Great saves or near misses? Severe maternal outcome in Metro East, South Africa: A region‐wide population‐based case‐control study

Heitkamp, Anke; Vollmer, Linda; Akker, Thomas van den; Gebhardt, Stefan; Sandberg, Evelien M.; Roosmalen, Jos van; Wee, Marieke M. ter; Vries, J.I. de; Theron, Gerhard

doi:10.1002/ijgo.13739

Cited by 7 publications

(15 citation statements)

References 26 publications

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“…The method of auditing MNMs can differ between institutions and between interviewed persons. In 2018, we discussed the data collection form used for MNMs in the Metro East health district, Western Cape Province, SA, [6] with the authors of articles on the Metro West district [7] and Pretoria, [8] who are also participants in the NCCEMD (see acknowledgement). Adjustments were based on the knowledge of the setting together with the Haydom criteria [9] from the literature and outcomes of a Delphi study for low-income countries.…”

Section: Methodsmentioning

confidence: 99%

“…supplementary file (https://www.samedical.org/file/1871) depicting the criteria for MNMs, underlying complications, details of women with an MNM and the assessment of avoidable factors, also used in our study in the Metro East district. [6]…”

Section: Researchmentioning

confidence: 99%

“…The search yielded a total of 797 results. Inclusion criteria were met by 15 articles [4,[6][7][8][11][12][13][14][15][16][17][18][19][20][21] (Supplementary Table 1, https://www.samedical. org/file/1872).…”

Section: Quantitativementioning

confidence: 99%

“…We found eight studies that applied the Mantel et al [4] SAMM criteria, [4,[11][12][13][14][15][16][17] one of which did so in a slightly adapted form. [15] The other seven studies used the WHO-MNM criteria, [6][7][8][18][19][20][21] two of which made adaptations to arrive at criteria relying on clinical assessment only and by adding diagnoses that are relatively frequent in SA [13,14] (Supplementary Table 1, https://www.samedical.org/file/1872).…”

Section: Quantitativementioning

confidence: 99%

“…This table lists MNM and mortality statistics for the nine studies that focused on MNM and mortality comprehensively rather than from a single cause. [4,[6][7][8][11][12][13][14]21] The median MNM-IR in the nine studies was 8.4/1 000 (5.6 -8.7) live births, the median MMR 130/100 000 (71.4 -226.0) live births, and the median MI 16.6% (11.7 -18.8). The main causes of MNMs were hypertensive disorders of pregnancy and obstetric haemorrhage..…”

Section: Quantitativementioning

confidence: 99%

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Every maternal near-miss counts: Need for a national audit in South Africa? A mixed-methods study

et al. 2022

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Background. To improve maternal health, studies of maternal morbidity are increasingly being used to evaluate the quality of maternity care, in addition to studies of mortality. While South Africa (SA) has a well-established confidential enquiry into maternal deaths, there is currently no structure in place to systematically collect and analyse maternal near-misses (MNMs) at national level.Objectives. To synthesise MNM indicators and causes in SA by performing a systematic literature search, and to investigate perceived needs for data collection related to MNMs and determine whether the MNM tool from the World Health Organization (WHO-MNM) would require adaptations in order to be implemented.Methods. The study used a mixed-methods approach. A systematic literature search was conducted to find all published data on MNM audits in SA. Semi-structured interviews were conducted virtually with maternal health experts throughout the country who had been involved in studies of MNMs, and main themes arising in the interviews were synthesised. A method for MNM data collection for SA use was discussed with these experts.Results. The literature search yielded 797 articles, 15 of which met the WHO-MNM or Mantel et al. severe acute maternal morbidity criteria. The median (interquartile range) MNM incidence ratio in SA was 8.4/1 000 (5.6 - 8.7) live births, the median maternal mortality ratio was 130/100 000 (71.4 - 226) live births, and the median mortality index was 16.6% (11.7 - 18.8). The main causes of MNMs were hypertensive disorders of pregnancy and obstetric haemorrhage. Eight maternal health experts were interviewed from May 2020 to February 2021. All participants focused on the challenges of implementing a national MNM audit, yet noted the urgent need for one. Recognition of MNMs as an indicator of quality of maternity care was considered to lead to improved management earlier in the chain of events, thereby possibly preventing mortality. Obtaining qualitative information from women with MNMs was perceived as an important opportunity to improve the maternity care system. Participants suggested that the WHO-MNM tool would have to be adapted into a simplified tool with more clearly defined criteria and a number of specific diagnoses relevant to the SA setting. This ‘Maternal near-miss: Inclusion criteria and data collection form’ is provided as a supplementary file.Conclusion. Adding MNMs to the existing confidential maternal death enquiry could potentially contribute to a more robust audit with data that may inform health systems planning. This was perceived by SA experts to be valuable, but would require context-specific adaptations to the WHO-MNM tool. The available body of evidence is sufficient to justify moving to implementation.

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Section: Methodsmentioning

confidence: 99%

Section: Researchmentioning

confidence: 99%

Section: Quantitativementioning

confidence: 99%

Section: Quantitativementioning

confidence: 99%

Section: Quantitativementioning

confidence: 99%

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Every maternal near-miss counts: Need for a national audit in South Africa? A mixed-methods study

et al. 2022

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Great saves or near misses? Severe maternal outcome in Metro East, South Africa: A region‐wide population‐based case‐control study

Heitkamp

Vollmer

Akker

et al. 2021

Intl J Gynecology & Obste

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Pulmonary oedema in the course of severe maternal outcome in South Africa: A cohort study combined with clinical audit

Heitkamp

Sandberg

Moodley

et al. 2023

Tropical Med Int Health

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Objectives: To describe the incidence and outcomes of pulmonary oedema in women with severe maternal outcome during childbirth and identify possible modifiable factors through audit. Methods: All women with severe maternal outcome (maternal deaths or near misses) who were referred to Tygerberg referral hospital from health facilities in Metro East district, South Africa, during 2014-2015 were included. Women with severe maternal outcome and pulmonary oedema during pregnancy or childbirth were evaluated using three types of critical incident audit: criterion-based case review by one consultant gynaecologist, monodisciplinary critical incident audit by a team of gynaecologists, multidisciplinary audit with expert review from anaesthesiologists and cardiologists. Results: Of 32,161 pregnant women who gave birth in the study period, 399 (1.2%) women had severe maternal outcome and 72/399 (18.1%) had pulmonary oedema with a case fatality rate of 5.6% (4/72). Critical incident audit demonstrated that pre-eclampsia/ HELLP-syndrome and chronic hypertension were the main conditions underlying pulmonary oedema (44/72, 61.1%). Administration of volumes of intravenous fluids in already sick women, undiagnosed underlying cardiac illness, administration of magnesium sulphate as part of pre-eclampsia management and oxytocin for augmentation of labour were identified as possible contributors to the pathophysiology of pulmonary oedema. Womenrelated factors (improved antenatal care attendance) and health care-related factors (earlier diagnosis and management) would potentially have improved maternal outcome. Conclusions: Although pulmonary oedema in pregnancy is rare, among women with severe maternal outcome a considerable proportion had pulmonary oedema (18.1%). Audit identified options for prevention of pulmonary oedema and improved outcome. These included early detection and management of preeclampsia with close monitoring of fluid intake and cardiac evaluation in case of suspected pulmonary oedema. Therefore, a multidisciplinary clinical approach is recommended.

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Great saves or near misses? Severe maternal outcome in Metro East, South Africa: A region‐wide population‐based case‐control study

Abstract: Systematic analysis of women with Severe Maternal Outcome with the help of the WHO-Maternal Near Miss tool gave insight into causes.

Cited by 7 publications

References 26 publications

Every maternal near-miss counts: Need for a national audit in South Africa? A mixed-methods study

Every maternal near-miss counts: Need for a national audit in South Africa? A mixed-methods study

Great saves or near misses? Severe maternal outcome in Metro East, South Africa: A region‐wide population‐based case‐control study

Pulmonary oedema in the course of severe maternal outcome in South Africa: A cohort study combined with clinical audit

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