Maternal near miss and predictive ability of potentially life-threatening conditions at selected maternity hospitals in Latin America

Adverse Delivery and Neonatal Outcomes Among Women with Severe Maternal Morbidity in Illinois, 2018-2019

Objective: To examine adverse delivery outcomes from 2018 to 2019 severe maternal morbidity (SMM) cases that were reviewed by facility-level review committees in Illinois (n = 666) and describe the burden of adverse delivery outcomes among demographic subgroups, SMM etiology, and whether the SMM event was potentially preventable. Materials and Methods: This is a descriptive analysis of the SMM review cohort. Consistent with expert recommendations to identify SMM for hospital quality review, SMM was defined as any intensive care or critical care unit admission and/or transfusion of four or more units of packed red blood cells from conception to 42 days postpartum. Adverse delivery outcomes were fetal death, low birthweight, preterm birth, neonatal intensive care unit admission, and 5-minute Apgar score <7. Chi square and Fisher's exact tests compared maternal demographic and delivery characteristics between the SMM sample and 2018-2019 deliveries in Illinois. Logistic regression modeled the associations between primary cause of morbidity, maternal race/ethnicity, adverse delivery outcomes, and opportunities to alter the outcome to assess whether the burden of adverse birth outcomes was distributed evenly across subcategories of the cohort. Results: Overall, 53.9% of women with SMM had at least one adverse delivery outcome. SMM events owing to preeclampsia/eclampsia (adjusted odds ratio [aOR] = 4.41, 95% confidence interval [CI] = 2.37-8.24) and infection/sepsis (aOR = 4.40, 95% CI = 1.79-11.04) were more likely to be accompanied by adverse delivery outcomes compared with hemorrhage-related SMM. Non-Hispanic Black women with SMM were more likely to have an adverse delivery outcome compared with non-Hispanic White women with SMM (aOR = 1.74, 95% CI = 1.01-3.02). Conclusion: A greater proportion of the SMM review cohort experienced adverse delivery outcomes compared with the overall birthing population in the state. Non-Hispanic Black women with SMM were almost twice as likely to have an adverse delivery outcome compared with non-Hispanic White women.

Neonatal outcomes according to different degrees of maternal morbidity: cross-sectional evidence from the Perinatal Information System (SIP) of the CLAP network

BACKGROUND

The burden of maternal morbidity in neonatal outcomes can vary with the adequacy of healthcare provision and tool implementation to improve monitoring. Such information is lacking in Latin American countries, where the decrease in severe maternal morbidity and maternal death remains challenging.

OBJECTIVES

To determine neonatal outcomes according to maternal characteristics, including different degrees of maternal morbidity in Latin American health facilities.

METHODS

This is a secondary cross-sectional analysis of the Perinatal Information System (SIP) database from eight health facilities in five Latin American and Caribbean countries. Participants were all women delivering from August 2018 to June 2021, excluding cases of abortion, multiple pregnancies and missing information on perinatal outcomes. As primary and secondary outcome measures, neonatal near miss and neonatal death were measured according to maternal/pregnancy characteristics and degrees of maternal morbidity. Estimated adjusted prevalence ratios (PRadj) with their respective 95% CIs were reported.

RESULTS

In total 85,863 live births were included, with 1,250 neonatal near miss (NNM) cases and 695 identified neonatal deaths. NNM and neonatal mortality ratios were 14.6 and 8.1 per 1,000 live births, respectively. Conditions independently associated with a NNM or neonatal death were the need for neonatal resuscitation (PRadj 16.73, 95% CI [13.29-21.05]), being single (PRadj 1.45, 95% CI [1.32-1.59]), maternal near miss or death (PRadj 1.64, 95% CI [1.14-2.37]), preeclampsia (PRadj 3.02, 95% CI [1.70-5.35]), eclampsia/HELPP (PRadj 1.50, 95% CI [1.16-1.94]), maternal age (years) (PRadj 1.01, 95% CI [<1.01-1.02]), major congenital anomalies (PRadj 3.21, 95% CI [1.43-7.23]), diabetes (PRadj 1.49, 95% CI [1.11-1.98]) and cardiac disease (PRadj 1.65, 95% CI [1.14-2.37]).

CONCLUSION

Maternal morbidity leads to worse neonatal outcomes, especially in women suffering maternal near miss or death. Based on SIP/PAHO database all these indicators may be helpful for routine situation monitoring in Latin America with the purpose of policy changes and improvement of maternal and neonatal health.

Surveillance of severe maternal morbidity and maternal mortality in maternity hospitals of the Latin American and Caribbean network - Red CLAP: study protocol

The sustained reduction in maternal mortality in America underlines the need to analyse women who survived a complication that could have been fatal if appropriate and timely care had not been taken. Analysis of maternal near-miss (MNM) cases, as well as potentially life-threatening conditions (PLTC), are considered indicators for monitoring the quality of maternal care. The specific objective of this study protocol is to develop a surveillance system for PLTC, MNM and maternal mortality, as primary outcomes, in Latin American and Caribbean maternal healthcare institutions. Secondarily, the study was designed to identify factors associated with these conditions and estimate how often key evidence-based interventions were used for managing severe maternal morbidity. This is a multicenter cross-sectional study with prospective data collection. The target population consists of all women admitted to health centres participating in the network during pregnancy, childbirth, or the postpartum period. Variables describing the sequence of events that may result in a PLTC, MNM or maternal death are recorded. Relevant quality control is carried out to ensure the quality of the database and confidentiality. Centres with approximately 2,500 annual deliveries will be included to achieve a sufficient number of cases for calculation of indicators. The frequency of outcome measures for PLTC, MNM and maternal mortality and their confidence intervals and differences between groups will be calculated using the most appropriate statistical tests. Similar procedures will be performed with variables describing the use of evidence-based practices. Networking creates additional possibilities for global information management and interaction between different research groups. Lessons can be learned and shared, generating scientific knowledge to address relevant health problems throughout the region with provision of efficient data management.

[Spatial analysis of maternal morbidity and mortality in users of the Brazilian Unified National Health System in the city of Rio de Janeiro, Brazil, 2014-2016]

The objective of this study is to analyze the maternal morbidity and mortality of women treated in hospitals of the Brazilian Unified National Health System (SUS) in the city of Rio de Janeiro in the period 2014-2016. An ecological study was conducted using data from the Brazilian Information System on Live Birth (SINASC), the Brazilian Mortality Information System (SIM), and the Brazilian Hospital Information System (SIH/SUS). For the analysis of the maternal mortality ratio (MMR), data from the SIM were used. For the analysis of maternal morbidity, World Health Organization criteria were used to estimate the ratios of maternal near miss and potentially life-threatening conditions. SINASC was used to retrieve data on the number of live births, for demographic characterization, social aspects, and access to prenatal care. To evaluate the spatial association between the indicators MMR, ratios of maternal near miss, and potentially life-threatening conditions and the demographic, social, obstetric, and access indicators, obtained from SINASC, the bivariate Moran Index was estimated with a significance level of 0.05, using the GeoDa program. In the period analyzed, the MMR in the Rio de Janeiro was 94.16/100,000 live births, the ratio of maternal near miss was 28.21/1,000 live births, and the potentially life-threatening conditions was 34.31/1,000 live births. Cases of potentially life-threatening conditions were used for the first time in this study and presented diagnoses and procedures during hospitalization more consistent with the maternal mortality profile in the city of Rio de Janeiro. There was a significant association between MMR and percentage of live births in SUS, potentially life-threatening conditions and percentage of live births in SUS, and potentially life-threatening conditions and being single.

Prevalence and determinants of maternal near miss in Ethiopia: a systematic review and meta-analysis, 2015-2023

BACKGROUND

One of the most challenging problems in developing countries including Ethiopia is improving maternal health. About 303,000 mothers die globally, and one in every 180 is at risk from maternal causes. Developing regions account for 99% of maternal deaths. Maternal near miss (MNM) resulted in long-term consequences. A systematic review and meta-analysis was performed to assess the prevalence and predictors of maternal near miss in Ethiopia from January 2015 to March 2023.

METHODS

A systematic review and meta-analysis cover both published and unpublished studies from different databases (PubMed, CINHAL, Scopus, Science Direct, and the Cochrane Library) to search for published studies whilst searches for unpublished studies were conducted using Google Scholar and Google searches. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Duplicated studies were removed using Endnote X8. The paper quality was also assessed based on the JBI checklist. Finally, 21 studies were included in the study. Data synthesis and statistical analysis were conducted using STATA Version 17 software. Forest plots were used to present the pooled prevalence using the random effect model. Heterogeneity and publication bias was evaluated using Cochran's Q test, (Q) and I squared test (I²). Subgroup analysis based on study region and year of publication was performed.

RESULT

From a total of 705 obtained studies, twenty-one studies involving 701,997 pregnant or postpartum mothers were included in the final analysis. The national pooled prevalence of MNM in Ethiopia was 140/1000 [95% CI: 80, 190]. Lack of formal education [AOR = 2.10, 95% CI: 1.09, 3.10], Lack of antenatal care [AOR = 2.18, 95% CI: 1.33, 3.03], history of cesarean section [AOR = 4.07, 95% CI: 2.91, 5.24], anemia [AOR = 4.86, 95% CI: 3.24, 6.47], and having chronic medical disorder [AOR = 2.41, 95% CI: 1.53, 3.29] were among the predictors of maternal near misses from the pooled estimate.

CONCLUSION

The national prevalence of maternal near miss was still substantial. Antenatal care is found to be protective against maternal near miss. Emphasizing antenatal care to prevent anemia and modifying other chronic medical conditions is recommended as prevention strategies. Avoiding primary cesarean section is recommended unless a clear indication is present. Finally, the country should place more emphasis on strategies for reducing MNM and its consequences, with the hope of improving women's health.

Predicting severe maternal outcomes in a network of sentinel sites in Latin-American countries

OBJECTIVE

This study aimed to determine incidences of potentially life-threatening conditions (PLTC), maternal near misses (MNM), and maternal deaths (MD) in women who gave birth in participating facilities, and to determine the probability that a pregnancy involving a PLTC would evolve into an MNM and/or an MD.

METHODS

This was a multicentric observational study implemented on a maternal network from August 2018 to May 2019 in five Latin-American countries. We summarized categorical variables as frequencies and continuous variables with median, interquartile range, and standard deviations. Positive and negative likelihood ratios were calculated and multivariate predictive models were built.

RESULTS

There were 33 901 deliveries and miscarriages, of which 8.0% had at least one PLTC and 0.6% had an MNM. Hypertensive disorder was the most frequent condition to evolve into a severe maternal outcome.

CONCLUSION

Identifying PLTC can help to prevent MNM and MD. The inclusion of these predictors in a real-time data registration system like the Perinatal Informatic System could work as a surveillance tool for early detection, leading to a reduction in the rate of worsening conditions.

Maternal Near Miss in Patients with Systemic Lupus Erythematosus

OBJECTIVE

 Systemic lupus erythematosus (SLE) may cause irreversible organ damage. Pregnancy with SLE may have severe life-threatening risks. The present study aimed to determine the prevalence of severe maternal morbidity (SMM) in patients with SLE and analyze the parameters that contributed to cases of greater severity.

METHODS

This is a cross-sectional retrospective study from analysis of data retrieved from medical records of pregnant women with SLE treated at a University Hospital in Brazil. The pregnant women were divided in a control group without complications, a group with potentially life-threatening conditions (PLTC), and a group with maternal near miss (MNM).

RESULTS

 The maternal near miss rate was 112.9 per 1,000 live births. The majority of PLTC (83.9%) and MNM (92.9%) cases had preterm deliveries with statistically significant increased risk compared with the control group (p = 0.0042; odds ratio [OR]: 12.05; 95% confidence interval [CI]: 1.5-96.6 for the MNM group and p = 0.0001; OR: 4.84; 95%CI: 2.2-10.8 for the PLTC group). Severe maternal morbidity increases the risk of longer hospitalization (p < 0.0001; OR: 18.8; 95%CI: 7.0-50.6 and p < 0.0001; OR: 158.17; 95%CI: 17.6-1424,2 for the PLTC and MNM groups, respectively), newborns with low birthweight (p = 0.0006; OR: 3.67; 95%CI: 1.7-7.9 and p = 0.0009; OR: 17.68; 95%CI: 2-153.6) for the PLTC and MNM groups, respectively] as well as renal diseases (PLTC [8.9%; 33/56; p = 0.0069] and MNM [78.6%; 11/14; p = 0.0026]). Maternal near miss cases presented increased risk for neonatal death (p = 0.0128; OR: 38.4; 95%CI: 3.3-440.3]), and stillbirth and miscarriage (p = 0.0011; OR: 7.68; 95%CI: 2.2-26.3]).

CONCLUSION

 Systemic lupus erythematosus was significantly associated with severe maternal morbidity, longer hospitalizations, and increased risk of poor obstetric and neonatal outcomes.

Adverse pregnancy and perinatal outcomes in Latin America and the Caribbean: systematic review and meta-analysis

Objective.

To estimate the point prevalence and likely ranges of pregnancy-induced hypertension, pre-eclampsia, gestational diabetes, low birth weight and preterm delivery in Latin America and the Caribbean, and evaluate the heterogeneity of the estimates.

Methods.

We conducted a systematic review and meta-analysis of observational studies reporting the prevalence of maternal and perinatal adverse outcomes in populations in Latin American and the Caribbean published between 2000 and 2019 in English, Spanish, or Portuguese. We searched PubMed, Embase, and LILACS. We estimated the point prevalence and evaluated overall heterogeneity and, in sub-group analyses, heterogeneity by study design and level of bias.

Results.

Of 1087 records retrieved, 50 articles were included in the review: two on hypertensive disorders of pregnancy, 14 on pre-eclampsia, six on gestational diabetes, nine on low birth weight and 19 on preterm birth. No meta-analysis for hypertensive disorders of pregnancy could be done because of the small number of studies. Point prevalence estimates and 95% confidence intervals (CIs) for pre-eclampsia, gestational diabetes, low birth weight, and preterm birth were: 6.6% (95% CI: 4.9%, 8.6%), 8.5% (95% CI: 3.9%, 14.7%), 8.5% (95% CI: 7.2%, 9.8%), and 10.0% (95% CI: 8.0%, 12.0%), respectively. We observed substantial heterogeneity overall and by study design. No major differences in estimates were observed by level of bias.

Conclusions.

The results of this study provide updated estimates of some of the most prevalent adverse pregnancy and perinatal outcomes in Latin America and the Caribbean. They highlight that important heterogeneity exists in prevalence estimates, which may reflect the diversity of populations in the region.

Global and regional estimates of maternal near miss: a systematic review, meta-analysis and experiences with application

Introduction

Maternal near miss (MNM) is a useful means to examine quality of obstetric care. Since the introduction of the WHO MNM criteria in 2011, it has been tested and validated, and is being used globally. We sought to systematically review all available studies using the WHO MNM criteria to develop global and regional estimates of MNM frequency and examine its application across settings.

Methods

We conducted a systematic review by implementing a comprehensive literature search from 2011 to 2018 in six databases with no language restrictions. The predefined data collection tool included sections on study characteristics, frequency of near-miss cases and study quality. Meta-analysis was performed by regional groupings. Reported adaptations, modifications and remarks about application were extracted.

Results

7292 articles were screened by title and abstract, and 264 articles were retrieved for full text review for the meta-analysis. An additional 230 articles were screened for experiences with application of the WHO MNM criteria. Sixty studies with near-miss data from 56 countries were included in the meta-analysis. The pooled global near-miss estimate was 1.4% (95% CI 0.4% to 2.5%) with regional variation in MNM frequency. Of the 20 studies that made adaptations to the criteria, 19 were from low-resource settings where lab-based criteria were adapted due to resource limitations.

Conclusions

The WHO MNM criteria have enabled the comparison of global and sub-national estimates of MNM frequency. There has been good uptake in low-resource countries but contextual adaptations are necessary.

Maternal mortality: near-miss events in middle-income countries, a systematic review

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.

Abortion-related morbidity in six Latin American and Caribbean countries: findings of the WHO/HRP multi-country survey on abortion (MCS-A)

INTRODUCTION

Abortion-related complications are a significant cause of morbidity and mortality among women in many Latin American and Caribbean (LAC) countries. The objective of this study was to characterise abortion-related complication severity, describe the management of these complications and report women's experiences with abortion care in selected countries of the Americas region.

METHODS

This is a cross-sectional study of 70 health facilities across six countries in the region. We collected data on women's characteristics including socio-demographics, obstetric history, clinical information, management procedures and using Audio Computer-Assisted Self-Interviewing (ACASI) survey the experience of abortion care. Descriptive bivariate analysis was performed for women's characteristics, management of complications and reported experiences of abortion care by severity of complications, organised in five hierarchical mutually exclusive categories based on indicators present at assessment. Generalised linear estimation models were used to assess the association between women's characteristics and severity of complications.

RESULTS

We collected data on 7983 women with abortion-related complications. Complications were classified as mild (46.3%), moderate (49.5%), potentially life-threatening (3.1%), near-miss cases (1.1%) and deaths (0.2%). Being single, having a gestational age of ≥13 weeks and having expelled products of conception before arrival at the facility were significantly associated with experiencing severe maternal outcomes compared with mild complications.Management of abortion-related complications included both uterotonics and uterine evacuation for two-thirds of the women while one-third received uterine evacuation only. Surgical uterine evacuation was performed in 93.2% (7437/7983) of women, being vacuum aspiration the most common one (5007/7437, 67.4%).Of the 327 women who completed the ACASI survey, 16.5% reported having an induced abortion, 12.5% of the women stated that they were not given explanations regarding their care nor were able to ask questions during their examination and treatment with percentages increasing with the severity of morbidity.

CONCLUSIONS

This is one of the first studies using a standardised methodology to measure severity of abortion-related complications and women's experiences with abortion care in LAC. Results aim to inform policies and programmes addressing sexual and reproductive rights and health in the region.

Applicability of the WHO maternal near-miss tool: A nationwide surveillance study in Suriname

BACKGROUND

Maternal near-miss (MNM) is an important maternal health quality-of-care indicator. To facilitate comparison between countries, the World Health Organization (WHO) developed the "MNM-tool". However, several low- and middle-income countries have proposed adaptations to prevent underreporting, ie, Namibian and Sub-Sahara African (SSA)-criteria. This study aims to assess MNM and associated factors in middle-income country Suriname by applying the three different MNM tools.

METHODS

A nationwide prospective population-based cohort study was conducted using the Suriname Obstetric Surveillance System (SurOSS). We included women with MNM-criteria defined by WHO-, Namibian- and SSA-tools during one year (March 2017-February 2018) and used hospital births (86% of total) as a reference group.

RESULTS

There were 9114 hospital live births in Suriname in the one-year study period. SurOSS identified 71 women with WHO-MNM (8/1000 live births, mortality-index 12%), 118 with Namibian-MNM (13/1000 live births, mortality-index 8%), and 242 with SSA-MNM (27/1000 live births, mortality-index 4%). Namibian- and SSA-tools identified all women with WHO-criteria. Blood transfusion thresholds and eclampsia explained the majority of differences in MNM prevalence. Eclampsia was not considered a WHO-MNM in 80% (n = 35/44) of cases. Nevertheless, mortality-index for MNM with hypertensive disorders was 17% and the most frequent underlying cause of maternal deaths (n = 4/10, 40%) and MNM (n = 24/71, 34%). Women of advanced age and maroon ethnicity had twice the odds of WHO-MNM (respectively adjusted odds ratio (aOR) = 2.6, 95% confidence interval (CI) = 1.4-4.8 and aOR = 2.0, 95% CI = 1.2-3.6). The stillbirths rate among women with WHO-MNM was 193/1000births, with six times higher odds than women without MNM (aOR = 6.8, 95%CI = 3.0-15.8). While the prevalence and mortality-index differ between the three MNM tools, the underlying causes of and factors associated with MNM were comparable.

CONCLUSIONS

The MNM ratio in Suriname is comparable to other countries in the region. The WHO-tool underestimates the prevalence of MNM (high mortality-index), while the adapted tools may overestimate MNM and compromise global comparability. Contextualized MNM-criteria per obstetric transition stage may improve comparability and reduce underreporting. While MNM studies facilitate international comparison, audit will remain necessary to identify shortfalls in quality-of-care and improve maternal outcomes.

Women's sexual health six months after a severe maternal morbidity event

OBJECTIVE

to investigate female sexual function in women six months postpartum and to compare sexual function among women who had and who did not have severe maternal morbidity (SMM).

METHOD

a cross-sectional study conducted with 110 women in the postpartum period, with and without SMM. Two instruments were used, one for the characterization of sociodemographic and obstetric variables and the Female Sexual Function Index (FSFI) for sexual function. Univariate, bivariate and regression model analyses were performed.

RESULTS

FSFI scores showed 44.5% of female sexual dysfunction, of which 48.7% were among women who had SMM and 42.0% among those who had not. There were significant differences between age (P=0.013) and duration of pregnancy (P<0.001) between women with or without SMM. Among the cases of SMM, hypertensive disorders were the most frequent (83%). An association was obtained between some domains of the FSFI and the following variables: orgasm and self-reported skin color, satisfaction and length of relationship, and pain and SMM.

CONCLUSION

white women have greater difficulty in reaching orgasm when compared to non-white women and women with more than 120 months of relationship feel more dissatisfied with sexual health than women with less time in a relationship. Women who have had some type of SMM have more dyspareunia when compared to women who have not had SMM.

Human Development Index of the maternal country of origin and its relationship with maternal near miss: A systematic review of the literature

Background

The reduction in maternal mortality worldwide has increased the interest in studying more frequent severe events such as maternal near miss. The Human Development Index is a sociodemographic country-specific variable that includes key human development indicators such as living a long and healthy life, acquiring knowledge, and enjoying a decent standard of living, allowing differentiation between countries. In a globalised environment, it is necessary to study whether the Human Development Index of each patient's country of origin can be associated with the maternal near-miss rate and thus classify the risk of maternal morbidity and mortality.

Methods

A systematic review of the literature published between 2008 and 2019 was conducted, including all articles that reported data about maternal near miss in their sample of pregnant women, in addition to describing the study countries of their sample population. The Human Development Index of the study country, the maternal near-miss rate, the maternal mortality rate, and other maternal-perinatal variables related to morbidity and mortality were used.

Results

After the systematic review, eighty two articles from over thirty countries were included, for a total of 3,699,697 live births, 37,191 near miss cases, and 4029 mortality cases. A statistically significant (p <0.05) inversely proportional relationship was observed between the Human Development Index of the study country and the maternal near-miss and mortality rates. The most common cause of maternal near miss was haemorrhage, with an overall rate of 38.5%, followed by hypertensive disorders of pregnancy (34.2%), sepsis (7.5%), and other undefined causes (20.9%).

Conclusions

The Human Development Index of the maternal country of origin is a sociodemographic variable allowing differentiation and classification of the risk of maternal mortality and near miss in pregnant women. The most common cause of maternal near miss published in the literature was haemorrhage.

Trial registration

PROSPERO ID: CRD 42019133464

Extreme Maternal Morbidity: a tracer event to improve the quality of obstetric care in Latin America

This article reviews critical aspects that have had an impact on the implementation of epidemiological surveillance of extreme maternal morbidity, as a tracer event of quality maternal care at population and institutional level; taking into account that maternal mortality has been usually monitored, and its analysis allows interventions to avoid maternal death. Until 2015, very few countries had been able to meet the goals established in the Millennium Development Goals (MDGs), especially MDG 5 - improving maternal health. As of today, it is observed that maternal mortality rate is quite heterogeneous, with rates from 1 case per 100,000 live births in developed countries, to more than 100 cases per 100,000 live births in developing countries. Therefore, complementary strategies such as surveillance of the extreme maternal morbidity could offer a more effective alternative to identify and implement interventions that allow us to prevent mortality and strengthen the quality of obstetric care. In addition, the importance of extreme maternal morbidity as a quality tracer event is that, unlike what is observed with maternal mortality, this is an event that occurs more frequently, is anticipatory of death, and the surviving pregnant woman is the primary source of information.

Comparison of four prognostic scales for predicting mortality in patients with severe maternal morbidity

OBJECTIVE

To compare the prognostic validity of the APACHE II-M and O-SOFA scales versus the APACHE II and SOFA to predict mortality in patients with severe maternal morbidity.

DESIGN

A retrospective, longitudinal and analytical cohort study was carried out.

SETTING

Medical-surgical intensive care unit (ICU) of a tertiary hospital.

PATIENTS

Pregnant or puerperal patients of any age admitted to the ICU.

INTERVENTIONS

Calculation of prognostic scores upon admission.

VARIABLES OF INTEREST

APACHE II, SOFA, APACHE II-M and O-SOFA scores and maternal mortality.

RESULTS

A total of 141 patients were included. The majority (70.2%) were puerperal. The most frequent diagnosis was gestational hypertensive disease (50 cases). The discrimination of each prognostic model was estimated with the area under the ROC curve (AUC-ROC). The calibration was estimated using the mortality ratio and the Hosmer-Lemeshow statistic. The four scales discriminated between survivors and non-survivors with areas under the curve >0.85. The APACHE II-M model was the predictive model with the highest discrimination and calibration. In the Hosmer-Lemeshow regression analysis, mortality as predicted by the APACHE II and O-SOFA was significantly different from the observed mortality.

CONCLUSIONS

The APACHE II-M exhibited the greatest prognostic validity in predicting maternal mortality. This difference was given by its improvement in calibration.

The global prevalence of maternal near miss: a systematic review and meta-analysis

Background: Improving the maternal health is one of the world’s most challenging problems. Despite significant movements over the past decades, maternal health has been still considered as a central goal for sustainable development. Maternal near miss (MNM) cases experience long-term physical and psychological effects. To present a clear portrait of the current situation, we performed a systematic review and meta-analysis with the purpose to assess the worldwide prevalence of MNM.

Methods: We conducted a systematic review on PubMed, Scopus and Web of Science electronic databases to find published papers in English, before March 2019 and regardless of the type of study. We, then, assessed the prevalence of MNM according to the World Health Organization(WHO) criteria. Finally, 49 papers were included in the study. Random effects meta-analysis was used to pool the available prevalence. The quality of studies was also evaluated.

Results: The weighted pooled worldwide prevalence of MNM, was 18.67/1000 (95% CI: 16.28-21.06). Heterogeneity was explored using subgroup analyses based on the continent and the country. We used meta-regression of MNM on MD which resulted in adjusted R-squared as78.88%.

Conclusion: The prevalence of MNM was considerable. Low- and middle-income countries should develop systematic approaches to improve quality of care in the facilities and to reducethe risk of MNM events, with the hope to women’s health.

Epidemiology of obstetric critical illness

Obstetric intensive care unit (ICU) admissions comprise only a small part of severe maternal morbidity. The incidence rate of both remains relatively unclear due to inconsistent definitions across publications, although this has begun to be addressed. There is a relative paucity of information regarding disease-specific survival following obstetric ICU admission, but outcomes are clearly related to the cause of admission and the quality of care. The ratio between maternal near-miss cases (many of whom are admitted to ICUs) and maternal death may provide insight into the preventability of death. Hemorrhage and pre-eclampsia constitute the leading causes of ICU admission and have relatively low mortality rates, perhaps demonstrating the impact of informed care in managing obstetric critical illness. Obstetric sepsis, heart disease and anesthesia complications should be the focus of future research. The incidence of obstetric sepsis has been increasing in the last decade, with mortality rates remaining relatively high. The incidence of obstetric heart disease is increasing and maternal complications have been attributed to fractionated care of mothers within this category. Anesthesia complications remain a predominant cause of maternal death and likely intensive care admission. Data are lacking regarding the relative proportion of cases per disease that remain treated outside the ICU; and the outcomes of various management strategies. The only study of the health status of survivors of obstetric ICU admission revealed that six months after hospital discharge, one in five women still had a poorer health-related quality of life than those of a reference age- and sex-matched cohort.

Transcriptomic analysis of fetal membranes reveals pathways involved in preterm birth

Background

Preterm birth (PTB), defined as infant delivery before 37 weeks of completed gestation, results from the interaction of both genetic and environmental components and constitutes a complex multifactorial syndrome. Transcriptome analysis of PTB has proven challenging because of the multiple causes of PTB and the numerous maternal and fetal gestational tissues that must interact to facilitate parturition. The transcriptome of the chorioamnion membranes at the site of rupture in PTB and term fetuses may reflect the molecular pathways of preterm labor.

Methods

In this work, chorioamnion membranes from severe preterm and term fetuses were analyzed using RNA sequencing. Functional annotations and pathway analysis of differentially expressed genes were performed with the GAGE and GOSeq packages. A subset of differentially expressed genes in PTB was validated in a larger cohort using qRT-PCR and by comparing our results with genes and pathways previously reported in the literature.

Results

A total of 270 genes were differentially expressed (DE): 252 were upregulated and 18 were down-regulated in severe preterm births relative to term births. Inflammatory and immunological pathways were upregulated in PTB. Both types of pathways were previously suggested to lead to PTB. Pathways that were not previously reported in PTB, such as the hemopoietic pathway, appeared upregulated in preterm membranes. A group of 18 downregulated genes discriminated between term and severe preterm cases. These genes potentially characterize a severe preterm transcriptome pattern and therefore are candidate genes for understanding the syndrome. Some of the downregulated genes are involved in the nervous system, morphogenesis (WNT1, DLX5, PAPPA2) and ion channel complexes (KCNJ16, KCNB1), making them good candidates as biomarkers of PTB.

Conclusions

The identification of this DE gene pattern will help with the development of a multi-gene disease classifier. These markers were generated in an admixed South American population in which PTB has a high incidence. Since the genetic background may differentially impact different populations, it is necessary to include populations such as those from South America and Africa, which are usually excluded from high-throughput approaches. These classifiers should be compared to those in other populations to obtain a global landscape of PTB.

Electronic supplementary material

The online version of this article (10.1186/s12920-019-0498-3) contains supplementary material, which is available to authorized users.

Adverse perinatal outcomes are associated with severe maternal morbidity and mortality: evidence from a national multicentre cross-sectional study

PURPOSE

To assess the association between maternal potentially life-threatening conditions (PLTC), maternal near miss (MNM), and maternal death (MD) with perinatal outcomes.

METHODS

Cross-sectional study in 27 Brazilian referral centers from July, 2009 to June, 2010. All women presenting any criteria for PLTC and MNM, or MD, were included. Sociodemographic and obstetric characteristics were evaluated in each group of maternal outcomes. Childbirth and maternal morbidity data were related to perinatal adverse outcomes (5th min Apgar score < 7, fetal death, neonatal death, or any of these). The Chi-squared test evaluated the differences between groups. Multiple regression analysis adjusted for the clustering design effect identified the independently associated maternal factors with the adverse perinatal outcomes (prevalence ratios; 95% confidence interval).

RESULTS

Among 8271 cases of severe maternal morbidity, there were 714 cases of adverse perinatal outcomes. Advanced maternal age, low level of schooling, multiparity, lack of prenatal care, delays in care, preterm birth, and adverse perinatal outcomes were more common among MNM and MD. Both MNM and MD were associated with Apgar score (2.39; 1.68-3.39); maternal hemorrhage was the most prevalent characteristic associated with fetal death (2.9, 95% CI 1.81-4.66) and any adverse perinatal outcome (2.16; 1.59-2.94); while clinical/surgical conditions were more related to neonatal death (1.56; 1.08-2.25).

CONCLUSION

We confirmed the association between MNM and MD with adverse perinatal outcomes. Maternal and perinatal issues should not be dissociated. Policies aiming maternal care should include social and economic development, and improvements in accessibility to specialized care. These, in turn, will definitively impact on childhood mortality rates.

Severe maternal outcomes in eastern Ethiopia: Application of the adapted maternal near miss tool

Background

With the reduction of maternal mortality, maternal near miss (MNM) has been used as a complementary indicator of maternal health. The objective of this study was to assess the frequency of MNM in eastern Ethiopia using an adapted sub-Saharan Africa MNM tool and compare its applicability with the original WHO MNM tool.

Methods

We applied the sub-Saharan Africa and WHO MNM criteria to 1054 women admitted with potentially life-threatening conditions (including 28 deaths) in Hiwot Fana Specialized University Hospital and Jugel Hospital between January 2016 and April 2017. Discharge records were examined to identify deaths or women who developed MNM according to the sub-Saharan or WHO criteria. We calculated and compared MNM and severe maternal outcome ratios. Mortality index (ratio of maternal deaths to SMO) was calculated as indicator of quality of care.

Results

The sub-Saharan Africa criteria identified 594 cases of MNM and all the 28 deaths while the WHO criteria identified 128 cases of MNM and 26 deaths. There were 7404 livebirths during the same period. This gives MNM ratios of 80 versus 17 per 1000 live births for the adapted and original WHO criteria. Mortality index was 4.5% and 16.9% in the adapted and WHO criteria respectively. The major difference between the two criteria can be attributed to eclampsia, sepsis and differences in the threshold for transfusion of blood.

Conclusion

The sub-Saharan Africa criteria identified all the MNM cases identified by the WHO criteria and all the maternal deaths. Applying the WHO criteria alone will cause under reporting of MNM cases (including maternal deaths) in this low-resource setting. The mortality index of 4.5% among women who fulfilled the adapted MNM criteria justifies labeling these women as having ‘life-threatening conditions’.

A retrospective cohort study of risk factors and pregnancy outcomes in 14,014 Chinese pregnant women

This study aims to investigate major complications or symptoms of pregnant women, causes of maternal near-miss, and issues that are relevant to severe maternal disease.A retrospective analysis was performed in the "maternal individual investigation form," which included all critical maternity patients admitted to the First Affiliated Hospital of Anhui Medical University from January 1, 2012 to September 31, 2015.A total of 14,014 pregnant patients who delivered at 28 to 42 weeks of gestation were included. Eight thousand eighty-six patients experienced complications or symptoms, and top 7 of these were postpartum hemorrhage, hypertension during pregnancy, diabetes, anemia, hepatopathy, nephroma, and connective tissue disease, of which the morbidity were 11.92%, 10.15%, 9.34%, 8.57%, 3.13%. 0.56%, and 0.55%, respectively. Delivery times, gestational weeks, and informal pregnancy examinations had significant correlation with maternal near-miss (P < .05); nevertheless, the age at pregnancy, number of pregnancies, and education were not so significant (P > .05). Two hundred sixty-five patients had severe maternal diseases (maternal near miss), and the top 5 causes for severe maternal morbidity were massive blood transfusion, thrombocytopenia, clinical feature of shock, uterus removal induced by uterus infection or bleeding, and coagulation dysfunction, of which the morbidity were 24.15%, 18.87%, 13.58%, 9.43%, and 6.79%, respectively.Delivery times, gestational weeks, and informal pregnancy examinations should be considered in maternal near miss patients. Moreover, hypertensive disorders during pregnancy, postpartum hemorrhage, anemia, thrombocytopenia, hepatopathy, and cardiopathy were the principal causes of maternal near miss. Therefore, the monitoring of these principal causes of severe maternity near miss is important for reducing the maternal morbidity and mortality.

One-Year Follow-Up of Women with Severe Acute Maternal Morbidity (SAMM): A Cohort Study

Background

Some women experience unforeseen complications during pregnancy and childbirth, which may be life threatening; their survival depends on intensive support and timely interventions. The aim of this study was to assess the long-term prevalence of adverse health conditions and their impact on quality of life in women who had severe acute maternal morbidity (SAMM).

Methods

This is a prospective cohort study comprising 43 women with SAMM during 2015 (exposure group) and 43 women who had an uneventful pregnancy and delivery (non-exposure group) during the same study period. Those who consented were given an additional follow-up date for free medical health check at 1 year.

Results

The incidence of SAMM during study period was 8.6/1000 births. There were five deaths in the exposure group. Adverse health events were seen in 30 (78.94%) out of 38 survivors. Abnormal lipid profile, thrombocytopenia, cardiac diastolic dysfunction, amenorrhoea, Sheehan and Asherman syndrome were major findings in the exposed group. Four (10.52%) women required re-admission, and eight (20.05%) required additional procedures to confirm screening abnormalities. The exposure group had higher mean scores on the EPDS scale, incidence of suicidal thoughts and poorer performance in the WHOQOL BREF psychological domain.

Conclusion

Health programmes need to focus on maternal health, provide medical treatment and psychological support for a longer duration than the traditional 6 weeks postpartum in women who experience SAMM.

A global view of severe maternal morbidity: moving beyond maternal mortality

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.

Adaptation of the WHO maternal near miss tool for use in sub-Saharan Africa: an International Delphi study

Background

Assessments of maternal near miss (MNM) are increasingly used in addition to those of maternal mortality measures. The World Health Organization (WHO) has introduced an MNM tool in 2009, but this tool was previously found to be of limited applicability in several low–resource settings. The aim of this study was to identify adaptations to enhance applicability of the WHO MNM tool in sub–Saharan Africa.

Methods

Using a Delphi consensus methodology, existing MNM tools were rated for applicability in sub-Saharan Africa over a series of three rounds. Maternal health experts from sub-Saharan Africa or with considerable knowledge of the context first rated importance of WHO MNM parameters using Likert scales, and were asked to suggest additional parameters. This was followed by two confirmation rounds. Parameters accepted by at least 70% of the panel members were accepted for use in the region.

Results

Of 58 experts who participated from study onset, 47 (81%) completed all three rounds. Out of the 25 WHO MNM parameters, all 11 clinical, four out of eight laboratory, and four out of six management–based parameters were accepted, while six parameters (PaO2/FiO2 < 200 mmHg, bilirubin >100 μmol/l or >6.0 mg/dl, pH <7.1, lactate >5 μmol/l, dialysis for acute renal failure and use of continuous vasoactive drugs) were deemed to not be applicable. An additional eight parameters (uterine rupture, sepsis/severe systemic infection, eclampsia, laparotomy other than caesarean section, pulmonary edema, severe malaria, severe complications of abortions and severe pre-eclampsia with ICU admission) were suggested for inclusion into an adapted sub-Saharan African MNM tool.

Conclusions

All WHO clinical criteria were accepted for use in the region. Only few of the laboratory- and management based were rated applicable. This study brought forward important suggestions for adaptations in the WHO MNM criteria to enhance its applicability in sub-Saharan Africa and possibly other low–resource settings.

Healthcare and sociodemographic conditions related to severe maternal morbidity in a state representative population, Federal District, Brazil: A cross-sectional study

Background

The concept of severe maternal morbidity (SMM)—a potentially life-threatening condition during pregnancy, childbirth or after termination of pregnancy—can be used as a quality indicator of the health care provided to mothers and children. The aim of this study was to investigate the SMM rate and the main factors associated with this condition among women living in the Federal District, Brazil.

Methods

We conducted a cross-sectional population-based sample survey using a structured questionnaire about the sociodemographic characteristics of the participants’ families. The data investigated included receipt of financial aid from the Federal Government, age, race, maternal educational level, prenatal care, mode of delivery, and serious complications during pregnancy and postpartum (SMM). 1042 mothers of children up to 1 year old were interviewed, representing a weighted estimated population of 36,724 mothers. The sample was representative of the whole Federal District state.

Results

Mothers were between 19 and 34 years old (69%), most of them were brown or black (59.7%), and they had more than 9 years of education (81.2%). Prenatal care was adequate for 91.9% of them, the most common mode of delivery was Cesarean section (61.3%), and most deliveries took place in public hospitals (57.3%). The prevalence of low birth weight (< 2,500 g) was 8.1%. We found 2072 events of SMM in 2060 mothers (SMM rate: 5.6%). There was an association between higher occurrence of SMM and older age (OR: 1.40; 1.26–1.56), lower maternal educational level (OR: 3.29; 2.78–3.90), and inadequate prenatal care (OR: 1.28; 1.09–1.51). Receipt of financial aid was also associated to increased risk for SMM (OR: 1.31; 1.16–1.48). Cesarean section and low birth weight reduced the risk of SMM (decrease of 49.0% and 46.0%, respectively).

Conclusions

The SMM rate in the Federal District was positively associated with higher maternal age, lower maternal educational level, inadequate prenatal care, and government financial aid program. Conversely, SMM was inversely associated with Cesarean delivery and low birth weight. This study showed that specific demographic groups are at higher risk for SMM. Therefore, actions should be focused primarily on those groups for greater effectiveness at reducing maternal mortality and providing better quality of maternal health care.