National Survey and Review of Maternal Near Miss in Oman

Abstract

Background: Review of the care provided to women who nearly died but survived complications occurring during pregnancy, childbirth, or the postnatal period, known as maternal near miss (MNM). It is one of the recommended approaches to improve the quality of care (QoC) especially in settings with few maternal deaths. Oman has a well-established maternal deaths surveillance system, but there has not been a significant decline in the maternal mortality ratio, and the majority of maternal deaths are considered preventable. In addition, the burden of severe maternal morbidity is unknown. This study explores the potential of MNM review to improve quality of care in Oman. The objectives are to determine the incidence, underlying causes of, and factors associated with MNM in Oman, to assess QoC and make recommendations for its improvement. Method: Existing WHO guidelines and criteria were reviewed, and a systematic review of the literature was conducted to establish criteria for the identification of MNM in Oman. A national survey with in-depth review of MNM cases was implemented. MNM cases were identified from 23 hospitals across all 11 governorates, capturing more than 90% of total deliveries in the country. Between October 2016 and September 2017 all cases fulfilling the MNM criteria were reviewed at the hospital and regional levels by trained reviewers. 50% of cases were reviewed additionally by the National Maternal Mortality Review Committee and a panel of international experts. The level of agreement between various levels of reviewers was determined using Cohen’s kappa coefficient. Results: During the one-year period of data collection a total of 25 maternal deaths and 312 MNM cases were reported, given an MNM incidence of 4.0 per 1000 women giving birth (deliveries), and a ratio of MNM: maternal mortality of 10.3:1. Hypertensive disorders (44%), obstetric haemorrhage (23%), and non-obstetric complications (18%) were the most common underlying causes of MNM. Previous caesarean sections (20.0%), medical disorders (20.0%), and grand-multiparity (20.0%) were the main contributory conditions to MNM. Overall there was good care given (43.6%). In up to 36.5% of cases improved care could have made a difference to the outcome. The most commonly identified associated factors were related to the healthcare team providing care (50.0%), in particular inappropriate management (28.2%) and failure to initially recognise the seriousness of the condition (25.6%). Factors related to the women themselves included non-adherence to prescribed treatment, delay in seeking care was associated with around one third of MNM events. Factors related to organisation of care were recorded in about a quarter of all MNM events with non-availability or outdated policy and guidelines identified as the most common identified factors. Conclusion: The study used a participatory process to develop criteria for identify MNM and a system for reviewing these. It demonstrated it is feasible to complement maternal deaths review with MNM review. The most common…