Grand Rounds

Maternal Near-Misses: An Investigation of Incidence and Causes

BACKGROUND AND PURPOSE:

While maternal mortality rates may decline, near-misses which outnumber mortality may still be high
Data is limited in low-income countries like Ghana with respect to actual near-misses and underlying causes
Oppong et al. (BJOG, 2018) estimated the incidence of near-misses in Ghana, as well as determined factors associated with a near-miss

Cross-sectional study with an embedded case–control study (Ghana)
Participants
- All women admitted to the three study facilities with pregnancy-related complications or for birth
Data collection
- Identification of near-miss: Adapted WHO Maternal Near-Miss Screening Tool (see ‘Learn More – Primary Sources’ below)
- Near-miss cases were compared with unmatched controls (uncomplicated deliveries) in a ratio of 1:2
Primary outcomes
- Incidence of maternal near-miss
- Maternal near-miss to maternal mortality ratio
- Cause of and factors associated with maternal near-miss

8433 live births were analyzed
- 288 maternal near-miss cases
- 62 maternal deaths
- 454 healthy controls
Incidence ratios
- Maternal near-miss: 34.2 per 1000 live births (95% CI, 30.2–38.1)
- Maternal death: 7.4 per 1000 live births (95% CI 5.5–9.2)
- Maternal near-miss to mortality ratio: 4.6:1
Causes of near-miss
- Pre-eclampsia/eclampsia (41.0%)
- Hemorrhage (12.2%)
- Maternal sepsis (11.1%)
- Ruptured uterus (4.2%)
Causes were not consistent between centers, although there were no significant demographic differences
Anemia was found to be a secondary, complicating factor in 28.1% of near-miss cases
Factors associated with near-miss
- Strongest factor: Maternal fever 7 days before birth associated with increased risk
  - OR 5.95, 95%CI 3.754–9.424
- Spontaneous onset of labor was protective
  - OR 0.09 (95% CI, 0.057–0.141)
Other Health-related variables included
- Previous caesarean | Non-spontaneous onset of labor | Multiple births | LBW

For every maternal death there were almost 5 near-misses
Authors suggest that screening for fever prior to delivery could potentially impact near-miss or mortality cases
The authors suggest that lack of demographic differences is due to the fact that this study compared near-miss cases to normal controls, and not to women who did not survive their complication

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