Analysis of the Factors leading to Severe Acute Maternal Morbidity and Maternal Mortality during COVID 19 Pandemic

Objective: To study severe acute maternal morbidity and maternal death in Ayder teaching Hospital.Methodology: Facility-based survey of severe acute maternal morbidity and maternal death with consecutive entry of casesfrom records for all pregnant, recently delivered or aborted patients who appeared and were admitted to Ayder referral teachingHospital from January, 2008 through December, 2010.Results: There were 2107 hospitalizations for maternal health services; of these, 204 were severe acute maternal morbiditiesand 9 direct maternal deaths with almost 23 severe acute morbidities for each maternal death, with an overall rate of severeacute maternal morbidity of 101 per 1000 deliveries and a maternal mortality ratio of 427 per 100,000 live births.Conclusion: In the era of countdown to 2015 and with the meager chance of Millennium Development Goals (MDG5) beingachieved in many African countries, including Ethiopia, the analysis of severe acute maternal morbidity along with maternaldeath should be a new paradigm in the assessment of maternal health and its progress at all levels. Ayder Teaching Hospitalshould have its own uniform criteria for inclusion of severe acute maternal morbidity based on other hospitals’ experiences andthe scientific plausibility to tackle facility-based avoidable severe maternal morbidity and mortality. Furthermore, a prospectivestudy should be done to exactly know the level of substandard care(Ethiopian Journal of Reproductive Health , 2012,6(1): 56-63).Key Words: Near miss, maternal, mortality, morbidity, Ayder, Survey, pregnancy, complication

To analyse severe acute maternal morbidity (SAMM) and maternal mortality in the Pretoria region over a 2-year period (2000-2001). Public hospitals in the Pretoria region, South Africa, serving a mainly indigent urban population. A descriptive study was performed whereby women with SAMM and maternal deaths were identified at daily audit meetings and an audit form was completed for all cases fulfilling the definition of SAMM ('near miss') and for all maternal deaths. The number of maternal deaths declined slightly but not significantly from 18 deaths in 2000 to 16 in 2001. This represents a change in the maternal mortality ratio (MMR) from 130/100,000 live births in 2000 to a MMR of 100/100,000 live births in 2001. However, when data for women with SAMM and maternal deaths were combined, there was a significant increase in major maternal morbidity from 90 cases (SAMM and maternal death rate 649/100,000 live births) in 2000 to 142 cases (SAMM and maternal death rate 889/100,000 live births) in 2001 (p = 0.006). This increase was due to a significant increase in severe maternal morbidity related to abortions and obstetric haemorrhages. Analysis of maternal deaths only in the Pretoria region failed to identify abortions and haemorrhages as major maternal care problems. When data for women with SAMM were combined with data for maternal deaths, however, these problems were clearly identified, and remedial action could be taken. Including SAMM in maternal death audits increases the rapidity with which health system problems can be identified.

Ways Forward in Preventing Severe Maternal Morbidity and Maternal Health Inequities: Conceptual Frameworks, Definitions, and Data, from a Population Health Perspective.

Anaemia is frequently diagnosed during pregnancy. However, there are few data regarding its incidence, and the association with severe maternal morbidity remains uncertain and potentially biased in high-resource countries. The purpose of this study was to explore the association between gestational anaemia and severe acute maternal morbidity during and after delivery. We performed a cohort-nested case-control analysis from the epidemiology of severe maternal mortality (EPIMOMS) prospective study conducted in six French regions (2012-2013, n=182,309 deliveries). There were 1669 women with severe acute maternal morbidity during or after delivery, according to a standardised definition obtained by expert consensus. The control group were randomly selected among women without severe morbidity who delivered in the same health centres (n=3234). We studied the association between gestational anaemia and severe acute maternal morbidity during or after delivery overall, by cause, and by mode of delivery, using multivariable logistic regression and multiple imputation. Gestational anaemia was significantly more frequent in women with severe acute maternal morbidity (25.3%) than in controls (16.3%), p<0.001, and mostly mild in both groups. After adjustment for confounders, women with gestational anaemia were at increased risk of overall severe acute maternal morbidity during and after delivery (adjusted OR (95%CI) 1.8 (1.5-2.1)). This association was also found for severe postpartum haemorrhage (adjusted OR (95%CI) 1.7 (1.5-2.0)), even after omitting the transfusion criterion (adjusted OR (95%CI) 1.9 (1.6-2.3)), and for severe acute maternal morbidity secondary to causes other than haemorrhage or pregnancy-related hypertensive disorders (adjusted OR (95%CI) 2.7 (1.9-4.0)). These results highlight the importance of optimising the diagnosis and management of anaemia during pregnancy.

Severe acute maternal morbidity in multiple pregnancies: a nationwide cohort study

To investigate the association between twin pregnancy and severe acute maternal morbidity, overall and by timing (before, during or after delivery) and underlying causal condition. We conducted a cohort-nested case-control analysis from the EPIMOMS prospective study conducted in six French regions from 2012-2013 (N=182,309 deliveries). The case group comprised 2,500 women with severe acute maternal morbidity (defined by a national expert consensus process) occurring from 22 weeks of gestation and up to 42 days postpartum. A random sample of 3,650 women who gave birth without severe acute maternal morbidity made up the control group. The association between twin pregnancy and severe acute maternal morbidity was analyzed with multilevel multivariable logistic regression. The role of cesarean delivery as an intermediate factor between twin pregnancy and severe acute maternal morbidity was assessed by path analysis. The population-based incidence of severe acute maternal morbidity was 6.2% (n=197/3,202, 95% CI 5.3-7.1) in twin pregnancies, and 1.3% (n=2,303/179,107, 95% CI 1.2-1.3) in singleton pregnancies. After controlling for confounders, the risk of severe acute maternal morbidity was higher in twin than in singleton pregnancies (adjusted odds ratio [OR] 4.2, 95% CI 3.1-5.8), both antepartum and intrapartum or postpartum, and regardless of the category of causal condition (severe hemorrhage, severe hypertensive complications, or other conditions). The association was also found for the most severe near-miss cases (adjusted OR 5.1, 95% CI 3.5-7.3). In path analysis, cesarean delivery mediated 20.6% (95% CI 12.9-28.2) of the total risk of intrapartum or postpartum severe acute maternal morbidity associated with twin pregnancy. Compared with women with singleton pregnancies, women with twin pregnancies have a fourfold increased risk for severe maternal complications both before and after delivery. About one fifth of the association between twin pregnancy and intrapartum or postpartum severe acute maternal morbidity may be mediated by cesarean delivery.

Severe acute maternal morbidity and mortality in the Pretoria Academic Complex: changing patterns over 4 years

BackgroundStudying severe acute maternal morbidity in the intensive care unit improves our understanding of potential factors affecting maternal health.AimTo review evidence on maternal exposure to intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit.MethodsThe protocol for this review was registered in PROSPERO (registration number CRD42016037492). A systematic search was performed in MEDLINE, CINAHL, ProQuest, LILACS and SciELO using the search terms “intensive care unit”, “intensive care”, “critical care” and “critically ill” in combination with “intimate partner violence”, “social determinants of health”, “severe acute maternal morbidity”, pregnancy, postpartum and other similar terms. Eligible studies were (i) quantitative, (ii) published in English and Spanish, (iii) from 2000 to 2021, (iv) with data related to intimate partner violence and/or social determinants of health, and (v) investigating severe acute maternal morbidity (maternity patients treated in the intensive care unit during pregnancy, childbirth or within 42 days of pregnancy termination). Of 52,866 studies initially identified, 1087 full texts were assessed and 156 studies included. Studies were independently assessed by two reviewers for screening, revision, quality assessment and abstracted data. Studies were categorised into high/middle/low-income countries and summarised data were presented using a narrative description, due to heterogenic data as: (i) exposure to intimate partner violence and (ii) social determinants of health.ResultsOne study assessed intimate partner violence among mothers with severe acute maternal morbidity in the intensive care unit and found that women exposed to intimate partner violence before and during pregnancy had a nearly four-fold risk of severe acute maternal morbidity requiring ICU admission. Few social determinants of health other than age were reported in most studies.ConclusionThis review identified a significant gap in knowledge concerning intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit, which is essential to better understand the complete picture of the maternal morbidity spectrum and reduce maternal mortality.

Introduction: As the absolute numbers of maternal deaths in an institution are few, maternal death audits may not provide the true picture of service provision. Therefore severe acute maternal morbidity (SAMM), also referred to as near misses, has been proposed as a supplementary indicator for the assessment of the quality of maternity care. Objective: To study SAMM in order to identify strategies which could be adopted to improve quality of care. Design, Setting and Methods: Using the WHO near-miss criteria, a clinical audit was carried out in all five consultant units of the Castle Street Hospital for Women (CSHW), Colombo from 1st February 2011 to 31st January 2012. Of the admissions to the intensive care, only those who conformed to the WHO near-miss inclusion criteria were studied. Results: There were 91 cases of SAMM and five maternal deaths out of 16511 live births, giving a maternal mortality ratio of 30.3/100,000 live births, a maternal near-miss ratio of 5.5/1000 live births and a maternal near miss: mortality ratio of 18.2. Of the 91 cases of SAMM, there were 35 (38.5%) cases of major post partum hemorrhage (PPH), 18 (19.8%) cases of thrombocytopenia and coagulopathy due to Dengue fever, nine (9.9%) cases with cardiac dysfunction, five (5.5%) cases of liver disease and six (6.6%) cases of eclampsia. There were 45 cases who had more than one inclusion criterion. Suboptimal management processes identified included incomplete documentation in some cases, non documentation of estimated blood loss in PPH, deficiencies in monitoring in labor and instrumental delivery, non use of uterine tamponade prior to proceeding to hysterectomy, and inadequate knowledge and experience of uterine tamponade insertion. Conclusions: SAMM is approximately 18 times greater than maternal deaths in the CSHW and approximately 39% of SAMM is due to major PPH. Dengue fever is an important course of SAMM in the CSHW. Appropriate steps should be adopted to correct the sub optimal practices identified. DOI: http://dx.doi.org/10.4038/sljog.v34i4.5930 Sri Lanka Journal of Obstetrics and Gynaecology 2012; 34 : 135-143

Introduction: Maternal mortality traditionally has been the indicator of maternal health all over the world. More recently review of the cases of severe acute maternal morbidity (SAMM), also termed as "near miss obstetrics events", has been found to be a useful supplementary indicator to investigate maternal health care. Cases of near miss are those in which women present with potentially fatal complication during pregnancy, delivery, or the puerperium and survive merely by chance or by good hospital care. This study was done with the objective to analyze cases of SAMM at Lumbini Medical College Teaching Hospital (LMCTH), Nepal.&#x0D; &#x0D; Methods: A retrospective study of all cases meeting the WHO criteria for SAMM, during May 2015, was done. Cases meeting the WHO eligibility criteria for near miss cases were included in the study. Medical record of such cases in past one year was reviewed. Their socio-demographic variables, parity, gestational age, associated organ dysfunction, ICU and hospital stay, management, and fetal and maternal outcome were noted.&#x0D; &#x0D; Results: During the study period, there were total of 28 cases of SAMM and two maternal mortality out of 2735 live births. Thus rate of SAMM was 1.02%, and maternal mortality rate was 0.07%. Majority of patients were unbooked (n=18, 64.28%) and 10 (35.71%) were illiterate. Commonest causes for admission to ICU was hemorrhage (n=10, 35.71%) followed by hypertensive disorders (n=9, 32.06%), sepsis (n=2, 7.14%), and obstructed labour (n=2, 7.14%). Laparotomy was performed in six (21.42%) women, obstetric hysterectomy in four (14.28%), and pelvic devascularization in two (10.71%).&#x0D; &#x0D; Conclusion: SAMM is a useful adjunct to maternal mortality to assess maternal health care. Improving facility based care and prompt referral, education of primary health care (PHC) staff can be a short term measure to quickly reduce the number of maternal deaths. Facility based monitoring and reporting of SAMM outcome is an important step for scaling up such efforts.

AimTo determine the frequency of near-miss (severe acute maternal morbidity) and the nature of near-miss events, and comparatively analysed near-miss morbidities and maternal deaths among pregnant women managed over a 3-year period in a Nigerian tertiary centre.MethodsRetrospective facility-based review of cases of near-miss and maternal death which occurred between 1 January 2002 and 31 December 2004. Near-miss case definition was based on validated disease-specific criteria, comprising of five diagnostic categories: haemorrhage, hypertensive disorders in pregnancy, dystocia, infection and anaemia. The near-miss morbidities were compared with maternal deaths with respect to demographic features and disease profiles. Mortality indices were determined for various disease processes to appreciate the standard of care provided for life-threatening obstetric conditions. The maternal death to near-miss ratios for the three years were compared to assess the trend in the quality of obstetric care.ResultsThere were 1501 deliveries, 211 near-miss cases and 44 maternal deaths. The total near-miss events were 242 with a decreasing trend from 2002 to 2004. Demographic features of cases of near-miss and maternal death were comparable. Besides infectious morbidity, the categories of complications responsible for near-misses and maternal deaths followed the same order of decreasing frequency. Hypertensive disorders in pregnancy and haemorrhage were responsible for 61.1% of near-miss cases and 50.0% of maternal deaths. More women died after developing severe morbidity due to uterine rupture and infection, with mortality indices of 37.5% and 28.6%, respectively. Early pregnancy complications and antepartum haemorrhage had the lowest mortality indices. Majority of the cases of near-miss (82.5%) and maternal death (88.6%) were unbooked for antenatal care and delivery in this hospital. Maternal mortality ratio for the period was 2931.4 per 100,000 deliveries. The overall maternal death to near-miss ratio was 1: 4.8 and this remained relatively constant over the 3-year period.ConclusionThe quality of care received by critically ill obstetric patients in this centre is suboptimal with no evident changes between 2002 and 2004. Reduction of the present maternal mortality ratio may best be achieved by developing evidence-based protocols and improving the resources for managing severe morbidities due to hypertension and haemorrhage especially in critically ill unbooked patients. Tertiary care hospitals in Nigeria could also benefit from evaluation of their standard of obstetric care by including near-miss investigations in their maternal death enquiries.

Objectives: Identification of severe acute maternal morbidity (SAMM) has gained importance in recent years in view of falling maternal death rates and thrust on improving quality of maternal health care. Although most of these events occur in developing countries, reporting system for SAMM is poorly developed in these regions. Aim of this study was to determine the incidence and direct causes of postpartum SAMM along with measuring of relevant new indicators on maternal health in an apex institute of India Materials and Methods: Hospital based cross sectional study conducted in India on 109 women with severe post partum complications. Outcome measures were SAMM or death. Results: 99 women had SAMM and there were 10 maternal deaths. Eclampsia was the most common cause of SAMM, but case fatality ratio was higher for PPH. SAMM ratio was 16.22/1000 live births and mortality index was 9.17%. Conclusion: 1 out of every 10 women with SAMM dies in developing countries. Improving facility based care and prompt referral can be a short term measure to quickly reduce the number of maternal deaths. Facility based monitoring and reporting of severe maternal outcome is an important step for scaling up such efforts.

Intimate partner violence is a prevalent public health issue associated with all-cause maternal mortality. This study investigated the relationship between intimate partner violence, severe acute maternal morbidity in the intensive care unit (ICU), and neonatal outcomes. This was a prospective case-control study in a hospital in Lima, Peru, with 109 cases (maternal ICU admissions) and 109 controls (obstetric patients not admitted to the ICU). Data were collected through face-to-face interviews and medical record review. Partner violence was assessed using the World Health Organization instrument. Multivariate logistic regression was used to model the association between intimate partner violence and severe acute maternal morbidity. There was a significantly higher rate of intimate partner violence both before and during pregnancy among cases (58.7%) than controls (27.5%). In multivariate analysis, intimate partner violence both before and during pregnancy (aOR 3.83 (95% CI: 1.99-7.37)), being married (3.86 (1.27-11.73)), having <8 antenatal care visits (2.78 (1.14-6.80)), and having previous abortions (miscarriage, therapeutic, or unsafe) (1.69 (1.13-2.51)) were significantly associated with severe acute maternal morbidity. The ICU admission rate was 18.8 (per 1000 live births), and ICU maternal mortality was 1.7%. The perinatal mortality rate was higher in cases (9.3%) than in controls (1.8%). Intimate partner violence was associated with an increased risk of severe acute maternal morbidity. This suggests a more severe impact of intimate partner violence on pregnancy than has been previously identified. Inquiring about intimate partner violence during prenatal visits may prevent further harm to the mother-baby dyad.

To validate the Obstetric Comorbidity Index (OB-CMI) and estimate its predictive and discriminative performance for maternal outcomes in the South Korean population. This study used data on births from the National Health Insurance Service Delivery Cohort database in South Korea. The data on pregnant people who gave birth during 2003–2019 were included. The obstetric comorbidities were identified using the Bateman’s OB-CMI. The outcomes were severe maternal morbidity (SMM) as defined by the CDC in the US; severe acute maternal morbidity (SAMM), as defined by EURONET; and maternal death within 30 days postpartum. The predictive and discriminative abilities of the index were calculated using the Brier score and area under the receiver operating characteristic curve (AUC). Of 6,527,810 births, 143,392 (2.2%), 84,994 (1.3%), and 555 (< 0.1%) resulted in SMM, SAMM, and maternal death, respectively. The predictive ability and discriminative performance of the OB-CMI were moderate and good (Brier scores of 0.02, 0.01, and 0.00 and AUC of 0.72, 0.68, and 0.78 for SMM, SAMM, and maternal death, respectively). The OB-CMI demonstrated moderate and good predictive and discriminative performance for SMM, SAMM, and maternal mortality in the South Korean population. These findings align with previous research, supporting OB-CMI as a valuable tool for identifying high-risk pregnancies.

To evaluate the association between the planned mode of delivery and severe acute maternal morbidity in women with twin pregnancies. In this planned secondary analysis of the JUmeaux MODe d'Accouchement cohort, a national prospective population-based study of twin deliveries conducted from February 2014 to March 2015 in 176 hospitals performing more than 1,500 annual deliveries in France, we included women with twin pregnancies at 24 weeks of gestation or greater with two live fetuses. Women delivering before 24 weeks of gestation, those with recognized indications for cesarean delivery, and those with severe acute maternal morbidity symptomatic before labor were excluded to limit confounding by indication. The primary outcome was a composite measure of intra- or postpartum severe acute maternal morbidity. Multivariate Poisson regression models and propensity score matching were used to control for potential confounding by indication. Analyses were conducted for the overall study cohort as well as stratified by maternal age in years (younger than 30, 30-34, 35 years or older). No adjustments were made for multiple comparisons. Among the 8,124 women included in this analysis, 3,062 (37.7%) had planned cesarean deliveries and 5,062 (62.3%) had planned vaginal deliveries, of whom 4,015 (79.3%) delivered both twins vaginally. No significant overall association was found between the planned mode of delivery and severe acute maternal morbidity (6.1% in the planned cesarean delivery group and 5.4% in the planned vaginal group; adjusted relative risk 1.00, 95% CI 0.81-1.24). In women 35 years or older, the risk of severe acute maternal morbidity was significantly higher for those with planned cesarean delivery than planned vaginal delivery (7.8% vs 4.6%, adjusted relative risk 1.44, 95% CI 1.02-2.06). Propensity score and secondary analyses yielded similar results. In twin pregnancies, there is no overall association between planned mode of delivery and severe acute maternal morbidity. Women older than 35 years may be at higher risk of severe acute maternal morbidity after planned cesarean delivery.