Maternal Near Miss Incidence Ratio Research Articles

A Study of Etiological Spectrum of Maternal Near-miss Cases and Quality Care Indicators in Western Region of India

Background: Maternal death review has remained the fundamental quality care indicator for any maternal health-care governance program. Maternal near-miss (MNM) cases which are the forerunner of mortality cases could serve as a proxy indicator to evaluate the obstetric quality care. Objectives: To calculate MNM to mortality ratio of the institute and to study the etiological spectrum of MNM cases. Materials and Methods: A hospital-based prospective observational study was carried out. Cases were taken as defined based on the WHO MNM criteria. Data collection was done through information retrieval from case records and by in-depth interviews with the help of semi-structured questionnaire of MNM cases from 2 days after their admission up till discharge. Each case was documented with respect to the demographic details, adverse events and aetiology. Results: The MNM to mortality ratio was 1.16:1, MNM incidence ratio in our study was 4.12 and the mortality index was 46.23. Seventy-six per cent of cases were referred cases. The main causes for near-miss were post-partum haemorrhage (30%) followed by pre-eclampsia (26%). Hypertension was the most significant comorbidity in 28% of cases, while 26% had cardiac disease and 26% had severe anaemia. Conclusions: Studying near-miss mortality cases provides a valuable insight of the quality of care of the institute. MNM case review should be a part of regular governance process of the maternity care unit to plan and implement focused care.

Severe Maternal Outcomes and Quality of Maternal Health Care in South Ethiopia.

ObjectiveTo assess the incidence of severe maternal outcomes (SMO) and quality of maternal health care in south Ethiopia.MethodsA facility-based prospective study was conducted in three hospitals among all women who presented while pregnant, during and after childbirth between 12 July and 26 November 2018. Participants were followed from the time of admission to discharge. The World Health Organization (WHO) maternal near-miss (MNM) approach was used to assess SMO indicators and quality of maternal health care.ResultsOf 2880 live births, 315 had potentially life-threatening conditions and 108 had SMOs (90 MNM and 18 maternal deaths). The SMO incidence ratio was 37.5 per 1000 live births (95% CI 30.6–44.4) and MNM incidence ratio was 31.3 per 1000 live births (95% CI 24.9–37.7). The ratio of near-miss to maternal deaths was 5:1. The hospitals’ maternal mortality ratio (MMR) was 625 per 100,000 live births. Most (82.1%) SMO cases were referred from other health facilities. The most common cause of SMO was eclampsia (37%) followed by postpartum haemorrhage (33.3%). The highest mortality index (MI) was among women with sepsis (27.3%). The intensive care unit (ICU) admission rate was 13% for women with SMO and 83.3% of maternal deaths occurred without ICU admission.ConclusionThe SMO ratio was comparable to other studies in the country. Most women with SMO were referred from other health facilities, which demonstrate the presence of the first delay (seeking care) and/or the second delay (reaching care) in the study area. The study suggests that effectively using the ICU, reducing delays, and improving the referral system may reduce SMO and improve the quality of care in the hospitals. Furthermore, continuous reviewing of SMO is needed to learn what treatment was given to women who experienced complications in the hospitals.

Women with maternal near-miss in the intensive care unit in Yangzhou, China: a 5-year retrospective study

BackgroundAnalysis of “maternal near-misses” is expected to facilitate assessment of the quality of maternity care in health facilities. Therefore, this study aimed to investigate incidence, risk factors and causes of maternal near-misses (MNM) admitted to the intensive care unit (ICU) within five years by using the World Health Organization’s MNM approach.MethodsA five-year retrospective study was conducted in Subei People’s Hospital of Yangzhou, Jiangsu Province from January 1, 2015 to December 31, 2019. Risk factors in 65 women with MNM in the intensive care unit (ICU) were explored by using chi-square tests and multivariable logistic regression analysis. Causes and interventions in MNM were investigated by descriptive analysis.ResultsAverage maternal near-miss incidence ratio (MNMIR) for ICU admission was 3.5 per 1000 live births. Average maternal mortality ratio (MMR) was 5 per 100,000 live births. MI for all MNM was 0.7%. Steady growth of MNMIR in ICU was witnessed in the five-year study period. Women who were referred from other hospitals (aOR 3.32; 95%CI 1.40–7.32) and had cesarean birth (aOR 4.96; 95%CI 1.66–14.86) were more likely to be admitted in ICU. Neonates born to women with MNM admitted in ICU had lower birthweight (aOR 5.41; 95%CI 2.53–11.58) and Apgar score at 5 min (aOR 6.39; 95%CI 2.20–18.55) compared with women with MNM outside ICU. ICU admission because of MNM occurred mostly postpartum (n = 63; 96.9%). Leading direct obstetric causes of MNM admitted in ICU were hypertensive diseases of pregnancy (n = 24; 36.9%), followed by postpartum hemorrhage (n = 14; 21.5%), while the leading indirect obstetric cause was heart diseases (n = 3; 4.6%).ConclusionsRisk factors that were associated with MNM in ICU were referral and cesarean birth. Hypertensive disease of pregnancy and postpartum hemorrhage were the main obstetric causes of MNM in ICU. These findings would provide guidance to improve professional skills of primary health care providers and encourage vaginal birth in the absence of medical indications for cesarean birth.

EVALUATION OF OBSTETRIC NEAR MISS & MATERNAL DEATHS IN A TERTIARY CARE TEACHING HOSPITAL

Background: Maternal Mortality is a critical indicator to assess the quality of services provided by a health care system.The concept of severe acute maternal morbidity (SAMM) has been found to complement the assessment of maternal health services, since pregnant women’s health status is not reflected by mortality indicators alone . Maternal near miss cases are more common than maternal deaths. Methods: A Retrospective analysis of maternal near miss cases and maternal deaths was undertaken in the Department of Obstetrics and Gynaecology, Narayana Medical College and Hospital, Nellore, Andhra Pradesh over a period of two years. This study was conducted to find out maternal near miss and maternal deaths. Results: There were 2000 deliveries, 66 MNM cases and 2 maternal deaths during the study period. The Maternal Near Miss Incidence Ratio (MNMIR) ratio was 33%.The maternal near miss to mortality ratio was 33% for each maternal death. The Maternal Mortality Ratio (MMR) was 100 per 1 lakh live births in our study. Conclusion: We suggest near miss approach to evaluate and improve the quality of care provided by the health care system. By reviewing the near miss cases we can learn about the processes and their deficiencies that are in place for the care of pregnant women.

Study of “three delay model” of maternal morbidity and mortality in two tertiary care hospitals of Belagavi

INTRODUCTION: Every year millions of women around the world suffer from pregnancy, childbirth, and postpartum complication. Approximately 810 women die every day worldwide from preventable causes related to pregnancy and delivery. The concept of severe acute maternal morbidity or near miss was aptly developed for the present health-care system. The World Health Organization (WHO) has defined “near-miss” as a woman, who is close to death, survives a complication that occurred during pregnancy, delivery, or up to 42 days after the termination of her pregnancy. The important causes of maternal mortality and morbidity have been summarized as the three delays. These delays have been identified to understand the gap in access to adequate obstetric management. Delays in access to quality care have been identified as one of the important determinants of preventable maternal death. The present study was planned to assess the “three delay model” leading to the occurrence of severe maternal outcome (SMO) in two tertiary care hospitals of Belagavi, Karnataka, as proposed by the WHO near-miss approach. OBJECTIVE: This study aimed to study the “three delay model” leading to maternal morbidity and mortality in two tertiary care hospitals of Belagavi. MATERIALS AND METHODS: A cross-sectional study was conducted in two major tertiary care hospitals of Belagavi, namely KLE Dr Prabhakar Kore Charitable Hospital and Belagavi Institute of Medical Sciences Hospital for a duration of 1 year among antepartum, intrapartum, and postpartum mothers experiencing SMO. A sample of 200 was calculated based on the prevalence of previous maternal near-miss (MNM) incidence ratio. To assess the MNM cases, “Modified Facility Based MNM Review Form” was used. RESULTS: Out of 200 MNM cases, 145 (72.5%) subjects belonged to the age group of 21–30 years and 17 (8.5%) of the women were aged ≥31 years. The mean ± standard deviation age of the study participant was 25.0 ± 4.45 years. Based on the obstetric profile of the study subject, it was noted that 139 (69.5%) participants had presented to the study hospitals as unbooked cases and 93 (46.5%) were primigravida. Majority (160, 80.0%) of the MNM women had presented as referred cases. The MNM incidence ratio in the present study was recorded as 12.05/1000 live births with a MNM: maternal death ratio of 3.3:1. All types of delays were noted among the study participant in our study. Type I delay that consisted of lack of awareness and resources was seen in 134 (67.0%) MNM cases, followed by 130 (65.0%) experiencing Type II delay comprising logistics delay between home and health-care facility and in between the health facilities along with lack of communication network and the third type of delay being observed at the referring health facility in all the referred study participant. Assessment of association between maternal outcome and the “3 delay model” by use of logistic regression analysis suggested that women who faced any kind of delay (I, II, and III) during their pregnancy were more likely to end up with poor maternal outcomes. CONCLUSION AND RECOMMENDATION: The present study aimed to assess the delays that lead to poor maternal outcomes. The current study revealed the deficiencies that need to be tackled and taken care of on an urgent basis. Hence, there must be a multidisciplinary approach to manage the high-risk maternal cases for timely intervention and management and reduce the burden of maternal morbidity and mortality on a global scale.

Maternal Near Miss: Unraveling Our Experience in the Tertiary Care Hospital of Andaman and Nicobar Islands.

Context:Women who survive life-threatening complications related to pregnancy and delivery have many common aspects with those who die of such complications. This similarity brought forward the near miss concept in maternal health. Analysis of the similarities, differences, and the relationship between these two groups of women provide a complete assessment of quality of maternal health care.Aims:The aim of this study is to assess the baseline indices of maternal near miss (MNM) and analyze the quality of care at a tertiary care center in Andaman and Nicobar Islands.Settings and Design:Facility-based, cross-sectional study.Subjects and Methods:The study was conducted for a period of 18 months from January 1, 2015, to August 31, 2016. Cases, who met the World Health Organization (WHO) criteria of severe obstetric morbidity, were included and followed up during their hospital stay and till their discharge or death. Quality of maternal health care was assessed through the WHO near-miss criteria and criterion-based clinical audit methodology.Statistical Analysis Used:Descriptive statistics using mean and percentages and Student's t-test were used.Results:Among 4720 women who delivered in our hospital, there were 4677 live births, 52 patients were near miss, and there were 9 maternal deaths. The MNM incidence ratio was 11.11%, the MNM mortality ratio was 5.77, and the mortality index 14.75%. The most common cause of maternal morbidity was hemorrhage followed by hypertensive disorders.Conclusions:Improving referral systems, effective use of critical care, and evidence-based interventions can potentially reduce severe maternal outcomes.

"Near-Miss" Obstetric Events and Maternal Deaths in a Rural Tertiary Care Center in North India.

IntroductionMaternal near-miss and maternal mortality cases have common characters, especially in terms of risk factors. Both of them are indicators of the quality of health care services provided to pregnant women. Our center is a tertiary care center in a rural area of western Uttar Pradesh (U.P.) so we get a large number of referred cases from most of the rural areas of western U.P. and the adjoining areas of other states too, which sometimes end up in mortality. Thus this study was planned to find out the incidence of maternal near-miss events and compare the nature of near-miss events with maternal mortality.Goal and objectivesThe main objectives of the study were to determine the frequency of maternal near-miss events, observe the trend of near-miss events, and compare the nature of near-miss events with maternal mortality.Materials and methodsIt was a retrospective study conducted in the department of obstetrics and gynecology at Uttar Pradesh University of Medical Sciences (UPUMS), Saifai, Etawah, from July 2018 - June 2019, over a period of one year. Potentially life-threatening conditions and maternal mortalities were noted from the records of the hospital after taking ethical clearance from the institute. Near-miss cases were noted based on the Health and Family Welfare Government of India guidelines 2014. Data were collected and statistical analysis was performed using the Statistical Package of the Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY).ResultsThe maternal near-miss incidence ratio was 16.6/1000 live births, the maternal near-miss to mortality ratio was 1.9:1, and the mortality index was 0.34%. Hypertensive disorders of pregnancy were the most common causes of near-miss events (45.8%) followed by hemorrhage (23.6%) in this study.ConclusionsHypertensive disorders in pregnancy and hemorrhage were the two leading causes of near-miss events and mortality followed by sepsis. As the near-miss analysis indicates, the quality of health care and causes are almost similar to maternal mortality, so its registry should be done along with maternal mortality.

Low Incidence of Maternal Near-Miss in Zhejiang, a Developed Chinese Province: A Cross-Sectional Study Using the WHO Approach.

Background and AimMaternal near-miss (MNM) surveillance has been developed to identify severe complications in pregnancy since 2011 in China. However, very little is known about MNM in China. This study aims to explore the prevalence of MNM, the risk factors, and perinatal outcomes using the WHO near-miss approach in a developed Chinese province.Materials and MethodsWe used data from China’s National Maternity Near Miss Obstetrics Surveillance System for the period 2012 to 2017, which included 18 hospitals in Zhejiang Province. Chi-squared tests were used to compare the socio-demographic factors, obstetric complications and perinatal outcomes between women with and without MNM. Logistic regression was used to examine the independent risk factors for MNM.ResultsA total of 612,264 pregnant women were recruited. There were 3208 MNM cases and 34 maternal deaths. The MNM incidence ratio was low at 5.9 per 1,000 live births, with an MNM mortality ratio of 98:1 and mortality index of 1.1%. Among 3208 women with MNM, postpartum hemorrhage was the commonest cause at 76.3% followed by severe anemia at 23.7% and placenta previa at 23.0%. Embolism was identified as having the highest risk for MNM (AOR 46.0; 95% CI 19.1–110.7), followed by postpartum hemorrhage (AOR 41.0; 95% CI 35.7–47.0), and severe anemia (AOR 36.6; 95% CI 16.0–84.1). MNM cases were significantly associated with severe perinatal outcome, including premature birth, low birth weight, multiple fetuses, stillbirth rates and neonatal mortality.ConclusionOverall near-miss indicators suggested a relatively high quality of maternal health care in a developed province of China. The identified risk factors may be helpful in developing targeted interventions for improving maternal safety.

Severe maternal outcomes: World health organization maternal near-miss and maternal mortality criteria in University Tertiary Hospital Egypt

Background: The World Health Organization (WHO) maternal near-miss (MNM) approach was developed to evaluate and improve the quality of obstetric care worldwide. Aim: The aim of this study was to evaluate the incidence of MNM and quality of care at a tertiary hospital in Egypt by applying this approach. Methods: A facility-based, retrospective study was conducted between January 2015 and December 2016. Participants' data were collected from medical records of the intensive care unit. Results: Among 28,877 deliveries over 2 years, 185 women suffered severe maternal outcome (SMO): 171 MNMs and 14 deaths. SMO ratio is 6.5/1000 live birth, MNM incidence ratio of 5.9/1000 live births, maternal death incidence ratio 0.5/1000 live birth, maternal mortality ratio of 48.48/100,000 live births, MNM mortality ratio is 12:1, and a mortality index of 7.5%. Hemorrhage (n = 107, 62.5%) and hypertensive disorders, including fits and hemolytic anemia, elevated liver enzymes, and low platelet count syndrome (n = 44, 25.5%) were the most common MNM conditions. Hemorrhage (n = 8, 57%) was the leading cause of maternal mortality and then cardiac diseases (n = 3, 21.5%). All cases were not receiving antenatal care in the Shatby Hospital or were not compliant to the hospital ANC and were referred or showed up at the time of delivery or after delivery with complication encountered. Nearly 71.5% of the died patients cases were younger than 30 years and 21.5% were primigravida. Conclusions: MNM is common in Egypt. The approach enabled us to identify pitfalls in clinical practice and referral system. The private sector in Egypt needs to evaluated and medical license should not be permanent.

Factors associated with maternal near miss: A study from Kerala.

Severe life-threatening situations leading to a "near-miss" event may arise unexpectedly in pregnancy. Delay in seeking help, delayed access to care, and poor quality of emergency obstetric services can lead to undesirable outcomes. Women meeting the WHO "near-miss" criteria were assessed using a cross-sectional study design. These women were interviewed to evaluate the circumstances leading to a near-miss event. Reasons for delays in getting proper care were studied using the "3 delays' model." Thirty-two women met the criteria for "near miss" during the 15-month study period, with a maternal near-miss incidence ratio of 9.27/1000 live births. One or more delays were identified in 21 (65.6%) near-miss cases. Delayed access to care was the most important factor for delay. A review of near-miss cases can be used to improve and optimize the existing obstetric services.

Severe maternal outcomes and quality of care at district hospitals in Rwanda\u2013 a multicentre prospective case-control study

BackgroundDespite a significant decrease in maternal mortality in the last decade, Rwanda needs further progress in order to achieve Sustainable Development Goals (SDG)3 which addresses among others maternal mortality. Analysis of severe maternal outcomes (SMO) was performed to identify their characteristics, causes and contributory factors, using standard indicators for quality of care.MethodsA prospective case-control study was conducted for which data were collected between November 2015 and April 2016 in four rural district hospitals. The occurrence of SMO with near miss incidence ratios was established, followed by an analysis of the characteristics, clinical outcomes, causes and contributory factors.ResultsThe SMO incidence ratio was 38.4 per 1000 live births (95% CI 33.4–43.4) and the maternal near-miss incidence ratio was 36 per 1000 live births (95% CI 31.1–40.9). The leading causes of SMO were postpartum haemorrhage (23.4%), uterine rupture (22.9%), abortion related complications (16.8%), malaria (13.6%) and hypertensive disorders (8.9%). The case fatality rate was high for women with hypertensive disorders (10.5%; CI 3.3–24.3) and severe postpartum haemorrhage (8%; CI 0.5–15.5). Stillbirth (OR = 181.7; CI 43.5–757.9) and length of stay at the hospital (OR = 7.9; CI 4.5–13.8) were strongly associated with severe outcomes.ConclusionsDespite the use of life saving interventions, SMO are frequent. Mortality index was found to be low at the level of district hospitals. SMO were associated with long stay at the hospital and stillbirth. There is a need for improvement of quality of care, referral practices and certain types of infrastructure, especially blood banks, which would ensure truly comprehensive emergency obstetric care and reduce the occurrence of SMO.

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.

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.

Magnitude and pattern of maternal near-miss cases admitted to Women's Health Hospital, Assiut University

Introduction Maternal near-miss (MNM) is one of the related concepts to maternal mortality. MNM is a special category of survivors, whose stories provide unique insights and valuable information on maternal mortality. Measuring MNM beside maternal mortality and identifying its causes is essential, and should be calculated regularly for the purpose of planning, monitoring, and evaluation of provided maternal healthcare. Objectives The objectives of the study were to determine the magnitude and to identify the patterns of MNM among cases admitted to Women's Health Hospital, Assiut University, Egypt. Methodology This paper is a part of a larger case–control prospective study; however, for this analysis, we are presenting only the findings of the MNM cases. (The full profile of the cases and controls was presented in another paper.) The study was conducted at Women's Health Hospital, Assiut University and included 342 MNM cases by total coverage of all eligible cases who met the criteria of MNM identification published in WHO bulletin (2011) throughout the 12 months' period of the study. A checklist was used to collect data from the hospital records of eligible respondents. Results During the 12 months' period of the study, there were 17 503 deliveries and 16 972 live births. The maternal mortality ratio was 276 per 100 000 live births and the MNM incidence ratio was 20 per 1000 live births. This means that there was one maternal death for every seven cases of MNM. The mean age of MNM cases was 28.4 ± 8.5, whereas the mean gestational age of MNM was 35.66 ± 8.6 weeks. The main direct obstetric causes of MNM were hypertensive disorders of pregnancy (49.8%), obstetric hemorrhage (38.3%) and dystocia (32.5%). On the other hand, cardiovascular disorder was the most prevalent nonobstetric cause among MNM cases (48.8%). The peak frequency of the cases occurred during the summer season. Conclusions and recommendations MNM and maternal mortality are alarmingly high. Hypertensive disorders of pregnancy and obstetric hemorrhage were the two main direct obstetric causes of near misses that require strict and quick management protocols.

“Near Miss” Obstetric Events and Maternal Deaths in a Tertiary Care Hospital: An Audit

Objectives. (1) To determine the frequency of maternal near miss, maternal near miss incidence ratio (MNMR), maternal near miss to mortality ratio and mortality index. (2) To compare the nature of near miss events with that of maternal mortality. (3) To see the trend of near miss events. Design. Audit. Setting. Kasturba Hospital, Manipal University, Manipal, India. Population. Near miss cases & maternal deaths. Methods. Cases were defined based on WHO criteria 2009. Main Outcome Measures. Severe acute maternal morbidity and maternal deaths. Results. There were 7390 deliveries and 131 “near miss” cases during the study period. The Maternal near miss incidence ratio was 17.8/1000 live births, maternal near miss to mortality ratio was 5.6 : 1, and mortality index was 14.9%. A total of 126 cases were referred, while 5 cases were booked at our hospital. Hemorrhage was the leading cause (44.2%), followed by hypertensive disorders (23.6%) and sepsis (16.3%). Maternal mortality ratio (MMR) was 313/100000 live births. Conclusion. Hemorrhage and hypertensive disorders are the leading causes of near miss events. New-onset viral infections have emerged as the leading cause of maternal mortality. As near miss analysis indicates the quality of health care, it is worth presenting in national indices.