Severe maternal outcomes in eastern Ethiopia: Application of the adapted maternal near miss tool

Background With the reduction of maternal mortality, maternal near miss (MNM) has been used as a complementary indicator of maternal health. The objective of this study was to assess the frequency of MNM in eastern Ethiopia using an adapted sub-Saharan Africa MNM tool and compare its applicability with the original WHO MNM tool. Methods We applied the sub-Saharan Africa and WHO MNM criteria to 1054 women admitted with potentially life-Threatening conditions (including 28 deaths) in Hiwot Fana Specialized University Hospital and Jugel Hospital between January 2016 and April 2017. Discharge records were examined to identify deaths or women who developed MNM according to the sub-Saharan or WHO criteria. We calculated and compared MNM and severe maternal outcome ratios. Mortality index (ratio of maternal deaths to SMO) was calculated as indicator of quality of care. Results The sub-Saharan Africa criteria identified 594 cases of MNM and all the 28 deaths while the WHO criteria identified 128 cases of MNM and 26 deaths. There were 7404 livebirths during the same period. This gives MNM ratios of 80 versus 17 per 1000 live births for the adapted and original WHO criteria. Mortality index was 4.5% and 16.9% in the adapted and WHO criteria respectively. The major difference between the two criteria can be attributed to eclampsia, sepsis and differences in the threshold for transfusion of blood. Conclusion The sub-Saharan Africa criteria identified all the MNM cases identified by the WHO criteria and all the maternal deaths. Applying the WHO criteria alone will cause under reporting of MNM cases (including maternal deaths) in this low-resource setting. The mortality index of 4.5% among women who fulfilled the adapted MNM criteria justifies labeling these women as having ‘life-Threatening conditions’. This study was conducted from January 2016 to April 2017 in Hiwot Fana Specialized University Hospital (HFSUH) and Jugel Regional Hospital in Harar town. HFSUH is a tertiary referral hospital affiliated with the College of Health and Medical Sciences of Haramaya University, Ethiopia. It is the major referral hospital in the eastern part of the country serving a catchment area with a population close to 3 million. HFSUH has two major operation rooms—one for general cases and one specifically for obstetrics—and a central intensive care unit with standby generator for use during power breaks. The maternity unit, consisting of 41 beds, serves both referred and self-referred women. During the study period, the unit was run by seven consultants, eight residents, and more than 20 nurse midwives. One anesthesiologist was available in the hospital, based on a monthly rotation from the capital. Jugel Hospital is a regional general hospital found in the same town, run by the Harari Regional Health Bureau. The maternity unit was run by integrated emergency surgical officers (associate clinicians) [21] under the supervision of consultants from HFSUH. Since HFSUH is relatively well equipped (including the only neonatal intensive care unit and pediatric ward in the region), the majority of complications are referred to this hospital. In this prospective cohort study, we included all women with MNM according to the sub-Saharan Africa or original WHO MNM criteria. Identification of MNM was a two-step process—we first identified all women with potentially life-threatening conditions (PLTC) as defined by WHO (severe postpartum hemorrhage, severe pre-eclampsia, eclampsia, uterine rupture, severe complications of abortion, and sepsis/severe systemic infections); received critical interventions (use of blood products, laparotomy other than cesarean section); or were admitted to the intensive care unit [8]. At discharge, we then selected those who developed life-threatening complications, consisting of MNM and maternal deaths, according to the sub-Saharan Africa or original WHO MNM criteria [8,20]. Maternal near miss refers to a woman who nearly died but survived a life-threatening complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy [7]. Severe maternal outcome includes women with life-threatening complications who survived the complications (near miss) or died. Eligible women were identified by trained research assistant nurse-midwives working in both hospitals through daily visits of obstetric ward, intensive care unit, emergency room, and gynaecology ward. Identified cases were evaluated and confirmed by the first author (AKT). Sample size was estimated based on the annual deliveries and maternal mortality ratio according to the recommendation by the WHO [22]. Considering the existing maternal mortality ratio (412) and the annual number of deliveries in both hospitals, we expected 7000 live births and 30 maternal deaths in 16 months. For all women with PLTC, or who received critical interventions, or admitted to the intensive care unit, basic identifying information (medical registration number, the underlying complication, and admission unit) were recorded daily and followed until discharge. Upon discharge, a thorough review of her medical record was conducted to collect detailed data on socio-demographic characteristics, history of morbidities, obstetric conditions, underlying complication, MNM event, treatments received, and maternal and perinatal outcomes. Information about referral status was also collected. Referred cases refers to women coming from health centers and district hospitals with existing complications. This enabled us to distinguish occurrence of MNM before or after admission—a good indicator of in hospital quality of care and referral system. The dependent variable was presence of maternal near miss or maternal death. Maternal death was defined as a death of woman while pregnant or within 42 days of termination of pregnancy. Maternal near miss was identified by the presence of any of the life-threatening complications listed in Table 1. Independent variables included socio-demographic characteristics (age, referral status, residence), obstetric conditions (parity, place of delivery, gravidity, antenatal care, mode of delivery), underlying medical complications, and infection. Data about the total number of deliveries was obtained from monthly hospital reports. In case of doubt and when additional information was required, attending clinicians were contacted for clarification. The overall data collection and quality of data was supervised by the first author (AKT) and two experienced researchers from the College of Health and Medical Sciences, Haramaya University. All completed questionnaires were checked for completeness and consistency before entry to the computer. Codes were used to identify each woman included in the study and no personal identifiers were included in the analysis or reporting. Access to collected data was restricted only to the research team and the questionnaire was kept in locked cabinet. a Acute cyanosis is blue or purple colouration of the skin or mucous membranes due to low oxygen saturation b Gasping is a terminal respiratory pattern, and the breath is convulsively and audibly caught. c Shock is persistent severe hypotension, defined as a systolic BP <90 mmHg for ≥60 min with a pulse rate at least 120 despite aggressive fluid replacement (>2l) d Oliguria is urinary output < 30 ml/h for 4 h or < 400 ml/24 h e Failure to form clots can be assessed by the bedside clotting test or absence of clotting from the IV site after 7–10 minutes f Loss of consciousness lasting >12h is a profound alteration of mental state that involves complete or near-complete lack of responsiveness to external stimuli. It is defined as a Glasgow Coma Scale <10 (moderate or severe coma) g Stroke is a neurological deficit of cerebrovascular cause that persists beyond 24 h or is interrupted by death within 24 h h Uncontrolled fits/total paralysis is refractory, persistent convulsions or status epilepticus i Pre-eclampsia is defined as the presence of hypertension associated with proteinuria. Hypertension is defined as a BP of at least 140/90 mmHg on at least two occasions and at least 4–6 h apart after the 20th week of gestation in women known to be normotensive beforehand. Proteinuria is defined as excretion of 300 mg or more of protein every 24 h. If 24-h urine samples are not available, proteinuria is defined as a protein concentration of 300 mg/l or more (≥1 on dipstick) in at least two random urine samples taken at least 4–6 h apart. j Eclampsia is diastolic BP ≥90 mmHg or proteinuria +3 and convulsion or coma k Uterine rupture is complete rupture of uterus during labour and/or confirmed later by laparotomy l Sepsis or severe systemic infection is defined as a clinical sign of infection and 3 of the following: temp >38 0C or <36°C, respiration rate >20/min, pulse rate >90/min, WBC >12,000 m Pulmonary edema is accumulation of fluids in the air spaces and parenchyma of the lungs n Severe abortion complications is defined as septic in incomplete abortion, complicated Gestational Trophoblastic Disease with anaemia o Severe malaria is defined as major signs of organ dysfunction and/or high-level parasitemia or cerebral malaria Data were entered using EpiData v3.1 (www.epidata.dk) and IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N.Y., USA) was used for analysis. Descriptive statistics of study participants and indicators of MNM were analyzed. Severe maternal outcome ratio, MNM ratio, mortality index and MNM to mortality ratio were calculated. Severe maternal outcome ratio is the total number of women with life-threatening complications (MNM and maternal deaths) per 1000 live births. Similarly, MNM ratio refers to the total number of MNM per 1000 live births. Mortality index is the ratio of maternal deaths to the total number of women with life-threatening complications [5]. A lower mortality index level indicates good quality of care. The study was approved by the Institutional Health Research Review Committee of the College of Health and Medical Sciences, Haramaya University, Ethiopia (Ref N: C/A/R/D/01/1681/16). Since data were collected from medical charts after discharge of the women and no patient interview was planned, the need for informed consent was waived. Permission was obtained from the respective officials in the regional health bureau and participating hospitals.