Maternal near miss
Encyclopedia
A maternal near miss is an event in which a pregnant woman comes close to maternal death
, but does not die – a "near-miss
". Traditionally, the analysis of maternal deaths has been the criteria of choice for evaluating women’s health and the quality of obstetric care. Due to the success of modern medicine such deaths have become very rare in developed countries, which has led to an increased interest in analyzing so-called "near miss" events.
to assess the quality of a health care system. The standard indicator is the Maternal Mortality Ratio, defined as the ratio of the number of maternal death
s per 100,000 live births. Due to improved health care the ratio has been declining steadily in developed countries. For example, in the UK 1952-1982 the ratio was halving every 10 years. In the European Union the ratio has now stabilized at around 10 to 20..
The small number of cases makes the evaluation of maternal mortality practically impossible Historically, the study of negative outcomes have been highly successful in preventing their causes, this strategy of prevention therefore faces difficulties when if the number of negative outcome drop to low levels. In the UK, for example, the most dramatic decline in maternal death was achieved in Rochdale
, an industrial town in the poorest area of England. In 1928 the town had a Maternal Mortality Ratio of over 900 per 100,000 live births, more than double the national average of the time. An enquiry into the causes of the deaths reduced the ratio to 280 per 100,000 pregnancies by 1934, only six years later, then the lowest in the country.
The very low figures of maternal mortality have therefore stimulated an interest in investigating cases of life threatening obstetric morbidity or maternal near miss. There are several advantages of investigating near miss events over events with fatal outcome
The growing interest is reflected in an increasing number of systematic reviews on the prevalence of near miss. The studies and reviews span
Cardiovascular dysfunction
a) Shock
b) Cardiac Arrest
c) Severe hypoperfusion (lactate >5 mmol/L or >45 mg/dL)
d) Severe acidosis (pH<7.1)
e) Use of continuous vasoactive drugs
f) Cardio-pulmonary resuscitation
Respiratory dysfunction
g) Acute cyanosis
h) Gasping
i) Severe tachypnea (respiratory rate>40 breaths per minute)
j) Severe bradypnea (respiratory rate<6 breaths per minute)
k) Severe hypoxemia
(O2 saturation <90% for ≥60min or PAO2/FiO2<200)
l) Intubation and ventilation not related to anaesthesia
Renal dysfunction
m) Oliguria non responsive to fluids or diuretics
n) Severe acute azotemia (creatinine >300umol/ml or >3.5 mg/dL)
o) Dialysis for acute renal failure
Coagulation dysfunction
p) Failure to form clots
q) Severe acute thrombocytopenia (<50,000 platelets/ml)
r) Massive transfusion of blood or red cells (≥ 5 units)
Hepatic dysfunction
s) Jaundice in the presence of pre-eclampsia
t) Severe acute hyperbilirubinemia (bilirubin>100umol/L or >6.0 mg/dL)
Neurologic dysfunction
u) Prolonged unconsciousness or coma (lasting >12 hours)
v) Stroke
w) Uncontrollable fit / status epilepticus
x) Global paralysis
Uterine dysfunction
y) Hysterectomy due to uterine infection or haemorrhage
Maternal death
Maternal death, or maternal mortality, also "obstetrical death" is the death of a woman during or shortly after a pregnancy. In 2010, researchers from the University of Washington and the University of Queensland in Brisbane, Australia, estimated global maternal mortality in 2008 at 342,900 , of...
, but does not die – a "near-miss
Near miss (safety)
See Close Call, for the 2002 film.A near miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage; in other words, a miss that was nonetheless very near...
". Traditionally, the analysis of maternal deaths has been the criteria of choice for evaluating women’s health and the quality of obstetric care. Due to the success of modern medicine such deaths have become very rare in developed countries, which has led to an increased interest in analyzing so-called "near miss" events.
Background
Maternal mortality is a sentinel eventSentinel event
A Sentinel Event is defined by The Joint Commission as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness...
to assess the quality of a health care system. The standard indicator is the Maternal Mortality Ratio, defined as the ratio of the number of maternal death
Maternal death
Maternal death, or maternal mortality, also "obstetrical death" is the death of a woman during or shortly after a pregnancy. In 2010, researchers from the University of Washington and the University of Queensland in Brisbane, Australia, estimated global maternal mortality in 2008 at 342,900 , of...
s per 100,000 live births. Due to improved health care the ratio has been declining steadily in developed countries. For example, in the UK 1952-1982 the ratio was halving every 10 years. In the European Union the ratio has now stabilized at around 10 to 20..
The small number of cases makes the evaluation of maternal mortality practically impossible Historically, the study of negative outcomes have been highly successful in preventing their causes, this strategy of prevention therefore faces difficulties when if the number of negative outcome drop to low levels. In the UK, for example, the most dramatic decline in maternal death was achieved in Rochdale
Rochdale
Rochdale is a large market town in Greater Manchester, England. It lies amongst the foothills of the Pennines on the River Roch, north-northwest of Oldham, and north-northeast of the city of Manchester. Rochdale is surrounded by several smaller settlements which together form the Metropolitan...
, an industrial town in the poorest area of England. In 1928 the town had a Maternal Mortality Ratio of over 900 per 100,000 live births, more than double the national average of the time. An enquiry into the causes of the deaths reduced the ratio to 280 per 100,000 pregnancies by 1934, only six years later, then the lowest in the country.
The very low figures of maternal mortality have therefore stimulated an interest in investigating cases of life threatening obstetric morbidity or maternal near miss. There are several advantages of investigating near miss events over events with fatal outcome
- near miss are more common than maternal deaths
- their review is likely to yield useful information on the same pathways that lead to severe morbidity and death,
- investigating the care received may be less threatening to providers because the woman survived
- one can learn from the women themselves since they can be interviewed about the care they received.
- all near misses should be interpreted as free lessons and opportunities to improve the quality of service provision
- it is also clear that maternal deaths merely are the tip of the iceberg of maternal disability. For every woman who dies, many more will survive but often suffer from life long disabilities.
The growing interest is reflected in an increasing number of systematic reviews on the prevalence of near miss. The studies and reviews span
- analytic attempts to define the concept more strictly,
- descriptive efforts to measure and quantify new indicators (prevalence) of near-miss for different geographical regions etc
- explanatory efforts of the leading cause for morbidity
Definition
The World Health Organization defines a maternal near-miss case as "a woman who nearly died but survived a complication that occurred during pregnancy,childbirth or within 42 days of termination of pregnancy."Identification Criteria
According to the World Health Organization, if a woman present any of the conditions below during pregnancy, childbirth or within 42 days of termination of pregnancy and survive, she is considered as a maternal near miss case.Cardiovascular dysfunction
a) Shock
b) Cardiac Arrest
c) Severe hypoperfusion (lactate >5 mmol/L or >45 mg/dL)
d) Severe acidosis (pH<7.1)
e) Use of continuous vasoactive drugs
f) Cardio-pulmonary resuscitation
Respiratory dysfunction
g) Acute cyanosis
h) Gasping
i) Severe tachypnea (respiratory rate>40 breaths per minute)
j) Severe bradypnea (respiratory rate<6 breaths per minute)
k) Severe hypoxemia
(O2 saturation <90% for ≥60min or PAO2/FiO2<200)
l) Intubation and ventilation not related to anaesthesia
Renal dysfunction
m) Oliguria non responsive to fluids or diuretics
n) Severe acute azotemia (creatinine >300umol/ml or >3.5 mg/dL)
o) Dialysis for acute renal failure
Coagulation dysfunction
p) Failure to form clots
q) Severe acute thrombocytopenia (<50,000 platelets/ml)
r) Massive transfusion of blood or red cells (≥ 5 units)
Hepatic dysfunction
s) Jaundice in the presence of pre-eclampsia
t) Severe acute hyperbilirubinemia (bilirubin>100umol/L or >6.0 mg/dL)
Neurologic dysfunction
u) Prolonged unconsciousness or coma (lasting >12 hours)
v) Stroke
w) Uncontrollable fit / status epilepticus
x) Global paralysis
Uterine dysfunction
y) Hysterectomy due to uterine infection or haemorrhage
Sources
(uses the term near-miss maternal death)- Say L, Souza JP, Pattinson RC; WHO working group on Maternal Mortality and Morbidity classifications. Maternal near miss—towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol. 2009 Jun;23(3):287-96.