for formal induction of labor in Enugu, Nigeria.

Methodology

A randomized controlled trial of 134 post-date pregnant women at the University of Nigeria Teaching Hospital, Enugu, Nigeria, from February to November 2012. The intervention group received membrane stripping while the control group did not receive membrane stripping.

Results

The incidence of post-term pregnancy in the membrane stripping group was 16.1 % (10/62) versus 39.3 % (24/61) in the control group (RR 0.41; 95 % CI 0.22–0.78; P = 0.004; NNT = 4). Membrane stripping reduced the duration of pregnancy by 3 days (P < 0.001). The procedure also significantly reduced the need for ‘formal’ labor induction [7/62 (11.3 %) vs. 23/61 (37.7 %); RR 0.30; 95 CI 0.14–0.65; P = 0.002]. However, maternal and neonatal complications were similar between the two groups.

Conclusion

Membrane stripping reduces the incidence of post-term pregnancy and need for formal induction of labor in post-date pregnant women, without increased maternal or neonatal complications.     

Pregnancy outcome in patients with idiopathic thrombocytopenic purpura

Objective

To study the outcome of pregnancy in women with idiopathic thrombocytopenic purpura.

Materials and methods

A retrospective analysis of 30 pregnancies in 26 women with idiopathic thrombocytopenic purpura was carried out at a tertiary hospital in India. The courses of the disease, maternal and perinatal outcome in these pregnancies were studied.

Results

Mean age of pregnant women with idiopathic thrombocytopenic purpura was 27.3 years and 61.5 % was primigravidae. Out of 26 patients with idiopathic thrombocytopenic purpura, 16 were already diagnosed while the other 10 were diagnosed during pregnancy. The incidence of bleeding episodes in antenatal period, severe thrombocytopenia and hemorrhagic complications at the time of delivery was 30, 37 and 11.1 %, respectively. Oral steroids were required in 40 % of pregnancies. Two patients received intravenous immunoglobulin therapy. Severe thrombocytopenia at the time of delivery was more commonly seen in women in whom ITP was diagnosed during pregnancy as compared to those in whom ITP was diagnosed prior to pregnancy (P = 0.04). Severe thrombocytopenia was seen in 18.5 % of neonates and intracranial hemorrhage was detected in 1 neonate. There were no still births or maternal mortality.

Conclusion

Pregnancy outcome in patients with idiopathic thrombocytopenic purpura is generally good.