Preventability of maternal near miss and mortality in Rwanda: A case series from the University Teaching Hospital of Kigali (CHUK).

Christophe Benimana,Maria Small,Stephen Rulisa,Justin R Ortiz

doi:10.1371/journal.pone.0195711

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https://doi.org/10.1371/journal.pone.0195711

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Abstract

ObjectiveAssess the primary causes and preventability of maternal near misses (MNM) and mortalities (MM) at the largest tertiary referral hospital in Rwanda, Kigali University Teaching Hospital (CHUK).MethodsWe reviewed records for all women admitted to CHUK with pregnancy-related complications between January 1st, 2015 and December 31st, 2015. All maternal deaths and near misses, based on WHO near miss criteria were reviewed (Appendix A). A committee of physicians actively involved in the care of pregnant women in the obstetric-gynecology department reviewed all maternal near misses/ pregnancy-related deaths to determine the preventability of these outcomes. Preventability was assessed using the Three Delays Model.[1] Descriptive statistics were used to show qualitative and quantitative outcomes of the maternal near miss and mortality.ResultsWe identified 121 maternal near miss (MNM) and maternal deaths. The most common causes of maternal near miss and maternal death were sepsis/severe systemic infection (33.9%), postpartum hemorrhage (28.1%), and complications from eclampsia (18.2%)/severe preeclampsia (5.8%)/. In our obstetric population, MNM and deaths occurred in 87.6% and 12.4% respectively. Facility level delays (diagnostic and therapeutic) through human error or mismanagement (provider issues) were the most common preventable factors accounting for 65.3% of preventable maternal near miss and 10.7% maternal deaths, respectively. Lack of supplies, blood, medicines, ICU space, and equipment (system issues) were responsible for 5.8% of preventable maternal near misses and 2.5% of preventable maternal deaths. Delays in seeking care contributed to 22.3% of cases and delays in arrival from home to care facilities resulted in 9.1% of near misses and mortalities. Cesarean delivery was the most common procedure associated with sepsis/death in our population. Previous cesarean delivery (24%) and obstructed/prolonged labor (13.2%) contributed to maternal near miss and mortalities.ConclusionThe most common preventable causes of MNM and deaths were medical errors, shortage of medical supplies, and lack of patient education/understanding of obstetric emergencies. Reduction in medical errors, improved supply/equipment availability and patient education in early recognition of pregnancy-related danger signs will reduce the majority of delays associated with MNM and mortality in our population.

Highlights

Maternal mortality remains a public health problem throughout the world, and largely affects low- income countries.In 2010, the WHO (World Health Organization), UNICEF (United Nations Children’s Fund), UNFPA (United Nations Fund for Population Activities) and the World Bank estimated that worldwide, about 260 women die per 100 000 live births
We identified 121 maternal near miss (MNM) and maternal deaths
maternal near-miss (MNM) and deaths occurred in 87.6% and 12.4% respectively

Summary

Introduction

In 2010, the WHO (World Health Organization), UNICEF (United Nations Children’s Fund), UNFPA (United Nations Fund for Population Activities) and the World Bank estimated that worldwide, about 260 women die per 100 000 live births. Most of these deaths occur in Sub-Saharan Africa.[2] The Maternal Mortality Ratio (MMR) of 620 per 100 000 live births is markedly elevated in comparison to Europe where the MMR is 21 maternal deaths per 100 000 live births. A maternal near-miss (MNM) is defined as “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”. A maternal near-miss (MNM) is defined as “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”. [6] In practice, maternal near misses denote women who survive lifethreatening events (i.e. organ dysfunction).[7]

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