Severe Maternal Outcomes: World Health Organization Maternal Near‐Miss and Maternal Mortality Criteria in University Tertiary Hospital Egypt

1. © 2019 Apollo Medicine | Published by Wolters Kluwer - Medknow74
Original Article
Introduction
Most maternal deaths occur during the intrapartum and
postpartum period are from direct preventable or treatable
causes such as hemorrhage, eclampsia, and sepsis.[1]
Most
maternal deaths occur in low‑income countries.[2]
The number
of qualified practitioners with low clinical experience is
low in Egypt although the equipment and facilities are
relatively sufficient. Obstetric audits at the facility level
may improve the quality of care[3]
along with the regulation
of private sector and re‑evaluation of the medical license
of doctors with introducing revalidation.[4‑6]
In 2011, the
World Health Organization (WHO) developed a systematic
maternal near‑miss (MNM) approach. The aim was to address
pitfalls in quality of obstetric care.[8]
MNM refers to “a
woman who almost died but survived a complication during
pregnancy, childbirth, or within 42 days after termination of
pregnancy,”[9,10]
The inclusion criteria for a maternal near miss
are categorised in three areas: clinical criteria, laboratory-
based criteria and management-based criteria. WHO near
miss criteria could identify all cases of maternal death and
almost all cases who experienced organ failure.[8,11‑14]
In Egypt,
the maternal mortality rate has been reduced to <50/100,000
live births in 2015 but still stationary over 10 years.[13‑18]
This
study aimed to assess MNM characteristics by applying the
WHO approach.
Severe Maternal Outcomes: World Health Organization
Maternal Near‑Miss and Maternal Mortality Criteria in
University Tertiary Hospital Egypt
Ahmed Samy El‑Agwany
Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
Background: The World Health Organization (WHO) maternal near‑miss (MNM) approach was developed to evaluate and improve the quality
of obstetric care worldwide. Aim: The aim of this study was to evaluate the incidence of MNM and quality of care at a tertiary hospital in
Egypt by applying this approach. Methods: A facility‑based, retrospective study was conducted between January 2015 and December 2016.
Participants’ data were collected from medical records of the intensive care unit. Results: Among 28,877 deliveries over 2 years, 185 women
suffered severe maternal outcome (SMO): 171 MNMs and 14 deaths. SMO ratio is 6.5/1000 live birth, MNM incidence ratio of 5.9/1000
live births, maternal death incidence ratio 0.5/1000 live birth, maternal mortality ratio of 48.48/100,000 live births, MNM mortality ratio is
12:1, and a mortality index of 7.5%. Hemorrhage (n = 107, 62.5%) and hypertensive disorders, including fits and hemolytic anemia, elevated
liver enzymes, and low platelet count syndrome (n = 44, 25.5%) were the most common MNM conditions. Hemorrhage (n = 8, 57%) was
the leading cause of maternal mortality and then cardiac diseases (n = 3, 21.5%). All cases were not receiving antenatal care in the Shatby
Hospital or were not compliant to the hospital ANC and were referred or showed up at the time of delivery or after delivery with complication
encountered. Nearly 71.5% of the died patients cases were younger than 30 years and 21.5% were primigravida. Conclusions: MNM is
common in Egypt. The approach enabled us to identify pitfalls in clinical practice and referral system. The private sector in Egypt needs to
evaluated and medical license should not be permanent.
Keywords: Audit, maternal morbidity, maternal mortality, maternal near miss, quality of care
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DOI:
10.4103/am.am_10_19
Address for correspondence: Dr. Ahmed Samy El‑Agwany,
Faculty of Medicine, El‑Shatby Maternity University Hospital, Alexandria
University, Alexandria, Egypt.
E‑mail: ahmedsamyagwany@gmail.com
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Web Publication: 19-Jun-2019
How to cite this article: El-AgwanyAS. Severe maternal outcomes: World
health organization maternal near-miss and maternal mortality criteria in
University Tertiary Hospital Egypt. Apollo Med 2019;16:74-8.
Abstract
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2. El‑Agwany: Severe maternal outcomes
Apollo Medicine ¦ Volume 16 ¦ Issue 2 ¦ April-June 2019 75
Methods
This was a retrospective cohort study that included women
who were admitted for delivery, pregnancy or labor‑related
complications in the intensive care unit (ICU) and who
sustained severe acute maternal morbidity or mortality at
the Shatby maternity tertiary hospital in Alexandria, Egypt,
between January 2015 and December 2016. The Shatby
Hospital acts as a provincial referral hospital for high‑risk
obstetric cases from health centers and other district
hospitals in Alexandria and three nearby provinces serving
ten million population. Annually, 14,455 deliveries were
conducted at the facility. Eligibility for the study was not
restricted by gestational age, including abortion, ectopic
pregnancy, postpartum complications, and those who met
the WHO criteria excluding other cases in the ICU whether
gynecological cases or patients on follow‑up with no single
criteria.[15‑19]
Women with complications >42 days after
termination of pregnancy were not eligible. We gathered
the data from the ICU medical records. Severe maternal
outcome (SMO) as our goal was defined as MNMs and
maternal deaths. We tried to apply the WHO criteria on all
cases, but some were not applied due to lack of laboratory
tests. For every case, information was collected regarding
sociodemographic characteristics, gestational age, maternal
outcome, main causes of MNM, and death and medical
condition associated.
Results
During the 24‑month study period, there were
28,877 deliveries, 185 women suffered SMO: 171 MNMs
and 14 deaths. SMO ratio is 6.5/1000 live birth, MNM
incidence ratio of 5.9/1000 live births, maternal death
incidence ratio 0.5/1000 live birth, maternal mortality
ratio of 48.48/100,000 live births, MNM mortality ratio is
12:1, and a mortality index of 7.5% (known figures of our
institution). Hemorrhage (n = 107, 62.5%) and hypertensive
disorders, including fits and hemolytic anemia, elevated
liver enzymes, and low platelet count syndrome (n = 44,
25.5%) were the most till common MNM conditions.
Hemorrhage (n = 8, 57%) was the leading cause of maternal
mortality and then cardiac diseases (n = 3, 21.5%). All cases
were not receiving antenatal care in the Shatby Hospital and
were referred at time of delivery or after delivery with the
complication encountered or were not compliant to hospital
ANC visits and policy. Nearly 71.5% of the died cases were
younger than 30 years and 21.5% of the died cases were
primigravida. The main WHO criteria encountered were the
ones related to hemorrhage. Young age pregnant females
can sustain hemoglobin <3 gm% after hemorrhage till blood
replacement. The ICU admission rate was 1.66% among
all delivering women, whereas ICU cases with SMO were
38.5% [Tables 1‑4].
Table 2: Medical disease associated
Maternal
near‑miss cases
Deceased
cases
Paraplegia 1 0
Deep venous thrombosis 1 0
Idiopathic thrombocytopenic purpura 1 0
Pregestational diabetes mellitus 2 0
Cardiac disease 4 1
Chronic renal failure 1 0
Aplastic anemia 1 0
Chronic hypertension 0 1
Table 1: Demography of patients
Parameter Number
Duration of study Two years from January 2015 to December 2016
Maternal near‑miss cases 171
Mortality cases 14
Total ICU cases 480
Total number of cases admitted to hospital for delivery 28877
Duration of stay in ICU Maternal near miss 1‑12 days
Dead cases 1 h‑4 days
Age of patients (years) 18‑38 years
10 cases died before 30 years age
Patient residence in Egypt Alexandria 109 patients then Behara, Kafr Elsheikh, and Matrouh
Gravidity 1‑10
Three cases died at first pregnancy
Parity 0‑6
Number of cesarean section 0‑6
Number of cases with cesarean section as mode of
delivery weather previous or current
Near near‑miss cases: 97
Died cases: 4
Not received in our hospital
Referral center and antenatal care 95%
ICU: Intensive care unit
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3. El‑Agwany: Severe maternal outcomes
Apollo Medicine ¦ Volume 16 ¦ Issue 2 ¦ April-June 201976
Shock is defined as a persistent severe hypotension, defined as a
systolicbloodpressure <90 mmHgfor60 minwithapulserateof
≥120/min despite aggressive fluid replacement (>2 L). Oliguria
is defined as a urinary output <30 mL/h for 4 h or <400 ml/24 h.
Coagulation disorder defined as the absence of clotting from the
IV site after 7–10 min. Unconsciousness/coma lasting >12 h is
defined as a profound alteration of mental state that involves
complete or near‑complete lack of responsiveness to external
stimuli or Glasgow Coma Scale <10. Cardiac arrest is defined
as the loss of consciousness and absence of pulse or heartbeat.
Stroke is defined as a neurological deficit of cerebrovascular
cause that persists ≥24 h or is interrupted by death within 24 h.
Uncontrollable fit is a condition in which the brain is in state of
continuous seizure. Preeclampsia: the presence of hypertension
associated with proteinuria. Hypertension is defined as a blood
pressure ≥140 mmHg (systolic) or ≥90 mmHg (diastolic).
Proteinuriais defined as the excretion of ≥300 mg protein/24 h or
300 mg protein/l urine or ≥1+ on a dipstick. Eclampsia is defined
as the presence of hypertension associated with proteinuria and
fits. Sepsis is defined as a clinical sign of infection and three
of the following: temperature >38°C or <36°C, respiration
rate >20/min, pulse rate >90/min, white blood cell count
>12,000/cmm, clinical signs of peritonitis. Uterine rupture is
defined as the complete rupture of a uterus during labor.[13‑18]
Discussion
The high‑MNM in our study may be explained by delayed
referral of SMO cases or the high proportion of women
without medical insurance which led to delay in seeking
for financial reasons care and limited experience and skills
in private sector, doctors` 1st
money earning and practicing
safe obstetrics in the form of cesarean section with poor
implementation of guidelines increasing placenta accreta
and previa in high fertility society.[8,13,14]
We serve a large
number of critically ill women in the low‑resource settings
with limited facilities that contributes to our facility mortality
and MNM rates as we are a tertiary hospital. The main direct
causes of SMO were obstetric hemorrhage and hypertensive
disorders comparable to other studies in the low‑resource
countries.[11‑14]
Mortality indices were lower than in other
studies, probably due to the wide availability of blood for
transfusion and magnesium sulfate in our setting with more
doctors`clinical experience and better care of patients.
Particular attention is needed for conditions with high
mortality as hemorrhage, sepsis, preeclampsia and cardiac
diseases.[14]
The relative inexperience from medical officers
working in district hospitals (generally recent medical school
graduates) may compound this problem,[20]
with improper
use of antibiotics and poor sterilization. Along with poor
ANC management audit of cesarean section indications.[21]
Is needed in every facility dealing with pregnant patient 95%
percent of SMO cases were referred in critical condition
from other facilities or home. Even came directly from home
taking time in transportation from district areas and even
without ambulance by relatives.[19]
It is essential to separate
referred near miss cases from those developing in the
hospital.[17,18]
95% percent of SMO cases were on admission.
This highlights potential interventions such as educating
pregnant women and caretakers on obstetric danger signs[21]
and training health‑care workers on emergency obstetric
care, improving resources of hospital and implementing
a medical insurance covering all patients.[22]
Poor use of
evidence‑based practices explains SMO cases as use of
oxytocin better than carbetocin in the emergency cesarean
section. That increase PPH as not using the routine first
line syntocinon infusion in vaginal delivery and emergency
section reserving carbetocin to elective section. The high
patient load at the facility might have a negative impact
on the quality of care as it deals with all cases of obstetrics
and gynecology even antenatal care is which should be
managed by primary facilities.[22]
It is easy to underestimate
severe morbidity in the absence of laboratory diagnostics
and shortage of nurse‑midwives and clinicians to identify
clinical signs of deteriorating patients.[12,13]
Studies have
shown maternal morbidity and mortality can be significantly
reduced by improving maternal health care when health
workers use audit to identify and analyze deficiencies and
apply the findings to improve obstetric care practices.[3]
Our
study assess SMO using the new WHO MNM criteria. The
advantage of this approach is its standardized methodology,
which may allow for a comparison of health facilities and
systems. The limitations were the lack of follow‑up after
discharge that may lead to underestimation of MNM and
maternal deaths, and the quality of medical records was
Table 3: Predisposing factor
Maternal
near miss
Deceased
cases
Placenta accreta 26 0
Accidental hemorrhage 19 1
Antepartum seizures 24 1
Disturbed ectopic pregnancy 14 0
Rupture uterus 11 1
Allergic reaction to antibiotics 1 0
Postpartum seizures 6 0
Hemolytic anemia, elevated liver
enzymes, and low platelet syndrome
14 0
Atonic postpartum hemorrhage 30 6
Anesthesia complication 2 0
Peripartum cardiomyopathy 1 2
Vulvar hematoma 1 0
Septic abortion 2 0
Pulmonary embolism 2 0
Acute pyelonephritis 1 0
Cardiac disease 1 1
Puerperal sepsis 2 1
Abortion 4 0
Placenta previa 2 0
Swine flu influenza 0 1
Diabetic ketoacidosis 10 0
Dehydration ketosis 8 0
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4. El‑Agwany: Severe maternal outcomes
Apollo Medicine ¦ Volume 16 ¦ Issue 2 ¦ April-June 2019 77
sometimes poor. We could not apply all the WHO criteria
due to limited resources at our hospital.[15‑19]
Conclusions
MNM is high at Egypt. Our study highlights some pitfalls in the
clinical practice and the referral system; improvements could
lead to further reductions in maternal mortality and morbidity.
The WHO MNM criteria are important for the evaluation of
care. Hemorrhage and preeclampsia and cardiac diseases are
still the main causes of death and MNM. The private sector
needs regulation. MNM is more important now as maternal
mortality is low and hence these patients are important as they
are living with long‑term disabilities and morbidities.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al.
Global causes of maternal death: A WHO systematic analysis. Lancet
Glob Health 2014;2:e323‑33.
2. World Health Organization. Evaluating the Quality of Care for Severe
Pregnancy Complications: The WHO Near‑Miss Approach for Maternal
Health. Geneva: World Health Organization; 2011.
3. van den Akker T, van Rhenen J, Mwagomba B, Lommerse K,
Vinkhumbo S, van Roosmalen J, et al. Reduction of severe acute
maternal morbidity and maternal mortality in Thyolo district, Malawi:
The impact of obstetric audit. PLoS One 2011;6:e20776.
4. Tunçalp O, Hindin MJ, Souza JP, Chou D, Say L. The prevalence of
maternal near miss: A systematic review. BJOG 2012;119:653‑61.
5. Maternal Health Division. Maternal Near Miss Review: Operational
Guidelines. Ministry of Health & Family Welfare. New Delhi:
Government of India; 2014.
6. Souza JP, Cecatti JG, Haddad SM, Parpinelli MA, Costa ML, Katz L,
et al. The WHO maternal near‑miss approach and the maternal severity
index model (MSI): Tools for assessing the management of severe
maternal morbidity. PLoS One 2012;7:e44129.
7. Tunçalp Ö, Hindin MJ, Adu‑Bonsaffoh K, Adanu RM. Assessment
of maternal near‑miss and quality of care in a hospital‑based study in
Accra, Ghana. Int J Gynaecol Obstet 2013;123:58‑63.
8. Say L, Souza JP, Pattinson RC; WHO working group on Maternal
Mortality and Morbidity Classifications. Maternal near miss – Towards
a standard tool for monitoring quality of maternal health care. Best Pract
Res Clin Obstet Gynaecol 2009;23:287‑96.
9. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM,
et al. Maternal mortality for 181 countries, 1980‑2008: A systematic
analysis of progress towards millennium development goal 5. Lancet
Table 4: The World Health Organization criteria
MNM (171) Deceased
patients (14)
Clinical criteria
Acute cyanosis 0 4
Gasping 1 3
Respiratory rate >40 or <6/min 47 3
Shock 47 3
Oliguria nonresponsive to fluids or diuretics 4 3
Coagulation disorders 63 5
Loss of consciousness lasting >12 h 13 5
Cardiac arrest 2 14
Stroke 12 0
Uncontrollable fit/total paralysis 0 1
Jaundice in the presence of preeclampsia 5 0
Laboratory‑based criteria
Oxygen saturation <90% for ≥60 min 47 14
PaO2/FiO2 ratio (the ratio of arterial oxygen partial pressure to fractional inspired oxygen) ≤200 mmHg Not available
Serum creatinine ≥3.5 mg/dL 19 4
Serum bilirubin 6.0 mg/dL 5 0
pH <7.1 60 10
Serum lactate >5 mEq/mL Not available
Acute thrombocytopenia (<50,000 platelets/ml) 62 9
Ketoacidosis in urine 18 0
Management‑based criteria
Admission to ICU 171 14
Use of continuous vasoactive drugs 30 14
Hysterectomy following infection or hemorrhage 40 6
Transfusion of ≥5 units of blood 90 10
Intubation and ventilation for ≥60 min 33 14
Dialysis for acute renal failure 9 0
Cardio‑pulmonary resuscitation 3 14
ICU: Intensive care unit
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2010;375:1609‑23.
10. Ali AA, Khojali A, Okud A, Adam GK, Adam I. Maternal near‑miss in
a rural hospital in Sudan. BMC Pregnancy Childbirth 2011;11:48.
11. van den Akker T, Beltman J, Leyten J, Mwagomba B, Meguid T,
Stekelenburg J, et al. The WHO maternal near miss approach:
Consequences at Malawian district level. PLoS One 2013;8:e54805.
12. Nelissen E, Mduma E, Broerse J, Ersdal H, Evjen‑Olsen B,
van Roosmalen J, et al. Applicability of the WHO maternal near miss
criteria in a low‑resource setting. PLoS One 2013;8:e61248.
13. Abdel Ghani RM, Berggren V. Parturient needs during labor: Egyptian
women’s perspective toward childbirth experience. J Basic Appl Sci Res
2011;1:2935‑43.
14. Ministry of Health and Population Egypt, Partnership for Maternal,
Newborn and Child Health, World Health Organization, World Bank and
Alliance for Health Policy and Systems Research. Success Factors for
Woman’s and Children’s: Egypt. Geneva: World Health Organization;
2014.
15. Saleh WF, Ragab WS, Aboulgheit SS. Audit of maternal mortality ratio
and causes of maternal deaths in the largest maternity hospital in Cairo,
Egypt (Kasr Al Aini) in 2008 and 2009: Lessons learned. Afr J Reprod
Health 2013;17:105‑9.
16. El‑Nemer A, Mosbah A. Maternal near – Misses in a university hospital.
IOSR J Nurs Health Sci 2015;4:48‑53.
17. Bashour H, Saad‑Haddad G, DeJong J, Ramadan MC, Hassan S,
Breebaart M, et al. A cross sectional study of maternal ‘near‑miss’cases
in major public hospitals in Egypt, Lebanon, Palestine and Syria. BMC
Pregnancy Childbirth 2015;15:296.
18. David E, Machungo F, Zanconato G, Cavaliere E, Fiosse S, Sululu C,
et al. Maternal near miss and maternal deaths in Mozambique:
A cross‑sectional, region‑wide study of 635 consecutive cases assisted
in health facilities of Maputo Province. BMC Pregnancy Childbirth
2014;14:401.
19. Mivumbi VN, Little SE, Rulisa S, Greenberg JA. Prophylactic ampicillin
versus cefazolin for the prevention of post‑cesarean infectious morbidity
in Rwanda. Int J Gynaecol Obstet 2014;124:244‑7.
20. Rijken MJ, Meguid T, van den Akker T, van Roosmalen J,
Stekelenburg J; Dutch Working Party for International Safe Motherhood
and Reproductive Health. Global surgery and the dilemma for
obstetricians. Lancet 2015;386:1941‑2.
21. Nyamtema AS, de Jong AB, Urassa DP, van Roosmalen J. Using audit
to enhance quality of maternity care in resource limited countries:
Lessons learnt from rural Tanzania. BMC Pregnancy Childbirth
2011;11:94.
22. Borchert M, Goufodji S, Alihonou E, Delvaux T, Saizonou J,
Kanhonou L, et al. Can hospital audit teams identify case management
problems, analyse their causes, identify and implement improvements?
A cross‑sectional process evaluation of obstetric near‑miss case reviews
in Benin. BMC Pregnancy Childbirth 2012;12:109.
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