Maternal near miss: an indicator for maternal health and maternal care

Retrospective evaluation of patients admitted to the intensive care unit due to obstetric reasons in terms of maternal near-miss, a five-year case-control study

BACKGROUND

Maternal Near-Miss (MNM) has become globally recognized as an indicator of pregnancy, birth and the first 42 days of postpartum care services. The World Health Organization has taken a new approach to detail and better analyze maternal deaths. The clinic-based criteria to evaluate maternal care and the quality of related care services have been developed.

METHODS

This is a retrospective case-control study that was conducted in a tertiary hospital. In the study, the medical files of all patients admitted to the intensive care unit during the five-year period between 2018 and 2022 were examined. All patients who met the MNM criteria of WHO during pregnancy, birth and puerperium were included in the case group of the study. Meanwhile, the participants in the control group were selected from mothers who gave birth in the same hospital between August 15 and October 31, 2023 and did not develop any complications during puerperium, using the systematic sampling method. Data collection was performed using an interviewer-administered structured questionnaire and data abstraction.

RESULTS

In this five-year period, 198 mothers were diagnosed with MNM. In our study, the prevalence of MNM was found as 218/100.000. The most common laboratory changes that met the MNM criteria were elevated lactate levels (38.89%), acidosis (24.24%) and acute thrombocytopenia. Patients were most frequently admitted to the intensive care unit due to hemorrhage (23.74%), placental abruption (18.18%), pre-eclampsia (15.66%) and cesarean Sect. (10.10%), respectively. The frequency of co-morbidities (Diabetes mellitus, Hypertension, Asthma, Hypothyroidism, etc.) in patients diagnosed with MNM (n = 48; 26.67%) was found to be 5.5 times that of the control group (n = 25; 6.20%) (p < 0.001).

CONCLUSIONS

It can be said that co-morbidities directly affect the course of motherhood. the education level and family income were found higher in the MNM group compared to the control group. In this regard, the results of our study differ from the studies in the literature in terms of the effects of the education level of mothers and the economic status of families. The effects of socioeconomic and cultural factors on MNM may vary.

Direct and indirect association of domestic violence against women and severe maternal morbidity: A case-control study

This study aimed to investigate the direct association between domestic violence and the indirect association of exposure through pregnancy, delivery, and neonatal risk factors with severe maternal morbidity (SMM). The target population of this case-control study included all women who gave birth in the hospitals of the Torbat Heidarieh University of Medical Science from June 2018 to May 2020. A total of 123 mothers with SMM according to the World Health Organization criteria were selected as cases, and 127 mothers who did not meet the World Health Organization criteria were included in the control group. Data were analyzed using Stata 14 and mediation packages with a counterfactual approach. The odds ratio of the pure direct effect of physical violence on SMM through pregnancy and neonatal risk factors is 2.26 and 2.29, respectively. The odds ratio of the pure direct effect of social violence on SMM through pregnancy, delivery, and neonatal risk factors was 2.54, 2.67, and 2.57, respectively, and that for economic violence through neonatal risk factors was 1.99. Additionally, the interaction between physical and social violence and pregnancy risk factors increased the risk of severe maternal morbidity by 394.6% and 360%, respectively. Domestic violence against women is directly associated with severe maternal morbidity. Physical and social violence showed a significant interaction with severe maternal morbidity. A preventive program for domestic violence should be considered an effective intervention to prevent severe maternal morbidity and improve the health of mothers by implementing control strategies.

Cross-sectional study evaluating the effectiveness of the Mozambique-Canada maternal health project abstraction tool for maternal near miss identification in Inhambane province, Mozambique

OBJECTIVES

The objectives of this study are to determine whether the additional clinical criteria of the Mozambique maternal near miss abstraction tool enhance the effectiveness of the original WHO abstraction tool in identifying maternal near miss cases and also evaluate the impact of sociodemographic factors on maternal near miss identification.

DESIGN

Cross-sectional study.

SETTING

Two secondary referral hospitals in Inhambane province, Mozambique from 2021 to 2022.

PARTICIPANTS

From August 2021 to February 2022, 2057 women presenting at two hospitals in Inhambane Province, Mozambique, were consecutively enrolled. Eligible participants included women admitted during pregnancy, labour, delivery, or up to 42 days post partum. Selection criteria focused on women experiencing obstetric complications, while those without complications or with incomplete medical records were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was identifying maternal near miss cases using the original WHO Disease criterion and the additional clinical criteria from the Mozambique-Canada Maternal Health Project abstraction tool. Secondary outcomes included the association between sociodemographic factors and maternal near miss identification. All outcomes were measured as planned in the study protocol.

RESULTS

The new Mozambique-Canada abstraction tool identified more maternal near miss cases (28.2% for expanded disease and 21.1% for comorbidities) compared with the original WHO tool (16.2%). Hypertension and anaemia from the newer criteria were strongly associated with the original WHO Disease criterion (p<0.001), with kappa values of 0.58 (95% CI 0.53 to 0.63) and 0.21 (95% CI 0.16 to 0.26), respectively. Distance to health facilities was significantly associated, with women living over 8 km away having higher odds (OR=2.47, 95% CI 1.92 to 3.18, p<0.001). Type of hospital also influenced identification, with lower odds at Vilankulo Rural Hospital for Expanded Disease criterion (OR=0.70, 95% CI 0.57 to 0.87, p=0.001), but higher odds for comorbidities criterion (OR=3.13, 95% CI 2.40 to 4.08, p<0.001). Finally, older age was associated with higher odds of identification under the comorbidities criterion, particularly for women aged 30-39 (OR=3.06, 95% CI 2.15 to 4.36) as well as those 40 years or older (OR=4.73, 95% CI 2.43 to 9.20, p<0.001).

CONCLUSIONS

The Mozambique-Canada Maternal Health Project tool enhances maternal near miss identification over the original WHO tool by incorporating expanded clinical criteria, particularly for conditions like hypertension and anaemia. Sociodemographic factors, including healthcare access, hospital type and maternal age, significantly impact near miss detection. These findings support integrating the expanded criteria into the WHO tool for improved identification of maternal near misses in Mozambique and similar low-resource settings. Future research should examine the tool's effectiveness across varied healthcare contexts and populations.

Prevalence, underlying causes, and determinants of maternal near miss in Ethiopia: a systematic review and meta-analysis

Background

Maternal near miss (MNM) is one of the newly adopted assessment parameters to gauge the quality of maternity care. In Ethiopia, several studies have been conducted to investigate the incidence, underlying causes, and determinants of MNM. However, the findings from those studies vary greatly and are largely inconsistent. Thus, this review aims to more robustly estimate the pooled prevalence, identify underlying causes, and single out determinants of MNM in Ethiopia.

Methods

Studies were searched from international databases (PubMed/ Medline, Cochrane Library, and Embase databases) and other potential sites. All observational studies were included. Heterogeneity between studies was checked using Cochrane Q test statistics and I2 test statistics and small study effects were checked using Egger's statistical test at a 5% significance level. Outcome measures were overall and specific underlying causes (obstetrics hemorrhage, hypertensive disorder pregnancy, pregnancy-related infection) rates of MNMs per 10,000 live births.

Result

The meta-analysis included 43 studies consisting of 77240 MNM cases. The pooled prevalence MNM per 1000 live births in Ethiopia was 54.33 (95% CI: 33.93 to 85.89). Between-study heterogeneity was high (I2 = 100%, P < 0.0001), with the highest rate observed in Amhara region (384.54 per 1000). The prevalence of obstetrics hemorrhage (14.56 per 1000) was higher than that of hypertensive disorder pregnancy (12.67 per 1000) and pregnancy-related infections (3.55 per 1000) were identified as underlying causes. Various factors, including socio demographic characteristics, previous medical and obstetrics history as well as access to and quality of care obtained, were associated with MNM.

Conclusion

Almost six women encounter near miss among a hundred live births in Ethiopia. Obstetric hemorrhage and hypertensive disorder pregnancy were the most common underlying causes of MNM. Both individual and facility level determinants were found to be associated with MNM. Considering the magnitude and identified factors, tailored measures should be taken at every stage of the continuum of care.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023395259.

Perinatal mortality, severe maternal morbidity and maternal near miss: protocol of a study integrated with the Birth in Brazil II survey

Brazil presents high maternal and perinatal morbidity and mortality. Cases of severe maternal morbidity, maternal near miss, and perinatal deaths are important health indicators and share the same determinants, being closely related to living conditions and quality of perinatal care. This article aims to present the study protocol to estimate the perinatal mortality rate and the incidence of severe maternal morbidity and maternal near miss in the country, identifying its determinants. Cross-sectional study integrated into the research Birth in Brazil II, conducted from 2021 to 2023. This study will include 155 public, mixed and private maternities, accounting for more than 2,750 births per year, participating in the Birth in Brazil II survey. We will collect retrospective data from maternal and neonatal records of all hospitalizations within a 30-day period in these maternities, applying a screening form to identify cases of maternal morbidity and perinatal deaths. Medical record data of all identified cases will be collected after hospital discharge, using a standardized instrument. Cases of severe maternal morbidity and maternal near miss will be classified based on the definition adopted by the World Health Organization. The perinatal deaths rate and the incidence of severe maternal morbidity and maternal near miss will be estimated. Cases will be compared to controls obtained in the Birth in Brazil II survey, matched by hospital and duration of pregnancy, in order to identify factors associated with negative outcomes. Results are expected to contribute to the knowledge on maternal morbidity and perinatal deaths in Brazil, as well as the development of strategies to improve care.

Road to maternal death: the pooled estimate of maternal near-miss, its primary causes and determinants in Africa: a systematic review and meta-analysis

BACKGROUND

Maternal near-miss (MNM) is defined by the World Health Organization (WHO) working group as a woman who nearly died but survived a life-threatening condition during pregnancy, childbirth, or within 42 days of termination of pregnancy due to getting quality of care or by chance. Despite the importance of the near-miss concept in enhancing quality of care and maternal health, evidence regarding the prevalence of MNM, its primary causes and its determinants in Africa is sparse; hence, this study aimed to address these gaps.

METHODS

A systematic review and meta-analysis of studies published up to October 31, 2023, was conducted. Electronic databases (PubMed/Medline, Scopus, Web of Science, and Directory of Open Access Journals), Google, and Google Scholar were used to search for relevant studies. Studies from any African country that reported the magnitude and/or determinants of MNM using WHO criteria were included. The data were extracted using a Microsoft Excel 2013 spreadsheet and analysed by STATA version 16. Pooled estimates were performed using a random-effects model with the DerSimonian Laired method. The I2 test was used to analyze the heterogeneity of the included studies.

RESULTS

Sixty-five studies with 968,555 participants were included. The weighted pooled prevalence of MNM in Africa was 73.64/1000 live births (95% CI: 69.17, 78.11). A high prevalence was found in the Eastern and Western African regions: 114.81/1000 live births (95% CI: 104.94, 123.59) and 78.34/1000 live births (95% CI: 67.23, 89.46), respectively. Severe postpartum hemorrhage and severe hypertension were the leading causes of MNM, accounting for 36.15% (95% CI: 31.32, 40.99) and 27.2% (95% CI: 23.95, 31.09), respectively. Being a rural resident, having a low monthly income, long distance to a health facility, not attending formal education, not receiving ANC, experiencing delays in health service, having a previous history of caesarean section, and having pre-existing medical conditions were found to increase the risk of MNM.

CONCLUSION

The pooled prevalence of MNM was high in Africa, especially in the eastern and western regions. There were significant variations in the prevalence of MNM across regions and study periods. Strengthening universal access to education and maternal health services, working together to tackle all three delays through community education and awareness campaigns, improving access to transportation and road infrastructure, and improving the quality of care provided at service delivery points are key to reducing MNM, ultimately improving and ensuring maternal health equity.

Maternal near miss hospitalizations in the Borana Zone, Ethiopia: A facility-based longitudinal cross-sectional study

Background

Maternal near miss refers to a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of pregnancy termination. While there has been considerable progress in reducing maternal mortality rates, maternal near miss cases can provide valuable insights into the quality of maternal healthcare and help identify areas for improvement. However, there is limited evidence on the factors contributing to maternal near miss cases, including health system failures, delays in care, and provider-related factors. Therefore, this study aimed to assess the incidence, causes, and factors associated with maternal near misses in public Hospitals of Borena Zone.

Methods

A facility-based longitudinal cross-sectional study design was employed at four Public Hospitals in Borena Zone from August 15, 2022, to November 15, 2022, using the WHO criteria for maternal near miss event. In total, 117 participants were included in the study. Eligibility was determined using key clinical, organ dysfunction, laboratory, and management criteria, as per the WHO guidelines for near-miss events. Underlying and contributing causes of maternal near misses were documented from each participant's records.

Result

There were 1421 deliveries during the study period and 117 eligible women developed potentially life-threatening conditions. Only 61 women experienced severe maternal outcomes (55 near misses and six maternal deaths). The maternal near miss incidence ratio was 38.7 per 1000 live births, with a mortality index of 9.8%. Hypertensive disorders and obstetric hemorrhage are the leading underlying causes of maternal near misses.

Conclusion

The incidence of maternal near miss was remarkably high when compared to previous studies. Giving special emphasis to life-saving interventions, critical care, reducing delays and improving the referral system are critical to improve quality of care.

Prospective assessment of mental and physical health of maternal near-miss women: A low-middle-income country's experience

Background

Traumatic birth experience is an unaddressed arena, especially in Asian women, with several societal stigmas lingering around.

Aim

A study was undertaken to simultaneously assess the post-partum mental and physical health follow-up of maternal near-miss (MNM) women and compare it with women of uneventful deliveries.

Materials and Methods

The prospective cohort study enrolled 88 MNM women (case cohort) and 80 women with an uneventful peri-partum period (control cohort) at the same time. The participants were followed up with Edinburgh Postnatal Depression Scale (EDPS), PTSD Checklist - Civilian Version (PLC-C), and a 36-item short-form-survey form over 6 months after the delivery.

Results

The case group had higher mean EPDS and PLC-C scores, with poor quality of life (QOL) performance, compared to the control group at 6 weeks and 3 months, and 6 months follow-up (P < 0.05). At the sixth-week follow-up visit, the study observed that 28 (31.8%) women from the case group required a psychiatry consultation compared to the control group with only two (2.5%) participants (P < 0.001). At 3 months, an evident difference was noted on various QOL parameters, such as limitations due to physical health and emotional problems, energy fatigue, general health, and health change parameters between the two groups (P < 0.05). The difference persisted at 6-month follow-up as well for limitations due to physical health, energy fatigue, and general health parameters only (P < 0.05).

Conclusion

There is an urgent need for a multi-departmental collaborative approach at the hospital level and policy-making decisions at higher levels for the mental health of Asian women facing MNM events.

[Maternal morbidity and mortality in Brazil and the urgency of a national surveillance system for maternal near miss]

The World Health Organization (WHO) recommends the analysis of severe maternal morbidity/maternal near miss cases as complementary to the analysis of maternal deaths since the incidence is higher and the predictive factors of the two outcomes are similar. Considering that the reasons for maternal mortality in Brazil have remained constant despite the commitment made during the General Assembly of the United Nations in 2015, this article aims to propose a nationwide maternal near miss surveillance system. We propose the inclusion of maternal near miss events in the National List of Compulsory Notification of Diseases, Injuries, and Public Health Events, via the compatibility of the diagnostic criteria of maternal near miss, informed by the WHO, with the codes of the International Classification of Diseases for the identification of cases. Considering that health surveillance is based on several sources of information, notification could be made by health service professionals as soon as a confirmed or suspected case is identified. With the study of the factors associated with the outcomes, we expect a qualified evaluation of the services focused on obstetric care and consequent implementation of more efficient policies to prevent not only maternal death but also events that can both cause irreversible sequelae to women's health and increase the risk of fetal and neonatal death.

Maternal Near-Miss Secondary to Concealed History: A Case Report

A mother and her child constitute an essential part of the healthcare system. Maternal death due to obstetrical causes is tragic for the family and the healthcare system. A maternal near-miss is a woman who survived problems during pregnancy and childbirth and has been examined as an intermediary for maternal deaths. Reviews of such situations are viewed as a less risky strategy by the service provider to improve maternal health care. This will allow us to take advantage of possibilities to prevent the deaths of mothers who may meet a similar fate. This is the case of a survivor of pregnancy termination challenges whose concealed history eventually led to a series of events compromising her health to a near-mortality condition. Providing complete information to a clinician is a crucial component of quality healthcare, as a family is the first in contact with a patient. The significance is evident in this case report.

Predictors and Pathway of Maternal Near Miss: A Case-Control Study in a Tertiary Care Facility in Kolkata

Background

Use of maternal near-miss (MNM) cases as an adjunct has been advocated to understand the processes of obstetric care because they share similar pathways as maternal deaths. Identifying the predictors and care pathway is crucial to improve the quality of care and end preventable maternal deaths.

Materials and Methods

This case-control study was conducted at a tertiary care facility in Kolkata from May 2019 to March 2020. Women admitted with complications during pregnancy, childbirth, or within 42 days of postpartum, who met the World Health Organization (WHO) near-miss criteria, were identified as cases, and equivalent age-group matched controls were recruited. Sample size of 60 cases and 60 controls was estimated, assuming a power of 80%, level of significance 0.05, and case-control ratio of 1. After obtaining approval from the institutional ethics committee and informed written consent from the participants, data was collected through face-to-face interview and review of records. Statistical analysis including care pathway analysis (using three-delay model) was performed using Statistical Package for Social Sciences version 16.

Results

Joint family type (adjusted odds ratio [AOR] [CI] = 5.06 [1.48, 7.28]), lack of antenatal checkups (AOR [CI] = 7.85 [1.47, 12.09]), previous history of cesarean section (AOR [CI] = 3.94 [1.09, 14.33]), first delay in seeking care (AOR [CI] = 13.84 [3.62, 32.83]), and preexisting medical disorders (AOR [CI] = 11.03 [4.62, 22.80]) were identified as significant predictors of MNM in the adjusted model. Significant difference in the proportion of first and second delays in the care pathway was observed between cases and controls.

Conclusions

Identification of risk factors of MNM and pattern of delays in the care pathway will help improving quality of obstetric care.

Near-Miss Incidents in Obstetric Patients Admitted to an Intensive Care Unit of a Tertiary Care Center in Eastern India: A Retrospective Cohort Study

Aim

Obstetric patients presenting to the intensive care units (ICU) with or without underlying medical or surgical comorbidities can be a challenge to both the treating obstetrician and the intensivist. They occasionally present with near-miss events which if left untreated, can result in death.

Objectives

To study the prevalence, indications of ICU admissions, near-miss events, and their effect on mortality in obstetric and puerperal patients.

Material & methods

We conducted a retrospective analysis of the health records of all the obstetric and puerperal patients (pregnant and until 6 weeks postpartum) admitted to our tertiary care hospital from January 2019 to December 2020. Patient demographic characteristics, obstetric, surgical, and medical conditions, acute physiology, and chronic health evaluation (APACHE) II scores, organ failures, treatment, ICU and hospital length of stay, and mortality outcomes were studied.

Results

A total of 22 obstetric patients were admitted to the ICU during the above study period. Mean age was 28.7 ± 6.24 years, mean gestation was 34.4 ± 6.61 weeks, mean APACHE II score was 12.68 ± 5.67, median ICU length of stay was 5 days, and median duration of hospital length of stay was 10 days. The antepartum risk factors such as severe preeclampsia (27%), antepartum bleeding (14%), and postpartum complications like postpartum haemorrhage (33%), sepsis with multiorgan failure (25%) are the commonest indications that resulted in ICU admission.

Conclusion

Higher APACHE II scores at the time of ICU admission, prolonged ICU, and hospital length of stay may be associated with high maternal mortality.

Maternal morbidity and mortality: an iceberg phenomenon

OBJECTIVE

To apply the iceberg model, quantifying absolute and relative incidence, to the four main causes of maternal morbidity and mortality in Ireland: haemorrhage, hypertension, sepsis and thrombosis.

DESIGN

Secondary analysis of national data on maternal morbidity and mortality.

SETTING

Republic of Ireland.

POPULATION OR SAMPLE

Approximately 715 000 maternities, 1 200 000 maternal hospitalisations, 2138 cases of severe maternal morbidity (SMM) and 54 maternal deaths.

METHODS

Incidence rates and case-fatality ratios were calculated.

MAIN OUTCOME MEASURES

Maternal death, SMM and hospitalisation.

RESULTS

At the 'tip of the iceberg', the incidence of maternal death per 10 000 maternities was 0.09 (95% CI 0.03-0.20) due to thrombosis and 0.03 (95% CI 0-0.11) due to haemorrhage, hypertension disorders or sepsis. For one death due to thrombosis there were 35 cases of pulmonary embolism and 257 thrombosis hospitalisations. For one death due to eclampsia, there were 58 eclampsia cases, 13 040 hospitalisations with pre-existing hypertension and 40 781 hospitalisations with gestational hypertension. For one death due to pregnancy-related sepsis, there were 92 cases of septicaemic shock and 9005 hospitalisations with obstetric sepsis. For one maternal death due to haemorrhage, there were 1029 cases of major obstetric haemorrhage and 53 715 maternal hospitalisations with haemorrhage. For every 100 maternities, there were approximately 16 hospitalisations associated with haemorrhage, 12 associated with hypertension disorders, three with sepsis and 0.2 with thrombosis.

CONCLUSIONS

Haemorrhage and hypertension disorders are leading causes of maternal morbidity in Ireland but they have very low case fatality. This indicates that these morbidities are managed effectively but their prevention requires more focus.

TWEETABLE ABSTRACT

Study shows that haemorrhage and hypertension are main causes of #maternalmorbidity in Ireland. Timely interventions for #maternalhealth and focus on prevention of severe and non-severe morbidities are needed. @NPEC #maternityservices #clinicalaudit #qualityimprovement.

Diagnostic performance of two different maternal near-miss approaches in a High Obstetric Risk Unit

Maternal near-miss (MNM) is a maternal quality care indicator. The World Health Organization (WHO) defines it as a state in which a woman nearly dies but survives due to a complication during pregnancy, birth, or puerperium. The Latin American Federation of Obstetrics and Gynecology (FLASOG) and the Colombian National Health Institute (INS) established recommendations for the event's epidemiological surveillance; nonetheless, the operational definitions of the cases are different. This retrospective study examined the approaches of FLASOG and INS versus the WHO approach (gold standard) for the assessment of MNM in a high obstetric risk unit. Patients admitted with at least one criterion of the WHO, FLASOG, or INS approach for the definition of MNM from March 2016 to March 2017 were included. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were evaluated, as well as the Receiver Operating Characteristics (ROC) curve of the FLASOG and INS. MNM classification compared to WHO system as reference. The results highlight that the WHO classification establishes very high boundaries for some of the diagnostic criteria and the lack of standardization of the MNM criteria among the different proposals in Latin America hinders the applicability in Colombia and other countries with a similar situation.

Determinants of maternal near miss among women admitted to maternity wards of tertiary hospitals in Southern Ethiopia, 2020: A hospital-based case-control study

BACKGROUND

A maternal near-miss (MNM) refers to when a gravely ill woman survives a complication as a result of the standard of care she receives or by chance during gestation, childbirth, or within 42 days of the termination of pregnancy. Rescuers of near-miss events share several features with mothers who have died and identifying MNM determinants will aid in improving the capacity of the health system to reduce severe maternal morbidity and mortality. Ethiopia is one of the countries in sub-Saharan Africa with high maternal mortality and morbidity, but there is little evidence on determinants of a MNM based on a WHO criteria. Hence, this study aimed at identifying determinants of MNM among women admitted to tertiary hospitals in southern Ethiopia, 2020.

METHODS

A facilities-based unmatched case-control study was conducted in five selected tertiary hospitals found in central southern Ethiopia from February 1 to June 1, 2020. A total of 322 (81 cases and 241 controls) study participants were included in the study. At the time of their discharge, cases were recruited consecutively, while controls were selected using a systematic sampling method. The cases were women admitted to hospitals during pregnancy, childbirth, or 42 days following termination of pregnancy who met at least one of the WHO near-miss criteria. Whereas the controls comprised of women who were admitted during pregnancy, childbirth, or 42 days following termination of pregnancy and discharged without severe obstetric complications. Data collection was conducted using the interviewer-administered structured questionnaire and data abstraction tool. The data was coded and entered into Epi-Data version 3.1 and exported to SPSS version 23 for analysis. Multivariable logistic regression analysis was conducted and determinants of MNM were established at p-value<0.05.

RESULTS

Severe postpartum hemorrhage (50.6%) and sepsis (23.4%) were the most common reasons for admission of cases. Lack of ANC [AOR = 3.25; 95%CI: 2.21,7.69], prior history of Cesarean section [AOR = 3.53; 95%CI:1.79,6.98], delaying more than 60 minute to access final place of care [AOR = 3.21; 95%CI:1.61,6.39], poor practice of Birth preparedness and complication readiness (BPCR) [AOR = 3.31; 95%CI:1.50,7.29], and history of preexisting medical disorders [AOR = 2.79; 95%CI:1.45,5.37] were identified as significantly determinants of maternal near miss.

CONCLUSION AND RECOMMENDATION

Stakeholders need to enhance their efforts for improving access to roads and transportations. Besides, women who have a prior history of Caesarean section, chronic medical conditions, and no ANC need special attention from their families and health care providers to proactively mitigate the occurrence of serious obstetric complications. More attention has to be paid to birth preparedness and complication readiness activities.

Maternal Near Miss: Unraveling Our Experience in the Tertiary Care Hospital of Andaman and Nicobar Islands

Context

Women who survive life-threatening complications related to pregnancy and delivery have many common aspects with those who die of such complications. This similarity brought forward the near miss concept in maternal health. Analysis of the similarities, differences, and the relationship between these two groups of women provide a complete assessment of quality of maternal health care.

Aims

The aim of this study is to assess the baseline indices of maternal near miss (MNM) and analyze the quality of care at a tertiary care center in Andaman and Nicobar Islands.

Settings and Design

Facility-based, cross-sectional study.

Subjects and Methods

The study was conducted for a period of 18 months from January 1, 2015, to August 31, 2016. Cases, who met the World Health Organization (WHO) criteria of severe obstetric morbidity, were included and followed up during their hospital stay and till their discharge or death. Quality of maternal health care was assessed through the WHO near-miss criteria and criterion-based clinical audit methodology.

Statistical Analysis Used

Descriptive statistics using mean and percentages and Student's t-test were used.

Results

Among 4720 women who delivered in our hospital, there were 4677 live births, 52 patients were near miss, and there were 9 maternal deaths. The MNM incidence ratio was 11.11%, the MNM mortality ratio was 5.77, and the mortality index 14.75%. The most common cause of maternal morbidity was hemorrhage followed by hypertensive disorders.

Conclusions

Improving referral systems, effective use of critical care, and evidence-based interventions can potentially reduce severe maternal outcomes.

Maternal Near-Miss as a Surrogate Indicator of the Quality of Obstetric Care: A Study in a Tertiary Care Hospital in Eastern India

Background

Monitoring severe acute maternal morbidity or maternal near-miss is currently proposed by WHO as a valuable tool to assess the quality of obstetric care and implement new strategies for improving maternal health.

Aim and objective

The objective of this study was to assess and analyze the incidence of maternal near-miss (MNM) and maternal death (MD) at Tata Main Hospital, Jamshedpur, a tertiary care hospital in eastern India.

Material and method

This study was a prospective observational study conducted at Tata Main Hospital from November 2016 to October 2019. The study population included all the pregnant women who fulfilled the WHO near-miss criteria based on organ dysfunction or failure and all the maternal deaths that occurred during the study period.

Results

During the study period, there were 15,377 deliveries and 14,636 live births. The MNM cases were 153, and 38 were maternal deaths. The maternal near-miss ratio (MNMR) and severe maternal outcome ratio (SMOR) were 19.9 and 13.1 per 1000 live births, respectively. The maternal near-miss to mortality ratio (MNM: 1 MD) was 4:1, and the mortality index (MI) was 19.9%. Haemorrhagic disorders were the leading cause (40.5%) of MNM, followed by hypertensive disorders (25.5%) and cardiac diseases (14.4%). Similarly, both haemorrhage (23.7%) and sepsis (23.7%) were the leading causes of death followed by hypertensive disorders (15.8%). On reviewing patients, 62% of near-miss and 92% of mortality cases had shown organ dysfunction on admission.

Conclusion

MNM and MD cases share similar pathology with a different outcome. Hence, monitoring a larger volume of MNM cases helps in identifying the causes of maternal adverse events and finding out the gaps in the management more effectively than auditing only the maternal deaths.

Determinants of Maternal Near Miss in Western Ethiopia

Background

Analysis of maternal near miss events and identification of factors resulting in maternal death are vital to improve the quality of obstetric care in any given setting. This study is aimed to determine the magnitude of maternal miss and identify its determinants.

Methods

A hospital-based unmatched case-control study design was used. Sixty one maternal near misses (as cases) and 122 mothers who had a normal obstetric outcome (as controls) at obstetrics and gynecology ward of Nekemte Referral Hospital were included from May 1st, 2018 to July 31st, 2018. The criteria set by the World Health Organization were used to identify maternal near miss cases. The data were collected via face-to-face interviews using pretested structured questionnaires and analyzed using SPSS version 22. For every case, two controls were recruited. Descriptive statistics and logistic regressions were used. A 95% CI and p-value of <0.05 were considered to be statistically significant.

Result

The magnitude of maternal near miss was 4.97%. Factors including multigravidity (AOR= 3.84, 95% CI: 1.23–11.91), lack of antenatal care (AOR=6.02, 95% CI: 1.55–23.28), delays in accessing health facility (AOR=12, 95% CI: 2.55–56.57) and induction of labor (AOR =9.4, 95% CI: 2.97–29.71) were strongly associated with maternal near miss. Hypertension during pregnancy (40.9%) and obstetric hemorrhage (39.3%) were identified as the major causes of maternal near miss.

Conclusion

The magnitude of maternal near miss was high but lower compared to magnitude in other parts of Ethiopia, and numerous preventable determinant factors were identified.

Preeclampsia Is a Syndrome with a Cascade of Pathophysiologic Events

This review integrates the currently available information on the molecular, cellular, and systemic mechanisms involved in the pathophysiology of preeclampsia. It highlights that the growth, protection, and promotion of the conceptus requires the modulation of an intact maternal immune system, communication between the mother and fetus, and adaptation of the maternal organic functions. A malfunction in any of these factors, on either side, will result in a failure of the cascade of events required for the normal course of pregnancy. Maladaptive processes, initially aiming to protect the conceptus, fail to anticipate the gradually increasing cardiovascular volume load during the course of pregnancy. As a result, multiple organ dysfunctions install progressively and eventually reach a state where mother and/or fetus are at risk of severe morbidity or even mortality, and where the termination of pregnancy becomes the least harmful solution. The helicopter view on pathophysiologic processes associated with preeclampsia, as presented in this paper, illustrates that the etiology of preeclampsia cannot be reduced to one single mechanism, but is to be considered a cascade of consecutive events, fundamentally not unique to pregnancy.

Retrospective analysis of patients with severe maternal morbidity receiving anaesthesia services using 'WHO near miss approach' and the applicability of maternal severity score as a predictor of maternal outcome

Background and Aims:

Risk stratification of severely morbid obstetric patients receiving anaesthesia services can be helpful in improving maternal outcomes. This study was undertaken to analyse these patients using the WHO near-miss (NM) approach and to assess the applicability of maternal severity score (MSS) to predict maternal mortality.

Methodology:

This is a one-year retrospective cohort analysis at a tertiary care centre. Of all the obstetric patients receiving anaesthesia, those with 'potentially life-threatening conditions' (PLTC) were identified. Amongst women with PLTC, those fulfilling the WHO NM criteria were grouped into either maternal near miss (MNM) or maternal death (MD) depending on final survival outcome. The MSS was assessed upon admission to post-anaesthesia ICU. The cases of “near miss” were compared to maternal death to determine the factors and WHO NM criteria significantly associated with mortality. Area under ROC curve (AUROC) was used to assess the accuracy of MSS to predict maternal mortality.

Results:

Of the 4351 anaesthetised obstetric patients, 301 were PLTC, 59 MNM and 11 MD. Obstetric haemorrhage was the commonest PLTC with the highest risk for MNM and MD. Preoperative organ dysfunction, referral from other centres, intra-uterine fetal death (IUFD) and WHO cardiovascular and respiratory NM criteria were significantly associated with mortality. MSS had excellent accuracy for the prediction of mortality (AUROC was 0.986 and 95% CI 0.966–0.996).

Conclusion:

Haemorrhage is the leading cause of MNM and MD. MSS is reliable in stratifying the severity of maternal morbidity and in predicting maternal mortality. Thus it can be used as an effective prognostic tool.

Human Development Index of the maternal country of origin and its relationship with maternal near miss: A systematic review of the literature

Background

The reduction in maternal mortality worldwide has increased the interest in studying more frequent severe events such as maternal near miss. The Human Development Index is a sociodemographic country-specific variable that includes key human development indicators such as living a long and healthy life, acquiring knowledge, and enjoying a decent standard of living, allowing differentiation between countries. In a globalised environment, it is necessary to study whether the Human Development Index of each patient's country of origin can be associated with the maternal near-miss rate and thus classify the risk of maternal morbidity and mortality.

Methods

A systematic review of the literature published between 2008 and 2019 was conducted, including all articles that reported data about maternal near miss in their sample of pregnant women, in addition to describing the study countries of their sample population. The Human Development Index of the study country, the maternal near-miss rate, the maternal mortality rate, and other maternal-perinatal variables related to morbidity and mortality were used.

Results

After the systematic review, eighty two articles from over thirty countries were included, for a total of 3,699,697 live births, 37,191 near miss cases, and 4029 mortality cases. A statistically significant (p <0.05) inversely proportional relationship was observed between the Human Development Index of the study country and the maternal near-miss and mortality rates. The most common cause of maternal near miss was haemorrhage, with an overall rate of 38.5%, followed by hypertensive disorders of pregnancy (34.2%), sepsis (7.5%), and other undefined causes (20.9%).

Conclusions

The Human Development Index of the maternal country of origin is a sociodemographic variable allowing differentiation and classification of the risk of maternal mortality and near miss in pregnant women. The most common cause of maternal near miss published in the literature was haemorrhage.

Trial registration

PROSPERO ID: CRD 42019133464

FREQUENCY, DISTRIBUTION BY PLACE OF DELIVERY AND PARITY, CAUSES, MANAGEMENT OPTIONS AND OUTCOME OF PRIMARY POSTPARTUM HAEMORRHAGE IN POSTPARTUM WOMEN OF DISTRICT PESHAWAR, PAKISTAN

Background: Primary postpartum haemorrhage (PPPH) is the leading cause of maternal morbidity and mortality in low resource countries like Pakistan. The objectives of this study were to determine the frequency, distribution by place of delivery and parity, causes, management options and outcome of PPPH in postpartum women of District Peshawar, Pakistan. Materials & Methods: This cross-sectional study was conducted in Department of Gynaecology & Obstetrics, Lady Reading Hospital, Peshawar, Pakistan from 1st January 2019 to 30th June 2019. Sample size of 4,034 was with 0.39342 % margin of error, 95% confidence level, prevalence of PPPH 2% and a population of 23,607 postpartum women. All postpartum women were eligible. Those with secondary PPH, surgical management for PPPH done at some other hospital, with known bleeding disorders and on anticoagulants were excluded. All these patients were managed according to standard protocols. Data was collected for following variables; presence of PPPH (yes/ no), place of delivery (in-hospital deliveries/ referred cases), parity (primipara/multipara/grandmultipara), causes of PPPH (uterus atony/retained placenta-RPOC/ruptured uterus/genital tract tears), management options of PPPH (conservative management/laparotomy with repair of ruptured uterus/laparotomy with uterine artery ligation and B-Lynch/repair of genital tract tears other than ruptured uterus/removal of retained placenta & RPOC/hysterectomy) and outcome of PPPH (uneventful recovery/maternal near miss/maternal mortality). Frequencies and percentages with confidence intervals were calculated for these variables. Results: Out of 4034 postpartum women, frequency of PPPH was 400 (9.92%). Out of 4034 women, distribution of 400 cases of PPPH by place of delivery was 222 (5.50%) in-hospital deliveries and 178 (4.42%) referred cases and by parity it was primipara 79 (1.96%), multipara 243 (6.03%) and grandmultipara 78 (1.93%) cases. Out of 400 cases of PPPH, frequency of uterine atony was 254 (63.50%) and conservative management 245 (61.25%). Out of 400 cases, frequency of uneventful recovery was 352 (88%), maternal near miss 40 (10%) and maternal mortality eight (2%) cases. Conclusion: Primary postpartum haemorrhage (PPPH) continues to be a common and serious complication of delivery with uterine atony being its most predominant cause.

Impact of Training on Awareness and Knowledge of Service Providers About Maternal Near-Miss Events in Maharashtra, India

Objective

To improve the awareness and knowledge regarding Maternal Near Miss (MNM) among health service providers in the selected districts and women's hospitals in Maharashtra, India.

Methods

A one-day training programme on MNM was conducted at four Family Welfare Training Centres in the state of Maharashtra, India, for the health service providers, viz. gynaecologists, pathologists, anaesthesiologists, medical officers, staff nurses, other paramedical workers of the selected 29 districts/women's hospitals in Maharashtra. A total of 147 participants participated in the training programme. The participants filled a questionnaire before (pretest) and after the training (post-test) with the same set of questions pertaining to knowledge on the basic and operational aspects of MNM.

Results

There was a significant improvement in the level of knowledge (post-test responses vs pretest responses) about the correct definition and classification of MNM, as per the instructions in the MNM-R guidelines by the Government of India. The service providers informed regarding the challenges in the implementation of the MNM-R guidelines at their hospitals such as shortage of manpower in terms of specialists and need of quality assurance.

Conclusion

The training programme improved the knowledge of the service providers about MNM, which would help them to implement the MNM-R guidelines effectively at their hospitals. This training effectively upgraded the knowledge level, and therefore, such trainings should be organized for all obstetricians, high-dependency unit (HDU) personnel and critical care teams.

Maternal near miss determinants at a maternity hospital for high-risk pregnancy in northeastern Brazil: a prospective study

Background

To investigate the association between sociodemographic and obstetric variables and delays in care with maternal near misses (MNMs) and their health indicators.

Methods

A prospective cohort study was conducted at a high-risk maternity hospital in northeastern Brazil from June 2015 to May 2016 that included all pregnant women seen at the maternity hospital during the data collection period and excluded those who had not been discharged at the end of the study or whom we were unable to contact after the 42nd postpartum day for MNM control. We used the MNM criteria recommended by the WHO. Risk ratios (RRs) and their 95% confidence intervals (CIs) were calculated. Hierarchical multiple logistic regression analysis was performed. The p values of all tests were two-tailed, and the significance level was set to 5%.

Results

A total of 1094 pregnant women were studied. We identified 682 (62.4%) women without adverse maternal outcomes (WOAMOs) and 412 (37.6%) with adverse maternal outcomes (WAMOs), of whom 352 had potentially life-threatening conditions (PLTCs) (85.4%), including 55 MNM cases (13.3%) and five maternal deaths (1.2%). During the study period, 1002 live births (LBs) were recorded at the maternity hospital, resulting in an MNM ratio of 54.8/1000 LB. The MNM distribution by clinical condition identified hypertension in pregnancy (67.2%), hemorrhage (42.2%) and sepsis (12.7%). In the multivariate analysis, the factors significantly associated with an increased risk of MNM were fewer than six prenatal visits (OR: 3.13; 95% CI: 1.74–5.64) and cesarean section in the current pregnancy (OR: 2.91; 95% CI: 1.45–5.82).

Conclusions

The factors significantly associated with the occurrence of MNM were fewer than six prenatal visits and cesarean section in the current pregnancy. These findings highlight the need for improved quality, an increased number of prenatal visits and the identification of innovative and viable models of labor and delivery care that value normal delivery and decrease the percentage of unnecessary cesarean sections.

Severe maternal morbidity (near-miss) and its correlates in the world's newest nation: South Sudan

Background

This study investigates the frequency of near-miss events and compares correlates in the world's newest nation.

Methods

A cross-sectional study was carried out to audit near-miss events and their causes. A total of 1,041 mothers were sampled. Data were gathered using World Health Organization near-miss evaluation tools according to morbidity and organ failure-based criteria. Intensive care unit admission criteria were not used (as there is no functional intensive care unit in Juba Teaching Hospital). Descriptive statistics and bivariate and multivariable logistic regression were used to analyze the data. The study adhered to the Declaration of Helsinki.

Results

Nearly half (49.7%) of the clients were young pregnant women (aged 15-24 years), with a mean age of 25.07±5.65 years. During the study period, there were 994 deliveries, 94 near-misses, and 10 maternal deaths. This resulted in maternal near-miss and mortality rates of 94.1 per 1,000 and 1,007 per 100,000 live births, respectively. Severe maternal outcome and maternal near-miss rates were 10.47 per 1,000 (morbidity-based criteria) and 41.3 per 1,000 (organ failure-based criteria), respectively. The likelihood of mortality was 25% (95% CI 10%-51%) for a ruptured uterus, 9% (95% CI 4%-17%) for severe postpartum hemorrhage, and 11% (95% CI 3%-30%) for eclampsia. Anemia, hemorrhage, and dystocia were the highest contributory factors in the occurrence of maternal near-misses.

Conclusion

The near-miss rate was high. Contributing factors were lack of resources, low quality of primary health care, and delays in care. All near-misses should be regarded as opportunities to improve the quality of maternity care. Health institutes should address delays in conducting interventions, referral barriers, and personnel gaps. Fully functional intensive-care units must be created in all facilities, including Juba Teaching Hospital and other hospitals. Notification policies for all near-miss cases should be in place in all health care units, with a "no shame, no blame" approach.

Applicability of the WHO maternal near miss tool in sub-Saharan Africa: a systematic review

Background

Applicability of the World Health Organization (WHO) maternal near miss criteria in low-income settings is not systematically addressed in the literature. The objective of this review was to determine the applicability of the WHO maternal near miss tool in sub-Saharan Africa.

Methods

We searched PubMed, Embase, Popline, CINAHL, AJOL, and Google scholar using key words for maternal near miss and sub-Saharan Africa. Studies which applied the WHO maternal near miss criteria, containing clear definitions, and published between January 1st, 2009 and December 31st, 2017 were included. Two authors independently extracted data. Quantitative analysis and narrative synthesis were conducted, and medians with interquartile range (IQR) were calculated for summarizing the findings. Methodological quality of the studies was assessed using the Estabrook’s quality assessment and validity tool.

Results

Fifteen studies from nine countries comprising 227,077 participants were included. Median maternal near miss ratio was 24.2 (IQR: 12.4–35.8) per 1000 live births ranging from 4.4 in a population-based study in South Africa to 198 in a rural private hospital in Nigeria. Eight studies reported challenges in implementing the WHO maternal near miss tool, especially related to the threshold for blood transfusion, and availability of several laboratory-based criteria. In three studies, local adaptations were made.

Conclusion

This review showed that the WHO maternal near miss tool is not uniformly applied in sub-Saharan Africa. Therefore, a common adaptation for the region is required to increase its applicability.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2225-7) contains supplementary material, which is available to authorized users.

Second trimester abortion as a cause of maternal death: a case report

Each year, an estimated 529 000 maternal deaths occur worldwide. In literature, it is known that maternal mortality can occur during pregnancy, peripartum and also in postpartum period. Although very rare, maternal deaths may occur after spontaneous abortion. In present case, 37 year old G5P4 (Caesarean Section) women was admitted to Adnan Menderes University, Obstetrics and Gynecology clinic with diagnosis of missed abortion at 18 weeks' gestation. She had been hospitalized in the public maternity hospital for five days due to abortus incipience and prolapse of amnion membranes but had no contractions. Fetal heart beats ceased at the second day of hospitalization. Medically induced abortion was recommended but not accepted by the patient. At the fifth day of hospitalization, she was referred to our clinic due to deterioration of general health condition, low blood pressure and tachycardia. In emergency department, it was determined that she was not oriented, had confusion, had blood pressure of 49/25 mmHg and tachycardia. In ultrasonographic examination, 18 week in utero ex fetus was determined and there was free fluid in abdominopelvic cavity. The free fluid was suspected to be amniotic fluid due to rupture of uterus. Laparotomy was performed, no uterine rupture, hematoma or atony was observed. However during laparotomy, a very bad smelling odor, might be due to septicemia, was felt in the operation room. Cardiac arrest occurred during that operation. In autopsy report, it was concluded that maternal death was because of remaining of inutero ex fetus for a long time. In conclusion, although very rare, maternal deaths after spontaneous abortion may occur. Because spontaneous abortion is a common outcome of pregnancy, continued careful, strict monitoring and immediate treatment of especially second trimester spontaneous abortion is recommended to prevent related, disappointing, unexpected maternal deaths.