Maternal near-miss surveillance, Namibia

Objective To analyse and improve the Namibian maternity care system by implementing maternal near-miss surveillance during 1 October 2018 and 31 March 2019, and identifying the challenges and benefits of such data collection. Methods From the results of an initial feasibility study, we adapted the World Health Organization’s criteria defining a maternal near miss to the Namibian health-care system. We visited most (27 out of 35) participating facilities before implementation and provided training on maternal near-miss identification and data collection. We visited all facilities at the end of the surveillance period to verify recorded data and to give staff the opportunity to provide feedback. Findings During the 6-month period, we recorded 37 106 live births, 298 maternal near misses (8.0 per 1000 live births) and 23 maternal deaths (62.0 per 100 000 live births). We observed that obstetric haemorrhage and hypertensive disorders were the most common causes of maternal near misses (each 92/298; 30.9%). Of the 49 maternal near misses due to pregnancies with abortive outcomes, ectopic pregnancy was the most common cause (36/298; 12.1%). Fetal or neonatal outcomes were poor; only 50.3% (157/312) of the infants born to maternal near-miss mothers went home with their mother. Conclusion Maternal near-miss surveillance is a useful intervention to identify within-country challenges, such as lack of access to caesarean section or hysterectomy. Knowledge of these challenges can be used by policy-makers and programme managers in the development of locally tailored targeted interventions to improve maternal outcome in their setting. All Namibian public hospitals, 1 tertiary, 4 regional and 30 district, participated in the surveillance of maternal near misses. The largest hospital complex, located in the capital of Windhoek and comprising the tertiary and a regional hospital, has around 12 000 births per annum. This hospital employs three consultant obstetrician-gynaecologists. The intensive care unit has advanced equipment including ventilators and dialysis. The other three regional hospitals (6500 births per year each) have high-dependency units with mechanical ventilation, and renal dialysis can be performed at two of these hospitals. District hospitals have two to eight general medical doctors who provide care across all specialities. District hospitals have basic haematology and chemistry laboratory tests available, such as blood count, renal function and basic liver function tests. Most district hospital blood banks only have access to 2 units of packed red cells. All hospitals are expected to have functioning operating theatres for basic surgical procedures, such as caesarean section or laparotomy for ruptured ectopic pregnancy. As a result of the limited availability of laboratory tests and management options resulting in the underreporting of maternal near-miss cases, other sub-Saharan African countries have indicated that the WHO maternal near-miss criteria may not be suitable for use in district hospitals in low-income settings.10,11 As 30 of the 35 Namibian hospitals are district hospitals, four of the authors of this study, together with several other clinicians working in Namibian public facilities, conducted a feasibility study in 2018 in four hospitals to compare WHO maternal near-miss criteria with a set of criteria proposed for low-income settings.12 This study was performed in the hospital complex in the capital and in a regional and two district hospitals. The authors of the feasibility study reported that the WHO criteria resulted in the underreporting of maternal near misses in Namibia; we therefore adapted the WHO maternal near-miss identification criteria to the Namibian health-care system (Box 1).13 Within management-based criteria, we adopted the lower threshold of 4 units of blood transfused and included laparotomy; we also included eclampsia and uterine rupture within the category of severe maternal complications. WHO: Acute cyanosis; gasping; respiratory rate > 40 or < 6/min; shock;a oliguria non-responsive to fluids or diuretics;b failure to form clots; loss of consciousness lasting > 12 hours (Glasgow coma scale < 10); cardiac arrest; stroke; uncontrollable fit/total paralysis; and jaundice in the presence of pre-eclampsia. Namibia: the same as WHO. WHO: Oxygen saturation < 90% for 60 minutes; Pao2/FiO2 < 200 mmHg; creatinine 300 μmol/L or 3.5 mg/dL; bilirubin > 100 mmol/L or > 6.0 mg/dL; pH < 7.1; lactate > 5 mq/mL; acute thrombocytopenia (< 50 000 platelets/mL); and loss of consciousness and ketoacids in urine. Namibia: the same as WHO. WHO: Use of continuous vasoactive drugs; hysterectomy following infection or haemorrhage; transfusion of 5 units of red blood cells; intubation and ventilation for 60 minutes not related to anaesthesia; dialysis for acute renal failure; cardio–pulmonary resuscitation. Namibia: As for WHO with the exception of transfusion of 4 units of blood products, and inclusion of laparotomy other than caesarean section or ectopic pregnancy of < 12 weeks gestation WHO: No criteria. Namibia: Eclampsia and uterine rupture.c FiO2: fraction of inspired oxygen; min: minute(s); Pao2: arterial oxygen partial pressure; WHO: World Health Organization. a Persistent systolic blood pressure of < 80 mmHg, or a persistent systolic blood pressure < 90 mmHg with a pulse rate of ≥ 120 bpm. b Urinary output < 30 mL/hour over 4 hours or < 400 mL per 24 hours. c Complete rupture of uterus during labour confirmed by laparotomy. FiO2: fraction of inspired oxygen; min: minute(s); Pao2: arterial oxygen partial pressure; WHO: World Health Organization. FiO2: fraction of inspired oxygen; min: minute(s); Pao2: arterial oxygen partial pressure; WHO: World Health Organization. a Persistent systolic blood pressure of < 80 mmHg, or a persistent systolic blood pressure < 90 mmHg with a pulse rate of ≥ 120 bpm. a Persistent systolic blood pressure of < 80 mmHg, or a persistent systolic blood pressure < 90 mmHg with a pulse rate of ≥ 120 bpm. b Urinary output < 30 mL/hour over 4 hours or < 400 mL per 24 hours. b Urinary output < 30 mL/hour over 4 hours or < 400 mL per 24 hours. c Complete rupture of uterus during labour confirmed by laparotomy. c Complete rupture of uterus during labour confirmed by laparotomy. Before national implementation of maternal near-miss surveillance, most participating facilities were visited; due to a lack of funding, eight smaller district hospitals could not be visited. Medical staff involved in the care of pregnant and/or postpartum women were trained in the identification of maternal near misses and relevant data collection. Staff at the eight hospitals that could not be visited received training when presenting at one of the referral hospitals (either a regional hospital or a larger, better-equipped district hospital) for other training courses. At all 35 hospitals, a maternal near-miss doctor and nurse were nominated to supervise data collection and provide the research team with verbal monthly updates during pre-arranged telephone calls. A case of a maternal near miss was defined as a woman either pregnant (independent of gestational age), or within 42 days of termination of pregnancy or birth, fulfilling at least one of the criteria listed in Box 1. Using a structured data collection tool (Maternal Near Miss Form, available in the data repository),14 nominated staff collected anonymous data from medical records on maternal sociodemographic characteristics, maternal outcome, the main underlying cause of the maternal near miss and the neonatal outcome. Stillbirths were defined as deaths before birth after 28 weeks of gestation, and documented as either fresh or macerated in the medical file. Neonatal death was defined as the death of an infant within the first 28 days of life. Since we aimed to assess maternal outcome, neonatal outcome was assessed upon discharge of the mother even if the infant was still being cared for in the intensive care unit. We identified possible missed cases in the Windhoek hospital complex during weekly ward visits or through personal communication with nominated medical staff. Although we had planned to visit all facilities 2 months after the onset of the surveillance, we had to cancel these visits because of a lack of resources. At the request of staff at two of the hospitals, we made an extra visit to provide additional training on data collection. After 6 months, we visited all hospitals to verify the recorded surveillance data against medical records. We screened the ward registers of maternity, female, high-dependency and intensive care units, theatre registers and referral registers for missed cases. During this visit, at least one member of the National Maternal Death Review Committee met with the local hospital staff, including the nominated doctor and nurse, the doctor and nurse in-charge, and all available doctors and nurses involved in the care of pregnant women. During these meetings, staff were given the opportunity to describe their experience with data collection and the challenges encountered related to clinical duties. We obtained the total number of live births in Namibia from the National Health Information Systems. We collected data on maternal deaths from the national reporting and audit system.15 Direct and indirect causes of maternal near misses were defined according to the International Statistical Classification of Diseases-Maternal Mortality definitions.16 We defined the number of severe maternal outcomes as the total of maternal near misses and maternal deaths. We calculated the incidence of the most common causes of, and other conditions contributing to, maternal near misses, namely major obstetric haemorrhage, eclampsia, uterine rupture and hysterectomy, per 1000 live births during the study period. We defined mortality index as the number of maternal deaths as a percentage of the number of severe maternal outcomes. As a result of poor documentation of blood loss, we diagnosed major obstetric haemorrhage as a woman with obstetric haemorrhage who either needed 4 units of blood; fulfilled the criteria of shock;17 had a laparotomy (to perform a B-lynch) or a hysterectomy; or had disseminated intravascular coagulopathy, requiring fresh frozen plasma. To diagnose eclampsia, uterine rupture and hysterectomy, we used definitions proposed by the International Network of Obstetric Survey Systems.18 Finally, because an outbreak of hepatitis E had been causing significant maternal mortality since December 2017, we also calculated the incidence and mortality index of severe maternal outcomes for women with acute hepatitis E with a bilirubin concentration of more than 100 mmol/L.19 We shared all findings with the executive management committee of the Ministry of Health and Social Services during a meeting in July 2019, attended by representatives of the departments of human resources, clinical support services and quality assurance division, responsible for training clinical staff. We addressed several issues and set priorities for the following year, namely: (i) the human resources department to focus on recruiting and retaining doctors and nurses with obstetric experience and/or essential surgical skills; and (ii) the clinical support services department to ensure functionality of operating theatres in district hospitals. We also discussed the possibility of launching a debate within parliament to legalize abortion, using data describing abortion-related complications. In the same month we also shared all findings with all participating facilities through video conferencing and during a 2-day national conference organized by the Ministry of Health and Social Services and the University of Namibia, funded by several Namibian companies, the WHO, United Nations Population Funds and the European Union. A doctor and nurse from each facility were invited to attend the conference, where we provided staff training and issued relevant guidelines according to the most common issues identified in the maternal near miss and death reviews. The guidelines were written by doctors working in maternity departments of the regional hospitals, and reviewed by members of the National Maternal Death Review Committee. Costs were kept as low as possible. When feasible, facility visits for maternal near-miss surveillance were combined with visits for other training courses. Most of the available budget was spent on travel and accommodation; the costs for two committee members to travel 9600 km to visit participating hospitals before and after completion of data collection were approximately 8000 United States dollars (US$). A further US$ 700 was spent on stationary, such as the printing of case reporting forms and guidelines. External advisors from outside Namibia were not remunerated. This study was reviewed and approved by the research unit of the Ministry of Health and Social Services. After stabilizing and treating the women, data were collected from medical records without identification of the patient; inclusion in the study had no effect on clinical management. The need for individual informed consent was therefore waived.