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

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).

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• namagembe, imelda
• nakimuli, annettee
• byamugisha, josephat
• moffett, ashley
• aiken, abigail
• aiken, catherine e.