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

METHODS:

• 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

RESULTS:

• 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

CONCLUSION:

• 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

Learn More – Primary Sources:

Incidence, causes and correlates of maternal near-miss morbidity: a multi-centre cross-sectional study

The WHO near-miss approach 

Related ObG Topics:

ACOG Preeclampsia Guidelines: Antenatal Management and Timing of Delivery

Postpartum Hemorrhage – Medications to Treat Uterine Atony 

SMFM & CMQCC Guidelines: Management of Sepsis in Pregnancy

Forceps/Vacuum Delivery vs Cesarean Section and Adverse Maternal and Perinatal Outcomes