Background
Methods
Researcher | Research assistant (I) | Research assistant (II) | Participants (Healthcare workers) | Participants (Families) | |
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Job title | Research fellow | Nurse Midwife Technician (NMT) | Research nurse | NMTs, clinical officers, matrons, RNs, NM | Unemployed, farmers, small business owners, and a teacher |
Gender | Female | Female | Male | Mixed | Mixed |
Age | 40 | 39 | 33 | Range: 24 - 47 | Range: 23 – 60+ |
Marital status | Married | Married | Married | Mixed | Mixed |
No. of children | 2 | 2 | 2 | ? | ? |
No. of years of education | 20+ | 15 | 15 | Range: 15-17 | Range: 3-16 |
Economic status | Non-poor | Non-poor | Non-poor | Non-poor | Mostly Poor |
Religious affiliation | Christian (Baptist/Lutheran) | Christian (Catholic) | Muslim | Mixed | Mixed |
Nationality | American (African descent) | Malawian | Malawian | Malawian + 1 Burundian | Malawian |
Research experience | Some experience working with research assts | Some experience as research asst/interpreter | Very experienced as research asst/interpreter | Range of experience as research participants | No experience participating in research |
Results
Identification of maternal death cases
Data collection
Chart review/extraction
Facility-based interviews
Community-based interviews
Family members
Traditional birth attendants
Language barrier
Reviewing cases and analyzing data
Case | Facility classification | Independent reviewers | ICD-10 code and comments |
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Cause of death | |||
01
| Cardiac arrest, Malaria & Anemia | Disagree | O99.0; O98.6; O99.4-I50.9 Protozoal diseases (Malaria) complicating pregnancy, childbirth and the puerperium; Anemia complicating pregnancy, childbirth and the puerperium; Diseases of the circulatory system complicating pregnancy, childbirth and the puerperium – Heart failure unspecified. |
Malaria is the cause of the woman’s severe anemia. Her cardiac arrest is her mode of death.
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02
| Valvular heart disease | Disagree | O99.4-I50.9 (O13 cofactor) Diseases of the circulatory system complicating pregnancy, childbirth and the puerperium – Heart failure unspecified (Gestational [pregnancy-induced] hypertension without significant proteinuria). |
Valvular heart disease is a very likely cause of heart failure in settings where late complications following rheumatic fever in childhood are commonplace. However, I simply question the validity of this diagnosis in this specific case. The findings available in the notes demonstrate high blood pressure and heart failure. The cardiac lesion may have been congenital. This is an example of where a common cause is inferred but not confirmed, but believed because, as it is said in medicine, “common is common”.
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03
| Puerperal sepsis | Agree | O85 Puerperal Sepsis |
04
| Peritonitis postpartum | Disagree | O85; O73.1 Puerperal sepsis; Retained portions of placenta and membranes, without hemorrhage |
The woman has a form of puerperal sepsis as is suggested by the clinicians. In the notes it seems evident that a contributing factor to the development of this disease process was the presence of retained products of conception.
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05
| Pre-eclampsia | Disagree | O85; O73.1 Obstetric blood-clot embolism; Pulmonary edema; Severe pre-eclampsia |
The woman develops severe respiratory distress and dies. She has pre-eclampsia. Two causes are possible that can arise as a result of pre-eclampsia. The first is a thrombotic pulmonary embolism. The second would be severe pulmonary edema. Both of these conditions may give rise to her clinical presentation. An autopsy would be able to discern between the two possible causes.
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06
| Renal failure due to puerperal sepsis | Disagree | O90.4; O85 Postpartum acute renal failure: Puerperal sepsis. |
The woman developed renal failure following delivery. She also developed puerperal sepsis. The renal failure is likely to be secondary to the development of sepsis, but the two conditions may be coincidental. The renal failure may have a separate, unknown cause. The mode of death is a failure of the woman’s kidneys to function. The cause is likely to be septicemia.
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07
| Lactic acidosis (HIV-related) | Disagree | O98.7; B20.9 HIV disease complicating pregnancy, childbirth and the puerperium; HIV disease resulting in unspecified infectious or parasitic disease. |
Lactic acidosis is a physiological state leading to, but not a cause of, death. The woman was sick and was HIV positive. I am inferring that the patient died of complications arising from AIDS.
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08
| Cryptococcal meningitis | Disagree | O98.8; B45.1; O98.7 Other maternal infectious and parasitic diseases complicating pregnancy, childbirth and the puerperium; Cerebral cryptococcosis; HIV disease complicating pregnancy, childbirth and the puerperium. |
Cryptococcal meningitis is a very serious and common cause of meningitis in people who are HIV positive. However, it must be noted that even though the woman was meningitic and HIV positive, the diagnosis of Cryptococcus is not confirmed by lumbar puncture. The causative organism may have been one other than Cryptococcus.
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09
| Heart failure pulmonary embolism | Disagree | O88.2; O99.4-I50.9 Obstetric blood-clot embolism; Diseases of the circulatory system complicating pregnancy, childbirth and the puerperium – Heart failure unspecified |
The most likely predisposing factor for an otherwise fit and healthy woman who develops a pulmonary embolism is thrombosis secondary to pregnancy.
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10
| Hypoxia, eclampsia | Disagree | O15 Eclampsia inn pregnancy. |
The cause of this woman’s death was eclamptic seizures. Her mode of death was lack of oxygen (hypoxia).
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11
| Concealed ruptured uterus due to obstructed labor | Disagree | O66.9 Obstructed labor, unspecified. |
Ruptured uterus is a complication of obstructed labor in a parous uterus. It is not always complicated by profound bleeding. The hemorrhage is the mode. Obstructed labor is the cause.
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12
| PPH | Agree | O72 Postpartum hemorrhage. |
13
| Intrapartum hemorrhage due to ruptured uterus | Disagree | O67.9; O71.1; O34.2 Intrapartum hemorrhage, unspecified; Rupture of uterus during labor; Maternal care due to uterine scar from previous surgery. |
For a uterus to rupture in the presence of a previous scar the labor does not necessarily need to be obstructed. If anemia arises as a result of rupture then it is secondary to a hemorrhage that is perhaps a little less profound, but just as lethal as the last case.
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14
| Valvular heart disease - stenosis | Disagree | O99.4; I50.9 Diseases of the circulatory system complicating pregnancy, childbirth and the puerperium – Heart failure unspecified. |
As in case no. 2, the cardiac lesion is assumed to be valvular stenosis. I do not doubt this condition as it is not an uncommon cardiac condition in Malawi. It will lead to congestive cardiac failure (more mode than cause). However, I felt that the diagnosis given was lacking confirmation in the details provided and was therefore assumed to be inferred.
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15
| PPH | Agree | O72 Postpartum hemorrhage. |
16
| Hypovolemic shock | Disagree | O72 Postpartum hemorrhage. |
Can arise from septicemia, and it can arise from exsanguinations. To me, the details available were most suggestive of shock (mode) secondary to a profound blood loss (cause). PPH
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17
| Hypoxia and severe pneumonia | Disagree | O99.4-I50.9; O99.0 Diseases of the circulatory system complicating pregnancy, childbirth and the puerperium – Heart failure unspecified; Anemia complicating pregnancy, childbirth and the puerperium. |
The patient was severely anemic. This will result in high output cardiac failure and respiratory distress. The terminal symptoms can mimic those of a patient presenting with severe pneumonia. However, I was not there. My opinion is based on the details presented.
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18
| PPH | Agree | O72 Postpartum hemorrhage. |
19
| Bacterial meningitis/severe malaria | Disagree | O98.6; Assumed B50.0 Protozoal diseases (Malaria) complicating pregnancy; Assumed Plasmodium falciparum malaria with cerebral complications. The woman was in a coma and had malaria. She may have had cerebral malaria. Bacterial meningitis was never confirmed by lumbar puncture.
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20
| Severe anemia | Disagree | O99.4-I50.9; O99.0 Diseases of the circulatory system complicating pregnancy, childbirth and the puerperium – Heart failure unspecified; Anemia complicating pregnancy, childbirth and the puerperium. |
Anemia (cause) resulting in circulatory collapse (mode).
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21
| Severe anemia | Disagree | O72; O99.0 Postpartum hemorrhage; Anemia complicating pregnancy, childbirth and the puerperium. |
Two causes. Neither were necessarily lethal enough alone, only in combination.
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22
| Peritonitis postpartum | Disagree | O85; O86.0 Puerperal sepsis; Infection of obstetric surgical wound (C-section). |
The woman had a puerperal sepsis, however it is important to highlight the fact that she underwent surgery prior to developing overt signs of infection. The surgery may be only coincidental. However, the details of this case suggest that the surgery was contributory to the development of lethal infection.
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23
| Hepatic failure | Disagree | O90.4 Hepatorenal syndrome following labor and delivery |
Hepatorenal failure is a specific ICD-10 code. There may be differing etiologies. In the absence of pre-existing liver or renal dysfunction one assumes that the cause of this organ failure was pregnancy-related. An example of this would be Acute fatty liver of pregnancy (AFLP).
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24
| Eclampsia | Agree | O15.0 Eclampsia in pregnancy. |
25
| Anemia | Agree | O99.0 Anemia complicating pregnancy, childbirth and the puerperium. |
26
| Anemia | Disagree | O99.0; O98.7 Anemia complicating pregnancy, childbirth and the puerperium; HIV disease complicating pregnancy, childbirth and the puerperium Anemia is a cause. The woman’s constitution was weakened as a result of her HIV infection which therefore contributory to the anemia, thus resulting in death.
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27
| PPH | Disagree | O72; O45.9 Postpartum hemorrhage; Premature separation of placenta, unspecified. |
The history sounds typical of a grade 3 abruption of the placenta. If coagulopathy results then this will in turn result in deadly hemorrhage if large transfusion of blood products is not performed immediately.
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28
| Hypovolemic shock | Disagree | O03.5 Spontaneous abortion - complete or unspecified, complicated by genital tract and pelvic infection. |
The woman presented with an incomplete miscarriage with signs of infection (cause). This resulted in hypovolemic shock and subsequent death (mode). The question is whether the miscarriage was spontaneous or procured.
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29
| Septicemia post delivery | Disagree | O85; O98.7; O98.6 Puerperal sepsis; HIV disease complicating pregnancy, childbirth and the puerperium; Protozoal diseases (Malaria) complicating pregnancy. |
Malaria was the working diagnosis presented in the details of the case, in a woman whose constitution is weakened by HIV. Other sources for infection are not forthcoming in the details, but that does not mean that they were not present.
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30
| Lactic acidosis (HIV-related) | Disagree | O98.6; O99.0 Protozoal diseases (Malaria) complicating pregnancy; Anemia complicating pregnancy, childbirth and the puerperium. |
Lactic acidosis is a physiological state that, if profound, can lead to death (mode). The details of the case highlight both malaria and coincidental or subsequent anemia.
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31
| Sepsis and induced abortion | Agree | O07.8 Failed attempt abortion with other and unspecified complications. |
32
| Cardiac arrest, severe pre-eclampsia | Disagree | Her cardiac arrest was her mode of death. (Unfortunately for this case, the comments have been lost)
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Synthesis of analyzed data
Recommendations
Evaluation
Discussion
Step in maternal death surveillance cycle | Implications for health facility |
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1. Identification of cases | Develop policy (or enforce existing policy) that all maternal cases within the hospital be reported to a designated unit (possibly the clerk’s office of the maternity unit?). |
Someone from the maternity unit should be designated to routinely (e.g. weekly or biweekly) visit (or call) all the possible departments where a woman of reproductive age may receive care and inquire about deaths and determine pregnancy status and cross check maternal death case numbers. | |
2. Data collection | Standard case note taking and medical record maintenance/storage should be enforced. Remedial training and sensitization on the importance of good record keeping practices should be provided. Systematic case-note audits should be regularly conducted. Additional funding from the Ministry of Health and appropriate collaborative partners should be provided to sustain and institutionalize good record keeping practices. |
Coordinate with the safe motherhood program (or designated community health personnel) so they can follow up with cases in the community. | |
3. Data analysis | Basic and advanced courses/training in ICD-10 coding, cause of death certification should be provided for appropriate healthcare personnel. |
Medical doctor or medical officer should facilitate maternal death audits. | |
Feedback loop to all appropriate healthcare staff, especially to those who were involved with caring for the patient in question. | |
4. Recommendations | Healthcare personnel formulate recommendations with senior staff. |
Additional funding from the Ministry of Health and appropriate collaborative partners should be provided to implement the recommendations. | |
Senior staff should take lead and ensure recommendations are implemented. | |
5. Evaluation | Indicators should be formulated and agreed upon by healthcare personnel and senior management. Routine evaluation conducted accordingly. |