Potentially Life-threatening Conditions Research Articles

Using the WHO individual near miss case review (NMCR) cycle to improve quality of emergency obstetric care and maternal outcome in Keren hospital, Eritrea: an interrupted time series analysis

BackgroundIn 2016, the WHO regional office for Europe prepared a manual for conducting routine facility based individual near miss case review cycle. This study evaluates the effectiveness of the individual near miss case review (NMCR) cycle in improving quality of emergency obstetric care and maternal outcome in Keren hospital.MethodsAn interrupted time series design was used to achieve the objectives of this study. Monthly data on women with potentially life-threatening conditions (PLTCs) admitted between April 2018 and October 2022 (i.e. 33 months pre-implementation and 22 months post-implementation) were collected from medical records. Segmented regression analysis was used to assess the intervention’s effect on three process and outcome measures, namely, SMO, delayed care, and substandard care. The intervention was expected a priori to show immediate improvements without time-lag followed by gradual increment in slope. Segmented regression analyses were performed using the “itsa’ command in STATA.ResultsDuring the entire study period, 4365 women with potentially life threatening conditions were identified. There was a significant reduction in the post-implementation period in the proportion of mothers with PLTC who experienced SMO (− 8.86; p < 0.001), delayed care (− 8.76; p < 0.001) and substandard care (− 5.58; p < 0.001) compared to pre-implementation period. Results from the segmented regression analysis revealed that the percentage of women with SMO showed a significant 4.75% (95% CI: − 6.95 to − 2.54, p < 0.001) reduction in level followed by 0.28 percentage points monthly (95% CI: − 0.37 to − 0.14, p < 0.001) drop in trend. Similarly, a significant drop of 3.50% (95% CI: − 4.74 to − 2.26, p < 0.001) in the level of substandard care along with a significant decrease of 0.21 percentage points (95% CI: − 0.28 to − 0.14, p < 0.001) in the slope of the regression line was observed. The proportion of women who received delayed care also showed a significant 7% (95% CI: − 9.28 to − 4.68, p < 0.001) reduction in post-implementation level without significant change in slope.ConclusionsOur findings suggest that the WHO individual NMCR cycle was associated with substantial improvements in quality of emergency obstetric care and maternal outcome. The intervention also bears a great potential for scaling-up following the guidance provided in the WHO NMCR manual.

Abortion-related complications in Brazil: results from the World Health Organization Multi-country Survey on Abortion (MCS-A).

This study aimed to describe the severity of abortion-related complications, factors associated with complications, the types of management and the experience of care in Brazil. A cross-sectional study in twenty hospitals (10 in Federal District, 3 in Rondônia and 7 in Maranhão). For 3 months, all women treated for abortion/miscarriage had their data collected. The severity of complications was defined according to World Health Organization criteria. Women with hemorrhage, infection or organs injury were invited to answer an interview about experience of care. Statistical analysis was performed using chi-square test and Poisson regression models. Among 1,683 women included, 82.5% had mild complications, 13.6% had moderate complications, 3.2% had potentially life-threatening conditions (PLTC) and 0.7% had severe maternal outcomes (SMO). Most women (94.2%) required uterine evacuation. Among these, 91.5% required surgical evacuation (with or without the use of uterotonics) and 8.5% used only uterotonics. The most frequent surgical evacuation method was curettage (66.9%), followed by manual vacuum aspiration (MVA) (32.3%). Factors associated with PLTC/SMO vs mild complications were having a gestational age ≥ 13 weeks (pravlence ratio - PR = 3.09; 95% confidence interval - 95%CI: 1.42-6.72), having been treated in Maranhão (PR = 0.27; 95%CI: 0.12-0.63) and in Rondônia (PR = 0.64; 95%CI: 0.20-0.99). Factors associated with moderate vs. mild complications were expulsion of products of conception before arrival to health facility (PR = 2.55; 95%CI: 1.64-3.96) and having been treated in Maranhão (PR = 0.58; 95%CI: 0.38-0.87). Most women who responded to the interview were treated kindly (95.6%), however, 66.7% felt stressed and 10.1% reported that their preferences were not respected during hospitalization. Nine out of ten women treated in Brazilian public hospitals due to abortion-related complications undergo some surgical procedure, the most common of which is uterine curettage. Approximately four in every hundred women experience severe complications. It is essential to ensure the supply of equipment for MVA and to encourage continuing medical education programs to increase the awareness of healthcare professionals about safer treatments for uterine evacuation.

Challenges in therapy of severe COVID-19 pneumonia with giant pneumatocele in a preterm newborn: How to optimize mechanical ventilation?

Introduction. Coronavirus disease 2019 (COVID-19) pneumonia is a potentially life-threatening condition that can require the use of mechanical ventilation (MV) and is rare in the neonatal population. Giant pneumatocele is an extremely rare complication of MV, which is practically unknown in neonates. Case report. We report a case of a two-week-old premature infant who developed severe acute respiratory distress syndrome (ARDS) due to COVID-19 and pneumatocele as a complication of MV. The newborn was admitted in a life-threatening condition with persistent hypercapnia, which, therefore, required pro-longed MV. Chest computed tomography (CT) was done to assess the degree of fibrosis caused by COVID-19, and as an accidental finding, a pneumatocele was observed. The patient was immediately started on high-frequency oscillatory ventilation as a way of conservative treatment. After prolonged duration and gradual separation from MV, the patient was extubated, and oxygen therapy was gradually discontinued. The patient was discharged in good condition, and the follow-up chest CT showed complete regression of pneumatocele. Conclusion. Optimization of MV parameters and adequate treatment of complications such as ARDS or giant pneumatocele in neonates is an area that still requires further research, primarily due to the specificity of the neonatal age compared to adult patients.

Maternal Near Miss in Patients with Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) may cause irreversible organ damage. Pregnancy with SLE may have severe life-threatening risks. The present study aimed to determine the prevalence of severe maternal morbidity (SMM) in patients with SLE and analyze the parameters that contributed to cases of greater severity. This is a cross-sectional retrospective study from analysis of data retrieved from medical records of pregnant women with SLE treated at a University Hospital in Brazil. The pregnant women were divided in a control group without complications, a group with potentially life-threatening conditions (PLTC), and a group with maternal near miss (MNM). The maternal near miss rate was 112.9 per 1,000 live births. The majority of PLTC (83.9%) and MNM (92.9%) cases had preterm deliveries with statistically significant increased risk compared with the control group (p = 0.0042; odds ratio [OR]: 12.05; 95% confidence interval [CI]: 1.5-96.6 for the MNM group and p = 0.0001; OR: 4.84; 95%CI: 2.2-10.8 for the PLTC group). Severe maternal morbidity increases the risk of longer hospitalization (p < 0.0001; OR: 18.8; 95%CI: 7.0-50.6 and p < 0.0001; OR: 158.17; 95%CI: 17.6-1424,2 for the PLTC and MNM groups, respectively), newborns with low birthweight (p = 0.0006; OR: 3.67; 95%CI: 1.7-7.9 and p = 0.0009; OR: 17.68; 95%CI: 2-153.6) for the PLTC and MNM groups, respectively] as well as renal diseases (PLTC [8.9%; 33/56; p = 0.0069] and MNM [78.6%; 11/14; p = 0.0026]). Maternal near miss cases presented increased risk for neonatal death (p = 0.0128; OR: 38.4; 95%CI: 3.3-440.3]), and stillbirth and miscarriage (p = 0.0011; OR: 7.68; 95%CI: 2.2-26.3]). Systemic lupus erythematosus was significantly associated with severe maternal morbidity, longer hospitalizations, and increased risk of poor obstetric and neonatal outcomes.

Quality and timeliness of emergency obstetric care and its association with maternal outcome in Keren Hospital, Eritrea

Despite the critical role quality comprehensive emergency obstetric care (CEmOC) plays in ensuring safe motherhood, only a few studies have attempted to measure the impact of substandard and delayed care on maternal outcome thus far. This study evaluates the association between various process and timeliness indicators of CEmOC and adverse maternal outcome in Keren Hospital. This study compared women with potentially life-threatening condition (PLTC) and women with severe maternal outcome (SMO) with respect to various process and timeliness indicators. Logistic regression analysis was employed to assess the association of timeliness and process indicators with SMO using SPSS version-22 computer software. In this study, we included 491 cases of PLTC and 210 cases of SMO (171 maternal near misses and 39 maternal deaths). The following process indicators showed significant association with SMO: failure to give uterotonics for the treatment of postpartum hemorrhage, failure to administer prophylactic antibiotics, and delayed laporatomy for uterine rupture. Moreover, delays in referral, triaging, seeing an obstetrician, and receiving definitive treatement were strongly associated with SMO. The following causes of delay were also found to be independently associated with SMO: erroneous diagnosis, inappropriate management, multiple referrals between health facilities, unavailability of a senior obstetrician, and poor communication during referral. Among the miscellaneous factors, nighttime admission and referral during the rainy season showed significant association with SMO. Findings of this study indicate that huge gap exists in providing quality and timely care in Keren Hospital. In general, most incidents of substandard and delayed care were due to poor referral system, insufficiency of medical staff, inadequacy of drugs and equipment, and unavailability of standard management protocol. Improving the referral system, upgrading the technical skills of health professionals, making sure life-saving drugs and equipment are available all the time, and posting standard treatment and management protocols in the maternity and emergency rooms will play a vital role in reducing the occurrence of SMO in Keren Hospital.

Severe maternal outcome in Afghan immigrant women: A study in Tehran, Iran.

To evaluate the risk factors for severe maternal outcome (SMO) in Afghan immigrant women. Women with potentially life-threatening conditions (PLTC) were selected. Then risk factors for those PLTC which led to SMO (maternal near-miss or maternal death) were evaluated. In addition, risk factors for those SMOs occurring on hospital admission or during the first 12hours after admission to the hospital (SMO12) were evaluated. Parity ≥3 (adjusted odds ratio [aOR] 3.24, 95% confidence interval [CI] 1.62-6.50, P=0.03), low literacy level in mother (aOR 2.99, 95% CI 1.16-5.01, P=0.03), inadequate prenatal care (aOR 2.74, 95% CI 1.2-3.87, P=0.01), multigravidity (gravidity ≥5: aOR 2.62, 95% CI 1.31-4.53, P=0.03), lack of health insurance (aOR 2.52, 95% CI 1.25-4.02, P=0.01), and low literacy level in husband (aOR=1.49, 95% CI 1.15-2.9, P=0.02) were the risk factors for SMO in women with PLTC. Inadequate prenatal care (aOR 4.2, 95% CI 2.05-8.25, P=0.04), low literacy level in mother (aOR 3.38, 95% CI 1.32-6.65, P=0.04), parity ≥3 (aOR 2.69, 95% CI 1.16-4.7, P=0.04), and lack of health insurance (aOR 2.13, 95% CI 1.25-3.67, P=0.03) were risk factors for SMO12. There was a higher rate of SMO and SMO12 cases among Afghan immigrant women.

An observational study on maternal mortality and maternal near miss in a selected facility of West Bengal.

An observational study was performed at Purba Medinipur District Hospital, West Bengal, from April 1, 2018, to December 31, 2020, with an aim to find out the magnitude of maternal mortality and near miss cases and to assess the utilization of available maternal health care services by the deceased women and near miss cases. Result showed 4.5% women developed potentially life-threatening condition (PLTC) of which 21% women developed LTC. Maternal Near Miss (MNM) ratio was 9.46/1000 live birth and the MNM-to-Maternal Mortality ratio was 8.3:1 and the leading causes of MNM and maternal death were hemorrhage, pregnancy induced hypertension/eclampsia. The utilization of maternal health-care services revealed that there is a scope to increase the service delivery. Study finding indicates that health-care programs need to enhance the existing efforts to improve timely health seeking behavior of women.

Applicability and comparison of the sub-Saharan Africa and original WHO maternal near-miss criteria in a rural hospital in Western Tanzania

# Background After the introduction of the maternal near-miss (MNM) criteria by the World Health Organization (WHO), an adapted version for low-income countries was defined but has never been validated in a rural hospital in this setting. Aim of this study was to identify the occurrence of MNM by both the use of the WHO and the adapted sub-Saharan Africa (SSA) MNM tool and to compare the applicability of both versions. # Methods This cross-sectional study was done between November 2019 and July 2020 in Ndala Hospital, Tanzania. All pregnant women and women within 42 days after giving birth or termination of pregnancy were included when fulfilling at least one criterion according to either the WHO or the SSA MNM tool. # Results The SSA MNM criteria identified 47 near-miss cases and all seven maternal deaths. The WHO criteria identified ten near-miss cases and five maternal deaths. There were 948 livebirths, consequently leading to maternal near-miss ratio (MNMR) of 50 (95% CI 34-60) and 11 (95% CI 4 – 16) per 1,000 livebirths for the SSA criteria and respectively the WHO MNM criteria. The difference in these numbers seems to be primarily attributed to the addition of defined severe complications in the clinical criteria and the adapted threshold for blood transfusions. Eclampsia and severe malaria form roughly half of these complications. # Conclusions SSA MNM criteria are more suitable than the WHO criteria to identify patients with potentially life-threatening conditions (PLTC) in this rural hospital. The addition of clinical criteria and rejection of several unapplicable laboratory and management-based parameters in the SSA MNM tool seem appropriate adaptations for low-resource settings. However, some non-acute cases are discussable near-misses and the criterion “severe pre-eclampsia with ICU admission” seems not feasible in similar settings. Implementation of the SSA MNM criteria forms a strong basis for auditing. Better monitoring and documentation of patients will improve the use of the criteria and potentially the quality of audit sessions.

Maternal near miss and potentially life-threatening condition determinants in patients with type 1 diabetes mellitus at a university hospital in S\xe3o Paulo, Brazil: a retrospective study

BackgroundTo date, the rates of potentially life-threatening condition (PTLC), maternal near miss (MNM) and maternal deaths in pregnant patients with type 1 diabetes mellitus (T1DM) and variables associated to it have not been studied.MethodsThis study was as a cross-sectional retrospective study conducted at São Paulo Hospital of Universidade Federal de São Paulo, a tertiary hospital that provides public medical care through the Brazilian unified health system to high-risk pregnancies. Inclusion criteria were T1DM pregnant women who delivered from January 2005 to December 2015. Three groups were established by the World Heath Organization criteria and associations were assessed using the chi-square test in between MNM and no morbidity or PLTC and no morbidity. A P value < 0.05 was considered statistically significant.ResultsThe final sample included 137 patients, 8 MNM cases (5.84%), 51 PLTC (37.23%), no cases of maternal deaths and 78 patients (56.93%) did not present any complication. Moreover, there were 122 live births, resulting in a near miss rate of 65.5 per 1.000 live births in patients with T1DM. Two of the MNM cases were for clinical criteria (uncontrollable fit in both) and laboratory criteria for the other six: one patient with severe acute azotemia (creatinine > 300 μmol/ml), one patient with severe hypoperfusion (lactate > 5 mmol/L) and four of them with loss of consciousness and the presence of glucose and ketoacids in urine. PLTC criteria were studied in MNM and PLTC cases. Prolonged hospital stay was the most prevalent PLTC criteria in both groups (100% of MNM cases and 96% of PLTC), followed by renal failure in 50% of MNM cases and severe preeclampsia in 22% of PLTC cases. This study could not find any association between prenatal factors or sociodemographic characteristics with maternal morbidity.ConclusionsMNM rate in T1DM was extremely high, and determined by complications of the primary disease or hypertensive disorders. No sociodemographic variables studied were related to maternal morbidity; therefore, we could not predict what increases MNM and PLTC in this specific population.

Surviving mothers and lost babies - burden of stillbirths and neonatal deaths among women with maternal near miss in eastern Ethiopia: a prospective cohort study.

BackgroundAlthough maternal near miss (MNM) is often considered a ‘great save’ because the woman survived life-threatening complications, these complications may have resulted in loss of a child or severe neonatal morbidity. The objective of this study was to assess proportion of perinatal mortality (stillbirths and early neonatal deaths) in a cohort of women with MNM in eastern Ethiopia. In addition, we compared perinatal outcomes among women who fulfilled the World Health Organization (WHO) and the sub-Saharan African (SSA) MNM criteria.MethodsIn a prospective cohort design, women with potentially life-threatening conditions (PLTC) (severe postpartum hemorrhage, severe pre-(eclampsia), sepsis/severe systemic infection, and ruptured uterus) were identified every day from January 1st, 2016, to April 30th, 2017, and followed until discharge in the two main hospitals in Harar, Ethiopia. Maternal and perinatal outcomes were collected using both sets of criteria. Numbers and proportions of stillbirths and early neonatal deaths were computed and compared.ResultsOf 1054 women admitted with PTLC during the study period, 594 women fulfilled any of the MNM criteria. After excluding near misses related to abortion, ectopic pregnancy or among undelivered women, 465 women were included, in whom 149 (32%) perinatal deaths occurred: 132 (88.6%) stillbirths and 17 (11.4%) early neonatal deaths. In absolute numbers, the SSA criteria picked up more perinatal deaths compared to the WHO criteria, but the proportion of perinatal deaths was lower in SSA group compared to the WHO (149/465, 32% vs 62/100, 62%). Perinatal mortality was more likely among near misses with antepartum hemorrhage (adjusted odds ratio (aOR) = 4.81; 95% CI = 1.76-13.20), grand multiparous women (aOR = 4.31; 95% confidence interval CI = 1.23-15.25), and women fulfilling any of the WHO near miss criteria (aOR = 4.89; 95% CI = 2.17-10.99).ConclusionWHO MNM criteria pick up fewer perinatal deaths, although perinatal mortality occurred in a larger proportion of women fulfilling the WHO MNM criteria compared to the SSA MNM criteria. As women with MNM have increased risk of perinatal deaths (in both definitions), a holistic care addressing the needs of the mother and baby should be considered in management of women with MNM.

Maternal near miss determinants at a maternity hospital for high-risk pregnancy in northeastern Brazil: a prospective study

BackgroundTo investigate the association between sociodemographic and obstetric variables and delays in care with maternal near misses (MNMs) and their health indicators.MethodsA prospective cohort study was conducted at a high-risk maternity hospital in northeastern Brazil from June 2015 to May 2016 that included all pregnant women seen at the maternity hospital during the data collection period and excluded those who had not been discharged at the end of the study or whom we were unable to contact after the 42nd postpartum day for MNM control. We used the MNM criteria recommended by the WHO. Risk ratios (RRs) and their 95% confidence intervals (CIs) were calculated. Hierarchical multiple logistic regression analysis was performed. The p values of all tests were two-tailed, and the significance level was set to 5%.ResultsA total of 1094 pregnant women were studied. We identified 682 (62.4%) women without adverse maternal outcomes (WOAMOs) and 412 (37.6%) with adverse maternal outcomes (WAMOs), of whom 352 had potentially life-threatening conditions (PLTCs) (85.4%), including 55 MNM cases (13.3%) and five maternal deaths (1.2%). During the study period, 1002 live births (LBs) were recorded at the maternity hospital, resulting in an MNM ratio of 54.8/1000 LB. The MNM distribution by clinical condition identified hypertension in pregnancy (67.2%), hemorrhage (42.2%) and sepsis (12.7%). In the multivariate analysis, the factors significantly associated with an increased risk of MNM were fewer than six prenatal visits (OR: 3.13; 95% CI: 1.74–5.64) and cesarean section in the current pregnancy (OR: 2.91; 95% CI: 1.45–5.82).ConclusionsThe factors significantly associated with the occurrence of MNM were fewer than six prenatal visits and cesarean section in the current pregnancy. These findings highlight the need for improved quality, an increased number of prenatal visits and the identification of innovative and viable models of labor and delivery care that value normal delivery and decrease the percentage of unnecessary cesarean sections.

Neonatal Near Miss among Newborns of Women with Type 1 Diabetes Mellitus.

Objective To investigate the frequency of neonatal near miss (NNM) and associate it with maternal morbidity in newborns of women with type 1 diabetes mellitus (T1DM). Methods This was a cross-sectional retrospective study from a secondary analysis of data retrieved from medical records of pregnant women with T1DM cared at a Brazilian university hospital between 2005 and 2015. Maternal near miss (MNM) and potentially life-threatening conditions (PTLC) were classified according to the World Health Organization criteria. NNM was classified according to the Pan American Health Organization Neonatal Near Miss Working Group criteria. Association of maternal morbidity with NNM was assessed using chi-square test. Results There were 122 newborns (NB) among 137 T1DM pregnancies. Thirty-seven NB presented NNM—incidence of 303 NNM per 1000 live births (37/122). NNM was associated with MNM (P < 0.001, OR (95% CI): 17.15 (1.85–159.12)). PLTC did not increase the odds of NNM (P=0.07; OR (95% CI): 2.1281 (0.92–4.91)). Seven newborns died, six of them from pregnancies without severe maternal morbidity. 71% of the neonatal death (5/7) occurred in malformed neonates. Conclusion MNM was associated with NNM among women with T1DM, and PLTC, paradoxically, did not increase NNM.

Skin Color and Severe Maternal Outcomes: Evidence from the Brazilian Network for Surveillance of Severe Maternal Morbidity.

Background Taking into account the probable role that race/skin color may have for determining outcomes in maternal health, the objective of this study was to assess whether maternal race/skin color is a predictor of severe maternal morbidity. Methods This is a secondary analysis of the Brazilian Network for Surveillance of Severe Maternal Morbidity, a national multicenter cross-sectional study of 27 Brazilian referral maternity hospitals. A prospective surveillance was performed to identify cases of maternal death (MD), maternal near miss (MNM) events, and potentially life-threatening conditions (PLTC), according to standard WHO definition and criteria. Among 9,555 women with severe maternal morbidity, data on race/skin color was available for 7,139 women, who were further divided into two groups: 4,108 nonwhite women (2,253 black and 1,855 from other races/skin color) and 3,031 white women. Indicators of severe maternal morbidity according to WHO definition are shown by skin color group. Adjusted Prevalence Ratios (PRadj - 95%CI) for Severe Maternal Outcome (SMO=MNM+MD) were estimated according to sociodemographic/obstetric characteristics, pregnancy outcomes, and perinatal results considering race. Results Among 7,139 women with severe maternal morbidity evaluated, 90.5% were classified as PLTC, 8.5% as MNM, and 1.6% as MD. There was a significantly higher prevalence of MNM and MD among white women. MNMR (maternal near miss ratio) was 9.37 per thousand live births (LB). SMOR (severe maternal outcome ratio) was 11.08 per 1000 LB, and MMR (maternal mortality ratio) was 170.4 per 100,000 LB. Maternal mortality to maternal near miss ratio was 1 to 5.2, irrespective of maternal skin color. Hypertension, the main cause of maternal complications, affected mostly nonwhite women. Hemorrhage, the second more common cause of maternal complication, predominated among white women. Nonwhite skin color was associated with a reduced risk of SMO in multivariate analysis. Conclusion Nonwhite skin color was associated with a lower risk for severe maternal outcomes. This result could be due to confounding factors linked to a high rate of Brazilian miscegenation.

Using Near Miss Model to Evaluate the Quality of Maternal Care at a Tertiary Health-Care Center: A Prospective Observational Study.

Near miss (NM) concept has led to a more comprehensive and better assessment of effect of care on maternal health. It indicates the degree of organ function failure in the wide spectrum of severity. This was a prospective observational study conducted from July 2015 to Feb 2016. Among women with potentially life-threatening conditions (PLTCs), those fulfilling one or more WHO NM criteria were included and followed up till the final outcome (NM or death). Various critical interventions done in them were associated with the final outcome. Standardized mortality ratio (SMR) was calculated for assessment of overall quality of health care provided. One thousand seven hundred and thirty-nine patients had PLTCs of which 174 (10%) patients were identified as NM. Of 174 patients, 116 patients (66.66%) were discharged in stable condition (group A) and 58 patients (33.34%) died (group B). Hemorrhage (31.8%) was the most frequent complication in group A followed by hypertensive disorders (18.1%) and severe anemia (11.2%). The two most common causes of maternal mortality were hypertensive disorders (27.6%) and hemorrhage (24.1%). Only two critical interventions (assisted ventilation and massive blood transfusion) had significant association with the final outcome. SMR of our center was 1.187 indicating adequate quality of provision of care to the patients. Hemorrhage and hypertensive disorders were the two most common causes of NM and deaths highlighting the importance of their prompt diagnosis and vigorous management. Periodic SMR calculation can be used as an audit to guide us in improving the overall status of maternal health.

Adverse perinatal outcomes are associated with severe maternal morbidity and mortality: evidence from a national multicentre cross-sectional study.

To assess the association between maternal potentially life-threatening conditions(PLTC), maternal near miss (MNM), and maternal death (MD) with perinatal outcomes. Cross-sectional study in 27 Brazilian referral centers from July, 2009 to June, 2010. All women presenting any criteria for PLTC and MNM, or MD, were included. Sociodemographic and obstetric characteristics were evaluated in each group of maternal outcomes. Childbirth and maternal morbidity data were related to perinatal adverse outcomes (5th min Apgar score < 7, fetal death, neonatal death, or any of these). The Chi-squared test evaluated the differences between groups. Multiple regression analysis adjusted for the clustering design effect identified the independently associated maternal factors with the adverse perinatal outcomes (prevalence ratios; 95% confidence interval). Among 8271 cases of severe maternal morbidity, there were 714 cases of adverse perinatal outcomes. Advanced maternal age, low level of schooling, multiparity, lack of prenatal care, delays in care, preterm birth, and adverse perinatal outcomes were more common among MNM and MD. Both MNM and MD were associated with Apgar score (2.39; 1.68-3.39); maternal hemorrhage was the most prevalent characteristic associated with fetal death (2.9, 95% CI 1.81-4.66) and anyadverseperinatal outcome (2.16; 1.59-2.94); while clinical/surgical conditions were more related to neonatal death (1.56; 1.08-2.25). We confirmed the association between MNM and MD with adverse perinatal outcomes. Maternal and perinatal issues should not be dissociated. Policies aiming maternal care should include social and economic development, and improvements in accessibility to specialized care. These, in turn, will definitively impact on childhood mortality rates.

Exploring Epidemiological Aspects, Distribution of WHO Maternal Near Miss Criteria, and Organ Dysfunction Defined by SOFA in Cases of Severe Maternal Outcome Admitted to Obstetric ICU: A Cross-Sectional Study.

Objective To explore the epidemiological aspects, to describe the frequency and distribution of WHO maternal near miss (MNM) criteria and the presence of organ dysfunction and failure measured by the maximum SOFA (Sequential Organ Failure Assessment) score (SOFA max) in cases of severe maternal outcome (SMO). Methods In an observational cross-sectional study performed between January 2013 and December 2015, 279 pregnant or postpartum women were admitted to an obstetric ICU (intensive care unit) in Brazil. MNM, maternal death (grouped as SMO), and potentially life-threatening conditions (PLTC) were defined according to WHO criteria. For categorical variables, a descriptive analysis was carried out. Frequency and distribution of WHO criteria, organ dysfunction, or failure defined by SOFA max were performed. Results WHO criteria identified 65 SMO and 214 PLTC. Management criteria were present in 58/65 (89.2%) while 61/65 (93.8%) of SMO cases had dysfunction or failure by SOFA. Conclusions The systematic evaluation of the organic function by SOFA max score identified the presence of organic dysfunction or failure in almost all SMO cases. Management criteria were present in all MD cases. Our results indicate the need for new studies evaluating the parameterization of the WHO laboratory criteria for values compatible with the definition of organic dysfunction by the SOFA to identify MNM.

Major Determinants of Maternal Near-Miss and Mortality at the Maternity Teaching Hospital, Erbil city, Iraq.

To find out the major determinants of maternal near-miss (NM)and maternal deaths (MDs) in Erbil city, Iraq, by comparative analysis of maternal NMs and MDs. We conducted a hospital-based cross-sectional study in the Maternity Teaching Hospital in Erbil city from 1 June to 31 December 2013. All MDs and NMs that occurred in the hospital during the study period were included in the study. Systematic identification of all eligible women was done. This identification included a baseline assessment of the severe pregnancy-related complications using the World Health Organization NM criteria. Severe preeclampsia and postpartum hemorrhage (PPH) constituted the highest proportions of complications in women with potentially life-threatening conditions (PLTCs) (30.5% and 30.0%, respectively). The highest mortality indexes were those for ruptured uterus (16.7) and severe complications of placenta previa (14.2). Factors that were significantly associated with MD (compared to NM) were hepatic dysfunction (p = 0.046), multiple/unspecified disorders (p = 0.003), arrival as an emergency condition by ambulance (p = 0.015), and history of previous cesarean section (p = 0.013). Severe preeclampsia and PPH are the main complications that lead to PLTCs. Factors found to be associated with MDs are hepatic dysfunction, multiple/unspecified disorders, arrival as an emergency condition by ambulance, and history of a previous cesarean section.

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

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.

Exploring the Concept of Degrees of Maternal Morbidity as a Tool for Surveillance of Maternal Health in Latin American and Caribbean Settings.

Objectives To assess a birth registry to explore maternal mortality and morbidity and their association with other factors. Study Design Exploratory multicentre cross-sectional analysis with over 700 thousand childbirths from twelve Latin American and Caribbean countries between 2009 and 2012. The WHO criteria for maternal morbidity were employed to split women, following a gradient of severity of conditions, into (1) maternal death (MD); (2) maternal near miss (MNM); (3) potentially life-threatening conditions (PLTC); (4) less severe maternal morbidity (LSMM); (5) any maternal morbidity; and (6) women with no maternal morbidity. Their prevalence and estimated risks of adverse maternal outcomes were assessed. Results 712,081 childbirths had a prevalence of MD and MNM of 0.14% and 3.1%, respectively, while 38% of women had experienced morbidity. Previous maternal morbidity was associated with higher risk of adverse maternal outcomes and also the extremes of reproductive ages, nonwhite ethnicity, no stable partner, no prenatal care, smoking, drug and alcohol use, elective C-section, or induction of labour. Poorer perinatal outcomes were proportional to the severity of maternal outcomes. Conclusions The findings corroborate WHO concept regarding continuum of maternal morbidity, reinforcing its importance in preventing adverse maternal outcomes and improving maternal healthcare in different settings.

Severe maternal morbidity due to respiratory disease and impact of 2009 H1N1 influenza A pandemic in Brazil: results from a national multicenter cross-sectional study.

BackgroundThe aim of this study was to assess the burden of respiratory disease, considering the influenza A pandemic season (H1N1pdm09), within the Brazilian Network for Surveillance of Severe Maternal Morbidity, and factors associated with worse maternal outcome.MethodsA multicenter cross-sectional study, involving 27 referral maternity hospitals in five Brazilian regions. Cases were identified in a prospective surveillance by using the WHO standardized criteria for potentially life-threatening conditions (PLTC) and maternal near miss (MNM). Women with severe complications from respiratory disease identified as suspected or confirmed cases of H1N1 influenza or respiratory failure were compared to those with other causes of severe morbidity. A review of suspected H1N1 influenza cases classified women as non-tested, tested positive and tested negative, comparing their outcomes. Factors associated with severe maternal outcome (SMO = MNM + MD) were assessed in both groups, in comparison to PLTC, using PR and 95 % CI adjusted for design effect of cluster sampling.ResultsAmong 9555 cases of severe maternal morbidity, 485 (5 %) had respiratory disease. Respiratory disease occurred in one-quarter of MNM cases and two-thirds of MD. H1N1 virus was suspected in 206 cases with respiratory illness. Around 60 % of these women were tested, yielding 49 confirmed cases. Confirmed H1N1 influenza cases had worse adverse outcomes (MNM:MD ratio < 1 (0.9:1), compared to 12:1 in cases due to other causes), and a mortality index > 50 %, in comparison to 7.4 % in other causes of severe maternal morbidity. Delay in medical care was associated with SMO in all cases considered, with a two-fold increased risk among respiratory disease patients. Perinatal outcome was worse in cases complicated by respiratory disease, with increased prematurity, stillbirth, low birth weight and Apgar score < 7.ConclusionsRespiratory disease, especially considering the influenza season, is a very severe cause of maternal near miss and death. Increased awareness about this condition, preventive vaccination during pregnancy, early diagnosis and treatment are required to improve maternal health.