Severe acute maternal morbidity in a tertiary care institution

Abstract

Objective The maternal mortality rate in Sri Lanka has been stagnant around 30 per 100 000 live birth over past few years. Thus, there is a necessity to identify strategies to improve quality of care. WHO severe acute maternal morbidity (SAMM) or 'near miss' approach has facilitated the identification of near misses with the aim of raising awareness and promote reflection of quality-of care. Design A prospective clinical audit was carried out at De Soysa Hospital for Women from 1st January 2015 to 1st January 2016 to assess maternal deaths and SAMM. Method Patients who fulfil WHO near-miss criteria were selected. Interventions such as regular Multidisciplinary meetings and staff training on emergency obstetric care were carried out and reaudit carried out from 1st January 2017 to 1st January 2018. Results There were 72 near misses and 7 maternal deaths for 8268 live births during the study period with a severe maternal outcome ratio of 9.55 per 1000 live births, a maternal near miss ratio of 8.7 per 1000 live births, and a Mortality index of 9.7%. In the re-audit, there were 62 near misses and 3 maternal deaths per 7942 births with a maternal outcome ratio of 8.68 per 1000 and a mortality index of 4.6%. The main contributory causes for near misses in the audit and reaudit were 25 and 7 cases due to haemorrhage, 22 and 19 cases due to hypertension and preeclampsia, 7 and 6 cases due to eclampsia, 9 and 10 cases due to heart disease, 5 and 8 cases due to dengue haemorrhagic fever, 2 cases due to respiratory disease, 2 and 8 cases due to sepsis and 2 cases due to renal disease accordingly. 1 case due to epilepsy in the initial audit and 1 case due to complications following abortion where the patient underwent hysterectomy and 1 case due to uterine artery embolization in the re-audit. Substandard care was identified in a significant proportion in the extents of inadequate prenatal care, lack of adherence to protocols, poor documentation, and underutilization of the resources. There is a significant improvement in the adherence to protocols especially in the management of Pre-eclampsia, Eclampsia and PPH following the intervention. There is need for improvement in non-technical skills like documentation and communication skills. Conclusion Severe acute maternal morbidity can be used as a tool to monitor the quality of care and make recommendations to provide better care.