New (or not so new?) lessons from maternal autopsy in Mozambique
Authors: Stefan Gebhardt
Journal: The Lancet Global Health (2020)

In The Lancet Global Health, Clara Menéndez and colleagues1Menéndez C Quintó L Castillo P et al.Quality of care and maternal mortality in a tertiary-level hospital in Mozambique: a retrospective study of clinicopathological discrepancies.Lancet Glob Health. 2020; 8: e965-e972Summary Full Text Full Text PDF PubMed Google Scholar report the results of a much needed study on clinicopathological discrepancies in maternal causes of death in Mozambique. Menéndez and colleagues repeated a study from 10 years ago2Ordi J Ismail MR Carrilho C et al.Clinico-pathological discrepancies in the diagnosis of causes of maternal death in sub-Saharan Africa: retrospective analysis.PLoS Med. 2009; 6e1000036Crossref PubMed Scopus (49) Google Scholar in Maputo Central Hospital. Regrettably, the message remains the same—potentially avoidable maternal deaths are occurring because of major errors in clinical diagnosis. This message needs scrutiny, as the obvious question is why has there been no improvement in the intervening years? Maternal deaths, in particular those due to non-pregnancy-related infections, are a serious burden in sub-Saharan Africa, particularly in Mozambique, where the lifetime risk of dying during childbirth (as estimated by UNICEF) is 1 in 67.3UNICEFTrends in maternal mortality 2000–2017.https://data.unicef.org/resources/trends-maternal-mortality-2000-2017/Date: September, 2019Date accessed: May 18, 2020Google Scholar A decline in the number of preventable maternal deaths is a good indicator of improvement in quality of care. A decline in the maternal mortality ratio of non-preventable maternal deaths is a good indicator of improvements in upstream factors (patient, community, and transport-related factors). These data can only be generated by a rigorous national confidential enquiry that includes a critical assessment of every maternal death. In a country where many women deliver (and die) outside health facilities and with poor infrastructure, it is difficult to institute a confidential enquiry. In Mozambique, a remarkable number of research publications on morbidity and mortality have originated from Maputo Central Hospital, a tertiary and quaternary public sector hospital with 1500 beds. Another series of studies on the pathology of maternal deaths from the country is therefore welcome. According to Menéndez and colleagues' study,1Menéndez C Quintó L Castillo P et al.Quality of care and maternal mortality in a tertiary-level hospital in Mozambique: a retrospective study of clinicopathological discrepancies.Lancet Glob Health. 2020; 8: e965-e972Summary Full Text Full Text PDF PubMed Google Scholar all maternal deaths in Mozambique must undergo a full diagnostic autopsy, except if the family refuses. Over a 17-month period, 91 autopsies were done for maternal deaths occurring at Maputo Central Hospital and the findings were correlated with patients' clinical diagnoses. A further 45 deaths did not undergo autopsy because of refusal of consent. A rigorous process was used to classify major discrepancies between the clinical diagnosis and autopsy findings. There was agreement between autopsy findings and clinical diagnosis in only 57 (63%) of 91 cases, which raises questions. First, although pathology was regarded as the gold standard for sensitivity calculations in this study, even a detailed autopsy might not always give a final diagnosis. Close collaboration is needed between clinicians and pathologists to guide the investigation. In Japan, Hasegwa and colleagues4Hasegawa J Wakasa T Matsumoto H et al.Analysis of maternal death autopsies from the nationwide registration system of maternal deaths in Japan.J Matern Fetal Neonatal Med. 2018; 31: 333-338Crossref Scopus (7) Google Scholar reported an autopsy diagnosis that was incompatible with the clinical course in 13 (27%) of 49 cases, and in a further three cases the cause of death could not be obtained from the autopsy. Second, making the correct clinical diagnosis does not necessarily imply that a patient would have received superior management and survived—there are many other factors at play (eg, delay in transport or severity of condition on arrival). Most women with antepartum haemorrhage might not even have made it to the hospital in time, which could also skew the data at a referral centre. Mortuaries can play an important part in counting indirect maternal deaths and those who never made it to a health-care facility. In a South African mortuary study of 114 deaths related to pregnancy,5Kahn A Kirk G Pregnancy related maternal deaths at Salt River Forensic Pathology Laboratory.https://open.uct.ac.za/bitstream/handle/11427/6662/thesis_hsf_2014_khan_a.pdf?sequence=1&isAllowed=yDate: April, 2014Date accessed: May 18, 2020Google Scholar 32 occurred at home. 39 (34%) of 114 women died from indirect causes, mostly homicide (intimate partner violence), accidental deaths, and suicide. That study also reported a 28% discrepancy between clinical diagnosis and the post-mortem cause of death.5Kahn A Kirk G Pregnancy related maternal deaths at Salt River Forensic Pathology Laboratory.https://open.uct.ac.za/bitstream/handle/11427/6662/thesis_hsf_2014_khan_a.pdf?sequence=1&isAllowed=yDate: April, 2014Date accessed: May 18, 2020Google Scholar Enquiries could be extended to surrounding mortuaries for a more complete picture of maternal deaths. When the Mozambique study was first done in 2009,2Ordi J Ismail MR Carrilho C et al.Clinico-pathological discrepancies in the diagnosis of causes of maternal death in sub-Saharan Africa: retrospective analysis.PLoS Med. 2009; 6e1000036Crossref PubMed Scopus (49) Google Scholar the major diagnostic discrepancies (70%) were in infection-related deaths. These deaths were predominantly in HIV-positive women and the missed diagnoses included tuberculosis, invasive fungal infections, and toxoplasmosis. 10 years later, infectious diseases were still overlooked and Menéndez and colleagues conclude that there was no improvement in the clinical recognition of non-pregnancy related infections.1Menéndez C Quintó L Castillo P et al.Quality of care and maternal mortality in a tertiary-level hospital in Mozambique: a retrospective study of clinicopathological discrepancies.Lancet Glob Health. 2020; 8: e965-e972Summary Full Text Full Text PDF PubMed Google Scholar Mozambique's antiretroviral programme is mostly dependent on international donors and there are challenges with monitoring of service quality and adherence to therapy.6Auld AF Shiraishi RW Couto A et al.A decade of antiretroviral therapy scale-up in Mozambique: evaluation of outcome trends and new models of service delivery among more than 300 000 patients enrolled during 2004–2013.J Acquir Immune Defic Syndr. 2016; 73: e11-e22Crossref PubMed Scopus (36) Google Scholar In neighbouring South Africa, a national rollout of antiretroviral therapy to all pregnant women has resulted in a substantial reduction in the maternal mortality ratio.7Moodley J Fawcus F Pattinson R Improvements in maternal mortality in South Africa.S Afr Med J. 2018; 108: S4-S8Google Scholar Policy makers and funders should look at this success story. I hope that the next 10 years in Mozambique are used to improve training in infectious disease management and funding for the reduction of infection. This strategy will benefit the whole population, as the country has a huge burden of HIV and tuberculosis.8Garcia-Basteiro AL Hurtado JC Castillo P et al.Unmasking the hidden tuberculosis mortality burden in a large postmortem study in Maputo Central Hospital, Mozambique.Eur Respir J. 2019; 541900312Crossref Scopus (9) Google Scholar I declare no competing interests. Quality of care and maternal mortality in a tertiary-level hospital in Mozambique: a retrospective study of clinicopathological discrepanciesDecreasing maternal mortality requires improvement of the pre-mortem diagnostic process and avoidance of clinical errors by refining clinical skills and increasing the availability and quality of diagnostic tests. Comparison of post-mortem information with clinical diagnosis will help monitor the reduction of clinical errors and thus improve the quality of care. Full-Text PDF Open Access