Anuj Mundra Moderator Dr A.M. Mehendale Maternal near-miss
reviews: lessons from a pilot programme in India C Purandare, A
Bhardwaj, M Malhotra, H Bhushan, S Chhabra, P Shivkumar British
Journal of Obstetrics and Gynaecology, 2014
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Learning objective To understand the concept of Maternal Near
Miss (MNM).
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Introduction Significant reduction in MMR has been made in
India to reach 178/100000 live births. The 12 th 5yr plan has set
an MMR target of 100/100000 to be achieved by 2017. Maternal death
review was launched in 2010 which provided information on various
factors at different levels to be addressed to reduce maternal
deaths. The concept of Maternal Near Miss (MNM) has gained
importance and has been considered as a less threatening approach
than maternal death to identify factors for improving maternal
health care by reducing fear of blame & punishment. Near-miss
cases are generally more frequent than maternal deaths and
therefore a more reliable quantitative analysis can be carried out,
which can give a more comprehensive information about the health
care status.
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Objectives 1. To agree on the national MNM policy framework and
definition of MNM in the Indian context, 2. To agree on the
criteria for identifying an MNM, 3. To agree on the tools for
recording and reporting an MNM case, 4. To pilot test, and make
recommendations for the next steps, including potential scale up
across the country.
Slide 5
Key partners and stakeholders Under the guidance of the GoI,
key stakeholders were identified and a National Technical Group
(NTG) was constituted. The NTG was given the task of fulfilling the
key objectives and developing a comprehensive way forward to guide
the Govt. for considering national implementation of MNM. The NTG
comprised technical experts from the Maternal Health division,
MoHFW; Federation of Obstetric and Gynaecological Societies of
India, Mahatma Gandhi Institute of Medical Sciences AVNI Health
Foundation, Development partners ( UN population Fund, UN Childrens
Fund, WHO) Other stakeholders - National Neonatological Forum,
Society of Midwives of India, Indian Nursing Council, IAP, NIHFW,
State government representatives of 6 states; and National Health
Systems Resource Centre The project was implemented in 6 medical
colleges in Aligarh, Bhopal, Chennai, Rohtak, Shimla,
Sewagram.
Slide 6
Implementation The policy was implemented in 10 phases over a
period of 16 months during 2012-13
Slide 7
Implementation The project was implemented in 10 phases over a
period of 16 months during 2012-13. The activities carried out in
each phase are: PhaseActivities IIdentification of partners for
design development & programme management IIDesk research,
through which secondary information related to near-miss audit from
across the world as well as in India were collected IIINTG was
constituted with all programme partners. IV The NTG met and agreed
a draft policy framework, case definitions and criteria for the
identification of a maternal near-miss and agreed on tools to be
used for reporting during the pilot phase. VPilot testing: 6
medical colleges reported their findings. 1 NTG member visited each
of the centres for guidance and mentoring. VIMid-term review of the
programme at 3 months. Reports review & changes in
definition/criteria/tools if required and were implemented
VIIRevised policy framework, definition, case selection criteria,
tools for reporting used by the pilot institutes VIIIData entry,
cleaning, quality checks and data analysis. IX NTG met for the
third time and reviewed the final report. Policy framework
finalized to be given to the GoI for its release as a national
policy for implementation X Report preparation, submission for
release of the MNM policy framework, definitions, criteria, and
tools, design and development of MNM software.
Slide 8
Definition & Criteria A case of MNM was defined as A women
who survives life-threatening condition during pregnancy,
termination of pregnancy, childbirth or within 42 days of pregnancy
termination, irrespective of receiving emergency medical/surgical
interventions or otherwise. For a case to be listed as MNM a min.
of 3 criteria in each section, one each from Clinical findings
(symptoms/signs) Investigations Interventions to manage the case,
OR any single criteria that signifies cardiorespiratory
collapse.
Slide 9
Adverse events identified 4 sections of adverse events that
could lead to MNM were identified: i. Pregnancy specific disorders-
Haemorrhage, sepsis, hypertension ii. Pre-existing disorders
aggravated during pregnancy- Anaemia, respiratory dysfunction,
cardiac dysfunction, hepatic dysfunction, endocrinal disorders
(diabetic ketoacidosis, thyroid crisis), neurological dysfunction,
renal dysfunction/failure iii. Pregnancy specific medical
disorders- Liver dysfunction/failure, cardiac dysfunction/failure
iv. Incidental and accidental causes of maternal death- Accident/
assault/ surgical problems, anaphylaxis, infections, embolism and
infarction.
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Results Total MNM 264/27433 (0.96%) Mean time reported from
onset of illness to admission 48.4 hours
Observations & way forward As a result of the pilot
programme, several points were highlighted: "Near-miss" events are
more common than maternal deaths and can be more comprehensive and
provide additional information, review of "near- miss" events may
give more insight into risk factors and possible means of
prevention of maternal mortality and morbidity. As the woman
survives, near miss reviews are less threatening than death reviews
for the teams reporting them. Building the skills of healthcare
providers in procedures such as repair of tears, resuscitation,
medical & surgical M/m of PPH like B-lynch suturing, stepwise
devascularisation and internal iliac ligation and peripartum
hysterectomy as well as the management of sepsis and hypertensive
disorders of pregnancy remain important.
Slide 24
Women and their families need to be educated regarding birth
preparedness and complication readiness because Type 1 delay was
still seen to be very high and was associated with severe maternal
morbidity in majority of cases. Prevention and timely treatment of
anaemia must receive more attention to reduce the risk of mortality
from obstetric haemorrhage. The tools developed currently capture
the location and facility details and can help to identify where an
MNM case has been referred to a higher level health facility. It
can help to focus interventions in that particular location.
Slide 25
MNM Data Management software linked to the MCTS and Maternal
Death Review software introduced in India has been developed and
can be used as soon as MNM review is launched nationally in India.
States and Districts will be able to access the reports directly,
enabling data sharing, which is more difficult with paper-based
reports. As the majority of MNM attend the tertiary facility level
and MNM reporting is less difficult in these settings, the focus of
MNM implementation will likely initially be at the tertiary level
(Medical Colleges/District Hospital converted to Medical
Colleges/Hospitals attached to Medical Colleges), then using the
Medical College experience and teams, MNM audit can be subsequently
scaled up to the District Hospital level. Based on this pilot
programme, a report on the benefits of MNM review and the need to
implement MNM review was prepared and submitted to the Government
of India in October 2013 along with the MNM policy framework.
Slide 26
Other studies on MNM Author YearPlace Findings Roopa PS,
Shailja Verma, Lavanya Rai, Pratap Kumar, Murlidhar V. Pai, Jyothi
Shetty 2013 Manipal, India 17.9/1000 live birth. Near miss:
mortality=5.6:1 Haemorrhage was the leading cause for near miss
followed by PIH and Sepsis. Sepsis leading cause for death. Cardiac
disease had highest mortality index. Chhbra P, Guleria K, Saini NK,
Anjur KT, Vaid NB 2008Delhi Incidence of severe morbidity was
33/1000 live birth. The leading causes were haemorrhage, PIH, and
sepsis. More than 50% required caesarean section. Kalra P,
kachhwaha CP 2014 Jodhpur, India Near miss incidence was 4.18/1000
live birth. Mortality ratio was 202 per lakh live birth. MNM:
mortality was 2.1. Haemorrhage, hypertension and sepsis were major
causes. Pandey A, Das V, Agarwal A, Agarwal S, Misra D, Jaiswal N
2014India MNM: mortality= 2.6. the MNM incidence was roughly 12%.
Haemorrhage and hypertensive disorders of pregnancy were leading
cause of MNM and maternal deaths.
Slide 27
Maternal near-miss indicators Maternal near miss (MNM)- A woman
who nearly died but survived a complication that occurred during
pregnancy, childbirth or within 42 days of termination of
pregnancy. Severe maternal outcomes- A life-threatening condition
(i.e. organ dysfunction), including all maternal deaths and
maternal near-miss cases. Women with life-threatening conditions
(WLTC)- All women who either qualified as maternal near-miss cases
or those who died (i.e. women presenting a severe maternal
outcome). Severe maternal outcome ratio (SMOR)- Number of women
with life-threatening conditions per 1000 live births. This
indicator gives an estimate of the amount of care and resources
that would be needed in an area or facility [SMOR = (MNM +
MD)/LB].
Slide 28
Maternal near-miss indicators MNM ratio (MNMR) - the number of
maternal near-miss cases per 1000 live births (MNMR = MNM/LB).
Maternal near-miss mortality ratio - the ratio between maternal
near-miss cases and maternal deaths (MNM : 1 MD). Higher ratios
indicate better care. Mortality index- The number of maternal
deaths divided by the number of women with life-threatening
conditions expressed as a percentage [MI = MD/(MNM + MD)]. The
higher the index the more women with life-threatening conditions
die, whereas the lower the index the fewer women with life-
threatening conditions die. Perinatal outcome indicators- (e.g.
perinatal mortality, neonatal mortality or stillbirth rates) in the
context of maternal near-miss could be useful to complement the
quality-of-care evaluation.
Slide 29
References Roopa PS, Shailja Verma, Lavanya Rai, Pratap Kumar,
Murlidhar V. Pai, and Jyothi Shetty, Near Miss Obstetric Events and
Maternal Deaths in a Tertiary Care Hospital: An Audit,Journal of
Pregnancy, vol. 2013, Article ID 393758, 5 pages, 2013.
doi:10.1155/2013/393758 Chhabra P, Guleria K, Saini NK, Anjur KT,
Vaid NB. Pattern of severe maternal morbidity in a tertiary
hospital of Delhi, India: a pilot study. Trop Doct. 2008
Oct;38(4):2014. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/18820181 Pandey A, Das V,
Agarwal A, Agrawal S, Misra D, Jaiswal N. Evaluation of obstetric
near miss and maternal deaths in a tertiary care hospital in north
India: shifting focus from mortality to morbidity. J Obstet
Gynaecol India. 2014 Dec;64(6):3949. Kalra P, Kachhwaha CP.
Obstetric near miss morbidity and maternal mortality in a Tertiary
Care Centre in Western Rajasthan. Indian J Public Health. 2014
Jan;58(3):199201. World Health Organization. Evaluating the quality
of care for severe pregnancy complications:The WHO near-miss
approach for maternal health. Geneva; 2011.