Priorities in emergency obstetric care in Bolivia––maternal mortality and near‐miss morbidity in metropolitan La Paz

Abstract

Objective To document the frequency and causes of maternal mortality and severe (near-miss) morbidity in metropolitan La Paz, Bolivia.Design Facility-based cross-sectional study.Setting Four maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government-subsidised programme.Population All maternal deaths and women with near-miss morbidity.Methods Inclusion of near-miss using clinical and managementbased criteria.Main outcome measures Maternal mortality ratio (MMR), severe morbidity ratio (SMR), mortality indices and proportion of nearmiss cases at hospital admission.Results MMR was 187/100 000 live births and SMR was 50/1000 live births, with a relatively low mortality index of 3.6%. Severe haemorrhage and severe hypertensive disorders were the main causes of near-miss, with 26% of severe haemorrhages occurring in early pregnancy. Sepsis was the most common cause of death. The majority of near-miss cases (74%) were in critical condition at hospital admission and differed from those fulfilling the criteria after admission as to diagnostic categories and socio-demographic variables.Conclusions Pre-hospital barriers remain to be of great importance in a setting of this type, where there is wide availability of free maternal health care. Such barriers, together with haemorrhage in early pregnancy, pre-eclampsia detection and referral patterns, should be priority areas for future research and interventions to improve maternal health. Near-miss upon arrival and near-miss after arrival at hospital should be analysed separately as that provides additional information about factors that contribute to maternal ill-health.Keywords Bolivia, maternal mortality, near-miss, severe maternal morbidity.Please cite this paper as: Rööst M, Altamirano V, Liljestrand J, Essén B. Priorities in emergency obstetric care in Bolivia--maternal mortality and near-miss morbidity in metropolitan La Paz.

Syndemic Approach in Preventing Perinatal Near Miss before First Phase of Three Delay Model

“…However, a study conducted in urban setting in Bolivia where there are several maternity hospitals and located in short distance found that majority of near miss cases arrived in critical condition [18]. It is quite obvious that the main obstacle to arrive timely is not a physical barrier like transportation but more towards nonphysical barriers.…”

“…Many recent studies found that third delay is significantly associated with a higher risk of developing severe maternal morbidity [26][27][28][29]. They found that majority of the patients arrived at the referral health facility in a critical condition or severe complication which indicates barriers to reach the treatment [15,18].…”

“…The first delay is often discussed as a barrier to the healthcare facilities utilization. It is a process depending on socioeconomic and cultural background, logistic and quality of care [11,18]. There are studies showing that women will only look for treatment when they had life threatening condition but some of them were not able to recognize the conditions [13,[19][20][21].…”

The role of delays in severe maternal morbidity and mortality: expanding the conceptual framework

“…31 Phase III The cumulative effect of phase I and II delays contributes to the number of women reaching facilities in a serious condition. 25,34,36 Many will never reach a hospital, 22,33 and even when they do, treatment may not be successful.…”

Maternal Near Miss Review: A Way Forward

“…maternal morbidity which has remained largely undescribed. In 2009, Roost et al [2] reported MMR as 187/100,000 LB and MNM as 50/1,000 LB, with a relatively low mortality index (MI) of 3.6 %.…”