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Grand Rounds

Maternal Near-Misses: An Investigation of Incidence and Causes

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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 

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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

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