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BRIEF RESEARCH ARTICLE
Year : 2017  |  Volume : 61  |  Issue : 4  |  Page : 305-308  

“Near-Miss” Obstetric events and maternal mortality in a Tertiary Care Hospital


1 Senior Resident, Department of Obstetrics and Gynaecology, Sri Venkateswara Medical College, Khairatabad, Hyderabad, Telangana, India
2 Professor and Head, Department of Urology, SVIMS, Tirupati, Andhra Pradesh, India
3 Professor, Department of Urology, SVIMS, Tirupati, Andhra Pradesh, India
4 Final Year Resident, Department of Urology, SVIMS, Tirupati, Andhra Pradesh, India

Date of Web Publication6-Dec-2017

Correspondence Address:
Shravya Tallapureddy
6-2-966/13, Hill Colony, Khairatabad, Hyderabad - 500 004, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_268_16

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   Abstract 


Obstetric near-miss or severe acute maternal morbidity is gaining interest internationally as a new indicator of the quality of obstetric care. This is a retrospective study conducted using “The WHO Near-Miss Approach” to provide insight into obstetric emergencies, near-miss cases, and maternal deaths in our hospital. The maternal near-miss ratio was 8.4/1000 live births, maternal near-miss to mortality ratio was 5.3:1. Hemorrhage was the leading cause (43.7%) of morbidity in near-miss cases while hypertensive disorders were the leading cause in maternal deaths (66.6%). Among women with potentially life-threatening conditions, severe preeclampsia was the most common complication (50.54%). The near-miss approach helps to evaluate and improve the quality of care provided by health system by identifying the pattern of severe maternal morbidity and mortality, strengths and weakness in the referral system and the clinical interventions available and the ways in which improvements can be made.

Keywords: Maternal mortality, obstetric near-miss, World Health Organization near-miss approach


How to cite this article:
Tallapureddy S, Velagaleti R, Palutla H, Satti CV. “Near-Miss” Obstetric events and maternal mortality in a Tertiary Care Hospital. Indian J Public Health 2017;61:305-8

How to cite this URL:
Tallapureddy S, Velagaleti R, Palutla H, Satti CV. “Near-Miss” Obstetric events and maternal mortality in a Tertiary Care Hospital. Indian J Public Health [serial online] 2017 [cited 2019 Nov 15];61:305-8. Available from: http://www.ijph.in/text.asp?2017/61/4/305/220060



“Near-miss” describes a patient with an acute organ system dysfunction, which, if not treated appropriately, could result in death.[1] Near-miss cases have similar pathways as maternal deaths, with the advantages of offering a larger number of cases for analysis, greater acceptability of individuals and institutions since death did not occur, and the possibility of interviewing the woman herself.

The maternal mortality ratio (MMR) of India was 178/100,000 live births (2010–2012), which was reduced to 167/100,000 live births (2011–2013) as per Sample Registration Survey.[2] Many other studies have reported obstetric near-miss to maternal death ratios ranging from 5:1 to 11:1. Hence, this study was conducted to provide insight into obstetric emergencies, near-miss cases, and maternal deaths in our tertiary care hospital and to determine the frequency of severe maternal complications, maternal near-miss cases, and maternal deaths in our tertiary care hospital.

The objectives of the study were to study severe maternal outcomes (SMOs) in our tertiary care hospital and assess the quality of maternal health care and lacunae using WHO Near-Miss Approach-2011.

This is a retrospective study of all obstetric cases managed at a tertiary referral center from January 2014 to August 2014. Ethical clearance was obtained from institutional ethics committee. All obstetric admissions in the above period were reviewed and followed up till six weeks after delivery. Patients who failed to attend the postnatal were followed up through phone/personal communication. Data pertaining to the age of the patient, admission details (booked/referral case), antenatal risk factors (obstetric formula, previous cesarean section, anemia, preeclampsia, diabetes, HIV), intrapartum events (mode of delivery, baby details), postpartum events (near-miss events, maternal deaths), Intensive Care Unit care details, other interventions, and complications of these patients were collected and spread on Microsoft Excel 2010 sheet.

Data were analyzed with “The WHO Near-Miss Approach” tool published in 2011.

Women were grouped into three categories:

  1. Women with severe maternal complications/potentially life-threatening conditions
  2. Women with “near-miss” events
  3. Maternal deaths.


Severe maternal complications are defined as “potentially life-threatening conditions.”[1]

A near-miss event is “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy.”[1]

Maternal death is defined as death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

SMO – A life-threatening condition (i.e., organ dysfunction) including all maternal deaths and maternal near-miss cases.[1]

SMO12 – Cases presenting with organ dysfunction or maternal death within 12 h of hospital stay.[1]

During the study period, there were a total of 3900 admissions and 3784 live births. A total of 184 women were identified with severe maternal complications while there were 32 near-miss cases and 6 maternal deaths.

[Table 1] shows the complications and critical interventions in women with potentially life-threatening conditions. Among women with potentially life-threatening conditions, severe preeclampsia was the most common complication, accounting for a total of 93/184 cases (50.54%) followed by antepartum hemorrhage (15.21%) and eclampsia (13.49%). Laparotomy was the most common intervention done in 22/184 cases (11.96%).
Table 1: Morbidity conditions in women with potentially life-threatening conditions

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Analysis of organ dysfunction showed that in 32 near-miss cases, coagulation/hematological dysfunction was the most common organ dysfunction seen in 11 cases (34.37%) followed by neurological in 5 cases (15.62%), renal dysfunction in 4 cases (12.5%), cardiovascular dysfunction in 3 cases (9.37%), hepatic dysfunction in 2 cases (6.25%), and respiratory dysfunction in 1 cases. Among six maternal deaths, respiratory dysfunction was the cause of death in 50% cases while coagulation dysfunction, neurological dysfunction, and multiorgan dysfunction syndrome were contributory in 1 case each.

Among near-miss cases, hemorrhage was the leading cause (43.7%) of morbidity, followed by hypertensive disorders (31.2%) and other causes (15.6%). Hypertensive disorders were the leading cause in both women with potentially life-threatening conditions (66.8%) and maternal deaths (66.6%).

When associated factors were analyzed, anemia was seen in 60.87% (112 cases) of potentially life-threatening conditions, 65.63% (21 cases) of maternal near-miss cases and in all (6) of maternal deaths. No maternal near-miss case had HIV infection. However, HIV infection was seen in 2.17% (4 cases) of potentially life-threatening condition cases and a maternal death. About 17.39% (32 cases) of potentially life-threatening condition cases, 21.87% (7 cases) of maternal near-miss cases, and 33.34% (2 cases) of maternal deaths had previous cesarean section.

Mode of delivery was also analyzed. Among cases with potentially life-threatening conditions, cesarean section was done in 40.22% (74 cases) while 41.85% (77 cases) had normal vaginal deliveries. Cesarean section was required in 37.5% (12 cases) while normal vaginal delivery was the mode of delivery in 34.38% (11 cases) in maternal near-miss cases. About 66.7% (4 cases) of maternal deaths had cesarean section in our study.

[Table 2] shows the summary of near-miss indicators analyzed in our study. There were a total of 3784 live births in our study. SMOs were seen in 38 cases, which included 6 maternal deaths and 32 maternal near-miss cases. The SMO ratio in our study is 10.04 and maternal near-miss ratio is 8.46. Three cases (50%) of total 6 maternal deaths and 24 cases (75%) of 32 near-miss cases were referred from other health facilities. There were a total of 29 (76.32%) SMO12 cases in our study. Of those 29 SMO12 cases, 21 cases (72.41%) were referral cases.
Table 2: Severe maternal outcomes and near-miss indicators

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Obstetric deaths may not reflect the global situation with regard to obstetric care in the present scenario. Hence, new “near-miss” criteria take over MMR. WHO criteria (2009)[1] are unique in considering not only clinical but also laboratory and management-based criteria thus minimizing the chance of missing the case.

Unlike many other studies where hemorrhage was the leading cause, hypertensive disorders (4/6) were leading cause for maternal deaths in our study due to better management of hemorrhage cases with 24-h working blood bank. Lower rates of deaths due to sepsis in our study indicate better quality of care at our facility. Mortality index in our setup was 15.79% which falls between that of earlier studies.[3],[4]

The maternal near-miss ratio (MNMR) was 8.46/1000 live births in our hospital. Studies done in the developing countries vary from anywhere between 7-40/1000 live births.[5],[6],[7] The near-miss to mortality ratio was 5.34:1 which is similar to those of other developing countries where the range is 5–12:1.[3],[4] This is a far cry from those reported in Western Europe where studies have reported a ratio of 117–223:1.[6]

Obstetric hemorrhage (43.75%) was the most common cause of near-miss in our study as in Purandare et al.'s [8] review of a pilot program on maternal near-miss in 2013. In a systematic review conducted by the WHO, hypertensive disorders were responsible for 25% deaths in Latin America and the Caribbean, while hemorrhage was the leading cause of maternal deaths in Africa (33.9%) and in Asia.[9]

Anemia as in our study was reported as an important associated cause in 12.8% deaths in Asia, 3.7% in Africa, and none in the developed countries.[9] Although HIV was reported as an important associated cause for near-miss and maternal death in Africa [9] where HIV is more prevalent, further studies with special emphasis on HIV as cause for maternal near-miss may provide better insight to its role in less prevalent areas.

In our study, cesarean section (CS) was done in 66.67% of maternal deaths and 37.5% of near-miss cases. However, this association may be affected by confounding factors. Whether CS is a risk factor for near-miss, or whether it is actually a consequence of this condition, is still unclear.[10]

The proportion of women arriving at a health-care facility with SMO provides information about the occurrence of the first delay or second delay and factors contributing to the delays.[11] In our study, proportion of SMO12 among all SMO cases was 76.32% (29 cases), and 74.21% (21 cases) of these were cases referred from other health facilities. This clearly shows that near-miss cases seek health care at the last minute of golden hour which might be due to various reasons. Availability, accessibility, cost of health care, and behavioral factors play an important role in the utilization of maternal health services.

Study limitations include the fact that a prospective follow-up of patients, which might have yielded more information and decreased losses, did not occur. Further, a longer duration and a multicenter study would provide broader perspective of the deficiencies in the present health care and identify measures to overcome them.

Reviewing near-miss cases helps in identifying the pattern of severe maternal morbidity and mortality, strengths and weakness in the referral system and the clinical interventions available and the ways in which improvements can be made. Hemorrhage and hypertensive disorders are the leading causes of near-miss events. Early identification of risk factors for preeclampsia and prompt initiation of treatment with correction of associated factors such as anemia play a critical role in optimal management of near-miss cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organisation. Evaluating the Quality of Care for Severe Pregnancy Complications: The WHO Near-Miss Approach for Maternal Health. Geneva, Switzerland: World Health Organisation; 2011.  Back to cited text no. 1
    
2.
Parmar NT, Parmar AG, Mazumdar VS. Incidence of maternal “Near-miss” events in a tertiary care hospital of central Gujarat, India. J Obstet Gynaecol India 2016;66:315-20.  Back to cited text no. 2
[PUBMED]    
3.
Nelissen EJ, Mduma E, Ersdal HL, Evjen-Olsen B, van Roosmalen JJ, Stekelenburg J, et al. Maternal near miss and mortality in a rural referral hospital in Northern Tanzania: A cross-sectional study. BMC Pregnancy Childbirth 2013;13:141.  Back to cited text no. 3
    
4.
Ps R, Verma S, Rai L, Kumar P, Pai MV, Shetty J, et al. “Near miss” obstetric events and maternal deaths in a tertiary care hospital: An audit. J Pregnancy 2013;2013:393758.  Back to cited text no. 4
    
5.
Lotufo FA, Parpinelli MA, Haddad SM, Surita FG, Cecatti JG. Applying the new concept of maternal near-miss in an Intensive Care Unit. Clinics (Sao Paulo) 2012;67:225-30.  Back to cited text no. 5
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6.
van Roosmalen J, Zwart J. Severe acute maternal morbidity in high-income countries. Best Pract Res Clin Obstet Gynaecol 2009;23:297-304.  Back to cited text no. 6
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7.
Souza JP, Cecatti JG, Parpinelli MA, Serruya SJ, Amaral E. Appropriate criteria for identification of near-miss maternal morbidity in tertiary care facilities: A cross sectional study. BMC Pregnancy Childbirth 2007;7:20.  Back to cited text no. 7
[PUBMED]    
8.
Purandare C, Bhardwaj A, Malhotra M, Bhushan H, Chhabra S, Shivkumar P, et al. Maternal near-miss reviews: Lessons from a pilot programme in India. BJOG 2014;121 Suppl 4:105-11.  Back to cited text no. 8
    
9.
David E, Machungo F, Zanconato G, Cavaliere E, Fiosse S, Sululu C, et al. Maternal near miss and maternal deaths in Mozambique: A cross-sectional, region-wide study of 635 consecutive cases assisted in health facilities of Maputo province. BMC Pregnancy Childbirth 2014;14:401.  Back to cited text no. 9
[PUBMED]    
10.
van Dillen J, Zwart JJ, Schutte J, Bloemenkamp KW, van Roosmalen J. Severe acute maternal morbidity and mode of delivery in the Netherlands. Acta Obstet Gynecol Scand 2010;89:1460-5.  Back to cited text no. 10
[PUBMED]    
11.
Kumar R. Prevention of maternal mortality: Why success eludes us? Indian J Public Health 2002;46:3-7.  Back to cited text no. 11
[PUBMED]    



 
 
    Tables

  [Table 1], [Table 2]


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