Severe acute maternal morbidity in a tertiary care institution

G A Ranatunga,S Samarathunga,J F Akbar,J M Kumarasiri,L Kariyawasam,Y A G Perera

doi:10.4038/sljog.v34i4.5930

Abstract

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

Highlights

As the absolute numbers of maternal deaths in an institution are few, maternal death audits may not provide the true picture of service provision
There were 45 cases who had more than one inclusion criterion
Vol 34, No 4, 2012 approximately 39% of severe acute maternal morbidity (SAMM) is due to major post partum hemorrhage (PPH)

Summary

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. As an example the tertiary referral centre Castle Street Hospital for Women (CSHW) in Colombo where 17000 – 19000 deliveries are conducted annually, analyzing 6 – 8 maternal deaths will not reflect the true picture of the quality of care given by the Institution This is further strengthened as some of these maternal deaths are only cases transferred from the periphery to the Intensive Care Unit (ICU) directly, not mothers who had antenatal care at the Institution. Studying cases of women who nearly died but survived a complication during pregnancy, childbirth or postpartum are increasingly recognized as a useful means to examine the quality of obstetric care These cases are referred to as maternal near misses or severe acute maternal morbidity (SAMM)[3,4,5,6,7,8]. The World Health Organization (WHO) has standardized definitions for severe morbidity and its main inclusion criteria[5,6]

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Results

Conclusion