Riches Jennifer, Jafali James, Twabi Hussein H, Chimwaza Yamikani, Onrust Marthe, Bilesi Rosemary, Gadama Luis, Kachale Fannie, Kuyere Annie, Makhaza Lumbani, Makuluni Regina, Munthali Laura, Musopole Owen, Ndamala Chifundo, Phiri Deborah A, Coomarasamy Arri, Merriel Abi, Waitt Catriona, Odland Maria Lisa, Lissauer David
Women's and Children's Health, University of Liverpool, Liverpool, UK
Maternal and Fetal Health Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
BMJ Glob Health. 2025 Jan 9;10(1):e015781. doi: 10.1136/bmjgh-2024-015781.
BACKGROUND: Despite strong evidence-based strategies for prevention and management, global efforts to reduce deaths from postpartum haemorrhage (PPH) have failed, and it remains the leading cause of maternal mortality. We conducted a detailed review of all maternal deaths from 33 facilities in Malawi to identify health system weaknesses leading to deaths from PPH. METHODS: Data were collected regarding every maternal death occurring across all district and central hospitals in Malawi. Deaths occurring from August 2020 to December 2022 were reviewed by multidisciplinary facility-based teams who compiled case narratives from clinical notes and then subsequently reviewed by obstetricians to confirm the cause of death according to international criteria. Data were summarised using proportions/frequencies, comparisons made using χ or Wilcoxon rank sum tests, and logistic regression conducted to calculate ORs with CIs. RESULTS: PPH was the cause of 20.4% of maternal deaths. Most deaths from PPH occurred within 24 hours of birth (80.0%), among women who had been referred to a higher-level facility (57.0%) and were admitted in stable condition (60.0%). Vacuum births carried an increased risk of death from PPH (OR 4.25 (95% CI 1.15 to 20.13, p=0.039)). Detailed reviews identified that deaths from PPH were more likely to be associated with factors such as 'lack of obstetric lifesaving skills' (26.7% vs 10.1%, p<0.001), 'inadequate monitoring' (51.5% vs 40.7%, p=0.012) and 'communication problems between facilities' (11.5% vs 6.2%, p=0.019) than deaths from other causes. CONCLUSIONS: Our analysis represents the largest published review of maternal deaths from PPH. We demonstrate that key health system weaknesses are contributing to these preventable maternal deaths. Case reviews conducted by multidisciplinary facility-based teams identified common and recurrent avoidable factors associated with deaths from PPH. Global efforts must now be focused on strategies that address these weaknesses, strengthening health systems and empowering healthcare workers to reduce maternal deaths from PPH.
背景：尽管有强有力的基于证据的预防和管理策略，但全球减少产后出血（PPH）死亡的努力仍未成功，产后出血仍是孕产妇死亡的主要原因。我们对马拉维33家医疗机构的所有孕产妇死亡病例进行了详细审查，以确定导致产后出血死亡的卫生系统薄弱环节。 方法：收集了马拉维所有地区医院和中心医院发生的每例孕产妇死亡的数据。2020年8月至2022年12月期间发生的死亡病例由多学科医疗机构团队进行审查，这些团队根据临床记录编写病例叙述，随后由产科医生根据国际标准审查以确认死亡原因。数据使用比例/频率进行汇总，使用χ检验或Wilcoxon秩和检验进行比较，并进行逻辑回归以计算带有置信区间的比值比（OR）。 结果：产后出血是20.4%孕产妇死亡的原因。大多数产后出血死亡发生在分娩后24小时内（80.0%），发生在被转诊到上级医疗机构的妇女中（57.0%），且入院时情况稳定（60.0%）。真空助产分娩使产后出血死亡风险增加（OR 4.25（95%CI 1.15至20.13，p = 0.039））。详细审查发现，与其他原因导致的死亡相比，产后出血死亡更可能与“缺乏产科救生技能”（26.7%对10.1%，p < 0.001）、“监测不足”（51.5%对40.7%，p = 0.012）和“医疗机构之间沟通问题”（11.5%对6.2%，p = 0.019）等因素相关。 结论：我们的分析是已发表的关于产后出血孕产妇死亡病例的最大规模审查。我们证明关键的卫生系统薄弱环节导致了这些可预防的孕产妇死亡。由多学科医疗机构团队进行的病例审查确定了与产后出血死亡相关的常见和反复出现的可避免因素。现在全球的努力必须集中在解决这些薄弱环节的策略上，加强卫生系统并增强医护人员能力，以减少产后出血导致的孕产妇死亡。
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