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Heitkamp A, Meulenbroek A, van Roosmalen J, Gebhardt S, Vollmer L, de Vries JI, Theron G, van den Akker T. Maternal mortality: near-miss events in middle-income countries, a systematic review. Bull World Health Organ 2021; 99:693-707F. [PMID: 34621087 PMCID: PMC8477432 DOI: 10.2471/blt.21.285945] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To describe the incidence and main causes of maternal near-miss events in middle-income countries using the World Health Organization's (WHO) maternal near-miss tool and to evaluate its applicability in these settings. METHODS We did a systematic review of studies on maternal near misses in middle-income countries published over 2009-2020. We extracted data on number of live births, number of maternal near misses, major causes of maternal near miss and most frequent organ dysfunction. We extracted, or calculated, the maternal near-miss ratio, maternal mortality ratio and mortality index. We also noted descriptions of researchers' experiences and modifications of the WHO tool for local use. FINDINGS We included 69 studies from 26 countries (12 lower-middle- and 14 upper-middle-income countries). Studies reported a total of 50 552 maternal near misses out of 10 450 482 live births. Median number of cases of maternal near miss per 1000 live births was 15.9 (interquartile range, IQR: 8.9-34.7) in lower-middle- and 7.8 (IQR: 5.0-9.6) in upper-middle-income countries, with considerable variation between and within countries. The most frequent causes of near miss were obstetric haemorrhage in 19/40 studies in lower-middle-income countries and hypertensive disorders in 15/29 studies in upper-middle-income countries. Around half the studies recommended adaptations to the laboratory and management criteria to avoid underestimation of cases of near miss, as well as clearer guidance to avoid different interpretations of the tool. CONCLUSION In several countries, adaptations of the WHO near-miss tool to the local context were suggested, possibly hampering international comparisons, but facilitating locally relevant audits to learn lessons.
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Affiliation(s)
- Anke Heitkamp
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Francie Van Zijl Avenue, Cape Town, 7505, South Africa
| | - Anne Meulenbroek
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Jos van Roosmalen
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Stefan Gebhardt
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Francie Van Zijl Avenue, Cape Town, 7505, South Africa
| | - Linda Vollmer
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Francie Van Zijl Avenue, Cape Town, 7505, South Africa
| | - Johanna I de Vries
- Department of Obstetrics and Gynaecology, Amsterdam UMC Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Gerhard Theron
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Francie Van Zijl Avenue, Cape Town, 7505, South Africa
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De Silva M, Panisi L, Lindquist A, Cluver C, Middleton A, Koete B, Vogel JP, Walker S, Tong S, Hastie R. Severe maternal morbidity in the Asia Pacific: a systematic review and meta-analysis. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2021; 14:100217. [PMID: 34528001 PMCID: PMC8358707 DOI: 10.1016/j.lanwpc.2021.100217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/27/2021] [Accepted: 06/29/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Monitoring rates of severe maternal morbidity (such as eclampsia and uterine rupture) is useful to assess the quality of obstetric care, particularly in low and lower-middle-income countries (LMICs). METHODS We undertook a systematic review characterising the proportion and causes of severe maternal morbidity in the Asia Pacific region. We searched Medline, Embase, Cochrane CENTRAL library and the World Health Organization Western Pacific Index database for studies in the Asia-Pacific reporting maternal morbidity/near miss using a predefined search strategy. We included cohort, case-control and cross-sectional studies published in English before September 2020. A meta-analysis was performed calculating the overall proportion of near miss events by sub-region, country, near miss definition, economic status, setting and cause using a random-effects model. FINDINGS We identified 26,232 articles, screened 24,306 and retrieved 454 full text articles. Of these, 197 studies spanning 27 countries were included. 13 countries in the region were not represented. There were 30,183,608 pregnancies and 100,011 near misses included. The total proportion of near miss events was 4•4 (95% CI 4•3-4•5) per 1000 total births. The greatest proportion of near misses were found in the Western Pacific region (around Papua New Guinea) at 11•8 per 1000 births (95% CI 6•6-17•1; I2 96.05%). Low-income countries displayed the greatest proportion of near misses (13•4, 95% CI 6•0-20•7), followed by lower-middle income countries (11•1; 95% CI 10•4 - 11•9). High-income countries had the lowest proportion (2•2, 95% CI 2•1-2•3). Postpartum haemorrhage was the most common near miss event (5•9, 95% CI 4•5-7•2), followed by eclampsia (2•7, 95% CI 2•4 - 2•9). INTERPRETATION There is a high burden of severe maternal morbidity in the Asia-Pacific. LMICs are disproportionately affected. Most of the common causes are preventable. This provides an opportunity to implement targeted interventions which could have major clinical impact.
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Affiliation(s)
- Manarangi De Silva
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia, 3084
- Mercy Perinatal, Mercy Hospital for Women, and Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital, Heidelberg, Australia, 3084
| | - Leeanne Panisi
- Department of Obstetrics and Gynaecology, National Referral Hospital, Honiara, Solomon Islands
| | - Anthea Lindquist
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia, 3084
- Mercy Perinatal, Mercy Hospital for Women, and Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital, Heidelberg, Australia, 3084
| | - Catherine Cluver
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia, 3084
- Mercy Perinatal, Mercy Hospital for Women, and Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital, Heidelberg, Australia, 3084
- Department of Obstetrics and Gynaecology, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Anna Middleton
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia, 3084
- Mercy Perinatal, Mercy Hospital for Women, and Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital, Heidelberg, Australia, 3084
| | - Benjamin Koete
- Department of Obstetrics and Gynaecology, National Referral Hospital, Honiara, Solomon Islands
| | - Joshua P. Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Susan Walker
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia, 3084
- Mercy Perinatal, Mercy Hospital for Women, and Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital, Heidelberg, Australia, 3084
| | - Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia, 3084
- Mercy Perinatal, Mercy Hospital for Women, and Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital, Heidelberg, Australia, 3084
| | - Roxanne Hastie
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia, 3084
- Mercy Perinatal, Mercy Hospital for Women, and Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital, Heidelberg, Australia, 3084
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Zakiyah N, van Asselt ADI, Setiawan D, Cao Q, Roijmans F, Postma MJ. Cost-Effectiveness of Scaling Up Modern Family Planning Interventions in Low- and Middle-Income Countries: An Economic Modeling Analysis in Indonesia and Uganda. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:65-76. [PMID: 30178267 DOI: 10.1007/s40258-018-0430-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The aim was to estimate the long-term cost-effectiveness of improved family planning interventions to reduce the unmet need in low- and middle-income countries, with Indonesia and Uganda as reference cases. METHODS The analysis was performed using a Markov decision analytic model, where current situation and several scenarios to reduce the unmet need were incorporated as the comparative strategies. Country-specific evidence was synthesized from the demographic and health survey and published studies. The model simulated the sexual and reproductive health experience of women in the reproductive age range over a time horizon of women's reproductive years, from the healthcare payer perspective. Modeled outcomes included clinical events, costs and incremental cost-effectiveness ratios (ICERs) expressed as cost per disability-adjusted life year (DALY) averted. Deterministic and probabilistic sensitivity analyses were conducted to assess the impact of parameter uncertainty on modeled outcomes. RESULTS In the hypothetical cohort of 100,000 women, scenarios to reduce the unmet need for family planning would result in savings within a range of US$230,600-US$895,100 and US$564,400-US$1,865,900 in Indonesia and Uganda, respectively. The interventions would avert an estimated 1859-3780 and 3705-12,230 DALYs in Indonesia and Uganda, respectively. The results of our analysis indicate that scaling up family planning dominates the current situation in all scenarios in both countries, with lower costs and fewer DALYs. These results were robust in sensitivity analyses. CONCLUSION Scaling up family planning interventions could improve women's health outcomes substantially and be cost-effective or even cost saving across a range of scenarios compared to the current situation.
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Affiliation(s)
- Neily Zakiyah
- Unit of PharmacoTherapy, Epidemiology and Economics (PTE2), Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands.
| | - A D I van Asselt
- Unit of PharmacoTherapy, Epidemiology and Economics (PTE2), Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands
- Unit of Patient Centered Health Technology Assessment, Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9700 RB, Groningen, The Netherlands
| | - D Setiawan
- Unit of PharmacoTherapy, Epidemiology and Economics (PTE2), Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - Q Cao
- Unit of PharmacoTherapy, Epidemiology and Economics (PTE2), Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - F Roijmans
- Unit Training, Consultancy and Projects, i + Solutions, 3447 GN, Woerden, The Netherlands
| | - M J Postma
- Unit of PharmacoTherapy, Epidemiology and Economics (PTE2), Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands
- Unit of Patient Centered Health Technology Assessment, Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9700 RB, Groningen, The Netherlands
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, 9713 GZ, Groningen, The Netherlands
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Akrawi VS, Al-Hadithi TS, Al-Tawil NG. Major Determinants of Maternal Near-Miss and Mortality at the Maternity Teaching Hospital, Erbil city, Iraq. Oman Med J 2017; 32:386-395. [PMID: 29026470 PMCID: PMC5632696 DOI: 10.5001/omj.2017.74] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/29/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To find out the major determinants of maternal near-miss (NM)and maternal deaths (MDs) in Erbil city, Iraq, by comparative analysis of maternal NMs and MDs. METHODS We conducted a hospital-based cross-sectional study in the Maternity Teaching Hospital in Erbil city from 1 June to 31 December 2013. All MDs and NMs that occurred in the hospital during the study period were included in the study. Systematic identification of all eligible women was done. This identification included a baseline assessment of the severe pregnancy-related complications using the World Health Organization NM criteria. RESULTS Severe preeclampsia and postpartum hemorrhage (PPH) constituted the highest proportions of complications in women with potentially life-threatening conditions (PLTCs) (30.5% and 30.0%, respectively). The highest mortality indexes were those for ruptured uterus (16.7) and severe complications of placenta previa (14.2). Factors that were significantly associated with MD (compared to NM) were hepatic dysfunction (p = 0.046), multiple/unspecified disorders (p = 0.003), arrival as an emergency condition by ambulance (p = 0.015), and history of previous cesarean section (p = 0.013). CONCLUSIONS Severe preeclampsia and PPH are the main complications that lead to PLTCs. Factors found to be associated with MDs are hepatic dysfunction, multiple/unspecified disorders, arrival as an emergency condition by ambulance, and history of a previous cesarean section.
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A systematic review of maternal near miss and mortality due to postpartum hemorrhage. Int J Gynaecol Obstet 2017; 137:1-7. [DOI: 10.1002/ijgo.12096] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/09/2016] [Accepted: 01/04/2017] [Indexed: 11/07/2022]
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Fottrell E, Högberg U, Ronsmans C, Osrin D, Azad K, Nair N, Meda N, Ganaba R, Goufodji S, Byass P, Filippi V. A probabilistic method to estimate the burden of maternal morbidity in resource-poor settings: preliminary development and evaluation. Emerg Themes Epidemiol 2014; 11:3. [PMID: 24620784 PMCID: PMC3975153 DOI: 10.1186/1742-7622-11-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 02/18/2014] [Indexed: 11/10/2022] Open
Abstract
Background Maternal morbidity is more common than maternal death, and population-based estimates of the burden of maternal morbidity could provide important indicators for monitoring trends, priority setting and evaluating the health impact of interventions. Methods based on lay reporting of obstetric events have been shown to lack specificity and there is a need for new approaches to measure the population burden of maternal morbidity. A computer-based probabilistic tool was developed to estimate the likelihood of maternal morbidity and its causes based on self-reported symptoms and pregnancy/delivery experiences. Development involved the use of training datasets of signs, symptoms and causes of morbidity from 1734 facility-based deliveries in Benin and Burkina Faso, as well as expert review. Preliminary evaluation of the method compared the burden of maternal morbidity and specific causes from the probabilistic tool with clinical classifications of 489 recently-delivered women from Benin, Bangladesh and India. Results Using training datasets, it was possible to create a probabilistic tool that handled uncertainty of women’s self reports of pregnancy and delivery experiences in a unique way to estimate population-level burdens of maternal morbidity and specific causes that compared well with clinical classifications of the same data. When applied to test datasets, the method overestimated the burden of morbidity compared with clinical review, although possible conceptual and methodological reasons for this were identified. Conclusion The probabilistic method shows promise and may offer opportunities for standardised measurement of maternal morbidity that allows for the uncertainty of women’s self-reported symptoms in retrospective interviews. However, important discrepancies with clinical classifications were observed and the method requires further development, refinement and evaluation in a range of settings.
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Affiliation(s)
- Edward Fottrell
- UCL Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, United Kingdom.
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Tunçalp Ö, Hindin MJ, Souza JP, Chou D, Say L. The prevalence of maternal near miss: a systematic review. BJOG 2012; 119:653-61. [DOI: 10.1111/j.1471-0528.2012.03294.x] [Citation(s) in RCA: 173] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Adler AJ, Filippi V, Thomas SL, Ronsmans C. Incidence of severe acute maternal morbidity associated with abortion: a systematic review. Trop Med Int Health 2011; 17:177-90. [DOI: 10.1111/j.1365-3156.2011.02896.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Haddad SM, Cecatti JG, Parpinelli MA, Souza JP, Costa ML, Sousa MH, Surita FG, Pinto E Silva JL, Pacagnella RC, Camargo RS, Bahamondes MV, Zotareli V, Gurgel LT, Say L, Pattinson RC. From planning to practice: building the national network for the Surveillance of Severe Maternal Morbidity. BMC Public Health 2011; 11:283. [PMID: 21549009 PMCID: PMC3101659 DOI: 10.1186/1471-2458-11-283] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 05/08/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving maternal health is one of the Millennium Development Goals for 2015. Recently some progress has been achieved in reducing mortality. On the other hand, in developed regions, maternal death is a relatively rare event compared to the number of cases of morbidity; hence studying maternal morbidity has become more relevant. Electronic surveillance systems may improve research by facilitating complete data reporting and reducing the time required for data collection and analysis. Therefore the purpose of this study was to describe the methods used in elaborating and implementing the National Network for the Surveillance of Severe Maternal Morbidity in Brazil. METHODS The project consisted of a multicenter, cross-sectional study for the surveillance of severe maternal morbidity including near-miss, in Brazil. RESULTS Following the development of a conceptual framework, centers were selected for inclusion in the network, consensus meetings were held among the centers, an electronic data collection system was identified, specific software and hardware tools were developed, research material was prepared, and the implementation process was initiated and analyzed. CONCLUSION The conceptual framework developed for this network was based on the experience acquired in various studies carried out in the area over recent years and encompasses maternal and perinatal health. It is innovative especially in the context of a developing country. The implementation of the project represents the first step towards this planned management. The system online elaborated for this surveillance network may be used in further studies in reproductive and perinatal health.
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Affiliation(s)
- Samira M Haddad
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.
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‘MAYBE IT WAS HER FATE AND MAYBE SHE RAN OUT OF BLOOD’: FINAL CAREGIVERS' PERSPECTIVES ON ACCESS TO CARE IN OBSTETRIC EMERGENCIES IN RURAL INDONESIA. J Biosoc Sci 2009; 42:213-41. [DOI: 10.1017/s0021932009990496] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
SummaryMaternal mortality persists in low-income settings despite preventability with skilled birth attendance and emergency obstetric care. Poor access limits the effectiveness of life-saving interventions and is typical of maternal health care in low-income settings. This paper examines access to care in obstetric emergencies from the perspectives of service users, using established and contemporary theoretical frameworks of access and a routine health surveillance method. The implications for health planning are also considered. The final caregivers of 104 women who died during pregnancy or childbirth were interviewed in two rural districts in Indonesia using an adapted verbal autopsy. Qualitative analysis revealed social and economic barriers to access and barriers that arose from the health system itself. Health insurance for the poor was highly problematic. For providers, incomplete reimbursements, and low public pay, acted as disincentives to treat the poor. For users, the schemes were poorly socialized and understood, complicated to use and led to lower quality care. Services, staff, transport, equipment and supplies were also generally unavailable or unaffordable. The multiple barriers to access conferred a cumulative disadvantage that culminated in exclusion. This was reflected in expressions of powerlessness and fatalism regarding the deaths. The analysis suggests that conceiving of access as a structurally determined, complex and dynamic process, and as a reciprocally maintained phenomenon of disadvantaged groups, may provide useful explanatory concepts for health planning. Health planning from this perspective may help to avoid perpetuating exclusion on social and economic grounds, by health systems and services, and help foster a sense of control at the micro-level, among peoples' feelings and behaviours regarding their health. Verbal autopsy surveys provide an opportunity to routinely collect
information on the exclusory mechanisms of health systems, important information for equitable health planning.
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Ronsmans C. Severe acute maternal morbidity in low-income countries. Best Pract Res Clin Obstet Gynaecol 2009; 23:305-16. [PMID: 19201657 DOI: 10.1016/j.bpobgyn.2009.01.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 01/05/2009] [Indexed: 10/21/2022]
Abstract
Although obstetric complications are sometimes presented as a relatively easy alternative to maternal deaths, difficulties remain in their definition and identification, and there is limited experience with the use of severe obstetric complications as a starting point for audits or case reviews or as an indicator for monitoring the success of safe motherhood programmes in low-income countries. In this paper we review published studies reporting on the measurement of severe acute maternal morbidity in low-income countries. We found 37 studies from 24 countries. We describe the definition and ascertainment of cases of severe acute maternal morbidity and we give examples of how information on severe acute maternal morbidity has been used to inform safe motherhood programmes in low-income countries.
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Affiliation(s)
- Carine Ronsmans
- Infectious Disease Epidemiology Unit, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, UK.
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