Critical obstetric conditions during pandemic (COVID-19) and pre-pandemic years

Aim. To assess the structure of critical obstetric conditions and maternal mortality in Transbaikal Region in pandemic (COVID-19) and pre-pandemic years (2020 and 2019, respectively).Materials and Methods. We retrospectively analysed “near miss” (NM) and maternal deaths (MD) in 2019 and 2020, further calculating the severe maternal outcome ratio (SMOR), the summary indicator which includes both NM and MD per 1000 live births.Results. In a pandemic year (2020), we observed an increase in SMOR in comparison with a pre-pandemic year (3.0 vs 2.0, respectively). In 2019, maternal mortality was exclusively caused by obstetric complications, while extragenital pathology (cardiovascular disease and COVID-19) was responsible for that in 2020. However, the main causes of «near miss» in 2019 and 2020 were similar, including obstetric haemorrhage because of placental abruption and severe pre-eclampsia. Maternal near-miss mortality ratio (MNM/MD) increased from 7.3: 1 in 2019 to 11.3: 1 in 2020, and mortality index (MD/(MNM + MD) × 100) reduced from 12.0 to 8.1. Therefore, fewer women with life-threatening conditions died in 2020 as compared with 2019, indicating a better quality of obstetric care.Conclusion. Analysis of the critical obstetric conditions can probably find regional issues of maternal healthcare during the COVID-19 pandemic and propel the policy makers to find additional resources to minimise maternal morbidity and mortality.

Factors Associated With Severe Maternal Outcomes at a Regional Referral Hospital in South-Western Uganda: A Case-Control Study

Background: The Sustainable Development Goal target is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. Maternal morbidity and mortality in sub-Saharan Africa remains high despite global efforts to reduce it. Severe maternal outcome studies offer a panoramic assessment of obstetric care. Objective: The study aimed at determining the factors associated with severe maternal outcomes among women admitted at the obstetrics and gynecology ward of Mbarara Regional Referral Hospital. Methods: In an unmatched case control (1:2) study conducted between February and May 2018, 162 pregnant women admitted on the obstetrics and gynecology ward of Mbarara Regional Referral Hospital, or who had delivered within the past 42 days were recruited. Near miss cases were defined based on the WHO criteria. Near-miss cases and events, maternal deaths and their causes were retrospectively reviewed. Three categories of risk factors (socio-demographic, obstetric and health system) were examined. P-values <0.05 were considered statistically significant. A multivariable logistic regression model was used to identify factors associated with severe maternal outcomes. All analyses were performed using Stata software (Version 12.0, StataCorp, and College Station, TX). Results: In the four-month period there were 2301 live births, there were 45 near miss cases and 9 maternal deaths resulting in a severe maternal outcome ratio of 23.5/1000 live births, maternal near miss ratio of 19.6/1,000 live births, maternal near-miss mortality ratio of 5 and mortality index of 16.7%. Severe obstetric hemorrhage (33%), ruptured uterus (27.8%), sepsis or severe systemic infection (16.7%) and hypertensive disorders in pregnancy (16.7%) were the direct causes of severe maternal outcomes. About seventy-seven percent (77.8%) of the mothers with severe maternal outcomes were referred in from the peripheral health facilities, with a 4-time risk increased risk of a severe maternal outcome (aOR, 4.00; 95 % CI, 1.84-6.66, p-<0.001). Conclusion: Of the severe maternal outcomes, direct causes were the most prevalent and most of which are preventable. Being referred in was significantly associated with severe maternal outcomes. The maternal near miss indicators indicate need for improved quality.

MATERNAL NEAR MISS AND MATERNAL DEATHS IN KERALA, INDIA - A REVIEW

Aim- To determine the prevalence and pattern of near miss cases/ severe acute maternal morbidity cases and maternal deaths in a tertiary centre. Materials and methods - WHO 2011 criteria was used for identication of near miss cases. Results- In the study period of 2 years, there were 131 cases of severe maternal outcome (105 near miss and 26 maternal deaths). Maternal near miss incidence ratio is 5.62/ 1000 live births. Maternal near miss to mortality ratio is 4.03:1. The mortality index is 19.8%. Hemorrhage was the leading cause of near miss cases (44.76%) followed by hypertension(27.6%) but indirect causes(42.3%) led to maximum number of maternal deaths followed by hemorrhage. Among the indirect causes, cardiac and neurological disorder caused maximum mortality. Conclusion - Hemorrhage and hypertension were the leading causes of near miss but maternal mortality was more due to indirect causes. So it's important to involve specialist doctors from other departments to improve care of mothers and hence reduce maternal deaths further.

Skin Color and Severe Maternal Outcomes: Evidence from the Brazilian Network for Surveillance of Severe Maternal Morbidity

Background. Taking into account the probable role that race/skin color may have for determining outcomes in maternal health, the objective of this study was to assess whether maternal race/skin color is a predictor of severe maternal morbidity. Methods. This is a secondary analysis of the Brazilian Network for Surveillance of Severe Maternal Morbidity, a national multicenter cross-sectional study of 27 Brazilian referral maternity hospitals. A prospective surveillance was performed to identify cases of maternal death (MD), maternal near miss (MNM) events, and potentially life-threatening conditions (PLTC), according to standard WHO definition and criteria. Among 9,555 women with severe maternal morbidity, data on race/skin color was available for 7,139 women, who were further divided into two groups: 4,108 nonwhite women (2,253 black and 1,855 from other races/skin color) and 3,031 white women. Indicators of severe maternal morbidity according to WHO definition are shown by skin color group. Adjusted Prevalence Ratios (PRadj - 95%CI) for Severe Maternal Outcome (SMO=MNM+MD) were estimated according to sociodemographic/obstetric characteristics, pregnancy outcomes, and perinatal results considering race. Results. Among 7,139 women with severe maternal morbidity evaluated, 90.5% were classified as PLTC, 8.5% as MNM, and 1.6% as MD. There was a significantly higher prevalence of MNM and MD among white women. MNMR (maternal near miss ratio) was 9.37 per thousand live births (LB). SMOR (severe maternal outcome ratio) was 11.08 per 1000 LB, and MMR (maternal mortality ratio) was 170.4 per 100,000 LB. Maternal mortality to maternal near miss ratio was 1 to 5.2, irrespective of maternal skin color. Hypertension, the main cause of maternal complications, affected mostly nonwhite women. Hemorrhage, the second more common cause of maternal complication, predominated among white women. Nonwhite skin color was associated with a reduced risk of SMO in multivariate analysis. Conclusion. Nonwhite skin color was associated with a lower risk for severe maternal outcomes. This result could be due to confounding factors linked to a high rate of Brazilian miscegenation.

Exploring Epidemiological Aspects, Distribution of WHO Maternal Near Miss Criteria, and Organ Dysfunction Defined by SOFA in Cases of Severe Maternal Outcome Admitted to Obstetric ICU: A Cross-Sectional Study

Objective. To explore the epidemiological aspects, to describe the frequency and distribution of WHO maternal near miss (MNM) criteria and the presence of organ dysfunction and failure measured by the maximum SOFA (Sequential Organ Failure Assessment) score (SOFA max) in cases of severe maternal outcome (SMO). Methods. In an observational cross-sectional study performed between January 2013 and December 2015, 279 pregnant or postpartum women were admitted to an obstetric ICU (intensive care unit) in Brazil. MNM, maternal death (grouped as SMO), and potentially life-threatening conditions (PLTC) were defined according to WHO criteria. For categorical variables, a descriptive analysis was carried out. Frequency and distribution of WHO criteria, organ dysfunction, or failure defined by SOFA max were performed. Results. WHO criteria identified 65 SMO and 214 PLTC. Management criteria were present in 58/65 (89.2%) while 61/65 (93.8%) of SMO cases had dysfunction or failure by SOFA. Conclusions. The systematic evaluation of the organic function by SOFA max score identified the presence of organic dysfunction or failure in almost all SMO cases. Management criteria were present in all MD cases. Our results indicate the need for new studies evaluating the parameterization of the WHO laboratory criteria for values compatible with the definition of organic dysfunction by the SOFA to identify MNM.

A Prospective Observational Study of Near-miss Events and Maternal Deaths in Obstetrics

ABSTRACT Purpose To study the incidence and causes of near-miss cases and maternal deaths (MDs) and also search the level of delay. Materials and methods The prospective observational study was carried out in the Department of Obstetrics and Gynecology for a period of one and a half year (September 2012 to February 2014). For identifying near-miss events, disease-specific criteria were used. Near-miss cases were identified among women with pregnancy-related complications whose diagnoses were meeting the criteria. Detailed information of maternal mortalities and near-miss cases for demographic features, underlying causes, treatment received, and level of delay were also obtained. Results There were 15,170 obstetric admission, 13,851 live births, 184 near-miss cases, and 60 MDs during the study period. The maternal near-miss (MNM) rate was 13.2/1,000 live births and maternal mortality ratio was 433.1/100,000 live births. The mortality index (MD/MNM+MD) was reported as 25%. The maternal mortality to near-miss ratio was 1:3.07. Severe maternal outcome rate (MNM/MNM+MD) was 17.6/1,000 live births. Hemorrhage (54.89%) was the leading cause of nearmiss events followed by hypertension (24.45%) and anemia (13.59%). Hypertension (26.66%) was responsible for most of the MDs followed by anemia (25%), hemorrhage (20%), and puerperal sepsis (10%). The most common level of delay was found on the part of women and/or family to seek help. Conclusion Hypertension, hemorrhage, and anemia are leading causes of maternal morbidity and mortality. Lessons need to be learnt from cases of near-miss, which can serve as a useful tool in making strategies and putting efforts to reduce maternal mortality. How to cite this article Yadav S, Nanda S. A Prospective Observational Study of Near-miss Events and Maternal Deaths in Obstetrics. J South Asian Feder Obst Gynae 2016;8(4):261-265.