RISKS OF ADVERSE MATERNAL AND PERINATAL OUTCOMES IN LOW AND MIDDLE-INCOME COUNTRIES (LMIC): SYSTEMATIC REVIEWS AND META-ANALYSES OF EVIDENCE
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Background Maternal death affects 303,000 women every year, with 99% of these occurring in low and middle-income countries (LMIC). Three in four direct maternal deaths are due to haemorrhage, followed by hypertension in pregnancy. The major causes of indirect deaths are pre-existing tuberculosis and anaemia. My thesis is focussed on quantifying the burden of maternal death and perinatal outcomes from these conditions, identifying risk factors, and assessing role of tests to detect high-risk condition. Methods Systematic reviews of observational, comparative and diagnostic accuracy studies Findings Anaesthesia was the primary cause of death in 1.2 per 1000 undergoing surgery in pregnancy. General anaesthesia administration and non-physician anaesthetist practitioners were associated with poorer outcomes. In women with pre-eclampsia, there was a seven fold increase in maternal death in pre-eclamptic women undergoing caesarean section with general compared to regional anaesthesia. The rate of maternal mortality in women undergoing Caesarean section was 4.8 per 1000 procedures, mainly from postpartum haemorrhage. Emergency and second stage caesarean sections increased mortality and morbidity. The cadre or seniority of staff performing the caesarean section did not increase the risk of mortality. Of the point of care tests identified to detect anaemia at a haemoglobin concentration of <110 g/l, Copper, Sahli’s and HemoCue had high sensitivity and specificity. In women with tuberculosis compared to those without, there was a significantly increased risk of poor fetal outcomes; perinatal death, preterm birth, low birth rate and birth asphyxia. Maternal outcomes were significantly worse. Conclusion Anaesthesia and caesarean sections contribute disproportionately to maternal deaths in LMIC. Copper, Sahli’s and HemoCue were found to be accurate point of care tests for anaemia and should be more widely available to increase diagnosis. Tuberculosis leads to worse maternal and fetal outcomes.
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