Confidential enquiry into maternal deaths occurred in Rwanda Health Facilities in

2018

Bucyana Tatien; Karangwa Eugene; Bikorimana Ferdinand, Sayinzoga Felix

Maternal Child and Community Health Division

Presentation outline

• Introduction/Rationale of confidential enquiry into maternal deaths

• Methodology

• Key findings: Socio-demographic profile of deceased woman

Pregnancy progress and care

Period of deaths Labor and condition of delivery

Type of maternal deaths and causes of direct maternal deaths (ICD 10)

Remediable character of deaths and contributing delays

• Key gaps identified

• Recommendations

Rationale of confidential enquiry into maternal deaths

• The Health facility based maternal death audit has the challenge of using a routine

internal evaluation methodology which may lead to insufficient analysis of maternal deaths occurred in the facility.

• An external deep review of number, causes and factors surround each maternal death is required for further improvement to eliminate preventable deaths.

• A confidential enquiry into maternal deaths is an anonymous study of all or a random sample of maternal deaths occurring in a specified area. It deeply studies causes and factors contributing to maternal deaths and evidence can be generated to help decision-makers to design and implement systematic solutions for improving Emergency Obstetric Care at all levels.

Methods

• Cross-sectional health facility survey conducted countywide in March 2019 by External trained and experienced evaluators

• A deep analysis of deaths occurred from January to December 2018

• The updated death review form based on WHO application of ICD-10 to deaths during pregnancy, childbirth and puerperium: ICD MM in classification of causes of deaths was used.

• Quantitative information were collected using the data collection form and qualitative information provided by surveyors after deep analysis of cases studied.

Methods

• This is cross-sectional health facility survey conducted countywide in March 2019

• External trained and experienced evaluators conducted a deep analysis of

deaths occurred from January to December 2018 • The updated death review form based on WHO application of ICD-10 to

deaths during pregnancy, childbirth and puerperium: ICD MM in classification of causes of deaths was used.

• Quantitative information were collected using the data collection form and

qualitative information provided by surveyors after deep analysis of cases studied.

Key findings

Comparison of maternal deaths annually notified and reviewed during survey

317 321

18 11 0

50

100

150

200

250

300

350

Nbr of deaths notified Nbr of deaths reviewed Number of deaths filesmissed

Nbr of deaths misclassified

Place and level of health facilities where death occurred

N Place of death Number Percentage

1 Health facility 297 93%

2 While being transferred to health facility 24 7%

Total 321 100%

N Level of health facility where death occurred Number Percentage

1 Health Centers and Health Post 18 6%

2 District and Provincial hospitals 148 46%

3 Referral Hospitals 20 6%

4 Tertiary hospitals 135 42%

Total 321 100%

Socio-demographic profile of deceased women

N Age category Number Percentage

1 <20 years 18 6%

2 20 - 25 years 53 17%

3 25- 35 years 131 41%

4 35 years and above 119 37%

Total 321 100%

N Martial status Number Percentage

1 Single 60 19%

2 Married 235 73%

3 Divorced 3 1%

4 Widowed 1 0%

5 Missed 22 7%

Total 321 100%

Pregnancy progress and care

N Gravida Number Percentage

1 G1 77 24%

2 G2-3 113 35%

3 G4-5 69 21%

4 G6-9 48 15%

5 G10> 8 2%

6 Missed 6 2%

Total 321 100%

N ANC attendance Number Percentage 1 Yes 125 39%

1 ANC Visit 16 13%

2 ANC Visits 48 38%

3 ANC Visits 42 34%

4 ANC Visits 18 14%

> 4 ANC Visits 1 1% 2 No 16 5%

3 Uknown/Not documented 180 56%

Total 321 100%

Pregnancy progress and care (Cont’d)

N ANC High level consulted Number Percentage

1 Health Center ( Nurse/Midwife) 110 88%

2 Hospital (GP/Gyneco-Obstetrician) 8 6%

3 Unknown/Not documented 7 6%

N Risk character of pregnancy Number Percentage

1 Yes 132 41%

2 No 112 35%

3 Uknown/Not documented 50 16%

4 Missed 27 8%

Total 321 100%

Period of Obstetric conditions at moment of death

11%

9%

64%

11%

2% 3%

Antepartum

Intrapartum

Postpartum

Post abortion

Ectopic

Missed

Onset of the labor and mode of delivery

13%

20%

61%

5%

Onset of the labor

C/Section beforeonset

Unknown

Spontaneous

Induced

49%

8%

42%

1%

Mode of delivery

C/Section

Laparotomy

Spontaneousvaginal delivery

Assisted vaginaldelivery

Facility episode

N Place of deaths Presence of fatal complications at admission

No Yes Total

1 Health center 11(61%) 7(39%) 18(100%)

2 District Hospital 73(57%) 64(43%) 129(100%)

3 Provincial Hospital 3(27%) 8(73%) 11(100%)

4 Referral hospital 9(45%) 11(55%) 20(100%)

5 Teaching hospital 11(8%) 124 (92%) 135(100%)

Grand Total 107 (33%) 214(67%) 321(100%)

Onset of the labor and mode of delivery

33%

27%

19%

12%

3%

3%

2%

2%

0% 10% 20% 30% 40%

Previous caesarean

Foetal distress

Obstructed labor

Obstetric haemorrhage

Uterine inertia

Placenta praevia

Pre-eclampsia

Indication not well…

Indication of C/Section

70%

27%

3%

Outcome of delivery

Live birth Stillbirth Unknown

Time of death in Postpartum period

32%

18%

6%

15%

30%

Within first 6 hours

Between 6 hours and 24 hours

Between 24 Hours and 48 Hours

Between 48 Hours and 7 days

Between 8 days and 42 days

Classification of maternal deaths and group of causes of direct maternal deaths (ICD 10)

70%

25%

5%

Classification of maternal death

Direct maternal death

Indirect maternal death

Unclassified maternal death

32%

18%

16%

14%

10%

8%

0% 5% 10% 15% 20% 25% 30% 35%

Group 3 :Obstetric haemorrhage

Group 4:Pregnancy related infection

Group 6: Unanticipated complicationsof management

Group 1: Pregnancy with abortiveoutcome

Group 5:Other obstetric complications

Group 2:Hypertensive disorders

Group 7:Suide

Group of direct maternal death

Top 3 Groups and underlying direct causes of deaths

Group 3 Obstetric haemorrhage 73 32%

1 Antepartum hemorrhage 5 7%

2 Intrapartum hemorrhage 31 42%

3 Postpartum hemorrhage (hemorrhage after delivery of fetus 36 49%

4 Missed 1 1%

Group 4 Pregnancy related infection 41 18%

1 Infections of genitourinary tract in pregnancy 1 2%

2 Infection of amniotic sac and membranes 3 7%

3 Puerperal sepsis 36 88%

4 Other puerperal infections developed 1 2%

Group 6 Unanticipated complications of management 34 15%

1 Complications of anesthesia during labor and delivery 3 9%

2 Complication of anesthesia during the puerperium 1 3%

3 Complications of Obstetric surgery and procedures 27 79%

4 Missed 1 3%

Obstetric hemorrhage and related potential causes of deaths

A. Antepartum hemorrhage 5 7%

1. Placenta praevia 1 20%

2. Antepartum hemorrhage, not elsewhere classified (Antepartum hemorrhage, unspecified 4 80%

B. Intrapartum hemorrhage 31 42%

1. Obstetric trauma :Rupture of uterus before onset of labour 1 3%

2. Obstetric trauma :Rupture of uterus during labour 23 74%

3. Obstetric laceration of cervix (Cervical tear) 4 13%

4. Obstetric high vaginal laceration alone( without mention of perineal laceration ) 1 3%

5. Intrapartum hemorrhage, unspecified 2 6%

C. Postpartum hemorrhage (hemorrhage after delivery of fetus ) 36 49%

1. Hemorrhage associated with retained, trapped or adherent placenta (Third-stage hemorrhage 8 22%

2. Postpartum atonic hemorrhage 14 39%

3. Postpartum coagulation defects(Postpartum afibrinogenemia, fibrinolysis) 9 25% 4. Delayed and secondary PPH (Hemorrhage associated with retained portions of placenta or membranes coming after 24 hours of delivery) 1 3%

5. Missed 4 11%

6. Underlying cause of obstetric hemorrhage missed 1 1%

Total obstetric hemorrhage 73 100%

Hypertensive disorders and related potential causes of deaths

A. Gestational [pregnancy-induced] hypertension without proteinuria 1 5% B. Pre-eclampsia

6 32%

1. Moderate pre-eclampsia 1 17%

2. Severe pre-eclampsia 3 50%

3. HELLP syndrome(Hemolysis + elevated liver enzymes and low platelet) 2 33%

C. Eclampsia 11 58%

1. Eclampsia in pregnancy 7 64%

2. Eclampsia in labour 1 9%

3. Eclampsia in the puerperium 3 27%

D. Unspecified maternal hypertension 1 5%

Total 19 100%

Obstetric related infections and related potential causes of deaths

A. Infections of genitourinary tract in pregnancy 1 2%

B. Infection of amniotic sac and membranes 3 7%

Amnionitis 1 33%

Chorioamnionitis 2 67%

C. Puerperal sepsis 36 88%

1. Endometritis 10 28%

2. Peritonitis 26 72%

D. Other puerperal infections developed in post partum period (Infection of obstetric surgical wound) 1 2%

Total Pregnancy related infection 41 100%

Pregnancies with abortive outcomes

A. Abortion 28 90%

1. Abortion complicated by delayed or excessive hemorrhage 8 29%

2. Abortion complicated by Genital tract and pelvic infection 18 64%

3. Abortion complicated by embolism 2 7%

B. Ectopic pregnancy 3 10%

1. Abdominal pregnancy 1 33%

2. Tubal pregnancy 1 33%

3. Missed 1 33%

Total pregnancy with abortive outcomes 31 100%

Remediable character of deaths and contributing delay

14%

78%

4% 4%

Remediable character of deaths according to opinion of surveyors

Not avoidable Potentially avoidable

Undetermined Missed

30%

3% 65%

2%

More contributing dealy according to opinion of surveyors

Delay 1: Seeking care

Delay 2: Reaching at right facility

Delay 3: Receiving care or quality of care

Missed

Underlying and potential causes of indirect maternal deaths

N Underlying and potential causes N % A Cardiac diseases in pregnancy ,childbirth and puerperium 10 12%

1.Pre-existing essential hypertension complicating pregnancy, childbirth and the puerperium 1 10%

2.Pre-existing hypertensive heart disease/cardiopathy complicating pregnancy, childbirth and the puerperium 9 90% B Diabetes mellitus in pregnancy Including in childbirth and the puerperium 1 1% C Maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy or postpartum

27 33% 1. Tuberculosis complicating pregnancy, childbirth and the puerperium 2 7% 2.Other infections with a predominantly sexual mode of transmission complicating pregnancy or postpartum

1 4% 3.Human immunodeficiency [HIV] disease complicating pregnancy, childbirth and the puerperium 5 19% 4.Viral hepatitis and Other viral diseases complicating pregnancy, childbirth and the puerperium 1 4% 5.Protozoal diseases including malaria complicating pregnancy, childbirth and the puerperium 16 59%

6.Other and unspecified maternal infectious and parasitic diseases complicating pregnancy and post partum 2 7% D Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium when

the reason for maternal care is that the condition is known or suspected to have affected the fetus 31 38% 1. Anemia complicating pregnancy, childbirth and the puerperium 2 6%

3.Diseases of the respiratory system including pneumonia complicating pregnancy and puerperium 13 42% 4.Diseases of the digestive system complicating pregnancy, childbirth and the puerperium 2 6% 5.Neoplasm diseases 1 3% 6. Other maternal diseases classifiable elsewhere not listed above 12 39%

E Missed 13 16% Grand Total 81 100%

Frequency of factors associated with delay within Health facilities

65%

48%

38%

38%

22%

21%

10%

10%

0% 10% 20% 30% 40% 50% 60% 70%

Mismanagement

Taking right decision

Error in diagnosis

Follow up after admission

Delayed calling for assistance

Insufficient investigations

Lack of suplies

Lack of assistance

Some gaps identified by surveyors

• Delay to perform hysterectomy

• Anesthesia procedures not well performed

• Insufficient skills to manage/recognize complications due to cesarian section

• Misdiagnosis (Ex:DPPN Vs placenta praevia

• Tentative of vaginal delivery for woman with previous scar in not specialized setting.

• Transfer of non stable patient

• Late recognition of peritonitis signsdue to insufficient follow up

• Mismanagement of malaria cases

Some gaps identified by surveyors (Cont’d)

• Delay in calling for help within the health facility (call for senior GP)

• Initial assessment not properly done

• Insufficient respect of infection prevention and control rules

• Insufficient involvement of anesthesiologist in patient’s resuscitation

• No admission of critical patient in ICU / close follow up

• Insufficient close follow up in immediate post partum period

Conclusion

• The survey showed that most of maternal deaths are remediable and are due to preventable causes like obstetric haemorrhage , infections ,complications of abortions and unanticipated complication of management

• Proper attention should be made on management of obstetrical complications to end preventable deaths by addressing challenges faced by health providers to provide quality maternal health services.

Recommendations

• Reinforce mentorship on quality C/S and related complications

• Strict follow up of protocols for post operative monitoring

• Perform complicated C/S in presence of experienced doctor

• Improve interprofessional collaboration/communication in referral hospital (obstetrician , GPs, midwifes/nurses)

• Ensure physical handover between 2 teams (shift) in presence of doctors, midwives, nurses

• Ensure that all women with previous scar or other conditions that need medical interventions are transferred before labor at hospital (<37 weeks of GA)

• Improve follow up in immediate post partum period

• Regular check of availability of blood.

Recommendations (cont’d)

• Clinical Directors to ensure the second call is always available for support and expertise

• RSOG to review the protocol of labor induction

• Mentors to Prepare practice based teaching on monitoring of labor

• Timely referral of cases that need specialized care at referral hospital and ensure they are stable

• Mandatory post op administration of antibiotics when patient operated with signs of chorioamnionitis

• Review of transfer policy and increase the number of ambulances

• Improve transportation means

Thank you, Murakoze