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Quality of maternal care in the WHO Multi-Country Survey

Dr Joshua Vogel

UNDP / UNFPA / WHO / WORLD BANK Special Programme of Research,

Development and Research Training in Human Reproduction (HRP)

WHO Department of Reproductive Health & Research

Geneva, Switzerland

Objective

New key findings on severe maternal outcomes, coverage of essential interventions and measures of quality of care from WHMOCS Strengths and limitations of facility-centred, criterion-based clinical audit methodology

Questions to discuss:

Application of similar methodology and indicator measurement to SPAs

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Maternal Near Miss

"A woman who nearly died but survived a

complication that occurred during pregnancy, childbirth or within 42 days of

termination of pregnancy"

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The continuum of severity

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WHO Maternal Near Miss identification criteria

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Prevalence and management of maternal and neonatal

conditions and quality of care

– Maternal death and maternal near miss

– availability and use of preventative and therapeutic interventions

Multi-country, facility-based, cross-sectional survey

The WHO Multi-Country Survey

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A woman who survived a complication that occurred during

pregnancy, childbirth or within seven days of termination of

pregnancy and presented any of the life-threatening

conditions listed in the previous slide should be classified

as a maternal near miss case.

Operational definition

Recruitment 29 countries

3 Provinces (capital city and 2 randomly selected provinces) 7 facilities per province (357 facilities)

– >1,000 deliveries per year – Capacity to perform C-sections

3 month data collection period

May 2010 to Dec 2011

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Eligibility Criteria Captured all deliveries (together with newborns) AND all women with SMO (death or near miss, regardless of delivery or not)

Maternal deaths up to the seventh postpartum day Women with organ dysfunction related to pregnancy Abortion and ectopic pregnancy included

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Study Procedures

Data abstracted from medical records

From admission to discharge, death or day 7 postpartum (whichever came first)

Women arriving to the hospital after the seventh postpartum day were not eligible

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Key findings – Severe maternal outcomes

314,623 women & 310,435 liveborns

• Women with severe maternal outcome N=3,024 (1.0%) • Maternal near miss cases n =2,538 (0.81%) • Maternal deaths n =486 (0.15%)

Low- MMR countries

Moderate-MMR

countries

High MMR- countries

Very-High MMR countries

Overall

Maternal Near Miss Ratio (MNMR)*

4.7 6.1 6.2 13.1 8.3

Severe Maternal Outcome Ratio (SMOR)**

4.7 6.5 8.6 15.9 9.9

Intra-hospital Maternal Mortality Ratio***

0.0 36 246 279 158

* Calculated as the number of maternal near-miss cases per 1,000 live births ** Calculated as the number of women with severe maternal outcomes per 1,000 live births ***Limited to seven days after pregnancy termination, per 100,000 live births

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Extreme analysis

How many maternal near miss cases did we fail to detect? •Low/mod MMR countries – 11-12% of near miss diagnoses based on laboratory criteria •Very high MMR countries – 3.5%

•Assume low to moderate MMR countries identify as many near miss cases as possible – impute to higher MMR countries

• 16% organ dysfunction not detected (overall) • 27% organ dysfunction not detected (very high MMR)

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Low- MMR countries

Moderate-MMR

countries

High MMR- countries

Very-High MMR countries

Overall p

Coverage of prophylactic oxytocin

81.8% 90.4% 88.1% 91.7% 90.1% <0.01

Coverage of therapeutic oxytocin

81.5% 88.1% 84.4% 85.6% 85.9% <0.01

Coverage of magnesium sulfate for eclampsia

75% 88.9% 80.4% 87.5% 85.7% 0.02

Coverage of prophylactic antibiotics for caesarean section

35.7% 91.7% 82.9% 82.5% 87.3% <0.01

Coverage of parenteral antibiotics for sepsis

69.1% 84.5% 62.6% 89.3% 78.5% <0.01

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Women without

SMO

Maternal near miss

Maternal death

Coverage of prophylactic oxytocin

90.1%

(280227/310954)

85.2%

(1228/1441)

83.3%

(220/264) <0.01

Coverage of therapeutic oxytocin

86.4%

(3376/3908)

83.7%

(569/680)

82.8%

(106/128) 0.10

Coverage of magnesium sulfate for eclampsia

85.5%

(613/717)

88.6%

(194/219)

79.2%

(57/72) 0.13

Coverage of prophylactic antibiotics for caesarean section

87.3%

(77234/88450)

84.2%

(783/930)

80.0%

(108/135) <0.01

Coverage of parenteral antibiotics for sepsis

76.9%

(759/987)

88.8%

(127/143)

79.1%

(68/86) <0.01

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Quality of care indicator

Maternal near miss mortality ratio

Proportion of near misses per maternal death

Near miss: 1 death

Maternal mortality index (case fatality)

Percentage of women with severe maternal outcome who are deaths

Maternal deaths (near miss+death)

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Maternal Mortality Index: quality of the management of severe complications

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Conclusions

• Beyond essential interventions • Haemorrhage and hypertensive disorders cause over

50% of maternal deaths, despite relatively high intra-hospital coverage of uterotonic use and MgSO4

• Quality of care issues:

• Delays in implementing interventions? • Quality of medicines? • Incorrectly performed interventions? • Delays in referral?

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Conclusions

• PPH • Uterotonics essential • So is surgical care and haemodynamic support

• Eclampsia

• MgSO4 critical • So is pre-delivery stabilization, severe hypertension

management or airway management • Infection

• Prevalence of infection increased as case severity increased. • Prevention, early identification and appropriate management of

secondary and non-obstetric infections is a priority.

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Limitations

• Facility-based survey • misses proportion of morbidity and mortality occurring

in the community • Biased towards larger, more complex referral facilities • Not representative of population

• 7 day follow up • Misses M&M occurring >7-42 days

• Data abstracted from medical record • Data quality issues

• Treatment/coverage prior to referral unknown

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Strengths

• Size and scope • Relatively inexpensive • Data abstracted from medical record

• Demonstrated data collection is possible with routine hospital records and mechanisms

• Criterion-based clinical audit approach can be

applied in any facility, regardless of laboratory/diagnostic capacity

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Questions & Discussion

Would it be useful/feasible to have labour/delivery component on SPAs? How does service readiness correlate to quality of care delivered? Measuring quality of care in facilities that tell us about population level quality of care?