International virtual confidential reviews of infection-related maternal deaths and near-miss in 11 low- and middle-income countries – case report series and suggested actions
Authors: Okafor Obiageli , Roos Nathalie , Abdosh Abdulfetah Abdulkadir , Adesina Olubukola , Alaoui Zaynab , Romero William Arriaga , Assarag Bouchra , Aworinde Olufemi , de Bernis Luc , Castro Rigoberto , Chrifi Hassan , Day Louise Tina , Demissew Rahel , Aceituno María Guadalupe Flores , Gadama Luis , Gashawbeza Biruck , Keke Sourou Goufodji , Govule Philip , Gwako George , Jayaratne Kapila , Komboigo Evelyne Béwendin , Lara Bredy , Madziyire Mugove Gerald , Mathai Matthews , Moulki Rachid , Moutaouadia Iatimad , Munjanja Stephen , Fletes Carlos Alberto Ochoa , Ortiz Edgar Ivan , Ouedraogo Henri Gautier , Qureshi Zahida , Recidoro Zenaida Dy , Senanayake Hemantha , Soma-Pillay Priya , Tin Khaing Nwe , Sedami Pascal , Worku Dawit , Bonet Mercedes ,   on behalf of the WHO Global Maternal Sepsis Study- Maternal Death and Near-miss Review Working Group, Keke Sourou Goufodji , Sedami Pascal , Batiene D. Vincent , Cisse Kadari , Komboigo Evelyne Béwendin , Ouedraogo Henri Gautier , Abdosh Abdulfetah Abdulkadir , Demissew Rahel , Gashawbeza Biruck , Mariye Ayalew , Mekuria Thomas , Tadesse Filagot , Temesgen Fikremelekot , Teklu Alula M. , Worku Dawit , Adanu Richard , Adu-Bonsaffoh Kwame , Govule Philip , Lwanga Charles Noora , Tamatey Ama Asantewa , Romero William Enrique Arriaga , Aceituno María Guadalupe Flores , Guerra Ligia María Palma , Bustillo Carolina , Castro Rigoberto , Fletes Carlos Alberto Ochoa , Lara Bredy , Gwako George , Osoti Alfred , Qureshi Zahida , Gadama Luis , Alaoui Zaynab , Assarag Bouchra , Chrifi Hassan , Moulki Rachid , Moutaouadia Iatimad , Einda Hla Mya Thway , Maung Thae , Soe Myint Moh , Tin Khaing Nwe , Adesina Olubukola , Aimakhu Chris , Aworinde Olufemi , Fawole Bukola , Recidoro Zenaida Dy , Jayakody Hemali , Jayaratne Kapila , Rowel Dhammica , Senanayake Hemantha , Madziyire Mugove , Magwali Thulani , Munjanja Stephen , de Bernis Luc , Day Louise Tina , Mathai Matthews , Ortiz Edgar Ivan , Soma-Pillay Priya , Bonet Mercedes , Okafor Obiageli , Roos Nathalie 
Published: May 2022

Abstract
Background
Obstetric infections are the third most common cause of maternal mortality, with the largest burden in low and middle-income countries (LMICs). We analyzed causes of infection-related maternal deaths and near-miss identified contributing factors and generated suggested actions for quality of care improvement.

Method
An international, virtual confidential enquiry was conducted for maternal deaths and near-miss cases that occurred in 15 health facilities in 11 LMICs reporting at least one death within the GLOSS study. Facility medical records and local review committee documents containing information on maternal characteristics, timing and chain of events, case management, outcomes, and facility characteristics were summarized into a case report for each woman and reviewed by an international external review committee. Modifiable factors were identified and suggested actions were organized using the three delays framework.

Results
Thirteen infection-related maternal deaths and 19 near-miss cases were reviewed in 20 virtual meetings by an international external review committee. Of 151 modifiable factors identified during the review, delays in receiving care contributed to 71/85 modifiable factors in maternal deaths and 55/66 modifiable factors in near-miss cases. Delays in reaching a GLOSS facility contributed to 5/85 and 1/66 modifiable factors for maternal deaths and near-miss cases, respectively. Two modifiable factors in maternal deaths were related to delays in the decision to seek care compared to three modifiable factors in near-miss cases. Suboptimal use of antibiotics, missing microbiological culture and other laboratory results, incorrect working diagnosis, and infrequent monitoring during admission were the main contributors to care delays among both maternal deaths and near-miss cases. Local facility audits were conducted for 2/13 maternal deaths and 0/19 near-miss cases. Based on the review findings, the external review committee recommended actions to improve the prevention and management of maternal infections.

Conclusion
Prompt recognition and treatment of the infection remain critical addressable gaps in the provision of high-quality care to prevent and manage infection-related severe maternal outcomes in LMICs. Poor uptake of maternal death and near-miss reviews suggests missed learning opportunities by facility teams. Virtual platforms offer a feasible solution to improve routine adoption of confidential maternal death and near-miss reviews locally.