Implementation of multidisciplinary care reduces maternal mortality in women with sickle cell disease living in low‐resource setting

Abstract

Sickle cell disease (SCD) is associated with adverse pregnancy outcome. In women with SCD living in low-resource settings, pregnancy is associated with significantly increased maternal and perinatal mortality rates. We tested the hypothesis that implementing a multidisciplinary obstetric and hematology care team in a low-resource setting would significantly reduce maternal and perinatal mortality rates. We conducted a before-and-after study, at the Korle-Bu Teaching Hospital in Accra, Ghana, to evaluate the effect of a multidisciplinary obstetric-hematology care team for women with SCD in a combined SCD-Obstetric Clinic. The pre-intervention period was assessed through a retrospective chart review to identify every death and the post-intervention period was assessed prospectively. Interventions consisted of joint obstetrician and hematologist outpatient and acute inpatient reviews, close maternal and fetal surveillance, and simple protocols for management of acute chest syndrome and acute pain episodes. Primary outcomes included maternal and perinatal mortality rates before and after the study period. A total of 158 and 90 pregnant women with SCD were evaluated in the pre-and post-intervention periods, respectively. The maternal mortality rate decreased from 10 791 per 100 000 live births at pre-intervention to 1176 per 100 000 at postintervention, representing a risk reduction of 89.1% (P 5 0.007). Perinatal mortality decreased from 60.8 per 1000 total births at pre-intervention to 23.0 per 1000 at post-intervention, representing a risk reduction of 62.2% (P 5 0.20). A multidisciplinary obstetric and hematology team approach can dramatically reduce maternal and perinatal mortality in a low-resource setting.

Multidisciplinary care results in similar maternal and perinatal mortality rates for women with and without SCD in a low‐resource setting

“…In a low‐resource setting, pregnant women with SCD have a 22 higher odds ratio of death when compared to women without SCD in the same setting . We previously demonstrated in a before‐and‐after study that a multidisciplinary care model reduced maternal mortality in women with SCD by nearly 90% . In this prospective cohort study, we have confirmed that implementing a multidisciplinary care strategy reduced maternal and perinatal mortality in women with SCD to similar levels in those without SCD in a low‐resource setting.…”

“…Previously, the clinic was staffed exclusively with obstetricians and midwives to care for pregnant women with SCD. Despite a dedicated clinic and team, the maternal mortality rate remained ~10% or 100 per 1000 live births. Comparatively, in the United States, the maternal mortality rate was similarly high in 1910 at 8.5% or 85 per 1000 live births .…”

“…Other adverse maternal outcomes in women with SCD include hypertensive disorders of pregnancy (preeclampsia, eclampsia), severe anemia, urinary tract infections, and increased odds of both antenatal and postnatal acute pain episodes . We have previously demonstrated, in a before‐and‐after study design, that multidisciplinary care of pregnant women with SCD reduced maternal mortality by 89% in a low‐resource setting in sub‐Saharan Africa …”

A case series describing causes of death in pregnant women with sickle cell disease in a low‐resource setting

“…Our intervention resulted in the reduction of maternal mortality by almost 90%. 7 Together, this study and our prior Direct obstetric deaths (n 5 6) 1 (6.7) 5 (17.9) Pregnancy-related infection 0 (0.0) 2 (7.1) Hypertensive disorders in pregnancy, childbirth and the puerperium 0 (0.0) 1 (3.6) Obstetric haemorrhage 1 (6.7) 2 (7.1) a Count (percentage) for categorical variables, median (Interquartile range) for continuous variables. b Not delivered includes IUFD and spontaneous abortions (< 28 weeks gestation).…”

White Paper: Pathways to Progress in Newborn Screening for Sickle Cell Disease in Sub-Saharan Africa

“…Screen pregnant women - Detecting that a pregnant woman has-SCD might permit more careful management, to try to reduce the 8-fold perinatal mortality [ 40 , 41 ]. Detecting that a mother has sickle cell trait could lead to targeted testing of the spouse and the newborn, as well as genetic counselling.…”