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

obtained from the Euro-Peristat project for assessing perinatal health in Europe. The data included births in 2010 among the 26 member countries of the European Union, Norway, Iceland and Switzerland. The countries included in the analysis provided aggregated data about overall rates of intervention and rates of cesarean section for specific high-risk subgroups. The primary outcome measure was mode of delivery. The analysis found a large variation in the rates of cesarean section across Europe, ranging from 14.8% in Iceland to 52.2% in Cyprus. The median rate among all countries was 25.2%. A wide difference was also noted among nations in the rates of instrumental vaginal delivery: 0.5 % in Romania to 16.4% in Ireland with a median rate for all countries of 7.5%. No statistical association could be established between rates of cesarean section and instrumental vaginal delivery. It was found that 4% of all births involved a breech presentation. Among 21 countries that had data specific to mode of delivery for breech presentation, the cesarean section rate was >80% in 16 countries with 9 countries reporting rates >90%. Twin births also had a high cesarean section rate. Overall, the cesarean section rate for women with a history of prior cesarean section was high but there was still wide variation among countries. Rates for Scandinavian countries and the Netherlands ranged from 45% to 55% while other countries like Latvia and Cyprus had rates >90%. A country’s rate of cesarean section for women without a previous cesarean correlated highly to its rate for women with a previous cesarean; those with the highest rates of cesarean after previous cesarean section generally had higher rates for women without a previous cesarean. The authors suggested that the wide range in caesarean and instrumental vaginal delivery rates among the European countries resulted from differences in healthcare practices across regions. This seemed to indicate a lack of consensus regarding best obstetric practices, which is concerning. These investigators recommended that further research be performed to better understand the reasons for such varying differences in practice among countries within a common geographic region. 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

A retrospective analysis was conducted on data obtained from the Euro-Peristat project for assessing perinatal health in Europe. The data included births in 2010 among the 26 member countries of the European Union, Norway, Iceland and Switzerland. The countries included in the analysis provided aggregated data about overall rates of intervention and rates of cesarean section for specific high-risk subgroups. The primary outcome measure was mode of delivery.
The analysis found a large variation in the rates of cesarean section across Europe, ranging from 14.8% in Iceland to 52.2% in Cyprus. The median rate among all countries was 25.2%. A wide difference was also noted among nations in the rates of instrumental vaginal delivery: 0.5 % in Romania to 16.4% in Ireland with a median rate for all countries of 7.5%. No statistical association could be established between rates of cesarean section and instrumental vaginal delivery. It was found that 4% of all births involved a breech presentation. Among 21 countries that had data specific to mode of delivery for breech presentation, the cesarean section rate was >80% in 16 countries with 9 countries reporting rates >90%. Twin births also had a high cesarean section rate. Overall, the cesarean section rate for women with a history of prior cesarean section was high but there was still wide variation among countries. Rates for Scandinavian countries and the Netherlands ranged from 45% to 55% while other countries like Latvia and Cyprus had rates >90%. A country's rate of cesarean section for women without a previous cesarean correlated highly to its rate for women with a previous cesarean; those with the highest rates of cesarean after previous cesarean section generally had higher rates for women without a previous cesarean.
The authors suggested that the wide range in caesarean and instrumental vaginal delivery rates among the European countries resulted from differences in healthcare practices across regions. This seemed to indicate a lack of consensus regarding best obstetric practices, which is concerning. These investigators recommended that further research be performed to better understand the reasons for such varying differences in practice among countries within a common geographic region.

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 (MDG-5) to reduce maternal mortality rates is a challenge in some low-income countries due to the lack of reliable data to evaluate progress and guide the appropriate actions. The aim of this study, the Nigeria Near-miss and Maternal Death Survey, was to determine the burden of maternal death and maternal near-miss occurrences through surveillance and data collection of life-threatening maternal complications or severe maternal outcomes (SMO) from Nigerian public tertiary hospitals.
This was a multicenter, cross-sectional study. The frequencies and cause distribution of maternal deaths and near-misses, substandard care provided to women who developed SMOs, and overall quality of care were evaluated. A total of 42 hospitals participated and provided data for the study. The study population included women admitted for delivery or within 42 days of delivery or spontaneous loss/termination of pregnancy over a 1-year period between 2012 and 2013. Maternal death was defined by the International Classification of Diseases (ICD-10), and maternal near-miss, SMOs, and other near-miss indicators were determined per the World Health Organization criteria. Data collection occurred daily at each hospital by a designated resident physician who was not directly providing care to the obstetric patients. For each patient identified as having an SMO, a standardized data form was completed. Demographic and obstetric characteristics as well as mode and timing of hospital admission were recorded. Data specific to the SMO that was collected included the primary complication leading to the near-miss or death, markers of organ dysfunction associated with the adverse outcome, time between diagnosis of the complication and definitive treatment, level of the most senior health care provider caring for the patient, and time until that provider physically was present caring for the patient. The frequencies of organ dysfunction markers among women with SMO was determined, and the total livebirths and stillbirths, maternal near-miss ratio, severe maternal outcome ratio, and intrahospital maternal mortality ratio was calculated. The frequencies of primary complications were determined, and the overall care performance for lifethreatening complications and direct obstetric complications was assessed by estimating mortality index and cause-specific case fatality rates, respectively.
Among 97,634 births, 91,724 were live births and 5910 were stillbirths (stillbirth rate: 60.5 per 1000 births). Maternal death occurred in 998 women while 1451 suffered a maternal near-miss. The intrahospital maternal mortality ratio was 1088/100,000 live births (1.1%), the maternal near-miss ratio was 15.8/1000 live births (1.6%) and the SMO ratio was 26.7/1000 live births (2.7%). The most common complications resulting in SMOs were hemorrhage (39%) and hypertensive disorders (24%). For maternal deaths, the most frequent contributing complications were hypertensive disorders (29.0%), obstetric hemorrhage (24.4%) and indirect causes (19.6%). Women with SMOs were most likely to exhibit organ dysfunction of the cardiovascular, respiratory, and coagulation systems. Renal and respiratory dysfunction had the worst mortality indices (64.3% and 63.3%, respectively), and multiorgan dysfunction occurred more than 2 times as often in women who died (93.4%) compared with those with near-misses (43.9%).
Definitive treatment/intervention was received by 2325 (94.9%) women with SMOs [1401 women (96.6%) with maternal near-miss and 924 women (92.5%) who died]. The median time between diagnosis and critical intervention was 60 minutes [interquartile range (IQR), 21 to 215 min). However, in 21.9% of cases, it was >4 hours. In addition, the median time to definitive intervention was 17 minutes shorter for those who survived versus those who died. In the clear majority of cases (83%) the most senior physician present caring for the patient was a senior registrar or consultant with the median time between diagnosis and the presence of this physician being 60 minutes. However, in nearly a quarter of cases it was >4 hours before arrival of the senior physician. In approximately 50% of patients with SMOs, the investigators determined deficiencies occurred in the management of the patient. The factors most frequently associated with substandard care included late presentation to the hospital (35.3%), lack of health insurance (17.5%) and nonavailability of blood/ blood products (12.7%). Deficiencies in care were significantly more likely to occur in women who died compare to those with near misses (59.8% vs. 42.6%, respectively, P < 0.0001).
The investigators concluded that the majority of parturients with life-threatening conditions did receive appropriate interventions, but only after significant delays. This led to a high number of maternal deaths. In order to improve maternal mortality rates in Nigeria, health policy needs to focus on increasing capacity so that the bottlenecks leading to delays in care are alleviated.