Near-miss Approach Research Articles

A mixed methods study on continuity and care coordination based on the obstetric near miss approach.

The near-miss approach assumes that mothers facing life-threatening conditions such as severe pre-eclampsia and postpartum haemorrhage share common risk factors. Among these women, those who survive (near-miss cases) can offer insights into the determinants, providing valuable lessons for understanding underlying factors. To investigate elements of continuity and coordination leading to obstetric near misses. A major referral hospital and its referral pathway in Kenya. Explanatory sequential mixed-methods design. Near-miss survivors had lower continuity and coordination of care indices during antenatal visits (COCI = 0.80, p = 0.0026), (modified continuity of care index [MCCI] = 0.62, p = 0.034), and those with non-life-threatening morbidity in the first trimester were more likely to experience a near miss (aOR = 4.34, p = 0.001). Facilities in the western region had a higher burden of near misses compared to the Eastern region. Qualitatively, three deductive themes were identified: sequential coordination, parallel coordination and continuity, along with factors classified as access. In mixed integration, poor continuity indices were explained by quality of interpersonal relationships and woman centredness. Poor coordination was explained by inadequate teamwork between providers in referring and referral facilities and between primary health facilities and the community. Higher near-miss rates in the western region resulted from differences in human and physical resources. Promoting woman-centred care, teamwork, improving communication and introducing innovative coordination roles like case and care managers can enhance continuity and coordination of maternal healthcare. This study contributes to our understanding of the challenges of continuity and coordination in maternal healthcare in resource-poor settings by applying the WHO operationalisation of continuity and coordination using mixed methodology.

Comparison of Causes of Maternal Near Miss and Maternal Mortality in a Tertiary Care Hospital: A Prospective Study

The Maternal Near miss (MNM) concept has led to a more comprehensive and better assessment of the effect of care on maternal health. Investigating severe life-threatening pregnancy complications that women encounter and maternal morbidities (near misses) may help evaluate the quality of care in health facilities and recommend ways to improve maternal survival, especially in poor resource settings. Aim This study aimed to identify causes, classify, and determine the nature of complications in maternal near misses and in maternal death. Material and Methods The hospital-based prospective cohort study was conducted in the Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Aligarh Muslim University of Aligarh from 2020 to 2022. The study was approved by the Institutional Ethics Committee and informed written consent was obtained from the study participants. The outcome measures included causes, organ dysfunction, complications, maternal morbidities, and neonatal outcome. Results: Higher rate of unbooked referrals was observed in our study. Hemorrhage was 42.9%, followed by 39.1% hypertensive disorders, 8.6% sepsis in the maternal near miss group while in the maternal mortality group, 26.1% had hypertensive disorders followed by 23.8% women had hemorrhagic disorders, and 20.4% had sepsis. There was a significant difference in HDU, ICU Hospital stay and IUDs in the maternal mortality group compared to the maternal near-miss group. Conclusion The WHO near-miss approach was found to represent a feasible strategy in low-resource settings each Near Miss should be evaluated in detail to diagnose underlying pathology, correct and timely detection of complications, prompt referral and early institution of essential and comprehensive obstetrics care are important for maternal and infant survival.

High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study)

BackgroundAbortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR).MethodsWe used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records’ reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity.ResultsWe analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%).ConclusionOur data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.

Self-reported continuity and coordination of antenatal care and its association with obstetric near miss in Uasin Gishu county, Kenya.

Continuity and coordination of care are core principles of high-quality primary health care. Optimising continuity and coordination improves maternal satisfaction. However, their association with morbidity and mortality outcomes is unclear. The obstetric near-miss approach can be used to investigate whether continuity and coordination influences the occurrence of a severe maternal outcome. To compare self-reported continuity and coordination of care between obstetric near-miss survivors and those without near miss during pregnancy, delivery and postpartum. Uasin Gishu county, Rift Valley region, Kenya. A cross-sectional survey targeting 340 postnatal mothers. Continuity of care index (COCI) and modified continuity of care index (MCCI) were used to estimate longitudinal continuity. The Likert scale was administered to measure perceived continuity and coordination of care. Mann-Whitney U test and binomial logistic regression were used for hypothesis testing. COCI and MCCI were lower among near-miss survivors (COCI = 0.80, p = 0.0026), (MCCI = 0.62, p = 0.034). Near-miss survivors scored lower on items assessing coordination between a higher-level provider and usual antenatal clinic (mean = 3.6, p = 0.006) and general coordination of care during pregnancy (mean = 3.9, p = 0.019). Presence of a non-life-threatening morbidity in pregnancy was associated with occurrence of near miss (aOR = 4.34, p = 0.001). Near-miss survivors scored lower on longitudinal continuity and coordination of care across levels. Further research should focus on strengthening coordination, determining the optimal level of longitudinal continuity and improving systems for early identification and management of morbidities in pregnancy.Contribution: The results of this study show that while longitudinal and relational COC is important during the antenatal period, the presence of a non-life-threatening condition in pregnancy remains the most important predictor of the occurrence of a near miss.

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.

Maternal near-miss and mortality associated with hypertensive disorders of pregnancy remote from term: a multicenter observational study in Ghana

BACKGROUNDMaternal death rates remain high in many low- and middle-income countries. Hypertensive disorders of pregnancy account for 18% of maternal mortality in Ghana. The maternal near-miss approach was designed to evaluate severe (acute) complications in pregnancy, which is useful to detect potential areas for clinical care improvement.OBJECTIVEThis study aimed (1) to determine the incidence of severe maternal complications, maternal near-miss cases, and mortality cases associated with hypertensive disorders of pregnancy remote from term and (2) to assess the health system's performance indicators for the management of hypertensive disorders of pregnancy remote from term in middle-income country referral hospitals.STUDY DESIGNThis study was nested in the ongoing Severe Preeclampsia adverse Outcome Triage study, a multicenter observational cohort study, and included women recruited from December 1, 2017, to May 31, 2020, from 5 referral hospitals in Ghana. Women aged >16 years, admitted to the hospital with hypertensive disorders of pregnancy, with gestational age between 26 and 34 weeks were eligible. Near miss was defined according to the World Health Organization and sub-Saharan African near-miss criteria. Descriptive statistics of pregnancy and maternal and perinatal outcomes up to 6 weeks after delivery of women with severe maternal outcomes were presented for maternal deaths and maternal near-miss casigurees and compared with that of women without severe maternal outcomes. The health system's maternal and perinatal performance indicators were calculated.RESULTSOverall, 447 women with hypertensive disorders of pregnancy were included in the analyses with a mean maternal age of 32 (±5.8) years and mean gestational age at recruitment of 30.5 (±2.4) weeks. Of these patients, 46 (10%) had gestational hypertension, 338 (76%) had preeclampsia, and 63 (14%) had eclampsia. There were 148 near-miss cases (33.1%) and 12 maternal deaths (2.7%). Severe maternal outcomes constituted complications from severe preeclampsia (80/160 [50%]) and eclampsia (63/160 [39.4%]). Concerning organ dysfunction, hematologic and respiratory dysfunctions constituted 59/160 [38.6%] and 23/160 [14.8%] respectively. Nearly all women had a cesarean delivery (347/447 [84%] and 140/160 [93%] in the severe maternal outcome group) and delivered prematurely (83%, with 178/379 [93%] at <32 weeks of gestation). Stillbirth and neonatal deaths occurred in 63 of 455 women (14%) and 81 of 392 women (19%), respectively, constituting a stillbirth ratio of 161 per 1000 live births and neonatal mortality rate of 207 per 1000 live births as there were 392 live births in this cohort. Overall, the intensive care unit admission rate was 12.7% (n=52/409); moreover, 45 of 52 women (86.5%) admitted to the intensive care unit had severe maternal outcomes. The maternal death ratio was 3100 per 100,000 live births, the maternal near-miss–to–mortality ratio was 12.3, and the mortality index was 8%.CONCLUSIONMaternal near miss and maternal and perinatal mortalities were common in women with hypertensive disorders of pregnancy remote from term in referral hospitals in Ghana. Providing appropriate patient-centered and multidisciplinary quality care for these women is crucial in improving pregnancy outcomes. Context-tailored interventions should be considered in the clinical management of complications associated with hypertensive disorders of pregnancy in resource-limited settings. Further research on interventions to improve timely referral and reduce in-hospital delays in care provision is recommended to facilitate emergency care services for women with hypertensive emergencies.

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.

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.

Major obstetric haemorrhage in Metro East, Cape Town, South Africa: a population-based cohort study using the maternal near-miss approach

BackgroundMajor obstetric haemorrhage is a leading cause of maternal mortality and accounts for one-third of maternal deaths in of Africa. This study aimed to assess the population-based incidence, causes, management and outcomes of major obstetric haemorrhage and risk factors associated with poor maternal outcome.MethodsWomen with major obstetric haemorrhage who met the WHO maternal near-miss criteria or died in the Metro East region, Cape Town, South Africa, were evaluated from November 2014–November 2015. Major obstetric haemorrhage was defined as haemorrhage in pregnancies of at least 20 weeks’ gestation or occurring up to 42 days after birth, and leading to hysterectomy, hypovolaemic shock or blood transfusion of ≥5 units of Packed Red Blood Cells. A logistic regression model was used to analyse associations with poor outcome, defined as major obstetric haemorrhage leading to massive transfusion of ≥8 units of packed red blood cells, hysterectomy or death.ResultsThe incidence of major obstetric haemorrhage was 3/1000 births, and the incidence of massive transfusion was 4/10.000 births in the Metro East region (32.862 births occurred during the studied time period). Leading causes of haemorrhage were placental abruption 45/119 (37.8%), complications of caesarean section 29/119 (24.4%) and uterine atony 13/119 (10.9%). Therapeutic oxytocin was administered in 98/119 (82.4%) women and hysterectomy performed in 33/119 (27.7%). The median numbers of packed red blood cells and units of Fresh Frozen Plasma transfused were 6 (interquartile range 4–7) and 3 (interquartile range 2–4), ratio 1.7:1. Caesarean section was independently associated with poor maternal outcome: adjusted OR 4.01 [95% CI 1.58, 10.14].ConclusionsAssessment of major obstetric haemorrhage using the Maternal Near Miss approach revealed that placental abruption and complications of caesarean section were the major causes of major obstetric haemorrhage. Caesarean section was associated with poor outcome.

Retrospective analysis of patients with severe maternal morbidity receiving anaesthesia services using 'WHO near miss approach' and the applicability of maternal severity score as a predictor of maternal outcome.

Background and Aims:Risk stratification of severely morbid obstetric patients receiving anaesthesia services can be helpful in improving maternal outcomes. This study was undertaken to analyse these patients using the WHO near-miss (NM) approach and to assess the applicability of maternal severity score (MSS) to predict maternal mortality.Methodology:This is a one-year retrospective cohort analysis at a tertiary care centre. Of all the obstetric patients receiving anaesthesia, those with 'potentially life-threatening conditions' (PLTC) were identified. Amongst women with PLTC, those fulfilling the WHO NM criteria were grouped into either maternal near miss (MNM) or maternal death (MD) depending on final survival outcome. The MSS was assessed upon admission to post-anaesthesia ICU. The cases of “near miss” were compared to maternal death to determine the factors and WHO NM criteria significantly associated with mortality. Area under ROC curve (AUROC) was used to assess the accuracy of MSS to predict maternal mortality.Results:Of the 4351 anaesthetised obstetric patients, 301 were PLTC, 59 MNM and 11 MD. Obstetric haemorrhage was the commonest PLTC with the highest risk for MNM and MD. Preoperative organ dysfunction, referral from other centres, intra-uterine fetal death (IUFD) and WHO cardiovascular and respiratory NM criteria were significantly associated with mortality. MSS had excellent accuracy for the prediction of mortality (AUROC was 0.986 and 95% CI 0.966–0.996).Conclusion:Haemorrhage is the leading cause of MNM and MD. MSS is reliable in stratifying the severity of maternal morbidity and in predicting maternal mortality. Thus it can be used as an effective prognostic tool.

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.

Validity of WHO's near-miss approach in a high maternal mortality setting.

ObjectiveTo evaluate the validity of WHO’s near-miss approach in a low-resource, high maternal mortality setting.DesignProspective cohort study.SettingMnazi Mmoja Hospital, the main referral hospital of Zanzibar, Tanzania, from 1 April 2017 until 31 December 2018.PopulationAll women, pregnant or until 42 days after the end of pregnancy, admitted at Mnazi Mmoja Hospital, the tertiary referral hospital in Zanzibar.MethodsCases of maternal morbidity and mortality were evaluated according to WHO’s near-miss approach. The approach’s performance was determined by calculating its accuracy through sensitivity, specificity and positive and negative likelihood ratios. The approach’s validity was assessed with Pearson’s correlation coefficient between the number of organ dysfunction markers and risk of mortality.Main outcomes measuresCorrelation between number of organ dysfunction markers and risk of mortality, sensitivity and specificity.Results26,842 women were included. There were 335 with a severe maternal outcome: 256 maternal near-miss cases and 79 maternal deaths. No signs of organ dysfunction were documented in only 4 of the 79 cases of maternal death. The number of organ dysfunction markers was highly correlated to the risk of mortality with Pearson’s correlation coefficient of 0.89.ConclusionsWHO’s near-miss approach adequately identifies women at high risk of maternal mortality in Zanzibar’s referral hospital. There is a strong correlation between the number of markers of organ dysfunction and mortality risk.

Incidence and determinants of severe maternal outcome in Jimma University teaching hospital, south-West Ethiopia: a prospective cross-sectional study

BackgroundInvestigating cases of severe maternal morbidity (SMM) and severe maternal outcome (SMO) and the quality of maternal health care using near-miss approach has become popular over recent years. The aim of this study was to determine facility based incidence and the determinants of severe maternal outcome (SMO) using this approach.MethodsProspective cross-sectional study among all mothers who presented to study facility while pregnant, during child birth and/or within 42 days after termination of pregnancy seeking care and found to have SMM and SMO during the study period was carried out.ResultsThere were total of 2737 live births, 202 SMM and 162 SMO (138 maternal near-misses (MNM) and 24 maternal deaths (MD)) cases. The SMO ratio was 59.2 per 1000 live births and the MNM mortality ratio, mortality index (MI) and maternal mortality ratio (MMR) were: 5.8:1, 14.8% and 876.9 per 100,000 live births respectively. Close to three-fourth of all women with SMO had evidence of organ dysfunction on arrival or within 12 h of hospitalization. The commonest underlying causes for SMO were uterine rupture 27%, followed by hypertensive disorders 24% and obstetric hemorrhage 24%. The highest case fatality rate was found to be associated with eclampsia 28%. Maternal age, residential area, educational status and occupation were associated with SMO (P < 0.0001). On binary multivariable logistic regression the occurrence of any delay, intrapartal detection of complication, the mode of delivery and duration of hospitalization had statically significant association with SMO (p < 0.05). Optimal number of antenatal care (ANC) visits and delivery by emergency cesarean section (C/S) were found to be protective of SMO.ConclusionThe occurance SMO in the facility thus in the population served was high. Most of these factors associated with SMO are modifiable; some amenable to social change and the others are within the control of the health system. Thus the finding of this research calls for planning for such changes which can enhance timely and proper detection and management of pregnancy related complications.

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.

Experiences of inequitable care among Afghan mothers surviving near-miss morbidity in Tehran, Iran: a qualitative interview study

BackgroundProviding equitable maternal care to migrants is a seriously challenging task for hosting countries. Iran, the second-most accessed country for refugees from Afghanistan, has achieved maternal health improvement. However, Afghan women with near-miss morbidity faced pre-hospital delays and disparity in maternal care at hospitals. This study explores experiences of maternal care among Afghan women surviving near-miss morbidity to increase insight into healthcare improvements for migrants.MethodsA qualitative study was conducted at university hospitals in Tehran, from April 2013 to May 2014. A total of 11 Afghan women and 4 husbands were interviewed when women recovered from near-miss morbidity that occurred around the childbirth period. Mothers were identified prospectively using the WHO maternal near-miss approach. Thematic analysis was used along with a data-driven approach to organize data guided by the ‘three delays model’ theoretical framework.ResultsMistreatment in the form of discrimination and insufficient medical attention were key experiences. Participants commonly perceived poor women–professional communication and delays in recognizing obstetric complications despite repeated care-seeking. Financial constraints, costly care, lack of health insurance, and low literacy were experienced barriers to accessing care to a lesser extent. Non-somatic consequences of near-miss morbidity affected mothers and families for extended periods.ConclusionsNear-miss survivors’ experiences provided remarkable insights into maternal care of Afghans in Iran. The challenge for the health system and professionals is to provide equitable care with dignity and improve communication skills with caring attitudes toward ethnic minorities. Antenatal visits provide the best and most appropriate opportunities to tackle health illiteracy in Afghan women.

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.

"Near-Miss" Obstetric events and maternal mortality in a Tertiary Care Hospital.

Obstetric near-miss or severe acute maternal morbidity is gaining interest internationally as a new indicator of the quality of obstetric care. This is a retrospective study conducted using "The WHO Near-Miss Approach" to provide insight into obstetric emergencies, near-miss cases, and maternal deaths in our hospital. The maternal near-miss ratio was 8.4/1000 live births, maternal near-miss to mortality ratio was 5.3:1. Hemorrhage was the leading cause (43.7%) of morbidity in near-miss cases while hypertensive disorders were the leading cause in maternal deaths (66.6%). Among women with potentially life-threatening conditions, severe preeclampsia was the most common complication (50.54%). The near-miss approach helps to evaluate and improve the quality of care provided by health system by identifying the pattern of severe maternal morbidity and mortality, strengths and weakness in the referral system and the clinical interventions available and the ways in which improvements can be made.

A cross sectional study of maternal 'near-miss' cases in major public hospitals in Egypt, Lebanon, Palestine and Syria.

BackgroundThe maternal near-miss approach has been increasingly used as a tool to evaluate and improve the quality of care in maternal health. We report findings from the formative stage of a World Health Organization (WHO) funded implementation research study that was undertaken to collect primary data at the facility level on the prevalence, characteristics, and management of maternal near-miss cases in four major public referral hospitals - one each in Egypt, Lebanon, Palestine and Syria.MethodsWe conducted a cross sectional study of maternal near-miss cases in the four contexts beginning in 2011, where we collected data on severe maternal morbidity in the four study hospitals, using the WHO form (Individual Form HRP A65661). In each hospital, a research team including trained hospital healthcare providers carried out the data collection.ResultsA total of 9,063 live birth deliveries were reported during the data collection period across the four settings, with a total of 77 cases of severe maternal outcomes (71 maternal near-miss cases and 6 maternal deaths). Higher indices for the maternal mortality index were found in both Al Galaa hospital, in Egypt (8.6 %) and Dar Al Tawleed hospital in Syria (14.3 %), being large referral hospitals, compared to Ramallah hospital in Palestine and Rafik Hariri University hospital in Lebanon. Compared to the WHO’s Multicountry Survey using the same data collection tool, our study’s mortality indices are higher than the index of 5.6 % among countries with a moderate maternal mortality ratio in the WHO Survey. Overall, haemorrhage-related complications were the most frequent conditions among maternal near-miss cases across the four study hospitals. In all hospitals, coagulation dysfunctions (76.1 %) were the most prevalent dysfunction among maternal near-miss cases, followed by cardiovascular dysfunctions. The coverage of key evidence-based interventions among women experiencing a near-miss was either universal or very high in the study hospitals.ConclusionsFindings from this formative stage confirmed the need for quality improvement interventions. The high reported coverage of the main clinical interventions in the study hospitals would appear to be in contradiction with the above findings as the level of coverage of key evidence-based interventions was high.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0733-7) contains supplementary material, which is available to authorized users.

Implementation of WHO Near-Miss Approach for Maternal Health at a Tertiary Care Hospital: An Audit.

The objective of this study was to evaluate severe maternal outcomes (including maternal deaths and maternal near-miss cases). A prospective study of severe maternal outcomes (including maternal deaths and maternal near-miss cases) from May 2012 to April 2013 was performed. For each woman, data were collected on the occurrence of selected severe pregnancy-related complications, the use of critical interventions, and admissions to intensive care unit. The total number of deliveries were 2340. The number of maternal deaths was three. The natures of the near-miss cases during the study period were recorded. Prevalence of SAMM (severe acute maternal morbidity) was 2.025%. In areas where the maternal mortality is low, there is a need to shift focus to maternal near-miss cases or SAMM, which is a useful adjunct to maternal death enquiries.

Maternal mortality and derivations from the WHO near-miss tool: An institutional experience over a decade in Southern India.

Preceding the use of World Health Organization (WHO) near-miss approach in our institute for the surveillance of Severe Maternal Outcome (SMO), we pilot-tested the tool on maternal death cases that took place over the last 10 years in order to establish its feasibility and usefulness at the institutional level. This was a retrospective review of maternal deaths in Christian Medical College Vellore, India, over a decade. Cases were recorded and analyzed using the WHO near-miss tool. The International Classification of Diseases, 10(th) Revision was used to define and classify maternal mortality. There were 98,139 total births and 212 recorded maternal deaths. Direct causes of mortality constituted 46.96% of total maternal deaths, indirect causes constituted 51.40%, and unknown cases constituted 1.9%. Nonobstetrical cause (48.11%) is the single largest group. Infections (19.8%) other than puerperal sepsis remain an important group, with pulmonary tuberculosis, scrub typhus, and malaria being the leading ones. According to the WHO near-miss criteria, cardiovascular and respiratory dysfunctions are the most frequent organ dysfunctions. Incidence of coagulation dysfunction is seen highest in obstetrical hemorrhage (64%). All women who died had at least one organ dysfunction; 90.54% mothers had two- and 38.52% had four- or more organ involvement. The screening questions of the WHO near-miss tool are particularly instrumental in obtaining a comprehensive assessment of the problem beyond the International Classification of Diseases-Maternal Mortality and establish the need for laboratory-based identification of organ dysfunctions and prompt availability of critical care facilities. The process indicators, on the other hand, inquire about the basic interventions that are more or less widely practiced and therefore give no added information at the institutional level.