Incidence and causes of maternal near-miss in selected hospitals of Addis Ababa, Ethiopia

Magnitude and Associated Factors of Maternal Near Miss in Public Hospitals of Tigrai, Northern Ethiopia: A Cross Sectional Study

The purpose of this study was to determine magnitude and associated factors of maternal near miss among women seeking obstetric and gynecologic care. A hospital based cross-sectional study design was implemented in selected public hospitals of Tigrai. Systematic random sampling method was used to select study participants. Data were entered to epi data manager version 4.1 and exported to Statistical Package for social science version 20 for analysis. Bivariate and multivariate logistic regression was used to identify factors associated with maternal near miss. The magnitude of maternal near miss was found to be 7.3%. Regression analysis showed that, mothers who reside in rural area, had distance of greater than 10 km, referred from low level health institution, and mothers had no antenatal care follow up were significantly associated with maternal near miss. Therefore, promoting antenatal care and increasing awareness in rural areas related with maternal health care services is recommended.

Maternal near miss hospitalizations in the Borana Zone, Ethiopia: A facility-based longitudinal cross-sectional study

Background

Maternal near miss refers to a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of pregnancy termination. While there has been considerable progress in reducing maternal mortality rates, maternal near miss cases can provide valuable insights into the quality of maternal healthcare and help identify areas for improvement. However, there is limited evidence on the factors contributing to maternal near miss cases, including health system failures, delays in care, and provider-related factors. Therefore, this study aimed to assess the incidence, causes, and factors associated with maternal near misses in public Hospitals of Borena Zone.

Methods

A facility-based longitudinal cross-sectional study design was employed at four Public Hospitals in Borena Zone from August 15, 2022, to November 15, 2022, using the WHO criteria for maternal near miss event. In total, 117 participants were included in the study. Eligibility was determined using key clinical, organ dysfunction, laboratory, and management criteria, as per the WHO guidelines for near-miss events. Underlying and contributing causes of maternal near misses were documented from each participant's records.

Result

There were 1421 deliveries during the study period and 117 eligible women developed potentially life-threatening conditions. Only 61 women experienced severe maternal outcomes (55 near misses and six maternal deaths). The maternal near miss incidence ratio was 38.7 per 1000 live births, with a mortality index of 9.8%. Hypertensive disorders and obstetric hemorrhage are the leading underlying causes of maternal near misses.

Conclusion

The incidence of maternal near miss was remarkably high when compared to previous studies. Giving special emphasis to life-saving interventions, critical care, reducing delays and improving the referral system are critical to improve quality of care.

Cost of maternal complications and its associated factors among mothers attending Hawassa public hospitals, Southern Ethiopia

Background

The cost of maternal complications is considered as an important factor hindering the utilization of maternal health care services. However, information of estimate of spending on maternal complication was lacking. This study was aimed to estimate the cost of maternal complications and associated factors among mother's attending Hawassa public hospitals, Sidama Regional state, Ethiopia.

Methods

A cross-sectional study design was conducted among 348 randomly selected mothers attending public hospitals in Hawassa from November 15 to December 15, 2021. Data was coded and entered into Epi Data version 3.1 and exported to STATA version 16.0 for analysis. Simple and multiple linear regression analysis was done. Correlation coefficient along with 95% CI was used to present the finding and p < 0.05 was used to declare statistical significance.

Results

This study found that total median cost of maternal complications was 4895.5 (IQR = 3779) ETB. The total median direct medical cost was 1765.5 (IQR = 1649.5) ETB. Number of days absent [(R = 0.028; 95% CI: (0.023, 0.033)], distance from facility [(R = 0.001; 95% CI: (0.000, 0.002)], site of laboratory diagnosis [(R = 0.230; 95% CI: (0.140, 0.320)], number of laboratory test conducted [(R = 0.045; 95% CI: (0.021, 0.069)] were found to be significance predictors of maternal complications costs.

Conclusions

Total median cost of maternal complications in current study was high. Respondents' site of diagnosis, number of days missed from work, number of laboratory tests, and distance from hospitals were independent predictors of maternal complications cost. Thus, we will recommend governments to introduce strategies that specifically help mothers with maternal complications.

Intimate partner violence as a determinant factor for spontaneous abortion during pregnancy: an unmatched case-control study

Background

Intimate partner violence affects a significant portion of women worldwide throughout their lifetimes. Ethiopia lacks data that policymakers could utilize to develop context-specific policies for handling intimate partner violence during pregnancy.

Objectives

To identify the determinants of spontaneous abortion among women survivors of intimate partner violence during pregnancy in Adigrat General Hospital, Northern Ethiopia, in 2020.

Methods

A facility based, case-control study design was employed to recruit 371 women (124 cases and 247 controls) attending maternal health services in Adigrat General Hospital, Northern Ethiopia, from March 13 to June 12, 2020. Cases and controls were selected using a consecutive sampling technique. A multivariable binary logistic regression model was carried out to identify potential factors, and a p-value of <0.05 was used to declare statistical significance.

Results

The proportion of any form of intimate partner violence during pregnancy among cases and controls was 53.23 and 34.82%, respectively. Any form of intimate partner violence (AOR = 3.66; 95% CI 1.69-7.95), physical intimate partner violence (AOR = 3.06; 95% CI 1.69-7.95), and an interpregnancy interval of <24 months (AOR = 4.46; 95% CI 1.65, 12.07), were the independent determinants of spontaneous abortion among survivors.

Conclusion

Spontaneous abortion was significantly associated with exposure to any form of intimate partner violence, including physical intimate partner violence, and a shorter inter-pregnancy interval.

Mortality Rate and Predictors Among Women With Obstructed Labor in a Tertiary Academic Medical Center of Ethiopia: A Retrospective Cohort Study

Introduction

Obstructed labor is one of the most common preventable causes of maternal morbidity and mortality. In Ethiopia, 36% of maternal mortality was due to obstructed labor with uterine rupture. Thus, this study proposed to measure predictors of maternal mortality among women with obstructed labor in a tertiary academic medical center in Southern Ethiopia.

Methods

An institution-based retrospective cohort study was conducted at Hawassa University Specialized Hospital from July 25 to September 30, 2018. Women who had obstructed labor from 2015 to 2017 were recruited. A pretested checklist was used to retrieve data from the woman's chart. A multivariable logistic regression model was employed to identify variables associated with maternal mortality, and variables with a p-value <.05 were considered significant at 95% CI.

Results

With a response rate of 96.3%, 156 moms who experienced labor obstruction were included in the study. Obstructed labor caused the deaths of 14 women, resulting in a maternal mortality rate of 8.9% (95% CI: 7.15, 16.4). Maternal mortality from obstructed labor was reduced in women who received antenatal care visits (AOR = 0.25, 95% CI: 0.13, 0.76) and blood transfusions (AOR =  0.49, 95% CI: 0.03, 0.89). Women who experienced uterine rupture (AOR =  6.25, 95% CI: 5.3, 15.6) and antepartum hemorrhage (AOR = 14, 95% CI: 2.45, 70.5) had a greater risk of maternal mortality than women who did not have the corresponding morbidity.

Conclusions

The center had a higher rate of maternal mortality due to obstructed labor. Early screening and improving the care for women at greatest risk of antenatal and postnatal co-morbidities like uterine rupture and shock were the major priorities and fundamental strategies to decreasing maternal mortality. It also showed that antenatal care visits, early referral, and blood transfusion for women with obstructed labor should be amended in order to lower maternal mortality.

Assessment of Organ Dysfunction and Underlying Causes in Maternal Near-miss Cases at Health Care Facilities in Doiwala Block of District Dehradun - A Retrospective Study

INTRODUCTION

The extent of maternal morbidity is a good gauge of a nation's maternal health care system. Maternal near-miss (MNM) cases need to be reviewed because they can indirectly contribute significantly to reducing the maternal mortality ratio in India. MNM cases can provide useful information in this context. Such women who survive these life-threatening conditions arising from complications during pregnancy, childbirth and post partum (42 days) share many commonalities with those who die because of such complications.

AIM

To assess the organ dysfunction and the underlying causes, associated/contributory factors associated with "maternal near-miss" cases in pregnant, in labor, post-partum women (upto42 days) in the health care facilities of Doiwala block, district Dehradun.

MATERIALS AND METHODS

The present study was conducted over a period of 6 months under the Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh. The cross-sectional study included the medical record files of all pregnant women attending the Department of Obstetrics and Gynecology, in the selected healthcare facilities of Doiwala block, district Dehradun. This study was conducted as per the WHO criteria for "near-miss" by using convenience sampling for the selection of healthcare facilities. The medical record files of all women who were pregnant, in labor, or who had delivered or aborted up to 42 days were included from a period of 01.06.2021 - 31.05.2022.

RESULTS

It was found that Out of the women with maternal near-miss (n=91), the majority of women had coagulation /hematological dysfunction (n=45, 49.4%), followed by neurologic dysfunction (n=15, 16.4%), cardio-vascular dysfunction (n=11, 12%). Out of the total women with a maternal near-miss (n = 91), 10 women underwent multiple organ dysfunctions. Of the total 91 maternal near-miss cases, the underlying cause of near-miss was obstetric hemorrhage in almost half the participants (n=45, 49.5%) followed by hypertensive disorders (n=36, 39.5%). Eleven women had a pregnancy with abortive outcomes (12%) and 7 women had pregnancy-related infection. It was also seen that, out of 91 near-miss women, the leading contributory /associated cause was Anemia (n=89, 97.8%) followed by women having a history of previous cesarean section (n=63, 69.2%). Sixteen women had prolonged /obstructed labor (n = 16, 17.58%).

CONCLUSION

Pregnancy should be a positive experience for every woman of childbearing age. A better understanding of pregnancy-related conditions enables early detection of complications and prevents the conversion of mild to moderate maternal morbidity outcomes to severe maternal outcomes with long-term health implications or death. There are already effective measures in place to reduce maternal and newborn mortality and morbidity.

Predictors and Pathway of Maternal Near Miss: A Case-Control Study in a Tertiary Care Facility in Kolkata

Background

Use of maternal near-miss (MNM) cases as an adjunct has been advocated to understand the processes of obstetric care because they share similar pathways as maternal deaths. Identifying the predictors and care pathway is crucial to improve the quality of care and end preventable maternal deaths.

Materials and Methods

This case-control study was conducted at a tertiary care facility in Kolkata from May 2019 to March 2020. Women admitted with complications during pregnancy, childbirth, or within 42 days of postpartum, who met the World Health Organization (WHO) near-miss criteria, were identified as cases, and equivalent age-group matched controls were recruited. Sample size of 60 cases and 60 controls was estimated, assuming a power of 80%, level of significance 0.05, and case-control ratio of 1. After obtaining approval from the institutional ethics committee and informed written consent from the participants, data was collected through face-to-face interview and review of records. Statistical analysis including care pathway analysis (using three-delay model) was performed using Statistical Package for Social Sciences version 16.

Results

Joint family type (adjusted odds ratio [AOR] [CI] = 5.06 [1.48, 7.28]), lack of antenatal checkups (AOR [CI] = 7.85 [1.47, 12.09]), previous history of cesarean section (AOR [CI] = 3.94 [1.09, 14.33]), first delay in seeking care (AOR [CI] = 13.84 [3.62, 32.83]), and preexisting medical disorders (AOR [CI] = 11.03 [4.62, 22.80]) were identified as significant predictors of MNM in the adjusted model. Significant difference in the proportion of first and second delays in the care pathway was observed between cases and controls.

Conclusions

Identification of risk factors of MNM and pattern of delays in the care pathway will help improving quality of obstetric care.

Obstructed labor and its effect on adverse maternal and fetal outcomes in Ethiopia: A systematic review and meta-analysis

Background

Obstructed labor is one of the five major causes of maternal mortality and morbidity in developing countries. In Ethiopia, it accounts for 19.1% of maternal death. The current review aimed to assess maternal and perinatal outcomes of obstructed labor in Ethiopia.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed for this systematic review and meta-analysis. A literature search was made using PubMed/MEDLINE, CINAHL, Summon country-specific search, and Cochrane Libraries’ online databases. Search terms were adverse outcome, obstructed labor, maternal outcome, fetal outcome, and Ethiopia. The Newcastle-Ottawa scale (NOS), based on a star scoring system, was used to assess the quality of the included studies. The meta-analysis was conducted using STATA 16 software. The pooled prevalence of an adverse maternal outcome, fetal outcome, and association between adverse outcome and obstructed labor was calculated using a random-effects model. Egger’s test and funnel plot were used to evaluate publication bias.

Result

Eighty-seven studies were included in this review, with an overall sample size of 104259 women and 4952 newborns. The pooled incidence of maternal death was estimated to be 14.4% [14.14 (6.91–21.37). The pooled prevalence of uterine rupture and maternal near-miss was 41.18% (95% CI: 19.83, 62.54) and 30.5% [30.5 (11.40, 49.59) respectively. Other complications such as postpartum hemorrhage, sepsis, obstetric fistula, hysterectomy, bladder injury, cesarean section, and labor abnormalities were also reported. The pooled prevalence of perinatal death was 26.4% (26.4 (95% CI 15.18, 37.7). In addition, the association of obstructed labor with stillbirth, perinatal asphyxia, and meconium-stained amniotic fluid was also demonstrated.

Conclusions

In Ethiopia, the incidence of perinatal and maternal mortality among pregnant women with obstructed labor was high. The rate of maternal death and maternal near miss reported in this review was higher than incidences reported from high-income and most low and middle-income countries. Uterine rupture, postpartum hemorrhage, sepsis, fistula, hysterectomy, and bladder injury were also commonly reported. To improve the health outcomes of obstructed labor, it is recommended to address the three delay models: enhancing communities’ health-seeking behavior, enhancing transportation for an obstetric emergency with different stakeholders, and strengthening the capacity of health facilities to handle obstetric emergencies.

Longitudinal path analysis for the directional association of depression, anxiety and posttraumatic stress disorder with their comorbidities and associated factors among postpartum women in Northwest Ethiopia: A cross-lagged autoregressive modelling study

Introduction

Vulnerability for depression, anxiety and posttraumatic stress disorder symptoms due to perceived traumatic birth increase during the postpartum period. Traumatic birth has been defined as an event occurring during labour and birth that may be a serious threat to the life and safety of the mother and/or child. However, the comorbidity and multimorbidity of depression, anxiety and PTSD with their direct and indirect predictors is not well investigated in the postpartum period. In addition, the longitudinal directional association of depression, anxiety and PTSD with their comorbidities is not studied in Ethiopia.

Objective

The aim of this study was to assess prevalence of postnatal comorbid and multimorbid anxiety, depression and PTSD. It also aimed to determine the directional association of postnatal anxiety, depression and PTSD with the comorbidity and multimorbidity of these mental health problems over time and to explore the factors that are directly or indirectly associated with comorbidity and multimorbidity of anxiety, depression and PTSD.

Methods

A total of 775 women were included at the first, second and third follow-up of the study (6^th, 12^th and 18^th week of postpartum period) during October, 2020 –March, 2021. A cross-lagged autoregressive path analysis was carried out using Stata 16.0 software in order to determine the autoregressive and cross-lagged effects of depression, anxiety and PTSD with their comorbidities. In addition, a linear structural equation modelling was also carried out to determine the direct and indirect effects of independent variables on the comorbidities of depression, anxiety and PTSD.

Results

Comorbidity of anxiety with depression was the most common (14.5%, 12.1% and 8.1%) at the 6^th, 12^th and 18^th week of postnatal period respectively. With regard to the direction of association, comorbidity of PTSD (due to perceived traumatic birth) with depression, PTSD with anxiety, depression with anxiety and triple comorbidity predicted depression and anxiety in subsequent waves of measurement. Direct and indirect maternal morbidity, fear of childbirth and perceived traumatic childbirth were found to have a direct and indirect positive association with comorbidities of depression, anxiety and PTSD. In contrast, higher parity, higher family size and higher social support had a direct and indirect negative association with these mental health disorders.

Conclusion

Postnatal mental health screening, early diagnosis and treatment of maternal morbidities, developing encouraging strategies for social support and providing adequate information about birth procedures and response to mothers’ needs during childbirth are essential to avert comorbidity of anxiety, depression and PTSD in the postpartum period.

Determinants of obstructed labour and its adverse outcomes among women who gave birth in Hawassa University referral Hospital: A case-control study

Background

Globally, obstructed labour accounted for 22% of maternal morbidities and up to 70% of perinatal deaths. It is one of the most common preventable causes of maternal and perinatal mortality in low-income countries. However, there are limited studies on the determinants of obstructed labor in Ethiopia. Therefore, this study was conducted to assess determinants and outcomes of obstructed labor among women who gave birth in Hawassa University Hospital, Ethiopia.

Methods

A hospital-based case-control study design was conducted in Hawassa University Hospital among 468 women. All women who were diagnosed with obstructed labour and two consecutive controls giving birth on the same day were enrolled in this study. A pretested data extraction tool was used for data collection from the patient charts. Multivariable logistic regression was employed to identify determinants of obstructed labor.

Results

A total of 156 cases and 312 controls were included with an overall response rate of 96.3%. Women who were primipara [AOR 0.19; 95% CI 0.07, 0.52] and multigravida [AOR 0.17; 95% CI 0.07, 0.41] had lower odds of obstructed labour. While contracted pelvis [AOR 3.98; 95% CI 1.68, 9.42], no partograph utilization [AOR 5.19; 95% CI 1.98, 13.6], duration of labour above 24 hours [AOR 7.61; 95% CI 2.98, 19.8] and estimated distance of 10 to 50 kilometers from the hospital [AOR 3.89; 95% CI 1.14, 13.3] had higher odds. Higher percentage of maternal (65.2%) and perinatal (60%) complications occurred among cases (p-value < 0.05). Obstructed labour accounted for 8.3% of maternal deaths and 39.7% of stillbirth. Uterine rupture, post-partum haemorrhage and sepsis were the common adverse outcomes among cases.

Conclusion

Parity, contracted pelvis, non-partograph utilization, longer duration of labour and longer distance from health facilities were determinants of obstructed labour. Maternal and perinatal morbidity and mortality due to obstructed labour are higher. Therefore, improvement of partograph utilization to identify complications early, birth preparedness, complication readiness and provision of timely interventions are recommended to prevent such complications.

Factors Associated with Caesarean and Peripartum Complications at Southern Mozambique’s Rural Hospitals: A Cross-Sectional Analytical Study

Information about factors underlying peripartum complications is needed to inform health programs in Mozambique. This retrospective study covered the period from January 2013 to December 2018 and was performed at three rural-district hospitals in southern Mozambique, aiming at assessing factors associated with caesarean and peripartum complications. Data were extracted by clinical criteria-based audits on randomly select clients’ files. Logistical regression was used to identify factors associated with peripartum complications. Amongst 5068 audited files, women mean age was 25 years (Standard Deviation (SD) = 7), gestational age was 38 weeks (SD = 2), 25% had “high obstetric-risk” and 19% delivered by caesarean. Factors significantly associated with caesarean included being transferred [Adjusted Odds Ratio (aOR) =1.8; 95% Confidence Interval (95%CI) = 1.3–2.6], preeclampsia [aOR (95%CI) = 2.0 (1.2–3.3)], age [aOR (95%CI) = 0.96 (0.93–0.99)] and “high obstetric-risk” [aOR (95%CI) = 0.54 (0.37–0.78)]. Factors significantly associated with neonatal complication included mother being transferred [aOR (95%CI) = 2.1 (1.8–2.6)], “high obstetric-risk” [aOR (95%CI) = 1.6 (1.3–1.96)], preeclampsia [aOR (95%CI) = 1.5 (1.2–1.8), mother’s age [aOR (95%CI) = −2% (−3%, −0.1%)] and gestational age [aOR (95%CI) = −8% (−13%, −6%)] increment. This study identified amendable factors associated with peripartum complications in rural referral health settings. Strengthening hospitals’ performance assurance is critical to address the identified factors and improve peripartum outcomes for mothers-neonate dyads.

Severe Maternal Outcomes and Quality of Maternal Health Care in South Ethiopia

Objective

To assess the incidence of severe maternal outcomes (SMO) and quality of maternal health care in south Ethiopia.

Methods

A facility-based prospective study was conducted in three hospitals among all women who presented while pregnant, during and after childbirth between 12 July and 26 November 2018. Participants were followed from the time of admission to discharge. The World Health Organization (WHO) maternal near-miss (MNM) approach was used to assess SMO indicators and quality of maternal health care.

Results

Of 2880 live births, 315 had potentially life-threatening conditions and 108 had SMOs (90 MNM and 18 maternal deaths). The SMO incidence ratio was 37.5 per 1000 live births (95% CI 30.6–44.4) and MNM incidence ratio was 31.3 per 1000 live births (95% CI 24.9–37.7). The ratio of near-miss to maternal deaths was 5:1. The hospitals’ maternal mortality ratio (MMR) was 625 per 100,000 live births. Most (82.1%) SMO cases were referred from other health facilities. The most common cause of SMO was eclampsia (37%) followed by postpartum haemorrhage (33.3%). The highest mortality index (MI) was among women with sepsis (27.3%). The intensive care unit (ICU) admission rate was 13% for women with SMO and 83.3% of maternal deaths occurred without ICU admission.

Conclusion

The SMO ratio was comparable to other studies in the country. Most women with SMO were referred from other health facilities, which demonstrate the presence of the first delay (seeking care) and/or the second delay (reaching care) in the study area. The study suggests that effectively using the ICU, reducing delays, and improving the referral system may reduce SMO and improve the quality of care in the hospitals. Furthermore, continuous reviewing of SMO is needed to learn what treatment was given to women who experienced complications in the hospitals.

Severe maternal morbidity and its associated factors: A cross-sectional study in Morang district, Nepal

BACKGROUND

Understanding maternal morbidity and its determinants can help identify opportunities to prevent obstetric complications and improvements for maternal health. This study was conducted to determine the prevalence of severe maternal morbidity (SMM) and the associated factors.

METHODS

A hospital-based cross-sectional study was conducted at Koshi Hospital, Nepal, from January to March 2020. All women who met the inclusion criteria of age ≥18 years of age, Morang residents of Nepalese nationality, had received routine antenatal care, and given birth at Koshi Hospital were recruited consecutively. The World Health Organization criteria were used to identify the women with SMM. A multiple logistic regression analysis was performed. Overall, 346 women were recruited.

FINDINGS

The prevalence of SMM was 6.6%. Among the SMM cases, the most frequently occurring SMM conditions were hypertensive disorders (12, 56.5%), hemorrhagic disorders (6, 26.1%), and severe management indicators (8, 34.8%). Women with no or primary education (adjusted odds ratio: 0.10, 95% confidence interval: 0.01, 0.76) decreased the odds of SMM compared to secondary education.

CONCLUSION

The approximately 7% prevalence of SMM correlated with global studies. Maternal education was significantly associated with SMM. If referral hospitals were aware of the expected prevalence of potentially life-threatening maternal conditions, they could plan to avert future reproductive complications.

Maternal near-miss and mortality in a teaching hospital in Tigray region, Northern Ethiopia

Objective:

This study seeks to examine the prevalence of maternal morbidities and deaths in Ayder Comprehensive Specialized Hospital from 1 July 2018 to 30 June 2019.

Methods:

This was a cross-sectional study. Total purposive sampling method was employed to collect data prospectively using modified World Health Organization criteria for baseline assessment of maternal near-miss and mortality. Pregnant women or those who are within 42 days postpartum/any form of pregnancy termination that satisfy the inclusion criteria were enrolled.

Results:

A total of 691 mothers were recorded as having severe maternal complications. Out of these, 170 women developed severe maternal outcome, ending with 146 maternal near-miss cases and 24 maternal deaths. The maternal near-miss ratio and maternal mortality ratio were 28.5 per 1000 live births and 469.1 per 100,000 live births, respectively. The overall mortality index was 14%. The top underlying causes of severe maternal complications were the infamous triads of preeclampsia (n = 303, 43.8%), obstetric hemorrhage (n = 166, 24.0%) and sepsis (n = 130, 18.8%). About 62.5% of mothers who died were not admitted to intensive care unit.

Conclusion:

This study found that the infamous triads of preeclampsia, obstetric hemorrhage and sepsis persist as the commonest causes of severe maternal complications in the study area. A significant number of women with severe maternal outcome were not admitted to intensive care unit. It also highlights that the severe maternal complications, severe maternal outcome, maternal near-miss ratio and mortality index in the study area are disproportionately higher than the global average. These staggering numbers call for a system re-thinking at multiple junctures.

Cost of maternal near miss and potentially life-threatening conditions, Kenya

OBJECTIVE

To estimate the direct costs of treating women with maternal near misses and potentially life-threatening conditions in Kenya and the factors associated with catastrophic health expenditure for these women and their households.

METHODS

As part of a prospective, nationally representative study of all women with near misses during pregnancy and childbirth or within 42 days of delivery or termination of pregnancy, we compared the cost of treating maternal near-miss cases admitted to referral facilities with that of women with potentially life-threatening conditions. We used logistic regression analysis to assess clinical, demographic and household factors associated with catastrophic health expenditure.

FINDINGS

Of 3025 women, 1180 (39.0%) had maternal near misses and 1845 (61.0%) had potentially life-threatening conditions. The median cost of treating maternal near misses was 7135 Kenyan shillings (71 United States dollars, US$) compared with 2690 Kenyan shillings (US$ 27) for potentially life-threatening conditions. Of the women who made out-of-pocket payments, 26.4% (122/462) experienced catastrophic expenditure. The highest median costs for treatment of near misses were in Nairobi and Central region (22 220 Kenyan shillings; US$ 222). Women with ectopic pregnancy complications and pregnancy-related infections had the highest median costs of treatment, at 7800 Kenyan shillings (US$ 78) and 3000 Kenyan shillings (US$ 30), respectively. Pregnancy-related infections, abortion, ectopic pregnancy, and treatment in secondary and tertiary facilities were significantly associated with catastrophic expenditure.

CONCLUSION

The cost of treating maternal near misses is high and leads to catastrophic spending through out-of-pocket payments. Universal health coverage needs to be expanded to guarantee financial protection for vulnerable women.

Effect of maternal near miss on neonatal mortality in selected hospitals: Prospective cohort study, Southeast Ethiopia

OBJECTIVE

The objective of this study was to assess effect of maternal near miss on neonatal mortality.

METHODS

Prospective cohort study was conducted on 384 pregnant women who came for delivery to purposely selected hospitals. The cohort was made up of 128 exposed (near miss) mothers and 256 non-exposed (non-near-miss) mothers. Women who came for delivery were only included. Those who came for services other than delivery such as abortion care, women who developed life-threatening condition not related to delivery, and those who come from no phone network area were excluded. A purposive sampling technique was used by including all mothers with near miss consecutively until the required sample size was obtained. Two non-near-miss mothers were selected using lottery for every near-miss mother. Survival analysis was done for both groups using Cox regression to look for effect of maternal near miss on neonatal mortality. Verbal informed consent from study participants was obtained.

RESULTS

A total of 354 (118 with near miss and 236 without near miss) women completed the follow-up time, yielding response rate of 92.2%. Of all, 55 (15.5%) of them have previous history of abortion, 44 (12.4%) were admitted to the intensive care unit during delivery, and 22 (6.2%) have history of past delivery of still birth. Severe preeclampsia with intensive care unit admission and severe anemia with transfusion of greater than 2 units of blood were common complications leading to maternal near miss. There were 17 (48 per 1000 live birth) neonatal death at the end of the study, of which 15 occurred among mothers with near miss. Monthly income (adjusted hazard ratio = 998, 95% confidence interval = 0.996-0.999), fetal presentation (adjusted hazard ratio = 6.48, 95% confidence interval = 1.84-22.73), APGAR score (adjusted hazard ratio = 0.746, 95% confidence interval = 0.620-0.898), and being near miss mother (adjusted hazard ratio = 8.40, 95% confidence interval = 1.638-43.118) were significantly affecting neonatal mortality.

CONCLUSION

Maternal near miss and other fetal and general maternal characteristics have effect on occurrence of neonatal mortality. Therefore, due attention should be given to these factors for improvement of neonatal survival.

Lived experiences of women with maternal near miss: a qualitative research

OBJECTIVE

A near-miss experience has long-term and major impacts on mothers and their families. Therefore, evaluating the nature of maternal near-miss (MNM) could shed light on various aspects of the associated complications in women. The present study aimed to determine the lived experiences of women with MNM.

METHODS AND MATERIALS

This qualitative research was conducted using conventional content analysis on 10 mothers with an MNM experience, who were selected based on the inclusion criteria. Data were collected via semi-structured interviews about the experiences of the mothers during and after the near-miss incident. Data analysis was performed using the conventional content analysis technique.

RESULTS

Five main categories were extracted, including fears and concerns, failure to accept and adapt, tolerating physical and psychological pain and hardships, death experience, and medical team mismanagement. Regret and fear of raising the child with siblings, fear of the re-marriage of the spouse, and fear of complications and costs were among the subcategories of fears and concerns. Lack of adaptation to the complications and prolonged mourning were the subcategories of failure to accept and adapt, and the subcategories of tolerating physical and psychological pain and hardships were a sense of guilt, tolerating physical pain, hopelessness, irritability, hatred toward the medical team, and postpartum depression. In addition, returning to normal life, and seeing/actually feeling death were the subcategories of the death experience. The subcategories of the medical team mismanagement included medical errors, lack of support/negligence, communication problems, and distrust of the medical center.

DISCUSSION

According to the results, the mothers were faced with multiple problems, including fears and concerns, failure to adapt to the problem, and numerous physical and psychological issues after an MNM experience. However, they believed that medical errors, the improper communications of the medical team, and their negligence toward patients were among the factors intensifying the complications.

Maternal near miss among women admitted in major private hospitals in eastern Ethiopia: a retrospective study

BACKGROUND

Since maternal mortality is a rare event, maternal near miss has been used as a proxy indicator for measuring maternal health. Maternal near miss (MNM) refers to a woman who nearly died but survived of complications during pregnancy, childbirth or within 42 days of termination of pregnancy. Although study of MNM in Ethiopia is becoming common, it is limited to public facilities leaving private facilities aside. The objective of this study was to assess MNM among women admitted in major private hospitals in eastern Ethiopia.

METHODS

An institution based retrospective study was conducted from March 05 to 31, 2020 in two major private hospitals in Harar and Dire Dawa, eastern Ethiopia. The records of all women who were admitted during pregnancy, delivery or within 42 days of termination of pregnancy was reviewed for the presence of MNM criteria as per the sub-Saharan African MNM criteria. Descriptive analysis was done by computing proportion, ratio and means. Factors associated with MNM were assessed using binary logistic regression with adjusted odds ratio (aOR) along with its 95% confidence interval (CI).

RESULTS

Of 1214 pregnant or postpartum women receiving care between January 09, 2019 and February 08, 2020, 111 women developed life-threatening conditions: 108 MNM and 3 maternal deaths. In the same period, 1173 live births were registered, resulting in an MNM ratio of 92.1 per 1000 live births. Anemia in the index pregnancy (aOR: 5.03; 95%CI: 3.12-8.13), having chronic hypertension (aOR: 3.13; 95% CI: 1.57-6.26), no antenatal care (aOR: 3.04; 95% CI: 1.58-5.83), being > 35 years old (aOR: 2.29; 95%CI: 1.22-4.29), and previous cesarean section (aOR: 4.48; 95% CI: 2.67-7.53) were significantly associated with MNM.

CONCLUSIONS

Close to a tenth of women admitted to major private hospitals in eastern Ethiopia developed MNM. Women with anemia, history of cesarean section, and old age should be prioritized for preventing and managing MNM. Strengthening antenatal care and early screening of chronic conditions including hypertension is essential for preventing MNM.

Obstructed labor and its association with adverse feto-maternal outcome in Ethiopia: a protocol for a systematic review and meta-analysis

BACKGROUND

Obstructed labor accounted for 22% of obstetrical complications and 9% of all maternal deaths in low- and middle-income countries. Even though there are separate studies regarding obstructed labor and its complication in Ethiopia, their results are inconsistent. The objectives of this review will be to estimate the pooled the prevalence of obstructed labor and to identify adverse feto-maternal outcomes associated with obstructed labor in Ethiopia.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline will be followed to conduct this systematic review and meta-analysis. The databases we will search will be PubMed, Cochrane Library, Google Scholar, CINAHL, African Journals Online, Dimensions, and Summon per country online databases. To search the relevant literature, we will use the following key search terms: "prevalence," "adverse outcome," "obstructed labour," "maternal near miss," "neonatal near miss," "perinatal outcome," "cesarean section," "obstetric fistula," "uterine rupture," and "Ethiopia." Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument will be used for evaluating the quality of the studies. Appropriate statistical tests will be conducted to quantify the between studies heterogeneity and for the assessment of publication bias. We will check individual study influence analysis and also do subgroup analysis. The STATA version 15 will be used for statistical analysis.

DISCUSSION

Our systematic review and meta-analysis will provide the pooled prevalence of obstructed labor and its association with adverse feto-maternal outcomes in Ethiopia. The finding of this study will be helpful to design appropriate preventive and promotive strategies for reducing of obstructed labor-related maternal mortality.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020196153 .

Cost of Treating Maternal Complications and Associated Factors in Mekelle General Hospital, Northern Ethiopia

Background

The government of Ethiopia introduced an exemption policy that guarantees free maternal healthcare services from public providers. This policy aims to ensure financial protection and enhance utilization of services especially for low-income people. However, patients in most cases incur health expenditure when seeking health care. This paper aims to assess direct and indirect medical costs of treating maternal complications and associated factors at a public hospital in Northern Ethiopia.

Methods

An institution-based cross-sectional study design was carried on 267 mothers with complications. A multivariate linear regression model at 5% level of significance was used to analyze factors driving the outcome.

Results

The median cost was more than seven times the monthly minimum wage, and this may cause severe financial consequences for the poor. Direct medical costs accounted for the major share (68%) of total cost, and this was mainly driven by lack of diagnostic services at public facilities and paying for private providers. Expenditure for treatment of maternal complications is positively associated with income, absence from work, travel time to the facility and being diagnosed at a private facility.

Conclusion

The overall evidence in this study poses a concern about the context in which fee exemption reforms are being implemented.

Factors associated with maternal near-miss at public hospitals of South-East Ethiopia: An institutional-based cross-sectional study

Introduction:

Maternal near-miss precedes maternal mortality, and women are still alive indicating that the numbers of near-misses occur more often than maternal mortality. This study aims to assess the prevalence of maternal near-miss and associated factors at public hospitals of Bale zone, Southeast Ethiopia.

Methods:

Facility-based cross-sectional study design was carried out from 1 October 2018 to 28 February 2019, among 300 women admitted to maternity wards. A structured questionnaire and checklist were used to collect data. Epi-info for data entry and statistical package for social science for analysis were used. The descriptive findings were summarized using tables and text. Adjusted odds ratio with 95% confidence interval and p-value < 0.05 were used to examine the association between the independent and dependent variables.

Result:

The prevalence of maternal near-miss in our study area was 28.7%. Age < 20 years, age at first marriage < 20 years, husbands with primary education, and being from rural areas are factors significantly associated with the prevalence of maternal near-miss. The zonal health department in collaboration with the education department and justice office has to mitigate early marriage by educating the community about the impacts of early marriage on health.

Determinants of Maternal Near Miss in Western Ethiopia

Background

Analysis of maternal near miss events and identification of factors resulting in maternal death are vital to improve the quality of obstetric care in any given setting. This study is aimed to determine the magnitude of maternal miss and identify its determinants.

Methods

A hospital-based unmatched case-control study design was used. Sixty one maternal near misses (as cases) and 122 mothers who had a normal obstetric outcome (as controls) at obstetrics and gynecology ward of Nekemte Referral Hospital were included from May 1st, 2018 to July 31st, 2018. The criteria set by the World Health Organization were used to identify maternal near miss cases. The data were collected via face-to-face interviews using pretested structured questionnaires and analyzed using SPSS version 22. For every case, two controls were recruited. Descriptive statistics and logistic regressions were used. A 95% CI and p-value of <0.05 were considered to be statistically significant.

Result

The magnitude of maternal near miss was 4.97%. Factors including multigravidity (AOR= 3.84, 95% CI: 1.23–11.91), lack of antenatal care (AOR=6.02, 95% CI: 1.55–23.28), delays in accessing health facility (AOR=12, 95% CI: 2.55–56.57) and induction of labor (AOR =9.4, 95% CI: 2.97–29.71) were strongly associated with maternal near miss. Hypertension during pregnancy (40.9%) and obstetric hemorrhage (39.3%) were identified as the major causes of maternal near miss.

Conclusion

The magnitude of maternal near miss was high but lower compared to magnitude in other parts of Ethiopia, and numerous preventable determinant factors were identified.

Delays in emergency obstetric referrals in Addis Ababa hospitals in Ethiopia: a facility-based, cross-sectional study

OBJECTIVE

To assess where the delays occur in the referral chain of most maternal health outcomes in Addis Ababa, Ethiopia, based on the three-delay model.

DESIGN

The study was a facility-based, cross-sectional study.

SETTING

Two public and tertiary hospitals in Addis Ababa.

PARTICIPANTS

All pregnant women who were referred only for labour and delivery services after 28 weeks of gestation between December 2018 and February 2019 in Zewditu and Gandhi Memorial Hospitals.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the type of delays, from the three-delay model, which met operationally defined time. The secondary outcome was maternal health outcomes based on the three-delay model.

RESULTS

A total of 403 pregnant women referred for delivery to the study hospitals were included in the study. Three-fourths (301, 74.7%) of the referred pregnant women experienced the third delay (delay in receiving appropriate care); 211 (52.4%) experienced the first delay (delay in making a decision to seek care). Overall 366 (90.8%) pregnant women had experienced at least one of the three delays and 71 (17.6%) experienced all three delays. Twenty-nine (7.2%) referred women had severe maternal outcomes. The leading causes/diagnoses of severe maternal outcomes were blood transfusion (17, 58.6%), followed by postpartum haemorrhage (15, 52%) and eclampsia (9, 31%). In addition, women who experienced severe maternal outcomes were 2.9 times more likely to have experienced at least one of the three delays.

CONCLUSION AND RECOMMENDATION

This study highlights the persistence of delays at all levels, and especially the third delay and its contribution to severe maternal outcomes. We recommend strengthening the health referral systems and addressing specific health system bottlenecks during labour and birth in order to ensure no mother is endangered. We also recommend conducting a qualitative method of study (focus group discussion and indepth interview) and observing tertiary hospitals' set-up and readiness to manage obstetric emergencies.

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

Severe Hypertensive Disorders of Pregnancy in Eastern Ethiopia: Comparing the Original WHO and Adapted sub-Saharan African Maternal Near-Miss Criteria

OBJECTIVES

To assess life-threatening complications among women admitted with severe hypertensive disorders of pregnancy and compare applicability of World Health Organization (WHO) maternal near-miss (MNM) criteria and the recently adapted sub-Saharan African (SSA) MNM criteria in eastern Ethiopia.

METHODS

Of 1,054 women admitted with potentially life-threatening conditions between January 2016 and April 2017, 562 (53.3%) had severe preeclampsia/eclampsia. We applied the definition of MNM according to the WHO MNM criteria and the SSA MNM criteria. Logistic regression was performed to identify factors associated with severe maternal outcomes (MNMs and maternal deaths).

RESULTS

The SSA MNM criteria identified 285 cases of severe maternal outcomes: 271 MNMs and 14 maternal deaths (mortality index 4.9%). The WHO criteria identified 50 cases of severe maternal outcomes: 36 MNMs and 14 maternal deaths (mortality index 28%). The MNM ratio was 36.6 per 1,000 livebirths according to the SSA MNM criteria and 4.9 according to the WHO criteria. More than 80% of women in both groups had MNM events on arrival or within 12 hours after admission. Women without antenatal care, from rural areas, referred from other facilities, and with concomitant hemorrhage more often developed severe maternal outcomes.

CONCLUSION

Regarding hypertensive disorders of pregnancy, the SSA tool is more inclusive than the WHO tool, while still maintaining a considerably high mortality index indicating severity of included cases. This may enable more robust audits. Strengthening the referral system and improving prevention and management of obstetric hemorrhage in women with hypertensive disorders of pregnancy are required to avert severe maternal outcomes.

The MOMENTUM study: Putting the 'Three Delays' to work to evaluate access to emergency obstetric and neonatal care in a remote island community in Western Kenya

Despite worldwide improvements in maternal and infant mortality, mothers and babies in remote, low-resource communities remain disproportionately vulnerable to adverse health outcomes. In these settings, delays in accessing emergency care are a major driver of poor outcomes. The 'Three Delays' model is now widely utilised to conceptualise these delays. However, in out-of-hospital contexts, operational and methodological constraints present major obstacles in practically quantifying the 'Three Delays'. Here, we describe a novel protocol for the MOMENTUM study (Monitoring of Maternal Emergency Navigation and Triage on Mfangano), a 12-month cohort design to assess delays during obstetric and neonatal emergencies within the remote villages of Mfangano Island Division, Lake Victoria, Kenya. This study also evaluates the preliminary impact of a community-based intervention called the 'Mfangano Health Navigation' programme. Utilising participatory case audits and contextually specific chronological reference strategies, this study combines quantitative tools with deeper-digging qualitative inquiry. This pragmatic design was developed to empower local research staff and study participants themselves as assets in unravelling the complex socio-economic, cultural, and logistical dynamics that contribute to delays, while providing real-time feedback for locally driven intervention. We present our methods as an adaptive framework for researchers grappling with similar challenges across fragmented, rural health landscapes.

Incidence of maternal near miss among women in labour admitted to hospitals in Ethiopia

OBJECTIVES

To assess the incidence of maternal near miss and contributing factors among hospitals in Ethiopia. The study also assessed the ability of hospitals to provide signal functions of emergency obstetric care and its regional distribution.

DESIGN

A national dataset accessed from the Ethiopian Public Health Institute were analysed to assess the incidence of maternal near miss and mortality index among women admitted to hospitals with obstetric complications.

SETTING

Maternal health indicators including obstetric complications, maternal deaths and births conducted at all hospitals available in Ethiopia were included.

MEASUREMENTS

The maternal near miss incidence ratio, which is the number of near miss cases per 1,000 live births, and the mortality index were presented descriptively. Chi-squared test at p value ≤ 0.05 was used to assess the presence of significant regional differences of the provision of signal functions of emergency obstetric care.

RESULTS

In 2015, 78,195 women were admitted to hospitals with both the direct (68,002) and indirect (10,193) causes of maternal mortality. Of women who experienced the direct causes, 435 died which means there were 67,567 maternal near miss cases. In the same year, 323,824 live births were reported in hospitals, making the crude maternal near miss incidence ratio of 20.8% (9.1-38.8%) and mortality index of 0.64% (435/68,002) for the direct causes of maternal mortality. A significant regional variation was observed with regard to incidence of maternal near miss, mortality index and the provision of signal functions of emergency obstetric care. Administration of parenteral antibiotics was the most frequently practiced signal function of emergency obstetric care while blood transfusion was the least provided signal function.

CONCLUSIONS

In Ethiopian hospitals, the incidence of maternal near miss was unacceptably high. A significant regional variation was detected with regard to maternal near miss incidence ratio, mortality index and the provision of signal functions of emergency obstetric care. The Ethiopian government needs to work on equitable resource distribution and quality improvement initiatives in order to close the detected regional variations.

IMPLICATIONS FOR PRACTICE

The Ethiopian government needs to practice evidence-based maternal health strategies, including capacity building of the regional hospitals in order to improve the distribution of resources and quality of maternal health.

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.

Impact of Training on Awareness and Knowledge of Service Providers About Maternal Near-Miss Events in Maharashtra, India

Objective

To improve the awareness and knowledge regarding Maternal Near Miss (MNM) among health service providers in the selected districts and women's hospitals in Maharashtra, India.

Methods

A one-day training programme on MNM was conducted at four Family Welfare Training Centres in the state of Maharashtra, India, for the health service providers, viz. gynaecologists, pathologists, anaesthesiologists, medical officers, staff nurses, other paramedical workers of the selected 29 districts/women's hospitals in Maharashtra. A total of 147 participants participated in the training programme. The participants filled a questionnaire before (pretest) and after the training (post-test) with the same set of questions pertaining to knowledge on the basic and operational aspects of MNM.

Results

There was a significant improvement in the level of knowledge (post-test responses vs pretest responses) about the correct definition and classification of MNM, as per the instructions in the MNM-R guidelines by the Government of India. The service providers informed regarding the challenges in the implementation of the MNM-R guidelines at their hospitals such as shortage of manpower in terms of specialists and need of quality assurance.

Conclusion

The training programme improved the knowledge of the service providers about MNM, which would help them to implement the MNM-R guidelines effectively at their hospitals. This training effectively upgraded the knowledge level, and therefore, such trainings should be organized for all obstetricians, high-dependency unit (HDU) personnel and critical care teams.

Maternal near miss determinants at a maternity hospital for high-risk pregnancy in northeastern Brazil: a prospective study

Background

To investigate the association between sociodemographic and obstetric variables and delays in care with maternal near misses (MNMs) and their health indicators.

Methods

A prospective cohort study was conducted at a high-risk maternity hospital in northeastern Brazil from June 2015 to May 2016 that included all pregnant women seen at the maternity hospital during the data collection period and excluded those who had not been discharged at the end of the study or whom we were unable to contact after the 42nd postpartum day for MNM control. We used the MNM criteria recommended by the WHO. Risk ratios (RRs) and their 95% confidence intervals (CIs) were calculated. Hierarchical multiple logistic regression analysis was performed. The p values of all tests were two-tailed, and the significance level was set to 5%.

Results

A total of 1094 pregnant women were studied. We identified 682 (62.4%) women without adverse maternal outcomes (WOAMOs) and 412 (37.6%) with adverse maternal outcomes (WAMOs), of whom 352 had potentially life-threatening conditions (PLTCs) (85.4%), including 55 MNM cases (13.3%) and five maternal deaths (1.2%). During the study period, 1002 live births (LBs) were recorded at the maternity hospital, resulting in an MNM ratio of 54.8/1000 LB. The MNM distribution by clinical condition identified hypertension in pregnancy (67.2%), hemorrhage (42.2%) and sepsis (12.7%). In the multivariate analysis, the factors significantly associated with an increased risk of MNM were fewer than six prenatal visits (OR: 3.13; 95% CI: 1.74–5.64) and cesarean section in the current pregnancy (OR: 2.91; 95% CI: 1.45–5.82).

Conclusions

The factors significantly associated with the occurrence of MNM were fewer than six prenatal visits and cesarean section in the current pregnancy. These findings highlight the need for improved quality, an increased number of prenatal visits and the identification of innovative and viable models of labor and delivery care that value normal delivery and decrease the percentage of unnecessary cesarean sections.

Clinical Spectrum of Near-miss Cases in Obstetrics

Introduction Near-miss obstetric cases are the ones which have survived childbirth after a life-threatening and complicated pregnancy. The aim of this study is to evaluate important characteristics and causes of near-miss cases, compare them with maternal deaths, and assess urgent interventions managing these patients. Materials and methods This prospective, cross-sectional study was conducted in the intensive care unit of the Obstetrics and Gynecology department. Clinical spectrum of near-miss patients was compared with that of maternal deaths. Data was entered and analyzed using Statistical Package for the Social Sciences (SPSS) Statistics for Windows, version 21.0 (IBM Corp., Armonk, NY). Results The incidence of near-miss events was 31.4/1,000 live births. The incidence of maternal mortality was 8.2/1,000 live births. The ratio of near-miss to maternal mortality was 3.8:1. Hemorrhage, hypertensive disorders, and puerperal sepsis were the leading causes of near-miss cases. Conclusion Evaluation of characteristics of near-miss cases helps in establishing severe maternal morbidity. These high-risk patients must be provided urgent interventions to prevent maternal mortality.

Applicability of the WHO maternal near miss tool in sub-Saharan Africa: a systematic review

Background

Applicability of the World Health Organization (WHO) maternal near miss criteria in low-income settings is not systematically addressed in the literature. The objective of this review was to determine the applicability of the WHO maternal near miss tool in sub-Saharan Africa.

Methods

We searched PubMed, Embase, Popline, CINAHL, AJOL, and Google scholar using key words for maternal near miss and sub-Saharan Africa. Studies which applied the WHO maternal near miss criteria, containing clear definitions, and published between January 1st, 2009 and December 31st, 2017 were included. Two authors independently extracted data. Quantitative analysis and narrative synthesis were conducted, and medians with interquartile range (IQR) were calculated for summarizing the findings. Methodological quality of the studies was assessed using the Estabrook’s quality assessment and validity tool.

Results

Fifteen studies from nine countries comprising 227,077 participants were included. Median maternal near miss ratio was 24.2 (IQR: 12.4–35.8) per 1000 live births ranging from 4.4 in a population-based study in South Africa to 198 in a rural private hospital in Nigeria. Eight studies reported challenges in implementing the WHO maternal near miss tool, especially related to the threshold for blood transfusion, and availability of several laboratory-based criteria. In three studies, local adaptations were made.

Conclusion

This review showed that the WHO maternal near miss tool is not uniformly applied in sub-Saharan Africa. Therefore, a common adaptation for the region is required to increase its applicability.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2225-7) contains supplementary material, which is available to authorized users.

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’.

Maternal near-miss and the risk of adverse perinatal outcomes: a prospective cohort study in selected public hospitals of Addis Ababa, Ethiopia

Background

Presence of maternal near-miss conditions in women is strongly associated with the occurrence of adverse perinatal outcomes, but not well-understood in low-income countries. The study aimed to ascertain the effect of maternal near-miss on the risk of adverse perinatal outcomes in Ethiopia.

Methods

A prospective cohort study was conducted in five public hospitals of Addis Ababa, Ethiopia. Women admitted from May 1, 2015 to April 30, 2016 were recruited for the study. We followed a total of 828 women admitted for delivery or treatment of pregnancy-related complications along with their singleton newborn babies. Maternal near-miss was the primary exposure and was ascertained using the World Health Organization criteria. Women who delivered without complications were taken as the non-exposed groups. The main outcome was adverse perinatal outcomes. Data on maternal near-miss and perinatal outcomes were abstracted from medical records of the participants. Exposed and non-exposed women were interviewed by well-trained data collectors to obtain information about potential confounding factors. Logistic regressions were performed using Stata version 13.0 to determine the adjusted odds of adverse perinatal outcomes.

Results

A total of 207 women with maternal near-miss and 621 women with uncomplicated delivery were included in the study. After adjusting for potential confounders, women with maternal near-miss condition had more than five-fold increased odds of adverse perinatal outcomes compared to women who delivered without any complications (AOR = 5.69: 95% CI; 3.69–8.76). Other risk factors that were independently associated with adverse perinatal outcomes include: rural residence, history of prior stillbirth and primary educational level.

Conclusions

Presence of maternal near-miss in women is an independent risk factor for adverse perinatal outcomes. Hence, interventions rendered at improvement in maternal health of Ethiopia can lead to an improvement in perinatal outcomes.

Predictors of maternal near miss among women admitted in Gurage zone hospitals, South Ethiopia, 2017: a case control study

BACKGROUND

Maternal mortality and morbidity remain unacceptably high in developing countries. Behind every maternal death, many other women suffered from acute and chronic obstetric complications. Women who survive severe acute maternal morbidities/near miss have many characteristics in common with maternal death events particularly on risk factors. Ethiopia is among countries with high maternal mortality and morbidities in sub-Saharan Africa. However there is scarce evidence on risk factors of severe acute maternal morbidities in Ethiopia. Therefore this study aimed to identify predictors of maternal near miss among women admitted in Gurage zone hospitals, south Ethiopia, 2017.

METHODS

Hospital based case control study was conducted to assess predictors of maternal near miss among women admitted in five hospitals of Gurage zone, South Ethiopia. Data of 229 (77 cases and 152 controls) women were included in the analysis. Cases were women admitted due to severe acute maternal morbidity while controls were women admitted for normal labor or women admitted due to mild to moderate obstetric complications. Cases were identified by validated-disease specific criteria. Then, two controls were selected for each verified case using lottery method among eligible women. Data were collected using interviewer administered questionnaire and reviewing patients' records. Data were entered using Epi Info 7 and analyzed by SPSS 21. Multivariable logistic regression analysis was done to identify independent predictors of maternal near miss.

RESULT

Majority of cases were admitted due to dystocia (57.1%) and obstetric hemorrhage (26%). The median first delay (delay to seek health care) among cases and controls was six and 4 h respectively. Prior history of cesarean section {AOR 7.68, 95%CI, 3.11-18.96}, first delay {AOR 2.79, 95%CI, 1.42-5.50}, and being referred from other health facilities {AOR 7.47, 95% CI, 2.27-24.51} were independent predictors of maternal near miss.

CONCLUSIONS

Prior history of cesarean section, being referred from other health facilities and first delay were factors associated with maternal near miss. Timely health care seeking behavior of women is uncommon in the study area. Therefore primary health care programs need to enhance the existing efforts to improve timely health care seeking behavior of women.

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.

Incidence and determinants of severe maternal outcome in Jimma University teaching hospital, south-West Ethiopia: a prospective cross-sectional study

Background

Investigating cases of severe maternal morbidity (SMM) and severe maternal outcome (SMO) and the quality of maternal health care using near-miss approach has become popular over recent years. The aim of this study was to determine facility based incidence and the determinants of severe maternal outcome (SMO) using this approach.

Methods

Prospective cross-sectional study among all mothers who presented to study facility while pregnant, during child birth and/or within 42 days after termination of pregnancy seeking care and found to have SMM and SMO during the study period was carried out.

Results

There were total of 2737 live births, 202 SMM and 162 SMO (138 maternal near-misses (MNM) and 24 maternal deaths (MD)) cases. The SMO ratio was 59.2 per 1000 live births and the MNM mortality ratio, mortality index (MI) and maternal mortality ratio (MMR) were: 5.8:1, 14.8% and 876.9 per 100,000 live births respectively. Close to three-fourth of all women with SMO had evidence of organ dysfunction on arrival or within 12 h of hospitalization. The commonest underlying causes for SMO were uterine rupture 27%, followed by hypertensive disorders 24% and obstetric hemorrhage 24%. The highest case fatality rate was found to be associated with eclampsia 28%. Maternal age, residential area, educational status and occupation were associated with SMO (P < 0.0001). On binary multivariable logistic regression the occurrence of any delay, intrapartal detection of complication, the mode of delivery and duration of hospitalization had statically significant association with SMO (p < 0.05). Optimal number of antenatal care (ANC) visits and delivery by emergency cesarean section (C/S) were found to be protective of SMO.

Conclusion

The occurance SMO in the facility thus in the population served was high. Most of these factors associated with SMO are modifiable; some amenable to social change and the others are within the control of the health system. Thus the finding of this research calls for planning for such changes which can enhance timely and proper detection and management of pregnancy related complications.

Hospitalization during pregnancy according to childbirth financial coverage: a population-based study

Objective To analyze the occurrence, profile and main causes of hospitalization during pregnancy according to the type of childbirth financial coverage. Method A cross-sectional population-based study carried out with puerperal women through a stratified sample, calculated according to the hospital and the type of childbirth financial coverage source: public sector (SUS) or private (not SUS). The sociodemographic profile, the rate of obstetric complications and the causes of hospitalization were analyzed, coded according to International Classification of Diseases. Results A total of 928 postpartum women were interviewed, of whom 32.2% reported at least one hospitalization during pregnancy. Those with childbirth covered by SUS were less favored because they were the majority among hospitalized women (57.2%), with a higher percentage of adolescents (18.1%), lower education level (91.8%), low family income (39.3%) and fewer prenatal consultations (25.3%). The most frequent causes of hospitalization were "other maternal diseases that complicate pregnancy" (24.6%) (with emphasis on anemia and influenza), urinary tract infection (13.1%), preterm labor (8.7%) and hypertension (7.2%). Conclusion Anemia, influenza, urinary tract infection, preterm labor and hypertension should especially be prevented and treated to avoid hospital admissions during pregnancy, especially among pregnant women covered by SUS.

Measuring the preparedness of health facilities to deliver emergency obstetric care in a South African district

BACKGROUND

Improving the delivery of emergency obstetric care (EmNOC) remains critical in addressing direct causes of maternal mortality. United Nations (UN) agencies have promoted standard methods for evaluating the availability of EmNOC facilities although modifications have been proposed by others. This study presents an assessment of the preparedness of public health facilities to provide EmNOC using these methods in one South African district with a persistently high maternal mortality ratio.

METHODS

Data collection took place in the final quarter of 2014. Cross-sectional surveys were conducted to classify the 7 hospitals and 8 community health centres (CHCs) in the district as either basic EmNOC (BEmNOC) or comprehensive EmNOC (CEmNOC) facilities using UN EmNOC signal functions. The required density of EmNOC facilities was calculated using UN norms. We also assessed the availability of EmNOC personnel, resuscitation equipment, drugs, fluids, and protocols at each facility. The workload of skilled EmNOC providers at hospitals and CHCs was compared.

RESULTS

All 7 hospitals in the district were classified as CEmNOC facilities, but none of the 8 CHCs performed all required signal functions to be classified as BEmNOC facilities. UN norms indicated that 25 EmNOC facilities were required for the district population, 5 of which should be CEmNOCs. None of the facilities had 100% of items on the EmNOC checklists. Hospital midwives delivered an average of 36.4±14.3 deliveries each per month compared to only 7.9±3.2 for CHC midwives (p<0.001).

CONCLUSIONS

The analysis indicated a shortfall of EmNOC facilities in the district. Full EmNOC services were centralised to hospitals to assure patient safety even though national policy guidelines sanction more decentralisation to CHCs. Studies measuring EmNOC availability need to consider facility opening hours, capacity and staffing in addition to the demonstrated performance of signal functions.

Distant and proximate factors associated with maternal near-miss: a nested case-control study in selected public hospitals of Addis Ababa, Ethiopia

Background

Ethiopia is one of the sub-Saharan Africa countries with the highest maternal mortality. Maternal near-misses are more common than deaths and statistically stronger for a comprehensive analysis of the determinants. The study aimed to identify the factors associated with maternal near-miss in selected public hospitals of Addis Ababa, Ethiopia.

Methods

We conducted a nested case-control study in five selected public hospitals of Addis Ababa, Ethiopia from May 1, 2015 to April 30, 2016. Participants were interviewed by well-trained data collectors using pre-tested questionnaire. Medical records were also reviewed to gather relevant information. World Health Organization criteria were used to identify maternal near-miss cases. A total of three controls matched for age and study area was selected for each maternal near-miss case. Bivariate and multivariable conditional logistic regressions were performed using Stata version 13.0.

Results

A total of 216 maternal near-miss cases and 648 controls were included in the study. The main factors associated with maternal near-miss were: history of chronic hypertension (AOR = 10.80,95% CI; 5.16–22.60), rural residency (AOR = 10.60,95% CI;4.59–24.46), history of stillbirth (AOR = 6.03,95% CI;2.09–17.41), no antenatal care attendance (AOR = 5.58,95% CI;1.94–16.07) and history of anemia (AOR = 5.26,95% CI;2.89–9.57).

Conclusions

There is a need for appropriate interventions in order to improve the identified factors. The factors can be modified through a better access to medical and maternity care, scaling up of antenatal care in rural areas, improve in infrastructure to fulfill referral chain from primary level to secondary and tertiary health care levels, and health education to pregnant women.