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
Anuj Mundra
Moderator – Dr A.M. Mehendale
Learning objective
To understand the concept of Maternal Near Miss (MNM).
Introduction
 Significant reduction in MMR has been made in India to reach 178/100000 live births. The
12th 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.
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.
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
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


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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 Children’s 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.
Implementation
 The policy was implemented
in 10 phases over a period of
16 months during 2012-13
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.
Adverse events identified
 4 sections of adverse events that could lead to MNM were identified:
Pregnancy specific disorders- Haemorrhage, sepsis, hypertension
Pre-existing disorders aggravated during pregnancyAnaemia, 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.
i.
ii.
Results
 Total MNM – 264/27433 (0.96%)
 Mean time reported from onset of illness to admission – 48.4 hours
Age distribution of cases
referral pattern
3 8
25
64
<19 yrs
20-29 yrs
30-40 yrs
>40 yrs
11.4
27.6
61
private
public
directly
Characteristics of women
identified as MNM
1.5 Timing of pregnancy
Antenatal
admitted with
SM
0.4
Intranatal
5.3
referred with
SM
12.1
Postnatal
24.6
65.2
3
6.9
Abortion &
Ectopic
Post abortion
Not Specified
39
42
admission with
no disorder &
became SM
Admission with
disorder &
became SM
80
Interventions
72
No. (%)
70
Immediate resuscitation
65 (24.6)
60
MechanicalVentilation
31 (11.7)
50
Uterine Evacuation
27 (10.2)
Laparotomy
48 (18.2)
Hysterectomy
39 (14.8)
Genital injury repair
19 (4.9)
Manual removal of placenta
3 (1.1)
Repositioning of inverted uterus
2 (0.8)
Internal iliac ligation
4 (1.5)
40
30
29.9
26.5
20
10
0
3.8
2.3
Others
Blood transfusion
137 (51.9)
227 (86)
Factors contributing to MNM
70
60
60.6
50
40
30
30.7
30.3
26.5
20
13.6
10
16.7
7.6
0
delay in lack of ANC
seeking t/t
care
Transport
Referral
lack of
lack of blood lack of skills
equipments
in health
personal
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 "nearmiss" 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.
 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.
 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.
Other studies on MNM
Author
Year
Place
Findings
Roopa PS, Shailja Verma,
Lavanya Rai, Pratap
Kumar, Murlidhar V. Pai,
Jyothi Shetty
17.9/1000 live birth. Near miss: mortality=5.6:1
Manipal, Haemorrhage was the leading cause for near miss followed by
2013
India
PIH and Sepsis. Sepsis leading cause for death. Cardiac disease
had highest mortality index.
Chhbra P, Guleria K,
Saini NK, Anjur KT, Vaid
NB
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
Pandey A, Das V, Agarwal
A, Agarwal S, Misra D,
Jaiswal N
2008
Delhi
Near miss incidence was 4.18/1000 live birth. Mortality ratio
Jodhpur,
2014
was 202 per lakh live birth. MNM: mortality was 2.1.
India
Haemorrhage, hypertension and sepsis were major causes.
2014
India
MNM: mortality= 2.6. the MNM incidence was roughly
12%. Haemorrhage and hypertensive disorders of pregnancy
were leading cause of MNM and maternal deaths.
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].
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 lifethreatening 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.
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):201–4. 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):394–9.
 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):199–201.
 World Health Organization. Evaluating the quality of care for severe pregnancy
complications:TheWHO near-miss approach for maternal health. Geneva; 2011.