1. Introduction

Maternal mortality is a serious health concern in developing country like ours. It projects not only the health status of women and the quality of health care delivery system of the country but also the social status of the women.

Traditionally, evaluation of maternal health relied on the enquiries into the maternal deaths. However, pregnant women’s health care status is not only reflected by the mortality indicators alone. Recently, the concept of reviewing severe acute maternal morbidity, “near miss obstetrics events” has been a useful tool to compliment the mortality indicators ^{[1, 2]}. Near miss events are defined as acute obstetric complications that immediately threatens a women’s survival but do not result in death either by chance or because of hospital care she receives during pregnancy, labour or within six weeks of termination of pregnancy or delivery ^[3]. The advantage of evaluating the near miss cases in adjunct to maternal deaths as compared to mortality alone is that near miss events are more frequent and hence, comprehensive and reliable information can be drawn and rapid audits can be conducted ^{[1, 2, 4, 5]}. At the same time, the survivor herself can be a source of information. As surviving a near miss event mainly occurs because of the care provided, inquiring into the events of near miss would boost up the morale of the care providers and the system unlike in cases of confidential inquiries into maternal deaths.

Usually, severe acute maternal morbidity precedes maternal death. Therefore, identifying and analyzing the cases of maternal near miss helps in understanding the factors that determine maternal mortality ^{[6, 7]}. Also since survival of near miss is based in the health care delivery system, strength and weaknesses of the system can be analyzed. This would help in bringing about improvements and subsequently in decreasing the maternal mortality.

There has been marked improvement in the maternal mortality status of Nepal with Maternal mortality Ratio (MMR) declining from 430 per 100,000 live births in 2000 to 190 per 100,000 live births in 2013 ^[8]. Nevertheless, we have a short time frame to meet the Millennium Development Goal (MDG). Analyzing near miss cases would be of help in adjunct to maternal deaths in bringing about the improvements.

There are many ways of identifying maternal near miss cases using various sets of criteria like disease specific, management specific and organ system dysfunction based. Amongst these, organ system dysfunction based criteria have been noted to be epidemiologically sound and less affected by bias in identifying maternal near miss cases ^[9]. In 2009, World Health Organization (WHO) has developed new system based on organ system dysfunction which incorporates clinical, laboratory and management based criteria for identifying maternal near miss ^[4]. It has been then after recommended that WHO near miss approach for maternal death be uniformly used in analyzing the cases of near miss maternal mortality ^[3], which has been followed in this study for identifying cases of maternal near miss.

Although maternal mortality is extensively reviewed in Nepal, experience with maternal near miss events is limited. Therefore, this study was conducted with the aim to determine the Maternal Near Miss (MNM) indicators and Maternal Deaths (MD). It also aims to find out the causes and nature of the Maternal Near Miss and Maternal Deaths.

2. Methodology

Pokhara is the headquarters of the Western Developmental region of Nepal. Manipal teaching hospital is a tertiary level 700 bedded referral care centre. This is a teaching hospital with undergraduate and postgraduate teaching programs. It serves as a tertiary care referral centre for the whole of Western Nepal. The department of obstetrics and gynecology has 118 beds. Obstetric case load of the department is high with about 250 to 300 monthly deliveries mostly of high risk pregnancies; with 30 to 35% cesarean deliveries. There are high risk pregnancy ward and well equipped labour ward. It provides antenatal care and delivery services to low risk as well as high risk pregnancies not only booked at the centre but referred from all over. Availability of intensive care unit and multidisciplinary services are the added advantage of our centre in managing the high risk cases.

This was a prospective observational study

This study was conducted to find out the maternal near miss and maternal deaths. It was conducted in the department of Obstetrics and Gynaecology of Manipal Teaching Hospital for 24 months from September 2013 to August 2015. Maternal near miss cases were those who met the WHO criteria for maternal near miss. WHO criteria included set of criteria based on clinical, laboratory or management based findings. The WHO criteria for Maternal Near Miss are presented in Table 1.

Table 1. WHO Criteria for Maternal Near Miss Mortality [3]

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View next table

Ethical clearance for the study was taken from the institutional ethical committee of Manipal teaching hospital. The participants were informed about the study and verbal consent taken.

Maternal near miss cases were identified during the morning meetings for handover of cases. They were identified from the labour, high risk pregnancy, postnatal and intensive care units as well. All those cases who met the WHO criteria for maternal near miss were included in the study. Cases of maternal deaths during the period were also reviewed. Data were taken from the patient themselves, from the case chart during the hospital stay and from the team of medical personnel whenever required. Preformed Performa was filled up which included the details of the patients and which criteria are met to be classified as maternal near miss.

Data were entered in the Microsoft excel sheet and analysis was done using simple percentage. Patients’ characteristics like age, parity, gestational age at time of death or near miss, status of booking at the institute, pregnancy and neonatal outcome were analyzed. Patients were categorized as direct or indirect causes of maternal near miss or deaths.

The indices like Maternal Near Miss Rate (MNMR), Mortality Index (MI), and Maternal Near Miss to Maternal Death ratio and maternal mortality ratio were also calculated.

3. Results

There were 40 cases of maternal near miss and 4 cases of maternal deaths. The indicators for maternal near miss and maternal deaths are presented in the following Table 2.

Table 2. Maternal Near Miss Indictors

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

View next table

The maternal characteristics are presented in Table 3.

Table 3. Characteristics of Maternal Near Miss and Maternal Deaths

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

View next table

Most of the maternal near miss mortality cases (90%) were between 20 to 35 years of age. Most of them were multiparous (82%) and were in third trimester (85%) at the time of near miss event.

Majority were not booked at our institute. Two out of 4 patients of maternal deaths were booked at our hospital.

Most of the cases of near miss delivered by vaginal route (42.5%) followed by cesarean section (40%). In one patient laparotomy was done for ruptured ectopic pregnancy. The delivery and its outcome were not known in two patients who had come during second trimester of pregnancy with a near miss event and were discharged later. They did not come later for delivery at our facility.

Table 4. Pregnancy Outcome of Maternal Near Miss and Maternal Deaths

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

View next table

Hypertensive disorders of pregnancy was the leading cause of maternal near miss events (45%) followed by postpartum hemorrhage (22.5%). Infection which is the indirect cause of maternal mortality and morbidity also contributed to 17.5% cases of maternal near miss cases. There was one case of near miss that had pelvic abscess following vaginal delivery. She underwent laparotomy and drainage of abscess. One patient had presented in septic shock and others were due to lower respiratory tract infection following delivery or cesarean section. There were two cases of near miss who presented with cardiovascular failure – both had presented with septic shock requiring use of ionotropes and admission to ICU.

While analyzing the maternal mortality, direct causes like hemoperitoneum post cesarean section and severe preeclampsia and indirect causes like cardiac disorder and intracerebral hemorhage contributed equally to the maternal deaths.

Table 5. Life Threatening Condition in Maternal Near Miss and Maternal Deaths

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

View next table

Hematological system dysfunction was commonly found in cases of maternal near miss requiring massive blood transfusion of more than five units. This was followed by neurological system dysfunction.

Table 6. Organ System Dysfunction in Maternal Near Miss and Maternal Deaths

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

View next table

As many as three- fourth of the women with maternal near miss events required admission to intensive care unit (ICU). Transfusion of the blood and blood products was the intervention done in most of the cases. One patient who had vaginal delivery developed pelvic abscess required laparotomy for drainage of abscess. Re-laparotomy was done in one patient for hemoperitonium following cesarean section. She was a referred case following cesarean section done at district hospital. Postpartum hysterectomy was done in four patients, three for ruptured uterus and one for PPH with morbidly adherent placenta. Craniotomy was done for a patient with pregnancy induced hypertension who developed intracranial hemorrhage in the postpartum period. Mechanical ventilation was required in two patients with eclampsia.

Table 7. Critical Intervention in Maternal Near Miss and Maternal Deaths

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

View next table

Table 8. Timing of Maternal Near Miss Event

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

4. Discussions

Maternal near miss compliments maternal mortality studies to access the maternal health status and the quality of obstetric care. The prevalence of near miss is much higher than the mortality but the causes are more or less similar. The maternal near miss indicators have been suggested to indicate the quality of care ^[10]. The morbidity data have been found to be significant for the policy makers to know the requirements of essential and emergency obstetric care. Morbidity data have been found to be better indicators for designing, monitoring and follow up of safe motherhood programs^{[1, 2, 11]}.

There were 40 cases of maternal near miss and 4 maternal deaths during the study period. The prevalence of maternal near miss was 0.75% of total deliveries. This was similar to other studies which use organ system dysfunction based criteria. ^[9] However, in other studies done in our country prevalence of near miss has been found to be 2.3% ^{[12, 13]}. The higher prevalence is due to different criteria used in identifying the cases of near miss.

The maternal near miss rate(MNMR) is defined as the number of maternal near miss cases to live births. It is as estimation of the amount of care and resources needed in the facility or area. ^[10] The MNMR in our study was 7.7 per 1000 live births. Another study conducted in group of Kathmandu Valley based hospitals showed maternal near miss rate of 3.8 per 1000 live births^[14]. This study had also used WHO organ dysfunction based criteria. Studies from the other countries but using WHO criteria showed MNMR ranging from 9.8 to 23.6 per 1000 live births ^{[15, 16, 17]}. Higher MNMR was found to be more due to difference in the geographical location where these studies were conducted.

Maternal near miss mortality ratio is the ratio of number of cases of near miss to number of maternal deaths, higher ratio indicates better care ^{[3, 18]}. In our study this ratio was 10 meaning that for every 10 life threatening condition, there was one maternal death. Maternal near miss mortality ratio in was 6 to 7.2 in other studies of Nepal ^{[13, 14]}. This indicates better care of patients at our centre. The increase in this ratio over time would indicate improvement in the care provided to the patients. The same ranged from 4.7 to 60, the lower ratio reported in Nigeria to the highest ratio in Syria ^{[15, 16, 17, 19, 20, 21]}.

Mortality index (MI) is defined as the number of maternal deaths divided by the number of women with life threatening condition and is expressed as percentage. Higher index suggest low quality of care as more women with life threatening condition is apt to die and lower index suggest better care. The MI in our study was 9.1% slightly better than those of other local studies while studies from African subcontinent showed high mortality index ^{[17, 19]}. Study in Syria showed a very low index of 1.7% ^[21].

Maternal mortality ratio (MMR) in this study was found to be 76.7 per 100,000 live births much lesser than the country figures as expected as this study was institute based unlike that of country which considers the whole of community as well.

Analyzing the life threatening obstetric event leading to maternal near miss, the two major contributors were hypertensive disorders (45%) and hemorrhage (30%). Postpartum hemorrhage contributed by 22.5%. Infection also contributed to 17.5% cases of maternal near miss. Uterine rupture was seen in 7.5% of cases. In case of maternal mortality, 50% was contributed by direct obstetric causes like PPH and hypertensive disorders and the remaining 50% of deaths were due to indirect cause – congenital heart disease with Eisenmengers syndrome and intracerebral hemorrhage. Hypertensive disorders came second after hemorrhage as a contributing factor of near miss in the other two studies of Nepal ^{[13, 14]} while hypertension was the major contributor in another study ^[12]. Hypertensive disorders have lead to neurological, respiratory, coagulation, renal and cardiac system dysfunction and the cases have been categorized as maternal near miss.

Most of the cases of our study were unbooked (92%) making early detection and management of these cases difficult and leading to severe obstetric morbidity. Amongst 12 cases of near miss with hemorrhage as the life threatening condition, there was 1 case each of ruptured ectopic pregnancy, incomplete abortion and hemoperitoneum following cesarean section. There were 9 cases of PPH, despite the fact that active management of third stage of labour is practiced in all patients delivered at our centre. All these patients required massive blood transfusion. Two out of 3 cases of ruptured uterus occurred after admission at our facility. Similar pattern of life threatening events were seen maternal near miss cases in studies from other parts of the world. ^{[16, 19, 20, 21]}. This indicates that there is so much room for improvement in the antenatal care by making early diagnosis of hypertension possible. Also active management of third stage of labour is to be emphasized to prevent PPH and its consequences. The fact that ruptured uterus had occurred after admission suggests need for improvement in intrapartum care.

Type of organ system dysfunction pattern in our study was similar to that in another study conducted in India ^[21]. Hematological system dysfunction was the commonest organ system affected with nearly 42.5% of cases requiring massive blood transfusion of five or more units. Blood transfusion was needed in all patients with haemorrhage and uterine dysfunction and some with infection. Neurological system (27.5%) came next following the haematological system. Compared to other studies, neurological organ system dysfunction is high in our study ^{[13, 14, 20, 21]} as all these patients met the criteria of poor level of consciousness requiring ICU admission in patients with eclampsia. This was followed by respiratory system (17.5%), coagulation system (12.5%) and uterine dysfunction (10%). Renal and hepatic system dysfunction contributed less to the cases of near miss. Vascular system dysfunction was found to be the commonest organ system to be affected in one study while in other it came second to uterine dysfunction in other ^{[13, 14]}.

ICU admission (72.5%) was the most frequent critical intervention required in our patients as was found in another study ^[13] followed by massive blood transfusion (40%). It was found to be more with almost 67% patients requiring massive blood transfusion in other studies which could be due to different criteria to indicate massive transfusion or due to difference in the organ system affected in these studies ^{[13, 14]}. Surgical intervention was required in 27.5% cases similar to other study ^[14].

Higher number of near miss events and mortality occurring after admission to hospital indicated room for improvements in the hospital care in our study. This pattern was almost similar to the other study ^[13].

5. Conclusion and Recommendation

The maternal near miss cases were almost ten times more common than the maternal deaths. The maternal near miss rate was 7.7 per 1000 live births and the maternal mortality ratio was 76 per 1000 live births. Hypertensive disorders and severe hemorrhage were the major causes of maternal near miss similar to maternal deaths. Therefore, efforts aimed at improving the management of near miss cases would ultimately assist in the reduction of maternal mortality. Evaluating the cases of maternal near miss is recommended to bring about improvements in the maternal health care delivery system.

Competing Interests

The authors hereby declare that there is no competing interest in the study.

Funding

No financial support for the research, authorship and/or publication of this article was received by the authors.

References

[1]	Ronsman C, Fillipi V. Reviewing severe maternal morbidity: learning from survivors from life threatening complications: reviewing deaths and complications to make pregnancy safer. Geneva: World Health Organization; 2004.p.103-24.
	In article
[2]	Pattinson RC, Buchmann E, Mantel G, Schoon M, Rees H. Can enquiries into severe acute maternal morbidity act as a surrogate maternal death enquiries? Br J Obstet Gynaecol 2003; 110:889-93.
	In article		View Article
[3]	Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health. Geneva: World Health Organization; 2011.
	In article
[4]	Say L, Souza JP, Pattison RC. Maternal near miss – towards a standard tool for monitoring quality of maternal health care. Best pract Res Clin Obstet Gynaecol 2009; 23:287-96. PMID: 1903368.
	In article		View Article  PubMed
[5]	Cochet L, Pattinson RC, Macdonald AP. Severe acute maternal morbidity and maternal death audit: a rapid diagnostic tool for evaluating maternal care. S Afr Med J2003; 93:700-2. 8.
	In article
[6]	Stones W, Lim W, Al-Azzawi F, Kelly M. An investigation of maternal morbidity with identification of life-threatening 'near miss” episodes. Health Trends1991; 23:13-5.
	In article		PubMed
[7]	Pattinson RC, Hall M. Near-misses: a useful adjunct to maternal death enquiries. Br Med Bull2003; 67:231-43.
	In article		View Article  PubMed
[8]	Trends in Maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, TheWorld Bank and the United Nations Population Division.
	In article
[9]	Say L, Pattison RC, Gulmezoglu AM. WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss). Reprod Health 2004;1:3.
	In article		View Article  PubMed
[10]	Chhabra P. Maternal Near Miss: An indicator for Maternal Health and Maternal Care. Indian J Community Med 2014; 39(3):132-137.
	In article		View Article  PubMed
[11]	Filippi V, Brugha R, Browne E, Gohou V, Bacci A, De Brouwere V , et al. Obstetric audit in resource poor settings: Lessons from a multi country project auditing “near miss” obstetric emergencies. Health Policy Plan. 200;19:57-66.
	In article		View Article
[12]	Upadhaya I, Chaudhary P. Severe Acute Maternal Morbidity and Intensive care in Paropakar Maternity and Women’s hospital. N.J. obstret. gynaecol. 2013;8(2): 38-41
	In article
[13]	Shrestha NS, Saha R, KArki C. Near miss maternal morbidity and maternal mortality in Kathmandu Medical College Teaching Hospital. Kathmandu Univ Med J (KUMJ)2010;8(2):222-226.
	In article		View Article
[14]	Rana A, Baral G, Dangal G. Maternal near miss: a multicentric surveillance in Kathmandu valley. J Nepal Med Assoc2013;52(190):299-304.
	In article		PubMed
[15]	Luexay P, Malinee L, Pisake L, Marie Helene BC. Maternal near miss and mortality in Sayaboury Province, Lao PDR. BMC Public Health 2014; 14:945
	In article		View Article  PubMed
[16]	Roopa PS, Verma S, Rai L, Kumar P, Pai MC, Shetty J. Near Miss Obstetric events and maternal deaths in a tertiary care hospital: An audit. Journal of Pregnancy 2013, article ID 393758
	In article
[17]	Nelissen EJT, Mduma E, Ersdal HL, Olsen BE, Roosmalen JJM, Stekelenburg J. Maternal near miss and mortality in a rural referral hospital in northern Tanzania: a cross sectional study. BMC
	In article
[18]	Cham M, Sundby J, Vangen S. Availability and quality of emergency obstetrics care in Gambia’s main referral hospital: Women-users’ testimonies. Reprod Health 2009;6:5
	In article		View Article  PubMed
[19]	Oladapo OT, Sule ODu AO, Olatunju AO, Daniel OJ. Near miss obstetric events and maternal deaths in Sagamu, Nigeria: a retrospective study. Reprod Health 2005;2:9.
	In article		View Article  PubMed
[20]	Mustafa R, Hashmi H. Near miss obstetric events and maternal deaths. J Coll Physicians Surg Pak 2009;19(12):781-785.
	In article		PubMed
[21]	Almerie Y, Almerie MQ, Matar HE, Shahrour Y, Chamat AAA, Abdulsalam A. Obstetric near miss and maternal mortality in maternity university hospital, Damascus, Syria: a retrospective study. BMC Pregnancy Childbirth 2010;10:65
	In article		View Article  PubMed
[22]	Taly A, Gupta S, Jain N. Maternal Intensive care and near miss mortality in Obstetrics. J Obstet Gynecol Ind 2004; 54(5):478-482.
	In article