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Ferreira MES, Coutinho RZ, Queiroz BL. [Maternal morbidity and mortality in Brazil and the urgency of a national surveillance system for maternal near miss]. CAD SAUDE PUBLICA 2023; 39:e00013923. [PMID: 37556612 PMCID: PMC10494698 DOI: 10.1590/0102-311xpt013923] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/07/2023] [Accepted: 05/11/2023] [Indexed: 08/11/2023] Open
Abstract
The World Health Organization (WHO) recommends the analysis of severe maternal morbidity/maternal near miss cases as complementary to the analysis of maternal deaths since the incidence is higher and the predictive factors of the two outcomes are similar. Considering that the reasons for maternal mortality in Brazil have remained constant despite the commitment made during the General Assembly of the United Nations in 2015, this article aims to propose a nationwide maternal near miss surveillance system. We propose the inclusion of maternal near miss events in the National List of Compulsory Notification of Diseases, Injuries, and Public Health Events, via the compatibility of the diagnostic criteria of maternal near miss, informed by the WHO, with the codes of the International Classification of Diseases for the identification of cases. Considering that health surveillance is based on several sources of information, notification could be made by health service professionals as soon as a confirmed or suspected case is identified. With the study of the factors associated with the outcomes, we expect a qualified evaluation of the services focused on obstetric care and consequent implementation of more efficient policies to prevent not only maternal death but also events that can both cause irreversible sequelae to women's health and increase the risk of fetal and neonatal death.
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Economic Impact Analysis of Incorporation of Elecsys sFlt-1/PlGF Ratio Into Routine Practice for the Diagnosis and Follow-Up of Pregnant Women With Suspected Preeclampsia in Argentina. Value Health Reg Issues 2023; 34:1-8. [PMID: 36335800 DOI: 10.1016/j.vhri.2022.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/01/2022] [Accepted: 09/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Preeclampsia (PE) is a hypertensive disorder of pregnancy that can cause severe complications and adverse fetal/maternal outcomes. We aimed to estimate the annual economic impact of incorporating Elecsys® sFlt-1/PlGF PE ratio, which measures soluble fms-like tyrosine kinase-1 and placental growth factor, into routine clinical practice in Argentina to aid diagnosis of PE and hemolysis, elevated liver enzymes, and low platelets syndrome from second trimester onward in pregnancies with clinical suspicion of PE. METHODS A decision tree was used to estimate annual economic impact on the Argentine health system as a whole, including relevant costs associated with diagnosis, follow-up, and treatment from initial presentation of clinically suspected PE to delivery. Annual costs of a standard-of-care scenario and a scenario including PE ratio (reference year 2021) were analyzed. RESULTS The economic model estimated that using the sFlt-1/PlGF ratio would enable the overall health system to save ∼$6987 million Argentine pesos annually (95% confidence interval $12 045-$2952 million), a 39.1% reduction in costs versus standard of care, mainly due to reduced hospitalizations of women with suspected PE. The economic impact calculation estimated net annual savings of approximately $80 504 Argentine pesos per patient with suspected PE. Based on the assumed uncertainty of the parameters, the likelihood the intervention would be cost saving was 100% for the considered scenarios. CONCLUSION Our analysis suggests that the implementation of the sFlt-1/PlGF ratio in women with suspected PE in Argentina will enable the health system to achieve significant savings, contributing to more efficient clinical management through the likely reduction of unnecessary hospitalizations, depending on assumptions. Results rest on the payers' ability to recover savings generated by the intervention.
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Leitao S, Manning E, Greene RA, Corcoran P. Maternal morbidity and mortality: an iceberg phenomenon. BJOG 2021; 129:402-411. [PMID: 34455672 DOI: 10.1111/1471-0528.16880] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To apply the iceberg model, quantifying absolute and relative incidence, to the four main causes of maternal morbidity and mortality in Ireland: haemorrhage, hypertension, sepsis and thrombosis. DESIGN Secondary analysis of national data on maternal morbidity and mortality. SETTING Republic of Ireland. POPULATION OR SAMPLE Approximately 715 000 maternities, 1 200 000 maternal hospitalisations, 2138 cases of severe maternal morbidity (SMM) and 54 maternal deaths. METHODS Incidence rates and case-fatality ratios were calculated. MAIN OUTCOME MEASURES Maternal death, SMM and hospitalisation. RESULTS At the 'tip of the iceberg', the incidence of maternal death per 10 000 maternities was 0.09 (95% CI 0.03-0.20) due to thrombosis and 0.03 (95% CI 0-0.11) due to haemorrhage, hypertension disorders or sepsis. For one death due to thrombosis there were 35 cases of pulmonary embolism and 257 thrombosis hospitalisations. For one death due to eclampsia, there were 58 eclampsia cases, 13 040 hospitalisations with pre-existing hypertension and 40 781 hospitalisations with gestational hypertension. For one death due to pregnancy-related sepsis, there were 92 cases of septicaemic shock and 9005 hospitalisations with obstetric sepsis. For one maternal death due to haemorrhage, there were 1029 cases of major obstetric haemorrhage and 53 715 maternal hospitalisations with haemorrhage. For every 100 maternities, there were approximately 16 hospitalisations associated with haemorrhage, 12 associated with hypertension disorders, three with sepsis and 0.2 with thrombosis. CONCLUSIONS Haemorrhage and hypertension disorders are leading causes of maternal morbidity in Ireland but they have very low case fatality. This indicates that these morbidities are managed effectively but their prevention requires more focus. TWEETABLE ABSTRACT Study shows that haemorrhage and hypertension are main causes of #maternalmorbidity in Ireland. Timely interventions for #maternalhealth and focus on prevention of severe and non-severe morbidities are needed. @NPEC #maternityservices #clinicalaudit #qualityimprovement.
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Affiliation(s)
- S Leitao
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | - E Manning
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | - R A Greene
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | - P Corcoran
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
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Spencer NM, Gabra M, Bedell SM, Scott DM, Rauk P. Improving compliance with guidelines for hypertensive disorders of pregnancy through an electronic health record alert: A retrospective chart review. Pregnancy Hypertens 2021; 25:1-6. [PMID: 34004478 DOI: 10.1016/j.preghy.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 03/28/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Improve appropriate and timely administration of rapid acting antihypertensive medication for the management of hypertensive emergency in pregnancy with utilization of an automated electronic health record (EHR) alert in an academic birthplace. STUDY DESIGN An automated alert was incorporated into an existing EHR that notified providers of a documented severe range blood pressure, defined as systolic blood pressure (SBP) ≥ 160 mmHg or diastolic blood pressure (DBP) ≥ 110 mmHg. Retrospective chart review was utilized to evaluate appropriate intervention before and after implementation of the alert (referred to as pre-implementation and post-implementation cohorts). MAIN OUTCOME MEASURES The primary outcome was appropriate administration of rapid-acting antihypertensive medication for the management of hypertensive emergency. Secondary outcomes included: appropriate administration of intravenous (IV) magnesium sulfate for seizure prophylaxis, initiation of oral antihypertensive medication postpartum, and appropriate timing of follow up for blood pressure evaluation following discharge. RESULTS Of 98 patients identified as having hypertensive emergency in the pre-implementation cohort, 34 (35%) received treatment with a rapid acting antihypertensive medication within one hour compared with 54 of 104 (55%) of patients in the post-implementation cohort (35% vs 55%, RR 1.40 95% CI 1.07-1.82). Significantly more patients followed up for a blood pressure check within one week of discharge (41% vs 31%; p = 0.02). There was not a significant effect on the administration of IV magnesium sulfate or initiation of oral medications postpartum. CONCLUSION An automated EHR alert improved timely administration of rapid-acting antihypertensive medications for hypertensive emergency and has the potential to improve compliance with national preeclampsia guidelines.
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Affiliation(s)
- Nicole M Spencer
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
| | - Martina Gabra
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Sabrina M Bedell
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Dana M Scott
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Phillip Rauk
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, 420 Delaware Street SE, Minneapolis, MN 55455, USA
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Dzakpasu S, Deb‐Rinker P, Arbour L, Darling EK, Kramer MS, Liu S, Luo W, Murphy PA, Nelson C, Ray JG, Scott H, VandenHof M, Joseph KS. Severe maternal morbidity surveillance: Monitoring pregnant women at high risk for prolonged hospitalisation and death. Paediatr Perinat Epidemiol 2020; 34:427-439. [PMID: 31407359 PMCID: PMC7383693 DOI: 10.1111/ppe.12574] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 06/26/2019] [Accepted: 06/30/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is no international consensus on the definition and components of severe maternal morbidity (SMM). OBJECTIVES To propose a comprehensive definition of SMM, to create an empirically justified list of SMM types and subtypes, and to use this to examine SMM in Canada. METHODS Severe maternal morbidity was defined as a set of heterogeneous maternal conditions known to be associated with severe illness and with prolonged hospitalisation or high case fatality. Candidate SMM types/subtypes were evaluated using information on all hospital deliveries in Canada (excluding Quebec), 2006-2015. SMM rates for 2012-2016 were quantified as a composite and as SMM types/subtypes. Rate ratios and population attributable fractions (PAF) associated with overall and specific SMM types/subtypes were estimated in relation to length of hospital stay (LOS > 7 days) and case fatality. RESULTS There were 22 799 cases of SMM subtypes (among 1 418 545 deliveries) that were associated with a prolonged LOS or high case fatality. Between 2012 and 2016, the composite SMM rate was 16.1 (95% confidence interval [CI] 15.9, 16.3) per 1000 deliveries. Severe pre-eclampsia and HELLP syndrome (514.6 per 100 000 deliveries), and severe postpartum haemorrhage (433.2 per 100 000 deliveries) were the most common SMM types, while case fatality rates among SMM subtypes were highest among women who had cardiac arrest and resuscitation (241.1 per 1000), hepatic failure (147.1 per 1000), dialysis (67.6 per 1000), and cerebrovascular accident/stroke (51.0 per 1000). The PAF for prolonged hospital stay related to SMM was 17.8% (95% CI 17.3, 18.3), while the PAF for maternal death associated with SMM was 88.0% (95% CI 74.6, 94.4). CONCLUSIONS The proposed definition of SMM and associated list of SMM subtypes could be used for standardised SMM surveillance, with rate ratios and PAFs associated with specific SMM types/subtypes serving to inform clinical practice and public health policy.
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Affiliation(s)
- Susie Dzakpasu
- Maternal, Child and Youth Health Division, Centre for Surveillance and Applied ResearchPublic Health Agency of CanadaOttawaONCanada
| | - Paromita Deb‐Rinker
- Maternal, Child and Youth Health Division, Centre for Surveillance and Applied ResearchPublic Health Agency of CanadaOttawaONCanada
| | - Laura Arbour
- Department of Medical GeneticsUniversity of British ColumbiaVictoriaBCCanada
| | | | - Michael S. Kramer
- Department of Pediatrics and of Epidemiology and BiostatisticsMcGill UniversityMontrealQCCanada
| | - Shiliang Liu
- Maternal, Child and Youth Health Division, Centre for Surveillance and Applied ResearchPublic Health Agency of CanadaOttawaONCanada
| | - Wei Luo
- Maternal, Child and Youth Health Division, Centre for Surveillance and Applied ResearchPublic Health Agency of CanadaOttawaONCanada
| | - Phil A. Murphy
- Perinatal Program of Newfoundland and LabradorSt. John’sNFLCanada
| | - Chantal Nelson
- Maternal, Child and Youth Health Division, Centre for Surveillance and Applied ResearchPublic Health Agency of CanadaOttawaONCanada
| | - Joel G. Ray
- Department of MedicineUniversity of TorontoTorontoONCanada
| | - Heather Scott
- Department of Obstetrics and GynaecologyDalhousie UniversityHalifaxNSCanada
| | - Michiel VandenHof
- Department of Obstetrics and GynaecologyDalhousie UniversityHalifaxNSCanada
| | - K. S. Joseph
- Department of Obstetrics and GynaecologyUniversity of British ColumbiaVancouverBCCanada
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Parsa S, Khajouei R, Baneshi MR, Aali BS. Improving the knowledge of pregnant women using a pre-eclampsia app: A controlled before and after study. Int J Med Inform 2019; 125:86-90. [PMID: 30914185 DOI: 10.1016/j.ijmedinf.2019.03.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 02/11/2019] [Accepted: 03/04/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the effect of a pre-eclampsia mobile application on the knowledge of pregnant women. METHODS Following development of a pre-eclampsia mobile application, we conducted a controlled before and after study during a three-month period in 2018. The study population consisted of pregnant women attended to obstetrician clinics and offices in Kerman, Iran of whom, 110 sample participants were divided into two intervention and control groups. The participants completed a questionnaire of pre-eclampsia knowledge at baseline and 1-month follow up. Data were analyzed using inferential statistics including chi-square, independent sample t-test, paired t-test and linear regression. RESULTS A total of 108 pregnant women with an average age of 28 years participated in this study. There was no significant difference between the scores of the two groups before the intervention (p=0.94). Their difference after the intervention was highly significant (p<0.001). The difference between the knowledge of the participants before and after the intervention was significant in the both groups (p<0.05). The results showed that the knowledge score of the participants after the intervention was significantly associated with their group and assessment score before the intervention (p<0.001). CONCLUSION The results showed that the use of a mobile-based educational application improves the knowledge of pregnant women about pre-eclampsia. Increasing women's knowledge about pre-eclampsia may enables them to identify its signs and symptoms, resulting in the early detection and management of this condition, and likely reduction of its adverse consequences. TRIAL REGISTRATION IRCT2017050633837N1.
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Affiliation(s)
- Sara Parsa
- Health Service Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Reza Khajouei
- Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
| | - Mohammad Reza Baneshi
- Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Bibi Shahnaz Aali
- Physiology Research Center, Department of Obstetrics and Gynecology, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
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Kallianidis AF, Schutte JM, van Roosmalen J, van den Akker T. Maternal mortality after cesarean section in the Netherlands. Eur J Obstet Gynecol Reprod Biol 2018; 229:148-152. [DOI: 10.1016/j.ejogrb.2018.08.586] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 08/19/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
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Engjom HM, Morken NH, Høydahl E, Norheim OF, Klungsøyr K. Risk of eclampsia or HELLP-syndrome by institution availability and place of delivery – A population-based cohort study. Pregnancy Hypertens 2018; 14:1-8. [DOI: 10.1016/j.preghy.2018.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 05/06/2018] [Accepted: 05/13/2018] [Indexed: 10/28/2022]
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Evaluating Adherence to Guideline-Based Quality Indicators for Postpartum Hemorrhage Care in the Netherlands Using Video Analysis. Obstet Gynecol 2018; 132:656-667. [DOI: 10.1097/aog.0000000000002781] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pieters A, van Oorschot KE, Akkermans HA, Brailsford SC. Improving inter-organizational care-cure designs: specialization versus integration. JOURNAL OF INTEGRATED CARE 2018. [DOI: 10.1108/jica-02-2018-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to investigate inter-organizational designs for care–cure conditions in which low-risk patients are cared for in specialized care organizations and high-risk patients are cared for in specialized cure organizations. Performance impacts of increasing levels of integration between these organizations are analyzed.
Design/methodology/approach
Mixed methods were used in Dutch perinatal care: analysis of archival data, clinical research and system dynamics simulation modeling.
Findings
Inter-organizational design has an effect on inter-organizational dynamics such as collaboration and trust, and also on the operational aspects such as patient flows through the system. Solutions are found in integrating care and cure organizations. However, not all levels of integrated designs perform better than a design based on organizational separation of care and cure.
Practical implications
A clear split between midwifery practices (care) and obstetric departments (cure) will not work since all pregnant women need both care and cure. Having midwifery practices only works well when there are high levels of collaboration and trust with obstetric departments in hospitals. Integrated care designs are likely to exhibit superior performance. However, these designs will have an adverse effect on organizations that are not part of this integration, since integrating only a subset of organizations will feed distrust, low collaboration and hence low performance.
Originality/value
The originality of this research is derived from its multi-method approach. Archival data and clinical research revealed the dynamic relations between organizations. The caveat of some integrated care models was found through simulation.
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Geller SE, Koch AR, Garland CE, MacDonald EJ, Storey F, Lawton B. A global view of severe maternal morbidity: moving beyond maternal mortality. Reprod Health 2018; 15:98. [PMID: 29945657 PMCID: PMC6019990 DOI: 10.1186/s12978-018-0527-2] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs). SEVERE MATERNAL MORBIDITY IN HIGH-INCOME COUNTRIES Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify "high risk" status, delays in diagnosis, and delays in treatment. SEVERE MATERNAL MORBIDITY IN LOW AND MIDDLE INCOME COUNTRIES The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity. EFFECTS OF SMM ON DELIVERY OUTCOMES AND INFANTS Severe maternal morbidity not only puts the woman's life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn. CONCLUSION Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women's and infants' health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.
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Affiliation(s)
- Stacie E. Geller
- Departments of Obstetrics & Gynecology and Medicine, University of Illinois at Chicago College of Medicine, Chicago, IL USA
- Center for Research on Women and Gender, University of Illinois at Chicago College of Medicine, Chicago, IL USA
| | - Abigail R. Koch
- Center for Research on Women and Gender, University of Illinois at Chicago College of Medicine, Chicago, IL USA
| | - Caitlin E. Garland
- Center for Research on Women and Gender, University of Illinois at Chicago College of Medicine, Chicago, IL USA
| | - E. Jane MacDonald
- Centre for Women’s Health Research, Victoria University of Wellington, Wellington, New Zealand
| | - Francesca Storey
- Centre for Women’s Health Research, Victoria University of Wellington, Wellington, New Zealand
| | - Beverley Lawton
- Centre for Women’s Health Research, Victoria University of Wellington, Wellington, New Zealand
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Rivera-Romero O, Olmo A, Muñoz R, Stiefel P, Miranda ML, Beltrán LM. Mobile Health Solutions for Hypertensive Disorders in Pregnancy: Scoping Literature Review. JMIR Mhealth Uhealth 2018; 6:e130. [PMID: 29848473 PMCID: PMC6000483 DOI: 10.2196/mhealth.9671] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 03/08/2018] [Accepted: 03/09/2018] [Indexed: 02/07/2023] Open
Abstract
Background Hypertensive disorders are the most common complications during pregnancy, occurring in 5% to 11% of pregnancies; gestational hypertension and preeclampsia are the leading causes of perinatal and maternal morbidity and mortality, especially in low- and middle-income countries (LMIC) where maternal and perinatal mortality ratios are still high. Pregnant women with hypertensive disorders could greatly benefit from mobile health (mHealth) solutions as a novel way to identify and control early symptoms, as shown in an increasing number of publications in the field. Such digital health solutions may overcome access limiting factors and the lack of skilled medical professionals and finances commonly presented in resource-poor environments. Objective The aim of this study was to conduct a literature review of mHealth solutions used as support in hypertensive disorders during pregnancy, with the objective to identify the most relevant protocols and prototypes that could influence and improve current clinical practice. Methods A methodological review following a scoping methodology was conducted. Manuscripts published in research journals reporting technical information of mHealth solutions for hypertensive disorders in pregnancy were included, categorizing articles in different groups: Diagnosis and Monitoring, mHealth Decision Support System, Education, and Health Promotion, and seven research questions were posed to study the manuscripts. Results The search in electronic research databases yielded 327 articles. After removing duplicates, 230 articles were selected for screening. Finally, 11 articles met the inclusion criteria, and data were extracted from them. Very positive results in the improvement of maternal health and acceptability of solutions were found, although most of the studies involved a small number of participants, and none were complete clinical studies. Accordingly, none of the reported prototypes were integrated in the different health care systems. Only 4 studies used sensors for physiological measurements, and only 2 used blood pressure sensors despite the importance of this physiological parameter in the control of hypertension. The reported mHealth solutions have great potential to improve clinical practice in areas lacking skilled medical professionals or with a low health care budget, of special relevance in LMIC, although again, no extensive clinical validation has been carried out in these environments. Conclusions mHealth solutions hold enormous potential to support hypertensive disorders during pregnancy and improve current clinical practice. Although very positive results have been reported in terms of usability and the improvement of maternal health, rigorous complete clinical trials are still necessary to support integration in health care systems. There is a clear need for simple mHealth solutions specifically developed for resource-poor environments that meet the United Nations Sustainable Development Goal (SDG); of enormous interest in LMIC.
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Affiliation(s)
| | - Alberto Olmo
- Department of Electronic Technology, Universidad de Sevilla, Sevilla, Spain
| | - Rocío Muñoz
- Instituto de Biomedicina de Sevilla (IBiS), Laboratorio de Hipertensión Arterial e Hipercolesterolemia, Servicio Andaluz de Salud / Consejo Superior de Investigaciones Científicas / Universidad de Sevilla, Seville, Spain
| | - Pablo Stiefel
- Instituto de Biomedicina de Sevilla (IBiS), Laboratorio de Hipertensión Arterial e Hipercolesterolemia, Servicio Andaluz de Salud / Consejo Superior de Investigaciones Científicas / Universidad de Sevilla, Seville, Spain.,Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - María Luisa Miranda
- Instituto de Biomedicina de Sevilla (IBiS), Laboratorio de Hipertensión Arterial e Hipercolesterolemia, Servicio Andaluz de Salud / Consejo Superior de Investigaciones Científicas / Universidad de Sevilla, Seville, Spain.,Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Luis M Beltrán
- Instituto de Biomedicina de Sevilla (IBiS), Laboratorio de Hipertensión Arterial e Hipercolesterolemia, Servicio Andaluz de Salud / Consejo Superior de Investigaciones Científicas / Universidad de Sevilla, Seville, Spain.,Hospital Universitario Virgen del Rocío, Sevilla, Spain
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13
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de Visser SM, Woiski MD, Grol RP, Vandenbussche FPHA, Hulscher MEJL, Scheepers HCJ, Hermens RPMG. Development of a tailored strategy to improve postpartum hemorrhage guideline adherence. BMC Pregnancy Childbirth 2018; 18:49. [PMID: 29422014 PMCID: PMC5806456 DOI: 10.1186/s12884-018-1676-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the introduction of evidence based guidelines and practical courses, the incidence of postpartum hemorrhage shows an increasing trend in developed countries. Substandard care is often found, which implies an inadequate implementation in high resource countries. We aimed to reduce the gap between evidence-based guidelines and clinical application, by developing a strategy, tailored to current barriers for implementation. METHODS The development of the implementation strategy consisted of three phases, supervised by a multidisciplinary expert panel. In the first phase a framework of the strategy was created, based on barriers to optimal adherence identified among professionals and patients together with evidence on effectiveness of strategies found in literature. In the second phase, the tools within the framework were developed, leading to a first draft. In the third phase the strategy was evaluated among professionals and patients. The professionals were asked to give written feedback on tool contents, clinical usability and inconsistencies with current evidence care. Patients evaluated the tools on content and usability. Based on the feedback of both professionals and patients the tools were adjusted. RESULTS We developed a tailored strategy to improve guideline adherence, covering the trajectory of the third trimester of pregnancy till the end of the delivery. The strategy, directed at professionals, comprehending three stop moments includes a risk assessment checklist, care bundle and time-out procedure. As patient empowerment tools, a patient passport and a website with patient information was developed. The evaluation among the expert panel showed all professionals to be satisfied with the content and usability and no discrepancies or inconsistencies with current evidence was found. Patients' evaluation revealed that the information they received through the tools was incomplete. The tools were adjusted accordingly to the missing information. CONCLUSION A usable, tailored strategy to implement PPH guidelines and practical courses was developed. The next step is the evaluation of the strategy in a feasibility trial. TRIAL REGISTRATION Clinical trial registration: The Fluxim study, registration number: NCT00928863 .
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Affiliation(s)
- Suzan M de Visser
- Department of Obstetrics and Gynecology, Radboud Institute for Health Science, Radboud University Medical Center, Geert Grootplein 10, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - Mallory D Woiski
- Department of Obstetrics and Gynecology, Radboud Institute for Health Science, Radboud University Medical Center, Geert Grootplein 10, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Richard P Grol
- Department of IQ Healthcare, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, Netherlands
| | - Frank P H A Vandenbussche
- Department of Obstetrics and Gynecology, Radboud Institute for Health Science, Radboud University Medical Center, Geert Grootplein 10, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Marlies E J L Hulscher
- Department of IQ Healthcare, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rosella P M G Hermens
- Department of IQ Healthcare, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, Netherlands
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Mohammadi S, Saleh Gargari S, Fallahian M, Källestål C, Ziaei S, Essén B. Afghan migrants face more suboptimal care than natives: a maternal near-miss audit study at university hospitals in Tehran, Iran. BMC Pregnancy Childbirth 2017; 17:64. [PMID: 28193186 PMCID: PMC5307813 DOI: 10.1186/s12884-017-1239-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 01/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM. METHODS An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined. RESULTS Afghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient- (31%, 17/54) and health system-related factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM. CONCLUSIONS Afghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants' specific needs during pregnancy may avert near-miss outcomes.
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Affiliation(s)
- Soheila Mohammadi
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden. .,Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Soraya Saleh Gargari
- Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Fallahian
- Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Carina Källestål
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden
| | - Shirin Ziaei
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden
| | - Birgitta Essén
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden
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Witteveen T, Van Den Akker T, Zwart JJ, Bloemenkamp KW, Van Roosmalen J. Severe acute maternal morbidity in multiple pregnancies: a nationwide cohort study. Am J Obstet Gynecol 2016; 214:641.e1-641.e10. [PMID: 26576487 DOI: 10.1016/j.ajog.2015.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/14/2015] [Accepted: 11/05/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adverse neonatal outcomes in multiple pregnancies have been documented extensively, in particular those associated with the increased risk of preterm birth. Paradoxically, much less is known about adverse maternal events. The combined risk of severe acute maternal morbidity in multiple pregnancies has not been documented previously in any nationwide prospective study. OBJECTIVE The objective of the study was to assess the risk of severe acute maternal morbidity in multiple pregnancies in a high-income European country and identify possible risk indicators. STUDY DESIGN In a population-based cohort study including all 98 hospitals with a maternity unit in The Netherlands, pregnant women with severe acute maternal morbidity were included in the period Aug. 1, 2004, until Aug. 1, 2006. We calculated the incidence of severe acute maternal morbidity in multiple pregnancies in The Netherlands using The Netherlands Perinatal Registry. Relative risks (RR) of severe acute maternal morbidity in multiple pregnancies compared with singletons were calculated. To identify possible risk indicators, we also compared age, parity, method of conception, onset of labor, and mode of delivery for multiple pregnancies using The Netherlands Perinatal Registry as reference. RESULTS A total of 2552 cases of severe acute maternal morbidity were reported during the 2 year study period. Among 202 multiple pregnancies (8.0%), there were 197 twins (7.8%) and 5 triplets (0.2%). The overall incidence of severe acute maternal morbidity was 7.0 per 1000 deliveries and 6.5 and 28.0 per 1000 for singletons and multiple pregnancies, respectively. The relative risk of severe acute maternal morbidity compared with singleton pregnancies was 4.3 (95% confidence interval [CI], 3.7-5.0) and increased to 6.2 (95% CI 2.5-15.3) in triplet pregnancies. Risk indicators for developing severe acute maternal morbidity in women with multiple pregnancies were age of ≥ 40 years, (RR, 2.5 95% CI, 1.4-4.3), nulliparity (RR, 1.8, 95% CI, 1.4-2.4), use of assisted reproductive techniques (RR, 1.9, 95% CI, 1.4-2.5), and nonspontaneous onset of delivery (RR, 1.6, 95% CI, 1.2-2.1). No significant difference was found between mono- and dichorionic twins (RR, 0.8, 95% CI, 0.6-1.2). CONCLUSION Women with multiple pregnancies in The Netherlands have a more than 4 times elevated risk of sustaining severe acute maternal morbidity as compared with singletons.
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Combined quality function deployment and logical framework analysis to improve quality of emergency care in Malta. Int J Health Care Qual Assur 2016; 29:123-40. [DOI: 10.1108/ijhcqa-04-2014-0040] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– The purpose of this paper is to develop an integrated patient-focused analytical framework to improve quality of care in accident and emergency (A
&
E) unit of a Maltese hospital.
Design/methodology/approach
– The study adopts a case study approach. First, a thorough literature review has been undertaken to study the various methods of healthcare quality management. Second, a healthcare quality management framework is developed using combined quality function deployment (QFD) and logical framework approach (LFA). Third, the proposed framework is applied to a Maltese hospital to demonstrate its effectiveness. The proposed framework has six steps, commencing with identifying patients’ requirements and concluding with implementing improvement projects. All the steps have been undertaken with the involvement of the concerned stakeholders in the A
&
E unit of the hospital.
Findings
– The major and related problems being faced by the hospital under study were overcrowding at A
&
E and shortage of beds, respectively. The combined framework ensures better A
&
E services and patient flow. QFD identifies and analyses the issues and challenges of A
&
E and LFA helps develop project plans for healthcare quality improvement. The important outcomes of implementing the proposed quality improvement programme are fewer hospital admissions, faster patient flow, expert triage and shorter waiting times at the A
&
E unit. Increased emergency consultant cover and faster first significant medical encounter were required to start addressing the problems effectively. Overall, the combined QFD and LFA method is effective to address quality of care in A
&
E unit.
Practical/implications
– The proposed framework can be easily integrated within any healthcare unit, as well as within entire healthcare systems, due to its flexible and user-friendly approach. It could be part of Six Sigma and other quality initiatives.
Originality/value
– Although QFD has been extensively deployed in healthcare setup to improve quality of care, very little has been researched on combining QFD and LFA in order to identify issues, prioritise them, derive improvement measures and implement improvement projects. Additionally, there is no research on QFD application in A
&
E. This paper bridges these gaps. Moreover, very little has been written on the Maltese health care system. Therefore, this study contributes demonstration of quality of emergency care in Malta.
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Cecatti JG, Costa ML, Haddad SM, Parpinelli MA, Souza JP, Sousa MH, Surita FG, Pinto E Silva JL, Pacagnella RC, Passini R. Network for Surveillance of Severe Maternal Morbidity: a powerful national collaboration generating data on maternal health outcomes and care. BJOG 2015; 123:946-53. [PMID: 26412586 DOI: 10.1111/1471-0528.13614] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To identify cases of severe maternal morbidity (SMM) during pregnancy and childbirth, their characteristics, and to test the feasibility of scaling up World Health Organization criteria for identifying women at risk of a worse outcome. DESIGN Multicentre cross-sectional study. SETTING Twenty-seven referral maternity hospitals from all regions of Brazil. POPULATION Cases of SMM identified among 82 388 delivering women over a 1-year period. METHODS Prospective surveillance using the World Health Organization's criteria for potentially life-threatening conditions (PLTC) and maternal near-miss (MNM) identified and assessed cases with severe morbidity or death. MAIN OUTCOME MEASURES Indicators of maternal morbidity and mortality; sociodemographic, clinical and obstetric characteristics; gestational and perinatal outcomes; main causes of morbidity and delays in care. RESULTS Among 9555 cases of SMM, there were 140 deaths and 770 cases of MNM. The main determining cause of maternal complication was hypertensive disease. Criteria for MNM conditions were more frequent as the severity of the outcome increased, all combined in over 75% of maternal deaths. CONCLUSIONS This study identified around 9.5% of MNM or death among all cases developing any severe maternal complication. Multicentre studies on surveillance of SMM, with organised collaboration and adequate study protocols can be successfully implemented, even in low-income and middle-income settings, generating important information on maternal health and care to be used to implement appropriate health policies and interventions. TWEETABLE ABSTRACT Surveillance of severe maternal morbidity was proved to be possible in a hospital network in Brazil.
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Affiliation(s)
- J G Cecatti
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - M L Costa
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - S M Haddad
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - M A Parpinelli
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - J P Souza
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - M H Sousa
- Centre for Research on Reproductive Health of Campinas (Cemicamp), Campinas, Brazil
| | - F G Surita
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - J L Pinto E Silva
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - R C Pacagnella
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
| | - R Passini
- Department of Obstetrics and Gynaecology, School of Medicine, University of de Campinas (UNICAMP), Campinas, Brazil
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Mooij R, Lugumila J, Mwashambwa MY, Mwampagatwa IH, van Dillen J, Stekelenburg J. Characteristics and outcomes of patients with eclampsia and severe pre-eclampsia in a rural hospital in Western Tanzania: a retrospective medical record study. BMC Pregnancy Childbirth 2015; 15:213. [PMID: 26350344 PMCID: PMC4563841 DOI: 10.1186/s12884-015-0649-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 09/02/2015] [Indexed: 12/21/2022] Open
Abstract
Background Eclampsia and pre-eclampsia are well-recognized causes of maternal and neonatal mortality in low income countries, but are never studied in a district hospital. In order to get reliable data to facilitate the hospital’s obstetric audit a retrospective medical record study was performed in Ndala Hospital, Tanzania. Methods All patients diagnosed with severe pre-eclampsia or eclampsia between July 2011 and December 2012 were included. Medical records were searched immediately following discharge or death. General patient characteristics, medical history, obstetrical history, possible risk factors, information about the current pregnancy, antenatal clinic attendance and prescribed therapy before admission were recorded. Symptoms and complications were noted. Statistical analysis was done with Epi Info®. Results Of the 3398 women who gave birth in the hospital 26 cases of severe pre-eclampsia and 55 cases of eclampsia were diagnosed (0.8 and 1.6 %). Six women with eclampsia died (case fatality rate 11 %). Convulsions in patients with eclampsia were classified as antepartum (44 %), intrapartum (42 %) and postpartum (15 %). Magnesium was given in 100 % of patients with eclampsia and was effective in controlling convulsions. Intravenous antihypertensive treatment was only started in 5 % of patients. Induction of labour was done in 29 patients (78 % of women who were not yet in labour). Delivery was spontaneous in 67 %, assisted vaginal (ventouse) in 14 % and by Caesarean section in 19 % of women. Perinatal deaths occurred in 30 % of women with eclampsia and 27 % of women with severe pre-eclampsia and were associated with low birth weight and prolonged time between admission and birth. Conclusions 2.4 % of women were diagnosed with severe pre-eclampsia or eclampsia. The case fatality rate and overall perinatal mortality were comparable to other reports. Better outcomes could be achieved by better treatment of hypertension and starting induction of labour as soon as possible.
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Affiliation(s)
- Rob Mooij
- Ndala Hospital, 15 Ndala, Tabora, Tanzania. .,Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | | | | | | | - Jeroen van Dillen
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Jelle Stekelenburg
- Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.
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Lindquist AC, Kurinczuk JJ, Wallace EM, Oats J, Knight M. Risk factors for maternal morbidity in Victoria, Australia: a population-based study. BMJ Open 2015; 5:e007903. [PMID: 26307615 PMCID: PMC4550708 DOI: 10.1136/bmjopen-2015-007903] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 07/21/2015] [Accepted: 07/27/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The aim of this analysis was to quantify the risk factors associated with maternal morbidity among women in Victoria, Australia, focusing particularly on sociodemographic factors. DESIGN Case-control analysis. PARTICIPANTS Data on all maternities in Victoria from 1 January 2006 to 31 December 2008. METHODS A case-control analysis was conducted using unconditional logistic regression to calculate adjusted ORs (aORs). Cases were defined as all women noted to have had a severe complication during the index pregnancy. Severe maternal morbidity was defined by the validated, composite Australian Maternal Morbidity Outcome Indicator. Socioeconomic position was defined by Socio-Economic Indices for Areas (SEIFA), specifically the Index of Relative Socioeconomic Disadvantage (IRSD), and other variables analysed were age, parity, Indigenous background, multiple pregnancy, country of birth, coexisting medical condition, previous caesarean section, spontaneous abortion or ectopic pregnancy. RESULTS The study population comprised 211,060 women, including 1119 cases of severe maternal morbidity (0.53%). Compared with the highest IRSD quintile, the aOR for the 2nd quintile was 1.23 (95% CI 1.03 to 1.49), 0.98 (95% CI 0.79 to 1.21) for the 3rd quintile, 1.55 (95% CI 1.28 to 1.87) for the 4th and 1.21 (95% CI 1.00 to 1.47) for the lowest (most deprived) quintile. Indigenous status was associated with twice (aOR 2.02; 95% CI 1.32 to 3.09) the odds of being a case. Other risk factors for severe maternal morbidity were age ≥ 35 years (aOR 1.22; 95% CI 1.04 to 1.44), coexisting medical condition (aOR 1.39; 95% CI 1.16 to 1.65), multiple pregnancy (aOR 2.30; 95% CI 1.71 to 3.10), primiparity (aOR 1.36; 95% CI 1.18 to 1.57), previous caesarean section (aOR 1.79; 95% CI 1.53 to 2.10) and previous spontaneous miscarriage (aOR 1.25; 95% CI 1.08 to 1.44). CONCLUSIONS The findings from Victoria strongly suggest that social disadvantage needs to be acknowledged and further investigated as an independent risk factor for adverse maternal outcomes in Australia and incorporated into appropriate policy planning and healthcare programmes.
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Affiliation(s)
- Anthea C Lindquist
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | | | - Euan M Wallace
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
- The Ritchie Centre, MIMR-PHI Institute of Medical Research, Clayton, Victoria, Australia
| | - Jeremy Oats
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
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Lange EMS, Shah AM, Braithwaite BA, You WB, Wong CA, Grobman WA, Toledo P. Readability, content, and quality of online patient education materials on preeclampsia. Hypertens Pregnancy 2015; 34:383-90. [DOI: 10.3109/10641955.2015.1053607] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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de Jonge A, Mesman JAJM, Manniën J, Zwart JJ, Buitendijk SE, van Roosmalen J, van Dillen J. Severe Adverse Maternal Outcomes among Women in Midwife-Led versus Obstetrician-Led Care at the Onset of Labour in the Netherlands: A Nationwide Cohort Study. PLoS One 2015; 10:e0126266. [PMID: 25961723 PMCID: PMC4427485 DOI: 10.1371/journal.pone.0126266] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/31/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To test the hypothesis that it is possible to select a group of low risk women who can start labour in midwife-led care without having increased rates of severe adverse maternal outcomes compared to women who start labour in secondary care. DESIGN AND METHODS We conducted a nationwide cohort study in the Netherlands, using data from 223 739 women with a singleton pregnancy between 37 and 42 weeks gestation without a previous caesarean section, with spontaneous onset of labour and a child in cephalic presentation. Information on all cases of severe acute maternal morbidity collected by the national study into ethnic determinants of maternal morbidity in the Netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, was merged with data from the Netherlands Perinatal Registry of all births occurring during the same period. Our primary outcome was severe acute maternal morbidity (SAMM, i.e. admission to an intensive care unit, uterine rupture, eclampsia or severe HELLP, major obstetric haemorrhage, and other serious events). Secondary outcomes were postpartum haemorrhage and manual removal of placenta. RESULTS Nulliparous and parous women who started labour in midwife-led care had lower rates of SAMM, postpartum haemorrhage and manual removal of placenta compared to women who started labour in secondary care. For SAMM the adjusted odds ratio's and 95% confidence intervals were for nulliparous women: 0.57 (0.45 to 0.71) and for parous women 0.47 (0.36 to 0.62). CONCLUSIONS Our results suggest that it is possible to identify a group of women at low risk of obstetric complications who may benefit from midwife-led care. Women can be reassured that we found no evidence that midwife-led care at the onset of labour is unsafe for women in a maternity care system with a well developed risk selection and referral system.
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Affiliation(s)
- Ank de Jonge
- Department of Midwifery Science, AVAG and the EMGO Institute of Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Judith Manniën
- Department of Midwifery Science, AVAG and the EMGO Institute of Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Joost J. Zwart
- Deventer Hospital, Department of Obstetrics, Deventer, the Netherlands
| | | | - Jos van Roosmalen
- Leiden University Medical Center, Department of Obstetrics, Leiden, the Netherlands
- Athena Institute, VU University Medical Center, Amsterdam, the Netherlands
| | - Jeroen van Dillen
- Radboud University Medical Center Nijmegen, Department of Obstetrics, Nijmegen, the Netherlands
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22
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Hypertensive disorders and pregnancy-related stroke: frequency, trends, risk factors, and outcomes. Obstet Gynecol 2015; 125:124-131. [PMID: 25560114 DOI: 10.1097/aog.0000000000000590] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate trends and associations of hypertensive disorders of pregnancy with stroke risk and test the hypothesis that hypertensive disorders of pregnancy-associated stroke results in higher rates of stroke-related complications than pregnancy-associated stroke without hypertensive disorders. METHODS A cross-sectional study was performed using 81,983,216 pregnancy hospitalizations from the 1994-2011 Nationwide Inpatient Sample. Rates of stroke hospitalizations with and without these hypertensive disorders were reported per 10,000 pregnancy hospitalizations. Using logistic regression, adjusted odds ratios (OR) with 95% confidence intervals were obtained. RESULTS Between 1994-1995 and 2010-2011, the nationwide rate of stroke with hypertensive disorders of pregnancy increased from 0.8 to 1.6 per 10,000 pregnancy hospitalizations (103%), whereas the rate without these disorders increased from 2.2 to 3.2 per 10,000 pregnancy hospitalizations (47%). Women with hypertensive disorders of pregnancy were 5.2 times more likely to have a stroke than those without. Having traditional stroke risk factors (eg, congenital heart disease, atrial fibrillation, sickle cell anemia, congenital coagulation defects) substantially increased the stroke risk among hypertensive disorders of pregnancy hospitalizations: from adjusted OR 2.68 for congenital coagulation defects to adjusted OR 13.1 for congenital heart disease. Stroke-related complications were increased in stroke with hypertensive disorders of pregnancy compared with without (from adjusted OR 1.23 for nonroutine discharge to adjusted OR 1.93 for mechanical ventilation). CONCLUSION Having traditional stroke risk factors substantially increased the stroke risk among hypertensive disorders of pregnancy hospitalizations. Stroke with hypertensive disorders in pregnancy had two distinctive characteristics: a greater increase in frequency since the mid-1990s and significantly higher stroke-related complication rates. LEVEL OF EVIDENCE III.
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Lawton B, MacDonald EJ, Brown SA, Wilson L, Stanley J, Tait JD, Dinsdale RA, Coles CL, Geller SE. Preventability of severe acute maternal morbidity. Am J Obstet Gynecol 2014; 210:557.e1-6. [PMID: 24508582 DOI: 10.1016/j.ajog.2013.12.032] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 12/16/2013] [Accepted: 12/19/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We sought to assess potential preventability of severe acute maternal morbidity (SAMM) cases admitted to intensive-care units (ICUs) or high-dependency units (HDUs). STUDY DESIGN Inclusion criteria were admissions to ICUs or HDUs of women who were pregnant or within 42 days of delivery in 4 District Health Board areas (accounting for a third of annual births in New Zealand) during a 17-month period. Cases were reviewed by external multidisciplinary panels using a validated model for assessing preventability. RESULTS In all, 98 SAMM cases were assessed; 38 (38.8%) cases were deemed potentially preventable, 36 (36.7%) not preventable but improvement in care was needed, and 24 (24.5%) not preventable. The most frequent preventable factors were clinician related: delay or failure in diagnosis or recognition of high-risk status (51%); and delay or inappropriate treatment (70%). The most common causes of preventable severe morbidity were blood loss and septicemia. CONCLUSION The majority of SAMM cases were potentially preventable or required improvement in care. Themes around substandard care related to delay in diagnosis and treatment for postpartum hemorrhage and septicemia. These findings can inform clinical educational programs and policies to improve maternal outcomes. This study has now been expanded to a national New Zealand audit of all SAMM cases admitted to an ICU/HDU.
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Sadler LC, Austin DM, Masson VL, McArthur CJ, McLintock C, Rhodes SP, Farquhar CM. Review of contributory factors in maternity admissions to intensive care at a New Zealand tertiary hospital. Am J Obstet Gynecol 2013; 209:549.e1-7. [PMID: 23911384 DOI: 10.1016/j.ajog.2013.07.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 05/27/2013] [Accepted: 07/27/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to identify factors that contributed to severe maternal morbidity, defined by admission of pregnant women and women in the postpartum period to the intensive care unit (ICU) from 2010-2011 at Auckland City Hospital (ACH), a tertiary hospital that delivers 7500 women/year, and to determine potentially avoidable morbidity with the use of local multidisciplinary review. STUDY DESIGN All admissions of pregnant women and women in the postpartum period (to 6 weeks) to the ICU at ACH from 2010-2011 were identified from hospital databases. Case notes were summarized and discussed by a multidisciplinary team. The presence of contributory factors and potentially avoidable morbidity were determined by consensus with a tool that was developed by the New Zealand Perinatal and Maternal Mortality Review Committee for the review of maternal and perinatal deaths. Specific recommendations for clinical management were identified by the multidisciplinary group. RESULTS Nine pregnant women and 33 women in the postpartum period were admitted to the ICU from 2010-2011. Contributory factors were identified in 30 cases (71%); 20 cases (48%) were considered to be potentially avoidable; personnel factors were the most commonly identified avoidable causes. Specific recommendations that resulted from the study included the need for the development of guidelines for puerperal sepsis, improved planning for women at known risk of postpartum hemorrhage, enhanced supervision of junior staff, and enhanced communication through multidisciplinary meetings. CONCLUSION Forty-eight percent of severe maternal morbidity, which was defined as admission to the ICU at ACH from 2010-2011, was considered to be potentially avoidable by a local multidisciplinary review team; priorities were identified for improvement of local maternity services.
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Smit M, Sindram SIC, Woiski M, Middeldorp JM, van Roosmalen J. The development of quality indicators for the prevention and management of postpartum haemorrhage in primary midwifery care in the Netherlands. BMC Pregnancy Childbirth 2013; 13:194. [PMID: 24139411 PMCID: PMC4016500 DOI: 10.1186/1471-2393-13-194] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 10/08/2013] [Indexed: 11/17/2022] Open
Abstract
Background At present, there are no guidelines on prevention and management of postpartum haemorrhage in primary midwifery care in the Netherlands. The first step towards implementing guidelines is the development of a set of quality indicators for prevention and management of postpartum haemorrhage for primary midwifery supervised (home) birth in the Netherlands. Methods A RAND modified Delphi procedure was applied. This method consists of five steps: (1) composing an expert panel (2) literature research and collection of possible quality indicators, (3) digital questionnaire, (4) consensus meeting and (5) critical evaluation. A multidisciplinary expert panel consisting of five midwives, seven obstetricians and an ambulance paramedic was assembled after applying pre-specified criteria concerning expertise in various domains relating to primary midwifery care, secondary obstetric care, emergency transportation, maternal morbidity or mortality audit, quality indicator development or clinical guidelines development and representatives of professional organisations. Results After literature review, 79 recommendations were selected for assessment by the expert panel. After a digital questionnaire to the expert panel seven indicators were added, resulting in 86 possible indicators. After excluding 41 indicators that panel members unanimously found invalid, 45 possible indicators were assessed at the consensus meeting. During critical evaluation 18 potential indicators were found to be overlapping and two were discarded due to lack of measurability. Conclusions A set of 25 quality indicators was considered valid for testing in practice.
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Affiliation(s)
- Marrit Smit
- Department of Obstetrics, Leiden University Medical Centre, Albinusdreef 2, Leiden, 2300 RC, The Netherlands.
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de Jonge A, Mesman JAJM, Manniën J, Zwart JJ, van Dillen J, van Roosmalen J. Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study. BMJ 2013; 346:f3263. [PMID: 23766482 PMCID: PMC3685517 DOI: 10.1136/bmj.f3263] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To test the hypothesis that low risk women at the onset of labour with planned home birth have a higher rate of severe acute maternal morbidity than women with planned hospital birth, and to compare the rate of postpartum haemorrhage and manual removal of placenta. DESIGN Cohort study using a linked dataset. SETTING Information on all cases of severe acute maternal morbidity in the Netherlands collected by the national study into ethnic determinants of maternal morbidity in the netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, merged with data from the Netherlands perinatal register of all births occurring during the same period. PARTICIPANTS 146 752 low risk women in primary care at the onset of labour. MAIN OUTCOME MEASURES Severe acute maternal morbidity (admission to an intensive care unit, eclampsia, blood transfusion of four or more packed cells, and other serious events), postpartum haemorrhage, and manual removal of placenta. RESULTS Overall, 92 333 (62.9%) women had a planned home birth and 54 419 (37.1%) a planned hospital birth. The rate of severe acute maternal morbidity among planned primary care births was 2.0 per 1000 births. For nulliparous women the rate for planned home versus planned hospital birth was 2.3 versus 3.1 per 1000 births (adjusted odds ratio 0.77, 95% confidence interval 0.56 to 1.06), relative risk reduction 25.7% (95% confidence interval -0.1% to 53.5%), the rate of postpartum haemorrhage was 43.1 versus 43.3 (0.92, 0.85 to 1.00 and 0.5%, -6.8% to 7.9%), and the rate of manual removal of placenta was 29.0 versus 29.8 (0.91, 0.83 to 1.00 and 2.8%, -6.1% to 11.8%). For parous women the rate of severe acute maternal morbidity for planned home versus planned hospital birth was 1.0 versus 2.3 per 1000 births (0.43, 0.29 to 0.63 and 58.3%, 33.2% to 87.5%), the rate of postpartum haemorrhage was 19.6 versus 37.6 (0.50, 0.46 to 0.55 and 47.9%, 41.2% to 54.7%), and the rate of manual removal of placenta was 8.5 versus 19.6 (0.41, 0.36 to 0.47 and 56.9%, 47.9% to 66.3%). CONCLUSIONS Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system.
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Affiliation(s)
- Ank de Jonge
- Department of Midwifery Science, AVAG and the EMGO Institute of Health and Care Research, VU University Medical Center, Amsterdam, Netherlands.
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Melman S, Schoorel ENC, Dirksen C, Kwee A, Smits L, de Boer F, Jonkers M, Woiski MD, Mol BWJ, Doornbos JPR, Visser H, Huisjes AJM, Porath MM, Delemarre FMC, Kuppens SMI, Aardenburg R, Van Dooren IMA, Vrouenraets FPJM, Lim FTH, Kleiverda G, van der Salm PCM, de Boer K, Sikkema MJ, Nijhuis JG, Hermens RPMG, Scheepers HCJ. SIMPLE: implementation of recommendations from international evidence-based guidelines on caesarean sections in the Netherlands. Protocol for a controlled before and after study. Implement Sci 2013; 8:3. [PMID: 23281646 PMCID: PMC3547819 DOI: 10.1186/1748-5908-8-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Accepted: 12/18/2012] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Caesarean section (CS) rates are rising worldwide. In the Netherlands, the most significant rise is observed in healthy women with a singleton in vertex position between 37 and 42 weeks gestation, whereas it is doubtful whether an improved outcome for the mother or her child was obtained. It can be hypothesized that evidence-based guidelines on CS are not implemented sufficiently. Therefore, the present study has the following objectives: to develop quality indicators on the decision to perform a CS based on key recommendations from national and international guidelines; to use the quality indicators in order to gain insight into actual adherence of Dutch gynaecologists to guideline recommendations on the performance of a CS; to explore barriers and facilitators that have a direct effect on guideline application regarding CS; and to develop, execute, and evaluate a strategy in order to reduce the CS incidence for a similar neonatal outcome (based on the information gathered in the second and third objectives). METHODS An independent expert panel of Dutch gynaecologists and midwives will develop a set of quality indicators on the decision to perform a CS. These indicators will be used to measure current care in 20 hospitals with a population of 1,000 women who delivered by CS, and a random selection of 1,000 women who delivered vaginally in the same period. Furthermore, by interviewing healthcare professionals and patients, the barriers and facilitators that may influence the decision to perform a CS will be measured. Based on the results, a tailor-made implementation strategy will be developed and tested in a controlled before-and-after study in 12 hospitals (six intervention, six control hospitals) with regard to effectiveness, experiences, and costs. DISCUSSION This study will offer insight into the current CS care and into the hindering and facilitating factors influencing obstetrical policy on CS. Furthermore, it will allow definition of patient categories or situations in which a tailor-made implementation strategy will most likely be meaningful and cost effective, without negatively affecting the outcome for mother and child. TRIAL REGISTRATION http://www.clinicaltrials.gov: NCT01261676.
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Affiliation(s)
- Sonja Melman
- GROW-School for Oncology and Developmental Biology, Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Binder P, Johnsdotter S, Essén B. Conceptualising the prevention of adverse obstetric outcomes among immigrants using the ‘three delays’ framework in a high-income context. Soc Sci Med 2012; 75:2028-36. [DOI: 10.1016/j.socscimed.2012.08.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Revised: 07/29/2012] [Accepted: 08/13/2012] [Indexed: 11/27/2022]
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REIME BIRGIT, JANSSEN PATRICIAA, FARRIS LILY, BORDE THEDA, HELLMERS CLAUDIA, MYEZWA HELLEN, WENZLAFF PAUL. Maternal near-miss among women with a migrant background in Germany. Acta Obstet Gynecol Scand 2012; 91:824-9. [DOI: 10.1111/j.1600-0412.2012.01390.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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de Graaf JP, Schutte JM, Poeran JJ, van Roosmalen J, Bonsel GJ, Steegers EAP. Regional differences in Dutch maternal mortality. BJOG 2012; 119:582-8. [DOI: 10.1111/j.1471-0528.2012.03283.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Small MJ, James AH, Kershaw T, Thames B, Gunatilake R, Brown H. Near-Miss Maternal Mortality. Obstet Gynecol 2012; 119:250-5. [DOI: 10.1097/aog.0b013e31824265c7] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bakker W, van den Akker T, Mwagomba B, Khukulu R, van Elteren M, van Roosmalen J. Health workers' perceptions of obstetric critical incident audit in Thyolo District, Malawi. Trop Med Int Health 2011; 16:1243-50. [PMID: 21767335 DOI: 10.1111/j.1365-3156.2011.02832.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess perceptions held by health workers in a Malawian district about obstetric critical incident audit. Insight into factors contributing to participation and endorsement may help to improve the audit process and reduce facility-based maternal and neonatal mortality and morbidity. METHODS This study involves semi-structured interviews with 25 district health workers, a focus group discussion and observation of audit sessions in health facilities in Thyolo District, Malawi, between August 2009 and January 2010. Data were analysed with maxqda 2010. RESULTS Findings were categorized into four major areas: (i) general knowledge of audit, (ii) participation in local audit and feedback sessions, (iii) the ability to reproduce the local audit cycle and (iv) effects and outcomes of audit and feedback. All health workers were familiar with the concept of audit and could reproduce the local cycle. Most health workers classified audit as an instructive and helpful tool to improve the quality of their work, provided that it is performed in a manner that enhances motivation and on-the-job learning. CONCLUSIONS Contradictory to recent reports from other African settings, which showed negative effects of audit on health workers' motivation, staff in this district considered audit and feedback valuable tools to enhance the quality of the care they provide. Audit has become part of the professional routine in the district, and its educational value was considered its most important appeal.
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Affiliation(s)
- Wouter Bakker
- Department of Medical Humanities, EMGO+ Institute, VU University Medical Centre, Amsterdam, The Netherlands
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Jayaratnam S, De Costa C, Howat P. Developing an assessment tool for maternal morbidity 'near-miss'- a prospective study in a large Australian regional hospital. Aust N Z J Obstet Gynaecol 2011; 51:421-5. [PMID: 21806590 DOI: 10.1111/j.1479-828x.2011.01330.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Maternal mortality is now a rare event in the developed world and its measurement is no longer a useful way of assessing obstetric care. Examination of cases of women who nearly died but survived a severe complication of pregnancy or childbirth - maternal 'near-misses' - is increasingly being recognised as potentially more useful, although severe maternal morbidity is much less easy to define and quantify than maternal death. AIM To identify and assess prospectively cases of severe maternal morbidity presenting to Cairns Base Hospital (CBH), to define cases as near-misses and thereby develop a tool for future assessment of obstetric care in CBH and elsewhere. METHODS Based on approaches recommended by the recent WHO working group on Maternal Mortality and Morbidity classifications, a data collection form was constructed using a combination of named morbidities and specific interventions. Over 1 year data from all cases of severe maternal morbidity was collected and analysed both prospectively and retrospectively to identify true near-misses. RESULTS Seventeen cases of true near-misses were identified, giving a near-miss rate of six per 1000 live births for CBH in the study period; 64% of cases were attributable to obstetric causes and 36% to non-obstetric causes. CONCLUSIONS Collection of near-miss data has the potential to become a useful tool for the assessment of obstetric care in both in CBH and in other Australian hospitals but is time-consuming and requires continuous surveillance by medical staff if cases are not to be overlooked.
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