Measuring maternal near-miss in a middle-income country: assessing the use of WHO and sub-Saharan Africa maternal near-miss criteria in Namibia

Steffie Heemelaar,Leonard Kabongo,Taati Ithindi,Christian Luboya,Fidelis Munetsi,Ann-Kathrin Bauer,Amelie Dammann,Anna Drewes,Jelle Stekelenburg,Thomas Van Den Akker,Shonag Mackenzie

doi:10.1080/16549716.2019.1646036

Abstract

ABSTRACTBackground: Namibia, a middle-income country in sub-Saharan Africa (SSA), plans to use the Maternal Near Miss (MNM) approach. Adaptations of the World Health Organization (WHO) MNM defining criteria (‘WHO MNM criteria’) were previously proposed for low-income settings in sub-Saharan Africa (‘SSA MNM criteria’), but whether these adaptations are required in middle-income settings is unknown.Objective: To establish MNM criteria suitable for use in Namibia, a middle-income country in SSA.Methods: Cross-sectional study from 1 March 2018 to 31 May 2018 in four Namibian hospitals. Pregnant women or within 42 days of termination of pregnancy or birth, fulfilling at least one WHO or SSA MNM criterion were included. Records of women identified by either only WHO criteria or only SSA criteria were assessed in detail.Results: 194 Women fulfilled any MNM criterion. WHO criteria identified 61 MNM, the SSA criteria 184 MNM. Of women who only fulfilled any of the unique SSA MNM criteria, 18 fulfilled the criterion ‘eclampsia’, one ‘uterine rupture’ and five ‘laparotomy’. These women were assessed to be MNM. Thresholds for blood transfusion to define MNM due to haemorrhage were two units in the SSA and five in WHO set. Two or three units were given to 95 women for mild/moderate haemorrhage or chronic anaemia who did not fulfil any WHO criterion and were not considered MNM. Fourteen women who were assessed to be MNM from severe haemorrhage received four units.Conclusions: WHO MNM criteria may underestimate and SSA MNM criteria overestimate the prevalence of MNM in a middle-income country such as Namibia, where MNM criteria ‘in between’ may be more appropriate. Namibia opts to apply a modification of the WHO criteria, including eclampsia, uterine rupture, laparotomy and a lower threshold of four units of blood to define MNM. We recommend that other middle-income countries validate our criteria for their setting.

Highlights

Namibia, a middle-income country in sub-Saharan Africa (SSA), plans to use the Maternal Near Miss (MNM) approach
In the three-month study period, 194 women were identified to be MNM according to the World Health Organization (WHO) and/or SSA criteria
Four of these nine women were included for ‘severe pre-eclampsia with Intensive Care Unit (ICU) admission’, these women were not admitted to an ICU department

Summary

Introduction

A middle-income country in sub-Saharan Africa (SSA), plans to use the Maternal Near Miss (MNM) approach. Adaptations of the World Health Organization (WHO) MNM defining criteria (‘WHO MNM criteria’) were previously proposed for low-income settings in sub-Saharan Africa (‘SSA MNM criteria’), but whether these adaptations are required in middle-income settings is unknown. To further improve quality of maternity care, the World Health Organization (WHO) has promoted the Maternal Near-Miss (MNM) approach since 2004 [6]. Women with an MNM event often share the same characteristics and risk factors as women who died, such as underlying medical or pregnancy-related conditions and delays in reaching and obtaining adequate health care. Much can be learned with regard to the functioning of the health system, and failing of the system, by analysing MNM and maternal deaths. MNM occurs in larger numbers and may be less threatening for health-care workers to discuss since these can be regarded as great saves [7,8]

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Conclusion