Maternity wards or emergency obstetric rooms? Incidence of near-miss events in African hospitals

Abstract

Background. This study examines near-miss obstetric events in African hospitals as to the frequency, nature, and ratio of near miss to death and considers whether these could become useful indicators for monitoring the performance of obstetric services in Africa. Methods. Prospective or retrospective reviews of medical records were conducted in nine referral hospitals in three countries (Benin, Co ˆte d'Ivoire, and Morocco). We calculated the incidence of near-miss obstetric events, near-miss cases, and maternal deaths related to hemorrhage, hypertensive diseases of pregnancy, dystocia, infections, and anemia and analyzed these according to hospital and timing relative to admission. Results. The incidence of near-miss cases was varied, and in some hospitals extremely large: from 1% to almost a quarter of all deliveries were near misses. Near-miss cases were 15 times more common than deaths (ranging from a ratio of 9 : 1-108 : 1). Most of the women with near-miss events (NMEs) (83%) were already in a critical condition on arrival at the hospital (range 54-90%), and two in three were referred from another facility. The most frequent types of NMEs were hemorrhage and hypertensive diseases of pregnancy, but anemia was the leading cause in three first referral level hospitals in Benin and Co ˆte d'Ivoire. Near-miss events due to infections were rare. Conclusions. Near-miss events are extremely common in some African hospitals, with a high proportion arriving in critical conditions. Near-miss events must be estimated separately for those already in a critical condition on arrival and those developing after admission; the first as a good indicator of the effectiveness of emergency referrals and the second as a potential tool for monitoring the performance of obstetric services.

Evaluation of Obstetric Near Miss and Maternal Deaths in a Tertiary Care Hospital in North India: Shifting Focus from Mortality to Morbidity

“…hemorrhage, hypertensive disorders of pregnancy, sepsis, and obstructed labor/rupture uterus. Like other studies [12,[15][16][17] hemorrhage and hypertensive disorders of pregnancy were the leading cause of MNM (45.7 and 24.2 %, respectively) and maternal deaths (28.7 and 21.5 %, respectively) in our setting too. Life-threatening obstetric hemorrhage was the commonest with a high prevalence ratio of 0.53, but mortality index of this condition was low (19.7 %) emphasizing a key role of timely management and blood transfusions in saving these women.…”

“…The list of primary obstetric complications was similar to the Diseasespecific criteria [12] for diagnosis of MNM. By first identifying cases of MNM using standardized WHO criteria, we could overcome the lack of specificity and bias associated with Disease-specific criteria.…”

“…Lack of proper antenatal care is another contributing factor as 66 % (n = 418) MNM cases in this study did not receive any antenatal care before reporting to the hospital with a complication. Although some authors suggest that MNM cases referred to a hospital in a critical state should not be used to assess the quality of care [12], the proportion of referred MNM cases reflects the ability of a health facility to prevent maternal deaths even in unmanaged, mismanaged, and unanticipated situations. In order to address the high MMR in developing countries, efforts should be made to improve standard of care and utilization of services at FRUs and primary and secondary healthcare units which are the main source of MNM cases managed at the tertiary care hospital.…”

“…There has been a lot of debate regarding the criteria for defining MNM. Several approaches have been proposed like the disease-specific criteria [12], organ dysfunction criteria [13], or management criteria [14] each having its own merits and demerits. The WHO has proposed a package of 25 severity markers including clinical signs, laboratory tests, and management parameters [6] to address the need for a consensus criteria which can be used all over the world.…”

Priorities in emergency obstetric care in Bolivia––maternal mortality and near‐miss morbidity in metropolitan La Paz

“…4 Clinical-and management-based criteria previously applied by Filippi et al were used for case identification, with modifications for inclusion of anaemia because of the high altitude of our setting. 16 The clinical criteria focused on five major diagnostic groups: severe haemorrhage, severe hypertensive disorders, sepsis, obstructed labour and severe anaemia. Haemorrhage was considered severe if it resulted in shock, hysterectomy or multiple blood transfusions.…”