Research Article: Clinico-Pathological Discrepancies in the Diagnosis of Causes of Maternal Death in Sub-Saharan Africa: Retrospective Analysis

Date Published: February 24, 2009

Publisher: Public Library of Science

Author(s): Jaume Ordi, Mamudo R Ismail, Carla Carrilho, Cleofé Romagosa, Nafissa Osman, Fernanda Machungo, Josep A Bombí, Juan Balasch, Pedro L Alonso, Clara Menéndez, Linda Wright

Abstract: BackgroundMaternal mortality is a major public-health problem in developing countries. Extreme differences in maternal mortality rates between developed and developing countries indicate that most of these deaths are preventable. Most information on the causes of maternal death in these areas is based on clinical records and verbal autopsies. Clinical diagnostic errors may play a significant role in this problem and might also have major implications for the evaluation of current estimations of causes of maternal death.Methods and FindingsA retrospective analysis of clinico-pathologic correlation was carried out, using necropsy as the gold standard for diagnosis. All maternal autopsies (n = 139) during the period from October 2002 to December 2004 at the Maputo Central Hospital, Mozambique were included and major diagnostic discrepancies were analyzed (i.e., those involving the cause of death). Major diagnostic errors were detected in 56 (40.3%) maternal deaths. A high rate of false negative diagnoses was observed for infectious diseases, which showed sensitivities under 50%: HIV/AIDS-related conditions (33.3%), pyogenic bronchopneumonia (35.3%), pyogenic meningitis (40.0%), and puerperal septicemia (50.0%). Eclampsia, was the main source of false positive diagnoses, showing a low predictive positive value (42.9%).ConclusionsClinico-pathological discrepancies may have a significant impact on maternal mortality in sub-Saharan Africa and question the validity of reports based on clinical data or verbal autopsies. Increasing clinical awareness of the impact of obstetric and nonobstetric infections with their inclusion in the differential diagnosis, together with a thorough evaluation of cases clinically thought to be eclampsia, could have a significant impact on the reduction of maternal mortality.

Partial Text: There is a general consensus that maternal mortality is a major health problem worldwide as well as a fundamental public health indicator [1]. The problem of maternal mortality is concentrated in low-income countries, particularly in sub-Saharan Africa, where one in 16 women die of pregnancy-related complications [2,3]. Reduction of this intolerable burden is one of the Millennium Development Goals set up by the United Nations in 2000 [2].

During the study period, there were 179 maternal deaths. In 139 women (77.6%) a complete autopsy with adequate histological sampling as well as clinical information was available.

This is, to our knowledge, the first study focused on the evaluation of diagnostic discrepancies in maternal mortality in sub-Saharan Africa and even in developing countries, based on complete autopsies and including a histological study. This study has shown a high frequency of major clinico-pathological discrepancies (40.3%) in maternal deaths in a tertiary-referral hospital in sub-Saharan Africa. In most cases a change in clinical management could have significantly modified the prognosis. The proportion of discrepancies observed in this study is higher than that currently reported in studies based on nonselected hospital patients [17,27]. Remarkably, this study, unlike most previous studies, was based only on maternal deaths. These are extremely infrequent in developed countries [2,28], and tend to show lower discrepancy rates between clinical and autopsy diagnoses [16,21].