Extreme Maternal Morbidity Extreme Maternal Morbidity and Maternal and Maternal Mortality Reduction by Implementing a Mortality Reduction by Implementing a

Surveillance System at the Gynecology and Surveillance System at the Gynecology and Obstetrics Hospital, Guatemala 2007-2009Obstetrics Hospital, Guatemala 2007-2009

Dr. Jorge David Alvarado AndradeFETP 2008 (Intermediate Level)Gynecology and Obstetrics Hospital, Social Security Institute

Maternal Mortality in Maternal Mortality in GuatemalaGuatemala• Guatemala

– 12,000.000 habitants – Annual LB: 369, 769 (2008)

• 51% attended by health workers– MMR: 153/100,000 LB

• Social Security (IGSS)– Attend the 8% de LB – Gynecology and Obstetric Hospital

(GOH)• Third level hospital • Annual attend LB:

16,000 (90% of IGSS)

BackgroundBackground

• In 2007, IGSS reported 42 cases of confirmed maternal deaths, of which only 1 occurred in the GOH.

• No cases of obstetric patients with extreme maternal morbidity (Near-Miss)

Real or underreporting?

How death was registered?How death was registered?

Maternal DeathsHospital

Maternal Deaths Records

Floor Supervisor or Ward Supervisor

Nursing Supervisor

Statistical Service

This occurred in 5% (2 / 42) of the cases

Extreme Maternal Morbidity (GOH)

Transferred to another unit of IGSS

(Intensive Care)

Dead

Admitted in the Transfer Unit

Hospital Discharge

Alive Statistical Service at the Transfer Unit

Happened in 95% (40/42) of cases

How Near-Miss was registered? How Near-Miss was registered? (II)(II)

ObjectivesObjectives

• Design and implementation of an improved Maternal Mortality Surveillance System (MMSS) based in GOH.

• Identify all cases of Maternal Mortality (MM) and Extreme Maternal Morbidity (EMM) that occur in the GOH (2009) and determine their causes

Phases of Development Phases of Development of the MMSSof the MMSS

1. Diagnosis the situation the MM (2007)

2. Create the SSMM Committee (2008)a. Development of the Protocol

b. Restructuring the System for EMM and MM cases recording

3. Active surveillance (2009)

EMM and MM Surveillance Committee

Analysis of Cases and Drafting

Conclusions and Recommendations

Results Dissemination

ResultsResultsCurrent Reporting SystemCurrent Reporting System

Maternal DeathsHospital

Maternal Deaths Records

Floor Supervisor or Ward

Supervisor

Nursing Supervisor

Statistical Unit

Chief resident and / or residents

III

ReferralNotification

EMM and MM Surveillance Committee

Case Analysis and Drafting

Conclusions and Recommendations

Results Dissemination

Feedback

Current Reporting System (II)Current Reporting System (II)Extreme Maternal

Morbidity (HGO)

Transferred to another unit of IGSS

(Intensive Care)

Dead

admitted in the transfer unit

Hospital Discharge

Alive

Statistical Service at the Transfer Unit

Data Analyzer

Overview of EMM population treated at the GOH Guatemala, 2009

Parity No. of Cases %Primigravida 1 0Secundigesta 111 31Multiparous 183 50No data available 68 19

Timing at Complication %Miscarriage 62 17Preterm 124 34Term 103 28Prolonged 5 1No data 4 1Puerperium 65 18

Procedure %Caesarea 274 75Delivery 23 6Curettage 8 2Other 55 15No data 3 1

n = 363

Morbility No. of Cases %Severe Hypertension 110 30Ectopic Pregnancy 50 14Pre-eclampsia / Eclampsia 49 13Acute Abdomen 28 08Placenta Previa Bleeding 25 07HELLP Syndrome 19 06Fetal Distress 18 05Failed Induction 12 03Placenta Accreta 11 03Uterine Atony 8 02Other Causes 33 09TOTAL 363 100

Top ten causes of EMM in patients treated at the GOH Guatemala, 2009

Source: Book of deliveries, cesarean sections and reports from team leaders

n = 363

Transfer Causes No. of Cases %Unstable Hypertension 18 36Hypovolemic Shock 11 22Septic Abortion 1 02Eclampsia 1 02Respiratory Failure 1 02Granulocytic Leukemia 1 02HELLP Syndrome 1 02Metabolic Disorder 1 02Inmunological Disease 1 02PostPartum Hemorrage 1 02Other Causes 13 26TOTAL 50 100

Top ten reasons for transfer patients treated with EMM to ICU from GOH. Guatemala, 2009

Source: Book of deliveries, cesarean sections and reports from team leaders

n = 50

Transfer Unit No. of Cases %Gynecology and Obstetrics Hospital

312 87.05

Intensive A 39 10.74Intensive B 10 02.75Infeccions Floor 1 00.28**No data 1 00.28TOTAL 363 100.00Transfer to Intensive 50

Place of transfer to intensive care for patients treated with EMM at GOH Guatemala, 2009.

Source: Book of deliveries, cesarean sections and reports from team leaders

Maternal Mortality Ratio at the GOH Guatemala, 2007 to 2009

Ca

ses

Maternal Mortality Ratio

*Absolute number of maternal deaths were 11(2009), 7(2008) and 4(2010)

n = 22

Years

Causes of MM at the GOHGuatemala, 2007 to 2009

2007 2008 2009

Cause of Death Cases % Cases % Cases %

Hipertensive Status

2 18 3 43 1 25

Postpartum Hemorrage

3 27 2 29 1 25

Septic Abortion 5 45 1 14 1 25Medical Complications

1 9 1 14 1 25

TOTAL 11 100 7 100 4 100

n = 22

Impact to Public HealthImpact to Public Health

Relationship between Maternal Mortality Ratio and Audit of cases at the GOH, Guatemala 2007 to 2009

Pe

rce

nta

ge

Years

Maternal Mortality Ratio

Audit Cases

Limitations of SSMMLimitations of SSMM

• Resistance to notify cases

• Lack of enforcement by IGSS of the new regulations for surveillance of MM

• Misclassification of maternal deaths

• Incomplete and/or inappropriate comicent of the reporting forms

AchievementsAchievements in 2010 in 2010• Audit of 92% of the cases of EMM and MM

• Risk factors for MM are being analyze

• System Surveillance delays are being evaluated

• Construction of the ICU in GOH

• Social Work Service was incorporated in to the MMSS as another source of reporting

Thanks for your attentionThanks for your attention

LakeAtitlàn GuatemalaLakeAtitlàn Guatemala

MethodsMethodsYears

2007 2008 2009

Conventional Statistical Record

Form the surveillance committee

Protocol Development and Implementation

Review of Cases occurred in 2007

Monitor and Audit Cases occurred in

2008

Active Surveillance of MM and MME

cases

Audit Cases of MM and EMM

Development and Dissemination of

Reports

Implementation of Control Measures

ActivitiesActivities

1. Create the Surveillance Committee for Maternal Mortality and Extreme Maternal Morbidity (2008)

2. Development of the Protocol:• Data Source• Notification Process (define scenarios)• Frequency of Notification• Operational Definitions• Inclusion and Exclusion Criteria• Type of surveillance

3. Data Analysis:• Classify the deaths as maternal or not maternal

related• Determine if MM were preventable• Explore the major risk factors

4. Analyze and interpret results

5. Present and discuss the results

6. Restructuring the system for EMM and MM cases recording

Activities (II)Activities (II)

Condition at Discharge No. of Cases %Alive 359 98Dead 4 2TOTAL 363 100

Maternal Mortality Ratio: 26.4 *100.000 live births

(4 deaths/15,161 births*100,000)Reason of nears-miss: 4/363 * 100 =1,1 (1 per 100)

Discharge status of patients with EMM attended at GOH, Guatemala, 2009.

Source: Book of deliveries, cesarean sections and reports from team leaders