ISSN: 2320-5407 Int. J. Adv. Res.

5(1), 2172-2178

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/2992

DOI URL: http://dx.doi.org/10.21474/IJAR01/2992

RESEARCH ARTICLE
A STUDY OF NEAR MISS OBSTETRIC EVENTS AND MATERNAL DEATHS IN A TERTIARY CARE
HOSPITAL

Shilpa Dhingra1, Reena Yadav2 and Chitra Raghudandan3.

1. Associate Professor, NDMC Medical College and Hindu Rao Hospital, Delhi.
2. Director Professor and Unit Head, Lady Hardinge Medical College and SSK Hospital, New Delhi.
3. Visiting Consultant Fortis Hospital Vasant Kunj, New Delhi and Eye Care Centre, C6/9,Safdarjung
Development Authority, New Delhi.
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Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Introduction: Maternal Near Miss refers to a women who nearly died
but survived a complication that occurred during pregnancy, childbirth
Received: 28 November 2016 or within 42 days of termination of pregnancy.
Final Accepted: 27 December 2016 Aims and Objective: To use the new WHO near miss criteria to
Published: January 2017
investigate maternal morbidity and mortality. To determine the
Key words:- Maternal Near Miss Incidence ratio, maternal near miss to mortality
Maternal near miss events, Maternal ratio and to calculate the mortality index for each event.
mortality, Severe acute maternal Methods: Women showing the presence of any one of the markers in
morbidity, Maternal morbidity WHO near miss criteria and all maternal deaths from October 2012 to
March 2014 were included in the study. The study was conducted in
department of Obstetrics and Gynaecology at Lady Hardinge Medical
College and SSK Hospital, New Delhi, India.
Observation: There were 19,077 deliveries, 18,631 live births, 161
near miss cases and 35 maternal deaths during the study period.
Haemorrhage accounted for most common near miss event (39%)
followed by infection (28.5%), anemia (19.2%) and eclampsia (13.3
%). The Mortality Index were 33.8%, 12.5%, 6% and 4.5 % for
infection, hypertensive disorder, anemia and haemorrhage respectively.
Near miss to maternal death ratio was 4.6:1 and maternal mortality
ratio was 188 per 1,00,000 live birth.
Conclusion: The quality of care received by critically ill obstetric
patients in this centre is optimal for near miss events like haemorrhage
and anemia as the mortality index were lowest for both events but
needs to be improved for infections and hypertensive disorders of
pregnancy.
Copy Right, IJAR, 2016,. All rights reserved.
……………………………………………………………………………………………………....
Introduction:-
Maternal mortality is frequently described as “Just the Tip of The Iceberg” alluding that there is a vast base to the
iceberg in the form of maternal near miss i.e. maternal morbidity which has remained largely undescribed.

Large differences were found among countries on the incidence of maternal near miss because of the different
settings and variation in the criteria used to define the maternal near miss. In 2009, World Health Organization

Corresponding Author:- Shilpa Dhingra. 2172

Address:- Associate Professor, NDMC Medical College and Hindu Rao Hospital, Delhi.
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(WHO) defined a maternal near miss case as “A woman who nearly died but survived a complication that occurred
during pregnancy, childbirth or within 42 days of termination of pregnancy”[1]

Considering the lack of standardization, WHO in 2009 has developed a set of criteria to identify near miss cases
[Table 1][1]. These criteria are intended to be used in any setting, regardless of the development status. The new
near miss definition may enable comparison between facilities and over time. Furthermore, relating the proportions
of maternal complications, maternal near miss cases and maternal deaths (i.e. mortality index or case fatality ratio)
would be useful to assess the quality of care that women with severe complications receive even in tertiary care
setting.

Survivors of severe complications related to pregnancy (condition known as maternal near miss cases) have been
studied in detail in recent years, mostly in developed countries. But, even in developing countries, information on
maternal near miss cases was found to be useful to identify health system failures in maternal health care. [2]This is
because near miss cases share many characteristics with maternal deaths and can directly inform on barriers that
have to be overcome after the onset of an acute complication. These cases can complement the information obtained
from reviewing maternal deaths and function as surrogates of maternal deaths. This will be a useful piece of
information in small and medium size health care facilities or settings where few maternal deaths occur
[3][4][5].Hence, this study was conducted to provide insight into the quality of maternal care provided in our
institution.

Material and Methods:-

This study was conducted in the Department of Obstetrics and Gynaecology in Lady Hardinge Medical College and
S.S.K Hospital, New Delhi for a period of 18 months from October 2012 to March 2014. This is a tertiary care
institution, which serves as the major referral centre for other public and private hospitals within New Delhi and
nearby states. In addition to providing emergency obstetric services to women referred from other centers, the
hospital also provides antenatal care and delivery services for both unreferred low and high risk pregnant women.
The hospital provides emergency obstetric and gynecological care for 24 hours a day.

The near miss cases were pregnant and parturient women showing the presence of any one of the markers of life
threatening conditions in all the three criteria (clinical, laboratory and management based) given by WHO as shown
in Table 1. All women during pregnancy and up to 42 days post delivery were included in the study. The maternal
deaths occurring during the study period were also reviewed.
.
In the present study, data was collected and extracted retrospectively from the case records by members of study
team in a structured performa. All maternal deaths were reviewed as well. Using the provisional and final diagnosis
documented in the admission- discharge register of the hospital, case files of women whose diagnoses met the WHO
criteria were extracted. Overall, 161 near- miss cases were collected. For each case, information on socio-
demographic characteristics, parity, gestational age at the time of the near miss morbidity, educational status, nature
of the obstetric complication, presence of organ and/or system dysfunction were collected. Socio-demographic
characteristic data, parity and gestational age were compared between the near-miss cases and maternal deaths.

The following near miss indices were calculated –

1. Maternal Mortality Ratio (MMR) calculated using live births as the denominator.
2. Maternal Near Miss Incidence ratio (MNMIR)- Refers to the number of near miss cases per 1000 live births
3. Mortality index for each near miss event in order to evaluate the standard of care provided for each disease
category. This is defined as the number of maternal deaths due to a particular obstetric condition divided by the
sum of near-miss morbidities and maternal deaths which resulted from this condition, expressed as a
percentage. It reflects the proportion of each life-threatening obstetric condition which ended in maternal death.
Higher the index indicates poor obstetrics care.
4. Maternal near miss: Mortality ratio- Proportion between maternal near miss cases and maternal death. Higher
ratio indicates better care.

Data was analyzed using SPSS software version 17. The study population was characterized using descriptive
statistics. The difference between proportions of two groups was analyzed using chi square/fischer exact test. P
value <0.05 was considered statistically significant.

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Above study was carried out after approval from ethical committee of our institution.

Results:-
During the 18 months period, there were total 19077 deliveries, 18631 live births, 161 near-miss cases and 35
maternal deaths. This resulted in a MMR of 188/100 000 live births and overall Mortality Index of 17.85%.
Maternal near miss incidence ratio was 8.43. Maternal near miss to mortality ratio was 4.6: 1 reflecting a suboptimal
care in the institution. 80% of maternal near miss cases and 86% of maternal deaths were referred from other health
centres.

Demographic characteristics of women who sustained near-miss complications and those who died are comparable
as presented in Table 2. Most of the women in each group were within the ages of 21 and 30 years and had
gestational age between 29 to 36 weeks. Most of the patients in both the group were unbooked for antenatal care. A
booked case is when the pregnant lady has had a minimum of three visits for antenatal checkup after she was
registered as per WHO criteria. There was no significant difference in age, parity, educational levels and booking
status in the near miss events compared with maternal deaths but for gestational age, significant difference was
found.

Hemorrhage accounted for the most common near miss event (39%), followed by infection (28.5%), anemia
(19.2%) and hypertensive disorders (13.3%) as shown in Table 3.

Most common cause of maternal death was septicemia (65.7%) followed by hypertensive disorders (8.6%) and
haemorrhage (8.6%) as presented in Table 4. The mortality index was 33.8%, 12.5%, 6% and 4.5% for infection,
hypertensive disorders, anemia and hemorrhage respectively as shown in Table 5.

The nature of organ-system dysfunction/failure and the associated obstetric factors among the near-miss cases and
maternal death are shown in Table 6. 68 (42.23%) of near miss cases have organ-system dysfunction. The two most
commonly affected organ- system were vascular and cardiac (pulmonary edema) systems.

Table 1:- The WHO Near Miss Criteria

Dysfunctional system Clinical Criteria Laboratory markers Management based
proxies
Cardiovascular Shock pH <7.1 Use of continuous
Cardiac Arrest Lactate>5mEq/ml vasoactive drugs
Cardio-pulmonary
resuscitation
Respiratory Acute cynosis Oxygen saturation<90% for ≥60 Intubation and
Gasping minutes ventilation not
Respiratory rate>40 or PaO2/FiO2<200mmHg related to anesthesia
<6bpm
Renal Oliguria non responsive Creatinine≥300µmol/l or Dialysis for acute
to fluids or diuretics ≥3.5mg/dl renal failure
Haematologic/Coagulati Failure to form clots Acute severe Transfusion of ≥5
on thrombocytopenia(<50,000 units of blood/ red
platelets/ml) cells
Hepatic Jaundice in the presence Bilirubin >100µmol/l or >6.0
of preeclampsia mg/dl
Neurologic Any loss of conciousness
lasting >12h
Stroke
Uncontrollable fit/ status
epilepticus
Total paralysis
Alternative severity Hysterectomy
proxy following infection
or haemorrhage

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Table 2:- Comparison of demographic characteristic of women with Near Miss Events and Maternal Death
Demographic characteristic Near miss Event Maternal death P value
(n=161) (n=35)
Age (Years) 0.05
<=20 8 5
21-25 70 17
26-30 53 12
31-35 26 0
.>35 4 1
Parity 0.35
0 59 11
1-2 77 15
3-4 25 9
Gestational Age (weeks) 0.005*
<=12 22 0
13-28 18 11
29-36 67 14
>=37 39 5
Postpartum 15 5
Illiteracy (%) 72 81 0.18
Booking Status (%) 82.4 88.2 0.23
(Unbooked)
*p value<0.05

Table 3:- Near Miss Events:

Near Miss Events Number Percentage
Haemorrhage
o Ectopic 11
o Abortion 4
o Placenta Previa 21 39
o Abruptio Placenta 5
o Postpartum Haemorrhage 22
o Total 63
Infection
o Puerperal Sepsis 2
o Chorioamnionitis 3
o Septic abortion 3 28.5
o Jaundice 24
o Others 14
o Total 46
Anemia 31 19.2
Hypertensive Disorders 21 13.3
Eclampsia
Pre eclampsia
Total 161 100

Table 4:- Causes of Maternal Mortality

Factor Maternal Death Percentage
Haemorrhage 3 8.6
Septicemia 23 65.7
Anemia 2 5.7
Heart Disease 2 5.7
Hypertensive Disorder 3 8.6
Amniotic fluid Embolism 2 5.7
Total 35 100

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Table 5:- The Mortality Index of Near Miss Events:

Event Near Miss Death Mortality Index (%)
Haemorrhage 63 3 4.5
Septicemia 46 23 33.8
Anemia 31 2 6
Heart Disease 0 2 0
Amniotic fluid Embolism 0 2 0
Hypertensive Disorder 21 3 12.5

Table 6:- Organ System Dysfunction in Near Miss Events and Maternal Death
Organ-System Near Miss Event Obstetric Cause Maternal Obstetric Cause
(n=161) Death
(n=35)
1.Cardiac (Pulmonery 43 S. Anemia (26) 5 S. Anemia (2)
edema) S. Pre eclampsia ( 9) S. Pre eclampsia (2)
Eclampsia ( 8) RHD* (1)
2. Coagulation 8 Jaundice (8) 5 Hepatic
Encephalopathy(5)
3. Renal 7 Puerperal Sepsis(2) 3 Hepatic
S. Preeclampsia(2) Encephalopathy(2)
Abruption(1) S. Preeclampsia(1)
Atonic PPH** (1)
Chorioamnionitis(1)
4. Vascular 35 Rup ectopic preg (11) 5 Amniotic fluid
Uterine Rupture (2) embolism (2)
PPH (22) PPH (3)
5. Respiratory 9 LRTI ***(9) 13 ARDS****(13)

6. Cerebral 1 Traumatic Quadriplegia (1) 3 Tubercular

meningitis (2)
Eclampsia (1)
7. Hysterectomy 22 Placenta percreta (8) 2 Rupture Uterus +
Placenta previa + PPH(7) PPH (1)
Retained placenta +PPH(3) Atonic PPH(1)
Rupture Uterus + PPH(2)
Abruption + PPH(2)
*Rheumatic heart disease
**Post partum haemorrhage
***Lower respiratory tract infection
****Acute Respiratory distress syndrome

Table 7:- Comparison of various studies in Near Miss Events and Maternal Death
STUDY MOST COMMON NEAR MOST COMMON MORTALITY INDEX
MISS EVENT CAUSE OF DEATH
Mental et al (S.Africa) Hypertention(26%) Hypertention (33%) -
1998 Haemorrhage( 26%) Infection (27%)
Oladapo et al Hypertention(31%) Hypertention(30%) -
(Nigeria) 2005 Haemorrhage(30%) Haemorrhage(21%)
Mustafa et al Haemorrhage(51%) Haemorrhage(83.3%) Infection (33.3%)
(Karachi) 2009 Haemorrhage (17.2%)
Adbel et al Haemorrhage(41%) Infection (35%) Infection (22.2%)
(Sudan)2011 Haemorrhage (23%) Haemorrhage (8.8%)
Fatima et al (Brazil) 2012 Haemorrhage(40%) Haemorrhage (40%) Overall 10.4%
Infection (20%)
Roopa et al (India) 2013 Haemorrhage (44.2%) Infection (52.2%) Overall 14.9%

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Hypertension (23.6%) Infection (36.3%)

Souza et al (WHOMCS)* Haemorrhage (26.7%) - Overall 16.07%
2013 Hypertension (25.9%)
Present Study Haemorrhage (39%) Infection (65.7%) Overall 17.8%
Infection (28.5%) Infection (33.8%)
*WHO Multicountry Survey

Discussion:-
Maternal mortality was used to assess the quality of obstetric care but this indicator is vulnerable to many flaws. A
better assessment of obstetrical care now includes near miss events to be a useful complement tool for investigation
of maternal mortality. Hence new “near miss” criteria take over maternal mortality ratio. In 2008, WHO
recommended investigating near miss as a benchmark tool for monitoring maternal health care and has standardized
the criteria for diagnosis. WHO criteria are unique in considering not only clinical but also laboratory and
management based criteria.

A statistically significant difference was found between near miss events and maternal deaths as regard the
gestational age because none of maternal deaths occurred before 12 weeks of gestation (Table 2).

In the present study, maternal mortality to near miss ratio was 1:4.6.This indicates that for every almost 5 women
who survived life threatening complications, one died. This reflects a poor care and high maternal mortality in this
setting. Other studies found the maternal death to near miss ratio as 1:5 and 1:7 respectively.[6][7] This is in contrast
to what is observed in developed countries of the world. Studies carried out in Europe revealed a ratio of 1:117-
223[8[[9].This ratio is indicative of the standard of obstetrical care. If this ratio decreases over a period of time, it
reflects on the improvement achieved in obstetric care.

The most common near miss event in the present study was haemorrhage (39%) followed by infection (28.5%),
anemia (19.2%) and hypertensive disorder (13.3%). The result were in accordance with various studies
[10][11][12][13][14] where haemorrhage was the most common near miss event. In contrast to other studies, [6][15]
hypertension was most common near miss event.

The most common cause of maternal mortality was septicemia (65.7%) followed by hypertensive disorders (8.6%)
and haemorrhage (8.6%) in the present study. Similar results were seen in study conducted in south India [13].The
maternal mortality ratio at our setting was 188/100000 live births. The Brazilian study showed a similar mortality
rate of 260/100000 live births [16]. In other developing countries the maternal mortality ratios were 423/100000 live
births and 324/100000 live births respectively [17][18]. The major cause of maternal mortality was infectious
diseases like tuberculosis, pneumonia and hepatic encephalopathy which were not related to pregnancy. There were
three deaths due to haemorrhage and three deaths due to hypertensive disorder complicated with pulmonary edema
and renal failure. Most of the maternal death were unpreventable in the present study as they occur in unbooked
emergency cases that present too late to the hospital and die shortly after admission.

In this setting, the health care providers were faced with a high percentage of life- threatening obstetric situations.
Despite the high morbidity from haemorrhage and anaemia (39%, 19.2% respectively) their mortality index was
lower than that of the other events. This is due to presence of trained personnel, strict adherence to evidence based
protocol and availability of all sorts of blood and blood products round the clock in the hospital. An increased level
of care and effort are required to deal with near-miss events with high mortality index, e.g., infection and
hypertensive disorder.

Lack of antenatal care services in peripheral health care centre, illiteracy, delayed diagnosis, late transfer, and
inadequate utilization of resources might have been the cause for maternal morbidities and mortalities in our study.

One of the limitations of this study is weakness of retrospective method of data collection with respect to the quality
of records. Other limitation is that ours is a tertiary referral center covering two nearby states, with most of the cases
being referred from other health care centre in an already moribund state. The delays in referrals are a major cause
of morbidity and mortality. Table 7 shows comparison of various studies in near miss and maternal death.

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Conclusion:-
The quality of care received by critically ill obstetric patients in this centre is optimal for near miss events like
haemorrhage and anemia as the mortality index were lowest for both events but needs to be improved for infections
and hypertensive disorders of pregnancy. In a tertiary care hospital, it is possible to save most of the patients
presenting with life threatening conditions by adopting evidence based protocol, training of personnel, improving
the resources and multidisciplinary approach for managing severe morbidities. Overall reduction in maternal
mortality can be achieved by improving the antenatal care and timely referral of cases to tertiary care hospital thus
aiming to meet the Sustainable Development Goal 3.

Financial support and Sponsorship:-

Nil

Conflicts of Interest:-
There are no conflicts of interest

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