Severe Hypertensive Disorders of Pregnancy in Eastern Ethiopia: Comparing the Original WHO and Adapted sub-Saharan African Maternal Near-Miss Criteria

Figures & data

Figure 1 Flowchart of severe HDPs in eastern Ethiopia: comparing the original WHO and adapted sub-Saharan African MNM criteria.

Abbreviations: HDPs, hypertensive disorders of pregnancy; WHO, World Health Organization; MNM, maternal near miss; MDs, maternal death.

Table 1 Sociodemographic Characteristics of Study Participants

	SSA, n=285 (%)	WHO, n=50 (%)	MDs, n=14 (%)	p-value
Age in years, mean (±SD)	23.8 (±5.5)	25.0 (±5.6)	24.4 (±4.8)
<20	53 (18.6)	6 (12.0)	2 (14.3)	0.770
20–34	207 (72.6)	38 (76.0)	11 (78.6)
≥35	25 (8.8)	6 (12.0)	1 (7.1)
Referred
Yes	184 (64.8)	35 (70.0)	13 (92.9)	0.081
No	100 (35.2)	15 (30.0)	1 (7.1)
Booked for ANC
Yes	94 (33.0)	9 (18.0)	2 (14.3)	0.043
No	191 (67.0)	41 (82.0)	12 (85.7)
Gestational age (weeks)
<28	10 (5.5)	2 (5.7)	1 (12.5)	0.049
28–36	103 (56.6)	28 (80.0)	6 (75.0)
≥37	69 (37.9)	5 (14.3)	1 (12.5)
Gravida
1	138 (48.6)	17 (34.0)	6 (42.8)	0.030
2–4	91 (32.0)	13 (26.0)	4 (28.6)
>4	55 (19.4)	20 (40.0)	4 (28.6)
Number of children
0	111 (38.9)	14 (28.0)	3 (21.4)	0.060
1–4	128 (44.9)	20 (40.0)	7 (50.0)
≥5	46 (16.2)	16 (32.0)	4 (28.6)
Mode of delivery
Vaginal	193 (67.7)	33 (70.2)	9 (64.3)	0.903
Cesarean section	92 (32.3)	14 (29.8)	5 (35.7)
Admission date
Working day	200 (70.2)	38 (76.0)	9 (64.3)	0.608
Not a working day	85 (29.8)	12 (24.0)	5 (35.7)

Notes: Bold values: respective Chi Square (X²) values for the significant ones are as follows: for ANC: X² cal =6.2705; Gestational age: X² cal=9.5597; Gravida: X² cal=10.7168.

Abbreviations: ANC, antenatal care; SSA, sub-Saharan Africa; WHO, World Health Organization, MDs, maternal deaths.

Table 2 Distribution of HDP-related Complications and MNM Indicators in Eastern Ethiopia

	All HDPs, n (%)	All SMOs		MNMs		MNM Ratio		MMR	SMO Ratio		MNM:MDs		MI		CFR
		SSA	WHO	SSA	WHO	SSA	WHO		SSA	WHO	SSA	WHO	SSA	WHO
SPE	337(60)	60	24	55	19	7.4	2.6	67.5	8.1	3.2	11	3.8	8.3	20.8	1.5
Eclampsia	225(40)	225	26	216	17	29.2	2.3	121.6	30.4	3.5	24	1.9	4.0	34.6	4.0
Total	562(100)	285	50	271	36	36.6	4.9	189.1	38.5	6.8	19.4	3.6	4.9	28.0	2.5

Abbreviations: S-PE, severe preeclampsia; SSA, sub-Saharan Africa; WHO, World Health Organization; HDPs, hypertensive disorders of pregnancy; MNMs, maternal near-misses; MMR, maternal mortality ratio; SMOs, severe maternal outcomes (MNMs + MDs); MDs, maternal deaths; MI, mortality index (MDs/SMOs × 100); CFR, casefatality rate.

Table 3 Distribution of Underlying and Contributing Factors of Severe Maternal Outcomes Among Women with HDPs in Eastern Ethiopia

	SSA Tool, n (%)	WHO Tool, n (%)
Underlying complications
Total	285	50
Severe preeclampsia	60 (21.1)	24 (48.0)
Eclampsia	225 (78.9)	26 (52.0)
Obstetric hemorrhage*	27 (9.5)	11 (22.0)
Abortion-related^a	2 (0.7)	0
Abruptio placenta	5 (1.8)	2 (4.0)
Placenta previa	2 (0.7)	0
Uterine rupture	3 (1.1)	2 (4.0)
Postpartum hemorrhage	10 (3.5)	6 (12.0)
Other	5 (1.8)	1 (2.0)
Sepsis or severe systemic infection*	19 (6.7)	8 (16.0)
Contributing factors
Anemia (<7g/dl)	31 (10.9)	8 (16.0)
Previous cesarean section	9 (3.2)	2 (4.0)
Critical interventions or ICU admission	141 (49.5)	37 (74)
Use of blood products	38 (13.3)	11 (22.0)
Admission to ICU	40 (14.0)	23 (46.0)
Cesarean section	87 (30.5)	13 (26.0)
Laparotomy	4 (1.4)	4 (8.0)

Notes: *In women with HDPs; ^adefinition of abortion in Ethiopia (<28 weeks).

Abbreviation: ICU, intensive care unit.

Table 4 Distribution of MNM Events in Women with HDPs in Eastern Ethiopia

	Sub-Saharan Africa			World Health Organization
	MNMs, n (%)	MDs, n (%)	MI (%)	MNMs, n (%)	MDs n (%)	MI (%)
Cardiovascular dysfunction	7 (2.6)	7 (50.0)	50.0	7 (19.4)	7 (50.0)	50.0
Respiratory dysfunction	15 (5.5)	8 (57.1)	34.8	15 (41.7)	8 (57.1)	34.8
Uterine dysfunction	2 (0.7)	3 (21.4)	60.0	2 (5.6)	3 (21.4)	60.0
Coagulation dysfunction	26 (9.6)	8 (57.1)	23.5	8 (22.2)	8 (57.1)	50.0
Renal dysfunction	1 (0.4)	1 (7.1)	50.0	1 (2.8)	1 (7.1)	50.0
Hepatic dysfunction	5 (1.8)	1 (7.1)	16.7	5 (13.9)	1 (7.1)	16.7
Neurologic dysfunction	7 (2.6)	6 (42.9)	46.2	7 (19.4)	6 (42.9)	46.2
Eclampsia	216 (79.4)	9 (64.3)	4.0	17 (47.2)	9 (64.3)	34.6
Severe preeclampsia with ICU admission	14 (5.2)	4 (28.6)	22.2	5 (13.9)	4 (28.6)	44.4
Sepsis or severe systemic infections	16 (5.9)	3 (21.4)	15.8	5 (13.9)	3 (21.4)	37.5
Pulmonary edema	6 (2.2)	2 (14.3)	25.0	4 (11.1)	2 (14.3)	33.3
Total	271 (100)	14 (100)	4.9	36 (100)	14 (100)	28.0

Abbreviations: ICU, intensive care unit; MNMs, maternal near-misses; MDs, maternal deaths; MI, mortality index (MDs/MNM + MDs).

Table 5 SMOs and MNM Indicators Among Women with HDPs in Eastern Ethiopia

	MNM Indicators
	SSA	WHO
1. All live births in the population under surveillance	7404	7404
2. SMOs (n)	285	50
MDs (n)	14	14
MNMs (n)	271	36
3. Overall near-miss indicators
SMO ratio (per 1,000 live births)	38.5	6.8
MNM ratio (per 1,000 live births)	36.6	4.9
MNM-mortality ratio (MNMs:MDs)	19.4	2.6
Mortality index (%)	4.9	28
4. Hospital-access indicators
SMO cases presenting the organ dysfunction or maternal death within 12 hours of hospital stay (SMO12; n)	251	41
Proportion of SMO12 cases among all SMO cases	88.1	82.0
Proportion of SMO12 cases coming from other health facilities	64.9	68.3
SMO12 rate (per 1,000 live births)	33.9	5.5
SMO12 mortality index (%)	4.8	29.3
5. Intrahospital care
Intrahospital SMOs (n)	34	9
Intrahospital SMO rate (per 1,000 live births)	4.6	1.2
Intrahospital mortality index (%)	5.9	22.2

Abbreviations: SMO, severe maternal outcome; SSA, sub-Saharan Africa; WHO, World Health Organization; MNM, maternal near-miss; MDs, maternal deaths.

Table 6 Factors Associated with Severe Maternal Outcomes Among Women with HDPs in Eastern Ethiopia

		SSA MNM Tool		WHO MNM Tool
		cOR	aOR	cOR	aOR
Age (years)	<20	1.0	1.0	1.0	1.0
	20–34	0.67 (0.42–1.06)	1.70 (0.76–3.78)	1.38 (0.57–3.38)	3.55 (0.57–22.29)
	≥35	0.57 (0.29–1.12)	1.89 (0.51–7.0)	1.69 (0.52–5.54)	1.75 (0.15–20.36)
Gravidity	1	1.0	1.0	1.0	1.0
	2–4	0.67 (0.45–0.98)	1.05 (0.48–2.27)	0.96 (0.45–2.02)	0.74 (0.20–2.70)
	≥5	0.50 (0.32–0.77)	0.77 (0.37–1.62)	2.27 (1.14–4.50)	1.65 (0.47–5.78)
Referred	No	1.0	1.0	1.0	1.0
	Yes	1.95 (1.39–2.74)	1.97 (1.13–3.41)	1.87 (1.0–3.51)	3.34 (1.20–9.31)
Received ANC	Yes	1.0	1.0	1.0	1.0
	No	3.43 (2.43–4.86)	3.13 (1.77–5.54)	4.70 (2.22–9.79)	3.17 (1.03–9.76)
Mode of delivery^a	Vaginal	1.0	1.0	1.0	1.0
	CS	0.71 (0.49–1.01)	1.31 (0.75–2.28)	0.68 (0.35–1.33)	0.89 (0.31–2.53)
Gestational age (weeks)	20–31	1.0	1.0	1.0	1.0
	32–36	1.15 (0.68–1.94)	1.05 (0.48–2.27)	1.26 (0.55–2.89)	2.02 (0.57–7.16)
	≥37	1.00 (0.59–1.69)	0.77 (0.37–1.62)	0.28 (0.09–0.85)	0.31 (0.07–1.40)
Hemorrhage	No	1.0	1.0	1.0	1.0
	Yes	1.05 (0.60–1.87)	2.37 (0.98–5.76)	3.24 (1.54–6.80)	3.76 (1.10–12.76)
Address	Urban	1.0	1.0	1.0	1.0
	Rural	3.76 (2.13–6.63)	2.32 (1.11–4.87)	2.68 (0.80–9.04)	0.94 (0.22–4.10)

Note: ^a“No delivery” and abortions excluded.

Abbreviations: SSA, sub-Saharan Africa; MNM, maternal near-miss; cOR, crude OR; aOR, adjusted OR; WHO, World Health Organization.