Maternal near miss and mortality in a rural referral hospital in northern Tanzania: A cross-sectional study

Background: Maternal morbidity and mortality in sub-Saharan Africa remains high despite global efforts to reduce it. In order to lower maternal morbidity and mortality in the immediate term, reduction of delay in the provision of quality obstetric care is of prime importance. The aim of this study is to assess the occurrence of severe maternal morbidity and mortality in a rural referral hospital in Tanzania as proposed by the WHO near miss approach and to assess implementation levels of key evidence-based interventions in women experiencing severe maternal morbidity and mortality.Methods: A prospective cross-sectional study was performed from November 2009 until November 2011 in a rural referral hospital in Tanzania. All maternal near misses and maternal deaths were included. As not all WHO near miss criteria were applicable, a modification was used to identify cases. Data were collected from medical records using a structured data abstraction form. Descriptive frequencies were calculated for demographic and clinical variables, outcome indicators, underlying causes, and process indicators.Results: In the two-year period there were 216 maternal near misses and 32 maternal deaths. The hospital-based maternal mortality ratio was 350 maternal deaths per 100,000 live births (95% CI 243-488). The maternal near miss incidence ratio was 23.6 per 1,000 live births, with an overall case fatality rate of 12.9%. Oxytocin for prevention of postpartum haemorrhage was used in 96 of 201 women and oxytocin for treatment of postpartum haemorrhage was used in 38 of 66 women. Furthermore, eclampsia was treated with magnesium sulphate in 87% of all cases. Seventy-four women underwent caesarean section, of which 25 women did not receive prophylactic antibiotics. Twenty-eight of 30 women who were admitted with sepsis received parenteral antibiotics. The majority of the cases with uterine rupture (62%) occurred in the hospital.Conclusion: Maternal morbidity and mortality remain challenging problems in a rural referral hospital in Tanzania. Key evidence-based interventions are not implemented in women with severe maternal morbidity and mortality. Progress can be made through up scaling the use of evidence-based interventions, such as the use of oxytocin for prevention and treatment of postpartum haemorrhage. © 2013 Nelissen et al.; licensee BioMed Central Ltd. This study is part of an intervention study. Data that were collected serve as baseline for an intervention with simulation-based training in routine delivery care, prevention and treatment of postpartum haemorrhage (PPH). This was a prospective cross-sectional study, conducted from November 2009 until November 2011 in Haydom Lutheran Hospital (HLH), a referral hospital in rural Northern Tanzania. HLH is a 400-bed hospital owned by the Mbulu Diocese of the Evangelical Lutheran Church in Tanzania. The hospital provides free reproductive and child health services, comprehensive emergency obstetric care, including ambulance and radio service. Furthermore there is an Intensive Care Unit (ICU) with 24-hours medical supervision and mechanical ventilation. Annually there are around 5000 deliveries. Extrapolating from the 2002 census, the immediate catchment area was covering a population of approximately 327,000 in 2010 [20]. The greater reference area covered a population of approximately 2,200,000 people [20]. The primary outcome measures were the total number of MD, MNM and live births (LB) in the hospital during the study period. Subsequently, outcome indicators were calculated such as the number of women with life-threatening conditions. As proposed by the WHO approach, overall near miss indicators were calculated such as the severe maternal outcome ratio, the maternal near miss incidence ratio, the maternal near-miss mortality ratio, and the case fatality rate. Hospital access indicators were calculated such as the number of women with life-threatening conditions at arrival, the proportion of these women among all women with life-threatening conditions, the proportion of these women coming from other hospitals, and the women with life-threatening conditions at arrival mortality index. Lastly, intra hospital care indicators were calculated: the number of maternal near misses and deaths who developed these conditions in the hospital and the intra hospital mortality index. Implementation levels of evidence-based interventions were measured, such as use of oxytocin for prevention and treatment of PPH, use of magnesium sulphate for treatment of eclampsia, use of prophylactic antibiotics during caesarean section, use of parenteral antibiotics for treatment of sepsis, and the proportion of women with uterine rupture that occurred in the hospital. All maternal deaths and maternal near misses that were admitted to HLH were prospectively included in the study during the above-mentioned period. A maternal death is defined as: the death of a woman while pregnant or within 42 days of termination of pregnancy from any cause. A maternal near miss is defined as: a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy [10]. The intention was to use the WHO near miss criteria for the identification of maternal near misses. However, not all WHO criteria were applicable, and the identification criteria were adapted to the local situation in HLH as is described elsewhere [21]. Table 1 shows an overview of the WHO near miss criteria and the Haydom modification. WHO near miss criteria adapted to the local context of HLH (reproduced from Nelissen et al.) Applicability of the WHO near miss criteria in a low resource setting. PLoS One 2013, 8:e61248. a: Shock is defined as a persistent severe hypotension, defined as a systolic blood pressure < 90 mmHg for 60 min with a pulse rate of ≥ 120/min despite aggressive fluid replacement (> 2 L). b: Oliguria is defined as an urinary output < 30 ml/hour for 4 hours or < 400 ml/24 hr. c: Failure to form clots is defined as the absence of clotting from the IV site after 7–10 minutes. d: Unconsciousness/coma lasting > 12 hours is defined as a profound alteration of mental state that involves complete or near-complete lack of responsiveness to external stimuli or Glasgow Coma Scale < 10. e: Cardiac arrest is defined as loss of consciousness and absence of pulse or heart beat. f: Stroke is defined as a neurological deficit of cerebrovascular cause that persists ≥ 24 hours, or is interrupted by death within 24 hours. g: Uncontrollable fit is a condition in which the brain is in state of continuous seizure. h: Pre-eclampsia: the presence of hypertension associated with proteinuria. Hypertension is defined as a blood pressure ≥ 140 mmHg (systolic) or ≥ 90 mmHg (diastolic). Proteinuria is defined as excretion of ≥ 300 mg protein/24 hr or 300 mg protein/litre urine or ≥ 1+ on a dipstick. i: Eclampsia is defined as the presence of hypertension associated with proteinuria and fits. Hypertension is defined as a blood pressure ≥ 140 mmHg (systolic) or ≥ 90 mmHg (diastolic). Proteinuria is defined as excretion of ≥ 300 mg protein/24 hr or 300 mg protein/litre urine or ≥ 1+ on a dipstick. j: Sepsis is defined as a clinical sign of infection and 3 of the following: temp > 38°C or < 36°C, respiration rate > 20/min, pulse rate > 90/min, WBC >12. k: Uterine rupture is defined as the complete rupture of a uterus (including peritoneum) with (partial) extrusion of the fetus during labour. Cases were identified on a daily basis by either the principal investigator (EN) or by one of the two trained research assistants (nurse-midwives). This was achieved through daily participation in the morning report and daily visits to the maternity ward, ICU and the internal medicine ward. When the inclusion criteria were met, a structured data abstraction form was filled out by the principal investigator or a research assistant. Data were obtained from the patient record. The facility medical staff was questioned in case of doubt or missing information. General information and obstetric details were collected. For the hospital access and intra hospital care indicators, the following information was registered: health status on arrival, maternal death within 24 hours, and referral status. For each case, one underlying cause was identified that started the cascade that led to maternal morbidity or mortality [22]. For example, a primipara was admitted with obstructed labour and had a caesarean section. After caesarean section she developed sepsis. The underlying cause that started the cascade that led to maternal morbidity or mortality was obstructed labour. This table shows one diagnosis per woman (mutually exclusive, totally inclusive). For the process indicators, information on preventive measures (measuring of vital signs, use of oxytocin or other uterotonics for prevention of PPH, use of prophylactic antibiotics during caesarean section) were registered, as well as the use of interventions (use of oxytocin or other uterotonics as treatment for PPH, IV-infusion, blood products, hysterectomy, magnesium sulphate or other anticonvulsant in case of eclampsia, parenteral therapeutic antibiotics, and laparotomy for uterine rupture). The completed data abstraction forms were checked by a second person on missing data or discrepancies. If needed, a copy of the hospital file was checked to validate the recordings. All MD cases were reviewed by a selection of the authors (EN, BEO, JVR and JS), as well as a random selection of the MNM cases and those cases, which were difficult to classify into an underlying cause. Observation bias was addressed by means of auditing all MD cases and a random sample of the MNM cases by four authors (EN, BEO, JVR, JS) until consensus was reached. All data were double entered and cross-checked in Epidata [23]. Data analysis consisted of frequencies of demographic and clinical variables and underlying causes. Demographic variables were cross-tabulated for maternal outcome at discharge, and compared using chi-square test for categorical variables and t-test for continuous variables. Outcome indicators were calculated using the total number of live births during the study period and the total number of MNM and MD in that same period. Descriptive frequencies were calculated for underlying causes and process indicators. All results are reported as number (n) and frequency (%). Analysis was performed using SPSS Statistics, version 20 (SPSS Inc. Chicago, Illinois). Ethical approval was obtained from the Tanzanian National Institute for Medical Research (NIMR) (reference NIMR/HQ/R.8a/Vol.IX/1247), the Tanzania Commission for Science and Technology (COSTECH) (reference 2012-56-NA-2011-201), and from the VU university medical center (VUmc), the Netherlands (reference 2011/389). Data were collected and extracted from patient records without identification of the subject. Data abstraction forms were filled in after discharge or death and therefore study inclusion did not have effect on the treatment. Considering these precautions, individually obtained informed consent was not required.