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BRIEF RESEARCH ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 3  |  Page : 371-374  

An observational study on maternal mortality and maternal near miss in a selected facility of West Bengal


1 District Public Health Nursing Officer, Department of Health & Family Welfare, Govt, of WB, Ph.D Scholar, The WB University of Health Sciences, Kolkata, West Bengal, India
2 Professor, Department of Obstetrics and Gynaecology, Midnapore Medical College and Hospital, Paschim Midnapore, West Bengal, India

Date of Submission11-Feb-2022
Date of Decision20-Jul-2022
Date of Acceptance03-Aug-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Sima Maity
Ratnali, Radhaballavpur, Tamluk, Purba Medinipur, Kolkata - 721 627, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_211_22

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   Abstract 


An observational study was performed at Purba Medinipur District Hospital, West Bengal, from April 1, 2018, to December 31, 2020, with an aim to find out the magnitude of maternal mortality and near miss cases and to assess the utilization of available maternal health care services by the deceased women and near miss cases. Result showed 4.5% women developed potentially life-threatening condition (PLTC) of which 21% women developed LTC. Maternal Near Miss (MNM) ratio was 9.46/1000 live birth and the MNM-to-Maternal Mortality ratio was 8.3:1 and the leading causes of MNM and maternal death were hemorrhage, pregnancy induced hypertension/eclampsia. The utilization of maternal health-care services revealed that there is a scope to increase the service delivery. Study finding indicates that health-care programs need to enhance the existing efforts to improve timely health seeking behavior of women.

Keywords: Maternal death, maternal mortality, maternal near miss, potentially life threatening condition


How to cite this article:
Maity S, Chaudhuri S. An observational study on maternal mortality and maternal near miss in a selected facility of West Bengal. Indian J Public Health 2022;66:371-4

How to cite this URL:
Maity S, Chaudhuri S. An observational study on maternal mortality and maternal near miss in a selected facility of West Bengal. Indian J Public Health [serial online] 2022 [cited 2022 Sep 28];66:371-4. Available from: https://www.ijph.in/text.asp?2022/66/3/371/356601



Pregnancy and childbirth complications are major causes of maternal morbidity and mortality globally and specially in the developing countries like India. Improving maternal health has received recognition at the global level as evidenced by its inclusion in top most-2015 sustainable development goal agendas and a target for maternal mortality ratio (MMR) is set as to fewer than 70 maternal deaths per 100,000 live births by 2030.[1]

As per the latest report of the Registrar General of India, Sample Registration System, MMR of India has shown a decline from 178/100,000 live births in the period 2010-12 to 103/100,000 in 2017–2019.[2]

At present, relying on maternal mortality is inadequate as it overlooks pregnancy complications which ultimately lead to maternal death. Complications in pregnancy may range in severity from minor morbidity to potentially life-threatening conditions (PLTC) and life-threatening conditions (LTC). The World Health Organization (WHO) defines Maternal Near Miss (MNM) as “a woman who almost dies but survives a complication during pregnancy, childbirth or within 42 days after termination of pregnancy.”[3]

As per MNM Review Operational guidelines by GOI “A Woman who survives LTC during pregnancy, abortion, and childbirth or within 42 days of pregnancy termination, irrespective of receiving emergency medical/surgical interventions, is called MNM.”[4]

MNM 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. Thus MNM is considered as a promising indicator to improve quality of obstetric care.

A descriptive observational study was conducted at Purba Medinipur District Hospital, Tamluk, Purba Medinipur, during the period of April 1, 2018–Decemebr 31, 2020 to find out the magnitude of maternal mortality and near miss cases and to assess the utilization of available maternal health care services by the deceased women and near miss cases.

Ethical approval for the study was obtained from the Institutional Ethics Committee, Midnapore Medical College.

Informed written consent was obtained from the woman or from her primary care giver (near relatives) for MNM cases. For Maternal Death (MD) cases record analysis done.

Inclusion criteria for the study were as per WHO Near Miss Approach [Supplementary File]. Women who were pregnant, in labor, or who delivered or aborted up to 42 days ago arriving at the facility with any of the listed conditions or those who developed any of those conditions during their stay at the health-care facility were included.

All women with obstetric complications were screened irrespective of the severity of complications. Depending on the severity, the women were further screened with the help of WHO Near Miss criteria. Data collection was done by the investigator by doing daily visit to the antenatal ward, postnatal ward, Labour room, CCU by using (i) structured interview schedule on background data of women, (ii) MNM tool of WHO for screening, (iii) Questionnaire on utilization of maternal health-care services, (iv) facility-based MNM review pro forma (as per Operational guideline from Govt. of India):- Applied for women who became MNM as per WHO MNM criteria, (v) Maternal death review pro forma (As per MDSR guideline).

The study result is shown in [Figure 1]; out of total admission of 39,310 women, 26,476 women had undergone the process of delivery and resulted 26,332 live births and 10,313 women were identified as women with obstetric complications. Out of all admitted women, 1768 (4.5%; 1768/39,310) women had PLTC and among these women with PLTC 376 (21%; 376/1768) women had LTC and were eligible for inclusion in the study as per the WHO criteria of LTC (near miss). However, 97 women out of 376 were excluded as they were referred to higher center. The referred women were not included in data analysis as the outcome of referred women was not available. Thus, 279 women were analyzed in the study, of which 249 women became MNM and 30 women died.
Figure 1: Flow diagram of obstetric events

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Of 249 MNM cases 96 were referred in from different block primary health centers, rural hospitals, subdivisional hospitals, super specialty hospitals and out of 30 MD 20 were referred in cases.

From the demographic and obstetric characteristics of the women, it is reflected that majority of the women who were MNM or died were <25 years of age (MNM - 58% and MD - 53%), Hindu (MNM - 74% and MD - 87%), rural background (MNM - 96% and MD - 100%), no or primary education (MNM - 61% and MD - 50%), low parity and admitted with gestational age 34–37 weeks of pregnancy (MNM - 32% and MD -33%).

The utilization of health-care services is shown in [Table 1]. The analysis reveals that among the 249 MNM cases 60%–70% women had satisfactory antenatal checkup as evidenced from blood pressure check, weight check, counseling about diet, rest in pregnancy, danger signs in pregnancy, Hb% estimation, routine urine analysis, and HIV testing. These parameters were almost similar (60%–75%) for women who died. Around half of the women who had near miss or died were admitted in hospital within 2 h of onset of complications and availed free government vehicle for transport to reach hospital. However, after getting admission in hospital, they were attended by a doctor within 1 h of admission.
Table 1: Frequency and percentage of utilization of maternal health care services among the maternal near miss and maternal death cases

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After analyzing the causes of MNM cases according to clinical diagnosis and WHO near miss criteria, it has been noted that for 249 MNM cases the main clinical diagnosis was hemorrhage antepartum hemorrhage postpartum hemorrhage (APH/PPH) - 36.1% (90/249), preeclampsia/eclampsia - 31.3% (78/249), ruptured ectopic - 14.45% (36/249), ruptured uterus - 8.83% (22/249), abortion - 5.22% (13/249), and sepsis - 2% (5/249).

Whereas for 30 MD cases, the main clinical diagnosis was hemorrhage (APH/PPH) - 33.3% (10/30), preeclampsia/eclampsia - 23.3% (7/30), ruptured ectopic -10% (3/30), ruptured uterus - 3.33% (1/30), abortion - 10% (3/30), and sepsis - 10% (3/30).

According to the analysis of the collected data in the present study, the severe maternal outcome ratio (SMOR) was 14.28/1000 live births, MNM ratio was 9.46/1000 live birth, the MNM-to-Mortality ratio was 8.3:1 and mortality index was 10.75%

This observational study shows 4.5% (1768/39,310) women developed PLTC of which 21% women (376/1768) developed LTC. We prospectively collected data of women with LTC (279) which resulted in 249 (89.25%, 249/279) near miss case and 30 (10.75%; 30/279) maternal deaths for clinically significant outcome. We finally analyzed 249 MNM cases and 30 maternal deaths.

For both MNM and MD cases hemorrhage (APH/PPH) - 36.1% (MNM) and 33.3% (MD), preeclampsia/eclampsia - 31.3% (MNM) and 23.3% (MD), ruptured ectopic - 14.45% (MNM) and 10% (MD), were three main causes but the percentage of suffering from abortion and sepsis increased in cases of MD-abortion - 5.22% (MNM) and 10% (MD) and sepsis - 2% (MNM) and 10% (MD).

However the mortality index was 10.8% (30/279) and MNM-to-mortality (MD) ratio was 8.3:1. This means that for every 9 women with LTC one woman died. A large percentage of these women (30%) had inadequate antenatal care, were unable to get admitted within 2 h of symptoms (50%) and half of them could not avail free transport to the hospital (48%).

The incidence of potentially life-threatening complication in our study was 4.5% is comparable with the incidence of PLTC in pregnancy of other studies.[5],[6] Jayaratnam et al.[7] showed that the maternal “near miss” index rate was 7/1000 live births, Aduloju et al.[8] found the MNM incidence ratio was 17.4/1000 live births with overall mortality index of 17.5%. Whereas in the present study, the incidence of MNM is 9.46/1000 live birth and the MNM-to-mortality ratio was 8.3:1. However, we need to remember that outcome of the women enrolled from March 2020 to December 2020 may be influenced by the COVID-19 pandemic.

The leading causes of severe maternal outcome in our study were hypertensive disorders (eclampsia/preeclampsia) and hemorrhage which were similar to other studies.[5],[9],[10] Eclampsia is largely preventable and hemorrhage can be effectively treated without any development of LTC in most cases. Our study indicates that in many women development of hypertension in pregnancy may not be detected early because of inadequate antenatal care and anemia may not be corrected during pregnancy because of lack of quality antenatal care. Moreover, there may be delay in initiation of care following development of complications as many women reached hospital after 2 h or more. This is in agreement with the concept that the main preventive factors in decreasing maternal mortality are delays in the care process, from symptom identification by the patient to the provision of adequate treatment by health-care professionals. Moreover, many women were referred to higher center with LTCs from our setup. This point out deficiency in infrastructure in care of critically ill women which is evidenced from inadequate number of CCU beds for obstetric mothers.

The main strength of our study is prospective nature of large number of data collection with every case of LTCs providing a complete account of events.

Our study result indicates that there is a need of better quality antenatal care and extra resources are needed in identification and transport of the women to reach hospital when the women develops complications. A near miss maternal death ratio of 8.3:1 and mortality index of 10.8% indicates women are dying frequently following LTC. There is need of the improvement of critical care in women who are suffering from LTC.

Acknowledgment

The authors are thankful to the mothers who participated in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
   References Top

1.
The Sustainable Development Goals and Maternal Mortality. Available from: https://www.mhtf.org/topics/the-sustainable-development-goals-and-maternal-mortality. [Last accessed on 2021 Mar 31].  Back to cited text no. 1
    
2.
Sample Registration System (SRS)-Special Bulletin on Maternal Mortality in India 2017-19, India; March, 2022. Available from: https://censusindia.gov.in/nada/index.php/catalog/40525. [Last accessed on 2022 Jul 19].  Back to cited text no. 2
    
3.
Evaluating the Quality of Care for Severe Pregnancy Complications the WHO Near-miss Approach for Maternal Health. World Health Organization; 2011. Available from: http://apps.who.int/iris/bitstream/handle/10665/44692/9789241502221_eng.pdf. [Last accessed on 2018 Aug 09].  Back to cited text no. 3
    
4.
Maternal Near Miss Review. Operational Guidelines Maternal Health Division Ministry of Health & Family Welfare Government of India; December, 2014.  Back to cited text no. 4
    
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Chaudhuri S, Nath S. Life-threatening complications in pregnancy in a teaching hospital in Kolkata, India. J Obstet Gynaecol India 2019;69:115-22.  Back to cited text no. 5
    
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Reena RP, Radha KR. Factors associated with maternal near miss: A study from Kerala. Indian J Public Health 2018;62:58-60.  Back to cited text no. 6
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7.
Jayaratnam S, Kua S, deCosta C, Franklin R. Maternal 'near miss' collection at an Australian tertiary maternity hospital. BMC Pregnancy Childbirth 2018;18:221.  Back to cited text no. 7
    
8.
Aduloju OP, Aduloju T, Ipinnimo OM. Profile of maternal near miss and determinant factors in a teaching hospital, Southwestern Nigeria. Int J Obstet Gynaecol Res (IJOGR) 2018;5:598-617.  Back to cited text no. 8
    
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Woldeyes WS, Asefa D, Muleta G. Incidence and determinants of severe maternal outcome in Jimma University teaching hospital, south-West Ethiopia: A prospective cross-sectional study. BMC Pregnancy Childbirth 2018;18:255.  Back to cited text no. 9
    
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Oppong SA, Bakari A, Bell AJ, Bockarie Y, Adu JA, Turpin CA, et al. Incidence, causes and correlates of maternal near-miss morbidity: A multi-centre cross-sectional study. BJOG 2019;126:755-62.  Back to cited text no. 10
    


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