Near miss maternal morbidity at the university teaching hospital,Lusaka: A descriptive study

Background
For every maternal death there are many others who suffer serious life- threatening complications of pregnancy, referred to as ‘near miss’ morbidity. In the past, maternal audit using deaths have traditionally been used to improve maternal health outcomes. Reviews of cases of survivors of life-threatening complications in pregnancy, in addition to maternal death reviews, are becoming an important method of evaluating and improving maternal health outcomes. Although maternal mortality has been studied in Zambia, the extent and types of ‘near miss’ morbidity are not well described.
Methods
The study was a cross-sectional descriptive study involving case file review of patients admitted as a life–threatening complication in pregnancy or the puerperium and survived to discharge. These patients, termed ‘near misses’ or severe maternal morbidity were admitted in the Department of Obstetrics and Gynaecology of the University Teaching Hospital, Lusaka over a 3 month period from 1st September to 30th November 2007. Data was collected on patient characteristics, past pregnancy, antenatal care, referral status, type of complication, mode of delivery, timing and availability of care, care provider, mode of delivery, and outcome.
Findings
There were 205 cases defined as ‘near-miss’ from within 5672 admissions (3.6%) during the study period. The ‘near misses’ according to clinical type were:
hypertensive disorders of pregnancy (HDP i.e. pre-eclampsia and eclampsia) (n=129, 62.9%), haemorrhage (43, 21.0%), abortions (16, 7.8%) and ‘others’ (17, 8.3% - including 10 cases of ectopic pregnancy and 2 of severe puerperal sepsis). There were 26 maternal deaths during this time and the case fatality for life-threatening complications was thus 26/(205+26)=11.3%; higher for haemorrhage (17.3%) compared to HDP (4.4%). Just under half were reviewed within 30 minutes and 22.9% required blood transfusion. Overall 41.5% were delivered by caesarean section (compared to the typical caesarean rate of under 20%). The fetal outcome was worse in cases of haemorrhage compared to HDP (32.6% vs. 11.6% deaths).
Interpretation
The study has described, for the first time, the extent and type of ‘near miss’ cases occurring at UTH, in addition to the timings and availability of care. The occurrence of more cases of ‘near miss’ morbidity as opposed to cases of maternal mortality offers an opportunity for further audit to improve upon maternity care in a less threatening manner.