Severe maternal morbidity in Zanzibar’s referral hospital: Measuring the impact of in-hospital care

Abstract

Objectiveto analyse the impact of in-hospital care on severe maternal morbidity using WHO’s near-miss approach in the low-resource, high mortality setting of Zanzibar’s referral hospital.SettingMnazi Mmoja Hospital, a tertiary care facility, in Zanzibar, Tanzania.MethodsWe identified all cases of morbidity and mortality in women admitted within 42 days after the end of pregnancy at Mnazi Mmoja Hospital in the period from April to October 2016. The severity of complications was classified using WHO’s near-miss approach definitions: potentially life-threatening condition (PLTC), maternal near-miss (MNM) or maternal death (MD). Quality of in-hospital care was assessed using the mortality index (MI) defined as ratio between mortality and severe maternal outcome (SMO) where SMO = MD + MNM, cause-specific case facility rates and comparison with predicted mortality based on the Maternal Severity Index model.Main outcomes5551 women were included. 569 (10.3%) had a potentially life-threatening condition and 65 (1.2%) a severe maternal outcome (SMO): 37 maternal near-miss cases and 28 maternal deaths. The mortality index was high at 0.43 and similar for women who developed a SMO within 12 hours of admission and women who developed a SMO after 12 hours. A standardized mortality ratio of 6.03 was found; six times higher than that expected in moderate maternal mortality settings given the same severity of cases. Obstetric haemorrhage was found to be the main cause of SMO. Ruptured uterus and admission to ICU had the highest case-fatality rates. Maternal death cases seemed to have received essential interventions less often.ConclusionsWHO’s near-miss approach can be used in this setting. The high mortality index observed shows that in-hospital care is not preventing progression of disease adequately once a severe complication occurs. Almost one in two women experiencing life-threatening complications will die. This is six times higher than in moderate mortality settings.

Rethinking the definition of maternal near‐miss in low‐income countries using data from 104 health facilities in Tanzania and Uganda

“…The present rates of near‐miss using the WHO standard definition (1.79% and 4.00% in Tanzania and Uganda, respectively) compare well with other studies using the WHO standard definition . Higher rates have been described elsewhere in sub‐Saharan Africa, for example, in Mozambique where a high prevalence of HIV and a low uptake of prenatal care in the population might increase the incidence of maternal‐near miss .…”

“…The mortality index (i.e., case‐fatality ratio) was found to range from 3% to 37% . A more recent review reported a median maternal near‐miss incidence of 2.4%, and other studies have reported low levels of near miss per 100 live births of 1.2 in Zanzibar, 2.5 in a rural hospital in Rwanda, 3.6 in district hospitals Rwanda, and 0.8 in Uganda (Supplementary Fig. S1).…”

Effect of locally tailored clinical guidelines on intrapartum management of severe hypertensive disorders at Zanzibar's tertiary hospital (the PartoMa study)

“…A previous facility‐based survey in low‐ and middle‐income countries found that the likelihood of maternal near‐miss was eightfold and perinatal death threefold higher in a group of women with pre‐eclampsia than in a reference group without HDP . Although most cases are preventable, undiagnosed or suboptimally treated HDP is repeatedly reported in sub‐Saharan Africa . This violates human rights and is a key priority for safe motherhood …”

“…Lifesaving treatment includes induction and/or oxytocin augmentation of labor while stabilizing blood pressure (BP) and supporting vital organ functions . In high‐volume low‐resource hospitals, urgent intrapartum diagnosis, surveillance, and management of such complex diseases are challenging and need realistic practical guidance …”

“…2 Although most cases are preventable, undiagnosed or suboptimally treated HDP is repeatedly reported in sub-Saharan Africa. [3][4][5][6][7][8][9][10] This violates human rights and is a key priority for safe motherhood. 11,12 Hypertensive disorders in pregnancy can rapidly progress in severity, with increased risk of organ failure such as cerebral hemorrhage, coagulopathy, eclampsia, and pulmonary edema.…”