The anaesthetic hazards for the obstetric patient are well known. Based on results of the first two reports on the confidential enquiry into maternal deaths in Malaysia for 1991 and 1992, ten cases of anaesthetic related deaths were analysed. There were 3 in 1991 and 7 in 1992 accounting for 1.34% and 2.8% of maternal deaths respectively. It was estimated that the crude mortality rate for the obstetric patient was 11.4 per 100,000 operative deliveries or a four-fold risk compared to the general surgical patient. One case resulted from administration of intravenous sedation while the rest involved general anaesthesia, seven of which were done under emergency conditions. Inadequate airway management and ventilation in the perioperative period, including during interhospital transfer was the single most important factor causing the majority of these deaths. The use of regional anaesthesia for Caesarean sections is strongly advocated. Substandard care was also present in all cases. Other issues pertinent to improvement of obstetric anaesthetic services are also discussed which include the quality of anaesthetic manpower, upgrading of infrastructure, facilities and staffing of operating and recovery areas, the use of regional anaesthesia, expanding the role of the anaesthetist and the quality of the anaesthetic services in general.
A confidential system of enquiry into maternal mortality was introduced in Malaysia in 1991. The methods used and the findings obtained up to 1994 are reported below and an outline is given of the resulting recommendations and actions.
PIP: This is a report on the methods, findings, resulting recommendations and actions of a study on maternal mortality in Malaysia during the period 1991-94. Maternal death was defined as the death of a woman while pregnant or within 42 days following termination of pregnancy from any cause related to the pregnancy or its management but not from accidental causes. Between 1991 and 1994 there were 1066 reported maternal deaths, and the maternal mortality ratios for the successive years were respectively 44, 48, 46 and 39 per 100,000 live births. The primary causes of maternal death were postpartum hemorrhage (24%), hypertensive disorders of pregnancy (16%), obstetric pulmonary embolism (13%), and associated medical conditions (7%). Analysis of the 375 deaths from 1992 - 1993 showed that the maternal mortality ratio was 53/100,000 live births for deliveries performed at home, 36/100,000 in government hospitals, and 21/100,000 in private institutions. Shortcomings among health personnel were detected in several cases; these involved failure to diagnose, failure to appreciate the severity of a patient's condition, inadequate therapy, and inappropriate, delayed or failed adherence to protocols. The high proportion of maternal mortality associated with substandard care demonstrates that it is important to make the standard of care more widely available. Reports have been circulated to institutions and organizations providing maternal care and to medical schools. Articles and case histories have been published, and many new protocols and procedures have been developed. Furthermore, seminars have been organized and training modules have been distributed to all involved in the provision of maternity care.
Maternal deaths in Kerian district during a 5 year period (1976-1980) is described. There were 35 maternal deaths in all and Malays constituted the majority 32 (91.4 percent). Most of the women were of low socio-economic status and only 20 percent had some formal education. The women were mainly multigravida and majority of them 20 (57.2 percent) were between 31-40 years of age. The main cause of death being PPH and PPH with retained placenta. Most of them died at home and were attended to by TBAs. The need to identify, train and utilise TBAs has been realised as they delivered about 41.4 percent of the deliveries in Kerian in 1976.
Pregnancy-related deaths in four published perioperative mortality review reports were analysed. The aim is to look at the quality of surgical and anaesthetic services along with the perioperative care provided. The audit identified shortfalls in the logistic and support services and recommended remedial strategies. The review was conducted by a committee consisting of practising anaesthetists, surgeons and obstetricians who analysed the questionnaires collectively. A consensus was reached to categorise the death. There were 280 pregnancy-related deaths. Post-partum haemorrhage accounted for 31.8%, followed by hypertensive disorders of pregnancy (20.0% obstetric embolism (16.1%), sepsis (10.7%) and associated medical conditions (21.4%). In brief, there were comings in preoperative, intra-operative and post-operative care in some of the cases. Increased consultant input, clinical audit, improvements in monitoring and expansion of critical care facilities were the integral issues recommended.