Maternal near-miss surveillance, Namibia Heemelaar, Steffie; Josef, Mirjam; Diener, Zoe ...
Bulletin of the World Health Organization,
08/2020, Letnik:
98, Številka:
8
Journal Article
Recenzirano
Odprti dostop
To analyse and improve the Namibian maternity care system by implementing maternal near-miss surveillance during 1 October 2018 and 31 March 2019, and identifying the challenges and benefits of such ...data collection.
From the results of an initial feasibility study, we adapted the World Health Organization's criteria defining a maternal near miss to the Namibian health-care system. We visited most (27 out of 35) participating facilities before implementation and provided training on maternal near-miss identification and data collection. We visited all facilities at the end of the surveillance period to verify recorded data and to give staff the opportunity to provide feedback.
During the 6-month period, we recorded 37 106 live births, 298 maternal near misses (8.0 per 1000 live births) and 23 maternal deaths (62.0 per 100 000 live births). We observed that obstetric haemorrhage and hypertensive disorders were the most common causes of maternal near misses (each 92/298; 30.9%). Of the 49 maternal near misses due to pregnancies with abortive outcomes, ectopic pregnancy was the most common cause (36/298; 12.1%). Fetal or neonatal outcomes were poor; only 50.3% (157/312) of the infants born to maternal near-miss mothers went home with their mother.
Maternal near-miss surveillance is a useful intervention to identify within-country challenges, such as lack of access to caesarean section or hysterectomy. Knowledge of these challenges can be used by policy-makers and programme managers in the development of locally tailored targeted interventions to improve maternal outcome in their setting.
Objectives
To assess the frequency of maternal death (MD) due to cardiac disease in low‐ and middle‐income countries (LMIC).
Methods
Systematic review searching Medline, EMBASE, Web of Science, ...Cochrane Library, Emcare, LILACS, African Index Medicus, IMEMR, IndMED, WPRIM, IMSEAR up to 01/Nov/2017. Maternal mortality reports from LMIC reviewing all MD in a given geographical area were included. Hospital‐based reports or those solely based on verbal autopsies were excluded. Numbers of MD and cardiac‐related deaths were extracted. We calculated cardiac disease MMR (cMMR, cardiac‐related MD/100 000 live births) and proportion of cardiac‐related MDs among all MDs. Frequency of cardiac MD was compared with the MMR of the country.
Results
Forty‐seven reports were included, which reported on 38,486 maternal deaths in LMIC. Reported cMMR ranged from 0/100 000 live births (Moldova, Ghana) to 31.9/100 000 (Zimbabwe). The proportion of cardiac‐related MD ranged from 0% (Moldova, Ghana) to 24.8% (Sri Lanka). In countries with a higher MMR, cMMR was also higher. However, the proportion of cardiac‐related MD was higher in countries with a lower MMR.
Conclusions
The burden of cardiac‐related mortality is difficult to assess due limited availability of mortality reports. The proportion of cardiac deaths among all MD appeared to be higher in countries with a lower MMR. This is in line with what has been called ‘obstetric transition’: pre‐existing medical diseases including cardiac disease are becoming relatively more important where the MMR falls.
ObjectifsEvaluer la fréquence des décès maternels (DM) dus à une maladie cardiaque dans les pays à revenu faible ou intermédiaire (PRFI).
MéthodesRevue systématique en recherchant sur Medline, EMBASE, Web of Science, Cochrane Library, Emcare, LILACS, African Index Medicus, IMEMR, IndMED , WPRIM, IMSEAR jusqu'au 1er novembre 2017. Les reports de mortalité maternelle provenant des PRFI examinant tous les DM dans une zone géographique donnée ont été inclus. Les reports en milieu hospitalier ou ceux basés uniquement sur des autopsies verbales ont été exclus. Le nombre de DM et de décès liés à la maladie cardiaque a été extrait. Nous avons calculé le taux de mortalité maternelle par maladie cardiaque (TMMc, DM lié à un effet cardiaque/100.000 naissances vivantes) et la proportion de DM cardiaques parmi tous les DM. La fréquence des DM cardiaques a été comparée au TMM du pays.
Résultats47 reports ont été inclus, faisant état de 38.486 décès maternels dans les PRFI. Le TMMc rapporté allait de 0/100.000 naissances vivantes (Moldavie, Ghana) à 31,9/100.000 (Zimbabwe). La proportion de DM d'origine cardiaque variait de 0% (Moldavie, Ghana) à 24,8% (Sri Lanka). Dans les pays avec un TMM plus élevé, le TMMc était également plus élevé. Cependant, la proportion de DM d'origine cardiaque était plus élevée dans les pays où le TMM était inférieur.
ConclusionsLa charge de la mortalité liée à une maladie cardiaque est difficile à évaluer en raison de la disponibilité limitée des rapports de mortalité. La proportion de décès cardiaques parmi tous les DM semble être plus élevée dans les pays où le TMM est plus faible. Cela correspond à ce que l'on a appelé la «transition obstétricale»: les maladies médicales préexistantes, y compris les maladies cardiaques, deviennent relativement plus importantes là où le TMM chute.
Background & Aims
Namibia has been suffering from an outbreak of hepatitis E genotype 2 since 2017. As nearly half of hepatitis E‐related deaths were among pregnant and postpartum women, we analysed ...maternal and fetal outcomes of pregnancies complicated by acute hepatitis E and assessed whether HIV‐status impacted on outcome.
Methods
A retrospective cross‐sectional study was performed at Windhoek Hospital Complex. Pregnant and postpartum women, admitted between 13 October 2017 and 31 May 2019 with reactive IgM for Hepatitis E, were included. Outcomes were acute liver failure (ALF), maternal death, miscarriage, intra‐uterine fetal death and neonatal death. Odds ratios (OR) and 95% confidence interval (CI) were calculated.
Results
Seventy women were included. ALF occurred in 28 (40.0%) of whom 13 died amounting to a case fatality rate of 18.6%. Sixteen women (22.9%) were HIV infected, compared to 16.8% among the general pregnant population (OR 1.47, 95% CI 0.84‐2.57, P = .17). ALF occurred in 4/5 (80%) HIV infected women not adherent to antiretroviral therapy compared to 1/8 (12.5%) women adherent to antiretroviral therapy (OR 28.0, 95% CI 1.4‐580.6). There were 10 miscarriages (14.3%), five intra‐uterine fetal deaths (7.1%) and four neonatal deaths (5.7%).
Conclusions
One in five pregnant women with Hepatitis E genotype 2 died, which is comparable to genotype 1 outbreaks. Despite small numbers, HIV infected women receiving antiretroviral therapy appear to be less likely to develop ALF in contrast with HIV infected women not on treatment. As there is currently no curative treatment, this phenomenon needs to be assessed in larger cohorts.
Background
Prolonged second stage of labour is an important cause of maternal and perinatal morbidity and mortality. Vacuum extraction (VE) and second‐stage caesarean section (SSCS) are the most ...commonly performed obstetric interventions, but the procedure chosen varies widely globally.
Objectives
To compare maternal and perinatal morbidity, mortality and other adverse outcomes after VE versus SSCS.
Search Strategy
A systematic search was conducted in PubMed, Cochrane and EMBASE. Studies were critically appraised using the Newcastle–Ottawa scale.
Selection Criteria
All artictles including women in second stage of labour, giving birth by vacuum extraction or cesarean section and registering at least one perinatal or maternal outcome were selected.
Data Collection and Analysis
The chi‐square test, Fisher exact's test and binary logistic regression were used and various adverse outcome scores were calculated to evaluate maternal and perinatal outcomes.
Main Results
Fifteen articles were included, providing the outcomes for a total of 20 051 births by SSCS and 32 823 births by VE. All five maternal deaths resulted from complications of anaesthesia during SSCS. In total, 133 perinatal deaths occurred in all studies combined: 92/20 051 (0.45%) in the SSCS group and 41/32 823 (0.12%) in the VE group. In studies with more than one perinatal death, both conducted in low‐resource settings, more perinatal deaths occurred during the decision‐to‐birth interval in the SSCS group than in the VE group (5.5% vs 1.4%, OR 4.00, 95% CI 1.17–13.70; 11% vs 8.4%, OR 1.39, 95% CI 0.85–2.26). All other adverse maternal and perinatal outcomes showed no statistically significant differences.
Conclusions
Vacuum extraction should be the recommended mode of birth, both in high‐income countries and in low‐ and middle‐income countries, to prevent unnecessary SSCS and to reduce perinatal and maternal deaths when safe anaesthesia and surgery is not immediately available.
Objectives
We sought to understand the facilitators and barriers impacting utilisation of follow‐up services for children born preterm as perceived by parents in a low‐resource setting.
Methods
We ...conducted a qualitative study at Mulago Hospital, Uganda, with parents of children born preterm and aged 22–38 months at the time of the study. We collected data using five in‐depth interviews and four focus group discussions. Data were analysed using thematic analysis informed by the social–ecological model.
Results
Ten subthemes emerged that could be grouped into three main themes: (1) Individual: parents' knowledge, parenting skills, perception of follow‐up and infant's condition; (2) Relationship: support for the mother and information sharing; (3) Institution: facility setup, cost of care, available personnel and distance from the facility. Parents of preterm infants perceived receiving timely information, better understanding of prematurity and its complications, support from spouses, availability of free services and encouragement from health workers as facilitators for utilisation of follow‐up services. Limited male involvement, parents' negative perception of follow‐up, stable condition of infant, health facility challenges especially congestion at the hospital, distance and care costs were key barriers.
Conclusion
An interplay of facilitators and barriers at individual, interpersonal and health system levels encourage or deter parents from taking their preterm children for follow‐up services. Improving utilisation of services will require educating parents on the importance of follow‐up even when children are not sick, eliciting maternal support from spouses and peers and addressing health system gaps that make follow‐up unattractive and costly.
Background
In the absence of robust vital registration systems, many low‐ and middle‐income countries (LMICs) rely on national surveys or routine surveillance systems to estimate the maternal ...mortality ratio (MMR). Although the importance of MMR estimates in ending preventable maternal deaths is acknowledged, there is limited research on how different approaches are used and adapted, and how these adaptations function.
Objectives
To assess methods for estimating maternal mortality in LMICs and the rationale for these modifications.
Search Strategy
A literature search with the terms “maternal death”, “surveys” and “low‐ and middle‐income countries” was performed in Medline, Embase, Web of Science, Scopus, CINAHL, APA PsycINFO, ERIC, and IBSS from January 2013 to March 17, 2023.
Selection Criteria
Studies were eligible if their main focus was to compare, adapt, or assess methods to estimate maternal mortality in LMICs.
Data Collection and Analysis
Titles and s were screened using Rayyan. Relevant articles were independently reviewed by two reviewers against inclusion criteria. Data were extracted on mortality measurement methods, their context, and results.
Main Results
Nineteen studies were included, focusing on data completeness, subnational estimates, and community involvement. Routinely generated MMR estimates are more complete when multiple data sources are triangulated, including data from public and private health facilities, the community, and local authorities (e.g. vital registration, police reports). For subnational estimates, existing (e.g. the sisterhood method and reproductive‐age mortality surveys RAMOS) and adapted methods (e.g. RAMOS 4 + 2 and Pictorial Sisterhood Method) provided reliable confidence intervals. Community engagement in data collection increased community awareness of maternal deaths, provided local ownership, and was expected to reduce implementation costs. However, most studies did not include a cost‐effectiveness analysis.
Conclusion
Household surveys with community involvement and RAMOS can be used to increase data validity, improve local awareness of maternal mortality estimates, and reduce costs in LMICs.
Synopsis
Scoping review evaluating 19 studies on estimating maternal mortality in low‐ and‐middle‐income countries, covering method completeness, provision of subnational estimates, and involvement of community members.
Background
Studies indicate unwarranted variation in a wide range of neonatal care practices, contributing to preventable morbidity and mortality. Unwarranted variation is the result of complex ...interactions and multiple determinants. One of the determinants contributing to unwarranted variation in care may be variation in local hospital protocols. The purpose of this study was to examine variation in the content of obstetric and neonatal protocols for six common indications for neonatal referral to the pediatrician: large for gestational age/macrosomia, small for gestational age/fetal growth restriction, meconium‐stained amniotic fluid, vacuum extraction, forceps extraction, and cesarean birth.
Methods
We conducted a nationwide cross‐sectional study examining protocols for neonatal referral to the pediatrician in the obstetric and neonatal departments of all Dutch hospitals. Variation in protocols was analyzed between regions, between neonatal and obstetrics departments located in the same hospital, and within neonatal and obstetrics departments.
Results
There was considerable variation in protocols between regions, between neonatal and obstetrics departments, and within neonatal and obstetrics departments. The results of this study showed considerable variation in recommendations for type of referral, admission, screening/diagnostic tests, treatment, and discharge. Furthermore, results generally showed lower referral thresholds in neonatal departments compared with obstetric departments, and higher referral thresholds in the eastern region of the Netherlands. We also found variation in local hospital protocols, which could not be explained by population characteristics but which may be explained by varying recommendations in existing national and international guidelines and/or lack of adherence to these guidelines.
Conclusions
To reduce unwarranted variation in local protocols, evidence‐based, multidisciplinary guidelines should be developed in the Netherlands. Further research addressing knowledge gaps is needed to inform these guidelines. Attention should be paid to the implementation of evidence, and only where evidence is lacking or inconclusive should agreements be based on multidisciplinary consensus. Where protocols deviate from evidence‐based guidelines because of specific local circumstances, clearer, more transparent justifications should be made. Uniformity in guidance will offer clear standards for care evaluation and provide opportunities to reduce inappropriate care.
Objective
The aim of the present study was to identify facility‐based incidence of severe obstetric complications through a newly established obstetric surveillance system in eastern Ethiopia.
...Methods
Monthly registration of obstetric hemorrhage, eclampsia, uterine rupture, severe anemia and sepsis was introduced in 13 maternity units in eastern Ethiopia. At each hospital, a designated clinician reported details of women admitted during pregnancy, childbirth or within 42 days of termination of pregnancy from April 01, 2021 to March 31, 2022 developing any of these conditions. Detailed data on sociodemographic characteristics, obstetric complications and status at discharge were collected by trained research assistants.
Results
Among 38 782 maternities during the study period, 2043 (5.3%) women had any of the five conditions. Seventy women died, representing a case fatality rate of 3.4%. The three leading reasons for admission were obstetric hemorrhage (972; 47.6%), severe anemia (727; 35.6%), and eclampsia (438; 21.4%). The majority of the maternal deaths were from obstetric hemorrhage (27/70; 38.6%) followed by eclampsia (17/70; 24.3%).
Conclusion
Obstetric hemorrhage, severe anemia and eclampsia were the leading causes of severe obstetric complications in eastern Ethiopia. Almost one in 29 women admitted with obstetric complications died. Audit of quality of care is indicated to design tailored interventions to improve maternal survival and obstetric complications.
Synopsis
One in 20 pregnant women admitted to hospitals in eastern Ethiopia developed one of the five major adverse obstetric conditions.
Among migrants in high-income countries, maternal mortality and severe morbidity generally occur more frequently as compared to host populations. There is marked variation between groups of migrants ...and host countries, with much elevated risks in some groups and no elevated risk at all in others. Those without a legal resident permit are most vulnerable. A reason for these elevated risks could be a different risk profile in migrants, but risk factors are unevenly distributed and not always present. Another reason is substandard care, which is identified more frequently in migrants, and comprises patient delays, for example, due to a lack of knowledge about the health system in the host country, and health worker delays, often compounded by communication barriers. Improvements in family planning and antenatal services are needed, and audits and confidential enquiries should be extended to include maternal morbidity and ethnic background. This requires scientific and political efforts.
Objective
To identify the incidence and characteristics of maternal suicide.
Design
Nationwide population‐based cohort study.
Setting
The Netherlands, 2006–2020.
Population
Women who died during ...pregnancy or within 1 year postpartum, and a reference population of women aged 25–45 years.
Methods
The Cause of Death Register and Medical Birth Register were linked to identify women who died within 1 year postpartum. Data were combined with deaths reported to the Audit Committee for Maternal Mortality and Morbidity (ACMMM), which performs confidential enquiries. Maternal suicides were compared with a previous period (1996–2005). Risk factors were obtained by combining vital statistics databases.
Main outcome measures
Comparison of incidence and proportion of maternal suicides among all maternal deaths over time, sociodemographic and patient‐related risk factors and underreporting of postpartum suicides.
Results
The maternal suicide rate remained stable with 68 deaths: 2.6 per 100 000 live births in 2006–2020 versus 2.5 per 100 000 in 1996–2005. The proportion of suicides among all maternal deaths increased from 18% to 28%. Most suicides occurred throughout the first year postpartum (64/68); 34 (53%) of the women who died by suicide postpartum were primiparous. Compared with mid‐level, low educational level was a risk factor (odds ratio 4.2, 95% confidence interval 2.3–7.9). Of 20 women reported to the ACMMM, 11 (55%) had a psychiatric history and 13 (65%) were in psychiatric treatment at the time of death. Underreporting to ACMMM was 78%.
Conclusions
Although the overall maternal mortality ratio declined, maternal suicides did not and are now the leading cause of maternal mortality if late deaths up to 1 year postpartum are included. Data collection and analysis of suicides must improve.
Linked article: This article is commented on by Griffiths pp. 1399 in this issue. To view this article visit https://doi.org/10.1111/1471‐0528.17804.
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