Woman’s Health and Midwifery Nursing Dep. Faculty of Nursing Egypt Quality of Maternal Health Care: Maternal Near –Misses in a University Hospital , Egypt Prof. Dr. Amina El-Nemer Woman’s Health and Midwifery Nursing Dep. Faculty of Nursing

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Introduction and background Maternal mortality is estimated at 287 000 women died in 2010. WHO reports that 10-15 million women experience sever illness and disabilities Five percent of maternal deaths occur in Arab countries and 390.000 women in Middle East are suffering of severe long lasting complications caused be pregnancy and delivery. 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Nursing & Healthcare, Nov.17-19,2014, Chicago, USA One of the Millennium Development Goals is to reduce maternal mortality ratio by 3/4 by 2015 especially in the sub-Saharan areas where the problem is more tragically. Recently Maternal Near Miss (MNM) indicator is increasingly being recognized as a potentially useful tool in assessing the quality of healthcare as it reflects the scope of complications during pregnancy and childbirth. 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Nursing & Healthcare, Nov.17-19,2014, Chicago, USA Maternal Near Miss (MNM) Is “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”. WHO Nowadays, in addition to studying the maternal deaths, the examination of women who survived a severe complication of pregnancy, childbirth or the puerperium (Near misses) 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Nursing & Healthcare, Nov.17-19,2014, Chicago, USA Despite all the efforts done by Egyptian government to achieve the Millennium Development goals, there is a question regarding the quality of care provided to the Egyptian women during pregnancy and delivery. is still high if compared with other Arab (CIA, World fact book, January 1, 2012). n Egypt women can develop sever complications during pregnancy and labour. Some of these women die some of them survive. Review the cases of maternal near miss has the potential to highlight both deficiencies and positive elements in the provision of obstetric care which will allow for more rapid reporting, more healthy conclusions and the comparisons made with maternal deaths will reinforce the lessons learnt and can inform the hospital managers and policy makers for establishing requirements for intensive care, comprehensive emergency obstetric care for better maternal outcomes. Maternal mortality has been studied but near miss is not described yet. 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Nursing & Healthcare, Nov.17-19,2014, Chicago, USA Objective To identify Maternal Near Miss in a teaching University hospital (MUH). A retrospective descriptive study. 80 women with potential life threatening conditions was reviewed to identify MNM Methodology: that occurred during pregnancy and immediately after delivery. A total numbers of 700 medical records for women who were admitted during the period of 6 months during a year of 2013 was reviewed and evaluated to identify the Maternal Near Misses by using the WHO Near Miss assessment tool. 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Nursing & Healthcare, Nov.17-19,2014, Chicago, USA Characteristics of Suspected Women with Potential Life Threatening Conditions. Mean (Minimum-maximum) Characteristics 22.8 (19-40) Women's age 29.2 (18-43) Gestational age 3 (1-5) Previous CS (18, 22.5) Referrals (67, 83.75) 20 (29.6) Private Obstetricians 30 (44.8) MOH Hospitals 10 (15.1) Private Hospitals 7 (10.5) Others 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Time and Types of Morbidity Conditions Developed after 12 hours At arrival or within 12 hours Morbidity conditions % No 1. Women with potentially life-threatening conditions 12.5 10 25 20 Severe postpartum haemorrhage 3.7 3 51.3 41 Severe pre-eclampsia 0.0 5.0 4 Eclampsia 2.5 2 Sepsis or severe systemic infection Ruptured uterus 16.2 13 83.8 67 Total women with severe complications 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Morbid Women Undergoing Critical Interventions % No 2. Women undergoing critical Interventions 43.8 35 Use of blood products 16.3 13 Laparotomy Admission to intensive care unit (65, 81.25) 53.8 29.2 7.7 6.2 3.1 19 5 4 2 Sever preeclampsia/Eclampsia Sever PPH Anemia Multiple organ dysfunctions Hystrectomy + Anemia 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

MNM and dead women who experienced organ dysfunctions. Near Miss Cases (67) Organ Dysfunctions % No 29.8 20 Cardiovascular dysfunction 13.4 9 Respiratory dysfunction 7.5 5 Renal dysfunction 11.9 8 Coagulation/haematologic dysfunction Hepatic dysfunction Neurologic dysfunction 3 2 Uterine dysfunction/hysterectomy 6 4 Multiple organ dysfunctions/died women 86.6 58 Total 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Causes of life-threatening conditions Near Misses 1. Underlying causes % No=63 3.2 2 Pregnancy with abortive outcome 31.7 20 Obstetric haemorrhage 55.5 35 Hypertensive disorders Pregnancy-related infection 7.9 5 Other obstetric disease or complication 19.1 11 Medical/Surgical/Mental disease or complication Unanticipated complications of management 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Previous caesarean section Prolonged / obstructed labour Contributory Causes 44.4 28 Anemia 23.8 15 Previous caesarean section 7.9 5 Prolonged / obstructed labour 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

End of pregnancy and pregnancy outcome % No Pregnancy out comes 3.2 2 Vaginal delivery 93.6 59 Caesarean Section Complete abortion 1.6 1 Laparotomy for ectopic pregnancy 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Process and outcome indicators among MNM Prevention of PPH 41.3 26 Oxytocina use 58.7 37 Use of any uterotonic (including oxytocin) TTT of sever PPH (20) 65.0 13 95.0 19 Ergometrine 20.0 4 Misoprostol Removal of retained products 45.0 9 Artery ligation 10.0 2 Hysterectomy Anticonvulsants for eclampsia (45) 88.9 40 Magnesium sulfate 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Process and outcome indicators among MNM % No Indicators Prevention of caesarean section related infection (59) 100 59 Antibiotics 98.4 56 Prophylactic antibiotic during caesarean section Treatment of sepsis (2) 2 Prenatal therapeutic antibiotics Preterm birth (6) 6 Corticosteroids for fetal lung maturation 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Nursing & Healthcare, Nov.17-19,2014, Chicago, USA Conclusion The main life threatening conditions were severe pre eclampsia, severe hemorrhage, eclampsia and sepsis. More than 80% of cases went through critical Intervention such as ICU, blood products and laparotomy (87.8). 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Nursing & Healthcare, Nov.17-19,2014, Chicago, USA Conclusion 79% of cases experienced organs dysfunction. 5% of women with life threatening conditions were died. Also, study revealed several issues regarding quality of obstetric care that need urgent attention and improvement to reduce maternal morbidity. . 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Nursing & Healthcare, Nov.17-19,2014, Chicago, USA Recommendations WHO auditing tool providing a thorough evaluation of the quality of healthcare and suggesting improvements in maternal outcomes. The results may help establish public healthcare policies and strategies aimed at tackling the issue of maternal morbidity and mortality. 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Nursing & Healthcare, Nov.17-19,2014, Chicago, USA Qualitative prospective studies should be conducted to acquire further information on the profile of cases and on the risk factors for MNM. Applying standardized protocols and guidelines in emergency and admission rooms. Listening to the women who have experienced events severe enough to be classified as SMM or NM will certainly form an important part of future studies. 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

Nursing & Healthcare, Nov.17-19,2014, Chicago, USA Thank you from Egypt P 9/17/2018 Nursing & Healthcare, Nov.17-19,2014, Chicago, USA