“Women are not dying because of diseases we cannot treat . They are dying because societies are yet to make the decision that their lives are worth saving.”

Mahmoud Fathalla , WHO 

India is committed to achieving Millennium Development Goal 5, which focuses on reducing maternal mortality. To support this goal, the country has implemented the Maternal Death Review system. While maternal deaths are the most visible indicators of this issue, they represent only the tip of the iceberg.

Many women experience life-threatening complications during pregnancy, childbirth, or within 42 days postpartum, and these complications can nearly result in death.

According to the World Health Organization (WHO), a Maternal Near Miss (MNM) case refers to a woman who narrowly survives a serious complication during pregnancy, childbirth, or within 42 days following the end of pregnancy. These near-miss cases are significant because they involve severe health issues that, if untreated, could ultimately lead to maternal death. The causes and risks associated with maternal near-miss cases are similar to those of maternal deaths, making the review of MNM cases essential for understanding the factors that contribute to severe complications.

Studying maternal near-miss events provides critical insights into gaps in the healthcare system and offers opportunities for improvement. The maternal near-miss ratio has increasingly been used as a tool to assess the quality of obstetric care, particularly in low-income countries. Incorporating this approach into healthcare systems can help track severe maternal complications, evaluate the effectiveness of healthcare interventions, and enhance efforts to reduce serious outcomes.

Since maternal near-miss cases often precede maternal deaths, investigating these incidents can help identify underlying causes and allow for the implementation of preventive measures. This prospective study conducted at our tertiary care

hospital aims to estimate the proportion, clinical presentation, causes, and maternal outcomes of near-miss cases to improve maternal health outcomes

MATERIALS AND METHODS

STUDY DESIGN

Prospective Observational

STUDY SITE

Department of Obstetrics and Gynaecology, Tertiary care teaching hospital

STUDY PERIOD

1^st November,2022 to 20^th July,2024

INCLUSION CRITERIA

Patient fulfilling criteria for identification of near miss cases as per Maternal Near miss Review Operational Guideline, maternal health division, Ministry of health and family welfare, Government of India (December 2024)

Patient who survived a complication that occurred during pregnancy, childbirth or within six weeks after pregnancy having Minimum 3 criteria: one from each

• Clinical findings
• Investigations
• Interventions done

OR any single criterion which signifies cardiorespiratory collapse. Those who give consent.

EXCLUSION CRITERIA

• Obstetric cases delivered uneventfully without any complication and who don’t fulfil criteria of near miss cases
• Those who don’t give consent
• Mothers who died due to complications

METHODOLOGY

All obstetrics admissions in the study setting during the study period were followed till 42 days after delivery, and cases were included as per inclusion criteria.

All the relevant data was collected in the proforma based on FACILITY BASED MATERNAL NEAR MISS REVIEW FORM (MNM –R FORM) in detail regarding demography, obstetrics history, gestational age, clinical findings, investigations,interventions taken, maternal outcome, causes and relevant details of near miss. Data was analysed with help of appropriate statistical tools.

OBSERVATION AND DISCUSSION

TABLE 1 : OBSTETRIC STATISTICS OF TERTIARY CARE HOSPITAL

As shown in Table 1 , there were 10,216 obstetric admissions. Out of these , 8100 patients were delivered at our hospital and there were 7859 live births. Maternal deaths were 15.

At the end of study,87 near miss cases were reported as per inclusion criteria.

TABLE 2 : SEVERE ACUTE MATERNAL MORBIDITY INDICATORS TABLE 2A

As shown in Table 2A , 12.98 women suffer from life threatening condition per 1000 live birth. SMOR gives an estimate of the amount of care and resources that would be needed in an area or facility. According to WHO, SMOR higher than 10 per 1000 live births indicates that a large percentage of women will need lifesaving interventions to survive their complications.

TABLE 2B

As shown in Table 2B , for every 1000 live birth, 11.07 women survived from life threatening complications.

TABLE 2C

As shown in Table 2C , for every 1000 live birth , 5.8 women survived from life threatening complications.

TABLE 2 D

As shown in TABLE 2D, for each maternal death 0.15 women faced life threatening complications during pregnancy. Lower rates indicate better quality of care.

TABLE 2E

As shown in Table 2E, for every 1000 admission in obstetrics , 8.52 women were maternal near miss.

TABLE 2F

As shown in Table 2F, for every 1000 obstetrics admission , 1.47 maternal deaths occurred.

TABLE 3

As shown in Table 3 , majority of MNM cases 25(28.7%) were gravida 4 or more while gravid 3, gravid 2 and primigravida were 16(18.4%), 18(20.6) and 20(23%) respectively. Out of 87, 2(2.3%) patients were primi para and 6(6.9%) were multi para patients.

TABLE 4

As shown in Table 4, most common presenting symptom was abdominal pain in 44 (50.57%) of MNM cases. Fever, bleeding per vaginum and convulsion were presenting symptoms in 15(17.24%),14(16.09%) and 5(5.95%) cases respectively.

TABLE 5

As shown in Table 5, pregnancy specific obstetric and medical disorders were reported in 53 (60.8%). Haemorrhage occurred in 27 (31%) cases. Hypertensive disorders of pregnancy were present in 20 (22.9%). Sepsis was present in 4 (4.6%). Liver dysfunction was present in 2 (2.3%) patients , both of them had acute fatty liver of pregnancy with severe jaundice.

TABLE 6

As shown in table 6 , most common adverse event leading to MNM cases was haemorrhage in our study. Roopa PS et al , Purandare et al, Sangeeta G et al, Bansal M et al and Rakesh HJ et al also reported haemorrhage as the most common cause of MNM . Whereas Yelikar KA et al , Patankar A et al and Kansara V et al reported hypertensive disorders as the most common cause of MNM.

TABLE 7

As shown in Table 7, among antenatal admission , LSCS was done in 42 (48.27%) of the cases, 15 (17.2%) had normal vaginal delivery, 1 (1.15%) had vaginal birth after Caesarean (VBAC). Although undesirable, high rates of caesarean section may be accepted among near miss patients due to the urgency required to resolve the gestation and the factors that may make vaginal delivery difficult to occur . in two cases laparotomy was done following caesarean section on post operative day 4 for bowel obstruction and the other one was done on post operative day 2 for hematoma. Laparotomy was done in two cases for ectopic pregnancy. Hysterotomy was done in two cases, one case was of eclampsia and one case was of abruption placenta.

TABLE 8

As shownin table 8, Yelikar KA et al , Kansara V et al , Ingole et al reported ventilatory support as the most common intervention done in MNM cases . Patankar A et al , Anuradha J et al reported vasopressor use as the most common intervention done in MNM cases.

TABLE 9

As shown in table 9, 52 (59.8%) cases required blood and/or blood products transfusion whereas 35(40.2%) cases didn’t require any type of blood or blood products transfusion.

CONCLUSIONS

Majority of maternal near miss cases were multigravida. Majority of maternal near miss cases were admitted in hospital with severe illness during antenatal period. Haemorrhage and hypertensive disorders were leading causes of maternal near miss cases. Anemia and infections were the third leading cause of maternal near miss cases. Ventilator support, vasopressor use , obstetric hysterectomy and laparotomy were the major interventions required in maternal near miss cases .Majority of maternal near miss cases required transfusion of blood and blood products. Perinatal mortality was high.

Therefore anticipation , early diagnosis and prompt treatment of maternal complications can reduce the feto maternal morbidity and mortality. A well equipped centre with HDU/ICU, operation theatre, blood bank, and multidisciplinary team along with NICU can go a long way in saving a critical mother and her baby.

Education and women empowerment , importance of antenatal care, importance of nutrition , awareness about warning signs , institutional delivery, timely reference of high risk patients to tertiary care hospital and awareness of various methods of contraception must be promoted in addition to strengthening of peripheral health systems. All the maternal near miss cases are living lessons , who in spite of their misery can enlighten us to fill in the gaps that has led to maternal near miss cases.

The most vital purpose of near miss approach is to improve clinical practice and reduce preventable morbidity and mortality through use of best evidence based practices.

BIBLIOGRAPHY

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