Maternal Death Review Research Articles

“We do these audits, but in the end, it’s useless.” How can facility-based maternal death reviews improve the quality of care in Benin?

Benin scaled up facility-based Maternal Death Reviewss (MDRs) in 2013 to address its high maternal mortality rate. This study aims to assess the extent to which facilitybased MDR captured the complex causes of maternal deaths in 2022. In this mixedmethod study, we first conducted a quantitative analysis of dysfunctions, root causes,and recommendations extracted from all facility-based MDR reports that occurred in Benin's health facilities in 2022. We calculated frequency distributions based on the systemic maternal care quality assessment framework's components and the iceberg model for system thinking's layers. Second, we conducted in-depth and informal interviews and (non)participant observations and reviewed facility-based MDR policyrelated documents. Content analysis was applied to qualitative data. facility-based MDR teams identified 1295 dysfunctions, 1216 root causes, and 1082 recommendations in facility-based MDR reports of 540 maternal deaths. One-fifth of reports were uninformative, lacking dysfunctions, root causes, or recommendations.Within the health system components, leadership and governance received the least attention regarding dysfunctions (1 %) and root causes (12 %).Most dysfunctions (87 %) and root causes (73 %) focused on the iceberg's tip, leading to reactive recommendations rather than addressing deeper systemic issues. Two main factors emerged: non-compliance with facility-based MDR requirements (time constraints, unreliable data, fear of strained provider relationships) and limitations in facility-based MDR processes (data collection and analysis tool constraints),

A Retrospective Analysis of Maternal Mortality in a Tertiary Care Centre at District Level

Background: Maternal mortality is a very sensitive indicator of our health system and services. Epidemiological data about maternal mortality is a vital requirement in every setting not only to design interventional programs but also to identify gaps in the existing structures, to reduce the ratio favorably. This study was an attempt to shed light on the mortality rate in our hospital, to analyze the epidemiological aspects, causes of maternal mortality, and types of delay, and to suggest recommendations for improvement. Methods: A retrospective study was done at a tertiary care center at the district level from January 2022 to December 2022. Demographic data and details of selected parameters were obtained from maternal death review forms and case records. Data analyzed and presented. Results: The majority of the maternal deaths could be attributed to direct obstetric causes like Eclampsia (29.41%), Pre-eclampsia (20.59%), and anemia (20.59%) followed by hemorrhage (14.71%), and septicemia (11.76%). Medical conditions contributing to death included liver disorders (5.8%), COVID-19 infection (5.8%), and cardiac disorders (2.9%). Conclusion: It is evident that the maternal mortality ratio is significantly high, with a majority of the deaths occurring due to avoidable causes. Leading contributory factors were due to delay in seeking help or delay in referral. High-risk cases must be identified at the earliest and referred to higher centers for management from the first trimester itself. Generating awareness among the common public and counseling the gravidas and their caretakers throughout pregnancy is equally important to prevent maternal mortality and near-miss cases.

Validating the indicator "maternal death review coverage" to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record data.

Understanding causes and contributors to maternal mortality is critical from a quality improvement perspective to inform decision making and monitor progress toward ending preventable maternal mortality. The indicator "maternal death review coverage" is defined as the percentage of maternal deaths occurring in a facility that are audited. Both the numerator and denominator of this indicator are subject to misclassification errors, underreporting, and bias. This study assessed the validity of the indicator by examining both its numerator-the number and quality of death reviews-and denominator-the number of facility-based maternal deaths and comparing estimates of the indicator obtained from facility- versus district-level data. We collected data on the number of maternal deaths and content of death reviews from all health facilities serving as birthing sites in 12 districts in three countries: Argentina, Ghana, and India. Additional data were extracted from health management information systems on the number and dates of maternal deaths and maternal death reviews reported from health facilities to the district-level. We tabulated the percentage of facility deaths with evidence of a review, the percentage of reviews that met the World Health Organization defined standard for maternal and perinatal death surveillance and response. Results were stratified by sociodemographic characteristics of women and facility location and type. We compared these estimates to that obtained using district-level data. and looked at evidence of the review at the district/provincial level. Study teams reviewed facility records at 34 facilities in Argentina, 51 facilities in Ghana, and 282 facilities in India. In total, we found 17 deaths in Argentina, 14 deaths in Ghana, and 58 deaths in India evidenced at facilities. Overall, >80% of deaths had evidence of a review at facilities. In India, a much lower percentage of deaths occurring at secondary-level facilities (61.1%) had evidence of a review compared to deaths in tertiary-level facilities (92.1%). In all three countries, only about half of deaths in each country had complete reviews: 58.8% (n = 10) in Argentina, 57.2% (n = 8) in Ghana, and 41.1% (n = 24) in India. Dramatic reductions in indicator value were seen in several subnational geographic areas, including Gonda and Meerut in India and Sunyani in Ghana. For example, in Gonda only three of the 18 reviews conducted at facilities met the definitional standard (16.7%), which caused the value of the indicator to decrease from 81.8% to 13.6%. Stratification by women's sociodemographic factors suggested systematic differences in completeness of reviews by women's age, place of residence, and timing of death. Our study assessed the validity of an important indicator for ending preventable deaths: the coverage of reviews of maternal deaths occurring in facilities in three study settings. We found discrepancies in deaths recorded at facilities and those reported to districts from facilities. Further, few maternal death reviews met global quality standards for completeness. The value of the calculated indicator masked inaccuracies in counts of both deaths and reviews and gave no indication of completeness, thus undermining the ultimate utility of the measure in achieving an accurate measure of coverage.

IJCM_211A: Evaluation of Maternal Death Surveillance In Relation To Eclampsia In Jabalpur Division Of Madhya Pradesh

Background: The GOI is striving towards bringing down the MMR. Objective: To describe the Maternal Death Surveillance and Response (MDSR) Programme and to assess the maternal deaths due to Eclampsia and factors associated with it in Jabalpur Division of M.P. Methodology: A descriptive Cross-sectional study was conducted in four purposively selected districts of Jabalpur Divisions from April 2021 to March 2022. In debth Interview was conducted with all stakeholders and verbal autopsy for 68 maternal deaths. Triangulation of data from district, verbal autopsies and in-depth interviews of stakeholders (health care providers) was done to identify the factors responsible for maternal deaths due to eclempsia at various levels. Results: There was only maternal death review being done but no surveillance and response system was found. 57.35% deceased women received >4 Antenatal checkups and 25% 3 ANC checkups. 54.38%, 52.63% and 36.84% antenatal deceased women had Anaemia, Edema and High Blood Pressure respectively. Which were diagnosed at First or Second trimester of pregnancy but were not corrected timely or treated effectively. Most of the deaths occurred in postnatal period, women had early marriage and early pregnancy and 55.88% belonged to ST category. Conclusion: Families faith on Quacks, Faith healer and Jhad Funk, Poor compliance against medical advice, various delays and multiple refferals found as contributors in maternal deaths. Most of the women died during or after third trimester and 84% had symptoms during first and second semester and those symptoms were treatable. Timely, correct and quality treatment could have been save those deceased women and their precious children.

Maternal death surveillance and response system reports from 32 low-middle income countries, 2011-2020: What can we learn from the reports?

Maternal Death Surveillance and Response (MDSR) systems generate information that may aid efforts to end preventable maternal deaths. Many countries report MDSR data, but comparability over time and across settings has not been studied. We reviewed MDSR reports from low-and-middle income countries (LMICs) to examine core content and identify how surveillance data and data dissemination could be improved to guide recommendations and actions. We conducted deductive content analysis of 56 MDSR reports from 32 LMICs. A codebook was developed assessing how reports captured: 1) MDSR system implementation, 2) monitoring of maternal death notifications and reviews, and 3) response formulation and implementation. Reports published before 2014 focused on maternal death reviews only. In September 2013, the World Health Organization and partners published the global MDSR guidance, which advised that country reports should also include identification, notification and response activities. Of the 56 reports, 33 (59%) described their data as incomplete, meaning that not all maternal deaths were captured. While 45 (80%) reports presented the total number of maternal deaths that had been notified (officially reported), only 16 (29%) calculated notification rates. Deaths were reported at both community and facility levels in 31 (55%) reports, but 25 (45%) reported facility deaths only. The number of maternal deaths reviewed was reported in 33 (59%) reports, and 17 (30%) calculated review completion rates. While 48 (86%) reports provided recommendations for improving MDSR, evidence of actions based on prior recommendations was absent from 40 (71%) of subsequent reports. MDSR reports currently vary in content and in how response efforts are documented. Comprehensive reports could improve accountability and effectiveness of the system by providing feedback to MDSR stakeholders and information for action. A standard reporting template may improve the quality and comparability of MDSR data and their use for preventing future maternal deaths.

Review of Maternal Deaths over 3 and a Half Years at the Kara University Hospital Center, Northern Togo: About 65 Cases

Review of Maternal Deaths over 3 and a Half Years at the Kara University Hospital Center, Northern Togo: About 65 Cases

Maternal mortality study in a level II hospital in guinea from 2016 to 2020

The objective of this work was to study the epidemiological profile of maternal deaths at the Forécariah prefectural hospital from January 1, 2016 to December 31, 2020. Methodology: this was a descriptive, cross-sectional study with retrospective collection, including women who died before, during or within 42 days after childbirth. Sociodemographic and clinical variables, circumstances and causes of death as well as the process of maternal death reviews (MDR) were studied. The data were analyzed using EPI Info version 7.2 6 software. Central tendency parameters (mean, standard deviation), relative and absolute frequencies were reported. Results: The maternal mortality ratio was 348 deaths per 100,000 live births. The average age was 31 ±5.65 years. The majority of deceased women were unemployed (67.69%), most of them married (72.31%), and multiparous in 33.85% of cases. Hemorrhages during delivery constituted 52.72% of the direct causes. The effectiveness of reviews of maternal deaths was 10.77% and deaths deemed avoidable represented 98.46%, mainly linked to the 3rd delay in 58.46% of cases. Conclusion: achieving the goal of sustainable development (SDG 3.1) requires community participation, reorganization of the health system and government involvement.

Provision and utilization of maternal health services during the COVID-19 pandemic in 16 hospitals in sub-Saharan Africa.

Maintaining provision and utilization of maternal healthcare services is susceptible to external influences. This study describes how maternity care was provided during the COVID-19 pandemic and assesses patterns of service utilization and perinatal health outcomes in 16 referral hospitals (four each) in Benin, Malawi, Tanzania and Uganda. We used an embedded case-study design and two data sources. Responses to open-ended questions in a health-facility assessment survey were analyzed with content analysis. We described categories of adaptations and care provision modalities during the pandemic at the hospital and maternity ward levels. Aggregate monthly service statistics on antenatal care, delivery, caesarean section, maternal deaths, and stillbirths covering 24 months (2019 and 2020; pre-COVID-19 and COVID-19) were examined. Declines in the number of antenatal care consultations were documented in Tanzania, Malawi, and Uganda in 2020 compared to 2019. Deliveries declined in 2020 compared to 2019 in Tanzania and Uganda. Caesarean section rates decreased in Benin and increased in Tanzania in 2020 compared to 2019. Increases in maternal mortality ratio and stillbirth rate were noted in some months of 2020 in Benin and Uganda, with variability noted between hospitals. At the hospital level, teams were assigned to respond to the COVID-19 pandemic, routine meetings were cancelled, and maternal death reviews and quality improvement initiatives were interrupted. In maternity wards, staff shortages were reported during lockdowns in Uganda. Clinical guidelines and protocols were not updated formally; the number of allowed companions and visitors was reduced. Varying approaches within and between countries demonstrate the importance of a contextualized response to the COVID-19 pandemic. Maternal care utilization and the ability to provide quality care fluctuated with lockdowns and travel bans. Women's and maternal health workers' needs should be prioritized to avoid interruptions in the continuum of care and prevent the deterioration of perinatal health outcomes.

Confidential Enquiry into Maternal Deaths in Namibia, 2018-2019: A Local Approach to Strengthen the Review Process and a Description of Review Findings and Recommendations.

First objective was to strengthen the national maternal death review, by addressing local challenges with each step of the review cycle. Second objective was to describe review findings and compare these with available findings of previous reviews. Confidential Enquiry into Maternal Deaths methodology was used to review maternal deaths. To improve reporting, the national committee focussed on addressing fear of blame among healthcare providers. Second focus was on dissemination of findings and acting on recommendations forthcoming the review. Reviewed were reported maternal deaths, that occurred between 1 April 2018 and 31 March 2019. Seventy maternal deaths were reported; for 69 (98.6%) medical records were available, compared to 80/119 (67.2%) in 2012-2015. Reported maternal mortality ratio increased with 48% (92/100,000 live births compared to 62/100,000 in 2012-2015). Obstetric haemorrhage was leading cause of death in the past three reviews. The "no name, no blame" policy, aiming to identify health system failures, rather than mistakes of individuals, was repeatedly explained to healthcare providers during facility visits. Recommendations based on findings of the review, such as retaining experienced staff, continuous in-service training and guidance, were shared with decision makers at regional and national levels. Healthcare providers received training based on review findings, which resulted in improved management of similar cases. Enhanced implementation of Confidential Enquiry into Maternal Deaths was possible after addressing local challenges. Focussing on obtaining trust of healthcare providers and feeding back findings, resulted in better reporting and prevention of potential maternal deaths.

Factors influencing maternal death surveillance and review implementation in Dodoma City, Tanzania. A qualitative case study.

With 295 000 maternal deaths in 2017, 94% in low- and middle-income countries, maternal death is a matter of global public health concern. To address it, Maternal Death Surveillance and Response (MDSR) strategy was introduced in 2013 by the World Health Organization. With a reported maternal mortality ratio of 556:100000 per live births, Tanzania adopted the strategy in 2015. Studies are needed to understand factors influencing the implementation of MDSR in this specific setting. The study aimed to assess the processes influencing MDSR implementation in Dodoma city council. A qualitative case study was conceptualized according to the Consolidated Framework for Implementation Research, focusing on implementation process domain. Members of MDSR committees were enrolled by purposeful sampling in the five health centres in Dodoma where the strategy was fully implemented and functional. In-depth interviews were conducted with key informants concerning the implementation processes influencing MDSR. Saturation was reached with the 15th respondent. Qualitative inductive content analysis was used to analyse data. The inclusiveness in participatory planning process, stakeholders' readiness and accountability and collective learning were acknowledged as factors positively influencing the implementation of MDSR strategy by respondents. The interaction and alignment of influential factors were essential for successful implementation. MDSR implementation is positively influenced by factors that interact and converge in the building of a learning health system, to increase knowledge through practice and improve practice through knowledge. Further studies are needed to analyse the influence of additional factors at different levels of implementation to fully understand and empower the MDSR implementation network, and to better target the goal of closing the knowledge to practice loop.

Global Stillbirth Policy Review - Outcomes And Implications Ahead of the 2030 Sustainable Development Goal Agenda.

Globally, data on stillbirth is limited. A call to action has been issued to governments to address the data gap by strengthening national policies and strategies to drive urgent action on stillbirth reduction. This study aims to understand the policy environment for stillbirths to advance stillbirth recording and reporting in data systems. A systematic three-step process (survey tool examination, identifying relevant study questions, and reviewing country responses to the survey and national documents) was taken to review country responses to the global 2018-2019 World Health Organization (WHO) Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Policy Survey. Policy Survey responses were reviewed to identify if and how stillbirths were included in national documents. This paper uses descriptive analyses to identify and describe the relationship between multiple variables. Responses from 155 countries to the survey were analysed, and over 800 national policy documents submitted by countries in English reviewed. Fewer than one-fifth of countries have an established stillbirth rate (SBR) target, with higher percentages reported for under-5 (71.0%) and neonatal mortality (68.5%). Two-thirds (65.8%) of countries reported a national maternal death review panel. Less than half (43.9%) of countries have a national policy that requires stillbirths to be reviewed. Two-thirds of countries have a national policy requiring review of neonatal deaths. WHO websites and national health statistics reports are the common data sources for stillbirth estimates. Countries that are signatories to global initiatives on stillbirth reduction have established national targets. Globally, nearly all countries (94.8%) have a national policy that requires every death to be registered. However, 45.5% of reviewed national policy documents made mention of registering stillbirths. Only 5 countries had national policy documents recommending training of health workers in filling out death certificates using the International Classification of Diseases (ICD)-10 for stillbirths. The current policy environment in countries is not supportive for identifying stillbirths and recording causes of death. This is likely to contribute to slow progress in stillbirth reduction. The paper proposes policy recommendations to make every baby count.

Facilitators for and Barriers to the Implementation of Performance Accountability Mechanisms for Quality Improvement in the Delivery of Maternal Health Services in a District Hospital in Pwani Region, Tanzania.

Tanzania experiences a burden of maternal mortality and morbidity. Despite the efforts to institute accountability mechanisms, little is known about quality improvement in the delivery of maternal health services. This study aimed at exploring barriers and facilitators to enforcing performance accountability mechanisms for quality improvement in maternal health services. A case study design was used to conduct semi-structured interviews with thirteen key informants. Data were analyzed using thematic analyses. The findings were linked to two main performance accountability mechanisms: maternal and perinatal death reviews (MPDRs) and monitoring and evaluation (M&E). Prioritization of the maternal health agenda by the government and the presence of maternal death review committees were the main facilitators for MPDRs, while negligence, inadequate follow-up, poor record-keeping, and delays were the main barriers facing MPDRs. M&E was facilitated by the availability of health management information systems, day-to-day ward rounds, online ordering of medicines, and the use of biometrics. Non-use of data for decision-making, supervision being performed on an ad hoc basis, and inadequate health workforce were the main barriers to M&E. The findings underscore that barriers to the performance accountability mechanisms are systemic and account for limited effectiveness in the improvement of quality of care.

Maternal Deaths Surveillance and Response System: A Case of Nepal

The objective of this paper is to share Nepali experience of maternal death surveillance and response in reducing
 preventable maternal deaths. Secondary data, mainly an assessment report of Maternal and Perinatal Death
 Surveillance and Response system, is used in developing this paper. To bridge the information gap, informal
 discussions were held with key informants. Reducing maternal mortality is an unfinished agenda of millennium
 development goals, which is carried over to sustainable development goals era. Nepal, building on an ongoing
 initiative of Maternal Death Review, established a Maternal and Perinatal Death Surveillance and Response
 system. It comprises: (a) maternal death review and response in community; and (b) maternal death review
 and response in hospitals. Until 2019, 11 districts implemented the former component, while 77 hospitals practiced the latter. The main reason underlying maternal death was delay in getting adequate care. Social factors contributed to delay in 89.6% of cases, while in 10.4% of cases, it was attributed to factors in health care. The paper concludes that public health measures and improved service quality was key in preventing maternal deaths. It is, however, imperative to undertake an in-depth review and thereby define interventions for strengthening and upscaling the initiative.

Binational confidential enquiry of maternal deaths due to postpartum hemorrhage in France and the Netherlands: Lessons learned through the perspective of a different contextof care.

To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level.

Challenges faced by midwives in the implementation of facility-based maternal death reviews in Malawi

BackgroundMaternal death reviews provide an in-depth understanding of the causes of maternal deaths. Midwives are well positioned to contribute to these reviews. Despite midwives’ participation as members of the facility-based maternal death review team, maternal mortality continues to occur, therefore, this study aimed to explore the challenges faced by midwives as they participate in maternal death reviews in the context of the healthcare system in Malawi.MethodsThis was a qualitative exploratory study design. Focus group discussions and individual face-to-face interviews were used to collect data in the study. A total of 40 midwives, who met the inclusion criteria, participated in the study. Data was analyzed manually using a thematic content procedure.ResultsChallenges identified were: knowledge and skill gaps; lack of leadership and accountability; lack of institutional political will and inconsistency in conducting FBMDR, impeding midwives’ effective contribution to the implementation of maternal death review. The possible solutions and recommendations that emerged were need-based knowledge and skills updates, supportive leadership, effective and efficient interdisciplinary work ethics, and sustained availability of material and human resources.ConclusionMidwives have the highest potential to contribute to the reduction of maternal deaths. Practice development strategies are required to improve their practice in all the areas they are challenged with.

A facility-based assessment of maternal mortality among all deaths in reproductive-aged women in Mzimba South District, Malawi.

Accurate reporting of maternal mortality is essential for effective health policy planning and achieving maternal death reduction in Sustainable Development Goals Target 3 (SDGs). This study aimed to identify gaps between facility-based maternal death reviews and the hospital Health Management Information System (HMIS) reports in Mzimba South District, Malawi from July 2013 to June 2018. A retrospective hospital-based medical record review was conducted to identify maternal deaths among women aged 15 to 49 years with all death causes. Out of 447 mortality records identified from the hospital wards, 89 maternal mortality cases were identified by the study review compared to 83 cases in the HMIS report. The HMIS report showed an underreporting rate of 6.7% (6/89) and a misclassification rate of 13.5% (12/89) within five years. These findings highlight the need for establishing mechanisms for the verification and monitoring of maternal mortality data reporting in health facilities. Improving the quality of maternal death reporting could help inform evidence-based interventions and policies that address the root causes of maternal mortality, and achieve SDGs in Malawi.

Changes in the health systems and policy environment for maternal and newborn health, 2008–2018: An analysis of data from 78 low-income and middle-income countries

BackgroundPolitical, social, economic, and health system determinants play an important role in creating an enabling environment for maternal and newborn health. This study assesses changes in health systems and policy indicators for maternal and newborn health across 78 low- and middle-income countries (LMICs) during 2008–2018, and examines contextual factors associated with policy adoption and systems changes. MethodsWe compiled historical data from WHO, ILO, and UNICEF surveys and databases to track changes in ten maternal and newborn health systems and policy indicators prioritized for tracking by global partnerships. Logistic regression was used to examine the odds of systems and policy change based on indicators of economic growth, gender equality, and country governance with available data from 2008 to 2018. ResultsFrom 2008 to 2018, many LMICs (44/76; 57·9%) substantially strengthened systems and policies for maternal and newborn health. The most frequently adopted policies were national guidelines for kangaroo mother care, national guidelines for use of antenatal corticosteroids, national policies for maternal death notification and review, and the introduction of priority medicines in Essential Medicines Lists. The odds of policy adoption and systems investments were significantly greater in countries that experienced economic growth, had strong female labor participation, and had strong country governance (all p < 0·05). ConclusionsThe widespread adoption of priority policies over the past decade is a notable step in creating an environment supportive for maternal and newborn health, but continued leadership and resources are needed to ensure robust implementation that translates into improved health outcomes.

Review of Maternal Deaths in Two Health Regions of Togo: About 69 Cases (Epidemiological and Sociodemographic Aspects)

Review of Maternal Deaths in Two Health Regions of Togo: About 69 Cases (Epidemiological and Sociodemographic Aspects)

A Study of Etiological Spectrum of Maternal Near-miss Cases and Quality Care Indicators in Western Region of India

Background: Maternal death review has remained the fundamental quality care indicator for any maternal health-care governance program. Maternal near-miss (MNM) cases which are the forerunner of mortality cases could serve as a proxy indicator to evaluate the obstetric quality care. Objectives: To calculate MNM to mortality ratio of the institute and to study the etiological spectrum of MNM cases. Materials and Methods: A hospital-based prospective observational study was carried out. Cases were taken as defined based on the WHO MNM criteria. Data collection was done through information retrieval from case records and by in-depth interviews with the help of semi-structured questionnaire of MNM cases from 2 days after their admission up till discharge. Each case was documented with respect to the demographic details, adverse events and aetiology. Results: The MNM to mortality ratio was 1.16:1, MNM incidence ratio in our study was 4.12 and the mortality index was 46.23. Seventy-six per cent of cases were referred cases. The main causes for near-miss were post-partum haemorrhage (30%) followed by pre-eclampsia (26%). Hypertension was the most significant comorbidity in 28% of cases, while 26% had cardiac disease and 26% had severe anaemia. Conclusions: Studying near-miss mortality cases provides a valuable insight of the quality of care of the institute. MNM case review should be a part of regular governance process of the maternity care unit to plan and implement focused care.

Socioeconomic and epidemiological milieu of maternal death due to eclampsia in West Bengal, India: A mixed methods study

AbstractBackgroundWest Bengal is experiencing an unanticipated risk of eclampsia among pregnant women and it persists as the leading cause of maternal mortality. This study aimed to investigate the predictors for maternal deaths due to eclampsia in West Bengal.MethodsThe study adopted retrospective mixed methods covering facility and community‐based maternal death review approaches. Facility‐based data were used for 317 deceased cases wherein the community‐based review approach was used in 40 cases. An in‐depth interview was also performed among 12 caregivers.ResultsOne‐third of maternal deaths occurred due to eclampsia, and this accounted for the leading cause of maternal deaths in West Bengal. A younger age, a primigravida or nulliparous status, absence of antenatal care (ANC), and residence in rural areas appeared to have the highest risk of developing eclampsia. The majority of pregnant women had an irregular antenatal check‐up history, particularly during the second trimester of pregnancy. The rate of eclampsia‐related maternal death was higher in women residing more than 49 km from the studied hospitals. Most of the deceased women were referred to three or more hospitals before their death. Gravidity, the number of ANC visits, the mode of delivery, and delays at different levels were significant confounders of death due to eclampsia. The risk of death due to eclampsia was two times higher among women without ANC and those who had a cesarean section than that in their counterparts.ConclusionsWomen in West Bengal have a high risk of preeclampsia and eclampsia resulting in maternal mortality and morbidity. Gravidity, the number of ANC visits, the mode of delivery, and delays in recognition of eclampsia contribute to the risk of maternal deaths. The establishment of separate eclampsia units, enhanced screening, and preventive and treatment procedures may optimize managing eclampsia.