Maternal mortality due to obstetric hemorrhage by surgical injury during cesarean section: A nationwide study.

INTRODUCTION: Obstetric hemorrhage remains a largely preventable cause of maternal mortality globally. The contribution of uterine atony to hemorrhage-related maternal mortality has decreased in France, while the contribution of other causes of obstetric hemorrhage such as surgical injury during cesarean has been reported to increase. However, little evidence exists regarding the risk factors and care processes of women who died from this cause of hemorrhage. Therefore, we aimed to describe the clinical profile, underlying mechanisms, and preventability factors among women who died from obstetric hemorrhage by surgical injury during cesarean section. MATERIAL AND METHODS: Nationwide analysis of all hemorrhage-related maternal deaths by surgical injury during cesarean in France identified by the nationwide permanent enhanced maternal mortality surveillance system (ENCMM) between 2007 and 2018. We described the characteristics of the women, delivery hospitals, circumstances of hemorrhage, features of obstetric and resuscitation/transfusion care, and main preventability factors. RESULTS: Between 2007 and 2018, hemorrhage-related maternal mortality in France decreased from 1.6/100 000 live births (95% CI 1.1-2.2) (39/2 472 650) in 2007-2009 to 0.8/100 000 live births (95% CI 0.5-1.3) (19/2 311 783) in 2016-2018. Hemorrhage-related maternal mortality ratio due to surgical injury during cesarean increased from 0.08 (95% CI 0.01-0.3) (2/2 472 650) to 0.2 (95% CI 0.07-0.5) (5/2 311 783) per 100 000 live births. Among the 18 women who died from surgical injury during cesarean over the 12-year study period, we report a high prevalence of obesity (67%, 12/18), previous cesarean (72%, 13/18), and second-stage cesareans (56%, 10/18). In 22% (4/18), cesarean section was performed in a hospital providing <1000 births annually, with no blood bank (39%, 7/18) or no adult intensive care (44%, 8/18) on-site. Overall preventability of deaths was 94% (17/18). Main preventability factors were related to delay in hemorrhage diagnosis (77%, 14/18) due to late recognition of abnormal parameters (33%, 6/18) and late bedside ultrasound (56%, 10/18), and delay in management due to insufficient surgical skills (56%, 10/18). CONCLUSIONS: In France, surgical injury during cesarean section is an increasing, largely preventable contributor to hemorrhage-related maternal mortality, as other causes of fatal hemorrhage have become less frequent. The profile of these women showed a high prevalence of obesity, previous cesarean, second-stage cesarean, and delivery in hospitals with limited medical and surgical resources, which suggests explanatory mechanisms for the fatal outcome and opportunities for prevention.

Pulmonary oedema in the course of severe maternal outcome in South Africa: A cohort study combined with clinical audit.

OBJECTIVES: To describe the incidence and outcomes of pulmonary oedema in women with severe maternal outcome during childbirth and identify possible modifiable factors through audit. METHODS: All women with severe maternal outcome (maternal deaths or near misses) who were referred to Tygerberg referral hospital from health facilities in Metro East district, South Africa, during 2014-2015 were included. Women with severe maternal outcome and pulmonary oedema during pregnancy or childbirth were evaluated using three types of critical incident audit: criterion-based case review by one consultant gynaecologist, monodisciplinary critical incident audit by a team of gynaecologists, multidisciplinary audit with expert review from anaesthesiologists and cardiologists. RESULTS: Of 32,161 pregnant women who gave birth in the study period, 399 (1.2%) women had severe maternal outcome and 72/399 (18.1%) had pulmonary oedema with a case fatality rate of 5.6% (4/72). Critical incident audit demonstrated that pre-eclampsia/HELLP-syndrome and chronic hypertension were the main conditions underlying pulmonary oedema (44/72, 61.1%). Administration of volumes of intravenous fluids in already sick women, undiagnosed underlying cardiac illness, administration of magnesium sulphate as part of pre-eclampsia management and oxytocin for augmentation of labour were identified as possible contributors to the pathophysiology of pulmonary oedema. Women-related factors (improved antenatal care attendance) and health care-related factors (earlier diagnosis and management) would potentially have improved maternal outcome. CONCLUSIONS: Although pulmonary oedema in pregnancy is rare, among women with severe maternal outcome a considerable proportion had pulmonary oedema (18.1%). Audit identified options for prevention of pulmonary oedema and improved outcome. These included early detection and management of preeclampsia with close monitoring of fluid intake and cardiac evaluation in case of suspected pulmonary oedema. Therefore, a multidisciplinary clinical approach is recommended.

Too busy to care? Analysing the impact of system-related factors on maternal mortality in Zanzibar's Referral Hospital.

This study analyses the contribution of system-related factors to maternal mortality in the low-resource setting of Mnazi Mmoja Hospital in Zanzibar, Tanzania. It is a retrospective cohort study including all maternal deaths (MD, n = 139) and maternal near-misses (MNM, n = 122) in Mnazi Mmoja Hospital with sufficient documentation during 2015 to 2018 (MD) and 2017 to 2018 (MNM). The number of admissions and surgical interventions per health care provider on the day of admission and the number of times vital signs were monitored per day were compared between MNM and MD cases using logistic regression. The mean number of times vital signs were monitored per day was associated with reduced odds of mortality (aOR 0.75, 95% CI 0.64-0.89), after adjustment for confounding factors such as severity of illness. The numbers of admissions or surgical procedures per health care provider were not associated with mortality. Concluding, the degree of monitoring of patients with life-threatening complications of pregnancy or childbirth is associated with the risk of mortality independent of the degree of severity. Preventing maternal mortality requires going beyond availability of essential interventions to tackle system-related factors that have a direct impact on the capacity to provide comprehensive care.Impact StatementWhat is already known on this subject? Root cause analyses of maternal deaths have identified many system-related factors, such as availability of health care providers, adequate training, and motivation to sustain high intensity monitoring (Madzimbamuto et al. 2014; Mahmood et al. 2018).What do the results of this study add? This is the first study to attempt to quantify the contribution of these system-related factors by comparing cases of maternal death with cases of maternal near-miss. We show that the degree of monitoring of patients with life-threatening complications is associated with the odds of mortality independent of the degree of severity. Even though this relation should not be regarded as causative, monitoring of vital signs can be seen as reflective of many system-related factors which hamper or facilitate comprehensive care.What are the implications of these findings for clinical practice and/or further research? This study helps increase general understanding of the factors leading to progression from severe disease to death in a high-volume low-income setting.

The Pattern and Spectrum of Severe Maternal Morbidities in Nigerian tertiary Hospitals.

Maternal morbidities are precursors to maternal mortality as well as potential causes of life time disability and poor quality of life. This study aimed to determine the pattern and spectrum of life-threatening maternal morbidities seen in tertiary reproductive health facilities in Nigeria. All cases of severe maternal outcome (SMO), maternal near-misses (MNM), or maternal death (MD), attending 42 tertiary hospitals across all geopolitical zones of Nigeria were prospectively identified using the WHO criteria over a period of 14 months. The main outcome measures were the incidence and outcome of severe maternal outcome by geopolitical regions of Nigeria. The participating hospitals recorded a total of 4383 severe maternal outcomes out of which were 3285 maternal near-misses and 998 maternal deaths. The proportion of maternal near-miss was similar across all the geopolitical zones but the maternal mortality ratio was highest in the southwestern zone (1,552) and least in the northcentral zone (750) of the country. Haemorrhage was the leading cause of severe maternal morbidities followed by hypertensive disorders of pregnancy. The mortality index of about 41% using the organ dysfunction criterion was triple the figures from other parts of the world. The findings reflect poor obstetric care in the tertiary hospitals in Nigeria. The health facilities in the country urgently need to be revamped.

Non-obstetric causes of severe maternal complications: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To evaluate the burden, causes and outcomes of severe non-obstetric maternal complications in Nigerian public tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary health facilities. POPULATION: Women admitted with complications during pregnancy, childbirth or puerperium. METHODS: All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) due to non-obstetric causes were prospectively identified over a 1-year period. Maternal near-miss was defined using organ-system dysfunction (WHO), clinical, or management-based criteria. MAIN OUTCOME MEASURES: Causes and contributions of non-obstetric complications to SMO; fetal and neonatal outcomes; health service events associated with non-obstetric complications; and mortality index (% of maternal death/SMO). RESULTS: Of 100 107 women admitted with complications, 9401 (9.4%) were for non-obstetric causes; and 4.0% (375/9401) suffered severe non-obstetric complications. Of the 375 cases of severe non-obstetric complications, 48.8% (183/375) were near-misses and 51.2% (192/375) were maternal deaths. Severe anaemia unrelated to haemorrhage contributed 61.2% of near-misses and 32.8% of maternal deaths. The highest mortality indices were observed for cancer (91.7%), hepatic diseases (81.8%) and HIV/AIDS/HIV wasting syndrome (80.4%). Fatality was significantly high with extremes of age and no formal education. Regarding organ dysfunctions, neurological (77.1%) and cardiovascular (75.0%) dysfunctions had the highest mortality indices. Perinatal mortality was 65.9%. Time from diagnosis of severe non-obstetric complications to review by senior medical personnel, and to definitive intervention was <30 minutes in 30.2% and 29.8% of women with SMO, respectively. However, over 240 minutes elapsed between diagnosis and definitive intervention in more than one-third of women with SMO. CONCLUSION: Non-obstetric complications are associated with poorer pregnancy outcomes and deserve attention similar to that accorded obstetric complications. FUNDING: The original research that generated the data for this secondary analysis and the publication of this secondary analysis were funded by the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization (WHO). TWEETABLE ABSTRACT: Non-obstetric causes are important contributors to maternal deaths and life-threatening morbidities in Nigerian hospitals.

Maternal near-miss and death among women with postpartum haemorrhage: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate the burden and health service events surrounding severe maternal outcomes (SMO) related to life-threatening postpartum haemorrhage (PPH) in Nigerian public tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth or puerperal complications. METHODS: All cases of SMO [maternal near miss (MNM) or maternal death (MD)] due to PPH were prospectively identified using WHO criteria over a 1-year period. MAIN OUTCOME MEASURES: Incidence of SMO, health service events, case fatality rate (CFR) and mortality index (MI: % of death/SMO). RESULTS: Postpartum haemorrhage occurred in 2087 (2.2%) of the 94 835 deliveries recorded during the study period. A total of 354 (0.3%) women had an SMO (103 MD; 251 MNM). It was the most frequent obstetric haemorrhagic complication across hospitals. PPH had the highest maternal mortality ratio (112/100 000 live births) and the recorded MI (29.1%) and CFR (4.9%) were second only to that of ruptured uterus. About 83% of women with SMO were admitted in a critical condition with over 50% being referred. MD was more likely when PPH led to neurological (80.8%), renal (73.5%) or respiratory (58.7%) organ dysfunction. Although the timing of life-saving interventions was not statistically different between the cases of MD and MNM, close to one-quarter of women who died received critical intervention at least 4 hours after diagnosis of life-threatening PPH. CONCLUSIONS: Postpartum haemorrhage was a significant contributor to obstetric haemorrhage and SMO in Nigerian hospitals. Emergency obstetric services should be enhanced at the lower levels of healthcare delivery to reduce avoidable deaths from PPH. FUNDING: The original research that generated the data for this secondary analysis, and the publication of this secondary analysis, was funded by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization. We have no other funding issue to declare for our study. TWEETABLE ABSTRACT: One hundred and three maternal deaths and 251 near-misses resulted from PPH in 42 Nigerian tertiary facilities in 1 year.

Maternal near-miss and death among women with hypertensive disorders in pregnancy: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate life-threatening maternal complications related to hypertensive disorders of pregnancy (HDP) in Nigerian public tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth or puerperal complications. METHOD: All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) due to HDP were prospectively identified using the WHO criteria over a 1-year period. MAIN OUTCOME MEASURES: Incidence of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO). RESULTS: Out of 100 107 admissions for maternal complications, 6753 (6.8%) women had HDP. Pre-eclampsia (PE) (54.5%) and eclampsia (E) (30.4%) were the most common HDP recorded. SMO occurred in 587 women with HDP: 298 maternal near-misses and 289 maternal deaths. The majority (93%) of the women with SMO due to HDP were admitted in a critical condition. The median diagnosis-definitive intervention interval was over 4 hours in a quarter of women who died from HDP. For PE and E, case fatality rates were 1.9 and 10.4%, respectively, although both conditions had a similar mortality index of 49.3%. Lack of antenatal care and place of residence further than 5 km from the hospital were associated with maternal death. CONCLUSIONS: Severe maternal outcomes from HDP were due to late presentations and health system challenges. To reduce maternal deaths from HDP, health system strengthening that would engender early hospital presentation and prompt treatment is recommended. FUNDING: The original research that generated the data for this secondary analysis was funded by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization (WHO). We have no other funding issue to declare for our study. TWEETABLE ABSTRACT: Eclampsia is the leading cause of maternal death in Nigerian hospitals.

Maternal near-miss and death among women with rupture of the gravid uterus: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate the burden of maternal near-miss and death due to rupture of the gravid uterus, the indicators of quality of care, and avoidable factors associated with care deficiencies for ruptured uterus in Nigerian tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth or puerperal complications. METHODS: Cases of severe maternal outcome [SMO: maternal near-miss (MNM) or maternal death (MD)] following uterine rupture were prospectively identified over 1 year. MAIN OUTCOME MEASURES: Incidence of SMO, indicators of quality of care, and avoidable factors associated with deficiencies in care. RESULTS: There were 91 724 live births and 3285 women with SMO during the study period. SMO due to uterine rupture occurred in 392 women: 305 MNM and 87 MD. Uterine rupture accounted for 11.9, 13.3, and 8.7% of all SMO, MNM, and MD, respectively. SMO, MNM, and intra-hospital maternal mortality ratios due to uterine rupture were 4.3/1000 live births, 3.3/1000 live births, and 94.8/100 000 live births, respectively. Mortality index (% of MD/SMO) was 22.2%, and MNM:MD ratio was 3.5. Avoidable factors contributing to deaths were related to patient-orientated problems, especially late hospital presentation and lack of insurance to cover life-saving interventions. Medical personnel problems contributed to care deficiencies in one-third of women who died. CONCLUSION: Uterine rupture significantly contributes to SMO in Nigerian tertiary hospitals. Strategies to improve maternal survival should address avoidable institutional factors and include community-based interventions to encourage skilled attendance at birth and early referral of complications. TWEETABLE ABSTRACT: Uterine rupture remains an important cause of maternal death in Nigerian tertiary hospitals.

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.

The burden of severe maternal outcomes and indicators of quality of maternal care in Nigerian hospitals: a secondary analysis comparing two large facility-based surveys.

OBJECTIVE: To compare severe maternal outcomes (SMOs) from two multi-centre surveys in Nigerian hospitals, and to evaluate how the SMO burden affects quality of secondary and tertiary hospital care. DESIGN: Two facility-based surveys of women experiencing SMO (maternal near-miss or maternal deaths). SETTING: Sixteen secondary and five tertiary facilities in Nigeria [WHO Multi-Country Survey on Maternal and Newborn Health (WHOMCS)] and 42 public tertiary facilities in Nigeria (Nigeria Near-Miss and Maternal Death Survey). POPULATION: 371 women in WHOMCS-Nigeria and 2449 women in Nigeria Near-Miss and Maternal Death Survey who experienced SMO. METHODS: Secondary analysis and comparison of SMO data from two surveys, stratified by facility level. MAIN OUTCOME MEASURES: Maternal mortality ratio (MMR) per 100 000 livebirths (LB), maternal near-miss (MNM) ratio per 1000 LB, SMO ratio per 1000 LB and mortality index (deaths/SMO). RESULTS: Maternal mortality ratio and mortality indices were highest in tertiary facilities of the WHOMCS-Nigeria (706 per 100 000; 26.7%) and the Nigeria Near-Miss and Maternal Death Survey (1088 per 100 000; 40.8%), and lower in secondary facilities of the WHOMCS-Nigeria (593 per 100 000; 17.9%). The MNM ratio and SMO ratio were highest in secondary WHOMCS-Nigeria facilities (27.2 per 1000 LB; 33.1 per 1000 LB). CONCLUSIONS: Tertiary-level facilities in Nigeria experience unacceptably high maternal mortality rates, but secondary-level facilities had a proportionately higher burden of severe maternal outcomes. Common conditions with a high mortality index (postpartum haemorrhage, eclampsia, and infectious morbidities) should be prioritised for action. Surveillance using SMO indicators can guide quality improvement efforts and assess changes over time. TWEETABLE ABSTRACT: 2820 Nigerian women with severe maternal outcomes: high mortality in tertiary level hospitals, higher burden in secondary level.

Comparison of outcome between intrauterine balloon tamponade and uterine artery embolization in the management of persistent postpartum hemorrhage: A propensity score-matched cohort study.

INTRODUCTION: The aim of this study was to compare the outcomes of women who were initially managed by intrauterine balloon tamponade or uterine artery embolization because of persistent postpartum hemorrhage demanding an immediate intervention to control bleeding. MATERIAL AND METHODS: Propensity score-matched cohort study including women who had intrauterine balloon tamponade or uterine artery embolization as initial management strategy to control persistent postpartum hemorrhage, that is, refractory to first-line therapy combined with at least one uterotonic agent. The primary outcome measure was a composite of peripartum hysterectomy and/or maternal mortality. Secondary outcomes measures were total volume of blood loss and total number of packed red blood cells transfused. RESULTS: Our 1:1 propensity score-matched cohort comprised of 50 women who had intrauterine balloon tamponade and 50 women who underwent uterine artery embolization at a blood loss between 1000 and 7000 mL. There was no statistically significant difference in the hysterectomy risk between the two groups (n = 6 in each group, odds ratio [OR] 1.00, 95% confidence interval [CI] .30-3.34), in total volume of blood loss (median 4500 mL, interquartile range [IQR] 3600-5400) for balloon vs 4000 mL (IQR 3250-5000) for embolization, P = 0.382) or in total units of packed red blood cells transfused (median 7 (IQR 5-10) for balloon vs 6 [IQR 4-9] for embolization, P = 0.319). Fifteen women (30%) who were initially managed by an intrauterine balloon still underwent uterine artery embolization, of whom one had an embolization-related thrombo-embolic event. Maternal mortality occurred in neither of the intervention groups. CONCLUSIONS: No difference in the risk of peripartum hysterectomy and/or maternal death was observed between women who had intrauterine balloon tamponade and women who underwent uterine artery embolization as an initial management for persistent postpartum hemorrhage. Although this study was underpowered to demonstrate equivalence, our study design provides a framework for future research in which intrauterine balloon tamponade may prove to be a suitable intervention of first choice in the management of persistent postpartum hemorrhage.

Incidence of maternal near miss in the public health sector of Harare, Zimbabwe: a prospective descriptive study.

BACKGROUND: Maternal 'near miss' can be a proxy for maternal death and it describes women who nearly died due to obstetric complications. It measures life threatening pregnancy related complications and allows the assessment of the quality of obstetric care. METHODS: A prospective descriptive study was carried out from October 1 2016 to 31 December 2016, using the WHO criteria for maternal 'near miss' at the two tertiary public hospitals which receive referrals of all obstetric complications in Harare city, Zimbabwe. The objective was to calculate the ratio of maternal 'near miss' and associated factors. All pregnant women who developed life threatening complications classified as maternal near miss using the WHO criteria were recruited and followed up for six weeks from discharge, delivery or termination of pregnancy or up to the time of death. RESULTS: During this period there were 11,871 births. One hundred and twenty three (123) women developed severe maternal outcomes, 110 were maternal 'near miss' morbidity and 13 were maternal deaths. The maternal 'near miss' ratio was 9.3 per 1000 deliveries, the mortality index (MI) was 10.6% and the maternal mortality ratio was 110 per 100,000 deliveries. The major organ dysfunction among cases with severe maternal outcomes (SMO) was cardiovascular dysfunction (76.9%). The major causes of maternal near miss were obstetric haemorrhage (31.8%), hypertensive disorders (28.2%) and complications of miscarriages (20%). The intensive care unit (ICU) admission rate was 7.3 per 100 cases of SMO and 88.8% of maternal deaths occurred without ICU admission. CONCLUSION: The MNM ratio was comparable to that in the region. Obstetric haemorrhage was a leading cause of severe maternal morbidity though with less mortality when compared to hypertensive disorders and abortion complications. Zimbabwe should adopt maternal near miss ratio as an indicator for evaluating its maternal health services.

Incidence and determinants of severe maternal outcome in Jimma University teaching hospital, south-West Ethiopia: a prospective cross-sectional study.

BACKGROUND: Investigating cases of severe maternal morbidity (SMM) and severe maternal outcome (SMO) and the quality of maternal health care using near-miss approach has become popular over recent years. The aim of this study was to determine facility based incidence and the determinants of severe maternal outcome (SMO) using this approach. METHODS: Prospective cross-sectional study among all mothers who presented to study facility while pregnant, during child birth and/or within 42 days after termination of pregnancy seeking care and found to have SMM and SMO during the study period was carried out. RESULTS: There were total of 2737 live births, 202 SMM and 162 SMO (138 maternal near-misses (MNM) and 24 maternal deaths (MD)) cases. The SMO ratio was 59.2 per 1000 live births and the MNM mortality ratio, mortality index (MI) and maternal mortality ratio (MMR) were: 5.8:1, 14.8% and 876.9 per 100,000 live births respectively. Close to three-fourth of all women with SMO had evidence of organ dysfunction on arrival or within 12 h of hospitalization. The commonest underlying causes for SMO were uterine rupture 27%, followed by hypertensive disorders 24% and obstetric hemorrhage 24%. The highest case fatality rate was found to be associated with eclampsia 28%. Maternal age, residential area, educational status and occupation were associated with SMO (P < 0.0001). On binary multivariable logistic regression the occurrence of any delay, intrapartal detection of complication, the mode of delivery and duration of hospitalization had statically significant association with SMO (p < 0.05). Optimal number of antenatal care (ANC) visits and delivery by emergency cesarean section (C/S) were found to be protective of SMO. CONCLUSION: The occurance SMO in the facility thus in the population served was high. Most of these factors associated with SMO are modifiable; some amenable to social change and the others are within the control of the health system. Thus the finding of this research calls for planning for such changes which can enhance timely and proper detection and management of pregnancy related complications.

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.

Maternal near miss hospitalizations in the Borana Zone, Ethiopia: A facility-based longitudinal cross-sectional study.

Background: Maternal near miss refers to a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of pregnancy termination. While there has been considerable progress in reducing maternal mortality rates, maternal near miss cases can provide valuable insights into the quality of maternal healthcare and help identify areas for improvement. However, there is limited evidence on the factors contributing to maternal near miss cases, including health system failures, delays in care, and provider-related factors. Therefore, this study aimed to assess the incidence, causes, and factors associated with maternal near misses in public Hospitals of Borena Zone. Methods: A facility-based longitudinal cross-sectional study design was employed at four Public Hospitals in Borena Zone from August 15, 2022, to November 15, 2022, using the WHO criteria for maternal near miss event. In total, 117 participants were included in the study. Eligibility was determined using key clinical, organ dysfunction, laboratory, and management criteria, as per the WHO guidelines for near-miss events. Underlying and contributing causes of maternal near misses were documented from each participant's records. Result: There were 1421 deliveries during the study period and 117 eligible women developed potentially life-threatening conditions. Only 61 women experienced severe maternal outcomes (55 near misses and six maternal deaths). The maternal near miss incidence ratio was 38.7 per 1000 live births, with a mortality index of 9.8%. Hypertensive disorders and obstetric hemorrhage are the leading underlying causes of maternal near misses. Conclusion: The incidence of maternal near miss was remarkably high when compared to previous studies. Giving special emphasis to life-saving interventions, critical care, reducing delays and improving the referral system are critical to improve quality of care.

Severe postpartum hemorrhage and the risk of adverse maternal outcome: A comparative analysis of two population-based studies in France and the Netherlands.

Objectives: Among women with severe PPH (sPPH) in France and the Netherlands, we compared incidence of adverse maternal outcome (major obstetric hemorrhage (≥2.5L blood loss) and/or hysterectomy and/or mortality) by mode of delivery. Second, we compared use and timing of resuscitation and transfusion management, second-line uterotonics and uterine-sparing interventions (intra-uterine tamponade, compression sutures, vascular ligation, arterial embolization) by mode of delivery. Methods:  Secondary analysis of two population-based studies of women with sPPH in France and the Netherlands. Women were selected by a harmonized definition for sPPH: (total blood loss ≥ 1500 ml) AND (blood transfusion of ≥ 4 units packed red blood cells and/or multicomponent blood transfusion). Findings: Incidence of adverse maternal outcome after vaginal birth was 793/1002, 9.1 % in the Netherlands versus 88/214, 41.1 % in France and 259/342, 76.2% versus 160/270, 59.3% after cesarean. Hemostatic agents such as fibrinogen were administered less frequently (p < 0.001) in the Netherlands (vaginal birth: 83/1002, 8.3% versus 105/2014, 49.5% in France; cesarean: 47/342, 13.7% and 152/270, 55.6%). Second-line uterotonics were started significantly later after PPH-onset in the Netherlands than France (vaginal birth: 46 versus 25 min; cesarean: 45 versus 18 min). Uterine-sparing interventions were less frequently (p < 0.001) applied in the Netherlands after vaginal birth (394/1002,39.3 %, 134/214, 62.6%) and cesarean (133/342, 38.9 % and 155/270, 57.4%), all initiated later after onset of refractory PPH in the Netherlands. Interpretation: Incidence of adverse maternal outcome was higher among women with sPPH in the Netherlands than France regardless mode of birth. Possible explanatory mechanisms are earlier and more frequent use of second-line uterotonics and uterine-sparing interventions in France compared to the Netherlands.

Maternal Near-Miss and Maternal Mortality in a Tertiary Care Center of Western Uttar Pradesh: A Retrospective Study.

INTRODUCTION: Maternal mortality is an important indicator to assess the quality of services provided by the health care system. However, maternal near-misses as well as maternal mortality are also indicators of how well the health care system serves pregnant women. To improve our healthcare system in terms of investigative capacity, infrastructure, and personnel, a near-miss registry can provide important information on gaps in pregnancy facilities. This will help us to identify the requirements for referral facility improvements and the need for various health awareness programs. We, therefore, designed this study to analyze the various near-miss events in mothers and compare them with maternal mortality. METHODS: Present study was conducted in the Department of Obstetrics and Gynecology, Lala Lajpat Rai Memorial (L.L.R.M.) Medical College associated with Sardar Vallabh Bhai Patel (S.V.B.P.) Hospital Meerut, Uttar Pradesh (UP), India for a period of one year and data were collected retrospectively from January 2022 to January 2023. All patients with life-threatening conditions such as excessive bleeding during pregnancy, hypertensive disorders of pregnancy (HDP), and septicemia that occurred during pregnancy or childbirth or within 42 days of termination of pregnancy and required ICU admissions, were included in the study. The total number of deliveries during the study period was 4,360 with 4,333 live births (LB). The total number of eligible cases was 79, out of which 52 were identified as maternal near misses and 27 were maternal mortality. Various maternal mortality and near-miss indices were analysed and statistical analysis was done using the SPSS version 21 (IBM Corp., Armonk, NY, USA). RESULTS: Our hospital's maternal mortality ratio (MMR) was 623/1lakh (0.623%), which is higher than the probability due to the deficiency of appropriate medical services in the nearby areas of western UP. The number of maternal near misses per 1000 LB (maternal near-miss ratio [MNMR]) was 12/1000 LB and the severe maternal outcome rate (SMOR) was 18/1000 LB (1.82%). In our study, hemorrhage and hypertensive disorder in pregnancy were the leading cause of morbidity and mortality followed by sepsis and severe anemia. Among organ dysfunction cardiac illness followed by respiratory dysfunction was the leading cause of morbidity and mortality. CONCLUSION: It is clear that there is a high burden of maternal near-miss in developing countries. There should be the establishment of well-equipped referral units at the periphery with trained manpower. The establishment of obstetrical high-dependence units (HDUs), rapid availability of blood and blood products, training of staff, and availability of multidisciplinary teams can minimize maternal mortality and morbidity.

The Association Between Severity of Anemia During Pregnancy and Severe Maternal Outcomes: A Retrospective Cohort Study.

Purpose: Anemia is a worldwide common condition during pregnancy, conferring a number of health risks to mothers. However, very little is known about the association between severity of anemia and severe maternal outcomes. This study aimed to assess the association between severity of anemia during pregnancy and the risk of severe maternal outcomes. Patients and Methods: This retrospective cohort study was based on data from China's National Maternal Near Miss Surveillance System for the period 2017-2018, which included 18 hospitals in southern China. Pregnant women admitted for delivery were divided into 4 groups based on severity of anemia during pregnancy: no anemia, mild anemia, moderate anemia, and severe anemia groups. Severe maternal outcomes were a composite of life-threatening conditions (ie, organ dysfunction) as defined by the WHO criteria, occurring at any time after admission until discharge or death. Modified Poisson regression analyses and propensity score-weighted regression analyses were used to estimate the relative risks (RRs) and 95% confidence intervals (CIs) of severe maternal outcomes among women with anemia of varying severity during pregnancy. Results: The incidence of severe maternal outcomes was 0.3% (417/138,556) in total, and the rates were 0.1% (85/99,755), 0.2% (30/18,502), 1.2% (234/19,697) and 11.3% (68/602) in no anemia, mild anemia, moderate anemia and severe anemia group, respectively. Compared with no anemia, the adjusted RR for severe maternal outcomes was 4.19 (95% CI, 3.20-5.50) in moderate anemia group and 22.12 (95% CI, 15.43-31.69) in severe anemia group; the weighted RR was 1.01 (95% CI, 1.01-1.01) in moderate anemia group and 1.11 (95% CI, 1.07-1.14) in severe anemia group. Conclusion: Moderate to severe anemia during pregnancy was independently associated with an increased risk of severe maternal outcomes. Maternal health care providers and pregnant women themselves should give more attention to the prevention and treatment of anemia during pregnancy, especially moderate to severe anemia.

Severe maternal outcome in Afghan immigrant women: A study in Tehran, Iran.

OBJECTIVE: To evaluate the risk factors for severe maternal outcome (SMO) in Afghan immigrant women. METHODS: Women with potentially life-threatening conditions (PLTC) were selected. Then risk factors for those PLTC which led to SMO (maternal near-miss or maternal death) were evaluated. In addition, risk factors for those SMOs occurring on hospital admission or during the first 12 hours after admission to the hospital (SMO12) were evaluated. RESULTS: Parity ≥3 (adjusted odds ratio [aOR] 3.24, 95% confidence interval [CI] 1.62-6.50, P = 0.03), low literacy level in mother (aOR 2.99, 95% CI 1.16-5.01, P = 0.03), inadequate prenatal care (aOR 2.74, 95% CI 1.2-3.87, P = 0.01), multigravidity (gravidity ≥5: aOR 2.62, 95% CI 1.31-4.53, P = 0.03), lack of health insurance (aOR 2.52, 95% CI 1.25-4.02, P = 0.01), and low literacy level in husband (aOR = 1.49, 95% CI 1.15-2.9, P = 0.02) were the risk factors for SMO in women with PLTC. Inadequate prenatal care (aOR 4.2, 95% CI 2.05-8.25, P = 0.04), low literacy level in mother (aOR 3.38, 95% CI 1.32-6.65, P = 0.04), parity ≥3 (aOR 2.69, 95% CI 1.16-4.7, P = 0.04), and lack of health insurance (aOR 2.13, 95% CI 1.25-3.67, P = 0.03) were risk factors for SMO12. CONCLUSION: There was a higher rate of SMO and SMO12 cases among Afghan immigrant women.

Impact of covid 19 pandemic on severe maternal outcomes -An observational study from a referral institute of India.

Introduction: Covid 19 pandemic has taken the world by storm. As far as maternal health is concerned, it has been affected both directly and indirectly. Not only are the women getting affected by COVID disease but also the health services are suffering in terms of availability, approachability and access. The study aimed to analyze the change in the trends of maternal near and maternal mortality comprising severe maternal outcome (SMO) between 2019 and 2020 in the department of obstetrics and gynaecology of our hospital due to COVID pandemic. Methods: This retrospective study was conducted in the Obstetrics and Gynaecology department of Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. The maternal death review data and maternal near miss statistics were analysed. This included assessing the change in the number of maternal deaths and obstetric near miss, their respective causes, and case fatality rate specific to COVID during pregnancy. Results: The total births decreased from 6056 in 2019-4140 in 2020 whereas women with severe maternal outcomes increased from 4.6% in 2019 to 6.5% in 2020(p value < 0.001). The incidence of nearmiss increased significantly from 3.5% in 2019 to 5.1% in 2020(p value < 0.0001) and maternal mortality ratio increased from 1122 per 1 lakh births to 1425 per 1 lakh births. Haemorrhage was the most common cause of maternal near miss with 45.8% in 2019 and an increase to 50.2% in 2020. The percentage of illiterate patients with near miss statistically reduced in 2020(p value - 0.004). Average hospital stay also reduced from 16.5+/-2.1 days to 12.6+/-6.3 days (p value < 0.0001). The average time taken to reach the hospital, however, increased from 27+/-3 h to 36+/-4 h (p value < 0.0001). The rate of direct maternal deaths increased from 45.6% to 52.5% between 2019 and 2020(p-value-0.434). Conclusion: Covid 19 pandemic has affected both maternal mortality and morbidity. Keeping the current situation in mind, it becomes increasingly important to develop patient education via electronic media and teleconsultations. One-stop portals and helplines which involve multidisciplinary teams should be available to all such pregnancies.