Indian Journal of Public Health

: 2018  |  Volume : 62  |  Issue : 1  |  Page : 58--60

Factors associated with maternal near miss: A study from Kerala

RP Reena1, KR Radha2,  
1 Associate Professor, Department of Obstetrics and Gynaecology, Government Medical College, Thrissur, Kerala, India
2 Additional Professor, Department of Obstetrics and Gynaecology, Government Medical College, Thrissur, Kerala, India

Correspondence Address:
Dr. R P Reena
Suryachithra, Chettupuzha, Thrissur - 680 012, Kerala


Severe life-threatening situations leading to a “near-miss” event may arise unexpectedly in pregnancy. Delay in seeking help, delayed access to care, and poor quality of emergency obstetric services can lead to undesirable outcomes. Women meeting the WHO “near-miss” criteria were assessed using a cross-sectional study design. These women were interviewed to evaluate the circumstances leading to a near-miss event. Reasons for delays in getting proper care were studied using the “3 delays’ model.” Thirty-two women met the criteria for “near miss” during the 15-month study period, with a maternal near-miss incidence ratio of 9.27/1000 live births. One or more delays were identified in 21 (65.6%) near-miss cases. Delayed access to care was the most important factor for delay. A review of near-miss cases can be used to improve and optimize the existing obstetric services.

How to cite this article:
Reena R P, Radha K R. Factors associated with maternal near miss: A study from Kerala.Indian J Public Health 2018;62:58-60

How to cite this URL:
Reena R P, Radha K R. Factors associated with maternal near miss: A study from Kerala. Indian J Public Health [serial online] 2018 [cited 2020 Oct 23 ];62:58-60
Available from:

Full Text

Maternal mortality remains unacceptably high in India, with about 120 maternal deaths in a day.[1] Apart from maternal deaths, several women survive severe life-threatening events during pregnancy and child birth, referred to as “maternal near-miss (MNM).”[2] Timely access to optimal emergency obstetric services can often save lives. However, delays do happen and often remain unnoticed.[3] Knowledge about these delays will help to improve access to care.

The underlying pathology and course of events that lead to a “near miss” or a maternal death are often similar.[4] We wanted to evaluate near-miss cases to find out the frequency, nature, and time of occurrence of “delays” in obtaining emergency obstetric care and to assess the maternal and perinatal outcomes.

We screened all women who got admitted with pregnancy-related complications at Government Medical College, Thrissur, Kerala, during the 15-month study period from August 1, 2011, to October 31, 2012, to identify cases of “near miss.” We used a census method of data collection and recruited all consenting individuals who met the WHO criteria for near miss.[4] These women and their family members were interviewed in detail by an experienced obstetrician after getting informed consent. We used a structured pro forma to collect sociodemographic and clinical details. We evaluated all near-miss cases for delays in getting obstetric care. The obstetrician specifically looked for delays in each of the three points described in the “3 delays’ model” and the circumstances surrounding access to emergency obstetric services.[5] The “3 delays” according to this model include: Delay-1: decision to seek care, Delay-2: access to adequate health care, and Delay-3: receipt of adequate and appropriate treatment. We gathered information regarding the evolution of symptoms and chronology of events leading to admission to our hospital and the subsequent course in our hospital. This allowed us to see if there were delays and consider various reasons for delay in each of the stages.

The maternal and perinatal outcomes were assessed. A descriptive analysis was done using means and percentages.

There were 3581 deliveries, including 3451 live births and 5 maternal deaths, during the 15-month study period. Thirty-two women met the WHO criteria for MNM. MNM incidence ratio (MNM IR) was 9.27/1000 live births. Twelve (37.5%) were primigravid women and 84% were in the third trimester. Twenty-seven (84%) women were from families that were below poverty line (BPL) as per the ration card issued by the state government. Two of them had no antenatal care at all, while three others were not regular with antenatal checkup. Twenty-seven (84%) women were referred to our center from elsewhere. Nine of them were provided free transport from the peripheral health-care facility and five among them were accompanied by paramedical personnel. Most of them (66.7%) had to make out-of-pocket payments for transport.

Most women (87.5%) were aged between 21 and 34 years. Nearly 90.6% of the women were educated up to higher secondary level or more. Thirteen women (40.6%) had severe preeclampsia, seven (21.8%) had abruptio placenta, and four (12.5%) had severe sepsis as the underlying obstetric problem. Almost half of the women (43.7%) had a scarred uterus from previous cesarean section or myomectomy. Multisystem involvement was present in most of the women. The hematological/coagulation system dysfunction was the most common (71.8%) followed by respiratory (15.6%), hepatic (12.5%), and renal dysfunction (3%). There were seven (21.9%) cases of obstetric hysterectomy.

We identified one or more delays in 21 (65.6%) of the near-miss cases. Delay in decision to seek care (delay 1) occurred in six (18.8%) women. Educational backwardness, ignorance of pregnancy itself, lack of regular antenatal care, and failure to give importance to warning signals were judged to be contributing to this. Delay in accessing adequate care (delay 2) was identified in 13 (40.6%) women. This included delay in recognition of potentially life-threatening conditions that occurred even after reaching health-care facilities. These centers did not have specialist workforce, infrastructure, and blood transfusion services. There was perceptible delay in making the decision to refer cases to a higher center. There was delay in receiving adequate and appropriate treatment (delay 3) in seven (21.8%) women. Delayed recognition of the emergence of a life-threatening condition or unwarranted persistence with conservative management had contributed to this.

The details of the type of delay leading to near miss are mentioned in [Table 1].{Table 1}

Major surgical interventions including cesarean section, obstetric hysterectomy, and laparotomy were required in 24 women (75%). Twenty-eight (87.5%) women needed more than a single unit of blood. There were two ruptured ectopic pregnancies and one abortion among the 32 near-miss cases. Twenty-two (75.9%) among the 29 women who delivered after the period of viability required surgical intervention. Twenty (68.9%) mothers, among the 29 who delivered including one twin pregnancy, did so prematurely (<37 completed weeks). There were 13 (43.3%) perinatal deaths in this group of 30 babies, which included eight fresh stillborns and five neonatal deaths. Of the 22 babies born alive, 13 (59%) needed care in the Neonatal Intensive Care Unit, with five of them not surviving beyond the 1st week. Twenty-seven (84.4%) women required hospitalization for a week or more.

Five maternal deaths occurred during the study period (maternal mortality ratio of 144.9/100,000 live births). The causes included placental abruption, disseminated intravascular coagulation, suspected pulmonary embolism, and cardiac arrest following manual removal of placenta. All these women, aged between 19 and 30 years, were referred to our center in a very morbid state. They were too sick to be interviewed and thus were not recruited.

The MNM IR was 9.27/1000 live births in our center. Previous reports of near-miss rates from India ranged from 3.98 to 17.38/1000 live births.[6] A vast majority of near-miss cases (84%) in our study came from families living BPL. This observation highlights the importance of social determinants in obstetric care. The modifiable risk factors for near miss include social and financial backwardness, inadequate antenatal care, mode of delivery, availability of blood products, and quality of care. The nonmodifiable risk factors related to near-miss events include age, parity, gestational age at delivery, pregnancy with a scarred uterus, and a preexisting comorbidity.

We could identify delays in almost two-thirds (65.6%) of the near-miss cases. The delays were more common at the point of access to care (delay 2) and in receiving adequate treatment (delay 3). Obstetric emergencies occur suddenly and unexpectedly. A well-organized referral system should therefore be operational. Efficient functioning of this system may often be the deciding factor between survival and death of the woman.

Social and educational backwardness contributes to the delay in seeking help. Lack of a family authority figure, financial resources, or transport facility could affect decision-making and cause delays in the first two points.[7] The first delay was identified in six (18.8%) of our near-miss cases. The second delay of accessing health care was identified in 13 (40.6%) women. Health-care personnel should be sensitized to recognize an obstetric emergency and refer promptly when needed. Delays in peripheral maternity wards, travel and multiple referrals from one facility to another can lead to poorer maternal and perinatal outcomes.[7]

The third delay is most often secondary to poor quality of emergency obstetric services. The third delay occurred in seven (21.8%) women. Many health facilities in the developing world are still chronically underresourced and unable to cope effectively with serious obstetric complications. We need to ensure improved access as well as optimal obstetric services to avoid these catastrophes. A near-miss surveillance system is crucial to improve the effectiveness of obstetric services. Our study was an attempt to collect such information.

This was a preliminary study. Our sample size was small, especially to estimate the frequency of delay in each of the three stages. As this was a hospital-based study, all mothers were not followed up through their postpartum period after discharge from hospital. Audit of maternal deaths is not easy while that of near-miss cases is less threatening to care providers.

One or more delays in seeking or receiving adequate obstetric care were identified in about two-thirds of women with near miss. A regular audit of near miss would facilitate collection of information regarding these delays. Knowledge about the circumstances which aided survival and recovery may also help. Promoting social development and equity, ensuring preparedness, appropriate and timely interventions, and optimizing and scaling up of existing obstetric services is the way forward.


We acknowledge the support from the Institutional Research Committee of Government Medical College, Thrissur.

Financial support and sponsorship

We have received financial support from the State Board of Medical Research, Government of Kerala, for the study.

Conflicts of interest

There are no conflicts of interest.


1Ministry of Statistics and Programme Implementation. Millennium Development Goals India Country Report 2015. New Delhi: Government of India; 2015.
2Chhabra P. Maternal near miss: An indicator for maternal health and maternal care. Indian J Community Med 2014;39:132-7.
3Pacagnella RC, Cecatti JG, Parpinelli MA, Sousa MH, Haddad SM, Costa ML, et al. Delays in receiving obstetric care and poor maternal outcomes: Results from a national multicentre cross-sectional study. BMC Pregnancy Childbirth 2014;14:159.
4World Health Organization. Evaluating the Quality of Care for Severe Pregnancy Complications: The WHO Near-miss Approach for Maternal Health. Geneva: World Health Organization; 2011.
5Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Soc Sci Med 1994;38:1091-110.
6Sangeeta G, Leena W, Taru G, Sushma K, Nupur G, Amrita P, et al. Evaluation of severe maternal outcomes to assess quality of maternal health care at a tertiary center. J Obstet Gynaecol India 2015;65:23-7.
7Assarag B, Dujardin B, Delamou A, Meski FZ, De Brouwere V. Determinants of maternal near-miss in Morocco: Too late, too far, too sloppy? PLoS One 2015;10:e0116675.