RESEARCH

 

Every maternal near-miss counts: Need for a national audit in South Africa? A mixed-methods study

 

 

A Heitkamp^{I, II}; J Suh^III; S Gebhardt^IV; J van Roosmalen^{V, VI}; L R Murray^VII; J I de Vries^VIII; T van den Akker^{IX, X}; G Theron^XI

^IMD; Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
^IIMD; Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam and Amsterdam Reproduction and Development Research Institute, The Netherlands
^IIIMSc; Athena Institute, Vrije Universiteit Amsterdam, The Netherlands
^IVMMed (O&G), PhD; Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
^VMD, PhD; Athena Institute, Vrije Universiteit Amsterdam, The Netherlands
^VIMD, PhD; Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
^VIIMMed (O&G), FCOG (SA); Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
^VIIIMD, PhD; Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam and Amsterdam Reproduction and Development Research Institute, The Netherlands
^IXMD, PhD; Athena Institute, Vrije Universiteit Amsterdam, The Netherlands
^XMD, PhD; Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
^XIMMed (O&G), MD; Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND: To improve maternal health, studies of maternal morbidity are increasingly being used to evaluate the quality of maternity care, in addition to studies of mortality. While South Africa (SA) has a well-established confidential enquiry into maternal deaths, there is currently no structure in place to systematically collect and analyse maternal near-misses (MNMs) at national level
OBJECTIVES: To synthesise MNM indicators and causes in SA by performing a systematic literature search, and to investigate perceived needs for data collection related to MNMs and determine whether the MNM tool from the World Health Organization (WHO-MNM) would require adaptations in order to be implemented
METHODS: The study used a mixed-methods approach. A systematic literature search was conducted to find all published data on MNM audits in SA. Semi-structured interviews were conducted virtually with maternal health experts throughout the country who had been involved in studies of MNMs, and main themes arising in the interviews were synthesised. A method for MNM data collection for SA use was discussed with these experts
RESULTS: The literature search yielded 797 articles, 15 of which met the WHO-MNM or Mantel et al. severe acute maternal morbidity criteria. The median (interquartile range) MNM incidence ratio in SA was 8.4/1 000 (5.6 - 8.7) live births, the median maternal mortality ratio was 130/100 000 (71.4 - 226) live births, and the median mortality index was 16.6% (11.7 - 18.8). The main causes of MNMs were hypertensive disorders of pregnancy and obstetric haemorrhage. Eight maternal health experts were interviewed from May 2020 to February 2021. All participants focused on the challenges of implementing a national MNM audit, yet noted the urgent need for one. Recognition of MNMs as an indicator of quality of maternity care was considered to lead to improved management earlier in the chain of events, thereby possibly preventing mortality. Obtaining qualitative information from women with MNMs was perceived as an important opportunity to improve the maternity care system. Participants suggested that the WHO-MNM tool would have to be adapted into a simplified tool with more clearly defined criteria and a number of specific diagnoses relevant to the SA setting. This 'Maternal near-miss: Inclusion criteria and data collection form' is provided as a supplementary file
CONCLUSION: Adding MNMs to the existing confidential maternal death enquiry could potentially contribute to a more robust audit with data that may inform health systems planning. This was perceived by SA experts to be valuable, but would require context-specific adaptations to the WHO-MNM tool. The available body of evidence is sufficient to justify moving to implementation

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Improving maternal and neonatal health is a global health priority. The World Health Organization (WHO) introduced the maternal near-miss (MNM) approach (WHO-MNM) in 2009 to robustly identify maternal morbidities at the severe end of the spectrum of pregnancy-related disease. This approach is increasingly used as an additional tool to monitor and evaluate the quality of maternity care at various levels of the healthcare system.^[1] According to the WHO, an MNM is defined as 'a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy'.^[1,2]

South Africa (SA) is one of the few countries worldwide where detailed information about maternal deaths is compiled. The National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) produces triennial reports called 'Saving Mothers', with the aim of identifying lessons learned and improving maternity care.^[3] While this committee has been systematically reviewing maternal deaths since 1998, in addition to the local reviews carried out by provincial health departments, no such comprehensive audit system for MNMs is currently in place. Before the WHO-MNM criteria were introduced, some regions in SA applied the criteria for severe acute maternal morbidity (SAMM) described by Mantel et al.^[4] to assess maternity care.

The primary objective of this mixed-methods study was to quantitatively synthesise MNM indicators and causes from SA publications to describe the burden of MNMs as a potential source for enhanced maternity care review. The secondary objective was to examine perspectives on the need for and methods of data collection pertaining to MNMs, if it were to be implemented in addition to the already existing and well-functioning NCCEMD.

 

Methods

A systematic literature search was conducted to collect quantitative data from studies of MNMs in SA, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).^[5] We conducted systematic searches in PubMed, Embase.com, Ebsco/CINAHL, Scopus and Google Scholar up to 1 April 2021 with index terms or free-text words 'Pregnancy Complications', 'Maternal Mortality', 'Maternal Morbidity', 'Near Miss', 'South Africa' (PubMed session results, Appendix 1, https://www.samedical.org/file/1870). References were searched for relevant publications and duplicate articles were excluded. No language was excluded.

Articles were uploaded to the online software Rayyan QCRI (https://rayyan.qcri.org), where identification of duplicates took place, followed by screening of titles and abstracts by two authors (JS and AH).

Included were SA studies using either the WHO-MNM or Mantel et al.^[4] SAMM criteria (both methods described in Table 1), and studies that provided quantitative statistics on the MNM incidence ratio (MNM-IR), maternal mortality ratio (MMR) and mortality index (MI). Articles were excluded if there was no clear use of either the WHO-MNM or Mantel et al.^[4] SAMM criteria, or if the study was a secondary analysis of previously published data.

The MNM-IR is expressed as the number of MNMs per 1 000 live births, the MMR as the number of maternal deaths per 100 000 live births, and the MI as the number of maternal deaths divided by the number of women who sustained an MNM + maternal deaths, expressed as a percentage. The MI is an indicator of the quality of maternity care for women with an MNM.^[1,2]

Full-text articles were found for the remaining studies, and those not fulfilling the inclusion criteria were independently excluded by two researchers (AH and JS). Selected articles were then exported to Endnote for referencing purposes and their study characteristics, including descriptive MNM statistics, settings and their methodologies specific to using the Mantel et al.^[4] SAMM or WHO-MNM criteria, were extracted. The literature selection flow chart is presented in Fig. 1.

 

 

To investigate the need for and methods of data collection of MNM in SA, the present study was conducted as a pilot using interviews to assess whether this topic has priority according to healthcare workers. Healthcare workers from various clinical professions who worked with clinical data of maternal morbidity in SA were recruited through convenience sampling.

Semi-structured interviews were conducted virtually by Zoom after informed consent had been obtained by the research student (JS), as part of a master's thesis in global health from the Vrije Universiteit Amsterdam (VU), supervised by AH and TvdA. The review was conducted according to the VU Faculty of Social Science Research Ethics Review Committee's ethical guidelines. This conforms to the ethical guidelines for 'standard' research and does not require further ethical review.

For this qualitative study, an interview guide was created (interview guide, Appendix 2, https://www.samedical.org/file/1870). The purpose of the sampling was to include a small number of diverse caregivers as a pilot study. Eleven individuals were approached for the interviews, all of whom had experience with MNM data collection and audit. All who participated signed an informed consent form beforehand.

The main themes of the interviews focused on experiences with MNM audits, including recollection of the process of collecting information on MNMs and any perceived difficulties of or benefits from the audits. Interviewees were also asked whether a national MNM audit was needed or would be wanted for SA to improve maternal health, and whether the WHO-MNM tool was suitable for that purpose. Interviews were transcribed, and any personal information that could be used for identification was removed to preserve anonymity. A 'code book' was developed in order to organise relevant quotes by theme, and ATLAS.ti software, version 22.0.5 (ATLAS.ti Scientific Software Development GmbH, Germany), was used to extract quotes from the transcripts (qualitative code book, Appendix 3, https://www.samedical.org/file/1870).

The method of auditing MNMs can differ between institutions and between interviewed persons. In 2018, we discussed the data collection form used for MNMs in the Metro East health district, Western Cape Province, SA,^[6] with the authors of articles on the Metro West district^[7] and Pretoria,^[8] who are also participants in the NCCEMD (see acknowledgement). Adjustments were based on the knowledge of the setting together with the Haydom criteria^[9] from the literature and outcomes of a Delphi study for low-income countries.^[10] This process led to some modifications of the WHO-MNM tool for South Africa: a reduction in administering blood products from >5 to >4 U and an additional list of diagnoses. The 'Maternal-near miss: Inclusion criteria and data collection form' is provided as a supplementary file (https://www.samedical.org/file/1871) depicting the criteria for MNMs, underlying complications, details of women with an MNM and the assessment of avoidable factors, also used in our study in the Metro East district.^[6]

 

Results

Quantitative

The search yielded a total of 797 results. Inclusion criteria were met by 15 articles^{[4,6-8,11-21]} (Supplementary Table 1, https://www.samedical.org/file/1872). We found eight studies that applied the Mantel et al.^[4] SAMM criteria,^[4,11-17] one of which did so in a slightly adapted form.^[15] The other seven studies used the WHO-MNM criteria,^[6-8,18-21] two of which made adaptations to arrive at criteria relying on clinical assessment only and by adding diagnoses that are relatively frequent in SA^[13,14] (Supplementary Table 1, https://www.samedical.org/file/1872).

The quantitative aspect of the study is briefly presented in the text, but more extensively depicted in Table 2. This table lists MNM and mortality statistics for the nine studies that focused on MNM and mortality comprehensively rather than from a single cause.^{[4,6-8,11-14,21]} The median MNM-IR in the nine studies was 8.4/1 000 (5.6 - 8.7) live births, the median MMR 130/100 000 (71.4 - 226.0) live births, and the median MI 16.6% (11.7 - 18.8). The main causes of MNMs were hypertensive disorders of pregnancy and obstetric haemorrhage.

Qualitative

Of the 11 maternal health experts who were approached, 8 (P1 - P8) responded and were interviewed between May 2020 and February 2021. The participants' professions were as follows: 1 nurse-midwife, 6 consultant obstetricians and gynaecologists, and 1 academic physician who also worked as a policymaker. All the participants were maternity care workers or policymakers who were not active as care workers any longer, who had been involved in auditing maternal morbidity in various capacities.

Two of the 8 interviewed participants used the MNM inclusion criteria and data collection form. Table 3 shows the items addressed in the interviews. When prompted to reflect on a national MNM audit, all the participants saw benefits or noted an urgent need for establishing such a system, even when they considered potential difficulties with implementation.

 

Discussion

The overall MNM-IR in SA was comparable with other middle-income countries,^[22] but varied according to region. Within SA, outcomes varied as a result of differing study methods and settings. The main causes of MNMs in SA were found to be consistent, with little variation: hypertensive disorders of pregnancy and obstetric haemorrhage. The main causes of maternal deaths according to the NCCEMD (2017 - 2019) were non-pregnancy-related infections (mostly advanced tuberculosis (TB) and HIV-related illness); hypertensive disorders of pregnancy and obstetric haemorrhage were the second and third important causes.^[3] This difference could be explained by the fact that most severely ill pregnant women with HIV/TB are managed by physicians in medical wards, and only referred to obstetric wards if their pregnancy is advanced. They would not be identified by an MNM audit in an obstetric setting unless they were in late pregnancy, in labour or postpartum.

It is helpful to try to reach consensus regarding which methodology would be best suited for collecting data on MNMs in SA, and the gap that exists in knowledge about countrywide differences in MNM statistics should be addressed. A national audit with a standardised data collection tool may fill that gap.

The lower the MI, the more women with an MNM survive. An MNM audit could result in important positive messages, boosting health worker morale, as opposed to only performing death reviews. Comparing these outcomes and differences between provinces may highlight possible lessons learned. The added value of auditing MNMs is regarded as useful, illustrated by P7's words: 'If you recognise severe morbidity, in time you are able to prevent mortality.' An MNM (avoiding mortality) can be seen as a positive outcome, supporting health workers who are often working under difficult conditions.

Included retrospective studies have reported common limitations inherently resulting from study design: incomplete data for reported cases, different applied definitions of maternal morbidity, and the possibility of under-reporting.^[7,8] However, none of the seven prospective reports mentioned limitations of their study designs. Most studies did not discuss their methodology extensively on their audit methods, making it difficult to determine which design may be better suited for an MNM audit.

Nevertheless, a national MNM audit would be similar to the ongoing death reviews of the NCCEMD, where information is gathered soon after the event. By applying standardised criteria and definitions, the above challenges and limitations could be mitigated. The fact that adaptations had to be made to the WHO-MNM tool for use in urban settings even in our middle-income country, compared with use in high-income settings, supports the opinion of the interviewees that applicability of the tool could even be lower in rural areas. The difference between settings would make it harder to identify appropriate criteria for use across the entire country. Of interest is that the literature search did not find any studies in SA where the WHO-MNM tool was used in rural areas or more under-resourced facilities. This is a limitation of our study. As we know from low-income settings, challenges in applying the WHO-MNM tool might be more pressing and under-reporting higher as a result of lack of equipment in such settings.^[23] Interviewees were nearly unanimous in pushing for a national MNM audit in SA, even though they felt that implementing such a national audit would involve logistical challenges, mainly because of lack of resources, staffing and time that might hinder implementation. SA has the largest wealth inequity in the world (Gini index 63 in 2014), so finding a standardised tool that works in both poor and rich communities served by the public and private healthcare systems is a significant hurdle to overcome.^'241 Interviewees felt that such challenges need to be faced, because having an MNM audit in place would allow participants to use data for learning lessons and motivate medical leaders to improve maternity care.

Added benefits of a national MNM audit may include identification and subsequent improvement of health system deficits. Another benefit would be the opportunity to compare data on national and international levels and participate in a database, such as the International Network of Obstetric Survey Systems (INOSS).^[25] A national database with a robust registration system could also be a valuable contribution to identifying complications of new health threats in pregnancy, including pandemics such as COVID-19.

Overall, the consensus was that if the WHO-MNM criteria were to be used for a nationwide standardised audit, they would have to be adapted in order to capture as many women with MNMs in the country as possible. This would, however, affect comparability with other countries and settings where the WHO-MNM criteria are also used. Nevertheless, accurate identification of women with MNMs was prioritised over the importance of having internationally comparable data. Much debate centres on the applicability of MNM criteria in SA as a whole. Even though funding in the public health services does provide for an equal distribution of resources within the country, owing to different management and different allocation of funds at provincial and local levels, some hospitals and clinics are under-resourced to a larger extent than others.^[26] The large disparities between the public and private health sectors must also be kept in mind.

Opinions from interviewed participants differed when it came to which criteria would work best, and additional efforts are needed to achieve consensus in this regard.

This study was set up as a pilot study to identify whether there was interest in and a need for further research on a national MNM audit. The available body of evidence (the publications from SA and the findings reported in this article) is sufficient to justify moving to implementation, with a stepped-wedge approach providing more information as implementation progresses. Moreover, with the present knowledge, more items can be applied in optimising and implementing the MNM inclusion criteria and data collection form.

 

Conclusion

MNM-IRs in SA are similar to those in other middle-income countries. MMRs and MIs, however, varied considerably between the different regions, possibly being influenced by lack of methodological consistency, high variability in study designs or differences in quality of maternity care. A national MNM audit was recommended by the interviewees to evaluate causes and improve maternal health. In their perspective, simplification of the WHO-MNM tool could be helpful, with inclusion of additional clinical criteria and context-specific diagnoses. There is a need for simplified methods of identification that would be applicable and acceptable to healthcare workers in under-resourced clinical settings, and a tool for implementation is added as a supplementary file. The recognition of early signs of maternal morbidity by healthcare workers, and their response, will result in a reduction of maternal morbidity and mortality.

Declaration. The research for this study was done in partial fulfilment of the requirements for AH's PhD degree at Stellenbosch University, SA, and Amsterdam UMC, The Netherlands (an official collaboration).

Acknowledgements. We thank all those who participated in the interviews, and Ralph de Vries, MSc, librarian at the VU, for assistance in the literature search. We are grateful to Prof. Sue Fawcus and Prof. Priya Soma-Pillay for the discussion on the form and help in refining the MNM inclusion criteria and data collection form for SA use.

Author contributions. AH identified women with MNMs in Metro East. AH and JS conceptualised the study, supervised by TvdA. JS did the literature search for the systematic review, and JS and AH performed the selection of articles and collected data. JS conducted and analysed the interviews. AH and JS prepared the first draft with TvdA and finalised the draft on the basis of comments from other authors and reviewer feedback. TvdA, LV, SG, JvR, JIdV and GT contributed to interpretation of the data, reviewed the study protocol, and critically commented on all drafts of the manuscript. JIdV and GT provided overall guidance and supervision. All authors approved the final manuscript for publication.

Funding. None.

Conflicts of interest. None.

 

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Correspondence:
A Heitkamp
a.heitkamp@amsterdamumc.nl

Accepted 17 May 2022