ArticlesMoving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study
Introduction
In recent years, two important changes in maternal health have taken place worldwide: first, a substantial reduction in global maternal mortality and second an increase in the proportion of childbirths occurring in health facilities.1 Although substantial progress has been made, not enough has been done to meet the fifth Millennium Development Goal. An estimated 287 000 women died in 2010 of causes related to pregnancy and childbirth and a substantial proportion of childbirths still occur in communities without skilled birth assistance.1 In this context, improving quality of care has become increasingly important to accelerate reduction in maternal mortality, to reduce maternal deaths in health facilities, and stimulate demand for institutional births.2, 3, 4, 5 In many settings, women prefer to deliver in the community because of concerns about perceived quality of care in health facilities.5
Good quality of care is a multidimensional notion that includes, among other factors, appropriate use of effective clinical and non-clinical interventions and strengthened health infrastructure and attitude of health providers, resulting in satisfaction of patients and providers and improved health outcomes.5, 6, 7 As part of strategies to improve maternal health care, great emphasis has been placed on maximising coverage of life-saving maternal health interventions (eg, uterotonics for prevention and treatment of post-partum haemorrhage or magnesium sulphate for prevention and treatment of eclampsia).8 Although coverage can be objectively monitored and assessed, other dimensions of quality are hard to measure.
Despite the global nature of the issue, maternal deaths are relatively rare events in individual facilities, complicating the assessment of effects of care on mortality. To overcome this epidemiological challenge, the notion of a near-miss event was introduced in maternal health, which is potentially able to complement the information obtained with reviews of maternal deaths.9 In 2004, the WHO published a systematic review10 about the prevalence of severe maternal morbidity and maternal near miss. In that review, the absence of standard definitions for both severe maternal morbidities and near-miss cases was a major constraint for obtaining an overall prevalence of these conditions. This difficulty led WHO to develop a standard definition of maternal near miss, based on markers of organ dysfunction (ie, survivors of organ dysfunction during pregnancy, childbirth, or after birth are classified as maternal near-miss cases).11 The WHO criteria for maternal near miss were developed through an international consultative process, which also included systematic reviews,10, 12 pilot studies,13, 14 and a multicentre validation study.15 Through coupling of maternal deaths and near-miss cases (both regarded as severe maternal outcomes [SMO]) and assessing their similarities and differences, a more robust analysis of the quality of maternal health care and its determinants can be made.11, 15 This collaborative effort allowed the development of the maternal severity index (MSI) model, which estimates the death probability of women with complications related to pregnancy.15 Comparison of observed mortality to the model-estimated mortality allows investigators to make an overall assessment of performance.15, 16, 17
The main goal of this study, the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), was to characterise the severe maternal, perinatal, and neonatal morbidity that occurs in a worldwide network of health facilities. Our analysis specifically aimed to describe maternal characteristics and perinatal outcomes, assesses the prevalence and severity of complications related to pregnancy, determines the coverage of key maternal health interventions, tests and externally validates the MSI model, and assesses the overall performance of care in participating facilities.
Section snippets
Study design and participants
The study protocol and other methodological details of the WHOMCS have been published previously.18 Briefly, the study was a cross-sectional analysis implemented in health facilities in 29 countries from Africa, Asia, Latin America, and the Middle East. Figure 1 shows countries included in this study, stratified by level of maternal mortality ratio (MMR).1 Most participating health facilities had also taken part in the previous WHO Global Survey on Maternal and Perinatal Health (2004–08).19
Results
Between May 1, 2010, and Dec 31, 2011, we included 314 623 women attending 357 health facilities in 29 countries (figure 2). Most health facilities were located in urban or periurban areas and 132 (37%) were tertiary hospitals (further details of the health facilities are contained in the appendix). The mean period of data collection in each facility was 89 days (SD 21).
Compared with women without an SMO, women with an SMO were more often older than 35 years, multiparous, with a partner, and
Discussion
About 7% of our study population of 314 623 women had potentially life-threatening disorders and about 1% developed an SMO. Despite the high coverage of interventions regarded as essential to prevent and treat key causes of maternal deaths in participating facilities, care performance and the outcomes of women overall were very variable. In our large network of health facilities, only a small proportion of women with an SMO did not receive the recommended essential intervention. The MSI was
References (23)
- et al.
Reducing intrapartum-related neonatal deaths in low- and middle-income countries—what works?
Semin Perinatol
(2010) - et al.
Strategies for reducing maternal mortality: getting on with what works
Lancet
(2006) Near miss audit in obstetrics
Best Pract Res Clin Obstet Gynaecol
(2009)- et al.
Maternal near miss—towards a standard tool for monitoring quality of maternal health care
Best Pract Res Clin Obstet Gynaecol
(2009) Trends in maternal mortality: 1990 to 2010
Global strategy for women's and children's health
- et al.
60 million non-facility births: who can deliver in community settings to reduce intrapartum-related deaths?
Int J Gynaecol Obstet
(2009) - et al.
Still too far to walk: literature review of the determinants of delivery service use
BMC Pregnancy Childbirth
(2009) Systems thinking for health system strengthening
Quality of care: a process for making strategic choices in health systems
WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss)
Reprod Health
Cited by (547)
Hospital padrino: a collaborative strategy model to tackle maternal mortality: a mixed methods study in a middle-income region
2024, Lancet Regional Health - AmericasExtended balloon labour induction: A single arm proof of concept trial
2023, European Journal of Obstetrics and Gynecology and Reproductive Biology: XImplementing uterine balloon tamponade (UBT) device for immediate postpartum hemorrhage management: Leveraging resource allocation and highlighting noteworthy experiences
2023, Gynecology and Obstetrics Clinical MedicineComparison of quantitative and calculated postpartum blood loss after vaginal delivery
2023, American Journal of Obstetrics and Gynecology MFMImproving team-based care in basic emergency obstetric clinics: Using factor analysis to develop a brief teamwork tool for real-time feedback
2023, Journal of Interprofessional Education and Practice