Maternal Near-miss Cases Research Articles

Facilitators and barriers to the effective implementation of the individual maternal near-miss case reviews in low/middle-income countries: a systematic review of qualitative studies

BackgroundThe maternal near-miss cases review (NMCR), a type of clinical audit, proved to be effective in improving quality of care and decreasing maternal mortality in low/middle-income countries (LMICs). However, challenges...

Effectiveness of the facility-based maternal near-miss case reviews in improving maternal and newborn quality of care in low-income and middle-income countries: a systematic review

ObjectivesThe maternal near-miss case review (NMCR) has been promoted by WHO as an approach to improve quality of care (QoC) at facility level. This systematic review synthesises evidence on the...

What is the quality of the maternal near-miss case reviews in WHO European Region? Cross-sectional study in Armenia, Georgia, Latvia, Republic of Moldova and Uzbekistan

ObjectivesThe maternal near-miss case review (NMCR) cycle is a type of clinical audit aiming at improving quality of maternal healthcare by discussing near-miss cases. In several countries this approach has...

Distant and proximate factors associated with maternal near-miss: a nested case-control study in selected public hospitals of Addis Ababa, Ethiopia

BackgroundEthiopia is one of the sub-Saharan Africa countries with the highest maternal mortality. Maternal near-misses are more common than deaths and statistically stronger for a comprehensive analysis of the determinants. The study aimed to identify the factors associated with maternal near-miss in selected public hospitals of Addis Ababa, Ethiopia.MethodsWe conducted a nested case-control study in five selected public hospitals of Addis Ababa, Ethiopia from May 1, 2015 to April 30, 2016. Participants were interviewed by well-trained data collectors using pre-tested questionnaire. Medical records were also reviewed to gather relevant information. World Health Organization criteria were used to identify maternal near-miss cases. A total of three controls matched for age and study area was selected for each maternal near-miss case. Bivariate and multivariable conditional logistic regressions were performed using Stata version 13.0.ResultsA total of 216 maternal near-miss cases and 648 controls were included in the study. The main factors associated with maternal near-miss were: history of chronic hypertension (AOR = 10.80,95% CI; 5.16–22.60), rural residency (AOR = 10.60,95% CI;4.59–24.46), history of stillbirth (AOR = 6.03,95% CI;2.09–17.41), no antenatal care attendance (AOR = 5.58,95% CI;1.94–16.07) and history of anemia (AOR = 5.26,95% CI;2.89–9.57).ConclusionsThere is a need for appropriate interventions in order to improve the identified factors. The factors can be modified through a better access to medical and maternity care, scaling up of antenatal care in rural areas, improve in infrastructure to fulfill referral chain from primary level to secondary and tertiary health care levels, and health education to pregnant women.

A maternal near-miss case of massive obstetric hemorrhage: Recent trends in management of hemostatic failure

Obstetric hemorrhage is a leading cause of maternal mortality and morbidity. Uterine atony is the major cause of postpartum hemorrhage (PPH) accounting for 79% of all cases besides genital trauma, placental causes and coagulation disorders. We present a case of massive obstetric hemorrhage secondary to uterine atony that was referred to our center in a state of hemorrhagic shock with severe metabolic acidosis, hypothermia and coagulopathy. Prompt activation of massive transfusion protocol, use of thromboelastography guided correction of coagulopathy and early hysterectomy to control hemorrhage played a vital role in successful patient management. Postoperative intensive management of ventilatory function, haemodynamics, kidney function and sepsis led to a favourable outcome. This case highlights the importance of multi-disciplinary team management involving anesthesiologist, emergency medical personnel, obstetrician, blood transfusion services and critical care team in optimizing the clinical condition of the critical patient.

Audit for quality of care and fate of maternal critical cases at Women's Health Hospital

Maternal deaths remain high, numbers at the facility level are relatively low. AimTo evaluate effect of management guidelines on occurrence of maternal near miss in Women's Health Hospital. DesignA cross-sectional study. SettingICU of Women's Health Hospital's at Assiut Main University Hospital and Al-fayoum University Hospital. SubjectsConvenient sample of 93 maternal near-miss cases including (Pregnancy or postpartum complications). Toolaudit the applied critical care for severe condition related to obstetric complications and consist of three parts: Patient's demographic data, Audit of critical care and “Maternal near-miss” Fate. Data collected during a period of 1/3/2015 to 30/8/2015 for management guidelines and maternal outcomes. ResultsA statistical significant differences between the medical management and occurrence of sever maternal complications such as (severe postpartum hemorrhage, severe pre-eclampsia, Sepsis or severe systemic infection, uterine hemorrhage, ruptured uterus) (P=0.000, P=0.031, P=0.036, P=0.052, P=0.012 respectively). ConclusionsThe maternal management guidelines was a successful tool in recording the gap between the current received management and standards management guidelines in ICU. Also they measure the effect of current management in ICU on maternal mortality and morbidity.

Severe maternal morbidity in Zanzibar's referral hospital: Measuring the impact of in-hospital care.

Objectiveto analyse the impact of in-hospital care on severe maternal morbidity using WHO’s near-miss approach in the low-resource, high mortality setting of Zanzibar’s referral hospital.SettingMnazi Mmoja Hospital, a tertiary care facility, in Zanzibar, Tanzania.MethodsWe identified all cases of morbidity and mortality in women admitted within 42 days after the end of pregnancy at Mnazi Mmoja Hospital in the period from April to October 2016. The severity of complications was classified using WHO’s near-miss approach definitions: potentially life-threatening condition (PLTC), maternal near-miss (MNM) or maternal death (MD). Quality of in-hospital care was assessed using the mortality index (MI) defined as ratio between mortality and severe maternal outcome (SMO) where SMO = MD + MNM, cause-specific case facility rates and comparison with predicted mortality based on the Maternal Severity Index model.Main outcomes5551 women were included. 569 (10.3%) had a potentially life-threatening condition and 65 (1.2%) a severe maternal outcome (SMO): 37 maternal near-miss cases and 28 maternal deaths. The mortality index was high at 0.43 and similar for women who developed a SMO within 12 hours of admission and women who developed a SMO after 12 hours. A standardized mortality ratio of 6.03 was found; six times higher than that expected in moderate maternal mortality settings given the same severity of cases. Obstetric haemorrhage was found to be the main cause of SMO. Ruptured uterus and admission to ICU had the highest case-fatality rates. Maternal death cases seemed to have received essential interventions less often.ConclusionsWHO’s near-miss approach can be used in this setting. The high mortality index observed shows that in-hospital care is not preventing progression of disease adequately once a severe complication occurs. Almost one in two women experiencing life-threatening complications will die. This is six times higher than in moderate mortality settings.

Validating the WHO maternal near miss tool: comparing high- and low-resource settings

BackgroundWHO proposed the WHO Maternal Near Miss (MNM) tool, classifying women according to several (potentially) life-threatening conditions, to monitor and improve quality of obstetric care. The objective of this study is to analyse merged data of one high- and two low-resource settings where this tool was applied and test whether the tool may be suitable for comparing severe maternal outcome (SMO) between these settings.MethodsUsing three cohort studies that included SMO cases, during two-year time frames in the Netherlands, Tanzania and Malawi we reassessed all SMO cases (as defined by the original studies) with the WHO MNM tool (five disease-, four intervention- and seven organ dysfunction-based criteria). Main outcome measures were prevalence of MNM criteria and case fatality rates (CFR).ResultsA total of 3172 women were studied; 2538 (80.0%) from the Netherlands, 248 (7.8%) from Tanzania and 386 (12.2%) from Malawi. Total SMO detection was 2767 (87.2%) for disease-based criteria, 2504 (78.9%) for intervention-based criteria and 1211 (38.2%) for organ dysfunction-based criteria. Including every woman who received ≥1 unit of blood in low-resource settings as life-threatening, as defined by organ dysfunction criteria, led to more equally distributed populations. In one third of all Dutch and Malawian maternal death cases, organ dysfunction criteria could not be identified from medical records.ConclusionsApplying solely organ dysfunction-based criteria may lead to underreporting of SMO. Therefore, a tool based on defining MNM only upon establishing organ failure is of limited use for comparing settings with varying resources. In low-resource settings, lowering the threshold of transfused units of blood leads to a higher detection rate of MNM. We recommend refined disease-based criteria, accompanied by a limited set of intervention- and organ dysfunction-based criteria to set a measure of severity.

Incidence and causes of maternal near-miss in selected hospitals of Addis Ababa, Ethiopia.

BackgroundBecause maternal mortality is a rare event, it is important to study maternal near-miss as a complement to evaluate and improve the quality of obstetric care. Thus, the study was conducted with the aim of assessing the incidence and causes of maternal near-miss.MethodsA facility-based cross-sectional study was conducted in five selected public hospitals of Addis Ababa, Ethiopia from May 1, 2015 to April 30, 2016. All maternal near-miss cases admitted to the selected hospitals during the study period were prospectively recruited. World Health Organization criteria were used to identify maternal near-miss cases. The number of maternal near-miss cases over one year per 1000 live births occurring during the same year was calculated to determine the incidence of maternal near-miss. Underlying and contributing causes of maternal near-miss were documented from each participant’s record.ResultsDuring the one-year period, there were a total of 238 maternal near-miss cases and 29,697 live births in all participating hospitals, which provides a maternal near-miss incidence ratio of 8.01 per 1000 live births. The underlying causes of the majority of maternal near-miss cases were hypertensive disorders and obstetric hemorrhage. Anemia was the major contributing cause reported for maternal near-miss. Most of the maternal near-miss cases occurred before the women’s arrival at the participating hospitals.ConclusionThe study demonstrated a lower maternal near-miss incidence ratio compared to previous country-level studies. The majority of the near-miss cases occurred before the women’s arrival at the participating hospitals, which underscores the importance of improving pre-hospital barriers. Efforts made toward improvement in the management of life-threatening obstetric complications could reduce the occurrence of maternal near-miss problems that occur during hospitalization.

Postpartum hemorrhage with transfusion: Trends, near misses, risk factors and management at the scale of a perinatal network

ObjectivesTo analyze temporal trends and management of postpartum hemorrhage (PPH) with transfusion and its related maternal near-miss (MNM) cases between 2006 and 2014 and to study risk factors. Material and methodsThis retrospective cohort study from two prospective databases included 156,047 women giving birth in all the maternity hospitals of Burgundy. We analyzed temporal trends and the distribution of PPH with transfusion, the circumstances of transfer of patients between hospitals and factors associated with PPH with transfusion. PPH with massive blood transfusion and/or non-medical treatment was defined as MNM. Statistical analysis included Chi2 tests and logistic regression for multivariate analysis. ResultsThe overall rate of PPH with transfusion was 7.3‰ and globally increased during the study period whereas the MNM rate did not. MNM represented 37% of patients with PPH with transfusion and 71% of transferred patients, but surgical treatments were performed before transfer. Factors associated with PPH with transfusion were maternal age>35 years (odds ratio [OR]=1.3), prematurity (OR=5.0), cesarean section (OR=4.8), placenta previa (OR=22.0), twin pregnancy (OR=6.6), HELLP syndrome (OR=17.9) and severe small-for-gestational-age infants (OR=2.0). The first four were also associated with MNM. ConclusionMNM cases of PPH rates were steady in Burgundy while rates of PPH with transfusion increased moderately.

Maternal near-miss and death incidences – Frequencies, causes and the referral chain in Somaliland: A pilot study using the WHO near-miss approach

Background Somaliland is a self-declared country with a population of 3.5 million. Most of its population reside in rural areas. The objective of this pilot near-miss study was to monitor the frequency and causes of maternal near-miss and deaths and the referral chain for women to access Skilled Birth Attendants (SBA). Method: A facility-based study of all maternal near-miss and mortality cases over 5months using the WHO near-miss tool in a main referral hospital. Reasons for bypassing the Antenatal Care facility (ANC) and late arrival to the referral hospital were investigated through verbal autopsy. Results: One hundred and thirty-eight (138) women with severe maternal complications were identified: 120 maternal near-miss, 18 maternal deaths. There were more near-miss cases on arrival (74.2%) compared with events that developed inside the hospital (25.8%). Likewise, there were more maternal deaths (77.8%) on arrival than was the case during hospitalization (22.2%). The most common mode of referral among maternal near-miss events was family referrals (66.7%). Of 18 maternal deaths, 15 were family referrals. Reasons for bypassing ANC were as follows: lack of confidence in the service provided; lack of financial resources; and lack of time to visit ANC. Reasons for late arrival to the referral hospital were as follows: lack of knowledge and transportation; and poor communication. Conclusion and clinical implication: To increase the utilization of ANC might indirectly lower the number of near-miss and death events. Collaboration between ANC staff and referral hospital staff and a more comprehensive near-miss project are proposed.

Afghan migrants face more suboptimal care than natives: a maternal near-miss audit study at university hospitals in Tehran, Iran

BackgroundWomen from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM.MethodsAn MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined.ResultsAfghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient- (31%, 17/54) and health system-related factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM.ConclusionsAfghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants’ specific needs during pregnancy may avert near-miss outcomes.

Delays associated with maternal near-miss cases admitted in Women's Health Hospital, Assiut University

Introduction Maternal near-miss (MNM) is recognized as a new concept and has emerged as an adjunct to investigation of maternal deaths as the two represent similar pathways. A conceptual model that had helped us to explain the underlying preventable causes of MNM by examining three phases of delay on maternal healthcare utilization was developed by Thaddeus and Maine. By identifying and reducing the three delays, we will have the greatest impact in reducing MNM and hence maternal deaths. Aim The aim of this study was to describe the extent, main types, and contributed factors for three delays in care associated with MNM among women admitted in Women's Health Hospital, Assiut University, Egypt. Methods A prospective case–control study was conducted over a period of 1 year from 1 May 2014 to 30 April 2015 at Women's Health Hospital, Assiut University; 342 MNM women and 684 age-matched control women were included in the study. The criteria we used for the identification of MNM were generally based on the presence of different levels of organ dysfunction, which have been identified as recommended by WHO. Data were collected through two approaches: record review and direct interview before discharge. Delays experienced by the study population were collected according to the three-delay model of Thaddeus and Maine. Results A high proportion of the MNM group had experienced delay irrespective of the type, with statically significant differences from their controls. Nearly 50% of near-miss cases were more likely to have experienced two or more types of delays compared with 7.7% of controls. Financial problems, fear of being maltreated in hospitals, lack of awareness about signs of obstetric complications, lack of participation in decision making, lack of antenatal care, negative attitude of healthcare worker, and lack of blood availability were associated with delays among MNM cases compared with controls. Having experienced third delay within the intermediate facilities (referral status) was the highest significant predictor that contributed to MNM by delay types. Conclusion and recommendations Third delay experienced by the women within the intermediate facilities (referral status) was the most prevalent delay among studied women. Reformation of healthcare system on multiple levels and improvement of the socioeconomic status of women are necessary in Upper Egypt to overcome causes of delay among MNM cases.

Delays associated with maternal near-miss cases admitted in Women's Health Hospital, Assiut University

IntroductionMaternal near-miss (MNM) is recognized as a new concept and has emerged as an adjunct to investigation of maternal deaths as the two represent similar pathways. A conceptual model that had helped us to explain the underlying preventable causes of MNM by examining three phases of delay on maternal healthcare utilization was developed by Thaddeus and Maine. By identifying and reducing the three delays, we will have the greatest impact in reducing MNM and hence maternal deaths.AimThe aim of this study was to describe the extent, main types, and contributed factors for three delays in care associated with MNM among women admitted in Women's Health Hospital, Assiut University, Egypt.MethodsA prospective case–control study was conducted over a period of 1 year from 1 May 2014 to 30 April 2015 at Women's Health Hospital, Assiut University; 342 MNM women and 684 age-matched control women were included in the study. The criteria we used for the identification of MNM were generally based on the presence of different levels of organ dysfunction, which have been identified as recommended by WHO. Data were collected through two approaches: record review and direct interview before discharge. Delays experienced by the study population were collected according to the three-delay model of Thaddeus and Maine.ResultsA high proportion of the MNM group had experienced delay irrespective of the type, with statically significant differences from their controls. Nearly 50% of near-miss cases were more likely to have experienced two or more types of delays compared with 7.7% of controls. Financial problems, fear of being maltreated in hospitals, lack of awareness about signs of obstetric complications, lack of participation in decision making, lack of antenatal care, negative attitude of healthcare worker, and lack of blood availability were associated with delays among MNM cases compared with controls. Having experienced third delay within the intermediate facilities (referral status) was the highest significant predictor that contributed to MNM by delay types.Conclusion and recommendationsThird delay experienced by the women within the intermediate facilities (referral status) was the most prevalent delay among studied women. Reformation of healthcare system on multiple levels and improvement of the socioeconomic status of women are necessary in Upper Egypt to overcome causes of delay among MNM cases.

Hypertension in Pregnancy Still Remains a Serious Complication Causing Severe Morbidity and Mortality of Mother

Objective(s): The aim of this study is to evaluate frequency and nature of maternal deaths and maternal near-miss cases in a tertiary care hospital.Materials and Methods: A retrospective examination was conducted on records of the16.612 women who delivered in a tertiary care center, over a ten-year period (1997-2006). The flow chart recommended by Say et al was used in the analysis of the maternal near-miss cases.Results: The ratios of mortality related with pregnancy, maternal mortality and maternal nearmiss were 68.11/100.000, 61.29/100.000 and 17.09/1000, respectively. The ratio of maternal near- miss to maternal mortality was 27.8 and the mortality index was 3.46%. Hypertensive disorders were the leading cause of maternal deaths and maternal near-miss events.Conclusion: Hypertensive disorders were still leading cause of maternal deaths and maternal near-miss events.Absence of antenatal care and disrupted referral chains were major problems.Bangladesh J Obstet Gynaecol, 2015; Vol. 30(2) : 92-97

Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011-2012.

BackgroundMaternal near-miss (MNM) audits are considered a useful approach to improving maternal healthcare. The aim of this study was to evaluate the factors associated with maternal near-miss cases in childbirth and the postpartum period in Brazil.MethodsThe study is based on data from a nationwide hospital-based survey of 23,894 women conducted in 2011–2012. The data are from interviews with mothers during the postpartum period and from hospital medical files. Univariate and multivariable logistic regressions were performed to analyze factors associated with MNM, including estimation of crude and adjusted odds ratios and their respective 95 % confidence intervals (95 % CI).ResultsThe estimated incidence of MNM was 10.2/1,000 live births (95 % CI: 7.5–13.7). In the adjusted analyses, MNM was associated with the absence of antenatal care (OR: 4.65; 95 % CI: 1.51–14.31), search for two or more services before admission to delivery care (OR: 4.49; 95 % CI: 2.12–9.52), obstetric complications (OR: 9.29; 95 % CI: 6.69–12.90), and type of birth: elective C-section (OR: 2.54; 95 % CI: 1.67–3.88) and forceps (OR: 9.37; 95 % CI: 4.01–21.91). Social and demographic maternal characteristics were not associated with MNM, although women who self-reported as white and women with higher schooling had better access to antenatal and maternity care services.ConclusionThe high proportion of elective C-sections performed among women in better social and economic situations in Brazil is likely attenuating the benefits that could be realized from improved prenatal care and greater access to maternity services. Strategies for reducing the rate of MNM in Brazil should focus on: 1) increasing access to prenatal care and delivery care, particularly among women who are at greater social and economic risk and 2) reducing the rate of elective cesarean section, particularly among women who receive services at private maternity facilities, where C-section rates reach 90 % of births.Electronic supplementary materialThe online version of this article (doi:10.1186/s12978-016-0232-y) contains supplementary material, which is available to authorized users.

Maternal near miss approach to evaluate quality of care in Alborz province, Iran

Objectivethe maternal near miss approach has been developed by World Health Organization for assessing and improving the quality of care. This study aimed to examine the incidence, characteristics, and features of the care provided for maternal near-miss cases in public and private hospitals in Alborz province, Iran. Methodsa cross sectional, facility-based study was conducted in all 13 public and private hospitals of Alborz province between April 2012 and December 2012. The World Health Organization near miss criteria were applied to gather and analyse the data, and indicators related to maternal near miss, access to and quality of maternal care. Findings38,715 deliveries were assessed. There were 38,663 live births, 419 (1.08%) had potentially life-threatening conditions and 199 had severe maternal outcomes (SMO) (192 near miss cases and 7 maternal deaths). The maternal near-miss ratio was 4.97 cases per 1000 live births. The incidence of severe maternal outcome was 5.15 cases per 1000 live births. Severe mortality outcomes index within 12 hours of hospital stay from admission (SMO12) was 3.52%. The proportion of SMO12 cases from the total SMO cases was 99.5%. The Intensive Care Unit (ICU) admission rate among women with SMO was 72.7%, while the overall admission rate was 0.7%. Overall, hypertensive disorder was the most frequent condition among women with potentially life-threatening conditions and maternal near-miss cases. Cardiovascular dysfunction and respiratory dysfunction were the most prevalent dysfunctions among maternal near miss (MNM) cases and maternal death cases respectively. Key conclusions and implications for practicethe WHO maternal near miss criteria help to identify issues that may lead to life threatening conditions and can be used to monitor and improve the quality of care in maternity settings. Hypertensive disorders related to near miss conditions need more attention to prevent maternal severe outcomes in Alborz province. Most of the process indicators were not satisfactory. The WHO tool enables health managers to improve maternal health care.

Severe maternal morbidity due to respiratory disease and impact of 2009 H1N1 influenza A pandemic in Brazil: results from a national multicenter cross-sectional study.

BackgroundThe aim of this study was to assess the burden of respiratory disease, considering the influenza A pandemic season (H1N1pdm09), within the Brazilian Network for Surveillance of Severe Maternal Morbidity, and factors associated with worse maternal outcome.MethodsA multicenter cross-sectional study, involving 27 referral maternity hospitals in five Brazilian regions. Cases were identified in a prospective surveillance by using the WHO standardized criteria for potentially life-threatening conditions (PLTC) and maternal near miss (MNM). Women with severe complications from respiratory disease identified as suspected or confirmed cases of H1N1 influenza or respiratory failure were compared to those with other causes of severe morbidity. A review of suspected H1N1 influenza cases classified women as non-tested, tested positive and tested negative, comparing their outcomes. Factors associated with severe maternal outcome (SMO = MNM + MD) were assessed in both groups, in comparison to PLTC, using PR and 95 % CI adjusted for design effect of cluster sampling.ResultsAmong 9555 cases of severe maternal morbidity, 485 (5 %) had respiratory disease. Respiratory disease occurred in one-quarter of MNM cases and two-thirds of MD. H1N1 virus was suspected in 206 cases with respiratory illness. Around 60 % of these women were tested, yielding 49 confirmed cases. Confirmed H1N1 influenza cases had worse adverse outcomes (MNM:MD ratio < 1 (0.9:1), compared to 12:1 in cases due to other causes), and a mortality index > 50 %, in comparison to 7.4 % in other causes of severe maternal morbidity. Delay in medical care was associated with SMO in all cases considered, with a two-fold increased risk among respiratory disease patients. Perinatal outcome was worse in cases complicated by respiratory disease, with increased prematurity, stillbirth, low birth weight and Apgar score < 7.ConclusionsRespiratory disease, especially considering the influenza season, is a very severe cause of maternal near miss and death. Increased awareness about this condition, preventive vaccination during pregnancy, early diagnosis and treatment are required to improve maternal health.

Analysis of near-miss and maternal mortality at tertiary referral centre of rural India.

(1) To determine the incidence of near-miss, maternal death and mortality index; (2) to compare near-miss cases as per WHO criteria with that of maternal mortality; and (3) to study the causes of near-miss and maternal deaths. Retrospective cohort study. Shri Vasantrao Naik Govt. Medical College, Yavatmal, India. All cases of near-miss as per newer WHO criteria and maternal deaths. A cohort of emergency obstetric admission in the study setting during the study period was followed till 42days after delivery, and cases fulfilled WHO set of severity markers for near-miss cases for severe acute maternal morbidity (SAMM) and mortality. All maternal deaths during the same period were analysed and compared with near-miss ones. During the study period, there were 29,754 emergency obstetric admissions, 21,992 (73.91%) total deliveries with 18,630 (84.71%) vaginal deliveries and 3360 (15.28%) caesarean deliveries. There were 161 near-miss cases and 66 maternal deaths occurred. The maternal near-miss incidence ratio was 7.56/1000 live births, while maternal mortality ratio was 2.99/1000 live births. Mortality index was 29.07, lower index indicative of better quality of health care. Maternal near-miss-to-mortality ratio was 3.43:1. Amongst near-miss cases, haemorrhage n=43 (26.70%), anaemia n=40 (24.84%), hepatitis n=27 (16.77%) and PIH n=19 (11.80%) were leading causes, while causes for maternal mortality were PIH n=18 (27.27%), haemorrhage n=13 (19.79%), sepsis n=12 (18.18%), anaemia n=11 (16.16%) and hepatitis n=11 (16.66%). Despite improvements in health care, haemorrhage, PIH, sepsis and anaemia remain the leading obstetric causes of near-miss and maternal mortality. All of them are preventable. The identification of maternal near-miss cases using new WHO set of severity markers of SAMM was concurrently associated with maternal death. Definite protocols and standards of management of SAMM should be established, especially in rural Indian settings.

Maternal Near Miss: A Bigger Challenge

Introduction:Maternal near-miss case is new concept and is defined as a woman who nearly died but survived complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”.The objectives of the present study were: to identify among all women admitted to hospital during pregnancy, delivery and in the postpartum period those that were indicative of severe acute maternal morbidity; to find out and analyse the cause of hospitalization. Materials & methods:This was descriptive study done for period of 24 months between 1st January 2013 and 31st December 2014 in our hospital. Cases of severe obstetric morbiditywere analyzed in regard to characteristics like age, parity, and gestational age at admission, Intensive Care Unit (ICU) admission, and surgical intervention to save the life of the mother were considered. Maternal near miss (MNM) indices were calculated. Results:There were 150 cases of near miss, 3123 live births and 9 cases of maternal deaths. Maternal near miss incidence ratio is 48.03. Maternal near miss mortality ratio is 16.66. Mortality index (MI)is 5.66%. Mostly near miss cases were antenatal at >28 weeks of gestation with hemorrhage and hypertension being commoner causes responsible. The highest mortality index was found with cardiac causes (25%) followed by sepsis (16.6%) and eclampsia (14.2%). Conclusion:All near misses should be interpreted as free lessons and opportunities to improve the quality of service provision.