Measuring maternal near-miss in a middle-income country: assessing the use of WHO and sub-Saharan Africa maternal near-miss criteria in Namibia

Abstract

Background : Namibia, a middle-income country in sub-Saharan Africa (SSA), plans to use the Maternal Near Miss (MNM) approach. Adaptations of the World Health Organization (WHO) MNM defining criteria (‘WHO MNM criteria’) were previously proposed for low-income settings in sub-Saharan Africa (‘SSA MNM criteria’), but whether these adaptations are required in middle-income settings is unknown. Objective : To establish MNM criteria suitable for use in Namibia, a middle-income country in SSA. Methods : Cross-sectional study from 1 March 2018 to 31 May 2018 in four Namibian hospitals. Pregnant women or within 42 days of termination of pregnancy or birth, fulfilling at least one WHO or SSA MNM criterion were included. Records of women identified by either only WHO criteria or only SSA criteria were assessed in detail. Results : 194 Women fulfilled any MNM criterion. WHO criteria identified 61 MNM, the SSA criteria 184 MNM. Of women who only fulfilled any of the unique SSA MNM criteria, 18 fulfilled the criterion ‘eclampsia’, one ‘uterine rupture’ and five ‘laparotomy’. These women were assessed to be MNM. Thresholds for blood transfusion to define MNM due to haemorrhage were two units in the SSA and five in WHO set. Two or three units were given to 95 women for mild/moderate haemorrhage or chronic anaemia who did not fulfil any WHO criterion and were not considered MNM. Fourteen women who were assessed to be MNM from severe haemorrhage received four units. Conclusions : WHO MNM criteria may underestimate and SSA MNM criteria overestimate the prevalence of MNM in a middle-income country such as Namibia, where MNM criteria ‘in between’ may be more appropriate. Namibia opts to apply a modification of the WHO criteria, including eclampsia, uterine rupture, laparotomy and a lower threshold of four units of blood to define MNM. We recommend that other middle-income countries validate our criteria for their setting.

Applicability of the WHO maternal near-miss tool: A nationwide surveillance study in Suriname

“…Laparotomy for ectopic pregnancy was only included if blood loss was ≥1000 mL, blood was transfused or if patient was hemodynamically unstable [ 12 ];…”

“…Following this concept, organ dysfunction markers (25 criteria) define MNM [ 2 ]. However, several studies in different settings demonstrated that the organ-dysfunction criteria may not be suitable and proposed adapted criteria to prevent underreporting of life-threatening disorders [ 8 - 12 ]. In 2017, a Delphi study suggested adaptations to the WHO-criteria for low-resource settings in Sub-Sahara Africa (SSA) [ 10 ].…”

“…The adapted MNM tool included several clinical conditions, such as eclampsia, sepsis and uterine ruptured and a lower threshold for blood transfusion, and performed well in Ethiopia [ 11 ]. A recent study in Namibia suggested that both tools were not suitable for middle-income countries and proposed criteria ‘in-between’ WHO-MNM and SSA-MNM [ 12 ]. However, the resulting heterogeneity of these adapted MNM criteria compromises comparability [ 3 ], which the WHO approach specifically intended to avoid.…”

Worldwide Original Research Production on Maternal Near-Miss: A 10-year Bibliometric Study

“…Other terms reported in more recent studies, such as cesarean section, preeclampsia, severe maternal outcome (smo), termination, case fatality rate, association and potentially life-threatening condition (pltc), as wellas terms that describe countries such as Brazil, Ethiopia, India, and Tanzania reflect that, in recent years, the authors have been conducting studies that measure the cases and rates of MNM according to specific maternal health conditions and their associated factors, [21][22][23][24][25] or studies for the validation of the MNM criteria in these countries. [26][27][28][29] Terms related to severe acute maternal morbidity were not included, since this is a term interchangeable with MNM, and the WHO does not recommend refering to severe, life-threatening obstetric complications. Similarly, since we did not include articles that did not have MNM as the main subject mentioned in the title, abstract or keywords, it is possible that some studies that evaluated MNM but did not include this information in these fields may have been excluded.…”

Effect of Interpregnancy Interval on Adverse Maternal and Perinatal Outcomes at Katutura Regional Referral Hospital in Namibia: A Retrospective Cohort Study, 2005 to 2015

“…The maternal mortality also is high as 265/100 000 live birth in 2015 [18]. The common causes of maternal and child mortality include postpartum hemorrhage, eclampsia, preterm birth and low birth weight [19]. All these conditions have been linked with sub-optimal IPI in the previous studies.…”