Maternal near-miss audit in the Metro West maternity service, Cape Town, South Africa: A retrospective observational study

Abstract

Background. A maternal near-miss is defined as a life-threatening pregnancy-related complication where the woman survives. The World Health Organization (WHO) has produced a tool for identifying near-misses according to criteria that include the occurrence of a severe maternal complication together with organ dysfunction and/or specified critical interventions. Maternal deaths have been audited in the public sector Metro West maternity service in Cape Town, South Africa, for many years, but there has been no monitoring of near-misses. Objectives. To measure the near-miss ratio (NMR), maternal mortality ratio (MMR) and mortality index (MI), and to investigate the near-miss cases. Methods. A retrospective observational study conducted during 6 months in 2014 identified and analysed all near-miss cases and maternal deaths in Metro West, using the WHO criteria. Results. From a total of 19 222 live births, 112 near-misses and 13 maternal deaths were identified. The MMR was 67.6 per 100 000 live births and the NMR 5.83 per 1 000 live births. The maternal near-miss/maternal death ratio was 8.6:1 and the MI 10.4%. The major causes of near-miss were hypertension ( n =50, 44.6%), haemorrhage ( n =38, 33.9%) and puerperal sepsis ( n =13, 11.6%). The first two conditions both had very low MIs (1.9% and 0%, respectively), whereas the figure for puerperal sepsis was 18.9%. Less common near-miss causes were medical/surgical conditions ( n =7, 6.3%), non-pregnancy-related infections ( n =2, 1.8%) and acute collapse ( n =2, 1.8%), with higher MIs (33.3%, 66.7% and 33.3%, respectively). Critical interventions included massive blood transfusion (34.8%), ventilation (40.2%) and hysterectomy (30.4%). Considering health system factors, 63 near-misses (56.3%) initially occurred at a primary care facility, and the patients were all referred to the tertiary hospital; 38 (33.9%) occurred at a secondary hospital, and 11 (9.8%) at the tertiary hospital. Analysis of avoidable factors identified lack of antenatal clinic attendance (11.6%), inter-facility transport problems (6.3%) and health provider-related factors (25.9% at the primary level of care, 38.2% at secondary level and 7.1% at tertiary level). Conclusions. The NMR and MMR for Metro West were lower than in other developing countries, but higher than in high-income countries. The MI was low for direct obstetric conditions (hypertension, haemorrhage and puerperal sepsis), reflecting good quality of care and referral mechanisms for these conditions. The MIs for non-pregnancy-related infections, medical/surgical conditions and acute collapse were higher, suggesting that medical problems need more focused attention.