This document discusses maternal near miss (MNM), which refers to women who nearly die but survive severe complications during pregnancy or childbirth. The World Health Organization recommends criteria for identifying MNM cases, including disease-specific conditions, management-based interventions, and organ dysfunction. Studying MNM provides advantages over solely examining maternal mortality, as MNM cases are more common and can reveal deficiencies in healthcare. Identifying and reviewing MNM cases can help reduce maternal mortality by informing actions to address gaps and improve quality of care. The document reviews several studies of MNM cases in Egypt which found the most common morbidities were related to preeclampsia, hemorrhage, and organ dysfunctions like coagulation issues. MNM

1. Maternal
Near Miss
Prof. Aboubakr
Elnashar
Benha University Hospital,
Egypt
elnashar53@hotmail.com
ABOUBAKR ELNASHAR

2. CONTENTS
I. MATERNAL MORTALITY
1. Definitions
2. Why is not sufficient?
II. MATERNAL NEAR MISS
1. Concept
2. Definition
3. Criteria
4. Indicators
5. Review
6. Advantages
7. Reduction of MM
8. Studies
 CONCLUSION
ABOUBAKR ELNASHAR

3. I. MATERNAL MORTALITY
1. DEFINITIONS
Maternal Death: MD
The death of a woman while
pregnant, or
within 42 days of termination of pregnancy,
irrespective of the duration and the site of the
pregnancy,
from any cause
related to or aggravated by the pregnancy or its
management (from direct or indirect obstetric
death)
but not from accidental or incidental causes.
ABOUBAKR ELNASHAR

4. Maternal Mortality Rate Vs Ratio
Many sources use the maternal mortality ratio and
the maternal mortality rate interchangeably
to mean the number of maternal deaths per 100,000
live births.
WHO, however, distinguishes the two:
ABOUBAKR ELNASHAR

5. Maternal mortality ratio:
The number of maternal deaths per 100,000 live
births
a measure of the risk of death once a woman has
become pregnant.
In Egypt: 2016
Number of maternal deaths: 1194
Live births: 2 600 173
MM Ratio: 45.9
ABOUBAKR ELNASHAR

6. Maternal mortality rate:
The number of maternal deaths (direct and indirect)
in a given period per 100,000 women of reproductive
age during the same time period.
ABOUBAKR ELNASHAR

7. 2. WHY MM IS NOT SUFFICIENT?
 Maternal mortality (MM)
 Now
not considered sufficient for evaluation of obstetric
health in isolation.
1. Maternal mortality is
 “just the tip of iceberg” with a vast base to the
iceberg-maternal morbidity-which
 remains un-described,
 relatively unevaluated.
ABOUBAKR ELNASHAR

8. ABOUBAKR ELNASHAR

9. 2. MMR has declined globally, more so in developed
countries.
3. Absolute number of maternal deaths is low
 it does not allow reliable quantitative analysis of
maternal health.
 In Egypt MMR has fallen from
1992: 174
2016: 46
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10. 3. Trends
Significant decline in the past 20 years.
From 2007 to 2013, there is no significant decrease in MMR
46
2016
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11. II. MATERNAL NEAR MISS
1.CONCEPT
 Maternal near miss =
 Severe Acute Maternal Morbidity (SAMM)
 Women who experienced and survived a severe
life threatening condition during pregnancy, child
birth / postpartum
 cases share many characteristics with maternal
deaths
ABOUBAKR ELNASHAR

12.  Maternal near miss =
 emerged as
 an adjunct and proxy measure to identify gaps
in maternal health services
 complementary to maternal mortality
 inform about obstacles that have to be
overcome after the onset of an acute
complication.
 Corrective actions for identified problems
 can then be taken to reduce related mortality
and long-term morbidity.
ABOUBAKR ELNASHAR

13. 2. DEFINITION
 “a woman who nearly died but survived a
complication that occurred during pregnancy,
childbirth or within 42 days of termination of
pregnancy”
(WHO,2004)
 In practical terms
 women are considered near miss cases when they
survive life-threatening conditions (i.e. organ
dysfunction).
 Woman who survives life threatening conditions
during pregnancy, abortion, and childbirth or within 42
days of pregnancy termination, irrespective of
receiving emergency medical/surgical interventions.
(Souza et al, 2007) ABOUBAKR ELNASHAR

14. 3. CRITERIA FOR IDENTIFICATION
WHO recommended 3 approaches
1. Disease specific criteria
severe preeclampsia/eclampsia
severe hemorrhage
severe sepsis
uterine rupture.
2. Management/Intervention based
admission to ICU
obstetric hysterectomy
massive blood transfusion
intubation/ventilation.
ABOUBAKR ELNASHAR

15. 3. Organ dysfunction based criteria –
 based on
 apparent clinical diseases,
 clinical markers
 management needs.
 The aim
 correction of that organ dysfunction
 arrest MNM progression to MD.
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16. ABOUBAKR ELNASHAR

17. ABOUBAKR ELNASHAR

18. 4. INDICATORS
 Useful for
 auditing quality of maternal health care
 assessing deficiencies and gaps between actual
use and optimal use of high priority interventions in
prevention and management of severe pregnancy
complications.
ABOUBAKR ELNASHAR

19. 1. Severe maternal outcome ratio (SMOR)
 number of women with life-threatening
conditions (MNM + MD) per 1000 live births
(LB).
 This gives an estimate of
 the amount of care
 resources that would be needed in an area
or facility
 [SMOR= (MNM +MD)/LB].
ABOUBAKR ELNASHAR

20. 2. MNM ratio (MNMR)
 number of maternal near-miss cases per 1000 live
births
 (MNMR = MNM/LB).
 It gives an estimation of
 the amount of care
 resources that would be needed in an area or
facility.
ABOUBAKR ELNASHAR

21. 3. Maternal near-miss mortality ratio
 (MNM: 1 MD)
 refers to the ratio between maternal near-miss
cases and maternal deaths.
 Higher ratios indicate better care.
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22. 4. Mortality index
 number of maternal deaths divided by 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 (low quality of care)
 The lower the index the fewer women with life-
threatening conditions die (better quality of care).
ABOUBAKR ELNASHAR

23. 5. WHAT IS MNM REVIEW?
 Process of MNM Review (MNM-R) involves the
following steps:
1. Identification of MNM cases
2. Notification to MO/HOD
3. Data transmission (institute district state)
4. Review (institutional and district level)
5. Analysis and feedback for necessary action
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24. 6. ADVANTAGES
1. Near miss cases are more common than maternal
deaths:
 adequate information and analysis.
 statistically reliable quantitative analysis
 comprehensive profile of functioning of health care
system.
ABOUBAKR ELNASHAR

25. 2. MNM shares MM.
 same pathway and pathological processes as
 Normal pregnancy
 Morbidity
 severe morbidity
 near miss
 Death
 The major reasons and causes:
valuable information regarding severe morbidity,
which, if untreated may lead to MM.
ABOUBAKR ELNASHAR

26. 3. MNM-R seems to be less threatening to service
providers.
 In Cases of MDR, health professionals and other stakeholders involved
in service delivery are fearful that the blame would fall on their
shoulders.
 MDR process is considered as a potential threat to expose them to
public enquiry and outrage.
 Investigating the instances of MNM-R may be less threatening to
providers because the woman survived.
 In MNM R, fear of blame and punishment is less.
 are willing and eager to share their „success‟
stories.
 more valuable information can be obtained and
utilized for improvement of obstetric health and
reduction of MMR.
ABOUBAKR ELNASHAR

27. 4. It enables us to learn from MNM survivors
as women themselves are available for interview about the
care they received.
They can share their experiences in ICU, psychological
devastation and trauma of being separated from newborn and
urge for breastfeeding, besides the psychological perspective
of other women who have faced severe maternal illness.
ABOUBAKR ELNASHAR

28. 5. MNM-R provides valuable information about
 social and family problems
 lack of awareness of health care facilities.
 Level of delays can also be identified where they
occur.
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29. 7. SIGNIFICANCE IN REDUCING MATERNAL
MORTALITY
 MNM-R
 relatively simpler to analyze
 easier to resolve
 complementary to MDR in appraisal of maternal
health.
ABOUBAKR ELNASHAR

30.  When used in conjunction with MDR
1. aids in recognizing patterns and trends of
maternal morbidity and mortality
2. helps in identifying contributory factors of maternal
deaths so that actions can be taken at various
levels.
3. assists in evaluation of quality of health care at a
facility and to monitor it.
4. facilitates detection of lacunae in existing system.
ABOUBAKR ELNASHAR

31. 5. helps in setting up a database to capture all locations and
facility details to identify where an MNM case comes from; this assists in
focusing interventions in a particular location.
6. beneficial in assessing and analyzing requirement
of health care facilities in terms of infrastructure, human resources
and interventional facilities, besides comparing the existing health care and
optimal health care of a facility.
ABOUBAKR ELNASHAR

32. 7. identification of delays at various levels can be done,
which lead to maternal morbidity and mortality
8. identify modifiable socio-demographic factors
responsible for maternal morbidity and mortality.
9. It assists in international comparisons in imparting
optimal health care.
ABOUBAKR ELNASHAR

33. 8. STUDIES
Arab countries
 Maternal mortality index
 Al Galaa hospital Egypt: 8.6 %
 Dar Al Tawleed hospital in Syria: 14.3 %
 countries with a moderate maternal mortality ratio
:5.6 %
(Bashour et al, 2015)
ABOUBAKR ELNASHAR

34.  MNM cases:
 haemorrhage-related complications were the most
frequent conditions
MNM dysfunction:
coagulation dysfunctions
cardiovascular dysfunctions.
(Bashour et al, 2015)
ABOUBAKR ELNASHAR

35. Kasr eleny Hospital
 The most common diagnosis encountered was
 Eclampsia: 58.7%
 Preeclampsia: 17.4%,
 APH and PPH: 8.7%
 Septic shock: 4.3%
 APP plus PPH in 2.2%
(Almonerary et al, 2012)
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36. Number Percent
Organ dysfunction*
Cardiovascular dysfunction 76 59.4%
Respiratory dysfunction 8 6.3%
Renal dysfunction 4 3.1%
Coagulation/haematologic dysfunction 96 75.0%
Hepatic dysfunction 16 12.5%
Neurologic dysfunction 8 6.3%
Uterine hysterectomy 28 21.9%
Elgalaa Hospital
Organ dysfunction in Near-Miss Women (N=128)
(Elshishini et al, 2018)
ABOUBAKR ELNASHAR

37.  Near miss clinical audit:
 improve
 performance and quality of care
 maternal health outcome indicators.
 The Severe Maternal outcome
 can be used to monitor and assess the
performance and health care level.
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38. Mansura university Hospital
Number and % of distribution of MNM and dead women
who experienced organ dysfunctions
(Mesbach et al, 2018)
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39.  The main life threatening
sever pre-eclampsia
sever post partum hemorrhage.
 Cesarean Section was the main delivery mood for the
near misses (93%).
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40. Elshatby university Hospital
 Severe pre-eclampsia: 40.2%
 post-partum hemorrhage: 23.8%
 Mortality index: 8.5%. .
(Sultan et al, 2017)
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41. CONCLUSION
 Investigating MNM cases aids in
taking measures for further improvement of service
delivery and programs.
 MNM is a vital tool that can go a long way in reducing
maternal mortality.
 MNM-R
 an eminent adjunctive strategy to help identify
gaps in health service provision.
ABOUBAKR ELNASHAR

42.  MNM-R and MDR are complementary to each other.
 When used together, they help in recognizing the
contributory factors of maternal deaths so that
appropriate actions can be adopted at community and
health systems level.
ABOUBAKR ELNASHAR