Retrospective analysis of patients with severe maternal morbidity receiving anaesthesia services using 'WHO near miss approach' and the applicability of maternal severity score as a predictor of maternal outcome

Global burden of potentially life-threatening maternal conditions: a systematic review and meta-analysis

BACKGROUND

Potentially life-threatening maternal conditions (PLTCs) is an important proxy indicator of maternal mortality and the quality of maternal health services. It is helpful to monitor the rates of severe maternal morbidity to evaluate the quality of maternal care, particularly in low- and lower-middle-income countries. This study aims to systematically identify and synthesize available evidence on PLTCs.

METHODS

We searched studies in English from 2009‒2023 in PubMed, the National Library of Medicine (NLM) Gateway, the POPLINE database, and the Science Direct website. The study team independently reviewed the illegibility criteria of the articles. Two reviewers independently appraised the included articles using the Joanna Briggs Instrument for observational studies. Disputes between the reviewers were resolved by consensus with a third reviewer. Meta-analysis was conducted in Stata version 16. The pooled proportion of PLTCs was calculated using the random effects model. The heterogeneity test was performed using the Cochrane Q test, and its level was determined using the I2 statistical result. Using Egger's test, the publication bias was assessed.

RESULT

Thirty-two cross-sectional, five case-control, and seven cohort studies published from 2009 to 2023 were included in the meta-analysis. The highest proportion of PLTC was 17.55% (95% CI: 15.51, 19.79) in Ethiopia, and the lowest was 0.83% (95% CI: 0.73, 0.95) in Iraq. The pooled proportion of PLTC was 6.98% (95% CI: 5.98-7.98). In the subgroup analysis, the pooled prevalence varied based on country income level: in low-income 13.44% (95% CI: 11.88-15.00) I2 = 89.90%, low-middle income 7.42% (95% CI: 5.99-8.86) I2 = 99.71%, upper-middle income 6.35% (95% CI: 4.21-8.50) I2 = 99.92%, and high-income 2.67% (95% CI: 2.34-2.99) I2 = 99.57%. Similarly, it varied based on the diagnosis criteria; WHO diagnosis criteria used 7.77% (95% CI: 6.10-9.44) I2 = 99.96% at P = 0.00, while the Centers for Disease Controls (CDC) diagnosis criteria used 2.19% (95% CI: 1.89-2.50) I2 = 99.41% at P = 0.00.

CONCLUSION

The pooled prevalence of PLTC is high globally, predominantly in low-income countries. The large disparity of potentially life-threatening conditions among different areas needs targeted intervention, particularly for women residing in low-income countries. The WHO diagnosis criteria minimize the underreporting of severe maternal morbidity.

TRIAL REGISTRATION

CRD42023409229.

External validation of the Maternal Severity Index for predicting maternal death following potentially life-threatening complications during pregnancy and childbirth: a single-centre, prospective observational study

OBJECTIVES

To perform an external validation to assess the usefulness of the Maternal Severity Index (MSI) in predicting maternal death among women with potentially life-threatening complications during pregnancy or childbirth.

DESIGN

Prospective observational study.

SETTING

A tertiary referral centre in southeastern India.

PARTICIPANTS

1833 women with potentially life-threatening complications identified using the WHO criteria.

PREDICTOR ASSESSED

MSI calculated based on the severity markers of the WHO criteria for maternal near-miss.

PRIMARY OUTCOME

Maternal death.

STATISTICAL ANALYSIS

Receiver operating characteristics (ROC) curve analysis was performed to assess discriminative performance, and agreement between expected and observed deaths was plotted to determine calibration.

RESULTS

The incidence of severe maternal outcomes was 10 per 1000 live births. There were 57 (151 per 100 000 live births) maternal deaths during the study period. Maternal Severity Score was significantly higher among those who died (2.8±1.3 vs 2.0±1.2, p<0.001). The mean MSI value was 1.03% (95% CI 0.7% to 1.2%). ROC curve analysis showed good discrimination (AUC(Area Under the Curve): 0.962, 95% CI 0.952 to 0.970); however, overfitting was seen with higher probabilities. The standardised mortality ratio (SMR) was 0.02 (95% CI 0.01 to 0.02), indicating good quality of care.

CONCLUSIONS

The MSI has good discriminative performance in distinguishing who succumbs to life-threatening complications, but needs recalibration to avoid overfitting. SMR of less than 0.5 indicates fewer than expected deaths, suggesting good quality of care in reducing maternal mortality in the study population.