Validating the maternal near miss review operational guidelines for teaching institutes in India: A retrospective five-year study

Materials & Methods

This is a retrospective cohort analysis conducted at the department of Obstetrics and Gynaecology, Ananta Institute of Medical Sciences and Research Centre, Rajsamand, Rajasthan, India. We studied all MNM cases admitted to our institute over five years from December 2017 to December 2022. The study received the necessary approval from the Institutional Ethics Committee. Given that this was a retrospective study, the requirement for patient consent was waived.

Ananta Institute of Medical Sciences and Research Centre serves as a tertiary care teaching institute and as a referral hospital for an underserved district in North India. The hospital is well-equipped for normal and high-risk obstetrics care, providing round-the-clock emergency services. The availability of a well-stocked blood bank and intensive care unit with multidisciplinary specialty services around the clock allows the department of Obstetrics and Gynaecology to manage severely morbid obstetric patients optimally.

Cases were selected according to the Maternal Near Miss Review Operational Guidelines MNM criteria⁴. We aimed to examine the frequency, risk factors, and outcomes of maternal near-miss cases. Additionally, our goal was to validate the MOHFW MNMR guidelines as a tool for medical colleges to record such cases and implement measures to enhance maternal healthcare services.

Results

Using the MOHFW MNM operational guidelines as data-keeping and analysis tools, our audit of five years revealed an MNM incidence of 324 cases among 7266 deliveries during the study period. Of the 7,266 obstetric admissions during the study period, 3,561 (49%) were referral cases. There were 6953 live births in the study period. Among the total admissions, 1,073 cases (14.8%) involved potentially life-threatening complications. Of these, 331 cases (30.9%) progressed to life-threatening conditions, while 742 (69.1%) did not. Within the life-threatening group, 324 cases (97.9%) were classified as maternal near misses, and 7 cases (2.1%) resulted in maternal deaths. Additionally, of the 3,561 referred cases, 209 (209 out of the 324 maternal near-miss cases, 64.5%) were transferred from lower-level facilities that were unable to manage the complications. Table I depicts the distribution of maternal near-miss cases according to sociodemographic characteristics. Table II summarises the patient status at admission, the modes of delivery, obstetric history, antenatal care status, type of admission, days since delivery at the time of admission, and duration of hospital and ICU stay.

Table III presents the underlying disorders at the time of admission. Haemorrhage either antepartum, intrapartum, or postpartum, stood out as the most common condition leading to MNM cases (250/324, 77.1%). High-grade fever with sepsis was present in 5.2 per cent (17/324) cases. Hypertensive disorders of pregnancy were present in 32.4 per cent (105/324) cases. Labor-related complications made up 18.5 per cent of our cases, and 38.2 per cent (124/324) patients had some underlying medical disorder complicating the pregnancy. It is important to note here that the underlying disorders usually present as a combination of two or more conditions rather than an isolated problem.

Table IV summarises the presenting complaints of our patients. The majority presented with vaginal bleeding and abdominal pain. However, other presenting complaints like fever, oedema, jaundice, and blurring of vision were also seen. Of all our patients who were admitted to ICU (n=324), 198 (61.1%) required resuscitative measures, 28 (8.6%) required mechanical ventilation, 79 (24.3%) needed the use of cardiotonics or vasopressors, 71 (21.9 %) needed laparotomy, and 3 (0.92%) needed obstetric hysterectomy. Twenty three patients (7.1 %) had manual removal of placenta, 71 (21.9 %) had repair of genital injuries, and 14 (4.3 %) of patients had repair of bowel and bladder. One patient had repositioning of an inverted uterus with B lynch suturing. Eight required dialysis, six had ketoacidosis, 13 were managed for cerebral oedema, and 38 required anticoagulant therapy. Packed cell transfusion was required by 77.1 per cent, 17.8 per cent needed whole blood, 33.9 per cent needed fresh frozen plasma, and 49 per cent needed transfusion of platelet-rich concentrates.

Table V summarises the levels of delay in seeking care like personal issues, logistics problems, and issues with the referral facility, which played a factor in delayed seeking of health care services and setting in of severe complications before appropriate treatment could be instituted. Delay 1, 2, 3 were observed in 199 (61.4 %), 78 (24 %), and 242 (78.4 %) cases, respectively.

According to the Ministry of Health and Family Welfare (MoHFW) guidelines, Maternal Near Miss (MNM) cases are identified based on specific clinical, laboratory, and management criteria indicative of severe complications during pregnancy, childbirth, or postpartum. Out of the 324 maternal near-miss cases in the study, 172 cases met all three near-miss criteria, while 81 cases met at least one criterion, including instances of cardio-respiratory collapse. All 324 maternal near-miss cases received timely life-saving interventions, including blood transfusions and surgeries. Post-discharge, 85 per cent of patients reported significant recovery within six wk, while 15 per cent required additional medical care.

Discussion

In this study, we analysed a total of 7266 obstetric admissions, identifying 1073 cases with potentially life-threatening complications, of which 331 presented with life-threatening conditions. We documented 324 MNM cases, resulting in a Near-Miss Incidence Ratio (NMIR) of approximately 46.6 per 1000 live births, which was high compared to a study by Verma et al⁶, which evaluated near-miss obstetric events as per the WHO 2009 criteria⁷. The Near-Miss Rate (NMR) was about 44.65 per 1000 obstetric admissions. The MNM to Maternal Death Ratio was calculated at 46.29, with a Mortality Index of 2.12 per cent. From our study, we realised that the majority of our patients suffered complications related to haemorrhage and hence, adequately stocking the blood banks in the various facilities in the chain of referral can make a huge impact on reducing the number of both MNM and MD. When comparing the main causes of severe maternal outcomes, obstetric haemorrhage and hypertension were the most common underlying factors, consistent with findings in other studies conducted in developing countries^8,9. Anaemia, both due to nutritional deficiency and secondary to haemorrhage, was a key contributing factor in 77.1 per cent of MNM cases. In the analysed cohort of maternal near-miss cases, anaemia was classified with 18 per cent of the cases presenting mild anaemia, 23 per cent moderate anaemia, and 59 per cent severe anaemia. This estimate was high when compared to a study which identified anaemia in more than 32.2 per cent of women who experienced the MNM morbidity¹⁰. Of the MNM cases, 92.9 per cent hailed from the rural areas and 30.2 per cent held a below-poverty-line status card.

Also, 61.4 per cent (199/324) of our patients suffered a delay before reaching our facility. Among the near-miss cases, 24.7 per cent had a history of previous caesarean sections, and the leading causes of maternal near-misses included haemorrhage (77.2%), and hypertensive disorders (32.4%). A majority of the cases (60%) occurred in tertiary hospitals, reflecting the importance of appropriate referral systems for managing complex cases. In terms of antenatal care, 29.3 per cent of women were booked, highlighting significant barriers faced by the 70.6 per cent who were unbooked, such as socio-economic challenges and lack of awareness. Many women faced challenges, such as transportation issues, financial constraints, and cultural beliefs that discouraged regular visits. In nearby communities, limited healthcare infrastructure or inadequate services also contributed to low antenatal care attendance. Furthermore, these women often lacked decision-making autonomy or feared medical interventions, leading to missed opportunities for early diagnosis and management of high-risk conditions. Additionally, 27.1 per cent of deliveries occurred at home, primarily due to cultural practices, lack of transportation, and perceived low-risk status. These findings underscore critical areas for improving maternal healthcare services and highlight the urgent need for targeted interventions to enhance care quality and access. This implies that awareness must be created among the general population regarding the importance of antenatal care by regularly conducting outreach camps. Patients and their caregivers should be made aware of Janani Suraksha and Janani Shishu Suraksha Yojna run by the Government of India, so that they do not refrain from seeking medical care because of a lack of financial resources¹¹. These schemes not only provide cash incentives to pregnant mothers to promote institutional deliveries but also serve to provide transportation services in low-resource areas. Assessing maternal near-miss (MNM) cases is critical for evaluating maternity care. Establishing consensus on indicators and data collection methods is imperative for conducting a comprehensive assessment of MNM, including long-term health impacts, preventability, and financial implications for healthcare services. A study by Jayaratnam et al¹² found substantial differences in the monitoring approach to MNM in the Australian region. In a paper by Kulkarni et al¹³ published in 2021, 25 studies of MNM were reviewed, which represented all the major regions of India. These 25 studies used varying criteria like, WHO criteria, Waterstone criteria, and Mantel’s criteria for selecting MNM¹³. Of note, 23 of these studies were conducted in urban settings. This reflects the lack of standard clinical criteria for the documentation and audit of MNM cases. The MOHFW MNM guidelines stem from a pilot study conducted across six medical colleges in India. These guidelines acknowledge the country’s health infrastructure and are tailored to meet our specific needs. We used MOHFW MNM operational guidelines as an effective tool for documenting, analysing, reporting, and auditing MNM cases and our paper validates these guidelines as an effective instrument for MNM data collection and the creation of summary estimates Additionally, our medical college caters to a rural population, further strengthening the data on the underserved pregnant population which contributes to the majority of the MNM cases.

The limitation of our study was that it was retrospective. We believe that multiple prospective studies analysing the MNM cases by using the MOHFW MNM operational guidelines are needed so that a meta-analysis of nationwide data can be attempted in the future.