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Brief Research Article

“Near‑Miss Obstetric Events” and Its Clinico‑Social Correlates

in a Secondary Referral Unit of Burdwan District in
West Bengal
Rakesh Kumar1, Aparna Tewari2
1
Assistant Professor, Department of Community Medicine, IQ City Medical College, 2Intern, IQ City Medical College, Durgapur, West Bengal, India

Summary
Near‑miss obstetric events (NMEs) refers to the situations where women experience severe, life‑threatening obstetric complications during
pregnancy, delivery, or postpregnancy (up to 42 days) which they survive either by chance or because they receive good care at a facility.
A cross‑sectional study was conducted from May to June 2016 at the subdivisional hospital of West Bengal. The WHO near‑miss criteria were
followed for case identification. Data were collected by interview and record review. No maternal deaths were reported during data collection
period; however, the frequency of NMEs was quite high (38%). Maternal near‑miss ratio was 379.51/1000 live births, and maternal mortality
index was 0%. Higher age group, below poverty line status, term pregnancy, and higher gravid and higher parity significantly favored the
occurrence of NMEs, while ANC registration and Iron and Folic Acid consumption were significantly protective against it. Early identification
of risk factors for NMEs and prompt initiation of treatment plays a critical role in the management of NMEs.

Key words: ANC, maternal complications, maternal mortality, near‑miss obstetric events

Severe maternal complications are defined as “potentially however, only 332 were included in the final analysis due to
life‑threatening conditions.”[1] Maternal near‑miss refers to the incomplete data of four participants. Mothers were interviewed
situations where women experience severe, life‑threatening using predesigned and pretested schedule. In case, the mother
obstetric complications during pregnancy, delivery, or post was unable to answer; then, a responsible close family member
pregnancy (up to 42 days) which they survive either by chance was interviewed. Maternal and child protection card was used
or because they receive good care at a facility.[2] A severe to collect information about antenatal care (ANC). Bed‑head
maternal outcome  (SMO) is defined as a life‑threatening tickets were reviewed for final diagnosis.
condition  (i.e., organ dysfunction) including all maternal
The final diagnosis was done by the treating obstetrician, and
deaths and maternal near‑miss cases.[1] In‑depth interviews
the treatment note was taken.
with women who survived a near‑miss event or with members
of their family have generated important evidence about The following disease‑specific criteria that were employed by
the factors that contribute to delays in accessing obstetric Filippi et al.[4] were applied for this study:
care.[3] Keeping in mind the potential to highlight the nature A. Hemorrhage: (leading to shock, emergency hysterectomy,
of obstetric services and with no such study in this region of and/or blood transfusions of ≥2 liters)
West Bengal, this study was carried out with the objectives to B. Hypertensive disorders in pregnancy:  (including both
determine the frequency of near‑miss obstetric events (NMEs) eclampsia and severe preeclampsia)
in a secondary referral unit of Burdwan District and to ascertain
the clinico‑social determinants of the near‑miss events. Address for correspondence: Dr. Rakesh Kumar,
Flat‑D, 1st Floor, JD‑3, IQ City Medical College, Durgapur ‑ 713 206,
We approached all women who admitted for delivery during West Bengal, India.
data collection period (May–June 2016) to participate in our E‑mail: dr.rakeshkr082@[Link]
study. Out of 344, 336 agreed to participate in our study;
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DOI: How to cite this article: Kumar R, Tewari A. “Near-miss obstetric

10.4103/ijph.IJPH_371_17 events” and its clinico-social correlates in a secondary referral unit of
Burdwan district in West Bengal. Indian J Public Health 2018;62:235-8.

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Kumar and Tewari: “Near‑miss obstetric events” and its clinico‑social correlates

C. Dystocia:  (uterine rupture and impending rupture, In our study, the frequency of NMEs was 38.0%. MNMR was
e.g., prolonged obstructed labor with previous C.S.) 379.51/1000 live births. This was much higher as compared
D. Infection: (infection with hyperthermia or hypothermia with to other studies conducted where the prevalence of near‑miss
a clear source of infection; and clinical sign of septic shock). cases was 5.3%.[7] High frequency of near‑miss cases may be
The presence of fever  (body temperature  >38°C), a because of the selective referral of high‑risk pregnancies to this
confirmed or suspected infection (e.g., chorioamnionitis, referral unit. It might also be due to the older disease‑specific
septic abortion, endometritis, and pneumonia), and at near‑miss criteria used in this study; although in the current
least one of the followings: heart rate >90, respiratory scenario, the WHO 2011 near‑miss guideline[1] are more
rate  >20, leukopenia  (white blood cells  <4000), and precise and practical tool. In our study, hypertensive disorders
leukocytosis (white blood cells >12 000) of pregnancy were the most common  (59.3%) NME while
E. Severe anemia: (Hb level <7 g/dl). anemia, PPH, infection, and dystocia were responsible for
22.7%, 8.9%, 6.2%, and 2.7% near‑miss cases, respectively.
Statistical analysis was performed using  SPSS software,
Higher age group significantly and adversely influenced
version 20.0 (SPSS Inc, Chicago, IL, USA). Chi‑square test pregnancy as 88.5% of the study population from age
was performed for categorical variables and Mann–Whitney group  ≥30  years experienced NMEs. Increasing maternal
U test was conducted to find out the difference between two age and its adverse impact on pregnancy were also found in
groups. P = ≤ 0.05 was considered as statistically significant. various other studies.[8] NMEs were significantly higher among
A total of 221 (66.6%) of the study participants were in the age study participants who were BPL and resided in a rural area as
group of 20–29 years followed by 85 (25.6%) and 26 (6.8%) 46.5% and 40.5% of the study participants belonging to BPL
in the age group  <20  years and  ≥30  years, respectively. and rural residence, respectively, experienced NMEs. Similar
280  (84.3%) of the study participants belonged to Hindu findings were reported by Montgomery et al.[8]
religion and rest were Muslims. About half  (51.8%) of the Although statistically not significant in our study, education of
participants were below poverty line  (BPL)  (those having the pregnant women was inversely proportion to the near‑miss
BPL card). 127 (38.3%) of them were educated up to primary events as only 32.1% of the mothers who received education
level only followed by 36.4% and 25.3% up to Class  X more than Class  X experienced near‑miss complications.
and  >Class  X, respectively. Approximately 50% of the Increasing gravida and parity adversely influenced the
participants were primigravida, whereas 43.4% and 3.6% course of pregnancy as 83.3% of gravida  ≥5 and 64.3% of
were multigravida and grand multigravida, respectively. parity 3–4 experienced near‑miss events. In our study, about
Although more than 90% of the study participants were 4/5th of NMEs were term deliveries and only about one‑fifth
registered for Antenatal Check‑up (ANC), only three‑fifth of of the NMEs were preterm deliveries. A similar association
them had ≥4 ANCs. About 73.3% of the registered participants of higher NMEs with term deliveries were also reported from
consumed Iron and Folic Acid  (IFA) supplements. The other studies.[8,9] ANC registration significantly protected
frequency of near‑miss was 126 (38%) though no maternal against NMEs as 66.7% of unregistered study participants
deaths were reported during the study. and only 34.5% of the booked cases experienced near‑miss
Maternal near‑miss ratio (MNMR) was 379.51/1000 live births, events. Mothers who consumed IFA tablets experienced less
and maternal mortality index was 0%. Hypertensive disorder NMEs, i.e., 27.2% as compared to 54.4% of study participants
of pregnancy constituted three‑fifth of the NMEs followed who did not consume it and were thus deprived of antenatal
by anemia  (22.7%), postpartum hemorrhage  (PPH)  (8.9%), care. A study population who had ≥4 antenatal care (ANC)
infection  (6.3%), and dystocia  (2.7%). Hypertensive visits experienced more NMEs, i.e., 39.2% followed by
disorders of pregnancy as the main cause of near‑miss events 32.2% in those who had <4 ANC visits. This may be due to
were also found in various other studies.[5] However, these the more vigilantism during ANC visits which resulted in early
findings differ from many studies in which hemorrhage detection of high‑risk pregnancies and their selective referral
was ranked first[6] hypertensive disorder of pregnancy was to secondary referral unit, or it may be by chance association
complicated with anemia, PPH, and infection in 7.1%, as the association is statistically not significant  [Table  1].
2.3%, and 1.5% of near‑miss cases, respectively. Anemia However, other studies reported the inverse association of
was complicated with infection in 1.5% of the near‑miss ANC with adverse pregnancy outcome.[8]
cases, while PPH was complicated with infection in 0.7% of As government mandate referral transport, vehicle should reach
cases. Higher age at conception, BPL status, rural residence, the patient within 30  min of receiving call and health‑care
high parity, high gravida, and term deliveries adversely facility in next 30 min.[10] In our study, first and second delays
influenced pregnancy and significantly (P < 0.05) favored the were significantly associated with NMEs [Table 2]. Although in
occurrence of NMEs. ANC registration and IFA consumption our study, mothers took slightly more time in deciding to seek
significantly protected against NMEs [Table 1]. While there help, the time (30 min) taken in second delay signifies robust
was no significant “Third Delay,” first and second delays referral system. Robust referral system and insignificant third
were significantly higher among mothers who experienced delay might have contributed in saving lives of the mother as
NMEs [Table 2]. reflected by 0% mortality index in this study.

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Kumar and Tewari: “Near‑miss obstetric events” and its clinico‑social correlates

Table 1: Clinico‑social characteristics of the study participants (n=332)

C‑S factors Near‑miss obstetric events Total, n (%) χ2 (df) P
Yes (%) No (%)
Age group (year)
<20 26 (30.6) 59 (69.4) 85 (100.0) 31.0 (2) 0.000
20‑29 77 (34.8) 144 (65.2) 221 (100.0)
≥30 23 (88.5) 3 (11.5) 26 (100.0)
Religion
Hindu 110 (39.3) 170 (60.7) 280 (100.0 1.4 (1) 0.245
Muslim 16 (30.8) 36 (69.2) 52 (100.0)
BPL status
BPL 80 (46.5) 92 (53.5) 172 (100.0) 11.1 (1) 0.001
Not BPL 46 (28.7) 114 (71.3) 160 (100.0)
Caste
SC 80 (46.5) 92 (53.5) 172 (100.0) 1.0 (3) 0.794
ST 22 (37.9) 36 ( 62.1) 58 (100.0)
OBC 17 ( 32.7) 35 ( 67.3) 51 (100.0)
General 45 (40.9) 65 (59.1) 110 (100.0)
Educational status
≤Class V 49 (38.6) 78 (61.4) 127 (100.0) 2.2 (3) 0.405
Class VI‑X 50 (41.3) 71 (58.7) 121 (100.0)
>Class X 27 (32.1) 57 (67.9) 84 (100.0)
Residence
Rural 106 (40.5) 156 (59.5) 262 (100.0) 3.3 (1) 0.049
Urban 20 (28.6) 50 (71.4) 70 (100.0)
Gestational age (weeks)
<37 26 (24.1) 82 (75.9) 108 (100.0) 13.1 (1) 0.000
≥37 100 (44.6) 124 (55.4) 224 (100.0)
Gravida
Primigravida 59 (33.5) 117 (66.5) 176 (100.0) 12.1 (2) 0.002
Multi gravida (2‑4) 57 (39.6) 87 (60.4) 144 (100.0)
Grand gravida (≥5) 10 (83.3) 2 (16.7) 12 (100.0)
Parity
P0 57 (32.0) 121 ( 68.0) 178 (100.0) 8.2 (2) 0.016
P1‑P2 60 (42.9) 80 (57.1) 140 (100.0)
P3‑P4 9 (64.3) 5 (35.7) 14 (100.0)
ANC registration
Registered 102 (34.5) 194 (65.5) 296 (100.0) 14.1 (1) 0.000
Unregistered 24 (66.7) 12 (33.3) 36 (100.0)
IFA consumption (n=296)*
Consumed 59 (27.2) 158 (72.8) 217 (100.0) 19.1 (1) 0.000
Not consumed 43 (54.4) 36 (45.6) 79 (100.0)
Number of ANC (n=296)*
<4 37 (32.2) 78 (67.8) 115 (100.0) 1.5 (1) 0.265
≥4 71 (39.2) 110 (60.8) 181 (100.0)
Mode of delivery
NVD 87 (39.5) 113 (60.5) 220 (100.0) 0.7 (1) 0.402
LUCS 39 (34.8) 73 (65.2) 112 (100.0)
*n=296 because only 296 study participants were registered for ANC. BPL: Below poverty line, ANC: Antenatal care, C‑S: Clinico‑social,
LUCS: Lower uterine cesarean section

Study limitations include older near‑miss criteria, shorter study Near‑miss cases review can help in identifying the pattern
duration, inclusion of only postnatal mothers, and lack of of SMOs, strengths, and weakness of healthcare delivery
follow‑up. The use of the WHO 2011 near‑miss guidelines,[1] system in terms of referral and clinical interventions and
inclusion of all obstetric admission and longer duration study the possible ways to improve it. Hypertensive disorder of
might have reflected true picture of the NMEs burden. pregnancy, anemia, and PPH is the leading causes of NMEs.

Indian Journal of Public Health ¦ Volume 62 ¦ Issue 3 ¦ July‑September 2018 237

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Kumar and Tewari: “Near‑miss obstetric events” and its clinico‑social correlates

Table 2: Median time of obstetric delays among study Conflicts of interest

participants (n=332) There are no conflicts of interest.

Delays Near
miss
n (%) Median
(IQR) min
Mann‑Whitney
U
P References
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1st Yes 126 (38.0) 47.5 (30.0‑90.0) Pregnancy Complications: The WHO Near‑Miss Approach for Maternal
delay* No 206 (62.0) 2.0 (1.0‑2.0) ‑11.1 0.000# Health. Geneva, Switzerland: World Health Organisation; 2011.
2nd Yes 126 (38.0) 30.0 (30.0‑50.0) 2. Say  L, Souza  JP, Pattinson RC; WHO working group on Maternal
delay* No 206 (62.0) 2.0 (1.0‑2.0) ‑8.2 0.000# Mortality and Morbidity classifications. Maternal near miss – Towards a
standard tool for monitoring quality of maternal health care. Best Pract
3rd Yes 126 (38.0) 8.0 (5.0‑10.0)
Res Clin Obstet Gynaecol 2009;23:287‑96.
delay* No 206 (62.0) 2.0 (1.0‑2.0) ‑1.0 0.312 3. Reddy P. Maternal Near Miss‑Protocol to be Defined. Available from:
*delay in minutes. #P value <0.05 was considered significant [Link]
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Early identification of risk factors for these diseases and prompt Maternity wards or emergency obstetric rooms? Incidence of near‑miss
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Acknowledgment mortality in a Tertiary Care Centre in Western Rajasthan. Indian J Public
The authors would like to thank Indian Council of Medical Health 2014;58:199‑201.
Research  (ICMR) for selecting this research proposal 7. Mustafa R, Hashmi H. Near‑miss obstetrical events and maternal deaths.
J Coll Physicians Surg Pak 2009;19:781‑5.
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Indian Council of Medical Research. Jabalpur: M/s Banarasi Das Bhanot; 2017. p. 487.

238 Indian Journal of Public Health ¦ Volume 62 ¦ Issue 3 ¦ July‑September 2018