Every maternal near-miss counts: Need for a national audit in South Africa? A mixed-methods study.

BACKGROUND: To improve maternal health, studies of maternal morbidity are increasingly being used to evaluate the quality of maternity care, in addition to studies of mortality. While South Africa (SA) has a well-established confidential enquiry into maternal deaths, there is currently no structure in place to systematically collect and analyse maternal near-misses (MNMs) at national level. OBJECTIVES: To synthesise MNM indicators and causes in SA by performing a systematic literature search, and to investigate perceived needs for data collection related to MNMs and determine whether the MNM tool from the World Health Organization (WHO-MNM) would require adaptations in order to be implemented. METHODS: The study used a mixed-methods approach. A systematic literature search was conducted to find all published data on MNM audits in SA. Semi-structured interviews were conducted virtually with maternal health experts throughout the country who had been involved in studies of MNMs, and main themes arising in the interviews were synthesised. A method for MNM data collection for SA use was discussed with these experts. RESULTS: The literature search yielded 797 articles, 15 of which met the WHO-MNM or Mantel et al. severe acute maternal morbidity criteria. The median (interquartile range) MNM incidence ratio in SA was 8.4/1 000 (5.6 - 8.7) live births, the median maternal mortality ratio was 130/100 000 (71.4 - 226) live births, and the median mortality index was 16.6% (11.7 - 18.8). The main causes of MNMs were hypertensive disorders of pregnancy and obstetric haemorrhage. Eight maternal health experts were interviewed from May 2020 to February 2021. All participants focused on the challenges of implementing a national MNM audit, yet noted the urgent need for one. Recognition of MNMs as an indicator of quality of maternity care was considered to lead to improved management earlier in the chain of events, thereby possibly preventing mortality. Obtaining qualitative information from women with MNMs was perceived as an important opportunity to improve the maternity care system. Participants suggested that the WHO-MNM tool would have to be adapted into a simplified tool with more clearly defined criteria and a number of specific diagnoses relevant to the SA setting. This 'Maternal near-miss: Inclusion criteria and data collection form' is provided as a supplementary file. CONCLUSION: Adding MNMs to the existing confidential maternal death enquiry could potentially contribute to a more robust audit with data that may inform health systems planning. This was perceived by SA experts to be valuable, but would require context-specific adaptations to the WHO-MNM tool. The available body of evidence is sufficient to justify moving to implementation.

Delivery mode for prolonged, obstructed labour resulting in obstetric fistula: a retrospective review of 4396 women in East and Central Africa.

OBJECTIVE: To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula. DESIGN: Retrospective record review. SETTING: Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia. POPULATION: A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014. METHODS: Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries. MAIN OUTCOME MEASURES: Mode of delivery, stillbirth. RESULTS: Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514). CONCLUSIONS: In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth. TWEETABLE ABSTRACT: Caesarean section is increasingly performed in African women with stillbirth treated for obstetric fistula.

Maternal mortality due to cardiovascular disease in the Netherlands: a 21-year experience.

OBJECTIVE: Cardiovascular disorders are the leading cause of indirect maternal mortality in Europe. The aim of this study is to present an extensive overview concerning the specific cardiovascular causes of maternal death and to identify avoidable contributing care factors related to these deaths. METHODS: We assessed all cases of maternal death due to cardiovascular disorders collected by a systematic national confidential enquiry of maternal deaths published by the Dutch Maternal Mortality and Morbidity Committee on behalf of the Netherlands Society of Obstetrics and Gynaecology over a 21-year period (1993-2013) in the Netherlands. RESULTS: There were 96 maternal cardiovascular deaths (maternal mortality rate due to cardiovascular diseases 2.4/100,000 liveborn children). Causes were aortic dissection (n = 20, 21%), ischaemic heart disease (n = 17, 18%), cardiomyopathies (including peripartum cardiomyopathy and myocarditis, n = 20, 21%) and (unexplained) sudden death (n = 27, 28%). Fifty-five percent of the deaths occurred postpartum (n = 55, 55%). Care factors that may have contributed to the adverse outcome were identified in 27 cases (28%). These factors were patient-related in 40% (pregnancy against medical advice, underestimation of symptoms) and healthcare-provider-related in 60% (symptoms not recognised, delay in diagnosis, delay in referral). CONCLUSION: The maternal cardiovascular mortality ratio is low in the Netherlands and the main causes of maternal cardiovascular mortality are in line with other European reports. In a minority of cases, care factors that were possibly preventable were identified. Women with cardiovascular disease should be properly counselled about the risks of pregnancy and the symptoms of complications. Education of care providers regarding the incidence, presentation and diagnosis of cardiovascular disease during pregnancy is recommended.

The International Network of Obstetric Survey Systems study of uterine rupture: a descriptive multi-country population-based study.

OBJECTIVE: International comparison of complete uterine rupture. DESIGN: Descriptive multi-country population-based study. SETTING: International. POPULATION: International Network of Obstetric Survey Systems (INOSS). METHODS: We merged individual data, collected prospectively in nine population-based studies, of women with complete uterine rupture, defined as complete disruption of the uterine muscle and the uterine serosa, regardless of symptoms and rupture of fetal membranes. MAIN OUTCOME MEASURES: Prevalence of complete uterine rupture, regional variation and correlation with rates of caesarean section (CS) and trial of labour after CS (TOLAC). Severe maternal and perinatal morbidity and mortality. RESULTS: We identified 864 complete uterine ruptures in 2 625 017 deliveries. Overall prevalence was 3.3 (95% CI 3.1-3.5) per 10 000 deliveries, 22 (95% CI 21-24) in women with and 0.6 (95% CI 0.5-0.7) in women without previous CS. Prevalence in women with previous CS was negatively correlated with previous CS rate (ρ = -0.917) and positively correlated with TOLAC rate of the background population (ρ = 0.600). Uterine rupture resulted in peripartum hysterectomy in 87 of 864 women (10%, 95% CI 8-12%) and in a perinatal death in 116 of 874 infants (13.3%, 95% CI 11.2-15.7) whose mother had uterine rupture. Overall rate of neonatal asphyxia was 28% in neonates who survived. CONCLUSIONS: Higher prevalence of complete uterine ruptures per TOLAC was observed in countries with low previous CS and high TOLAC rates. Rates of hysterectomy and perinatal death are about 10% following complete uterine rupture, but in women undergoing TOLAC the rates are extremely low (only 2.2 and 3.2 per 10 000 TOLACs, respectively.) TWEETABLE ABSTRACT: Prevalence of complete uterine rupture is higher in countries with low previous CS and high TOLAC rates.

Effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia at the referral hospital of Zanzibar: a quasi-experimental pre-post study (The PartoMa study).

OBJECTIVE: To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia. DESIGN: Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice. SETTING: Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital. POPULATION: Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention month (1 October 2015 until 31 January 2016) [corrected]. METHODS: Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively). MAIN OUTCOME MEASURES: Stillbirths and neonates with 5-minute Apgar score ≤5. RESULTS: Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53-0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41-0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60-240) to 74 minutes (IQR 30-130) (Mann-Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37-0.81) and timely use improved. CONCLUSION: Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. TWEETABLE ABSTRACT: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital PLAIN LANGUAGE SUMMARY: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th-12th month of use. Such a 'before-after' study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines.

Assisted vaginal delivery in low and middle income countries: an overview.

OBJECTIVE: To assess the use of assisted vaginal delivery (AVD) in low- and middle-income countries (LMICs), highlighting what level of care procedures were performed and identifying systemic barriers to its use. DESIGN: Cross-sectional health facility assessments. SETTING: Up to 40 countries in Latin America, sub-Saharan Africa and Asia. POPULATION: Assessments tended to be national in scope and included all hospitals and samples of midlevel facilities in public and private sectors. METHODS: Descriptive secondary data analysis. MAIN OUTCOME MEASURES: Percentage of facilities where health workers performed AVD in the 3 months prior to the assessment, instrument preference, which health workers performed the procedure, and reasons AVD was not practiced. RESULTS: Fewer than 20% of facilities in Latin America reported performing AVD in the last 3 months. In sub-Saharan Africa, 53% of 1728 hospitals had performed AVD but only 6% of nearly 10 000 health centres had done so. It was not uncommon to find <1% of institutional births delivered by AVD. Vacuum extraction appears preferred over forceps. Lack of equipment and trained health workers were the most frequent reasons for non-performance. CONCLUSIONS: The low use of AVD in LMICs is in contrast with many high-income countries, where high caesarean rates are also associated with significant rates of AVD. In many LMICs, rising caesarean rates have not been associated with maintenance of skills and practice of AVD. AVD is underused precisely in countries where pregnant women continue to face hardships accessing emergency obstetric care and where caesarean delivery can be relatively unsafe. TWEETABLE ABSTRACT: Many LMICs exhibit low use of assisted vaginal delivery where access to EmONC continues to be a hardship.

Increasing the availability and quality of caesarean section in Tanzania.

OBJECTIVE: To describe the results of increasing availability and quality of caesarean deliveries and anaesthesia in rural Tanzania. DESIGN: Before-after intervention study design. SETTINGS: Rural Tanzania. METHODS: Ten health centres located in rural areas were upgraded to provide comprehensive emergency obstetric care (CEmOC) and the four related district hospitals were supported. Upgrading entailed constructing and equipping maternity blocks, operation rooms and laboratories; installing solar systems, backup generators and water supply systems. Associate clinicians were trained in anaesthesia and in CEmOC. Mentoring and audit of reasons for caesarean section (CS) and maternal deaths were carried out. Measures of interest were compared using analysis of variance (ANOVA) statistical tests. MAIN OUTCOME MEASURES: Trends in CS rates, proportion of unjustified CS, use of spinal anaesthesia, and the risk of death from complications related to CS and anaesthesia. RESULTS: During the audit period (2012-2014), 5868 of 58 751 deliveries were by CS (10%). The proportion of CS considered to be unjustified decreased from 30 to 17% in health centres (P = 0.02) and from 37 to 20% in hospitals (P < 0.001). Practice of spinal anaesthesia for CS increased from 10% to 64% in hospitals (P < 0.001). Of 110 maternal deaths, 18 (16.4%) were associated with complications of CS, giving a risk of 3.1 per 1000 CS; three (2.7%) were judged to be anaesthetic-associated deaths with a risk of 0.5 per 1000 caesarean deliveries. CONCLUSIONS: Increasing availability and quality of CS by improving infrastructure, training and audit of reasons for CS is feasible, acceptable and required in low resource settings. TWEETABLE ABSTRACT: Increasing availability and quality of CS in rural Africa is feasible.

Opportunities for male involvement during pregnancy in Magu district, rural Tanzania.

BACKGROUND: Male involvement during antenatal care is promoted to be an important intervention to increase positive maternal and new born health outcomes. Despite active promotion to stimulate male involvement during antenatal care, few men in Tanzania accompany women to their antenatal care visits. This study aims to understand perceptions, attitudes and behaviour of men regarding their role and involvement during pregnancy and antenatal care visits in a rural district in Tanzania. METHODS: Data collection took place in Magu District between September 2013 and March 2014, using a mixed method approach. This included observations at six government health facilities, nine focus group discussions (with a total of 76 participants) and 26 semi-structured interviews of participants, included through convenience- and snowball sampling. Additionally, a questionnaire was distributed among 156 women attending antenatal care, regarding their partners' involvement in their pregnancy. Qualitative analysis was done through coding of themes based on the Three Delays Framework. Descriptive analysis was used for quantitative data. RESULTS: Male involvement in pregnancy and antenatal care in Magu district is low. Although men perceived antenatal care as important for pregnant women, most husbands had a passive attitude concerning their own involvement. Barriers for male involvement included: traditional gender roles, lack of knowledge, perceived low accessibility to join antenatal care visits and previous negative experiences in health facilities. CONCLUSION: Although several barriers impede male involvement during antenatal care, men's internal motivation and attitudes towards their role during pregnancy was generally positive. Increasing community awareness and knowledge about the importance of male involvement and increasing accessibility of antenatal clinics can reduce some of the barriers.

Criteria-based audit of caesarean section in a referral hospital in rural Tanzania.

OBJECTIVE: WHO uses the Caesarean section (CS) rate to monitor implementation of emergency obstetric care (EmOC). Although CS rates are rising in sub-Saharan Africa, maternal outcome has not improved. We audited indications for CS and related complications among women with severe maternal morbidity and mortality in a referral hospital in rural Tanzania. METHODS: Cross-sectional study was from November 2009 to November 2011. Women with severe maternal morbidity and mortality were identified and those with CS were included in this audit. Audit criteria were developed based on the literature review and (inter)national guidelines. Tanzanian and Dutch doctors reviewed hospital notes. The main outcome measured was prevalence of substandard quality of care leading to unnecessary CS and delay in performing interventions to prevent CS. RESULTS: A total of 216 maternal near misses and 32 pregnancy-related deaths were identified, of which 82 (33.1%) had a CS. Indication for CS was in accordance with audit criteria for 36 of 82 (44.0%) cases without delay. In 20 of 82 (24.4%) cases, the indication was correct; however, there was significant delay in providing standard obstetric care. In 16 of 82 (19.5%) cases, the indication for CS was not in accordance with audit criteria. During office hours, CS was more often correctly indicated than outside office hours (60.0% vs. 36.0%, P < 0.05). DISCUSSION: Caesarean section rate is not an useful indicator to monitor quality of EmOC as a high rate of unnecessary and potentially preventable CS was identified in this audit.

Eclampsia, a comparison within the International Network of Obstetric Survey Systems.

OBJECTIVE: To compare incidences, characteristics, management and outcome of eclampsia in the Netherlands and the UK. DESIGN: A comparative analysis of two population-based prospective cohort studies. SETTING: All hospitals with consultant-led maternity units. POPULATION: Women with eclampsia in the Netherlands (226) and the UK (264). METHODS: Comparison of individual level data from national studies in the Netherlands and the UK (LEMMoN 2004-06; UKOSS 2005/06). MAIN OUTCOME MEASURES: Incidence, maternal complications and differences in management strategies. RESULTS: Incidences of eclampsia differed significantly between both countries: the Netherlands 5.4/10,000 deliveries versus UK 2.7/10,000 (relative risk [RR] 1.94, 95% confidence intervals [95% CI] 1.6-2.4). The proportion of women with a preceding diagnosis of pre-eclampsia was comparable between both countries (the Netherlands 42%; UK 43%), as was the proportion who received magnesium sulphate prophylaxis. Women in the Netherlands had a significantly higher maximum diastolic blood pressure (111 mmHg versus 95 mmHg, P < 0.001); significantly fewer received anti-hypertensive medication (16% versus 71%; RR 0.2, 95% CI 0.1-0.3) and were treated less often with magnesium sulphate after their first fit (95% versus 99%; RR 0.96, 95% CI 0.92-0.99). Maternal death occurred in three cases in the Netherlands compared with zero in the UK. CONCLUSIONS: The incidence of eclampsia in the Netherlands was twice as high compared with the UK when using uniform definitions. Women with eclampsia in the Netherlands were not managed according to guidelines, particularly with respect to blood pressure management. Changes in management practice may reduce both incidence and poor outcomes.

Involving women in personalised decision-making on mode of delivery after caesarean section: the development and pilot testing of a patient decision aid.

OBJECTIVE: To develop a patient decision aid (PtDA) for mode of delivery after caesarean section that integrates personalised prediction of vaginal birth after caesarean (VBAC) with the elicitation of patient preferences and evidence-based information. DESIGN: A PtDA was developed and pilot tested using the International Patients Decision Aid Standards (IPDAS) criteria. SETTING: Obstetric health care in the Netherlands. POPULATION: A multidisciplinary steering group, an expert panel, and 25 future users of the PtDA, i.e. women with a previous caesarean section. METHODS: The development consisted of a construction phase (definition of scope and purpose, and selection of content, framework, and format) and a pilot testing phase by interview. The process was supervised by a multidisciplinary steering group. MAIN OUTCOME MEASURES: Usability, clarity, and relevance. RESULTS: The construction phase resulted in a booklet including unbiased balanced information on mode of birth after caesarean section, a preference elicitation exercise, and tailored risk information, including a prediction model for successful VBAC. During pilot testing, visualisation of risks and clarity formed the main basis for revisions. Pilot testing showed the availability of tailored structured information to be the main factor involving women in decision-making. The PtDA meets 39 out of 50 IPDAS criteria (78%): 23 out of 23 criteria for content (100%) and 16 out of 20 criteria for the development process (80%). Criteria for effectiveness (n = 7) were not evaluated. CONCLUSIONS: An evidence-based PtDA was developed, with the probability of successful VBAC and the availability of structured information as key items. It is likely that the PtDA enhances the quality of decision-making on mode of birth after caesarean section.

Course of HbA1c in non-diabetic pregnancy related to birth weight.

BACKGROUND: Despite good glycaemic control (according to the internationally accepted level of HbA1c < 7% (53.0 mmol/mol)) the incidence of macrosomia in pregnant women with diabetes is still very high. We measured HbA1c levels in each of the three trimesters of pregnancy in a cohort of healthy women to determine whether the upper reference level for good glycaemic control in diabetic pregnant females should be lower than the internationally accepted level. Secondly we investigated whether changes in HbA1c values in the course of pregnancy are associated with birth weight. METHODS: We determined HbA1c by high-performance liquid chromatography in 103 healthy pregnant women. The results were corrected with a method which was certified by the National Glycohaemoglobin Standardisation Program (NGSP) and standardised to the Diabetes Control and Complication trial reference assay. All women had a body mass index (BMI) < 30, none of the women had diabetes in the family in the first and/or second degree. The multiparous women had no history of macrosomia or small for gestational age infants. RESULTS: In the first trimester mean ± SD (range) HbA1c (n=93) was 4.7 ± 1.25% (27.9 ± 13.7 mmol/mol) (3.9-5.4% (19.1-35.5 mmol/mol)), in the second trimester (n=86) 4.6 ± 1.33% (26.8 ± 14.6 mmol/mol) (3.7-5.7% (16.9-38.8 mmol/mol)) and in the third trimester (n=71) 4.9 ± 1.39% (30.1 ± 15.2 mmol/mol) (4.0-6.0% (20.2-42.1 mmol/mol)). The calculated upper reference HbA1c values for the three trimesters were 5.4, 5.5 and 5.8% (35.5, 36.6 and 39.9 mmol/mol), respectively, compared with 6.5% (47.5 mmol/mol) in non-pregnant women in our hospital. We found a significant correlation between the differences of the first and second trimester HbA1c values and the birth weight percentiles (r=-0.251; p=0.032). All 44 women with a decrease in the HbA1c value from the first to the second trimester had a birth weight percentile ≤ 90. In the 30 women with no change or an increase in the HbA1c value from the first to the second trimester there was no relation between HbA1c values and birth weight percentiles, but seven of the 30 (23.3%) had a birth weight percentile of > 90. CONCLUSIONS: HbA1c is lower in all three trimesters of normal pregnancy compared with the level in non-pregnant women, and the change in HbA1c from the first to the second trimester predicts (the percentile of) birth weight. This could implicate that in order to prevent macrosomia in pregnant women with diabetes one should aim at lower HbA1c levels than the internationally accepted level, and at a decrease in HbA1c from the first to the second trimester.

RELAPSING FEVER, A DISAPPEARING CAUSE OF FEVER AND MATERNAL DEATH IN SENGEREMA, TANZANIA, EAST AFRICA.

OBJECTIVE: To study the incidence of tick borne relapsing fever (TBRF) during the last 50 years, once like malaria an endemic disease in Sengerema, Tanzania. DESIGN: By analyzing the annual reports, focusing on the number of admissions, maternal deaths, blood smears of patients with fever for Borrelia. SETTING: Sengerema district, Tanzania. SUBJECT: Admissions in Sengerema Hospital due to TBRF. MAIN OUTCOME MEASURES: From 1960 to 2010, we analyzed the incidence of TBRF. RESULT: Forty annual admissions in the sixties/seventies, 200 in the eighties (range from 37 in 1964 to 455 in 1988), dropping to 30 in the nineties. For the last nine years no Borrelia spirochetes were found in blood smears at the laboratory anymore and no admissions for TBRF were registered. The number of maternal deaths due to relapsing fever decreased simultaneously; the last one recordedwas in 2002. CONCLUSION: During the last century, we have witnessed the disappearing of tick borne relapsing fever in Sengerema. Increase of gold mining, improved local economy, housing and standards of living after the nineties resulted in an almost complete eradication of the incidence of TBRF.

The clinical benefit of blood transfusion: a hypothetical experiment based on a nationwide survey of severe maternal morbidity.

BACKGROUND: It is beyond doubt that blood transfusion services have added to the decline in maternal mortality in high-resource countries. To quantify the clinical benefit of red blood cell (RBC) transfusion in obstetric care, we performed a hypothetical experimental study using data from a prospective nationwide cohort of women giving birth in the Netherlands. STUDY DESIGN AND METHODS: Data were abstracted from a nationwide cohort study on severe maternal morbidity, including obstetric haemorrhage requiring 4 or more units of RBC, to obtain an observed and a hypothetical control group consisting of the same women. In the hypothetical control group, we simulated a situation where RBC transfusion was unavailable and estimated how many of these women would have died in that situation. A questionnaire survey asked experts in major (obstetric) haemorrhage to choose a critical minimal number of RBC transfusions at which a woman with obstetric haemorrhage would have died if RBC transfusion was not available. Maternal mortality rate per 100,000 maternities [maternal mortality ratios (MMR)] and relative risk were calculated for the observed and hypothetical group. RESULTS: The observed MMR was 13 per 100,000 maternities. According to 47 responding experts, the median number of RBC units without which a woman would have most probably died was nine, resulting in a hypothetical MMR of 87 per 100,000 maternities (relative risk 6·5; 95% confidence interval 4·2-10·0). CONCLUSIONS: It can be expected that unavailability of RBC transfusion in obstetric care increases the risk of maternal death 6.5-fold. Blood transfusion thus largely contributes to the decline of MMR and would also be an important pillar of improving quality of care in resource-poor settings.

Survey of prophylactic use of uterotonics in the third stage of labour in the Netherlands.

OBJECTIVE: aim of this study was to investigate current knowledge and practice regarding AMTSL in midwifery practices and obstetric departments in the Netherlands. DESIGN: web-based and postal questionnaire. SETTING: in August and September 2011 a questionnaire was sent to all midwifery practices and all obstetric departments in the Netherlands. PARTICIPANTS: all midwifery practices (528) and all obstetric departments (91) in the Netherlands. MEASUREMENTS AND FINDINGS: the response was 87.5%. Administering prophylactic uterotonics was seen as a component AMTSL by virtually all respondents; 96.1% of midwives and 98.8% of obstetricians. Cord clamping was found as a component of AMTSL by 87.4% of midwives and by 88.1% of obstetricians. Uterine massage was only seen as a component of AMTSL by 10% of the midwives and 20.2% of the obstetricians. Midwifery practices routinely administer oxytocin in 60.1% of births. Obstetric departments do so in 97.6% (p<0.01). Compared to 1995, the prophylactic use of oxytocin had increased in 2011 both by midwives (10-59.1%) and by obstetricians (55-96.4%) (p<0.01). KEY CONCLUSIONS: prophylactic administration of uterotonics directly after childbirth is perceived as the essential part of AMTSL. The administration of uterotonics has significantly increased in the last decade, but is not standard practice in the low-risk population supervised by midwives. IMPLICATIONS FOR PRACTICE: the evidence for prophylactic administration of uterotonics is convincing for women who are at high risk of PPH. Regarding the lack of evidence of AMTSL to prevent PPH in low risk (home) births, further research concerning low-risk (home) births, supervised by midwives in industrialised countries is indicated. A national guideline containing best practices concerning management of the third stage of labour supervised by midwives, should be composed and implemented.

Fatal meningitis during pregnancy in the Netherlands: a nationwide confidential enquiry.

OBJECTIVE: To determine the incidence of maternal deaths attributable to meningitis in the Netherlands, and to assess clinical features and risk factors. DESIGN: Confidential enquiry into the causes of maternal deaths. SETTING: Nationwide in the Netherlands. POPULATION: A total of 4 784 408 live births. METHODS: Analysis of all maternal deaths due to meningitis in pregnancy and puerperium from 1983 up to and including 2007 reported to the Maternal Mortality Committee of the Dutch Society of Obstetrics and Gynaecology. MAIN OUTCOME MEASURES: Incidence, clinical features and risk factors. RESULTS: Fifteen maternal deaths occurred due to meningitis, representing 4.4% of all maternal deaths. Twelve women (80%) presented with meningitis during pregnancy, 8 (66%) of them in the third trimester. Presenting symptoms were altered mental status (11; 73%), fever (9; 60%), nuchal rigidity (5; 33%) and headache (13; 87%). Nine women (60%) had otolaryngological infection at presentation or in the previous days or weeks. Twelve women (80%) underwent radiological examination, of which 5 (33%) showed distinct abnormalities. Cerebrospinal fluid (CSF) examination showed infected CSF in 8 (53%) women. In ten women (67%) Streptococcus pneumoniae was isolated. Substandard care was identified in 4 (27%) women. CONCLUSION: Pregnant or puerperal women presenting with classical symptoms of meningitis, particularly those with a history of otolaryngological infection or headache, should undergo thorough investigation and radiological and CSF examinations. Early diagnosis and immediate antibiotic treatment are imperative because of rapid deterioration in pregnant women. In case of doubt, the threshold for antibiotic treatment should be low and close monitoring is warranted.

Regional differences in Dutch maternal mortality.

OBJECTIVE: To study regional differences in maternal mortality in the Netherlands. DESIGN: Confidential inquiry into the causes of maternal mortality. SETTING: Nationwide. POPULATION: A total of 3 108 235 live births and 337 maternal deaths. METHODS: Data analysis of all maternal deaths in the period 1993-2008. MAIN OUTCOME MEASURE: Maternal mortality. RESULTS: The overall national maternal mortality ratio was 10.8 per 100 000 live births. In the 12 provinces of the Netherlands, the maternal mortality ratio ranged from 6.2 in Noord Brabant to 16.3 per 100 000 live births in Zeeland. In the four largest cities, maternal mortality varied from 9.3 in Amsterdam to 21.0 in Rotterdam. At a national level, the most frequent direct cause was pre-eclampsia. Increased risks for maternal mortality were found for women living in deprived neighbourhoods (RR 1.41), women from non-Western origin (RR 1.59), and women who were 35 years or older (RR 1.61). CONCLUSION: There are significant variations in maternal mortality ratios in the Netherlands between cities, provinces, and neighbourhoods. In addition, higher maternal mortality was observed in women of non-Western origin and in women who were 35 years of age or older.