Thomas van den Akker

Prevalence, Indications, Risk Indicators, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis.

OBJECTIVE: To compare prevalence, indications, risk indicators, and outcomes of emergency peripartum hysterectomy across income settings. DATA SOURCES: PubMed, MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases up to March 30, 2015. METHODS OF STUDY SELECTION: Studies including emergency peripartum hysterectomies performed within 6 weeks postpartum. Not eligible were comments, case reports, elective hysterectomies for associated gynecologic conditions, studies with fewer than 10 inclusions, and those reporting only percentages published in languages other than English or before 1980. Interstudy heterogeneity was assessed by &khgr;2 test for heterogeneity; a random-effects model was applied whenever I 2 exceeded 25%. TABULATION, INTEGRATION, AND RESULTS: One hundred twenty-eight studies were selected, including 7,858 women who underwent emergency peripartum hysterectomy, of whom 87% were multiparous. Hysterectomy complicated almost 1 per 1,000 deliveries (range 0.2–10.1). Prevalence differed between poorer (low and lower middle income) and richer (upper middle and high income) settings: 2.8 compared with 0.7 per 1,000 deliveries, respectively (relative risk 4.2, 95% confidence interval [CI] 4.0–4.5). Most common indications were placental pathology (38%), uterine atony (27%), and uterine rupture (26%). Risk indicators included cesarean delivery in the current pregnancy (odds ratio [OR] 11.38, 95% CI 9.28–13.97), previous cesarean delivery (OR 7.5, 95% CI 5.1–11.0), older age (mean difference 6.6 years between women in the case group and those in the control group, 95% CI 4.4–8.9), and higher parity (mean difference 1.4, 95% CI 0.7–2.2). Having attended antenatal care was protective (OR 0.12, 95% CI 0.06–0.25). Only 3% had accessed arterial embolization to prevent hysterectomy. Average blood loss was 3.7 L. Mortality was 5.2 per 100 hysterectomies (reported range 0–59.1) and higher in poorer settings: 11.9 compared with 2.5 per 100 hysterectomies (relative risk 4.8, 95% CI 3.9–5.9). CONCLUSION: Emergency peripartum hysterectomy is associated with considerable morbidity and mortality and is more frequent in lower-income countries, where it contains a higher risk of mortality. A (previous) cesarean delivery is associated with a higher risk of emergency peripartum hysterectomy.

Barriers to conducting effective obstetric audit in Ifakara: a qualitative assessment in an under-resourced setting in Tanzania.

Objective  To explore barriers to and solutions for effective implementation of obstetric audit at Saint Francis Designated District Hospital in Ifakara, Tanzania, where audit results have been disappointing 2 years after its introduction.

Validating the WHO Maternal Near Miss Tool in a high-income country

This study was performed to assess the applicability of the WHO Maternal Near Miss Tool (MNM Tool) and the organ dysfunction criteria in a high‐income country.

Maternal mortality and severe morbidity in a migration perspective.

Among migrants in high-income countries, maternal mortality and severe morbidity generally occur more frequently as compared to host populations. There is marked variation between groups of migrants and host countries, with much elevated risks in some groups and no elevated risk at all in others. Those without a legal resident permit are most vulnerable. A reason for these elevated risks could be a different risk profile in migrants, but risk factors are unevenly distributed and not always present. Another reason is substandard care, which is identified more frequently in migrants, and comprises patient delays, for example, due to a lack of knowledge about the health system in the host country, and health worker delays, often compounded by communication barriers. Improvements in family planning and antenatal services are needed, and audits and confidential enquiries should be extended to include maternal morbidity and ethnic background. This requires scientific and political efforts.

Global surgery and the dilemma for obstetricians

www.thelancet.com Vol 386 November 14, 2015 1941 Despite discussions within the EU and proposals for coordinated action of post-authorisation assessment of orphan drugs, the systems in place are largely unchanged. We propose the launch of collaborative registries that are independent from the pharmaceutical industry and are based on the features summarised in the panel, to promote appropriate use of orphan drugs and management of costs.

Local health workers’ perceptions of substandard care in the management of obstetric hemorrhage in rural Malawi

BackgroundTo identify factors contributing to the high incidence of facility-based obstetric hemorrhage in Thyolo District, Malawi, according to local health workers.MethodsThree focus group discussions among 29 health workers, including nurse-midwives and non-physician clinicians (‘medical assistants’ and ‘clinical officers’).ResultsFactors contributing to facility-based obstetric hemorrhage mentioned by participants were categorized into four major areas: (1) limited availability of basic supplies, (2) lack of human resources, (3) inadequate clinical skills of available health workers and (4) substandard referrals by traditional birth attendants and lack of timely self-referrals of patients.ConclusionHealth workers in this district mentioned important community, system and provider related factors that need to be addressed in order to reduce the impact of obstetric hemorrhage.

Women's perceptions of the quality of emergency obstetric care in a referral hospital in rural Tanzania

To assess perceptions of the quality of obstetric care of women who delivered in a rural Tanzanian referral hospital.

Repeat HIV testing during pregnancy and delivery: missed opportunities in a rural district hospital in Zambia

To assess coverage of repeat HIV testing among women who delivered in a Zambian hospital. HIV testing of pregnant women and repeat testing every 3 months during pregnancy and breastfeeding is the recommended policy in areas of high HIV prevalence.

Severe acute maternal morbidity in multiple pregnancies: a nationwide cohort study

BACKGROUND Adverse neonatal outcomes in multiple pregnancies have been documented extensively, in particular those associated with the increased risk of preterm birth. Paradoxically, much less is known about adverse maternal events. The combined risk of severe acute maternal morbidity in multiple pregnancies has not been documented previously in any nationwide prospective study. OBJECTIVE The objective of the study was to assess the risk of severe acute maternal morbidity in multiple pregnancies in a high-income European country and identify possible risk indicators. STUDY DESIGN In a population-based cohort study including all 98 hospitals with a maternity unit in The Netherlands, pregnant women with severe acute maternal morbidity were included in the period Aug. 1, 2004, until Aug. 1, 2006. We calculated the incidence of severe acute maternal morbidity in multiple pregnancies in The Netherlands using The Netherlands Perinatal Registry. Relative risks (RR) of severe acute maternal morbidity in multiple pregnancies compared with singletons were calculated. To identify possible risk indicators, we also compared age, parity, method of conception, onset of labor, and mode of delivery for multiple pregnancies using The Netherlands Perinatal Registry as reference. RESULTS A total of 2552 cases of severe acute maternal morbidity were reported during the 2 year study period. Among 202 multiple pregnancies (8.0%), there were 197 twins (7.8%) and 5 triplets (0.2%). The overall incidence of severe acute maternal morbidity was 7.0 per 1000 deliveries and 6.5 and 28.0 per 1000 for singletons and multiple pregnancies, respectively. The relative risk of severe acute maternal morbidity compared with singleton pregnancies was 4.3 (95% confidence interval [CI], 3.7-5.0) and increased to 6.2 (95% CI 2.5-15.3) in triplet pregnancies. Risk indicators for developing severe acute maternal morbidity in women with multiple pregnancies were age of ≥ 40 years, (RR, 2.5 95% CI, 1.4-4.3), nulliparity (RR, 1.8, 95% CI, 1.4-2.4), use of assisted reproductive techniques (RR, 1.9, 95% CI, 1.4-2.5), and nonspontaneous onset of delivery (RR, 1.6, 95% CI, 1.2-2.1). No significant difference was found between mono- and dichorionic twins (RR, 0.8, 95% CI, 0.6-1.2). CONCLUSION Women with multiple pregnancies in The Netherlands have a more than 4 times elevated risk of sustaining severe acute maternal morbidity as compared with singletons.

Emergency obstetric care provision in Southern Ethiopia: A facility-based survey

Objectives To assess the provision of basic emergency obstetric and newborn care (BEmONC), knowledge of high-risk pregnancies and referral capacity at health centres in Southern Ethiopia. Design A facility-based survey, using an abbreviated version of the Averting Maternal Death and Disability needs assessment tool for emergency obstetric and newborn care. Modules included infrastructure, staffing, number of deliveries, maternal and perinatal mortality, BEmONC signal functions, referral capacity and knowledge of risk factors in pregnancy. Setting Primary healthcare centres providing delivery services in the Eastern Gurage Zone, a predominantly rural area in Southern Ethiopia. Participants All 20 health centres in the study area were selected for the assessment. One was excluded, as no delivery services had been provided in the 12 months prior to the study. Results Three out of 19 health centres met the government’s staffing norm. In the 12 months prior to the survey, 10 004 (X−=527±301) deliveries were attended to at the health centres, but none had provided all seven BEmONC signal functions in the three months prior to the survey (X−=3.7±1.2). Eight maternal and 32 perinatal deaths occurred. Most health centres had performed administration of parenteral uterotonics (17/89.5%), manual removal of placenta (17/89.5%) and neonatal resuscitation (17/89.5%), while few had performed assisted vaginal delivery (3/15.8%) or administration of parenteral anticonvulsants (1/5.3%). Reasons mentioned for non-performance were lack of patients with appropriate indications, lack of training and supply problems. Health workers mentioned on average 3.9±1.4 of 11 risk factors for adverse pregnancy outcomes. Five ambulances were available in the zone. Conclusion BEmONC provision is not guaranteed to women giving birth in health centres in Southern Ethiopia. Since the government aims to increase facility deliveries, investments in capacity at health centres are urgently needed.