Maternal near-miss and mortality associated with hypertensive disorders of pregnancy remote from term: a multicenter observational study in Ghana

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

Interpretação

BACKGROUND: Maternal death rates remain high in many low- and middle-income countries. Hypertensive disorders of pregnancy account for 18% of maternal mortality in Ghana. The maternal near-miss approach was designed to evaluate severe (acute) complications in pregnancy, which is useful to detect potential areas for clinical care improvement. OBJECTIVE: This study aimed (1) to determine the incidence of severe maternal complications, maternal near-miss cases, and mortality cases associated with hypertensive disorders of pregnancy remote from term and (2) to assess the health system’s performance indicators for the management of hypertensive disorders of pregnancy remote from term in middle-income country referral hospitals. STUDY DESIGN: This study was nested in the ongoing Severe Preeclampsia adverse Outcome Triage study, a multicenter observational cohort study, and included women recruited from December 1, 2017, to May 31, 2020, from 5 referral hospitals in Ghana. Women aged >16 years, admitted to the hospital with hypertensive disorders of pregnancy, with gestational age between 26 and 34 weeks were eligible. Near miss was defined according to the World Health Organization and sub-Saharan African near-miss criteria. Descriptive statistics of pregnancy and maternal and perinatal outcomes up to 6 weeks after delivery of women with severe maternal outcomes were presented for maternal deaths and maternal near-miss casigurees and compared with that of women without severe maternal outcomes. The health system’s maternal and perinatal performance indicators were calculated. RESULTS: Overall, 447 women with hypertensive disorders of pregnancy were included in the analyses with a mean maternal age of 32 (±5.8) years and mean gestational age at recruitment of 30.5 (±2.4) weeks. Of these patients, 46 (10%) had gestational hypertension, 338 (76%) had preeclampsia, and 63 (14%) had eclampsia. There were 148 near-miss cases (33.1%) and 12 maternal deaths (2.7%). Severe maternal outcomes constituted complications from severe preeclampsia (80/160 [50%]) and eclampsia (63/160 [39.4%]). Concerning organ dysfunction, hematologic and respiratory dysfunctions constituted 59/160 [38.6%] and 23/160 [14.8%] respectively. Nearly all women had a cesarean delivery (347/447 [84%] and 140/160 [93%] in the severe maternal outcome group) and delivered prematurely (83%, with 178/379 [93%] at <32 weeks of gestation). Stillbirth and neonatal deaths occurred in 63 of 455 women (14%) and 81 of 392 women (19%), respectively, constituting a stillbirth ratio of 161 per 1000 live births and neonatal mortality rate of 207 per 1000 live births as there were 392 live births in this cohort. Overall, the intensive care unit admission rate was 12.7% (n=52/409); moreover, 45 of 52 women (86.5%) admitted to the intensive care unit had severe maternal outcomes. The maternal death ratio was 3100 per 100,000 live births, the maternal near-miss–to–mortality ratio was 12.3, and the mortality index was 8%. CONCLUSION: Maternal near miss and maternal and perinatal mortalities were common in women with hypertensive disorders of pregnancy remote from term in referral hospitals in Ghana. Providing appropriate patient-centered and multidisciplinary quality care for these women is crucial in improving pregnancy outcomes. Context-tailored interventions should be considered in the clinical management of complications associated with hypertensive disorders of pregnancy in resource-limited settings. Further research on interventions to improve timely referral and reduce in-hospital delays in care provision is recommended to facilitate emergency care services for women with hypertensive emergencies. This analysis was nested within the ongoing Severe Preeclampsia adverse Outcome Triage (SPOT) study, a multicenter observational prospective cohort study in Ghana, which aims to validate previously developed risk prediction models for the management of women with preeclampsia and other HDP.18,19 Of note, 4 major referral hospitals in the Greater Accra Region (Greater Accra Regional Hospital [Ridge Hospital], Korle-Bu Teaching Hospital, La General Hospital, and Tema General Hospital) and 1 hospital in the Eastern Region of Ghana (Koforidua Regional Hospital) were selected on the basis of their large patient volume and infrastructure to conduct this study. The total number of deliveries in these facilities exceeds 30,000 annually, and all hospitals have neonatal intensive care units (NICUs). Moreover, HDP are a leading cause of maternal morbidities in these facilities and account for 18% of all maternal mortalities in the country.7 Women aged ≥16 years with a diagnosis of preeclampsia or another HDP (definitions are provided in Supplementary A) at a gestational age between 26 and 34 weeks admitted to any 1 of the participating facilities were eligible for participation in the SPOT study. The exclusion criteria were spontaneous active labor at admission and occurrence of any of the adverse maternal outcomes before meeting the inclusion criteria or collecting the independent variables. In this analysis, all women who were recruited between December 1, 2017, and May 31, 2020, were included. Women who died during admission or within the follow-up period of 6 weeks because of pregnancy-related complications were classified as maternal deaths (MDs). In all surviving women, those who met the WHO or sub-Saharan African (SSA) MNM criteria were considered MNM. Supplementary B provides an overview of the criteria. This approach was chosen because of the appropriateness of SSA in this context.20 The fulfillment of at least 1 criterion was enough to consider a woman as MNM.9,17 The SSA criterion on severe complications of abortion was not applicable as only pregnant women with a gestational age >26 weeks were considered eligible. Several other criteria were not included because of (1) limited access to laboratory tests (ie, pH or lactate), (2) nonrecording of observations that were not commonly documented in medical files (ie, acute cyanosis, gasping, or jaundice), and (3) other data that were not included in the case report forms of the SPOT study (ie, respiratory rates, urine production, loss of consciousness, cardiopulmonary resuscitation, or severe malaria). Definitions of clinical conditions and diseases that were included as maternal outcomes (eg, severe postpartum hemorrhage and severe preeclampsia) followed WHO MNM guideline definitions (Supplementary A).9 Intensive care unit (ICU) was defined as a ward where mechanical ventilation and administration of continuous vasoactive drugs were possible. This included an extended stay at the postoperative recovery room >6 hours, considering the limited availability of actual ICU departments.21 Body mass index was calculated on the basis of height in meters and weight in kilogram at first booking in antenatal care (ANC). All MNM cases and MDs conjointly were categorized as “severe maternal outcomes” (SMOs). Women who did not experience MD or near miss were considered as the comparison group. Data on near-miss cases, MDs, SMO cases, stillbirths, and neonatal mortality cases were presented as ratio per 1000 live births. The MNM mortality ratio (=MNM cases/MDs), mortality index (=MDs/SMO cases × 100%), and ICU admission rate (which is equal to the number of women admitted to the ICU/all included women) in total and among SMO cases were calculated to assess complexity and performance of care. All ratios are listed in Supplementary A.9 Trained research assistants prospectively collected data from medical records supplemented by face-to-face interview of the women to complete the information that were not initially obtained from the medical records, using standardized data collection forms designed for the SPOT study. Information regarding sociodemographic characteristics (eg, ethnicity, religion, marital status, and the highest level of education), medical history, obstetrical history (especially previous pregnancy complications), and information regarding current pregnancy and ANC services provided were recorded within 24 hours after admission. Symptoms and clinical signs of organ dysfunction were documented at the time of admission and daily during hospitalization. When delivery occurred during admission, circumstances of delivery, required interventions and maternal and neonatal outcomes were recorded. In case of discharge before delivery or data collection completion, information regarding pregnancy outcomes was collected at follow-up. Data of any readmissions before the end of pregnancy were added to the study file. Late maternal complications and neonatal outcomes were obtained at follow-up, during a routine visit, 6 weeks after delivery. All available data at the time of analysis were considered for this study. Baseline characteristics and maternal and pregnancy outcomes for all women with HDP were presented using descriptive statistics for women without SMOs, women with SMOs, near-miss cases, and MDs. Categorical variables were presented as frequency (percentage), whereas continuous variables were presented as mean (standard deviation) and transformed into categorical groups when necessary. P values were calculated using the chi-square, Fisher exact, or unpaired 2-samples Wilcoxon test. Outcomes among the 5 study sites were compared using stratified analyses. Missing values and inconsistent data were cross-checked, source documents consulted, and missing data were excluded in the analyses. All analyses were executed using R statistics (version 4.0.2; R Foundation for Statistical Computing, Vienna, Austria). The SPOT study protocol was approved by the Ghana Health Service Ethical Review Committee (protocol ID GHSERC-GHSERC015/09/17) and the Ethical and Protocol Review Committee of the College of Health Sciences, University of Ghana (protocol ID GHSERC-CHS-EtM.4-P1.2/2017-2018). All participants gave their written informed consent.

AI Digest

Study Justification:

– Maternal death rates are high in low- and middle-income countries.
– Hypertensive disorders of pregnancy account for 18% of maternal mortality in Ghana.
– The study aims to evaluate severe complications in pregnancy and identify areas for clinical care improvement.
– The study focuses on the management of hypertensive disorders of pregnancy remote from term in middle-income country referral hospitals.

Study Highlights:

– The study included 447 women with hypertensive disorders of pregnancy.
– The mean maternal age was 32 years and the mean gestational age at recruitment was 30.5 weeks.
– 148 near-miss cases (33.1%) and 12 maternal deaths (2.7%) were identified.
– Severe maternal outcomes were primarily due to severe preeclampsia and eclampsia.
– Hematologic and respiratory dysfunctions were the most common organ dysfunctions.
– Cesarean delivery and premature delivery were common among women with severe maternal outcomes.
– Stillbirth and neonatal deaths occurred in 14% and 19% of cases, respectively.
– The intensive care unit admission rate was 12.7%.
– The maternal death ratio was 3100 per 100,000 live births, the maternal near-miss-to-mortality ratio was 12.3, and the mortality index was 8%.

Recommendations for Lay Reader and Policy Maker:

– Providing appropriate patient-centered and multidisciplinary quality care for women with hypertensive disorders of pregnancy is crucial in improving pregnancy outcomes.
– Context-tailored interventions should be considered in the clinical management of complications associated with hypertensive disorders of pregnancy in resource-limited settings.
– Further research is recommended to improve timely referral and reduce in-hospital delays in care provision for women with hypertensive emergencies.

Key Role Players:

– Healthcare providers (doctors, nurses, midwives) for patient care and management.
– Hospital administrators for resource allocation and infrastructure improvement.
– Policy makers and government officials for policy development and implementation.
– Researchers and academics for further research and evidence-based interventions.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers.
– Infrastructure improvement in referral hospitals.
– Equipment and supplies for patient care.
– Implementation of context-tailored interventions.
– Research funding for further studies and interventions.
– Monitoring and evaluation of the implemented recommendations.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a multicenter observational study in Ghana, which provides valuable data on the incidence of severe maternal complications and mortality associated with hypertensive disorders of pregnancy. The study design and inclusion criteria are clearly described. However, the abstract lacks specific details on the methodology, sample size, and statistical analysis. To improve the strength of the evidence, the abstract could include more information on the study population, data collection methods, and statistical tests used. Additionally, providing information on the limitations of the study would enhance the overall quality of the evidence.

Resumo

Materiais

https://efashare.b-cdn.net/materials/9f176183bf04218c9002c9605373ab76b70342e7284861c41730fa479ec44769/mmc1.docx

Inovações

Based on the provided information, here are some potential innovations that could be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can improve access to maternal health by allowing pregnant women in remote areas to consult with healthcare providers through video calls or phone calls. This can help in early detection and management of hypertensive disorders of pregnancy.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information and reminders about prenatal care, nutrition, and warning signs of complications can empower pregnant women to take better care of their health. These apps can also facilitate communication between pregnant women and healthcare providers.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in underserved areas can improve access to maternal health services. These workers can also identify high-risk pregnancies and refer women to appropriate healthcare facilities.

4. Transportation solutions: Improving transportation infrastructure and providing transportation services specifically for pregnant women can help overcome geographical barriers and ensure timely access to healthcare facilities for prenatal care and emergency obstetric services.

5. Task-shifting: Training and empowering non-specialist healthcare providers, such as nurses and midwives, to provide comprehensive prenatal care and manage hypertensive disorders of pregnancy can help alleviate the shortage of obstetricians and improve access to maternal health services.

6. Health information systems: Implementing electronic health records and data management systems can improve the collection, analysis, and sharing of maternal health data. This can help identify gaps in care, monitor outcomes, and inform evidence-based interventions to improve access to maternal health services.

7. Public-private partnerships: Collaborating with private healthcare providers and organizations can help expand the availability and accessibility of maternal health services. This can include partnerships for the establishment of maternity clinics, mobile clinics, or telemedicine services in underserved areas.

It is important to note that the specific context and needs of the target population should be considered when implementing these innovations to ensure their effectiveness and sustainability.

AI Innovations Description

Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Implement context-tailored interventions: Develop and implement interventions specifically tailored to the clinical management of complications associated with hypertensive disorders of pregnancy in resource-limited settings like Ghana. These interventions should take into account the unique challenges and limitations of the healthcare system in these settings.

2. Improve timely referral: Focus on improving the timely referral of women with hypertensive emergencies to appropriate healthcare facilities. This can be achieved through the establishment of clear referral pathways, training healthcare providers on recognizing and managing hypertensive emergencies, and strengthening communication and coordination between primary healthcare centers and referral hospitals.

3. Reduce in-hospital delays in care provision: Identify and address factors contributing to delays in the provision of care within healthcare facilities. This may involve improving the availability of essential resources and equipment, ensuring an adequate number of skilled healthcare providers, and implementing protocols and guidelines for the management of hypertensive disorders of pregnancy.

4. Enhance patient-centered and multidisciplinary care: Provide comprehensive and multidisciplinary care for women with hypertensive disorders of pregnancy. This includes ensuring access to obstetricians, midwives, anesthesiologists, and other relevant healthcare professionals, as well as promoting patient-centered care that takes into account the individual needs and preferences of each woman.

5. Conduct further research: Conduct further research to evaluate the effectiveness of interventions aimed at improving access to maternal health in resource-limited settings. This research should focus on interventions that address the specific challenges identified in the study, such as timely referral and in-hospital delays in care provision.

By implementing these recommendations, it is expected that access to maternal health will be improved, leading to better outcomes for women with hypertensive disorders of pregnancy in Ghana and similar settings.

AI Innovations Methodology

To improve access to maternal health, here are some potential recommendations:

1. Strengthening Antenatal Care (ANC) Services: Enhance the quality and availability of ANC services by ensuring regular check-ups, providing comprehensive health education, and promoting early detection and management of hypertensive disorders of pregnancy.

2. Task-Shifting and Training: Train and empower midwives and other healthcare providers to identify and manage hypertensive disorders of pregnancy. This can help alleviate the burden on obstetricians and increase access to timely and appropriate care.

3. Telemedicine and Mobile Health (mHealth) Solutions: Utilize telemedicine and mHealth technologies to provide remote consultations, monitoring, and support for women with hypertensive disorders of pregnancy. This can improve access to specialized care, especially in remote or underserved areas.

4. Community-Based Interventions: Implement community-based programs that focus on health promotion, education, and early detection of hypertensive disorders of pregnancy. This can involve community health workers, outreach programs, and partnerships with local organizations to reach pregnant women in their own communities.

5. Strengthening Referral Systems: Improve the efficiency and effectiveness of referral systems to ensure timely access to higher-level facilities for women with severe complications. This can involve establishing clear protocols, improving communication between healthcare facilities, and providing transportation support when needed.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as the number of women receiving ANC services, the proportion of women with hypertensive disorders of pregnancy detected early, the percentage of women referred to higher-level facilities, and the timeliness of receiving appropriate care.

2. Collect baseline data: Gather data on the current status of access to maternal health services, including the number of women accessing ANC, the prevalence of hypertensive disorders of pregnancy, the referral patterns, and the time taken to receive care.

3. Develop a simulation model: Create a simulation model that incorporates the potential recommendations mentioned above. This model should consider factors such as population demographics, healthcare infrastructure, resource availability, and the implementation timeline for each recommendation.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the impact of each recommendation on the identified indicators. This can involve adjusting parameters such as the coverage of ANC services, the training capacity for healthcare providers, the availability of telemedicine services, and the effectiveness of community-based interventions.

5. Analyze results: Analyze the simulation results to determine the potential impact of each recommendation on improving access to maternal health. This can include assessing changes in the indicators, identifying bottlenecks or challenges, and evaluating the cost-effectiveness of each recommendation.

6. Refine and validate the model: Refine the simulation model based on the analysis and feedback from stakeholders. Validate the model by comparing the simulated results with real-world data or conducting pilot studies to assess the feasibility and effectiveness of implementing the recommendations.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different innovations and interventions on improving access to maternal health. This can inform decision-making and resource allocation to prioritize the most effective strategies.

Autores & Coautores

Statistics:

Authors: 6

Identifiers:

DOI: 10.1016/j.xagr.2021.100045

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ghana

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory, Quasi Experimental Study

Study Approach:

Quantitative

Participants Gender:

Female

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