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What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! Recommended%citation:%% ten!Hoope!Bender,!P.,!Speciale,!A.M,!Guerra!Arias,!M.,!and!Campbell,!J.!(2013).!What%is%the%evidence% on%the%number%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist% care?%A%rapid%literature%review.!!ICS!Integrare,!Barcelona.!January!2013.!! ! Prepared!for!the!World!Health!Organization!(WHO),!Geneva,!Switzerland.!! ! Contributors:% % Petra%ten%Hoope%Bender!is!the!Director!for!Reproductive,!Maternal!and!Newborn!Child!Health!at!ICS! Integrare.! ! She! is! a! midwife! and! executive! manager! with! 20! years! of! experience! in! midwifery! and! management!of!organisations!in!the!international!health!arena.! ! Anna%Maria%Speciale!is!a!Research!Associate!at!ICS!Integrare.!!She!is!a!midwife!and!researcher!with! 10! years! experience! in! international! health! since! completing! Yale! University’s! graduate! Midwifery! program.!She!also!holds!postgraduate!degrees!in!Epidemiology!and!Population!Studies.! ! Maria% Guerra% Arias! is! a! Research! Associate! at! ICS! Integrare.! ! She! holds! a! MPhil! in! Development! Studies!from!the!University!of!Cambridge.!! % Jim% Campbell,! is! the! Director! of! ICS! Integrare.! He! was! a! coUauthor! of! the! State! of! the! World's! Midwifery!report!in!2011,!works!extensively!in!the!field!of!Human!Resources!for!Health!with!research! interests! in! urban/rural! and! socioUeconomic! inequities! in! access! to! health! services.! Jim! holds! postgraduate!degrees!in!Public!Health!and!Development!Administration!and!is!preparing!his!doctoral! thesis!on!evidenceUbased!decisionUmaking!on!human!resources!for!maternal!and!newborn!health.!! !! % Acknowledgements:! ! Our! appreciation! is! extended! to! Hannah! Wood,! Information! Specialist! and! Julie! Glanville,! Project! Director! (Information! Services)! at! York! Health! Economics! Consortium,! for! their! support! in! the! development!of!the!search!strategy.!!! ! We! also! thank! the! participants! of! the! WHO! Global! Consultation! on! Producing! and! Developing! an! Appropriate!Midwifery!Workforce!for!Low!and!Middle!Income!Countries,!held!in!Geneva!Switzerland,! December!4U6,!2012!for!their!invaluable!contributions!and!feedback!on!the!initial!findings.! ! Prof.!Paul!van!Look!conducted!the!external,!peerUreview.!!

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What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! ! Table%of%Contents% !

1! Summary%.....................................................................................................................%3! 2! Introduction%.................................................................................................................%5! 2.1!Rationale!...........................................................................................................................................!5! 2.2!Objective!...........................................................................................................................................!9! 3! Methods%......................................................................................................................%9! 3.1!Eligibility!criteria!...............................................................................................................................!9! 3.2!Information!sources!..........................................................................................................................!9! 3.3!Search!strategy!...............................................................................................................................!10! 3.4!Study!selection!................................................................................................................................!10! 3.5!Data!collection!process!...................................................................................................................!10! 3.6!Data!items!.......................................................................................................................................!11! 3.7!Risk!of!bias!in!individual!studies!.....................................................................................................!11! 3.8!Summary!measures/!Synthesis!of!results!.......................................................................................!11! 3.9!Risk!of!bias!across!studies!...............................................................................................................!11! 4! Results%........................................................................................................................%12! 4.1!Study!selection!................................................................................................................................!12! 4.2!Study!characteristics!.......................................................................................................................!13! 4.3!Risk!of!bias!within!studies!...............................................................................................................!14! 4.4!Results!of!individual!studies!...........................................................................................................!14! 4.5!Synthesis!of!results!.........................................................................................................................!18! 5! Discussion%...................................................................................................................%18! 5.1!Summary!of!evidence!.....................................................................................................................!18! 5.2!Limitations!......................................................................................................................................!20! 5.3!Issues!arising!...................................................................................................................................!20! 6! Conclusions%.................................................................................................................%22! 6.1!Next!steps!.......................................................................................................................................!22! 7! Funding%.......................................................................................................................%23! 8! Annexes%......................................................................................................................%24! Annex!1.!Conceptual!graphic!of!emergency!complications!..................................................................!24! Annex!2.!Search!strategy!!.....................................................................................................................!25! Annex!3.!!Extraction!tool!......................................................................................................................!29! Annex!4.!Extraction!process!..................................................................................................................!30! Annex!5.!Summary!characteristics!of!studies!.......................................................................................!31! Annex!6!Bibliography!of!articles!retrieved!for!evaluation!....................................................................!44! ! !

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What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! ! 1

Summary%

! Objective:! To! summarise! the! evidence! from! articles! published! in! peerUreviewed! journals! on! the! estimated! proportion! of! pregnancies! that! give! rise! to! obstetric! complications,! in! order! to! inform! benchmarks!for!maternal!and!newborn!health!(MNH)!policy!and!programming.! ! Methods:! A! rapid! literature! review! was! conducted,! searching! for! relevant! studies! published! during! the!10Uyear!period!since!2002.!Articles!obtained!from!the!search!and!subsequent!screening!process! were! reviewed! using! a! preUdefined! extraction! tool.! The! tool! focused! on! obstetric! complications! as! defined! by! UNFPA/WHO/UNICEF:! haemorrhage! (antepartum! or! postpartum);! prolonged! or! obstructed! labour;! postpartum! sepsis;! complications! of! abortion;! preUeclampsia/eclampsia;! ectopic! pregnancy;!and!ruptured!uterus.!! ! Results:! ! 53! studies! were! included! in! the! final! analysis,! with! 42! providing! data! on! at! least! 1! of! the! UNFPA/WHO/UNICEF! recognized! obstetric! complications.! The! results! indicate! that! the! more! prevalent! obstetric! complications! show! greater! variation;! there! is! less! variation! for! complications! that! are! rarer.! Excluding! highest! and! lowest! values,! articles! relating! to! postpartum! sepsis! yielded! a! range!of!prevalence/incidence1!of!0.5U1.1!per!1000!deliveries,!eclampsia!1U9!per!1000!deliveries!and! ruptured!uterus!0.1U7!per!1000!deliveries.!Ranges!for!hypertensive!disorders!were!much!greater!(4.3U 97,!mean!39.9!per!1000!deliveries).!Prolonged/obstructed!labour!findings!varied!from!19U78!per!1000! deliveries,! mean! 45.5/1000! deliveries.! Means! for! rates! of! haemorrhage! per! 1000! deliveries! also! varied! across! three! classifications! of! antepartum,! postpartum! and! general! haemorrhage.! Greater! consistency! was! found! across! studies! that! differentiated! between! antepartum! (mean! 32.8/1000! deliveries,! range! 16.0U50.0/1000! deliveries)! and! postpartum! haemorrhage! (mean! 36.8/1000! deliveries,!range!20.0.0U67.0/1000!deliveries).!! ! Discussion:!The!retrieved!articles!were!not!greatly!comparable!in!the!chosen!obstetric!complications,! leading! to! a! number! of! issues! in! trying! to! appreciate! potential! incidence/prevalence! trends! across! studies!that!might!lend!themselves!to!the!creation!of!global!estimates.!Few!published!studies!were! conducted! with! the! intention! to! provide! globally! applicable! data! on! the! prevalence/incidence! of! obstetric! complications;! studies! focus! exclusively! on! facility! deliveries! –! even! in! regions/countries! where!the!majority!of!births!take!place!outside!facilities;!the!lack!of!uniformity!in!diagnostic!criteria! for! identifying! and! classifying! obstetric! complications! constitutes! an! important! technical! complication;!prevalence!and!incidence!are!used!interchangeably,!and!at!times!inconsistently,!across! studies;! and,! certain! complications! were! more! commonly! studied! than! others.! The! exclusive! consideration! of! published,! peerUreviewed! articles! with! predominant! focus! on! facility! deliveries! almost!certainly!does!not!provide!an!accurate!reflection!of!the!rates!at!which!obstetric!complications! are! occurring! throughout! the! world! and! across! settings.! Publications! tend! to! evaluate! limited! populations!in!specific!settings;!they!are!rarely!populationUbased!and!more!commonly!facilityUbased.! The! complexity! of! obstetric! complications! adds! further! to! the! complexity! of! studying! this! subject.!! Obstetric! complications! are! often! the! result! of! multiple! and! dynamic! factors,! such! as! preUexisting! health,! age! and! obstetric! risk! combined! with! key! social! and! societal! components! such! as! lifeUstyle! and!habits,!socioUeconomic!status,!careUseeking!behaviours!and!access!to!timely!and!effective!care.!! The! intricate! interconnections! between! these! factors! raise! the! ! question! whether! a! uniform! benchmark! for! human! resource! planning! of! the! needed! workforce! with! obstetric! skills! is! both! feasible!and!appropriate.!!Creating!a!universal!benchmark!for!the!productive!capacity!of!the!obstetric! healthUworkforce!based!on!the!global!prevalence!of!obstetric!complications!may!ignore!the!multiple! variables!that!impact!this!metric.! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 1

!As!both!incidence!and!prevalence!are!addressed!across!the!body!of!literatura!included!in!the!review!the!phrasing! “incidence/prevalence�!is!used.!

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What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! ! Conclusions:! We! conclude! that! there! is! a! continued! lack! of! empirical! evidence! to! support! the! discussion! on! the! incidence! of! obstetric! complications.! This! impedes! the! current! work! on! health! systems!and!human!resources!benchmarking.!Further!discussion!is!needed!on!whether!and!how!to! adjust! these! gaps! in! knowledge! to! usefully! inform! the! next! steps! in! benchmark! development,! or! whether! to! accept! the! limitations! and! work! on! both! topUdown! and! bottomUup! workforce! planning! models!for!a!‘typical’!district!population.!!A!uniform!method!for!reporting!on!obstetric!complications! would! allow! for! better! estimates! of! prevalence/incidence! and! MNH! workforce! requirements.!

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What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! !

%

2

Introduction%

2.1%Rationale% The! World! Health! Organization! (WHO)! is! currently! reviewing! the! benchmarks! that! are! utilized! for! policy!and!planning!of!maternal!and!newborn!health!(MNH)!services.!One!of!the!benchmarks!flagged! for! review! is! the! number/frequency! of! pregnancies/live! births! that! give! rise! to! obstetric! complications.!% ! WHO,!UNICEF!and!UNFPA!guidelines!currently!cite!the!benchmark!of!20%!of!pregnancies/15%!of!live! births!for!obstetric!complications.2!!This!figure!is!based!on!sources!from!the!1970s!and!1980s,3,4!and! has!been!questioned.!Critics!argue!that!it!is!not!supported!by!empirical!evidence.!A!WHO!Technical! Working! Group! has! described! it! as! a! “guestimate”! which! is! possibly! underestimating! incidences! of! complications.!5!Pittrof! and! Campbell! (2000)! describe! it! as! having! a! “weak”! empirical! basis!6!and,! similarly,!Ronsmans!et!al.!(2002)!indicate!that!this!figure!has!never!been!empirically!verified.7!! ! To! support! WHO’s! discussions! on! the! validity,! or! otherwise,! of! the! current! benchmark,! a! rapid! literature!review!was!commissioned!by!WHO!to!collate!available!evidence!on!the!metric!and!inform! any!potential!revision.!The!rapid!review!was!conducted!in!the!period!November!2012!–!January!2013! for!reporting!in!February!2013.!Preliminary!findings!were!discussed!at!an!expert!meeting!in!Geneva! on!4!December!2012.! 2.1.1 Defining%‘obstetric%complications’% There!are!several!definitions!of!“obstetric!complications”!in!the!literature.8!This!review!will!use!the! UNFPA/WHO/UNICEF!definition!of!“complicated!cases”!which!includes!the!following!conditions!that! can!arise!during!the!obstetric!period!(which!includes!pregnancy,!birth,!and!the!postpartum!period!or! puerperium):! haemorrhage! (antepartum! or! postpartum);! prolonged! or! obstructed! labour;! postpartum! sepsis;! complications! of! abortion;! preUeclampsia/eclampsia;! ectopic! pregnancy;! and! ruptured!uterus!(see!Table!1).!! ! These! complications! are! all! direct! causes! of! obstetric! death! and! morbidity.! In! addition! to! this,! obstetric! death! and! morbidity! can! also! be! caused! by! indirect! causes,! due! to! existing! medical! conditions!that!are!aggravated!by!pregnancy!or!delivery.9!Some!authors!indicate!that!these!indirect! causes,!such!as!anaemia,!malaria!and!tuberculosis,!should!also!be!a!part!of!the!definition!of!obstetric! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 2

!United!Nations!Population!Fund!(UNFPA),!World!Health!Organization!(WHO)!&!United!Nations!Children’s!Fund!(UNICEF),! 1997.!Guidelines%for%Monitoring%the%Availability%and%Use%of%Obstetric%Services,!New!York:!UNICEF.! 3 !Hartfield,!V.J.,!1980.!Maternal!mortality!in!Nigeria!compared!with!earlier!international!experience.!International%Journal%of% Gynaecology%and%Obstetrics,18:70–75.!Cited!in!!United!Nations!Population!Fund!(UNFPA),!World!Health!Organization! (WHO)!&!United!Nations!Children’s!Fund!(UNICEF),!1997.!Guidelines%for%Monitoring%the%Availability%and%Use%of%Obstetric% Services,!New!York:!UNICEF.! 4 !Hibbard,!L.T.!1978.!Complications!of!Pregnancy!and!Delivery.!In!Current%Obstetric%and%Gynecological%Diagnosis%and% Treatment,!Lange,!ed.!Los!Altos,!Calif.:!R.C.!Benson;!pp.!664U86.!Cited!in!United!Nations!Population!Fund!(UNFPA),!World! Health!Organization!(WHO)!&!United!Nations!Children’s!Fund!(UNICEF),!1997.!Guidelines%for%Monitoring%the%Availability%and% Use%of%Obstetric%Services,!New!York:!UNICEF.! 5 !World!Health!Organization!(WHO),!1999.!Indicators%to%Monitor%Maternal%Health%Goals:%Report%of%a%Technical%Working% Group,!Geneva:!WHO.! 6 !Pittrof,!R.!&!Campbell,!O.,!2000.!Quality%of%Maternity%Care:%Silver%Bullet%or%Red%Herring?!!London:!Maternal!Health! Programme,!Department!of!Infectious!and!Tropical!Diseases,!London!School!of!Hygiene!&!Tropical!Medicine.! 7 !Ronsmans,!C.!et!al.,!2002.!Questioning!the!indicators!of!need!for!obstetric!care.!Bulletin%of%the%World%Health%Organization,! 80(4),!pp.317–24.! 8 !Ronsmans,!C.!et!al.,!2002.!Questioning!the!indicators!of!need!for!obstetric!care.!Bulletin%of%the%World%Health%Organization,! 80(4),!pp.317–24.! 9 !McCarthy,!J.!&!Maine,!D.,!1992.!A!framework!for!analyzing!the!determinants!of!maternal!mortality.!Studies%in%Family% Planning,!23(1),!pp.23–33.!

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What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! complications.10!However,! the! inclusion! of! indirect! causes! lies! beyond! the! scope! of! this! current! review.! % Table%1:%Complications%by%stage%of%the%obstetric%period%% Stage% Antepartum% Antepartum% Antepartum% Antepartum% Intrapartum% Intrapartum% Intrapartum% Intrapartum% Post%partum% Post%partum% Post%partum%

Condition% AP!haemorrhage! PreUeclampsia/!eclampsia! Ectopic!pregnancy! Complications!of!abortion! Prolonged!labour! Obstructed!labour! PreUeclampsia/eclampsia! Ruptured!uterus! Postpartum!haemorrhage! PreUeclampsia/eclampsia! Postpartum!sepsis!

! 2.1.2 Existing%research% Research! to! date! on! the! topic! tends! to! focus! mostly! on! complications! that! are! severe,! lifeU! threatening,! and/or! require! emergency! obstetric! interventions.! Several! different! approaches! have! been!used!to!look!at!this!subset!of!severe!complications,!including!Absolute!Maternal!Indications!and! Severe!Acute!Maternal!Morbidity!(SAMM)!or!“near!misses”.! % Absolute%Maternal%Indications% Various! authors,! including! the! Unmet! Obstetric! Need! (UON)! Network,! use! the! concept! of! Absolute! Maternal! Indications! (AMI).! AMI! are! defined! as! lifeUthreatening! complications! that! have! a! high! likelihood!of!resulting!in!maternal!death!or!permanent!morbidity!unless!the!patient!has!timely!access! to! a! Major! Obstetric! Intervention! (MOI).! 11, 12 , 13 !There! are! several! different! definitions! of! what! constitutes!an!AMI,!with!no!clear!consensus!(see!Table!2!below).14,15!For!further!details!on!AMI!and! MOI,!see!annex!7.!! ! Table%2:%Classifications%of%obstetric%complications% Study% UON%Network,%1999.%Tackling) Unmet)Need)for)Major) Obstetric)Interventions:)Part)1.) Concepts,)General)Principles) and)International)Network,% Antwerpen:%UON%Network.% %

Indicator% of% obstetric% Conditions%included% complications% Absolute!Maternal!Indication! Severe!antepartum! haemorrhage!caused!by!a! placenta!praevia!or!a!retroU placental!haematoma;! incoercible!postpartum! haemorrhage;!major!fetoUpelvic! disproportion!(due!to!a!narrow!

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!AbouZahr,!C.,!2003.!Global!burden!of!maternal!death!and!disability.!British%Medical%Bulletin,!67(1),!pp.1–11.! !UON!Network,!1999.!Tackling%Unmet%Need%for%Major%Obstetric%Interventions:%Part%1.%Concepts,%General%Principles%and% International%Network,!Antwerpen:!UON!Network.! 12!Prytherch,!H.!et!al.,!2007.!The!unmet!need!for!emergency!obstetric!care!in!Tanga!Region,!Tanzania.!BMC%Pregnancy%and% Childbirth,!7,!p.16.!! 13 !Belghiti,!A.!et!al.,!1998.!Monitoring!unmet!obstetric!need!at!district!level!in!Morocco.!Tropical%Medicine%&%International% Health,!3(7),!pp.584–91.!Available!at:!http://www.ncbi.nlm.nih.gov/pubmed/9705194.! 14 !Ronsmans,!C.!et!al.,!2002.!Questioning!the!indicators!of!need!for!obstetric!care.!Bulletin%of%the%World%Health% Organization,!80(4),!pp.317–24.! 15 !Ronsmans,!C.!et!al.,!2004.!Measuring!the!need!for!lifeUsaving!obstetric!surgery!in!developing!countries.!BJOG :%An% International%Journal%of%Obstetrics%and%Gynaecology,!111(10),!pp.1027–30.!! 11

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What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! Study%

Indicator% of% complications%

obstetric% Conditions%included%

Prytherch,%H.%et%al.,%2007.%The% unmet%need%for%emergency% obstetric%care%in%Tanga%Region,% Tanzania.%BMC)Pregnancy)and) Childbirth,%7,%p.16.% %

Absolute!Maternal!Indication!

Belghiti,%A.%et%al.,%1998.% Monitoring%unmet%obstetric% need%at%district%level%in% Morocco.%Tropical)Medicine)&) International)Health,%3(7),% pp.584–91.%%

Absolute!Maternal!Indication!

pelvis!or!a!hydrocephaly);! transverse!position!(shoulders! neglected);!face!presentation.! Antepartum!haemorrhage!due! to!placenta!praevia!or!abruptio! placentae;!malpresentation! (transverse!lie,!brow! presentation,!etc.);!ruptured! uterus;!cephaloUpelvic! disproportion/obstructed! labour!based!on!partograph! with!action!line!crossed!by!the! dilation!line.! Severe!antepartum! haemorrhage;!placenta!praevia! and!abruptio!placentae;!severe! postpartum!haemorrhage! requiring!surgical!intervention;! fetoUpelvic!disproportion,! including!preUrupture!and! uterine!rupture;!shoulder!or! transverse!lie!and!brow! presentation.!

! Near%misses% Another!concept!used!to!examine!severe!obstetric!complications!is!that!of!“near!misses”!or!severe! acute! maternal! morbidity! (SAMM). 16 !A! near! miss! is! the! survival! outcome! of! a! lifeUthreatening! complication17,!or!“a!very!ill!woman!who!would!have!died!had!it!not!been!that!luck!or!good!care!was! on!her!side”18.!For!the!purposes!of!our!assessment,!near!misses!are!important!to!understanding!the! overall! prevalence/incidence! of! complications,! but! only! constitute! a! part! of! the! whole! picture,! as! they!are!the!subset!of!those!complications!that!become!lifeUthreatening!but!do!not!result!in!maternal! mortality!(see!Figure!1!below).!% % Figure%1:%AMI%and%Near%Misses%% %

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!Say,!L.,!Pattinson,!R.C.!&!Gülmezoglu,!M.,!2004.!WHO!systematic!review!of!maternal!morbidity!and!mortality:!the! prevalence!of!severe!acute!maternal!morbidity!(near!miss).!Reproductive%Health,!1(1),!p.3.!! 17 !World!Health!Organization!(WHO),!2004.!Beyond%the%Numbers:%Reviewing%Maternal%Deaths%and%Complications%to%Make% Pregnancy%Safer,!Geneva:!World!Health!Organization.! 18 !Mantel,!G.D.!et!al.,!1998.!Severe!acute!maternal!morbidity:!a!pilot!study!of!a!definition!for!a!nearUmiss.!British%Journal%of% Obstetrics%and%Gynaecology,!105(9),!p.985U90.!!

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What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! !

! (Figure!not!representing!proportions)! ! In!the!sense!that!Absolute!Maternal!Indications!are!defined!as!lifeUthreatening!complications!(see! above),!then!near!misses!can!be!understood!as!a!subset!of!AMI.!Based!on!this!understanding,!an!AMI! is!a!specific!case!of!a!lifeUthreatening!complication,!and!a!near!miss!is!one!of!the!possible!outcomes! to!this!complication!(the!other!being!maternal!death).!! ! However,!caution!must!be!exercised!when!trying!to!reconcile!the!concepts!in!this!way.!As!discussed! above,!different!studies!use!different!definitions!of!AMI,!and!the!same!is!true!for!near!misses.!! ! To!avoid!confusion!over!the!different!classifications!of!maternal!morbidity!/!pregnancy!complications! in! the! literature,! the! extraction! framework! of! this! literature! review! includes! an! assessment! of! the! exact! definitions! used! by! each! of! the! studies! surveyed.! This! serves! to! avoid! problems! of! crossU comparability!of!the!data.!! ! Existing%systematic%reviews% Several! systematic! reviews! have! been! conducted! to! date! on! the! topic! of! obstetric! complications.! Minkauskiene!et!al.!(2004)!use!the!concept!of!severe!maternal!morbidity!for!their!systematic!review,! which! looks! at! the! prevalence! of! severe! complications,! possible! risk! factors! and! related! medical! interventions.19!This!review!also!notes!the!use!of!overlapping!terminology!in!the!literature,!such!as! “cases! of! ‘near! miss’,! morbidity! of! severe! obstetric! disease,! morbidity! of! acute! severe! obstetric! disease,! morbidity! of! severe! disease! of! pregnant! and! labouring! women”.! Say,! Pattinson! and! Gülmezoglu! (2004)! conduct! a! review! of! SAMM! or! “near! miss”,! and! note! the! difficulties! in! pooling! data! or! establishing! comparisons! due! to! the! variations! in! case! identification.20!Another! systematic! review! conducted! by! Hofmeyr,! Say! and! Gülmezoglu! (2005)! is! limited! to! studying! the! prevalence! of! uterine!rupture!only.21! ! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 19

!Minkauskiene,!M.!et!al.,!2004.!Systematic!review!on!the!incidence!and!prevalence!of!severe!maternal!morbidity.! Medicina%(Kaunas,%Lithuania),!40(4),!pp.299–309.!! 20 !Say,!L.,!Pattinson,!R.C.!&!Gulmezoglu,!A.M.,!2004.!WHO!systematic!review!of!maternal!morbidity!and!mortality:!The! prevalence!of!severe!acute!maternal!morbidity!(near!miss).!Reproductive%Health,!1.!! 21 !Hofmeyr,!G.J.,!Say,!L.!&!Gulmezoglu,!A.M.,!2005.!WHO!systematic!review!of!maternal!mortality!and!morbidity:!the! prevalence!of!uterine!rupture.!BJOG:%An%International%Journal%of%Obstetrics%and%Gynaecology,!112(9),!pp.1221–1228.! !

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What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! Thus,!the!current!literature!lacks!a!review!that!looks!at!the!overall!incidence!of!complications!during! pregnancy! and! not! exclusively! at! severe! or! lifeUthreatening! complications.! This! review! will! also! recognize!that!the!prevalence!of!obstetric!complications!cannot!be!separated!from!the!wider!context! of! biological,! cultural,! socioeconomic,! and! other! underlying! factors! which! influence! a! woman’s! likelihood! of! suffering! an! obstetric! complication! (see! figure! in! Annex! 1).! Recognizing! that! obstetric! complications!can!depend!on!genetic!factors,22!health!status,23,24,25!reproductive!status!(including!age! and!parity)26!and!access!to!health!services,27!which!in!turn!depend!on!underlying!social,!cultural!and! economic! factors,! it! must! be! acknowledged! that! this! review! may! not! uncover! a! universal! rate! of! prevalence,! but! rather! highlight! that! prevalence! is! dependent! on! the! specific! characteristics! of! different!populations.! ! 2.2%Objective% The! objective! of! this! rapid! literature! review! is! to! inform! benchmarks! for! maternal! and! newborn! health! (MNH)! policy! and! programming.! It! has! particular! relevance! for! lowU! and! middleUincome! countries! and! the! required! infrastructure! and! staffing! to! provide! quality! emergency! obstetric! care! services.! It! seeks! to! identify,! collate! and! summarise! published! evidence! on! the! estimated! number,! proportion,! and/or! frequency! of! both! pregnancies! and! live! births! that! are! affected! by! obstetric! complications.!! ! 3

Methods%

3.1%Eligibility%criteria% The! rapid! review! focused! on! published,! peerUreviewed! publications.! Grey! literature,! including! Emergency!Obstetric!Care!(EmOC)!assessments!conducted!within!lowU!and!middleUincome!countries,! using!standard!methods!developed!by!UNFPA,!WHO!and!the!Averting!Maternal!Death!and!Disability! (AMDD)!programme!at!Columbia!University,!were!therefore!excluded.28!! ! The! search! strategy! concentrated! on! new! literature! from! 2002! onwards,! to! complement! observations! of! Ronsmans! et! al.29!which! explored! evidence! published! prior! to! that! point! in! time.! There!was!no!limit!on!the!time!period!covered!by!the!data!retrieved.!! ! 3.2%Information%sources% We! searched! EMBASE,! LILACS! and! MEDLINE! for! all! papers! in! the! 10Uyear! period! from! 2002.! These! were! selected! based! on! the! findings! of! the! 2004! World! Health! Organization! systematic! review! of! maternal!mortality!and!morbidity.30!!This!paper!discussed!the!utility!of!information!resources!in!this! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 22

!Ronsmans,!C.!et!al.,!2002.!Questioning!the!indicators!of!need!for!obstetric!care.!Bulletin%of%the%World%Health% Organization,!80(4),!pp.317–24.! 23 !McCarthy,!J.!&!Maine,!D.,!1992.!A!framework!for!analyzing!the!determinants!of!maternal!mortality.!Studies%in%Family% Planning,!23(1),!pp.23–33.! 24 !Ronsmans,!C.!et!al.,!2002.!Questioning!the!indicators!of!need!for!obstetric!care.!Bulletin%of%the%World%Health% Organization,!80(4),!pp.317–24.! 25 !Mulligan,!J.!et!al.,!2010.!Improving%Reproductive,%Maternal%and%Newborn%Health:%Burden,%Determinants%and%Health% Systems.%Evidence%Overview,!London:!DFID.! 26 !McCarthy,!J.!&!Maine,!D.,!1992.!A!framework!for!analyzing!the!determinants!of!maternal!mortality.!Studies%in%Family% Planning,!23(1),!pp.23–33.! 27 !Ronsmans,!C.!et!al.,!2002.!Questioning!the!indicators!of!need!for!obstetric!care.!Bulletin%of%the%World%Health% Organization,!80(4),!pp.317–24.! 28 !A!synthesis!of!all!available!EmOC!assessments!has!been!commissioned!by!UNFPA!and!will!potentially!be!available!in!2013! to!add!to!the!evidence!base.! 29 !Ronsmans,!C.!et!al.,!2002.!Questioning!the!indicators!of!need!for!obstetric!care.!Bulletin%of%the%World%Health% Organization,!80(4),!pp.317–24! 30 !Gülmezoglu,!a!M.!et!al.,!2004.!WHO!systematic!review!of!maternal!mortality!and!morbidity:!methodological!issues!and! challenges.!BMC%Medical%Research%Methodology,!4,!p.16.!

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What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! topic!area!identifying!MEDLINE!and!EMBASE!as!essential!sources!as!they!retrieved!the!largest!volume! of!unique!references.31!LILACS!was!the!source!of!the!third!largest!number!of!unique!references!and! provided!valuable!information!from!journals!published!outside!of!Western!Europe!and!the!USA.!! ! 3.3%Search%strategy% The!search!strategy!was!developed!and!iteratively!refined!through!testing/reUtesting!to!improve!its! precision,! as! an! original! version! of! the! strategy! identified! 18’894! peerUreviewed! articles.! Adaptions! were!tested!against!published,!relevant!systematic!reviews!to!check!that!sensitivity!was!preserved.! 32,33 !The!original!MEDLINE!search!was!adapted!for!the!other!search!resources.!! The!full!search!strategy!is!available!as!Annex!2.!! ! 3.4%Study%selection% Records!retrieved!from!the!search!were!subject!to!two!successive!screenings.!For!the!first!of!these,! records!were!screened!against!two!eligibility!criteria:!! ! 1. Does!the!study!refer!to!incidence/prevalence!rates!of!obstetric!complications?!! 2. Is!the!number!of!study!participants!greater!than!500?! ! For! this! screening,! records! were! categorized! according! to! the! search! terms! that! retrieved! them.! Those! identified! from! higher! priority! search! terms! (“obstetric! complications”! or! “morbidity”)! were! subject! to! a! title! and! abstract! review.! Those! identified! from! lower! priority! search! terms! (all! other! search!terms)!were!subject!to!an!initial!title!review!and!an!abstract!review!where!necessary.!! ! The!second!screening,!given!the!scope!of!the!rapid!review,!aimed!to:! • Identify! records! meeting! the! inclusion! criteria,! i.e.,! with! reference! to! any! of! the! following! obstetric! complications! (as! per! the! UNFPA,! WHO! and! UNICEF! definition)34:! haemorrhage! (antepartum! or! postpartum);! prolonged! or! obstructed! labour;! postpartum! sepsis;! complications! of! abortion;! preUeclampsia/eclampsia;! ectopic! pregnancy;! and! ruptured! uterus.!! • Exclude!any!records!referring!to!sources!from!which!complete!data!could!not!be!extracted.! Records!were!excluded!if!they!referred!to!studies!not!in!the!English!language,!to!studies!that! were!irretrievable,!or!to!poster!abstracts.!! ! For! all! records! passing! the! two! successive! screening! processes! (i.e.! meeting! both! eligibility! and! inclusion!criteria),!the!full!text!was!retrieved!for!data!extraction.!!!! % 3.5%Data%collection%process% FullUtext!articles!obtained!after!the!screening!process!were!reviewed!against!a!predefined!extraction! tool!(see!Annex!3).!The!tool!contains!three!sections,!covering!the!general!characteristics!of!the!study;! prevalence! or! incidence! rates! of! obstetric! complications/obstetric! morbidity;! and! a! quality! assessment.!This!tool!is!based!on!the!data!extraction!form!developed!for!the!2004!WHO!systematic! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 31

!Betran,! A.P.! et! al.! 2005.! Effectiveness! of! different! databases! in! identifying! studies! for! systematic! reviews:! experience! from!the!WHO!systematic!review!of!maternal!morbidity!and!mortality.!BMC%Methodological%Research!5:6.!! 32 !Minkauskiene,! M.! et! al.,! 2004.! Systematic! review! on! the! incidence! and! prevalence! of! severe! maternal! morbidity.!Medicina%(Kaunas,%Lithuania),!40(4),!pp.299–309.! 33 !Tunçalp,! O.! et! al.! 2012! The! prevalence! of! maternal! near! miss:! a! systematic! review.!!BJOG:% an% International% Journal% of% Obstetrics%and%Gynaecology,!119!(6),pp.653U61.! 34 !United!Nations!Population!Fund!(UNFPA),!World!Health!Organization!(WHO)!&!United!Nations!Children’s!Fund!(UNICEF),! 1997.!Guidelines%for%Monitoring%the%Availability%and%Use%of%Obstetric%Services,!New!York:!UNICEF.!

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10!


What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! review!of!maternal!mortality!and!morbidity.35!Data!extraction!of!the!selected!articles!went!through!a! threeUtiered!process!of!initial!data!extraction,!second!detailed!revision!and!extraction!of!all!articles! by!a!second!reviewer,!and!final!evaluation!by!a!third!reviewer.!! ! 3.6%Data%items% Data! were! extracted! for! UNFPA/WHO/UNICEF! recognized! categories! of! obstetric! complications.! Where! possible,! prevalence/incidence! was! calculated!in! relation! to! the! number! of! deliveries,! given! that! most! of! the! articles! used! this! measure! rather! than! pregnancies,! live! births! or! population.!! Obstetric! complications! studied! were! the! following:! antepartum! haemorrhage,! postpartum! haemorrhage,! haemorrhage! (in! studies! that! did! not! specify! whether! antepartum! or! postpartum);! prolonged! or! obstructed! labour;! postpartum! sepsis;! complications! of! abortion;! hypertensive! disorders!excluding!eclampsia;!eclampsia;!ectopic!pregnancy;!ruptured!uterus.!!% ! 3.7%Risk%of%bias%in%individual%studies% The!data!extraction!tool!included!questions!relevant!to!potential!bias!in!individual!studies,!including! consideration! of! sampling! methods,! eligibility! and! exclusion! criteria,! data! sources,! population! characteristics,! diagnostic! criteria,! health! characteristics! of! those! included! in! the! study! and! conditions!that!may!contribute!to!the!presence!or!absence!of!obstetric!complications.!!! % 3.8%Summary%measures/%Synthesis%of%results% Data! regarding! incidence/prevalence! of! the! selected! obstetric! complications! were! evaluated! as! presented! in! each! of! the! selected! articles! and! then,! where! possible,! converted! to! cases! of! each! obstetric! complication! per! 1000! deliveries 36 .! When! possible,! data! given! as! percentages! were! confirmed!by!recalculating!cases!over!study!population!prior!to!conversion!per!1000!deliveries.! For! each! complication,! the! maximum,! minimum,! median! and! mean! values! were! calculated.! ! To! reduce! the! effect! of! potential! outliers,! a! second! analysis! was! done! in! which! the! maximum! and! minimum! values!were!taken!away!prior!to!calculating!the!mean!and!range.! !! Some! studies! combined! hypertensive! disorders! into! one! condition,! while! others! provided! separate! data! regarding! rates! of! pregnancyUinduced! hypertension/gestational! hypertension,! preUeclampsia! and/or! eclampsia.! To! allow! for! appropriate! comparison,! two! variables! were! created:! hypertensive! disorders! of! pregnancy! and! eclampsia.! Cases! of! hypertensive! disorders! of! pregnancy! per! 1000! deliveries! were! calculated! by! adding! the! total! number! of! cases! of! hypertension/gestational! hypertension! and! preUeclampsia! over! the! study! population! and! expressed! as! cases! per! 1000! deliveries.! Eclampsia! was! kept! separate! as! prevalence/incidence! of! eclampsia! is! much! lower! than! other!hypertensive!disorders!of!pregnancy.!!Similarly,!haemorrhage!was!treated!as!three!variables:! antepartum!haemorrhage,!postpartum!haemorrhage!and!haemorrhage,!depending!on!how!the!data! were! presented! in! the! article.! ! Dystocia,! and! prolonged! and! obstructed! labour! were! considered! as! one!variable.!!! % 3.9%Risk%of%bias%across%studies% Given!the!rapid!nature!of!this!review!to!inform!ongoing!discussions!on!benchmarks!for!MNH,!a!full! assessment!of!methodological!bias!across!the!studies!was!not!conducted.!However,!given!that!most! of! the! studies! analysed! refer! to! measured! rates! of! prevalence! in! individual! settings,! rather! than! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 35

!GĂźlmezoglu,!M.!et!al.,!2004.!WHO!systematic!review!of!maternal!mortality!and!morbidity:!methodological!issues!and! challenges.!BMC%Medical%Research%Methodology,!4,!p.16.! 36 !With!the!exception!of!ectopic!pregnancy!and!complication!of!abortion!which!were!presented!as!per!1000!pregnancies,! with!the!exception!of!Mbele!et!al!which!did!include!data!for!“critically!illâ€?!(as!a!result!of!abortion)/1000!births!

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11!


What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! distributions! across! populations,! issues! of! statistical! bias! are! not! highly! relevant.! This! issue! is! addressed!in!further!detail!in!the!Results!and!Discussion!sections!of!this!paper.!

% 4

Results%

4.1%Study%selection% The!search!retrieved!4’416!records!(2’017!for!MEDLINE,!1’527!for!EMBASE!and!872!for!LILACS).!1’256! duplicates!were!identified!using!Mendeley’s!bibliography!management!software37,!resulting!in!3’160! original!records!for!screening!on!their!relevance!to!the!review.% ! A! total! of! 324! records! passed! the! first! screening! process.! Records! excluded! failed! to! meet! the! two! eligibility! criteria,! i.e.! they! did! not! refer! to! prevalence/! incidence! rates! of! obstetric! complications! and/or!did!not!include!more!than!500!cases.! ! !A! second! screening! was! conducted! to! identify! those! records! with! reference! to! obstetric! complications,!as!defined!by!the!UNFPA/WHO/UNICEF38:!haemorrhage!(antepartum!or!postpartum);! prolonged! or! obstructed! labour;! postpartum! sepsis;! complications! of! abortion;! preU eclampsia/eclampsia;! ectopic! pregnancy;! ruptured! uterus;! and! to! also! exclude! those! records! from! which!it!was!not!possible!to!extract!data.!At!this!stage,!256!records!were!excluded!for!not!meeting! the! inclusion! criteria! (i.e.! referring! to! the! abovementioned! complications),! with! the! additional! exclusion!of!four!records!unavailable!in!English!language,!two!records!not!obtainable!in!any!format,! and! two! records! referring! to! poster! abstracts! rather! than! published! articles.! These! exclusions! resulted!in!a!final!selection!of!60!articles!that!were!retrieved!for!a!detailed!evaluation.! ! Data! were! extracted! from! these! 60! articles,! with! 53! providing! data! against! at! least! one! of! the! UNFPA/WHO/UNICEF!recognized!categories!for!obstetric!complications.!The!seven!remaining!articles! were:!four!which!did!not!address!any!of!the!WHO!obstetric!complications!as!defined!by!this!review;! two! which! contained! no! data! on! prevalence/incidence;! and! one! article! which! was! found! to! have! a! sample! size! of! fewer! than! 500! participants.! These! records! had! not! been! removed! earlier! in! the! screening! process! as! their! abstracts! did! not! make! these! limitations! clear,! which! only! became! apparent!upon!full!review!of!the!text.! ! Of! the! 53! studies! providing! data,! 42! contained! data! that! could! be! converted! to! cases! per! 1000!! deliveries! by! complication,! for! an! initial! descriptive! analysis.! ! Data! from! the! remaining! 11! studies! were!also!considered!to!assess!consistency!with!the!findings!of!the!42!studies.!The!study!selection! process!is!shown!in!Figure!2!below.!! ! Figure%2.%Study%selection%

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 37

!Mendeley!Ltd.,!Mendeley!Desktop.! !United!Nations!Population!Fund!(UNFPA),!World!Health!Organization!(WHO)!&!United!Nations!Children’s!Fund!(UNICEF),! 1997.!Guidelines%for%Monitoring%the%Availability%and%Use%of%Obstetric%Services,!New!York:!UNICEF.!

38

February!2013!!

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12!


What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! 4416$records$identified$through$ database$searching$ 1256$duplicate$records$ removed$$ 3160$records$after$removal$$ of$duplicates$$

2836$records$excluded$for$ not$meeting$eligibility$ criteria$

$ $

324$records$meeting$eligibility$ criteria$

256$records$excluded$for$ not$referring$to$WHO$ complications;$$ 4$not$in$English;$ 2$unobtainable;$ 2$poster$abstracts$only$

60$studies$retrieved$for$detailed$ evaluation$ $

2$studies$with$no$ prevalence$data;$ 4$studies$with$no$data$on$ WHO$complications;$$$ 1$with$insufficient$sample$ size$

53$studies$included$in$analysis$$

42$studies$with$data$ convertible$to$prevalence$ per$1000$deliveries$$

11$studies$with$other$ relevant$data$

%

!

4.2%Study%characteristics% Key! characteristics! from! the! final! selection! of! 53! studies! are! summarized! in! Annex! 5.! The! studies! cover!various!geographical!areas:!North!America!leads!with!12!studies,!followed!by!Asia!(Southeast! Asia!and!Eurasia!included)!with!11!studies.!There!are!9!studies!from!Africa!and!8!from!Europe,!5!from! Latin! America,! 4! from! the! Middle! East! and! 2! studies! from! Oceania.! Finally,! 2! studies! include! a! combination!of!regions.!! ! The! split! between! lowUincome! and! highUincome! countries! is! 33! studies! from! highUincome! countries! (according!to!the!World!Bank!classification!of!highUincome!and!upperUmiddleUeconomies)39,!15!lowU income! countries! (according! to! World! Bank! classification! of! lowUincome! and! lowerUmiddleUincome! economies)40!and!5!studies!containing!a!mixture!of!countries!from!both!highUincome!and!lowUincome! countries.! ! None! of! the! articles! addressed! the! complete! group! of! obstetric! complications,! as! defined! by! UNFPA/WHO/UNICEF,!and!only!8!studies!looked!at!more!than!three!complications.!One!study!from!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 39

!World!Bank,!2013.!Country!and!Lending!Groups.!Available!at:!http://data.worldbank.org/about/countryU classifications/countryUandUlendingUgroups![Accessed!January!10,!2013].! 40 !World!Bank,!2013.!Country!and!Lending!Groups.!Available!at:!http://data.worldbank.org/about/countryU classifications/countryUandUlendingUgroups![Accessed!January!10,!2013].!

February!2013!!

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13!


What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review.! ! Nigeria! (Akwuruoha! et! al.! 2011),41!looked! at! 18! complications! (five! of! which! are! included! in! this! analysis),! but! was! restricted! to! one! facility! in! one! city,! reducing! its! representativeness! for! the! full! Nigerian!population.! ! Population!sizes!vary!widely!between!the!papers,!from!almost!40!million!in!an!American!study,42!to! just!over!500!in!a!study!from!Belgium.43!! ! Table%3:%%Studies%classified%by%obstetric%complication% ! Complication% Complications%of%abortion% Ectopic%pregnancy% Prececlampsia/pregnancyc induced%hypertension% (Hypertensive%disorders%of% pregnancy)% Eclampsia% Antepartum%haemorrhage% Postpartum%haemorrhage% Haemorrhage%(obstetric,% unspecified)% Prolonged/obstructed%labour% Ruptured%uterus% Postpartum%sepsis%

Number%of%articles% 4! 3! 28!

14! 10! 14! 6! 9! 17! 8!

! 4.3%Risk%of%bias%within%studies%% Some!of!the!studies!are!based!on!selfUreported!data.!In!one!study,!this!was!validated!by!a!physician,! but!included!‘complications’!like!postpartum!insomnia!and!breastfeeding!problems44.!Another!study,! which! included! interviews! at! multiple! points! of! the! pregnancy! and! postpartum! period,! included! postpartum! physician! examinations! at! 14U22! days! postpartum,! though! these! were! not! intended! to! validate!selfUreported!complications.45!!Including!selfUreported!rates!of!complications!may!influence! the!results!of!this!review,!as!their!inclusion!could!increase!the!likelihood!of!misdiagnosis!of!obstetric! complications.! However,! the! exclusion! of! articles! with! selfUreported! data! may! introduce! bias! favouring!information!on!hospital!births,!as!existing!files!on!deliveries!occurring!out!of!hospital!may! not!be!readily!accessible.!! % 4.4%Results%of%individual%studies% Table! 4! shows! the! results! of! the! 53! articles! included! in! the! study! against! the! agreed! obstetric! complications.! ! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 41

!Akwuruoha,!E.!et!al.,!2011.!Grandmultiparity!and!pregnancy!outcome!in!Aba,!Nigeria:!a!caseUcontrol!study.!Archives%of% Gynecology%and%Obstetrics,!283(2),!pp.167–72.! 42 !Berg,!C.J.!et!al.,!2009.!Overview!of!maternal!morbidity!during!hospitalization!for!labor!and!delivery!in!the!United!States:! 1993U1997!and!2001U2005.!Obstetrics%and%Gynecology,!113(5),!pp.1075–1081.! 43 !Brosens,!I.A.!et!al.,!2007.!Endometriosis!is!associated!with!a!decreased!risk!of!preUeclampsia.!Human%Reproduction,!22(6),! pp.1725–1729.! 44 !Bang,!R.A.!et!al.,!2004.!Maternal!morbidity!during!labour!and!the!puerperium!in!rural!homes!and!the!need!for!medical! attention:!A!prospective!observational!study!in!Gadchiroli,!India.!BJOG :%an%international%journal%of%obstetrics%and% gynaecology,!111(3),!pp.231–238.! 45 !Fronczak,!N.!et!al.,!2005.!DeliveryUrelated!complications!and!early!postpartum!morbidity!in!Dhaka,!Bangladesh.! International%Journal%of%Gynecology%and%Obstetrics,!91(3),!pp.271–278.!

February!2013!!

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14!


! Table&4.&Rates&of&obstetric&complications&in&the&53&selected&articles& & Rate0per01000

Author(s)

Year

Unit0 (delivery/0 pregnancy/0 live0birth/0 vaginal0 birth/0etc)0

Agrawal,(S.,(Agarwal,(A.(&( Das,(V.

2011

Akwuruoha,(E.(et(al.

Hypertensive0 disorders0of0 Complications0 pregnancy000 of0abortion (HTN0 disorders,0PIH,0 preeclampsia)0

Eclampsia0

Ectopic0 pregnancy

Ruptured0 uterus0

Any0or0 combination0 of0 complications

6

9

6

4

6

6

29

6

6

7

6

6

6

24.7

6

6

6

6

19

6

6

34

8

6

6

6

6

6

6

6

6

6

6

1.1

6

6

6

6

0.5

6

15.1

1.7

6

1

6

6

32

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

0.3

6

0.31

6

Period(A

6

20

16

6

1

6

6

1

6

1

6

Period(B

6

26

16

6

1

6

6

1

6

1

6

deliveries

6

6

6

6

6

6

34.7

6

6

6

6

deliveries

6

53

50

6

6

6

120

6

6

6

6

pregnancies

6

6

6

6

6

86

6

6

9

6

6

deliveries

6

6

45.3

6

6

6

64.2

6

6

6

6

pregnancies

6

6

6

6

6

13

6

6

13

6

6

Haemorrhage

Postpartum0 haemorrhage

Antepartum0 haemorrhage0

Prolonged/ obstructed0 labour

deliveries

6

6

6

9

6

6

2011

deliveries

6

42

6

58

14

Al6Mulhim,(A6A(et(al.(

2003

deliveries

6

6

6

6

Ali,(A.(A.(et(al.(

2012

deliveries

6

8

23

Ali,(A.M.(&(Abu6Heija,(A.T

2002

deliveries

6

6

Almerie,(Y.(et(al.(

2010

deliveries

11.4

Bang,(R.(A.(et(al.(

2004

deliveries

Baskett,(T.F.(&(O’Connell,( C.M.

2005

deliveries

Berg,(C.(J.(et(al.

2009

deliveries

Brosens,(I.(A.,(et(al.(

2007

Bruce,(F.(C.(et(al.(

2008

Bruce,(F.(C.(et(al.(

Group

Postpartum0 sepsis0

2012

Camargo,(R.S.(et(al.

2011

deliveries

92

6

6

6

6

6

6

6

6

6

6

Chhabra,(S.,(Bhagwat,(N.( &(Chakravorty,(A.

2002

deliveries

6

6

6

6

6

6

6

6

6

0.62

6

Clausen,(T.(et(al.

2006

deliveries

6

6

6

6

6

6

73.7

6

6

6

6

Cleary6Goldman,(J.(et(al.((

2005

deliveries

6

6

6

6

6

6

70

6

6

6

6

Croft,(M.(et(al.

2010

deliveries

6

6

60

6

6

6

75

0.13

6

6

6

Danel,(I.(et(al.(

2003

deliveries

6

20

16

6

0.2

6

6

6

6

1

6

Elsmen,(E.(et(al.(

2006

deliveries

6

6

6

6

6

6

29.36

6

6

6

6

! January!2013!

!

15!


! Rate0per01000

Author(s)

Year

Unit0 (delivery/0 pregnancy/0 live0birth/0 vaginal0 birth/0etc)0

Fronczak,*N.*et*al.

2005

Galambosi,*P.J.*et*al.

Hypertensive0 disorders0of0 Complications0 pregnancy000 of0abortion (HTN0 disorders,0PIH,0 preeclampsia)0

Eclampsia0

Ectopic0 pregnancy

Ruptured0 uterus0

Any0or0 combination0 of0 complications

90

10

7

7

7

7

10

7

7

7

7

7

7

7

7

7

7

7

7

7

7

7

7

7

7

7

Haemorrhage

Postpartum0 haemorrhage

Antepartum0 haemorrhage0

Prolonged/ obstructed0 labour

deliveries

7

7

7

7

7

7

2012

deliveries

7

7

78

7

7

Geller,*E.*et*al.*

2010

deliveries

7

57.56

7

7

Guendelman,*S.*et*al.*

2006

deliveries

7

24.3

7

Healy,*D.L.*et*al.

Group

Postpartum0 sepsis0

2010

deliveries

7

79

36

7

7

7

7

7

7

7

7

Hofmeyr,*G.*J.,*Say,*L.,*&* Gulmezoglu,*A.*M

2005

systematic* review

7

7

7

7

7

7

7

7

7

0.53**

7

Hoque,*M.

2011

deliveries

7

4.8

6.4

29.1

7

7

7

7

7

7

21.4*

Hoque,*M.*and*Hoque,*S.

2010

deliveries

7

7

7

7

7

7

63.4

16.4

7

7

7

Huda,*F.*A.*et*al.

2012

deliveries

19.7

7

7

161.4

0.5

7

29.6

7

7

7

7

Islam,*M.*A.*et*al.

2004

pregnancies

7

7

7

7

7

7

7

7

7

7

914.4

Kaye,*D.*et*al.

2011

systematic* review

3*7*302

7

7

20.57201

0.9783

7

7

1.97249

7

*1745

7

Liu,*S.*et*al.

2010

deliveries

7

7

7

7

1.1

7

0.9

7

7

1.01

7

Luke,*B.*&*Brown,*M.*B.

2007

live*births

7

7

7

7

7

7

37.57*111.7

7

7

7

7

Lumbiganon,*P.*et*al.*

2010

deliveries

7

7

7

7

7

7

59

3.7

7

7

7

Matsuda,*Y.*et*al.*

2011

live*births

7

7

7

7

7

7

30.4

7

7

7

7

Mbele,*A.M.,*Snyman,*L.* &*Pattison,*R.C.

Period*A

7

7

7

7

7

3.05***

7

7

7

7

7

2006

pregnancies* Period*B

7

7

7

7

7

2.92***

7

7

7

7

7

Miller,*S.*et*al.*

2007

only*vaginal* deliveries

7

134

7

7

7

7

189

7

7

7

7

Myles,*T.

2003

deliveries

7

37

7

78

7

7

7

7

7

7

7

Nomura,*R.*et*al.

2004

deliveries

7

7

7

7

7

7

176

7

7

7

7

Nwogu7Ikojo,*E.E.,*Nweze,* S.O.*&*Ezegwui,*H.U.

2008

deliveries

7

7

7

27

7

7

7

7

7

7

7

! January!2013!

!

16!


! Rate0per01000

Author(s)

Year

Unit0 (delivery/0 pregnancy/0 live0birth/0 vaginal0 birth/0etc)0

Ould%El%Joud,%D.%et%al.

2002

Ozdemir,%I.,%Yucel,%N.%&% Yucel,%O.

Hypertensive0 disorders0of0 Complications0 pregnancy000 of0abortion (HTN0 disorders,0PIH,0 preeclampsia)0

Eclampsia0

Ectopic0 pregnancy

Ruptured0 uterus0

Any0or0 combination0 of0 complications

5

5

5

1.2

5

5

5

5

5

0.1

5

5

5

5

5

5

7.4

5

5

5

5

30.8

5

5

5

5

5

5

5

5

42.76

5

5

5

5

5

5

5

5

5

98.5

5

5

5

5

Haemorrhage

Postpartum0 haemorrhage

Antepartum0 haemorrhage0

Prolonged/ obstructed0 labour

deliveries

5

5

5

5

5

5

2005

deliveries

5

5

5

5

5

Rizwan,%N.,%Abbasi,%R.M.% &%Uddin,%S.F.

2011

deliveries

5

5

5

5

Rode,%L.%et%al.

2005

deliveries

5

5

5

non5obese

5

5

Roman,%H.%et%al.%

2007

deliveries obese

5

Group

Postpartum0 sepsis0

Ronsmans,%C.%et%al.%

2009

pregnancies

5

30.4

34.3

2.48

5

13.8

6.36

17.3

16.6

6.7

5

Rouzi,%A.A.%et%al.

2003

deliveries

5

5

5

5

5

5

5

5

5

1

5

Salihu,%H.%M.%et%al.

2011

deliveries

5

5

5

5

5

5

5

5

5

5

340

Souza,%J.%P.%et%al.%

2010%(1)

deliveries

5

5

5

5

5

5

66

4

5

5

5

Souza,%J.%P.%et%al.%

2010%(2)

deliveries

5

5

5

5

5

5

97

2.6

5

5

5

Souza,%J.%P.%et%al.%

2010%(3)

pregnancies

184

5

5

5

5

5

5

6

5

5

229

Villar,%J.%et%al.

2007

deliveries

5

5

5

5

5

5

5

5

5

5

89*

Walker,%M.%C.%et%al.

2004

deliveries

5

46.5

5

5

5

5

35.6

5

5

5

5

Zhang,%W.%H.%et%al.%

2005

deliveries

4.6

5

5

5

0.8

5

4.3

5

5

5

5

HTN=%hypertensive.%PIH%=%pregnancy5induced%hypertension. *%combines%hypertensive%disorders%of%pregnancy%including%eclampsia **%median%for%pregnant%population ***%critically%ill%per%1000%births

! January!2013!

!

17!


!

4.5$Synthesis$of$results$$ Evaluation! of! the! 42! articles! with! data! converted! to! cases! per! 1000! showed! great! heterogeneity! between! studies,! even! after! omitting! the! maximum! and! minimum! values! as! potential! outliers.! Variation!was!greater!for!the!more!prevalent!obstetric!complications!whereas!complications!that!are! rarer!had!tighter!margins.!!For!example,!postpartum!sepsis!yielded!a!range!of!prevalence/incidence! of!0.5F1.1!(mean!0.82;!median!.9)!per!1000!deliveries,!eclampsia!0.3F14!(mean!4.3;!median!3.7)!per! 1000!deliveries!and!ruptured!uterus!0.3F7!(mean!2.0;!median!1)!per!1000!deliveries.!!The!diagnosis! “hypertensive!disorders”!had!much!greater!variation!(4.3!–!120;!mean!52;!median!42.76)!per!1000! deliveries.! Prolonged/obstructed! labour! varied! from! 19F78! (mean! 42.2;! median! 29.1)! per! 1000! deliveries.!And!the!means!for!rates!of!haemorrhage!per!1000!deliveries!also!varied!across!the!three! classifications!as!follows:!nonFspecific!obstetric!haemorrhage!(range!11.4F19.7;!mean!15.55;!median! 15.55!per!1000!deliveries),!antepartum!haemorrhage!!(range!16.0F60.0;!mean!32.8;!median!29.5!per! 1000! deliveries)! and! postpartum! haemorrhage! (range! 8F57.6;! mean! 33.3;! median! 32! per! 1000! deliveries).!!! ! A! few! articles! containing! data! that! could! not! be! converted! to! rates! per! 1000! deliveries! were! considered!and!also!showed!great!heterogeneity.!!Included!in!this!analysis!is!a!systematic!review!by! Kaye! et! al.! (2011)46!on! severe! maternal! morbidity! in! subFSaharan! Africa.! ! This! study! found! wide! variation! across! rates! of! haemorrhage! ranging! from! 3! –! 302/1000! deliveries 47 !across! the! study! populations.!!A!study!of!selfFreported!conditions!from!DHS!surveys!in!Brazil!by!Souza!et!al.!(201048)! reported! that! 18.4%! of! women! surveyed! claimed! to! have! had! obstetric! haemorrhage! during! their! pregnancy! (184/1000),! a! rate! well! above! other! studies.! Kaye! et! al.! (2011)! also! found! wide! ranges! (20.5F201/1000 49 )! in! rates! of! prolonged/obstructed! labour! across! the! articles! included! in! their! systematic! review.! ! Rates! for! complications! of! abortion! were! addressed! in! four! studies! and! ranged! from! 13F86! per! 1000! pregnancies.! ! A! study! by! Mebele! et! al.! (2006)50!reported! that! abortion! led! to! critically!ill!outcomes!in!2.92/1000!births!and!3.05/1000!births!over!the!two!periods!studied.!!Rates! for! ectopic! pregnancy! were! discussed! in! three! studies! with! a! fairly! tight! range! of! 9! –! 16.6! /1000! pregnancies.!Three!studies51,52,53!provided!data!on!grouped!obstetric!complications!with!rates!ranging! from!229/1000!pregnancies,!914/1000!pregnancies!and!340/1000!deliveries.!!! ! $ 5

Discussion$$

5.1$Summary$of$evidence$ This!rapid!review!of!published!peerFreviewed!papers!on!obstetric!complications!has!given!insight!into! ranges!of!occurrence!per!complication!despite!the!fact!that!none!of!them!were!specifically!designed! to!report!on!prevalence!or!incidence!of!complications!on!a!global!level.!!The!two!systematic!reviews! included! in! the! analysis! provide! additional! insight! into! the! difficulty! of! appreciating! the! incidence/prevalence! of! obstetric! complications! through! the! analysis! of! published,! peerFreviewed! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 46

!Kaye,!D.K.,!Kakaire,!O.!&!Osinde,!M.O.,!2011.!Systematic!review!of!the!magnitude!and!case!fatality!ratio!for!severe! maternal!morbidity!in!subFSaharan!Africa!between!1995!and!2010.!BMC$Pregnancy$and$Childbirth,!11,!p.65.! 47 !Data!from!deliveries!only! 48 !Souza,!J.P.!et!al.,!2010.!Maternal!morbidity!and!near!miss!in!the!community:!findings!from!the!2006!Brazilian! demographic!health!survey.!BJOG:$An$International$Journal$of$Obstetrics$and$Gynaecology,!117(13),!pp.1586–1592.! 49 !Data!includes!pregnancies,!deliveries!and!live!births! 50 !Mbele,!A.M.,!Snyman,!L.!&!Pattison,!R.C.,!2006.!Impact!of!the!Choice!on!Termination!of!Pregnancy!Act!on!maternal! morbidity!and!mortality!in!the!west!of!Pretoria.!South$African$Medical$Journal,!96(11),!pp.1196–1198.! 51 !Islam,!M.A.!et!al.,!2004.!A!multistage!model!for!maternal!morbidity!during!antenatal,!delivery!and!postpartum!periods.! Statistics$in$Medicine,!23(1),!pp.137–158.! 52 !Salihu,!H.M.!et!al.,!2004.!PregnancyFassociated!morbidity!in!Northern!Nigeria.!Journal$of$Obstetrics$and$Gynaecology,! 24(4),!pp.367–371.! 53 !Souza,!J.P.!et!al.,!2010.!Maternal!morbidity!and!near!miss!in!the!community:!findings!from!the!2006!Brazilian! demographic!health!survey.!BJOG:$An$International$Journal$of$Obstetrics$and$Gynaecology,!117(13),!pp.1586–1592.!

! January!2013!

!

18!


What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! ! articles!which!are!targeted!to!answer!different!research!questions.!!Hofmeyr!et!al.!(2005)54!focused! on!the!single!complication!of!ruptured!uterus!and!found!wide!variation!across!countries!in!function! of!their!level!of!development,!with!rates!ranging!from!0.006F0.92%!in!developed!countries,!0.1F19%! in! less! developed! countries! and! 0.21F25%! in! the! least! developed! countries55.! ! It! is! noteworthy! that! the! width! of! the! range! increases! greatly! in! lesser! and! least! developed! countries.! ! This! speaks! to! concerns! identified! by! Kaye! et! al.! (2011) 56 !that! the! contexts! and! settings! may! greatly! impact! outcomes! and! that! variations! in! criteria! may! impede! the! ability! to! fully! understand! the! true! scope! and!nature!of!maternal!morbidity!across!populations.!!Kaye!et!al.!(2011)!also!propose!the!formation! of! a! classification! system! so! that! comparisons! between! countries! and! regions! may! be! understood! and! addressed.! ! It! should! be! noted! that,! for! the! purposes! of! the! data! synthesis,! these! systematic! reviews! were! not! included! as! the! data! could! not! be! converted! to! rates! per! 1000! deliveries,! which! also!avoided!issues!that!could!have!arisen!with!doubleFcounting!the!data.!! ! The!roles!that!socioFeconomic!status,!nonFobstetric!health!conditions!and!obstetric!risk!factors!may! play!in!the!incidence!of!obstetric!complications!across!populations!can!also!be!observed!through!the! identified!studies.!!Clausen!et!al.!(2006)57!examine!how!low!socioFeconomic!status!is!linked!to!higher! rates! of! obstetric! complications! in! urban! neighbourhoods! of! Oslo,! considering! factors! such! as! educational! status,! marital! status! and! age.! ! These! authors! also! consider! lifestyle! habits! such! as! smoking!and!confirm!the!relationship!between!preFconceptual!body!mass!index!(BMI)!and!the!risk!of! complications! during! pregnancy.! Roman! et! al.! (2007) 58 !also! focused! on! the! negative! impact! of! obesity,! but! also! considered! lifestyle! habits,! such! as! smoking! and! drinking! alcohol,! as! well! as! preF existing! health! conditions,! such! as! chronic! hypertension! and! chronic! diabetes.! ! Guendelman! et! al.! (2006)59!focused!on!variations!in!rates!of!obstetric!complications!for!women!of!various!ethnicities!in! California!(USA)!and!found!black!women!to!have!greater!rates!of!obstetric!complications,!and!Latina! women!to!have!lower!rates,!compared!to!white!women!and!Asian!women.!!Bruce!et!al.!(2008)60!and! Bruce! et! al.! (2012) 61 !also! supplied! data! on! race/ethnicity! in! relationship! to! rates! of! obstetric! complications.! ! Maternal! age! as! an! obstetric! risk! factor! is! considered! in! several! studies.! ! ClearyF Goldman! et! al.! (2005)62!found! that! women! aged! 35F39! years! and! over! 40! years! had! much! greater! odds!of!having!an!obstetric!complication!(adjusted!OR!2.0!and!2.4,!respectively)!than!women!under! the!age!of!35.!On!the!other!side!of!the!spectrum,!Hoque!and!Hoque!(2010)63!focused!on!the!risk!of! obstetric! complications! in! an! adolescent! population,! but! they! did! not! find! significant! differences! in! the!groups!of!young!mothers!studied!(ages!13F15!years;!16F18!years;!and!19F21!years).!Finally,!the!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 54

!Hofmeyr,!G.J.,!Say,!L.!&!Gulmezoglu,!A.M.,!2005.!WHO!systematic!review!of!maternal!mortality!and!morbidity:!the! prevalence!of!uterine!rupture.!BJOG:$An$International$Journal$of$Obstetrics$and$Gynaecology,!112(9),!pp.1221–1228.!! 55 !Studies!included!utilized!a!wide!range!of!study!populations!and!data!was!not!presented!in!the!subcategories!of! pregnancies,!live!births,!pregnancies!etc! 56 !Kaye,!D.K.,!Kakaire,!O.!&!Osinde,!M.O.,!2011.!Systematic!review!of!the!magnitude!and!case!fatality!ratio!for!severe! maternal!morbidity!in!subFSaharan!Africa!between!1995!and!2010.!BMC$Pregnancy$and$Childbirth,!11,!p.65.! 57 !Clausen,!T.,!Oyen,!N.!&!Henriksen,!T.,!2006.!Pregnancy!complications!by!overweight!and!residential!area.!A!prospective! study!of!an!urban!Norwegian!cohort.!Acta$Obstetricia$et$Gynecologica$Scandinavica,!85(5),!pp.526–533.! 58 !Roman,!H.!et!al.,!2007.!Obstetrical!and!neonatal!outcomes!in!obese!women.!West$Indian$Medical$Journal,!56,!pp.421– 426.! 59 !Guendelman,!S.!et!al.,!2006.!Obstetric!complications!during!labor!and!delivery:!assessing!ethnic!differences!in!California.! Women’s$Health$Issues,!16(4),!pp.189–197.! 60 !Bruce,!F!Carol!et!al.,!2008.!Maternal!morbidity!rates!in!a!managed!care!population.!Obstetrics$and$Gynecology,!111(5),! pp.1089–1095.! 61 !Bruce,!F!C!et!al.,!2012.!Extent!of!maternal!morbidity!in!a!managed!care!population!in!Georgia.!Paediatric$and$Perinatal$ Epidemiology,!26,!pp.497–505.! 62 !ClearyFGoldman,!J.!et!al.,!2005.!Impact!of!maternal!age!on!obstetric!outcome.!Obstetrics$and$Gynecology,!105(5,1),! pp.983–990.! 63 !Hoque,!M.!&!Hoque,!S.,!2010.!Comparison!of!perinatal!and!obstetrics!outcomes!among!early!adolescents,!late! adolescents!and!adult!pregnant!women!from!rural!South!Africa.!East$African$Journal$of$Public$Health,!7(2),!pp.171–176.!

February!2013!!

!

19!


What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! ! issue!of!access!to!care!is!included!in!several!studies.!Hoque!(2011)64!found!that!women!who!did!not! have!prenatal!care!were!twice!as!likely!to!have!complications.!!Similarly,!Almerie!et!al.!(2010)65!made! the! recommendation! for! improving! access! to! antenatal! care! as! well! as! improving! protocols! and! referral!systems!as!a!key!measure!to!lowering!rates!of!obstetric!complications.!!! ! 5.2$Limitations$ The! process! of! extracting! the! prevalence/incidence! data! identified! an! important! limitation:! few$ studies$ were$ conducted,$ and$ their$ results$ published,$ with$ the$ intention$ to$ provide$ globally$ applicable$ data$ on$ the$ prevalence/incidence$ of$ obstetric$ complications.! Most! discuss! a! specific! complication,! intervention! or! programme! and! collect! incidence! or! prevalence! in! response! to! the! research!question.!This!can!lead!to!specific!selection!or!combinations!of!study!populations,!resulting! in!bias!with!respect!to!the!prevalence!of!obstetric!complications!across!the!whole!population.!Given! the! current! focus! on! clinical! interventions! to! reduce! maternal! mortality,! many! researchers! are! looking!at!single!issues!rather!than!at!the!big!picture,!which!raises!the!question!as!to!whether!peerF reviewed! literature! is! the! correct! source! for! incidence/prevalence! data.! Many! studies! focused! on! specific! obstetric! populations,! such! as! obese! mothers,! twin! gestations,! grandFmultiparity,! or! pregnancies!resulting!from!assisted!reproductive!therapies,!comparing!cases!and!controls.! ! Additionally,! the! majority! of! studies$ focus$ exclusively$ on$ facility$ deliveries$ –$ even$ in$ regions/countries$ where$ the$ majority$ of$ births$ take$ place$ outside$ facilities.! ! This! may! limit! our! results! to! women! who! are! connected! to! the! established! health! system! or! with! the! means! to! seek! care.! ! However,! Bang! et! al.! (2004) 66 ,! focusing! on! outFofFhospital! birth,! discussed! the! need! for! emergency! obstetric! care! for! those! delivering! at! home! as! well! as! homeFbased! postpartum! care.!! Similarly,!Rizwan!et!al.!(2011)67!cited!prolonged!neglected!obstructed!labour,!the!need!for!antenatal! care!and!(lack!of)!training!for!health!workers!as!key!social!causes!for!uterine!rupture.!!Hofmeyr!et!al.! (2005)68!noticed!greater!rates!of!uterine!rupture!in!lessFdeveloped!countries!and!Ould!et!al.!(2002)69! continued!in!that!vein,!when!addressing!elevated!rates!of!uterine!rupture,!stating!that!even!in!large! cities!an!absence!of!adequate!facilities!can!be!noted.!!Bruce!et!al.!(2012)70!give!evidence!that!in!highF income! countries,! inequities! in! access! continue! to! contribute! to! health! outcomes,! suggesting! that! comprehensive!health!insurance!may!lessen!the!risk!of!maternal!morbidity.!!! ! ! 5.3$Issues$arising$ The!analyses!of!the$retrieved$articles$showed$no$specific$patterns$or$obvious$trends,!other!than!an! increase!in!caesarean!section!rate.!Despite!the!increased!sensitivity!in!the!iterations!of!the!searches,! few!articles!allowed!likeFforFlike!comparison!and!the!subsequent!drawing!of!conclusions.!Population! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 64

!Hoque,!M.,!2011.!Incidence!of!Obstetric!and!Foetal!Complications!during!Labor!and!Delivery!at!a!Community!Health! Centre,!Midwives!Obstetric!Unit!of!Durban,!South!Africa.!ISRN$Obstetrics$and$Gynecology,!pp.1–6.! 65 !Almerie,!Y.!et!al.,!2010.!Obstetric!nearFmiss!and!maternal!mortality!in!maternity!university!hospital,!Damascus,!Syria:!a! retrospective!study.!BMC$Pregnancy$&$Childbirth,!10,!p.65.! 66 !Bang,!R.A.!et!al.,!2004.!Maternal!morbidity!during!labour!and!the!puerperium!in!rural!homes!and!the!need!for!medical! attention:!A!prospective!observational!study!in!Gadchiroli,!India.!BJOG!:$an$international$journal$of$obstetrics$and$ gynaecology,!111(3),!pp.231–238.! 67 !Rizwan,!N.,!Abbasi,!R.M.!&!Uddin,!S.F.,!2011.!Uterine!rupture,!frequency!of!cases!and!fetomaternal!outcome.!JPMA.$The$ Journal$of$the$Pakistan$Medical$Association,!61(4),!pp.322–324.! 68 !Hofmeyr,!G.J.,!Say,!L.!&!Gulmezoglu,!A.M.,!2005.!WHO!systematic!review!of!maternal!mortality!and!morbidity:!the! prevalence!of!uterine!rupture.!BJOG:$An$International$Journal$of$Obstetrics$and$Gynaecology,!112(9),!pp.1221–1228.! 69 !Ould!El!Joud,!D.!et!al.,!2002.!Epidemiological!features!of!uterine!rupture!in!West!Africa!(MOMA!Study).!Paediatric$and$ Perinatal$Epidemiology,!16(2),!pp.108–114.! 70 !Bruce,!F!C!et!al.,!2012.!Extent!of!maternal!morbidity!in!a!managed!care!population!in!Georgia.!Paediatric$and$Perinatal$ Epidemiology,!26,!pp.497–505.!

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What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! ! sizes,! years! of! study,! period! length! for! data! collection,! unit! of! measure! (pregnancies,! live! births,! deliveries)!vary!greatly.!!! ! Similarly,! the! lack! of! uniformity$ in$ diagnostic$ criteria$ for$ the$ reviewed$ studies$ constitutes$ an$ important$ technical$ complication!in!our!review.!!Studies!included!in!our!analysis!contained!varying! levels! of! information! on! diagnostic! criteria! for! each! of! the! obstetric! complications! discussed.! Additionally,! studies! differed! with! regard! to! validation! of! diagnoses,! as! data! sources! varied! from! hospital!records,!interviews!and!selfFreporting!to!national!or!regional!databases.!The!complications! themselves! were! not! uniformly! named! or! grouped! throughout! the! articles.! For! example,! hypertensive! disorders! of! pregnancy! varied! greatly! across! the! studies! because! some! studies! combined!hypertensive!disorders!into!one!condition!and!others!provided!separate!data!on!rates!of! pregnancyFinduced! hypertension/gestational! hypertension,! preFeclampsia! and/or! eclampsia.! Therefore,! to! allow! for! appropriate! comparison,! all! hypertensive! disorders!were!compiled!into!two! broader! variables:! hypertensive! disorders! of! pregnancy! and! eclampsia.! Variations! in! how! haemorrhage! was! presented! led! to! the! creation! of! a! third! category! (obstetric! haemorrhage,! nonF specified)!to!allow!for!the!inclusion!of!studies!that!did!not!specify!when!the!haemorrhage!occurred.!! Sometimes,!dystocia,!prolonged!and!obstructed!labour!were!grouped!together!despite!the!important! difference! in! clinical! severity! between! these! conditions.! ! And! finally,! the! terms! prevalence$ and$ incidence$ were$ used$ interchangeably$ and$ at$ times$ inconsistently$ across$ studies,! leading! to! the! inclusion!of!both!prevalence!and!incidence!data!in!this!review.!!$ ! Additionally,! certain$ complications$ were$ more$ commonly$ studied! than! others.! ! Based! on! the! retrieved! articles,! only! four! articles! related! to! complications! of! abortion! and! the! same! number! studied! ectopic! pregnancy,! while! 28! published,! peerFreviewed! papers! had! data! regarding! hypertensive! disorders! of! pregnancy.! ! This! is! likely! attributable! to! the! greater! incidence! and! prevalence! of! hypertensive! disorders! of! pregnancy! which,! like! haemorrhage,! is! a! major! cause! of! maternal! morbidity! and! mortality! across! the! globe.! ! In! contrast,! obstetric! interventions! such! as! vacuum! extraction,! induction! and/or! augmentation! of! labour,! and! caesarean! sections! were! not! covered! in! the! final! list! of! articles! reviewed.! These! procedures! will! influence! the! total! number! of! interventions!carried!out!and!thus!the!possible!caseload!for!the!MNH!workforce.!Further!collection! and!analysis!of!related!data!is!required!to!inform!the!development!of!an!appropriate!benchmark!that! appreciates!potential!workload!as!well!as!skill!mix.! ! ! To!that!end,$the$exclusive$consideration$of$published,$peerGreviewed$articles$is$unlikely$to$provide$ an$ accurate$ indication$ regarding$ the$ rates$ at$ which$ obstetric$ complications$ are$ occurring! throughout! the! world! and! across! settings.! Publications! tend! to! evaluate! limited! populations! in! specific!settings;!they!are!rarely!populationFbased!and!more!commonly!facilityFbased.!There!may!also! be! a! publicationFbias! that! considers! obstetric! complications! and! interventions! more! readily! marketable! than! their! prevalence/incidence.! ! ! Similarly,! by! the! nature! of! the! publication,! peerF reviewed! articles! are! generally! limited! in! the! amount! of! data! that! can! be! included.! In! further! investigation!of!this!topic,!relevant$information$may$also$be$obtained$through$grey$literature,$field$ studies$ and$ programme$ analysis$ reports.! ! While! such! sources! may! not! be! peerFreviewed! by! a! journal,! they! may! have! been! subject! to! other! quality! and! peerFreview! mechanisms! and! be! appropriate!to!the!purpose.!!! ! A! final! set! of! concerns! regarding! bias$ within$ studies$ stemmed$ from$ the$ very$ specific$ research$ questions! presented! in! some! of! the! articles.! ! One! study! by! Ali! and! AbuFHeija! (2002)71!considers! a! very! precise!case!group,! namely!women! of! gravida! 5! or! greater! with! a! previous! caesarean! section.! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 71

!Ali,!A.M.!&!AbuFHeija,!A.T.,!2002.!Obstetric!and!perinatal!outcome!of!women!para!>!or!=!5!including!one!lower!segment! cesarean!section.!The$Journal$of$Obstetrics$and$Gynaecology$Research,!28(3),!pp.163–165.!

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What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! ! Roman! et! al.! (2007) 72 !compare! outcomes! of! obese! and! nonFobese! women,! measuring! rates! of! complications! through! matched! case! and! control! groups.! ! Obesity! is! an! important! risk! factor! for! several!obstetric!complications,!and!the!obese!group!had!over!twice!the!number!of!cases!compared! to!the!nonFobese!group.!!Recalculating!rates!so!that!the!case!and!control!groups!represent!a!single! population!raised!the!rate!of!hypertensive!disorders!by!60%!when!compared!to!the!nonFobese!group! alone.!!! ! 6

Conclusions$

The!complexity$of$understanding$obstetric$complications$and$their$prevalence$is$evident!from!the! present!rapid!review.!!Obstetric!complications!and!their!occurrence!are!often!the!result!of!multiple! and!dynamic!factors!such!as!preFexisting!health,!age!and!obstetric!risk!combined!with!key!social!and! societal! components! such! as! lifeFstyle! and! habits,! socioFeconomic! status,! careFseeking! behaviours! and!access!(geographic,!financial,!etc.)!to!timely!and!effective!care.!!These!factors!lend!themselves!to$ question$whether$a$uniform$benchmark$for$human$resource$planning$is$possible.!!! ! Creating$ a$ universal$ guideline$ regarding$ the$ productive$ capacity$ of$ a$ health$ worker$ based$ on$ an$ overview$ of$ the$ global$ prevalence$ of$ obstetric$ complications$ may$ ignore$ the$ multiple$ variables$ that$ impact$ prevalence.! ! The! creation! of! a! universal! paradigm! for! appreciating! obstetric! complications! that! considers! the! social,! regional! and! biophysical! factors! that! impact! obstetric! complications!is!crucial!for!the!development!of!fully!functional!health!systems,!with!an!appropriately! equipped! and! located! workforce! who! is! enabled! and! trained! to! address! maternal! mortality! and! morbidity.! ! 6.1$Next$steps$ There!are!several!possible!avenues!that!may!provide!further!evidence!to!inform!the!benchmarking! discussions.! The! WHO! MultiFCountry! Survey! may! give! some! new! global! data,! but! has! not! yet! been! published.! This! is! the! largestFever! study! on! the! prevalence! of! pregnancyFrelated! complications! and! severe!maternal!outcomes!using!standardized!definitions!across!29!countries.!Data!are!collected!on! more!than!314’000!women,!312’000!infants!born!alive!and!4000!stillbirths.!Approximately!7%!of!the! population! presented! with! potentially! lifeFthreatening! conditions! and! about! 1%! of! the! study! population!developed!a!severe!maternal!outcome!(i.e.!maternal!death!or!near!miss).!However,!the! study! only! included! hospitals! with! more! than! 1000! births! per! year.! Whether! these! data! can! be! extrapolated! to! show! prevalence! in! the! entire! population! is! questionable.! It! is! known! that! access,! utilisation! and! referral! to! larger! hospitals! can! be! large! barriers! for! women! from! poor! or! rural! backgrounds! and! hence! there! is! a! high! probability! that! their! pregnancy! outcomes! are! not! represented.! ! EmOC! assessment! reports! (e.g.! AMDD)! could! be! another! source! of! information! on! numbers! of! obstetric!complications.!!Similarly,!the!US!Centers!for!Disease!Control!and!Prevention!(CDC)!produce! surveillance!data!that!could!contribute!to!the!existing!knowledge!as!do!the!WHO!Service!Availability! and! Readiness! Assessment! (SARA)! reports! and! the! Indepth! network! data,! among! others.! !CountryF level! data! were! collected! in! the! Matlab! studies! and! prevalence! could! also! be! found! in! the! malaria! studies! from! Mozambique.! However,! as! these! sources! are! not! published! in! peerFreviewed! journals! they! were! not! eligible! for! consideration! in! this! review.! Also! excluded! from! this! current! effort! are! older!articles,!before!2002.!For!instance,!studies!reporting!on!caesarean!sections!in!Britain!and!the! USA73,!74!considered!incidence!of!selected!obstetric!complications!as!possible!determinants!of!rising! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 72

!Roman,!H.!et!al.,!2007.!Obstetrical!and!neonatal!outcomes!in!obese!women.!West$Indian$Medical$Journal,!56,!pp.421–426! !Francome,!C.!&!Savage,!W.,!1993.!Caesarean!section!in!Britain!and!the!United!States!12%!or!24%:!is!either!the!right!rate?! Social$Science$&$Medicine,!37(10),!pp.1199–218.!Available!at:!http://www.ncbi.nlm.nih.gov/pubmed/8272899.! 74 !Butler,!N.R.!&!Bonham,!D.G.,!1963.!Section!I!Postmortem!findings.!In!Perinatal$Mortality:$First$Report$of$the$British$ Perinatal$Mortality$Survey.!Edinburgh:!Churchill!Livingstone,!pp.!143–176.! 73

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What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! ! caesarean!section!rates.!$ In! conclusion,! the! earlier! work! by! Pittrof! &! Campbell! (2000)75!and! Ronsmans! (2002)76!seems! to! be! confirmed.! The! articles! retrieved! from! the! agreed! search! criteria! and! extraction! tool! for! this! rapid! review! found! no! research! focused! on! the! prevalence! of! obstetric! complications.! This! results! in! a! continued$ lack$ of$ empirical$ evidence$ to$ support$ the$ discussion$ on$ the$ occurrence$ of$ obstetric$ complications$ and$ the$ need$ for$ interventions,! seriously! curtailing! the! work! on! health! system! and! human!resource!development!in!this!field!of!medicine.! ! Further! discussion! is! needed! on! whether! and! how! to! adjust! these! gaps! in! knowledge! for! the! next! steps!in!benchmark!development,!or!whether!to!accept!the!limitations!and!work!on!topFdown!and! bottomFup!workforce!planning!models!for!a!‘typical’!district!population.! ! 7

Funding$

The! Instituto! de! Cooperación! Social! Integrare! conducted! this! rapid! review! with! funding! made! available!by!World!Health!Organization,!Geneva.!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 75

!Pittrof,!R.!&!Campbell,!O.,!2000.!Quality$of$Maternity$Care:$Silver$Bullet$or$Red$Herring?,!London:!London!School!of! Hygiene!&!Tropical!Medicine..!! 76 !!Ronsmans,!C.!et!al.,!2002.!Questioning!the!indicators!of!need!for!obstetric!care.!Bulletin$of$the$World$Health$ Organization,!80(4),!pp.317–24.!!

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What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! !

$ 8

Annexes$

Annex$1.$Conceptual$graphic$of$obstetric$complications$

Underlying!determinants! !

Women’s! status!

Employment! Autonomy!

Biological( (genetic))factors! !

Health&status! Nutritional!status! Infectious!diseases! HIV/AIDS! Chronic!conditions!

%!Complications!

Family’s!status! within! community!

Reproductive+ status! Age!

Community’s! status!

Parity!

Health&seeking& behavior! Use!of!ANC! Use!of!delivery!care! Unsafe!abortion!

Functionality! of!health! system!

Measurement!!issues!

Socioeconomic!!status!

Education!

Immediate!determinants!

Definition! problems! ! Variations!in! severity!! ! Data! collection! issues! ! ! ! !

Measured!%!of! complications!

Access%to%health% services! Physical!access!(transport,!location)!

Financial!access! Availability!of!HRH,!infrastructure,! supplies! Quality!of!care!

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What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! ! $ Annex$2.$Search$strategy$$ ! â&#x20AC;˘ Ovid!MEDLINE(R)!InFProcess!&!Other!NonFIndexed!Citations!and!Ovid!MEDLINE(R)!<1946!to! Present>!22/11/12! ! 1!!!!!Obstetric!Labor!Complications/ep,!mo!(2121)! 2!!!!!Pregnancy!Complications/mo!(1204)! 3!!!!!1!or!2!(3191)! 4!!!!!((obstetric$1!or!obstetrical!or!maternal!or!pregnan$)!adj4!nearFmiss$).ti,ab.!(105)! 5! ! ! ! ! ((obstetric$1! or! obstetrical)! adj3! emergenc$! adj4! (ratio! or! rate! or! trend$1! or! number$1! or! frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(29)! 6! ! ! ! ! ((postFpartum! or! postpartum! or! obstetric$! or! emergency! or! periFpartum! or! peripartum)! adj4! hysterectom$!adj4!(ratio!or!rate!or!trend$1!or!number$1!or!frequency!or!estimate$1!or!incidence!or! prevalence)).ti,ab.!(83)! 7! ! ! ! ! ((admission$1! or! admitted)! adj4! (obstetric$1! or! obstetrical! or! maternal)! adj4! (icu! or! intensive! care!or!critical!care!or!high!dependency)).ti,ab.!(124)! 8!!!!!(pregnan$!adj3!morbidit$!adj4!(ratio!or!rate!or!trend$1!or!number$1!or!frequency!or!estimate$1! or!incidence!or!prevalence)).ti,ab.!(33)! 9! ! ! ! ! (pregnan$! adj3! complication$1! adj4! (ratio! or! rate! or! trend$1! or! number$1! or! frequency! or! estimate$1!or!incidence!or!prevalence)).ti,ab.!(519)! 10!!!!!((anteFpartum!or!antepartum)!adj3!complication$1!adj4!(ratio!or!rate!or!trend$1!or!number$1! or!frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(11)! 11! ! ! ! ! ((obstetric$1! or! obstetrical)! adj3! morbidit$! adj4! (ratio! or! rate! or! trend$1! or! number$1! or! frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(14)! 12! ! ! ! ! ((intraFpartum! or! intrapartum)! adj3! morbidit$! adj4! (ratio! or! rate! or! trend$1! or! number$1! or! frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(3)! 13!!!!!((intraFpartum!or!intrapartum)!adj3!complication$1!adj4!(ratio!or!rate!or!trend$1!or!number$1! or!frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(32)! 14!!!!!((obstetric$1!or!obstetrical)!adj3!complication$1!adj4!(ratio!or!rate!or!trend$1!or!number$1!or! frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(248)! 15!!!!!(severe!maternal!morbidit$!or!acute!maternal!morbidit$!or!serious!maternal!morbidit$).ti,ab.! (233)! 16!!!!!or/4F15!(1336)! 17!!!!!3!or!16!(4336)! 18!!!!!animals/!not!humans/!(3718640)! 19!!!!!(letter!or!editorial!or!case!reports).pt.!(2552898)! 20!!!!!17!not!(18!or!19)!(3941)! 21!!!!!limit!20!to!yr="2002!FCurrent"!(2017)! 22!!!!!limit!20!to!yr="1992!FCurrent"!(2823)! ! â&#x20AC;˘ Embase!via!Ovid!<1974!to!2012!November!21>!26/11/12! ! 1!!!!!labor!complication/ep![Epidemiology]!(888)! 2!!!!!maternal!morbidity/ep,!et![Epidemiology,!Etiology]!(105)! 3!!!!!1!or!2!(990)! 4!!!!!((obstetric$1!or!obstetrical!or!maternal!or!pregnan$)!adj4!nearFmiss$).ti,ab.!(147)! 5! ! ! ! ! ((obstetric$1! or! obstetrical)! adj3! emergenc$! adj4! (ratio! or! rate! or! trend$1! or! number$1! or! frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(46)!

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What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! ! 6! ! ! ! ! ((postFpartum! or! postpartum! or! obstetric$! or! emergency! or! periFpartum! or! peripartum)! adj4! hysterectom$!adj4!(ratio!or!rate!or!trend$1!or!number$1!or!frequency!or!estimate$1!or!incidence!or! prevalence)).ti,ab.!(111)! 7! ! ! ! ! ((admission$1! or! admitted)! adj4! (obstetric$1! or! obstetrical! or! maternal)! adj4! (icu! or! intensive! care!or!critical!care!or!high!dependency)).ti,ab.!(192)! 8!!!!!(pregnan$!adj3!morbidit$!adj4!(ratio!or!rate!or!trend$1!or!number$1!or!frequency!or!estimate$1! or!incidence!or!prevalence)).ti,ab.!(38)! 9! ! ! ! ! (pregnan$! adj3! complication$1! adj4! (ratio! or! rate! or! trend$1! or! number$1! or! frequency! or! estimate$1!or!incidence!or!prevalence)).ti,ab.!(694)! 10!!!!!((anteFpartum!or!antepartum)!adj3!complication$1!adj4!(ratio!or!rate!or!trend$1!or!number$1! or!frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(10)! 11! ! ! ! ! ((obstetric$1! or! obstetrical)! adj3! morbidit$! adj4! (ratio! or! rate! or! trend$1! or! number$1! or! frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(20)! 12! ! ! ! ! ((intraFpartum! or! intrapartum)! adj3! morbidit$! adj4! (ratio! or! rate! or! trend$1! or! number$1! or! frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(4)! 13!!!!!((intraFpartum!or!intrapartum)!adj3!complication$1!adj4!(ratio!or!rate!or!trend$1!or!number$1! or!frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(36)! 14!!!!!((obstetric$1!or!obstetrical)!adj3!complication$1!adj4!(ratio!or!rate!or!trend$1!or!number$1!or! frequency!or!estimate$1!or!incidence!or!prevalence)).ti,ab.!(354)! 15!!!!!(severe!maternal!morbidit$!or!acute!maternal!morbidit$!or!serious!maternal!morbidit$).ti,ab.! (325)! 16!!!!!or/4F15!(1832)! 17!!!!!3!or!16!(2749)! 18!!!!!(animal/!or!nonhuman/)!not!human/!(4533005)! 19!!!!!case!report/!(1905984)! 20!!!!!(letter!or!editorial).pt.!(1225595)! 21!!!!!17!not!(18!or!19!or!20)!(2579)! 22!!!!!limit!21!to!yr="2002!FCurrent"!(1527)! ! â&#x20AC;˘ LILACS!via!iAH!form!http://bases.bireme.br/cgiF bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&base=LILACS&lang=i&form=A!27/11/12!! ! Note:$ Due$ to$ the$ failure$ of$ the$ export$ option$ in$ the$ Virtual$ Health$ Library$ interface,$ these$ searches$ were$run$using$the$iAH$form.$$This$interface$has$limited$functionality$which$impacted$on$the$adaption$ of$the$search.$$ $ Due$ to$ the$ difficultly$ limiting$ the$ search$ by$ date,$ records$ from$ all$ years$ were$ downloaded$ into$ EndNote.$ $ Here,$ the$ preW2002$ records$ were$ removed$ and$ the$ remainder$ saved$ as$ RIS$ files$ for$ the$ client.$$$$ ! (TW! obstetric$! OR! TW! materna$! OR! TW! pregnan$! OR! TW! embaraz$! OR! TW! gravide$! OR! MH! pregnancy)!AND!(TW!near!AND!TW!miss$)!23! ! (TW! obstetric$! OR! TW! materna$! OR! TW! pregnan$! OR! TW! embaraz$! OR! TW! gravide$! OR! MH! pregnancy)!AND!(TW!emergenc$!OR!TW!urgencias!medicas!OR!MH!emergencies)!AND!(TW!ratio!OR! TW!rate!OR!TW!trend$!OR!TW!number!OR!TW!frequency!OR!TW!estimate!OR!TW!incidence!OR!TW! prevalence!OR!MH!incidence!OR!MH!prevalence)!57! ! (TW!postFpartum!OR!TW!postpartum!OR!TW!obstetric$!OR!TW!emergenc$!OR!TW!periFparum!OR!TW! peripartum)!AND!(TW!hysterectom$!OR!MH!hysterectomy!OR!TW!histerectom$)!AND!(TW!ratio!OR!

February!2013!!

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What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! ! TW!rate!OR!TW!trend$!OR!TW!number!OR!TW!frequency!OR!TW!estimate!OR!TW!incidence!OR!TW! prevalence!OR!MH!incidence!OR!MH!prevalence)!34! ! (TW! admission$! OR! TW! admitted! OR! TW! admitido! OR! TW! admision$! OR! TW! admissoes! OR! TW! admissao)!AND!(TW!"intensive!care"!OR!TW!ICU!OR!TW!"critical!care"!OR!TW!"high!dependancy"!OR! MH! intensive! care! OR! MH! intensive! care! unit! OR! TW! "cuidados! intensivos"! OR! TW! "Terapia! Intensiva")!OR!(TW!obstetric$!OR!TW!materna$)!20! ! (TW! pregnan$! OR! TW! embaraz$! OR! TW! gravide$)! AND! (TW! morbidit$! OR! TW! morbilidad! OR! TW! morbidade)! AND! (TW! ratio! OR! TW! rate! OR! TW! trend$! OR! TW! number! OR! TW! frequency! OR! TW! estimate!OR!TW!incidence!OR!TW!prevalence!OR!MH!incidence!OR!MH!prevalence)!354! ! (TW!anteFpartum!OR!TW!antepartum)!AND!complication$1!AND!(TW!ratio!OR!TW!rate!OR!TW!trend$! OR! TW! number! OR! TW! frequency! OR! TW! estimate! OR! TW! incidence! OR! TW! prevalence! OR! MH! incidence!OR!MH!prevalence)!10! ! (TW! obstetric$)! AND! (TW! morbidit$! OR! TW! morbilidad! OR! TW! morbidade)! AND! (TW! ratio! OR! TW! rate! OR! TW! trend$! OR! TW! number! OR! TW! frequency! OR! TW! estimate! OR! TW! incidence! OR! TW! prevalence!OR!MH!incidence!OR!MH!prevalence)!!32! ! (TW! intrapartum! OR! TW! intraFpartum)! AND! (TW! morbidit$! OR! TW! morbilidad! OR! TW! morbidade)! AND!(TW!ratio!OR!TW!rate!OR!TW!trend$!OR!TW!number!OR!TW!frequency!OR!TW!estimate!OR!TW! incidence!OR!TW!prevalence!OR!MH!incidence!OR!MH!prevalence)!4! ! (TW!intrapartum!OR!TW!intraFpartum)!AND!(TW!complication$)!AND!(TW!ratio!OR!TW!rate!OR!TW! trend$!OR!TW!number!OR!TW!frequency!OR!TW!estimate!OR!TW!incidence!OR!TW!prevalence!OR! MH!incidence!OR!MH!prevalence)!!14! ! (TW!obstetric$)!AND!TW!complication$!AND!(TW!ratio!OR!TW!rate!OR!TW!trend$!OR!TW!number!OR! TW! frequency! OR! TW! estimate! OR! TW! incidence! OR! TW! prevalence! OR! MH! incidence! OR! MH! prevalence)!310! ! TW! “severe! maternal! morbidity”! OR! TW! “acute! maternal! morbidity”! OR! TW! “serious! maternal! morbidity”!14! ! Search$process$ The! original! search! was! designed! to! retrieve! papers! on! rates! of! complications,! causes! of! mortality,! and!rates!of!interventions.!!No!date,!geographical,!language!or!sample!size!limits!were!applied.!!This! very!broad!search!retrieved!too!many!results!to!be!manageable!and!so!it!was!necessary!to!revise!the! scope! of! the! search! and! increase! the! precision! of! the! strategy.! ! Adaptions! were! tested! against! published,!relevant!systematic!reviews!to!test!that!sensitivity!was!preserved!(Tunclap!et!al.!2012!and! Minkauskiene! et! al.! 2004).! ! Sample! results! were! reviewed! in! order! to! identify! any! further! refinements.!!Key!changes!to!the!initial!strategy!include:!! ! • Removing!searches!related!to!outcomes!for!the!infant!such!as!premature!birth!or!stillbirth.!! • Removing!searches!for!specific!obstetric!complications.!!These!search!lines!retrieved!a!large! number! of! irrelevant! results.! ! An! analysis! of! relevant! records! showed! that! restricting! the! search! to! the! more! generic! terms! did! not! have! a! significant! impact! on! sensitivity,! but! did! greatly!increase!precision.!!!

February!2013!!

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What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! ! • Removing!searches!for!rates!of!maternal!mortality!as!a!large!number!of!these!studies!did!not! provide! the! required! data! on! causation.! ! It! was! accepted! that! this! may! result! in! some! potentially!relevant!studies!reporting!maternal!death!by!cause!being!missed.!! • The! addition! of! searches! to! capture! rates! of! emergency! hysterectomy! and! obstetric! ICU! admission! as! indicators! of! obstetric! complication.! ! Rates! of! caesarean! section! was! not! searched! for! specifically! as! there! is! a! large! volume! of! literature! associated! with! this! topic,! much!of!it!concerned!with!elective!or!nonFmaternally!indicated!procedures.!!! • Restricting! the! subject! heading! searches! to! the! two! headings! found! most! frequently! in! relevant! studies.! ! PubReMiner! was! also! employed! to! confirm! the! suitability! of! these! index! terms.!!Although!the!subject!heading!searches!bring!back!a!large!number!of!false!positives,!it! was! decided! not! to! remove! them.! ! The! variability! of! language! in! the! title! and! abstracts! of! relevant!papers!meant!that!relying!on!keyword!searches!would!result!in!an!unacceptable!loss! of!sensitivity.!! • Introducing!a!date!limit!of!2002!to!current.!!! ! The!search!was!restricted!to!three!electronic!databases.!!These!were!selected!based!on!the!findings! of! a! 2004! World! Health! Organization! systematic! review! of! maternal! mortality! and! morbidity.! ! The! paper! they! published! discussing! the! utility! of! information! resources! in! this! topic! area! identified! MEDLINE!and!EMBASE!as!essential!sources!as!they!retrieved!the!largest!volume!of!unique!references! (Betran! et! al.! 2005).! ! ! LILACS! was! the! source! of! the! third! largest! number! of! unique! references! and! provided!valuable!information!from!journals!published!outside!of!Western!Europe!and!the!USA.!! ! The! MEDLINE! searches! were! adapted! for! the! other! search! resources.! ! In! LILACS,! key! terms! were! translated!into!Spanish!and!Portuguese!and!added!to!the!search.!!

February!2013!!

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What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! !

$ Annex$3.$$Extraction$tool$ ! Screening$ 1. Does!the!report!refer!to!incidence/prevalence!rates!of!obstetric!complications?!! 2. Is!the!methodology!of!the!study!described?! 3. Does!the!report!specify!dates!for!data!collection?! 4. Is!the!number!of!study!participants!more!than!500?! $ Section$A:$General$Characteristics$of$the$Study$ 5. What!is!the!study!country?! 6. What!is!the!type!of!study?!(census,!crossFsectional,!cohort/longitudinal,!controlled!trial,! incidence/prevalence!survey)! 7. What!is!the!sampling!method?!(random!sample,!nonFrandom!sample,!total!population)! 8. What!is!the!source!of!the!data?!(vital!statistics/census,!medical!records,!special! survey/interview,!multiple!sources,!clinical!data!collected!for!study)! 9. What!is!the!sample!size?! 10. What!is!the!evaluated!population?! 10.1. Urban/rural/mixed?! 10.2. Are!the!characteristics!of!the!population!described?!(socioFeconomic!status,!ethnic! group,!age!group,!etc.)! 10.3. Are!the!health!characteristics!of!the!population!described?!(healthy!women,!women! with!a!specific!condition,!etc.)! 11. Is!there!information!about!eligible/lost!subjects!and!their!characteristics?! 12. What!is!the!place!studied?!(national,!province/region,!city,!medical!facility,!etc.)! 13. What!is!the!place!of!delivery/abortion?!(home,!hospital,!mixed,!unknown,!n/a,!etc.)! $ Section$B:$Prevalence/Incidence$of$Obstetric$Complications/Maternal$Morbidity$$ 14. Which!conditions!are!investigated?! 15. What!are!the!diagnostic!criteria?! 16. How!many!cases!are!recorded!per!condition?! 17. What!is!the!prevalence/incidence!of!the!conditions!investigated?! 18. Are!background!causes!of!the!complications!examined?! ! Section$C:$Quality$Assessment$of$Morbidity$Reports$ 19. Are!all!concepts!and!conditions!clearly!defined?$ 20. Is!the!diagnostic!procedure!described?$ ! ! ! ! ! ! ! ! ! ! ! ! ! ! February!2013!!

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What$ is$ the$ evidence$ on$ the$ proportion$ of$ pregnancies$ that$ result$ in$ obstetric$ complications$ and$ require$referral$to$specialist$care?$A$rapid$literature$review.! ! ! Annex$4.$Extraction$process$! $ Screening$strategy$ The! databases! EMBASE,! LILACS! and! MEDLINE! were! searched! using! the! developed! search! strategy.! Number!of!articles!found!was!2017!for!MEDLINE,!1527!for!EMBASE!and!872!for!LILACS.!Screening!out! of! duplicates! using! Mendeley! rendered! 3160! original! articles! for! revision.! ! These! articles! were! organized!into!subsets!based!on!the!search!terms!that!obtained!them.!This!allowed!for!prioritization! of! the! most! relevant! article! sets! for! a! more! exhaustive! review! process.! HighFpriority! sets! (search! terms:! obstetric! complications! or! morbidity)! were! screened! through! a! detailed! abstract! review,! whereas! lowFpriority! sets! (all! related! search! terms)! were! screened! through! a! title! review! and! abstract!review!where!necessary.!! ! Screening!consisted!of!four!essential!questions:!! 1. Does! the! report! refer! to! incidence/prevalence! rates! of! obstetric! complications! within! a! normal!population?!! 2. Is!the!methodology!of!the!study!described?! 3. Does!the!report!specify!dates!for!data!collection?! 4. Is!the!number!of!study!participants!greater!than!500?! ! A!total!of!324!articles!were!selected!as!having!passed!the!screening!process.!Given!time!constraints,! a! second! screening! was! performed! on! these! articles! to! identify! those! with! a! high! relevance! to! the! purpose!of!the!review,!that!is,!those!with!reference!to!any!of!the!following!obstetric!complications,! as! defined! by! UNFPA/WHO/UNICEF 77 :! haemorrhage! (antepartum! or! postpartum);! prolonged! or! obstructed! labour;! postpartum! sepsis;! complications! of! abortion;! preFeclampsia/eclampsia;! ectopic! pregnancy;! ruptured! uterus.! A! total! of! 60! articles! were! obtained! from! this! secondary! screening! process.! ! ! !

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 77

!United!Nations!Population!Fund!(UNFPA),!World!Health!Organization!(WHO)!&!United!Nations!Childrenâ&#x20AC;&#x2122;s!Fund!(UNICEF),! 1997.!Guidelines$for$Monitoring$the$Availability$and$Use$of$Obstetric$Services,!New!York:!UNICEF.!

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What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Annex%5.%Summary%characteristics%of%studies%% Publication

6Study6 Country

Title

Author(s)

Impact'of' grandmultiparity'on' obstetric'outcome'in' low'resource'setting.

The'Journal'of' Agrawal,'S.,' Obstetrics'and' Agarwal,'A.'&'Das,' Gynaecology' V.,' research

Grandmultiparity'and' pregnancy'outcome'in' Aba,'Nigeria:'a'caseP control'study.

This'study'compared'the'incidence'of' antenatal'and'intrapartum' complications'and'perinatal'outcomes' Archives'of' Akwuruoha,'E.'et' among'women'who'had'delivered'five' Gynecology'and' 2011 Nigeria al. or'more'times'(grandmultiparous)'with' Obstetrics those'of'agePmatched'controls'who'had' delivered'two'to'four'times' (multiparous).

PrePeclampsia:'maternal' AlPMulhim,'APA'et' Fetal'Diagnosis' risk'factors'and' al.' and'Therapy perinatal'outcome.

High'incidence'of' obstetric'complications' Ali,'A.'A.'et'al.' in'Kassala'Hospital,' Eastern'Sudan.

February"2013""

Journal'of' Obstetrics'and' Gynaecology

Year Description

To'evaluate'the'impact'of' grandmultiparity'on'obstetric'outcome' in'a'low'resource'setting,'this'study' 2011 compared'282'antenatal' India grandmultiparous'women'(parity'≥'4)' with'consecutive'564'antenatal'women' with'parity'1–3.

Type6of6Study

Sampling6 Method

Data6Source

Antenatal'women' Retrospective' with'parity'1P3' Hospital' case'control' used'as'control' records study group

Retrospective'review'of'the'medical' files'of'women'delivered'at'Kassala' Sudan Hospital,'Eastern'Sudan'in'the'period'of' JanuaryPDecember'2009.'

"

Eligible6subjects

564'women

Parity'1P3

AgePmatching'to' grandP Maternal'case' CasePcontrol 734'women multiparous' records women

The'aim'of'this'study'was'to'throw'light' on'the'incidence'of'prePeclampsia'(PE)' in'women'attending'for'care'and' delivery'at'a'hospital'in'Saudi'Arabia,' and'analyze'the'maternal'risk'factors' Women' and'outcome'of'mothers'and'neonates' Retrospective' delivering'in'the' Hospital' 2003 Saudi'Arabia in'pregnancies'complicated'by'PE.'This' study hospital'during' records retrospective'study'involved'almost'all' the'study'period women'(n'='27,787)'who'delivered'at' King'Fahad'Hospital'of'the'University'in' a'10Pyear'period'(1992P2001).'

2012

Sample6Size

Retrospective' chart'review' All'deliveries (descriptive' analysis)

Hospital' records

27'787' maternities

4689' deliveries

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given There'were'13'403'deliveries'over'the'study'period.'The' prevalence'of'grandmultipara'was'2.3%.' Grandmultipara'were'older'(P'<'0.001)'and'more' commonly'from'rural'areas'(P'<'0.001)'as'compared'to' the'control'group.'The'percentage'of'Muslims'among' grandmultipara'(23.8%)'was'higher'than'among' controls'(16.5%),'P'<'0.01.'Grandmultipara'had' significantly'higher'prevalence'of'anaemia'(P'<'0.001),' Pregnancy'induced'hypertension;' malpresentation'(P'='0.01)'and'rupture'uterus'(P'<' eclampsia;'obstructed'labour;'ruptured' 0.001).'Abruptio'placenta,'placenta'previa'and' uterus obstructed'labour'were'seen'more'often'in' grandmultipara,'and'the'difference'was'statistically' significant'(P'<'0.01'in'each'group).'There'was'no' difference'in'terms'of'mode'of'delivery,'sex'of'newborn' or'the'prevalence'of'low'birthweight'(<2.5'kg)'babies.' Stillbirths'were'more'common'in'grandmultiparas'(P'<' 0.001).

Primigravidae' excluded

PregnancyPinduced'hypertension:'defined' as'blood'pressure'measurement'of'140' mmHg'systolic'or'higher'and/or'90'mmHg' diastolic'or'higher'on'two'occasions'at' least'6'h'apart;'prolonged'labour;' obstructed'labour;'puerperal'sepsis;' uterine'rupture;'primary'postpartum' haemorrhage:'defined'as'the'loss'of'500' ml'of'blood'or'more'within'24'h'of' delivery,'using'visual'estimation'which' was'correlated'with'clinical'presentation.

Not'described

Study'documents'a'hospitalPbased'incidence'rate'of'PE' of'2.47%,'with'a'high'proportion'of'PE'cases'occurring' among'nulliparous'women'and'those'at'the'extreme' Severe'hypertension:'diastolic'blood' ends'of'the'reproductive'age.'More'maternal'and' pressure'measurement'of'≥120'mm'Hg'on' neonatal'complications'were'encountered'in'women' one'occasion,'or'≥110'mm'Hg'on'2' with'PE'when'the'PE'was'severe,'when'the'pregnancy' occasions,'4'hours'apart.' had'to'be'terminated'early,'when'there'was'no'regular' antenatal'care,'the'birthPweight'was'low,'or'the' proteinuria'was'severe

All'deliveries

31"

PrePeclampsia;'eclampsia;'APH;'PPH;' obstructed'labour;'ruptured'uterus.'

Study'shows'that'there'is'an'increased'risk'of'antenatal' anaemia,'multiple'pregnancy,'primary'postpartum' haemorrhage,'and'adverse'perinatal'outcomes'in' grandmultiparous'women'independent'of'maternal' age.

Out'of'4,689'delivered'women,'14.7%'were'teenagers,' 67.1%'had'no'antenatal'care'and'12.6%'were'grandP' multiparous.'Obstetric'complications'included:'preP term'birth'(2.6%);'prePeclampsia/eclampsia'(4.2%);' haemorrhage'(2.9%);'malpresentation'(5.5%);' obstructed'labour'(1.9%)'and'ruptured'uterus'(0.6%).' Caesarean'delivery'rate'was'31.1%.'While'89.4%'of'the' newborn'babies'were'taken'home,'6%'were'admitted' to'the'nursery,'4.4%'were'stillbirths,'and'0.2%' immediate'neoP'natal'deaths.'There'were'26'maternal' deaths'(550'per'100,000'live'births),'mainly'due'to' septicaemia'(38.4%),'haemorrhage'(19.2%),'embolism' (15.3%)'and'malaria'(11.5%).'Thus,'there'is'a'high' frequency'of'maternal'morbidities'and'mortality'which' needs'improvement'in'obstetric'care.'


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Author(s)

Obstetric)and)perinatal) outcome)of)women) Ali,)A.M.)&)Abu= para)>)or)=)5)including) Heija,)A.T one)lower)segment) cesarean)section.

Obstetric)near=miss)and) maternal)mortality)in) maternity)university) Almerie,)Y.)et)al.) hospital,)Damascus,) Syria;)a)retrospective) study

Maternal)morbidity) during)labour)and)the) puerperium)in)rural) homes)and)rhe)need)for) Bang,)R.)A.)et)al.) medical)attention:)A) prospective) observational)study)in) Gadchiroli,)India

Severe)obstetric) maternal)morbidity:)a) 15=year)population= based)study.

Baskett,)T.F.)&) O’Connell,)C.M.

February"2013""

6Study6 Country

Year

The)Journal)of) Obstetrics)and) Gynaecology) Research

All)women) delivering)at) hospital,)cases) are)those)with)5) The)aim)of)this)study)was)to)investigate)) or)more) the)prevalence)of)antenatal,) deliveries)and)a) intrapartum)and)postnatal) Retrospective) previous) Hospital) 2002 complications)and)their)perinatal) Saudi)Arabia case=control) caesarean) records outcome)in)women)who)are)delivering) study section,)control) for)the)6th)time)and)have)also)had)one) all)others)except) cesarean)section. those)with)2) caesarean) sections)(only) planned)vaginal) deliveries)

BMC)Pregnancy) and)Childbirth

The)aims)of)this)study)are)to)document) the)frequency)and)nature)of)maternal) near=miss)at)hospital)level)in)Damascus,) Capital)of)Syria;)and)to)evaluate)the) level)of)care)at)maternal)life=saving) emergency)services)by)comparatively) 2010 analysing)near=misses)and)maternal) Syria mortalities.)A)retrospective)facility= based)review)of)cases)of)near=miss)and) maternal)mortality)that)took)place)in) the)years)2006=2007)at)Damascus) Maternity)University)Hospital,)Syria)was) conducted.)

BJOG:)an) International) Journal)of) Obstetrics)and) Gynaecology

This)prospective)observational)study) aimed)to)estimate)the)incidence)of) maternal)morbidity)during)labour)and) the)puerperium)in)rural)homes;)the) association)with)perinatal)outcome;)and) the)proportion)of)women)needing) 2004 medical)attention.)Thirty=nine)villages)in) India the)Gadchiroli)district,)Maharashtra,) India,)were)surveyed,)with)772)women) recruited)over)a)one)year)period)(1995= 1996))and)followed)up)from)the) seventh)month)in)pregnancy)to)28)days) postpartum)(up)to)10)visits)in)total).

Journal)of) Obstetrics)and) Gynaecology

Description

This)study)chose)five)markers)of) maternal)morbidity:)blood)transfusion) ≥5)units,)emergency)hysterectomy,) complete)uterine)rupture,)eclampsia,) and)the)need)for)intensive)care)(ICU)) that)are)considered)to)cover)the)main) complications)threatening)maternal) health)including:)haemorrhage)and) disseminated)intravascular)coagulation;) complications)of)hypertensive) 2005 Canada disorders,)including)pulmonary)oedema,) coma,)renal)dysfunction;)sepsis;)and) other)major)medical)disorders)that) require)intensive)care.)In)a)population= based)study)these)markers)of)maternal) morbidity)were)assessed)and)related)to) age,)parity)and)method)of)delivery.))The) primary)obstetric)complication)leading) to)the)morbidity)was)ascertained.

"

Type6of6Study

Sampling6 Method

Publication

Data6Source

All)admissions)to) Retrospective) maternity) Hospital) study hospital)in)2006= records 07

All)women) Observational) delivering)in)39) study study)villages.)

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given The)incidence)of)malpresentation)was)higher)in)the) study)group.)The)incidence)of)uterine)rupture)and) uterine)scar)dehiscence)was)significantly)higher)in)the) study)group,)but)there)was)no)perinatal)or)maternal) death)associated)with)this)and)in)all)cases)the)uterus) Control)group) was)preserved.)More)women)managed)to)deliver) excludes)those) vaginally)after)the)cesarean)section)in)the) with)previous)c= grandmultiparous)women)compared)with)the)women) sections,)case) 2708)cases) in)the)control)group)(81.5%)vs)63.0%))P)<)0.00006,) group)is)only)those) Uterine)scar)dehiscence)and/or)rupture. and)controls. where)the)cesarean)section)rate)was)significantly)higher) with)at)least)5) (P)<)0.02).)There)were)no)significant)differences)in)the) deliveries)(and)1) incidences)of)preterm)labor,)lethal)malformations,) C/S).))No)planned) stillbirths)and)neonatal)deaths)in)the)two)groups)of) C/S)are)included. women.)There)was)one)case)of)cesarean)hysterectomy) in)each)group)due)to)placenta)accreta)and)atonic) postpartum)hemorrhage,)and)one)maternal)death)in) the)control)group. Sample6Size

Severe)haemorrhage)(leading)to)shock,) emergency)hysterectomy,)coagulation) defects)and/or)blood)transfusion)of)≥)2) litres);)hypertensive)disorders)in) pregnancy)which)include)eclampsia,) 28)025) All)women)giving) severe)pre=eclampsia)(BP)>140/)90)mmHg) deliveries)or) birth)at)the)facility) and)proteinuria)>)1g/24hrs))or)HELLP) 27)350)live) during)the)study) syndrome;)sepsis)defined)as)a) births period. temperature)<)36°C)or)>)38°C)and)clinical) signs)of)shock)(systolic)BP)<)90)mmHg)and) heart)rate)>)120)beats)per)minute);) dystocia)which)includes)uterine)rupture) and)impending)rupture;

Observation)by) village)health) 772) worker,) pregnancies validated)by) physician.)

All)deliveries) Retrospective) (≥500g))in)Nova) Perinatal) study Scotia)hospitals,) database 1988=2002.))

Eligible6subjects

159896) deliveries

All)deliveries

There)were)28)025)deliveries,)15)maternal)deaths)and) 901)near=miss)cases.)The)study)showed)a)MNMR)of) 32.9/1000)live)births,)a)MMR)of)54.8/100)000)live)births) and)a)relatively)low)mortality)index)of)1.7%.) Hypertensive)disorders)(52%))and)haemorrhage)(34%)) were)the)top)causes)of)near=misses.)Late)pregnancy) haemorrhage)was)the)leading)cause)of)maternal) mortality)(60%))while)sepsis)had)the)highest)mortality) index)(7.4%).

The)incidence)of)maternal)morbidity)was)52.6%,)17.7%) during)labour)and)42.9%)during)puerperium.)The)most) common)intrapartum)morbidities)were)prolonged) Prolonged)labour:)labour)duration)greater) labour)(10.1%),)prolonged)rupture)of)membranes) than)24)hours)from)the)onset)of)mild)pains) (5.7%),)abnormal)presentation)(4.0%))and)primary) to)the)birth)of)baby;)Primary)postpartum) postpartum)haemorrhage)(3.2%).)The)postpartum) haemorrhage)(PPH):)Excessive)bleeding)on) morbidities)included)breast)problems)(18.4%),) first)day)and)mother)hypothermic) secondary)postpartum)haemorrhage)(15.2%),)puerperal) (<35.0jC))or)unconscious;)Puerperal) genital)infections)(10.2%))and)insomnia)(7.4%).) infection)of)genital)tract:)Foul)smelling) Abnormal)presentation)and)some)puerperal) vaginal)discharge)and)fever;)or)foul) complications)(infection,)fits,)psychosis)and)breast) smelling)vaginal)discharge)and)secondary) problems))were)significantly)associated)with)adverse) PPH;) perinatal)outcomes,)but)prolonged)labour)was)not.)A) third)of)the)mothers)were)in)need)of)medical)attention:) 15.3%)required)emergency)obstetric)care)and)24.0%) required)non=emergency)medical)attention.

There)were)159,896)mothers)delivered)of)whom)313) (2.0/1000))had)385)markers)of)severe)morbidity)(257) had)one,)42)had)two,)12)had)three,)and)two)had)four).) The)following)rates)of)morbidity)were)recorded:)blood) transfusion)55)units)119)(0.74/1000);)emergency) hysterectomy)88)(0.55/1000);)uterine)rupture)49) (0.31/1000);)eclampsia)46)(0.28/1000);)ICU)83) Excludes) Eclampsia;)Complete)uterine)rupture:)full) (0.52/1000).)There)was)a)statistically)significant) miscarriage)and) thickness)of)uterine)muscle)and) association)between)multiparity)≥1,)and)emergency) ectopic)pregnancy. peritoneum. hysterectomy)and)uterine)rupture;)between)age)≥35) years,)and)emergency)hysterectomy,)uterine)rupture) and)ICU;)and)between)caesarean)delivery)and)blood) transfusion)≥5)units,)emergency)hysterectomy,)uterine) rupture,)eclampsia)and)ICU.)The)main)contributing) obstetric)complications)were)haemorrhage)(64.7%))and) complications)of)hypertensive)disorders)(16.8%).

32"


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Author(s)

Overview'of'maternal' morbidity'during' hospitalization'for'labor' Berg,'C.'J.'et'al. and'delivery'in'the' United'States:'1993> 1997'and'2001>2005.

Endometriosis'is' associated'with'a' decreased'risk'of'pre> eclampsia.

Brosens,'I.'A.,'et' al.'

Publication

Obstetrics'and' Gynecology

Human' Reproduction'

6Study6 Country

Year Description

Type6of6Study

Sampling6 Method

This'study'assesses'progress'toward' meeting'the'U.S.'Healthy'People'2010' Data'from' objective'of'reducing'the'rate'of' National'Hospital' maternal'morbidity'at'delivery' Discharge'Survey,' hospitalization'by'comparing'National' which,'with' National' Hospital'Discharge'Survey'data'from' Retrospective' application'of' Hospital' 2009 two'time'periods.'Rates'of'intrapartum' United'States cohort'study appropriate' Discharge' morbidity'defined'by'obstetric' sampling'weights,' Survey complications,'preexisting'medical' represents'all' conditions,'and'caesarean'delivery' hospitalizations'in' during'2001>2005'are'compared''with' the'US.' rates'published'for'1993>1997.' This'retrospective'case–control'study,' set'at'the'University'of'Ghent'IVF' centre,'compared'the'incidence'of'pre> eclampsia'and'pregnancy>induced' hypertension'(PIH)'following'the'clinical' and/or'laparoscopic'diagnosis'of' endometriosis>associated'infertility' 2007 with'the'incidence'of'these'obstetric' Belgium complications'in'pregnancies'following' treatment'for'male>factor'infertility.' Pregnancy'data'were'obtained'by' searching'electronic'databases'and' postal'questionnaires.'The'case'and' control'groups'were'matched'for'age,' parity'and'multiple'pregnancies.

Patients'in' fertility'clinic'for' endometriosis' Retrospective' associated' case>control infertility.'Male' factor'infertility' used'as'a'control' group.

Extent'of'maternal' Paediatric'and' morbidity'in'a'managed' Bruce,'F.'C.'et'al.' Perinatal' care'population'in' Epidemiology Georgia

To'obtain'an'accurate'assessment'of' maternal'morbidity,'this'study'applied'a' validated'computerised'algorithm'to' identify'pregnancies'and'pregnancy> related'complications'in'a'defined' United' 2012 population'enrolled'in'a'health' States maintenance'organisation'in'the'south> eastern'US.'Most'common'morbidities' were'examined'by'pregnancy'outcome' and'maternal'characteristics.

Data'from'Health' Management' Organization' searched'for' Retrospective' pregnancy' study episodes'and' outcomes'using'a' computerized' algorithm.

Maternal'morbidity' Obstetrics'and' rates'in'a'managed'care' Bruce,'F.'C.'et'al.' Gynecology population.

This'study'aimed'to'identify'and' estimate'prevalence'rates'of'maternal' morbidities'by'pregnancy'outcome'and' selected'covariates'during'the' antepartum,'intrapartum,'and' postpartum'periods'in'a'defined' population'of'pregnant'women.' Electronic'data'systems'of'a'large,' vertically'integrated,'group>model' United' 2008 health'maintenance'organization' States (HMO)'were'used'to'develop'an' algorithm'that'searched'International' Classification'of'Diseases,'9th'Revision,' Clinical'Modification,'codes'for'38' predetermined'groups'of'pregnancy> related'complications'among'women' enrolees'of'this'HMO'between'January' 1,'1998,'and'December'31,'2001.

Data'from'Health' Management' Organization' searched'for' Retrospective' pregnancy' study episodes'and' outcomes'using'a' computerized' algorithm.

February"2013""

Data6Source

"

Eligible6subjects

39'067'000' deliveries

Excludes'all' deliveries' APH;'PPH;'pre>eclampsia'and'eclampsia;' associated'with' uterine'rupture;'sepsis'>'all'defined' hydatidiform'mole,' according'to'International'Classification'of' ectopic'pregnancy,' Diseases,'9th'Revision,'Clinical' spontaneous'or' Modification'(ICD>9>CM)'criteria. induced'abortion

Health' Management' Organization' (HMO)' database

'Between'1993>1997'and'2001>2005,'the'rate'of' obstetric'complications'remained'unchanged'at'28.6%;' the'prevalence'of'preexisting'medical'conditions'at' delivery'increased'from'4.1%'to'4.9%.'Rates'of'chronic' hypertension'and'preeclampsia,'gestational'and' preexisting'diabetes,'asthma,'and'postpartum' haemorrhage'increased,'whereas'rates'of'third>'and' fourth>degree'lacerations'and'various'types'of'infection' decreased.'The'caesarean'delivery'rate'increased'from' 21.8%'to'28.3%.

The'incidence'of'pre>eclampsia'was'significantly'lower' in'the'case'group'(0.8%)'when'compared'with'control' group'(5.8%).'Analysis'of'obstetric'outcome'in'the' subgroup'of'patients'with'laparoscopic'data'confirmed' the'lower'risk'of'pre>eclampsia'in'the'case'(1.2%)' PIH:'persistently'raised'blood'pressure' versus'control'(7.4%)'groups.'PIH'occurred'in'3.5%'and' (≥140/'90'mmHg)'starting'after'the'20th' Excludes'multiple' 8.7%'of'case'and'control'pregnancies,'respectively.'The' week'of'gestation'in'an'otherwise' cause'infertility. odds'of'developing'pre>eclampsia'were'5.67'times' normotensive'woman;'Pre>eclampsia:'PIH' higher'in'the'control'group'than'in'pregnancies' with'proteinuria'(≥300'mg/24'h). following'endometriosis>associated'infertility.'In' multiple'pregnancies,'the'odds'of'developing'pre> eclampsia'increased'1.93'times'per'additional'child,' with'or'without'endometriosis.'

Medical' database'and' 519' postal' deliveries questionnaires

Health' Management' Organization' (HMO)' database

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given

Sample6Size

The'study'identified'37'741'pregnancies;'in'half' (50.7%),'at'least'one'complication'occurred.'The'five' most'common'were'urinary'tract'infections,'anaemia,' mental'health'conditions,'pelvic'and'perineal' complications,'and'obstetrical'infections.'Complications' were'more'likely'in'women'with'low'socio>economic' status'(SES),'and'among'non>Hispanic'Black'women' Pregnancy>induced'hypertension;'APH'>'all' compared'with'non>Hispanic'White'women.' defined'according'to'ICD>9>CM'criteria. Multivariable'models'stratified'by'race/'ethnicity' indicated'that'in'pregnancies'among'non>Hispanic' White'women,'low'SES'had'a'modest'effect'on'the'odds' of'having'preexisting'medical'conditions'[adjusted'odd' ratio'(AOR)'1.3'[95%'confidence'interval'(CI)'1.2,'1.5]]' or'having'any'morbidity'(AOR'1.3'[95%'CI'1.2,'1.4]).'Low' SES'had'little'effect'on'complications'among'non> Hispanic'Black'women.

37'741' pregnancies

Excludes' pregnancies'that' end'in'a'livebirth' and'a'stillbirth.'

24'481' pregnancies

Females'aged' 12–55'years,' whose'pregnancy' episode'occurred' completely'within' APH;'PPH;'uterine'rupture;'hypertensive' the'study'period' disorders'of'pregnancy'>'all'defined' (1998–2001)'and' according'to'ICD>9>CM'criteria who'were'still' members'of'the' HMO'at'the'date'of' the'pregnancy' outcome.'

33"

Study'identified'24,481'pregnancies'among'21,011' women.'Although'prevalence'and'type'of'morbidity' varied'by'pregnancy'outcome,'overall,'50%'of'women' had'at'least'one'complication.'The'most'common' complications'were'anaemia'(9.3%),'urinary'tract' infections'(9.0%),'mental'health'conditions'(9.0%),' hypertensive'disorders'(8.5%),'and'pelvic'and'perineal' trauma'(7.0%).'The'most'common'complications'we' found'usually'do'not'require'hospitalization'so'would' be'missed'in'studies'that'use'only'hospitalization'data.


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Author(s)

Severe%maternal% morbidity%and%factors% Camargo,%R.S.%et% associated%with%the% al. occurrence%of%abortion% in%Brazil.

Reduction%in%the% Chhabra,%S.,% occurrence%of%uterine% Bhagwat,%N.%&% rupture%in%Central%India. Chakravorty,%A.

Pregnancy% complications%by% overweight%and% residential%area.%A% Clausen,%T.%et%al. prospective%study%of%an% urban%Norwegian% cohort.

Publication

Objective%of%this%study%was%to%evaluate% the%reported%occurrence%of% spontaneous%and%induced%abortion,%and% abortionFassociated%severe%maternal% International% morbidity%in%Brazil.%A%secondary%analysis% Journal%of% 2011 of%the%2006%Brazilian%Demographic% Brazil Gynaecology%and% Health%Survey%was%conducted.%Interview% Obstetrics data%on%women's%experience%of% spontaneous/induced%abortion%and% associated%factors%were%analyzed% overall%and%by%geographic%region.%

Journal%of% Obstetrics%and% Gynaecology

Acta%Obstetricia% et%Gynecologica% Scandinavica

Impact%of%Maternal%Age% ClearyFGoldman,% Obstetrics%and% on%Obstetric%Outcome J.%et%al.%% Gynecology

February"2013""

6Study6 Country

Year Description

Study%of%cases%of%uterine%rupture%in%the% Department%of%Obstetrics%and% 2002 Gynaecology%of%the%Mahatma%Gandhi% India Institute%of%Medical%Sciences,%Sevagram,% Central%India,%between%1989%and%2000.%

This%prospective%cohort%%study% compares%risks%of%pregnancy% 2006 complications%in%Oslo%according%to% Norway prevalence%of%overweight%and%areas%of% residency.

Objective%of%this%study%was%to%estimate% the%effect%of%maternal%age%on%obstetric% outcomes.%A%prospective%database%from% a%multicenter%investigation%of% singletons,%the%FASTER%trial,%was% studied.%Multivariable%logistic% United% 2005 regression%analysis%was%used%to%assess% States the%effect%of%age%on%outcomes%after% adjusting%for%race,%parity,%body%mass% index,%education,%marital%status,% smoking,%medical%history,%use%of% assisted%conception,%and%patient’s%study% site.

"

Type6of6Study

Sampling6 Method

Secondary% analysis

Interview%data%on% women's% experience%of% spontaneous/ind uced%abortion%for% Demographic% previous%5%years% Health%Survey and%associated% factors%analyzed% overall%and%by% geographic% region.%

Retrospective% All%records study

Data6Source

Hospital% records

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given The%reported%lifetime%rates%of%spontaneous%and%induced% abortion%were%13.3%%and%2.3%,%respectively,%and%were% highest%in%the%north%(4.3%)%and%northeast%(3.5%).%The% rate%of%spontaneous%abortion%was%higher%among% women%aged%40F49%years%(odds%ratio%[OR]%1.15;%95%% confidence%interval%[CI],%1.03F1.30)%and%among%those% 5500% Some%losses%to% with%0%or%1%children%or%delivery%(OR%1.97;%95%%CI,%1.36F pregnancies% followFup,%mainly% Eclampsia;%haemorrhage;%infection;%any% 2.85%vs%OR%1.98;%95%%CI,%1.37F2.86).%Induced%abortion% and%4340% from%refusal%to% complication/procedure% was%not%associated%with%sociodemographic%factors.% women% participate Abortion%significantly%increased%the%risk%of% complications%(haemorrhage%and%infection).,% CONCLUSION:%Spontaneous%abortion%was%significantly% associated%with%parity%and%maternal%age.%Abortion%in% general%carried%a%higher%risk%of%severe%maternal% complications. Sample6Size

25%546% deliveries

All%pregnant% women% (Norwegian% ancestry)%in% hospital%area% receiving% appointment%for% Prospective% 3677% ultrasound% Medical%records cohort%study deliveries screening%during% December%1994%F% August%1996,% saving%exclusions% (see% eligibible/lost% subjects).

All%subjects%with% complete% Medical%trial% outcome% data:% information% Retrospective% questionnaire,% 36056% included%in%the% audit patient% deliveries FASTER%trial,%from% interview,% 15%centres% medical%records throughout%the% US.%

Eligible6subjects

All%deliveries

The%incidence%of%rupture%of%the%pregnant%uterus%was% 0.62%per%1000%births.%No%teenager%or%elderly%woman% (over%40)%or%grandmultipara%sustained%a%uterine% rupture.%Four%women%had%a%rupture%of%a%previous%scar.% In%five%rupture%had%occurred%in%association%with% malpresentations,%one%was%a%case%of%hydrocephalus,% two%had%a%morbidly%adherent%placenta%praevia%and%four% Complete%uterine%rupture:%all%the%layers%of% had%a%normal%presentation,%with%lack%of%progress%in% uterine%wall%had%given%way.% labour.%Perinatal%mortality%was%77e77%%compared%to% 5e88%%maternal%and%100%%perinatal%mortality%in%the% cases%reported%previously%between%83%and%88,%from%the% same%institution.%Overall,%there%is%some%improvement%in% perinatal%survival%and%oneFquarter%incidence%of%rupture% of%the%pregnant%uterus.

Pregnant%women%from%areas%of%lower%socioeconomic% status%(Oslo%East)%had%higher%prevalence%of%overweight% Excluded:% than%women%from%areas%of%higher%status%(Oslo%West).% pregnancies% DoseFresponse%relationships%were%found%between%body% ending%in%abortions% mass%index%and%increased%risk%of%pregnancy% PreFeclampsia:%PregnancyFinduced% <24%weeks,% complications%(preFeclampsia,%gestational%hypertension,% hypertension%and%proteinuria%(pregnancyF multiple% gestational%diabetes%mellitus,%macrosomia,%cesarean% induced%hypertension%required%blood% pregnancies,% deliveries,%acute%cesarean%deliveries,%transfer%of%the% pressure%≥140/90%mmHg%or%an%increase%in% women%who%did% newborn%to%neonatal%intensive%care%unit).%Comparing% diastolic%pressure%of%≥%15mmHg%compared% not%speak% Oslo%East%with%Oslo%West%the%relative%risks%of%pregnancy% with%average%measurements%before%20% Norwegian,% complications%were%1.8%for%preFeclampsia,%1.6%for% weeks’%gestation,%measured%twice%at%least% nonresidents%of% gestational%diabetes,%1.4%for%acute%cesarean%deliveries,% 6%h%apart;%proteinuria%was%defined%≥+1%on% Oslo,%women%who% 1.6%for%low%birth%weight%(<%or%=2,500%g)%and%1.5%for% a%dipstick%(300mg/24h)%read%at%least%twice,% delivered%at%other% transfer%to%neonatal%intensive%care.%Adjustment%for% with%an%interval%of%≥6h);%Gestational% hospitals,%women% body%mass%index%did%not%change%the%increased%risks%of% hypertension:%pregnancyFinduced% lost%to%followFup% preFeclampsia,%acute%cesarean%deliveries,%low%birth% hypertension%without%proteinuria. before%screening,% weight,%or%transfer%to%neonatal%intensive%care%among% missing%medical% Oslo%East%women.%Only%the%increased%risk%of%gestational% records.% diabetes%could%partially%be%explained%by%higher%body% mass%index. Eligible%subjects:% viable%singleton% intraF%uterine% pregnancy%without% evidence%of% anencephaly%or% cystic%hygroma,% which%was% confirmed%by% ultrasound% examination%at%the% time%of%trial% enrolment.

34"

Gestational%hypertension%(blood%pressure% >%140/90%on%at%least%2%occasions%greater% than%6%hours%apart%without%evidence%of% chronic%hypertension%or%significant% proteinuria);%Preeclampsia%(criteria%for% gestational%hypertension%and%significant% proteinuria).

Increasing%age%was%significantly%associated%with% miscarriage,%chromosomal%abnormalities,%congenital% anomalies,%gestational%diabetes,%placenta%previa,%and% caesarean%delivery.%Patients%aged%35–39%years%were%at% increased%risk%for%macrosomia.%Increased%risk%for% abruption,%preterm%delivery,%low%birth%weight,%and% perinatal%mortality%was%noted%in%women%aged%40%years% and%older.


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Author(s)

Publication

6Study6 Country

Year Description

PopulationCbased'record'linkage'case' cohort'of'239,995'births,'to'119,214' women,'born'in'Western'Australia'from' 2010 1980'to'2001'inclusive,'was'used'to' Australia measure'the'recording'of'selected' indicators'of'maternal'health'(current' and'prior)'during'pregnancy.

Type6of6Study

Sampling6 Method

Data6Source

Recorded'pregnancy' histories'of'the'mothers' of'singletons'and'the' Croft,'M.L.'et'al. mothers'of'twins:'a' longitudinal' comparison.

Twin'Research' and'Human' Genetics

Magnitude'of'maternal' morbidity'during'labor' Danel,'I.'et'al.' and'delivery:'United' States,'1993C1997.

This'study'sought'to'determine'the' prevalence'of'maternal'morbidity' during'labour'and'delivery'in'the'United' American'Journal' United' 2003 States.'Analyses'focused'on'National' of'Public'Health States Hospital'Discharge'Survey'data'available' for'women'giving'birth'between'1993' and'1997.

Descriptive' analysis

Fetal'gender'and' gestationalCageCrelated' Elsmen,'E.'et'al.' incidence'of'preC eclampsia.

Aim'of'this'populationCbased'study'was' to'investigate'whether'the'fetal'and' newborn'gender'is'associated'with'the' Acta'Obstetricia' incidence'of'antenatal'maternal' et'Gynecologica' 2006 Sweden pregnancy'complications,'and'to' Scandinavica investigate'if'genderCassociated'risk' changes'with'gestational'age'at' delivery.

All'newborn' infants'registered' in'the'Medical' Retrospective' Birth'Register' National'birth' populationC (MBR)'during'a' database. based'study. 12Cyear'period:' January'1,'1990' to'December'31,' 2001.

The'objective'of'this'study'was'to' describe'deliveryCrelated'complications' and'postpartum'morbidity'of'women' Delivery'related' International' living'in'slum'areas'of'Dhaka,' complications'and'early' Journal'of' Bangladesh.'From'November'1993'to' Fronczak,'N.,'et'al. 2005 Bangladesh postpartum'morbidity'in' Gynaecology'and' May'1995,'1506'women'were' Dhaka,'Bangladesh Obstetrics interviewed'regarding'deliveryCrelated' complications'and'postpartum' morbidities.

Comparison'of''648'pregnancies' exposed'to'lowCmolecularCweight' Safety'of'lowCmolecularC European'Journal' heparin'(LMWH)'treatment'during' weight'heparin'during' of'Obstetrics,' pregnancy'for'the'mother'and'the' Galambosi,'P.J.'et' pregnancy:'a' Gynecology,'and' 2012 foetus'with'626'unexposed' Finland al. retrospective'controlled' Reproductive' pregnancies.'Principal'characteristics,' cohort'study. Biology indications'for'LMWH'use,'and' maternal'and'foetal'complications'were' reported'for'each'pregnancy.

February"2013""

"

Retrospective' Record'linkage'of' Populational' case'cohort' singleton'births' study study to'twin'births

All' hospitalizations' for'delivery' included'in'the' National'Hospital' Discharge'Survey

National' Hospital' Discharge' Survey

MultiCstage' Prospective,' probability' communityC methodology' Interviews based'study. used'for'selection' of'women.

Control'group'for' women'treated' Retrospective' with'LMHW,' Hospital' controlled' matched'for'age' records cohort'study and'delivery' route

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given

Sample6Size

Eligible6subjects

117'647' women

Eligibility:'all' women'in'the' Pathways'study,' with'at'least'two' births'recorded' between' PreCeclampsia;'Eclampsia;'APH'(placenta' 1980–2001,'whose' praevia);'APH'with'abruptio'placentae;' first'child'was'a' APH'(other) singleton'born' during'1980'to' 2001'inclusive,'and' whose'second' born'infants'were'' singletons

154'001' records' representing' All'deliveries 19'081'038' deliveries

APH;'PPH;'preCeclampsia;'eclampsia;' uterine'rupture;'sepsis'C'all'according'to' ICDC9CCM'criteria.

'Women'with'twins'were'significantly'older'and'taller,' with'similar'rates'of'medical'conditions'and'pregnancy' complications'during'first'singleton'pregnancies' compared'with'women'with'two'consecutive' singletons.'However,'during'their'second'pregnancy,' women'with'twins'had'significantly'higher'rates'of' essential'hypertension,'preCeclampsia,'threatened' abortion,'premature'rupture'of'the'membranes'and' ante'partum'hemorrhage'with'abruption'than'women' with'singletons.'For'both'groups,'maternal'conditions'in' the'first'pregnancy'were'underreported'in'the'second' pregnancy,'including'diabetes,'epilepsy,'asthma,' chronic'renal'dysfunction'and'essential'hypertension.'

The'prevalence'of'specific'types'of'maternal'morbidity' was'low,'but'the'burden'of'overall'morbidity'was'high.' 43%'of'women'experienced'some'type'of'morbidity' during'their'delivery'hospitalization.'31%'(1.2'million' women)'had'at'least'1'obstetric'complication'or'at'least' 1'preexisting'medical'condition.

1158276' deliveries'

Included:'live'born' infants'of'all' gestations,'and' stillborn'infants'≥ 28'weeks' gestation.' Singletons'as'well' as'multiple' pregnancies'were' included.

When'all'gestational'ages'were'evaluated,'male' newborn'gender'was'associated'with'increased'odds' PreCeclampsia:'pregnancyCspecific' ratios'for'all'five'diagnosis'groups,'and'for'preterm' syndrome'observed'after'the'20th'week'of' birth'before'37'weeks'gestation.'In'very'preterm'births' pregnancy'with'systolic'blood'pressure'of' (gestational'age'below'32'weeks),'male'newborn' ≥140mmHg'and/or'diastolic'blood' gender'was'associated'with'a'significantly'lower'risk'for' pressure'of'≥90'mmHg'accompanied'by' preCeclampsia,'and'a'marginally'lower'risk'for' significant'proteinuria'(i.e.'urinary' polyhydramnios.'The'finding'could'be'due'to'an' excretion'of'≥0.3'g'protein'in'a'24Ch' increased'risk'for'spontaneous'abortions'in'pregnancies' specimen). with'male'fetuses,'but'could'also'be'associated'with'the' etiology'of'these'conditions.

1506' deliveries.

Eligibility:'women' living'in'slums,' completed'at'least' 7'months'of' pregnancy,' planning'to'give' birth'in'Dhaka.

ThirtyCsix'percent'of'women'described'serious'deliveryC related'complications'and'75%'of'women'reported' Severe'antepartum'bleeding;'Intrapartum' postpartum'morbidity.'There'were'two'maternal' bleeding;'Hypertensive'disorders;'PreC deaths'among'1471'live'births.'When'maternal'reports' eclampsia;'Eclampsia;'Prolonged'labour' were'related'to'corroborating'information,'the' (>18'hours'and'≥6'hours).' proportion'of'women’s'reports'of'serious'complications' and'morbidity'appears'reasonably'accurate'for'some' conditions.

626' pregnancies

Singleton' pregnancies'only

35"

Antenatal'bleeding;'PreCeclampsia:' systolic'blood'pressure'≥160'mmHg' and/or'diastolic'blood'pressure'≥110' mmHg'and'proteinuria'≥5'g/day

The'incidence'rates'of'various'pregnancy'complications' did'not'differ'between'the'groups'(LMWH'group'vs' control'group):'1.56%'vs'1.1%'for'thrombocytopenia,' 8.7%'vs'6.5%'for'preterm'delivery,'0.7%'vs'0.3%'for' stillbirth,'1.4%'vs'1.0%'for'severe'preCeclampsia,'2.7%' vs'2.2%'for'foetal'growth'restriction,'and'10.7%'vs'7.8%' for'antenatal'bleeding.'One'serious'antenatal'maternal' haemorrhage'occurred'in'the'LMWH'group'(0.15%),'but' this'was'unrelated'to'LMWH'use.'The'caesarean'section' rate'and'the'amount'of'bleeding'during'delivery'were' similar'in'the'two'groups'(21%'vs'19%'and'500'vs'450' ml,'respectively).'The'risk'of'major'blood'loss'during' labour'(>1000'ml)'was'no'higher'in'the'LMWH'group' compared'with'the'control'group.'In'conclusion,'this' study'indicates'that'the'use'of'LMWH'is'safe'during' pregnancy.


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Author(s)

Maternal(outcomes( associated(with(planned( vaginal(versus(planned( Geller,(E.,(et(al. primary(caesarean( delivery

Publication

Year

6Study6 Country

Description

This(study(compared(maternal( morbidity(between(planned(vaginal(and( American(Journal( planned(cesarean(delivery.(A(university( United( 2010 of(Perinatology hospitalâ&#x20AC;&#x2122;s(database(was(queried(for( States delivery(outcomes,(between(1995(and( 2005.

Obstetric(complications( The(aim(of(this(study(was(to(compare( during(labour(and( obstetric(complications(during(labour( Guendelman,(S.(et( Women's(Health( United( delivery:(assessing( 2006 and(delivery(among(white(nonKLatina( al.( issues States ethnic(differences(in( (white),(black,(Asian,(and(Latina(women( California who(delivered(in(California(hospitals.

Prevalence(and(risk( factors(for(obstetric( haemorrhage(in(6730( singleton(births(after( assisted(reproductive( technology(in(Victoria( Australia.

Healy,(D.L.(et(al.

WHO(systematic(review( of(maternal(mortality( Hofmeyr,(G.(J.,( and(morbidity:(the( Say,(L.,(&( prevalence(of(uterine( Gulmezoglu,(A.(M rupture.

Incidence(of(Obstetric( and(Foetal( Complications(during( Labor(and(Delivery(at(a( Hoque,(M.( Community(Health( Centre,(Midwives( Obstetric(Unit(of( Durban,(South(Africa.

February"2013""

Type6of6Study

Sampling6 Method

All(deliveries( (1995K2005)(in( Retrospective( Hospital( hospital(database( study database meeting(study( criteria.

Human( Reproduction

Record(linkage( with(women( Retrospective( conceiving(after( cohort(study IVF(or(ICSI( (random( selection)

BJOG:(an( International( Journal(of( Obstetrics(and( Gynaecology

The(aim(of(this(systematic(review(was( to(determine(the(prevalence(of(uterine( rupture(worldwide.(All(available(data( 2005 since(1990(was(reviewed.(83( Global communityKbased(and(facility(based( reports(from(urban(and(rural(studies(( are(included(in(the(final(review.(

Systematic( review

The(objectives(of(this(retrospective( cohort(study(were(to(estimate(the( incidence(of(obstetric(complications( during(labor(and(delivery(and(their( demographic(predictors.(A(total(of(2706( Retrospective( 2011 South(Africa pregnant(women,(consecutively( cohort(study admitted(to(a(midwife(obstetric(unit( with(labor(pain(between(January(and( December(2007,(constituted(the( sample.

"

Sample6Size

4048( deliveries.

All(complete( records(of(Latina,( Black,(White(and( Asian(women(in( California(state( Retrospective( database,( 1426854( State(database study constituting(93%( deliveries of(women(that( gave(birth(in( California( between(1996( and(1998

This(retrospective(cohort(study( compared(the(prevalence(of( antepartum(haemorrhage((APH),( placenta(praevia,(placental(abruption( 2010 Australia and(primary(postKpartum(haemorrhage( (PPH)(in(women(with(singleton(births( between(1991(and(2004(in(Victoria( Australia.(

ISRN(Obstetrics( and(Gynecology

Data6Source

Perinatal(data( collection(unit

Medical(and( Database(search( social(science( with(published( databases;( methodology other(sources

All(women( consecutively( admitted(to(MW( Hospital( unit(with(labor( records pain(between( January(and( December(2007

24(619( deliveries

NA

2706( pregnancies

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given There(were(3868(planned(vaginal(deliveries(and(180( Exclusion(criteria( planned(cesarean(deliveries.(Planned(cesarean(delivery( included( had(less(chorioamnionitis((2.2%(versus(17.2%),( multiparity((i.e.,( postpartum(hemorrhage((1.1%(versus(6.0%),(uterine( any(prior(delivery( atony((0.6%(versus(6.4%),(and(prolonged(rupture(of( beyond(20(weeksâ&#x20AC;&#x2122;( Postpartum(haemorrhage:(defined(as( membranes((2.2%(versus(17.5%)(but(a(longer(hospital( gestation),( blood(loss(of(at(least(500(mL(during( stay((3.2(versus(2.6(days).(There(were(no(differences(in( multiple(gestation,( vaginal(birth(or(1000(mL(during(cesarean( transfusion(rates.(For(healthy(primiparous(women,( gestational(age( birth. planned(cesarean(delivery(decreases(certain( less(than(37(weeks,( morbidities.(Labored(cesarean(delivery(had(increased( and(any(major( risks(compared(with(both(vaginal(delivery(and( maternal( unlabored(cesarean(delivery. comorbidity.( Eligible6subjects

Excluded:(women( of(other(racial( groups(such(as( One(out(of(5(deliveries(had(>1(complication.(White( American(Indians( (21.3%)(and(Asian(women((21.1%)(had(similar( (due(to(small( prevalence(rates,(whereas(black(women((24.2%)(had( sample(sizes);( higher(and(Latina(women((19.6%)(had(lower(rates.( women(not( Postpartum(haemorrhage;(Major( After(adjusting(for(covariates,(the(odds(of(experiencing( residing(in( puerperal(infections.(All(defined(according( >1(complication(was(lower(for(Asians((and(Latinas(than( California(at(the( to(ICKD9KCM(criteria. whites;(the(odds(for(black(women(remained(elevated.( time(of(delivery,(or( Asian(women(stood(a(higher(risk(of(deliveries(with( whose(records( major(lacerations,(postpartum(haemorrhage,(and(major( were(missing( puerperal(infections.(Rates(for(the(latter(complication( maternal( were(higher(among(all(women(of(colour. birthplace( information. Obstetric(haemorrhages(were(defined( using(the(Victorian(PDCU(electronic(user( manual.(APH:(bleeding(of(15(ml(or(more( The(IVF/ICSI(group(had(more(APH:(6.7(versus(3.6%( from(the(birth(canal(after(20(weeks( (adjusted(OR(2.0;(95%(CI(1.8K2.3),(PP:(2.6(versus(1.1%( gestation(and(before(the(birth(of(the(baby.( (2.3;(1.9K2.9),(PA:(0.9(versus(0.4%((2.1;(1.4K3.0)(and( Only(singleton( PPH:(blood(loss(greater(than(500(ml(within( PPH:(11.1(versus(7.9%((1.3;(1.2K1.4)(than(the(general( births 24(h(of(vaginal(delivery(or(childbirth(or( population.(APH,(PP(and(PA(were(as(frequent(in(the( greater(than(750(ml(after(Caesarean( GIFT(group(as(in(the(IVF/ICSI(group,(but(were(less( section.(Consistent(with(the(International( frequent(in(the(nonKART(group.( Classification(of(Diseases((ICD10)(coding( system. Prevalence(figures(for(uterine(rupture(were(available( for(86(groups(of(women.(For(unselected(pregnant( women,(the(prevalence(of(uterine(rupture(reported( was(considerably(lower(for(communityKbased((median( 0.053,(range(0.016K0.30%)(than(for(facilityKbased( studies((0.31,(0.012K2.9%).(The(prevalence(tended(to(be( lower(for(countries(defined(by(the(United(Nations(as( Uterine(rupture:(various(definitions( NA developed(than(the(less(or(least(developed(countries.( considered. For(women(with(previous(caesarean(section,(the( prevalence(of(uterine(rupture(reported(was(in(the( region(of(1%.(Only(one(report(gave(a(prevalence(for( women(without(previous(caesarean(section,(from(a( developed(country,(and(this(was(extremely(low( (0.006%).

Excludes(women( discharged(after(6( hours(for(false( labour(or(other( pregnancy(related( conditions,(and( women(in(labour( referred(to( hospitals(for( obstetric(and(nonK obstetrical(risk( factors.

36"

16%(of(women(admitted(to(the(midwife(obstetric(unit( with(labor(pain(were(diagnosed(with(obstetrical(and( foetal(complications.(The(most(frequently(observed( Hypertensive(disorders(of(pregnancy;(CPD:( foetal(and(obstetric(complications(were(foetal(distress( measured(by(grading(of(moulding(and( (35.5/1000)(and(poor(progress(of(labor((28.3/1000),( formation(of(caput(on(foetal(head(with(no( respectively.(Primigravid(and(grandmultiparity(women( descent(of(foetal(head(but(foetal( were(12((OR(=(11.89)(and(5((OR(=(4.575)(times,( presentation(and(condition(are(found( respectively,(more(likely(to(have(complications(during( normal;(APH;(PPH:(excessive(vaginal( labor(and(delivery.(Women(without(antenatal(care(had( bleeding(after(delivery(on(the(first(day(and( doubled((OR(=(1.815,(95%(CI,(1.310;(2.515)(the(chance( the(mother(becomes(hypothermic((<35â&#x2014;ŚC)( of(having(complications.(Mothers(age(<20(years(was( or(unconscious.( protective((OR(=(0.579,(95%(CI,(0.348;(0.963)(of( complications(during(delivery(compared(to(women(who( were(>=35(years.


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Author(s)

Comparison*of*perinatal* and*obstetrics* outcomes*among*early* Hoque,*M.*and* adolescents,*late* Hoque,*S. adolescents*and*adult* pregnant*women*from* rural*South*Africa.

Profile*of*maternal*and* foetal*complications* during*labour*and* delivery*among*women* Huda,*F.*A.*et*al. giving*birth*in*hospitals* in*Matlab*and* Chandpur,*Bangladesh.

Publication

February"2013""

6Study6 Country

Description

Type6of6Study

Sampling6 Method

Data6Source

Sample6Size

The*objectives*of*this*retrospective* study*were*to*calculate*the*incidences* East*African* of*the*obstetric*and*perinatal* Retrospective* All*deliveries*in* 2870* Journal*of*Public* 2010 complications*at*the*time*of*delivery*of* South*Africa comparative* hospital*between* Hospital*records deliveries Health early*adolescent*and*late*adolescent* study AprilHDec*2004. mothers*and*then*compare*the*same* with*adult*pregnant*mothers.

This*paper*documents*the*types*and* severity*of*maternal*and*foetal* complications*among*women*who*gave* birth*in*hospitals*in*Matlab*and* Chandpur,*Bangladesh,*during*2007H 2008.*The*Community*Health*Research* Workers*(CHRWs)*of*the*icddr,b*service* area*in*Matlab*prospectively*collected* Journal*of*Health,* data*for*the*study*from*4,817*women* Population,*and* 2012 on*their*places*of*delivery*and* Bangladesh Nutrition pregnancy*outcomes..*Review*of* hospitalHrecords*was*attempted*for* 2,102*women*who*gave*birth*only*in* the*Matlab*Hospital*of*icddr,b*and*in* other*public*and*private*hospitals*in*the* Matlab*and*Chandpur*area.*Among* those,*1,927*records*were*found*and* reviewed*by*a*physician.

A*multistage*model*for* maternal*morbidity* Statistics*in* during*antenatal,* Islam,*M.*A.*et*al. Medicine delivery*and* postpartum*periods.

Systematic*review*of* the*magnitude*and*case* fatality*ratio*for*severe* maternal*morbidity*in* Kaye,*D.*K.*et*al. subHSaharan*Africa* between*1995*and* 2010.

Year

BMC*Pregnancy* and*Childbirth

This*study*employs*a*multistage*model* that*involves*transitions*at*different* stages*to*complications.*The*proposed* model*appears*to*display*more* meaningful*explanation*concerning*the* impact*of*different*factors*on*the* 2004 Bangladesh incidence*of*complications*taking*into* account*types*of*transitions.*Two* alternative*models*are*also*presented*in* this*paper*in*order*to*demonstrate* possible*simplifications*of*the*proposed* model.*

Targeted*all* pregnant*women* Survey*and* delivering*in* record*review Matlab*service* area*in*2007H08

Multistage* model.

This*study*assesses*the* prevalence/incidence*of*maternal*near* miss,*maternal*mortality*and*case* fatality*ratio*through*systematic*review* of*studies*on*severe*maternal*morbidity* in*subHSaharan*Africa.*Studies*that* SubHSaharan* *Systematic* 2011 reported*prevalence/incidence*of* Africa review severe*maternal*morbidity*(maternal* near*misses)*during*pregnancy,* childbirth*and*postpartum*period* between*1996*and*2010*were* examined.

"

Multistage* sampling*design* used*to*collect* data*used*in*the* study.

Community* Health* Research* Workers* (CHRWs)* prospectively* gather*data*on* women*in* icddr,*B.*

Eligible6subjects

All*women*on* hospital*registry* under*21.*

4817*women,* with*1927* All*abortions* delivery* excluded. records* reviewed

Maternal* Morbidity* 993* survey:*uses* All*pregnancies. pregnancies. observations* and*interviews.*

12*studies* (samples*of* Medical*and* selected*articles* social*science* varied*from*557H databases 23026).*

NA

NA

37"

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given Anaemia*in*pregnancy*was*considerably*high*among* the*early*adolescent*pregnant*mothers*(23%)*compared* to*older*adolescent*(15%)*and*adult*pregnant*mothers* (14%).*Other*conditions*such*as*pregnancy*induced* hypertension,*eclampsia,*and*diabetes*were*not* Hypertension;*Eclampsia;*PostHpartum* notably*different*among*the*groups.*Early*adolescents* haemorrhage.* mothers*were*twice*(OR*=*2.022,*95%*CI:*1.226*H*3.337)* as*likely*to*be*anaemic*during*pregnancy*compared*to* adult*mothers.*Low*birth*weight*delivery,*FSB*and*MSB* rates*among*the*groups*were*significantly*different*(p*>* 0.05). Haemorrhage:*Severe*antepartum*and* postpartum*haemorrhage*(bleeding*with* shock*or*transfused*with*2*or*more*units* of*blood);*Hypertensive*disorders*of* pregnancy:*Eclampsia*(seizures*associated* with*hypertension,*i.e.*diastolic*blood* pressure*â&#x2030;Ľ110*mmHg)*and*severe*preH eclampsia*(hypertension*with*proteinuria* >2*++,*blurred*vision,*or*hyperreflexia);* Septic*shock*or*septicaemia:*genital* source*of*infection*and*hyperthermia* (fever*38.3*°C*and*above*for*>48*hours)*or* hypothermia*and*low*blood*pressure* (systolic*<90*mmHg)*or*confusion*or* unconsciousness*or*scanty*urine*output* (<30*mL/hour)*and*faster*pulse*rate*(110* or*more/minute)*or*rapid*breathing*(30*or* more*breaths/minute)

By*reviewing*the*hospitalHrecords,*7.3%*of*the*women* who*gave*birth*in*the*local*hospitals*were*diagnosed* with*a*severe*maternal*complication,*and*16.1%*with*a* lessHsevere*maternal*complication.*Twelve*maternal* deaths*occurred*during*the*study*period;*most*(83%)*of* them*had*been*in*contact*with*a*hospital*before*death.*

This*study*reveals*that*the*women*who*suffer*from*one* or*more*of*the*major*complications*during*pregnancy* are*expected*to*have*a*substantially*higher*risk*of* Pregnancy*complications:*haemorrhage,* suffering*from*complications*during*postpartum*period,* oedema,*excessive*vomiting,* irrespective*of*no*complications*or*complications* fits/convulsion;*Delivery*complications:* during*delivery.*Generally*speaking,*higher*economic* excessive*haemorrhage*before*or*after* status*can*reduce*the*complications*at*the*postpartum* delivery,*retained*placenta,*obstructed* stage,*although*women*belonging*to*higher*economic* labour,*prolonged*labour,*other* status*may*suffer*from*complications*during*pregnancy* complications;*Postpartum*complications:* and*delivery*at*a*higher*rate.*It*is*surprising*that* haemorrhage,*any*other*discharge,*pelvic* antenatal*visit*is*positively*associated*with*incidence*of* pain,*cough*or*fever*for*more*than*3*days,* complications*during*pregnancy*and*delivery,*but* fits/convulsion. antenatal*visit*reduces*complications*at*the*postpartum* stage.

Ruptured*uterus;*sepsis,*obstructed* labour;*haemorrhage

12*studies*were*identified.*The*sample*size*varied*from* 557*women*to*23,026.*Different*definitions*and* terminologies*for*maternal*near*miss*included*acute* obstetric*complications,*severe*life*threatening* obstetric*complications*and*severe*obstetric* complications.*The*incidence/prevalence*ratio*and*caseH fatality*ratio*for*maternal*near*misses*ranged*from* 1.1%H*10.1%*and*3.1%H37.4%*respectively.*Ruptured* uterus,*sepsis,*obstructed*labor*and*hemorrhage*were* the*commonest*morbidities*that*were*analyzed.*The* incidence/prevalence*ratio*of*hemorrhage*ranged*from* 0.06%*to*3.05%,*while*the*case*fatality*ratio*for* hemorrhage*ranged*from*2.8%*to*27.3%.*The* prevalence/incidence*ratio*for*sepsis*ranged*from* 0.03%*to*0.7%,*while*the*case*fatality*ratio*ranged*from* 0.0%*to*72.7%.*The*incidence/prevalence*ratio*and*case* fatality*ratio*of*maternal*near*misses*are*very*high*in* studies*from*subHSaharan*Africa.*Large*differences*exist* between*countries*on*the*prevalence/incidence*of* maternal*near*misses.*This*could*be*due*to*different* contexts/settings,*variation*in*the*criteria*used*to* define*the*maternal*near*misses*morbidity,*or*rigor* used*carrying*out*the*study.*

%


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Temporal)trends)and) regional)variations)in) severe)maternal) morbidity)in)Canada,) 2003)to)2007.

Author(s)

Liu,)S.)et)al.

Publication

Journal)of) Obstetrics)and) Gynaecology) Canada

Contemporary)risks)of) maternal)morbidity)and) Luke,)B.)&)Brown,) Fertility)and) adverse)outcomes)with) M.)B. Sterility increasing)maternal)age) and)plurality

Method)of)delivery)and) pregnancy)outcomes)in) Asia:)the)WHO)global) Lumbiganon,)P.)et) Lancet survey)on)maternal)and) al.) perinatal)health)2007] 08.

Impact)of)maternal)age) The)Journal)of) on)the)incidence)of) Obstetrics)and) Matsuda,)Y.)et)al.) obstetrical) Gynaecology) complications)in)Japan. Research

February"2013""

6Study6 Country

Year Description

2010

Study)aimed)to)identify)temporal)trends) and)regional)variations)in)severe) Canada maternal)morbidity)in)Canada)using) routine)hospitalization)data.

Population]based,)historic)cohort)study) which)evaluates)the)risks)of)pregnancy) United) 2007 complications)and)adverse)outcomes) States associated)with)increasing)maternal)age) and)higher)plurality.

This)Article)reports)the)third)phase)of) the)WHO)global)survey,)which)aimed)to) estimate)the)rate)of)different)methods) of)delivery)and)to)examine)the)relation) 2010 between)method)of)delivery)and) maternal)and)perinatal)outcomes)in) selected)facilities)in)Africa)and)Latin) America)in)2004–05,)and)in)Asia)in) 2007–08.

9)Asian) countries:) Cambodia,) China,)India,) Japan,) Nepal,) Philippines,) Sri)Lanka,) Thailand,) and) Vietnam.

This)cohort)and)case]cohort)study) aimed)to)clarify)the)effect)of)maternal) age)on)obstetrical)complications.)242) 715)births)at)125)centres)of)a)perinatal) 2011 network)in)Japan)from)2001)through) Japan 2005)were)studied)as)a)base)cohort.) Women)with)single)pregnancies)who) delivered)after)22)weeks)of)gestation) were)included)in)the)study.

"

Type6of6Study

Sampling6 Method

Retrospective) All)hospital) study discharges

Population] based,) Entire)database historic) cohort)study.

Data6Source

Health) database

Birth) certificates

Sample6Size

1)336)356) deliveries

23320195) deliveries

All)women) submitted)for) delivery)for)3) months)in) Global) selected)) retrospective) 107950) institutions)with) Medical)records survey)of) deliveries 6000)or)fewer) deliveries deliveries,)and)2) months)in)those) with)more)than) 6000)deliveries.

Cohort)and) case]cohort) study

Not)clear)if)initial) 242)715)were)all) deliveries) meeting)criteria) Perinatal) for)main)cohort)in) registry) centre)(not) database specified).)) Subcohort:)By) random)selection) 3749)births)

242)715) deliveries

Eligible6subjects

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given

All)deliveries

The)overall)rate)of)severe)maternal)morbidity)was)13.8) per)1000)deliveries)(95%)CI)13.6)to)14.0).)Five)provinces) or)territories)had)rates)that)were)significantly)higher) than)those)in)the)rest)of)the)country:)Newfoundland) Eclampsia;)haemorrhage)with)coagulation) and)Labrador)(19.0)per)1000;)95%)CI)17.2)to)20.8),) defect;)rupture)of)uterus)before)labour;) Saskatchewan)(16.9)per)1000;)95%)CI)15.9)to)18.0),) rupture)of)uterus)during)labour;)puerperal) Alberta)(15.4)per)1000;)95%)CI)14.9)to)15.9),)Northwest) sepsis;)intrapartum)haemorrhage)with) Territories)(22.5)per)1000;)95%)CI)18.0)to)27.7),)and) blood)transfusion;)postpartum) Nunavut)(20.2)per)1000;)95%)CI)14.2)to)27.8).)Rates)of) haemorrhage)with)blood)transfusion;) some)illnesses)declined)(e.g.,)eclampsia)rates)decreased) postpartum)haemorrhage)with) from)12.4)in)2003)to)5.7)per)10)000)deliveries)in)2007,) hysterectomy. P<0.001),)while)others)increased)(e.g.,)postpartum) haemorrhage)with)blood)transfusion)rates)increased) from)36.6)in)2003)to)44.3)per)10)000)deliveries)in)2007,) P<0.001).)

Compared)to)singletons,)the)risks)for)all)adverse) outcomes)among)multiple)pregnancies)were) significantly)elevated,)and)were)highest)for)tocolysis,) Pregnancy]associated)hypertension:)an) delivery)<29)weeks,)and)infant)mortality.)Within) increase)in)blood)pressure)of)at)least)30) pluralities,)increasing)maternal)age)was)associated)with) mm)Hg)systolic)or)15)mm)diastolic)on)two) All)singleton,)twin,) significantly)higher)risks)of)pregnancy]associated) measurements)taken)6)hours)apart)after) and)triplet)live) hypertension,)excessive)bleeding,)and)incompetent) the)20th)week)of)gestation;)all)excessive) births)20)weeks) cervix,)but)for)twin)and)triplet)pregnancies,)significantly) bleeding)in)labour)and)delivery:)this)risk) gestation)or) lower)risks)for)tocolysis)(ages)>=40,)singleton)adjusted) was)calculated)as)including)the)risk)factors) greater odds)ratio)[AOR])0.97,)twin)AOR)0.67,)triplet)AOR)0.72),) of)abruptio)placenta,)placenta)previa,)and) delivery)<29)weeks)(ages)>=40,)singleton)AOR)1.55,) other)excessive)bleeding)during)labour) twin)AOR)0.72,)triplet)AOR)0.52),)and)infant)mortality) and)delivery. (ages)>=40,)singleton)AOR)1.34,)twin)AOR)0.71,)triplet) AOR)0.42).

All)women)giving) birth)in)the)study) period)were) included

Singleton) pregnancies)with) delivery)after)22) weeks.

38"

Pregnancy]induced)hypertension;)Pre] eclampsia;)Eclampsia)

The)study)obtained)data)for)109)101)of)112)152) deliveries)reported)in)122)recruited)facilities)(97%) coverage),)and)analysed)107)950)deliveries.)The)overall) rate)of)caesarean)section)was)27h3%)(n=29)428))and)of) operative)vaginal)delivery)was)3h2%)(n=3465).)Risk)of) maternal)mortality)and)morbidity)index)(at)least)one)of:) maternal)mortality,)admission)to)intensive)care)unit) [ICU],)blood)transfusion,)hysterectomy,)or)internal)iliac) artery)ligation))was)increased)for)operative)vaginal) delivery)(adjusted)odds)ratio)2h1,)95%)CI)1h7–2h6))and) all)types)of)caesarean)section)(antepartum)without) indication)2h7,)1h4–5h5;)antepartum)with)indication) 10h6,)9h3–12h0;)intrapartum)without)indication)14h2,) 9h8–20h7;)intrapartum)with)indication)14h5,)13h2–16h0).) For)breech)presentation,)caesarean)section,)either) antepartum)(0h2,)0h1–0h3))or)intrapartum)(0h3,)0h2–0h4),) was)associated)with)improved)perinatal)outcomes,)but) also)with)increased)risk)of)stay)in)neonatal)ICU)(2h0,) 1h1–3h6;)and)2h1,)1h2–3h7,)respectively).

The)incidence)proportion)of)pregnancy]induced) hypertension,)cervical)insufficiency,)placenta)previa,) and)placental)abruption)increased)with)age,)whereas) the)incidence)proportion)of)preterm)labour)and) Pregnancy)induced)hypertension:)systolic) chorioamnionitis)were)higher)at)younger)maternal)age.) blood)pressure)≥140)mmHg)or)diastolic) The)RR)of)women)in)the)age)groups)35]39)years)and) blood)pressure)≥90)mmHg)with)or)without) >=40)years)(with)the)reference)of)1.0)for)women)in)the) proteinuria)occurring)after)the)20th)week) age)group)of)20]34)years))were)determined:)pregnancy] of)gestation)but)resolving)by)the)12th) induced)hypertension,)1.66,)2.55;)placenta)previa,)1.76,) week)of)postpartum.) 2.19;)and)placental)abruption,)1.18,)1.5.)The)RR)of) preterm)labour)for)women)in)the)age)group)of)<20) years)was)1.78.


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Author(s)

6Study6 Country

Year Description

Impact'of'the'Choice'on' Termination'of' Mbele,'A.M.,' Pregnancy'Act'on' Snyman,'L.'&' maternal'morbidity'and' Pattison,'R.C. mortality'in'the'west'of' Pretoria.

South'African' Medical'Journal

The'objective'of'this'study'was'to' evaluate'the'impact'of'the'Choice'on' Termination'of'Pregnancy'Act'on' All'abortions' maternal'morbidity'and'mortality'in'the' Retrospective' 2006 South'Africa treated'in'study' west'of'Pretoria.'Data'were'collected'on' study area. all'abortions'(incomplete'or'induced)' treated'in'the'hospitals'in'the'study' area'in'1997'N'1998'and'2003'N'2005.'

Maternal'and'neonatal' outcomes'of'hospital' Miller,'S.'et'al.' vaginal'deliveries'in' Tibet.

The'aim'of'this'prospective' observational'study'was'to'determine' International' the'outcomes'of'vaginal'deliveries'in' Journal'of' 2007 three'study'hospitals'in'Lhasa,'Tibet' Tibet Gynaecology'and' Autonomous'Region'(TAR),'People's' Obstetrics Republic'of'China'(PRC),'at'high'altitude' (3650'm).'

Is'there'an'obstetric'July' Myles,'T. phenomenon?

Obstetrics'and' Gynecology

This'study'examined'whether'variations' in'intrapartum'management'and' United' 2003 complications'exist'with'regard'to'the' States time'of'delivery'within'the'academic' year.'

The'aim'of'this'retrospective'study'was' Maternal'complications' to'analyze'maternal'complications' associated'with'type'of' Revista'de'Saude' Nomura,'R.'et'al.' 2004 associated'to'type'of'delivery,' Brazil delivery'in'a'university' Publica comparing'cesarean'section'with' hospital. vaginal'delivery.

Obstructed'labour'in' Enugu,'Nigeria.

NwoguNIkojo,'E.E.,' Journal'of' Nweze,'S.O.'&' Obstetrics'and' Ezegwui,'H.U. Gynaecology

February"2013""

Study'of'all'cases'of'obstructed'labour' seen'and'managed'at'the'University'of' 2008 Nigeria'Teaching'Hospital,'Enugu,' Nigeria Nigeria,'between'January'1999'and' December'2004.

"

Type6of6Study

Sampling6 Method

Publication

Data6Source

Sample6Size

Medical' database

2050' abortions'in' 1997N98'and' External'referrals' 3999' excluded. abortions'in' 2003N05.

All'women'with' singleton' intrauterine' pregnancy'of'â&#x2030;Ľ'28' weeks'gestation' Prospective' Observation,' 1121' delivering' cohort'study medical'records deliveries. between'January' 2004'and'May' 2005'at'3' maternity' hospitals.

Retrospective' All'obstetric' study patients

Hospital' records

All'deliveries'in' computer'record' Retrospective' system'of' Hospital' study newborn'over' records 500g'in'period' AprilNDec'2001.

Retrospective' All'deliveries study

Hospital' records

7814' deliveries

1748' deliveries

4521' deliveries

Eligible6subjects

CNsections' excluded.

Gestation'>20' weeks

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given In'1997'N'1998'there'were'2050'abortions,'of'which' 80.2%'were'regarded'as'being'incomplete,'and'in'2003'N' 2005'there'were'3'999'abortions,'of'which'42.8%'were' Critically'ill'women'due'to'abortion:' regarded'as'incomplete.'TwentyNfour'women'who'were' defined'as'a'woman'who'had'SAMM'or' critically'ill'due'to'complications'of'abortion'presented' who'died;''Severe'morbidity'rate'for' in'1997'N'1998'(a'rate'of'3.05/1'000'births),'compared' abortion:'defined'as'the'percentage'of' with'50'(2.76/1'000'births)'in'2003'N'2005.'There'were'5' women'who'were'critically'ill'due'to' deaths'in'1997'N'1998'compared'with'1'death'in'2003'N' abortion'per'total'abortion'cases. 2005.'The'MI'fell'from'21.7%'to'2.0%.'The'MMR'was' 63.6/100'000'births'in'1997'N'1998'compared'with' 5.54/100'000'in'2003'N'2005.

Postpartum'haemorrhage:'â&#x2030;Ľ500ml;'PreN eclampsia/gestational'hypertension.

The'first'halfNyear'overall'caesarean'rate'was'higher' (15.8%'versus'14.3%,'P'<'.03).'Primary'caesarean'rates' were'similar.'No'other'differences'were'found'by'term' half'year.'More'perineal'trauma'was'noted'in'the' fourth'quarter'(first'3.3%,'second'4.5%,'third'3.7%,' fourth'5.5%,'P'<'.037).'Episiotomy'usage'was'higher'in' both'the'first'and'fourth'quarters'(13.0%,'11.3%,'10.6%,' Postpartum'haemorrhage:'defined'as'>' and'14.8%,'P'<'.002).'More'cases'of'chorioamnionitis' 500'mL'for'a'vaginal'delivery'and'1000'mL' occurred'in'the'fourth'quarter'(first'3.4%,'second'3.1%,' for'caesarean;'Prolonged'second'stage'of' third'2.6%,'fourth'4.0%,'P'<'.038,'third'versus'fourth' labour:'defined'as'>'120'minutes. quarter).'Chorioamnionitis'occurred'more'frequently'in' July'(July'5.0%'versus'AugustNJune'3.1%,'P'<'.005).' There'were'no'other'clinically'significant'differences.'In' conclusion,'although'small'differences'in'outcome'exist' with'respect'to'the'academic'time'of'the'year,'the' timing'of'these'differences'indicates'that'there'is'not'a' "July'phenomenon"'in'obstetrics'at'our'institution.

Excluded:'newborn' Hypertensive'complications;'Puerperal' weighing'under' infection:'infection'originated'in'the' 500g. genital'apparatus'after'recent'delivery.

All'deliveries

39"

PreNeclampsia/gestational'hypertension'(PE/GH)'was' the'most'common'maternal'complication'18.9%' (n=212),'followed'by'postpartum'hemorrhage'(blood' loss'>'or'='500'ml)'13.4%.'There'were'no'maternal' deaths.'Neonatal'complications'included:'low'birth' weight'(10.2%),'small'for'gestational'age'(13.7%),'preN term'delivery'(4.1%)'and'low'Apgar'(3.7%).'There'were' 11'stillbirths'(9.8/1000'live'births)'and'19'early' neonatal'deaths'(17/1000'live'births).

CNsections'were'performed'on'988'patients'(56.5%).' Hemorrhagic'complications'occurred'in'1.2%'of'cN sections'and'in'0.8%'of'normal'deliveries,'with'no' statistically'significant'difference'between'both'groups.' Endometritis'was'observed'in'0.4%'of'cNsections'and'in' 0.1%'of'vaginal'deliveries,'without'statistically' significant'difference.'Two'cases'of'puerperal'infection' evolved'to'hysterectomies,'in'the'cNsection'group.' There'were'no'maternal'deaths'related'to'cNsection.

2.7%'of'deliveries'were'complicated'by'obstructed' labour.'Of'the'120'women,'68'(56.7%)'were'nullipara.'A' total'of'41'women'(34.2%)'were'booked,'70'(58.3%)' Obstructed'labour:'labour'is'obstructed' uncooked,'and'9'(7.5%)'booked'elsewhere.'Most' when'further'progress'is'not'possible'(due' women'were'in'occupational'social'class'V.'The'cause' to'a'mechanical'barrier),'in'spite'of'the' of'obstruction'was'cephalopelvic'disproportion'in'68' presence'of'strong'uterine'contractions' women'(56.6%).'The'most'common'intervention'was'a' without'intervention. lower'segment'caesarean'section.'Perinatal'mortality' was'30%.'There'were'four'maternal'deaths'(3.3%).


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Epidemiological, features,of,uterine, rupture,in,West,Africa, (MOMA,Study).

Author(s)

Publication

Paediatric,and, Ould,El,Joud,,D.,et, perinatal, al. epidemiology

Archives,of, Rupture,of,the,pregnant, Ozdemir,,I.,,Yucel,, Gynecology,and, uterus:,A,9Eyear,review N.,&,Yucel,,O. Obstetrics

Uterine,rupture,, Rizwan,,N.,, frequency,of,cases,and, Abbasi,,R.M.,&, fetomaternal,outcome. Uddin,,S.F.,,

ObesityErelated, complications,in,Danish, Rode,,L.,et,al. single,cephalic,term, pregnancies.

February"2013""

Year

6Study6 Country

Description

Sampling6 Method

Data6Source

Sample6Size

All,pregnant, women,living,in, geographic,area, West,Africa:, during,study, Original,data, This,prospective,and,populationEbased, Burkina, period., collection:, study,aimed,to,assess,the,incidence,of, Faso;,Ivory, Prospective,, Geographic,areas, survey;,physical, 20,326, 2002 uterine,rupture,in,West,Africa;,to, Coast;,Mali;, populationE selected,based,on, examination;, pregnant, identify,its,risk,factors,there;,and,to, Mauritania;, based,study population, questionnaires, women, assess,their,predictability. Niger;, characteristics,to, for,health, Senegal. represent, professionals diversity,of, populations,of, the,entire,zone.

2005

This,study,presents,a,retrospective, chart,view,of,all,patients,with,ruptured, Turkey uterus,over,a,9Eyear,period,from,1995, to,2003.

This,descriptive,case,series,was, conduced,at,the,Department,of, Gynaecology,and,Obstetrics,,Liaquat, The,Journal,of,the, University,of,Medical,&,Health,Sciences,, Pakistan,Medical, 2011 Jamshoro,from,January,2008,to, Pakistan Association December,2008.,All,cases,of,ruptured, uterus,,who,were,either,admitted,with, this,complication,or,who,developed,it,in, the,hospital,,were,included,in,the,study.

Obstetrics,and, Gynecology

Type6of6Study

Objective,of,the,study,was,to, investigate,the,relationship,between, prepEpregnancy,and,obstetric,body, 2005 mass,index,(BMI),as,well,as,foetal, complications,in,a,large,,unselected, cohort,of,Danish,women,with,single, cephalic,pregnancies.

"

Denmark

Retrospective, All,deliveries study

Descriptive, case,series/, All,deliveries observational, study

All,women, Retrospective, participating,in, cohort,study first,trimester, study

Hospital, records

Observation

Study,records

Eligible6subjects

Inclusion,criteria, not,given

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given The,study,identified,,an,incidence,rate,of,1.2,uterine, ruptures,per,1000,deliveries.,Five,variables,were, significantly,associated,with,uterine,rupture:,uterine, scars,,malpresentation,,limping,,cephalopelvic, Uterine,rupture:,the,case,definition, disproportion,and,high,parity,(>or=7).,In,conclusion,,the, included,severe,abdominal,pain,and,a, incidence,of,uterine,rupture,is,high,in,West,Africa,,even, vaginal,or,intraE,abdominal,bleeding,with, in,large,cities,where,essential,obstetric,care,is,available, or,without,one,or,more,of,the,following, and,despite,the,low,prevalence,of,uterine,scars.,A, symptoms,and,signs:,shock,,abdominal, uterine,scar,multiplies,the,risk,of,uterine,rupture,by,11., distension,,abnormal,uterine,contour,, Uterine,rupture,cannot,be,predicted,from,currently, tender,abdomen,,easily,palpable,foetal, known,risk,factors,,including,uterine,scars.,The,high, parts,,absence,of,foetal,movements,,rapid, case,fatality,rate,(33.3%),and,the,associated,perinatal, maternal,pulse., mortality,(52%),bear,witness,to,the,absence,or, inadequacy,of,health,facilities,in,providing,essential, obstetric,care,and,to,the,poor,quality,of,maternal, health,care,,even,in,major,cities. During,the,study,period,there,were,17,cases,of, ruptured,uterus,among,a,total,of,117,095,deliveries,, giving,an,incidence,of,1,in,6,888,deliveries.,Thirteen, patients,(76.5%),were,multiparous,and,mean,parity,was, Uterine,rupture,was,defined,as,a,fullE 1.9.,Uterine,rupture,occurred,following,vaginal,delivery, thickness,uterine,wall,defect,,with,acute, in,ten,patients.,Caesarean,delivery,was,performed,in, maternal,bleeding,necessitating,operative, seven,(41.2%),patients,,of,which,five,(29.4%),patients, intervention.,All,cases,of,uterine, had,a,history,of,previous,caesarean,section.,Abdominal, dehiscence,,defined,as,a,small,uterine,wall, hysterectomy,was,performed,in,12,patients,(70.6%),,of, defect,that,needs,no,emergency, which,9,(75.0%),were,total,and,3,(25.0%),were, laparotomy,,were,excluded subtotal.,The,other,five,patients,(29.4%),had,suture, repairs.,In,seven,patients,(41.2%),,uterine,rupture,was, associated,with,oxytocin,use.,There,were,one,maternal, and,three,perinatal,(17.6%),deaths.,

117,095, deliveries

All,deliveries

2010, deliveries

All,cases,of, ruptured,uterus,, who,were,either, admitted,with,this, complication,or, who,developed,it, in,the,hospital,, were,included,in, Uterine,rupture the,study.,Patients, having,ruptured, uterus,due,to, congenital, abnormality,were, excluded,from,the, study.,

6350, pregnancies

Only,singleton, cephalic,term, delivery

40"

,There,were,15,cases,(0.74%),of,uterine,rupture.,Most, of,the,patients,(60%),presented,between,the,ages,26E 30.,Majority,of,uterine,rupture,occurred,in,para,2E4,, (53.33%).,Common,cause,of,uterine,rupture,was, prolonged,neglected,obstructed,labour.,Previous, caesarean,section,scar,was,found,in,41.66%.,Anterior, uterine,wall,was,involved,in,60%,of,cases.,Rupture,was, complete,in,73.33%,of,cases.,Hysterectomy,was, performed,in,53.33%.,There,were,three,maternal,(20%), and,11,intrauterine,deaths,(73.33%).,Live,birth,rate,was, 26.66%.,,CONCLUSION:,This,study,showed,that, prolonged,neglected,obstructed,labour,is,the,main, cause,of,uterine,rupture,followed,by,scarred,uterus., Proper,antenatal,care,and,updated,training, programmes,for,health,care,providers,is,the,need,of, time,to,prevent,this,catastrophic,but,avoidable, complication.

Overweight,women,had,an,odds,ratio,(OR),of,3.4,for, diabetes,,1.9,for,hypertension,,1.7,for,preeclampsia,, and,1.5,for,caesarean,delivery.,The,corresponding, figures,for,obese,women,were,15.3,,4.8,,2.7,,and,1.7,, respectively.,No,relationship,was,found,between,BMI, and,vacuum,extraction.,Obese,women,had,an, Hypertension:,defined,as,a,systolic,blood, increased,risk,of,delivering,macrosomic,but,also,low, pressure,of,greater,than,140,mm,Hg,and,a, birth,weight,children.,No,differences,existed,among,the, diastolic,blood,pressure,of,greater,than, 3,weight,groups,with,regard,to,neonatal,morbidity, 90mmHg,or,an,increase,of,20,mm,Hg,or, estimated,by,Apgar,score,,umbilical,cord,pH,,or, greater,in,the,diastolic,blood,pressure, admittance,to,a,neonatal,intensive,care,unit., during,pregnancy;,,Preeclampsia:,defined, Nulliparous,women,had,an,increased,incidence,of, as,hypertension,(as,mentioned,previously), preeclampsia,(OR,2.8),,hypertension,(OR,1.9),, and,significant,proteinuria,(protein,>,0.5, emergency,caesarean,delivery,(OR,3.4),,vacuum, g/d)., extraction,(OR,5.6),,and,perineal,rupture,(OR,1.7),but,a, lower,frequency,of,elective,caesarean,delivery,(OR, 0.25).,In,conclusion,,the,rate,of,complications,during, pregnancy,and,delivery,increases,with,an,increasing, prepregnancy,BMI,in,women,with,single,cephalic,term, pregnancies,,particularly,in,nulliparous,women.


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Obstetrical+and+ neonatal+outcomes+in+ obese+women

Author(s)

Roman,+H.+et+al.+

Estimation+of+ populationEbased+ incidence+of+pregnancyE Ronsmans,+C.+et+ related+illness+and+ al.+ mortality+(PRIAM)+in+ two+districts+in+West+ Java,+Indonesia.

Uterine+rupture+ incidence,+risk+factors,+ and+outcome.

PregnancyEassociated+ morbidity+in+Northern+ Nigeria.

Rouzi,+A.A.+et+al.

Type6of6Study

Sampling6 Method

West+Indian+ Medical+Journal

The+objective+of+this+study+was+to+ compare+the+incidence+of+antenatal+and+ intrapartum+complications+and+neonatal+ outcomes+among+preEpregnant+obese+ women.+At+the+SudEReunion+Hospital's+ Reunion+ maternity,+Reunion+Islands,+France,+over+ Island+ a+54Emonth+period,+each+obese+ 2007 (FrenchE pregnant+woman+(BMI+>+or+=+30+kg/m2)+ owned+ delivering+a+singleton+after+22Eweeks+ territory) gestation+was+compared+to+the+next+age+ and+parityEmatched+woman+of+normal+ preEpregnancy+weight+(BMI+18.5E25+ kg/m2),+who+delivered+after+the+index+ case.

Retrospective ,+crossE sectional,+age+ and+parity+ matched

Age+and+parityE matched+women+ of+normal+preE pregnancy+ Maternity+ weight,+delivering+ database+ after+the+index+ case+of+obese+ women.+

BJOG:+an+ International+ Journal+of+ Obstetrics+and+ Gynaecology

The+objective+of+this+study+was+to+ introduce+a+new+and+untested+approach+ for+the+measurement+of+lifeEthreatening+ maternal+morbidity.+By+defining+ complications+at+the+very+extreme+end+ of+the+severity+spectrum,+this+study+ postulate+that+the+count+in+hospitals+can+ be+used+to+represent++incidence+in+the+ general+population.+All+cases+of+lifeE 2009 Indonesia threatening+obstetric+morbidity+in+ hospitals+and+all+maternal+deaths+in+the+ population+were+counted.+Using+these+ data,+the+study+describes+the+incidence+ of+lifeEthreatening+morbidity+in+the+total+ population,+examines+its+variation+ across+geographical+areas+and+ investigates+its+relationship+with+ maternal+mortality.

Ectopic+pregnancy;+Antepartum+ haemorrhage+(including+placenta+praevia,+ placental+abruption+and+unspecified);+ Postpartum+haemorrhage+(including+ Hospital+case+ uterine+atony,+retained+placenta,+tear+and+ All+pregnancyE notes+for+ unspecified);+PreEeclampsia+and+ 3006+ The+incidence+of+maternal+mortality+and+lifeE related+ identification+of+ hypertension;+Eclampsia;+Uterine+Rupture;+ pregnancyE Eligible:+all+hospital+ threatening+complications+at+the+population+level+was+ admissions+in+ morbidity;+ Prolonged+labour.+A+combination+of+organ+ related+ admissions,+which+ 421+and+1416+per+100+000+births,+respectively,+resulting+ four+hospitals,+ national+ dysfunction+criteria+and+managementE Retrospective+ admissions+ may+not+be+ in+an+overall+ratio+of+PRIAM+of+1837+per+100+000.+The+ covering+almost+ statistical+data+ based+criteria+used+in+definitions.+For+ study correspondin representative+of+ overall+incidence+of+PRIAM+was+much+lower+in+rural+ all+pregnancyE for+population+ vascular+dysfunction:+Hypovolaemia+ g+to+36658+ all+complications+in+ than+in+urban+areas+(1529+and+2880+per+100+000,+ related+hospital+ size;+populationE requiring+four+or+more+units+of+blood,+ expected+ the+population. respectively,+P+<+0.001),+and+it+was+lowest+in+rural+ admissions+in+two+ based+survey+ blood+loss+with+hypovolaemic+shock+ births. Serang+(1304+per+100+000). districts. reporting+ (systolic+blood+pressure+<90+mmHg+or+ births. undetectable+pulse),+infusion+and/or+ transfusion+of+≥1+l+in+2+hours+and+freeEflow+ infusion.+Clinical+diagnosis+is+used+for+ eclampsia,+uterine+rupture+and+ectopic+ pregnancy+but+is+not+clearly+described.+

Publication

Year Description

Saudi+Medical+ Journal

Journal+of+ Salihu,+H.+M.+et+al.+ Obstetrics+and+ Gynaecology

February"2013""

6Study6 Country

This+study+reviewed+the+hospital+ records+of+the+Maternity+and+Children's+ Hospital+(MCH),+in+Makkah,+Kingdom+of+ Saudi+Arabia+from+April+1999+to+ Retrospective+ 2003 December+2000+to+identify+women+with+ Saudi+Arabia All+records study ruptured+uterus.+Relevant+data+relating+ to+the+clinical+features,+risk+factors,+ operative+procedures,+and+maternal+ and+foetal+outcomes+were+assessed.

This+study+sought+to+determine+the+ magnitude+and+spatioEtemporal+pattern+ 2004 of+maternal+morbidity+in+Kano+State,+ Nigeria Nigeria.+Analysis+was+on+deliveries+ within+the+period+1990E1999.+

"

Retrospective+ All+deliveries+ cohort+study 1990E1999

Data6Source

Hospital+ records

Sample6Size

2081+ deliveries

23+245+ deliveries

National+ hospital+ 171621+ registry,+part+of+ deliveries vital+statistics+ system.

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given Incidences+of+preEeclampsia,+chronic+and+pregnancyE induced+hypertension,+chronic+and+gestational+diabetes+ mellitus+were+increased+in+the+obese+women+group.+ Prenatal+care+in+obese+women+required+a+high+rate+of+ hospitalizations+as+well+as+a+high+rate+of+insulin+ treatment.+Obese+women+were+more+likely+to+be+ delivered+by+Caesarean+section.+The+rate+of+in+utero+ PreEeclampsia;+pregnancyEinduced+ BMI+18.5–25+kg/m² foetal+death,+neonatal+and+perinatal+death+was+ hypertension significantly+higher+in+the+obese+women+group.+The+high+ BMI+in+relation+with+both+preEeclampsia+and+in+utero+ foetal+death+remained+unchanged+after+adjustment+of+ other+risk+factors.++Obese+women+were+more+likely+to+ present+several+obstetric+complications+and+to+be+ delivered+by+Caesarean+section.+ Eligible6subjects

All+deliveries

No+exclusions

41"

Uterine+rupture

Maternal+complications+(not+defined).+

Incidence+of+uterine+rupture+was+1+in+1011+deliveries.+ Fifteen+(65.2%)+occurred+in+women+with+previous+ caesarean+scar+and+8+(34.8%)+women+had+no+previous+ uterine+surgery.+In+the+15+women+with+uterine+rupture+ and+previous+caesarean+section+there+was+no+maternal+ death.+They+were+treated+by+repair+of+the+uterus.+Two+ women+sustained+bladder+injury,+and+one+subsequently+ developed+vesicoEvaginal+fistula.+In+contrast,+in+the+8+ women+with+no+previous+uterine+surgery,+one+woman+ died,+one+woman+developed+renal+failure,+and+there+ were+3+foetal+losses.+Four+women+needed+total+ abdominal+hysterectomy,+and+4+women+needed+repair.+ Two+women+needed+internal+iliac+ligation+in+addition+to+ the+hysterectomy. We+counted+59+772+maternal+complications+among+171+ 621+deliveries,+yielding+an+overall+maternal+morbidity+ ratio+of+34.8%.+We+observed+yearly+variations+and+ increment+in+the+number+of+complications+among+ mothers+(p=0.04).+A+total+of+4154+maternal+deaths+were+ registered+within+the+period.+The+level+of+maternal+ deaths+correlated+significantly+with+burden+of+morbidity+ (r=0.44;+p=0.0008).+Case+fatality+rate+was+6.9%+with+ temporal+fluctuations,+and+wide+variations+among+the+ various+health+institutions.


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Author(s)

Caesarean'section' without'medical' indications'is'associated' with'an'increased'risk'of' adverse'short5term' Souza,'J.'P.'et'al.' maternal'outcomes:'the' 200452008'WHO'Global' Survey'on'Maternal'and' Perinatal'Health.

Maternal'near'miss'and' maternal'death'in'the' World'Health Organizationâ&#x20AC;&#x2122;s'2005' Souza,'J.'P.'et'al.' global'survey'on' maternal'and'perinatal health

Maternal'morbidity'and' near'miss'in'the' community:'findings' Souza,'J.'P.'et'al.' from'the'2006'Brazilian' demographic'health' survey.

Maternal'and'neonatal' individual'risks'and' benefits'associated'with' Villar,'J.'et'al.' caesarean'delivery:' multicentre'prospective' study.

February"2013""

Publication

BMC'Medicine

Bulletin'of'WHO

BJOG:'an' International' Journal'of' Obstetrics'and' Gynaecology

BMJ'(Clinical' Research'ed.)

6Study6 Country This'multicountry,'facility5based'survey,' used'a'stratified'multistage'cluster' sampling'design'to'obtain'a'sample'of' countries'and'health'institutions' worldwide.'A'total'of'24'countries'and' 373'health'facilities'participated'in'this' study.'Data'collection'took'place'during' 2004'and'2005'in'Africa'and'the' 24'countries' 2010' Americas'and'during'2007'and'2008'in' in'Africa,' (1) Asia.'All'women'giving'birth'at'the' Asia,' facility'during'the'study'period'were' Americas included'and'had'their'medical'records' reviewed'before'discharge'from'the' hospital.'Univariate'and'multilevel' analysis'were'performed'to'study'the' association'between'each'groupâ&#x20AC;&#x2122;s'mode' of'delivery'and'the'severe'maternal'and' perinatal'outcome. Year

Description

Type6of6Study

Sampling6 Method

Data6Source

Multi5 country,' facility'based' Multistage'cluster' Hospital' survey,' sampling records descriptive' analysis'

Sample6Size

286'565' deliveries

This'multicenter'cross5sectional'study' collects'maternal'and'perinatal'data' from'the'hospital'records'of'a'sample'of' women'admitted'for'delivery'over'a' Multi5center' period'of'two'to'three'months'in'120' 2010' cross5 120'randomly' 97'095' hospitals'located'in'eight'Latin' 8'Latin'American'countries Hospital'records (2) sectional' selected'hospitals deliveries American'countries.'The'intra5hospital' study occurrence'of'severe'maternal' morbidity'was'assessed,'and'its' association'with'maternal' characteristics'and'perinatal'outcomes.

The'objective'of'this'study'was'to' obtain'an'estimate'of'the'prevalence'of' 2010' potentially'life5threatening'maternal' Brazil (3) conditions'and'near5miss'events'in' Brazil,'and'to'explore'the'factors' associated'with'these'complications.

The'aim'of'this'prospective'cohort'study' 8'Latin' was'to'assess'the'risks'and'benefits' 2007 American' associated'with'caesarean'delivery' countries' compared'with'vaginal'delivery.

"

Secondary' analysis'of' DHS

Prospective' cohort'study

DHS'used'a' probabilistic,' complex'sampling' design:'the'data' were'stratified' and'clustered'in' Brazilian' two'stages'(with' Demographic' stratification'by' Health'Survey' census'area'and' (DHS) house5'hold' situation,' respectively),'and' weighted.

6833' pregnancies

Random'selection' of'123' institutions'in'8' randomly' selected'Latin' American' countries'using'a' multi5stage' stratified' sampling' procedure.'In' 94307' each'selected' Medical'records deliveries institution,'all' women'admitted' for'delivery' during'a'fixed' period'were' studied,' depending'on'the' total'annual' number'of' expected' deliveries.

Eligible6subjects

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given

All'women'giving' birth'at'the'facility' Eclampsia;'hypertension during'the'study' period.

The'overall'caesarean'section'rate'was'25.7%'and'a' total'of'1.0'percent'of'all'deliveries'were'caesarean' sections'without'medical'indications,'either'due'to' maternal'request'or'in'the'absence'of'other'recorded' indications.'Compared'to'spontaneous'vaginal'delivery,' all'other'modes'of'delivery'presented'an'association' with'the'increased'risk'of'death,'admission'to'ICU,' blood'transfusion'and'hysterectomy,'including' antepartum'caesarean'section'without'medical' indications'(Adjusted'Odds'Ratio'(Adj'OR),'5.93,'95%' Confidence'Interval'(95%'CI),'3.88'to'9.05)'and' intrapartum'caesarean'section'without'medical' indications'(Adj'OR,'14.29,'95%'CI,'10.91'to'18.72).'In' addition,'this'association'is'stronger'in'Africa,' compared'to'Asia'and'Latin'America.

Excluded'from'the' analysis'women' with'no' Eclampsia;'hypertension information'for'life' status'on' discharge.'

Of'the'97,095'women'studied,'2964'(34'per'1000)'were' at'higher'risk'of'dying'in'association'with'one'or'more' of'the'following:'being'admitted'to'the'intensive'care' unit'(ICU),'undergoing'a'hysterectomy,'receiving'a' blood'transfusion,'suffering'a'cardiac'or'renal' complication,'or'having'eclampsia.'Being'older'than'35' years,'not'having'a'partner,'being'a'primipara'or'para'>' 3,'and'having'had'a'Caesarean'section'in'the'previous' pregnancy'were'factors'independently'associated'with' the'occurrence'of'severe'maternal'morbidity.'They' were'also'positively'associated'with'an'increased' occurrence'of'low'and'very'low'birth'weight,'stillbirth,' early'neonatal'death,'admission'to'the'neonatal'ICU,'a' prolonged'maternal'postpartum'hospital'stay'and' Caesarean'section.

Eligible:'all'women' reporting'at'least' one'live'birth'in' the'5'years' preceding'the' interview.'

Eclampsia:'had'seizures'during'pregnancy,' delivery'and'postpartum'(and'had'not'had' them'before);'Haemorrhage:'had'heavy' bleeding'(wetting'clothes,'etc.)'during' pregnancy'or'in'the'first'3'days' postpartum;'Infection:'had'high'fever' after'delivery/abortion'with'chills'and'a' malodorous'vaginal'discharge

Excluded:'multiple' births,'emergency' caesarean' Pregnancy5induced'hypertension;'Pre5 deliveries,'women' eclampsia;'Eclampsia with'incomplete' delivery'data.

42"

Around'22%'of'women'reported'complications'during' pregnancy.'The'prevalence'of'maternal'near'miss'in' Brazil,'using'the'pragmatic'definition,'was'21.1'per' 1000'live'births.'An'increased'risk'of'severe'maternal' morbidity'was'found'in'women'aged'>=40'years'and'in' those'with'low'levels'of'education.

Women'undergoing'caesarean'delivery'had'an' increased'risk'of'severe'maternal'morbidity'compared' with'women'undergoing'vaginal'delivery.'The'risk'of' antibiotic'treatment'after'delivery'for'women'having' either'type'of'caesarean'was'five'times'that'of'women' having'vaginal'deliveries.'With'cephalic'presentation,' there'was'a'trend'towards'a'reduced'odds'ratio'for' fetal'death'with'elective'caesarean,'after'adjustment' for'possible'confounding'variables'and'gestational'age.' With'breech'presentation,'caesarean'delivery'had'a' large'protective'effect'for'fetal'death.'With'cephalic' presentation,'independent'of'possible'confounding' variables'and'gestational'age,'intrapartum'and'elective' caesarean'increased'the'risk'for'a'stay'of'seven'or'more' days'in'neonatal'intensive'care'and'the'risk'of'neonatal' mortality'up'to'hospital'discharge,'which'remained' higher'even'after'exclusion'of'all'caesarean'deliveries' for'fetal'distress.'Such'increased'risk'was'not'seen'for' breech'presentation.'Lack'of'labour'was'a'risk'factor'for' a'stay'of'seven'or'more'days'in'neonatal'intensive'care' and'neonatal'mortality'up'to'hospital'discharge'for' babies'delivered'by'elective'caesarean'delivery,'but' rupturing'of'membranes'may'be'protective.


What%is%the%evidence%on%the%proportion%of%pregnancies%that%result%in%obstetric%complications%and%require%referral%to%specialist%care?%A%rapid%literature%review." " Title

Author(s)

Adverse'maternal' Walker,'M.'C.'et' outcomes'in'multifetal' al. pregnancies.

Year Description

BJOG:'an' International' Journal'of' Obstetrics'and' Gynaecology

This'is'a'retrospective'cohort'study' comparing'the'incidence'of' complications'in'165,188'singleton' 2004 Canada pregnancies'and'44,674'multipleLfoetal' pregnancies'in'Canada'from'1984'to' 2000.'

Incidence'of'severe'preL eclampsia,'postpartum' BJOG:'an' haemorrhage'and'sepsis' International' as'a'surrogate'marker' Zhang,'W.'H.'et'al.' Journal'of' for'severe'maternal' Obstetrics'and' morbidity'in'a'European' Gynaecology populationLbased'study:' the'MOMSLB'survey.

February"2013""

6Study6 Country

Publication

The'objective'of'this'study'was'to' describe'the'incidence'of'three' conditions'of'acute'severe'maternal' morbidity'in'selected'regions'in'nine' European'countries.'Eleven'regions'in' nine'countries'of'Europe,'were' 9'European' 2005 selected,'with'all'the'pregnant'women' countries in'each'region'who'had'delivered'during' the'period'covered'by'the'study.'The' incidence'of'three'main'severe'obstetric' conditions'was'measured:'preL eclampsia,'postpartum'haemorrhage' and'sepsis.

"

Sampling6 Data6Source Method All'multiple' gestations' selected'from' Discharge' Database'of' Canadian' Institute'of' Discharge' Retrospective' Health' Abstract' cohort'study Information' Database (representative'of' all'births'in' Canada),'and'4' singleton' matches'selected' for'each Type6of6Study

Retrospective' Survey'in'11' survey,' countries,'some' descriptive' by'region,'some' analysis by'entire'country.

Population' based' questionnaire' survey

Sample6Size

Eligible6subjects

165'188' singleton''44' All'deliveries 674'multiple' births

182'734' women

'Women' completing'24' weeks'gestation' and''with'1'or' more'of'the' conditions' considered.'

43"

Relevant6complications6investigated6and6 Findings diagnostic6criteria6given

PreLeclampsia;'postpartum'haemorrhage

Multiple'gestation'pregnancies'were'associated'with' significant'increases'in'cardiac'morbidity,'hematologic' morbidity,'amniotic'fluid'embolus,'preLeclampsia,' gestational'diabetes,'postpartum'haemorrhage,' prolonged'hospital'stay,'the'need'for'obstetric' intervention,'hysterectomy'and'blood'transfusion.' Multiple'gestation'pregnancies'are'associated'with'an' increased'risk'of'morbidity'for'the'mother.'

Severe'preLeclampsia;'eclampsia;'severe' haemorrhage;'sepsis

The'study'identified'1734'women'with'at'least'one'of' the'three'conditions,'with'847'experiencing'severe' haemorrhage,'793'experiencing'severe'preLeclampsia' and'142'experiencing'severe'sepsis.'There'were'wide' variations'in'incidence'of'three'conditions'combined,' ranging'from'14.7'per'thousand'deliveries'in'Brussels,' Belgium'to'6.0'per'thousand'deliveries'in'Upper' Austria.


What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review." " Annex%6%Bibliography%of%articles%retrieved%for%evaluation%% 1. Agrawal,"S.,"Agarwal,"A."&"Das,"V.,"2011."Impact"of"grandmultiparity"on"obstetric"outcome"in" low"resource"setting."The%Journal%of%Obstetrics%and%Gynaecology%Research,"37(8),"pp.1015– 1019." 2. Akwuruoha,"E."et"al.,"2011."Grandmultiparity"and"pregnancy"outcome"in"Aba,"Nigeria:"a"caseP control"study."Archives%of%Gynecology%and%Obstetrics,"283(2),"pp.167–172." 3. AlPMulhim,"A.PA."et"al.,"2003."PrePeclampsia:"maternal"risk"factors"and"perinatal"outcome." Fetal%Diagnosis%and%Therapy,"18(4),"pp.275–280." 4. Ali,"A.A."et"al.,"2012."High"incidence"of"obstetric"complications"in"Kassala"Hospital,"Eastern" Sudan."Journal%of%Obstetrics%and%Gynaecology,"32(2),"pp.148–149." 5. Ali,"A.M."&"AbuPHeija,"A.T.,"2002."Obstetric"and"perinatal"outcome"of"women"para">"or"="5" including"one"lower"segment"cesarean"section."The%Journal%of%Obstetrics%and%Gynaecology% Research,"28(3),"pp.163–165." 6. Almerie,"Y."et"al.,"2010."Obstetric"nearPmiss"and"maternal"mortality"in"maternity"university" hospital,"Damascus,"Syria:"a"retrospective"study."BMC%Pregnancy%&%Childbirth,"10,"p.65." 7. Bang,"R.A."et"al.,"2004."Maternal"morbidity"during"labour"and"the"puerperium"in"rural"homes" and"the"need"for"medical"attention:"A"prospective"observational"study"in"Gadchiroli,"India." BJOG!:%an%international%journal%of%obstetrics%and%gynaecology,"111(3),"pp.231–238." 8. Baskett,"T.F."&"O’Connell,"C.M.,"2005."Severe"obstetric"maternal"morbidity:"a"15Pyear" populationPbased"study."Journal%of%Obstetrics%and%Gynaecology,"25(1),"pp.7–9." 9. Berg,"Cynthia"J"et"al.,"2009."Overview"of"maternal"morbidity"during"hospitalization"for"labor" and"delivery"in"the"United"States:"1993P1997"and"2001P2005."Obstetrics%and%Gynecology," 113(5),"pp.1075–1081." 10. Betrán,"A.P."et"al.,"2009."WHO"global"survey"on"maternal"and"perinatal"health"in"Latin" America:"classifying"caesarean"sections."Reproductive%Health,"6,"p.18." 11. Brosens,"I.A."et"al.,"2007."Endometriosis"is"associated"with"a"decreased"risk"of"prePeclampsia." Human%Reproduction,"22(6),"pp.1725–1729." 12. Bruce,"F"C"et"al.,"2012."Extent"of"maternal"morbidity"in"a"managed"care"population"in" Georgia."Paediatric%and%Perinatal%Epidemiology,"26,"pp.497–505." 13. Bruce,"F"Carol"et"al.,"2008."Maternal"morbidity"rates"in"a"managed"care"population." Obstetrics%and%Gynecology,"111(5),"pp.1089–1095." 14. Camargo,"Rodrigo"S"et"al.,"2011."Severe"maternal"morbidity"and"factors"associated"with"the" occurrence"of"abortion"in"Brazil."International%Journal%of%Gynecology%and%Obstetrics,"112(2)," pp.88–92." 15. Chhabra,"S.,"Bhagwat,"N."&"Chakravorty,"A.,"2002."Reduction"in"the"occurrence"of"uterine" rupture"in"Central"India."Journal%of%Obstetrics%and%Gynaecology,"22(1),"pp.39–42." 16. Clausen,"T.,"Oyen,"N."&"Henriksen,"T.,"2006."Pregnancy"complications"by"overweight"and" residential"area."A"prospective"study"of"an"urban"Norwegian"cohort."Acta%Obstetricia%et% Gynecologica%Scandinavica,"85(5),"pp.526–533." 17. ClearyPGoldman,"J."et"al.,"2005."Impact"of"maternal"age"on"obstetric"outcome."Obstetrics%and% Gynecology,"105(5,1),"pp.983–990." 18. Croft,"M.L."et"al.,"2010."Recorded"pregnancy"histories"of"the"mothers"of"singletons"and"the" mothers"of"twins:"a"longitudinal"comparison."Twin%Research%and%Human%Genetics,"13(6)," pp.595–603." 19. Danel,"I."et"al.,"2003."Magnitude"of"maternal"morbidity"during"labor"and"delivery:"United" States,"1993P1997."American%Journal%of%Public%Health,"93(4),"pp.631–634." 20. Elsmen,"E."et"al.,"2006."Fetal"gender"and"gestationalPagePrelated"incidence"of"prePeclampsia." Acta%Obstetricia%et%Gynecologica%Scandinavica,"85(11),"pp.1285–1291." 21. Fronczak,"N."et"al.,"2005."DeliveryPrelated"complications"and"early"postpartum"morbidity"in" Dhaka,"Bangladesh."International%Journal%of%Gynecology%and%Obstetrics,"91(3),"pp.271–278."

February"2013""

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What% is% the% evidence% on% the% proportion% of% pregnancies% that% result% in% obstetric% complications% and% require%referral%to%specialist%care?%A%rapid%literature%review." " study:"the"MOMSPB"survey."BJOG:%An%International%Journal%of%Obstetrics%and%Gynaecology," 112(1),"pp.89â&#x20AC;&#x201C;96."

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