Severe Acute Maternal Morbidity Research Articles

Severe Acute Maternal Morbidity: An indicator of Obstetric Care

Severe Acute Maternal Morbidity: An indicator of Obstetric Care

Severe acute maternal morbidity reporting in Australia: Why is it so hard?

Adverse outcomes associated with pregnancy, including severe acute maternal morbidity (SAMM) and mortality, are internationally regarded as important indicators of quality of maternity services. Varied definitions and processes are barriers for SAMM recording, reporting and review. Identifying and documenting these cases of SAMM is a critical first step. Case reviews allow exploration of factors contributing to SAMM. Translation of the lessons learnt into practice improvement strategies and dissemination of this knowledge is essential for continual quality improvement. This review will outline the current status of SAMM review internationally and in Australia.

A Retrospective Study in 12-Year cohort of 216 Parturients with Invasive Placentation in a Tertiary Care Centre in Oman: Clinical Outcomes Indicate Severe Maternal Morbidity

Placenta accreta spectrum (PAS) comprising placenta accreta, increta, and percreta, is 1 of the leading causes of peripartum hemorrhage and accounts for up to 50% of all cesarean hysterectomies (CH). We analyzed the data of 216 parturients with PAS who underwent cesarean delivery (CD) and/or CH. Intraoperative surgical complications were noted in 215 (99.5%). The mean estimated blood loss was 2743 (1790) mL, and 105 parturients (48.6%) lost ≥2500 mL. The patients experienced high rates of severe acute maternal morbidity [162 (75%)], hysterectomy [82 (38%)], large volume blood loss, blood transfusion, peripartum anemia, and prolonged hospital stay.

Social determinants and exposure to intimate partner violence in women with severe acute maternal morbidity in the intensive care unit: a systematic review

BackgroundStudying severe acute maternal morbidity in the intensive care unit improves our understanding of potential factors affecting maternal health.AimTo review evidence on maternal exposure to intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit.MethodsThe protocol for this review was registered in PROSPERO (registration number CRD42016037492). A systematic search was performed in MEDLINE, CINAHL, ProQuest, LILACS and SciELO using the search terms “intensive care unit”, “intensive care”, “critical care” and “critically ill” in combination with “intimate partner violence”, “social determinants of health”, “severe acute maternal morbidity”, pregnancy, postpartum and other similar terms. Eligible studies were (i) quantitative, (ii) published in English and Spanish, (iii) from 2000 to 2021, (iv) with data related to intimate partner violence and/or social determinants of health, and (v) investigating severe acute maternal morbidity (maternity patients treated in the intensive care unit during pregnancy, childbirth or within 42 days of pregnancy termination). Of 52,866 studies initially identified, 1087 full texts were assessed and 156 studies included. Studies were independently assessed by two reviewers for screening, revision, quality assessment and abstracted data. Studies were categorised into high/middle/low-income countries and summarised data were presented using a narrative description, due to heterogenic data as: (i) exposure to intimate partner violence and (ii) social determinants of health.ResultsOne study assessed intimate partner violence among mothers with severe acute maternal morbidity in the intensive care unit and found that women exposed to intimate partner violence before and during pregnancy had a nearly four-fold risk of severe acute maternal morbidity requiring ICU admission. Few social determinants of health other than age were reported in most studies.ConclusionThis review identified a significant gap in knowledge concerning intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit, which is essential to better understand the complete picture of the maternal morbidity spectrum and reduce maternal mortality.

Fetomaternal outcome of scarred uterine rupture compared with primary uterine rupture: a retrospective cohort study.

Literature comparing maternal and perinatal outcomes among women with scarred and primary uterine rupture are limited. Therefore, the study aimed to compare maternal and perinatal outcomes and associated risk factors of uterine rupture among scarred and unscarred uterus. This retrospective cohort study was performed at a large tertiary care of India between July 1, 2011 and June 30, 2020. We analysed all the cases of complete uterine rupture beyond the 20th week of gestation. The outcome measures were live birth rate, perinatal mortality, maternal mortality and morbidity. A total of 115 complete uterine ruptures were noted in 148,102 pregnancies. Of those 115 uterine ruptures, 89 (77.3 %) uterine ruptures occurred in women with a history of caesarean delivery, and 26 (22.6 %) uterine ruptures occurred in primary uterine rupture. The primary uterine rupture group had a significantly higher incidence of lower parity, breech presentation and mean birth weight. The live birth rate (68.18% vs. 42.85 %; p=0.04) was significantly higher in the scarred group, and the stillbirth rate (57.14% vs. 31.86 %; p=0.009) was significantly higher in the primary uterine rupture group. Hypoxic ischemic encephalopathy, APGAR score, and neonatal intensive care unit admission were comparable. Postpartum haemorrhage, blood transfusion, severe acute maternal morbidity and intensive care unit stay were more frequently reported in the primary uterine rupture group. The maternal and perinatal outcomes appear less favourable among women with primary uterine rupture than scarred uterine rupture.

The challenge of defining women at low-risk for childbirth: analysis of peripartum severe acute maternal morbidity in women considered at low-risk according to French guidelines.

The challenge of defining women at low-risk for childbirth: analysis of peripartum severe acute maternal morbidity in women considered at low-risk according to French guidelines.

Peripartum severe acute maternal morbidity in low-risk women: A population-based study

BackgroundKnowledge of severe acute maternal morbidity (SAMM) and its risk factors is constantly growing, but studies have rarely focused on the specific population of low-risk women. AimTo estimate the prevalence and to identify subgroups at risk of peripartum SAMM in low-risk women MethodsFrom a population-based cohort-nested case-control study conducted in six French regions, i.e., 182 309 women who gave birth at ≥22 weeks in 119 maternity units, we selected women considered at low risk up to the end of pregnancy before labour according to the NICE guidelines and compared those experiencing peripartum SAMM (during birth and up to 7 days postpartum; n = 489) to a 2% random sample of women without peripartum SAMM from the same units (n = 1800). Risk factors for peripartum SAMM were identified by multivariable logistic regression. Findingsamongst low-risk women, the estimated rate of SAMM was 0.548/100 deliveries (95%CI 0.501–0.599). Severe obstetric haemorrhage was the main cause (83.6% of SAMM cases). Main risk factors for peripartum SAMM were primiparity (aOR 2.4, 95%CI 1.9–3.0), IVF pregnancy (aOR 1.8, 1.0–3.4), third-trimester anaemia (aOR 1.7, 1.3–2.3), being born out of Europe or Africa (aOR 1.9, 1.2–3.0). Conclusionamongst women considered at low risk up to the end of pregnancy before labour, peripartum SAMM is rare but still exists. Knowledge of risk factors of SAMM in this population will inform the discussion on peripartum risks and the most appropriate place of birth for each woman.

Postpartum severe acute maternal morbidity according to gestational age at delivery in twin pregnancies: A prospective cohort study.

To assess the association between gestational age at delivery and postpartum severe acute maternal morbidity (SAMM) in twin pregnancies. Secondary analysis of the JUMODA cohort, a national, prospective, population-based study of twin pregnancies in France. We excluded women with delivery before 32 weeks of pregnancy, with a fetal death or medical termination, with antepartum SAMM, or with antepartum conditions responsible for postpartum SAMM. The primary outcome was a composite of postpartum SAMM. We assessed the association between gestational age at delivery and SAMM by using multivariable multilevel modified Poisson regression modeling. Among the 7713 women included, 410 (5.3%) developed postpartum SAMM. Compared with the reference category of 37 weeks of pregnancy, the risk of postpartum SAMM was significantly lower for all categories of earlier gestational age at delivery (from an adjusted relative risk [RR] of 0.34, 95% confidence interval [CI] 0.17-0.68 at 32 weeks to an adjusted RR of 0.71, 95% CI 0.54-0.94 at 36 weeks), and did not differ for later gestational ages. In twin pregnancies, compared with delivery at 37 weeks of pregnancy, delivery at earlier gestational ages was associated with a lower risk of postpartum SAMM. Continuing pregnancy beyond 37 weeks of pregnancy is not associated with an increased risk of postpartum SAMM.

Analysis of the Factors leading to Severe Acute Maternal Morbidity and Maternal Mortality during COVID 19 Pandemic

Aims: To determine prevalence, causes and factors leading to severe acute maternal morbidity and mortality during COVID 19 pandemic.
 Methods: The was a cross sectional observational study conducted in the department of Obstetrics and Gynaecology of Manipal teaching hospital from March 2020 to February 2022 amid COVID 19 pandemic. Women who sustained severe acute maternal morbidity (according to World health organization organ system criteria) and maternal deaths during pregnancy, labour and six weeks postpartum were included. Maternal characteristics, total live births, pregnancy outcome, causes and factors leading to morbidity and mortality were noted. The acquisitioned data was analyzed using Statistical Package for Social Sciences version 21.
 Results: There were 37 cases of severe acute maternal morbidity and 2 cases of maternal deaths. The severe acute maternal morbidity ratio was 9.4 per 1000 live births and maternal mortality ratio was 51 per 100,000 live births. Therefore, severe acute maternal morbidity mortality ratio was 18.5:1 and mortality index 5.1%. Haematological and coagulation system (45.9%) and neurological system (29.7%) were the common organ systems involved. Hypertensive disorders (40.5%) and haemorrhage (32.4%) were the main causes of severe acute morbidity. Both maternal deaths occurred due to eclampsia. There was no severe acute maternal morbidity or mortality due to COVID infection in pregnancy. Delay in seeking and reaching to the health centre (65%) was major delay leading to severe morbidity and mortality.
 Conclusions: Indices and causes of severe acute maternal morbidity and mortality during COVID 19 pandemic was not worse compared to those prior to COVID 19 pandemic. Primary delay in seeking and reaching health care was the main factor leading to severe morbidity and mortality.

Every maternal near-miss counts: Need for a national audit in South Africa? A mixed-methods study.

To improve maternal health, studies of maternal morbidity are increasingly being used to evaluate the quality of maternity care, in addition to studies of mortality. While South Africa (SA) has a well-established confidential enquiry into maternal deaths, there is currently no structure in place to systematically collect and analyse maternal near-misses (MNMs) at national level. To synthesise MNM indicators and causes in SA by performing a systematic literature search, and to investigate perceived needs for data collection related to MNMs and determine whether the MNM tool from the World Health Organization (WHO-MNM) would require adaptations in order to be implemented. The study used a mixed-methods approach. A systematic literature search was conducted to find all published data on MNM audits in SA. Semi-structured interviews were conducted virtually with maternal health experts throughout the country who had been involved in studies of MNMs, and main themes arising in the interviews were synthesised. A method for MNM data collection for SA use was discussed with these experts. The literature search yielded 797 articles, 15 of which met the WHO-MNM or Mantel et al. severe acute maternal morbidity criteria. The median (interquartile range) MNM incidence ratio in SA was 8.4/1 000 (5.6 - 8.7) live births, the median maternal mortality ratio was 130/100 000 (71.4 - 226) live births, and the median mortality index was 16.6% (11.7 - 18.8). The main causes of MNMs were hypertensive disorders of pregnancy and obstetric haemorrhage. Eight maternal health experts were interviewed from May 2020 to February 2021. All participants focused on the challenges of implementing a national MNM audit, yet noted the urgent need for one. Recognition of MNMs as an indicator of quality of maternity care was considered to lead to improved management earlier in the chain of events, thereby possibly preventing mortality. Obtaining qualitative information from women with MNMs was perceived as an important opportunity to improve the maternity care system. Participants suggested that the WHO-MNM tool would have to be adapted into a simplified tool with more clearly defined criteria and a number of specific diagnoses relevant to the SA setting. This 'Maternal near-miss: Inclusion criteria and data collection form' is provided as a supplementary file. Adding MNMs to the existing confidential maternal death enquiry could potentially contribute to a more robust audit with data that may inform health systems planning. This was perceived by SA experts to be valuable, but would require context-specific adaptations to the WHO-MNM tool. The available body of evidence is sufficient to justify moving to implementation.

Maternal Intensive Care Unit Admission as an Indicator of Severe Acute Maternal Morbidity: A Population-based Study

(Anesth Analg. 2022;134:581–591) Severe acute maternal morbidity (SAMM) is an important indicator of maternal care due to the lowering rates of maternal deaths. One criterion for the diagnosis of SAMM is admission to the intensive care unit (ICU). Other aspects that would meet the diagnosis of SAMM is obstetric bleeding, eclampsia, severe preeclampsia, pulmonary embolism, cerebrovascular events, ICU admission, laparotomy after delivery, maternal death, or disorders of the hepatic, hematologic, respiratory, cardiovascular, renal, or neurologic systems. This study investigated if ICU admission serves as a valid indicator of SAMM. Using the Data from the EPIMOMS study which examined 182,309 women from 6 regions of France, 2540 met the criteria for SAMM or were admitted to the ICU. From this cohort, maternal characteristics, preexisting medical conditions, pregnancy characteristics, length of ICU stay, and organ dysfunction were recorded. The cohort was divided into 3 different groups: those with SAMM not admitted to an ICU, SAMM patients admitted to the ICU, and patients admitted to the ICU not meeting the criteria for SAMM. Statistical analysis was performed and univariable and multivariable multinomial logistic regression models to account for variables in all groups, histograms for continuous variables, standard deviation for normally distributed variables, Kruskal-Wallis test for ICU length of stay, and Fisher exact tests for categorical variables. The study used multiple imputations with chained equations to ascribe missing multivariable analysis model data values followed by a complete case multivariable logistic regression analysis. The results were at a α=0.05 significance level, a statistical power of 80%, an odds ratio of ≥1.4 or ≥2.0.

Comparison of global indicators for severe maternal morbidity among South Korean women who delivered from 2003 to 2018: a population-based retrospective cohort study

BackgroundEven though several severe maternal morbidity (SMM) indicators exist globally, indicators that can serve as international standards are needed. Therefore, this study aimed to compare the SMM risk assessment using four international indicators and identify the factors underlying the differences among the risk assessments obtained by the various indicators.MethodsThis study used the National Health Insurance delivery cohort in South Korea from 2003 to 2018. SMM was estimated using four indicators: the United States Centers for Disease Control and Prevention (US-CDC) SMM algorithm, the American College of Obstetricians and Gynecologists (ACOG) gold standard guidelines, Zwart et al.’s indicators for the Netherlands, and the European Network on Severe Acute Maternal Morbidity (EURONET-SAMM) index. Generalized estimating equations models were used to identify the relationships between SMM indicators and risk factors.ResultsThe SMM incidence rates in 6,421,091 deliveries, were 2.36%, 3.12%, 0.31%, and 1.36% using the US-CDC, ACOG, Zwart et al.’s, and EURONET SAMM indicators, respectively. In sub indicators, hemorrhage-related codes constituted the highest proportion of all SMM indicators. Advanced maternal age was related to high risk in all four SMM indicators (US-CDC: 40–44 years, RR 1.67, 95% CI 1.63–1.71; ACOG’s guidelines: 40–44 years, RR 1.52, 95% CI 1.49–1.56; Zwart’s indicators: RR 2.72, 95% CI 2.55–2.90; EURONET-SAMM: RR 2.04, 95% CI 1.97–2.11) compared to those aged 25–29 years. In residential area, women who lived in rural area had approximately 1.2- to 1.5-fold higher risk of SMM compared to those who lived in Seoul. Additionally, inadequate prenatal care was associated with a 1.1- to 1.4-fold higher risk of SMM compared to adequate prenatal care.ConclusionsSMM was associated with maternal age, socioeconomic status, and adverse obstetric factors using various international SMM indicators. Further studies are needed to further determine risk and preventable factors for SMM and to identify more specific causes associated with the frequent sub-indicators of SMM.

Hapū Ora (pregnancy wellness): Māori research responses from conception, through pregnancy and ‘the first 1000 days’ – a call to action for us all

ABSTRACT Aims To describe a body of Māori translational research responses that challenge colonialised systems. Methods To delineate and link ongoing Kaupapa Māori and Māori-led translational research. Results He Tapu Te Whare Tangata explores human papilloma virus (HPV) screening. Te Hā o Whānau presents a culturally responsive framework of maternity care. E Hine describes young Māori mothers’ experiences of Hapū Ora. Severe Acute Maternal Morbidity (SAMM) and SAMM Kids identify opportunities to improve avoidable morbidity. He Tamariki Kokoti Tau – Babies born prematurely, is a qualitative study of Māori experiences of preterm birth. He Tamariki Kokoti Tau – Tackling Preterm, is a quantitative analysis. He Korowai Manaaki is a wraparound maternity pathway. Whānau Manaaki – Methamphetamine aims to reduce the impact of methamphetamine. Calls for action reflect shared desires for system transformation. Conclusion We lay the wero (challenge) down to all to transform our current systems. Action is needed! Abbreviations: HPV: human papilloma virus, SAMM: severe acute maternal morbidity, ICU: intensive care unit, HDU: high dependency unit, RCT: randomised controlled trial, HQSC: Health Quality and Safety Commission.

Major obstetric hemorrhage management

Postpartum hemorrhage (PPH) is to this day one of the leading causes of maternal death and its diagnosis is still highly subjective, as it relies on unprecise estimates of the amount of blood loss. There are three areas in which PPH outcomes can be improved: prevention, treatment and rescue. PPH can escalate to a graver clinical picture of Severe Acute Maternal Morbidity (SAMM) due to an inaccurate estimate of the blood loss, inability to identify an at-risk patient, delays in testing and availability of hemoderivatives, and lack of clear guidelines and interdisciplinary communication. Many factors can predispose to PPH and in clinical practice the many causes of its insurgence are summarized with the 4T formula: Tone (uterine atony), Trauma (laceration/hematoma), Tissue (retained tissue/invasive placenta), Thrombin (coagulation). Some precautions can be taken in preventing PPH such as the use of uterotonics, the administration of oxytocin, the timing of umbilical cord clamping, and the monitoring of anemia and the platelet to fibrinogen concentration ratio. In recent years studies have been published with the goal of leading PPH diagnosis and management through universal guidelines, point-of-care testing and interdisciplinary approaches. The proposed algorithms, albeit not yet validated, are useful in the clinical practice; similarly beneficial is the use of reliable predictive panels such as the Modified Early Obstetric Warning System.

Maternal Near Miss in A Tertiary Care Hospital : An Observational Study

Background: The term maternal near miss refer to women who have escaped death either by chance or due to good health care after experiencing severe life threatening complications during pregnancy, labour and within six weeks after termination of pregnancy. Severe Acute Maternal Morbidity (SAMM) or Maternal Near Miss (MNM) is a complement of maternal mortality. The aim of this study is to state the need of patient’s health education, importance of emergency transportation as well as to evaluate the standard of effective quality & evidence based care in the facility to reduce maternal mortality and morbidity.
 Materials and methods : This observational study conducted for the period of January to December 2019 at Chattogram Maa-O-Shishu Hospital Medical College (CMOSHMC). Among 8976 total patients, MNM were 44 and total Maternal Death (MD) 13. Maternal Near miss clinical criteria – haemorrhage, hypertensive disorder of pregnancy, dystocia, sepsis & severe anaemia, organ dysfunction, based on management of ICU, blood transfusion, Maternal near miss are used to indicate quality of health care. Exclusion criteria- maternal death.
 Results: Total admitted patients in Obs & Gynae department in this study period were 8976. Obstetric patient 7422 & total deliveries 6027. MNM 44 in number & MD were 13. Main causes of MNM were hypertensive disorders (Severe preeclampsia, Eclampsia, HELLP syndrome)-23 (52.3%), obstetric haemorrhage (Placenta praevia, abruption placenta, rupture uterus, rupture ectopic pregnancy, incomplete abortion with shock, DIC)-14 (31.8%) Cardiopulmonary dysfunction (Cardiac arrest, cardiomyopathy, heart failure) – 7 (15.9%). Among the 44 near miss management, LSCS – 32 (73%) vaginal deliveries – 4 (9%), laparotomy – 5 (11%), peripartum hysterectomy – 3 (7%). Women with life threatening condition (MNM & MD) – 57. MNM ratio 6.8 per thousand live birth, MNM & MD ratio – 3.4:1
 Conclusion : SAMM or MNM is a pro-indicator to improve quality of obstetric care. Monitoring the near miss morbidity in conjunction with mortality surveillance could help to identify effective preventable measure for potentially life threatening morbidity.
 Chatt Maa Shi Hosp Med Coll J; Vol.21 (1); January 2022; Page 57-60

Ways Forward in Preventing Severe Maternal Morbidity and Maternal Health Inequities: Conceptual Frameworks, Definitions, and Data, from a Population Health Perspective.

Ways Forward in Preventing Severe Maternal Morbidity and Maternal Health Inequities: Conceptual Frameworks, Definitions, and Data, from a Population Health Perspective.

Severe maternal morbidity in the Slovak Republic in the years 2012-2018.

Analysis of maternal morbidity in the Slovak Republic in the years 2012-2018. The analysis of selected maternal morbidity data prospectively collected in the years 2012-2018 from all obstetric units in the Slovak Republic. In the years 2012-2018, incidence of severe peripartum bleeding was 2.17, peripartum hysterectomy was 0.89, maternal admission to intensive care units was 1.59, eclampsia was 0.21, HELLP syndrome was 0.73, abnormally invasive placentation was 0.37, uterine rupture was 0.68, severe sepsis in pregnancy and puerperium was 0.18 and nonfatal amniotic fluid embolism was 0.027 per 1,000 births. Incidence of total severe acute maternal morbidity in the Slovak Republic was 6.84 per 1,000 births. In Slovak local conditions, there is still room for reduction of severe acute maternal morbidity.

Women's experiences of breech birth decision making: An integrated review.

INTRODUCTIONCurrently, caesarean section is the primary mode of birth for a breech presenting fetus, leading to a deskilling of clinicians and limitation of birth choices for women. The aim of this review is to present a synthesized summary of existing literature related to women’s experiences of breech birth mode decision-making.METHODSA systematic search of the literature was conducted in April 2021, utilizing five databases to identify and obtain peer-reviewed articles meeting the predetermined selection criteria.RESULTSFour major categories were synthesized from the integrated review: 1) Women who desire a vaginal birth may experience a range of negative emotions such as feelings of disempowerment, loss, uncertainty and a sense of isolation; 2) Women who experience a breech presentation at term experience significant pressures to conform to expectations of medical professionals and their families due to perceptions of risk related to breech birth; 3) Breech birth decision-making in a limiting system; and 4) Overall satisfaction with the decision to plan a vaginal breech birth.CONCLUSIONWomen with a breech presenting fetus at term experience a complex range of emotions and internal and external pressures due to perceptions of risk around breech birth. Midwives were seen as helpful throughout the breech experience. The reduced caesarean section rate for breech, observed in studies exploring specialized care pathways or dedicated services, could reduce the incidence of Severe Acute Maternal Morbidity.

Risk of severe acute maternal morbidity according to gestational age at delivery in twin pregnancies

Gestational age at delivery minimizing fetal and neonatal mortality in twin pregnancies seems to be 37 weeks of gestation. Our objective was to assess the so far unexplored association between gestational age at delivery and severe acute maternal morbidity (SAMM) in women with twin pregnancies.

Gestational Anemia and Severe Acute Maternal Morbidity: A Population-based Study

(Anaesthesia. 2021;76:61–71) Gestational anemia (GA) has been associated with preterm birth, low birth weight, and maternal morbidity. However, the connection between maternal morbidity and GA is based on studies that focused on specific maternal complications, used interventions as proxies for complications, or lacked data about the timing of anemia and severe maternal complication. This prospective, population-based study aimed to investigate the association between GA and severe acute maternal morbidity (SMM).