The Geller Criteria proposes a scoring system to identify women with near-miss maternal morbidity by assigning points for clinical factors like organ failure, extended intubation, ICU admission, surgical intervention, and significant transfusion. The scoring system was developed and tested at a large tertiary care hospital serving an urban population. The total score on the proposed scoring systems could help differentiate near-miss cases from those with only severe but not life-threatening conditions.

1. Near Miss Mortality
Candidate: Dr Amenda Ann Davis
Consultant Guide: Dr Rajesh Kumari
SR Guide: Dr Bhawani Shekhar

2. Outline
 Problem Statement – The Epidemiology of maternal mortality and near miss mortality
 Key Definitions
 Criteria to define near miss mortality
 Mantel Criteria
 Waterstone Criteria
 Geller Criteria
 WHO Criteria
 The WHO 2011 near miss approach for maternal health
 Delays in health care
 Type A Delay – JSY, JSSK, WHO 2016 ANC Guidelines
 Type B Delay – Emergency Obstetric Care Services

3. Millennium Development Goal – 5
To improve maternal health
Target 1a: To reduce by
three quarters
between 1990 and
2015 the maternal
mortality ratio
Target 1b: To ensure
universal access to
reproductive health

4. 2015: Maternal Mortality
Ratio (MMR) – number
of maternal deaths per
100 000 live births – was
estimated at 216
globally.
Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA,
World Bank Group and the United Nations Population Division

5. Sustainable Development Goals- The New Era
• SDG Goal 3: Ensure healthy lives and promote wellbeing for all, at all ages
• SDG Target 3.1: By 2030, reduce the global maternal mortality ratio to less than
70 per 100, 000 live births

6. Maternal mortality ratio (per 100 000 live births), 2015
Trends in maternal mortality: 1990 to 2015.
Estimates by WHO, UNICEF, UNFPA, World Bank
Group and the United Nations Population
Division

7. Global Causes of Maternal Mortality
Say L et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health
2014;2(6):e323–e333

8. The Indian Scenario
(Sample Registration System, 2016)
Aetiology of Maternal Mortality (2016)
Maternal mortality rate, 2016: 167 / 1,00,000 live births.
Reduced from 560 / 1,00,000 live births in 1990.

9. The AIIMS Scenario
Year Number of Live
Births
Number of
Maternal
Mortalities
Booked Cases Unbooked Cases Maternal
Mortality Rate
2014 2605 8 2 6 307
2015 2562 11 4 7 429
2016 2667 21 11 10 787
Overall 7834 40 17 (42.5%) 23 (57.5%) 510
(Courtesy Dr. P Vanamail)
Higher MMR due to
• High risk pregnancies at the onset
• Referral of unbooked cases near term
29%
41%
14%
7%
9%
Etiology of Maternal Mortality
Cardiac Disease
Sepsis
Hemorrhage
Hypertensive Disorders
Other Underlying
Disorders
Other disorders included aplastic anemia, liver failure, diabetic
ketoacidosis, hepatospenomegaly

10. Why Maternal “Near Miss”?
Life
(Maternal
Near
Miss)
Death
(Maternal
Mortality)

11. Why Maternal “Near Miss”?
• Near miss cases more common than maternal deaths.
• The major causes are the same for both near miss and mortality.
• Investigating the instances of severe morbidity may be less threatening to providers
because the woman survived.
• One can learn from the patients themselves since they survived and are available for
interview about the care they received.
• Opportunities to improve the quality of health care.

12. Spectrum of Near Miss Mortality
All women
during
pregnancy,
childbirth, or
post partum <42
days
Women with
complications
Women without
complications
Women with
potentially life
threatening
conditions
Women without
potentially life
threatening
conditions
Women without life
threatening
conditions
Women with life
threatening
conditions
Maternal
Near Miss
Maternal
Death

13. Key Definitions
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.
(Pattinson R et al. WHO Bulletin, 2009)

14. Maternal death (MD): Death of a woman while pregnant or within 42 days
of termination of pregnancy or its management, but not from accidental or
incidental causes.
Direct Obstetric Deaths:
Due to obstetric complications
of the pregnancy state.
Indirect obstetric deaths: Due
to previous existing disease
exacerbated by pregnancy.

15. Severe maternal outcome:
A life-threatening condition (i.e. organ dysfunction)
Women with life-threatening conditions:
(WLTC = MNM + MD)
All women who either qualified as maternal near-miss cases or those
who died (i.e. women presenting a severe maternal outcome).

16. Severe maternal outcome ratio (SMOR): Number of women with life-
threatening conditions per 1000 live births (LB).
SMOR = MNM+ MD / 1000 LB
MNM ratio (MNMR): Number of maternal near-miss cases per 1000 live
births (MNMR = MNM/LB).
Estimate of the amount of care and resources that would be needed in an
area or facility. MNMR ~ 15-40 / live births in developing countries.
(Journal of Pregnancy 2013;201:1118-24)

17. • Maternal near-miss mortality ratio (MNM : 1 MD): Ratio between
maternal near miss cases and maternal deaths.
Higher ratios indicate better care. MNM ~ 5 to 10 :1 in developing
countries.

18. • Mortality index: Number of maternal deaths divided by the number
of women with life-threatening conditions expressed as a percentage
[MI = MD/(MNM + MD)].
• Higher index
• More women with life-threatening
conditions die
• Low quality of care
• Lower index
• Fewer women with life-threatening
conditions die
• Better quality of care

19. Global Statistics
Range(0.02–5.07))
0
1
2
3
4
5
6
7
8
9
10
Africa Asia Europe Latin
america
Maternal Near Miss Ratio
Near miss cases per 1000
live births
Range(0.05-14.98)
(Tunclop et al BJOG 2012;119:653-61)

20. Aetiology of Maternal Near Miss
(Souza JP et al, Lancet 2013;381:1747-55)
*Similar aetiology of near
miss cases and mortalities*

21. Near Miss Mortality- Studies in India

22. Author Journal Setting Design No. of
Deliveries
MNM Ratio
(per 1000 live
births)
Near
miss to
mortality
ratio
MMR
(per
100,000
live
births)
Causes
Priyanka
Kalra et al.
Indian Journal
of Public
Health (2014)
Dr. S. N.
Medical
College,
Jodhpur
Cross Sectional 27,958 4.18 N/A N/A • Haemorrhage 56%
• Hypertensive
disorders-20%
Archana D.
Rathod et
al.
The Journal of
Obstetrics and
Gynecology of
India (2016)
GMC
Aurangabad
Retrospective
cohort
21,992 7.56 N/A 299 • Hemorrhage -27 %
• Anaemia 25%
• Hepatitis 17 %
• PIH 12 %.
Mamta
Bansal et al.
International
Journal of
Reproduction,
Contraception,
Obstetrics and
Gynecology
(2014)
B.R.K.M. Govt
Medical
College, Bastar
Retrospective
Cohort
3539 11.9 2.05 : 1 580 • Hemorrhage 44%
• Severe anemia 15%
• Rupture uterus 15%
• PIH 13%
• Sepsis 5%
• Complicated
malaria 5%
Hepatitis 2%
Roopa PS et
al.
Journal of
Pregnancy
(2013)
KMC, Manipal Retrospective
Cohort
7390 17.8 5.6 : 1 313 • Hemorrhage – 44%
• PIH- 24%
• Sepsis 16%

23. ICD- 10 Classification of Maternal Deaths

24. Category Examples
1. Pregnancies with abortive
outcomes
Abortion, miscarriage, ectopic pregnancy complicated by infection,
haemorrhage, or embolism
2. Hypertensive disorders Gestational hypertension, pre eclampsia, eclampsia
3. Obstetric haemorrhage PPH, Abruption, Rupture uterus, Morbidity adherent placenta,
placenta previa, instrumental injury
4. Pregnancy related infections GUI tract infections, Chorioamnitis, Puerperal sepsis, surgical site
infection
5. Other Obstetric Complications Hyperemesis gravidarum, thromboembolism, hepatic disorders like
ICP, uterine inversion
(International statistical classification of diseases and related health problems. Tenth revision, Volume 2)
Direct Obstetric Causes

25. Category Examples
6. Unanticipated complications of
management
All anaesthetic complications: Aspiration pneumonitis, cardiac
failure, arrest during anaesthesia, failed or difficult intubation,
toxic reaction to local anaesthesia
7. Non- obstetric complications Medical comorbidities: cardiac disease, renal disease, pre
existing hypertension, CNS disorders
8. Unknown/ undetermined
9. Death due to external causes Road traffic accident, assault
Indirect Obstetric Causes
(International statistical classification of diseases and related health problems. Tenth revision, Volume 2)

26. Criteria to Define
Near Miss
Mantel Criteria
WHO Criteria
Waterstone
Criteria
**Recommended Criteria **
Geller Criteria

27. Mantel Criteria

28. Objective To test the application of a clinical definition of severe acute maternal morbidity.
Design A one-year prospective descriptive multi-centre study.
Setting Kalafong and Pretoria Academic hospitals, catering for the delivery of indigent women in the Pretoria Health Region.
Methods A ‘near-miss’ describes a patient with an acute organ system dysfunction, which if not treated appropriately, could result in
death. The case notes of women fitting this definition and all maternal deaths were analysed and compared.
Outcome measure Determine the primary obstetric factors and the organ systems that failed. Identification of episodes of sub-standard care and
missed opportunities.
Results One hundred and forty-seven near misses and 30 maternal deaths were identified. The commonest reasons for a near-miss were:
emergency hysterectomy in 42 women (29%); severe hypotension in 40 (27%); and pulmonary oedema in 24 (16%). The most common
initiating obstetric conditions were hypertension in 38 women (26%); haemorrhage in 38 (26%); and abortion or puerperal sepsis in 29 (20%).
The primary obstetric factors amongst the maternal deaths were: hypertension (33%); sepsis (27%); and maternal medical diseases (17%) in 10,
8 and 5 women respectively. Sub-standard care was identified in 82 cases. Breakdown in the health care administration was identified in 33, and
patient-orientated missed opportunities on 34 occasions.
Conclusions The definition of severe acute maternal morbidity identified nearly five times as many cases as maternal death. This
definition allows for an effective audit system of maternal care because it is clinically based, the definition is robust and the cases identified
reflect the pattern of maternal death.
• Defines “near miss” as a patient with acute organ system dysfunction which if not
treated can result in death.
• Uses 2 criteria to identify “ near miss”
1. Organ system based
2. Management based

29. Mantel Criteria- Organ System Based
ORGAN SYSTEM BASED MARKERS
Cardiac dysfunction • Pulmonary oedema
• Cardiac arrest
Vascular • Hypotension requiring > 5 units whole or packed cell transfusion
Immunological • ICU admission for sepsis
• Emergency peripartum hysterectomy for sepsis
Respiratory • Intubation for >60 min for reasons other than GA
• SpO2 <90% for >60 min
• Pao2/FiO2 <3
Renal • Oliguria <400 ml/ 24 hours
• Acute rise of Urea> 15 mmol/ L or creatinine >400 mmol/L
Liver • Jaundice in presence of pre eclampsia
Metabolic • DKA, Thyroid crisis
Coagulation • Acute thrombocytopenia requiring platelet transfusion
Cerebral • Coma >12 hours
• SAH or intracranial haemorrhage

30. Mantel Criteria- Management Based
MANAGEMENT BASED MARKERS
Intensive care admission • For any reason
Emergency peripartum
hysterectomy
• For any reason
Anaesthetic incidents • Severe hypotension associated with spinal or epidural anaesthetic
(SBP<90 mm for >60 min )
• Failed tracheal intubation requiring anaesthetic reversal

31. Waterstone Criteria

32. • Objective To estimate the incidence and predictors of severe obstetric morbidity.
• Design Development of definitions of severe obstetric morbidity by literature review. Case control study from a defined delivery population
with four randomly selected pregnant women as controls for every case.
• Setting All 19 maternity units within the South East Thames region and six neighbouring hospitals caring for pregnant women from the
region between 1 March 1997 and 28 February 1998.
• Participants 48, 865 women who delivered during the time frame.
• Results There were 588 cases of severe obstetric morbidity giving an incidence of 12.0/1000 deliveries (95% confidence interval 11.2 to
13.2). During the study there were five maternal deaths attributed to conditions studied. Disease specific morbidities per 1000 deliveries were
6.7 (6.0 to 7.5) for severe haemorrhage, 3.9 (3.3 to 4.5) for severe preeclampsia, 0.2 (0.1 to 0.4) for eclampsia, 0.5 (0.3 to 0.8) for HELLP
(Haemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, 0.4 (0.2 to 0.6) for severe sepsis, and 0.2 (0.1 to 0.4) for uterine rupture.
Age over 34 years, non white ethnic group, past or current hypertension, previous postpartum haemorrhage, delivery by emergency caesarean
section, antenatal admission to hospital, multiple pregnancy, social exclusion, and taking iron or antidepressants at antenatal booking were all
independently associated with morbidity after adjustment.
• Conclusion Severe obstetric morbidity and its relation to mortality may be more sensitive measures of pregnancy outcome than mortality
alone. Most events are related to obstetric haemorrhage and severe preeclampsia. Caesarean section quadruples the risk of morbidity.
Development and evaluation of ways of predicting and reducing risk are required with particular emphasis paid on the management of
haemorrhage and preeclampsia.
• Case control study to develop definitions of severe obstetric morbidity based on
clinical causes.
• Identified the following as most prevalent causes (The Waterstone Criteria)
1. Severe Pre-eclampsia
2. Eclampsia
3. HELLP
4. Severe haemorrhage
5. Severe sepsis
6. Uterine rupture

33. Results
CATEGORY OF MORBIDITY NO. OF CASES % OF DELIVERIES
All cases of near miss 588 1.2
Hypertensive Disorders of Pregnancy
Severe Pre-eclampsia 187
Eclampsia 12
HELLP Syndrome 25
Total 224 0.46
Hemorrhage
Blood loss >1500 mL 180
Hb drop by 4 mg/dl 96
Transfused 4 units blood 51
Total 327 0.67
Severe Sepsis 17 0.04
Uterine Rupture 12 0.03
Others 8

34. Geller Criteria

35. Abstract
Objective: The objective of this study was to develop a scoring system for identifying women with near-miss maternal morbidity,
and differentiating these women from those with severe but not life-threatening conditions.
Study Design and Setting: The study was conducted at the University of Illinois Medical Center at Chicago (UIMC), which is a
tertiary care hospital with approximately 2,220 births per year. UIMC is in a major urban area serving a predominantly African–
American and Latina population. This article focuses on five clinical factors: organ failure (1 system), extended intubation (>12 hr),
ICU admission, surgical intervention, and transfusion (3 units), grouped into several scoring system alternatives. The total score on
each scoring system was calculated as the weighted sum of the clinical factors present for each woman.
Results: The five-factor scoring system had the highest specificity (93.9%), but the four-factor scoring system, which eliminated
organ system failure for simplification of data collection, still had a specificity of 78.1%.
Conclusion: Near-miss morbidities identified using the scoring systems presented can be incorporated into clinical case review and
epidemiologic studies to enhance the monitoring of obstetric care and to improve estimates of the incidence of life-threatening
complications in pregnancy.
Journal of Clinical Epidemiology 57 (2004) 716–720
Five Factor Scoring System
1. Organ failure (1 system)
2. Extended intubation (>12 hr)
3. ICU admission
4. Surgical intervention
5. Blood transfusion (3 units)
93.9% specificity of identifying risk of maternal death
Four Factor Scoring System – Simplifies data collection
1. Organ failure
2. Extended intubation (>12 hr)
3. ICU admission
4. Surgical intervention
5. Blood transfusion (3 units)
78.1% specificity of identifying risk of maternal death

36. Evaluating the quality of care for severe pregnancy
complications
The WHO near-miss
approach for maternal health
(2011)

37. • What is it? Standard approach for monitoring the implementation of critical
interventions in maternal health care.
• For whom? Health care workers and policy makers.
• Principle: Criterion-based clinical audit.
• Assumption: All maternal deaths involve at least one life-threatening condition
(organ dysfunction).
• Purpose: is to improve clinical practice and reduce preventable morbidity and
mortality through the use of best evidence-based practices.

38. Reassessment, situation analysis, and adjustment of intervention to further improve care
Baseline Assessment
Near Miss Criteria
based clinical audit
Health care consumers,
providers, manager views
Situation Analysis
Identification of Opportunities and
obstacles for improving care
Implementation of tailored intervention for improving care
Audit and Feedback
Standard Operating
ProtocolsProspective Case
Identification
Evidence Based
Checklists
Reminders and
Educational Activities

39. Baseline Assessment
• Systematically identify women with severe complications of
pregnancy.
• Women who are pregnant, in labour, or who delivered or aborted up
to 42 days ago arriving at the facility who fulfil inclusion criteria.
• Women brought dead on arrival are also included as they represent
delay in critical care.

40. Inclusion Criteria for
Baseline Assessment
of Quality of Care
Severe maternal
complications
Life threatening
conditions
(near miss criteria)
Maternal vital status
(maternal death)
Women
requiring critical
interventions

41. Severe Maternal Complications
• Severe post partum haemorrhage
• Severe pre eclampsia
• Eclampsia
• Ruptured uterus
• Severe complications of abortion
(Inclusion Criteria for Baseline Assessment of Quality of Care)
Genital bleeding after delivery, with at least one of: >/-1000 mL bleeding, hypotension, or blood transfusion.
• Persistent systolic blood pressure of 160 mmHg or more or a diastolic blood pressure of 110 mmHg
• proteinuria of 5 g or more in 24 hours
• oliguria of less than 400 ml in 24 hours
• HELLP syndrome
• Pulmonary oedema.
• Excludes eclampsia.
Generalized fits in a patient without previous history of epilepsy. Includes coma in pre-eclampsia.

42. Critical Interventions (Management Based)
• ICU admission
• Interventional radiology
• Laparotomy (includes peripartum hysterectomy, excludes C-section)
• Use of blood products (>/- 5 units blood)
(Inclusion Criteria for Baseline Assessment of Quality of Care)

43. Life threatening conditions (Near Miss Criteria)
Cardiovascular dysfunction
1. Shock
2. Cardiac arrest
3. Use of continuous vasoactive
drugs
4. CPR
5. Severe hypotension
6. Lactate >45 mg/dl
7. Severe acidosis (pH<7.1)
Respiratory dysfunction
8. Acute cyanosis
9. Gasping
10. Severe tachypnea
(RR>40/min) or bradypnea
(RR<6/min)
11. Intubation and ventilation not
related to anaesthesia
12. Hypoexemia (spO2 <90% for
>60 min or PAo2/FiO2<200)
Renal dysfunction
13. Oliguria non responsive to
fluids or diurectics
14. Dialysis for ARF
15. Severe acute azotemia (Creat >
3.5 mg/dl)
Hematological Dysfunction
16. Failure to form clots
17. Massive transfusion (>/= 5
units)
18. Severe acute
thrombocytopenia (Plt <50,000)
Hepatic dysfunction
19. Jaundice in presence of pre
eclampsia
20. Severe acute
hyperbilirubinemia (>6 mg/dl)
Neurological dysfunction
21. Prolonged unconsciousness
lasting >/= 12 hours
22. Stroke
23. Uncontrollable seizures
24. Total paralysis
Uterine dysfunction
25. Uterine haemorrhage or infection leading to hysterectomy

47. Data Collection
• Records of occurrence of severe pregnancy-related complications
• Severe maternal outcomes
• Use of critical/key interventions
• Timing of incident (before, during or after delivery).
• Data on total number of deliveries and total number of live births at
the facility during the data collection period.

48. Sample Size
• The minimum sample size for producing near miss and process
indicators has not been formally established.
• Prevalence of severe maternal outcomes is generally expected to be
around 7.5 cases/1000 deliveries.
• At least 20 women with severe maternal outcomes should be present in
the data collected for it to have meaningful result.

49. Example:
Average annual number of deliveries at AIIMS  2611
Expected number of eligible women  37-300 (~75)
Expected number of women with SMO  7-30 (~ 15)

50. Reassessment, situation analysis, and adjustment of intervention to further improve care
Baseline Assessment
Near Miss Criteria
based clinical audit
Health care consumers,
providers, manager views
Situation Analysis
Identification of Opportunities and
obstacles for improving care
Implementation of tailored intervention for improving care
Audit and Feedback
Standard Operating
ProtocolsProspective Case
Identification
Evidence Based
Checklists
Reminders and
Educational Activities

51. Operational
Definitions,
Standard Care,
and Process
Indicators
Severe Post Partum
Haemorrhage
Severe Pre
eclampsia
Eclampsia
Severe Systemic
Infection or Sepsis
Uterine Rupture

52. Severe Post Partum Haemorrhage
Definition Genital bleeding after delivery, with at least one of: >/-1000 mL bleeding,
hypotension, or blood transfusion.
Standard Care Prevention: All women should receive 10 IU of oxytocin just after delivery for the
prevention of postpartum haemorrhage.
Treatment: All women with postpartum haemorrhage should receive oxytocin
Process Indicator Prevention: The number of women who received a single dose of oxytocin divided
by the number of all women giving birth (vaginal delivery + caesarean section)
Treatment: The number of women with postpartum haemorrhage who received
therapeutic oxytocin divided by the number of all women with postpartum
haemorrhage.
(WHO Guidelines for the management of postpartum
haemorrhage and retained placenta, 2009).

53. Severe Pre Eclampsia and Eclampsia
Definition
Pre Eclampsia: Persistent systolic blood pressure of 160 mmHg or more or a
diastolic blood pressure of 110 mmHg; proteinuria of 5 g or more in 24 hours;
oliguria of less than 400 ml in 24 hours; and HELLP syndrome or pulmonary
oedema. Excludes eclampsia.
Eclampsia: Generalized fits in a patient without previous history of epilepsy.
Includes coma in pre-eclampsia.
Standard Care All women with eclampsia should receive magnesium sulphate.
Process Indicator The number of women with eclampsia who received magnesium sulphate divided
by the number of all women with eclampsia.
(Duley L et al. Cochrane Database of Systematic Reviews, 2007)

54. Severe Systemic Infection and Sepsis
Definition
Presence of fever (body temperature >38°C), a confirmed or suspected infection, and at least
one of the following: heart rate >/-90, respiratory rate >/-20, leukopenia (white blood cells
</-4000), or leukocytosis (white blood cells /->12, 000).
Standard
Care
Prevention: All women having a caesarean section should receive prophylactic antibiotics.
Treatment: All women with severe systemic infections or sepsis should receive intravenous
antibiotics.
Process
Indicator
Prevention: The number of women having a C-section and receiving prophylactic antibiotics
divided by the number of all women having C-sections.
Treatment: The number of women with severe systemic infections or sepsis who received
antibiotics divided by the number of all women with severe systemic infections or sepsis.
(Dellinger RP et al.; Surviving Sepsis Campaign: international guidelines for management
of severe sepsis and septic shock: Critical Care Medicine, 2008)

55. Reassessment, situation analysis, and adjustment of intervention to further improve care
Baseline Assessment
Near Miss Criteria
based clinical audit
Health care consumers,
providers, manager views
Situation Analysis
Identification of Opportunities and
obstacles for improving care
Implementation of tailored intervention for improving care
Audit and Feedback
Standard Operating
ProtocolsProspective Case
Identification
Evidence Based
Checklists
Reminders and
Educational Activities

56. Inclusion Criteria
1. Severe complications
2. Critical interventions
3. Organ dysfunction
4. Maternal death
Demographic Data
Process Indicators
1. Referral process
2. Interventions
- PPH
- Eclampsia
- Antibiotics
Underlying causes of
death (ICD Classification)

57. SOFA Scoring System for Risk Stratification
System Group A (LESS SEVERE) Group B (MORE SEVERE)
Cardiovascular System • Shock
• Lactate > 5 m
• pH<7.1
• Use of continuous vasoactive drugs
• Cardiac arrest
• CPR
Respiratory Dysfunction • Acute cyanosis
• Respiratory rate >40 or <6
• O2 saturation <90% for >60 min
• Gasping
• PaO2<FiO2<200
• Intubation and Ventilation
Renal Dysfunction • Oliguria non responsive to fluids or diuretics • Creatinine >/= 3.5 mg/dl
• Dialysis for acute renal failure
Coagulation/ Hematological
Dysfunction
• Clotting failure • Acute thrombocytopenia (Plt <50,000)
Hepatic Dysfunction • Jaundice in presence of pre eclampsia • Bilirubin >6 mg /dl
Neurological Dysfunction • Metabolic coma
• Stroke
• Status epilepticus
• Coma / loss of consciousness lasting
12 hours or more
Uterine Dysfunction • Hysterectomy
(Lapinsky SE et al., Evaluation of standard and modified severity of illness scores
in the obstetric patient. J Crit Care 2011)
• Sequential Organ Failure Assessment.
• Classifies the WHO criteria into Group A (less severe) and
Group B (more severe).
• A potential tool in near miss audits.

58. Abstract
Objectives: To validate the WHO maternal near-miss criteria and develop a benchmark tool for severe maternal morbidity
assessments.
Methods: In a multicenter cross-sectional study implemented in 27 referral maternity hospitals in Brazil, a one-year prospective
surveillance on severe maternal morbidity and data collection was carried out. Diagnostic accuracy tests were used to assess the
validity of the WHO maternal near-miss criteria. Binary logistic regression was used to model the death probability among women
with severe maternal complications and benchmark the management of severe maternal morbidity.
Results: Of the 82,388 women having deliveries in the participating health facilities, 9,555 women presented pregnancy related
complications, including 140 maternal deaths and 770 maternal near misses. The WHO maternal near-miss criteria were found to
be accurate and highly associated with maternal deaths (Positive likelihood ratio 106.8 (95% CI 99.56–114.6)). The maternal
severity index (MSI) model was developed and found to able to describe the relationship between life threatening conditions and
mortality (Area under the ROC curve: 0.951 (95% CI 0.909–0.993)).
Conclusion: The identification of maternal near-miss cases using the WHO list of pregnancy-related life-threatening conditions was
validated. The MSI model can be used as a tool for benchmarking the performance of health services managing women with severe
maternal complications and provide case-mix adjustment.
Conclusions:
- Validation of maternal near miss cases using the WHO list of pregnancy related
life threatening conditions.
- Maternal severity index (MSI) model developed to describe relationship
between life threatening conditions and mortality.
PLOS ONE (2012) ; 7(8): e44129

59. Maternal severity index (MSI) model
• The study evaluated the prevalence of each of the 25 WHO near miss criteria and the
condition specific mortality.
• The prevalence of each condition ranged from 0.19 to 3.55 cases per 1000 deliveries and
the condition specific mortality ranged between 12.9% and 85.0%.
• All life threatening conditions were highly associated with maternal deaths, but
heterogeneity was observed.
• Based on the relative risk of each condition to mortality, using a model based on
multivariate analysis, an MSI model developed.

60. Near Miss Surveillance
Retrospective
-From case registers
Prospective
- By identifying potentially life threatening complications
- By identifying high risk patients at early stages of pregnancy

61. Delays in Health Care
To understand the gaps in access to adequate
management of obstetric emergencies leading to severe
maternal complications and death, three delays have
been identified.

62. Delays in Health Care
Type A Delay Type B Delay
Life threatening
complications present
during admission
Life threatening
complications present
after admission
First Delay Second Delay Third Delay
Delay in deciding to seek
medical help in obstetric
emergency
Delay in reaching
appropriate health facility
Delay in receiving
appropriate care once
facility is reached
• Involve trained birth attendants
for early recognition and referral
• National schemes to promote
institutional delivery
• Improve referral services
• Minimum number of
antenatal visits (WHO
Recommendations 2016)
• Improve facilities
• Train health care providers in
hospital procedures
• 24*7 coverage of emergency
obstetric care

63. Type A Delays
• Involve trained birth attendants for early recognition and referral
• National schemes to promote institutional delivery
• Improve referral services
• WHO Recommendations (2016) on antenatal care for timely identification
and referral of high risk pregnancies and preventive strategies where
applicable.
Life threatening
complications present
during admission

64. Janani Shishu Suraksha Karyakram (JSSK)
• AIM: to decrease MMR and IMR by institutional deliveries
• Free drug and consumables
• Free referral transport
• Free diagnostic tests up to 6 weeks post partum
• Free treatment to sick neonates up to 30 days
• Free diet to women up to 3 days after delivery and 7 days after cesarean
section
• Free blood
• Exemption from user charges up to 30 days
(NRHM, 2011)
The proportion of institutional
deliveries has risen from
25.4% in 2001 to 38.8% in
2006, 47% in 2007-08 and
72.9% in the recent Coverage
Evaluation Survey (CES 2009).
(Coverage Evaluation
Survey. Government of India, Ministry of Health & Family
Welfare and UNICEF. 2009)

65. Janani Suraksha Yojana (JSY)
• Launched in 2005 under NRHM; centrally sponsored
• Identifies ASHA (accredited social health activist), trained birth attendants (TBA)
and Anganwadi workers to identify pregnant women and refer them to
institutions for antenatal care and delivery.
• Offers cash incentive for women delivering in institutions.
(NRHM, 2011)

66. • ABSTRACT The Government of India initiated a cash incentive scheme—Janani Suraksha Yojana (JSY)—to promote
institutional deliveries with an aim to reduce maternal mortality ratio (MMR). An observational study was conducted in a
tertiary-care hospital of Madhya Pradesh, India, before and after implementation of JSY, with a sample of women
presenting for institutional delivery. The objectives of this study were to: (i) determine the total number of institutional
deliveries before and after implementation of JSY, (ii) determine the MMR, and (iii) compare factors associated with
maternal mortality and morbidity. The data were analyzed for two years before implementation of JSY (2003-2005) and
compared with two years following implementation of JSY (2005-2007). Overall, institutional deliveries increased by 42.6%
after implementation, including those among rural, illiterate and primary-literate persons of lower socioeconomic strata.
The main causes of maternal mortality were eclampsia, pre-eclampsia and severe anaemia both before and after
implementation of JSY. Anaemia was the most common morbidity factor observed in this study. Among those who had
institutional deliveries, there were significant increases in cases of eclampsia, pre-eclampsia, polyhydramnios,
oligohydramnios, antepartum haemorrhage (APH), postpartum haemorrhage (PPH), and malaria after implementation of
JSY. The scheme appeared to increase institutional delivery by at-risk mothers, which has the potential to reduce maternal
morbidity and mortality, improve child survival, and ensure equity in maternal healthcare in India. The lessons from this
study and other available sources should be utilized to improve the performance and implementation of JSY scheme in
India.
Objectives
(i) To determine the total number of institutional deliveries before and after implementation of JSY
(ii) To determine the MMR
(iii) To compare factors associated with maternal mortality and morbidity.
Results
• Institutional deliveries increased by 42.6% after implementation of JSY.
• Main causes of maternal mortality were eclampsia, pre-eclampsia and severe anaemia both
before and after implementation of JSY.
• Anaemia was the most common morbidity factor.
• Among those who had institutional deliveries, there were significant increases in cases of
eclampsia, pre-eclampsia, polyhydramnios, oligohydramnios, antepartum haemorrhage (APH),
postpartum haemorrhage (PPH), and malaria after implementation of JSY.
The scheme appeared to increase institutional delivery by at-risk mothers.
Impact of Janani Suraksha Yojana on Institutional Delivery Rate and
Maternal Morbidity and Mortality: An Observational Study in India
Sanjeev K. Gupta1, Dinesh K. Pal2, Rajesh Tiwari2, Rajesh Garg3, Ashish K. Shrivastava2, Radha Sarawagi4, Rajkumar Patil1, Lokesh Agarwal1, Prashant
Gupta5, Chandrakant Lahariya6
1Department of Community Medicine, Mahatma Gandhi Medical College & Research Institute, Cuddalore Main Road, Pillayarkuppam, Pondicherry, India; 2Department of Community Medicine, NSCB Medical College, Jabalpur,
Madhya Pradesh, India; 3Department of Community Medicine, VCSG Medical Sciences & Research Institute, Srikot-Ganganali, Pauri Garhwal, Uttarakhand, India; 4Department of Radiology, Mahatma Gandhi Medical College &
Research Institute, Cuddalore Main Road, Pillayarkuppam, Pondicherry, India; 5Indian Institute of Public Health, Delhi, India; 6Department of Community Medicine, aGR Medical College, Gwalior, Madhya Pradesh, India
J HEALTH POPUL NUTR 2012 Dec;30(4):464-471

67. WHO Recommendations on
antenatal care for a
positive pregnancy experience (2016)

68. “Within the continuum of reproductive health care, antenatal care
provides a platform for important health-care functions, including
health promotion, screening and diagnosis, and disease prevention. It
has been established that by implementing timely and appropriate
evidence-based practices, ANC can save lives.”
-Ban Ki-moon, United Nations Secretary-General

69. WHO 2016 ANC Recommendations
A positive pregnancy experience is defined as:
• maintaining physical and sociocultural normality
• maintaining a healthy pregnancy for mother and baby
(including preventing and treating risks, illness and death)
• having an effective transition to positive labour and birth,
and
• achieving positive motherhood (including maternal self-
esteem, competence and autonomy)
Alkema L, et al.; Global, regional, and national levels and trends in maternal mortality
between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the
UN Maternal Mortality Estimation Inter-Agency Group. Lancet. 2016;387(10017):462–74.
Evidence Based Recommendations grouped
according to type of intervention
A. Nutritional interventions
B. Maternal and fetal assessment
C. Preventive measures
D. Interventions for common physiological
symptoms
E. Health systems interventions to improve the
utilization and quality of ANC.

70. A healthy diet contains adequate energy, protein,
vitamins and minerals, obtained through the
consumption of a variety of foods, including green
and orange vegetables, meat, fish, beans, nuts, whole
grains and fruit.
The equivalent of 60 mg of elemental iron is 300 mg of
ferrous sulphate heptahydrate, 180 mg of ferrous
fumarate or 500 mg of ferrous
gluconate.

72. *Evidence on essential ANC activities, such as
measuring maternal blood pressure, proteinuria and
weight, is not included as these activities are
considered to be part of good clinical practice.

73. From the WHO publication Diagnostic criteria and classification of hyperglycaemia first detected in
pregnancy (2013),
GDM should be diagnosed at any time in pregnancy if
• fasting plasma glucose 92–125 mg/dL
• 1-hour plasma glucose > (180 mg/dL) following a 75 g oral glucose load
• 2-hour plasma glucose 153–199 mg/dL following a 75 g oral glucose load.
Diabetes mellitus in pregnancy should be diagnosed if
• fasting plasma glucose > 126 mg/dL
• 2-hour plasma glucose > 200 mg/dL following a 75 g oral glucose load
• random plasma glucose >200 mg/dL in the presence of diabetes symptoms.
The incidence of new cases of TB in India is 217 (112–355)
per 100,000 population.
(WHO Global TB Report, 2016)
Should we be actively screening for
tuberculosis in all antenatal patients?

78. Focused ANC Model
Various studies conducted by WHO in facilities practicing FANC model:
• No significant reduction in Caesarean rate
• No reduction in perinatal mortality rate
• Variable omission of good ANC practices like BP measuring, screening for anemia,
checking for proteinuria.

79. WHO - 2016 ANC Model
Antenatal care models with a
minimum of eight contacts are
recommended to reduce perinatal
and maternal morbidity and mortality
and improve women’s experience of
care.

80. Type B Delays
Life threatening complications
present after admission
Ensuring emergency obstetric care services is the main
component of reducing third delay.
Minimum coverage rates are expected to be 1
Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per
500,000 population.

81. Access to Emergency Obstetric Care
Basic EOC services Comprehensive EOC services
1. IV/IM antibiotics All included in Basic EOC (1–7) plus:
2. IV/IM oxytocic drugs 8. Caesarean Section
3. IV/IM anticonvulsants 9. Blood Transfusion
4. Removal of retained products of conception(e.g. by
manual vacuum aspiration)
5. Manual removal of placenta
6. Assisted vaginal delivery (usually ventouse delivery)
7. Resuscitation of the new born baby using a bag and
mask
(WHO 2009: Managing emergency obstetric care: a handbook)

82. Abstract
Background: Ensuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and
newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000
population.
Methods and Findings: A cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria,
Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide
BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and
only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be
provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts
(total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded
the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The
population based Caesarean Section rate was estimated to be 2%, the maternal Case Fatality Rate (CFR) for obstetric complications
ranged from 2.0–9.3% and still birth (SB) rates ranged from 1.9–6.8%.
Conclusions: Availability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not
currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015,
there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and
improve the quality of services provided so that CFR and SB rates decline.
Results (Pertaining to India )
• 34 facilities were studied in poor performance states of MP, Bihar, Chhatisgarh, Orissa.
• 9/21 (43%) of CEOC facilities provided all 9 signal functions.
• 2/13 (15%) of BEOC facilities provided all 7 signal functions.
Parenteral
antibiotics
Parenteral
oxytocics
Parenteral
anticonvulsants
Manual
removal
of placenta
Removal of
retained
products
Assisted vaginal
delivery
Neonatal
Resuscitation
Caesarean
section
Blood
transfusion
All(34) 100% (34) 94% (32) 65% (22) 62% (21) 53% (18) 38% (13)
CEOC(21) 100% (21) 100% (21) 76% (16) 76% (16) 48% (10) 81% (17) N/A 62% (13) 67% (14)
BEOC (13) 100% (13) 85% (11) 46% (6) 38% (5) 15% (2) 23% (3) 85% (11) - -
PLoS ONE 7(2012): e49938

83. Essential Obstetric Skills
1. Manage PPH – medical
management, B-Lynch sutures,
uterine and internal iliac ligation,
peripartum hysterectomy
2. Manage eclampsia
3. Manual removal of RPOC
4. Manual removal of placenta
5. Assisted vaginal delivery
6. Manual reposition of inverted uterus
7. Genital injury repair
8. Immediate resuscitation measures,
mechanical ventilation, CPR

84. Conclusions
• Near miss mortality is a better indicator of studying the quality of care than
mortality.
• Near miss audits are essential to understand and bridge the gaps in health care.
• WHO criteria are universally recommended.
• Most common but not exclusive causes are haemorrhage, hypertensive disorders
and infections.
Prevention is better than cure…