|BRIEF RESEARCH ARTICLE
|Year : 2018 | Volume
| Issue : 3 | Page : 235-238
“Near-Miss obstetric events” and its clinico-social correlates in a secondary referral unit of Burdwan District in West Bengal
Rakesh Kumar1, Aparna Tewari2
1 Assistant Professor, Department of Community Medicine, IQ City Medical College, Durgapur, West Bengal, India
2 Intern, IQ City Medical College, Durgapur, West Bengal, India
|Date of Web Publication||12-Sep-2018|
Flat-D, 1st Floor, JD-3, IQ City Medical College, Durgapur - 713 206, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Near-miss obstetric events (NMEs) refers to the situations where women experience severe, life-threatening obstetric complications during pregnancy, delivery, or postpregnancy (up to 42 days) which they survive either by chance or because they receive good care at a facility. A cross-sectional study was conducted from May to June 2016 at the subdivisional hospital of West Bengal. The WHO near-miss criteria were followed for case identification. Data were collected by interview and record review. No maternal deaths were reported during data collection period; however, the frequency of NMEs was quite high (38%). Maternal near-miss ratio was 379.51/1000 live births, and maternal mortality index was 0%. Higher age group, below poverty line status, term pregnancy, and higher gravid and higher parity significantly favored the occurrence of NMEs, while ANC registration and Iron and Folic Acid consumption were significantly protective against it. Early identification of risk factors for NMEs and prompt initiation of treatment plays a critical role in the management of NMEs.
Keywords: ANC, maternal complications, maternal mortality, near-miss obstetric events
|How to cite this article:|
Kumar R, Tewari A. “Near-Miss obstetric events” and its clinico-social correlates in a secondary referral unit of Burdwan District in West Bengal. Indian J Public Health 2018;62:235-8
|How to cite this URL:|
Kumar R, Tewari A. “Near-Miss obstetric events” and its clinico-social correlates in a secondary referral unit of Burdwan District in West Bengal. Indian J Public Health [serial online] 2018 [cited 2019 Jul 15];62:235-8. Available from: http://www.ijph.in/text.asp?2018/62/3/235/241099
Severe maternal complications are defined as “potentially life-threatening conditions.” Maternal near-miss refers to the situations where women experience severe, life-threatening obstetric complications during pregnancy, delivery, or post pregnancy (up to 42 days) which they survive either by chance or because they receive good care at a facility. A severe maternal outcome (SMO) is defined as a life-threatening condition (i.e., organ dysfunction) including all maternal deaths and maternal near-miss cases. In-depth interviews with women who survived a near-miss event or with members of their family have generated important evidence about the factors that contribute to delays in accessing obstetric care. Keeping in mind the potential to highlight the nature of obstetric services and with no such study in this region of West Bengal, this study was carried out with the objectives to determine the frequency of near-miss obstetric events (NMEs) in a secondary referral unit of Burdwan District and to ascertain the clinico-social determinants of the near-miss events.
We approached all women who admitted for delivery during data collection period (May–June 2016) to participate in our study. Out of 344, 336 agreed to participate in our study; however, only 332 were included in the final analysis due to incomplete data of four participants. Mothers were interviewed using predesigned and pretested schedule. In case, the mother was unable to answer; then, a responsible close family member was interviewed. Maternal and child protection card was used to collect information about antenatal care (ANC). Bed-head tickets were reviewed for final diagnosis.
The final diagnosis was done by the treating obstetrician, and the treatment note was taken.
The following disease-specific criteria that were employed by Filippi et al. were applied for this study:
- Hemorrhage: (leading to shock, emergency hysterectomy, and/or blood transfusions of ≥2 liters)
- Hypertensive disorders in pregnancy: (including both eclampsia and severe preeclampsia)
- Dystocia: (uterine rupture and impending rupture, e.g., prolonged obstructed labor with previous C.S.)
- Infection: (infection with hyperthermia or hypothermia with a clear source of infection; and clinical sign of septic shock). The presence of fever (body temperature >38°C), a confirmed or suspected infection (e.g., chorioamnionitis, septic abortion, endometritis, and pneumonia), and at least one of the followings: heart rate >90, respiratory rate >20, leukopenia (white blood cells <4000), and leukocytosis (white blood cells >12 000)
- Severe anemia: (Hb level <7 g/dl).
Statistical analysis was performed using SPSS software, version 20.0 (SPSS Inc, Chicago, IL, USA). Chi-square test was performed for categorical variables and Mann–Whitney U test was conducted to find out the difference between two groups. P = ≤ 0.05 was considered as statistically significant.
A total of 221 (66.6%) of the study participants were in the age group of 20–29 years followed by 85 (25.6%) and 26 (6.8%) in the age group <20 years and ≥30 years, respectively. 280 (84.3%) of the study participants belonged to Hindu religion and rest were Muslims. About half (51.8%) of the participants were below poverty line (BPL) (those having BPL card). 127 (38.3%) of them were educated up to primary level only followed by 36.4% and 25.3% up to Class X and >Class X, respectively. Approximately 50% of the participants were primigravida, whereas 43.4% and 3.6% were multigravida and grand multigravida, respectively. Although more than 90% of the study participants were registered for Antenatal Check-up (ANC), only three-fifth of them had ≥4 ANCs. About 73.3% of the registered participants consumed Iron and Folic Acid (IFA) supplements. The frequency of near-miss was 126 (38%) though no maternal deaths were reported during the study.
Maternal near-miss ratio (MNMR) was 379.51/1000 live births, and maternal mortality index was 0%. Hypertensive disorder of pregnancy constituted three-fifth of the NMEs followed by anemia (22.7%), postpartum hemorrhage (PPH) (8.9%), infection (6.3%), and dystocia (2.7%). Hypertensive disorders of pregnancy as the main cause of near-miss events were also found in various other studies. However, these findings differ from many studies in which hemorrhage was ranked first  hypertensive disorder of pregnancy was complicated with anemia, PPH, and infection in 7.1%, 2.3%, and 1.5% of near-miss cases, respectively. Anemia was complicated with infection in 1.5% of the near-miss cases, while PPH was complicated with infection in 0.7% of cases. Higher age at conception, BPL status, rural residence, high parity, high gravida, and term deliveries adversely influenced pregnancy and significantly (P < 0.05) favored the occurrence of NMEs. ANC registration and IFA consumption significantly protected against NMEs [Table 1]. While there was no significant “Third Delay,” first and second delays were significantly higher among mothers who experienced NMEs [Table 2].
|Table 1: Clinico-social characteristics of the study participants (n=332)|
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|Table 2: Median time of obstetric delays among study participants (n=332)|
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In our study, the frequency of NMEs was 38.0%. MNMR was 379.51/1000 live births. This was much higher as compared to other studies conducted where the prevalence of near-miss cases was 5.3%. High frequency of near-miss cases may be because of the selective referral of high-risk pregnancies to this referral unit. It might also be due to the older disease-specific near-miss criteria used in this study; although in the current scenario, the WHO 2011 near-miss guideline  are more precise and practical tool. In our study, hypertensive disorders of pregnancy were the most common (59.3%) NME while anemia, PPH, infection, and dystocia were responsible for 22.7%, 8.9%, 6.2%, and 2.7% near-miss cases, respectively. Higher age group significantly and adversely influenced pregnancy as 88.5% of the study population from age group ≥30 years experienced NMEs. Increasing maternal age and its adverse impact on pregnancy were also found in various other studies. NMEs were significantly higher among study participants who were BPL and resided in a rural area as 46.5% and 40.5% of the study participants belonging to BPL and rural residence, respectively, experienced NMEs. Similar findings were reported by Montgomery et al.
Although statistically not significant in our study, education of the pregnant women was inversely proportion to the near-miss events as only 32.1% of the mothers who received education more than Class X experienced near-miss complications. Increasing gravida and parity adversely influenced the course of pregnancy as 83.3% of gravida ≥5 and 64.3% of parity 3–4 experienced near-miss events. In our study, about 4/5th of NMEs were term deliveries and only about one-fifth of the NMEs were preterm deliveries. A similar association of higher NMEs with term deliveries were also reported from other studies., ANC registration significantly protected against NMEs as 66.7% of unregistered study participants and only 34.5% of the booked cases experienced near-miss events. Mothers who consumed IFA tablets experienced less NMEs, i.e., 27.2% as compared to 54.4% of study participants who did not consume it and were thus deprived of antenatal care. A study population who had ≥4 antenatal care (ANC) visits experienced more NMEs, i.e., 39.2% followed by 32.2% in those who had <4 ANC visits. This may be due to the more vigilantism during ANC visits which resulted in early detection of high-risk pregnancies and their selective referral to secondary referral unit, or it may be by chance association as the association is statistically not significant [Table 1]. However, other studies reported the inverse association of ANC with adverse pregnancy outcome.
As government mandate referral transport, vehicle should reach the patient within 30 min of receiving call and health-care facility in next 30 min. In our study, first and second delays were significantly associated with NMEs [Table 2]. Although in our study, mothers took slightly more time in deciding to seek help, the time (30 min) taken in second delay signifies robust referral system. Robust referral system and insignificant third delay might have contributed in saving lives of the mother as reflected by 0% mortality index in this study.
Study limitations include older near-miss criteria, shorter study duration, inclusion of only postnatal mothers, and lack of follow-up. The use of the WHO 2011 near-miss guidelines, inclusion of all obstetric admission and longer duration study might have reflected true picture of the NMEs burden.
Near-miss cases review can help in identifying the pattern of SMOs, strengths, and weakness of healthcare delivery system in terms of referral and clinical interventions and the possible ways to improve it. Hypertensive disorder of pregnancy, anemia, and PPH is the leading causes of NMEs. Early identification of risk factors for these diseases and prompt initiation of treatment plays a critical role in the management of NMEs.
The authors would like to thank Indian Council of Medical Research (ICMR) for selecting this research proposal and accepting final report under “Short Term Studentship 2016 (ICMR-STS 2016)” program and giving stipend to carry out this project.
Financial support and sponsorship
This study was supported by INR - 10,000/- Stipend from Indian Council of Medical Research.
Conflicts of interest
There are no conflicts of interest.
| References|| |
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.
Say L, Souza JP, Pattinson RC; WHO working group on Maternal Mortality and Morbidity classifications. Maternal near miss – Towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009;23:287-96.
Filippi V, Ronsmans C, Gohou V, Goufodji S, Lardi M, Sahel A, et al
. Maternity wards or emergency obstetric rooms? Incidence of near-miss events in African hospitals. Acta Obstet Gynecol Scand 2005;84:11-6.
Chhabra P. Maternal near miss: An indicator for maternal health and maternal care. Indian J Community Med 2014;39:132-7.
] [Full text]
Kalra P, Kachhwaha CP. Obstetric near miss morbidity and maternal mortality in a Tertiary Care Centre in Western Rajasthan. Indian J Public Health 2014;58:199-201.
] [Full text]
Mustafa R, Hashmi H. Near-miss obstetrical events and maternal deaths. J Coll Physicians Surg Pak 2009;19:781-5.
Montgomery AL, Ram U, Kumar R, Jha P; Million Death Study Collaborators. Maternal mortality in India: Causes and healthcare service use based on a nationally representative survey. PLoS One 2014;9:e83331.
Oladapo OT, Sule-Odu AO, Olatunji AO, Daniel OJ. “Near-miss” obstetric events and maternal deaths in Sagamu, Nigeria: A retrospective study. Reprod Health 2005;2:9.
Park K. Park's Textbook of Preventive and Social Medicine. 24th
ed. Jabalpur: M/s Banarasi Das Bhanot; 2017. p. 487.
[Table 1], [Table 2]