Introduction

Evaluating the effectiveness of a healthcare system relies significantly on assessing maternal

mortality, with the Maternal Mortality Ratio (MMR) being the established measure. MMR is
defined as the ratio of maternal deaths per 100,000 live births. While there has been a global
decline in MMR, India is also experiencing a steady decrease, attributed to the increased
efforts and resources allocated to healthcare through the National Health Mission (NHM). To
achieve both national and international goals, there is a imperative to expedite this decline
further.

Maternal near miss is characterized as the survival of a woman who has encountered
complications during pregnancy, childbirth, or within 42 days after the termination of
pregnancy. In practical terms, women are identified as near miss cases when they manage to
survive critical conditions, such as organ dysfunctions, which pose a threat to their lives.1

On the other hand, 'Maternal death' is defined as the demise of a woman during pregnancy or
within 42 days after the termination of pregnancy. This definition encompasses any cause
linked to or worsened by pregnancy or its management, regardless of the pregnancy's
duration and site. However, it excludes deaths resulting from accidental or incidental causes.

While maternal mortality continues to pose a noteworthy public health concern, the actual
occurrences of maternal deaths are infrequent, particularly within a specific community.
Consequently, evaluating the impact of care becomes challenging. 2 To address this difficulty,
the concept of severe acute maternal morbidity (SAMM) and near-miss events has been
introduced in maternal healthcare. This serves to supplement the information obtained
through the review of maternal deaths.3

Reducing maternal mortality stands as a crucial aspect of achieving the Millennium

Development Goal (MDG).4 Despite a notable decrease in maternal deaths, the rate of decline
falls short of the necessary pace to meet the MDG target. Countries with limited resources,
such as India, as well as various nations in Asia and Africa, bear the brunt, where women still
face a high lifetime risk of mortality during pregnancy and childbirth compared to developed
countries.

Maternal deaths, however, only represent the visible part of the problem. Beneath the surface
lies a broader issue involving women who narrowly escaped life-threatening situations
related to pregnancy, childbirth, or pregnancy termination within 42 days – termed as
maternal near-miss cases.5 Traditionally, epidemiologists and caregivers rely on maternal
death as an indicator of maternal health across various levels, from communities to entire
countries.

The auditing of such near miss cases serves various purposes. A higher number of cases
allows for the simultaneous gathering of more information. Additionally, insights gained from
managing cases of women who survived are more valuable than those from cases resulting in
death. This is because there's an opportunity to directly interview the woman herself in near-
miss cases. Therefore, near-miss cases serve as a control for fatalities and the ratio of death to
severe morbidity, indicating the quality of maternal care.

For years, the implementation of maternal near-miss cases as a dependable tool for assessing
maternal health faced challenges due to inconsistent criteria definitions, leading to irregular
calculation of its incidence. In 2009, in an effort to standardize the criteria used to define
maternal near miss, the World Health Organization (WHO) proposed a uniform classification
system based on 25 criteria related to organ and system dysfunction, including
cardiovascular, respiratory, renal, hepatic, neurologic, coagulation, and uterine surgeries.
Consequently, numerous studies from diverse countries and institutions have since been
published based on these standardized criteria.6

Despite diminishing national figures, smaller communities may still experience maternal
mortality, and analyzing a limited sample size might not expose the true deficiencies in the
healthcare system. Consequently, examining near-miss cases, which offer a more substantial
sample size, can more effectively uncover gaps in healthcare delivery.

Furthermore, near-miss data serves as a valuable tool for policymakers, aiding in the
understanding of essential and emergency obstetric care needs. It proves instrumental in
formulating, implementing, and monitoring safe motherhood programs. Consequently,
numerous institutions and healthcare facilities worldwide have started scrutinizing near-miss
cases as an efficient means of auditing maternal care.

The proposed study aims to address several potential lacunae in the existing scientific
literature. Firstly, there is a lack of comprehensive data specific to the less developed sections
of Indian society, especially the rural sector , hindering a nuanced understanding of the
region's maternal health landscape. Additionally, the focus on obstetric care as a surrogate
indicator introduces a novel perspective, potentially filling gaps in current research that
primarily emphasizes direct maternal near miss indicators. This study aims to shed light on
the efficacy and challenges of obstetric care in predicting and preventing maternal near miss
cases, offering valuable insights for healthcare interventions tailored to the local context in
poor infrastructure environment. Furthermore, the research may contribute to the limited
literature on tertiary care centers in this region, offering a more nuanced understanding of the
healthcare infrastructure's role in maternal outcomes.
Review of Literature

Maternal Mortality

The Millennium Development Goals, established in 2000 following the United Nations
Millennium Summit, consisted of eight international development objectives to be achieved
by 2015. Goal 5 specifically aimed at enhancing maternal health. Target 5A sought to
decrease the Maternal Mortality Ratio (MMR) by 75% between 1990 and 2015, while Target
5B aimed at attaining universal access to reproductive health.

Maternal Mortality Ratio

The Maternal Mortality Ratio (MMR) is defined as the ratio of maternal deaths per 100,000
live births during a specified time period. Globally, the MMR is 210/100,000 births, with
developing countries experiencing a higher rate at 240/100,000 births, compared to
14/100,000 births in developed countries. In India, MMR showed a decline from 398/100,000
births in 1997-1998 to 167/100,000 births in 2011-2013.

India (1997-1998) - 398/100,000 births

(2001-2003) - 301/100,000 births

(2007-2009) - 212/100 000 births

(2010-2012) -178/ 100 000 births

(2011-2013) -167/100 000 births

Maternal Near Miss

Maternal Near Miss refers to a severely ill pregnant or recently delivered woman who almost
died but survived a complication during pregnancy, childbirth, or within 42 days of
termination of pregnancy. SAMM (Severe Acute Maternal Morbidity) denotes a life-
threatening condition that may lead to a near miss, with or without residual morbidity or
mortality.
 Potentially
Life
Identification
Threatenin
Method
g
conditions
Maternal
Near Miss
& Life
Criteria
Threatenin
g
Conditions
Maternal
Near Miss -
Definition nearly died
but
survived

Causes of
Causes Maternal
Near Miss

Why focus on Maternal Near Miss?

Maternal Near Miss cases exhibit similar traits to maternal deaths, providing valuable
insights into the challenges to be addressed following the onset of a severe complication.

Identifying and addressing these issues promptly allows for targeted interventions to decrease
both mortality rates and long-term health complications.

Fig: Use of
Maternal Near
Miss in Health
Research
Identification Of Near Miss Cases

Various criterias have been used to identify maternal near-miss cases. Some of them are
described as follows.

1. Waterstone's Criteria: Clinical diagnosis based7

 Severe preeclampsia
 Severe sepsis
 Uterine rupture
 Eclampsia
 HELLP syndrome
 Severe hemorrhage

2. Mantel's Criteria: Clinically based (on organ dysfunction) and management based8

 Admission to the intensive care unit (ICU) for any cause

 Hypovolemia necessitating the transfusion of five or more units of packed red blood
cells
 Development of pulmonary edema
 Emergency hysterectomy performed for any indication
 ICU admission due to sepsis
 Requirement for endotracheal intubation and mechanical ventilation exceeding 60
minutes, excluding instances of general anesthesia
 Onset of diabetic ketoacidosis
 Prolonged coma lasting over 12 hours
 Occurrence of cardiorespiratory arrest
 Peripheral oxygen saturation persistently below 90% for more than 60 minutes
 Ratio of arterial partial pressure of oxygen (PaO2) to fractional inspired oxygen
(FiO2) falling below 300 mmHg
 Oliguria, characterized by urine output below 400 ml within a 24-hour period,
resistant to hydration, furosemide, or dopamine therapy
 Acute elevation of blood urea nitrogen to 15 mmol/L or serum creatinine exceeding
400 mmol/L
 Manifestation of jaundice in the presence of preeclampsia
 Thyrotoxic crisis occurrence
 Acute thrombocytopenia necessitating platelet transfusion
 Development of subarachnoid or intraparenchymal hemorrhage
 Anesthetic accident:
a. severe hypotension associated with epidural or rachidian anesthesia –
hypotension defined as systolic pressure <90 mmHg for more than 60 minutes
b. failure in tracheal intubation requiring anesthetic reversion.

3. Pattinson et al. criteria9

 Hemorrhage resulting in shock, urgent obstetric hysterectomy, coagulation

abnormalities, and/or a blood transfusion of 2 liters
 Hypertensive complications during pregnancy, such as eclampsia and severe
preeclampsia, with clinical or laboratory indications necessitating termination of
pregnancy to preserve the woman's life
 Dystocia leading to uterine rupture or imminent rupture (resulting from prolonged
obstructed labor or prior cesarean section)
 Infections leading to fever or hypothermia, or evident infection focus with clinical
signs of septic shock
 Anemia with hemoglobin levels below 6 g/dl or clinical signs of severe anemia in a
woman without significant hemorrhage

4. WHO criteria: Clinically laboratory and management based 6

 Shock,
 Cardiac arrest
 Use of continuous vasoactive drugs
 Cardiopulmonary resuscitation
 pH < 7.1
 Lactate > 5 mmol/L
 Acute cyanosis
 Gasping
 Respiratory rate > 40 or < 6 breaths per minute
 Intubation and ventilation not related to anaesthesia
 Oxygen saturation < 90% for ≥ 60 minute.
 PaO2/FiO2 ratio < 200 mm Hg
 Oliguria non-responsive to fluids
 Dialysis for acute renal failure
 Creatinine ≥ 300 mmol/L or ≥ 3.5 mg/dL
 Failure to form clots
 Transfusion of ≥ 5 units of blood or packed red blood cells
 Acute severe thrombocytopoenia (platelet count ≤ 50 000/mm3)
 Jaundice with preeclampsia
 Bilirubin > 100 mmol/L or > 6.0 mg/dL
 Loss of consciousness or coma (lasting > 12 hours)
 Stroke
 Status epilepticus or uncontrollable fits
 Total paralysis
 Haemorrhage leading to hysterectomy

5. Roberts et al. criteria: ICD-code based (diagnosis or procedures)10

 Shock
 Cardiac failure
 Cardiac arrest or infarction
 Obstetric embolism
 Acute severe asthma
 Assisted ventilation including tracheostomy
 Acute renal failure
 Dialysis
 Any transfusion of blood or coagulation factors
 Disseminated intravascular coagulation
 Sickle cell anaemia with crisis
 Cerebral oedema or coma
 Status epilepticus
 Cerebrovascular accident
 Uterine rupture
 Repair of rupture of inverted uterus
 Reclosure of disrupted caesarean section wound
 Evacuation of haematoma
 Hysterectomy
 Dilatation and curettage under general anaesthesia
 Interventions to control bleeding
 Repair of bladder or cystostomy
 Repair of intestine

6. Chou et al. criteria: (Global Network criteria)11

 Shock
 Cardiac arrest
 Use of continuous vasoactive drugs
 Cardiopulmonary resuscitation
 Acute cyanosis
 Gasping
 Respiratory rate > 40 or < 6 breaths per minute
 Intubation and ventilation not related to anaesthesia
 Non-responsive to fluids
 Dialyses for acute renal failure
 Failure to form clots
 Blood transfusion (any volume)
  Jaundice with preeclampsia
 Eclampsia
 Loss of consciousness
 Stroke
 Fits
 Paralyses
 Surgical procedure to stop bleeding

Operational Definitions

Severe postpartum hemorrhage

Severe postpartum hemorrhage (PPH) is a potentially life-threatening obstetric emergency

characterized by excessive bleeding following childbirth, typically defined as blood loss of
1000 mL or more within the first 24 hours after vaginal delivery, or 1500 mL or more after
cesarean section. Severe PPH can lead to hypovolemic shock, organ failure, and maternal
mortality if not promptly recognized and managed.12

Severe pre-eclampsia

Severe pre-eclampsia is a serious complication of pregnancy characterized by high blood

pressure and significant proteinuria (excess protein in the urine) occurring after 20 weeks of
gestation, along with one or more of the following features:

 Severe hypertension (systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure

≥ 110 mm Hg)
 Severe proteinuria (≥ 5 grams in a 24-hour urine collection or ≥ 3+ on dipstick)
 Signs and symptoms of end-organ damage, such as visual disturbances, severe
headaches, epigastric or right upper quadrant pain, impaired liver function,
thrombocytopenia, pulmonary edema, or renal insufficiency
 Fetal growth restriction or abnormal Doppler flow studies
Severe pre-eclampsia requires close monitoring and may necessitate hospitalization for
management and potential delivery to prevent maternal and fetal complications. 13

Eclampsia

Eclampsia is a severe complication of pregnancy characterized by the onset of seizures

(convulsions) in a woman with pre-eclampsia, a condition marked by high blood pressure and
proteinuria (excess protein in the urine) occurring after 20 weeks of gestation. Eclampsia
seizures are typically tonic-clonic (grand mal) in nature and may occur before, during, or
after labor. Eclampsia poses significant risks to both the mother and the fetus and requires
urgent medical intervention.13

Severe systemic infection or sepsis

Severe systemic infection or sepsis is a life-threatening condition characterized by a

dysregulated host response to infection, leading to widespread inflammation and organ
dysfunction. It can occur due to various infections, including bacterial, viral, fungal, or
parasitic. Signs and symptoms may include fever, rapid heart rate, rapid breathing, altered
mental status, low blood pressure, and evidence of organ dysfunction.14

Uterine Rupture

Uterine rupture is a serious obstetric complication characterized by a tear or rupture in the

wall of the uterus, often occurring during labor and delivery. This condition is associated with
a high risk of maternal and fetal morbidity and mortality due to potential hemorrhage, fetal
distress, and other complications. Uterine rupture can lead to severe maternal blood loss, fetal
distress, and may necessitate emergency delivery by cesarean section.15

Definitive Criteria

Acute severe azotemia Creatinine ≥300 μmol/l or ≥3.5 mg/dl.

 Prolonged prothrombin time >16s

Acute thrombocytopenia <50 000 platelets

Elevated D-dimer >1000 ng/dl

Low fibrinogen <100 mg/dl

Severe acute hyperbilirubinemia Bilirubin >100 μmol/l or >6.0 mg/dl

Severe acute thrombocytopenia <50 000 platelets/ml

Oliguria Not responding to fluids or diuretics

Urinary output <30 ml/h for 4 hours
<400 ml/24hours
Severe bradypnea Respiratory rate <six breaths/min

Severe hypoperfusion Lactate >5 mmol/l or 45 mg/dl

Shock Persistent systolic BP <80 mmHg

With a pulse rate >100bpm
Prolonged unconsciousness Loss of consciousness for > 12 hours

Severe acidosis blood pH <7.1

Delays in Maternal Healthcare

The delays in accessing maternal health care can lead to severe complications and even death
for pregnant women. These delays are categorized into three main factors.

The first delay involves a hesitation to seek medical assistance by the woman or her family
due to a lack of awareness about potential risks or a failure to recognize symptoms of danger.
Additionally, inadequate support from the family can contribute to this delay.
The second delay refers to difficulties in reaching a healthcare facility, often due to factors
such as long distances or a lack of transportation options.

The third delay occurs when proper care is not received at the healthcare facility, potentially
due to issues like incorrect diagnosis, poor clinical decision-making, insufficient staff, or
shortages of essential medicines.

In developing nations, a significant portion of women experiencing severe maternal

complications arrive at healthcare facilities in critical condition, underscoring the importance
of addressing the first two delays.

Policy changes in India:

 Promotion of institutional births

 Delivery by skilled birth attendants
 Provision of Emergency Obstetric Care

Maternal Near Miss Indices

 Severe maternal outcome/ Women with life-threatening conditions (WLTC)

Life-threatening condition = maternal deaths + maternal near miss cases

 Severe maternal outcome ratio (SMOR)

Number of women with life-threatening conditions (MNM + MD) per 1000 live births
(LB). This denotes the degree of care and resources needed in a health facility

 Maternal Near Miss ratio (MNMR)

 Number of maternal near-miss cases per 1000 live births

 Maternal near-miss mortality ratio (MNMMR)

Ratio between maternal near miss cases and maternal deaths

 Mortality index (MI)

Number of maternal deaths divided by the number of women with life-threatening

conditions

 Maternal mortality ratio (MMR)

Number of maternal deaths in a given period divided by 100,000 live births during the
same period
Agarwal et al (2022) studied 100 mothers who met the WHO criteria for maternal near miss
(MNM) were included, with two control subjects matched to each near miss case. These
controls were women experiencing similar pregnancy-related conditions but who did not
develop a near miss event within a week of enrollment. Maternal and fetal outcomes were
compared between these groups and with a group of mothers who initially presented as near
miss but later died (MD group). Results revealed obstetric hemorrhage as the most prevalent
life-threatening complication in both MNM and MD groups. Multiple logistic regression
analysis identified organ dysfunction as an independent predictor of near miss, and the need
for mechanical ventilation and coagulation dysfunction as independent predictors of maternal
death. Mothers in the near miss or death groups had significantly higher chances of delivering
stillborn infants (p < 0.001). Although the risk of neonatal death after admission to the
neonatal intensive care unit (NICU) was numerically higher in the near miss and death groups
compared to controls, it was not statistically significant (p > .05). The conclusion highlights
the need for developing countries to strengthen primary care infrastructure and referral
systems despite significant progress in tertiary-level obstetric care, emphasizing the
importance of health education for pregnant women and improvements in antenatal services
to enhance maternal care.16

A research study by Singh et al (2021) was a prospective observational investigation carried

out at Tata Main Hospital from November 2016 to October 2019, focusing on pregnant
women who met the WHO near-miss criteria due to organ dysfunction or failure, as well as
maternal deaths within the same timeframe. Among 15,377 deliveries and 14,636 live births,
there were 153 cases of maternal near-miss (MNM) and 38 maternal deaths. This resulted in
maternal near-miss and severe maternal outcome ratios of 19.9 and 13.1 per 1000 live births,
respectively, with a MNM to mortality ratio of 4:1 and a mortality index of 19.9%.
Hemorrhagic disorders were the primary cause of MNM (40.5%), while hemorrhage and
sepsis were the leading causes of maternal mortality (23.7% each). Organ dysfunction on
admission was prevalent in 62% of near-miss cases and 92% of mortality cases. The study
concludes that monitoring a larger cohort of MNM cases can aid in understanding the
underlying causes of maternal adverse events and identifying management gaps more
effectively than focusing solely on maternal deaths.17
Mahesh et al (2019) conducted a case-control study on postnatal women admitted to KIMS
Hospital. They administered a structured pre-tested questionnaire to 82 participants,
comprising 27 cases (maternal near miss - MNM) and 55 controls. Information regarding
biodata, sociodemographic characteristics, medical history, previous pregnancies, current
pregnancy outcomes, and complications was collected. Among the enrolled members, 27
were MNM cases and 55 were controls. The majority of women in both groups had non-
consanguineous marriages. Multiparous women were significantly more prevalent in both
groups (p<0.05). The proportion of cases residing in joint families was significantly higher
compared to controls (67% vs. 38%, p<0.05). MNM cases differed significantly from
controls in terms of maternal education, religion, and the presence of danger signs during
pregnancy. While most women in the study were literate, the proportion of illiterate women
was significantly higher among MNM cases than controls (26% vs. 2.27%, p<0.05). A higher
proportion of MNM cases belonged to the Muslim religion compared to the control group
(74% vs. 42%, p<0.05). The presence of danger signs during pregnancy also significantly
differed between the MNM group and the control group (26% vs. 5%, p<0.05). However,
there were no significant differences between the two groups regarding consanguinity,
mother's occupation, socioeconomic status, husband's education and occupation, alcohol
intake by the husband, mode of delivery, and the presence of pregnancy-induced
hypertension.18

AIwuh et al (2018) revealed that among 19,222 total live births, 112 were classified as near-
misses, and 13 were maternal deaths. The maternal mortality rate (MMR) was calculated at
67.6 per 100,000 live births, while the neonatal mortality rate (NMR) stood at 5.83 per 1,000
live births. The ratio of maternal near-miss to maternal death was 8.6 to 1, with a maternal
index (MI) of 10.4%. Predominant causes of near-miss cases included hypertension (n=50,
44.6%), hemorrhage (n=38, 33.9%), and puerperal sepsis (n=13, 11.6%). Hypertension and
hemorrhage exhibited low MI percentages (1.9% and 0%, respectively), contrasting with
puerperal sepsis at 18.9%. Less common causes comprised medical/surgical conditions (n=7,
6.3%), non-pregnancy-related infections (n=2, 1.8%), and acute collapse (n=2, 1.8%), with
higher MI percentages of 33.3%, 66.7%, and 33.3%, respectively. Notable critical
interventions included massive blood transfusion (34.8%), ventilation (40.2%), and
hysterectomy (30.4%). Regarding health system factors, 63 near-misses (56.3%) originated at
primary care facilities, with subsequent referral to tertiary hospitals; 38 (33.9%) occurred at
secondary hospitals, and 11 (9.8%) at tertiary hospitals. Analysis of avoidable factors
highlighted: 1) lack of antenatal clinic attendance (11.6%), 2) issues with inter-facility
transport (6.3%), and 3) health provider-related factors (25.9% at the primary level, 38.2% at
secondary level, and 7.1% at tertiary level).19

Panda and colleagues (2018) found that among 1406 deliveries examined, there were 89 near-
miss cases. During the study period, there were a total of 1349 live births and 8 maternal
deaths, resulting in a maternal mortality ratio of 593 per 100,000 live births. The maternal
near-miss incidence ratio was 65.95, and the mortality index was 8.2 according to their
research. The primary cause of near-miss cases was preeclampsia, accounting for 40.4% of
morbidity, followed by severe anemia at 29.2%, and eclampsia at 19.1%.20

Niviti et al (2018) conducted a study involving 100 participants, with a mean age of 27.63
years. Among them, 41.0% were primigravida, while 19.0% were multigravida. Clinical
criteria were observed in 55% of cases, followed by both clinical and management criteria
according to WHO identification in 16% of cases. Organ dysfunction was noted in 5% of
cases. Severe postpartum hemorrhage occurred in 14% of cases, while anemia was present in
13%. Severe acute thrombocytopenia and ruptured uterus were each reported in 4% of cases,
and liver dysfunction in 4%. Eclampsia was observed in 12% of cases, while cardiac and
neurological dysfunction were each reported in 1% of cases.21

Mehak et al (2018) conducted a study where a total of 158 maternal near-miss cases admitted
during the research period were assessed for various parameters. The majority of the patients,
comprising 70 individuals (44.30%), fell within the age group of 20-25 years. Among the
patients, 91 (57.59%) were multigravida. A significant portion, 112 (70.89%), presented to
our center during the antenatal period, while the remaining delivered at other centers and
were subsequently referred for the management of postpartum complications. It's noteworthy
that the majority of patients presenting at our center were unbooked, totaling 143 (90.50%).
This highlights the critical importance of booking and regular antenatal checkups.22
In a retrospective cross-sectional study by Khan et al, pregnant women who encountered
acute life-threatening pregnancy-related complications at Deen Dayal Upadhyay Hospital,
New Delhi, India, from September 1, 2009, to August 31, 2011, were examined. The analysis
aimed to explore factors associated with maternal near miss (MNM) events and maternal
deaths. A total of 369 patients were examined, among whom 302 MNM events and 67
maternal deaths were documented. Causes of MNM events included hemorrhage,
hypertensive disorders, severe anemia with cardiac failure, organ failure, and infection in
varying proportions. Significantly higher rates of anemia and infection were observed among
patients in the maternal death group compared to the MNM group. Hemorrhage and
hypertension emerged as primary contributors to MNM events, suggesting significant
challenges in reducing maternal mortality in low-income settings. Furthermore, anemia and
infection were identified as notable prognostic factors for maternal death in this study,
indicating the potential utility of MNM as a surrogate marker for maternal mortality in the
context of standard obstetric care.23

Gayathri et al (2017) conducted a prospective audit of antenatal and delivery data registry
within the Department of Obstetrics at a tertiary care teaching hospital in South India. Their
study utilized WHO 2009 criteria to identify all near miss cases, with the main outcome
measure being severe acute maternal morbidity. Among 1400 deliveries, there were 104
potentially life-threatening cases and 16 life-threatening cases during the study period. The
Maternal near miss incidence ratio was calculated to be 11.4 per 1000 live births.
Hemorrhage emerged as the major cause (3.21%), followed by hypertensive disorders
(3.07%), and thrombotic complications (0.35%). Hemorrhage and hypertensive disorders
were identified as the primary causes of near miss events. The authors highlight that near
miss analysis serves as an indicator of healthcare quality, complementing maternal mortality
assessments and aiding in the evaluation of obstetric care quality within their institution. 24

Sreekumari et al (2017) reported a total of 18,663 live births during their study period. They
identified 88 near-miss cases and 26 maternal deaths. The incidence proportion of maternal
near-miss was calculated at 4.71 per 1000 live births, while the rate of severe maternal
outcome was 6 per 1000 live births. Remarkably, for every maternal death, there were 3.38
near-miss cases. The mortality index of the institute was calculated at 22.8%, and the
maternal mortality ratio (MMR) for the study setting was 139 per 100,000 live births. Post-
partum hemorrhage emerged as the leading cause of near-miss cases, while systemic diseases
were identified as the major contributors to mortality in their study.25

Kamal et al (2017) reported findings from a two-year study period involving 20,000
deliveries in their institution. They identified 480 women as near-miss obstetrical cases using
a five-factor scoring system. The prevalence of near-miss cases in their study was 2.4%, with
a rate of 24 near-miss cases per 1000 deliveries. The maternal death to near-miss ratio was
1:7.2. Hemorrhage accounted for 42.5% of maternal near-miss cases, followed by
hypertensive disorders of pregnancy at 23.5%. They noted that morbidity was particularly
high among unbooked cases.26

Mbachu et al (2017) found that during their research period, there were a total of 262
deliveries. Among these, 5 women passed away and 52 experienced a near-fatal event. The
maternal mortality rate was 1908 per 100,000 births. The ratio of maternal near-misses to
maternal deaths was 11.4:1, with a mortality index of 8.8%. Notably, 3 out of the 5 deaths
occurred in women aged 20–24 years. The primary cause of maternal mortality was abortion,
accounting for 2 out of the 5 cases. The severe maternal outcome ratio was 218 per 1000
deliveries, and the incidence ratio of maternal near-misses was 198 per 1000 deliveries.
Hypertensive disorders of pregnancy were the leading contributors to severe maternal
outcomes, accounting for 28.1% of cases, followed by obstetric hemorrhage and abortion,
which contributed 24.6% of cases. Regarding treatment response time, 6 out of the near-miss
cases received intervention within 30 minutes of diagnosis, while 19 cases waited for more
than 240 minutes before intervention. Importantly, there was a statistically significant
association between the timing of intervention and the final maternal outcome (p-value =
0.003). Administrative delays were observed in 20 cases, while patient-related delays were
reported in 44 cases.27

Anuradha and colleagues (2017) conducted a study focusing on high-risk maternal cases
referred to the tertiary care center at King George Hospital, Visakhapatnam. Throughout the
study period, there were 7639 live births. Among them, 485 cases of Maternal Near Miss
(MNM) were identified, and there were 72 maternal deaths. The Maternal Near Miss
Incidence Ratio (MNMIR) was calculated as 63.48 per 1000 live births. The majority of
complications occurred during the third trimester of pregnancy, affecting 65% of the women,
while 16% experienced complications in the postnatal period. Hence, it's evident that most
life-threatening conditions developed during the third trimester.28

Parmar et al (2016) found that among 1,929 live births, there were 18 maternal deaths and 46
cases identified as "near-miss." Of these near-miss cases, 57 near-miss events were
recognized. The calculated maternal near-miss (MNM) ratio was 23.85 per 1,000 live births,
with an MNM rate of 20.6 per 1,000 obstetric admissions. The ratio of maternal death to
MNM event was 1 to 2.6, and the overall mortality index was 28.1%. Among the near-miss
cases, 42% involved preterm delivery, and the stillbirth rate was 35%. Among the 46 MNMs,
pregnancies were continued in 3 cases, while 43 pregnancies were terminated (25 live births,
16 stillbirths, 2 abortions).29

Patankar et al (2016) reported findings from their study, where they identified a total of 98
near-miss cases during the study period, indicating a prevalence of 2.19%. The average age,
represented as mean ± standard deviation, was 27.84 ± 3.43 years. The majority of cases were
nulliparous (33.68%), predominantly from rural areas (63.26%), with only primary education
(62.25%), and belonging to a lower socio-economic status (66.33%). A significant proportion
of cases (80.62%) were unbooked, and 69 cases were referred from the periphery. Among the
cases, 88 were antenatal, with 52 of them being beyond 37 weeks of gestational age.
Cesarean section was the most common mode of delivery (46.93%). Hypertensive disorders
of pregnancy were the leading cause of near miss (51.02%), followed by obstetric
hemorrhage (43.87%), maternal medical diseases (13.26%), and obstetric sepsis (3.06%).
Dysfunction of the vascular and coagulation systems was the most prevalent (28.57%),
followed by cardiac (21.42%), respiratory (19.38%), immunological (12.24%), hepatic
(8.16%), cerebral (6.1%), and renal (5.1%) dysfunction. Approximately 64.28% of patients
required admission to maternal intensive care. Management strategies for these near-miss
cases included various interventions such as platelet and blood transfusions, vasopressors,
furosemide, mechanical ventilation, dialysis, and hysterectomy.30
Bakshi et al (2014) reported a significant association between maternal outcome and the age
of the study population. Among the total 937 pregnant women included in the study, a
significant association was observed between the state of residence and the development of
potentially life-threatening conditions (PLTC). The majority (52.94%) of "near miss" cases
occurred in women with gestational ages ranging between 24-36 weeks. Regarding maternal
deaths, 50% occurred in women with gestational ages exceeding 36 weeks.31

Pandey et al (2014) reported findings from 6,357 deliveries, resulting in 5,273 live births, 247
maternal deaths, and 633 cases of maternal near miss (MNM). According to WHO criteria for
near miss, shock, bilirubin levels exceeding 6 mg/dL, and the use of vasoactive drugs were
the most common clinical, laboratory, and management parameters. Hemorrhage (45.7%) and
hypertensive disorders of pregnancy (24.2%) were identified as the leading causes of MNM
and maternal deaths. The highest prevalence rate, case fatality ratio, and mortality index were
observed in hemorrhage (0.53), respiratory diseases (0.46), and liver disorders (51.9%),
respectively.32

Chhabra et al (2014) noted that while maternal mortality serves as a crucial measure of
maternal healthcare, the actual occurrence of maternal deaths within a community is
relatively rare despite a persistently high maternal mortality ratio. To address this challenge,
the concept of maternal near miss has been proposed as a complementary measure to
maternal death. Maternal near miss refers to instances where pregnant or recently delivered
women survive complications during pregnancy, childbirth, or within 42 days after pregnancy
termination. Various terms and criteria have been utilized to identify maternal near miss
cases, leading to a lack of uniformity in identification methods. Recently, the World Health
Organization has introduced criteria based on indicators of management and organ
dysfunction, aiming to standardize data collection and facilitate summary estimates of near
miss cases. The prevalence of near miss is notably higher in developing countries, with
causes mirroring those of maternal mortality, including hemorrhage, hypertensive disorders,
heart disease, sepsis, and obstructed labor. Conducting audits of near miss cases offers
valuable insights into health-seeking behaviors and helps pinpoint deficiencies in the
healthcare system, thereby contributing to quality assessment and improvement in maternal
healthcare. Specific indicators for maternal near miss have been proposed to gauge the
quality of care provided. The obstetric near miss (ONM) approach emerges as a crucial tool
for evaluating and refining strategies aimed at enhancing maternal health outcomes. 33

Kalra et al (2014) defined obstetric near-miss as a critical situation involving potentially

lethal complications during pregnancy, labor, or the postpartum period, in which the woman
survives either due to medical intervention or by sheer chance. They conducted a cross-
sectional observational study employing a five-factor scoring system to identify near-miss
cases among instances of severe obstetric morbidity. The study also involved an assessment
of the causes behind maternal mortality and near-miss obstetric cases. The observed obstetric
near-miss rate was 4.18 per 1000 live births. During the study period, a total of 54 maternal
deaths occurred, resulting in a ratio of 202 maternal deaths per 100,000 live births.
Hemorrhage, hypertension, and sepsis emerged as the primary causes of near-miss maternal
morbidity and mortality, respectively.34

Oliveira et al (2013) reported the inclusion of 246 cases of maternal near miss in their study.
Among the women examined, hypertensive disorders were present in 62.7%, with HELLP
syndrome accounting for 41.2% of cases, and meeting the laboratory criteria for near miss in
59.6% of cases. There were 48 stillbirths (19.5%) and 19 neonatal deaths (7.7%). Upon
analyzing the variables, those statistically associated with fetal and neonatal deaths included
severe preeclampsia, placental abruption, endometritis, cesarean delivery, prematurity, and
meeting the laboratory criteria for maternal near miss.35

Roopa et al (2013) documented that during the study period, out of a total of 7,390 deliveries,
7,330 resulted in live births, 131 were categorized as near miss cases, and 23 resulted in
maternal deaths. Primiparas were more prevalent in the near-miss group. The majority of
patients (57.2%) experienced near-miss events during the third trimester, while in the
maternal death group, postnatal patients with puerperal sepsis following cesarean section
were more prominent (n=2012). A significant proportion of maternal near-miss cases (96.2%)
and maternal deaths (86.96%) were referred. Among the identified potentially life-threatening
conditions, a total of 755 were noted, with 131 being near miss cases. The maternal near-miss
incidence ratio was 17.8 per 1000 live births, with a maternal near-miss to mortality ratio of
5.6 to 1. The mortality index stood at 14.9%. Approximately 62.6% of the cases required
admission to the intensive care unit (ICU). Hemorrhage was identified as the leading cause of
near-miss events, accounting for 44.2%, followed by hypertension at 23.6%. Sepsis ranked
third among the causes, with cardiac disease being the least common cause.36

Adeoye et al (2008) found that the incidence of near misses was 12%. Direct causes of near
misses included severe obstetric hemorrhage (41.3%), hypertensive disorders in pregnancy
(37.3%), prolonged dystocia (23%), sepsis (18.6%), and severe anemia (14.6%). Significant
risk factors identified were chronic hypertension, emergency cesarean section, and assisted
vaginal delivery. Protective factors included attending antenatal care at a tertiary facility and
having knowledge of pregnancy complications. Stillbirth emerged as the most significant
adverse perinatal outcome associated with near miss events.37

Taly et al (2004) identified 100 near misses and 16 maternal deaths during their study. The
most frequent reasons for near misses were severe hypertension (42%), pulmonary edema
(23%), and emergency hysterectomy (10%). The leading initiating obstetric conditions
included hemorrhage (43.75%), acute severe hypertension (34%), and sepsis (4%). Among
maternal deaths, the primary obstetric factors were hemorrhage (43.75%), maternal disease
(25.09%), and hypertension (18.79%), respectively.38
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