Risk factors for postpartum maternal mortality and hospital readmission in low- and middle-income countries: a systematic review

Symonds et al. BMC Pregnancy and Childbirth https://doi.org/10.1186/s12884-023-05459-y (2023) 23:303 BMC Pregnancy and Childbirth Open Access RESEARCH Risk factors for postpartum maternal mortality and hospital readmission in low‑ and middle‑income countries: a systematic review Nicola E. Symonds1, Marianne Vidler2*, Matthew O. Wiens3,4,5, Shazmeen Omar2, L. Lacey English6, U. Vivian Ukah7, J. Mark Ansermino1,3, Joseph Ngonzi8, Lisa M. Bebell9, Bella Hwang1, Astrid Christoffersen‑Deb2, Niranjan Kissoon1,10 and Beth A. Payne11 Abstract Background In low- and middle-income countries, approximately two thirds of maternal deaths occur in the post‑ partum period. Yet, care for women beyond 24 h after discharge is limited. The objective of this systematic review is to summarize current evidence on socio-demographic and clinical risk factors for (1) postpartum mortality and (2) postpartum hospital readmission. Methods A combination of keywords and subject headings (i.e. MeSH terms) for postpartum maternal mortality or readmission were searched. Articles published up to January 9, 2021 were identified in MEDLINE, EMBASE, and CINAHL databases, without language restrictions. Studies reporting socio-demographic or clinical risk factors for postpartum mortality or readmission within six weeks of delivery among women who delivered a livebirth in a low- or middle-income country were included. Data were extracted independently by two reviewers based on study characteristics, population, and outcomes. Included studies were assessed for quality and risk of bias using the Downs and Black checklist for ratings of rand‑ omized and non-randomized studies. Results Of 8783 abstracts screened, seven studies were included (total N = 387,786). Risk factors for postpartum mortality included Caesarean mode of delivery, nulliparity, low or very low birthweight, and shock upon admission. Risk factors for postpartum readmission included Caesarean mode of delivery, HIV positive serostatus, and abnormal body temperature. Conclusions Few studies reported individual socio-demographic or clinical risk factors for mortality or readmis‑ sion after delivery in low- and middle-income countries; only Caesarean delivery was consistently reported. Further research is needed to identify factors that put women at greatest risk of post-discharge complications and mortal‑ ity. Understanding post-discharge risk would facilitate targeted postpartum care and reduce adverse outcomes in women after delivery. Trial registration PROSPERO registration number: CRD42018103955. *Correspondence: Marianne Vidler Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Symonds et al. BMC Pregnancy and Childbirth (2023) 23:303 Page 2 of 10 Keywords Postpartum period, Maternal mortality, Readmission, Post-discharge risk, Low- and middle-income countries Background The proportion of maternal deaths occurring in the postpartum period is increasing globally [1–3]. In low- and middle-income countries (LMICs), approximately two-thirds of maternal deaths occur in the postpartum period. Despite more women delivering in health facilities, which is known to improve outcomes due to appropriate and timely access to skilled care [4, 5], many women are still at high risk of death [6]. Among women who die in the postpartum period, 80% of deaths occur within one week of delivery [7]. Women who do deliver in health facilities are typically discharged within 24 h without further follow-up, resulting in a gap in care during a high-risk period [6]. Further, postpartum care beyond 24 h after delivery is often limited, evidenced by the fact that the majority of women do not complete the three recommended postnatal visits [8–10]. Studies in high-income countries (HICs) have begun to evaluate risk factors for adverse postpartum and post-discharge outcomes [11, 12], yet little is known regarding the risk factors for complications or readmission following delivery in LMICs where postpartum morbidity and mortality is greatest. Stillbirth has previously been reported in the literature as a known risk factor for postpartum mortality and is responsible for a disproportionate number of deaths after pregnancy compared to a livebirth [13, 14]. However, to our knowledge, few studies have identified risk factors other than stillbirth for postpartum mortality or readmission in LMICs. The ability to identify women at higher risk of postpartum complications prior to discharge could help reduce mortality and morbidty. An improved understanding of how to estimate postpartum risk is essential for designing and implementing targeted interventions in the postpartum period. The objective of this systematic review is to summarize current evidence on individual socio-demographic and clinical risk factors for (1) postpartum mortality and (2) postpartum hospital readmission that could be used for post-discharge risk stratification in LMICs. The ultimate goal of this review is to identify individual risk factors that could be used to determine if a women is at high risk after delivery for postpartum death or complication requiring readmission to hospital. We aim to compel further research and eventually develop interventions to reduce maternal mortality and rehospitalization in the postpartum period. Methods Search strategy This systematic review was conducted according to PRISMA guidelines [15] and was registered on PROSPERO prior to completing the final search (CRD4201813955). Articles published from database inception to January 9, 2021 were identified using MEDLINE, EMBASE, and CINAHL databases, with no language restrictions. References of systematic reviews and included studies were also reviewed. Search terms included a combination of keywords and subject headings (i.e. MeSH terms). See online supplement for each database’s full search strategy (see Additional files 1, 2 and 3). (...truncated)