Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania

Abstract

BackgroundThe maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications.MethodsWe performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital in Dar es Salaam, Tanzania. Cases were assessed individually to determine their association with CS. Main outcome measures included MNM ratio; maternal mortality ratio; proportion of MNM and death associated with CS complications; and the risk for such outcomes per 1,000 operations. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was calculated.ResultsWe identified 467 MNM events and 77 maternal deaths. The MNM ratio was 36 per 1,000 live births (95% CI 33–39) and the maternal mortality ratio was 587 per 100,000 live births (95% CI 460–730). Major causes were eclampsia and postpartum haemorrhage, but we also detected nine MNM events and five deaths from iatrogenic complications. CS complications accounted for 7.9% (95% CI 5.6–11) of the MNM events and 13% (95% CI 6.4–23) of the maternal deaths. The risk of experiencing a life-threatening CS complication was three times higher at the regional hospital (22/1,000 operations, 95% CI 12–37) compared to the university hospital (7.0/1,000 operations, 95% CI 3.8–12) (risk ratio 3.2, 95% CI 1.5–6.6).ConclusionsThe occurrence of MNM and death at the two hospitals was high, and many cases were associated with CS complications. The maternal risks of CS in low-resource settings must not be overlooked, and measures should be taken to avoid unnecessary CSs. More comprehensive training of staff, improved postoperative surveillance, and a more even distribution of resources within the health care system might reduce the risks of CS.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2393-14-244) contains supplementary material, which is available to authorized users.

A clinical audit and confidential enquiry of caesarean section indications at rural tertiary health care centre

“…5,6 This is probably because our institute is a tertiary institute receiving referral from neighboring areas. [7][8][9][10][11][12] In present study Caesarean section is classified on basis of urgency as Category I, II, III and IV as in NICE guidelines .Women were categorized in four categorize and different indications in each category were studied.…”

Preventing deaths from complications of labour and delivery

“…By contrast, in highresource settings the safety of caesarean delivery is similar to that of vaginal birth, allowing guidelines to include 'maternal request' as an indication for surgery following appropriate counselling [16]. In low-resource settings the challenge is to extend access to caesarean delivery beyond the low levels currently found in population surveys, for example 4.6% for Malawi [17], while avoiding the excess morbidity and mortality seen in referral hospitals where caesarean delivery rates now approach 50% [18]. Key clinical considerations for safe caesarean delivery are discussed below.…”

Morbidity and Mortality among Patients Referred from District Hospitals to Butare University Teaching Hospital Chub/Obgyn Department in Post-Partum and Post-Operative Period

“…Our results are not far from those of other results that show that women suffer pregnancy-related complications before, during and even after delivery and among post-partum complications include PPH, Post-partum infection, pre-eclampsia and eclampsia with DVT (Ferdous et al, 2012;Conde-Agudelo et al, 2004;WHO, 2012;Iyengar et al, 2012). In a study done in Tanzania on maternal near miss (MNM) showed that major causes were eclampsia and postpartum haemorrhage and CS complications accounted for 7.9% of the MNM events and 13% of the maternal deaths (Litorp et al, 2014). Another study done at three university hospitals with a high rate of CS in Tehran-Iran on Maternal near miss revealed that Severe postpartum hemorrhage (35%, 29/82), severe preeclampsia (32%, 26/82), and placenta previa/abnormally invasive placenta (10%, 8/82) were the most frequent causes of MNM (Mohammadi et al, 2016).…”

“…The above management is comparable to the management of such patients from other studies as they mention that the first step is to attempt conservative management by giving uterotonics like oxytocin, cytotec, ergot alkaloids such ergometrine or its derivative methylergonovine (methylergometrine, methergine), if conservative management fails invasive treatment of PPH is initiated to avoid severe morbidity and mortality ; uterine balloon tamponade, uterine compression sutures, angiographic arterial embolisation, uterine ligation and hysterectomy are being used in this case. However Bassey et al, in their study on emergency peripartum hysterectomy in a low resource setting found that the commonest indication of peripartum hysterectomy was uterine rupture but for us hysterectomy was done when uterus was damaged either through fetal extraction and unable to repair or when there is atonic uterine that is responding to conservative and invasive procedure rather than hysterectomy (Rwanda et al, 2009;Litorp et al, 2014).…”

“…In Rwanda, a comparison of maternal mortality ratios from 2000,2010and 2014-2015 revealed that maternal mortality has been continuously decreasing overtime from 1071,750,476and 210deaths per 100,000livebirths respectively (National institute of statistics, Rwanda., Ministry of Finance and Economic Planning, Rwanda., Ministry of Health, Rwanda, 2016).…”