Measuring maternal near-miss in a middle-income country: assessing the use of WHO and sub-Saharan Africa maternal near-miss criteria in Namibia

Figures & data

Table 1. Characteristics of all maternal near-miss women.

Characteristics	(n = 194)	%
Age
<20	32	16.5%
21–34	130	67.0%
≥35	32	16.5%
Parity
Para 0	60	30.9%
Para 1–3	114	58.8%
≥4	18	9.3%
Unknown	2	1.0%
Gestational age^a
≤12 weeks	32	16.5%
13–26 weeks	25	12.9%
27–36 weeks	46	23.7%
≥37 weeks	80	41.2%
Unknown	11	5.7%
Previous CS
No	155	79.9%
Yes	32	16.5%
Unknown	7	3.6%
HIV status
Positive	18	9.3%
Negative	144	74.2%
Unknown	32	16.5%
Chronic anemia
No	118	60.8%
Yes	32	16.5%
Unknown	44	22.7%
Other comorbidities
Astma	1	0.5%
GDM	2	1.0%
Chronic hypertension	3	1.5%
TB	1	0.5%
Nephrotic syndrome	1	0.5%
Unknown	6	3.1%
Pregnancy outcome
NVD	57	29.4%
Vacuum	3	1.5%
CS	71	36.6%
Laparotomy uterine rupture	2	1.0%
Miscarriage	31	16.0%
Ectopic	15	7.7%
Undelivered	14	7.2%
TOP	1	0.5%

NVD, normal vaginal delivery; CS, Caesarean section; TOP, termination of pregnancy; GDM, gestational diabetes mellitus. ^aNumber of completed weeks at the end of pregnancy or on admission if undelivered.

Table 2. For each hospital number of live births, maternal near-miss, maternal deaths, MNM ratio and the SMO ratio.

Facilities	Livebirths	MNM	MD	MNM/ 1000 LB	95% CI	SMO/ 1000 LB	95% CI
Hospital A	3515	150	6	43	36–50	44	37–51
Hospital B	1326	30	3	23	15–31	25	16–33
Hospital C	664	12^a	0	18	8–28	18	8–28
Hospital D	267	6^a	0	22	4–40	22	4–40
Total	5772	194	9	34	29–38	35	30–40

^aThree MNM women from hospital C and one MNM woman from Hospital D were referred to hospital A and part of the total number of these hospitals. MNM, Maternal Near Miss; MD, Maternal Death; LB, livebirths; CI, Confidence Interval; SMO, severe maternal outcome.

Figure 1. Primary cause of maternal near miss. N = 194. ^aTwo women with eclampsia also had HELLP syndrome and are counted twice.

Table 3. Frequencies of maternal near-miss by type of organ system dysfunction.

MNM identification criteria	Total per MNM criterion N, % (95% CI)	MNM by SSA only	MNM by WHO only
Severe maternal complications	72, 37.3% (30.3–44.3)
Eclampsia	26	18
Sepsis or severe systemic infection	26	16
Uterine rupture	2	1
Pulmonary oedema	7	2
Severe abortion complications	8	3
Severe malaria	4	0
Severe pre-eclampsia with ICU admission	4	1
Laparotomy other than caesarean section or ectopic pregnancy	12	5
Cardiovascular dysfunction	21, 10.8% (6.8–16.1)
Shock	20
Cardiac arrest	0
Use of continuous vasoactive drugs	3		0
CPR	0
pH < 7.1	1		1
Lactate >5 mEq/mL	0		0
Respiratory function	16, 8.2% (4.8–13.0)
Acute cyanosis	0
Gasping	0
Respiratory rate >40 or <6/min	5
Intubation and ventilation for ≥60 minutes not related to anaesthesia	11
Oxygen saturation <90% for ≥60 minutes	4
Renal dysfunction	4, 2.1% (0.6–5.2)
Oliguria non-responsive to fluids or diuretics	4
Creatinine ≥300 µmol/l or ≥3.5 dL/dL	1
Dialysis for acute renal failure	1		0
Coagulation/hematologic dysfunction	147, 75.8% (69.1–81.6)
Failure to form clots	6
Transfusion of ≥ 2 units of red blood cells	140	103
Acute thrombocytopenia (<50,000 platelets/ml)	12
Hepatic dysfunction	13, 6.7% (3.6–11.2)
Jaundice in the presence of pre-eclampsia	0
Bilirubin >100 mmol/l or >6.0 dL/dL	13		9
Neurological dysfunction	8, 4.1% (1.8–8.0)
Loss of consciousness lasting 12 hours (GCS < 10)	6
Stroke	0
Loss of consciousness and ketoacids in urine	0
Uncontrollable fit	1
New onset of paralysis	1
Uterine dysfunction	6, 3.1% (1.1–6.6)
Hysterectomy following infection or haemorrhage	6
Total	194	133	10

In italics unique SSA criteria and underlined unique WHO criteria. A woman could fulfil more than one MNM criterion. At the top of each section the total number of women with each organ dysfunction, followed by the proportion, calculated by the total divided by 194 MNM women and presented as percentage. The second and third column presents the number of women that only fulfilled criteria of either the WHO or SSA set and would have been missed if the other set was applied. MNM, Maternal near miss; CI, Confidence interval; SSA, sub-Saharan Africa; WHO, World Health organization, ICU, intensive care unit; CPR, cardiopulmonary resuscitation; GCS, Glasgow coma scale.

Figure 2. Summary of number of women who received two or more units of blood transfusion. In white the women that did not fulfil another criterion of the WHO set and would have been missed by the WHO MNM criteria. In grey the number of women that did fulfil another criteria of the WHO MNM criteria. RCC, red cell concentrate.

Text box 1. Summary of cases missed by WHO criteria sorted by assessment of research team as severe or not severe morbidity case. CS, caesarean section; G, gravida; P, parity; Hb, haemoglobin; WBC, white blood cells x 10⁹/L; RCC, red cell concentrate.

Severe morbidity

Eclampsia

(1) A 17-year old primigravida fitted eight times due to eclampsia at home and in a small district hospital 119 km away from hospital B. She was referred to hospital B were a CS was done. She recovered well.

Uterine rupture

(2) A 28-year old G3P2 with one previous CS was admitted in active labour in hospital A. An emergency CS was done and a uterine rupture found. A fresh stillborn baby was delivered. The woman developed a vesicovaginal fistula and received 1 unit of blood during admission.

Laparotomy other than CS or ectopic

(3) A 33-year old G3P2 presented to Hospital A with a septic cervical pregnancy. A hysterotomy, abdominal approach, was done to remove the pregnancy since a vaginal approach was deemed not to be feasible. To control the bleeding a bilateral ligation of the uterine arteries was done. The woman did not fulfil the criteria of shock. She received four units of blood and two units fresh frozen plasma.

Transfusion of 2 or more units of blood

(4) A 21-year old primigravida presented to hospital D with severe bleeding due to an incomplete miscarriage. Her Hb was 5.2 g/dL, she received four units of blood and the retained products of conception were removed.

No severe morbidity

Sepsis

(1) A 27-year old woman developed fever 1 day after her normal delivery in hospital A. She had a heart rate of 100/min, WBC of 9. She was not acutely ill, endometritis was suspected and she recovered well on intravenous antibiotics.

Transfusion of 2 or more units of blood

(2) A 28-year old G5P4 presented to hospital A with symptomatic anaemia at 32 weeks of gestation. Her Hb was 6.8 g/dL and she was transfused 2 RCCs.

(3 A 17-year old primigravida gave birth in Hospital B with minimal blood loss. During antenatal care an Hb of 5.9 g/dl was found. Three units of blood were transfused postpartum.

Appendix 1. Comparison of WHO MNM criteria and SSA MNM criteria.

WHO near-miss criteria	Sub-Saharan Africa near-miss criteria
Clinical criteria	Clinical criteria
Acute cyanosis	Acute cyanosis
Gasping	Gasping
Respiratory rate >40 or <6/min	Respiratory rate >40 or <6/min
Shock^a	Shock
Oliguria non-responsive to fluids or diuretics^b	Oliguria non-responsive to fluids or diuretics
Failure to form clots	Failure to form clots
Loss of consciousness lasting >12 h	Loss of consciousness lasting 12 hours
Cardiac arrest	Cardiac arrest
Stroke	Stroke
Uncontrollable fit / total paralysis	Uncontrollable fit / total paralysis
Jaundice in the presence of pre-eclampsia	Jaundice in the presence of pre-eclampsia
Laboratory-based criteria	Laboratory-based criteria
Oxygen saturation <90% for ≥60 minutes	Oxygen saturation <90% for ≥60 minutes
PaO2/FiO2 <200 mmHg
Creatinine ≥300µmol/l or ≥3.5mg/dL	Creatinine ≥300µmol/l or ≥3.5mg/dL
Bilirubin >100mmol/l or >6.0 mg/dL
pH < 7.1
Lactate >5 mEq/mL
Acute thrombocytopenia (<50,000 platelets/ml)	Acute thrombocytopenia (<50,000 platelets/ml)
Loss of consciousness and ketoacids in urine	Loss of consciousness and ketoacids in urine
Management-based criteria	Management-based criteria
Use of continuous vasoactive drugs
Hysterectomy following infection or haemorrhage	Hysterectomy following infection or haemorrhage
Transfusion of ≥5 units of red cells	Transfusion of ≥ 2 units of red cells
Intubation and ventilation for ≥60 minutes not related to anaesthesia	Intubation and ventilation for ≥60 minutes not related to anaesthesia
Dialysis for acute renal failure
Cardio-pulmonary resuscitation	Cardio-pulmonary resuscitation
	Laparotomy other than caesarean section or ectopic pregnancy
Severe maternal complications	Severe maternal complications
	Eclampsia
	Sepsis or severe systemic infection^c
	Uterine rupture^d
	Pulmonary oedema
	Severe abortion complications^e
	Severe malaria^f
	Severe pre-eclampsia with ICU admission

MNM, Maternal near-miss; SSA, sub-Saharan Africa; WHO, World Health organisation, ICU, intensive care unit; CPR, cardio pulmonary resuscitation; GCS, Glasgow coma scale. ^apersistent systolic blood pressure <80 mmHg or a persistent systolic blood pressure <90 mmHg with a pulse rate at least 120 bpm, ^burinary output <30 ml/hour over 4 hours or <400 ml/24 hr, ^cpresence of fever (Temp >38°C) AND confirmed or suspected infection AND at least one of the following: heart rate >90, respiratory rate >20, WBC > 12 or < 4 x 10⁹/L, ^dcomplete rupture of uterus during labour confirmed by laparotomy, ^eseptic incomplete abortion, complicated gestational trophoblastic disease with anaemia, ^fmajor signs of organ dysfunction and/or high level parasitaemia or cerebral malaria.

Appendix 2. Frequencies of maternal near-miss by type of organ system dysfunction in the four hospitals

	Facilities
	A	B	C	D	Total
Severe maternal complications	52	16	4	0	72, 37.3%
Eclampsia	17	7	2	0	26
Sepsis or severe systemic infection^b	22	2	2	0	26
Uterine rupture^c	1	1	0	0	2
Pulmonary oedema	5	2	0	0	7
Severe abortion complications^d	7	1	0	0	8
Severe malaria^e	0	4	0	0	4
Severe pre-eclampsia with ICU admission	1	3	0	0	4
Laparotomy other than caesarean section or ectopic pregnancy	12	0	0	0	12
Cardiovascular dysfunction	17	2	2	0	21, 10.8%
Shock^f	16	2	2	0	20
Cardiac arrest	0	0	0	0	0
Use of continuous vasoactive drugs	3	0	0	0	3
CPR	0	0	0	0	0
pH < 7.1	1	0	0	0	1
Lactate >5 mEq/mL	0	0	0	0	0
Respiratory function	14	2	0	0	16, 8.3%
Acute cyanosis	0	0	0	0	0
Gasping	0	0	0	0	0
Respiratory rate >40 or <6/min	4	1	0	0	5
Intubation and ventilation for ≥60 minutes not related to anaesthesia	10	1	0	0	11
Oxygen saturation <90% for ≥60 minutes	4	0	0	0	4
Renal dysfunction	3	1	0	0	4, 2.0%
Oliguria non-responsive to fluids or diuretics^g	3	1	0	0	4
Creatinine ≥300µmol/l or ≥3.5mg/dL	1	0	0	0	1
Dialysis for acute renal failure	1	0	0	0	1
Coagulation/hematologic dysfunction	112	24	6	5	147, 75.8%
Failure to form clots	4	2	0	0	6
Transfusion of ≥ 2 units of red blood cells	108	21	6	5	140
Acute thrombocytopenia (<50,000 platelets/ml)	8	4	0	0	12
Hepatic dysfunction	12	1	0	0	13, 6.7%
Jaundice in the presence of pre-eclampsia	0	0	0	0	0
Bilirubin >100mmol/l or >6.0 mg/dL	12	1	0	0	13
Neurological dysfunction	6	2	0	0	8, 4.2%
Loss of consciousness lasting 12 hours (GCS < 10)	4	2	0	0	6
Stroke	0	0	0	0	0
Loss of consciousness and ketoacids in urine	0	0	0	0	0
Uncontrollable fit	1	0	0	0	1
New onset of paralysis	1	0	0	0	1
Uterine dysfunction	5	1	0	0	6, 3.0%
Hysterectomy following infection or haemorrhage	5	1	0	0	6
Total	150	30	9	5	194

Italics unique SSA criteria and underlined unique WHO criteria. A woman could fulfil more than one MNM criterion. At the top of each section the total number of women with each organ dysfunction, followed by the proportion, calculated by this total divided by 194 MNM women and presented as percentage. MNM, Maternal near miss; SSA, sub-Saharan Africa; WHO, World Health organisation, ICU, intensive care unit; CPR, cardio pulmonary resuscitation; GCS, Glasgow coma scale.

^bpresence of fever (Temp >38°C) AND confirmed or suspected infection AND at least one of the following: heart rate >90, respiratory rate >20, WBC > 12 or < 4 x 10⁹/L; ^ccomplete rupture of uterus during labour confirmed by laparotomy; ^dseptic incomplete abortion, complicated gestational trophoblastic disease with anaemia; ^emajor signs of organ dysfunction and/or high level parasitaemia or cerebral malaria; ^fpersistent systolic blood pressure <80 mmHg or a persistent systolic blood pressure <90 mmHg with a pulse rate at least 120 bpm; ^gurinary output <30 ml/hour over 4 hours or <400 ml/24 hr.

Data availability statement

Data supporting the findings are available upon reasonable request.