SEVERE ACUTE MATERNAL
MORBIDITY/NEAR MISS
MATERNAL MORBIDITY
Sangeetagupta
Seniorconsultant&HOD,
Deptt of Obst.&Gynae,ESIPGIMSR,Basaidarapur
I keep six honest serving men,
They taught me all I knew,
Their names are What ,Why, When
, How ,Where and Who.
Rudyard Kipling
MATERNAL MORTALITY IS “JUST THE TIP OF
ICEBERG” HAS VAST BASE TO THE
ICEBERG—MATERNAL MORBIDITY-WHICH
REMAINS UNDESCRIBED
WHO
A maternal near-miss case “awoman who
nearly died but survived a complication
that occurred during pregnancy, childbirth or
within 42 days of termination of pregnancy”
 In practical terms, women are considered
nearmiss cases when they survive lifethreatening conditions (i.e. organd ysfunction).



A severe life-threatening obstetric
complication necessitating an urgent
medical intervention in order to prevent
likely death of the mother.
Any pregnant or recently delivered woman,
in whom immediate survival is threatened
and who survives by chance or because of
the hospital care she received.
A very ill woman who would have died had it
not been that luck and good care was on her
side.
Why maternal near miss?
two decades ago.
In low maternal mortality
settings
morbidity useful
indicator of obstetric care
in recent years analyzing near
miss/SAMM cases
understanding health system
failures in
relation to obstetric care
Why maternal
near miss?
Near miss/SAMM cases share many characteristics
with maternal deaths and can directly inform on
obstacles that had to be overcome after the onset of an
acute complication.
 Corrective actions for identified problems can be
taken to reduce related mortality and long-term
morbidity.


Near miss cases occur more often than
maternal death and may generate more
information because the woman herself
can be a source of data.
 Once
severe maternal morbidity precedes
maternal death, the systematic
identification and the study of near miss
cases may provide further understanding
of the determinants of maternal mortality
5th MDG
is calling
for improving maternal health
World wide.
MORBIDITY>>>MORTALITY
THE CONTINUUM
Death
Organ Failure
Near Miss
Organ Dysfunction
Clinical problem
(Morbidity)
Normal Pregnancy
Normal
Morbidity
Severe
Morbidity
Near
Miss
Death
Mantel et al
BJOG 1998
UNDERSTANDING
TRENDS IN MORBIDITY
Normal
Morbidity
Severe
Morbidity
Near
Miss
Death
Anticipate/ react to illnesses
>>> reduce MMR
Identify common predictive factors
>>> more effective preventative strategies
~~HOW TO IDENTIFY
CASES OF NEAR MISS
MATERNAL
MORBIDITY~~
Severe acute morbidity/Complication
Severe maternal outcome
Near miss
(narrowly escapes death)
Maternal death
WHO NEAR MISS APPROACH
Severe maternal complications are defined
as “potentially life-threatening conditions”. This
is an extensive category of clinical conditions,
including diseases that can threaten a woman’s life
during pregnancy ,labour and after termination
of pregnancy.
WHO NEAR MISS APPROACH
Severe maternal complications
• Severe postpartum haemorrhage
• Severe pre-eclampsia
• Eclampsia
• Sepsis or severe systemic infection
• Ruptured uterus
• Severe complications of abortion
WHO NEAR MISS APPROACH
• Admission to intensive care unit
• Interventional radiology
• Laparotomy(includes hysterectomy, excludes
caesarean section)
• Use of blood products
WHO NEAR MISS APPROACH
Life Threatening conditions
Cardiovascular dysfunction
• Respiratory dysfunction
• Renal dysfunction
• Coagulation/haematological dysfunction
• Hepatic dysfunction
• Neurological dysfunction
• Uterine dysfunction
Uterine haemorrhage or infection leading
to hysterectomy
Severe maternal outcome refers to a lifethreatening condition (i.e. organ dysfunction),
\including all maternal deaths and maternal nearmiss cases.
 Women with life-threatening conditions
(WLTC) refers to all women who either qualified
as maternal near-miss cases or those who died
(i.e. women presenting a severe maternal
outcome). It is the sum of maternal near-miss
and maternal deaths (WLTC = MNM + MD).



WHO systematic review of maternal morbidity and
mortality: the prevalence of severe acute maternal morbidity (near miss)\
Prevalences
0.80% – 8.23% in studies that use---- disease-specific
criteria
0.38% – 1.09% in the group that use ---organ-system based
criteria and included unselected group of women.
0.01% and 2.99% in studies using management-based
criteria.
 In
resource-poor settings, 4–8% of pregnant
women who deliver in the hospitals will
experience SAMM


This rate is around 1% when the organ failure is considered.
In more developed country settings, the rates are around 1% with disease-specific
and 0.4% with organ-system based criteria, respectively. The results also suggest
that the use of organ-system based criteria is more specific in identifying the real
SAMM cases.

UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction
(HRP), published/unpublished data from 1997 to 2002.

Lale Say1*,
prevalence of SAMM is higher in
studies conducted in less developed
country settings
 Obstetric
HDU is highly
specialised and discrete area
within the delivery suite/labour
room for SAMM WITH BEST
FACILITY AND TEAM TO
TREAT .
ADVANTAGES OF HDU
EARLY INTERVENTION AND SPECIALISED
TREATMENT CAN PREVENT SERIOUS
COMPLICATION AND AVOIDS HAZARDS OF
TRANSFER OF PATIENT TO ICU IN
SEPARATE LOCATION
 ANTENATAL , INTRAPARTUM AND POST
NATAL CARE CAN BE PROVIDED BY THE
SAME TEAM

HDU MAY AVOID EXPOSURE OF
CRITICALLY ILL PREGNANT PATIENTS TO
HAZARDOUS ICU ENVIRONMENT WITH
RISK OF HOSPITAL ACQUIRED
INFECTIONS.
 IT IS A NEED OF MOST TERTIARY CENTRES
,
 High dependency care opposed to full intensive
care has a valid option in terms of efficacy and
cost benefit

Conclusions


Reviewing cases of severe maternal morbidity
can provide useful complimentary insights into
quality of care.
A good quality medical system is required
Missing Mothers.avi