Impact of the ICD-9-CM to ICD-10-CM transition on the incidence of severe maternal morbidity among delivery hospitalizations in the United States.

BACKGROUND: Surveillance of maternal mortality and severe maternal morbidity is important to identify temporal trends, evaluate the impact of clinical practice changes or interventions, and monitor quality of care. A common source for severe maternal morbidity surveillance is hospital discharge data. On October 1, 2015, all hospitals in the United States transitioned from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for diagnoses and procedures. OBJECTIVE: This study aimed to evaluate the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding systems on the incidence of severe maternal morbidity in the United States in hospital discharge data. STUDY DESIGN: Using data from the National Inpatient Sample, obstetrical deliveries between January 1, 2012, and December 31, 2017, were identified using a validated case definition. Severe maternal morbidity was defined using the International Classification of Diseases, Ninth Revision, Clinical Modification (January 1, 2012, to September 30, 2015) and the International Classification of Diseases, Tenth Revision, Clinical Modification (October 1, 2015, to December 31, 2017) codes provided by the Centers for Disease Control and Prevention. An interrupted time series and segmented regression analysis was used to assess the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding on the incidence of severe maternal morbidity per 1000 obstetrical deliveries. RESULTS: From 22,751,941 deliveries, the incidence of severe maternal morbidity in the International Classification of Diseases, Ninth Revision, Clinical Modification coding era was 19.04 per 1000 obstetrical deliveries and decreased to 17.39 per 1000 obstetrical deliveries in the International Classification of Diseases, Tenth Revision, Clinical Modification coding era (P<.001). The transition to International Classification of Diseases, Tenth Revision, Clinical Modification coding led to an immediate decrease in the incidence of severe maternal morbidity (-2.26 cases of 1000 obstetrical deliveries) (P<.001). When blood products transfusion was removed from the case definition, the magnitude of the decrease in the incidence of SMM was much smaller (-0.60 cases/1000 obstetric deliveries), but still significant (P<.001). CONCLUSION: After the transition to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for health diagnoses and procedures in the United States, there was an abrupt statistically significant and clinically meaningful decrease in the incidence of severe maternal morbidity in hospital discharge data. Changes in the underlying health of the obstetrical population are unlikely to explain the sudden change in severe maternal morbidity. Although much work has been done to validate the International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe maternal morbidity, it is critical that validation studies be undertaken to validate the International Classification of Diseases, Tenth Revision, Clinical Modification codes for severe maternal morbidity to permit ongoing surveillance, quality improvement, and research activities that rely on hospital discharge data.

Time to recovery from Eclampsia and its determinants in east Gojjam zone hospitals, Amhara, Ethiopia, 2017/18.

BACKGROUND: Eclampsia is a tonic clonic type of seizure among pre-eclamptic mothers. Time to recovery from eclampsia is to mean that the time when the mother recovered from severity features of pre-eclampsia. As far as the mother is not free from severity features, she is in a potential to end-up with repeated seizure (eclampsia). Therefore, combating eclampsia through controlling severity features is crucial to enhance maternal health quality, reduce maternal morbidity and mortality, and improve prenatal outcomes. There was no literature that describes the recovery time of eclampsia and its determinants in Ethiopia. Therefore, this study aimed to assess the recovery time from eclampsia and its determinants in East Gojjam zone hospitals. METHODS: An institutional based retrospective follow up study was conducted between January 2014 and December 2017 among 608 eclamptic mothers in East Gojjam zone Hospitals. Simple random sampling technique was used. Data were coded and entered to Epidata version 3.1 and was exported to SPSS version 20 and then to Stata 14. We used the adjusted hazard ratio (AHR) with 95% confidence interval at p-value less than 0.05 to measure strength of association. RESULT: The median recovery time of eclampsia was 12 h with inter-quartile range of (1-48 h). The rate of recovery from eclampsia among mothers aged more than 20 years was reduced by half (AHR 0.50 (0.28, 0.89)) than the teenagers. The rate of recovery from eclampsia among mothers who had prolonged labor was 1.3 times (AHR 1.26 (1.01, 1.57)) than those whose labor was less than 12 h. About 32% of mothers with multiple convulsions recoverd later than (AHR 0.68 (0.52, 0.87)) those who had single convulsion. As compared to antepartum convulsion, the rate of recovery from postpartum eclampsia was 1.8 times faster (AHR 1.81(1.17, 2.81)). CONCLUSION: The median recovery time from severity features among eclamptic mothers in East Gojjam zone hospitals was half a day. It is affected by age, duration of labor, number of convulsions and time of occurrence of the event. Special attention for elders, prevent recurrent convulsion and faster termination for the antepartum eclamptic mothers are recommended from this follow-up study.

Maternal near miss and mortality attributable to hypertensive disorders in a tertiary hospital, Tanzania; a cross-sectional study.

BACKGROUND: Hypertensive disorders in pregnancy is the second most common direct cause of maternal deaths accounting for 14% of maternal deaths worldwide. Severe pre-eclampsia and eclampsia are among the hypertensive disorders in pregnancy causing significant morbidity and mortality, hence categorized as Maternal Near Miss. At Muhimbili National Hospital these are the leading causes of maternal deaths accounting for 19.9% of maternal death. This study aimed to determine the proportion of severe maternal outcomes and maternal near-miss indices among patients with severe pre-eclampsia and eclampsia at Muhimbili National Hospital in Tanzania. METHODS: A descriptive cross-sectional study was conducted between September 2017 to January 2018 at Muhimbili National Hospital. Women with severe pre-eclampsia and eclampsia were recruited. Data were extracted from patient files after admission, and followed up until discharge or death; after discharge was categorized as maternal near miss or death as maternal death. The outcome indicators were calculated using the total number of live births during the study period, the number of maternal deaths and maternal near-miss due to severe pre-eclampsia/ eclampsia in the same period. RESULTS: Nearly two-thirds of women recruited, 199 (62.2%) had severe preeclampsia while 121 (37.8%) had eclampsia, 71 (22.1%) had severe maternal outcome whereby 63 had maternal near-miss with organ dysfunction and 8 maternal deaths. The overall maternal near-miss ratio was 87.4 while that for severe pre-eclampsia was 54, and 33 per 1000 live births for eclampsia. Overall severe maternal outcome ratio was 19.4 while that for severe pre-eclampsia was 12 and that for eclampsia was 9.5 per 1000 live births. Mortality index was 11% and the Case fatality rate was 2.5%. CONCLUSION: There is a high proportion of women with severe maternal outcome attributable to severe pre-eclampsia and eclampsia, with a reduced proportion of maternal deaths. This signifies improvement of performance in our facility in dealing with patients with severe morbidities due to severe pre-eclampsia and eclampsia, however, more effort should be put to further reduce maternal mortality.

Preeclampsia knowledge among postpartum women treated for preeclampsia and eclampsia at Korle Bu Teaching Hospital in Accra, Ghana.

BACKGROUND: Preeclampsia/eclampsia is a major cause of maternal morbidity and mortality worldwide, yet patients' perspectives about their diagnosis are not well understood. Our study examines patient knowledge among women with preeclampsia/eclampsia in a large urban hospital in Ghana. METHODS: Postpartum women diagnosed with preeclampsia or eclampsia were asked to complete a survey 2-5 days after delivery that assessed demographic information, key obstetric factors, and questions regarding provider counseling. Provider counseling on diagnosis, causes, complications, and future health effects of preeclampsia/eclampsia was quantified on a 4-point scale ('Counseling Composite Score'). Participants also completed an objective knowledge assessment regarding preeclampsia/eclampsia, scored from 0 to 22 points ('Preeclampsia/Eclampsia Knowledge Score' (PEKS)). Linear regression was used to identify predictors of knowledge score. RESULTS: A total of 150 participants were recruited, 88.7% (133) with preeclampsia and 11.3% (17) with eclampsia. Participants had a median age of 32 years, median parity of 2, and mean number of 5.4 antenatal visits. Approximately half of participants reported primary education as their highest level of education. While 74% of women reported having a complication during pregnancy, only 32% of participants with preeclampsia were able to correctly identify their diagnosis, and no participants diagnosed with eclampsia could correctly identify their diagnosis. Thirty-one percent of participants reported receiving no counseling from providers, and only 11% received counseling in all four categories. Even when counseled, 40-50% of participants reported incomplete understanding. Out of 22 possible points on a cumulative knowledge assessment scale, participants had a mean score of 12.9 ± 0.38. Adjusting for age, parity, and the number of antenatal visits, higher scores on the knowledge assessment are associated with more provider counseling (ß 1.4, SE 0.3, p < 0.001) and higher level of education (ß 1.3, SE 0.48, p = 0.008). CONCLUSIONS: Counseling by healthcare providers is associated with higher performance on a knowledge assessment about preeclampsia/eclampsia. Patient knowledge about preeclampsia/eclampsia is important for efforts to encourage informed healthcare decisions, promote early antenatal care, and improve self-recognition of warning signs-ultimately improving morbidity and reducing mortality.

Mortality Synopsis Among Women of Reproductive Age Group in Nigeria: A Hospital-Based Study.

PURPOSE: Identification of health problems of women of reproductive age, using a reliable mortality data, is essential in evading preventable female deaths. This study aimed at investigating mortality profile of women of reproductive age group in Nigeria. MATERIALS AND METHODS: This is a descriptive, retrospective study involving women of reproductive age group of 15-49 years that died at DELSUTH from 1st January 2016 to 31st December 2018. The age, date of death and cause of death were retrieved from the hospital records and subsequently analyzed using SPSS version 21. RESULTS: One hundred and eighty-seven eligible deaths were encountered in this study, constituting 17.5% of all deaths in the hospital. Twenty four (12.8%) cases were of maternal etiology while 163 (87.2%) were of non-maternal causes. Non-communicable disease, communicable disease and external injuries accounted for 100 (53.5%), 44 (23.5%) and 19 (10.2%) deaths among the non-maternal causes. The mean age and the peak age group are 34.4 years and the 4th decade respectively. The leading specified non-maternal causes of death (in descending order) are AIDS/TB, cerebrovascular accidents (CVA), breast cancer, road traffic accident (RTA), diabetes, perioperative death and sepsis while the leading maternal causes of death are abortion, postpartum hemorrhage, eclampsia and puerperal sepsis. CONCLUSION: Most deaths affecting WRAG are preventable, with non-maternal causes in excess of maternal causes. There is need for holistic life-long interventional policies and strategies that will address the health need of these women, using evidence-based research findings.

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.

Confidential enquiries into maternal deaths in Ondo State, Nigeria - a comparative analysis.

BACKGROUND: Paucity of data on state-wide maternal mortality in Nigeria hampers planning, monitoring and evaluation of the impact of interventions. The Confidential Enquiry into Maternal Deaths in Ondo State was initiated to overcome this problem. This study aimed to compare trends of maternal mortality ratios, causes of deaths, geographical distribution and other associated factors in 12-monthly reports of the Confidential Enquiry into Maternal Deaths in Ondo State. METHODS: Notification forms were distributed throughout the State to focal persons and medical records officers at community and facility levels, respectively. Maternal deaths, as defined in the International Classification of Diseases 10th version, were recorded prospectively over 3 years from 1st June 2012 to 30th May, 2015. Forms were submitted, collated and data analysed by a multidisciplinary review committee. RESULTS: Reported numbers of maternal deaths (and maternal mortality ratios) were 114 (253 per 100,000 births), 89 (192) and 81 (170), respectively per year, indicating a 33% reduction in maternal mortality ratio over the course of the study period. Assuming that the confidential enquiry process was the only intervention at the time aimed at reducing maternal mortality, simple linear regression with a correlation coefficient of 0.9314, showed a relationship though the difference in the values were not statistically significant (95% CI = - 184.55 to 101.55, p = 0.169). Postpartum haemorrhage and eclampsia were the leading causes of deaths. CONCLUSION: There was a trend of reduction in maternal mortality ratio during the period of study with postpartum haemorrhage as the major cause of death. The positive association between the confidential enquiry reports and maternal mortality ratios make us recommend that our model be adopted in other states and at the federal level.

Policy review on the management of pre-eclampsia and eclampsia by community health workers in Mozambique.

BACKGROUND: Pre-eclampsia is one of the leading causes of maternal death in Mozambique. Limited access to health care facilities and a lack of skilled health professionals contribute to the high maternal morbidity and mortality rates in Mozambique and indicate a need for community-level interventions. The aim of this review was to identify and characterise health policies related to the role of CHWs in the management of pre-eclampsia and eclampsia in Mozambique. METHODS: The policy review was based on three methods: a desk review of relevant documents from the Mozambique Ministry of Health (n = 7), contact with 28 key informants in the field of health policy in Mozambique (n = 5) and literature review (n = 699). Policy documents obtained included peer-reviewed articles, government and institutional policies, reports and action plans. Seven hundred and eleven full-text documents were assessed for eligibility and included based on pre-defined criteria. Qualitative analysis was done to identify main themes using content analysis. RESULTS: A total of 56 papers informed the timeline of key events. Three main themes were identified from the qualitative review: establishment of the community health worker programme and early challenges, revitalization of the CHW programme and the integration of maternal health in the community health tasks. In 1978, following the Alma Alta Declaration, the Mozambique government brought in legislation establishing primary health care and the CHW programme. Between the late 1980s and early 1990s, this programme was scaled down due to several factors including a prolonged civil war; however, the decision to revitalise the programme was made in 1995. In 2010, a revitalised programme was re-launched and expanded to include the management of common childhood illnesses, detection of warning signs of pregnancy complications, referrals for maternal health and basic health promotion. To date, their role has not included management of emergency conditions of pregnancy including pre-eclampsia and eclampsia. CONCLUSION: The role of CHWs has evolved over the last 40 years to include care of childhood diseases and basic maternal health counselling. Studies to assess the impact of CHWs in providing services to reduce maternal morbidity and mortality are recommended.

Maternal Mortality due to Eclampsia in Khyber Pakhtunkhwa: Identifying Underlying Risk Factors, and Care-seeking Behaviours.

OBJECTIVE: To identify the characteristics of women at risk of death due to eclampsia, and steps to improve maternal outcome. METHODS: This study is a part of a retrospective study conducted in 2016 and included Mansehra, Swabi, Haripur, Nowshera, Kohat, and Dera Ismail Khan districts of the Khyber Pakhtunkhwa province of Pakistan, and used information cited by a 2016 study to estimate the maternal mortality rate in the province based on data pertaining to the 2013-14 period. The Maternal Death from Informants / Maternal Death Follow-on Review method was applied to identify the magnitude, causes and circumstances of maternal deaths in the province. SPSS 21 was used for data analysis. RESULTS: Of the 958 cases of maternal death identified, 167(17%) were related to eclampsia. The median age of such women was 28 years (interquartile range: 11 years). Of them, 88 (53%) died undelivered, 48 (29%) had a live birth while 31 (18%) had a stillbirth or abortion. Mothers aged 25 years or above (p<0.01), primiparous (p<0.01) and those with a previous history of stillbirth (p<0.005) carried higher risk, while higher socioeconomic status had a protective effect (p<0.007). CONCLUSIONS: Eclampsia deaths can be prevented through Continuum of Care approach and by ensuring provision of basic health facilities across the board.

Risk factors and outcome of patients with eclampsia at a tertiary hospital in Egypt.

BACKGROUND: Eclampsia is a major cause of maternal and neonatal morbidity and mortality in low and middle income countries. The aim of this study was to assess the risk factors and maternal and perinatal outcome in patients with eclampsia in order to get reliable data that helps in reducing the incidence and improving the outcome in an area with high incidence of eclampsia. METHODS: Retrospective study including 250 patients diagnosed with eclampsia at Minia Maternity University Hopsital, Minia, Egypt in the period between January 2013 and December 2014.We analyzed the data obtained from medical records of these patients including patient characteristics, medical, obstetric, current pregnancy history, data on hospital admission, treatment given at hospital and maternal and perinatal outcome. Statistical analysis was done using SPSS version 21. RESULTS: During the study period, 21690 women gave birth in the hospital; of which 250 cases of eclampsia were diagnosed (1.2%).Four women died (case fatality rate 1.6%). The main risk factors identified were young age, nulliparity, low level of education, poor ante-natal attendance and pre-existing medical problems. The most common complication was HELLP syndrome (15.6%). Magnesium sulphate therapy was given to all patients but there was lack of parenteral anti-hypertensive therapy. Forty six cases delivered vaginally (18.4%). Assisted delivery was performed in 22 (8.8%) cases and caesarean section in 177 (70.8%) cases; 151(60.4%) primary caesarean sections and 26 (10.4%) intra-partum. Perinatal deaths occurred in 11.9% on cases. Prematurity and poor neonatal services were the main cause. CONCLUSION: Morbidity and mortality from eclampsia are high in our setting. Improving ante-natal and emergency obstetric and neonatal care is mandatory to improve the outcome.

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.

A 10 years autopsy-based study of maternal mortality in Lagos State University Teaching Hospital, Lagos, Nigeria.

BACKGROUND: Maternal mortality is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy. Nigeria is among the six countries that record over 50% of all maternal deaths in the world. There are few papers on autopsy based causes of maternal mortality. This paper is to present the causes of maternal mortality that had postmortem done in our center. MATERIALS AND METHODS: This is a 10-year retrospective study of all maternal deaths seen in our center from January 01, 2005 to December 31, 2014. Lagos State University Teaching Hospital is the only state-owned tertiary center and the main referral center in Lagos State. Autopsy records are taken from the death register and other information were extracted from the postmortem reports. RESULTS: Most maternal deaths 98/328 (29.9%) were seen in the age group 26-30 years which was followed by 31-35 years (24.7%). Postpartum hemorrhage was the most common cause of death followed by eclampsia. Direct causes accounted for 60% of maternal deaths with hemorrhage as the most common while cardiovascular related diseases are the most common indirect cause of death. CONCLUSION: The leading causes of death in this study, hemorrhage, cardiovascular disease and eclampsia are highly avoidable and treatable. We recommend that thorough cardiovascular management should be instituted during antenatal care, and the government should focus more on an emergency response such as availability of adequate blood and blood products in the hospitals.

Factors associated with maternal death from direct pregnancy complications: a UK national case-control study.

OBJECTIVE: To investigate the factors associated with maternal death from direct pregnancy complications in the UK. DESIGN: Unmatched case-control analysis. SETTING: All hospitals caring for pregnant women in the UK. POPULATION: A total of 135 women who died (cases) between 2009 and 2012 from eclampsia, pulmonary embolism, severe sepsis, amniotic fluid embolism, and peripartum haemorrhage, using data from the Confidential Enquiry into Maternal Death, and another 1661 women who survived severe complications (controls) caused by these conditions (2005-2013), using data from the UK Obstetric Surveillance System. METHODS: Multivariable regression analyses were undertaken to identify the factors that were associated with maternal deaths and to estimate the additive odds associated with the presence of one or more of these factors. MAIN OUTCOME MEASURES: Odds ratios associated with maternal death and population-attributable fractions, with 95% confidence intervals. Incremental risk of death associated with the factors using a 'risk factors' score. RESULTS: Six factors were independently associated with maternal death: inadequate use of antenatal care (adjusted odds ratio, aOR 15.87, 95% CI 6.73-37.41); substance misuse (aOR 10.16, 95% CI 1.81-57.04); medical comorbidities (aOR 4.82, 95% CI 3.14-7.40); previous pregnancy problems (aOR 2.21, 95% CI 1.34-3.62); hypertensive disorders of pregnancy (aOR 2.44, 95% CI 1.31-4.52); and Indian ethnicity (aOR 2.70, 95% CI 1.14-6.43). Of the increased risk associated with maternal death, 70% (95% CI 66-73%) could be attributed to these factors. Odds associated with maternal death increased by three and a half times per unit increase in the 'risk factor' score (aOR 3.59, 95% CI 2.83-4.56). CONCLUSIONS: This study shows that medical comorbidities are importantly associated with direct (obstetric) deaths. Further studies are required to understand whether specific aspects of care could be improved to reduce maternal deaths among women with medical comorbidities in the UK.

Reducing maternal mortality from preeclampsia and eclampsia in low-resource countries--what should work?

OBJECTIVE: Preeclampsia/eclampsia (PE/E) remains a major cause of maternal death in low-income countries. We evaluated interventions to reduce PE/E-related maternal mortality in sub-Saharan Africa. DESIGN: Mathematical model to assess impact of interventions on PE/E-related maternal morbidity and mortality. SETTING: Sub-Saharan Africa countries. POPULATION: Pregnant women in sub-Saharan Africa in 2012. METHODS: A systematic literature review populated a decision-tree mathematical model with interventions to diagnose, prevent, and treat women with PE/E. The impact of increased use of interventions [diagnostics, transfer to a hospital, magnesium sulfate (MgSO4 ) use, cesarean section/labor induction] on PE/E-related maternal mortality was analyzed. MAIN OUTCOME MEASURES: Prevalence of PE/E and PE/E-associated maternal mortality rates in sub-Saharan Africa. RESULTS: Without interventions, an estimated 20 570 PE/E-associated deaths would have occurred in sub-Saharan Africa in 2012. With current low rates of diagnosis, MgSO4 use, transfers and cesarean section/induction rates, about 17 520 maternal deaths were associated with PE/E in 2012. Higher use of MgSO4 would have prevented about 610 deaths. With high diagnostic levels, MgSO4 use, transfer and cesarean section/induction, mortality was reduced to 3750 annual deaths, saving about 13 770 maternal lives. If all MgSO4 use was removed from the model, 4060 maternal deaths would occur, increasing maternal deaths by only 310. CONCLUSIONS: In sub-Saharan Africa, our model suggests that increasing use of PE/E diagnostics, transfer to higher levels of care and increased hospitalization with cesarean section/induction of labor would substantially reduce maternal mortality from PE/E. Increasing use of MgSO4 would have a smaller impact on maternal mortality.

Maternal death reviews at Bugando hospital north-western Tanzania: a 2008-2012 retrospective analysis.

BACKGROUND: Unacceptably high levels of maternal deaths still occur in many sub-Saharan countries and the health systems may not favour effective use of lessons from maternal death reviews to improve maternal survival. We report results from the analysis of data from maternal death reviews at Bugando Medical Centre north-western Tanzania in the period 2008-2012 and highlight the process, challenges and how the analysis provided a better understanding of maternal deaths. METHODOLOGY: Retrospective analysis using maternal death review data and extraction of missing information from patients' files. Analysis was done in STATA statistical package into frequencies and means ± SD and median with 95% CI for categorical and numerical data respectively. RESULTS: There were 80 deaths; mean age of the deceased 27.1 ± 6.2 years and a median hospital stay of 11.0 days [95% CI 11.0-15.3]. Most deaths were from direct obstetric causes (90); 60% from eclampsia, severe pre-eclampsia, sepsis, abortion and anaesthetic complications. Information on ANC attendance was recorded in 36.2% of the forms and gestation age of the pregnancy resulting into the death in 23.8%. Sixty one deaths (76.3%) occurred after delivery. The mode of delivery, place of delivery and delivery assistant were recorded in 44 (72.1), 38 (62.3) and 23 (37.7%) respectively. CONCLUSION: Routine maternal death reviews in this setting do not involve comprehensive documentation of all relevant information, including actions taken to address some identified systemic weaknesses. Periodic analysis of available data may allow better understanding of vital information to improve the quality of maternity care.

Characteristics and outcomes of patients with eclampsia and severe pre-eclampsia in a rural hospital in Western Tanzania: a retrospective medical record study.

BACKGROUND: Eclampsia and pre-eclampsia are well-recognized causes of maternal and neonatal mortality in low income countries, but are never studied in a district hospital. In order to get reliable data to facilitate the hospital's obstetric audit a retrospective medical record study was performed in Ndala Hospital, Tanzania. METHODS: All patients diagnosed with severe pre-eclampsia or eclampsia between July 2011 and December 2012 were included. Medical records were searched immediately following discharge or death. General patient characteristics, medical history, obstetrical history, possible risk factors, information about the current pregnancy, antenatal clinic attendance and prescribed therapy before admission were recorded. Symptoms and complications were noted. Statistical analysis was done with Epi Info®. RESULTS: Of the 3398 women who gave birth in the hospital 26 cases of severe pre-eclampsia and 55 cases of eclampsia were diagnosed (0.8 and 1.6%). Six women with eclampsia died (case fatality rate 11%). Convulsions in patients with eclampsia were classified as antepartum (44%), intrapartum (42%) and postpartum (15%). Magnesium was given in 100% of patients with eclampsia and was effective in controlling convulsions. Intravenous antihypertensive treatment was only started in 5% of patients. Induction of labour was done in 29 patients (78% of women who were not yet in labour). Delivery was spontaneous in 67%, assisted vaginal (ventouse) in 14% and by Caesarean section in 19% of women. Perinatal deaths occurred in 30% of women with eclampsia and 27% of women with severe pre-eclampsia and were associated with low birth weight and prolonged time between admission and birth. CONCLUSIONS: 2.4% of women were diagnosed with severe pre-eclampsia or eclampsia. The case fatality rate and overall perinatal mortality were comparable to other reports. Better outcomes could be achieved by better treatment of hypertension and starting induction of labour as soon as possible.

Evaluation of maternal mortality ratio and causes in a university hospital in eastern Turkey.

AIM: To investigate the maternal mortality ratio (MMR) and causes of maternal death in order to decrease these deaths. MATERIALS AND METHODS: The number of live births, maternal deaths, and the causes of deaths in Yuzuncu Yil University were recorded between 2004 and 2013. RESULTS: The MMR was 268 per 100,000. Forty-nine maternal deaths were examined in terms of cause. The most frequent cause of death is eclampsia (33%) and associated intracerebral complications. The antenatal follow-up rate was 23.3%. The majority of patients had low income (92.3%), 72.2% were from rural areas, and 95.5% were illiterate. CONCLUSION: The high MMR may arise from the high incidence of pregnancy complications in eastern Turkey, the rareness of antenatal follow-ups, and the present hospital being a referral hospital. The most frequent cause of maternal mortality is eclampsia and associated complications, followed by bleeding.

Maternal mortality in obstetrics and gynaecology in a tertiary care hospital.

Maternal mortality is the leading causes of death and disability of reproductive age in the developing countries. Bangladesh is one of the developing countries where maternal mortality is very high. The purpose of the present study was to see the causes of maternal deaths at Obstetrics and Gynaecology ward. This retrospective study was carried out in the Department of Obstetrics and Gynaecology at Dhaka Medical College Hospital (DMCH). All maternal deaths were included in this study from July 2003 to June 2004 for a period of one year. The incidence of maternal death was 18.5/1000 live birth. Hypertensive disorder of pregnancy (41.84%) was the most common cause of maternal death followed by unsafe abortions (21.4%), PPH (10.2%), obstructed labour (8.2%). Among 98 patients 36(36.7%) cases are died due to eclampsia. Death due to pre-eclampsia (5.1%), unsafe Abortion (21.4%), Obstetric haemorrhage (18.4%) and obstructed labour (8.3%) were commonly found in this study. The study permits to conclude that Hypertensive disorder of pregnancy is the leading cause of pregnancy related deaths followed by unsafe abortions and obstetric haemorrhage. Other causes include obstructed labour, anaesthetic complications and others.

Pre-eclampsia, eclampsia and adverse maternal and perinatal outcomes: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health.

OBJECTIVE: To assess the incidence of hypertensive disorders of pregnancy and related severe complications, identify other associated factors and compare maternal and perinatal outcomes in women with and without these conditions. DESIGN: Secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health (WHOMCS) database. SETTING: Cross-sectional study implemented at 357 health facilities conducting 1000 or more deliveries annually in 29 countries from Africa, Asia, Latin America and the Middle East. POPULATION: All women suffering from any hypertensive disorder during pregnancy, the intrapartum or early postpartum period in the participating hospitals during the study period. METHODS: We calculated the proportion of the pre-specified outcomes in the study population and their distribution according to hypertensive disorders' severity. We estimated the association between them and maternal deaths, near-miss cases, and severe maternal complications using a multilevel logit model. MAIN OUTCOME MEASURES: Hypertensive disorders of pregnancy. Potentially life-threatening conditions among maternal near-miss cases, maternal deaths and cases without severe maternal outcomes. RESULTS: Overall, 8542 (2.73%) women suffered from hypertensive disorders. Incidences of pre-eclampsia, eclampsia and chronic hypertension were 2.16%, 0.28% and 0.29%, respectively. Maternal near-miss cases were eight times more frequent in women with pre-eclampsia, and increased to up to 60 times more frequent in women with eclampsia, when compared with women without these conditions. CONCLUSIONS: The analysis of this large database provides estimates of the global distribution of the incidence of hypertensive disorders of pregnancy. The information on the most frequent complications related to pre-eclampsia and eclampsia could be of interest to inform policies for health systems organisation.

Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on Maternal and Newborn Health.

OBJECTIVE: We aimed to determine the prevalence and risks of late fetal deaths (LFDs) and early neonatal deaths (ENDs) in women with medical and obstetric complications. DESIGN: Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS). SETTING: A total of 359 participating facilities in 29 countries. POPULATION: A total of 308 392 singleton deliveries. METHODS: We reported on perinatal indicators and determined risks of perinatal death in the presence of severe maternal complications (haemorrhagic, infectious, and hypertensive disorders, and other medical conditions). MAIN OUTCOME MEASURES: Fresh and macerated LFDs (defined as stillbirths ≥ 1000 g and/or ≥28 weeks of gestation) and ENDs. RESULTS: The LFD rate was 17.7 per 1000 births; 64.8% were fresh stillbirths. The END rate was 8.4 per 1000 liveborns; 67.1% occurred by day 3 of life. Maternal complications were present in 22.9, 27.7, and 21.2% [corrected] of macerated LFDs, fresh LFDs, and ENDs, respectively. The risks of all three perinatal mortality outcomes were significantly increased with placental abruption, ruptured uterus, systemic infections/sepsis, pre-eclampsia, eclampsia, and severe anaemia. CONCLUSIONS: Preventing intrapartum-related perinatal deaths requires a comprehensive approach to quality intrapartum care, beyond the provision of caesarean section. Early identification and management of women with complications could improve maternal and perinatal outcomes.