NEHARIKA'S PAPER AT AICOG MUMBAI

2.  Despite therapeutic advances during this century and a
growing perception of the safety of child birth, morbidity and
mortality continue to occur in obstetric patients. More than
one woman dies every TEN minute from such causes.
 In addition to maternal death, women experience more than
50 million maternal health problems annualiy.
 As many as 300 million women-more than one quarter of all
adult women living in the developing world currently suffer
from short or Iong term illness and injuries related to
pregnancy and child birth.
 For every maternal death there are many serious life
threatening complications of pregnancy.
 Yet relatively little attention has been given to identifying a
general category of morbidity that could be called near-misses

3.  The analysis of maternal deaths has long been used for the
evaluation of women’’s ealth and the qualityof obstetric care
h
 Over the last decade, the identification of cases of severe
maternal morbidity has emerged as a promising complement
or alternative to the investigation of maternal deathS.
 It has been suggested that with the observed decline in
maternal mortality, analysis of well defined near-miss cases
may be a more sensitive measure of the standard of obstetric
care.
 Incorporation of near-misses into maternal death enquiries
would strengthen these audits by allowing for more rapid
reporting; more robust conclusions, comparisons to be made
with maternal deaths, reinforcing lessons learnt, establishing
requirement for intensive care and calculating comparative
indices

4. WHATS A NEAR MISS?
 Every woman can experience sudden
and unexpected complications during
pregnancy, child birth and just after
delivery.
 Morbidity during pregnancy represents
part of a continuum between extremes
of good health and death.
 On this continuum a pregnancy may be
thought of as being uncomplicated,
complicated, severely complicated or life
threatening

5.  Near Miss Maternal Mortality is a term which is very
difficult to define.Any pregnant women or recently
delivered women within 6 weeks of delivery or
termination of pregnancy in whom immediate
survival is threatened and who survives by the
medical intervention and hospital care can be termed
as Near Miss
 By Mantel GD et al, a near miss describes a patient
with acute organ system dysfunction, which if not
treated appropriately, could result in death.
 Prual A et al, has defined severe maternal morbidity
as severe complications from 28th week of gestation
to 42nd day postpartum that would have resulted in
death of the mother or a definite invalidating
sequelae without medical intervention.

8.  In different studies, the primary obstetric causes of
severe maternal morbidities have been found to be
hypertensive disorders of pregnancy, massive obstetric
haemorrhage.
 Obstructed labour has been found to be an important
cause in some studies.

11. Risk factors
The risk factors of severe maternal morbidites have been identified as:
 Maternal age >34
 social exclusion
 Hypertension,
 Previous PPH
 Delivery by emergency caesarean section,
 Multiple pregnancy
 Anaemia
 Low status of women who do not attend antenatal care in a given
health unit but are referred there when they develop life-threatening
obstetric complications, contribute significantly to maternal
morbidity.
 Induced abortions conducted by untrained village midwife (DAI) is
still a major cause of morbidity in the developing countries

12. MATERIAL AND METHODS
 222 potentially Life threatening cases were studied in a
private hospital (Malhotra Nursing Home) in Agra(INDIA)
in past five years . And we did a comparison with a rural
hospital where we found out about 1080 potentially life
threatening cases in past three years.
 The main outcome measures were: rate of near miss and
its primary determinant factors, criteria for its
identification, total hospital stay, ICU stay, and number
and kind of special procedures performed.
 Complete statistical Analysis was done related to the
causes and preventive measures and hospital recovery
stay in the study.

14. OUR STATISTICS
TOTAL NUMBER Private hospital Rural Hospital
OF DELIVERIES (Five years) (Three years)
(PAST 5 YRS)
NO OF LIVE BIRTHS 1909 6480
NO OF NEAR MISS 32 482
NO OF MATERNAL 0 9
DEATHS
NO OF LIVE BIRTHS 19 250
IN NEAR MISS

15. Private Hospital
32
1.67%

16. Rural Hospital
278
482 287
6480 (7.4%) 4.29%
MATERNAL MORTALITY- 9

17. POSSIBLY LIFE RURAL HOSP % PRIVATE %
THREATENING
N= 1080 N=222
CASES
PRE- 391 36.5% 122 54.5%
ECLAMPSIA/H
ELLP
HAMEORRHA 270 25% 34 15.3%
GE
ABRUPTIO 100 10.8% 14 6.3%
THROMBOCY 78 7.2% 15 6.7%
TOPENIA
INFECTION/SE 154 14.2% 8 3.6%
PSIS
CHD 17 1.5% 8 3.6%
PULMONARY 19 1.7% 5 2.2%
OEDEMA
SICKLE CELL 21 2.0% 4 1.8%
JAUNDICE/DIC 30 2.7% 4 1.8%

18. NEAR MISS CASES N =32(private) % N=287(rural) %
INTUBATION AND 16 49% 87 31%
VENTILATION
CLOTTING FAILURE 10 32.2% 30 10.4%
BLOOD 8 25.8% 56 19.51%
TRANSFUSIONS>5
UNITS
THROMBOCYTOPENI 7 22.6% 23 8.2%
A
HYSTERECTOMY 4 12.9% 17 5.9%
RE-EXPLORATION 3 9.7% 29 11%
DIALYSIS 1 3.22% 4 1.3%
SHOCK 6 19.3% 21 7.3%
BILIRUBIN>6mg/dl 4 12.9% 20 7%

19. MATERNAL
MORTALITY 0
IN PRIVATE
MATERNAL
MORTALITY IN 9
RURAL

22. CONCLUSION
 Efforts geared towards improvement in the management of near-miss
morbidities would definitely go a long way in reducing the present
maternal mortality ratio.
 From the findings of this review, attempts to reduce maternal deaths
may best be achieved by developing evidence-based protocols for the
management of severe hypertension and haemorrhage especially for
critically ill referred patients.
 In addition, considerable efforts should be made to improve maternal
care for infrequent but important life-threatening obstetric conditions
such as uterine rupture and infection. Necessary facilities should be
made available and training of personnel and emergency drills should
be frequently conducted to combat the identified disease processes
that received suboptimal care.
 Although this study did not specifically address avoidable factors, it
has nevertheless raised awareness of the deficiencies in the
management of serious maternal illnesses