Clinico-Pathological Discrepancies in the Diagnosis of Causes of Maternal Death in Sub-Saharan Africa: Retrospective Analysis

Abstract

BackgroundMaternal mortality is a major public-health problem in developing countries. Extreme differences in maternal mortality rates between developed and developing countries indicate that most of these deaths are preventable. Most information on the causes of maternal death in these areas is based on clinical records and verbal autopsies. Clinical diagnostic errors may play a significant role in this problem and might also have major implications for the evaluation of current estimations of causes of maternal death.Methods and FindingsA retrospective analysis of clinico-pathologic correlation was carried out, using necropsy as the gold standard for diagnosis. All maternal autopsies (n = 139) during the period from October 2002 to December 2004 at the Maputo Central Hospital, Mozambique were included and major diagnostic discrepancies were analyzed (i.e., those involving the cause of death). Major diagnostic errors were detected in 56 (40.3%) maternal deaths. A high rate of false negative diagnoses was observed for infectious diseases, which showed sensitivities under 50%: HIV/AIDS-related conditions (33.3%), pyogenic bronchopneumonia (35.3%), pyogenic meningitis (40.0%), and puerperal septicemia (50.0%). Eclampsia, was the main source of false positive diagnoses, showing a low predictive positive value (42.9%).ConclusionsClinico-pathological discrepancies may have a significant impact on maternal mortality in sub-Saharan Africa and question the validity of reports based on clinical data or verbal autopsies. Increasing clinical awareness of the impact of obstetric and nonobstetric infections with their inclusion in the differential diagnosis, together with a thorough evaluation of cases clinically thought to be eclampsia, could have a significant impact on the reduction of maternal mortality.

What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries

“…One factor that may have contributed to this increase is the misclassification of death due to HIV/AIDS that can occur in settings where there is a large number of undiagnosed HIV/AIDS cases, such as South Africa. 17 In this situation, using only the MMR for all-cause maternal deaths masks the greater increase in, and the growing problem of, the indirect causes of maternal death.…”

Validity of a Minimally Invasive Autopsy for Cause of Death Determination in Adults in Mozambique: An Observational Study

“…However, although verbal autopsy provides a broad syndromic approach, its performance for etiological diagnosis is very limited, and it tends to misclassify a substantial number of deaths [1]. Finally, clinical records generally show a high rate (10%–30%) of discordance with the results of CDAs [8,9], and this discordance further increases in resource-constrained settings, where the availability of ancillary diagnostic tests such as imaging or microbiological exams is scarce or suboptimal [10,11]. …”

Etiologies of Illness Among Patients Meeting Integrated Management of Adolescent and Adult Illness District Clinician Manual Criteria for Severe Infections in Northern Tanzania: Implications for Empiric Antimicrobial Therapy

“…Our findings add to the work of others highlighting the knowledge gap on the causes of severe infectious syndromes in resource-limited settings. [38][39][40][41] Although the etiologic diagnoses elucidated in our cohort indicate a substantial proportion were pathogens that would not be responsive to ceftriaxone, among the agents we assessed for each clinical syndrome no agent would provide better empiric coverage than ceftriaxone. Additionally, as our analysis was retrospective and as none of the diagnostic tests performed is 100% sensitive, our results likely underestimate the proportion of patients with an etiologic diagnosis that was not detected but nonetheless would be responsive to ceftriaxone.…”