The epidemiology of life-threatening complications associated with reproductive process in public hospitals in Argentina

Epidemiological characteristics and risk factors of obstetric infection after the Universal Two-Child Policy in North China: a 5-year retrospective study based on 268,311 cases

BACKGROUND

Obstetrical infection is one of the causes of maternal death and a difficult problem for many clinicians. Changes in the demographic and obstetric background of pregnant women following the Universal Two-Child Policy may have an impact on some fertility phenomena. And with the increase in the number of deliveries, the limited medical resources become more scarce. How will China's health system quickly adapt to the growing needs and expectations for maternal health and ensure the provision of qualified and accessible medical services? In addition, what social support measures should be provided to reduce preventable obstetric complications? Given the relatively low per capita share of medical resources in China, how should China deal with the impact of the Universal Two-Child Policy? Therefore, more studies based on the change of fertility policy are needed. We try to analyze the epidemiological characteristics and risk factors of obstetric infection before and after the Universal Two-Child Policy, with a view to providing reference for the prevention and control of obstetric infection in regions after the change of fertility policy, and also hope to make corresponding contributions to the solution of the above problems through relevant studies.

METHODS

The subjects of the survey were 268,311 pregnant women from Hebei Province Maternal Near Miss Surveillance System (HBMNMSS) of Hebei Women and Children's Health Center from January 1, 2013 to December 31, 2017. We analyzed the region, time and population distribution characteristics of obstetric infection, compared the epidemiological factors of obstetric infection before and after the Universal Two-Child Policy, and analyzed the relevant risk factors of obstetric infection.

RESULTS

The incidence of obstetric infection increased nearly twice after the Universal Two-Child Policy. The incidence of obstetric infection was highest in Chengde (1.9%), a city with a northward geographical distribution, Baoding (1.6%), Cangzhou (1.5%) followed; The higher the hospital grade, the higher the incidence; The incidence of obstetric infections in hospitals at all levels has increased; The age of onset before the Universal Two-Child Policy was (27.82 ± 5.047) years old, and the age after the Universal Two-Child Policy was (28.97 ± 4.880) years old; The incidence of obstetric infections is higher in winter. The rate of abortion-related infection (increased from 0.61 to 1.65%) and the rate of pregnant women with high school education (increased from 0.35 to 0.74%) increased significantly. The results of multivariate Logistic regression analysis after the Universal Two-Child Policy showed that anemia (OR = 1.249, 95%CI: 1.071-1.458), chronic hypertension (OR = 1.934, 95%CI: 1.375-2.722), mild preeclampsia (OR = 2.103, 95%CI: 1.323-3.344) and severe preeclampsia (OR = 2.228, 95%CI: 1.703-2.916) were independent risk factors for obstetric infection. Gestational age ≥ 37 weeks was a protective factor.

CONCLUSION

After the Universal Two-Child Policy, the prevention and control of obstetric infections should be strengthened, especially for abortion-related infections and elderly maternal with obstetric complications and complication in high-grade hospitals in winter. Educational background is also one of the factors that should be considered in the prevention of obstetric sensation. Prolonging gestational age is helpful to reduce the incidence of obstetric infection.

Quality and outcomes of maternal and perinatal care for 76,563 pregnancies reported in a nationwide network of Nigerian referral-level hospitals

BACKGROUND

The WHO in collaboration with the Nigeria Federal Ministry of Health, established a nationwide electronic data platform across referral-level hospitals. We report the burden of maternal, foetal and neonatal complications and quality and outcomes of care during the first year.

METHODS

Data were analysed from 76,563 women who were admitted for delivery or on account of complications within 42 days of delivery or termination of pregnancy from September 2019 to August 2020 across the 54 hospitals included in the Maternal and Perinatal Database for Quality, Equity and Dignity programme.

FINDINGS

Participating hospitals reported 69,055 live births, 4,498 stillbirths and 1,090 early neonatal deaths. 44,614 women (58·3%) had at least one pregnancy complication, out of which 6,618 women (8·6%) met our criteria for potentially life-threatening complications, and 940 women (1·2%) died. Leading causes of maternal death were eclampsia (n = 187,20·6%), postpartum haemorrhage (PPH) (n = 103,11·4%), and sepsis (n = 99,10·8%). Antepartum hypoxia (n = 1455,31·1%) and acute intrapartum events (n = 913,19·6%) were the leading causes of perinatal death. Predictors of maternal and perinatal death were similar: low maternal education, lack of antenatal care, referral from other facility, previous caesarean section, latent-phase labour admission, operative vaginal birth, non-use of a labour monitoring tool, no labour companion, and non-use of uterotonic for PPH prevention.

INTERPRETATION

This nationwide programme for routine data aggregation shows that maternal and perinatal mortality reduction strategies in Nigeria require a multisectoral approach. Several lives could be saved in the short term by addressing key predictors of death, including gaps in the coverage of internationally recommended interventions such as companionship in labour and use of labour monitoring tool.

FUNDING

This work was funded by MSD for Mothers; and UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization (WHO).

Human Development Index of the maternal country of origin and its relationship with maternal near miss: A systematic review of the literature

Background

The reduction in maternal mortality worldwide has increased the interest in studying more frequent severe events such as maternal near miss. The Human Development Index is a sociodemographic country-specific variable that includes key human development indicators such as living a long and healthy life, acquiring knowledge, and enjoying a decent standard of living, allowing differentiation between countries. In a globalised environment, it is necessary to study whether the Human Development Index of each patient's country of origin can be associated with the maternal near-miss rate and thus classify the risk of maternal morbidity and mortality.

Methods

A systematic review of the literature published between 2008 and 2019 was conducted, including all articles that reported data about maternal near miss in their sample of pregnant women, in addition to describing the study countries of their sample population. The Human Development Index of the study country, the maternal near-miss rate, the maternal mortality rate, and other maternal-perinatal variables related to morbidity and mortality were used.

Results

After the systematic review, eighty two articles from over thirty countries were included, for a total of 3,699,697 live births, 37,191 near miss cases, and 4029 mortality cases. A statistically significant (p <0.05) inversely proportional relationship was observed between the Human Development Index of the study country and the maternal near-miss and mortality rates. The most common cause of maternal near miss was haemorrhage, with an overall rate of 38.5%, followed by hypertensive disorders of pregnancy (34.2%), sepsis (7.5%), and other undefined causes (20.9%).

Conclusions

The Human Development Index of the maternal country of origin is a sociodemographic variable allowing differentiation and classification of the risk of maternal mortality and near miss in pregnant women. The most common cause of maternal near miss published in the literature was haemorrhage.

Trial registration

PROSPERO ID: CRD 42019133464

High fever after sublingual administration of misoprostol for treatment of post-partum haemorrhage: a hospital-based, prospective observational study in Argentina

Objective

To characterise the occurrence of fever (≥38.0°C) after treatment for post‐partum haemorrhage (PPH) with sublingual misoprostol 800 mcg in Latin America, where elevated rates of misoprostol’s thermoregulatory effects and recipients’ increased susceptibility to high fever have been documented.

Methods

A prospective observational study in hospitals in Argentina enrolled consenting women with atonic PPH after vaginal delivery, eligible to receive misoprostol. Corporal temperature was assessed at 30, 60, 90 and 120 min post‐treatment; other effects were recorded. The incidence of high fever ≥ 40.0°C (primary outcome) was compared to the rate observed previously in Ecuador. Logistic regressions were performed to identify clinical and population‐based predictors of misoprostol‐induced fever.

Results

Transient shivering and fever were experienced by 75.5% (37/49) of treated participants and described as acceptable by three‐quarters of women interviewed (35/47). The high fever rate was 12.2% (6/49), [95% Confidence Interval (CI) 4.6, 24.8], compared to Ecuador’s rate following misoprostol treatment (35.6% (58/163) [95% CI 28.3, 43.5], P = 0.002). Significant predictors of misoprostol‐induced fever (model dependent) were as follows: pre‐delivery haemoglobin < 11.0g/dl, rapid placental expulsion, and higher age of the woman. No serious outcomes were reported prior to discharge.

Conclusions

Misoprostol to treat PPH in Argentina resulted in a significantly lower rate of high fever than in Ecuador, although both are notably higher than rates seen elsewhere. A greater understanding of misoprostol’s side effects and factors involved in their occurrence, including genetics, will help alleviate concerns. The onset of shivering may be the simplest way to know if fever can also be expected.

[Experiences of survivors of maternal near miss in Mexico: a qualitative study based on the three delays model]

The objectives were to analyze the experiences of survivors of maternal near miss based on the three delays model and to identify the obstacles to this process in the state of San Luis Potosí, Mexico. In 2016-2017, a qualitative study was performed with 27 women who had experienced maternal near miss in public hospitals between 2014 and 2016. The informants were selected with theoretical sampling and interviewed at their homes. Data analysis was based on the theoretical framework proposed by Strauss & Corbin. The categories associated with the first delay were: (1) missed opportunities for identification of maternal near miss; (2) failure of the women to voice their symptoms out of fear of reprimand; (3) dilemma between fear and the faith that a higher power will solve the problem; and (4) development of the perception of obstetric risk. The second delay involved: (1) lack of urban transportation infrastructure to access healthcare services; (2) lack of regulation of transportation costs; (3) lack of clarity on itineraries and critical routes to access care; and (4) lack institutional coordination for timely transportation. The third delay involved: (1) institutional refusal of care; (2) deficient infrastructure, personnel, and equipment; and (3) lack of expertise and experience in the healthcare personnel. The shared experiences reveal challenges for public policies and inter-sector work to improve the results in maternal near miss.

Governance commitment to reduce maternal mortality. A political determinant beyond the wealth of the countries

Some countries reached, in 2015, the Millennium Development Goal of reducing maternal mortality to 96 or less maternal deaths per 100,000 live births. Others, however, did not. This paper analyses the strength of the association between maternal mortality and each of the six components of Governance-a political determinant scarcely explored in the literature-in 174 countries. It was found that the greater the governance, the lower maternal mortality, independently of a country's wealth. We used all six indicators of the World Bank's Worldwide Governance Indicators Project in 2015: government effectiveness, regulatory quality, rule of law, control of corruption, voice and accountability, and political stability and absence of violence. Findings were encouraging as maternal mortality in low-income countries with higher government effectiveness and regulatory quality was similar to that of medium-income countries with lower government effectiveness and regulatory quality. To achieve the post-2015 sustainable development goal on preventable maternal mortality-which persists despite economic development-all governance dimensions are essential and represent interdependent cornerstones.

Life-threatening Complications in Pregnancy in a Teaching Hospital in Kolkata, India

Objectives

To test the application of a clinical definition of life-threatening complications in pregnancy and determine the level of near miss maternal morbidity and mortality.

Methods

A prospective observational study was conducted in the obstetrics and gynaecology department, NRS Medical College, Kolkata, India, to identify life-threatening complications using a modification of the Mantel's criteria. The main outcome measures were validity of identification criteria, main causes and incidence of life-threatening complications in pregnancy, maternal near miss: case fatality rates, morbidity-mortality index and use rate of effective interventions.

Results

In total, 177 maternal near miss and 23 maternal deaths were identified in the screened 4400 women. The incidence of near miss was 4.02%. Main causes of maternal mortality were hypertensive disorders (43%) and renal failure (21%). Main causes of near miss were hypertensive disorders (55%), ectopic pregnancy (19%). Near miss mortality index was 7.7:1.

Conclusions

A high proportion of women with life-threatening complications and all women who died were referred from peripheral hospitals. This signals that there may have been important failures in the referral system relating to maternal care and there is a need for further investigation.

Exploring barriers to reproductive, maternal, child and neonatal (RMNCH) health-seeking behaviors in Somali region, Ethiopia

Introduction

Health-seeking behaviours are influenced by internal and external contributing factors. Internal factors include attitudes, beliefs and core values, life adaptation skills, psychological disposition whereas external factors include social support, media, socio-cultural, political, economic and biological aspects, health care systems, environmental stressors and societal laws and regulations. This study was meant to explore factors affecting health-seeking behaviors in the Somali regional state of Ethiopia. The study employed a cross-sectional study design using qualitative data collection tools. Data were collected from 50 individual interviews and 17 focused group discussions (FGD) on women of reproductive age and their partners, health extension workers (HEWs), health care providers and health administrators. To ensure representativeness, the region was categorized into three zones based on their settlement characteristics as agrarian, pastoralist and semi-pastoralist. Two districts (one from high and the other from low performance areas) were selected from each category. The data were entered, coded, categorized and analyzed using NVIVO version 11 software. The Socio-ecologic Model (SEM) was used for categorization.

Results

Using the social ecological model, the following major barriers for health seeking behaviors were identified. Low socio-demographic and economic status, poor exposure to health information or mass media, detrimental preferences of breast feeding methods and short acting family planning (FP) methods were identified barriers at the individual level; male dominance in decision making, the influence of the husband and society and the role of word of mouth were identified barriers at the interpersonal level and lack of acceptance, fear of modern health practices, unclean health facility environment, lack of well-equipped facilities shortage of trained staffs and barriers relating to distance and transportation were barriers identified at organizational and policy level.

Conclusion

Overall, factors at various level affected health seeking behaviors of the Somali community. Socio-demographic and economic factors, non-responsive bureaucratic system, shortages or absence of medical supplies and human resources, lack of supportive supervision, a shortage of water and electricity at the health facility and an unclean service delivery environment are significant barriers to health-seeking behaviors for the community.

[Foundations for the development and implementation of a women's and perinatal health information model for management in Latin AmericaFundamentos do desenvolvimento e implementação de um modelo de informação em saúde da materna e perinatal orientado à gestão na América Latina]

OBJECTIVE

The Perinatal Information System (SIP) represents a milestone in the use of systematized information in the Region of the Americas. What has been learned from the system has contributed to the development of a model based on a set of core indicators (SCI). The objective of the study was to describe the historical and methodological process involved in the development, implementation, and territorial scaling-up of an SCI to monitor and evaluate women's and perinatal health policies, programs, and services geared to management (SIP-GESTIÓN).

METHODS

The study was conducted in two stages: 1) a four-phase validation of an SCI in a hospital network: a) construction of the theoretical indicator model, b) operations research, c) final selection of the indicators, and d) the definition of reference standards; and 2) territorial scaling-up.

RESULTS

A total of 17 indicator models were identified. The initial model included 177 indicators divided into seven dimensions (context, habits, accessibility, use of services, quality of care, maternal and fetal impact, and maternal and neonatal impact), with 21 indicators remaining after three Delphi rounds. The final model (SIP-GESTIÓN), which included 40 indicators, was then used to study 240,021 (79.1%) of the 303,559 deliveries attended in 122 selected maternity facilities in 24 jurisdictions (100%) in Argentina. The information is presented in national terms and by health region, province, and hospital.

CONCLUSIONS

This model has made it possible to achieve high levels of information coverage and quality and territorial scaling-up and is useful for management, research, and the reorientation of programs and policies.

Use of a qualitative case study to learn lessons from severe preeclampsia causing a maternal near-miss: a case report

BACKGROUND

Maternal mortality is a critical indicator in assessing the quality of services provided by a health care system. Approximately 99% of all maternal deaths occur in developing countries; where a majority of the causes of these deaths are preventable.

CASE PRESENTATION

A 25-year-old, married, multigravida, black woman who has had six live births presented to a health center with the chief compliant of abnormal body swelling of 2 days' duration and loss of consciousness. On arrival to the first contact health center her blood pressure was 170/105 mmHg and her temperature was 36.5 °C. She had generalized swelling, a history of blurred vision, and headache. She had no history of abortion, stillbirth, and cesarean section and no history of antenatal care follow-up. She gave birth to her previous children at home with no history of obstetric complications. The gestational age at the time of arrival was 37 weeks. She was referred to a general hospital for further management. At the general hospital she was diagnosed as having severe preeclampsia and she was managed with magnesium sulfate and an antihypertensive medication for 2 days. She was counseled to have induction of labor by the attending physician but refused to give consent and went home. She returned to the referral hospital 2 days later after labor had started spontaneously at home and the delivery was a spontaneous vaginal delivery with outcome of a live male baby, his Apgar score was 6/10 immediately after birth and he weighed 1.9 kg.

CONCLUSIONS

If there were no previous obstetric problems, the women perceived that she will not face complications in her future pregnancies and stay home until she had developed life-threatening complications. If women visit health facilities and if the health care providers are responsive and there is robust referral in place, maternal and fetal complications will be prevented.

A global view of severe maternal morbidity: moving beyond maternal mortality

BACKGROUND

Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).

SEVERE MATERNAL MORBIDITY IN HIGH-INCOME COUNTRIES

Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify "high risk" status, delays in diagnosis, and delays in treatment.

SEVERE MATERNAL MORBIDITY IN LOW AND MIDDLE INCOME COUNTRIES

The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.

EFFECTS OF SMM ON DELIVERY OUTCOMES AND INFANTS

Severe maternal morbidity not only puts the woman's life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.

CONCLUSION

Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women's and infants' health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

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.

Severe maternal morbidity in Zanzibar's referral hospital: Measuring the impact of in-hospital care

Objective

to analyse the impact of in-hospital care on severe maternal morbidity using WHO’s near-miss approach in the low-resource, high mortality setting of Zanzibar’s referral hospital.

Setting

Mnazi Mmoja Hospital, a tertiary care facility, in Zanzibar, Tanzania.

Methods

We identified all cases of morbidity and mortality in women admitted within 42 days after the end of pregnancy at Mnazi Mmoja Hospital in the period from April to October 2016. The severity of complications was classified using WHO’s near-miss approach definitions: potentially life-threatening condition (PLTC), maternal near-miss (MNM) or maternal death (MD). Quality of in-hospital care was assessed using the mortality index (MI) defined as ratio between mortality and severe maternal outcome (SMO) where SMO = MD + MNM, cause-specific case facility rates and comparison with predicted mortality based on the Maternal Severity Index model.

Main outcomes

5551 women were included. 569 (10.3%) had a potentially life-threatening condition and 65 (1.2%) a severe maternal outcome (SMO): 37 maternal near-miss cases and 28 maternal deaths. The mortality index was high at 0.43 and similar for women who developed a SMO within 12 hours of admission and women who developed a SMO after 12 hours. A standardized mortality ratio of 6.03 was found; six times higher than that expected in moderate maternal mortality settings given the same severity of cases. Obstetric haemorrhage was found to be the main cause of SMO. Ruptured uterus and admission to ICU had the highest case-fatality rates. Maternal death cases seemed to have received essential interventions less often.

Conclusions

WHO’s near-miss approach can be used in this setting. The high mortality index observed shows that in-hospital care is not preventing progression of disease adequately once a severe complication occurs. Almost one in two women experiencing life-threatening complications will die. This is six times higher than in moderate mortality settings.

Healthcare and sociodemographic conditions related to severe maternal morbidity in a state representative population, Federal District, Brazil: A cross-sectional study

Background

The concept of severe maternal morbidity (SMM)—a potentially life-threatening condition during pregnancy, childbirth or after termination of pregnancy—can be used as a quality indicator of the health care provided to mothers and children. The aim of this study was to investigate the SMM rate and the main factors associated with this condition among women living in the Federal District, Brazil.

Methods

We conducted a cross-sectional population-based sample survey using a structured questionnaire about the sociodemographic characteristics of the participants’ families. The data investigated included receipt of financial aid from the Federal Government, age, race, maternal educational level, prenatal care, mode of delivery, and serious complications during pregnancy and postpartum (SMM). 1042 mothers of children up to 1 year old were interviewed, representing a weighted estimated population of 36,724 mothers. The sample was representative of the whole Federal District state.

Results

Mothers were between 19 and 34 years old (69%), most of them were brown or black (59.7%), and they had more than 9 years of education (81.2%). Prenatal care was adequate for 91.9% of them, the most common mode of delivery was Cesarean section (61.3%), and most deliveries took place in public hospitals (57.3%). The prevalence of low birth weight (< 2,500 g) was 8.1%. We found 2072 events of SMM in 2060 mothers (SMM rate: 5.6%). There was an association between higher occurrence of SMM and older age (OR: 1.40; 1.26–1.56), lower maternal educational level (OR: 3.29; 2.78–3.90), and inadequate prenatal care (OR: 1.28; 1.09–1.51). Receipt of financial aid was also associated to increased risk for SMM (OR: 1.31; 1.16–1.48). Cesarean section and low birth weight reduced the risk of SMM (decrease of 49.0% and 46.0%, respectively).

Conclusions

The SMM rate in the Federal District was positively associated with higher maternal age, lower maternal educational level, inadequate prenatal care, and government financial aid program. Conversely, SMM was inversely associated with Cesarean delivery and low birth weight. This study showed that specific demographic groups are at higher risk for SMM. Therefore, actions should be focused primarily on those groups for greater effectiveness at reducing maternal mortality and providing better quality of maternal health care.

A cross sectional study of maternal near miss and mortality at a rural tertiary centre in southern nigeria

BACKGROUND

The study evaluated the pattern of severe maternal outcome, near miss indicators and associated patient and healthcare factors at a private referral hospital in rural Nigeria.

METHODS

This was a cross sectional study conducted from September 2014 to August 2015 in Madonna University Teaching Hospital Elele, Rivers State, Nigeria. Pregnant and postpartum women were recruited for the study using Nigeria near miss network proforma which was adopted from the WHO near miss proforma. We explored administrative, patient related and medical delays. Statistical analysis was done using SPSS version 20.

RESULTS

Of the 262 deliveries, 5 women died and 52 women had a near miss event. The maternal mortality rate was 1908/100,000. The maternal near miss mortality ratio was 11.4: 1 while the mortality index was 8.8%. Three out of the five deaths that occurred were in the age category of 20-24 years. Abortive outcome was the leading cause of maternal mortality contributing 2 of the 5 maternal mortality. The severe maternal outcome ratio was 218/1000 and maternal near miss incidence ratio was 198/1000. Hypertensive disorders of pregnancy contributed 16(28.1%) of the 57 cases with severe maternal outcome while Obstetrics hemorrhage and abortive outcome each contributed 14(24.6%). 6(10.5%) received treatment within 30 min of diagnosis while 19(33.3%) waited for greater than 240 min before they received intervention. There was a statistically significant association between time of intervention and final maternal outcome (p-value = 0.003). Administrative delay was noted in 20 cases, while patient related delay was noted in 44 cases.

CONCLUSION

There is a high burden of near miss and unmet need for reproductive health services in rural areas of Nigeria. Different levels of delays abound and contribute to the disease burden. Periodic reviews will aid in elimination of the delays. There should be better communication between different levels of care and emphasis should be on early identification and referral of women for prompt management.

[Tacit and explicit knowledge: comparative analysis of the prioritization of maternal health problems in Mexico]

OBJECTIVE

To identify coincidences and differences in the identification and prioritization of maternal healthcare service problems in Mexico based on the perspective of tacit knowledge and explicit knowledge that may offer evidence that can contribute to attaining the Sustainable Development Goals.

METHODS

Mixed study performed in three stages: 1) systematization of maternal healthcare service problems identified by tacit knowledge (derived from professional experience); 2) identification of maternal healthcare service problems in Latin America addressed by explicit knowledge (scientific publications); 3) comparison between the problems identified by tacit and explicit knowledge.

RESULTS

The main problems of maternal health services identified by tacit knowledge are related to poor quality of care, while the predominant problems studied in the scientific literature are related to access barriers to health services. Approximately, 70% of the problems identified by tacit knowledge are also mentioned in the explicit knowledge. Conversely, 70% of the problems identified in the literature are also considered by tacit knowledge. Nevertheless, when looking at the problems taken one by one, no statistically significant similarities were found.

CONCLUSIONS

The study discovered that the identification of maternal health service problems by tacit knowledge and explicit knowledge is fairly comparable, according to the comparability index used in the study, and highlights the interest of integrating both approaches in order to improve prioritization and decision making towards the Sustainable Development Goals.

When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country

OBJECTIVE

To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.

DESIGN

Nationwide cross-sectional study.

SETTING

Forty-two tertiary hospitals.

POPULATION

Women admitted for pregnancy, childbirth and puerperal complications.

METHODS

All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period.

MAIN OUTCOME MEASURES

Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).

RESULTS

Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care.

CONCLUSIONS

Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care.

TWEETABLE ABSTRACT

Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

Application of WHO 'Near-Miss' Tool Indicates Good Quality of Maternal Care in Rural Healthcare Setting in Uttarakhand, Northern India

INTRODUCTION

Women who experienced and survived a severe health condition during pregnancy, childbirth or postpartum are considered as 'near-miss' or severe acute maternal morbidity (SAMM) cases. Women who survive life-threatening conditions arising from complications related to pregnancy and childbirth have many common aspects with those who die of such complications.

AIM

To evaluate health-care facility preparedness and perfor-mance in reducing severe maternal out comes at all levels of health care.

MATERIALS AND METHODS

The present study was carried out over a period of 12 months under the Department of Community Medicine. The cross-sectional study included all the women (937) attending health-care facilities, at all levels of health care i.e. Primary, Secondary & Tertiary level in Doiwala block of Dehradun district. This study was conducted as per the WHO criteria for 'near-miss' by using probability sampling for random selection of health facilities. All eligible study subjects visiting health-care facilities during the study period were included, i.e. who were pregnant, in labour, or who had delivered or aborted up to 42 days ago.

RESULTS

It was found that all women delivering at the THC received oxytocin to prevent postpartum haemorrhage. Treatment of severe post-partum haemorrhage by removal of retained products was significantly associated with levels of health care. Majority (94.73%) women who had eclampsia received magnesium sulfate as primary treatment.

CONCLUSION

Application of WHO 'near-miss' tool indicates good quality of maternal care in rural healthcare setting in Uttarakhand, North India. The women would have otherwise died due to obstetrics complications, had proper care not been provided to them in time.

Effects of medical co-morbidities on severe maternal morbidities in China: a multicenter clinic register study

OBJECTIVE

To investigate the incidence of severe maternal morbidities (SMM) in China and explore effects of medical co-morbidities on SMM.

DESIGN

Proactive multicenter clinic register collaboration.

SETTING

Data on all deliveries at eight hospitals in Sichuan province, China, collected from 1 January 2009 to 12 December 2010.

POPULATION

33 993 delivering women and 34 547 live births.

METHODS

We defined SMM as a combination indicator of severe maternal complications, critical interventions, admission to the intensive care unit and maternal near-miss instances. We randomly selected 80% of the data from the entire database to build a logistic regression model. The remaining 20% were used to test the predictive power of the model.

MAIN OUTCOME MEASURES

SMM incidence, adjusted odds ratios (aORs), and area under a receiver operating characteristic (ROC) curve.

RESULTS

Severe maternal morbidities incidence was 43.4/1000 live births [confidence interval (CI) 41.24-45.56]. Fifteen variables were independent contributors to the model. Seven medical co-morbidities significantly affected the occurrence of SMM, including iron-deficiency anemia (aOR 3.07, CI 2.47-3.83) and other hematological diseases (aOR 5.82, CI 3.50-9.69), hepatitis-B virus infection (aOR 1.48, CI 1.12-1.97) and other hepatic diseases (aOR 3.81, CI 1.61-9.04), cardiopathy (aOR 3.59, CI 2.62-4.93), hypertension (aOR 5.23, CI 4.06-6.75), and respiratory diseases (aOR 2.10, CI 1.25-3.52). The area under the ROC curve was 0.8127.

CONCLUSIONS

The incidence of SMM was typical of a low resource area. There is a need to identify medical co-morbidities and to adopt prophylactic measures and interventions.

Robson Ten Group Classification System applied to women with severe maternal morbidity

OBJECTIVE

To evaluate the distribution of women with severe maternal morbidity according to Robson Ten Group Classification System (RTGCS).

METHODS

Secondary analysis of a multicenter cross-sectional study in 27 obstetric units in Brazil, using RTGCS. Cases were classified into potentially life-threatening condition or a maternal near miss or death, according to severity. Certain groups were subdivided for further analysis. Cesarean delivery (CD) rates were reported.

RESULTS

Among 7,247 women with severe maternal morbidity, 73.2 percent underwent CD. Group 10 (single, cephalic, preterm) was the most prevalent (33.9%). Groups mostly associated with a severe maternal outcome were: 7 (multiparous, breech), 9 (all abnormal lies, single, term), 8 (all multiple), and 10. Groups 1 (nulliparous, single, cephalic, term, spontaneous) and 3 (multiparous, single, cephalic, term, spontaneous) were associated with better maternal outcome. Group 3 had one severe maternal morbidity to 29 cases of potentially life-threatening, but the ratio was 1:10 for women undergoing CD, indicating a worse outcome. Group 4a (multiparous, no previous CD, single, cephalic, term, induced labor) had a better maternal outcome than those delivered by CD before labor (group 4b). Hypertension was the most common condition of severity.

CONCLUSIONS

The RTGCS was useful to consider severe maternal morbidity, showing groups with higher CD rates and worse maternal outcomes.