Applicability of the WHO maternal near miss tool in sub-Saharan Africa: a systematic review

Investigating the depression, anxiety, and stress-related factors in near-miss mothers

BACKGROUND

Life-threatening complications during pregnancy and childbirth could have an impact on the physical and mental health of mothers. The present research aimed to investigate the factors related to depression, anxiety, and stress among mothers who have survived maternal near-miss situations.

MATERIALS AND METHODS

This is a descriptive-analytical study, and the data have been collected cross-sectionally. Near-miss mothers who had given birth within the past year were selected through the census method (having at least one criterion of the clinical, laboratory, and management standard of the World Health Organization). The Depression, Anxiety, and Stress Scale (DASS-21) and a demographic questionnaire on personal, family, fertility, and care information were filled out by these mothers.

RESULTS

One hundred fifty-four near-miss mothers were investigated. The findings indicated that lack of social support, domestic violence, and marital dissatisfaction leads to a significant increase in the mean score of depression among near-miss mothers. In addition, according to the findings, an unemployed spouse, low level of education, lack of social support, recent unintended pregnancy, high blood pressure, and bleeding during pregnancy result in a significant increase in the mean score of stress among near-miss mothers. The findings also showed that domestic violence, a history of infertility, heart disease, and bleeding complications significantly increase anxiety in near-miss mothers.

CONCLUSION

Considering the high levels of depression, anxiety, and stress in near-miss mothers, it is of utmost importance to pursue and check up on their mental health, as they are one of the most vulnerable groups in society. It is crucial to provide them support long after discharge to reintegrate these mothers into normal living as per the present study's findings.

Road to maternal death: the pooled estimate of maternal near-miss, its primary causes and determinants in Africa: a systematic review and meta-analysis

BACKGROUND

Maternal near-miss (MNM) is defined by the World Health Organization (WHO) working group as a woman who nearly died but survived a life-threatening condition during pregnancy, childbirth, or within 42 days of termination of pregnancy due to getting quality of care or by chance. Despite the importance of the near-miss concept in enhancing quality of care and maternal health, evidence regarding the prevalence of MNM, its primary causes and its determinants in Africa is sparse; hence, this study aimed to address these gaps.

METHODS

A systematic review and meta-analysis of studies published up to October 31, 2023, was conducted. Electronic databases (PubMed/Medline, Scopus, Web of Science, and Directory of Open Access Journals), Google, and Google Scholar were used to search for relevant studies. Studies from any African country that reported the magnitude and/or determinants of MNM using WHO criteria were included. The data were extracted using a Microsoft Excel 2013 spreadsheet and analysed by STATA version 16. Pooled estimates were performed using a random-effects model with the DerSimonian Laired method. The I2 test was used to analyze the heterogeneity of the included studies.

RESULTS

Sixty-five studies with 968,555 participants were included. The weighted pooled prevalence of MNM in Africa was 73.64/1000 live births (95% CI: 69.17, 78.11). A high prevalence was found in the Eastern and Western African regions: 114.81/1000 live births (95% CI: 104.94, 123.59) and 78.34/1000 live births (95% CI: 67.23, 89.46), respectively. Severe postpartum hemorrhage and severe hypertension were the leading causes of MNM, accounting for 36.15% (95% CI: 31.32, 40.99) and 27.2% (95% CI: 23.95, 31.09), respectively. Being a rural resident, having a low monthly income, long distance to a health facility, not attending formal education, not receiving ANC, experiencing delays in health service, having a previous history of caesarean section, and having pre-existing medical conditions were found to increase the risk of MNM.

CONCLUSION

The pooled prevalence of MNM was high in Africa, especially in the eastern and western regions. There were significant variations in the prevalence of MNM across regions and study periods. Strengthening universal access to education and maternal health services, working together to tackle all three delays through community education and awareness campaigns, improving access to transportation and road infrastructure, and improving the quality of care provided at service delivery points are key to reducing MNM, ultimately improving and ensuring maternal health equity.

A cohort study of maternal near-miss events and its adverse perinatal outcomes: an obstetrical finding in Northwest Ethiopia

BACKGROUND

Globally, various studies have reported that most adverse perinatal outcomes were associated with maternal near-misses. In Ethiopia, studies on adverse perinatal outcomes from maternal near-miss are scarce.

OBJECTIVE

This study aimed to assess the incidence, determinants, and maternal near-miss effects on perinatal outcomes among women at public hospitals in the South Gondar zone in 2021.

STUDY DESIGN

A facility-based prospective cohort study was conducted from January 10, 2021, to May 10, 2021. The chi-square test, multivariable logistic regression methods, and SPSS software were used. The strength of associations and significance level were examined using P values and odds ratios with 95% confidence intervals, respectively. In addition, multicollinearity and model fitness were checked.

RESULTS

A total of 304 respondents (76 exposed and 228 unexposed) were included in the study with a response rate of 100.0%. The incidence rates of adverse perinatal outcomes among exposed and unexposed groups were 71.1% (95% confidence interval, 60.0-73.8) and 21.1% (95% confidence interval, 15.8-28.8), respectively. Multivariable logistic regression showed that short interbirth interval (adjusted odds ratio, 8.39; 95% confidence interval, 5.36-16.08), lower household income (adjusted odds ratio, 3.61; 95% confidence interval, 1.12-6.54), rural residence (adjusted odds ratio, 2.54; 95% confidence interval, 1.21-4.07), previous stillbirth (adjusted odds ratio, 4.24; 95% confidence interval, 1.04-17.31), absence of antenatal care (adjusted odds ratio, 9.84; 95% confidence interval, 4.89-17.51), and anemia (adjusted odds ratio, 4.19; 95% confidence interval, 1.01-17.46) were significantly associated with increased odds of adverse perinatal outcomes.

CONCLUSION

This study revealed that the incidence of adverse perinatal outcomes was significantly higher among exposed groups than unexposed groups. The result signified the need for improving the health of mothers by all stakeholders to improve perinatal outcomes.

Clinical, epidemiological and laboratory characteristics of cases of Covid-19-related maternal near miss and death at referral units in northeastern Brazil: a cohort study

Objective: Covid-19 poses a major risk during pregnancy and postpartum, resulting in an increase in maternal mortality worldwide, including in Brazil; however, little research has been conducted into cases of a near miss. This study aimed to describe the frequency of COVID-19-related near miss and deaths during pregnancy or in the postpartum in referral centers in northeastern Brazil, as well as the clinical, epidemiological, and laboratory characteristics of the women who experienced a severe maternal outcome.Methods: A retrospective and prospective cohort study was performed between April 2020 and June 2021 with hospitalized pregnant and postpartum women with a diagnosis of COVID-19 confirmed by real-time polymerase chain reaction (RT-PCR). Data from five tertiary hospitals in northeastern Brazil were evaluated. Descriptive statistical analysis was performed using Epi Info, version 7.2.5.0.Results: A total of 463 patients were included. Of these, 64 (14% of the sample) had a severe maternal outcome, with 42 cases of near miss (9%) and 22 maternal deaths (5%). Patients who had a severe maternal outcome were predominantly young (median age 30 years) and 65.6% were black or brown-skinned. The women had between 6 and 16 years of schooling; 45.3% had a stable partner; 81.3% were pregnant at the time of admission to the study; and 76.6% required a Cesarean section. The great majority (82.8%) had severe acute respiratory syndrome (SARS). Other complications included hypertensive syndromes (40.6%), pneumonia (37.5%), urinary tract infections (29.7%), acute renal failure (25.0%) and postpartum hemorrhage (21.9%). Sepsis developed in 18.8% of cases, neurological dysfunction in 15.6%, and hepatic dysfunction and septic shock in 14.1% of cases each. The relative frequency of admission to an intensive care unit was 87.5%, while 67.2% of the patients required assisted mechanical ventilation, and 54.7% required noninvasive ventilation. Antibiotics were prescribed in 93.8% of cases and corticosteroids in 71.9%, while blood transfusion was required in 25.0% of cases and renal replacement therapy in 15.6%. Therapeutic anticoagulants were administered to 12.5% of the patients. Of the patients who had a severe maternal outcome, the frequency of respiratory dysfunction was 93.8%, with 50.0% developing neurological dysfunction and 37.5% cardiovascular dysfunction. Hematological dysfunction was found in 29.7%, renal dysfunction in 18.8%, and uterine dysfunction in 14.1%. Hepatic dysfunction occurred in 7.8% of the sample. The near-miss ratio for Covid-19 was 1.6/1000 live births and the maternal mortality ratio for Covid-19 was 84.8/100,000 live births, with a mortality index of 34.4% in the sample.Conclusion: This study revealed a low Covid-19-related maternal near miss (MNM) ratio of 1.6/1000 live births and a high Covid-19-related maternal mortality ratio (MMR) of 84.81/100,000 live births. The mortality index was also high. Most of the patients were admitted while pregnant, were young, married and black or brown-skinned, and none had completed university education. The majority had SARS and required admission to an intensive care unit and mechanical ventilation. Most were submitted to a Cesarean section.

Maternal near-miss prediction model development among pregnant women in Bahir Dar City administration, northwest Ethiopia: a study protocol

INTRODUCTION

Maternal near-miss is a condition when a woman nearly died but survived from complications that happened during pregnancy, childbirth or within 42 days after delivery. Maternal near-miss is more prevalent among women in developing nations. Previous studies have identified the impact of different predictor variables on maternal near-miss but shared prognostic predictors are not adequately explored in Ethiopia. It is therefore necessary to build a clinical prediction model for maternal near-misses in Ethiopia. Hence, the aim of this study is to develop and validate a prognostic prediction model, and generate a risk score for maternal near-miss among pregnant women in Bahir Dar City Administration.

METHODS AND ANALYSIS

A prospective follow-up study design will be employed among 2110 selected pregnant women in the Bahir Dar City administration from 1 May 2023 to 1 April 2024. At the initial antenatal visit, pregnant women will be systematically selected. Then, they will be followed until 42 days following birth. Data will be collected using structured questionnaires and data extraction sheet. The model will be created using Cox proportional hazard regression analysis. The performance of the model will be assessed based on its capacity for discrimination using c-index and calibration using calibration plot, intercept and slope. The model's internal validity will be evaluated through the bootstrapping method. Ultimately, the model will be illustrated through a nomogram and decision tree, which will be made available to prospective users.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Institutional Review Board of the College of Medicine and Health Sciences, Bahir Dar University (protocol number 704/2023). Findings will be published in peer-reviewed journals and local and international seminars, conferences, symposiums and workshops. Manuscripts will be prepared and published in scientifically reputable journals. In addition, policy briefs will be prepared.

"Living in a vacuum": Lived experiences of maternal near-miss among women with placenta accreta spectrum

BACKGROUND

Placenta accreta spectrum (PAS) is one of the life-threatening complications of pregnancy, the prevalence of which has increased in parallel with the caesarean section rate.

OBJECTIVE

The purpose of this study was to investigate the experiences of mothers with PAS who have also experienced maternal near miss.

METHODS

The participants of this study included 8 mothers who had experienced near miss due to placenta accreta during the past year, as well as two husbands and two health care professionals. Data collection was done using face-to-face, in-depth virtual and in-person interviews. In this qualitative study, the interpretive phenomenological analysis approach was used to analyse the data.

RESULTS

The superordinate theme that emerged from the lived experiences of the studied mothers is 'Living in a vacuum', which was derived from 3 main themes. The theme of 'distorted identity' is related to the mothers' experience of losing the uterus as a symbol of femininity and nostalgia for the former self. The theme of 'exacerbated exhaustion' indicates the burnout and fatigue perceived by these mothers and has dimensions far beyond the exhaustion caused by performing parenting duties. The third theme, 'a threatened future', reflects these mothers' vague image of the future in terms of health, preservation of life, and the continuation of living together with the husband.

CONCLUSIONS

It seems that mothers with PAS need to be covered by integrated and well-organised psycho-social support from the time they are diagnosed with the complication until long after delivery due to the high potentiality of maternal near miss.

Examining maternal morbidity across a spectrum of delivery locations: An analysis of the Global Network's Maternal and Neonatal Health Registry

OBJECTIVE

To better understand maternal morbidity, using quality data from low- and middle-income countries (LMICs), including out-of-hospital deliveries. Additionally, to compare to the WHO estimate that maternal morbidity occurs in 15% of pregnancies, which is based largely on hospital-level data.

METHODS

The Global Network for Women's and Children's Health Research Maternal Newborn Health Registry collected data on all pregnancies from seven sites in six LMICs between 2015 and 2020. Rates of maternal mortality and morbidity and the differences in morbidity across delivery location and birth attendant type were evaluated.

RESULTS

Among the 280 584 deliveries included in the present analysis, the overall maternal mortality ratio was 138 per 100 000, while 11.7% of women experienced at least one morbidity. Rates of morbidity were generally higher for deliveries occurring within hospitals (19.8%) and by physicians (23.6%). The lowest rates of morbidity were noted among women delivering in non-hospital healthcare facilities (5.6%) or with non-physician clinicians (e.g. nurses, midwives [5.4%]).

CONCLUSION

The present study shows important differences in reported maternal morbidity across delivery sites, with a trend towards lower morbidity in non-hospital healthcare facilities and among non-physician clinicians.

External validation of the Maternal Severity Index for predicting maternal death following potentially life-threatening complications during pregnancy and childbirth: a single-centre, prospective observational study

OBJECTIVES

To perform an external validation to assess the usefulness of the Maternal Severity Index (MSI) in predicting maternal death among women with potentially life-threatening complications during pregnancy or childbirth.

DESIGN

Prospective observational study.

SETTING

A tertiary referral centre in southeastern India.

PARTICIPANTS

1833 women with potentially life-threatening complications identified using the WHO criteria.

PREDICTOR ASSESSED

MSI calculated based on the severity markers of the WHO criteria for maternal near-miss.

PRIMARY OUTCOME

Maternal death.

STATISTICAL ANALYSIS

Receiver operating characteristics (ROC) curve analysis was performed to assess discriminative performance, and agreement between expected and observed deaths was plotted to determine calibration.

RESULTS

The incidence of severe maternal outcomes was 10 per 1000 live births. There were 57 (151 per 100 000 live births) maternal deaths during the study period. Maternal Severity Score was significantly higher among those who died (2.8±1.3 vs 2.0±1.2, p<0.001). The mean MSI value was 1.03% (95% CI 0.7% to 1.2%). ROC curve analysis showed good discrimination (AUC(Area Under the Curve): 0.962, 95% CI 0.952 to 0.970); however, overfitting was seen with higher probabilities. The standardised mortality ratio (SMR) was 0.02 (95% CI 0.01 to 0.02), indicating good quality of care.

CONCLUSIONS

The MSI has good discriminative performance in distinguishing who succumbs to life-threatening complications, but needs recalibration to avoid overfitting. SMR of less than 0.5 indicates fewer than expected deaths, suggesting good quality of care in reducing maternal mortality in the study population.

Obstructed labor and its effect on adverse maternal and fetal outcomes in Ethiopia: A systematic review and meta-analysis

Background

Obstructed labor is one of the five major causes of maternal mortality and morbidity in developing countries. In Ethiopia, it accounts for 19.1% of maternal death. The current review aimed to assess maternal and perinatal outcomes of obstructed labor in Ethiopia.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed for this systematic review and meta-analysis. A literature search was made using PubMed/MEDLINE, CINAHL, Summon country-specific search, and Cochrane Libraries’ online databases. Search terms were adverse outcome, obstructed labor, maternal outcome, fetal outcome, and Ethiopia. The Newcastle-Ottawa scale (NOS), based on a star scoring system, was used to assess the quality of the included studies. The meta-analysis was conducted using STATA 16 software. The pooled prevalence of an adverse maternal outcome, fetal outcome, and association between adverse outcome and obstructed labor was calculated using a random-effects model. Egger’s test and funnel plot were used to evaluate publication bias.

Result

Eighty-seven studies were included in this review, with an overall sample size of 104259 women and 4952 newborns. The pooled incidence of maternal death was estimated to be 14.4% [14.14 (6.91–21.37). The pooled prevalence of uterine rupture and maternal near-miss was 41.18% (95% CI: 19.83, 62.54) and 30.5% [30.5 (11.40, 49.59) respectively. Other complications such as postpartum hemorrhage, sepsis, obstetric fistula, hysterectomy, bladder injury, cesarean section, and labor abnormalities were also reported. The pooled prevalence of perinatal death was 26.4% (26.4 (95% CI 15.18, 37.7). In addition, the association of obstructed labor with stillbirth, perinatal asphyxia, and meconium-stained amniotic fluid was also demonstrated.

Conclusions

In Ethiopia, the incidence of perinatal and maternal mortality among pregnant women with obstructed labor was high. The rate of maternal death and maternal near miss reported in this review was higher than incidences reported from high-income and most low and middle-income countries. Uterine rupture, postpartum hemorrhage, sepsis, fistula, hysterectomy, and bladder injury were also commonly reported. To improve the health outcomes of obstructed labor, it is recommended to address the three delay models: enhancing communities’ health-seeking behavior, enhancing transportation for an obstetric emergency with different stakeholders, and strengthening the capacity of health facilities to handle obstetric emergencies.

Every maternal near-miss counts: Need for a national audit in South Africa? A mixed-methods study

Background. To improve maternal health, studies of maternal morbidity are increasingly being used to evaluate the quality of maternity care, in addition to studies of mortality. While South Africa (SA) has a well-established confidential enquiry into maternal deaths, there is currently no structure in place to systematically collect and analyse maternal near-misses (MNMs) at national level.Objectives. To synthesise MNM indicators and causes in SA by performing a systematic literature search, and to investigate perceived needs for data collection related to MNMs and determine whether the MNM tool from the World Health Organization (WHO-MNM) would require adaptations in order to be implemented.Methods. The study used a mixed-methods approach. A systematic literature search was conducted to find all published data on MNM audits in SA. Semi-structured interviews were conducted virtually with maternal health experts throughout the country who had been involved in studies of MNMs, and main themes arising in the interviews were synthesised. A method for MNM data collection for SA use was discussed with these experts.Results. The literature search yielded 797 articles, 15 of which met the WHO-MNM or Mantel et al. severe acute maternal morbidity criteria. The median (interquartile range) MNM incidence ratio in SA was 8.4/1 000 (5.6 - 8.7) live births, the median maternal mortality ratio was 130/100 000 (71.4 - 226) live births, and the median mortality index was 16.6% (11.7 - 18.8). The main causes of MNMs were hypertensive disorders of pregnancy and obstetric haemorrhage. Eight maternal health experts were interviewed from May 2020 to February 2021. All participants focused on the challenges of implementing a national MNM audit, yet noted the urgent need for one. Recognition of MNMs as an indicator of quality of maternity care was considered to lead to improved management earlier in the chain of events, thereby possibly preventing mortality. Obtaining qualitative information from women with MNMs was perceived as an important opportunity to improve the maternity care system. Participants suggested that the WHO-MNM tool would have to be adapted into a simplified tool with more clearly defined criteria and a number of specific diagnoses relevant to the SA setting. This ‘Maternal near-miss: Inclusion criteria and data collection form’ is provided as a supplementary file.Conclusion. Adding MNMs to the existing confidential maternal death enquiry could potentially contribute to a more robust audit with data that may inform health systems planning. This was perceived by SA experts to be valuable, but would require context-specific adaptations to the WHO-MNM tool. The available body of evidence is sufficient to justify moving to implementation.

The global use of the International Classification of Diseases to Perinatal Mortality (ICD-PM): A systematic review

Background

The World Health Organization launched the International Classification of Diseases for Perinatal Mortality (ICD-PM) in 2016 to uniformly report on the causes of perinatal deaths. In this systematic review, we aim to describe the global use of the ICD-PM by reporting causes of perinatal mortality and summarizing challenges and suggested amendments.

Methods

We systematically searched MEDLINE, Embase, Global Health, and CINAHL databases using key terms related to perinatal mortality and the classification for causes of death. We included studies that applied the ICD-PM and were published between January 2016 and June 2021. The ICD-PM data were extracted and a qualitative analysis was performed to summarize the challenges of the ICD-PM. We applied the PRISMA guidelines, registered our protocol at PROSPERO [CRD42020203466], and used the Appraisal tool for Cross-Sectional Studies (AXIS) as a framework to evaluate the quality of evidence.

Results

The search retrieved 6599 reports. Of these, we included 15 studies that applied the ICD-PM to 44 900 perinatal deaths. Most causes varied widely; for example, "antepartum hypoxia" was the cause of stillbirths in 0% to 46% (median = 12%, n = 95) in low-income settings, 0% to 62% (median = 6%, n = 1159) in middle-income settings and 0% to 55% (median = 5%, n = 249) in high-income settings. Five studies reported challenges and suggested amendments to the ICD-PM. The most frequently reported challenges included the high proportion of antepartum deaths of unspecified cause (five studies), the inability to determine the cause of death when the timing of death is unknown (three studies), and the challenge of assigning one cause in case of multiple contributing conditions (three studies).

Conclusions

The ICD-PM is increasingly being used across the globe and gives health care providers insight into the causes of perinatal death in different settings. However, there is wide variation in reported causes of perinatal death across comparable settings, which suggests that the ICD-PM is applied inconsistently. We summarized the suggested amendments and made additional recommendations to improve the use of the ICD-PM and help strengthen its consistency.

Registration

PROSPERO [CRD42020203466].

Global and regional estimates of maternal near miss: a systematic review, meta-analysis and experiences with application

Introduction

Maternal near miss (MNM) is a useful means to examine quality of obstetric care. Since the introduction of the WHO MNM criteria in 2011, it has been tested and validated, and is being used globally. We sought to systematically review all available studies using the WHO MNM criteria to develop global and regional estimates of MNM frequency and examine its application across settings.

Methods

We conducted a systematic review by implementing a comprehensive literature search from 2011 to 2018 in six databases with no language restrictions. The predefined data collection tool included sections on study characteristics, frequency of near-miss cases and study quality. Meta-analysis was performed by regional groupings. Reported adaptations, modifications and remarks about application were extracted.

Results

7292 articles were screened by title and abstract, and 264 articles were retrieved for full text review for the meta-analysis. An additional 230 articles were screened for experiences with application of the WHO MNM criteria. Sixty studies with near-miss data from 56 countries were included in the meta-analysis. The pooled global near-miss estimate was 1.4% (95% CI 0.4% to 2.5%) with regional variation in MNM frequency. Of the 20 studies that made adaptations to the criteria, 19 were from low-resource settings where lab-based criteria were adapted due to resource limitations.

Conclusions

The WHO MNM criteria have enabled the comparison of global and sub-national estimates of MNM frequency. There has been good uptake in low-resource countries but contextual adaptations are necessary.

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

BACKGROUND

Maternal 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.

OBJECTIVE

This 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 DESIGN

This 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.

RESULTS

Overall, 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%.

CONCLUSION

Maternal 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.

Severe maternal morbidity and its associated factors: A cross-sectional study in Morang district, Nepal

BACKGROUND

Understanding maternal morbidity and its determinants can help identify opportunities to prevent obstetric complications and improvements for maternal health. This study was conducted to determine the prevalence of severe maternal morbidity (SMM) and the associated factors.

METHODS

A hospital-based cross-sectional study was conducted at Koshi Hospital, Nepal, from January to March 2020. All women who met the inclusion criteria of age ≥18 years of age, Morang residents of Nepalese nationality, had received routine antenatal care, and given birth at Koshi Hospital were recruited consecutively. The World Health Organization criteria were used to identify the women with SMM. A multiple logistic regression analysis was performed. Overall, 346 women were recruited.

FINDINGS

The prevalence of SMM was 6.6%. Among the SMM cases, the most frequently occurring SMM conditions were hypertensive disorders (12, 56.5%), hemorrhagic disorders (6, 26.1%), and severe management indicators (8, 34.8%). Women with no or primary education (adjusted odds ratio: 0.10, 95% confidence interval: 0.01, 0.76) decreased the odds of SMM compared to secondary education.

CONCLUSION

The approximately 7% prevalence of SMM correlated with global studies. Maternal education was significantly associated with SMM. If referral hospitals were aware of the expected prevalence of potentially life-threatening maternal conditions, they could plan to avert future reproductive complications.

Maternal near-miss and mortality in a teaching hospital in Tigray region, Northern Ethiopia

Objective:

This study seeks to examine the prevalence of maternal morbidities and deaths in Ayder Comprehensive Specialized Hospital from 1 July 2018 to 30 June 2019.

Methods:

This was a cross-sectional study. Total purposive sampling method was employed to collect data prospectively using modified World Health Organization criteria for baseline assessment of maternal near-miss and mortality. Pregnant women or those who are within 42 days postpartum/any form of pregnancy termination that satisfy the inclusion criteria were enrolled.

Results:

A total of 691 mothers were recorded as having severe maternal complications. Out of these, 170 women developed severe maternal outcome, ending with 146 maternal near-miss cases and 24 maternal deaths. The maternal near-miss ratio and maternal mortality ratio were 28.5 per 1000 live births and 469.1 per 100,000 live births, respectively. The overall mortality index was 14%. The top underlying causes of severe maternal complications were the infamous triads of preeclampsia (n = 303, 43.8%), obstetric hemorrhage (n = 166, 24.0%) and sepsis (n = 130, 18.8%). About 62.5% of mothers who died were not admitted to intensive care unit.

Conclusion:

This study found that the infamous triads of preeclampsia, obstetric hemorrhage and sepsis persist as the commonest causes of severe maternal complications in the study area. A significant number of women with severe maternal outcome were not admitted to intensive care unit. It also highlights that the severe maternal complications, severe maternal outcome, maternal near-miss ratio and mortality index in the study area are disproportionately higher than the global average. These staggering numbers call for a system re-thinking at multiple junctures.

How communication can help women who experience a maternal near-miss: a qualitative study from Tanzania

OBJECTIVES

This study aimed to explore experiences of communication as an element of quality of care, among women surviving a maternal near-miss event, thus women who nearly died but survived haemorrhage, or pre-eclampsia complication during pregnancy, childbirth or within 42 days of termination of pregnancy.

DESIGN

A descriptive, phenomenological, qualitative study using semistructured interviews with women who survived a maternal near-miss in Southern Tanzania.

SETTING

The participants were recruited from two selected hospitals in Mtwara Region, where women sought child birth care and developed near-miss condition.

PARTICIPANTS

Participants for this study were women who experienced and survived a maternal near-miss event and who had lived in the study area for at least 1 year. Women were recruited using an adapted version of the WHO criteria for maternal near-miss.

DATA COLLECTION

We identified 16 women and were able to conduct 10 in-depth interviews with women at their homes, 4 weeks after they were discharged. The interviews were audiorecorded and transcribed and translated word for word from Kiswahili. Thematic analysis was used to identify emerging themes.

RESULTS

Three major themes evolved: (1) Being informed about the care and interaction, (2) Being engaged and encouraged and (3) Being afraid to ask questions. The study highlighted that good communication with women during the provision of care helped women feel grateful, supported and cared for. Women who were unconscious during care were often not informed later of what happened. This created some negative feelings and anxiety.

CONCLUSION

This study highlights the importance of communication, and of being informed of what happened and why. Empathetic communication with sufficient explanation on what happened and why created trust among women-a positive finding which should encourage the development of consistent approaches to strengthen healthcare provider communication skills.

Maternal mortality: near-miss events in middle-income countries, a systematic review

OBJECTIVE

To describe the incidence and main causes of maternal near-miss events in middle-income countries using the World Health Organization's (WHO) maternal near-miss tool and to evaluate its applicability in these settings.

METHODS

We did a systematic review of studies on maternal near misses in middle-income countries published over 2009-2020. We extracted data on number of live births, number of maternal near misses, major causes of maternal near miss and most frequent organ dysfunction. We extracted, or calculated, the maternal near-miss ratio, maternal mortality ratio and mortality index. We also noted descriptions of researchers' experiences and modifications of the WHO tool for local use.

FINDINGS

We included 69 studies from 26 countries (12 lower-middle- and 14 upper-middle-income countries). Studies reported a total of 50 552 maternal near misses out of 10 450 482 live births. Median number of cases of maternal near miss per 1000 live births was 15.9 (interquartile range, IQR: 8.9-34.7) in lower-middle- and 7.8 (IQR: 5.0-9.6) in upper-middle-income countries, with considerable variation between and within countries. The most frequent causes of near miss were obstetric haemorrhage in 19/40 studies in lower-middle-income countries and hypertensive disorders in 15/29 studies in upper-middle-income countries. Around half the studies recommended adaptations to the laboratory and management criteria to avoid underestimation of cases of near miss, as well as clearer guidance to avoid different interpretations of the tool.

CONCLUSION

In several countries, adaptations of the WHO near-miss tool to the local context were suggested, possibly hampering international comparisons, but facilitating locally relevant audits to learn lessons.

Severe maternal morbidity in the Asia Pacific: a systematic review and meta-analysis

BACKGROUND

Monitoring rates of severe maternal morbidity (such as eclampsia and uterine rupture) is useful to assess the quality of obstetric care, particularly in low and lower-middle-income countries (LMICs).

METHODS

We undertook a systematic review characterising the proportion and causes of severe maternal morbidity in the Asia Pacific region. We searched Medline, Embase, Cochrane CENTRAL library and the World Health Organization Western Pacific Index database for studies in the Asia-Pacific reporting maternal morbidity/near miss using a predefined search strategy. We included cohort, case-control and cross-sectional studies published in English before September 2020. A meta-analysis was performed calculating the overall proportion of near miss events by sub-region, country, near miss definition, economic status, setting and cause using a random-effects model.

FINDINGS

We identified 26,232 articles, screened 24,306 and retrieved 454 full text articles. Of these, 197 studies spanning 27 countries were included. 13 countries in the region were not represented. There were 30,183,608 pregnancies and 100,011 near misses included. The total proportion of near miss events was 4•4 (95% CI 4•3-4•5) per 1000 total births. The greatest proportion of near misses were found in the Western Pacific region (around Papua New Guinea) at 11•8 per 1000 births (95% CI 6•6-17•1; I² 96.05%). Low-income countries displayed the greatest proportion of near misses (13•4, 95% CI 6•0-20•7), followed by lower-middle income countries (11•1; 95% CI 10•4 - 11•9). High-income countries had the lowest proportion (2•2, 95% CI 2•1-2•3). Postpartum haemorrhage was the most common near miss event (5•9, 95% CI 4•5-7•2), followed by eclampsia (2•7, 95% CI 2•4 - 2•9).

INTERPRETATION

There is a high burden of severe maternal morbidity in the Asia-Pacific. LMICs are disproportionately affected. Most of the common causes are preventable. This provides an opportunity to implement targeted interventions which could have major clinical impact.

Diagnostic performance of two different maternal near-miss approaches in a High Obstetric Risk Unit

Maternal near-miss (MNM) is a maternal quality care indicator. The World Health Organization (WHO) defines it as a state in which a woman nearly dies but survives due to a complication during pregnancy, birth, or puerperium. The Latin American Federation of Obstetrics and Gynecology (FLASOG) and the Colombian National Health Institute (INS) established recommendations for the event's epidemiological surveillance; nonetheless, the operational definitions of the cases are different. This retrospective study examined the approaches of FLASOG and INS versus the WHO approach (gold standard) for the assessment of MNM in a high obstetric risk unit. Patients admitted with at least one criterion of the WHO, FLASOG, or INS approach for the definition of MNM from March 2016 to March 2017 were included. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were evaluated, as well as the Receiver Operating Characteristics (ROC) curve of the FLASOG and INS. MNM classification compared to WHO system as reference. The results highlight that the WHO classification establishes very high boundaries for some of the diagnostic criteria and the lack of standardization of the MNM criteria among the different proposals in Latin America hinders the applicability in Colombia and other countries with a similar situation.

Abortion-related near-miss morbidity and mortality in 43 health facilities with differences in readiness to provide abortion care in Uganda

Introduction

With a view to inform policy for improved postabortion care, we describe abortion-related near-miss and mortality by sociodemographic risk factors and management options by pregnancy trimester in Uganda.

Methods

This secondary data analysis used an adapted WHO near-miss methodology to collect cross-sectional maternal near-miss and abortion complications data at 43 health facilities in Central and Eastern Uganda in 2016–2017. We computed abortion severe morbidity, near-miss and mortality ratios per 100 000 live births, and described the proportion of cases that worsened to an abortion near-miss or death, stratified by geographical region and trimester. We tested for association between independent variables and abortion near-miss, and obtained prevalence ratios for association between second trimester near-miss and independent demographic and management indicators. We assessed health facility readiness for postabortion care provision in Central and Eastern regions.

Results

Of 3315 recorded severe abortion morbidity cases, 1507 were near-misses. Severe abortion morbidity, near-miss and mortality ratios were 2063, 938 and 23 per 100 000 live births, respectively. Abortion-related mortality ratios were 11 and 57 per 100 000 in Central and Eastern regions, respectively. Abortion near-miss cases were significantly associated with referral (p<0.001). Second trimester had greater abortion mortality than first trimester. Eastern region had greater abortion-related morbidity and mortality than Central region with facilities in the former characterised by inferior readiness to provide postabortion care.

Conclusions

Uganda has a major abortion near-miss morbidity and mortality; with mortality higher in the second trimester. Life-saving commodities are lacking especially in Eastern region compromising facility readiness for postabortion care provision.

Effects of antenatal care service utilization on maternal near miss in Gamo Gofa zone, southern Ethiopia: retrospective cohort study

Background

Antenatal care (ANC) provides an opportunity to prevent, identify and intervene maternal health problems. Maternal near miss (MNM), as an indicator of maternal health, is increasingly gaining global attention to measure these problems. However, little has been done to measure the effect of ANC on MNM in Ethiopia. Therefore, this study is aimed at determining the effect of ANC on MNM and its associated predictors at Gamo Gofa zone, southern Ethiopia.

Methods

Employing a retrospective cohort study design, 3 years data of 1440 pregnant mothers (480 ANC attendant and 960 non-attendant) were collected from all hospitals in the zone. Taking ANC visit as an exposure variable; we used a pretested checklist to extract relevant information from the study participants’ medical records. Characteristics of study participants, their ANC attendance status, MNM rates and associated predictors were determined.

Results

Twenty-five (5.2%) ANC attendant and seventy-one (7.4%) non-attendant mothers experienced MNM, (X² = 2,46, df = 2, p = 0.12). The incidence rates were 59.6 (95% CI: 40.6–88.2) and 86.1 (95%CI: 67.3–107.2)/1000 person-years for the ANC attendant and non-attendant mothers, respectively. Mothers who were living in rural areas had higher hazard ratio of experiencing MNM than those who were living in urban areas, with an adjusted hazard ratio (AHR) of 1.68 (95% CI, 1.01, 2.78).

Conclusion

ANC attendance tended to reduce MNM. However, late initiation and loss to follow-up were higher in the current study. Therefore, on time initiation and consistent utilization of ANC are required.

Maternal near miss among women admitted in major private hospitals in eastern Ethiopia: a retrospective study

BACKGROUND

Since maternal mortality is a rare event, maternal near miss has been used as a proxy indicator for measuring maternal health. Maternal near miss (MNM) refers to a woman who nearly died but survived of complications during pregnancy, childbirth or within 42 days of termination of pregnancy. Although study of MNM in Ethiopia is becoming common, it is limited to public facilities leaving private facilities aside. The objective of this study was to assess MNM among women admitted in major private hospitals in eastern Ethiopia.

METHODS

An institution based retrospective study was conducted from March 05 to 31, 2020 in two major private hospitals in Harar and Dire Dawa, eastern Ethiopia. The records of all women who were admitted during pregnancy, delivery or within 42 days of termination of pregnancy was reviewed for the presence of MNM criteria as per the sub-Saharan African MNM criteria. Descriptive analysis was done by computing proportion, ratio and means. Factors associated with MNM were assessed using binary logistic regression with adjusted odds ratio (aOR) along with its 95% confidence interval (CI).

RESULTS

Of 1214 pregnant or postpartum women receiving care between January 09, 2019 and February 08, 2020, 111 women developed life-threatening conditions: 108 MNM and 3 maternal deaths. In the same period, 1173 live births were registered, resulting in an MNM ratio of 92.1 per 1000 live births. Anemia in the index pregnancy (aOR: 5.03; 95%CI: 3.12-8.13), having chronic hypertension (aOR: 3.13; 95% CI: 1.57-6.26), no antenatal care (aOR: 3.04; 95% CI: 1.58-5.83), being > 35 years old (aOR: 2.29; 95%CI: 1.22-4.29), and previous cesarean section (aOR: 4.48; 95% CI: 2.67-7.53) were significantly associated with MNM.

CONCLUSIONS

Close to a tenth of women admitted to major private hospitals in eastern Ethiopia developed MNM. Women with anemia, history of cesarean section, and old age should be prioritized for preventing and managing MNM. Strengthening antenatal care and early screening of chronic conditions including hypertension is essential for preventing MNM.

Determinants of maternal near-miss in private hospitals in eastern Ethiopia: A nested case–control study

Objective:

Maternal near-miss refers to a woman who nearly died but survived complications in pregnancy, childbirth, or within 42 days of termination of pregnancy. The study of maternal near-miss has become essential for improving the quality of obstetric care. The objective of this study was to identify the determinants of maternal near-miss among women admitted to major private hospitals in eastern Ethiopia.

Method:

An unmatched nested case–control study was conducted in major private hospitals in eastern Ethiopia from 5 March to 31 March 2020. Cases were women who fulfilled the sub-Saharan African maternal near-miss criteria and those admitted to the same hospitals but discharged without any complications under the sub-Saharan African maternal near-miss tool were controls. For each case, three corresponding women were randomly selected as controls. Factors associated with maternal near-misses were analyzed using binary and multiple logistic regressions with an adjusted odds ratio along with a 95% confidence interval. Finally, p-value < 0.05 was considered as a cut-off point for the significant association.

Results:

A total of 432 women (108 cases and 324 controls) participated in the study. History of prior cesarean section (AOR = 4.33; 95% CI = 2.36–7.94), anemia in index pregnancy (AOR = 4.38; 95% CI = 2.43–7.91), being ⩾ 35 years of age (AOR = 2.94; 95% CI = 1.37–6.24), not attending antenatal care (AOR = 3.11; 95% CI = 1.43–6.78), and history of chronic medical disorders (AOR = 2.18; 95% CI = 1.03–4.59) were independently associated with maternal near-miss.

Conclusion:

Maternal age ⩾ 35 years, had no antenatal care, had prior cesarean section, being anemic in index pregnancy, and have history of chronic medical disorders were the determinants of maternal near-miss. Improving maternal near-misses requires strengthening antenatal care (including supplementation of iron and folic acid to reduce anemia) and prioritizing women with a history of chronic medical illnesses. Interventions for preventing primary cesarean sections are crucial in this era of the cesarean epidemic to minimize its effect on maternal near-miss.

Maternal near miss: reaching the last mile

Maternal mortality misses the morbidity associated with pregnancy and delivery. Maternal Near Miss is an alternate measure that reflects maternal morbidity and in areas with low maternal mortality improves comparability. Maternal Near Miss is a proxy indicator of the quality of healthcare services and helps in understanding health system failures with relation to obstetric care and addressing them. But regional variations in availability of resources have led to a dozen different adapted versions of WHO Maternal Near Miss criteria. This creates confusion and reduces comparability, nationally and internationally. A review of articles defining maternal near miss was conducted using a PubMed search to compare and assess the various definitions of MNM. The present article summarises the available criteria and discusses the advantages and drawbacks of WHO MNM criteria as compared to others. The objective is to impress the need to have comprehensive criteria that can be applied in different settings and ensure comparability.Impact statementWhat is already known on this subject? Many different definitions and criteria to diagnose Maternal Near Miss are available. They are diverse, thereby reducing comparability both nationally and internationally.What do the results of this study add? This article summarises the differences in the available definitions and classifying criteria. It also highlights the difficulty in usage of the criteria in different settings.What are the implications of these findings for clinical practice and/or further research? This calls for researchers working in areas of maternal health to further simplify the definitions and criteria used for identification of Maternal Near Miss to improve comparability and uniformity.

Applicability of the WHO maternal near-miss tool: A nationwide surveillance study in Suriname

BACKGROUND

Maternal near-miss (MNM) is an important maternal health quality-of-care indicator. To facilitate comparison between countries, the World Health Organization (WHO) developed the "MNM-tool". However, several low- and middle-income countries have proposed adaptations to prevent underreporting, ie, Namibian and Sub-Sahara African (SSA)-criteria. This study aims to assess MNM and associated factors in middle-income country Suriname by applying the three different MNM tools.

METHODS

A nationwide prospective population-based cohort study was conducted using the Suriname Obstetric Surveillance System (SurOSS). We included women with MNM-criteria defined by WHO-, Namibian- and SSA-tools during one year (March 2017-February 2018) and used hospital births (86% of total) as a reference group.

RESULTS

There were 9114 hospital live births in Suriname in the one-year study period. SurOSS identified 71 women with WHO-MNM (8/1000 live births, mortality-index 12%), 118 with Namibian-MNM (13/1000 live births, mortality-index 8%), and 242 with SSA-MNM (27/1000 live births, mortality-index 4%). Namibian- and SSA-tools identified all women with WHO-criteria. Blood transfusion thresholds and eclampsia explained the majority of differences in MNM prevalence. Eclampsia was not considered a WHO-MNM in 80% (n = 35/44) of cases. Nevertheless, mortality-index for MNM with hypertensive disorders was 17% and the most frequent underlying cause of maternal deaths (n = 4/10, 40%) and MNM (n = 24/71, 34%). Women of advanced age and maroon ethnicity had twice the odds of WHO-MNM (respectively adjusted odds ratio (aOR) = 2.6, 95% confidence interval (CI) = 1.4-4.8 and aOR = 2.0, 95% CI = 1.2-3.6). The stillbirths rate among women with WHO-MNM was 193/1000births, with six times higher odds than women without MNM (aOR = 6.8, 95%CI = 3.0-15.8). While the prevalence and mortality-index differ between the three MNM tools, the underlying causes of and factors associated with MNM were comparable.

CONCLUSIONS

The MNM ratio in Suriname is comparable to other countries in the region. The WHO-tool underestimates the prevalence of MNM (high mortality-index), while the adapted tools may overestimate MNM and compromise global comparability. Contextualized MNM-criteria per obstetric transition stage may improve comparability and reduce underreporting. While MNM studies facilitate international comparison, audit will remain necessary to identify shortfalls in quality-of-care and improve maternal outcomes.

Quality and women's satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review

Background

sub-Saharan African Low and Lower-Middle Income Countries (sSA LLMICs) have the highest burden of maternal and perinatal morbidity and mortality in the world. Timely and appropriate maternal referral to a suitable health facility is an indicator of effective health systems. In this systematic review we aimed to identify which referral practices are delivered according to accepted standards for pregnant women and newborns in sSA LLMICs by competent healthcare providers in line with the needs of pregnant women.

Methods

Six electronic databases were systematically searched for primary data studies (2009–2018) in English reporting on maternal referral practices and their effectiveness. We conducted a content analysis guided by a framework for assessing the quality of maternal referral. Quality referral was defined as: timely identification of signal functions, established guidelines or standards, adequate documentation, staff accompaniment and prompt care by competent healthcare providers in the receiving facility.

Results

Seventeen articles were included in the study. Most studies were quantitative (n = 11). Two studies reported that women were dissatisfied due to delays in referral processes that affected their health. Most articles (10) reported that women were not accompanied to higher levels of care, delays in referral processes, transport challenges and poor referral documentation. Some healthcare providers administered essential drugs such as misoprostol prior to referral.

Conclusions

Efforts to improve maternal health in LLMICs should aim to enhance maternity care providers’ ability to identify conditions that demand referral. Low cost transport is needed to mitigate barriers of referral. To ensure quality maternal referral, district level health managers should be trained and equipped with the skills needed to monitor and evaluate referral documentation, including quality and efficiency of maternal referrals.

Trial registration

Systematic review registration: PROSPERO registration CRD42018114261.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12884-020-03339-3.

Analysis of the Severe Maternal Outcomes between Resource-Poor and Resource-Rich Hospitals in China’s Hunan Province from 2012 to 2018

Background. This facility-based study analyzed the epidemiology and incidence of maternal near miss (MNM) and mortality by hospital level as part of Hunan Province’s efforts to raise the quality of hospital care for women. Methods. We used data for MNM and mortality cases for 2012–2018 from 17 hospitals (12 resource-poor facilities, five resource-rich facilities) that receive referrals for obstetric complications in Hunan Province. Data were drawn from China’s National Maternal Near Miss Surveillance System and collected using the World Health Organization near miss tool. We calculated the ratio of severe maternal outcomes (SMO) (i.e., MNM and maternal death (MD) cases), mortality index (MI), and MNM to mortality ratio (MNM : MD), and epidemiological factors, organ dysfunction, and maternal complications stratified by hospital level. The chi-square tests to examine differences between groups and total ratios and 95% CI were calculated. Results. There were 518 SMO cases (489 MNM and 29 MD) among 279407 live births (LBs) and 1299 SMO cases (1262 MNM and 37 MD) among 232386 LBs in resource-poor and resource-rich facilities. The total MNM ratio in resource-poor and resource-rich hospitals was 1.75 (95% CI: 1.60–1.91) and 5.43 (95% CI: 5.14–5.74) per 1000 LBs, respectively. There were differences in SMO cases between resource-poor and resource-rich hospitals in maternal age, education, parity, antenatal visits, and history of cesarean sections. In MNM cases, coagulation dysfunction was the main organ dysfunction (resource-poor hospitals: 59.10%; resource-rich hospitals: 79.32%), and the main maternal complications were obstetric hemorrhage (resource-poor hospitals: 71.98%) and hepatopathy (resource-rich hospitals: 69.49%). For MD cases, the main maternal complications were neurologic dysfunction (resource-poor hospitals: 41.38%) and coagulation dysfunction (resource-rich hospitals: 42.55%). Anemia was the main maternal complication for SMO cases in both resource-poor (69.69%) and resource-rich (68.59%) hospitals. Conclusions. MNM and MD are higher in resource-rich hospitals compared with resource-poor hospitals. The obstetric emergency capacity of resource-rich hospitals is higher than that of resource-poor hospitals. Future government policies should consider upgrading the obstetric emergency treatment capacity in resource-poor hospitals or to redistinguish the social functions of different medical institutions.

Incidence of maternal near-miss in Kenya in 2018: findings from a nationally representative cross-sectional study in 54 referral hospitals

Although the Kenyan government has made efforts to invest in maternal health over the past 15 years, there is no evidence of decline in maternal mortality. To provide necessary evidence to inform maternal health care provision, we conducted a nationally representative study to describe the incidence and causes of maternal near-miss (MNM), and the quality of obstetric care in referral hospitals in Kenya. We collected data from 54 referral hospitals in 27 counties. Individuals admitted with potentially life-threatening conditions (using World Health Organization criteria) in pregnancy, childbirth or puerperium over a three month study period were eligible for inclusion in our study. All cases of severe maternal outcome (SMO, MNM cases and deaths) were prospectively identified, and after consent, included in the study. The national annual incidence of MNM was 7.2 per 1,000 live births and the intra-hospital maternal mortality ratio was 36.2 per 100,000 live births. The major causes of SMOs were postpartum haemorrhage and severe pre-eclampsia/eclampsia. However, only 77% of women with severe preeclampsia/eclampsia received magnesium sulphate and 67% with antepartum haemorrhage who needed blood received it. To reduce the burden of SMOs in Kenya, there is need for timely management of complications and improved access to essential emergency obstetric care interventions.

Measuring maternal near-miss in a middle-income country: assessing the use of WHO and sub-Saharan Africa maternal near-miss criteria in Namibia

Background: Namibia, a middle-income country in sub-Saharan Africa (SSA), plans to use the Maternal Near Miss (MNM) approach. Adaptations of the World Health Organization (WHO) MNM defining criteria (‘WHO MNM criteria’) were previously proposed for low-income settings in sub-Saharan Africa (‘SSA MNM criteria’), but whether these adaptations are required in middle-income settings is unknown.

Objective: To establish MNM criteria suitable for use in Namibia, a middle-income country in SSA.

Methods: Cross-sectional study from 1 March 2018 to 31 May 2018 in four Namibian hospitals. Pregnant women or within 42 days of termination of pregnancy or birth, fulfilling at least one WHO or SSA MNM criterion were included. Records of women identified by either only WHO criteria or only SSA criteria were assessed in detail.

Results: 194 Women fulfilled any MNM criterion. WHO criteria identified 61 MNM, the SSA criteria 184 MNM. Of women who only fulfilled any of the unique SSA MNM criteria, 18 fulfilled the criterion ‘eclampsia’, one ‘uterine rupture’ and five ‘laparotomy’. These women were assessed to be MNM. Thresholds for blood transfusion to define MNM due to haemorrhage were two units in the SSA and five in WHO set. Two or three units were given to 95 women for mild/moderate haemorrhage or chronic anaemia who did not fulfil any WHO criterion and were not considered MNM. Fourteen women who were assessed to be MNM from severe haemorrhage received four units.

Conclusions: WHO MNM criteria may underestimate and SSA MNM criteria overestimate the prevalence of MNM in a middle-income country such as Namibia, where MNM criteria ‘in between’ may be more appropriate. Namibia opts to apply a modification of the WHO criteria, including eclampsia, uterine rupture, laparotomy and a lower threshold of four units of blood to define MNM. We recommend that other middle-income countries validate our criteria for their setting.

Incidence of maternal near miss among women in labour admitted to hospitals in Ethiopia

OBJECTIVES

To assess the incidence of maternal near miss and contributing factors among hospitals in Ethiopia. The study also assessed the ability of hospitals to provide signal functions of emergency obstetric care and its regional distribution.

DESIGN

A national dataset accessed from the Ethiopian Public Health Institute were analysed to assess the incidence of maternal near miss and mortality index among women admitted to hospitals with obstetric complications.

SETTING

Maternal health indicators including obstetric complications, maternal deaths and births conducted at all hospitals available in Ethiopia were included.

MEASUREMENTS

The maternal near miss incidence ratio, which is the number of near miss cases per 1,000 live births, and the mortality index were presented descriptively. Chi-squared test at p value ≤ 0.05 was used to assess the presence of significant regional differences of the provision of signal functions of emergency obstetric care.

RESULTS

In 2015, 78,195 women were admitted to hospitals with both the direct (68,002) and indirect (10,193) causes of maternal mortality. Of women who experienced the direct causes, 435 died which means there were 67,567 maternal near miss cases. In the same year, 323,824 live births were reported in hospitals, making the crude maternal near miss incidence ratio of 20.8% (9.1-38.8%) and mortality index of 0.64% (435/68,002) for the direct causes of maternal mortality. A significant regional variation was observed with regard to incidence of maternal near miss, mortality index and the provision of signal functions of emergency obstetric care. Administration of parenteral antibiotics was the most frequently practiced signal function of emergency obstetric care while blood transfusion was the least provided signal function.

CONCLUSIONS

In Ethiopian hospitals, the incidence of maternal near miss was unacceptably high. A significant regional variation was detected with regard to maternal near miss incidence ratio, mortality index and the provision of signal functions of emergency obstetric care. The Ethiopian government needs to work on equitable resource distribution and quality improvement initiatives in order to close the detected regional variations.

IMPLICATIONS FOR PRACTICE

The Ethiopian government needs to practice evidence-based maternal health strategies, including capacity building of the regional hospitals in order to improve the distribution of resources and quality of maternal health.

Current Resources for Evidence-Based Practice, November 2019

A review of new resources to support the provision of evidence-based care for women and infants.