Soins maternels intensifs (Maternal Intensive Care) en Belgique - KCE

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24 Maternal Intensive Care in Belgium KCE Reports 94 ADVANTAGES AND DISADVANTAGES The criteria are easy to interpret, and the quality of care for a particular disease can be assessed. Also, data can be collected retrospectively from case notes or registers, providing population-based estimates for maternal morbidity. On the negative side, this approach yields the highest number of non-severe morbidities, as well as hospitalizations that are not related to the health of the mother. Accordingly, estimates of maternal morbidity using disease-based criteria are higher than among studies using other definition types. A systematic review of studies of maternal morbidity by the World Health Organization observed that rates were higher in studies using diseasebased criteria as compared to those using organ system-based definitions, suggesting less specificity in identifying near-miss cases 20 . Another disadvantage is that trends over time may reflect trends in organization of care and hospitalization for particular conditions. An example of this might be insulin requiring gestational diabetes, a condition which has increased in prevalence while decreasing in occupancy of hospital beds over the last decades. The reason of this apparent paradox is that it used to be recommended to admit these patients, but now the accent is put on domiciliary management, eventually with home visits. Another issue related with disease as the underlying concept is that there may occur diagnostic bias when more advanced technology is available, as with pulmonary embolism, the prevalence of which will directly reflect the use of ventilation perfusion scan. The prevalence will therefore be directly related to the quality and acceptability of the definitions used, and will require on-going audit in routine systems, or good monitoring in ad hoc surveys. D. Management-based definitions of maternal morbidity Admission to an intensive care unit or the requirement of critical care has been used in most developed countries to identify near-miss morbidity. However, other interventions such as peri-partum laparotomy, embolisation, ventilation, or massive blood transfusion and others have also been used to define near-miss cases. ADVANTAGES AND DISADVANTAGES This category of definition is apparently simple to apply and presents an adequate proxy for severe conditions which are life threatening for mothers and related to maternal death. A relatively large number of non population based studies have used this definition to collect data from ICU admission. However in Belgium, an attempt to do this in the late 1990s revealed that ICU units (e.g. surveillance at week-ends after general anaesthesia) were being used for non ICU needs. Conversely, some cases of life-threatening morbidity are managed either inside the highly equipped obstetrical service, while others are managed in hospitals that do not have intensive care units. To illustrate this, in the UK, for example, only 31% of maternal deaths were recorded as having intensive care (NHS, 2000), while Bouvier-Colle et al reported that in France most maternal deaths had been seen in intensive care 21 22 . Problems of change in management standards over time, which have already been discussed in relation to gestational diabetes, will be even more obvious for management based criteria as can be observed in the following figure 23 .
KCE Reports 94 Maternal Intensive Care in Belgium 25 Figure 1: Ratio of antenatal hospitalization per 100 deliveries, Canada excluding Nova Scotia, Quebec and Manitoba, 1991/92 to 2002/03 In conclusion, management based definitions require once more clear definitions and good monitoring of their application. E. Organ failure-based definitions of maternal morbidity As Pattinson describes 24 , “this type of definition is based on the concept that there is a sequence of events leading from good health to death. The sequence is clinical insult, followed by a systematic inflammatory response syndrome, organ dysfunction, organ failure, and death. Near-misses include women with organ dysfunction and organ failure who survive.” ADVANTAGES AND DISADVANTAGES According to Geller 3 who evaluated this as one of their five factors in a scoring system, “organ failure” as an indicator definition identified the vast majority of near misses and excluded the vast majority of other severe morbidities from the near-miss group, with a sensitivity of 95% and a specificity of 87.8%. This approach is the most labour-intensive for identifying cases. Retrospective identification of cases is difficult because of the inability to identify cases from registers. F. Combination approaches A small number of studies use a combined approach, mixing more than one definition type. The EU group has suggested this type of approach. The European group has suggested for EU data to collect systematically the following combination: • Eclampsia (a disease and an organ failure condition), • Markers of management of severe haemorrhage, • Ventilation, • ICU admission. 3.2.3.1 Prevalence of maternal morbidity in large studies These studies are not very numerous and have often used different approaches. However, it is of interest to note that the baseline order of magnitude of events is similar in all studies. Major studies are summarised below. A. Canadian study The Canadian study 23 pertains to all hospitalised woman. It does have the advantage of giving a good distribution of causes of admission, as well as of length of stay.
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Soins maternels intensifs (Maternal Intensive Care) en Belgique - KCE

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