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BRIEF RESEARCH ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 1  |  Page : 49-52  

Experiences and challenges during implementation of operational guidelines of Maternal Near Miss Review of the Government of India at tertiary hospitals in Maharashtra


1 MD Community Medicine, Scientist E, Department of Operational Research, ICMR-National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
2 Masters in Community Health, Scientist G and Head, Department of Operational and Clinical Research, ICMR-National Institute for Research in Reproductive Health, Indian Council of Medical Research, Mumbai, Maharashtra, India

Date of Submission21-Apr-2021
Date of Decision20-Oct-2021
Date of Acceptance15-Nov-2021
Date of Web Publication5-Apr-2022

Correspondence Address:
Ragini Nitin Kulkarni
Department of Operational Research, ICMR-National Institute for Research in Reproductive Health, Indian Council of Medical Research, JM Street, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1068_21

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   Abstract 


The Government of India released operational guidelines for Maternal Near Miss-Review (MNM-R) in December 2014 for implementation at all the tertiary hospitals in India. An implementation research study was conducted at two selected tertiary hospitals in Maharashtra to assess the feasibility of implementation of the MNM-R guidelines at these hospitals and document the experiences and challenges during this process. The study findings suggest that for implementation of MNMR guidelines at these tertiary hospitals, there is need of dedicated staff; revision of MNM facility based form and critical review of the criteria for identification of MNM cases. MNM meetings could not be conducted with Maternal Death Review Committee meetings as mentioned in the guidelines. More efforts are needed for follow-up of the implementation of the corrective measures recommended by the MNM Committee. The study findings indicate that it is feasible to implement the MNM-R guidelines at the tertiary hospitals, if the above points are considered at these hospitals.

Keywords: Guidelines, hospitals, India, Maternal Near Miss, tertiary


How to cite this article:
Kulkarni RN, Chauhan S, The Maternal Near Miss Working Group. Experiences and challenges during implementation of operational guidelines of Maternal Near Miss Review of the Government of India at tertiary hospitals in Maharashtra. Indian J Public Health 2022;66:49-52

How to cite this URL:
Kulkarni RN, Chauhan S, The Maternal Near Miss Working Group. Experiences and challenges during implementation of operational guidelines of Maternal Near Miss Review of the Government of India at tertiary hospitals in Maharashtra. Indian J Public Health [serial online] 2022 [cited 2022 May 24];66:49-52. Available from: https://www.ijph.in/text.asp?2022/66/1/49/342583

Maternal Near Miss Working Group: Dr. Juzar Fidvi, MD, Obstetrics and Gynecology, Ex. Prof. and Head, Department of Obstetrics and Gynecology, Government Medical College and Hospital, Nagpur, Maharashtra, India; Dr. Arun Nayak, MD, Obstetrics and Gynecology, Prof. and Head, Department of Obstetrics and Gynecology, Lokmanya Tilak Municipal General Hospital and Medical College, Sion, Mumbai, Maharashtra, India; Dr. Anil Humane, MD, Obstetrics and Gynecology, Associate Professor, Department of Obstetrics and Gynecology, Government Medical College and Hospital, Nagpur, Maharashtra, India; Dr. Rahul Mayekar, MD, Obstetrics and Gynecology, Associate Professor, Department of Obstetrics and Gynecology, Lokmanya Tilak Municipal General Hospital and Medical College, Sion, Mumbai, Maharashtra, India; Dr. Anushree Patil, MD, Obstetrics and Gynaecology, Scientist E, Department of Clinical Research, ICMR.National Institute for Research in Reproductive Health (NIRRH), Indian Council of Medical Research (ICMR), JM Street, Parel, Mumbai . 400 012, Maharashtra, India; Dr. Shahina Begum, Ph. D Biostatistics, Scientist E, Head, Department of Biostatistics, ICMR.National Institute for Research in Reproductive Health (NIRRH), Indian Council of Medical Research (ICMR), JM Street, Parel, Mumbai . 400 012, Maharashtra, India; Dr. Niranjan Mayadeo, Ex Prof. and Head, MD, Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Lokmanya Tilak Municipal General Hospital and Medical College Sion Mumbai, India




The maternal mortality ratio (MMR) for India is declining over the last decade. The current MMR for India is 113/1 lakh live births.[1] The Government of India (GOI) initiated Maternal Death Review (MDR) to identify the gaps in implementation of maternal health programs and take corrective actions based on it. However, if we have to reduce the MMR further, the number of maternal deaths per facility is not sufficient to understand the causes and implement interventions accordingly. In addition, the disadvantage in reviewing maternal deaths is that the woman is not available to narrate her experiences and the service providers consider it as a “blame game” and fear punitive actions against them. Hence, for the last two decades, there has been interest internationally and nationally to shift the focus on Maternal Near Miss (MNM).

MNM is defined as “A woman who survives life-threatening conditions during pregnancy, abortion, and childbirth or within 42 days of pregnancy termination, irrespective of receiving emergency medical/surgical interventions.[2] There are several advantages of MNM-R as compared to MDR. A number of MNM events are more as compared to maternal deaths; they provide useful information on the pathways that lead to mortality; the review is less threatening for the service providers as woman is survived and she is available to describe the chain of events which helps to know the positive factors which saved her life. It provides useful information about the strengths and deficiencies in the health-care system indicating the quality of maternal health-care services. The review identifies gaps based on the three-delay model and provides recommendations for implementation of corrective actions at various levels. The operational guidelines of GOI were released in December 2014. As per these guidelines, MNM-R will be implemented in selected well-performing medical colleges or tertiary hospitals initially, and then can be extended to district hospitals. The current scenario is that the operational guidelines of MNM-R are not implemented at all the tertiary hospitals in India.

An ICMR-funded study on MNM review and corrective measures was undertaken by ICMR-NIRRH (coordinating center) at two selected tertiary hospitals in Maharashtra from 2018 to 2020. The present study is part of this larger study, which was conducted with an objective to test the feasibility of implementation of the guidelines at selected tertiary hospitals in Maharashtra and document the experiences and challenges during this process.

Approval was obtained from ethics committees of coordinating center and both the selected tertiary hospitals. One scientist B-medical and one data entry operator were recruited at the coordinating center, and one research assistant (RA) for data collection was recruited at each hospital.

The staff at the selected tertiary hospitals from departments of gynecology and obstetrics, medicine, surgery, and anesthesia was sensitized and trained for identifying MNM cases as per the criteria given in GOI guidelines. The project staff at both the hospitals was also trained for filling up of the forms and identification of the MNM cases at these hospitals.

The trained staff at both the hospitals (scientist B and RA with guidance from the investigators at both these hospitals) identified MNM cases in the hospital. They visited all the wards, intensive care unit, and other departments to ensure that no cases of MNM were missed. After identification of the case, the facility-based MNM form for each case was filled as given in the operational guidelines of GOI. The woman was interviewed on the previous day of discharge when she was stable. Written informed consent was taken from the woman as per protocol before interviewing her. The filled forms were checked by the co-investigator from the tertiary hospital and investigators at the coordinating center. Data entry and analysis were done in SPSS software version 19. Data collection period was from February 2019 to January 2020.

The guidelines were implemented successfully at the two tertiary hospitals. During the study, we experienced that it was not possible by the MDR Committee to review MNM cases at both the hospitals; hence MNM Review Committee was formed in January 2019 involving experts from all facets with multidisciplinary approach at both the centers. Expert committee comprised three external experts and five internal experts. Head of department, obstetrics and gynecology, was appointed as member secretary. Internal experts were included from medicine, surgery, anesthesia, community medicine, and a layperson. The three external experts selected in both the hospitals were obstetricians and gynecologists (involved as chairpersons), a public health specialist, and one social scientist. MNM meetings were conducted every month from March 2019 to February 2020. In each meeting, all the MNM cases were discussed in detail and committee suggested recommendations for implementation of corrective measures based on the gaps identified as per the three-delay model. Implementation of corrective measures was done at each hospital as per the recommendations of the MNM Committee. Follow-up of recommendations (i.e., implementation of corrective measures) was discussed in the consecutive MNM meetings conducted every month [Table 1].
Table 1: Recommendations and corrective measures taken at tertiary hospitals

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Regarding staff responsible for implementation of MNM guidelines, the role of incharge of health facility, facility nodal officer, and duty medical officer has been mentioned. As per our experience, they could identify the MNM cases as per the criteria of GOI guidelines, however, the facility-based MNM form is too lengthy for them to fill it completely. Hence, they needed assistance from additional staff for this activity. A dedicated staff was needed at both the tertiary hospitals for this activity. The existing staff at the hospitals was not able to take this additional responsibility as per our experience.

The facility-based MNM form was revised to add more information such as occupation, age at marriage and first pregnancy, weight and height at the time of admission, ANC history such as number of TT injections taken, and no of iron and folic acid tablets taken and family income. This important information could help to understand the factors related to MNM and hence could be added in the facility-based MNM form.

The total number of cases identified at the two selected tertiary hospitals was 228 during the data collection period (2019–2020). This number identified as per the GOI guidelines in the present study at the two selected tertiary hospitals was quite less as compared to other studies conducted in India[3],[4],[5],[6],[7],[8],[9],[10] in which other criteria such as WHO,[3],[4],[5],[6],[7] modified Mantel's criteria,[8] Fillipi criteria,[9] and five scoring system[10] were used. The GOI guidelines mention that at least one among the three categories (symptoms/signs/investigations and interventions) or cardiorespiratory collapse should be present which is quite stringent. As per the WHO and other criteria, more MNM cases are identified as only single criteria (clinical, organ system dysfunction, or management) has to be met. Hence, there is a need to review the MNM criteria of GOI. For women referred from lower facilities, though referral slips were given, these were incomplete, thus making it difficult to identify all the reasons for referral.

As per the GOI guidelines, MNM meetings should be conducted with the MDR meetings. In the present study, MNM meetings were conducted separately at tertiary hospitals as the MDR Committee was already overworked to review maternal deaths. At tertiary hospitals, if the MDR Committee should review MNM cases as per GOI guidelines, it needs to be mentioned in the guidelines whether all cases of MNM can be reviewed in the monthly meeting or a selected sample of cases could be reviewed. Selected cases could be identified from each category of adverse events such as hemorrhage, pregnancy-induced hypertension, and sepsis, and the level of delay in these cases can be identified. This would facilitate to have a comprehensive discussion of factors of MNM and how they can be prevented in future based on the three-delay model.

Follow-up of the actions/corrective measures as per the recommendations made in the MNM review meetings at the selected hospitals was challenging. It needed frequent follow-up with the concerned authorities. It was difficult to take certain corrective actions and hence these were communicated to the Municipal Corporation of Greater Mumbai.

The findings of the study at the selected hospitals have been communicated to the Government of Maharashtra and Ministry of Health and Family Welfare, GOI.

Our study findings indicate that it is feasible to implement the MNM-R guidelines at the tertiary hospitals, if the points mentioned in the present study are considered. The experiences and challenges in the present study provide valuable inputs to GOI for scaling up of the implementation of guidelines at all the tertiary hospitals in India.

Acknowledgment

The authors are thankful to the Indian Council of Medical Research (ICMR) for providing funding support.

Financial support and sponsorship

Indian Council of Medical Research (ICMR).

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Government of India. Operational Guidelines for Maternal Near Miss Review. Ministry of Health and Family Welfare; December 2014. Available from: http://www.nrhmorissa.gov.in/writereaddata/Upload/Documents/Maternal_Near_Miss_Operational_Guidelines.pdf. [ZLast accessed 2021 Mar 12].  Back to cited text no. 1
    
2.
Venkatesh S, Chinmayi, Ramkumar V, Sheela CN, Thomas A. Implementation of WHO near-miss approach for maternal health at a tertiary care hospital: An audit. J Obstet Gynaecol India 2016;66:259-62.  Back to cited text no. 2
    
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Abha S, Chandrashekhar S, Sonal D. Maternal near miss: A valuable contribution in maternal care. J Obstet Gynaecol India 2016;66:217-22.  Back to cited text no. 3
    
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Patankar A, Uikey P, Rawlani N. Severe acute maternal morbidity (near miss) in a tertiary care center in Maharashtra: A prospective study. International Journal of Scientific Study 2016;4:7.  Back to cited text no. 4
    
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Kulkarni R, Chauhan S, Daver R, Nandanwar Y, Patil A, Bhosale A. Prospective observational study of near-miss obstetric events at two tertiary hospitals in Mumbai, Maharashtra, India. Int J Gynaecol Obstet 2016;132:170-3.  Back to cited text no. 5
    
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Reena RP, Radha KR. Factors associated with maternal near miss: A study from Kerala. Indian J Public Health 2018;62:58-60.  Back to cited text no. 6
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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. 7
    
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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.  Back to cited text no. 8
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Kamal S, Roy P, Singh S, Minz J. A study of maternal near miss cases at tertiary medical college of Jharkhand, India. Int J Reprod Contracept Obstet Gynecol 2017;6:2375-80.  Back to cited text no. 9
    
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Chaudhuri S, Nath S. Life-threatening complications in pregnancy in a teaching hospital in Kolkata, India. J Obstet Gynaecol India 2019;69:115-22.  Back to cited text no. 10
    



 
 
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