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Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell kvinno- & mödrahälsovård och migration/Essén)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell kvinno- & mödrahälsovård och migration/Essén)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell kvinno- & mödrahälsovård och migration/Essén)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell sexuell och reproduktiv hälsa/Larsson)
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2014 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, no 1, 244- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

The maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications.

METHODS:

We performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital in Dar es Salaam, Tanzania. Cases were assessed individually to determine their association with CS. Main outcome measures included MNM ratio; maternal mortality ratio; proportion of MNM and death associated with CS complications; and the risk for such outcomes per 1,000 operations. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was calculated.

RESULTS:

We identified 467 MNM events and 77 maternal deaths. The MNM ratio was 36 per 1,000 live births (95% CI 33-39) and the maternal mortality ratio was 587 per 100,000 live births (95% CI 460-730). Major causes were eclampsia and postpartum haemorrhage, but we also detected nine MNM events and five deaths from iatrogenic complications. CS complications accounted for 7.9% (95% CI 5.6-11) of the MNM events and 13% (95% CI 6.4-23) of the maternal deaths. The risk of experiencing a life-threatening CS complication was three times higher at the regional hospital (22/1,000 operations, 95% CI 12-37) compared to the university hospital (7.0/1,000 operations, 95% CI 3.8-12) (risk ratio 3.2, 95% CI 1.5-6.6).

CONCLUSIONS:

The occurrence of MNM and death at the two hospitals was high, and many cases were associated with CS complications. The maternal risks of CS in low-resource settings must not be overlooked, and measures should be taken to avoid unnecessary CSs. More comprehensive training of staff, improved postoperative surveillance, and a more even distribution of resources within the health care system might reduce the risks of CS.

Place, publisher, year, edition, pages
2014. Vol. 14, no 1, 244- p.
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:uu:diva-229946DOI: 10.1186/1471-2393-14-244ISI: 000340799000001PubMedID: 25056517OAI: oai:DiVA.org:uu-229946DiVA: diva2:738503
Available from: 2014-08-18 Created: 2014-08-18 Last updated: 2017-12-05Bibliographically approved
In thesis
1. 'What about the Mother?': Rising Caesarean Section Rates and their Association with Maternal Near-Miss Morbidity and Death in a Low-Resource Setting
Open this publication in new window or tab >>'What about the Mother?': Rising Caesarean Section Rates and their Association with Maternal Near-Miss Morbidity and Death in a Low-Resource Setting
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In recent decades, there has been a seemingly inexhaustible rise in the use of caesarean section (CS) worldwide. The overall aim with this thesis is to explore the effects of and reasons for an increase in the CS rate at a university hospital in Dar es Salaam, Tanzania.

In Study I, we analysed time trends in CS rates and maternal and perinatal outcomes between 2000 and 2011 among different obstetric groups. In Study II, we documented the occurrence and panorama of maternal ‘near-miss’ morbidity and death, and analysed their association with CS complications. We also strived to determine if women with previous CS scars had an increased risk of maternal near-miss, death, or adverse perinatal outcomes in subsequent pregnancies. Studies III and IV explored women’s and caregivers’ in-depth perspectives on CS and caregivers’ rationales for their hospital’s high CS rate.

During the study period, the CS rate increased from 19% to 49%. The rise was accompanied by an increased maternal mortality ratio (odds ratio [OR] 1.5, 95% Confidence Interval [CI] 1.2–1.8) and improved perinatal outcomes. CS complications accounted for 7.9% (95% CI 5.6–11) of the maternal near-miss events and 13% (95% CI 6.4–23) of the maternal deaths. Multipara with previous CS scars had no increased risk of maternal near-miss or death compared with multipara with previous vaginal deliveries, and a lower risk of adverse perinatal outcomes (adjusted OR 0.51, 95% CI 0.33–0.80). Both women and caregivers stated they preferred vaginal birth, but caregivers also had a favourable attitude towards CS. Both groups justified maternal risks with CS by the need to ‘secure’ a healthy baby. Caregivers stated that they sometimes performed CSs on doubtful indications, partly due to dysfunctional team-work and a fear of being blamed by colleagues. 

This thesis raises a concern that maternal health, interests, and voices are overlooked through the CS decision for the benefit of perinatal outcomes and caregivers’ liability. An overuse of CS should be seen as a sign of substandard care and preventing such overuse needs to be among the key actions when formulating new targets for the post-2015 era.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. 114 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1063
Keyword
caesarean section, complications, attitudes, women, caregivers, low-income countries, Tanzania
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-238626 (URN)978-91-554-9134-5 (ISBN)
Public defence
2015-02-19, Rosénsalen, Kvinnokliniken, Ing. 95/96, Akademiska sjukhuset, Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2015-01-29 Created: 2014-12-15 Last updated: 2015-03-09

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Litorp, HelenaRööst, MattiasAbeid, MuzdalifatEssén, Birgitta

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