Severe maternal morbidity in Zanzibar's referral hospital: Measuring the impact of in-hospital care.

Tanneke Herklots,Lieke Van Acht,Tarek Meguid,Benoit Jacod,Arie Franx,Umberto Simeoni

doi:10.1371/journal.pone.0181470

Abstract

Objectiveto analyse the impact of in-hospital care on severe maternal morbidity using WHO’s near-miss approach in the low-resource, high mortality setting of Zanzibar’s referral hospital.SettingMnazi Mmoja Hospital, a tertiary care facility, in Zanzibar, Tanzania.MethodsWe identified all cases of morbidity and mortality in women admitted within 42 days after the end of pregnancy at Mnazi Mmoja Hospital in the period from April to October 2016. The severity of complications was classified using WHO’s near-miss approach definitions: potentially life-threatening condition (PLTC), maternal near-miss (MNM) or maternal death (MD). Quality of in-hospital care was assessed using the mortality index (MI) defined as ratio between mortality and severe maternal outcome (SMO) where SMO = MD + MNM, cause-specific case facility rates and comparison with predicted mortality based on the Maternal Severity Index model.Main outcomes5551 women were included. 569 (10.3%) had a potentially life-threatening condition and 65 (1.2%) a severe maternal outcome (SMO): 37 maternal near-miss cases and 28 maternal deaths. The mortality index was high at 0.43 and similar for women who developed a SMO within 12 hours of admission and women who developed a SMO after 12 hours. A standardized mortality ratio of 6.03 was found; six times higher than that expected in moderate maternal mortality settings given the same severity of cases. Obstetric haemorrhage was found to be the main cause of SMO. Ruptured uterus and admission to ICU had the highest case-fatality rates. Maternal death cases seemed to have received essential interventions less often.ConclusionsWHO’s near-miss approach can be used in this setting. The high mortality index observed shows that in-hospital care is not preventing progression of disease adequately once a severe complication occurs. Almost one in two women experiencing life-threatening complications will die. This is six times higher than in moderate mortality settings.

Highlights

World Health Organization (WHO)’s near-miss approach can be used in this setting
The high mortality index observed shows that in-hospital care is not preventing progression of disease adequately once a severe complication occurs
During the six-month data collection period, 5551 women admitted at Mmoja Hospital (MMH)–pregnant or within 42 days after end of pregnancy–were included

Summary

Introduction

It represents the most visible result of shortcomings of maternal health care systems in many low and middle income countries [1]. It has been targeted by the Millennium Development Goals until 2015 and by the Sustainable Development Goals since. Maternal death reviews are one way of identifying possible deficiencies in maternal care [4]. Their low number at facility level, even in high mortality settings, may hamper the generalization of their findings. Not unequivocal [5] and might not always represent the same pathways as that leading to maternal death [6]

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