Preventing death following unsafe abortion: a case series from urban Uganda

AJOG Global Reports, Volume 2, No. 1, Year 2022

Interpretation

BACKGROUND: Maternal deaths from unsafe abortion continue to occur globally, with particularly high rates in Sub-Saharan Africa where most abortions are classified as unsafe. Maternal death reviews are an effective part of cohesive strategies to prevent future deaths while abortion remains illegal. OBJECTIVE: This study aimed to conduct maternal death reviews for all deaths occurring following unsafe abortion during the study period, to assess preventability, and to synthesize key learning points that may help to prevent future maternal deaths following unsafe abortions. STUDY DESIGN: Full case reviews of all maternal deaths (350 cases from Jan 2016 to Dec 2018) at the study center (a national referral hospital in urban Uganda) were conducted by specially trained multidisciplinary panels of obstetricians and midwives. We extracted the reviews of women who died following unsafe abortions (13 [2.6%]) for further analysis. RESULTS: Most maternal deaths owing to unsafe abortion were found to be preventable. The key recommendations that emerged from the reviews were (1) that clinicians should maintain a high index of suspicion for delayed presentation and rapid decompensation in cases where unsafe abortion has occurred, (2) that a low threshold for early intravenous antibiotic therapy should be applied, and (3) that any admission with complications following an unsafe abortion merits review by an experienced clinician as soon as possible. CONCLUSION: Postabortion care is part of essential emergency medical care and should be provided with high standards, especially in areas where there is limited or no legal access to abortion care. Implementing the recommended learning points is likely to be feasible even in low-resource obstetrical settings and, given the high rates of preventability found in maternal deaths owing to unsafe abortion, is likely to be effective. We conducted a full case review of all maternal deaths at the study center between January 1, 2016, and December 31, 2018. During this period, 401 maternal deaths were identified in the register of maternity admissions, which was cross-checked against all mortuary records for women of reproductive age. Moreover, 51 cases were excluded as the medical notes were not identifiable or were incomplete or maternal death was not confirmed on the case review. Overall, 350 maternal deaths were included in the study cohort. Furthermore, we extracted the cases of women who died following unsafe abortions (13 [2.6%]) for further analyses. The Mulago-Kawempe National Referral Site is the tertiary referral center for obstetrics in Uganda with between 25,000 and 32,000 deliveries per year.19 The center is one of the busiest maternity units in Africa and offers comprehensive obstetrics and gynecology services round the clock. The average number of maternal deaths at the center per year is approximately 136 to 140.20 The hospital is located in Kampala and serves a local low-resource urban population in addition to receiving referrals from other parts of Uganda. All case notes were identified from the institutional records and retrieved by the study team. Each medical record was reviewed by members of a local multidisciplinary review team convened for the specific purpose of this study. All clinicians who participated in review panels (12 obstetricians and 8 highly experienced midwives) received specific training in maternal death case review by the study team and all signed a confidentiality agreement before reviewing any cases. All review panel members had received previous training in maternal death surveillance and response by the Ugandan Ministry of Health within 2 years and had some previous experience of conducting such reviews. Study-specific training was conducted at face-to-face courses, each lasting 1.5 working days. Each course was led by members of the research team and involved multidisciplinary groups of 5 participants (usually 3 obstetricians and 2 midwives). A training slide was developed for didactic teaching, followed by group discussions and a practice review of deidentified case records to ensure consistent standards and familiarity with the research data collection tool. The research tool used for data collection was adapted from the standardized Ugandan national maternal death audit or review form with extra questions added to assess the preventability of death and detail any delays in care. The training involved specific practice on consensus building within multidisciplinary groups on these aspects of the death reviews. All identifying information of both the patient and medical team were obscured from the review panel. Every panel involved at least 1 obstetrician and 1 experienced midwife who were familiar with usual clinical practice and facilities at the study center. The study team ensured that no clinician reviewed any case in which they had any personal involvement. The review panels categorized each case according to key medical and demographic characteristics and produced a detailed narrative summary for each patient. Furthermore, the review panel recorded their opinion on the preventability of each death and any missed opportunities in the care provided. In the absence of postmortem findings, all available sources of evidence were examined by the review panels to determine an accurate representation of the causes contributing to the death as specified by the International Classification of Diseases (ICD). The main source of information was the medical notes, a particularly detailed examination of the medical history, clinical findings, and contemporaneously recorded diagnoses of the treating clinicians. These were interpreted by the review panels given their extensive context-specific clinical experience. Moreover, the panel noted the diagnoses given on the maternal death audit forms (for those deaths audited). In several cases, the panel could consider documented collateral history (usually from a relative or friend) for patients who were admitted in critical condition plus some aspects of verbal autopsy from relatives and friends. Additional opinions on these aspects were sought where appropriate from other expert local clinicians—for example, obstetrical anesthetists or physicians. Each case summary was further independently reviewed by an international obstetrician who visited the study center on several occasions to become familiar with local contextual factors. We presented summary statistics for the case reviews where death was because of unsafe abortion. Furthermore, cases were presented as anonymized illustrative narratives. The key elements of each case have been preserved, but some details have been changed to preserve the anonymity of the patient and small number suppression has been applied to demographic data to ensure anonymity where relevant. The study was approved by the Makerere University Higher Degrees School of Medicine Research and Ethics Committee (#REC Ref 2018-001) and the Uganda National Council of Science and Technology (reference number SS4797).

AI Digest

Study Justification:

– Maternal deaths from unsafe abortion are a global issue, particularly prevalent in Sub-Saharan Africa.
– Maternal death reviews are an effective strategy to prevent future deaths.
– This study aimed to conduct maternal death reviews for deaths following unsafe abortion, assess preventability, and identify key learning points.

Highlights:

– Full case reviews of 350 maternal deaths at a national referral hospital in urban Uganda were conducted.
– 13 deaths (2.6%) were due to unsafe abortions.
– Most maternal deaths from unsafe abortion were found to be preventable.
– Key recommendations emerged from the reviews, including maintaining a high index of suspicion for delayed presentation, applying a low threshold for early intravenous antibiotic therapy, and reviewing any admission with complications following an unsafe abortion by an experienced clinician.

Recommendations:

Key Role Players:

– Clinicians (obstetricians and midwives)
– Multidisciplinary review team
– Ugandan Ministry of Health
– Expert local clinicians (obstetrical anesthetists, physicians)

Cost Items for Planning Recommendations:

– Training for clinicians in maternal death case review
– Research team coordination and support
– Data collection and analysis
– Review panel meetings and logistics
– International obstetrician visits
– Ethical approval process
Please note that the actual cost of implementing these recommendations would require a detailed budget analysis.

Strength of Evidence

N/A

Abstract

We conducted a full case review of all maternal deaths at the study center between January 1, 2016, and December 31, 2018. During this period, 401 maternal deaths were identified in the register of maternity admissions, which was cross-checked against all mortuary records for women of reproductive age. Moreover, 51 cases were excluded as the medical notes were not identifiable or were incomplete or maternal death was not confirmed on the case review. Overall, 350 maternal deaths were included in the study cohort. Furthermore, we extracted the cases of women who died following unsafe abortions (13 [2.6%]) for further analyses. The Mulago-Kawempe National Referral Site is the tertiary referral center for obstetrics in Uganda with between 25,000 and 32,000 deliveries per year.19 The center is one of the busiest maternity units in Africa and offers comprehensive obstetrics and gynecology services round the clock. The average number of maternal deaths at the center per year is approximately 136 to 140.20 The hospital is located in Kampala and serves a local low-resource urban population in addition to receiving referrals from other parts of Uganda. All case notes were identified from the institutional records and retrieved by the study team. Each medical record was reviewed by members of a local multidisciplinary review team convened for the specific purpose of this study. All clinicians who participated in review panels (12 obstetricians and 8 highly experienced midwives) received specific training in maternal death case review by the study team and all signed a confidentiality agreement before reviewing any cases. All review panel members had received previous training in maternal death surveillance and response by the Ugandan Ministry of Health within 2 years and had some previous experience of conducting such reviews. Study-specific training was conducted at face-to-face courses, each lasting 1.5 working days. Each course was led by members of the research team and involved multidisciplinary groups of 5 participants (usually 3 obstetricians and 2 midwives). A training slide was developed for didactic teaching, followed by group discussions and a practice review of deidentified case records to ensure consistent standards and familiarity with the research data collection tool. The research tool used for data collection was adapted from the standardized Ugandan national maternal death audit or review form with extra questions added to assess the preventability of death and detail any delays in care. The training involved specific practice on consensus building within multidisciplinary groups on these aspects of the death reviews. All identifying information of both the patient and medical team were obscured from the review panel. Every panel involved at least 1 obstetrician and 1 experienced midwife who were familiar with usual clinical practice and facilities at the study center. The study team ensured that no clinician reviewed any case in which they had any personal involvement. The review panels categorized each case according to key medical and demographic characteristics and produced a detailed narrative summary for each patient. Furthermore, the review panel recorded their opinion on the preventability of each death and any missed opportunities in the care provided. In the absence of postmortem findings, all available sources of evidence were examined by the review panels to determine an accurate representation of the causes contributing to the death as specified by the International Classification of Diseases (ICD). The main source of information was the medical notes, a particularly detailed examination of the medical history, clinical findings, and contemporaneously recorded diagnoses of the treating clinicians. These were interpreted by the review panels given their extensive context-specific clinical experience. Moreover, the panel noted the diagnoses given on the maternal death audit forms (for those deaths audited). In several cases, the panel could consider documented collateral history (usually from a relative or friend) for patients who were admitted in critical condition plus some aspects of verbal autopsy from relatives and friends. Additional opinions on these aspects were sought where appropriate from other expert local clinicians—for example, obstetrical anesthetists or physicians. Each case summary was further independently reviewed by an international obstetrician who visited the study center on several occasions to become familiar with local contextual factors. We presented summary statistics for the case reviews where death was because of unsafe abortion. Furthermore, cases were presented as anonymized illustrative narratives. The key elements of each case have been preserved, but some details have been changed to preserve the anonymity of the patient and small number suppression has been applied to demographic data to ensure anonymity where relevant. The study was approved by the Makerere University Higher Degrees School of Medicine Research and Ethics Committee (#REC Ref 2018-001) and the Uganda National Council of Science and Technology (reference number SS4797).

Materials

N/A

Innovations

The study titled “Preventing death following unsafe abortion: a case series from urban Uganda” conducted a comprehensive review of maternal deaths at a national referral hospital in urban Uganda between January 2016 and December 2018. The study aimed to assess the preventability of maternal deaths following unsafe abortions and identify key recommendations to prevent future deaths.

The study found that most maternal deaths resulting from unsafe abortions were preventable. Based on the case reviews, the following key recommendations emerged:

1. Clinicians should maintain a high index of suspicion for delayed presentation and rapid decompensation in cases where unsafe abortion has occurred.
2. A low threshold for early intravenous antibiotic therapy should be applied.
3. Any admission with complications following an unsafe abortion should be reviewed by an experienced clinician as soon as possible.

The study highlights the importance of postabortion care as an essential part of emergency medical care, particularly in areas where access to legal abortion care is limited or nonexistent. Implementing these recommended learning points is feasible even in low-resource obstetrical settings and can effectively reduce maternal deaths resulting from unsafe abortions.

The study was published in AJOG Global Reports, Volume 2, No. 1, Year 2022. It received approval from the Makerere University Higher Degrees School of Medicine Research and Ethics Committee and the Uganda National Council of Science and Technology.

AI Innovations Description

The study titled “Preventing death following unsafe abortion: a case series from urban Uganda” conducted a full case review of maternal deaths at a national referral hospital in urban Uganda between January 2016 and December 2018. The study aimed to assess the preventability of maternal deaths following unsafe abortions and identify key recommendations to prevent future deaths.

The study found that most maternal deaths resulting from unsafe abortions were preventable. The key recommendations that emerged from the case reviews were:

1. Clinicians should maintain a high index of suspicion for delayed presentation and rapid decompensation in cases where unsafe abortion has occurred.
2. A low threshold for early intravenous antibiotic therapy should be applied.
3. Any admission with complications following an unsafe abortion should be reviewed by an experienced clinician as soon as possible.

The study emphasizes that postabortion care is an essential part of emergency medical care, especially in areas where there is limited or no legal access to abortion care. Implementing these recommended learning points is likely to be feasible even in low-resource obstetrical settings and can effectively reduce maternal deaths resulting from unsafe abortions.

The study was published in AJOG Global Reports, Volume 2, No. 1, Year 2022. It was approved by the Makerere University Higher Degrees School of Medicine Research and Ethics Committee and the Uganda National Council of Science and Technology.

AI Innovations Methodology

To simulate the impact of the main recommendations from the study on improving access to maternal health, you could consider the following methodology:

1. Identify target healthcare facilities: Select a sample of healthcare facilities in urban Uganda that provide obstetric and gynecological services, particularly those that handle cases of unsafe abortions. These facilities should represent a range of resource levels, including low-resource settings.

2. Training and education: Develop a training program for healthcare providers in these facilities based on the key recommendations from the study. The training should focus on increasing awareness and knowledge about the preventability of maternal deaths following unsafe abortions, as well as the specific actions recommended in the study.

3. Implementation of recommendations: Implement the recommendations in the selected healthcare facilities. This could involve incorporating the recommendations into clinical protocols and guidelines, ensuring that healthcare providers are aware of and follow the recommendations in their practice.

4. Monitoring and evaluation: Establish a system to monitor the implementation of the recommendations and track their impact on maternal health outcomes. This could include regular data collection on maternal deaths, complications following unsafe abortions, and adherence to the recommended practices. Evaluate the data to assess changes in preventable maternal deaths and improvements in access to postabortion care.

5. Feedback and continuous improvement: Provide regular feedback to healthcare providers and facility administrators on the outcomes of the interventions. Use this feedback to identify areas for improvement and make necessary adjustments to the implementation strategy.

6. Scaling up and dissemination: If the interventions prove to be effective in reducing maternal deaths and improving access to maternal health, consider scaling up the implementation to a larger number of healthcare facilities in urban Uganda. Additionally, disseminate the findings and lessons learned from the study to other relevant stakeholders, such as policymakers, to advocate for the adoption of these recommendations on a broader scale.

By following this methodology, you can simulate the impact of the main recommendations from the study on improving access to maternal health in urban Uganda and potentially reduce preventable maternal deaths resulting from unsafe abortions.

Author

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1016/j.xagr.2021.100039

Research Areas:

Health System and Policy, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Technology and Innovations, Workforce

Study Countries:

Uganda

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory, Narrative Study

Study Approach:

Qualitative

Participants Gender:

Female