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Brief Research Article
Obstetric Near Miss Morbidity and Maternal Mortality in a Tertiary Care Centre in Western Rajasthan *Priyanka Kalra1, Chetan Prakash Kachhwaha2 1
Senior Resident, 2Associate Professor, Department of Obstetrics and Gynaecology, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
Summary Obstetric near-miss (ONM) describes a situation of lethal complication during pregnancy, labor or puerperium in which the woman survives either because of medical care or just by chance. In a cross-sectional observational study, five factor scoring system was used to identify the near-miss cases from all the cases of severe obstetric morbidity. Assessment of the causes of maternal mortality and near-miss obstetric cases was done. The ONM rate in this study was 4.18/1000 live births. Totally 54 maternal deaths occurred during this period, resulting in a ratio of 202 maternal deaths per 100,000 live births. Hemorrhage, hypertension and sepsis were major causes of near-miss maternal morbidity and mortality, respectively in descending order.
Keywords: Five factor scoring system, Maternal mortality, Near-miss obstetric morbidity
Obstetric near-miss (ONM) or severe acute maternal morbidity is gaining interest internationally as a new indicator of the quality of obstetric care following maternal mortality statistics.1 “Near-miss” describes a patient with an acute organ system dysfunction, which, if not treated appropriately, could result in death.2 It has also been described as a situation of lethal complication during pregnancy, labor or puerperium in which the woman survives either because of medical care or just by chance.3 The death to severe morbidity ratio reflects the standard of maternal care. The maternal mortality ratio (MMR) of India was 254 (2004-2006), which was reduced to 200 (2010).4 India is signatory to millennium declaration and is committed to *Corresponding Author: Dr. Priyanka Kalra, Senior Resident, Department of Obstetrics and Gynaecology, Dr. S. N. Medical College, Jodhpur, Rajasthan, India. E-mail:
[email protected]
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Website: www.ijph.in DOI: 10.4103/0019-557X.138635 PMID: ***
achieving the target of millennium development goals by reducing MMR to 100. Known obstacles to reducing the MMR in developing countries, include lack of material and human resources, as well as difficulties in accessing services due to financial, geographical, and cultural limitations. Near-miss cases have similar pathways as maternal deaths, with the advantages of offering a larger number of cases for analysis, greater acceptability of individuals and institutions since death did not occur, and the possibility of interviewing the woman herself. However, there is no definite denominator population in a hospital; the data for total number of deliveries and live births is available, which was used to calculate the maternal mortality and ONM ratios. International studies have reported ONM to maternal death ratios ranging from 5:12 up to 11:1.5 Worldwide, some studies have described it according to common obstetric disease states, e.g., hemorrhage, preeclampsia,1 whereas others used either criteria related to the response to the disease (e.g., hysterectomy or admission to Intensive Care Unit [ICU]) or specific organ system dysfunction, that is specific criteria of dysfunction or failure of specific organ system.6 Hence, this study was conducted to provide insight into the problem of maternal near-miss and mortality in Western Rajasthan, India. This cross-sectional observational study was conducted in the Department of Obstetrics and Gynecology, of a
Indian Journal of Public Health, Volume 58, Issue 3, July-September, 2014
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Kalra and Kachhwaha: Obstetric Near Miss Morbidity and Maternal Mortality
Medical College Hospital of Western Rajasthan for a period of 18 months from May 2011 to October 2012. For identifying near-miss cases five-factor scoring system as described by Geller et al. was used.7 The five-factor scoring system has the specificity of 93.9% and sensitivity 100%. It comprises of organ-system failure, ICU admission, transfusion >3 units of blood, extended intubation (>12 h), and surgical intervention (hysterectomy, relaparotomy). These factors are given the score of 5, 4, 3, 2, and 1 respectively. A five factor scoring system can theoretically have score from 0 to 15 (no clinical factor present to all clinical factors present).The cut off point for near-miss case is a score of 8 or greater. Patient characteristics such as age, parity, antenatal booking status and details of disease-specific condition and their management were recorded in a semi-structured proforma from case records. Statistical analysis was performed. The ONM incidence was calculated as the number of near-miss cases per 1000 live births in the hospital. MMR was calculated as the number of maternal deaths per 100,000 live births. In the 18 months study period, there were 27,958 deliveries and 26,734 live births. Totally 112 patients were identified as ONMs as per the Geller’s five point scoring system, while there were 54 maternal deaths. The ONM rate was 4.18/1000 live births. The demographic features of the patients have been given in Table 1. The mean age of the near-miss patients was 24 ± 3.11 years, while that of mortality group was 26 ± 2.44 years. Majority of the patients were unbooked in both near-miss and maternal deaths group. Most of the critical obstetric events occurred in postpartum period. Total near-miss cases were 112 and 60.7% of the nearmiss patients were critical on admission. 72 (64.2%) Table 1: Demographic characteristics of women with near-miss morbidity and maternal death Characteristics Parity P0 P1–P2 P3–P4 P ≥5 Gestational age 3 units of blood was needed in 66 patients. Our center is one of the most crowded hospitals in India with more than 20,000 deliveries in a year. Besides the case load is ever increasing after the introduction of the maternal and child beneficiary scheme called “Janani Shishu Suraksha Karyakram” which provides for free of cost treatment and hospitalization. A lot depends on the commitment of the managers and staff of the institutions and on the health system to provide support for revising the events, implementing and evaluating the healing interventions, thereby ensuring full auditing process within the routine clinical activities. The study was conducted in a tertiary care center, it did not represent the status in private sector. Hence, the observations in our study reflect the status of obstetric care in the tertiary care hospitals with the ever rising patient load. To a certain extent, it will help health care providers and policy makers to design strategies to improve maternal health services in India and to achieve millennium development goal. The major causes of near-miss cases were similar to the causes of maternal mortality of India. Lessons can be learned from cases of near-miss, which can serve as a useful tool in reducing MMR. Need for development of an effective audit system for both near-miss obstetric morbidity and mortality is felt.
Acknowledgment I would like to thank Dr. Sumitra Bora, Professor and Head, Department of Obstetrics and Gynecology, Dr. S. N. Medical College, Jodhpur, Rajasthan for providing their support for the study.
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Indian Journal of Public Health, Volume 58, Issue 3, July-September, 2014
