When getting there is not enough: a nationwide cross‐sectional study of 998 maternal deaths and 1451 near‐misses in public tertiary hospitals in a low‐income country

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Abstract

Objective

To investigate the burden and causes of life‐threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.

Design

Nationwide cross‐sectional study.

Setting

Forty‐two tertiary hospitals.

Population

Women admitted for pregnancy, childbirth and puerperal complications.

Methods

All cases of severe maternal outcome ( SMO: maternal near‐miss or maternal death) were prospectively identified using the WHO criteria over a 1‐year period.

Main outcome measures

Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/ SMO).

Results

Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near‐misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre‐eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life‐threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes ( IQR: 21–215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non‐availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care.

Conclusions

Improving the chances of maternal survival would not only require timely application of life‐saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care.

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Of 998 maternal deaths and 1451 near‐misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

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Of 998 maternal deaths and 1451 near‐misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

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Most cited references 17

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Too far to walk: maternal mortality in context.

S Thaddeus, D Maine (1994)

The Prevention of Maternal Mortality Program is a collaborative effort of Columbia University's Center for Population and Family Health and multidisciplinary teams of researchers from Ghana, Nigeria and Sierra Leone. Program goals include dissemination of information to those concerned with preventing maternal deaths. This review, which presents findings from a broad body of research, is part of that activity. While there are numerous factors that contribute to maternal mortality, we focus on those that affect the interval between the onset of obstetric complication and its outcome. If prompt, adequate treatment is provided, the outcome will usually be satisfactory; therefore, the outcome is most adversely affected by delayed treatment. We examine research on the factors that: (1) delay the decision to seek care; (2) delay arrival at a health facility; and (3) delay the provision of adequate care. The literature clearly indicates that while distance and cost are major obstacles in the decision to seek care, the relationships are not simple. There is evidence that people often consider the quality of care more important than cost. These three factors--distance, cost and quality--alone do not give a full understanding of decision-making process. Their salience as obstacles is ultimately defined by illness-related factors, such as severity. Differential use of health services is also shaped by such variables as gender and socioeconomic status. Patients who make a timely decision to seek care can still experience delay, because the accessibility of health services is an acute problem in the developing world. In rural areas, a woman with an obstetric emergency may find the closest facility equipped only for basic treatments and education, and she may have no way to reach a regional center where resources exist. Finally, arriving at the facility may not lead to the immediate commencement of treatment. Shortages of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanagement, become documentable contributors to maternal deaths. Findings from the literature review are discussed in light of their implications for programs. Options for health programs are offered and examples of efforts to reduce maternal deaths are presented, with an emphasis on strategies to mobilize and adapt existing resources.

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Maternal near miss--towards a standard tool for monitoring quality of maternal health care.

Lale Say, João Souza, Robert C Pattinson … (2009)

Maternal mortality is still among the worst performing health indicators in resource-poor settings. For deaths occurring in health facilities, it is crucial to understand the processes of obstetric care in order to address any identified weakness or failure within the system and take corrective action. However, although a significant public health problem, maternal deaths are rare in absolute numbers especially within an individual facility. Studying cases of women who nearly died but survived a complication during pregnancy, childbirth or postpartum (maternal near miss or severe acute maternal morbidity) are increasingly recognized as useful means to examine quality of obstetric care. Nevertheless, routine implementation and wider application of this concept in reviewing clinical care has been limited due to the lack of a standard definition and uniform case-identification criteria. WHO has initiated a process in agreeing on a definition and developing a uniform set of identification criteria for maternal near miss cases aiming to facilitate the reviews of these cases for monitoring and improving quality of obstetric care. A list of identification criteria was proposed together with one single definition. This article presents the proposed definition and the identification criteria of maternal near miss cases. It also suggests procedures to make maternal near miss audits operational in monitoring/evaluating quality of obstetric care. The practical implementation of maternal near miss concept should provide an important contribution to improving quality of obstetric care to reduce maternal deaths and improve maternal health.

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Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study of 371,000 pregnancies.

Joost J Zwart, J Richters, Jeroen den Dunnen … (2008)

To assess incidence, case fatality rate, risk factors and substandard care in severe maternal morbidity in the Netherlands. Prospective population-based cohort study. All 98 maternity units in the Netherlands. All pregnant women in the Netherlands. Cases of severe maternal morbidity were collected during a 2-year period. All pregnant women in the Netherlands in the same period acted as reference cohort (n = 371,021). As immigrant women are disproportionately represented in Dutch maternal mortality statistics, special attention was paid to the ethnic background. In a subset of 2.5% of women, substandard care was assessed through clinical audit. Incidence, case fatality rates, possible risk factors and substandard care. Severe maternal morbidity was reported in 2552 women, giving an overall incidence of 7.1 per 1000 deliveries. Intensive care unit admission was reported in 847 women (incidence 2.4 per 1000), uterine rupture in 218 women (incidence 6.1/10,000), eclampsia in 222 women (incidence 6.2/10,000) and major obstetric haemorrhage in 1606 women (incidence 4.5 per 1000). Non-Western immigrant women had a 1.3-fold increased risk of severe maternal morbidity (95% CI 1.2-1.5) when compared with Western women. Overall case fatality rate was 1 in 53. Substandard care was found in 39 of a subset of 63 women (62%) through clinical audit. Severe maternal morbidity complicates at least 0.71% of all pregnancies in the Netherlands, immigrant women experiencing an increased risk. Since substandard care was found in the majority of assessed cases, reduction of severe maternal morbidity seems a mandatory challenge.

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Author and article information

Journal

Journal ID (nlm-ta): BJOG

Journal ID (iso-abbrev): BJOG

Journal ID (doi): 10.1111/(ISSN)1471-0528

Journal ID (publisher-id): BJO

Title: Bjog

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Print): 1470-0328

ISSN (Electronic): 1471-0528

Publication date (Electronic): 14 May 2015

Publication date (Print): May 2016

Volume: 123

Issue: 6 ( doiID: 10.1111/bjo.2016.123.issue-6 )

Pages: 928-938

Affiliations

[ ¹ ] Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research Development and Research Training in Human Reproduction (HRP)World Health Organization GenevaSwitzerland

[ ² ] Department of Obstetrics and GynaecologyOlabisi Onabanjo University Teaching Hospital SagamuNigeria

[ ³ ] Department of Obstetrics and GynaecologyUniversity of Abuja Teaching Hospital GwagwaladaNigeria

[ ⁴ ] Department of Obstetrics and GynaecologyUniversity of Maiduguri Teaching Hospital MaiduguriNigeria

[ ⁵ ] Department of Obstetrics and GynaecologyUniversity of Calabar Teaching Hospital CalabarNigeria

[ ⁶ ] Department of Obstetrics and GynaecologyUniversity of Ilorin Teaching Hospital IlorinNigeria

[ ⁷ ] Department of Obstetrics and GynaecologyUniversity of Nigeria Teaching Hospital EnuguNigeria

[ ⁸ ] Department of Obstetrics and GynaecologyUniversity of Uyo Teaching Hospital UyoNigeria

[ ⁹ ] Department of Obstetrics and GynaecologyFederal Medical Centre Birnin‐KebbiNigeria

[ ¹⁰ ] Department of Obstetrics and GynaecologyLagos University Teaching Hospital Idi‐ArabaNigeria

[ ¹¹ ] Department of Obstetrics and GynaecologyUniversity College Hospital IbadanNigeria

[ ¹² ] Department of Obstetrics and GynaecologyFederal Medical Centre OwoNigeria

[ ¹³ ] Department of Obstetrics and GynaecologyAbubakar Tafawa Balewa University Teaching Hospital BauchiNigeria

[ ¹⁴ ] Department of Obstetrics and GynaecologyUniversity of Benin Teaching Hospital Benin‐CityNigeria

[ ¹⁵ ] Department of Obstetrics and GynaecologyFederal Medical Centre Birnin‐KuduNigeria

[ ¹⁶ ] Department of Obstetrics and GynaecologyFederal Medical Centre NguruNigeria

[ ¹⁷ ] Department of Obstetrics and GynaecologyLagos State University Teaching Hospital IkejaNigeria

[ ¹⁸ ] Department of Obstetrics and GynaecologyNnamdi Azikwe University Teaching Hospital NnewiNigeria

[ ¹⁹ ] Department of Obstetrics and GynaecologyObafemi Awolowo University Teaching Hospital Complex Ile‐IfeNigeria

[ ²⁰ ] Department of Obstetrics and GynaecologyFederal Medical Centre BidaNigeria

[ ²¹ ] Department of Obstetrics and GynaecologyDelta State University Teaching Hospital AbrakaNigeria

[ ²² ] Department of Obstetrics and GynaecologyUsmanu DanFodiyo University Teaching Hospital SokotoNigeria

[ ²³ ] Department of Obstetrics and GynaecologyAminu Kano University Teaching Hospital KanoNigeria

[ ²⁴ ] Department of Obstetrics and GynaecologyFederal University Teaching Hospital AbakalikiNigeria

[ ²⁵ ] Department of Obstetrics and GynaecologyNational Hospital AbujaNigeria

[ ²⁶ ]Centre for Research in Reproductive Health SagamuNigeria

Author notes

[*] [* ] Correspondence: Dr OT Oladapo, Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Avenue Appia 20, Geneva 27, CH‐1211 Switzerland. Email: oladapoo@ 123456who.int

[†]

The members of Nigeria Near‐miss and Maternal Death Surveillance Network are in Appendix 1.

Article

Publisher ID: BJO13450

DOI: 10.1111/1471-0528.13450

PMC ID: 5016783

PubMed ID: 25974281

SO-VID: 77fca3f3-d7ad-4e16-bcae-f8a40200acac

License:

This is an open access article distributed under the terms of the Creative Commons Attribution IGO License which permits unrestricted use, distribution and reproduction in any medium, provided that the original work is properly cited.

History

Date accepted : 25 March 2015

Page count

Pages: 11

Funding

Funded by: The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization

Funded by: Merck

Custom metadata

source-schema-version-number 2.0

component-id bjo13450

cover-date May 2016

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:4.9.4 mode:remove_FC converted:09.09.2016

ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: clinical audit,maternal death,maternal near miss,quality of care,severe acute maternal morbidity,who near‐miss criteria

Data availability:

ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: clinical audit, maternal death, maternal near miss, quality of care, severe acute maternal morbidity, who near‐miss criteria

When getting there is not enough: a nationwide cross‐sectional study of 998 maternal deaths and 1451 near‐misses in public tertiary hospitals in a low‐income country

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Abstract

Objective

Design

Setting

Population

Methods

Main outcome measures

Results

Conclusions

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Tweetable abstract

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Advocacy for Maternal and Women’s Health

Most cited references 17

Too far to walk: maternal mortality in context.

Maternal near miss--towards a standard tool for monitoring quality of maternal health care.

Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study of 371,000 pregnancies.

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