DOI: 10.1111/1471-0528.12868
Commentary
www.bjog.org
Maternal near-miss audits to improve quality of care € Tuncßalp,a JP Souzaa,b O a HRP—UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland b Department of Social Medicine, Ribeir~ao Preto Medical School, University of S~ao Paulo, Ribeir~ao Preto, SP, Brazil € Tuncßalp, HRP—UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Correspondence: O Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, Geneva, Switzerland. Email [email protected]
Accepted 11 March 2014. € Souza JP. Maternal near-miss audits to improve quality of care. BJOG 2014; 121 (Suppl. 4): 102–104. Please cite this paper as: Tuncßalp O,
Introduction Quality of care is a multidimensional concept that involves infrastructure, process of care, accessibility, effectiveness, impact on health outcomes and satisfaction.1,2 Patient satisfaction, which also relates to demand for services, emerges from the interaction of different dimensions of quality, particularly the process of care, in which respectful care plays a central role. There are a number of effective strategies used to improve quality of care in maternity services, one of which is the implementation of maternal death reviews. However, as maternal deaths become less frequent and facility deliveries increase, conducting near-miss reviews in addition to maternal death reviews becomes the necessary next step to improve quality of maternal care.
Beyond maternal mortality: maternal near-miss Definitions and identification criteria for severe acute maternal morbidity varies across studies and countries.3 In 2009, the World Health Organization (WHO) led the development of a set of criteria for identifying women with life-threatening conditions during pregnancy, childbirth and the postpartum period, defined as maternal near-miss cases. The presentation and severity of maternal morbidity are within a spectrum.4 Therefore, based on WHO guidance, identifying near-miss cases can be viewed as a two-step process.5 Firstly, women with ‘potentially life-threatening conditions’ are identified, based on whether they had any severe complication (e.g. severe postpartum haemorrhage, severe pre-eclampsia, eclampsia, sepsis or severe systemic infection, ruptured uterus) or whether they received a critical intervention (e.g. blood products, laparotomy, admis-
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sion to intensive care unit). The use of locally relevant potentially life-threatening conditions is encouraged and the WHO guidance provides a basic set of conditions together with operational definitions.5 Secondly, as the clinical course of the complication unfolds and an outcome is reached (i.e. survival or nonsurvival), near-miss cases are further classified using stricter criteria based on identification of organ dysfunction by clinical, laboratory and management markers4 (Box 1). In this classification, near-miss cases are considered to be those presenting and surviving ‘life-threatening conditions’. Even though the near-miss criteria are aimed to be used at health facilities with a minimum level of care and basic care monitoring capacity,4 the list of potentially life-threatening conditions proposed by WHO can be used as pragmatic criteria for identification of ‘near-miss cases at large’ in the community and primary health centres.6 This approach may produce less comparable but locally relevant information, and is an alternative for settings where the use of WHO near-miss criteria, which are based on organ dysfunction, is deemed difficult or not feasible. These approaches should not compete with, but should complement each other in obtaining actionable information to improve the quality of maternal health.
Maternal near-miss audits: surveillance and response Audits are proven to be effective tools in improving professional practice7 and to enable assessment and improvement of care at facilities, a set of indicators was developed leading to an audit tool for maternal near-miss.5 It should be noted that there are different approaches to reviewing clinical practice for audits ranging from informal discussion of
ª 2014 Royal College of Obstetricians and Gynaecologists
Quality of care and severe maternal morbidity
Box 1. WHO criteria to identify potentially life-threatening conditions and near-miss5 Step 1: Potentially life-threatening conditions Severe complications
1. Severe postpartum haemorrhage: genital bleeding after delivery, with at least one of the following: perceived abnormal bleeding (≥1000 ml) or any bleeding with hypotension or blood transfusion 2. Severe pre-eclampsia: persistent systolic blood pressure of ≥160 mmHg or a diastolic blood pressure of 110 mmHg; proteinuria of ≥5 g in 24 hours; oliguria of 38°C), a confirmed or suspected infection (e.g. chorioamnionitis, septic termination of pregnancy, endometritis, pneumonia), and at least one of the following— heart rate >100, respiratory rate >20, leucopenia (white blood cells 12 000) 5. Ruptured uterus: ruptured uterus during labour Critical interventions
1. Use of blood products 2. Laparotomy (including hysterectomy, excluding caesarean section) 3. Admission to intensive care unit Step 2: Maternal near-miss (life-threatening conditions) Clinical organ dysfunction
1. Acute cyanosis 2. Gasping 3. Respiratory rate >40 or 12 hours 8. Stroke 9. Uncontrollable fit/status epilepticus 10. Global paralysis 11. Jaundice in the presence of pre-eclampsia Laboratory markers of organ dysfunction
12. 13. 14. 15. 16. 17. 18.
O2 saturation 3.5 mg/dl Bilirubin >100 lmol/l or >6.0 mg/dl pH 5 mEq/l Acute thrombocytopenia (5 units of blood or red cells
ª 2014 Royal College of Obstetricians and Gynaecologists
a selected number of cases among clinicians to structured reviews involving statistical analysis of a large number of cases. The maternal near-miss audit tool falls under the latter category, where a set of explicit, measurable criteria for case management are agreed upon, which can then be used to monitor practice and determine if standards of care have been met.8 As the data are analysed at an aggregate level, the patterns of deficiencies in care as well as opportunities for improvement are easier to observe. Since their publication, the WHO maternal near-miss criteria and the audit tool have been applied in over 30 countries.9–13 Furthermore, a maternal severity index has been developed to estimate the probability of mortality among women with complications related to pregnancy.14 It facilitates an objective assessment, comparison and tracking of health facility performance by enabling a benchmark approach to quality of care of women experiencing severe complications related to pregnancy.14 Using an estimation of the overall severity associated with a population, for example the population served by a facility, the maternal severity index provides an estimate of the risk of mortality for this population.9 Overall, maternal death and near-miss audits generate valuable information, but this is not enough to create and sustain a change in clinical practice. To ‘activate’ the information, a systems approach for surveillance and response is advised, because not all of the roadblocks identified will be related to clinical management. Also demonstrated by the maternal death surveillance and response framework, the surveillance component through prospective identification of severe morbidity cases is responsible for the generation of actionable information that effectively guides immediate and longer-term actions.15 Compared with clinical audits focusing on maternal mortality, there are various advantages associated with near-miss audits. They are more likely to function as a positive entry point for critical assessment and subsequent behaviour change as health professionals are more open to discuss failures and successes during care, and what made these women survive and not become a maternal death. It also allows direct interviews with survivors providing an important and complementary perspective on how the care has been accessed, received and perceived including aspects of respectful care.5 Implementing prospective surveillance also contributes to establishing an institutional culture of emergency preparedness, which is potentiated by training and emergency drills. The response component engages and promotes the interaction within multiple health service and health system building blocks, including the governance, information systems, finances, supplies, health services and human resources.16 This is why it is essential that various key
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stakeholders are involved along with the different cadres of health professionals and sentinel units in the health service, such as in the emergency rooms, intensive care units or blood banks.5 Prioritising avoidable factors identified in the situation analysis and using evidence-based approaches will make the response more effective. Overall, the ‘blame and shame’ attitude should be avoided while conducting maternal death and maternal near-miss reviews because it erodes institutional cooperation and intrinsic motivation of health professionals. Identifying locally relevant process and outcome indicators (e.g. coverage of women with pre-eclampsia who received magnesium sulphate, the ratio between maternal near-miss cases and maternal deaths), establishing targets, and making this information publicly available through transparent mechanisms is a powerful strategy to motivate institutions to seek quality care improvement and promote social participation in a continuous manner.
Conclusions As a tool to improve quality of care in facilities, tracking and evaluating the care provided to maternal near-miss cases has the potential to function as a catalyst for both improving women’s delivery experiences and outcomes and strengthening the health systems. As countries progress through the stages of obstetric transition,17 maternal mortality decreases and women increasingly deliver in facilities, it is paramount to ensure that facilities and health systems have the tools to measure and improve quality of care. Furthermore, accurate and routine measurement of the spectrum of maternal morbidity is necessary to inform policy and programme decisions to further reduce maternal mortality and morbidity.18
Disclosure of interests We have nothing to declare.
Contribution to authorship OT and JPS wrote and finalised the article.
Details of ethics approval No ethics approval was required.
Funding No funding was received.
Acknowledgements We would like to thank Dr Metin G€ ulmezoglu and Dr Lale Say for their feedback on earlier versions of the article. &
104
References 1 Bruce J. Fundamental elements of the quality of care: a simple framework. Stud Fam Plann 1990;21:61–91. 2 Hulton L, Matthews Z, Stones W. A Framework for Evaluation of Quality of Care in Maternity Services. Southampton, UK: University of Southampton, 2000. 3 Tuncalp O, Hindin MJ, Souza JP, Chou D, Say L. The prevalence of maternal near miss: a systematic review. BJOG 2012;119:653–61. 4 Say L, Souza JP, Pattinson RC. Maternal near miss—towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009;23:287–96. 5 World Health Organization. Evaluating the Quality of Care for Severe Pregnancy Complications: the WHO Near-Miss Approach for Maternal Health. Geneva, Switzerland: WHO, 2011. 6 Souza JP, Say L, Gulmezoglu M. Practical criteria for maternal near miss needed for low-income settings—Authors’ reply. Lancet 2013;382:505. 7 Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012;(6):CD000259. 8 Graham W, Wagaarachchi P, Penney G, McCaw-Binns A, Antwi KY, Hall MH. Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries. Bull WHO 2000;78:614–20. 9 Souza JP, Gulmezoglu AM, Vogel J, Carroli G, Lumbiganon P, Qureshi Z, et al. Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. Lancet 2013;381:1747–55. 10 van den Akker T, Beltman J, Leyten J, Mwagomba B, Meguid T, Stekelenburg J, et al. The WHO maternal near miss approach: consequences at Malawian District level. PLoS One 2013;8:e54805. 11 Tuncalp O, Hindin MJ, Adu-Bonsaffoh K, Adanu RM. Assessment of maternal near-miss and quality of care in a hospital-based study in Accra, Ghana. Int J Gynaecol Obstet 2013;123:58–63. 12 Nelissen E, Mduma E, Broerse J, Ersdal H, Evjen-Olsen B, van Roosmalen J, et al. Applicability of the WHO maternal near miss criteria in a low-resource setting. PLoS One 2013;8:e61248. 13 Jabir M, Abdul-Salam I, Suheil DM, Al-Hilli W, Abul-Hassan S, Al-Zuheiri A, et al. Maternal near miss and quality of maternal health care in Baghdad, Iraq. BMC Pregnancy Childbirth 2013;13:11. 14 Souza JP, Cecatti JG, Haddad SM, Parpinelli MA, Costa ML, Katz L, et al. The WHO maternal near-miss approach and the maternal severity index model (MSI): tools for assessing the management of severe maternal morbidity. PLoS One 2012;7:e44129. 15 World Health Organization. Maternal Death Surveillance Response Technical Guidance: information for Action to Prevent Maternal Death. Geneva, Switzerland: World Health Organization, 2013. 16 World Health Organization. Systems Thinking for Health System Strengthening. Geneva, Switzerland: World Health Organization, 2009. 17 Souza JP, Tuncalp O, Vogel JP, Bohren M, Widmer M, Oladapo O, et al. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG 2014;121(suppl.): 1–4. 18 Firoz T, Chou D, von Dadelszen P, Agrawal P, Vanderkruik R, Tuncalp O, et al. Measuring maternal health: focus on maternal morbidity. Bull WHO 2013;91:794–6.
ª 2014 Royal College of Obstetricians and Gynaecologists
Commentary
www.bjog.org
Maternal near-miss audits to improve quality of care € Tuncßalp,a JP Souzaa,b O a HRP—UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland b Department of Social Medicine, Ribeir~ao Preto Medical School, University of S~ao Paulo, Ribeir~ao Preto, SP, Brazil € Tuncßalp, HRP—UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Correspondence: O Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, Geneva, Switzerland. Email [email protected]
Accepted 11 March 2014. € Souza JP. Maternal near-miss audits to improve quality of care. BJOG 2014; 121 (Suppl. 4): 102–104. Please cite this paper as: Tuncßalp O,
Introduction Quality of care is a multidimensional concept that involves infrastructure, process of care, accessibility, effectiveness, impact on health outcomes and satisfaction.1,2 Patient satisfaction, which also relates to demand for services, emerges from the interaction of different dimensions of quality, particularly the process of care, in which respectful care plays a central role. There are a number of effective strategies used to improve quality of care in maternity services, one of which is the implementation of maternal death reviews. However, as maternal deaths become less frequent and facility deliveries increase, conducting near-miss reviews in addition to maternal death reviews becomes the necessary next step to improve quality of maternal care.
Beyond maternal mortality: maternal near-miss Definitions and identification criteria for severe acute maternal morbidity varies across studies and countries.3 In 2009, the World Health Organization (WHO) led the development of a set of criteria for identifying women with life-threatening conditions during pregnancy, childbirth and the postpartum period, defined as maternal near-miss cases. The presentation and severity of maternal morbidity are within a spectrum.4 Therefore, based on WHO guidance, identifying near-miss cases can be viewed as a two-step process.5 Firstly, women with ‘potentially life-threatening conditions’ are identified, based on whether they had any severe complication (e.g. severe postpartum haemorrhage, severe pre-eclampsia, eclampsia, sepsis or severe systemic infection, ruptured uterus) or whether they received a critical intervention (e.g. blood products, laparotomy, admis-
102
sion to intensive care unit). The use of locally relevant potentially life-threatening conditions is encouraged and the WHO guidance provides a basic set of conditions together with operational definitions.5 Secondly, as the clinical course of the complication unfolds and an outcome is reached (i.e. survival or nonsurvival), near-miss cases are further classified using stricter criteria based on identification of organ dysfunction by clinical, laboratory and management markers4 (Box 1). In this classification, near-miss cases are considered to be those presenting and surviving ‘life-threatening conditions’. Even though the near-miss criteria are aimed to be used at health facilities with a minimum level of care and basic care monitoring capacity,4 the list of potentially life-threatening conditions proposed by WHO can be used as pragmatic criteria for identification of ‘near-miss cases at large’ in the community and primary health centres.6 This approach may produce less comparable but locally relevant information, and is an alternative for settings where the use of WHO near-miss criteria, which are based on organ dysfunction, is deemed difficult or not feasible. These approaches should not compete with, but should complement each other in obtaining actionable information to improve the quality of maternal health.
Maternal near-miss audits: surveillance and response Audits are proven to be effective tools in improving professional practice7 and to enable assessment and improvement of care at facilities, a set of indicators was developed leading to an audit tool for maternal near-miss.5 It should be noted that there are different approaches to reviewing clinical practice for audits ranging from informal discussion of
ª 2014 Royal College of Obstetricians and Gynaecologists
Quality of care and severe maternal morbidity
Box 1. WHO criteria to identify potentially life-threatening conditions and near-miss5 Step 1: Potentially life-threatening conditions Severe complications
1. Severe postpartum haemorrhage: genital bleeding after delivery, with at least one of the following: perceived abnormal bleeding (≥1000 ml) or any bleeding with hypotension or blood transfusion 2. Severe pre-eclampsia: persistent systolic blood pressure of ≥160 mmHg or a diastolic blood pressure of 110 mmHg; proteinuria of ≥5 g in 24 hours; oliguria of 38°C), a confirmed or suspected infection (e.g. chorioamnionitis, septic termination of pregnancy, endometritis, pneumonia), and at least one of the following— heart rate >100, respiratory rate >20, leucopenia (white blood cells 12 000) 5. Ruptured uterus: ruptured uterus during labour Critical interventions
1. Use of blood products 2. Laparotomy (including hysterectomy, excluding caesarean section) 3. Admission to intensive care unit Step 2: Maternal near-miss (life-threatening conditions) Clinical organ dysfunction
1. Acute cyanosis 2. Gasping 3. Respiratory rate >40 or 12 hours 8. Stroke 9. Uncontrollable fit/status epilepticus 10. Global paralysis 11. Jaundice in the presence of pre-eclampsia Laboratory markers of organ dysfunction
12. 13. 14. 15. 16. 17. 18.
O2 saturation 3.5 mg/dl Bilirubin >100 lmol/l or >6.0 mg/dl pH 5 mEq/l Acute thrombocytopenia (5 units of blood or red cells
ª 2014 Royal College of Obstetricians and Gynaecologists
a selected number of cases among clinicians to structured reviews involving statistical analysis of a large number of cases. The maternal near-miss audit tool falls under the latter category, where a set of explicit, measurable criteria for case management are agreed upon, which can then be used to monitor practice and determine if standards of care have been met.8 As the data are analysed at an aggregate level, the patterns of deficiencies in care as well as opportunities for improvement are easier to observe. Since their publication, the WHO maternal near-miss criteria and the audit tool have been applied in over 30 countries.9–13 Furthermore, a maternal severity index has been developed to estimate the probability of mortality among women with complications related to pregnancy.14 It facilitates an objective assessment, comparison and tracking of health facility performance by enabling a benchmark approach to quality of care of women experiencing severe complications related to pregnancy.14 Using an estimation of the overall severity associated with a population, for example the population served by a facility, the maternal severity index provides an estimate of the risk of mortality for this population.9 Overall, maternal death and near-miss audits generate valuable information, but this is not enough to create and sustain a change in clinical practice. To ‘activate’ the information, a systems approach for surveillance and response is advised, because not all of the roadblocks identified will be related to clinical management. Also demonstrated by the maternal death surveillance and response framework, the surveillance component through prospective identification of severe morbidity cases is responsible for the generation of actionable information that effectively guides immediate and longer-term actions.15 Compared with clinical audits focusing on maternal mortality, there are various advantages associated with near-miss audits. They are more likely to function as a positive entry point for critical assessment and subsequent behaviour change as health professionals are more open to discuss failures and successes during care, and what made these women survive and not become a maternal death. It also allows direct interviews with survivors providing an important and complementary perspective on how the care has been accessed, received and perceived including aspects of respectful care.5 Implementing prospective surveillance also contributes to establishing an institutional culture of emergency preparedness, which is potentiated by training and emergency drills. The response component engages and promotes the interaction within multiple health service and health system building blocks, including the governance, information systems, finances, supplies, health services and human resources.16 This is why it is essential that various key
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stakeholders are involved along with the different cadres of health professionals and sentinel units in the health service, such as in the emergency rooms, intensive care units or blood banks.5 Prioritising avoidable factors identified in the situation analysis and using evidence-based approaches will make the response more effective. Overall, the ‘blame and shame’ attitude should be avoided while conducting maternal death and maternal near-miss reviews because it erodes institutional cooperation and intrinsic motivation of health professionals. Identifying locally relevant process and outcome indicators (e.g. coverage of women with pre-eclampsia who received magnesium sulphate, the ratio between maternal near-miss cases and maternal deaths), establishing targets, and making this information publicly available through transparent mechanisms is a powerful strategy to motivate institutions to seek quality care improvement and promote social participation in a continuous manner.
Conclusions As a tool to improve quality of care in facilities, tracking and evaluating the care provided to maternal near-miss cases has the potential to function as a catalyst for both improving women’s delivery experiences and outcomes and strengthening the health systems. As countries progress through the stages of obstetric transition,17 maternal mortality decreases and women increasingly deliver in facilities, it is paramount to ensure that facilities and health systems have the tools to measure and improve quality of care. Furthermore, accurate and routine measurement of the spectrum of maternal morbidity is necessary to inform policy and programme decisions to further reduce maternal mortality and morbidity.18
Disclosure of interests We have nothing to declare.
Contribution to authorship OT and JPS wrote and finalised the article.
Details of ethics approval No ethics approval was required.
Funding No funding was received.
Acknowledgements We would like to thank Dr Metin G€ ulmezoglu and Dr Lale Say for their feedback on earlier versions of the article. &
104
References 1 Bruce J. Fundamental elements of the quality of care: a simple framework. Stud Fam Plann 1990;21:61–91. 2 Hulton L, Matthews Z, Stones W. A Framework for Evaluation of Quality of Care in Maternity Services. Southampton, UK: University of Southampton, 2000. 3 Tuncalp O, Hindin MJ, Souza JP, Chou D, Say L. The prevalence of maternal near miss: a systematic review. BJOG 2012;119:653–61. 4 Say L, Souza JP, Pattinson RC. Maternal near miss—towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009;23:287–96. 5 World Health Organization. Evaluating the Quality of Care for Severe Pregnancy Complications: the WHO Near-Miss Approach for Maternal Health. Geneva, Switzerland: WHO, 2011. 6 Souza JP, Say L, Gulmezoglu M. Practical criteria for maternal near miss needed for low-income settings—Authors’ reply. Lancet 2013;382:505. 7 Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012;(6):CD000259. 8 Graham W, Wagaarachchi P, Penney G, McCaw-Binns A, Antwi KY, Hall MH. Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries. Bull WHO 2000;78:614–20. 9 Souza JP, Gulmezoglu AM, Vogel J, Carroli G, Lumbiganon P, Qureshi Z, et al. Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. Lancet 2013;381:1747–55. 10 van den Akker T, Beltman J, Leyten J, Mwagomba B, Meguid T, Stekelenburg J, et al. The WHO maternal near miss approach: consequences at Malawian District level. PLoS One 2013;8:e54805. 11 Tuncalp O, Hindin MJ, Adu-Bonsaffoh K, Adanu RM. Assessment of maternal near-miss and quality of care in a hospital-based study in Accra, Ghana. Int J Gynaecol Obstet 2013;123:58–63. 12 Nelissen E, Mduma E, Broerse J, Ersdal H, Evjen-Olsen B, van Roosmalen J, et al. Applicability of the WHO maternal near miss criteria in a low-resource setting. PLoS One 2013;8:e61248. 13 Jabir M, Abdul-Salam I, Suheil DM, Al-Hilli W, Abul-Hassan S, Al-Zuheiri A, et al. Maternal near miss and quality of maternal health care in Baghdad, Iraq. BMC Pregnancy Childbirth 2013;13:11. 14 Souza JP, Cecatti JG, Haddad SM, Parpinelli MA, Costa ML, Katz L, et al. The WHO maternal near-miss approach and the maternal severity index model (MSI): tools for assessing the management of severe maternal morbidity. PLoS One 2012;7:e44129. 15 World Health Organization. Maternal Death Surveillance Response Technical Guidance: information for Action to Prevent Maternal Death. Geneva, Switzerland: World Health Organization, 2013. 16 World Health Organization. Systems Thinking for Health System Strengthening. Geneva, Switzerland: World Health Organization, 2009. 17 Souza JP, Tuncalp O, Vogel JP, Bohren M, Widmer M, Oladapo O, et al. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG 2014;121(suppl.): 1–4. 18 Firoz T, Chou D, von Dadelszen P, Agrawal P, Vanderkruik R, Tuncalp O, et al. Measuring maternal health: focus on maternal morbidity. Bull WHO 2013;91:794–6.
ª 2014 Royal College of Obstetricians and Gynaecologists
