The right timing for surgical exploration is the key to saving lives: An analysis of near- miss mortality cases in a tertiary care hospital in North East India

Those pregnant women who suffer severe complications and come close to maternal death but do not die are the “near misses”. As India being a country with higher maternal mortality, maternal death review system has been institutionalised in India, however much more needs to be known. Near miss cases often precede the loss but are largely ignored because nothing (death) happened. Sometimes we may face difficulty in diagnosing of these near miss cases due to presence of complex presentation.These cases were documented to highlight the importance of appropriate management at the appropriate time to save the patient’s life, which were diagnostic challenge and near miss cases.

ANALYSIS OF MATERNAL MORTALITY: A RETROSPECTIVE STUDY AT TERTIARY CARE CENTRE

Background: Mother is the pillar of the family and maternal deaths during pregnancy and delivery are great loss to baby, family, society and country too. Objective: This study was design to evaluate the mortality rate in our hospital, to assess the epidemiological aspects and cause of maternal mortality, types of delay and to suggest recommendations for improvement. Method: was obtained from Sir T hospital record in form of maternal death review form which was filled by Gynec department after every maternal mortality in Sir T Hospital. From Year 2011 to 2020, data were collected and reviewed and exclude those deliveries in which accidental, incidental and non-obstetrics causes were found. Result and conclusion: On basis of this study thus we know the common cause of maternal mortality and with what it may associated, so we can overcome it and reduced the mortality. Keyword: Maternal mortality, Anaemia, Postpartum haemorrhage, Eclampsia.

Classifying maternal deaths in Suriname using WHO ICD-MM: different interpretation by Physicians, National and International Maternal Death Review Committees

Plain English summary The World Health Organization (WHO) provides a framework (ICD-MM) to classify pregnancy-related deaths systematically, which enables global comparison among countries. We compared the classification of pregnancy-related deaths in Suriname by the attending physician and by the national maternal death review (MDR) committee and among the MDR committees of Suriname, Jamaica and the Netherlands. There were 89 possible pregnancy-related deaths in Suriname between 2010 and 2014. Nearly half (47%) were classified differently by the Surinamese MDR committee as compared to the classification of the attending physicians. All three MDR committees agreed that 18% (n = 16/89) of the cases were no maternal deaths. Out of the remaining 73 cases, there was disagreement regarding whether 15% (n = 11) were maternal deaths. The Surinamese and Jamaican MDR committees achieved greater consensus in classification than the Surinamese and the Netherlands MDR committees. The Netherlands MDR committee classified more deaths as unspecified than Surinamese and the Jamaican MDR committees. Underlying causes that achieved a high level of agreement among the three committees were abortive outcomes and obstetric hemorrhage, while little agreement was reported for unspecified and other direct causes. The issues encountered during maternal death classification using the ICD-MM guidelines included classification of suicide during early pregnancy; when to assume pregnancy without objective evidence; how to count maternal deaths occurring outside the country of residence; the relevance of direct or indirect cause attribution; and how to select the underlying cause when direct and indirect conditions or multiple comorbidities co-occur. Addressing these classification barriers in future revisions of the ICD-MM guidelines could enhance the feasibility of maternal death classification and facilitate global comparison. Background Insight into the underlying causes of pregnancy-related deaths is essential to develop policies to avert preventable deaths. The WHO International Classification of Diseases-Maternal Mortality (ICD-MM) guidelines provide a framework to standardize maternal death classifications and enable comparison in and among countries over time. However, despite the implementation of these guidelines, differences in classification remain. We evaluated consensus on maternal death classification using the ICD-MM guidelines. Methods The classification of pregnancy-related deaths in Suriname during 2010–2014 was compared in the country (between the attending physician and the national maternal death review (MDR) committee), and among the MDR committees from Suriname, Jamaica and the Netherlands. All reviewers applied the ICD-MM guidelines. The inter-rater reliability (Fleiss kappa [κ]) was used to measure agreement. Results Out of the 89 cases certified by attending physicians, 47% (n = 42) were classified differently by the Surinamese MDR committee. The three MDR committees agreed that 18% (n = 16/89) of these cases were no maternal deaths, and, therefore, excluded from further analyses. However, opinions differed whether 15% (n = 11) of the remaining 73 cases were maternal deaths. The MDR committees achieved moderate agreement classifying the deaths into type (direct, indirect and unspecified) (κ = 0.53) and underlying cause group (κ = 0.52). The Netherlands MDR committee classified more maternal deaths as unspecified (19%), than the Jamaican (7%) and Surinamese (4%) committees did. The mutual agreement between the Surinamese and Jamaican MDR committees (κ = 0.69 vs κ = 0.63) was better than between the Surinamese and the Netherlands MDR committees (κ = 0.48 vs κ = 0.49) for classification into type and underlying cause group, respectively. Agreement on the underlying cause category was excellent for abortive outcomes (κ = 0.85) and obstetric hemorrhage (κ = 0.74) and fair for unspecified (κ = 0.29) and other direct causes (κ = 0.32). Conclusions Maternal death classification differs in Suriname and among MDR committees from different countries, despite using the ICD-MM guidelines on similar cases. Specific challenges in applying these guidelines included attribution of underlying cause when comorbidities occurred, the inclusion of deaths from suicides, and maternal deaths that occurred outside the country of residence.

Classifying maternal deaths in Suriname using WHO ICD-MM: different interpretation by physicians, national and international maternal death review committees

Background Insight into the underlying causes of pregnancy-related deaths is essential to develop policies to avert preventable deaths. The WHO International Classification of Diseases-Maternal Mortality (ICD-MM) guidelines provide a framework to standardize maternal death classifications and enable comparison in and among countries over time. However, despite the implementation of these guidelines, differences in classification remain. We evaluated consensus on maternal death classification using the ICD-MM guidelines. Methods The classification of pregnancy-related deaths in Suriname during 2010-2014 was compared in the country (between the attending physician and the national maternal death review (MDR) committee), and among the MDR committees from Suriname, Jamaica and the Netherlands. All reviewers applied the ICD-MM guidelines. The inter-rater reliability (Fleiss kappa [κ]) was used to measure agreement.Results Out of the 89 cases certified by attending physicians, 47% (n=42) were classified differently by the Surinamese MDR committee. The three MDR committees agreed that 18% (n=16/89) of these cases were no maternal deaths, and, therefore, excluded from further analyses. However, opinions differed whether 15% (n=11) of the remaining 73 cases were maternal deaths. The MDR committees achieved moderate agreement classifying the deaths into type (direct, indirect and unspecified) (κ=0.53) and underlying cause group (κ=0.52). The Netherlands MDR committee classified more maternal deaths as unspecified (19%), than the Jamaican (7%) and Surinamese (4%) committees did. The mutual agreement between the Surinamese and Jamaican MDR committees (κ=0.69 vs κ=0.63) was better than between the Surinamese and the Netherlands MDR committees (κ=0.48 vs κ=0.49) for classification into type and underlying cause group, respectively. Agreement on the underlying cause category was excellent for abortive outcomes (κ=0.85) and obstetric hemorrhage (κ=0.74) and fair for unspecified (κ=0.29) and other direct causes (κ=0.32). Conclusions Maternal death classification differs in Suriname and among MDR committees from different countries, despite using the ICD-MM guidelines on similar cases. Specific challenges in applying these guidelines included attribution of underlying cause when comorbidities occurred, the inclusion of deaths from suicides, and maternal deaths that occurred outside the country of residence.

From Passive Surveillance to Response: Suriname's Steady Efforts to Implement Maternal Death Surveillance and Response (MDSR)

Background Maternal death surveillance and response (MDSR) is essential in preventing avoidable maternal deaths. The cycle starts by accurately capturing maternal deaths with a surveillance system, followed by an audit to give insight into the underlying causes and "lessons learned." Subsequently, recommendations are formulated and targeted multisectoral responses such as quality of care improvement strategies, including clinical guidelines update, health promotion interventions, research to fulfill knowledge gaps, enabling policies and legislation and interventions addressing social determinants. Finally, continuous evaluation and monitoring close the MDSR cycle. We aim to describe the MDSR implementation process in Suriname to share valuable lessons with other countries.Methods We provide an overview of the evolvement from improved maternal death surveillance, toward review, response, and monitoring to fulfill the MDSR cycle in Suriname. Findings Middle-income country Suriname called for many years for improved surveillance and review, and in 2000 the first action was commenced by extension of maternal death case capturing from death certificates to active hospital surveillance. Consequently, the maternal mortality ratio increased in the following years. However, not the full MDSR cycle was completed in 2015, and local health care providers initiated the next step of the MDSR cycle with the installation of a national maternal death review committee (MaMS). Since then, the committee reviews each maternal death applying the "no blame, no shame" culture, formulates, and disseminates recommendations. Collaboration with the Ministry of Health (MOH), Bureau of Public Health (BOG), and the Pan American Health Organization (PAHO) should ensure progress to the sustainable implementation of MDSR. Committee MaMS demonstrates that maternal death review and recommended high impact interventions can only be effectively implemented and sustained, through strong professional and government commitment and practical, solution-oriented responses. Conclusions Crucial elements for a successful MDSR implementation are Commitment, "no blame, no shame" Culture, Coordination, Collaboration, and Communication (5 C's).We hope that describing this process toward successful nationwide MDSR implementation, with its facilitators and barriers, is helpful for other countries with similar ambitions.

Classifying maternal deaths in Suriname using WHO ICD-MM: different interpretation by physicians, national and international maternal death review committees

Background: Insight into the underlying causes of pregnancy-related deaths is essential to develop policies to avert preventable deaths. The WHO International Classification of Diseases-Maternal Mortality (ICD-MM) guidelines provide a framework for uniform classifications which enables comparison within and between countries and over time. However, despite using the guidelines, differences in classifying pregnancy-related deaths within and among countries remain. We evaluated consensus on maternal death classification using ICD-MM.Methods: Classification of the 2010-2014 pregnancy-related deaths in Suriname were compared (1) between the attending physician (death certificate/medical record) and the national maternal death review (MDR) committee; and (2) between MDR committees from Suriname, Jamaica and the Netherlands. All reviewers applied ICD-MM. The inter-rater reliability (Fleiss kappa [κ]) was used to measure agreement.Results: Nearly half (n=42) of the 89 cases reviewed by the Surinamese MDR committee were classified differently by the attending physicians. There was consensus among the three committees that 16 (18%) possible pregnancy-related deaths were not maternal, with opinions differing on 11 (15%, n=73) maternal deaths. Classification agreement into direct, indirect or unspecified (κ=0.53) and underlying cause attribution (κ=0.52) was moderate. The Dutch committee classified more maternal deaths as unspecified (19%), than the Jamaican (7%) and Surinamese MDR committees (4%). The Surinamese and Jamaican committees achieved better mutual agreement (κ=0.69) than Surinamese and the Dutch committees (κ=0.48). Agreement on the underlying cause category was best for abortive outcomes (κ=0.85) and obstetric hemorrhage (κ=0.74) and worst for unspecified (κ=0.29) and other direct causes (κ=0.32). Conclusions: Maternal death classification differs within Suriname and among MDR committees from different countries. Specific challenges applying ICD-MM included attribution of underlying cause when co-morbidities occur, inclusion of suicides, and maternal deaths occurring outside the country of residence.