Beyond the numbers: classifying contributory factors and potentially avoidable maternal deaths in New Zealand, 2006-2009

Beyond the numbers: Classifying contributory factors and potentially avoidable adverse events in the gynaecology service of National Women's Health at Auckland District Health Board

BACKGROUND

Adverse events (AEs) during health care are common and may have long-term consequences for patients. Although there is a tradition of reviewing morbidity and mortality in gynaecology, there is no recommended system for reporting contributory factors and potential avoidability.

AIMS

To identify factors that contributed to AEs in the gynaecology service at National Women's Health at Auckland District Health Board and to determine potential avoidability, with the use of a multidisciplinary morbidity review.

MATERIALS AND METHODS

Contributory factors from a review of AEs in gynaecology services were identified and classified as organisational and/or management factors, personnel factors and barriers to patients accessing and engaging with care. Potential avoidability of the AE was also considered. A descriptive analysis of the morbidity review of patients who had an AE from 2019 to 2022 was undertaken.

RESULTS

One hundred and fifty-three cases of AEs were reviewed and 77 (50.3%) were associated with contributory factors. Of all cases, 45 (29.4%) had organisational factors, 54 (35.3%) had personnel factors and patient factors resulting in barriers to care contributing to 11 (7.2%) cases. Sixty-five cases (42.5%) were classified as potentially avoidable. Of these 65 cases, 38 (58.5%) had organisational factors, 48 (73.8%) had personnel factors and nine (13.9%) had barriers to care.

CONCLUSIONS

The AE review process reported 50.3% of AEs had contributory factors that were classified as organisational, personnel and barriers to patients accessing care and that 42.5% of the AEs were potentially avoidable. These reviews can be used for making recommendations that potentially lead to improvements in gynaecology.

Reducing trainee mistakes. Better performance with changing to a high-fidelity simulation system?

BACKGROUND

Postpartum hemorrhage is a significant cause of both maternal morbidity and mortality worldwide and is increasing in incidence. This study aimed to assess improvement and identify shortcomings in trainee performance in different simulation systems in the management of postpartum hemorrhage.

OBJECTIVE

To perform a pilot study evaluating and comparing high- and low-fidelity simulation models, assessing improvement in repeated performance with high-fidelity mode and identifying mistakes made assessed using Objective Structured Assessment of Technical Skills and thereby exploring what aspects of emergency management of postpartum hemorrhage should be prioritized in teaching settings and assessing what simulation setup is most effective in achieving competence.

STUDY DESIGN

This was a prospective randomized, single-blinded, single-institution trial in a population of 17 junior obstetrical trainees at the Charité University Hospital Obstetric Simulation Center in Berlin. Trainees were randomized into 2 groups, with either initial low-fidelity simulation or high-fidelity simulation, followed by repeated assessment of performance, using the high-fidelity model simulation system. Individual simulation sessions were video-recorded and transcribed, and the timing of interventions was documented. Strandardized Objective Structured Assessment of Technical Skills forms were used as a checklist for performance.

RESULTS

There was a statistically significant general improvement in performance (P=.02; 24.7-27.2 of 31.0 points; average of 8.7%) in the second cycle of simulation assessment and a statistically significant training effect (P=.043; 24.4-28.4 of 31.0 points; average of 12.9%) in the group that underwent repeat simulation assessment from the initial low-fidelity system to the high-fidelity system compared with the group using the same high-fidelity setup (P=.276; 25.0-25.8 of 31.0; average of 2.4%).

CONCLUSION

There was an improvement in the performance when trainees underwent a repeated cycle of simulation assessment changing from a low-fidelity system to a high-fidelity system. Simulation assessment can identify mistakes and learning gaps that are important for obstetrical trainees. This study found that trainees make the same mistakes, regardless of which simulation model was initially used.

[National confidential enquiry into maternal deaths in France, a 25-year enhanced surveillance system, essential for the reliable characterization of maternal deaths]

Although maternal mortality is rare in wealthy countries, it remains a fundamental indicator of maternal health. It is considered to be a "sentinel event", the occurrence of which indicates dysfunctions, often cumulative, in the healthcare system. In addition to the classic epidemiological surveillance findings - number of deaths, maternal mortality ratio, distribution of medical causes, sub-groups of women at risk - its study, through a precise analysis of the history of each woman who died, enables to highlight areas for improvement in the content or organisation of care, the correction of which will make it possible to prevent not only deaths but also upstream morbid events involving the same mechanisms. To achieve this dual epidemiological and clinical audit objective, an ad hoc "enhanced" system is needed. France has had such a system since 1996, the Enquête Nationale Confidentielle sur la Mortalité Maternelle (ENCMM), under the joint supervision of Santé Publique France and Inserm. The ENCMM method aims to identify maternal deaths exhaustively and reliably up to 1 year after the end of pregnancy, and to document each death as fully as possible. The 1st step is the multi-source identification (direct declaration, death certificates, linkage with birth certificates, hospital stay database) of women who died during pregnancy or in the year following its end. The 2nd step is the collection of detailed information for each death by a pair of clinical assessors. The 3rd step is the review of these anonymised documents by the National Expert Committee on Maternal Mortality, which establishes the maternal nature of the death (causal link with pregnancy) and, with a stated aim of improvement rather than judgement, assesses the adequacy of care and the preventability of the death. The summary of the information gathered for maternal deaths in the 2016-2018 period is presented in the other articles of this special issue.

Midwives' recognition and response to maternal deterioration: A national cross-sectional study

BACKGROUND

Early warning systems (EWS) are used across health care settings as a tool for the early identification of clinical deterioration and to determine the need to escalate care. Early detection of clinical deterioration and appropriate escalation of care in maternity settings is critical to the safety of pregnant women and infants; however, underutilization of EWS tools and reluctance to escalate care have been consistently reported. Little is known about midwives' use of EWS in the Australian context.

METHODS

Using a cross-sectional approach, we elicited the attitudes, beliefs, and behaviors of a purposive sample of Australian midwives (n = 87) with respect to the Maternal Early Warning Trigger Tool (MEWT). Participants answered a 25-question Likert scale survey and one open-ended question. Qualitative answers were analyzed using consensus coding.

RESULTS

Midwives reported positive attitudes toward the MEWT, describing it as a valuable tool for identifying clinical deterioration, especially when used as an adjunct to clinical judgment. However, midwives also identified training gaps; 25% had received no training, and only half of those who had received training felt it was effective. In addition, professional tension can create a significant barrier to the effective use of the MEWT. Midwives also reported feeling influenced by their peers in their decision-making with respect to use of the MEWT and being afraid they would be chastised for escalating care unnecessarily.

CONCLUSIONS

Although the MEWT is valued by Australian midwives as a useful tool, barriers exist to its effective use. These include a lack of adequate, ongoing training and professional tension. Improving interdisciplinary collaboration could enhance the use of this tool for the safety of birthing women and their infants.

Social determinants and inequitable maternal and perinatal outcomes in Aotearoa New Zealand

Objectives:

Aotearoa New Zealand has demonstrable maternal and perinatal health inequity. We examined the relationships between adverse outcomes in a total population sample of births and a range of social determinant variables representing barriers to equity.

Methods:

Using the Statistics New Zealand Integrated Data Infrastructure suite of linked administrative data sets, adverse maternal and perinatal outcomes (mortality and severe morbidity) were linked to socio-economic and health variables for 97% of births in New Zealand between 2003 and 2018 (~970,000 births). Variables included housing, economic, health, crime and family circumstances. Logistic regression examined the relationships between adverse outcomes and social determinants, adjusting for demographics (socio-economic deprivation, education, parity, age, rural/urban residence and ethnicity).

Results:

Māori (adjusted odds ratio = 1.21, 95% confidence interval = 1.18–1.23) and Asian women (adjusted odds ratio 1.39, 95% confidence interval = 1.36–1.43) had poorer maternal or perinatal outcomes compared to New Zealand European/European women. High use of emergency department (adjusted odds ratio = 2.68, 95% confidence interval = 2.53–2.84), disability (adjusted odds ratio = 1.98, 95% confidence interval = 1.83–2.14) and lack of engagement with maternity care (adjusted odds ratio = 1.89, 95% confidence interval = 1.84–1.95) had the strongest relationship with poor outcomes.

Conclusion:

Maternal health inequity was strongly associated with a range of socio-economic and health determinants. While some of these factors can be targeted for interventions, the study highlights larger structural and systemic issues that affect maternal and perinatal health.

Quality Assurance and Quality Improvement in the Labor and Delivery Setting

Quality assurance (QA) is the maintenance of a desired level of quality, whereas quality improvement (QI) is the continuous process of creating systems to make things better. Implementation science promotes the systematic uptake of best practices. Bundles are a structured list of best practices whereas toolkits provide the necessary details, rationale, and implementation materials, such as sample policies and protocols. Metrics that can guide care on the labor and delivery (L&D) floor may be related to team structure (obstetric, multidisciplinary, anesthetic), processes (patient monitoring, team effects), and outcomes (postpartum hemorrhage, venous thromboembolism). Multiple anesthetic quality metrics have been proposed, including the mode of anesthesia for cesarean delivery.

Health system and quality of care factors contributing to maternal deaths in East Java, Indonesia

Despite most Indonesian women now receiving antenatal care on the nationally recommended four occasions and being delivered by skilled birth attendants, the nation’s maternal mortality ratio (MMR) is estimated as 177 per 100,000 live births. Recent research in a rural district of Indonesia has indicated that poor service quality due to organizational and personnel factors is now a major determinant of this high MMR. The present research is an in-depth analysis of possible health service organizational and quality of care related causes of death among 30 women admitted to a peak referral hospital in a major Indonesian city. Despite their condition being complex or deteriorating, most of these women arrived at the hospital in a state where it was feasible to prevent death with good quality care. Poor application of protocols, poor information flow from frontline hospitals to the peak referral hospital, delays in emergency care, and delays in management of deteriorating patients were the main contributing factors to these deaths. Pyramidal referrals also contributed, as many women were initially referred to hospitals where their condition could not be effectively managed. While generic quality improvement measures, particularly training and monitoring for rigorous application of clinical protocols (including forward planning for deteriorating patients) will help improve the situation, the districts and hospitals need to develop capacity to assess their local situation. Unless local organisational factors, staff knowledge and skill, blood and blood product availability, and local reasons for delays in providing care are identified, it may not be possible to effectively reduce the adverse pregnancy outcomes.

Do maternity services in New Zealand's public healthcare system deliver on equity? Findings from structural equation modelling of national maternal satisfaction survey data

BACKGROUND

Birthing outcomes in New Zealand are demonstrably inequitable based on governmental reports and research. However, the last Ministry of Health maternal satisfaction survey in 2014 indicated that 77% of women were satisfied or very satisfied with care. This study used data from the maternal satisfaction survey to examine aspects of inequity in reported satisfaction with care.

METHODS

Structural Equation Modelling (SEM) was used to infer latent variables of satisfaction with equity domains from responses to the satisfaction survey. Additional data (residential location and deprivation score), not used in the Ministry of Health primary analysis, were provided and included in this modelling.

RESULTS

SEM showed that satisfaction was not equitably distributed. Younger women, those from areas of high socio-economic deprivation, and remote rural women were most likely to be affected by dissatisfaction associated with physical access, cultural care, information provided, and/or barriers to equity associated with additional costs (all p<0.05). Financial burden of additional costs was also unevenly distributed.

CONCLUSION

While these findings are congruent with other research on the association between social determinants and maternal satisfaction, it is concerning that they remain sources of inequity in New Zealand twenty years after they were first identified as priorities to address. On the basis of this study, urgent attention needs to be paid to removing sources of inequity within the health system and maternity care in particular.

[Enhanced system for maternal mortality surveillance in France, context and Methods]

Maternal mortality, despite its rarity in rich countries, remains a fundamental indicator of maternal health. It is considered as a "sentinel event", consequence of dysfunctions of the health care system, often cumulative. In addition to the classical epidemiological surveillance outcomes-number of deaths, maternal mortality ratio and identification of the subgroups of women at higher risk-its study allows an accurate analysis of each deceased woman's trajectory to identify opportunities for improvements in the content or organization of care; the correction of which will make it possible to prevent deaths but also upstream morbid events affected by the same dysfunctions. To achieve this dual epidemiological and clinical audit objective, an ad hoc enhanced system is needed. France has had such a system since 1996, the National Confidential enquiry into maternal deaths (ENCMM), coordinated by the Inserm Epopé team. The methodology has been adapted over time to improve completeness and better document cases. The first step is the multi-source identification (direct declaration, death certificate, birth certificates, hospital discharge data) of women who died during pregnancy or within one year of its end, in metropolitan France and overseas departments. The second step is the collection of detailed information for each death by a pair of clinical assessors. Recent evolutions aim to better document the social context of women as well as the background of women who have died of suicide. Psychiatrists have been included among the assessors. The third stage is the review of these anonymized documents by the National Committee of Experts on Maternal Mortality, which judges whether the death is maternal (causal link) and makes a judgment on the adequacy of care and avoidability of death. A psychiatrist is now associated to the CNEMM for the assessment of maternal suicides. The synthesis of the information thus collected for maternal deaths in the period 2013-2015 is presented in these articles of this special issue.

Barriers to equitable maternal health in Aotearoa New Zealand: an integrative review

Background

The purpose of this review was to examine the literature for themes of underlying social contributors to inequity in maternal health outcomes and experiences in the high resource setting of Aotearoa New Zealand. These ‘causes of the causes’ were explored and compared with the international context to identify similarities and New Zealand-specific differences.

Method

A structured integrative review methodology was employed to enable a complex cross disciplinary analysis of data from a variety of published sources. This method enabled incorporation of diverse research methodologies and theoretical approaches found in the literature to form a unified overall of the topic.

Results

Six integrated factors – Physical Access, Political Context, Maternity Care System, Acceptability, Colonialism, and Cultural factors – were identified as barriers to equitable maternal health in Aotearoa New Zealand. The structure of the maternal health system in New Zealand, which includes free maternity care and a woman centred continuity of care structure, should help to ameliorate inequity in maternal health and yet does not appear to. A complex set of underlying structural and systemic factors, such as institutionalised racism, serve to act as barriers to equitable maternity outcomes and experiences. Initiatives that appear to be working are adapted to the local context and involve self-determination in research, clinical outreach and community programmes.

Conclusions

The combination of six social determinants identified in this review that contribute to maternal health inequity is specific to New Zealand, although individually these factors can be identified elsewhere; this creates a unique set of challenges in addressing inequity. Due to the specific social determinants in Aotearoa New Zealand, localised solutions have potential to further maternal health equity.

The use of the Modified Early Obstetric Warning System (MEOWS) in women after pregnancies: a descriptive study

Abstract Objectives: to evaluate the modified early obstetric warning system (MEOWS) in women after pregnancies in a tertiary hospital in Brazil. Methods: a descriptive study was conducted with 705 hospitalized women. Vital signs (systolic and diastolic blood pressure, heart rate, respiratory rate, temperature) and lochia were registered on medical records and transcribed into the MEOWS chart of physiological parameters. On this graphic chart, yellow alerts were used to present moderate abnormalities in vital signs, while severe abnormalities were presented in red. The presence of at least one red alert or two yellow alerts were triggered to indicate the need for medical evaluation. Results: although abnormalities were found in the physiological parameters of 49.8% of the women identified from MEOWS triggers, medical evaluation was only requested for three patients (0.8%). Conclusions: in a retrospective application of the use of MEOWS showed a significant number of patients had triggered in which the nursing team did not recognize 99.2% of cases. This finding could be attributed to the fact that MEOWS has not been yet adopted in this service as part of the nursing care. The application of this tool would result in a better care because critical situations would be recognized and corrected quickly, avoiding unfavorable outcomes.

Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014: a case note review study

OBJECTIVES

Local reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews.

DESIGN

Anonymised case notes review.

PARTICIPANTS

All 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012-2014.

MAIN OUTCOME MEASURES

The number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed.

RESULTS

The care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140).

CONCLUSIONS

This systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time.

Surgical treatment of postpartum haemorrhage: national survey of French residents of obstetrics and gynecology

Background

Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and one of the leading causes of maternal mortality worldwide. Many medical treatments and interventions are available nowadays, but surgical treatment is sometimes required when less invasive methods are unsuccessful. This study aimed to assess the theoretical and practical knowledge of French residents of Obstetrics and Gynecology concerning the surgical treatment of postpartum haemorrhage.

Study design

We performed a questionnaire study for senior residents of Obstetrics and Gynecology in France (fourth and fifth year of training). An anonymous survey was sent by email. Between December 2013 and April 2014, a total of 370 residents responded.

Result

The response rate was 47.6% (176/370). Only 156 questionnaires were fully completed and included for analysis. In all, 74% (115/156) of residents reported not mastering sufficiently or at all the technique for bilateral ligation of uterine arteries, 79% (123/156) for uterine compression sutures, 95% (148/156) for ligation of the internal iliac arteries, and 78% (122/156) for emergency peripartum hysterectomy. More than half of respondents (55%, 86/156) stated that they had not mastered any of these techniques.

Conclusion

An alarmingly high number of French senior residents in Obstetrics and Gynecology report that they have not acquired the sufficient surgical skills during their training to be able to perform the surgeries required for the management of PPH.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2237-3) contains supplementary material, which is available to authorized users.

Contributory factors and potentially avoidable neonatal encephalopathy associated with acute peripartum events: An observational study

BACKGROUND

In 25% of affected babies, neonatal encephalopathy results from acute peripartum events, but rigorous review of these cases for quality improvement is seldom reported. New Zealand has maintained a national database of all babies diagnosed with Sarnat moderate and severe neonatal encephalopathy since 2010 under the Perinatal and Maternal Mortality Review Committee.

AIMS

To determine the rate of contributory factors, potentially avoidable mortality or morbidity, and to identify key areas for improvements to maternity and neonatal care among cases of neonatal encephalopathy following an acute peripartum event.

MATERIALS AND METHODS

Sarnat moderate and severe cases identified from the national collection of neonatal encephalopathy with a history of an acute peripartum event were reviewed using a standardised independent multidisciplinary methodology and a tool for assessing contributory factors and potential avoidability, with the addition of a human factors lens.

RESULTS

Forty-seven cases from 2013 to 2015 were reviewed. The most common acute peripartum events were placental abruption (12) and shoulder dystocia (11). Contributory factors were identified in 89%, and the severity of outcome was potentially avoidable in 66%. Key modifiable areas included dynamic risk assessment, preparedness for obstetric and neonatal emergencies, best practice for maternal and fetal surveillance in labour, and documentation.

CONCLUSIONS

There is significant potential to improve quality and safety in acute peripartum care to reduce the risk of neonatal encephalopathy. Human factors were not well captured by the clinical notes or review tool. Attention to human factors by improved methodology can enhance review of neonatal encephalopathy.

Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry No. 015/063, March 2016)

Purpose

This is an official interdisciplinary guideline, published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG), the Austrian Society of Gynaecology and Obstetrics (OEGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG). The guideline was developed for use in German-speaking countries and is backed by the German Society of Anaesthesiology and Intensive Medicine (DGAI), the Society of Thrombosis and Haemostasis Research (GTH) and the German Association of Midwives. The aim is to provide a consensus-based overview of the diagnosis and management of peripartum bleeding obtained from an evaluation of the relevant literature.

Methods

This S2k guideline was developed from the structured consensus of representative members of the various professional associations and professions commissioned by the Guideline Commission of the DGGG.

Recommendations

The guideline encompasses recommendations on definitions, risk stratification, prevention and management.

Impact of violence against women on severe acute maternal morbidity in the intensive care unit, including neonatal outcomes: a case-control study protocol in a tertiary healthcare facility in Lima, Peru

INTRODUCTION

Preventing and reducing violence against women (VAW) and maternal mortality are Sustainable Development Goals. Worldwide, the maternal mortality ratio has fallen about 44% in the last 25 years, and for one maternal death there are many women affected by severe acute maternal morbidity (SAMM) requiring management in the intensive care unit (ICU). These women represent the most critically ill obstetric patients of the maternal morbidity spectrum and should be studied to complement the review of maternal mortality. VAW has been associated with all-cause maternal deaths, and since many women (30%) endure violence usually exerted by their intimate partners and this abuse can be severe during pregnancy, it is important to determine whether it impacts SAMM. Thus, this study aims to investigate the impact of VAW on SAMM in the ICU.

METHODS AND ANALYSIS

This will be a prospective case-control study undertaken in a tertiary healthcare facility in Lima-Peru, with a sample size of 109 cases (obstetric patients admitted to the ICU) and 109 controls (obstetric patients not admitted to the ICU selected by systematic random sampling). Data on social determinants, medical and obstetric characteristics, VAW, pregnancy and neonatal outcome will be collected through interviews and by extracting information from the medical records using a pretested form. Main outcome will be VAW rate and neonatal mortality rate between cases and controls. VAW will be assessed by using the WHO instrument. Binary logistic followed by stepwise multivariate regression and goodness of fit test will assess any association between VAW and SAMM.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the La Trobe University, Melbourne-Australia and the tertiary healthcare facility in Lima-Peru. This research follows the WHO ethical and safety recommendations for research on VAW. Findings will be presented at conferences and published in peer-reviewed journals.

Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors

Background

Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants.

Method

Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays.

Findings

The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals.

Conclusion

There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped.

[Enhanced system for maternal mortality surveillance in France, context and methods]

Maternal mortality, despite its rarity in rich countries, remains a fundamental indicator of maternal health. It is considered as a "sentinel event", consequence of dysfunctions of the health care system, often cumulative. In addition to the classical epidemiological surveillance outcomes-number of deaths, maternal mortality ratio and identification of the subgroups of women at risk-its study allows an accurate analysis of each deceased woman's trajectory to identify opportunities for improvements in the content or organization of care; the correction of which will make it possible to prevent deaths but also upstream morbid events affected by the same dysfunctions. To achieve this dual epidemiological and clinical audit objective, an ad hoc enhanced system is needed. France has had such a system since 1996, the National Confidential enquiry into maternal deaths (ENCMM), coordinated by the Inserm Epopé team. The first step is the multi-source identification (direct declaration, death certificate, birth certificates, hospital discharge data) of women who died during pregnancy or within one year of its end. The second step is the collection of detailed information for each death by a pair of clinical assessors. The third stage is the review of these anonymized documents by the National Committee of Experts on Maternal Mortality, which judges whether the death is maternal (causal link) and makes a judgment on the adequacy of care and avoidability of death. The synthesis of the information thus collected for maternal deaths in the period 2010-2012 is the subject of the last report.

Vaginal omentum prolapse due to uterine anterior wall necrosis after prophylactic compression suture for postpartum hemorrhage: case report and review of the literature

Introduction

Postpartum or peripartum hemorrhage (PPH) is a major cause of maternal death in Western industrialized countries. Fertility preserving second stage interventions following uterotonic drugs include embolization or ligation of relevant arteries, uterine tamponade or compression sutures. Little is known about the complications due to uterine compression sutures. We describe a case report in association with uterine compression sutures and provide a systematic review on necrosis due to compression sutures (CSU).

Data sources

A PubMed database search was done up to October 1, 2016 without any restrictions of publication date or journal, using the following key words: “compression suture” and “postpartum hemorrhage” or “peripartum hemorrhage”. Reported cases were considered eligible when reason for postpartum hemorrhage (PPH), type of compression suture, suture material and type of complication were described.

Results

Among 199 publications a total of 11 reported on uterus necrosis after CSU applied for PPH. B-Lynch and modifications were applied in seven cases, Cho compression sutures in three cases and in one case B-Lynch and Cho techniques were combined. In six cases no additional measures were applied, in two cases vessel ligation, in one case embolization and in one case intrauterine balloon application were applied. In one case of partial necrosis it is not reported if additional measures were applied.

Discussion and conclusion

Uterine compression sutures are a useful method for fertility preserving management of postpartum hemorrhage. The risk of serious complications demands the careful consideration of its use. More research is necessary to improve the technique.

Intimate partner violence and pregnancy: epidemiology and impact

Intimate partner violence is a significant public health problem in our society, affecting women disproportionately. Intimate partner violence takes many forms, including physical violence, sexual violence, stalking, and psychological aggression. While the scope of intimate partner violence is not fully documented, nearly 40% of women in the United States are victims of sexual violence in their lifetimes and 20% are victims of physical intimate partner violence. Other forms of intimate partner violence are likely particularly underreported. Intimate partner violence has a substantial impact on a woman's physical and mental health. Physical disorders include the direct consequences of injuries sustained after physical violence, such as fractures, lacerations and head trauma, sexually transmitted infections and unintended pregnancies as a consequence of sexual violence, and various pain disorders. Mental health impacts include an increased risk of depression, anxiety, posttraumatic stress disorder, and suicide. These adverse health effects are amplified in pregnancy, with an increased risk of pregnancy outcomes such as preterm birth, low birthweight, and small for gestational age. In many US localities, suicide and homicide are leading causes of pregnancy-associated mortality. We herein review the issues noted previously in greater depth and introduce the basic principles of intimate partner violence prevention. We separately address current recommendations for intimate partner violence screening and the evidence surrounding effectiveness of intimate partner violence interventions.

The experiences of women with maternal near miss and their perception of quality of care in Kelantan, Malaysia: a qualitative study

BACKGROUND

Maternal mortality has been the main way of ascertaining the outcome of maternal and obstetric care. However, maternal morbidities occur more frequently than maternal deaths; therefore, maternal near miss was suggested as a more useful indicator for the evaluation and improvement of maternal health services. Our study aimed to explore the experiences of women with maternal near miss and their perception of the quality of care in Kelantan, Malaysia.

METHODS

A qualitative phenomenological approach with in-depth interview method was conducted in two tertiary hospitals in Kelantan, Malaysia. All women admitted to labour room, obstetrics and gynaecology wards and intensive care units in 2014 were screened for the presence of any vital organ dysfunction or failure based on the World Health Organization criteria for maternal near miss. Pregnancy irrespective of the gestational age was included. Women younger than 18 years old, with psychiatric disorder and beyond 42 days of childbirth were excluded.

RESULTS

Thirty women who had experienced maternal near miss events were included in the analysis. All were Malays between the ages of 22 and 45. Almost all women (93.3%) had secondary and tertiary education and 63.3% were employed. The women's perceptions of the quality of their care were influenced by the competency and promptness in the provision of care, interpersonal communication, information-sharing and the quality of physical resources. The predisposition to seek healthcare was influenced by costs, self-attitude and beliefs.

CONCLUSIONS

Self-appraisal of maternal near miss, their perception of the quality of care, their predisposition to seek healthcare and the social support received were the four major themes that emerged from the experiences and perceptions of women with maternal near miss. The women with maternal near miss viewed their experiences as frightening and that they experienced other negative emotions and a sense of imminent death. The factors influencing women's perceptions of quality of care should be of concern to those seeking to improve services at healthcare facilities. The addition of a maternal near miss case review programme, allows for understanding on the factors related to providing care or to the predisposition to seek care; if addressed, may improve future healthcare and patient outcomes.

Maternal early warning systems-Towards reducing preventable maternal mortality and severe maternal morbidity through improved clinical surveillance and responsiveness

Despite increasing awareness of obstetric safety initiatives, maternal mortality and severe maternal morbidity in the United States have continued to increase over the past 20 years. Since results from large-scale surveillance programs suggest that up to 50% of maternal deaths may be preventable, new efforts are focused on developing and testing early warning systems for the obstetric population. Early warning systems are a set of specific clinical signs or symptoms that trigger the awareness of risk and an urgent patient evaluation, with the goal of reducing severe morbidity and mortality through timely diagnosis and treatment. Early warning systems have proven effective at predicting and reducing mortality and severe morbidity in medical, surgical, and critical care patient populations; however, there has been limited research on how to adapt these tools for use in the obstetric population, where physiologic changes of pregnancy render them inadequate. In this article, we review the available obstetric early warning systems and present evidence for their use in reducing maternal mortality and severe maternal morbidity. We also discuss considerations and strategies for implementation and acceptance of these early warning systems for clinical use in obstetrics.

Identification and Management of Obstetric Hemorrhage

Obstetric hemorrhage remains the leading cause of maternal death and severe morbidity worldwide. Although uterine atony is the most common cause of peripartum bleeding, abnormal placentation, coagulation disorders, and genital tract trauma contribute to adverse maternal outcomes. Given the inability to reliably predict patients at high risk for obstetric hemorrhage, all parturients should be considered susceptible, and extreme vigilance must be exercised in the assessment of blood loss and hemodynamic stability during the peripartum period. Obstetric-specific hemorrhage protocols, facilitating the integration and timely escalation of pharmacologic, radiological, surgical, and transfusion interventions, are critical to the successful management of peripartum bleeding.

Performance of the Obstetric Early Warning Score in critically ill patients for the prediction of maternal death

BACKGROUND

Every day, about 830 women die worldwide from preventable causes related to pregnancy and childbirth. Obstetric early warning scores have been proposed as a potential tool to reduce maternal morbidity and mortality, based on the identification of predetermined abnormal values in the vital signs or laboratory parameters, to generate a rapid and effective medical response. Several early warning scores have been developed for obstetrical patients, but the majority are the result of a clinical consensus rather than statistical analyses of clinical outcome measures (ie, maternal deaths). In 2013, the Intensive Care National Audit and Research Center Case Mix Program reported the first statistically validated early warning scoring system for pregnant women.

OBJECTIVE

We sought to assess the performance of the Intensive Care National Audit and Research Center Obstetric Early Warning Score in predicting death among pregnant women who required admission to the intensive care unit.

STUDY DESIGN

This retrospective cohort study included pregnant women admitted to the intensive care unit at a tertiary referral center from January 2006 through December 2011 in Colombia, a developing country, with direct and indirect obstetric-related conditions. The Obstetric Early Warning Score was calculated based on data collected during the first 24 hours of intensive care unit admission. The Obstetric Early Warning Score is calculated based on values of the following variables: systolic and diastolic blood pressure, respiratory rate, heart rate, fraction of inspired oxygen (FiO₂) required to maintain an oxygen saturation ≥96%, temperature, and level of consciousness. The performance of the Obstetric Early Warning Score was evaluated using the area under the receiver operator characteristic curve. Outcomes selected were: maternal death, need for mechanical ventilation, and/or vasoactive support. Statistical methods included distribution appropriate univariate analyses and multivariate logistic regression.

RESULTS

During the study period, 50,897 births were recorded. There were 724 obstetric admissions to critical care, for an intensive care unit admission rate of 14.22 per 1000 deliveries. A total of 702 women were included in the study, with 29 (4.1%) maternal deaths, and a mortality ratio of 56.98 deaths per 100,000 live births. The most frequent causes of admission were direct, obstetric-related conditions (n = 534; 76.1%). The Obstetric Early Warning Score value was significantly higher in nonsurvivors than in survivors [12 (interquartile range 10-13) vs 7 (interquartile range 4-9); P < .001]. Peripartum women with normal values of Obstetric Early Warning Score had 0% mortality rate, while those with high Obstetric Early Warning Score values (>6) had a mortality rate of 6.3%. The area under the receiver operator characteristic curve of the Obstetric Early Warning Score in discrimination of maternal death was 0.84 (95% confidence interval, 0.75-0.92). The overall predictive value of the Obstetric Early Warning Score was better when the main cause of admission was directly related to pregnancy or the postpartum state. The area under the receiver operator characteristic curve of the score in conditions directly related to pregnancy and postpartum was 0.87 (95% confidence interval, 0.79-0.95), while in indirectly related conditions the area under the receiver operator characteristic curve was 0.77 (95% confidence interval, 0.58-0.96).

CONCLUSION

Although there are opportunities for improvement, Obstetric Early Warning Score obtained upon admission to the intensive care unit can predict survival in conditions directly related to pregnancy and postpartum. The use of early warning scores in obstetrics may be a highly useful approach in the early identification of women at an increased risk of dying.

Social determinants and maternal exposure to intimate partner violence of obstetric patients with severe maternal morbidity in the intensive care unit: a systematic review protocol

INTRODUCTION

Maternal mortality is a potentially preventable public health issue. Maternal morbidity is increasingly of interest to aid the reduction of maternal mortality. Obstetric patients admitted to the intensive care unit (ICU) are an important part of the global burden of maternal morbidity. Social determinants influence health outcomes of pregnant women. Additionally, intimate partner violence has a great negative impact on women's health and pregnancy outcome. However, little is known about the contextual and social aspects of obstetric patients treated in the ICU. This study aimed to conduct a systematic review of the social determinants and exposure to intimate partner violence of obstetric patients admitted to an ICU.

METHODS AND ANALYSIS

A systematic search will be conducted in MEDLINE, CINAHL, ProQuest, LILACS and SciELO from 2000 to 2016. Studies published in English and Spanish will be identified in relation to data reporting on social determinants of health and/or exposure to intimate partner violence of obstetric women, treated in the ICU during pregnancy, childbirth or within 42 days of the end of pregnancy. Two reviewers will independently screen for study eligibility and data extraction. Risk of bias and assessment of the quality of the included studies will be performed by using the Critical Appraisal Skills Programme (CASP) checklist. Data will be analysed and summarised using a narrative description of the available evidence across studies. This systematic review protocol will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines.

ETHICS AND DISSEMINATION

Since this systematic review will be based on published studies, ethical approval is not required. Findings will be presented at La Trobe University, in Conferences and Congresses, and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

CRD42016037492.

Contributory factors and potentially avoidable neonatal encephalopathy associated with perinatal asphyxia

BACKGROUND

The recently published monograph, Neonatal encephalopathy and neurologic outcome, from the American College of Obstetricians and Gynecologists calls for a root cause analysis to identify components of care that contributed to cases of neonatal encephalopathy to design better practices, surveillance mechanisms, and systems. All cases of infants born in New Zealand with moderate and severe neonatal encephalopathy were reported to the New Zealand Perinatal and Maternal Mortality Review Committee from 2010. A national clinical review of these individual cases has not previously been undertaken.

OBJECTIVES

The objective of the study was to undertake a multidisciplinary structured review of all cases of neonatal encephalopathy that arose following the onset of labor in the absence of acute peripartum events in 2010-2011 to determine the frequency of contributory factors, the proportion of potentially avoidable morbidity and mortality and to identify themes for quality improvement.

STUDY DESIGN

National identification of, and collection of clinical records on, cases of moderate or severe neonatal encephalopathy occurring after the onset of labor in the absence of an acute peripartum event, excluding those with normal gases and Apgar scores at 1 minute, among all cases of moderate and severe neonatal encephalopathy at term in New Zealand in 2010-2011 was undertaken. Cases were included if they had abnormal gases as defined by any of pH of ≤ 7.2, base excess of ≤ -10, or lactate of ≥ 6 or if there were no cord gases, an Apgar score at 1 minute of ≤ 7. A clinical case review was undertaken by a multidisciplinary team using a structured tool to record contributory factors (organization and/or management, personnel, and barriers to access and/or engagement with care), potentially avoidable morbidity and mortality and to identify themes to guide quality improvement.

RESULTS

Eighty-three babies fulfilled the inclusion criteria for the review, 56 moderate (67%) and 27 severe (33%), 21 (25%) of whom were deceased prior to hospital discharge. Eighty-four percent of 64 babies with cord gas results had one of pH of ≤ 7.0, base excess of ≤ -12, or lactate of ≥ 6; and 42% (8 of 19) without cord gases had 5 minute Apgar scores < 5. Excluding 5 babies who died within a day of birth, all but 1 baby were admitted to a neonatal unit within 1 day of birth. Contributory factors were identified in 84% of 83 cases, most commonly personnel factors (76%). Fifty-five percent of cases with morbidity or mortality were considered to be potentially avoidable, and 52% of cases were considered potentially avoidable because of personnel factors. The most frequently identified theme related to the use and interpretation of cardiotocography in labor.

CONCLUSION

A multidisciplinary case review of neonatal encephalopathy following apparently uncomplicated labor identified a high rate of potentially avoidable morbidity and mortality and issues amenable to quality improvement such as multidisciplinary training of staff in fetal surveillance in labor.

Staff and Institutional Factors Associated with Substandard Care in the Management of Postpartum Hemorrhage

Objective

to identify staff and institutional factors associated with substandard care by midwives managing postpartum hemorrhage (PPH).

Methods

A multicenter vignette-based study was e-mailed to a random sample of midwives at 145 French maternity units that belonged to 15 randomly selected perinatal networks. Midwives were asked to describe how they would manage two case-vignettes about PPH and to complete a short questionnaire about their individual (e.g., age, experience, and full- vs. part-time practice) and institutional (private or public status and level of care) characteristics. These previously validated case-vignettes described two different scenarios: vignette 1, a typical immediate, severe PPH, and vignette 2, a severe but gradual hemorrhage. Experts consensually defined 14 criteria to judge adherence to guidelines. The number of errors (possible range: 0 to 14) for the 14 criteria quantified PPH guideline adherence, separately for each vignette.

Results

450 midwives from 87 maternity units provided complete responses. Perfect adherence (no error for any of the 14 criteria) was low: 25.1% for vignette 1 and 4.2% for vignette 2. After multivariate analysis, midwives’ age remained significantly associated with a greater risk of error in guideline adherence in both vignettes (IRR 1.19 [1.09; 1.29] for vignette 1, and IRR 1.11 [1.05; 1.18] for vignette 2), and the practice of mortality and morbidity reviews in the unit with a lower risk (IRR 0.80 [0.64; 0.99], IRR 0.78 [0.66; 0.93] respectively). Risk-taking scores (IRR 1.41 [1.19; 1.67]) and full-time practice (IRR 0.83 [0.71; 0.97]) were significantly associated with adherence only in vignette 1.

Conclusions

Both staff and institutional factors may be associated with substandard care in midwives’ PPH management.

[Management of postpartum hemorrhage (PPH): algorithm of the interdisciplinary D-A-CH consensus group PPH (Germany - Austria - Switzerland)]

Postpartum hemorrhage (PPH) is one of the main causes of maternal deaths even in industrialized countries. It represents an emergency situation which necessitates a rapid decision and in particular an exact diagnosis and root cause analysis in order to initiate the correct therapeutic measures in an interdisciplinary cooperation. In addition to established guidelines, the benefits of standardized therapy algorithms have been demonstrated. A therapy algorithm for the obstetric emergency of postpartum hemorrhage in the German language is not yet available. The establishment of an international (Germany, Austria and Switzerland D-A-CH) "treatment algorithm for postpartum hemorrhage" was an interdisciplinary project based on the guidelines of the corresponding specialist societies (anesthesia and intensive care medicine and obstetrics) in the three countries as well as comparable international algorithms for therapy of PPH.The obstetrics and anesthesiology personnel must possess sufficient expertise for emergency situations despite lower case numbers. The rarity of occurrence for individual patients and the life-threatening situation necessitate a structured approach according to predetermined treatment algorithms. This can then be carried out according to the established algorithm. Furthermore, this algorithm presents the opportunity to train for emergency situations in an interdisciplinary team.

A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement

Background

In 2007, 95% of women in Botswana delivered in health facilities with 73% attending at least 4 antenatal care visits. HIV-prevalence in pregnant women was 28.7%. The maternal mortality ratio in 2010 was 163 deaths per 100 000 live births versus the government target of 130 for that year, indicating that the Millennium Development Goal 5 was unlikely to be met. A root-cause analysis was carried out with the aim of determining the underlying causes of maternal deaths reported in 2010, to categorise contributory factors and to prioritise appropriate interventions based on the identified causes, to prevent further deaths.

Methods

Case-notes for maternal deaths were reviewed by a panel of five clinicians, initially independently then discussed together to achieve consensus on assigning contributory factors, cause of death and whether each death was avoidable or not at presentation to hospital. Factors contributing to maternal deaths were categorised into organisational/management, personnel, technology/equipment/supplies, environment and barriers to accessing healthcare.

Results

Fifty-six case notes were available for review from 82 deaths notified in 2010, with 0–4 contributory factors in 19 deaths, 5–9 in 27deaths and 9–14 in nine. The cause of death in one case was not ascertainable since the notes were incomplete. The high number of contributory factors demonstrates poor quality of care even where deaths were not avoidable: 14/23 (61%) of direct deaths were considered avoidable compared to 12/32 (38%) indirect deaths. Highest ranking categories were: failure to recognise seriousness of patients’ condition (71% of cases); lack of knowledge (67%); failure to follow recommended practice (53%); lack of or failure to implement policies, protocols and guidelines (44%); and poor organisational arrangements (35%). Half the deaths had some barrier to accessing health services.

Conclusions

Root-cause analysis demonstrates the interactions between patients, health professionals and health system in generating adverse outcomes for patients. The lessons provided indicate where training of undergraduate and postgraduate medical, midwifery and nursing students need to be intensified, with emphasis on evidence-based practice and adherence to protocols. Action plans and interventions aimed at changing the circumstances that led to maternal deaths can be implemented and re-evaluated.

Preventability of severe acute maternal morbidity

OBJECTIVE

We sought to assess potential preventability of severe acute maternal morbidity (SAMM) cases admitted to intensive-care units (ICUs) or high-dependency units (HDUs).

STUDY DESIGN

Inclusion criteria were admissions to ICUs or HDUs of women who were pregnant or within 42 days of delivery in 4 District Health Board areas (accounting for a third of annual births in New Zealand) during a 17-month period. Cases were reviewed by external multidisciplinary panels using a validated model for assessing preventability.

RESULTS

In all, 98 SAMM cases were assessed; 38 (38.8%) cases were deemed potentially preventable, 36 (36.7%) not preventable but improvement in care was needed, and 24 (24.5%) not preventable. The most frequent preventable factors were clinician related: delay or failure in diagnosis or recognition of high-risk status (51%); and delay or inappropriate treatment (70%). The most common causes of preventable severe morbidity were blood loss and septicemia.

CONCLUSION

The majority of SAMM cases were potentially preventable or required improvement in care. Themes around substandard care related to delay in diagnosis and treatment for postpartum hemorrhage and septicemia. These findings can inform clinical educational programs and policies to improve maternal outcomes. This study has now been expanded to a national New Zealand audit of all SAMM cases admitted to an ICU/HDU.

Review of contributory factors in maternity admissions to intensive care at a New Zealand tertiary hospital

OBJECTIVE

The purpose of this study was to identify factors that contributed to severe maternal morbidity, defined by admission of pregnant women and women in the postpartum period to the intensive care unit (ICU) from 2010-2011 at Auckland City Hospital (ACH), a tertiary hospital that delivers 7500 women/year, and to determine potentially avoidable morbidity with the use of local multidisciplinary review.

STUDY DESIGN

All admissions of pregnant women and women in the postpartum period (to 6 weeks) to the ICU at ACH from 2010-2011 were identified from hospital databases. Case notes were summarized and discussed by a multidisciplinary team. The presence of contributory factors and potentially avoidable morbidity were determined by consensus with a tool that was developed by the New Zealand Perinatal and Maternal Mortality Review Committee for the review of maternal and perinatal deaths. Specific recommendations for clinical management were identified by the multidisciplinary group.

RESULTS

Nine pregnant women and 33 women in the postpartum period were admitted to the ICU from 2010-2011. Contributory factors were identified in 30 cases (71%); 20 cases (48%) were considered to be potentially avoidable; personnel factors were the most commonly identified avoidable causes. Specific recommendations that resulted from the study included the need for the development of guidelines for puerperal sepsis, improved planning for women at known risk of postpartum hemorrhage, enhanced supervision of junior staff, and enhanced communication through multidisciplinary meetings.

CONCLUSION

Forty-eight percent of severe maternal morbidity, which was defined as admission to the ICU at ACH from 2010-2011, was considered to be potentially avoidable by a local multidisciplinary review team; priorities were identified for improvement of local maternity services.

Maternal mortality

PURPOSE OF REVIEW

This review summarizes recent developments in maternal mortality surveillance, and draws from recent confidential mortality reports to suggest ways the anesthesiologist can contribute to safer systems of care.

RECENT FINDINGS

Maternal mortality rates appear to be static in much of the developed world, but are increasing in the USA. While improvements in ascertainment explain some of these trends, deferred childbearing, increasing population rates of coexisting disease, multifetal pregnancy, and emerging infections also contribute. Risk is markedly elevated among certain racial and ethnic minorities, due to a confluence of factors that includes behavior, biology, environmental exposures, social circumstances, and the quality of clinical care. Approximately 30-40% of maternal deaths are potentially preventable, and recent maternal mortality reviews suggest specific strategies that may improve outcomes for women suffering from the most common causes of death: cardiovascular disease, hemorrhage, hypertensive disorders of pregnancy, venous thromboembolism, infection, and other medical conditions.

SUMMARY

A growing number of countries and organizations have established systems for comprehensive maternal death surveillance and confidential review to ensure that each death counts and that the lessons learned are widely disseminated to improve future maternal safety.