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Extreme Maternal Morbidity Extreme Maternal Morbidity and Maternal and Maternal Mortality Reduction by Implementing a Mortality Reduction by Implementing a
Surveillance System at the Gynecology and Surveillance System at the Gynecology and Obstetrics Hospital, Guatemala 2007-2009Obstetrics Hospital, Guatemala 2007-2009
Dr. Jorge David Alvarado AndradeFETP 2008 (Intermediate Level)Gynecology and Obstetrics Hospital, Social Security Institute
Maternal Mortality in Maternal Mortality in GuatemalaGuatemala• Guatemala
– 12,000.000 habitants – Annual LB: 369, 769 (2008)
• 51% attended by health workers– MMR: 153/100,000 LB
• Social Security (IGSS)– Attend the 8% de LB – Gynecology and Obstetric Hospital
(GOH)• Third level hospital • Annual attend LB:
16,000 (90% of IGSS)
BackgroundBackground
• In 2007, IGSS reported 42 cases of confirmed maternal deaths, of which only 1 occurred in the GOH.
• No cases of obstetric patients with extreme maternal morbidity (Near-Miss)
Real or underreporting?
How death was registered?How death was registered?
Maternal DeathsHospital
Maternal Deaths Records
Floor Supervisor or Ward Supervisor
Nursing Supervisor
Statistical Service
This occurred in 5% (2 / 42) of the cases
Extreme Maternal Morbidity (GOH)
Transferred to another unit of IGSS
(Intensive Care)
Dead
Admitted in the Transfer Unit
Hospital Discharge
Alive Statistical Service at the Transfer Unit
Happened in 95% (40/42) of cases
How Near-Miss was registered? How Near-Miss was registered? (II)(II)
ObjectivesObjectives
• Design and implementation of an improved Maternal Mortality Surveillance System (MMSS) based in GOH.
• Identify all cases of Maternal Mortality (MM) and Extreme Maternal Morbidity (EMM) that occur in the GOH (2009) and determine their causes
Phases of Development Phases of Development of the MMSSof the MMSS
1. Diagnosis the situation the MM (2007)
2. Create the SSMM Committee (2008)a. Development of the Protocol
b. Restructuring the System for EMM and MM cases recording
3. Active surveillance (2009)
EMM and MM Surveillance Committee
Analysis of Cases and Drafting
Conclusions and Recommendations
Results Dissemination
ResultsResultsCurrent Reporting SystemCurrent Reporting System
Maternal DeathsHospital
Maternal Deaths Records
Floor Supervisor or Ward
Supervisor
Nursing Supervisor
Statistical Unit
Chief resident and / or residents
III
ReferralNotification
EMM and MM Surveillance Committee
Case Analysis and Drafting
Conclusions and Recommendations
Results Dissemination
Feedback
Current Reporting System (II)Current Reporting System (II)Extreme Maternal
Morbidity (HGO)
Transferred to another unit of IGSS
(Intensive Care)
Dead
admitted in the transfer unit
Hospital Discharge
Alive
Statistical Service at the Transfer Unit
Data Analyzer
Overview of EMM population treated at the GOH Guatemala, 2009
Parity No. of Cases %Primigravida 1 0Secundigesta 111 31Multiparous 183 50No data available 68 19
Timing at Complication %Miscarriage 62 17Preterm 124 34Term 103 28Prolonged 5 1No data 4 1Puerperium 65 18
Procedure %Caesarea 274 75Delivery 23 6Curettage 8 2Other 55 15No data 3 1
n = 363
Morbility No. of Cases %Severe Hypertension 110 30Ectopic Pregnancy 50 14Pre-eclampsia / Eclampsia 49 13Acute Abdomen 28 08Placenta Previa Bleeding 25 07HELLP Syndrome 19 06Fetal Distress 18 05Failed Induction 12 03Placenta Accreta 11 03Uterine Atony 8 02Other Causes 33 09TOTAL 363 100
Top ten causes of EMM in patients treated at the GOH Guatemala, 2009
Source: Book of deliveries, cesarean sections and reports from team leaders
n = 363
Transfer Causes No. of Cases %Unstable Hypertension 18 36Hypovolemic Shock 11 22Septic Abortion 1 02Eclampsia 1 02Respiratory Failure 1 02Granulocytic Leukemia 1 02HELLP Syndrome 1 02Metabolic Disorder 1 02Inmunological Disease 1 02PostPartum Hemorrage 1 02Other Causes 13 26TOTAL 50 100
Top ten reasons for transfer patients treated with EMM to ICU from GOH. Guatemala, 2009
Source: Book of deliveries, cesarean sections and reports from team leaders
n = 50
Transfer Unit No. of Cases %Gynecology and Obstetrics Hospital
312 87.05
Intensive A 39 10.74Intensive B 10 02.75Infeccions Floor 1 00.28**No data 1 00.28TOTAL 363 100.00Transfer to Intensive 50
Place of transfer to intensive care for patients treated with EMM at GOH Guatemala, 2009.
Source: Book of deliveries, cesarean sections and reports from team leaders
Maternal Mortality Ratio at the GOH Guatemala, 2007 to 2009
Ca
ses
Maternal Mortality Ratio
*Absolute number of maternal deaths were 11(2009), 7(2008) and 4(2010)
n = 22
Years
Causes of MM at the GOHGuatemala, 2007 to 2009
2007 2008 2009
Cause of Death Cases % Cases % Cases %
Hipertensive Status
2 18 3 43 1 25
Postpartum Hemorrage
3 27 2 29 1 25
Septic Abortion 5 45 1 14 1 25Medical Complications
1 9 1 14 1 25
TOTAL 11 100 7 100 4 100
n = 22
Impact to Public HealthImpact to Public Health
Relationship between Maternal Mortality Ratio and Audit of cases at the GOH, Guatemala 2007 to 2009
Pe
rce
nta
ge
Years
Maternal Mortality Ratio
Audit Cases
Limitations of SSMMLimitations of SSMM
• Resistance to notify cases
• Lack of enforcement by IGSS of the new regulations for surveillance of MM
• Misclassification of maternal deaths
• Incomplete and/or inappropriate comicent of the reporting forms
AchievementsAchievements in 2010 in 2010• Audit of 92% of the cases of EMM and MM
• Risk factors for MM are being analyze
• System Surveillance delays are being evaluated
• Construction of the ICU in GOH
• Social Work Service was incorporated in to the MMSS as another source of reporting
Thanks for your attentionThanks for your attention
LakeAtitlàn GuatemalaLakeAtitlàn Guatemala
MethodsMethodsYears
2007 2008 2009
Conventional Statistical Record
Form the surveillance committee
Protocol Development and Implementation
Review of Cases occurred in 2007
Monitor and Audit Cases occurred in
2008
Active Surveillance of MM and MME
cases
Audit Cases of MM and EMM
Development and Dissemination of
Reports
Implementation of Control Measures
ActivitiesActivities
1. Create the Surveillance Committee for Maternal Mortality and Extreme Maternal Morbidity (2008)
2. Development of the Protocol:• Data Source• Notification Process (define scenarios)• Frequency of Notification• Operational Definitions• Inclusion and Exclusion Criteria• Type of surveillance
3. Data Analysis:• Classify the deaths as maternal or not maternal
related• Determine if MM were preventable• Explore the major risk factors
4. Analyze and interpret results
5. Present and discuss the results
6. Restructuring the system for EMM and MM cases recording
Activities (II)Activities (II)
Condition at Discharge No. of Cases %Alive 359 98Dead 4 2TOTAL 363 100
Maternal Mortality Ratio: 26.4 *100.000 live births
(4 deaths/15,161 births*100,000)Reason of nears-miss: 4/363 * 100 =1,1 (1 per 100)
Discharge status of patients with EMM attended at GOH, Guatemala, 2009.
Source: Book of deliveries, cesarean sections and reports from team leaders
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