Indian Journal of Public Health

: 2014  |  Volume : 58  |  Issue : 3  |  Page : 199--201

Obstetric near miss morbidity and maternal mortality in a Tertiary Care Centre in Western Rajasthan

Priyanka Kalra1, Chetan Prakash Kachhwaha2,  
1 Senior Resident, Department of Obstetrics and Gynaecology, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
2 Associate Professor, Department of Obstetrics and Gynaecology, Dr. S. N. Medical College, Jodhpur, Rajasthan, India

Correspondence Address:
Dr. Priyanka Kalra
Senior Resident, Department of Obstetrics and Gynaecology, Dr. S. N. Medical College, Jodhpur, Rajasthan


Obstetric near-miss (ONM) describes a situation of lethal complication during pregnancy, labor or puerperium in which the woman survives either because of medical care or just by chance. In a cross-sectional observational study, five factor scoring system was used to identify the near-miss cases from all the cases of severe obstetric morbidity. Assessment of the causes of maternal mortality and near-miss obstetric cases was done. The ONM rate in this study was 4.18/1000 live births. Totally 54 maternal deaths occurred during this period, resulting in a ratio of 202 maternal deaths per 100,000 live births. Hemorrhage, hypertension and sepsis were major causes of near-miss maternal morbidity and mortality, respectively in descending order.

How to cite this article:
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

How to cite this URL:
Kalra P, Kachhwaha CP. Obstetric near miss morbidity and maternal mortality in a Tertiary Care Centre in Western Rajasthan. Indian J Public Health [serial online] 2014 [cited 2021 Mar 3 ];58:199-201
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Full Text

Obstetric near-miss (ONM) or severe acute maternal morbidity is gaining interest internationally as a new indicator of the quality of obstetric care following maternal mortality statistics. [1] "Near-miss" describes a patient with an acute organ system dysfunction, which, if not treated appropriately, could result in death. [2] It has also been described as a situation of lethal complication during pregnancy, labor or puerperium in which the woman survives either because of medical care or just by chance. [3] The death to severe morbidity ratio reflects the standard of maternal care.

The maternal mortality ratio (MMR) of India was 254 (2004-2006), which was reduced to 200 (2010). [4] India is signatory to millennium declaration and is committed to achieving the target of millennium development goals by reducing MMR to 100. Known obstacles to reducing the MMR in developing countries, include lack of material and human resources, as well as difficulties in accessing services due to financial, geographical, and cultural limitations. 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. However, there is no definite denominator population in a hospital; the data for total number of deliveries and live births is available, which was used to calculate the maternal mortality and ONM ratios. International studies have reported ONM to maternal death ratios ranging from 5:1 [2] up to 11:1. [5] Worldwide, some studies have described it according to common obstetric disease states, e.g., hemorrhage, preeclampsia, [1] whereas others used either criteria related to the response to the disease (e.g., hysterectomy or admission to Intensive Care Unit [ICU]) or specific organ system dysfunction, that is specific criteria of dysfunction or failure of specific organ system. [6] Hence, this study was conducted to provide insight into the problem of maternal near-miss and mortality in Western Rajasthan, India.

This cross-sectional observational study was conducted in the Department of Obstetrics and Gynecology, of a Medical College Hospital of Western Rajasthan for a period of 18 months from May 2011 to October 2012. For identifying near-miss cases five-factor scoring system as described by Geller et al. was used. [7] The five-factor scoring system has the specificity of 93.9% and sensitivity 100%. It comprises of organ-system failure, ICU admission, transfusion >3 units of blood, extended intubation (>12 h), and surgical intervention (hysterectomy, relaparotomy). These factors are given the score of 5, 4, 3, 2, and 1 respectively. A five factor scoring system can theoretically have score from 0 to 15 (no clinical factor present to all clinical factors present).The cut off point for near-miss case is a score of 8 or greater. Patient characteristics such as age, parity, antenatal booking status and details of disease-specific condition and their management were recorded in a semi-structured proforma from case records. Statistical analysis was performed. The ONM incidence was calculated as the number of near-miss cases per 1000 live births in the hospital. MMR was calculated as the number of maternal deaths per 100,000 live births.

In the 18 months study period, there were 27,958 deliveries and 26,734 live births. Totally 112 patients were identified as ONMs as per the Geller's five point scoring system, while there were 54 maternal deaths. The ONM rate was 4.18/1000 live births. The demographic features of the patients have been given in [Table 1]. The mean age of the near-miss patients was 24 ± 3.11 years, while that of mortality group was 26 ± 2.44 years. Majority of the patients were unbooked in both near-miss and maternal deaths group. Most of the critical obstetric events occurred in postpartum period.{Table 1}

Total near-miss cases were 112 and 60.7% of the near-miss patients were critical on admission. 72 (64.2%) of the patients were referred from other health centres. MMR per 100,000 deliveries was 202. The maternal death to near-miss ratio was 1:2.07.

In the present study, near-miss morbidity identified nearly two times as many cases as maternal deaths, that is, the maternal deaths to near-miss ratio being 1:2.07. Studying these cases was an opportunity to review the wide spectrum of clinical conditions that threaten the life of a pregnant woman, and provided data to ascertain the causes and factors governing maternal morbidity and mortality. However, different studies across the world have shown a large variation in deaths: Near-miss ratio ranging from 1:19 (France) to 1:11 (London). [8],[9] Most of the variation in the ratio described was due to difference in diagnostic criteria and sample size. Our common reasons for those in being classified as maternal near-miss were comparable with Geller et al.'s study. [7]

According to WHO bulletin 2010, the study of secondary analysis of WHO global survey on Latin America described near-miss in 120 institutions and recorded MMR 15:1. [10] Souza et al. in a current demographic health survey reported ONM prevalence as 21.3/1000 live births in Brazil. [10] Compared with them, ONM rate of 0.4% in our study is low, while the maternal deaths to near-miss rate of 1:2.07 is very high indicating that there is a high rate of maternal mortality in the developing countries.

As far as near-miss obstetric morbidity was concerned the most common complication was hemorrhage accounting for 56% cases (28.5% was due to postpartum and remaining nearly 28% was due to antepartum hemorrhage). Second leading cause was hypertension in form of eclampsia and preeclampsia accounting for 20 (17.8%) of total near-miss cases. Other complications were infections (5.35%), ruptured uterus (8.92%), and medical complications (11.6%).

Similar nature of complications was also found in cases of obstetric mortality with hemorrhage accounting for 34 (62.9%) cases. Among them, 22 (40.7%) cases were of postpartum hemorrhage. However, second leading cause of obstetric mortality was infections (12.96%), followed by hypertension (11.1%). Rupture uterus and medical complications contributed 7.4% and 5.5%, respectively. Taly et al. from India reported hemorrhage (60%) and hypertensive disorders (34%) to be the leading initiating causes of near-miss, with sepsis being third in rank (4%). They also described maternal mortality to near-miss ratio of 1:6. [11] These findings were similar to those of the present study. According to a study from Kathmandu Teaching Hospital, hemorrhage accounted for 41.66% and hypertensive disorders for 21.77% cases, but near-miss prevalence rates were higher at 2.3%. [12]

As per the Geller's scoring system, ICU admission and surgical intervention were the commonest factors amongst the near-miss cases with frequencies being 84 and 68, respectively. Extended intubation and organ system failure were seen in nearly 20 patients. However, transfusion of >3 units of blood was needed in 66 patients.

Our center is one of the most crowded hospitals in India with more than 20,000 deliveries in a year. Besides the case load is ever increasing after the introduction of the maternal and child beneficiary scheme called "Janani Shishu Suraksha Karyakram" which provides for free of cost treatment and hospitalization. A lot depends on the commitment of the managers and staff of the institutions and on the health system to provide support for revising the events, implementing and evaluating the healing interventions, thereby ensuring full auditing process within the routine clinical activities.

The study was conducted in a tertiary care center, it did not represent the status in private sector. Hence, the observations in our study reflect the status of obstetric care in the tertiary care hospitals with the ever rising patient load. To a certain extent, it will help health care providers and policy makers to design strategies to improve maternal health services in India and to achieve millennium development goal.

The major causes of near-miss cases were similar to the causes of maternal mortality of India. Lessons can be learned from cases of near-miss, which can serve as a useful tool in reducing MMR. Need for development of an effective audit system for both near-miss obstetric morbidity and mortality is felt.


I would like to thank Dr. Sumitra Bora, Professor and Head, Department of Obstetrics and Gynecology, Dr. S. N. Medical College, Jodhpur, Rajasthan for providing their support for the study.


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