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Abera Kenay Tura,1,2 Sicco Scherjon,2 Jelle Stekelenburg,3,4 Jos van Roosmalen,5,6 Thomas van den Akker,5,6 Joost Zwart7 1School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia; 2Department of Obstetrics and Gynecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands; 3Department of Health Sciences, Global Health, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands; 4Department of Obstetrics and Gynecology, Leeuwarden Medical Centre, Leeuwarden, The Netherlands; 5Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; 6Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands; 7Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, Deventer, The NetherlandsCorrespondence: Abera Kenay TuraSchool of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, POB 235, Harar, EthiopaEmail a.k.tura@haramaya.edu.etObjectives: To assess life-threatening complications among women admitted with severe hypertensive disorders of pregnancy and compare applicability of World Health Organization (WHO) maternal near-miss (MNM) criteria and the recently adapted sub-Saharan African (SSA) MNM criteria in eastern Ethiopia.Methods: Of 1,054 women admitted with potentially life-threatening conditions between January 2016 and April 2017, 562 (53.3%) had severe preeclampsia/eclampsia. We applied the definition of MNM according to the WHO MNM criteria and the SSA MNM criteria. Logistic regression was performed to identify factors associated with severe maternal outcomes (MNMs and maternal deaths).Results: The SSA MNM criteria identified 285 cases of severe maternal outcomes: 271 MNMs and 14 maternal deaths (mortality index 4.9%). The WHO criteria identified 50 cases of severe maternal outcomes: 36 MNMs and 14 maternal deaths (mortality index 28%). The MNM ratio was 36.6 per 1,000 livebirths according to the SSA MNM criteria and 4.9 according to the WHO criteria. More than 80% of women in both groups had MNM events on arrival or within 12 hours after admission. Women without antenatal care, from rural areas, referred from other facilities, and with concomitant hemorrhage more often developed severe maternal outcomes.Conclusion: Regarding hypertensive disorders of pregnancy, the SSA tool is more inclusive than the WHO tool, while still maintaining a considerably high mortality index indicating severity of included cases. This may enable more robust audits. Strengthening the referral system and improving prevention and management of obstetric hemorrhage in women with hypertensive disorders of pregnancy are required to avert severe maternal outcomes.Keywords: severe maternal outcomes, hypertensive disorders of pregnancy, maternal near-miss, maternal mortality, sub-Saharan Africa

Objective: International comparison of complete uterine rupture.Design: Descriptive multi-country population-based study.Setting: International.Population: International Network of Obstetric Survey Systems (INOSS).Methods: We merged individual data, collected prospectively in nine population-based studies, of women with complete uterine rupture, defined as complete disruption of the uterine muscle and the uterine serosa, regardless of symptoms and rupture of fetal membranes.Main Outcome Measures: Prevalence of complete uterine rupture, regional variation and correlation with rates of caesarean section (CS) and trial of labour after CS (TOLAC). Severe maternal and perinatal morbidity and mortality.Results: We identified 864 complete uterine ruptures in 2 625 017 deliveries. Overall prevalence was 3.3 (95% CI 3.1-3.5) per 10 000 deliveries, 22 (95% CI 21-24) in women with and 0.6 (95% CI 0.5-0.7) in women without previous CS. Prevalence in women with previous CS was negatively correlated with previous CS rate (ρ = -0.917) and positively correlated with TOLAC rate of the background population (ρ = 0.600). Uterine rupture resulted in peripartum hysterectomy in 87 of 864 women (10%, 95% CI 8-12%) and in a perinatal death in 116 of 874 infants (13.3%, 95% CI 11.2-15.7) whose mother had uterine rupture. Overall rate of neonatal asphyxia was 28% in neonates who survived.Conclusions: Higher prevalence of complete uterine ruptures per TOLAC was observed in countries with low previous CS and high TOLAC rates. Rates of hysterectomy and perinatal death are about 10% following complete uterine rupture, but in women undergoing TOLAC the rates are extremely low (only 2.2 and 3.2 per 10 000 TOLACs, respectively.) TWEETABLE ABSTRACT: Prevalence of complete uterine rupture is higher in countries with low previous CS and high TOLAC rates. [ABSTRACT FROM AUTHOR]

Background It is beyond doubt that blood transfusion services have added to the decline in maternal mortality in high-resource countries. To quantify the clinical benefit of red blood cell (RBC) transfusion in obstetric care, we performed a hypothetical experimental study using data from a prospective nationwide cohort of women giving birth in the Netherlands. Study Design and Methods Data were abstracted from a nationwide cohort study on severe maternal morbidity, including obstetric haemorrhage requiring 4 or more units of RBC, to obtain an observed and a hypothetical control group consisting of the same women. In the hypothetical control group, we simulated a situation where RBC transfusion was unavailable and estimated how many of these women would have died in that situation. A questionnaire survey asked experts in major (obstetric) haemorrhage to choose a critical minimal number of RBC transfusions at which a woman with obstetric haemorrhage would have died if RBC transfusion was not available. Maternal mortality rate per 100 000 maternities [maternal mortality ratios (MMR)] and relative risk were calculated for the observed and hypothetical group. Results The observed MMR was 13 per 100 000 maternities. According to 47 responding experts, the median number of RBC units without which a woman would have most probably died was nine, resulting in a hypothetical MMR of 87 per 100 000 maternities (relative risk 6·5; 95% confidence interval 4·2-10·0). Conclusions It can be expected that unavailability of RBC transfusion in obstetric care increases the risk of maternal death 6.5-fold. Blood transfusion thus largely contributes to the decline of MMR and would also be an important pillar of improving quality of care in resource-poor settings. [ABSTRACT FROM AUTHOR]

Please cite this paper as: van Dillen J, Mesman J, Zwart J, Bloemenkamp K, van Roosmalen J. Introducing maternal morbidity audit in the Netherlands. BJOG 2010;117:416–421. Objective To describe the panel audit process and to identify substandard care in selected women from a nationwide prospective cohort study into severe acute maternal morbidity (SAMM) in the Netherlands. Design Prospective audit of selected women with SAMM. Setting Eight audit meetings held throughout the Netherlands. Population All pregnant women in the Netherlands. Methods Before each meeting, SAMM details of selected women were sent to all panel members for individual assessment by completing an audit form. During a subsequent plenary meeting, findings were discussed and substandard care factors as judged by the majority of assessors were scored. Main outcome measures Incidence of substandard care and recommendations for improving the quality of care. Results Substandard care was identified in 53 of 67 women (79%). Specific recommendations were formulated concerning the procedure of audit and concerning local as well as national management guidelines. Conclusion Our findings reflect SAMM in the Netherlands and substandard care is present in four out of five women. Ongoing audit of women with SAMM is promoted both at local and national level. [ABSTRACT FROM AUTHOR]

Objective To determine the risk of maternal mortality and serious maternal morbidity because of major obstetric haemorrhage in Jehovah’s witnesses in the Netherlands. Design A retrospective study of case notes. Setting All tertiary care centres, general teaching hospitals and other general hospitals in the Netherlands. Sample All cases of maternal mortality in the Netherlands between 1983 and 2006 and all cases of serious maternal morbidity in the Netherlands between 2004 and 2006. Methods Study of case notes using two different nationwide enquiries over two different time periods. Main outcome measures Maternal mortality ratio (MMR) and risk of serious maternal mortality. Results The MMR for Jehovah’s witnesses was 68 per 100 000 live births. We found a risk of 14 per 1000 for Jehovah’s witnesses to experience serious maternal morbidity because of obstetric haemorrhage while the risk for the total pregnant population was 4.5 per 1000. Conclusions Women who are Jehovah’s witnesses are at a six times increased risk for maternal death, at a 130 times increased risk for maternal death because of major obstetric haemorrhage and at a 3.1 times increased risk for serious maternal morbidity because of obstetric haemorrhage, compared to the general Dutch population. [ABSTRACT FROM AUTHOR]

Objective To assess incidence, case fatality rate, risk factors and substandard care in severe maternal morbidity in the Netherlands. Design Prospective population-based cohort study. Setting All 98 maternity units in the Netherlands. Population All pregnant women in the Netherlands. Methods Cases of severe maternal morbidity were collected during a 2-year period. All pregnant women in the Netherlands in the same period acted as reference cohort ( n = 371 021). As immigrant women are disproportionately represented in Dutch maternal mortality statistics, special attention was paid to the ethnic background. In a subset of 2.5% of women, substandard care was assessed through clinical audit. Main outcome measures Incidence, case fatality rates, possible risk factors and substandard care. Results Severe maternal morbidity was reported in 2552 women, giving an overall incidence of 7.1 per 1000 deliveries. Intensive care unit admission was reported in 847 women (incidence 2.4 per 1000), uterine rupture in 218 women (incidence 6.1/10 000), eclampsia in 222 women (incidence 6.2/10 000) and major obstetric haemorrhage in 1606 women (incidence 4.5 per 1000). Non-Western immigrant women had a 1.3-fold increased risk of severe maternal morbidity (95% CI 1.2–1.5) when compared with Western women. Overall case fatality rate was 1 in 53. Substandard care was found in 39 of a subset of 63 women (62%) through clinical audit. Conclusions Severe maternal morbidity complicates at least 0.71% of all pregnancies in the Netherlands, immigrant women experiencing an increased risk. Since substandard care was found in the majority of assessed cases, reduction of severe maternal morbidity seems a mandatory challenge. [ABSTRACT FROM AUTHOR]

Objective: To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH‐related maternal deaths in France and the Netherlands. Methods: In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH‐related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. Results: For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non‐obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. Conclusion: A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level. Synopsis: Multinational maternal death reviews provide opportunities for care improvement beyond improvable factors already identified by national maternal death enquiries, through the perspective of a different care context. [ABSTRACT FROM AUTHOR]