Abstract
SummaryBackgroundAlthough an increasing number of pregnant women in resource-limited areas deliver in health-care facilities, maternal mortality remains high in these settings. Inadequate diagnosis and management of common life-threatening conditions is an important determinant of maternal mortality. We analysed the clinicopathological discrepancies in a series of maternal deaths from Mozambique and assessed changes over 10 years in the diagnostic process. We aimed to provide data on clinical diagnostic accuracy to be used for improving quality of care and reducing maternal mortality.MethodsWe did a retrospective analysis of clinicopathological discrepancies in 91 maternal deaths occurring from Nov 1, 2013, to March 31, 2015 (17 month-long period), at a tertiary-level hospital in Mozambique, using complete diagnostic autopsies as the gold standard to ascertain cause of death. We estimated the performance of the clinical diagnosis and classified clinicopathological discrepancies as major and minor errors. We compared the findings of this analysis with those of a similar study done in the same setting 10 years earlier.FindingsWe identified a clinicopathological discrepancy in 35 (38%) of 91 women. All diagnostic errors observed were classified as major discrepancies. The sensitivity of the clinical diagnosis for puerperal infections was 17% and the positive predictive value was 50%. The sensitivity for non-obstetric infections was 48%. The sensitivity for eclampsia was 100% but the positive predictive value was 33%. Over the 10-year period, the performance of clinical diagnosis did not improve, and worsened for some diagnoses, such as puerperal infection.InterpretationDecreasing maternal mortality requires improvement of the pre-mortem diagnostic process and avoidance of clinical errors by refining clinical skills and increasing the availability and quality of diagnostic tests. Comparison of post-mortem information with clinical diagnosis will help monitor the reduction of clinical errors and thus improve the quality of care.FundingBill & Melinda Gates Foundation and Instituto de Salud Carlos III.
Highlights
The increasing number of pregnant women delivering in health facilities in low-income and middle-income countries (LMICs; 58% in 1990 and 78·3% in 2016)[1] has not resulted in the expected reduction in maternal mortality
For maternal deaths in LMICs, data on clinicopathological discrepancies are limited to two studies from Nigeria and Mozambique, reporting either a low[10] or high[11] frequency of clinical errors.[10,11]
Our findings show that a major clinical diagnostic error was identified in almost 40% of patients, and clinical diagnosis had low sensitivity for both puerperal and non-obstetric infections
Summary
The increasing number of pregnant women delivering in health facilities in low-income and middle-income countries (LMICs; 58% in 1990 and 78·3% in 2016)[1] has not resulted in the expected reduction in maternal mortality. A key factor not sufficiently recognised that leads to provision of poor quality care to pregnant women in health facilities is imprecise diagnosis of the illnesses that led to death. Clinical diagnoses should be compared against complete diagnostic autopsy, the gold standard for ascertainment of cause of death, to determine the frequency and magnitude of clinical errors.[3,4] Historically, comparative analysis of clinicopathological discrepancies has shown that clinical errors are not uncommon, even in hospitals in highincome countries.[5,6,7] In sub-Saharan Africa, where access to diagnostic tools is restricted and infectious diseases are extremely prevalent, the rate of clinicopathological discrepancies is very high.[8,9] For maternal deaths in LMICs, data on clinicopathological discrepancies are limited to two studies from Nigeria and Mozambique, reporting either a low[10] or high[11] frequency of clinical errors.[10,11]
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