Abstract
AimTo determine the frequency of near-miss (severe acute maternal morbidity) and the nature of near-miss events, and comparatively analysed near-miss morbidities and maternal deaths among pregnant women managed over a 3-year period in a Nigerian tertiary centre.MethodsRetrospective facility-based review of cases of near-miss and maternal death which occurred between 1 January 2002 and 31 December 2004. Near-miss case definition was based on validated disease-specific criteria, comprising of five diagnostic categories: haemorrhage, hypertensive disorders in pregnancy, dystocia, infection and anaemia. The near-miss morbidities were compared with maternal deaths with respect to demographic features and disease profiles. Mortality indices were determined for various disease processes to appreciate the standard of care provided for life-threatening obstetric conditions. The maternal death to near-miss ratios for the three years were compared to assess the trend in the quality of obstetric care.ResultsThere were 1501 deliveries, 211 near-miss cases and 44 maternal deaths. The total near-miss events were 242 with a decreasing trend from 2002 to 2004. Demographic features of cases of near-miss and maternal death were comparable. Besides infectious morbidity, the categories of complications responsible for near-misses and maternal deaths followed the same order of decreasing frequency. Hypertensive disorders in pregnancy and haemorrhage were responsible for 61.1% of near-miss cases and 50.0% of maternal deaths. More women died after developing severe morbidity due to uterine rupture and infection, with mortality indices of 37.5% and 28.6%, respectively. Early pregnancy complications and antepartum haemorrhage had the lowest mortality indices. Majority of the cases of near-miss (82.5%) and maternal death (88.6%) were unbooked for antenatal care and delivery in this hospital. Maternal mortality ratio for the period was 2931.4 per 100,000 deliveries. The overall maternal death to near-miss ratio was 1: 4.8 and this remained relatively constant over the 3-year period.ConclusionThe quality of care received by critically ill obstetric patients in this centre is suboptimal with no evident changes between 2002 and 2004. Reduction of the present maternal mortality ratio may best be achieved by developing evidence-based protocols and improving the resources for managing severe morbidities due to hypertension and haemorrhage especially in critically ill unbooked patients. Tertiary care hospitals in Nigeria could also benefit from evaluation of their standard of obstetric care by including near-miss investigations in their maternal death enquiries.
Highlights
For many years, evaluation of maternal healthcare services aimed at improving the quality of obstetric care has traditionally relied on enquiries into maternal deaths
Hospital Setting The study was conducted at the obstetric unit of Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, a publicly funded tertiary care institution, which serves as the major referral centre for other public and private hospitals within Ogun State, in southwest Nigeria
Evaluation of obstetric performance in many Nigerian hospitals is limited to investigations of maternal deaths, an indicator that is vulnerable to many flaws in this environment
Summary
Evaluation of maternal healthcare services aimed at improving the quality of obstetric care has traditionally relied on enquiries into maternal deaths. Review of cases at the very severe end of the maternal morbidity spectrum, described as "near-miss" (those who nearly died), has been found to be a useful complement to investigation of maternal mortality [1,2]. Unlike in the developed countries, there is limited experience with the use of near-miss reviews as a tool for monitoring the quality of maternity services in developing countries. This is probably as a result of the persistently high levels of maternal mortality that has overshadowed other severe obstetric complications, from which lessons could be learned. Because nearmisses occur much more frequently than maternal deaths, more comprehensive and statistically reliable quantitative analyses that are of value to clinical audit can be rapidly conducted [1,2,3,4]]
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