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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 74-78

Severe maternal outcomes: World health organization maternal near-miss and maternal mortality criteria in University Tertiary Hospital Egypt


Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Alexandria, Egypt

Date of Submission17-Mar-2019
Date of Acceptance30-Apr-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Ahmed Samy El-Agwany
Faculty of Medicine, El-Shatby Maternity University Hospital, Alexandria University, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_10_19

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  Abstract 


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


How to cite this article:
El-Agwany AS. Severe maternal outcomes: World health organization maternal near-miss and maternal mortality criteria in University Tertiary Hospital Egypt. Apollo Med 2019;16:74-8

How to cite this URL:
El-Agwany AS. Severe maternal outcomes: World health organization maternal near-miss and maternal mortality criteria in University Tertiary Hospital Egypt. Apollo Med [serial online] 2019 [cited 2019 Jul 20];16:74-8. Available from: http://www.apollomedicine.org/text.asp?2019/16/2/74/260680




  Introduction Top


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],[5],[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],[12],[13],[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],[14],[15],[16],[17],[18] This study aimed to assess MNM characteristics by applying the WHO approach.


  Methods Top


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],[16],[17],[18],[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 Top


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% [Table 1], [Table 2], [Table 3], [Table 4].
Table 1: Demography of patients

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Table 2: Medical disease associated

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Table 3: Predisposing factor

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Table 4: The World Health Organization criteria

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Shock is defined as a persistent severe hypotension, defined as a systolic blood pressure <90 mmHg for 60 min with a pulse rate of ≥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). Proteinuria is 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],[14],[15],[16],[17],[18]


  Discussion Top


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],[12],[13],[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 sometimes poor. We could not apply all the WHO criteria due to limited resources at our hospital.[15],[16],[17],[18],[19]


  Conclusions Top


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 Top

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.  Back to cited text no. 1
    
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.  Back to cited text no. 2
    
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.  Back to cited text no. 3
    
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Tunçalp O, Hindin MJ, Souza JP, Chou D, Say L. The prevalence of maternal near miss: A systematic review. BJOG 2012;119:653-61.  Back to cited text no. 4
    
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Maternal Health Division. Maternal Near Miss Review: Operational Guidelines. Ministry of Health & Family Welfare. New Delhi: Government of India; 2014.  Back to cited text no. 5
    
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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.  Back to cited text no. 6
    
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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.  Back to cited text no. 7
    
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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.  Back to cited text no. 8
    
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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 2010;375:1609-23.  Back to cited text no. 9
    
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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.  Back to cited text no. 10
    
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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.  Back to cited text no. 11
    
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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.  Back to cited text no. 12
    
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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.  Back to cited text no. 13
    
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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.  Back to cited text no. 14
    
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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.  Back to cited text no. 15
    
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El-Nemer A, Mosbah A. Maternal near – Misses in a university hospital. IOSR J Nurs Health Sci 2015;4:48-53.  Back to cited text no. 16
    
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Bashour H, Saad-Haddad G, DeJong J, Ramadan MC, Hassan S, Breebaart M, et al. Across sectional study of maternal 'near-miss' cases in major public hospitals in Egypt, Lebanon, Palestine and Syria. BMC Pregnancy Childbirth 2015;15:296.  Back to cited text no. 17
    
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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.  Back to cited text no. 18
    
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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.  Back to cited text no. 19
    
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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.  Back to cited text no. 20
    
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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.  Back to cited text no. 21
    
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.  Back to cited text no. 22
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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