A global view of severe maternal morbidity: moving beyond maternal mortality

Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estima...

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Published inReproductive health Vol. 15; no. S1; pp. 98 - 43
Main Authors Geller, Stacie E., Koch, Abigail R., Garland, Caitlin E., MacDonald, E. Jane, Storey, Francesca, Lawton, Beverley
Format Journal Article
LanguageEnglish
Published England BioMed Central Ltd 22.06.2018
BioMed Central
BMC
Subjects
Banks (Finance)
Births
Blood transfusions
Cesarean Section
Childbirth & labor
Clinical practice guidelines
Failure
Female
Health aspects
Health risk assessment
Health surveillance
Hemorrhage
High income
Humans
Hypertension
Hypertension, Pregnancy-Induced - epidemiology
Infant, Newborn
Maternal & child health
Maternal Mortality
Morbidity
Mothers
Newborn babies
Objectives
Obstetrics
Patient outcomes
Population Surveillance
Postpartum Hemorrhage - epidemiology
Pregnancy
Public health
Reproductive health
Review
Sepsis
Women
Womens health
Brazil
United States > US
Africa
Latin America
Online AccessGet full text
ISSN1742-4755
1742-4755
DOI10.1186/s12978-018-0527-2

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Abstract Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs). Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify "high risk" status, delays in diagnosis, and delays in treatment. The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity. Severe maternal morbidity not only puts the woman's life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn. Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women's and infants' health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.
AbstractList Table 1 Estimates of the Prevalence of Severe Maternal Morbidity in High-Income Countries Author (Year) Country Definition of SMM Estimated Prevalencea Leading Causes Bouvier-Colle (2012) [13] 17 EU Countries Eclampsia 0.2–1.6 3 EU Countries ICU Admission 0.5–3.1 10 EU Countries Blood Transfusion 0.1–11.5 15 EU Countries Hysterectomy 0.2–1.0 7 EU Countries Embolisation 0.0–0.3 Colmorn (2015) [71] Denmark, Finland, Iceland, Norway, and Sweden Complete uterine rupture 5.6 Deneux-Tharaux (2017) [16] France Obstetric hemorrhage, hypertensive complications, Psychiatric disorder, decompensation of preexisting condition, pulmonary embolism, sepsis, stroke, amniotic fluid embolism, other 13.9 Obstetric hemorrhage (65.2%), hypertensive conditions (21.6%) Jayaratnam (2016) [45] Australia WHO criteria 4.8 Hemorrhage Jayaratnam (2011) [72] Australia Antepartum hemorrhage requiring emergency surgery, PPH requiring surgery, any postnatal patient requiring surgery, severe pre-eclampsia/eclampsia/HELLP, ICU admission, shock, acute ruptured ectopic, pulmonary embolism, other conditions requiring immediate medical assessment 6.0 Kilpatrick (2016) [43] United States CDC method with chart review to confirm condition was truly life-threatening 7.3 Hemorrhage, hypertensive disorders Lawton (2016) [personal communication] New Zealand ICU/HDU admission 6.2 Major blood loss, pre-eclampsia, sepsis Lyndon (2012) [73] United States CDC method supplemented with birth certificate data 5.8 Main (2016) [74] United States “Gold standard” clinical guidelines 7.3 Marr (2014) [40] Scotland Major obstetric hemorrhage, eclampsia, renal or liver dysfunction, pulmonary edema, acute respiratory distress, coma, cerebrovascular event, status epilepticus, anaphylactic shock, septicemic shock, anesthetic problem, massive pulmonary embolism, ICU/coronary care unit admission 6.1 Major obstetric hemorrhage, ICU/coronary care admission Nair (2016) [20] England Acute abdomen 0.01 Acute renal failure 0.08 Acute psychosis 0.05 Cardiac arrest/failure or infarction 0.05 Cerebral edema or coma 0.01 DIC 0.01 Cerebrovascular accident 0.04 Major complications of anesthesia 0.06 Obstetric embolism (inc. The most common preventable factors were delays in diagnosis and treatment. Since the WHO recommended that HICs with low maternal mortality ratios should begin to examine SMM to identify systems failures and intervention priorities [9], researchers in many HICs have turned their attention to SMM. Table 2 Estimates of the Prevalence of Severe Maternal Morbidity in Sub-Saharan Africa Article Country Setting Definition of SMM Estimated Prevalencea Leading Causes Adeoye 2013 [66] Nigeria 1 tertiary referral hospital, Ile-Ife Filippi et al. 2005 109.9b Hemorrhage, hypertensive disorders, dystocia Ali 2011 [77] Sudan 1 tertiary referral hospital, Kalassa Filippi et al. 2005 22.1 Hemorrhage, infection, hypertensive disorders David 2014 [78] Mozambique 5 health facilities, Maputo city/province eclampsia, infection hypertension, anemia, dystocia 20.2 Hemorrhage, hypertensive disorders, infection Gebrehiwot 2014 [59] Ethiopia 10 public hospitals hypertensive disorders, obstetric hemorrhage, dystocia, infection, anemia 90.8 Dystocia or uterine rupture, hypertensive disorders, hemorrhage Goldenberg 2017 [51] Democratic Republic of Congo 14 health centers and 3 hospitals, Equateur province Modified WHO 37.3b Not reported by country Goldenberg 2017 Kenya 23 health facilities and 3 referral hospitals, Busia, Bungoma and Kakamega counties Modified WHO 31.2b Not reported by country Goldenberg 2017 Zambia 8 health posts, 3 district hospitals and 1 referral hospital, Kafue and Chongwe districts Modified WHO 13.0b Not reported by country Herklots 2017 [79] Tanzania Tertiary referral hospital, Zanzibar WHO 9.0 Hemorrhage, hypertensive disorders Kalisa 2016 [80] Rwanda Provincial referral hospital, Musanze district Modified WHO 21.5 Hemorrhage, hypertensive disorders Kiruja 2017 [81] Somaliland Main referral hospital WHO 88.6 Hemorrhage, hypertensive disorders, infection Litorp 2014 [82] Tanzania 2 hospitals, Dar es Salaam WHO 36 Hypertensive disorders, hemorrhage Liyew 2017 [83] Ethiopia 5 public hospitals, Addis Ababa WHO 8.1 Hypertensive disorders, hemorrhage, abortive outcome Lori 2012 [62] Liberia Rural county Modified WHO and Filippi et al. 2005 16% of deliveries Hemorrhage, anemia, sepsis Mbachu 2017 [54] Nigeria Private hospital, Elele WHO 198 Hemorrhage, abortive outcome, hypertensive disorders Mekango 2017 [84] Ethiopia 6 public hospitals, Tigray Filippi et al. 2005 101 Hemorrhage, hypertensive disorders, dystocia Nakimuli 2016 [85] Uganda 2 referral hospitals, Central Uganda WHO 8.42 Hypertensive disorders, hemorrhage Nelissen 2013 [86] Tanzania Referral hospital, rural Modified WHO 23.6 Hemorrhage, abortive outcome, dystocia Oladapo 2016 [57] Nigeria 42 public tertiary hospitals WHO 15.8 Hemorrhage, hypertensive disorders, abortive outcome Rulisa 2015 [87] Rwanda University hospital, Kigali WHO 8 Sepsis, hypertensive disorders, hemorrhage Sayinzoga 2017 [88] Rwanda 4 rural district hospitals Modified WHO 36 Hemorrhage, uterine rupture, abortive outcome Soma-Pillay 2015 [89] South Africa 9 delivery facilities, Gauteng province WHO 4.4c Hemorrhage, hypertensive disorders, sepsis Tuncalp 2013 [90] Ghana Tertiary referral hospital, Accra WHO 28.6 Not reported aper 1000 live births bper 1000 deliveries cper 1000 pregnancies Table 3 Estimates of the Prevalence of Severe Maternal Morbidity in North Africa and Middle East Article Country Setting Definition of SMM Estimated Prevalencea Leading Causes Akrawi 2017 [91] Iraq Public tertiary hospital, Erbil City Modified WHO 8.2 Hypertensive disorders, hemorrhage Assarag 2015 [92] Morocco 3 public referral hospital, Marrakech Sahel et al. 2011 12 Hemorrhage Bashour 2015 [93] Egypt Public tertiary hospital, Cairo WHO 12.1 Hemorrhage Bashour 2015 Lebanon Public hospital, Beirut WHO 4.3 Hemorrhage Bashour 2015 Palestine Public referral hospital, Ramallah WHO 12.9 Hemorrhage Bashour 2015 Syria University hospital, Damascus WHO 4.5 Hemorrhage Ghardallou 2016 [94] Tunisia Public tertiary hospital, Sousse WHO 5.86 Hemorrhage, hypertensive disorders Ghazivakili 2016 [95] Iran 13 public and private hospital, Alborz province WHO 4.97 Hypertensive disorders, hemorrhage Jabir 2013 [63] Iraq 6 public hospital, Baghdad WHO 5.06 Hemorrhage, hypertensive disorders aper 1000 live births Table 4 Estimates of the Prevalence of Severe Maternal Morbidity in Asia Article Country Setting Definition of SMM Estimated Prevalencea Leading Causes Bolnga 2017 [96] Papua New Guinea Provincial hospital, Madang Province Modified WHO 25.4 Hemorrhage Goldenberg 2017 [51] India 18 primary health centers, 3 tertiary hospitals and 8 secondary hospitals Belagavi Modified WHO 28.1b Not reported by country Goldenberg 2017 India 20 primary health centers, 10 tertiary hospitals and 129 secondary hospitals, Nagpur Modified WHO 4.4b Not reported by country Goldenberg 2017 Pakistan 47 primary health clinics, 25 secondary care facilities and 3 referral hospitals, Thatta district Modified WHO 81.9b Not reported by country Kalra 2014 [97] India Tertiary hospital, Rajasthan Geller et al. 2004 4.8 Hemorrhage, hypertensive disorders Khan 2017 [98] India Tertiary referral hospital, New Delhi Geller et al. 2004, Pattinson et al. 2003, ICD-10 14 Hemorrhage, hypertensive disorders, anemia Luexay 2014 [99] Laos Community survey, Sayaboury province WHO 9.8 Hemorrhage, hypertensive disorders Mazhar 2015 [100] Pakistan 16 government hospitals WHO 7.0 Hemorrhage, hypertensive disorders, uterine rupture Norhayati 2016 [101] Malaysia 2 tertiary hospitals, Kelantan WHO 2.2 Hemorrhage, hypertensive disorders Roopa 2013 [102] India Tertiary referral hospital, Manipal WHO 17.8 Hemorrhage, hypertensive disorders, sepsis Pandey 2014 [55] India Medical college hospital, Uttar Predesh WHO 120 Hemorrhage, hypertensive disorders, anemia Purandare 2014 [60] India 6 medical college hospitals Pregnancy-specific disorders. [...]increases in maternal morbidity not only are failures to achieve broad public health goals of improved women’s health, but also contribute to sub-optimal delivery outcomes and poor infant health. [...]it is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.
Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).BACKGROUNDMaternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify "high risk" status, delays in diagnosis, and delays in treatment.SEVERE MATERNAL MORBIDITY IN HIGH-INCOME COUNTRIESSince the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify "high risk" status, delays in diagnosis, and delays in treatment.The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.SEVERE MATERNAL MORBIDITY IN LOW AND MIDDLE INCOME COUNTRIESThe highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.Severe maternal morbidity not only puts the woman's life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.EFFECTS OF SMM ON DELIVERY OUTCOMES AND INFANTSSevere maternal morbidity not only puts the woman's life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women's and infants' health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.CONCLUSIONIncreasing global maternal morbidity is a failure to achieve broad public health goals of improved women's and infants' health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.
Abstract Background Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs). Severe maternal morbidity in high-income countries Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify “high risk” status, delays in diagnosis, and delays in treatment. Severe maternal morbidity in low and middle income countries The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity. Effects of SMM on delivery outcomes and infants Severe maternal morbidity not only puts the woman’s life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn. Conclusion Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women’s and infants’ health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.
Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs). Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify "high risk" status, delays in diagnosis, and delays in treatment. The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity. Severe maternal morbidity not only puts the woman's life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn. Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women's and infants' health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.
ArticleNumber 98
Audience Academic
Author Lawton, Beverley
MacDonald, E. Jane
Storey, Francesca
Geller, Stacie E.
Garland, Caitlin E.
Koch, Abigail R.
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  givenname: Caitlin E.
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  givenname: Francesca
  surname: Storey
  fullname: Storey, Francesca
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  givenname: Beverley
  surname: Lawton
  fullname: Lawton, Beverley
BackLink https://www.ncbi.nlm.nih.gov/pubmed/29945657$$D View this record in MEDLINE/PubMed
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Snippet Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more...
Table 1 Estimates of the Prevalence of Severe Maternal Morbidity in High-Income Countries Author (Year) Country Definition of SMM Estimated Prevalencea Leading...
Abstract Background Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of...
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SubjectTerms Banks (Finance)
Births
Blood transfusions
Cesarean Section
Childbirth & labor
Clinical practice guidelines
Failure
Female
Health aspects
Health risk assessment
Health surveillance
Hemorrhage
High income
Humans
Hypertension
Hypertension, Pregnancy-Induced - epidemiology
Infant, Newborn
Maternal & child health
Maternal Mortality
Morbidity
Mothers
Newborn babies
Objectives
Obstetrics
Patient outcomes
Population Surveillance
Postpartum Hemorrhage - epidemiology
Pregnancy
Public health
Reproductive health
Review
Sepsis
Women
Womens health
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Title A global view of severe maternal morbidity: moving beyond maternal mortality
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https://doaj.org/article/65b9877dacb94041bdd16c3d697fce28
Volume 15
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