Maternal near-miss and death among women with postpartum haemorrhage: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey

Abstract

Objective: To investigate the burden and health service events surrounding severe maternal outcomes (SMO) related to life-threatening postpartum haemorrhage (PPH) in Nigerian public tertiary hospitals.

Design: Secondary analysis of a nationwide cross-sectional study.

Setting: Forty-two tertiary hospitals.

Population: Women admitted for pregnancy, childbirth or puerperal complications.

Methods: All cases of SMO [maternal near miss (MNM) or maternal death (MD)] due to PPH were prospectively identified using WHO criteria over a 1-year period.

Main outcome measures: Incidence of SMO, health service events, case fatality rate (CFR) and mortality index (MI: % of death/SMO).

Results: Postpartum haemorrhage occurred in 2087 (2.2%) of the 94 835 deliveries recorded during the study period. A total of 354 (0.3%) women had an SMO (103 MD; 251 MNM). It was the most frequent obstetric haemorrhagic complication across hospitals. PPH had the highest maternal mortality ratio (112/100 000 live births) and the recorded MI (29.1%) and CFR (4.9%) were second only to that of ruptured uterus. About 83% of women with SMO were admitted in a critical condition with over 50% being referred. MD was more likely when PPH led to neurological (80.8%), renal (73.5%) or respiratory (58.7%) organ dysfunction. Although the timing of life-saving interventions was not statistically different between the cases of MD and MNM, close to one-quarter of women who died received critical intervention at least 4 hours after diagnosis of life-threatening PPH.

Conclusions: Postpartum haemorrhage was a significant contributor to obstetric haemorrhage and SMO in Nigerian hospitals. Emergency obstetric services should be enhanced at the lower levels of healthcare delivery to reduce avoidable deaths from PPH.

Funding: The original research that generated the data for this secondary analysis, and the publication of this secondary analysis, was funded by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization. We have no other funding issue to declare for our study.

Tweetable abstract: One hundred and three maternal deaths and 251 near-misses resulted from PPH in 42 Nigerian tertiary facilities in 1 year.

Keywords: Maternal death; maternal near-miss; obstetric haemorrhage; postpartum haemorrhage; severe maternal outcome.