Maternal near misses from two referral hospitals in Uganda: a prospective cohort study on incidence, determinants and prognostic factors

Midwife-led birthing centres in Bangladesh, Pakistan and Uganda: an economic evaluation of case study sites

INTRODUCTION

Achieving the Sustainable Development Goals to reduce maternal and neonatal mortality rates will require the expansion and strengthening of quality maternal health services. Midwife-led birth centres (MLBCs) are an alternative to hospital-based care for low-risk pregnancies where the lead professional at the time of birth is a trained midwife. These have been used in many countries to improve birth outcomes.

METHODS

The cost analysis used primary data collection from four MLBCs in Bangladesh, Pakistan and Uganda (n=12 MLBC sites). Modelled cost-effectiveness analysis was conducted to compare the incremental cost-effectiveness ratio (ICER), measured as incremental cost per disability-adjusted life-year (DALY) averted, of MLBCs to standard care in each country. Results were presented in 2022 US dollars.

RESULTS

Cost per birth in MLBCs varied greatly within and between countries, from US$21 per birth at site 3, Bangladesh to US$2374 at site 2, Uganda. Midwife salary and facility operation costs were the primary drivers of costs in most MLBCs. Six of the 12 MLBCs produced better health outcomes at a lower cost (dominated) compared with standard care; and three produced better health outcomes at a higher cost compared with standard care, with ICERs ranging from US$571/DALY averted to US$55 942/DALY averted.

CONCLUSION

MLBCs appear to be able to produce better health outcomes at lower cost or be highly cost-effective compared with standard care. Costs do vary across sites and settings, and so further exploration of costs and cost-effectiveness as a part of implementation and establishment activities should be a priority.

Road to maternal death: the pooled estimate of maternal near-miss, its primary causes and determinants in Africa: a systematic review and meta-analysis

BACKGROUND

Maternal near-miss (MNM) is defined by the World Health Organization (WHO) working group as a woman who nearly died but survived a life-threatening condition during pregnancy, childbirth, or within 42 days of termination of pregnancy due to getting quality of care or by chance. Despite the importance of the near-miss concept in enhancing quality of care and maternal health, evidence regarding the prevalence of MNM, its primary causes and its determinants in Africa is sparse; hence, this study aimed to address these gaps.

METHODS

A systematic review and meta-analysis of studies published up to October 31, 2023, was conducted. Electronic databases (PubMed/Medline, Scopus, Web of Science, and Directory of Open Access Journals), Google, and Google Scholar were used to search for relevant studies. Studies from any African country that reported the magnitude and/or determinants of MNM using WHO criteria were included. The data were extracted using a Microsoft Excel 2013 spreadsheet and analysed by STATA version 16. Pooled estimates were performed using a random-effects model with the DerSimonian Laired method. The I2 test was used to analyze the heterogeneity of the included studies.

RESULTS

Sixty-five studies with 968,555 participants were included. The weighted pooled prevalence of MNM in Africa was 73.64/1000 live births (95% CI: 69.17, 78.11). A high prevalence was found in the Eastern and Western African regions: 114.81/1000 live births (95% CI: 104.94, 123.59) and 78.34/1000 live births (95% CI: 67.23, 89.46), respectively. Severe postpartum hemorrhage and severe hypertension were the leading causes of MNM, accounting for 36.15% (95% CI: 31.32, 40.99) and 27.2% (95% CI: 23.95, 31.09), respectively. Being a rural resident, having a low monthly income, long distance to a health facility, not attending formal education, not receiving ANC, experiencing delays in health service, having a previous history of caesarean section, and having pre-existing medical conditions were found to increase the risk of MNM.

CONCLUSION

The pooled prevalence of MNM was high in Africa, especially in the eastern and western regions. There were significant variations in the prevalence of MNM across regions and study periods. Strengthening universal access to education and maternal health services, working together to tackle all three delays through community education and awareness campaigns, improving access to transportation and road infrastructure, and improving the quality of care provided at service delivery points are key to reducing MNM, ultimately improving and ensuring maternal health equity.

Maternal near miss as a predictor of adverse perinatal outcomes: findings from a prospective cohort study in southwestern Uganda

BACKGROUND

Despite efforts, Uganda has not met the World Health Organization target of < 12 newborn deaths per 1,000 live births. Severe maternal morbidity or 'near miss' is a major contributor to adverse perinatal outcomes, particularly in low-resource settings. However, the specific impact of maternal near miss on perinatal outcomes in Uganda remains insufficiently investigated. We examined the association between maternal near miss and adverse perinatal outcomes at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda.

METHODS

We conducted a prospective cohort study among women admitted for delivery at MRRH's maternity ward from April 2022 to August 2022. We included mothers at ≥ 28 weeks of gestation with singleton pregnancies, while intrauterine fetal death cases were excluded. For the near-miss group, we consecutively included mothers with any one of the following: antepartum hemorrhage with shock, uterine rupture, hypertensive disorders, coma, and cardiac arrest; those without these complications constituted the non-near-miss group. We followed the mothers until delivery, and their infants until seven days postpartum or death. Adverse perinatal outcomes considered were low birth weight (< 2,500 g), low Apgar score (< 7 at five minutes), intrapartum stillbirths, early neonatal death, or admission to neonatal intensive care unit. Multivariable log-binomial regression was used to determine predictors of adverse perinatal outcomes.

RESULTS

We enrolled 220 participants (55 maternal near misses and 165 non-near misses) with a mean age of 27 ± 5.8 years. Most of the near misses were pregnancies with hypertensive disorders (49%). Maternal near misses had a four-fold (adjusted risk ratio [aRR] = 4.02, 95% CI: 2.32-6.98) increased risk of adverse perinatal outcomes compared to non-near misses. Other predictors of adverse perinatal outcomes were primigravidity (aRR = 1.53, 95%CI: 1.01-2.31), and gestational age < 34 weeks (aRR = 1.81, 95%CI: 1.19-2.77).

CONCLUSION

Maternal near misses, primigravidity, and preterm pregnancies were independent predictors of adverse perinatal outcomes in this study. We recommend implementing maternal near-miss surveillance as an integral component of comprehensive perinatal care protocols, to improve perinatal outcomes in Uganda and similar low-resource settings. Targeted interventions, including specialized care for women with maternal near misses, particularly primigravidas and those with preterm pregnancies, could mitigate the burden of adverse perinatal outcomes.

Barriers and facilitators to maternal death surveillance and response at a busy urban National Referral Hospital in Uganda

Background: Preventable maternal and newborn deaths remain a global concern, particularly in low- and- middle-income countries (LMICs) Timely maternal death surveillance and response (MDSR) is a recommended strategy to account for such deaths through identifying contextual factors that contributed to the deaths to inform recommendations to implement in order to reduce future deaths. Implementation of MDSR is still suboptimal due to barriers such as inadequate skills and leadership to support MDSR. With the leadership of WHO and UNFPA, there is momentum to roll out MDSR, however, the barriers and enablers for implementation have received limited attention. These have  implications for successful implementation. The aim of this study was: To assess barriers and facilitators to implementation of MDSR at a busy urban National Referral Hospital as perceived by health workers, administrators, and other partners in Reproductive Health. Methods: Qualitative study using in-depth interviews (24), 4 focus-group discussions with health workers, 15 key-informant interviews with health sector managers and implementing partners in Reproductive-Health. We conducted thematic analysis drawing on the Theory of Planned Behaviour (TPB).   Results: The major barriers to implementation of MDSR were: inadequate knowledge and skills; fear of blame / litigation; failure to implement recommendations; burn out because of workload   and inadequate leadership- to support health workers. Major facilitators were involving all health workers in the MDSR process, eliminate blame, strengthen leadership, implement recommendations from MDSR and functionalize lower health facilities (especially Health Centre -IVs). Conclusions: The barriers of MDSR include knowledge and skills gaps, fear of blame and litigation, and other health system factors such as erratic emergency supplies, and leadership/governance challenges. Recommendation: Efforts to strengthen MDSR for impact should use health system responsiveness approach to address the barriers identified, constructive participation of health workers to harness the facilitators and addressing the required legal framework.

Mortality Rate and Predictors Among Women With Obstructed Labor in a Tertiary Academic Medical Center of Ethiopia: A Retrospective Cohort Study

Introduction

Obstructed labor is one of the most common preventable causes of maternal morbidity and mortality. In Ethiopia, 36% of maternal mortality was due to obstructed labor with uterine rupture. Thus, this study proposed to measure predictors of maternal mortality among women with obstructed labor in a tertiary academic medical center in Southern Ethiopia.

Methods

An institution-based retrospective cohort study was conducted at Hawassa University Specialized Hospital from July 25 to September 30, 2018. Women who had obstructed labor from 2015 to 2017 were recruited. A pretested checklist was used to retrieve data from the woman's chart. A multivariable logistic regression model was employed to identify variables associated with maternal mortality, and variables with a p-value <.05 were considered significant at 95% CI.

Results

With a response rate of 96.3%, 156 moms who experienced labor obstruction were included in the study. Obstructed labor caused the deaths of 14 women, resulting in a maternal mortality rate of 8.9% (95% CI: 7.15, 16.4). Maternal mortality from obstructed labor was reduced in women who received antenatal care visits (AOR = 0.25, 95% CI: 0.13, 0.76) and blood transfusions (AOR =  0.49, 95% CI: 0.03, 0.89). Women who experienced uterine rupture (AOR =  6.25, 95% CI: 5.3, 15.6) and antepartum hemorrhage (AOR = 14, 95% CI: 2.45, 70.5) had a greater risk of maternal mortality than women who did not have the corresponding morbidity.

Conclusions

The center had a higher rate of maternal mortality due to obstructed labor. Early screening and improving the care for women at greatest risk of antenatal and postnatal co-morbidities like uterine rupture and shock were the major priorities and fundamental strategies to decreasing maternal mortality. It also showed that antenatal care visits, early referral, and blood transfusion for women with obstructed labor should be amended in order to lower maternal mortality.

Determinants of Obstetric Near Miss in a Tertiary Hospital in Kenya: A Retrospective Study

BACKGROUND

Kenya has a high burden of facility maternal deaths but there is scarce utilization of the near miss approach to understand facility related determinants of maternal mortality. The aim of this study was to investigate determinants of near miss in a major refferal hospital in Kenya using the World Health Organization near miss approach.

METHODS

A retrospective study design was used in a referral hospital in Kenya. Prevalence, direct and indirect causes of near miss were determined. Binomial logistic regression was used to determine associations between maternal characteristics and maternal near miss.

RESULTS

Maternal near miss ratio was 8.7 per 1000 live births. The most prevalent direct factors were: Severe post-partum hemorrhage (35%), eclampsia (18.9%) severe pre-eclampsia (17.4%), blood transfusion (79%), and hepatic dysfunction (3.7%). Anemia, previous ceaserean section and prolonged/obstructed labor were the most important contributory factors. The prevalence of organ dysfunction at admission was 39%. Only 74% of eclampsia cases had received magnesium sulphate on referral. Higher gestation at delivery (AOR = 0.640, 95% C.I =0.477–0.858) and those who received antenatal care from a level two or three facility (AOR = 0.190, 95% CI = 0.042–0.856) were less likely to experience a near miss.

CONCLUSION

Obstetric hemorrhage and pregnancy induced hypertension were the most important direct determinants of near miss, while anemia was the most important indirect determinant. Organ dysfunction on admission to the tertiary referral facility was high, suggesting delays in interventions at lower level facilities. Interventions addressing obstetric hemorrhage, pregnancy induced hypertension and pre-natal anemia may reduce the burden of near miss and mortality.

Incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia

BACKGROUND

Of the 1010 reported maternal deaths in 2018, just over 65% occurred in hospitals in Ethiopia. However, there is a lack of standardised data about the contributing factors. This study aimed to investigate the incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia.

METHODS

A retrospective cohort design was used; an audit of 1060 maternity care logbooks of adult women post-partum at Felege Hiwot Referral Hospital and University of Gondar Comprehensive Specialized Hospital. The data were abstracted between December 2018 and May 2019 using a systematic random sampling technique. We used the Facility Based Maternal Death Abstraction Form containing sociodemographic characteristics, women's medical history, and partographs. Primary postpartum haemorrhage was defined as the estimated blood loss recorded by the staff greater or equal to 500 ml for vaginal births and 1000 ml for caesarean section births, or the medical doctor diagnosis and recording of the woman as having primary postpartum haemorrhage. The data analysis was undertaken using Stata version 15. Variables with P ≤ 0.10 for significance were selected to run multivariable logistic analyses. Variables that had associations with primary postpartum haemorrhage were identified based on the odds ratio, with 95% confidence interval (CI) and P-value less than 0.05.

RESULTS

The incidence of primary postpartum haemorrhage in the hospitals was 8.8% (95% CI: 7.2, 10.6). Of these, there were 7.4% (95% CI: 2.1, 13.3) maternal deaths. Eight predictor variables were found to be independently associated with primary postpartum haemorrhage, including age ≥35 years (AOR: 2.20; 95% CI: 1.08, 4.46; P = 0.03), longer than 24 hours duration of labour (AOR: 7.18; 95% CI: 2.73, 18.90; P = 0.01), vaginal or cervical lacerations (AOR: 4.95; 95% CI: 2.49, 9.86; P = 0.01), instrumental (forceps or vacuum)-assisted birth (AOR: 2.92; 95% CI: 1.25, 6.81; P = 0.01), retained placenta (AOR: 21.83; 95% CI: 6.33, 75.20; P = 0.01), antepartum haemorrhage in recent pregnancy (AOR: 6.90; 95% CI: 3.43, 13. 84; p = 0.01), women in labour referred from primary health centres (AOR: 2.48; 95% CI: 1.39, 4.42; P = 0.02), and births managed by medical interns (AOR: 2.90; 95% CI: 1.55, 5.37; P = 0.01).

CONCLUSION

We found that while the incidence of primary postpartum haemorrhage appeared to be lower than in other studies in Africa the associated maternal mortality was higher. Although most factors associated with primary postpartum haemorrhage were consistent with those identified in the literature, two additional specific factors, were found to be prevalent among women in Ethiopia; the factors were referred women in labour from primary health facilities and births managed by medical interns. Maternal healthcare providers in these hospitals require training on the management of a birthing emergency.

Global and regional estimates of maternal near miss: a systematic review, meta-analysis and experiences with application

Introduction

Maternal near miss (MNM) is a useful means to examine quality of obstetric care. Since the introduction of the WHO MNM criteria in 2011, it has been tested and validated, and is being used globally. We sought to systematically review all available studies using the WHO MNM criteria to develop global and regional estimates of MNM frequency and examine its application across settings.

Methods

We conducted a systematic review by implementing a comprehensive literature search from 2011 to 2018 in six databases with no language restrictions. The predefined data collection tool included sections on study characteristics, frequency of near-miss cases and study quality. Meta-analysis was performed by regional groupings. Reported adaptations, modifications and remarks about application were extracted.

Results

7292 articles were screened by title and abstract, and 264 articles were retrieved for full text review for the meta-analysis. An additional 230 articles were screened for experiences with application of the WHO MNM criteria. Sixty studies with near-miss data from 56 countries were included in the meta-analysis. The pooled global near-miss estimate was 1.4% (95% CI 0.4% to 2.5%) with regional variation in MNM frequency. Of the 20 studies that made adaptations to the criteria, 19 were from low-resource settings where lab-based criteria were adapted due to resource limitations.

Conclusions

The WHO MNM criteria have enabled the comparison of global and sub-national estimates of MNM frequency. There has been good uptake in low-resource countries but contextual adaptations are necessary.

Preventing death following unsafe abortion: a case series from urban Uganda

BACKGROUND

Maternal deaths from unsafe abortion continue to occur globally, with particularly high rates in Sub-Saharan Africa where most abortions are classified as unsafe. Maternal death reviews are an effective part of cohesive strategies to prevent future deaths while abortion remains illegal.

OBJECTIVE

This study aimed to conduct maternal death reviews for all deaths occurring following unsafe abortion during the study period, to assess preventability, and to synthesize key learning points that may help to prevent future maternal deaths following unsafe abortions.

STUDY DESIGN

Full case reviews of all maternal deaths (350 cases from Jan 2016 to Dec 2018) at the study center (a national referral hospital in urban Uganda) were conducted by specially trained multidisciplinary panels of obstetricians and midwives. We extracted the reviews of women who died following unsafe abortions (13 [2.6%]) for further analysis.

RESULTS

Most maternal deaths owing to unsafe abortion were found to be preventable. The key recommendations that emerged from the reviews were (1) that clinicians should maintain a high index of suspicion for delayed presentation and rapid decompensation in cases where unsafe abortion has occurred, (2) that a low threshold for early intravenous antibiotic therapy should be applied, and (3) that any admission with complications following an unsafe abortion merits review by an experienced clinician as soon as possible.

CONCLUSION

Postabortion care is part of essential emergency medical care and should be provided with high standards, especially in areas where there is limited or no legal access to abortion care. Implementing the recommended learning points is likely to be feasible even in low-resource obstetrical settings and, given the high rates of preventability found in maternal deaths owing to unsafe abortion, is likely to be effective.

Women with maternal near-miss in the intensive care unit in Yangzhou, China: a 5-year retrospective study

BACKGROUND

Analysis of "maternal near-misses" is expected to facilitate assessment of the quality of maternity care in health facilities. Therefore, this study aimed to investigate incidence, risk factors and causes of maternal near-misses (MNM) admitted to the intensive care unit (ICU) within five years by using the World Health Organization's MNM approach.

METHODS

A five-year retrospective study was conducted in Subei People's Hospital of Yangzhou, Jiangsu Province from January 1, 2015 to December 31, 2019. Risk factors in 65 women with MNM in the intensive care unit (ICU) were explored by using chi-square tests and multivariable logistic regression analysis. Causes and interventions in MNM were investigated by descriptive analysis.

RESULTS

Average maternal near-miss incidence ratio (MNMIR) for ICU admission was 3.5 per 1000 live births. Average maternal mortality ratio (MMR) was 5 per 100,000 live births. MI for all MNM was 0.7%. Steady growth of MNMIR in ICU was witnessed in the five-year study period. Women who were referred from other hospitals (aOR 3.32; 95%CI 1.40-7.32) and had cesarean birth (aOR 4.96; 95%CI 1.66-14.86) were more likely to be admitted in ICU. Neonates born to women with MNM admitted in ICU had lower birthweight (aOR 5.41; 95%CI 2.53-11.58) and Apgar score at 5 min (aOR 6.39; 95%CI 2.20-18.55) compared with women with MNM outside ICU. ICU admission because of MNM occurred mostly postpartum (n = 63; 96.9%). Leading direct obstetric causes of MNM admitted in ICU were hypertensive diseases of pregnancy (n = 24; 36.9%), followed by postpartum hemorrhage (n = 14; 21.5%), while the leading indirect obstetric cause was heart diseases (n = 3; 4.6%).

CONCLUSIONS

Risk factors that were associated with MNM in ICU were referral and cesarean birth. Hypertensive disease of pregnancy and postpartum hemorrhage were the main obstetric causes of MNM in ICU. These findings would provide guidance to improve professional skills of primary health care providers and encourage vaginal birth in the absence of medical indications for cesarean birth.

Abortion-related near-miss morbidity and mortality in 43 health facilities with differences in readiness to provide abortion care in Uganda

Introduction

With a view to inform policy for improved postabortion care, we describe abortion-related near-miss and mortality by sociodemographic risk factors and management options by pregnancy trimester in Uganda.

Methods

This secondary data analysis used an adapted WHO near-miss methodology to collect cross-sectional maternal near-miss and abortion complications data at 43 health facilities in Central and Eastern Uganda in 2016–2017. We computed abortion severe morbidity, near-miss and mortality ratios per 100 000 live births, and described the proportion of cases that worsened to an abortion near-miss or death, stratified by geographical region and trimester. We tested for association between independent variables and abortion near-miss, and obtained prevalence ratios for association between second trimester near-miss and independent demographic and management indicators. We assessed health facility readiness for postabortion care provision in Central and Eastern regions.

Results

Of 3315 recorded severe abortion morbidity cases, 1507 were near-misses. Severe abortion morbidity, near-miss and mortality ratios were 2063, 938 and 23 per 100 000 live births, respectively. Abortion-related mortality ratios were 11 and 57 per 100 000 in Central and Eastern regions, respectively. Abortion near-miss cases were significantly associated with referral (p<0.001). Second trimester had greater abortion mortality than first trimester. Eastern region had greater abortion-related morbidity and mortality than Central region with facilities in the former characterised by inferior readiness to provide postabortion care.

Conclusions

Uganda has a major abortion near-miss morbidity and mortality; with mortality higher in the second trimester. Life-saving commodities are lacking especially in Eastern region compromising facility readiness for postabortion care provision.

Pregnancy Induced Hypertension and Uric Acid Levels among Pregnant Women Attending Ruhengeri Referral Hospital, in Rwanda

Background:

Pregnancy Induced Hypertension (PIH) is a common burden during pregnancy usually associoted with adverse maternal and paternal outcomes. The uric acid serum level was identified as an important biochemical marker which can predict preeclampsia, a type of PIH. This study was conducted to evaluate the effects of serum uric acid levels in association with blood pressure among pregnant women attending Ruhengeri Referral Hospital.

Methodology:

A cross-sectional study was designed and 80 pregnant women in different gestation trimesters participated in the study. Data was collected from September to October 2018. Digital sphygmomanometer was used to test blood pressures for participants. Blood samples were collected in red top tubes and centrifuged to obtain serum for uric acid levels. Using Humastar 80, uric acid levels were measured for each participant. Data was analysed using Statistical Package for Social Sciences (SPSS) version 23.0. Bivariate correlation was used to analyse the relationship between uric acid levels and participants’ blood pressure.

Results:

The median age was 27 in interquartile 23-31 ranging from 19 to 39 years. 58.75% of participants were in their 1^st trimester, followed by 21.25% in the 2^nd trimester and 20% in the 3^rd trimester. The prevalence of hypertension was 11.3% (7.5% for stage 1 and 3.8% for stage 2). Hyperuricemia was found in 15% of the participants. The mean of uric acid level was 7.12 ±1.86 mg/dl in the hypertensive group and 4.49 ±1.22 mg/dl in the non-hypertensive group. The study revealed a strong positive correlation between uric acid levels and systolic/diastolic blood pressure.

Conclusion:

High prevalence of hypertension among pregnant women was revealed. The association of hypertension and hyperuricemia was recorded with a strong correlation between blood pressures and serum uric acid levels. Examination of Uric acid levels among pregnant women should be routinely performed for early identification and management of hypertension.

Determinants of maternal near-miss cases at two selected central hospitals in Malawi

BACKGROUND

Maternal near-miss cases occur in larger numbers than maternal deaths hence they require comprehensive analysis when studied. However, there is scarcity of information on determinants of maternal near-miss cases in Malawi. Therefore, this study aimed at establishing the determinants of maternal near-miss cases at two selected central hospitals in Malawi.

METHODS

This was a case control study that utilized a quantitative approach. A random sample of 458 case files comprising maternal near-miss cases (161) and non-cases (297) was drawn using a ratio of 1:1.8. Data were analyzed using Stata 14 to generate descriptive statistics, Chi Square values to describe the data and determine associations among variables and logistic regression was conducted to determine the determinants of maternal near-miss.

RESULTS

We found significant differences between demographic characteristics (marital status, occupation, admission mode, means of transport and age) of maternal near-miss cases and the non-cases (P<0.05). Age and mode of birth were found to be significantly associated (P<0. 05) with maternal near-miss. Women aged 31-35 years were 3.14 times more likely to experience maternal near-miss [OR=3.14, 95% CI: 1.09, 9.02, p=0.03] compared to those aged less than 20 years. Furthermore, emergency caesarean [OR=4.08, 95% CI: 2.34, 7.09, p=0.001] and laparotomy for uterine rupture [OR=83.49, 95% CI: 10.49, 664.55, P=0.001] were significantly associated with maternal near-miss.

CONCLUSION

Among pregnant women, health workers need to pay close attention to factors such as age and mode of birth for them to implement targeted maternal health services in order to reduce incidence of maternal near-miss cases.

Predictive Factors for Severe Maternal Morbidity in Brazil: A Case-Control Study

The maternal mortality or "maternal near miss" ratio in Brazil reflects the socioeconomic indicators as well as the healthcare quality in some areas of this country, pointing out fragile points in the health services. The aim of this study was to estimate the association of diverse variables related to pregnancy and the occurrence of Near Miss in a population of women who were cared in public maternity wards in Brazil. A case-control study was performed. The association between variables and outcomes was verified through a chi-square test. A multiple analysis was carried out, producing odds ratio (OR) estimates with values of p≤0.25 in the univariate model. The results point to the following risk factors for Severe Maternal Morbidity: non-white (<0.001, OR 2.973), family income of up to two minimum wage salaries (<0.001; OR 2.159), not having a partner (<0.001, OR 2.694), obesity (<0.001, OR 20.852), not having received pre-natal care (<0.001, OR 2.843), going to less than six prenatal appointments (<0.001, OR 3.498), undergoing an inter-hospital transfer (<0.001, OR 24.655), and the absence of labor during admission (<0.001, OR 25.205). Although the results vary, the incidence of women with potential life-threatening complications is high in Brazil, which reinforces the need to universalize more complex interventions as well as coverage of primary care. The presence of precarious socio-economic indicators and unqualified obstetric care were risk factors for Severe Maternal Morbidity.

Anemia in Ugandan pregnant women: a cross-sectional, systematic review and meta-analysis study

Background

Anemia in pregnancy represents a global public health concern due to wide ranging maternal and neonatal adverse outcomes in all peripartum periods. We estimated the prevalence and factors associated with anemia in pregnancy at a national obstetrics and gynecology referral hospital in Uganda and in addition performed a systematic review and meta-analysis of the overall burden of anemia in pregnancy in Uganda.

Methods

We conducted a cross-sectional study among 263 pregnant women attending the antenatal care clinic of Kawempe National Referral Hospital, Kampala, Uganda, in September 2020. Anemia in pregnancy was defined as a hemoglobin level of < 11.0 g/dl and microcytosis as a mean corpuscular volume (MCV) of < 76 fL. We also performed a systematic review (PROSPERO Registration ID: CRD42020213001) and meta-analysis of studies indexed on MEDLINE, Embase, African Journal Online, ClinicalTrials.gov, ICTRP, and the Cochrane Library of systematic review between 1 January 2000 and 31 September 2020 reporting on the prevalence of anemia in pregnancy in Uganda.

Results

The prevalence of anemia was 14.1% (n= 37) (95%CI 10.4–18.8), of whom 21 (56.8%) had microcytic anemia. All cases of anemia occurred in the second or third trimester of pregnancy and none were severe. However, women with anemia had significantly lower MCV (75.1 vs. 80.2 fL, p<0.0001) and anthropometric measurements, such as weight (63.3 vs. 68.9kg; p=0.008), body mass index (25.2 vs. 27.3, p=0.013), hip (98.5 vs. 103.8 cm, p=0.002), and waist (91.1 vs. 95.1 cm, p=0.027) circumferences and mean systolic blood pressure (BP) (118 vs 125 mmHg, p=0.014). Additionally, most had BP within the normal range (59.5% vs. 34.1%, p=0.023). The comparison meta-analysis of pooled data from 17 published studies of anemia in pregnancy in Uganda, which had a total of 14,410 pregnant mothers, revealed a prevalence of 30% (95% CI 23–37).

Conclusions

Despite our study having a lower prevalence compared to other studies in Uganda, these findings further confirm that anemia in pregnancy is still of public health significance and is likely to have nutritional causes, requiring targeted interventions. A larger study would be necessary to demonstrate potential use of basic clinical parameters such as weight or blood pressure as screening predictors for anemia in pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41182-021-00309-z.

Wireless versus routine physiologic monitoring after cesarean delivery to reduce maternal morbidity and mortality in a resource-limited setting: protocol of type 2 hybrid effectiveness-implementation study

BACKGROUND

Women in sub-Saharan Africa have the highest rates of morbidity and mortality during childbirth globally. Despite increases in facility-based childbirth, gaps in quality of care at facilities have limited reductions in maternal deaths. Infrequent physiologic monitoring of women around childbirth is a major gap in care that leads to delays in life-saving interventions for women experiencing complications.

METHODS

We will conduct a type-2 hybrid effectiveness-implementation study over 12 months to evaluate using a wireless physiologic monitoring system to detect and alert clinicians of abnormal vital signs in women for 24 h after undergoing emergency cesarean delivery at a tertiary care facility in Uganda. We will provide physiologic data (heart rate, respiratory rate, temperature and blood pressure) to clinicians via a smartphone-based application with alert notifications if monitored women develop predefined abnormalities in monitored physiologic signs. We will alternate two-week intervention and control time periods where women and clinicians use the wireless monitoring system during intervention periods and current standard of care (i.e., manual vital sign measurement when clinically indicated) during control periods. Our primary outcome for effectiveness is a composite of severe maternal outcomes per World Health Organization criteria (e.g. death, cardiac arrest, jaundice, shock, prolonged unconsciousness, paralysis, hysterectomy). Secondary outcomes include maternal mortality rate, and case fatality rates for postpartum hemorrhage, hypertensive disorders, and sepsis. We will use the RE-AIM implementation framework to measure implementation metrics of the wireless physiologic system including Reach (proportion of eligible women monitored, length of time women monitored), Efficacy (proportion of women with monitoring according to Uganda Ministry of Health guidelines, number of appropriate alerts sent), Adoption (proportion of clinicians utilizing physiologic data per shift, clinical actions in response to alerts), Implementation (fidelity to monitoring protocol), Maintenance (sustainability of implementation over time). We will also perform in-depth qualitative interviews with up to 30 women and 30 clinicians participating in the study.

DISCUSSION

This is the first hybrid-effectiveness study of wireless physiologic monitoring in an obstetric population. This study offers insights into use of wireless monitoring systems in low resource-settings, as well as normal and abnormal physiologic parameters among women delivering by cesarean.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04060667 . Registered on 08/01/2019.

[Severe maternal morbidity in public hospitals in Ribeirão Preto, São Paulo State, Brazil]

This study analyzed the occurrence of severe maternal morbidity, the most frequent diagnostic criteria, and the quality of obstetric care in public hospitals in Ribeirão Preto, São Paulo State, Brazil. A quantitative surveillance survey of severe maternal morbidity used World Health Organization (WHO) criteria for potentially life-threatening conditions and maternal near miss. Cases were identified from August 1, 2015, to February 2, 2016. The sample included 259 women with severe maternal morbidity (potentially life-threatening conditions/maternal near miss) during the gestational and postpartum cycle, hospitalized for childbirth in the four public institutions providing obstetric care in the city. The descriptive analysis was based on absolute and relative rates of diagnostic criteria for potentially life-threatening conditions and maternal near miss, besides description of the women in the sample (sociodemographic characteristics, obstetric history, and prenatal and childbirth care). Quality of care indicators set by the WHO based on morbimortality were also calculated. There were 3,497 deliveries, 3,502 live births in all the hospitals in the city, two maternal deaths, and 19 maternal near miss. Maternal near miss ratio was 5.4 cases per 1,000 live births, and the maternal mortality ratio was 57.1 deaths per 100,000 live birth. The mortality rate among cases with severe maternal outcome (maternal near miss plus maternal death) was 9.5%. The study revealed important potentially life-threatening conditions and maternal near miss rates. The occurrence of deaths from hemorrhagic causes highlights the need to improve the quality of obstetric care. The findings can potentially help improve local policy for obstetric care.

Factors Associated with Maternal Near Miss among Women Admitted in West Arsi Zone Public Hospitals, Ethiopia: Unmatched Case-Control Study

Background

Maternal near miss refers to a very ill pregnant or delivered woman who nearly died but survived a complication during pregnancy, childbirth, or within 42 days of termination of pregnancy. Maternal death; the most catastrophic end is frequently described as just “tip of the iceberg,” whereas maternal near-miss as the “base.” Therefore, this study aimed at assessing the factors associated with maternal near-miss among women admitted in public hospitals of West Arsi zone, Ethiopia.

Methods

A facility-based unmatched case-control study was conducted from Mar 1 to Apr 30, 2019. Three hundred twenty-one (80 cases and 241 controls) study participants were involved in the study. Cases were recruited consecutively as they present, whereas controls were selected by systematic sampling method. Cases were women admitted to hospitals during pregnancy, delivery, or within 42 days of termination of pregnancy and fulfilled at least one of the maternal near-miss disease-specific criteria, while controls were women admitted and gave birth by normal vaginal delivery. The interviewer-administered structured questionnaire and data abstraction tool was used to collect data. Data were entered Epi data 3.1 and then transferred into SPSS 20 for analysis. Multivariable logistic regression was used, and the significance level was declared at p value ≤ 0.05.

Results

The major maternal near-miss morbidities were severe obstetric hemorrhage (32.5%), pregnancy-induced hypertensive disorders (31.3%), and obstructed labor (26.3%), followed by 6.3% and 3.8% of severe anemia and pregnancy-induced sepsis, respectively. The odds of maternal near miss were statistically significantly associated with women's lack of formal education [AOR = 2.24, 95% CI: (1.17, 4.31)]. Not attending antenatal care [AOR = 3.71, 95% CI: (1.10, 12.76)], having prior history of cesarean section [AOR = 3.53, 95% CI: (1.49, 8.36)], any preexisting chronic medical disorder [AOR = 2.04, 95% CI: (1.11, 3.78)], and having experienced first delay [AOR = 5.74, 95% CI: (2.93, 11.2)].

Conclusions

Maternal education, antenatal care, chronic medical disorders, previous cesarean section, and first delay of obstetric care-seeking were identified as factors associated with maternal near-miss morbidity. Therefore, this finding implies the need to get better with those factors, to preclude severe maternal complications and subsequent maternal mortality.

Retrospective analysis of patients with severe maternal morbidity receiving anaesthesia services using 'WHO near miss approach' and the applicability of maternal severity score as a predictor of maternal outcome

Background and Aims:

Risk stratification of severely morbid obstetric patients receiving anaesthesia services can be helpful in improving maternal outcomes. This study was undertaken to analyse these patients using the WHO near-miss (NM) approach and to assess the applicability of maternal severity score (MSS) to predict maternal mortality.

Methodology:

This is a one-year retrospective cohort analysis at a tertiary care centre. Of all the obstetric patients receiving anaesthesia, those with 'potentially life-threatening conditions' (PLTC) were identified. Amongst women with PLTC, those fulfilling the WHO NM criteria were grouped into either maternal near miss (MNM) or maternal death (MD) depending on final survival outcome. The MSS was assessed upon admission to post-anaesthesia ICU. The cases of “near miss” were compared to maternal death to determine the factors and WHO NM criteria significantly associated with mortality. Area under ROC curve (AUROC) was used to assess the accuracy of MSS to predict maternal mortality.

Results:

Of the 4351 anaesthetised obstetric patients, 301 were PLTC, 59 MNM and 11 MD. Obstetric haemorrhage was the commonest PLTC with the highest risk for MNM and MD. Preoperative organ dysfunction, referral from other centres, intra-uterine fetal death (IUFD) and WHO cardiovascular and respiratory NM criteria were significantly associated with mortality. MSS had excellent accuracy for the prediction of mortality (AUROC was 0.986 and 95% CI 0.966–0.996).

Conclusion:

Haemorrhage is the leading cause of MNM and MD. MSS is reliable in stratifying the severity of maternal morbidity and in predicting maternal mortality. Thus it can be used as an effective prognostic tool.

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

The national maternal near miss surveillance in China: A facility-based surveillance system covered 30 provinces

To introduce the National Maternal Near Miss Surveillance System (NMNMSS) in detail and to report the composition of maternal near miss (MNM) in China.The NMNMSS was established by the National Health Commission at the end of 2010, covered over 400 health facilities from 30 provinces in China. The NMNMSS was designed to collect individual information for every pregnant woman admitted to obstetric department in the sampled health facilities. Cross tabulations and correlations were used to describe the distribution of population and sampled facilities in the NMNMSS, and to calculate the MNM mortality ratio for different complications and organ dysfunctions.The individual survey forms of 9,051,638 pregnant women were collected in the NMNMSS between 2012 and 2017. Compared with urban areas, there are very few well-quality medical resources in rural areas. Most women with pregnancy complications in rural areas can only be treated in Level 2 and lower hospitals. MNM in women with indirect obstetric complications received treatment more frequently in Level 3 hospital. The most common maternal complications in severe maternal outcomes (including maternal near miss and maternal death) are obstetrics hemorrhage (58.7%), hypertension disorder (28.0%), and severe anemia (20.6%). The overall MNM mortality ratio is 38:1. The MNM mortality ratios are lowest in amniotic fluid embolism, HIV/AIDS, heart disease, thrombophlebitis, and sepsis. For different organ dysfunctions, the ranks of the MNM mortality ratio from low to high are renal dysfunction, respiratory dysfunction, cardiovascular dysfunction, hepatic dysfunction, neurologic dysfunction, uterine dysfunction, coagulation dysfunction.The NMNMSS is a well-established hospital-based surveillance system for maternal complications in China. It can identify the maternal complications that need to improve health care immediately in China through a powerful longitudinal real-world evidence.

The global prevalence of maternal near miss: a systematic review and meta-analysis

Background: Improving the maternal health is one of the world’s most challenging problems. Despite significant movements over the past decades, maternal health has been still considered as a central goal for sustainable development. Maternal near miss (MNM) cases experience long-term physical and psychological effects. To present a clear portrait of the current situation, we performed a systematic review and meta-analysis with the purpose to assess the worldwide prevalence of MNM.

Methods: We conducted a systematic review on PubMed, Scopus and Web of Science electronic databases to find published papers in English, before March 2019 and regardless of the type of study. We, then, assessed the prevalence of MNM according to the World Health Organization(WHO) criteria. Finally, 49 papers were included in the study. Random effects meta-analysis was used to pool the available prevalence. The quality of studies was also evaluated.

Results: The weighted pooled worldwide prevalence of MNM, was 18.67/1000 (95% CI: 16.28-21.06). Heterogeneity was explored using subgroup analyses based on the continent and the country. We used meta-regression of MNM on MD which resulted in adjusted R-squared as78.88%.

Conclusion: The prevalence of MNM was considerable. Low- and middle-income countries should develop systematic approaches to improve quality of care in the facilities and to reducethe risk of MNM events, with the hope to women’s health.

Maternal near miss determinants at a maternity hospital for high-risk pregnancy in northeastern Brazil: a prospective study

Background

To investigate the association between sociodemographic and obstetric variables and delays in care with maternal near misses (MNMs) and their health indicators.

Methods

A prospective cohort study was conducted at a high-risk maternity hospital in northeastern Brazil from June 2015 to May 2016 that included all pregnant women seen at the maternity hospital during the data collection period and excluded those who had not been discharged at the end of the study or whom we were unable to contact after the 42nd postpartum day for MNM control. We used the MNM criteria recommended by the WHO. Risk ratios (RRs) and their 95% confidence intervals (CIs) were calculated. Hierarchical multiple logistic regression analysis was performed. The p values of all tests were two-tailed, and the significance level was set to 5%.

Results

A total of 1094 pregnant women were studied. We identified 682 (62.4%) women without adverse maternal outcomes (WOAMOs) and 412 (37.6%) with adverse maternal outcomes (WAMOs), of whom 352 had potentially life-threatening conditions (PLTCs) (85.4%), including 55 MNM cases (13.3%) and five maternal deaths (1.2%). During the study period, 1002 live births (LBs) were recorded at the maternity hospital, resulting in an MNM ratio of 54.8/1000 LB. The MNM distribution by clinical condition identified hypertension in pregnancy (67.2%), hemorrhage (42.2%) and sepsis (12.7%). In the multivariate analysis, the factors significantly associated with an increased risk of MNM were fewer than six prenatal visits (OR: 3.13; 95% CI: 1.74–5.64) and cesarean section in the current pregnancy (OR: 2.91; 95% CI: 1.45–5.82).

Conclusions

The factors significantly associated with the occurrence of MNM were fewer than six prenatal visits and cesarean section in the current pregnancy. These findings highlight the need for improved quality, an increased number of prenatal visits and the identification of innovative and viable models of labor and delivery care that value normal delivery and decrease the percentage of unnecessary cesarean sections.

Using Near Miss Model to Evaluate the Quality of Maternal Care at a Tertiary Health-Care Center: A Prospective Observational Study

Background

Near miss (NM) concept has led to a more comprehensive and better assessment of effect of care on maternal health. It indicates the degree of organ function failure in the wide spectrum of severity.

Methods

This was a prospective observational study conducted from July 2015 to Feb 2016. Among women with potentially life-threatening conditions (PLTCs), those fulfilling one or more WHO NM criteria were included and followed up till the final outcome (NM or death). Various critical interventions done in them were associated with the final outcome. Standardized mortality ratio (SMR) was calculated for assessment of overall quality of health care provided.

Results

One thousand seven hundred and thirty-nine patients had PLTCs of which 174 (10%) patients were identified as NM. Of 174 patients, 116 patients (66.66%) were discharged in stable condition (group A) and 58 patients (33.34%) died (group B). Hemorrhage (31.8%) was the most frequent complication in group A followed by hypertensive disorders (18.1%) and severe anemia (11.2%). The two most common causes of maternal mortality were hypertensive disorders (27.6%) and hemorrhage (24.1%). Only two critical interventions (assisted ventilation and massive blood transfusion) had significant association with the final outcome. SMR of our center was 1.187 indicating adequate quality of provision of care to the patients.

Conclusion

Hemorrhage and hypertensive disorders were the two most common causes of NM and deaths highlighting the importance of their prompt diagnosis and vigorous management. Periodic SMR calculation can be used as an audit to guide us in improving the overall status of maternal health.

Validity of WHO's near-miss approach in a high maternal mortality setting

Objective

To evaluate the validity of WHO’s near-miss approach in a low-resource, high maternal mortality setting.

Design

Prospective cohort study.

Setting

Mnazi Mmoja Hospital, the main referral hospital of Zanzibar, Tanzania, from 1 April 2017 until 31 December 2018.

Population

All women, pregnant or until 42 days after the end of pregnancy, admitted at Mnazi Mmoja Hospital, the tertiary referral hospital in Zanzibar.

Methods

Cases of maternal morbidity and mortality were evaluated according to WHO’s near-miss approach. The approach’s performance was determined by calculating its accuracy through sensitivity, specificity and positive and negative likelihood ratios. The approach’s validity was assessed with Pearson’s correlation coefficient between the number of organ dysfunction markers and risk of mortality.

Main outcomes measures

Correlation between number of organ dysfunction markers and risk of mortality, sensitivity and specificity.

Results

26,842 women were included. There were 335 with a severe maternal outcome: 256 maternal near-miss cases and 79 maternal deaths. No signs of organ dysfunction were documented in only 4 of the 79 cases of maternal death. The number of organ dysfunction markers was highly correlated to the risk of mortality with Pearson’s correlation coefficient of 0.89.

Conclusions

WHO’s near-miss approach adequately identifies women at high risk of maternal mortality in Zanzibar’s referral hospital. There is a strong correlation between the number of markers of organ dysfunction and mortality risk.

Maternal near-miss and death associated with abortive pregnancy outcome: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey

OBJECTIVE

To investigate the prevalence of life-threatening complications related to pregnancies with abortive outcome and the associated health service events and performance in Nigerian public tertiary hospitals.

DESIGN

Secondary analysis of a nationwide cross-sectional study.

SETTING

Forty-two tertiary hospitals.

POPULATION

Women admitted for pregnancy-related complications.

METHODS

All cases of severe maternal outcomes (SMO: maternal near-miss or death) due to abortive pregnancy complications (defined as spontaneous or induced abortion, and ectopic pregnancy) were prospectively identified over 1 year using uniform identification criteria.

MAIN OUTCOME MEASURES

Prevalence of SMO, mortality index (% maternal death/SMO), case fatality rate, time until death after admission, and health service performance.

RESULTS

Of 5779 women admitted with abortive pregnancy complications, 444 (7.9%) experienced an SMO: 366 maternal near-misses and 78 maternal deaths. Intra-hospital maternal mortality ratio from complicated abortive pregnancy outcome was 85/100 000 live births. Case fatality rate was worst for abortion-related infections (19.1%). A quarter of maternal deaths occurred on the same day of admission; however, the peak time of occurrence of death was 3-7 days of admission. Women experiencing cardiovascular, renal or coagulation organ dysfunction were less likely to survive. Higher level of maternal education and closer residence to a health facility improved chance of maternal survival.

CONCLUSIONS

Abortive outcome remains a major contributor to SMO in Nigeria. Although early hospital presentation by women is critical to surviving abortive pregnancy complications, improved, appropriate, and timely management is essential to enhance maternal survival.

TWEETABLE ABSTRACT

78 maternal deaths and 366 near-misses occurred from abortions and ectopic pregnancies in 42 Nigerian referral hospitals in 1 year.

Applicability of WHO Maternal Severity Score (MSS) and Maternal Severity Index (MSI) Model to predict the maternal outcome in near miss obstetric patients: a prospective observational study

OBJECTIVE

To assess the applicability of WHO Maternal Severity Score (MSS) and Maternal Severity Index (MSI) Model in near miss (NM) obstetric patients METHODS: It was a prospective observational study conducted at a tertiary health care center from July 2015 to Feb 2016. All patients fulfilling one or more WHO NM criteria were included. MSS and MSI were calculated for all NM patients on admission. They were then followed up till the final outcome (NM or death). Each NM parameter, system-wise MSS, total MSS and MSI were then associated with the final outcome.

RESULTS

Of 4822 patients, 1739 had potentially life-threatening conditions of which 174 were identified as NM. The average MSS and MSI of patients who remained NM was 4.41 and 11.67%, respectively, and those who died was 9.47 and 58.16%, respectively. Both were found to be significantly associated with the outcome (p < 0.001). MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC - 0.838 [95% CI 0.766-0.910]). However, of 25 NM criteria, only 17 NM criteria and 3 system dysfunctions (cardiovascular, respiratory and neurological) were found to associate significantly with the outcome.

CONCLUSION

MSS and MSI act as good prognostic tools to assess the severity of maternal complications and estimate the probability of death in NM patients. As all NM parameters are not equally predictive of severity of maternal morbidity, different scores per NM parameter and system should be assigned while calculating MSS for better prognostication.

Patterns and causes of hospital maternal mortality in Tanzania: A 10-year retrospective analysis

BACKGROUND

Maternal mortality is among the most important public health concerns in Sub-Saharan Africa. There is limited data on hospital-based maternal mortality in Tanzania. The objective of this study was to determine the causes and maternal mortality trends in public hospitals of Tanzania from 2006-2015.

METHODS AND FINDINGS

This retrospective study was conducted between July and December 2016 and involved 34 public hospitals in Tanzania. Information on causes of deaths due to pregnancy and delivery complications among women of child-bearing age (15-49 years old) recorded for the period of 2006-2015 was extracted. Data sources included inpatient and death registers and International Classification of Disease (ICD)-10 report forms. Maternal deaths were classified based on case definition by ICD 10 and categorized as direct and indirect causes. A total of 40,052 deaths of women of child-bearing age were recorded. There were 1,987 maternal deaths representing 5·0% of deaths of all women aged 15-49 years. The median age-at-death was 27 years (interquartile range: 22, 33). The average age-at-death increased from 25 years in 2006 to 29 years in 2015. Two thirds (67.1%) of the deaths affected women aged 20-34 years old. The number of deaths associated with teenage pregnancy (15-19 years) declined significantly (p-value<0·001) from 17.8% in 2006-2010 to 11.1% in 2011-2015. The proportion of deaths among 30-34 and 35-39 years old (all together) increased from 13% in 2006-2010 to 15·3% in 2011-2015 (p-value = 0.081). Hospital-based maternal mortality ratio increased from 40.24 (2006) to 57.94/100000 births in 2015. Of the 1,987 deaths, 83.8% were due to direct causes and 16.2% were due to indirect causes. Major direct causes were eclampsia (34.0%), obstetric haemorrhage (24.6%) and maternal sepsis (16.7%). Anaemia (14.9%) and cardiovascular disorders (14.0%) were the main indirect causes. Causes of maternal deaths were highly related; being attributed to up to three direct causes (0.12%). Cardiovascular disorders and anaemia had strong linkage with haemorrhage. While there was a decline in the number of deaths due to eclampsia and abortion, those due to haemorrhage and cardiovascular disoders increased during the period.

CONCLUSIONS

During the ten year period (2006-2015) there was an increase in the number of hospital maternal deaths in public hospitals in Tanzania. Maternal deaths accounted for 5% of all women of child-bearing age in-hospital mortalities. Most maternal deaths were due to direct causes including eclampsia, haemorrhage and sepsis. The findings of this study provide evidence for better planning and policy formulation for reproductive health programmes to reduce maternal deaths in Tanzania.

Applicability of the WHO maternal near miss tool in sub-Saharan Africa: a systematic review

Background

Applicability of the World Health Organization (WHO) maternal near miss criteria in low-income settings is not systematically addressed in the literature. The objective of this review was to determine the applicability of the WHO maternal near miss tool in sub-Saharan Africa.

Methods

We searched PubMed, Embase, Popline, CINAHL, AJOL, and Google scholar using key words for maternal near miss and sub-Saharan Africa. Studies which applied the WHO maternal near miss criteria, containing clear definitions, and published between January 1st, 2009 and December 31st, 2017 were included. Two authors independently extracted data. Quantitative analysis and narrative synthesis were conducted, and medians with interquartile range (IQR) were calculated for summarizing the findings. Methodological quality of the studies was assessed using the Estabrook’s quality assessment and validity tool.

Results

Fifteen studies from nine countries comprising 227,077 participants were included. Median maternal near miss ratio was 24.2 (IQR: 12.4–35.8) per 1000 live births ranging from 4.4 in a population-based study in South Africa to 198 in a rural private hospital in Nigeria. Eight studies reported challenges in implementing the WHO maternal near miss tool, especially related to the threshold for blood transfusion, and availability of several laboratory-based criteria. In three studies, local adaptations were made.

Conclusion

This review showed that the WHO maternal near miss tool is not uniformly applied in sub-Saharan Africa. Therefore, a common adaptation for the region is required to increase its applicability.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2225-7) contains supplementary material, which is available to authorized users.

Incidence, causes and correlates of maternal near-miss morbidity: a multi-centre cross-sectional study

OBJECTIVE

To explore the incidence and factors associated with maternal near-miss.

DESIGN

Cross-sectional study with an embedded case-control study.

SETTING

Three tertiary referral hospitals in southern Ghana.

POPULATION

All women admitted to study facilities with pregnancy-related complications or for birth.

METHODS

An adapted version of the WHO Maternal Near Miss Screening Tool was used to identify maternal near-miss cases. These were compared with unmatched controls (uncomplicated deliveries) in a ratio of 1:2.

MAIN OUTCOME MEASURES

Incidence of maternal near-miss, maternal near-miss to maternal mortality ratio, and cause of and factors associated with maternal near-miss.

RESULTS

Out of 8433 live births, 288 maternal near-miss cases and 62 maternal deaths were identified. In all, 454 healthy controls were recruited for comparison. Maternal near-miss and maternal death incidence ratios were 34.2 (95% CI 30.2-38.1) and 7.4 (95% CI 5.5-9.2) per 1000 live births, respectively with a maternal near-miss to mortality ratio of 4.6:1. Cause of near-miss was pre-eclampsia/eclampsia (41.0%), haemorrhage (12.2%), maternal sepsis (11.1%) and ruptured uterus (4.2%). A major factor associated with maternal near-miss was maternal fever within the 7 days before birth (OR 5.95, 95%CI 3.754-9.424). Spontaneous onset of labour was protective against near-miss (OR 0.09 95% CI 0.057-0.141).

CONCLUSION

For every maternal death, there were nearly five maternal near-misses. Women having a fever in the 7 days before delivery were six times more likely to experience a near-miss than women not having fever.

TWEETABLE ABSTRACT

Maternal near-miss exceeds maternal death by 5:1, with the leading cause of maternal near-miss was pre-eclampsia/eclampsia.

Comparison between near miss criteria in a maternal intensive care unit

OBJECTIVE

The aim of this study was to compare the incidence of different criteria of maternal near miss in women admitted to an obstetric intensive care unit and their sensitivity and specificity in identifying cases that have evolved to morbidity.

METHOD

A cross-sectional analytical epidemiological study was conducted with women admitted to the intensive care unit of the Maternity School Assis Chateaubriand in Ceará, Brazil. The Chi-square test and odds ratio were used.

RESULTS

560 records were analyzed. The incidence of maternal near miss ranged from 20.7 in the Waterstone criteria to 12.4 in the Geller criteria. The maternal near-miss mortality ratio varied from 4.6:1 to 7.1:1, showing better index in the Waterstone criteria, which encompasses a greater spectrum of severity. The Geller and Mantel criteria, however, presented high sensitivity and low specificity. Except for the Waterstone criteria, there was an association between the three other criteria and maternal death.

CONCLUSION

The high specificity of Geller and Mantel criteria in identifying maternal near miss considering the World Health Organization criteria as a gold standard and a lack of association between the criteria of Waterstone with maternal death.

Predictors of maternal near miss among women admitted in Gurage zone hospitals, South Ethiopia, 2017: a case control study

BACKGROUND

Maternal mortality and morbidity remain unacceptably high in developing countries. Behind every maternal death, many other women suffered from acute and chronic obstetric complications. Women who survive severe acute maternal morbidities/near miss have many characteristics in common with maternal death events particularly on risk factors. Ethiopia is among countries with high maternal mortality and morbidities in sub-Saharan Africa. However there is scarce evidence on risk factors of severe acute maternal morbidities in Ethiopia. Therefore this study aimed to identify predictors of maternal near miss among women admitted in Gurage zone hospitals, south Ethiopia, 2017.

METHODS

Hospital based case control study was conducted to assess predictors of maternal near miss among women admitted in five hospitals of Gurage zone, South Ethiopia. Data of 229 (77 cases and 152 controls) women were included in the analysis. Cases were women admitted due to severe acute maternal morbidity while controls were women admitted for normal labor or women admitted due to mild to moderate obstetric complications. Cases were identified by validated-disease specific criteria. Then, two controls were selected for each verified case using lottery method among eligible women. Data were collected using interviewer administered questionnaire and reviewing patients' records. Data were entered using Epi Info 7 and analyzed by SPSS 21. Multivariable logistic regression analysis was done to identify independent predictors of maternal near miss.

RESULT

Majority of cases were admitted due to dystocia (57.1%) and obstetric hemorrhage (26%). The median first delay (delay to seek health care) among cases and controls was six and 4 h respectively. Prior history of cesarean section {AOR 7.68, 95%CI, 3.11-18.96}, first delay {AOR 2.79, 95%CI, 1.42-5.50}, and being referred from other health facilities {AOR 7.47, 95% CI, 2.27-24.51} were independent predictors of maternal near miss.

CONCLUSIONS

Prior history of cesarean section, being referred from other health facilities and first delay were factors associated with maternal near miss. Timely health care seeking behavior of women is uncommon in the study area. Therefore primary health care programs need to enhance the existing efforts to improve timely health care seeking behavior of women.

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.

Severe maternal outcomes and quality of care at district hospitals in Rwanda- a multicentre prospective case-control study

Background

Despite a significant decrease in maternal mortality in the last decade, Rwanda needs further progress in order to achieve Sustainable Development Goals (SDG)3 which addresses among others maternal mortality. Analysis of severe maternal outcomes (SMO) was performed to identify their characteristics, causes and contributory factors, using standard indicators for quality of care.

Methods

A prospective case-control study was conducted for which data were collected between November 2015 and April 2016 in four rural district hospitals. The occurrence of SMO with near miss incidence ratios was established, followed by an analysis of the characteristics, clinical outcomes, causes and contributory factors.

Results

The SMO incidence ratio was 38.4 per 1000 live births (95% CI 33.4–43.4) and the maternal near-miss incidence ratio was 36 per 1000 live births (95% CI 31.1–40.9). The leading causes of SMO were postpartum haemorrhage (23.4%), uterine rupture (22.9%), abortion related complications (16.8%), malaria (13.6%) and hypertensive disorders (8.9%). The case fatality rate was high for women with hypertensive disorders (10.5%; CI 3.3–24.3) and severe postpartum haemorrhage (8%; CI 0.5–15.5). Stillbirth (OR = 181.7; CI 43.5–757.9) and length of stay at the hospital (OR = 7.9; CI 4.5–13.8) were strongly associated with severe outcomes.

Conclusions

Despite the use of life saving interventions, SMO are frequent. Mortality index was found to be low at the level of district hospitals. SMO were associated with long stay at the hospital and stillbirth. There is a need for improvement of quality of care, referral practices and certain types of infrastructure, especially blood banks, which would ensure truly comprehensive emergency obstetric care and reduce the occurrence of SMO.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1581-4) contains supplementary material, which is available to authorized users.

Maternal mortality in the indigenous and non-indigenous population in Pará: contribution to the surveillance of deaths

Abstract Objective: To analyze the occurrence of Maternal Mortality in general and in the indigenous population in the state of Pará. Method: A quantitative, analytical and retrospective study was performed, covering a historical series from 2005 to 2014. For the analysis of the results, non-parametric statistical tests, the Chi-square test and the G test were processed in the BioStat 5.0 software program. Results: A total of 884 maternal deaths were reported in the state of Pará, corresponding to a Mortality Rate of 60.7 per 100,000 live births for non-indigenous women and 135.8 per 100,000 live births for indigenous women. Oedema, proteinuria and hypertensive disorders in pregnancy, childbirth and puerperium corresponded to 30.5% (n = 270). Conclusion and Implications for the Practice: Maternal mortality remains a serious public health problem in the state of Pará, clearly demonstrating that indigenous pregnant women require greater care, since they showed higher Maternal Mortality Rates when compared to non-indigenous women.

Institutional maternal and perinatal deaths: a review of 40 low and middle income countries

BACKGROUND

Understanding the magnitude and clinical causes of maternal and perinatal mortality are basic requirements for positive change. Facility-based information offers a contextualized resource for clinical and organizational quality improvement. We describe the magnitude of institutional maternal mortality, causes of death and cause-specific case fatality rates, as well as stillbirth and pre-discharge neonatal death rates.

METHODS

This paper draws on secondary data from 40 low and middle income countries that conducted emergency obstetric and newborn care assessments over the last 10 years. We reviewed 6.5 million deliveries, surveyed in 15,411 facilities. Most of the data were extracted from reports and aggregated with excel.

RESULTS

Hemorrhage and hypertensive diseases contributed to about one third of institutional maternal deaths and indirect causes contributed another third (given the overrepresentation of sub-Saharan African countries with large proportions of indirect causes). The most lethal obstetric complication, across all regions, was ruptured uterus, followed by sepsis in Latin America and the Caribbean and sub-Saharan Africa. Stillbirth rates exceeded pre-discharge neonatal death rates in nearly all countries, possibly because women and their newborns were discharged soon after birth.

CONCLUSIONS

To a large extent, facility-based findings mirror what population-based systematic reviews have also documented. As coverage of a skilled attendant at birth increases, proportionally more deaths will occur in facilities, making improvements in record-keeping and health management information systems, especially for stillbirths and early neonatal deaths, all the more critical.

Major Determinants of Maternal Near-Miss and Mortality at the Maternity Teaching Hospital, Erbil city, Iraq

OBJECTIVES

To find out the major determinants of maternal near-miss (NM)and maternal deaths (MDs) in Erbil city, Iraq, by comparative analysis of maternal NMs and MDs.

METHODS

We conducted a hospital-based cross-sectional study in the Maternity Teaching Hospital in Erbil city from 1 June to 31 December 2013. All MDs and NMs that occurred in the hospital during the study period were included in the study. Systematic identification of all eligible women was done. This identification included a baseline assessment of the severe pregnancy-related complications using the World Health Organization NM criteria.

RESULTS

Severe preeclampsia and postpartum hemorrhage (PPH) constituted the highest proportions of complications in women with potentially life-threatening conditions (PLTCs) (30.5% and 30.0%, respectively). The highest mortality indexes were those for ruptured uterus (16.7) and severe complications of placenta previa (14.2). Factors that were significantly associated with MD (compared to NM) were hepatic dysfunction (p = 0.046), multiple/unspecified disorders (p = 0.003), arrival as an emergency condition by ambulance (p = 0.015), and history of previous cesarean section (p = 0.013).

CONCLUSIONS

Severe preeclampsia and PPH are the main complications that lead to PLTCs. Factors found to be associated with MDs are hepatic dysfunction, multiple/unspecified disorders, arrival as an emergency condition by ambulance, and history of a previous cesarean section.

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.

Maternal near miss in low-resource areas

OBJECTIVE

To describe the Global Network Near-Miss Maternal Mortality System and its application in seven sites.

METHODS

In a population-based study, pregnant women eligible for enrollment in the Maternal and Newborn Health Registry at seven sites (Democratic Republic of the Congo; Guatemala; Belagavi and Nagpur, India; Kenya; Pakistan; and Zambia) between January 2014 and April 2016 were screened to identify those likely to have a near-miss event. The WHO maternal near-miss criteria were modified for low-resource settings. The ratio of near-miss events to maternal deaths was calculated.

RESULTS

Among 122 707 women screened, 18 307 (15.0%) had a potential near-miss event, of whom 4866 (26.6%; 4.0% of all women) had a near-miss maternal event. The overall maternal mortality ratio was 155 per 100 000 live births. The ratio of near-miss events to maternal deaths was 26 to 1. The most common factors involved in near-miss cases were the hematologic/coagulation system, infection, and cardiovascular system.

CONCLUSION

By using the Global Network Near-Miss Maternal Mortality System, large numbers of women were screened for near-miss events, including those delivering at home or a low-level maternity clinic. The 4.0% incidence of near-miss maternal mortality is similar to previously reported data. The ratio of 26 near-miss cases to 1 maternal death suggests that near miss might evaluate the impact of interventions more efficiently than maternal mortality.

Incidence and causes of maternal near-miss in selected hospitals of Addis Ababa, Ethiopia

BACKGROUND

Because maternal mortality is a rare event, it is important to study maternal near-miss as a complement to evaluate and improve the quality of obstetric care. Thus, the study was conducted with the aim of assessing the incidence and causes of maternal near-miss.

METHODS

A facility-based cross-sectional study was conducted in five selected public hospitals of Addis Ababa, Ethiopia from May 1, 2015 to April 30, 2016. All maternal near-miss cases admitted to the selected hospitals during the study period were prospectively recruited. World Health Organization criteria were used to identify maternal near-miss cases. The number of maternal near-miss cases over one year per 1000 live births occurring during the same year was calculated to determine the incidence of maternal near-miss. Underlying and contributing causes of maternal near-miss were documented from each participant's record.

RESULTS

During the one-year period, there were a total of 238 maternal near-miss cases and 29,697 live births in all participating hospitals, which provides a maternal near-miss incidence ratio of 8.01 per 1000 live births. The underlying causes of the majority of maternal near-miss cases were hypertensive disorders and obstetric hemorrhage. Anemia was the major contributing cause reported for maternal near-miss. Most of the maternal near-miss cases occurred before the women's arrival at the participating hospitals.

CONCLUSION

The study demonstrated a lower maternal near-miss incidence ratio compared to previous country-level studies. The majority of the near-miss cases occurred before the women's arrival at the participating hospitals, which underscores the importance of improving pre-hospital barriers. Efforts made toward improvement in the management of life-threatening obstetric complications could reduce the occurrence of maternal near-miss problems that occur during hospitalization.

Maternal near-misses at a provincial hospital in Papua New Guinea: A prospective observational study

BACKGROUND

Maternal near-miss indices are World Health Organisation (WHO) recognised indicators that may improve our understanding of factors associated with maternal morbidity and mortality. In Papua New Guinea (PNG) where maternal mortality is among the highest in the world, only one study has documented near-miss indices in a tertiary-level hospital, but none from provincial hospitals where the majority of under-privileged women access healthcare services.

AIMS

To determine the near-miss ratio, maternal mortality index (MMI), and associated maternal indices for Modilon Hospital in Madang Province of PNG.

METHODS

All women attending Modilon Hospital who met the WHO maternal near-miss definition and/or a WHO-modified (PNG-specific) near-miss definition, were prospectively enrolled.

RESULTS

There were 6019 live births during the audit period; 163 women presented with life-threatening conditions (153 near-misses and 10 maternal deaths). The maternal near-miss ratio was 25.4/1000 live births and the maternal mortality ratio (MMR) was 166/100 000 live births, with a maternal death to near-miss ratio of 1:15.3. The severe maternal outcome ratio was 27.1/1000 live births and the total mortality index was 6.8%. Higher proportions of near-miss women were aged ≥30 years, nulliparous, illiterate, from rural communities, lacked formal employment, referred from peripheral health facilities, unbooked, had history of still births and were anaemic.

CONCLUSION

Sociodemographic factors such as women's rights, education level and status in society, in addition to appropriate health reforms with greater financial and political support are urgently needed to ensure underprivileged women in rural PNG have access to family planning, supervised deliveries and skilled emergency obstetric care.

The burden of maternal morbidity and mortality attributable to hypertensive disorders in pregnancy: a prospective cohort study from Uganda

BACKGROUND

Hypertensive disorders of pregnancy are a major cause of morbidity and mortality. The objective was to estimate the disease burden attributable to hypertensive disorders of pregnancy in two referral hospitals in Uganda.

METHODS

Through a prospective cohort study conducted in Jinja and Mulago hospitals in Uganda from March 1, 2013 and February 28, 2014, hypertension-related cases were analyzed. Maternal near miss cases were defined according to the WHO criteria. Maternal deaths were also analyzed. The maternal near miss incidence ratio, the case-specific severe maternal outcome ratio, the case-specific maternal mortality ratio and the case-fatality ratio were computed.

RESULTS

Of 403 women with hypertensive disorders of pregnancy, 218 (54.1 %) had severe preeclampsia, 172 (42.7 %) had eclampsia, and 13 had chronic hypertension or Hemolysis, elevated liver enzymes or low platelets (HELLP) syndrome. The case-specific maternal near miss incidence ratios was 8.60 per 1,000 live births for all hypertensive disorders, 3.06 per 1,000 live births for severe preeclampsia and 5.11 per 1,000 live births for eclampsia. The case-specific severe maternal outcome ratio was 9.37 per 1,000 live births for all hypertensive disorders, and was 3.25 per 1,000 live births for severe preeclampsia and 5.61 per 1,000 live births for eclampsia. The case-specific maternal mortality ratio was 780 per 100,000 live births for all hypertensive disorders, and was 1940 per 100,000 live births for severe preeclampsia and 501 per 100,000 live births for eclampsia. The case-fatality ratio was 5.1 % overall (for all hypertensive disorders), but was 8 times higher for eclampsia compared to severe preeclampsia. Cyanosis, abnormal respiration, oliguria, circulatory collapse, coagulopathy, thrombocytopenia, and elevated serum lactate were significantly associated with severe maternal outcomes.

CONCLUSION

There is high morbidity attributable to hypertensive disorders in pregnancy. Since some of the complications associated with morbidity can be recognized early, it is possible to prevent severe morbidity through early intervention with delivery, antihypertensive therapy and prophylactic magnesium sulphate treatment. The findings highlight the feasibility of implementing a facility-based surveillance system for severe maternal morbidity due to hypertensive disorders.