Trends in maternal mortality in Suriname: 3 confidential enquiries in 3 decades.

BACKGROUND: The Sustainable Development Goal target 3.1 aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births. Great disparities reported in maternal mortality ratio between and within countries make this target unachievable. To gain more insight into such disparities and to monitor and describe trends, confidential enquiries into maternal deaths are crucial. OBJECTIVE: We aimed to study the trend in maternal mortality ratio, causes, delay in access and quality of care, and "lessons learned" in Suriname, over almost 3 decades with 3 confidential enquiries into maternal deaths and provide recommendations to prevent maternal deaths. STUDY DESIGN: The third national confidential enquiry into maternal deaths was conducted between 2015 and 2019 in Suriname by prospective, population-based surveillance and multidisciplinary systematic maternal death review. Subsequently, a comparative analysis with previous confidential enquiry into maternal deaths was performed: confidential enquiry into maternal deaths I (a prospective study, 1991-1993) and confidential enquiry into maternal deaths II (a retrospective study, 2010-2014). RESULTS: We identified 62 maternal deaths and recorded 48,881 live births (maternal mortality ratio, 127/100,000 live births) between 2015-2019. Of the women who died, 14 of 62 (23%) were in poor condition when entering a health facility, whereas 11 of 62 (18%) died at home or during transportation. The maternal mortality ratio decreased over the years, (226 [n=64]; 130 [n=65]; and 127 [n=62]), with underreporting rates of 62%, 26%, and 24%, respectively in confidential enquiry into maternal deaths I, II and III. Of the women deceased, 36 (56%), 37 (57%), and 40 (63%) were of African descent; 46 (72%), 45 (69%), and 47 (76%) died after birth; and 47 (73%), 55 (84%), and 48 (77%) died in the hospital, respectively, in confidential enquiries into maternal deaths I, II, and III. Significantly more women were uninsured in confidential enquiry into maternal deaths III (15 of 59 [25%,]) than in confidential enquiry into maternal deaths II (0%) and I (6 of 64 [9%]). Obstetrical hemorrhage was less often the underlying cause of death over the years (19 of 64 [30%], vs 13 of 65 [20%], vs 7 of 62 [11%]), whereas all other obstetrical causes occurred more often in confidential enquiry into maternal deaths III (eg, suicide [0; 1 of 65 (2%); 5 of 62 (8%)]) and unspecified deaths (1 of 64 [2%]; 3 of 65 [5%]; and 11 of 62 [18%] in confidential enquiry into maternal deaths I, II and III respectively). Maternal deaths were preventable in nearly half of the cases in confidential enquiry into maternal deaths II (28 of 65) and III (29 of 62). Delay in quality of care occurred in at least two-thirds of cases (41 of 62 [65%], 47 of 59 [80%], and 47 of 61 [77%]) over the years. CONCLUSION: Suriname's maternal mortality rate has decreased throughout the past 3 decades, yet the trend is too slow to achieve the Sustainable Development Goal 3.1. Preventable maternal deaths can be reduced by ensuring high-quality facility-based obstetrical and postpartum care, universal access to care especially for vulnerable women (of African descent and low socioeconomic class), and by addressing specific underlying causes of maternal deaths.

Applicability of the WHO maternal near-miss tool: A nationwide surveillance study in Suriname.

BACKGROUND: Maternal near-miss (MNM) is an important maternal health quality-of-care indicator. To facilitate comparison between countries, the World Health Organization (WHO) developed the "MNM-tool". However, several low- and middle-income countries have proposed adaptations to prevent underreporting, ie, Namibian and Sub-Sahara African (SSA)-criteria. This study aims to assess MNM and associated factors in middle-income country Suriname by applying the three different MNM tools. METHODS: A nationwide prospective population-based cohort study was conducted using the Suriname Obstetric Surveillance System (SurOSS). We included women with MNM-criteria defined by WHO-, Namibian- and SSA-tools during one year (March 2017-February 2018) and used hospital births (86% of total) as a reference group. RESULTS: There were 9114 hospital live births in Suriname in the one-year study period. SurOSS identified 71 women with WHO-MNM (8/1000 live births, mortality-index 12%), 118 with Namibian-MNM (13/1000 live births, mortality-index 8%), and 242 with SSA-MNM (27/1000 live births, mortality-index 4%). Namibian- and SSA-tools identified all women with WHO-criteria. Blood transfusion thresholds and eclampsia explained the majority of differences in MNM prevalence. Eclampsia was not considered a WHO-MNM in 80% (n = 35/44) of cases. Nevertheless, mortality-index for MNM with hypertensive disorders was 17% and the most frequent underlying cause of maternal deaths (n = 4/10, 40%) and MNM (n = 24/71, 34%). Women of advanced age and maroon ethnicity had twice the odds of WHO-MNM (respectively adjusted odds ratio (aOR) = 2.6, 95% confidence interval (CI) = 1.4-4.8 and aOR = 2.0, 95% CI = 1.2-3.6). The stillbirths rate among women with WHO-MNM was 193/1000births, with six times higher odds than women without MNM (aOR = 6.8, 95%CI = 3.0-15.8). While the prevalence and mortality-index differ between the three MNM tools, the underlying causes of and factors associated with MNM were comparable. CONCLUSIONS: The MNM ratio in Suriname is comparable to other countries in the region. The WHO-tool underestimates the prevalence of MNM (high mortality-index), while the adapted tools may overestimate MNM and compromise global comparability. Contextualized MNM-criteria per obstetric transition stage may improve comparability and reduce underreporting. While MNM studies facilitate international comparison, audit will remain necessary to identify shortfalls in quality-of-care and improve maternal outcomes.

Why magnesium sulfate 'coverage' only is not enough to reduce eclampsia: Lessons learned in a middle-income country.

OBJECTIVES: Determine the eclampsia prevalence and factors associated with eclampsia and recurrent seizures in Suriname and evaluate quality-of-care indicator 'magnesium sulfate (MgSO4) coverage'. STUDY DESIGN: A two-year prospective nationwide cohort study was conducted in Suriname and included women with eclampsia at home or in a healthcare facility. MAIN OUTCOME MEASURES: We calculated the prevalence by the number of live births obtained from vital registration. Risk factor denominator data concerned hospital births. Descriptive statistics and multivariate regression analysis were performed. RESULTS: Seventy-two women with eclampsia (37/10.000 live births) were identified, including two maternal deaths (case-fatality 2.8%). Nulliparity, African-descent and adolescence were associated with eclampsia. Adolescents with eclampsia had significantly lower BPs (150/100 mmHg) than adult women (168/105 mmHg). The first seizure occurred antepartum in 54% (n = 39/72), intrapartum in 19% (n = 14/72) and postpartum in 26% (n = 19/72). Recurrent seizures were observed in 60% (n = 43/72). MgSO4 was administered to 99% (n = 69/70) of women; however 26% received no loading dosage and, in 22% of cases MgSO4 duration was <24 h, i.e. guideline adherence existed in only 43%. MgSO4 was ceased during CS in all women (n = 40). Stable BP was achieved before CS in 46%. The median seizure-to-delivery interval was 27 h, and ranged from four to 36 h. CONCLUSION: Solely 'MgSO4 coverage' is not a reliable quality-of-care indicator, as it conceals inadequate MgSO4 dosage and timing, discontinuation during CS, stabilization before delivery, and seizure-to-delivery interval. These other quality-of-care indicators need attention from the international community in order to reduce the prevalence of eclampsia.