maternal(near*misses(( insrilanka• maternal deaths up to 7th postpartum day • women with organ...
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Learning from the Pregnant Mothers Just Escaped from Death: Maternal Near-‐Misses in Sri Lanka
Kapila Jayaratne MBBS,MSc, DCH,MD (Com Med) Consultant Community Physician
Na=onal Program Manager – Maternal Morbidity and Mortality Surveillance
Family Health Bureau – Ministry of Health Sri Lanka
Sri Lanka
Country Profile
Indicator Value Year
Land Area 62,705 Sq.Km 2009
Total PopulaGon 20.27 Million 2012
PopulaGon Density 326 Persons per Sq. Km 2012
PopulaGon growth 1.1 % 2009
GDP per Capita 3280 US$ 2013
PopulaGon below Poverty Line 8.9 % 2012
Literacy Rate 91.3 % >15 Yrs 2008 Unemployment Rate 5.8 % 2009
Life Expectancy Male
Female
74.0 70.3 77.9
Yrs 2007 2007
Human Development Index 0.702 (Min 0 – Max 1.0) 2013
Maternal Care Service Provision
Methodologies for Maternal Deaths Reviews
Community-‐based Maternal death review
Facility-‐based Maternal death review
ConfidenGal Enquiries into Maternal Deaths
Near-‐Miss Enquiry
Clinical Audit
üü
?ü
ü
Na=onal Maternal Death Surveillance & Response System – Sri Lanka
One of best organized and quality MDSR
System
2327.4
2493.6
2270.1
1767.1
2156.1 2136.0
2679.6
2013.1
1334.7
1694.0
579.8
278.5
75.8 50.6 23.5
0.0
500.0
1000.0
1500.0
2000.0
2500.0
3000.0 1911
1914
1917
1920
1923
1926
1929
1932
1935
1938
1941
1944
1947
1950
1953
1956
1959
1962
1965
1968
1971
1974
1977
1980
1983
1986
1989
1992
1995
Maternal Mortality Ra=o 1911 – 1995 Source: Registrar General’s Department
At independence in 1948
Maternal Mortality Ra=o 1995 -‐ 2014 Source: FHB Maternal Mortality Surveillance System
61.0
62.0
63.0
53.0
55.8 55.6
46.6
53.4
42.4 40.0
44.3
39.3
38.4
33.4
40.2
31.1
32.5
37.7
32.5 32
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2014 MMR = 32.0 per
100000 Live Births
Number of Maternal Deaths (2001 – 2014)
167
194
154 144
167
146
141 133
160
126 118
134
0
50
100
150
200
250
119
2014
112 deaths
Cause of Maternal Deaths -‐ 2014
* Number of deaths
2
3
5
6
6
9
9
11
12
14
17
18
0 2 4 6 8 10 12 14 16 18 20
Suicide
Sepsis
Hypertensive Disorders
Liver disease
Ectopic Pregnancy
Amnio=c Fluid Embolism
Other
Obstetric Haemorrhage
Medical other
Sep=c Abor=on
Heart Disease
Respiratory Disease
54 / 112 Medical causes
Pregnancy Data -‐ Sri Lankan context 2014
Non-‐life-‐threatening condi=ons
Poten=ally life-‐threatening condi=ons
Non-‐Life-‐threatening condiGons
Life-‐threatening condiGons
Maternal Near Misses
????
Maternal Deaths 112
Non-‐Complicated Pregnancies
297,258 Complicated Pregnancies
52,457 Total Live Births
349715
The Need
• Ever reducing number of maternal deaths -‐Emerging indirect causes -‐Mostly difficult and complex cases -‐Query over small sample size in MDSR and place for generalizability -‐Stagnant or slowly reducing MMR over the last decade
§ Growing emphasis on quality of care § Clinical governance
Objec=ves
1. To determine the prevalence of maternal near-‐miss cases in selected health facili=es
2. To describe the associated factors of maternal near-‐misses
3. To assess the country needs 4. To apply findings in country se_ngs
WHO MulG-‐Country Survey in Sri Lanka • MulGstage cluster sampling method
Capital City & Suburbs + 02 Randomly selected Provinces (Southern & Eastern)
14 health faciliGes
Selected Health Facili=es • TH Castle street Hospital for women • TH De Soyza Maternity Hospital • TH Colombo South • GH Sri Jayawardanepura • BH Awissawella • BH Horana • Durdens Hospital • TH Mahamodara • BH BalapiGya • GH Matara • BH KamburupiGya • BH Hambantota • GH Ampara • TH Bakcaloa
Private Sector
Eligibility Criteria • All women giving birth• Maternal deaths up to 7th postpartum day• Women with organ dysfunction related to
pregnancy (i.e. the life-threatening conditions), including abortion and ectopic pregnancy
This included the near-‐miss cases related to aborGon, ectopic pregnancy, non terminated pregnancies (i.e. women who survive to life threatening condiGons and remain pregnant) and women arriving at the hospital at the first postpartum week with life-‐threatening condiGons.
DuraGon of study Health Facility
Average births (per
year)
Dura=on of study (months)
TH-‐ Castle Street Hospital for Women 18000 2 TH – De Soyza Hospital for Women 10265 2 TH – Colombo South 10680 2 GH – Sri Jayawardenapura 4800 3 BH – Awissawella 4050 3 BH – Horana 4440 3 Durdens Hospital 4800 3 GH – Matara 16800 2 BH – KamburupiGya 3000 3 TH – Mahamodara 14400 2 BH – BalapiGya 3600 3 BH – Hambantota 4900 3 GH – Ampara 4800 3 TH – Bakcaloa 6000 2
Average deliveries < 5000 / yr – 3 months > 5000 / yr – 2 months
Results
Study PopulaGon Facility n %
Castle Street Hospital for Women 2641 14.6 TH Mahamodara 2131 11.8 GH Matara 1715 9.5 De Soyza Hospital for Women 1578 8.7 BH Hambantota 1394 7.7 TH Colombo South 1385 7.6 TH Bakcaloa 1213 6.7 BH Awissawella 1206 6.7 GH Sri Jayawardenapura 1054 5.8 GH Ampara 1007 5.6 BH BalapiGya 985 5.4 BH Horana 911 5 Durdans Hospital 478 2.6 BH KamburupiGya 431 2.4
Total 18129 100.0
18129 Deliveries 17988 Live births
Age DistribuGon
Age n % <20 years 1095 6.0 20-34 years 14339 79.1 >34 years 2695 14.9
-Majority in 20 – 34 age gp -Significant number (15%) > 34 yrs old
Marital status n % Single/ separate/ widow / divorce 153 0.9
Married/ cohabiting 17235 99.1
No formal educaGon , 65,
0%
Primary , 360, 3%
Post primary , 7464, 57%
Secondary , 5245, 40%
TerGary , 13, 0%
Education
>99% - Living together >97% - Well educated
1 7396 41%
2 5862 32%
3 3155 18%
4 1141 6%
5 or more 568 3%
None 15473 85%
1 2115 12%
2 or more 502 3%
Parity Previous Caesarian Sec=on
Parity > two -‐ 27% Previous CS -‐ 15%
Current Pregnancy : Mode of delivery
n %
Vaginal delivery 11947 65.9 Caesarean section 6161 34.0 Laparotomy for ectopic 2 0.01 Curettage 1 0.01 Other 5 0.03
Estimated POA
Median = 39 weeks Inter-‐quar=le range = 38-‐40 Wks
Nearly 1 / 3 Caesarean Sec=ons
Complica=ons of pregnancy, interven=ons and dysfunc=ons
• At least one major complicaGon
354 233
124 80
71 50
15 11 10 5 2 2 2
0 50 100 150 200 250 300 350 400
Haemorrhage Hypertensive disorders
Heart disease Anaemia
Lung disease Infec=ons
Renal disease Coincidental condi=ons
Hepa=c disease Malararia/dengue
HIV+/AIDS/HIV was=ng syndrome Embolic disease
Cancer
Cause % Haemorrhage 41 Hypertensive disorders 27 Heart disease 14 Anaemia 9 Lung disease 8 Infec=ons 6
862 (4.8%)
Translates to 16900 complicated pregnancies each year
Interven=ons received by women with complica=ons
Interventions n % Haemorrhage
Oxytocin for treatment of PPH 201 23.3 Ergotamine for treatment of PPH 102 11.8 Misoprostol for treatment of PPH 60 7.0 Balloon or condom tamponade 25 2.9 Artery ligation or embolization 18 2.1 Other uterotonic for treatment of PPH 8 .9
Infections Therapeutic antibiotics 91 10.6
Hypertension Magnesium anticonvulsant 35 4.1 Other anticonvulsant 17 2.0
Other interventions Blood products 183 21.2 Admission to ICU 125 14.5 Manual removal of placenta 42 4.9 Removal of retained products 31 3.6 Laparotomy 21 2.4
Es=mated no of cases necessita=ng selected interven=ons in a year in the country:
Oxytocin 3945 Misoprostol 1180 MgSO4 690 Blood Products 3592 ICU 2455 MRP 825 Laparotomy 412
The WHO Near Miss criteria Dysfunctional system Clinical criteria Laboratory markers Management based
proxies CVS Shock
Cardiac arrest pH<7.1 Lactate >5 mEq/mL
Use of continuous vasoactive drugs Cardio-pulmonary resuscitation
Respiratory Acute cyanosis Gasping Respiratory rate >40 or <6 bpm
Oxygen saturation < 90% for ≥ 60 mts PaO2 / FiO2 <200 mmHg
Intubation and ventilation not related to anaesthesia
Renal Oliguria non responsive to fluids or diuretics
Creatinine ≥300µmol/l or ≥3.5 mg/dL Dialysis for acute renal failure
Haematologic/ Coagulation Failure to form clots Acute severe thrombocytopaenia
(<50,000 platelets/ml) Transfusion of ≥ 5 units of blood / red cells
Hepatic Jaundice in the presence of preeclampsia
Bilirubin>100 µmol/l or >6.0 mg/dL
Neurologic Any loss of consciousness lasting >12h, Stroke Uncontrollable fit / status epilepticus Total paralysis
Alternative severity proxy
Hysterectomy following infection or haemorrhage
A woman presenGng any of these life-‐threatening condiGons and surviving a complicaGon during pregnancy, childbirth or within 42 days of terminaGon of pregnancy are considered a near miss case
Maternal Severe Outcomes • Of the 862 women with complicaGons, 73 (8.7%) had organ dysfuncGons
• Three deaths – (postpartum haemorrhage, dengue and a coincidental death)
Indicator n Events per 100,000 live
births
Maternal near-miss ratio 73 405.8
Intra-hospital maternal mortality ratio (limited to 7 days postpartum)
3 16.7
Severe maternal outcome ratio 76 422.5
Main indicators of maternal severe outcomes
No of Live Births = 17988
Applica=on to country contexts: Live births (2014) = 349,715 Maternal deaths = 112 MMR (2014) = 32.03 (per 100000 LBs) Es=mated no of maternal near-‐misses = 1419 / year in the country For each maternal death, 13 cases of near-‐misses
Organ DysfuncGons Dysfunctions n %
Cardiovascular dysfunctions Shock 13 1.5 Use of continuous vasoactive drugs 8 0.9 Cardio pulmonary resuscitation 2 0.2 Cardiac arrest 2 0.2 Severe acidosis 1 0.1
Respiratory dysfunctions Intubation and ventilation not related to anaesthesia
10 1.2
Oliguria non responsive to fluids or diuretics
8 0.9
Severe hypoxemia 4 0.5 Severe tachypnea 3 0.3 Acute cyanosis 3 0.3 Severe bradypnea 2 0.2
Renal dysfunctions Severe acute azotemia 4 0.5 Dialysis for acute renal failure 4 0.5
Dysfunctions n % Coagulation dysfunctions
Massive transfusion of blood or red cells 38 4.4 Severe acute thrombocytopenia 18 2.1 Failure to from clots 10 1.2
Hepatic dysfunctions Severe acute hyperbilirubinemia 5 0.6 Jaundice in the presence of pre-eclampsia
4 0.5
Neurological dysfunctions Uncontrollable fit /status epilepticus 1 0.1
Uterine dysfunctions Uterine infection or haemorrhage leading to hysterectomy 33 3.8
Leading Organ Dysfunc=ons: Massive transfusion of blood or red cells Severe acute thrombocytopenia Cardiogenic Shock Failure to form clots Intubation and ventilation Use of continuous vasoactive drugs Oliguria
Underlying Cause of Maternal Near-‐misses
Complication n % Haemorrhage 50 68.5 Hypertensive disorders 11 15.1 Anaemia 12 16.4 Abortion related infection 2 2.7 Malararia/dengue 2 2.7 Influenza 1 1.4 Other infections 7 9.6 Heart disease 3 4.1 Renal disease 3 4.1 Hepatic disease 3 4.1 Embolic disease 1 1.4 Lung disease 1 1.4
Variable P value Age > 35 years < 0.001 Schooling < 9 yrs 0.018 Previous births > 1 < 0.001 No Labour / Induced labour < 0.001 Mode Delivery – Caesarian SecGon < 0.001
Associated factors of Maternal Near-‐misses
Marital status had no influence
Country Scenario…
31
349715 Live Births
16900
Complicated
Pregnancies
1419 Maternal-‐Nearmisses
112 Maternal-‐Deaths
TranslaGng findings in to acGon
-‐Availability of a tool -‐Establishment of a Near-‐Miss Enquiry Surveillance System -‐Comparison between countries / faciliGes and over Gme.
Introducing a NaGonal Maternal Nearmiss Enquiry System in the country
Facilita=ng factors • EsGmated number of maternal nearmisses
= 1400 – 1500 –manageable • Sample size more than MDs • Nearmisses share a common pathway as in MDs • Main character / consumer alive to tell the story unlike in MDSR –more informaGon and a comprehensive picture could be compiled
• Number of health faciliGes with specialized obstetric faciliGes = 72 (94% deliveries)
• Easy to introduce and integrate into the health system Availability of local guidelines and protocols on major disease condiGons
§ WHO NM criteria is applicable in Sri Lankan sekngs –needs minor adaptaGons
§ Availability of specialized and other supporGve services –ICU / Anaesthesia / Laboratory / Blood transfusion
§ Family Health Bureau’s role as the central organizaGon for maternal morbidity and mortality surveillance is highly accepted
• Sharing the research finding with stakeholders
Adapta=on of NM criteria Suppor=ve format development Implementa=on mechanism
• Scale up at na=onal level
The Way Forward
