Substandard care in maternal mortality due to hypertensive disease in pregnancy in the Netherlands

Abstract

Objectives To review the standard of care in cases of maternal mortality due to hypertensive diseases in pregnancy and to make recommendations for its improvement. Design Care given to women with hypertensive disease in pregnancy was audited and substandard care factors identified. Setting Confidential enquiry by the Dutch Maternal Mortality Committee (MMC) from the Netherlands Society of Obstetrics and Gynaecology. Population All maternal deaths reported to the MMC due to hypertensive disease in pregnancy in the Netherlands during the years 2000–04. Methods Assessment for substandard care factors using a checklist based on the Dutch guideline of ‘Hypertensive Disorders in Pregnancy’. Main outcome measures Substandard care in cases of maternal mortality due to hypertensive diseases in pregnancy. Results A total of 27 cases of maternal death due to hypertensive disease in pregnancy were reported to the committee in the study period. In 26 cases (96%), substandard care factors were present, of which in 17 cases (63%), these were for more than five different items. In community midwifery care, the most frequent substandard care factor was no testing for proteinuria when clearly indicated (41%). In hospital care, the most frequent substandard care was related to insufficient diagnostic testing when indicated (41%), insufficient management of hypertension by obstetricians (85%), no use or inadequate use of magnesium sulphate (67%), inadequate stabilisation before transport to tertiary care centres and/or delivery (52%) and failure to consider timely delivery (44%). Conclusions Education of pregnant women concerning danger signs of hypertensive disease should be improved. Training of midwives and obstetricians should be improved in the following areas: performing basic diagnostic tests, adequate management of hypertension and eclampsia, with more attention to treatment of systolic blood pressure. This training should be guided by clear local protocols. Delivery should not be delayed in serious cases of hypertensive disease in pregnancy, not only after 32–34 weeks but also in early‐onset pre‐eclampsia as maternal risks often outweigh possible fetal benefits of temporising management.

Mortalidade materna no Brasil: o que mostra a produção científica nos últimos 30 anos?

“…Na África do Sul 68 , entre 2002 e 2004, essa morbidade repre-sentou 19% do total de causas diretas, e em 50% dos casos a eclampsia foi o diagnóstico. Na Holanda, onde a RMM é baixa, variando em torno de 9 a 12/100.000 NV, a pré-eclampsia foi a causa principal de morte 69,70 . Segundo Duley 71 , 10% a 15% das mortes maternas por causa direta em todo o mundo estão associadas à pré-eclampsia e eclampsia.…”

“…O estudo de Alves 56 foi o único a usar uma classificação de adequação do pré-natal e ratificou a associação entre o cuidado inadequado e maior mortalidade materna. Em outros países, mesmo naqueles com baixa RMM, tem sido enfatizada a relação entre o padrão de cuidado pré-natal e a morte materna 66,69,70 .…”

Regional differences in Dutch maternal mortality

“…34 A lack of proficiency in Dutch and therefore an inability to access adequate antenatal care is a more plausible explanation. This can result in late antenatal care, 35 insufficient understanding of warning symptoms, 6,36 inadequate diagnosis, and poor compliance with the advice of the midwife or doctor. [36][37][38] In this study, women aged 35 years or older were also at increased risk of maternal mortality, probably because of a deterioration of pre-existing disease.…”

“…Substandard care, both in community and hospital care, has previously been shown to be involved. 36 In 2005, the Dutch Society of Obstetrics and Gynaecology (DSOG) implemented the revised Guideline Hypertensive Disease in Pregnancy. 39,40 Since 2005, a total of eight regional audits were organised to evaluate adherence to these guidelines and compliance with its protocols.…”

Management of Eclampsia and Imminent Eclampsia, Maternal and Perinatal Outcome in 666 Cases—2003-2007 at Government Maternity Hospital in Hyderabad

“…In the UK, substandard care contributes to 72% of maternal deaths that are related to hypertensive disease in pregnancy and to 96% of those in the Netherlands [11]. In the Dutch enquiry [11], no instructions about danger signs to women had been documented in 80% of cases.…”