Maternal near miss: incidence, causes, factors and adverse perinatal outcomes in Addis Ababa
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Date
2018-05
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Addis Ababa Universty
Abstract
Background: A maternal near-miss event or severe acute maternal morbidity is defined by the
World Health Organization as „a woman who nearly died but survived a complication that
occurred during pregnancy, childbirth or within 42 days of termination of pregnancy‟. Since
maternal mortality is a rare event in each health facility, it is important to study maternal nearmiss
as a complement to evaluate and improve the quality of obstetric care. Studies addressing
the incidence, causes, factors and adverse perinatal outcomes of maternal near-miss are rare in
Ethiopia. Thus, the findings of the current study are important to provide a reliable evidence for
policy makers, programmers and health practitioners.
Objectives: The study aimed to assess the incidence, causes, factors and adverse perinatal
outcomes of maternal near-miss.
Methods: The study was conducted in five selected public hospitals of Addis Ababa, Ethiopia
from May 1, 2015 to April 30, 2016. The hospitals were selected based on the number of
deliveries they managed per year. In addition, presence of an Intensive Care Unit, maternity
ward, blood transfusion service and availability of cesarean section delivery were considered in
the selection of hospitals. A mix of methods was used to address the objectives of the study. A
facility-based cross-sectional study was used to determine the incidence and causes of maternal
near miss (Objective I). All maternal near-miss cases admitted to the selected hospitals during
the study period were prospectively recruited. Maternal near-miss was ascertained using the
World Health Organization criteria. A nested case-control design was used for identifying factors
associated with maternal near-miss (Objective II). All women who developed maternal near-miss
during the study period were included as cases, and those who delivered without any
complications within the same day of the near-miss event were enrolled as controls. A total of
three controls matched for age and study area were selected for each maternal near-miss case. A
prospective cohort study design was used to examine adverse perinatal outcomes of maternal
near-miss (Objective III). Women who were admitted to the participating hospitals during the
study period and developed maternal near-miss according to the World Health Organization
criteria were included as exposed group. Women who delivered without any complications were
enrolled as non-exposed group. We followed a total of 828 women admitted for delivery or
treatment of pregnancy-related complications along with their singleton newborn babies. The
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main outcomes of interest were adverse perinatal outcomes and defined with a composite
measure.
Participants were interviewed by well-trained data collectors using pre-tested questionnaire.
Medical records were also reviewed to abstract relevant information. In order to review the
participants‟ record, permission was obtained from the participants and administrators of each
participating hospital. Univariate analysis was performed to know the underlying and
contributing causes of maternal near-miss. The number of maternal near-miss cases over one
year per 1000 live births occurring during the same year was calculated to determine the
incidence of maternal near-miss. Bivariate and multivariable conditional logistic regressions
were performed to identify factors associated with maternal near-miss. Multivariable logistic
regressions were also performed to determine the adjusted risk of adverse perinatal outcomes.
Stata version 13 was used for the analysis.
Results: During a one-year period, a total of 238 maternal near-miss cases and 29,697 live births
were reported in the hospitals included in the study, which produced a total maternal near-miss
incidence ratio of 8.01 per 1000 live births (95% CI; 7.06 – 9.09). The underlying causes of the
majority of maternal near-miss cases were hypertensive disorders and obstetric hemorrhage.
Anemia was the major contributing cause reported for maternal near-miss. Most of the maternal
near-miss cases occurred before the women‟s arrival at the participating hospitals. The main
factors associated with maternal near-miss were: history of chronic hypertension (AOR=10.79,
95% CI; 5.15 – 22.64), rural residence (AOR=10.68, 95% CI; 4.60 – 24.78), history of stillbirth
(AOR=6.06, 95% CI; 2.09 – 17.49), no antenatal care attendance (AOR=5.58, 95% CI; 1.82 –
17.05) and history of anemia (AOR=5.16, 95% CI; 2.81 – 9.47). After adjusting for potential
confounders, women with maternal near-miss condition had more than five-fold increased odds
of adverse perinatal outcomes compared to women without maternal near-miss (AOR=5.69: 95%
CI; 3.69 – 8.76). Other risk factors that were independently associated with adverse perinatal
outcomes included: rural residence (AOR=2.16: 95% CI; 1.03 – 4.53), history of prior stillbirth
(AOR=2.39; 95% CI; 1.12 – 5.10) and primary educational level (AOR=1.89: 95% CI; 1.07 –
3.34).
Conclusions and recommendations: The majority of maternal near-miss cases have already
occurred on the women‟s arrival at the participating hospitals, implying the need to focus on
existing pre-hospital barriers. However, near-miss cases that develop during hospitalization can
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help to measure the quality of obstetric care provided within the health facilities. Efforts made
towards improvement in the management of life-threatening obstetric complications could
reduce the occurrence of maternal near-miss problems that occur during hospitalization. There is
a need for appropriate interventions in order to improve the identified factors of maternal nearmiss.
The factors can be modified through a better access to medical and maternity care, scaling
up of antenatal care in rural areas, improve in infrastructure to fulfill referral chain from primary
level to secondary and tertiary health care level, and, health education to pregnant women.
Presence of maternal near-miss in women is an independent risk factor for adverse perinatal
outcomes. Hence, interventions rendered at improvement in maternal health can lead to an
improvement in perinatal outcomes. The follow-up time used by the World Health Organization
to define maternal near-miss has duration of 42 days postpartum. However, because of logistic
and feasibility concerns, our follow-up time was limited to only the length of the hospital stay.
This might have caused us to underestimate the magnitude of maternal near-miss and hindered us
not to investigate the occurrence of other events such as maternal deaths occurred after maternal
discharge.
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Keywords
Maternal near-miss, Incidence, Causes, Factors, Adverse perinatal outcomes, Public Hospitals, Addis Ababa, Ethiopia