NEAR MISS MATERNAL MORTALITY

DR NEHARIKA MALHOTRAAICOG(2013)

Despite therapeutic advances during this century and a growing perception of the safety of child birth, morbidity and mortality continue to occur in obstetric patients. More than one woman dies every TEN minute from such causes.

In addition to maternal death, women experience more than 50 million maternal health problems annualiy.

As many as 300 million women-more than one quarter of all adult women living in the developing world currently suffer from short or Iong term illness and injuries related to pregnancy and child birth.

For every maternal death there are many serious life threatening complications of pregnancy.

Yet relatively little attention has been given to identifying a general category of morbidity that could be called near-misses

The analysis of maternal deaths has long been used for the evaluation of women’s health and the �qualityof obstetric care

Over the last decade, the identification of cases of severe maternal morbidity has emerged as a promising complement or alternative to the investigation of maternal deathS.

It has been suggested that with the observed decline in maternal mortality, analysis of well defined near-miss cases may be a more sensitive measure of the standard of obstetric care.

Incorporation of near-misses into maternal death enquiries would strengthen these audits by allowing for more rapid reporting; more robust conclusions, comparisons to be made with maternal deaths, reinforcing lessons learnt, establishing requirement for intensive care and calculating comparative indices

WHATS A NEAR MISS?

Every woman can experience sudden and unexpected complications during pregnancy, child birth and just after delivery.

Morbidity during pregnancy represents part of a continuum between extremes of good health and death.

On this continuum a pregnancy may be thought of as being uncomplicated, complicated, severely complicated or life threatening

Near Miss Maternal Mortality is a term which is very difficult to define.Any pregnant women or recently delivered women within 6 weeks of delivery or termination of pregnancy in whom immediate survival is threatened and who survives by the medical intervention and hospital care can be termed as Near Miss

By Mantel GD et al, a near miss describes a patient with acute organ system dysfunction, which if not treated appropriately, could result in death.

Prual A et al, has defined severe maternal morbidity as severe complications from 28th week of gestation to 42nd day postpartum that would have resulted in death of the mother or a definite invalidating sequelae without medical intervention.

In different studies, the primary obstetric causes of severe maternal morbidities have been found to be hypertensive disorders of pregnancy, massive obstetric haemorrhage.

Obstructed labour has been found to be an important cause in some studies.

Risk factorsThe risk factors of severe maternal morbidites have been identified as:

Maternal age >34

social exclusion

Hypertension,

Previous PPH

Delivery by emergency caesarean section,

Multiple pregnancy

Anaemia

Low status of women who do not attend antenatal care in a given health unit but are referred there when they develop life-threatening obstetric complications, contribute significantly to maternal morbidity.

Induced abortions conducted by untrained village midwife (DAI) is still a major cause of morbidity in the developing countries

MATERIAL AND METHODS

222 potentially Life threatening cases were studied in a private hospital (Malhotra Nursing Home) in Agra(INDIA) in past five years . And we did a comparison with a rural hospital where we found out about 1080 potentially life threatening cases in past three years.

The main outcome measures were: rate of near miss and its primary determinant factors, criteria for its identification, total hospital stay, ICU stay, and number and kind of special procedures performed.

Complete statistical Analysis was done related to the causes and preventive measures and hospital recovery stay in the study.

OUR STATISTICS

TOTAL NUMBER OF DELIVERIES (PAST 5 YRS)

Private hospital(Five years)

Rural Hospital(Three years)

NO OF LIVE BIRTHS

1909 6480

NO OF NEAR MISS

32 482

NO OF MATERNAL DEATHS

0 9

NO OF LIVE BIRTHS IN NEAR MISS

19 250

Private Hospital

1.67%

32

Rural Hospital

4.29%

278

6480482(7.4%)

287

MATERNAL MORTALITY- 9

POSSIBLY LIFE THREATENING CASES

RURAL HOSP

N= 1080

% PRIVATEN=222

%

PRE-ECLAMPSIA/HELLP

391 36.5% 122 54.5%

HAMEORRHAGE

270 25% 34 15.3%

ABRUPTIO 100 10.8% 14 6.3%

THROMBOCYTOPENIA

78 7.2% 15 6.7%

INFECTION/SEPSIS

154 14.2% 8 3.6%

CHD 17 1.5% 8 3.6%

PULMONARY OEDEMA

19 1.7% 5 2.2%

SICKLE CELL

21 2.0% 4 1.8%

JAUNDICE/DIC

30 2.7% 4 1.8%

NEAR MISS CASES

N =32(private)

% N=287(rural)

%

INTUBATION AND VENTILATION

16 49% 87 31%

CLOTTING FAILURE 10 32.2% 30 10.4%

BLOOD TRANSFUSIONS>5 UNITS

8 25.8% 56 19.51%

THROMBOCYTOPENIA

7 22.6% 23 8.2%

HYSTERECTOMY 4 12.9% 17 5.9%

RE-EXPLORATION 3 9.7% 29 11%

DIALYSIS 1 3.22% 4 1.3%

SHOCK 6 19.3% 21 7.3%

BILIRUBIN>6mg/dl 4 12.9% 20 7%

MATERNAL MORTALITYIN PRIVATE

MATERNAL MORTALITY IN RURAL

0

9

CONCLUSION Efforts geared towards improvement in the management of near-

miss morbidities would definitely go a long way in reducing the present maternal mortality ratio.

From the findings of this review, attempts to reduce maternal deaths may best be achieved by developing evidence-based protocols for the management of severe hypertension and haemorrhage especially for critically ill referred patients.

In addition, considerable efforts should be made to improve maternal care for infrequent but important life-threatening obstetric conditions such as uterine rupture and infection. Necessary facilities should be made available and training of personnel and emergency drills should be frequently conducted to combat the identified disease processes that received suboptimal care.

Although this study did not specifically address avoidable factors, it has nevertheless raised awareness of the deficiencies in the management of serious maternal illnesses