Mortality after near-miss obstetric complications in Burkina Faso: medical, social and health-care factors

Bull World Health Organ 2012;90:418–425B | doi:10.2471/BLT.11.094011 Research 418 Mortality after near-miss obstetric complications in Burkina Faso: medical, social and health-care factors Katerini T Storeng,a Seydou Drabo,b Rasmané Ganaba,c Johanne Sundby,b Clara Calvertd & Véronique Filippid Introduction International discussions about maternal health in low-income countries tend to focus on maternal deaths. However, there is increasing concern that these deaths are only the tip of the iceberg in terms of the health effects of the poor availability and quality of maternity services.1 In addition, countries with high maternal mortality also have a large burden of pregnancy-relat- ed complications and associated disabilities. It is estimated that “for every woman who dies from a pregnancy-related cause, about 20 more – roughly 7 million women yearly – experience injury, infection, disease or disability”.1 Of growing interest are “near-miss” obstetric complications – complications so severe that they would probably have killed the woman had she not received timely medical care.2 In low-income countries, near misses are often considered obstetric successes because ultimately the woman’s life was saved by a focused medical intervention.2,3 However, little is known about long-term outcomes following these complica- tions.4 Recent studies document a substantial degree of physi- cal and psychological morbidity in their aftermath5–10 and the high cost of emergency obstetric care has serious social and economic consequences.11,12 Although women’s lives are known to remain at risk for several months beyond the 42-day cut-off used in standard definitions of maternal death,13 few studies have examined survival beyond this period in women who experience severe obstetric complications. To what extent does surviving a near-miss obstetric com- plication mean that a maternal death has actually been averted? Our aim was to investigate maternal mortality in the 4 years after hospital discharge following a near-miss complication in Burkina Faso. We used data from a longitudinal, mixed- methods, cohort study to describe patterns of mortality and analysed the medical, social and health-care-related causes of death after near-miss complications. Finally, we considered the implications of our study findings for strategies that promote safe motherhood. Methods Study setting Burkina Faso is an impoverished country in western Af- rica that is ranked 177th out of 182 countries in terms of human development; 81% of the population live on less than 2 United States dollars a day.14 The country’s scores on reproductive health indicators are among the worst in the world. The fertility rate is 6.2 children per woman.15 According to the most recent national census,16 the mater- nal mortality ratio is 307 per 100 000 live births, and the World Health Organization’s estimate is 560 per 100 000 live births.17 Burkina Faso’s district health system func- tions poorly and existing safe motherhood programmes do not address the availability of comprehensive obstetric care.18 Only 73.2% of births are assisted by a skilled birth attendant – a figure that hides significant regional and so- cioeconomic disparities.19 User fees for maternal health care, especially emergency care, are often unaffordable.11 In 2007, the health ministry introduced an 80% subsidy for facility- based delivery to reduce out-of-pocket expenditure,20 but its effect is still unclear.21,22 Objective To investigate mortality in women in Burkina Faso in the 4 years following a life-threatening near-miss obstetric complication and to identify the medical, social and health-care-related causes of death. Methods In total, 1014 women were recruited after hospital discharge and followed for up to 4 years: 337 had near-miss complications and 677 had uncomplicated pregnancies. Significant differences in mortality between the groups were assessed using Fisher’s exact test. The medical causes of death were identified from medical records and verbal autopsy data; social and health-care-related factors associated with death were identified from interviews with the deceased women’s relatives. Findings In the 4 years, 15 (5.3%) women died in the near-miss group and 5 (0.9%) died after uncomplicated pregnancies (P < 0.001). More than half the deaths after a near miss, but none after an uncomplicated delivery, were pregnancy-related. Indirect factors contributed to many of these deaths, particularly human immunodeficiency virus infection. Relatives’ accounts suggested that the high cost and poor quality of health care, a lack of follow-up care and an unmet need for contraception contributed to the excess mortality in the near-miss group. Conclusion Women in Burkina Faso who initially survived a near-miss obstetric complication had an increased risk of all-cause and pregnancy-related death in the ensuing 4 years. The likelihood of survival over the longer term could be increased by offering a continuum of care that addresses the indirect and social causes of death and supplements the emergency intrapartum obstetric care provided by current safe motherhood programmes. a Centre for Development and the Environment, University of Oslo, PB 1116 Blindern, Oslo 0317, Norway. b Institute of Health and Society, University of Oslo, Oslo, Norway. c AFRICSanté, Bobo-Dioulasso, Burkina Faso. d London School of Hygiene and Tropical Medicine, London, England. Correspondence to Katerini T Storeng (e-mail: Katerini.storeng@sum.uio.no). (Submitted: 29 July 2011 – Revised version received: 18 November 2011 – Accepted: 23 January 2012 – Published online: 13 March 2012 ) Bull World Health Organ 2012;90:418–425B | doi:10.2471/BLT.11.094011 419 Research Mortality after obstetric near misses in Burkina FasoKaterini T Storeng et al. Data collection We followed a cohort of 1014 women for 4 years after they were discharged from seven hospitals across Burkina Faso between November 2004 and March 2005. Women were recruited at hospital discharge to avoid exposure misclassifica- tion.23 Of the 1014 women in the cohort, 337 had experienced a near-miss obstet- ric complication: the pregnancy ended in a live birth in 199 cases, in a perinatal death in 74 and in a miscarriage, ectopic pregnancy or abortion in 64. For each woman who had a near miss, we recruited an average of two unmatched controls from the seven hospitals. Usually the next two women to have an uncomplicated live delivery, as confirmed by medical notes, were selected, though some hospi- tals recruited more controls than others. The total number of controls was 677. Trained lay interviewers made six fol- low-up visits: on day three after discharge, at 3 months, 6 months and 12 months, and in the third and fourth years after the end of the pregnancy. We investi- gated whether any woman not found for the interview had moved away or died. Interviews explored women’s health, re- productive history, socioeconomic status, experience of health care, and health-care costs. Medical information was extracted from routine hospital records at discharge and from reports of medical examina- tions conducted 6 and 12 months later. In parallel, anthropologists carried out a detailed follow-up of a subsample of 82 women: 64 had near misses and 18 had uncomplicated deliveries. Findings from the first year of follow-up have been reported elsewhere.8,11,12 We used the verbal autopsy method to make detailed enquiries about any woman who died. This approach deter- mines the cause of death by asking lay respondents about the signs exhibited and the symptoms experienced by the deceased and is used when data from routine information systems are incom- plete.24 Generally, respondents were the woman’s husband, relatives who had participated closely in the woman’s care and, when possible, health workers. A physician conducted verbal autopsies at the end of the first year, and the an- thropologist conducted interviews at the end of follow-up. Additionally, an open-ended in-depth interview or social autopsy25,26 was carried out to identify any social or health-care-related factors that could have contributed to the death. Data analysis The proportion of women who survived at each follow-up visit was calculated for women who experienced near misses and for those who had uncomplicated deliveries. We used Fisher’s exact test to determine whether the post-discharge mortality rate differed significantly be- tween the two groups. We compared the marital status, age and parity at baseline of women who survived and who died within 4 years of follow-up in both the group of women who had uncomplicat- ed deliveries and in the group that had near misses. We used the chi squared test to assess the association between baseline characteristics and death. The most likely medical cause of death was assigned independently and agreed on by two clinical researchers on the basis of data from the verbal autopsy combined with additional information from medical records and reports of medical examinations (Table 1, avail- able at: http://www.who.int/bulletin/ volumes/90/6/11-094011). Comorbid conditions that may have contributed to the death were taken into account. In addition, we analysed records of the in-depth interviews thematically to de- rive non-medical causes of death.27 This analysis was guided by our knowledge of the social circumstances of women in Burkina Faso and the health systems they use, gained over the course of the study.11,12 Moreover, two of the deceased women belonged to the anthropologists’ subsample and had participated in sev- eral interviews before their deaths. Ethical approval The study was approved by the ethics committees of the London School of Hygiene and Tropical Medicine, United Kingdom of Great Britain and Northern Ireland, and the Ministry of Health of Burkina Faso. Study participants gave their free and informed consent. Results Mortality Fig. 1 shows the number of participants included at each stage of the study. Of the 1014 women recruited, 695 attended the final interview at the end of the 4-year fol- low-up and 20 had died. Post-discharge mortality was significantly higher among women who had a near-miss obstetric complication than among controls who had uncomplicated deliveries (P < 0.001). Fig. 2 shows the proportion of women who survived at each follow-up visit. Six (1.9%) women in the near-miss group died within 1 year, and none died in the control group. The corresponding figures at the end of the 4-year follow-up period were 15 (5.3%) and 5 (0.9%) in the two groups, respectively. No significant difference was found in age (P = 0.47) or parity at baseline (P = 0.42) between women in the near-miss group who died and those who survived and com- pleted follow-up. However, women who died were more likely to be single at baseline (P = 0.001; Table 2). We could draw no such comparisons in the control group because of the small number of deaths. Medical causes of death Verbal autopsy data were available for 18 of the 20 deaths (Table 1). The relatives of the remaining two women could not be located. In the near-miss group, 9 of the 15 deaths (60%) were pregnancy-related, compared with none in the control group (Table 1). Moreover, six of these nine pregnancy-related deaths occurred within 1 year of the near-miss obstetric complication or the end of the pregnancy. The most likely medical causes of these six deaths were: organ failure following septic abortion in one woman with a human immunodeficiency virus (HIV) infection; tuberculosis related to HIV infection in one woman with puerperal sepsis; anaemia with possible sepsis or immunity problems in one woman; probable anaemia in one; infection in one; and hypertension (i.e. eclampsia) in one. The remaining three pregnancy- related deaths in the near-miss group occurred within 42 days of a subsequent pregnancy: one was due to hyperten- sion, one to septic abortion and one to haemorrhage following caesarean section suture complications. At least three of the nine women who died from a pregnancy- related cause were HIV-positive. The causes of the remaining six deaths in the near-miss group were: HIV infection in one, hypertension in one, possible infection related to tuberculosis in one, a suspected traffic accident in one and unknown due to insufficient data in two. Of the five deaths in the control group, one was caused by malaria and three by acquired immunodeficiency syndrome (AIDS); the cause of one death remained undetermined due to insufficient data. The contribution of Bull World Health Organ 2012;90:418–425B | doi:10.2471/BLT.11.094011420 Research Mortality after obstetric near misses in Burkina Faso Katerini T Storeng et al. HIV infection and tuberculosis to deaths in the two groups is notable. By the end of follow-up, three of the seven babies born to women who had a near-miss complication and who subse- quently died had also died. One of the babies died a few days before his mother, at the age of 28 days. This baby was probably born with intrauterine growth retardation. The other two died after their mothers: one from malnutrition at 5 months and one from an unknown cause at 15 months. No deaths occurred among the five babies born to women in the control group who subsequently died. These babies were older at the time of their mothers’ deaths and therefore less vulnerable. Health-care-related and social causes of deaths Relatives of the women who died within a year of a near-miss complication be- lieved the women had been discharged prematurely. Correspondingly,17% of these women had not fully recovered when discharged, according to medi- cal records.8 Some left hospital because they could no longer afford to pay for care or to remain absent from their regular activities. Inadequate follow-up of unresolved health problems may have compounded the burden of premature discharge, as in the case of a 25-year-old woman who died of sepsis 7 months after an unsafe abortion (Box 1). As a whole, respondents noted that poor links between different parts of the health-care system (e.g. between a dis- trict hospital and a national hospital) delayed or prevented access to care. Similarly, relatives of the three women in the near-miss group who died of pregnancy-related causes after a sub- sequent pregnancy identified a range of health-care-related contributing factors. None of these women received specific follow-up during antenatal care despite having had a near-miss complication in a recent pregnancy. The reason may be that in Burkina Faso no midwife and certainly no specialist normally participates in antenatal care, which is often delivered in a ritualistic way without addressing chronic ailments or risk factors. An unmet need for contraception, which is costly and poorly available, contributed to one of the maternal deaths because it led to an unwanted pregnancy. According to this woman’s husband, the new preg- nancy exacerbated the hypertension that resulted in the near miss less than 2 years earlier (Box 2). Both relatives and health- Fig. 1. Study participants, maternal mortality in the 4 years after pregnancy, Burkina Faso, 2004–2009 1042 eligible women 17 refused 11 lost to follow-up 20 lost to follow-up 3 died 24 lost to follow-up 2 died 28 lost to follow-up 1 died 163 lost to follow-up 9 died 64 lost to follow-up 5 died 1014 women recruited 991 eligible women 965 eligible women 936 eligible women 764 eligible women 695 eligible women Approached for recruitment Medical records reviewed and attended interview Attended interview at 3 monthsa Attended interview or medical exam at 6 monthsa Attended interview or medical exam at 12 monthsa Attended interview in year 3a Attended interview in year 4a a Some women missed one interview but attended a later one, so were not counted as being lost to follow-up. Fig. 2. Maternal survival after the end of pregnancy, by pregnancy outcome, Burkina Faso, 2004–2009 Months UncomplicatedNear missa 0 10 20 30 40 50 60 Su rv iv al (% ) 100 99 98 97 96 95 94 93 92 91 90 a A near-miss complication is a severe obstetric complication that would probably kill the woman without timely medical care. Bull World Health Organ 2012;90:418–425B | doi:10.2471/BLT.11.094011 421 Research Mortality after obstetric near misses in Burkina FasoKaterini T Storeng et al. care workers strongly believed that better care could have saved the woman, who died of haemorrhage following caesarean section suture complications. She was discharged from hospital prematurely – within 24 hours of the emergency cae- sarean section – and was left untreated overnight, then readmitted with heavy bleeding and an open caesarean section wound the following evening. She died the next morning. Relatives regarded the women’s deaths as particularly tragic in light of the resources initially invested in saving them after the near miss and in treating subsequent associated health problems. Cost barriers disrupted referral chains for these women and impeded access to care for chronic health complaints, which may have indirectly or directly contributed to their deaths (Box 1). The cost barrier was particularly high for women with chronic health conditions. Lack of or inadequate treatment of pregnancy-related ailments, such as puerperal infection and anaemia, or of underlying infections or chronic conditions, such as hypertension, HIV infection, tuberculosis or malaria, appear to have contributed to several maternal deaths. These difficulties were exacer- bated by social disadvantage, including a lack of social and material support, especially among single women. Discussion Our findings show that the limited availability and poor quality of maternal health-care services can lead not only to immediate death or longer-term dis- ability or illness in women who experi- ence a near miss from severe pregnancy complications, but also to an increased risk of death as long as 4 years after the event. Although targeted emergency care initially saved many women who experienced obstetric complications, those who had a near miss were sig- nificantly more likely to die within the Table 2. Maternal mortality in the four years after pregnancy, by pregnancy outcome, age, parity and marital status, Burkina Faso, 2004–2009 Characteristic Pregnancy outcome Uncomplicated pregnancy Near-miss complicationa Women alive at 4 yearsb Women deceased at 4 years Women lost to follow-upc Pd Women alive at 4 years Women deceased at 4 years Women lost to follow-upe Pd No. % No. % No. % No. % No. % No. % Age (years) < 20 90 18.7 0 0 37 19.6 36 17.0 2 13.3 36 33.0 20–24 135 28.1 0 0 71 37.6 61 28.8 2 13.3 36 33.0 25–29 117 24.3 4 80.0 45 23.8 44 20.8 5 33.3 18 16.5 ≥ 30 139 28.9 1 20.0 36 19.1 NA 71 33.5 6 40.0 19 17.4 0.47 Parity 0 NA NA NA NA NA NA 20 9.4 3 20.0 17 15.5 1–3 344 71.4 4 80.0 155 82.0 132 62.3 8 53.3 72 65.5 4+ 138 28.6 1 20.0 34 18.0 0.67 60 28.3 4 26.7 21 19.1 0.42 Marital status Married or in a relationship 446 92.5 5 100.0 167 88.4 191 90.1 9 60.0 90 81.8 Single 36 7.5 0 0 22 11.6 NA 21 9.9 6 40.0 20 18.8 0.001 NA, not applicable. a A near-miss complication is a severe obstetric complication that would probably kill the woman without timely medical care. b Data were missing on age for two women, on parity for one and on marital status for one. c Data were missing on age for two women, on parity for two and on marital status for two. d P-values were calculated using the chi squared test, where possible, for differences between women who died and those who were alive and completed follow-up. Due to the small number of deaths among women with an uncomplicated delivery, it was not possible to calculate a P-value for the difference in age or marital status between women who died and those who survived. e Data were missing on age for three women, on parity for two and on marital status for two. Box 1. Example of a late pregnancy-related death after a near-miss complication,a Burkina Faso, 2005 The 25-year-old womanb moved from a rural village to a town to work in a bar. She became pregnant while in a relationship with a visiting bureaucrat. Her partner revealed he was married with children, pressured her to terminate the pregnancy and paid for an illegal abortion. She was hospitalized with a near-miss septic abortion after intense stomach aches resulting from the botched abortion, underwent manual vacuum aspiration for the incomplete abortion and was treated for infection before discharge. She suffered stigmatization, lost her income and job and became disillusioned. An unresolved abortion-related infection left untreated due to the cost of care resulted in another hospitalization 6 months after discharge. The woman’s brothers paid for her hospitalization for more than 1 month but were unable to afford prescribed referral to a tertiary hospital in a major city 170 km away. The woman died at her brothers’ home 7 months after the septic abortion. The brothers had substantial financial problems even 3 years after the woman’s death: they were in debt, had lost income and their farm’s yield was reduced because they had to sell some animals to cover the health-care costs. a A near-miss complication is a severe obstetric complication that would probably kill the woman without timely medical care. b Woman 4 in Table 1 (available at: http://www.who.int/bulletin/volumes/90/6/11-094011). Bull World Health Organ 2012;90:418–425B | doi:10.2471/BLT.11.094011422 Research Mortality after obstetric near misses in Burkina Faso Katerini T Storeng et al. next 4 years than those who had an un- complicated hospital delivery. Notably, these women had a higher risk of dying from a pregnancy-related cause, whether associated with the initial near miss or with the complications of a subsequent pregnancy. Single women were at a particularly high risk, perhaps because of poor material and social support. In addition, an infant born to a woman who had a near miss and subsequently died was also at an increased risk of death. The risk was higher both after the mother’s death and before, as the mother may have been too sick or poor to pro- duce breast milk or to properly care for her infant.28 By contrast, no women with an uncomplicated delivery died from a pregnancy-related cause, and the babies of those who did die survived. Although we lack survival data on women lost to follow-up, we observed that those who had a near miss were more often lost to follow-up than those who did not. Consequently, unrecorded deaths were more likely among these women than among controls. The verbal autopsy approach used in this study has well-known limita- tions, including recall bias, since data are sometimes collected months or years after a death.24,29 The validity and reliability of lay respondents’ reports of medical symptoms can also be prob- lematic; their descriptions can be vague and non-medical and can point to a diagnosis that differs from the physi- cian’s. Moreover, respondents cannot provide information on signs that are not detectable without laboratory test- ing or clinical autopsy. Although verbal autopsies cannot unequivocally identify the immediate cause of death or exclude competing causes, they can indicate the most likely contributing factors. In the absence of death registries, verbal autop- sies provide the best means of identify- ing the likely medical cause of death. Women clearly remain at risk of a pregnancy-related death for longer than the 42 days used in standard definitions of maternal death.30 Consequently, the contribution of pregnancy-related deaths to mortality among women of reproduc- tive age is likely to be underestimated. In- deed, extending the definition to include all deaths within 3 months of delivery increases current estimates of maternal mortality in low-income settings by 10% to 15%.30–32 Incorporating late maternal deaths within 1 year of the end of preg- nancy would further increase the figure. Current assessment methods may underrepresent indirect causes of mater- nal death, which could be aggravated by pregnancy.33 Our study showed that co- morbid conditions, such as HIV/AIDS, and diseases of poverty, such as anaemia, contributed to late pregnancy-related deaths after a near miss. Except for direct obstetric complications, HIV infection was the most important contributor to pregnancy-related deaths in our study. This finding supports recent analyses that highlight the contribution of HIV infection to high maternal mortality rates in Africa.34 Our analysis of the structural con- straints that limited access to health care and reduced the quality of the care received by women in our study helped us to understand the broader circum- stances leading to their deaths. The relatives of women who died highlighted various possible contributing factors: premature hospital discharge; poor postpartum follow-up; inadequately treated underlying conditions; unmet need for contraception; lack of appro- priate antenatal care, and inadequate emergency obstetric care in subsequent pregnancies.35 Although firm general conclusions about the health-care sys- tem cannot be drawn without support- ing data from health-care providers and other stakeholders, studies from Burkina Faso11,18 and other high-mortality coun- tries36 support our informants’ reports that poor service supply and demand act as barriers to maternal health care, both during and after pregnancy. Policy implications Because most maternal and neonatal deaths occur around the time of de- livery,13 the maternal health strategy throughout the world has long empha- sized intrapartum care. This includes skilled birth attendance for all women and emergency obstetric care to prevent maternal death from direct causes such as haemorrhage, obstructed labour, hypertension, infection and anaemia.37 However, although good intrapartum care can ensure safe delivery, it does not suffice to prevent death in the aftermath of severe complications, sometimes over the long term. Our study findings on the indirect causes of maternal death, the weaknesses in the health-care system and the social and structural barriers to health care suggest the need for a more compre- hensive, life-cycle approach to women’s health. The solution may be longer and more differentiated clinical man- agement, including family planning. Moreover, we also found that underly- ing chronic health problems increase the risk of maternal death. The solution may be integrated health care, with in- tegration across the entire reproductive cycle (i.e. family planning, pregnancy and delivery care, and postpartum care) and across different vertical treatment programmes, and with integration of specialist and generalist care. It has become evident in recent years that a well-functioning health-care system and the provision of a continuum of care are essential for achieving the United Nations Millenium Develop- ment Goals pertaining to health. For instance, international policy-makers postulate a continuum of care for ma- ternal, neonatal and child health that Box 2. Example of a maternal death from a new pregnancy after a near-miss complication,a Burkina Faso, 2006–8 The 23-year-old Muslim womanb divorced after the death of her first child and was betrothed to a subsistence farmer, a relative, as his second wife. She experienced a stillbirth after a near-miss delivery involving eclampsia; the resulting health-care expenditure was ”catastrophic” for the hous ehold. She had difficulty participating in household activities due to chronic ill health related to hypertension that started in pregnancy. The support of her partner and his co-wife enabled the woman to be temporarily absent from subsistence agricultural work and domestic chores. She took medication only on alternate weeks due to its cost. She wanted to delay a new pregnancy but was unable to acquire appropriate contraception because it was costly and unavailable at the local health centre. She had a new pregnancy within 1 year of the near-miss complication. The new pregnancy was difficult because of hypertension and she had a hospital delivery. She became ill in the postpartum period and died while asleep 28 days after delivery, most likely from hypertensive disease. The baby died shortly afterwards. Her husband was financially “ruined” by the health-care expenditure, which was exacerbated by new responsibilities for the widow and three children of a brother who had died. a A near-miss complication is a severe obstetric complication that would probably kill the woman without timely medical care. b Woman 8 in Table 1 (available at: http://www.who.int/bulletin/volumes/90/6/11-094001). Bull World Health Organ 2012;90:418–425B | doi:10.2471/BLT.11.094011 423 Research Mortality after obstetric near misses in Burkina FasoKaterini T Storeng et al. involves integrating health care for these different groups across time and place.38 Such a continuum would include post- partum care as a priority and provide links between reproductive and sexual health-care services and maternal health care. In addition, ways of simultaneously addressing the social and economic determinants of health are receiving increasing attention.39 Despite these policy changes and the greater priority afforded to ma- ternal health both internationally and nationally,40 achieving a comprehensive continuum of care remains challenging. For example, few health-care services address the specific needs of women in the year following childbirth.5 More often, safe motherhood programmes in low-income countries, including Burkina Faso, are implemented verti- cally and focus almost exclusively on the birth period. They rarely address the underlying factors that undermine health, such as economic and social disadvantage, chronic health problems and poor access to individual, continu- ous and preventive health care. In conclusion, surviving a near- miss obstetric complication is no guarantee that a pregnancy-related death has been averted. In Burkina Faso, women who experienced a near- miss complication had a higher risk of all-cause and pregnancy-related death, even 4 years later, due to a combination of medical, social and health-care- related factors. Current safe mother- hood programmes emphasize emer- gency intrapartum obstetric care that targets the direct causes of maternal mortality. These programmes are in- sufficient for tackling excess mortality over the longer term. Survival in this period requires the introduction of a comprehensive continuum of care that addresses the indirect and social causes of death. ■ Acknowledgements The authors thank Mélanie Akoum, Oona Campbell, Patrick Ilboudo, Birgit Kvernflaten, Hanne Lichtwarck, Tom Marshall, Nicolas Meda, Susan Murray, Fatoumata Ouattara, Thomas Ouédraogo, Carine Ronsmans, Steven Russell, Henri Somé, seminar partici- pants at the University of Uppsala and the Christian Michelsen Institute in Bergen and all women, their relatives, health workers and interviewers in- volved in the study. Funding: Immpact, the Hewlett Founda- tion and the UK Economic and Social Research Council (Grant number RES- 183-25-0011) funded the first stages of the study. The Research Council of Nor- way’s ECONPOP programme (Project number 199730/H30) supported verbal autopsy data collection and analysis. Competing interests: None declared. صخلم ةيحصلا ةياعرلا لماوعو ةيعماتجلااو ةيبطلا لماوعلا :وساف انيكروب في ةكيشولا ةدلاولا تافعاضم دعب تايفولا لدعم في وساف انيكروب في ءاسنلا ىدل تايفولا لدعم ثحب ضرغلا ةكيشولا ةدلاولا تافعاضم ىدحإ ثودلح ةيلاتلا ةعبرلأا ماوعلأا تاذو ةيعماتجلااو ةيبطلا ةافولا بابسأ ديدتحو ةايحلل ةددهلما .ةيحصلا ةياعرلاب ةلصلا نم نهجورخ دعب ةديس 1014 هيلاجمإ ام رايتخا مت ةقيرطلا ةديس 337 ىدل تناك :تاونس 4 ةدلم نهتعباتمو ىفشتسلما ةبوحصم يرغ ةديس 677 لحم تلااح تناكو ةكيشو تافعاضم ينب تايفولا لدعم في ةيرهولجا تافلاتخلاا مييقت مت .تافعاضمب بابسلأا ديدتح متو .قيقدلا شريف رابتخا مادختساب تاعومجلما متو ؛ةيظفللا حيشرتلا تانايبو ةيبطلا تلاجسلا نم ةافولل ةيبطلا ةيحصلا ةياعرلاب ةلصلا تاذ لماوعلاو ةيعماتجلاا لماوعلا ديدتح تاديسلا براقأ عم تيرجأ يتلا تلاباقلما نم ةافولاب ةطبترلما .تايفوتلما ةئفلا في ةديس )% 5.3( 15 تيفوت ،تاونس 4 للاخ جئاتنلا تافعاضمب بوحصم يرغ لحم دعب )% 0.9( تاديس 5و ةكيشولا ةافولا تلااح فصن نع ديزي ام تناكو .)0.001 < لماتحلاا( نم يأ لملحاب طبتري لم ينح في ،لملحاب ةطبترم ةكيشو ةلاح دعب تهماسو .ضارعأب ةبوحصلما يرغ ةدلاولا دعب ةافولا تلااح صخلأابو ،هذه ةافولا تلااح نم ديدعلا في ةشرابلما يرغ لماوعلا براقلأا ريراقت تدافأو .يشربلا يعانلما زوعلا سويرف ىودع راقتفلااو ،اتهدوج فعضو ةيحصلا ةياعرلل ةظهابلا ةفلكتلا نأب لملحا عنم لئاسول اهتيبلت متي لم يتلا ةجالحاو ةعباتلما ةياعر لىإ .ةكيشولا ةئفلا في تايفولا لدعم ةدايز في تهماس نم ينجن تياوللا وساف انيكروب في تاديسلا تضرعت جاتنتسلاا نع ةتجانلا ةافولل ةدئاز ةروطخ لىإ ةكيشولا ةدلاولا تافعاضم نكميو .ةيلاتلا ةعبرلأا ماوعلأا في لملحاب ةطبترلماو بابسلأا عيجم ةيرارمتسا يرفوت قيرط نع ليوطلا ىدلما لىع ةاجنلا ةيلماتحا ةدايز ،ةافولل ةيعماتجلااو ةشرابلما يرغ بابسلأا جلاعت يتلا ةياعرلا نم ةمدقلما عضولا ءانثأ ةئراطلا تلاالحا في ديلوتلا ةياعر معدتو .ةيلالحا ةنومألما ةموملأا جمارب بناج 摘要 布基纳法索频临死亡分娩并发症导致的死亡率:医疗、社会和保健因素 目的 调查布基纳法索患有威胁生命的频临死亡并发症的 女性在随后4 年中的死亡率并确定医疗、社会和保健相关 的死亡原因。 方法 总计招募了1014 名出院后的产妇,并跟踪达4 年:337 名产妇患有频临死亡的并发症,677 名女性无妊娠期并发 症。使用Fisher精确检验评估两组间死亡率的明显不同。 根据医疗记录和文字尸检数据确定死亡的医疗原因;通过 对已故产妇亲属的访谈确定死亡相关的社会和医疗因素。 结果 在4 年中,濒临死亡组中有15(5.3%)名产妇死亡,无妊娠 期并发症的有5(0.9%)名产妇死亡(P < 0.001)。濒临死亡后 的死亡有半数以上是因为与怀孕相关的间接因素造成了很 多这种死亡,尤其是艾滋病毒感染,而无妊娠期并发症生产后 的死亡都不存在这样的因素。亲属的说明显示高成本和低 质量医疗保健、缺少后续照顾以及避孕需求没有得到满足 导致了濒临死亡组的过高死亡率。 结论 在布基纳法索,最初从频临死亡的产科并发症中幸存的 产妇,在随后4 年中会面临更高因各种原因以及与怀孕相关 的原因而死亡的风险。通过提供连续照顾来消除间接和社 会的死亡原因,以及通过当前的安全妈妈计划为紧急分娩产 科护理提供补充,可提高在更长的时间里生存的可能性。 Bull World Health Organ 2012;90:418–425B | doi:10.2471/BLT.11.094011424 Research Mortality after obstetric near misses in Burkina Faso Katerini T Storeng et al. Résumé Mortalité suite aux complications obstétricales évitées de justesse au Burkina Faso: facteurs médicaux, sociaux et sanitaires Objectif Explorer la mortalité chez les femmes du Burkina Faso durant les 4 années suivant une complication obstétricale fatale évitée de justesse (“near-miss”) et identifier les causes médicales, sociales et sanitaires du décès. Méthodes Au total, 1 014 femmes ont été recrutées après la sortie de l’hôpital et suivies durant 4 ans: 337 ont vécu des “near-miss” et 677 ont eu des grossesses sans complications. Des différences significatives de mortalité entre les groupes ont été identifiées en utilisant le test exact de Fisher. Les causes médicales du décès ont été identifiées à partir des dossiers médicaux et des données verbales d’autopsie; les facteurs sociaux et de soins de santé liés au décès ont été constatés à partir d’entretiens avec les proches des femmes décédées. Résultats Durant les 4 années, 15 (5,3%) femmes sont mortes dans le groupe “near-miss” et 5 (0,9%) sont décédées après des grossesses sans complication (P <0,001). Plus de la moitié des décès après un “near-miss”, mais aucun après un accouchement sans complications, étaient liés à une grossesse. Des facteurs indirects ont contribué à bon nombre de ces décès, en particulier les infections par le HIV. Les comptes rendus des proches font supposer que le coût élevé et la mauvaise qualité des soins de santé, un manque de suivi des soins et un besoin non satisfait de contraception ont contribué à la mortalité augmentée dans le groupe “near-miss”. Conclusion Les femmes au Burkina Faso qui ont initialement survécu à une complication obstétricale évitée de justesse présentaient un risque accru de décès pour toute cause ou lié à la grossesse les 4 années suivantes. La probabilité de survie sur le long terme pourrait être augmentée en offrant un continuum de soins qui s’attaque aux causes indirectes et sociales des décès et complémente les soins obstétricaux d’urgence fournis par les programmes actuels de maternité sans risque. Резюме Смертность после родовых осложнений, связанных с угрозой жизни, в Буркина-Фасо: медицинские, социальные и медико-санитарные факторы Цель Изучить смертность среди женщин в Буркина-Фасо в течение 4 лет после родовых осложнений, связанных с угрозой жизни, а также медицинские, социальные и медико-санитарные факторы смертности. Методы В общей сложности исследование охватывает 1 014 женщин, которые наблюдались в течение 4 лет с момента выписки из больницы: У 337 роды сопровождались осложнениями, связанными с угрозой жизни, а у 677 беременность прошла без осложнений. Значимость разницы в уровне смертности между группами оценивалась с помощью точного критерия Фишера. Медицинские причины смерти выявлялись на основе медицинских документов и устных сведений о вскрытии; социальные и медико- санитарные факторы, связанные со смертью, определялись с помощью интервью с родственниками умерших женщин. Результаты В течение 4 лет умерли 15 (5,3%) женщин из группы, в которой роды сопровождались осложнениями, связанными с угрозой жизни, и умерли 5 (0,9%) женщин, у которых роды прошли без осложнений (P < 0,001). С беременностью были связаны более половины смертей после родов, сопровождавшихся осложнениями, связанными с угрозой жизни, и ни одной после не осложненных родов. Многим из этих смертей способствовали косвенные факторы, особенно вирус иммунодефицита человека. Информация, полученная от родственников, свидетельствует, что высокой смертности в группе женщин, у которых роды сопровождались осложнениями, связанными с угрозой жизни, способствовала дороговизна и низкое качество медицинского обслуживания, отсутствие амбулаторного наблюдения и неудовлетворенная потребность в контрацептивах. Вывод Женщины в Буркина-Фасо, которые выжили после родовых осложнений, связанных с угрозой жизни, в последующие 4 года сталкиваются с повышенным риском смерти как от общих причин, так и от причин, связанных с беременностью. Шансы на выживание в долгосрочной перспективе могут быть увеличены за счет предоставления постоянной помощи, направленной борьбу с косвенными и социальными причинами смерти. Такая помощь должна дополнять экстренную родовую помощь, предусмотренную действующими программами безопасного материнства. Resumen La mortalidad después de complicaciones obstétricas graves en Burkina Faso: factores médicos, sociales y sanitarios Objetivo Investigar la mortalidad entre mujeres en Burkina Faso en los cuatro años posteriores a una complicación obstétrica potencialmente mortal e identificar las causas médicas, sociales y sanitarias relacionadas con el fallecimiento. Métodos Se realizó un seguimiento durante un máximo de cuatro años a un total de 1014 mujeres inscritas después de haber recibido el alta médica: De ellas, 337 habían sufrido complicaciones obstétricas graves y 677 habían disfrutado de embarazos sin complicaciones. Se empleó el test exacto de Fisher para evaluar las diferencias significativas en la mortalidad entre ambos grupos. Las causas médicas de la mortalidad se identificaron a través de los historiales médicos y los datos de autopsias verbales. Las entrevistas con los familiares de las mujeres fallecidas permitieron identificar los factores sociales y sanitarios vinculados con el fallecimiento. Resultados Durante esos cuatro años, fallecieron 15 (5,3%) mujeres del grupo con embarazos con complicaciones y cinco (0,9%) del grupo con embarazos sin complicaciones (P <0,001). Más de la mitad de los fallecimientos después de una complicación obstétrica grave estuvieron relacionados con el embarazo, pero ninguno después un parto sin complicaciones. Factores indirectos, en particular una infección con el virus de la inmunodeficiencia humana, contribuyeron a muchos de esos fallecimientos. Las explicaciones de los familiares sugirieron que los altos costes y la baja calidad de la asistencia sanitaria, la falta de un seguimiento y las necesidades desatendidas en materia de anticoncepción contribuyeron a esa elevada mortalidad en el grupo con complicaciones obstétricas graves. Conclusión Las mujeres en Burkina Faso que inicialmente sobrevivieron a una complicación obstétrica grave presentaron un riesgo mayor de fallecer en los cuatro años siguientes. La probabilidad de supervivencia a largo plazo podría aumentar si se ofreciera una asistencia continuada que abordara las causas indirectas y sociales de la mortalidad y que complementara la atención obstétrica de emergencia durante el parto que proporcionan los programas actuales de maternidad sin riesgo. Bull World Health Organ 2012;90:418–425B | doi:10.2471/BLT.11.094011 425 Research Mortality after obstetric near misses in Burkina FasoKaterini T Storeng et al. References 1. Paxton A, Wardlaw T. Are we making progress in maternal mortality? N Engl J Med 2011;364:1990–3. doi:10.1056/NEJMp1012860 PMID:21612467 2. Ronsmans C, Filippi V. Reviewing severe maternal morbidity: learning from women who survive life-threatening complications. In: Lewis G, editor. Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. Geneva: World Health Organization; 2003. 3. Kessels-Habraken M, Van der Schaaf T, De Jonge J, Rutte C. Defining near misses: towards a sharpened definition based on empirical data about error handling processes. Soc Sci Med 2010;70:1301–8. doi:10.1016/j. socscimed.2010.01.006 PMID:20153573 4. Pacagnella RC, Cecatti JG, Camargo RP, Silveira C, Zanardi DT, Souza JP et al. Rationale for a long-term evaluation of the consequences of potentially life-threatening maternal conditions and maternal “near-miss” incidents using a multidimensional approach. J Obstet Gynaecol Can 2010;32:730–8. PMID:21050503 5. Chersich MF, Kley N, Luchters SM, Njeru C, Yard E, Othigo MJ et al. Maternal morbidity in the first year after childbirth in Mombasa Kenya; a needs assessment. BMC Pregnancy Childbirth 2009;9:51. doi:10.1186/1471-2393-9- 51 PMID:19891784 6. Murphy DJ, Charlett P. Cohort study of near-miss maternal mortality and subsequent reproductive outcome. Eur J Obstet Gynecol Reprod Biol 2002;102:173–8. doi:10.1016/S0301-2115(01)00320-7 PMID:11950486 7. Wilson RE, Salihu HM. The paradox of obstetric “near misses”: converting maternal mortality into morbidity. Int J Fertil Womens Med 2007;52:121–7. PMID:18320871 8. Filippi V, Ganaba R, Baggaley RF, Marshall T, Storeng KT, Sombié I et al. Health of women after severe obstetric complications in Burkina Faso: a longitudinal study. Lancet 2007;370:1329–37. doi:10.1016/S0140- 6736(07)61574-8 PMID:17933647 9. Filippi V, Goufodji S, Sismanidis C, Kanhonou L, Fottrell E, Ronsmans C et al. Effects of severe obstetric complications on women’s health and infant mortality in Benin. Trop Med Int Health 2010;15:733–42. doi:10.1111/j.1365- 3156.2010.02534.x PMID:20406426 10. Ganaba R, Marshall T, Sombié I, Baggaley RF, Ouédraogo TW, Filippi V. Women’s sexual health and contraceptive needs after a severe obstetric complication (“near-miss”): a cohort study in Burkina Faso. Reprod Health 2010;7:22. doi:10.1186/1742-4755-7-22 PMID:20799964 11. Storeng KT, Baggaley RF, Ganaba R, Ouattara F, Akoum MS, Filippi V. Paying the price: the cost and consequences of emergency obstetric care in Burkina Faso. Soc Sci Med 2008;66:545–57. doi:10.1016/j. socscimed.2007.10.001 PMID:18061325 12. Storeng KT, Murray SF, Akoum MS, Ouattara F, Filippi V. Beyond body counts: a qualitative study of lives and loss in Burkina Faso after ‘near-miss’ obstetric complications. Soc Sci Med 2010;71:1749–56. doi:10.1016/j. socscimed.2010.03.056 PMID:20541307 13. Hurt LS, Alam N, Dieltiens G, Aktar N, Ronsmans C. Duration and magnitude of mortality after pregnancy in rural Bangladesh. Int J Epidemiol 2008;37:397–404. doi:10.1093/ije/dym274 PMID:18276635 14. Human Development Report 2009. Overcoming barriers: human mobility and development. New York: United Nations Development Program; 2009. 15. Institut National de la Statistique et de la Démographie. Recensement général de la population et de l’habitation de 2006 (RGPH-2006). Thème 6: natalité - fécondité. Ouagadougou: Ministère de l’Économie et des Finances du Burkina Faso; 2009. 16. Institut National de la Statistique et de la Démographie. Recensement général de la population et de l’habitation de 2006 (RGPH-2006). Thème 7: la mortalité. Ouagadougou: Ministère de l’Économie et des Finances du Burkina Faso; 2009. 17. Trends in maternal mortality 1990 to 2008: estimates developed by WHO, UNICEF, UNFPA and World Bank. Geneva: World Health Organization; 2010. 18. Hounton SH, Meda N, Hussein J, Sombie I, Conombo G, Graham WJ. Describing safe motherhood programs for priority setting: the case of Burkina Faso. Int J Gynaecol Obstet 2005;91:97–104. doi:10.1016/j. ijgo.2005.06.027 PMID:16115635 19. Ministère de la santé du Burkina Faso. Annuaire statistique 2009. Ouagadougou: Ministère de la Santé du Burkina Faso; 2010. 20. Ministère de la Santé du Burkina Faso. Stratégie national de subvention des accouchements et des soins obstétricaux er néonataux d’urgence au Burkina Faso. Ouagadougou: Ministère de la Santé du Burkina Faso; 2006. 21. De Allegri M, Ridde V, Louis VR, Sarker M, Tiendrebéogo J, Yé M et al. Determinants of utilisation of maternal care services after the reduction of user fees: a case study from rural Burkina Faso. Health Policy 2011;99:210–8. doi:10.1016/j.healthpol.2010.10.010 PMID:21056505 22. Ridde V, Richard F, Bicaba A, Queuille L, Conombo G. The national subsidy for deliveries and emergency obstetric care in Burkina Faso. Health Policy Plan 2011;26(Suppl 2):ii30–40. doi:10.1093/heapol/czr060 PMID:22027917 23. Stewart MK, Festin M. Validation study of women’s reporting and recall of major obstetric complications treated at the Philippine General Hospital. Int J Gynaecol Obstet 1995;48(Suppl):S53–66. doi:10.1016/0020- 7292(95)02320-C PMID:7672175 24. Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. Geneva: World Health Organization; 2004. 25. D’Ambruoso L, Byass P, Qomariyah SN, Ouédraogo M. A lost cause? Extending verbal autopsy to investigate biomedical and socio-cultural causes of maternal death in Burkina Faso and Indonesia. Soc Sci Med 2010;71:1728–38. doi:10.1016/j.socscimed.2010.05.023 PMID:20646807 26. Kalter HD, Salgado R, Babille M, Koffi AK, Black RE. Social autopsy for maternal and child deaths: a comprehensive literature review to examine the concept and the development of the method. Popul Health Metr 2011;9:45 PMID:21819605 27. Bernard HR. Research methods in anthropology: qualitative and quantitative approaches, 5th edition. Walnut Creek: Alta Mira Press; 2011. 28. Ronsmans C, Chowdhury ME, Dasgupta SK, Ahmed A, Koblinsky M. Effect of parent’s death on child survival in rural Bangladesh: a cohort study. Lancet 2010;375:2024–31. doi:10.1016/S0140-6736(10)60704-0 PMID:20569842 29. Soleman N, Chandramohan D, Shibuya K. Verbal autopsy: current practices and challenges. Bull World Health Organ 2006;84:239–45. doi:10.2471/ BLT.05.027003 PMID:16583084 30. Høj L, da Silva D, Hedegaard K, Sandström A, Aaby P. Maternal mortality: only 42 days? BJOG 2003;110:995–1000. PMID:14592584 31. Hurt LS, Ronsmans C, Campbell OM, Saha S, Kenward M, Quigley M. Long- term effects of reproductive history on all-cause mortality among adults in rural Bangladesh. Stud Fam Plann 2004;35:189–96. doi:10.1111/j.1728- 4465.2004.00022.x PMID:15511062 32. Pradhan EK, West KP Jr, Katz J, Christian P, Khatry SK, Leclerq SC et al. Risk of death following pregnancy in rural Nepal. Bull World Health Organ 2002;80:887–91. PMID:12481211 33. Menéndez C, Romagosa C, Ismail MR, Carrilho C, Saute F, Osman N et al. An autopsy study of maternal mortality in Mozambique: the contribution of infectious diseases. PLoS Med 2008;5:e44. doi:10.1371/journal. pmed.0050044 PMID:18288887 34. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010;375:1609– 23. doi:10.1016/S0140-6736(10)60518-1 PMID:20382417 35. Storeng KT, Drabo S, Filippi V. Too poor to live: a case study of vulnerability and maternal mortality in Burkina Faso. Glob Health Promot 2012. Forthcoming doi:10.1146/annurev-publhealth-031210-101220 PMID:21219162 36. Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, Anwar I et al. Going to scale with professional skilled care. Lancet 2006;368:1377–86. doi:10.1016/S0140-6736(06)69382-3 PMID:17046470 37. Campbell OM, Graham WJ. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006;368:1284–99. doi:10.1016/S0140- 6736(06)69381-1 PMID:17027735 38. Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet 2007;370:1358–69. doi:10.1016/S0140- 6736(07)61578-5 PMID:17933651 39. Friel S, Marmot MG. Action on the social determinants of health and health inequities goes global. Annu Rev Public Health 2011;32:225–36. doi:10.1146/ annurev-publhealth-031210-101220 PMID:21219162 40. Analysing commitment to advance the global strategy for women’s and children’s. Geneva: Partnership for Maternal, Newborn & Child Health (PMNCH); 2011. Available from: http://www.who.int/pmnch/topics/ part_publications/2011_pmnch_report/en/index.html [accessed 3 February 2012]. Bull World Health Organ 2012;90:418–425B | doi:10.2471/BLT.11.094011 425A Research Mortality after obstetric near misses in Burkina FasoKaterini T Storeng et al. Ta bl e 1. W om en w ho d ie d w ith in fo ur ye ar s o f t he e nd o f a p re gn an cy , B ur ki na Fa so , 2 00 4– 20 09 Ca se Da te o f e nd o f pr eg na nc y W om an ’s ag e an d no . o f pr eg na nc ie s a t s tu dy re cr ui tm en t M ar ita l s ta tu s at re cr ui tm en t Pr eg na nc y o ut co m e, kn ow n m ed ica l co nd iti on Ti m e w om an re po rt ed a s l os t t o fo llo w - u p Ti m e of w om an ’s de at h af te r t he e nd o f pr eg na nc y M ed ica l c au se o f de at ha St at us o f i nd ex ch ild a t l as t in te rv ie w No . o f pr eg na nc ie s s in ce in de x p re gn an cy 1 26 Ja nu ar y 20 05 23 y ea rs , fi rs t p re gn an cy Si ng le N ea r- m iss co m pl ic at io n, b l iv e bi rt h, h yp er te ns io n Ye ar 4 in te rv ie w 2 ye ar s a nd 5 m on th s H yp er te ns io n, p os sib le hy pe rt en siv e st ro ke un re la te d to p re gn an cy Al iv e 0 2 27 Ja nu ar y 20 05 25 y ea rs , fi rs t p re gn an cy M ar rie d N ea r- m iss co m pl ic at io n, li ve b irt h, in fe ct io ns Ye ar 3 in te rv ie w U nk no w n, 1 –3 y ea rs U nk no w n U nk no w n U nk no w n 3 13 M ar ch 2 00 5 26 y ea rs , t hi rd p re gn an cy Si ng le N ea r- m iss co m pl ic at io n, e ar ly pr eg na nc y lo ss , ha em or rh ag e, in fe ct io ns Ye ar 3 in te rv ie w 2 ye ar s a nd 5 m on th s Po ss ib le tr affi c ac ci de nt N A 0 4 Ar ou nd 9 Fe br ua ry 2 00 5 25 y ea rs , t hi rd p re gn an cy Si ng le N ea r- m iss co m pl ic at io n, e ar ly pr eg na nc y lo ss , s ep sis , H IV + M on th 1 2 in te rv ie w 7 m on th s Se pt ic a bo rt io n w ith ge ne ra l i nf ec tio n co m pl ic at ed b y or ga n fa ilu re , H IV in fe ct io n (la te p re gn an cy -re la te d de at h) N A 0 5 17 M ar ch 2 00 5 30 y ea rs , f ou rt h pr eg na nc y M ar rie d N ea r- m iss co m pl ic at io n, li ve b irt h, dy st oc ia Ye ar 3 in te rv ie w 1 ye ar a nd 2 m on th s U nk no w n Al iv e 0 6 26 M ar ch 2 00 5 34 y ea rs , e ig ht h pr eg na nc y Si ng le N ea r- m iss co m pl ic at io n, li ve b irt h, in fe ct io ns , H IV + M on th 3 in te rv ie w 35 d ay s Tu be rc ul os is, H IV in fe ct io n (la te pr eg na nc y- re la te d de at h) D ea d at 2 8 da ys , po ss ib le in tra ut er in e gr ow th re ta rd at io n 0 7 30 D ec em be r 20 04 30 y ea rs , fi rs t p re gn an cy Si ng le N ea r- m iss co m pl ic at io n, p er in at al de at h, in fe ct io ns Ye ar 3 in te rv ie w 2 ye ar s a nd 1 2 m on th s Se ps is, o rg an fa ilu re , H IV /A ID S N A 0 8 26 Ja nu ar y 20 05 23 y ea rs , s ec on d pr eg na nc y Co ha bi tin g (p ol yg am y) N ea r- m iss co m pl ic at io n, p er in at al de at h, h yp er te ns io n Ye ar 3 in te rv ie w Be tw ee n 1 an d 3 ye ar s (th e da te p ro vi de d w as un lik el y) Es se nt ia l h yp er te ns io n, po ss ib le H EL LP sy nd ro m e, m at er na l de at h in n ew pr eg na nc y (p os sib ly pr eg na nc y- re la te d) N A 1 9 2 M ar ch 2 00 5 40 y ea rs , s ix th p re gn an cy M ar rie d (p ol yg am y) U nc om pl ic at ed b irt h Ye ar 4 in te rv ie w Ar ou nd 4 y ea rs Tu be rc ul os is, H IV /A ID S, or ga n fa ilu re Al iv e at y ea r 3 in te rv ie w 0 10 25 F eb ru ar y 20 05 32 y ea rs , s ix th p re gn an cy M ar rie d (p ol yg am y) N ea r- m iss co m pl ic at io n, e ar ly pr eg na nc y lo ss , ha em or rh ag e Ye ar 3 in te rv ie w 1 ye ar a nd 6 m on th s Se pt ic a bo rt io n, o rg an fa ilu re , m at er na l d ea th in n ew p re gn an cy N A 1 (c on tin ue s … ) 425B Bull World Health Organ 2012;90:418–425B | doi:10.2471/BLT.11.094011 Research Mortality after obstetric near misses in Burkina Faso Katerini T Storeng et al. Ca se Da te o f e nd o f pr eg na nc y W om an ’s ag e an d no . o f pr eg na nc ie s a t s tu dy re cr ui tm en t M ar ita l s ta tu s at re cr ui tm en t Pr eg na nc y o ut co m e, kn ow n m ed ica l co nd iti on Ti m e w om an re po rt ed a s l os t t o fo llo w - u p Ti m e of w om an ’s de at h af te r t he e nd o f pr eg na nc y M ed ica l c au se o f de at ha St at us o f i nd ex ch ild a t l as t in te rv ie w No . o f pr eg na nc ie s s in ce in de x p re gn an cy 11 15 M ar ch 2 00 5 26 y ea rs , e ig ht h pr eg na nc y M ar rie d (p ol yg am y) N ea r- m iss co m pl ic at io n, li ve b irt h, an ae m ia M on th 3 in te rv ie w 2 m on th s An ae m ia , p os sib le im m un e pr ob le m s, po ss ib le se ps is, (l at e pr eg na nc y- re la te d de at h) D ea d at 5 m on th s 0 12 7 M ar ch 2 00 5 30 y ea rs , f ou rt h pr eg na nc y M ar rie d (p ol yg am y) N ea r- m iss co m pl ic at io n, e ar ly pr eg na nc y lo ss , ha em or rh ag e, in fe ct io ns , o rg an fa ilu re Ye ar 3 in te rv ie w 3 ye ar s Ca es ar ea n co m pl ic at io n in vo lv in g ha em or rh ag e, su tu re fa ilu re a nd su bs eq ue nt in fe ct io n, m at er na l d ea th in n ew pr eg na nc y N A 2 13 23 D ec em be r 20 04 29 y ea rs , f ou rt h pr eg na nc y M ar rie d U nc om pl ic at ed b irt h Ye ar 4 in te rv ie w Be tw ee n 3 an d 4 ye ar s M al ar ia Al iv e at v er ba l au to ps y in 2 01 0 0 14 25 D ec em be r 20 04 38 y ea rs , s ev en th pr eg na nc y M ar rie d (p ol yg am y) N ea r- m iss co m pl ic at io n, p er in at al de at h, in fe ct io ns Ye ar 3 in te rv ie w 2 ye ar s a nd 1 m on th Ch ro ni c in fe ct io n po ss ib ly re la te d to tu be rc ul os is, se ps is, re na l f ai lu re N A 0 15 10 Ja nu ar y 20 05 26 y ea rs , s ec on d pr eg na nc y Co ha bi tin g (p ol yg am y) U nc om pl ic at ed b irt h Ye ar 3 in te rv ie w 2 ye ar s a nd 4 m on th s Se ps is w ith c hr on ic in fe ct io n or im m un e dy sf un ct io n, p os sib ly re la te d to H IV in fe ct io n Al iv e at v er ba l au to ps y in te rv ie w 0 16 19 Ja nu ar y 20 05 17 y ea rs , fi rs t p re gn an cy Si ng le N ea r- m iss co m pl ic at io n, p er in at al de at h, a na em ia M on th 6 in te rv ie w 4 m on th s In fe ct io ns (l at e pr eg na nc y- re la te d de at h) N A 0 17 19 F eb ru ar y 20 05 25 y ea rs , s ec on d pr eg na nc y M ar rie d N ea r- m iss co m pl ic at io n, li ve b irt h, se ps is, H IV + M on th 3 in te rv ie w 40 d ay s Po ss ib le a na em ia (l at e pr eg na nc y- re la te d de at h) D ea d at 15 m on th s 0 18 23 F eb ru ar y 20 05 29 y ea rs , f ou rt h pr eg na nc y M ar rie d U nc om pl ic at ed b irt h Ye ar 4 in te rv ie w U nk no w n, 1 –3 y ea rs U nk no w n Al iv e at y ea r 2 in te rv ie w 0 19 10 M ar ch 2 00 5 27 y ea rs , t hi rd p re gn an cy M ar rie d U nc om pl ic at ed b irt h Ye ar 4 in te rv ie w 3 ye ar s a nd 1 1 m on th s Tu be rc ul os is or po ss ib le H IV in fe ct io n Al iv e at v er ba l au to ps y in te rv ie w 1 20 22 F eb ru ar y 20 05 18 y ea rs , fi rs t p re gn an cy Co ha bi tin g N ea r- m iss co m pl ic at io n, li ve b irt h, pr e- ec la m ps ia M on th 6 in te rv ie w U nk no w n, w ith in 6 m on th s Co m a, p os sib le ec la m ps ia (l at e pr eg na nc y- re la te d de at h) Al iv e at v er ba l au to ps y in te rv ie w 0 AI D S, a cq ui re d im m un od efi ci en cy sy nd ro m e; H IV h um an im m un od efi ci en cy v iru s; N A, n ot a pp lic ab le . a T he m ed ic al c au se o f d ea th w as d et er m in ed fr om v er ba l a ut op sy d at a, m ed ic al re co rd s a nd re po rts o f m ed ic al e xa m in at io ns . b A n ea r-m iss c om pl ic at io n is a se ve re o bs te tri c co m pl ic at io n th at w ou ld p ro ba bl y ha ve k ill ed th e w om an h ad sh e no t r ec ei ve d tim el y m ed ic al c ar e. (… co nt in ue d)