Includes bibliographical references / Background: A near miss occurs when a pregnant woman experiences a severe life threatening complication during pregnancy or up to 42 days after the end of the pregnancy and survives. The near miss rate is defined as the number of near misses per 1000 live births. In 2011, World Health Organization (WHO) produced a useful tool for identifying near misses according to composite criteria which include the occurrence of a severe maternal complication together with organ dysfunction and/or specified critical interventions. The ratio of maternal near miss cases to maternal deaths and the mortality index both reflect the quality of care provided in a maternity service Maternal deaths have been audited in the Metro West maternity service for many years but there has been no routine monitoring or evaluation of maternal near misses. Aim of study: The study aim was to perform a near miss audit in Metro West, specifically (a) measuring the near miss rate, the maternal mortality ratio and the mortality index, (b) performing an in-depth investigation of the associated demographic, clinical and health system factors of the near miss cases, and (c) providing input into the development of an on -going system of auditing near misses cases in Metro West. Methods: A retrospective observational study conducted over 6 months between mid- March 2014 to mid -September 2014. This service includes 9 level one maternity facilities which refer all complicated maternal cases to two secondary hospitals, New Somerset (NSH) and Mowbray Maternity (MMH); or to the tertiary hospital, Groote Schuur Maternity Center (GSH). All cases of near miss managed at the three hospitals were identified weekly by the author with the assistance of onsite health providers. These cases included near misses that occurred at level one facilities and were referred on to one or more of the three hospitals. Strict criteria were used to ascertain a case as a near miss according to the WHO near miss definitions. The folders of all the near misses were reviewed and relevant data entered into a data collection form which was adapted from the WHO near miss data form. In addition, these identified folders were reviewed by two senior obstetric specialists to confirm adherence to the WHO inclusion criteria for near miss classification, and also to determine avoidable factors in the management of the near miss cases. Maternal deaths occurring during the same time period of the Near Miss audit were identified from monthly mortality meetings and the ongoing maternal mortality audit system in Metro West. Results: 112 near miss cases and 13 maternal deaths were identified, giving a total of 125 women with severe maternal outcomes. There were a total of 19,222 live births in Metro West facilities. The Maternal mortality ratio (M MR) was 67.6 per 100,000 live births and the maternal near miss rate was 5.83 per 1000 live births. The maternal near miss to death ratio was 8.6:1 and the mortality index was 10.4% Hypertension, obstetric hemorrhage and pregnancy related sepsis were the major causes of the near miss cases accounting for 50(44.6%), 38(33.9%), and 13 (11.6%) of near misses respectively. These three conditions all had low mortality indices; 1.9%, 1.9% and 0 for hypertension, pregnancy related sepsis and hemorrhage respectively. Less common conditions were, medical /surgical conditions, non-pregnancy related infections and acute collapse, accounting for 7 (6.3%), 2 (1.8%), and 2 (1.8%) of near misses respectively. Although these numbers were small, these three conditions accounted for more maternal deaths with mortality indices of 66.7 %, 33.3% and 33.3% for non- pregnancy related infections, medical /surgical conditions, and acute collapse respectively. There were 25 (22.3%) of the near miss cases who were HIV positive. The majority of near misses 99(88.4%) had antenatal care. Analysis of avoidable factors showed that, the most common problems were lack of antenatal clinic attendance (11.6%) and inter-facility transport problems (6.3%). For health provider related avoidable factors, the highest number of avoidable factors were identified at level 2 (38.2%), followed by level one (25.9%) and level 3 (7.1%). The most common factors were problem recognition, monitoring and substandard care Discussion and Conclusions: The near miss rates and maternal mortality ratio in Metro West were lower than for some other developing countries, but higher than rates in high income countries. The mortality index was low for direct obstetric conditions such as hypertensive disorders, obstetric hemorrhage and pregnancy related sepsis, reflecting good quality of care and referral mechanisms for these conditions. The mortality indices for non-pregnancy related infections, medical/surgical conditions and acute collapse were much higher and, suggest that medical problems may need more focused attention. Ongoing near miss audit would be valuable for Metro West but would require identification and monitoring systems to be institutionalized.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:uct/oai:localhost:11427/16525 |
| Date | January 2015 |
| Creators | Enyeribe Iwuh, Ibezimako Augustus |
| Contributors | Fawcus, Susan R, Schoeman, Leann |
| Publisher | University of Cape Town, Faculty of Health Sciences, Department of Obstetrics and Gynaecology |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Master Thesis, Masters, MMed |
| Format | application/pdf |
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