Incidence, Causes, and Determinants of Maternal Near-Miss among Women Attending Public Hospitals in Borena Zone of Oromia Region, Ethiopia

doi:10.21203/rs.3.rs-2825582/v1

Background: Maternal near-miss refers to an event where a woman who nearly died but survived complications that occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy. Survivors of near-miss events share several characteristics with mothers who would have died. Thus, up-to-date information on the magnitude and causes of maternal near-miss is vital to improve the quality of maternal care.

Methods: A facility-based cross-sectional study was conducted among women attending public hospitals in Borena zone from August 15 to November 15, 2022. All women admitted to participating hospitals during pregnancy, childbirth, or within 42 days following termination of pregnancy who met the WHO near-miss criteria were enrolled into the study.

Result: Out of the total 1421 deliveries during the study period, we were able to identify 117 women that developed potentially life-threatening conditions, with 61 of these women experiencing severe maternal outcomes (55 near-misses and 6 maternal deaths). The maternal near-miss incidence ratios was estimated to be 38.7 per 1000 live births and a mortality index of 9.8%. Hypertensive disorders, 61.8% (CI: 48% - 74%), and obstetric hemorrhage, 29.1% (CI: 18% - 42%) were the leading underlying causes of maternal near-misses.

Conclusion: The incidence of maternal near-miss was remarkably high when compared to previous studies. Giving special emphasis to life-saving interventions, critical care, reducing delays and improving the referral system are critical to improve quality of care.

Maternal near-miss

Severe maternal outcome

WHO

Public hospital

Borena

Pregnancy-related morbidity and mortality continue to have a serious impact on the lives of women all over the world (1,2). Sub-Saharan Africa and Southern Asia accounted for approximately 86% of the estimated global maternal deaths (2,3). Many women who experience life-threatening complications may die, and a proportion may narrowly escape death due to a lifesaving obstetric intervention (4). A maternal near-miss (MNM) is referred to as a woman who nearly died, but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy (4,5). Nowadays, MNM is considered a vital indicator used to monitor the quality of obstetric care services (4). It serves as a crucial tool for determining the most common pregnancy problems, underlying risk factors, and the availability of life-saving obstetric treatments (6,7).

According to a recent systematic review and meta-analysis study, the global prevalence of maternal near miss was 1.4% (11). Among the studies that have been conducted in Africa, the weighted pooled prevalence of MNM was 31.9 per 1000 live births, with significant heterogeneity between studies (6). Near miss events are common and are estimated to be around 12 times more frequent than maternal deaths (8–11). The 2016 Ethiopian Demographic and Health Survey (EDHS) reported 412 maternal deaths per 100,000 live births (7). Studies have shown that predictors of maternal near misses are postpartum hemorrhage, pregnancy induced hypertension, sepsis, ruptured uterus, and abortion(1,4,12).

Improving maternal health remains an important topic of SDG, which is to reduce the global Maternal Mortality Ratio (MMR) to less than 70 per 100,000 live births by 2030. Ethiopia also intends to achieve this target by 2030 (2,13). In this regard, although a promising reduction had been made in past few decades, maternal near-miss, pregnancy related complications, and deaths were still exceptionally high, particularly in communities that are hard-to-reach and resources-limited areas (4,8). Thus, up-to-date information on the magnitude and causes maternal near miss is important to know areas of interventions that help to improve maternal and perinatal health. Additionally, knowledge of the causes and determinants of maternal near-miss is important in the design of quality assessment checklists for the performance based financing (PBF) for health programs as Ethiopia seeks to scale up PBF as one of the health financing mechanisms in the country. Within the PBF project, quality assessments on several areas related to the health system, including maternal services, are conducted on a monthly basis, with the quality assessments focused on the structural components and less on the processes of care.

Study Setting

A facility-based cross-sectional study design was used at four (4) public hospitals in Borena zone, Southern Oromia, from August 15 to November 15, 2022. The study was conducted as part of a project aimed at complimenting the efforts of performance based financing (PBF) for health project in Borena zone, Southern Oromia, Ethiopia.

Study population and data collection

This study included all women who were pregnant, in labor, or who delivered or aborted in the past 42 days arriving at the facility with complications or who developed those complications during their stay at the health facilities. Women who developed complications after 42 days of termination of pregnancy were excluded from the study. Data was collected using the WHO near-miss criteria (4) with some adaptations to include process and contextual factors. All relevant dates were collected along with the referral process followed, total live births, and condition of the woman on arrival. Participants’ medical records and charts were reviewed until participants were discharged from the hospital.

Data processing and Analysis

The total incidence of maternal near-miss in the hospitals involved in this study was calculated using the maternal near-miss incidence ratio (MNMIR) formula. Hospital access indicators, such as the number of women with a maternal near-miss condition before arrival at the hospital, were calculated. Intra-hospital care indicators, such as the number of women with near-miss who developed conditions in the hospital, were also calculated.

Socio-demographic characteristics

A total of 1421 live births were recorded from all participating hospitals during the study period. A total 117 of women developed potentially life-threatening conditions. The average age of women who developed potentially life-threatening diseases was around 25.5 years old, with a standard deviation of 5.5 and most participant’s age fall under the age category of 25-34. More than half (55.7%) of the cases were illiterate (had no formal education). About 23.9% of cases did not attend ANC (Antenatal Care) service. The majority (64.1%) of the cases were referred from lower health facilities (Table 1).

Table 1. Socio-demographic and Socioeconomic characteristic of mother with severe maternal outcome at public Hospitals in Borena Zone, Ethiopia, 2022 (n=117)

Characteristics	Categories	Frequency	Percent
Characteristics	Categories	Frequency	Percent
Age	15–24	46	39.3%
	25–34	57	48.8%
	≥35	14	11.9%
Residence	Urban	80	68.4%
Residence	Rural	37	31.6%
Marital status	Married	114	97.4%
Marital status	Single/separated/divorced	3	2.6%
Educational status	No formal education	55	47.1%
Educational status	Has formal education	62	52.9%
Age at first marriage	below 18 years	42	35.9%
Age at first marriage	18 years and above	75	64.1%
ANC	Yes	89	76.1%
ANC	No	28	23.9%
Referral status	Referred from other facility	75	64.1%
Referral status	Not referred	42	35.9%

Morbidity among women with potentially life-threatening conditions

Among women had potentially life-threatening conditions, severe pre-eclampsia (48.7%) and severe postpartum hemorrhage (22.2%) were the leading severe maternal complications for hospitalization. A substantial number of women underwent critical interventions of which the use of blood products (29.5%) and admission to the intensive care unit (ICU) (27.4%) were the common interventions. The number of major organ dysfunctions seen in most cases were respiratory and cardiovascular dysfunctions at 53.6% and 33.3% respectively (Table 2).

Table2. Morbidity conditions in the audited sample of women with potentially life-threatening conditions at public health facilities in Borena Zone, Ethiopia, 2022. (n=117)

Women with severe complications	Number	Percentage
Severe postpartum hemorrhage	26	22.2%
Severe pre-eclampsia	57	48.7%
Eclampsia	21	17.9%
Sepsis or severe systemic infection	14	12.0%
Ruptured uterus	2	1.7%
Women undergoing critical Interventions
Use of blood products	35	29.9%
Interventional radiology	2	1.7%
Laparotomy	10	8.5%
Admission to intensive care unit	32	27.4%
Women with Organ dysfunction
Cardiovascular dysfunction	39	33.3%
Respiratory dysfunction	51	53.6%
Renal dysfunction	9	7.7%
Coagulation/hematologic dysfunction	6	5.1%
Hepatic dysfunction	8	6.8%
Neurologic dysfunction	8	6.8%
Multiple organ dysfunction	43	36.7%

Incidence of maternal near miss (MNM)

From the 117 women who developed potentially life-threatening conditions 55 women experienced near misses and 6 resulted in maternal deaths. The maternal near-miss (MNM) and severe maternal outcomes (SMO) incidence ratios were 38.7 and 42.9 per 1000 live births, respectively. The maternal near-miss to maternal mortality ratio was 9.17 to 1 with a mortality index of 9.8% (Table 3).

Table 3. Near miss incidence and outcome indicators at public Hospitals in Borena Zone, Ethiopia, 2022 (n=117).

*Outcomes*	*Near-miss indicators*
All live births in the population under surveillance	1421
Women with potentially life-threatening conditions	117
Severe maternal outcomes (SMO) cases (number)	61
Maternal deaths (n)	6
Maternal near-miss cases (n)	55
Overall near-miss indicators
Severe maternal outcome ratio (per 1000 live births)	42.93
Maternal near-miss ratio (per 1000 live births)	38.71
Maternal near-miss mortality ratio	9.17: 1
Mortality index	9.8%

Underlying and contributory causes

In this study, the leading causes of MNM were Hypertensive disorders (severe pre-eclampsia and eclampsia) 61.8% (CI; 48%-74%) and obstetric hemorrhage at 29.1% (CI; 18%- 42%). Sepsis or pregnancy related infection (66.7%) was the leading cause of maternal death. The majors contributing cause of maternal near-miss (43.6%) (CI; 30%-57%) reported was anemia(Table 4).

Table 4. Underlying and contributory causes of maternal near miss at public Hospitals in Borena Zone, Ethiopia, 2022 (n=55)

Underlying causes and associated conditions	Maternal near-miss cases		Mortality Ratio	Mortality Index
Underlying causes and associated conditions	*Number*	Percent	Ratio	Percent
Underlying causes
Abortion	9	16.4%	9.0:1	10.0%
Obstetric hemorrhage	16	29.1%	16.0:1	5.9%
Hypertensive disorders	34	61.8%	11.3:1	8.1%
Pregnancy-related infection	16	29.1%	4.0:1	20.0%
Contributory Causes
Anemia	24	43.6%	24.0:1	4.0%
Previous caesarean section	2	3.6%	-	0.0%
Prolonged / obstructed labor	2	3.6%	-	0.0%

Process or facility related indicators.

Out of the total 61 SMO cases, 23 (37.7%) of women presented with life-threatening conditions on arrival or within the first 12 hours of hospital admission (SMO12). The mortality index (MI) of women with SMO on arrival or within the first 12 hours of hospital admission was 21.7%. The intrahospital SMO rate was 26.7 per 1000 live births and the mortality index was 2.6%. The ICU admission rate was 2.3%, while the ICU admission rate among women with SMO was 24.6%. Half (50%) of the maternal deaths occurred without ICU admission. All (100%) of the women with severe PPH received uterotonics where oxytocin was the most common uterotonics used. Of the 21 cases with eclampsia 20 (95.2%) received anticonvulsants in which most of the anticonvulsants given was magnesium sulfate (Table 5).

Table 5. Process or facility related indicators in public Hospitals of Borena Zone, Ethiopia

Use of Intervention and Treatment	Percentage
Treatment of severe postpartum hemorrhage
Oxytocin use	100.0%
Ergometrine	11.5%
Anticonvulsants for eclampsia
Magnesium sulphate	95.2%
Treatment for sepsis
Parenteral therapeutic antibiotics	85.7%
Proportion of SMO12 cases among all SMO cases	37.7%
SMO12 mortality index	21.7%
Intrahospital care
Intrahospital SMO rate (per 1000 live births)	26.74
Intrahospital mortality index	2.6%
Intensive care use
ICU admission rate	2.3%
ICU admission rate among women with SMO	24.6%
Proportion of maternal deaths assisted without ICU admission	50%

According to a recent WHO report, an MNM or SMO ratio higher than 10 per 1000 live births indicates that a large percentage of women will need lifesaving interventions to survive their complications (4). The MNMR found in this study (38.7 per 1000 live births) is higher than previous studies conducted in different parts of Ethiopia (8.01 in Addis Ababa (14), 16.1 in Hawassa (15), 24.3 in South Region (16), and 28.5 in Tigray Ethiopia (3)). It also higher than in studies conducted in the East African Region (Tanzania (17), Sudan (18), Uganda (19)). This may be due to differences in case definition in the different studies and also types of health facilities included. However, contextual factors such as prolonged severe drought within the Borana region cannot be ruled out as a possible cause the high MNMR, signaling a possible health emergency in the area. Conversely, the magnitude of MNM is this study is lower than prior studies conducted in eastern Ethiopia (80 per 1000 live births) (20), and south-west Ethiopia (50.4 per 1000 live births) (21). The prior studies used disease-based criteria, which were less stringent than the WHO criteria for identifying maternal near-miss cases.

The current study showed that the leading causes of MNM were pregnancy induced hypertension and severe postpartum hemorrhage, which are comparable to the findings of studies conducted elsewhere in Ethiopia (14,15,21–24) and other African countries (17,18). Pregnancy related infection (sepsis) was associated with the highest case fatality which is similar with the findings of earlier studies done in other parts of the country (23,25) and other developing countries (17,18).

Near-miss cases that develop during hospitalization can help to measure the quality of obstetric care provided within the health facilities (4,23). In line with previous findings, this study showed that most women experienced SMO on admission or within 12 hours of arrival at hospitals (9,14,23). This suggests the existence of substandard obstetrics care at lower level health facilities (health centres) and a weak referral system. According to the WHO, the presence of a large proportion of women who arrive at health facilities with SMO suggests either a delay in seeking care (first delay) or delay in reaching a health facility (second delay) (4).

This study noted that ICU admission rate among women with SMO is low and about half of maternal deaths occurred without ICU admission. This low percentage of women with SMO admitted to the ICU and the high percentage of maternal deaths that occurred without ICU admission suggest a shortage of ICU beds (1,4,23). Therefore, it is necessary to set up ICUs dedicated solely to the obstetric population. Appropriate use of effective interventions results in improved health outcomes (1,2,4).

This study has added to the literature by assessing interventions provided for women with maternal near-miss and hospital access indicators, which are essential components of quality of care. The use of prospective data to identify women with SMO and the quality of care provided to women with life-threatening conditions using a validated WHO tool add valuable information that can used to design programs and interventions aimed at improving maternal health in resource limited and remote settings. However, because of logistics, feasibility concerns and budget limitations, our follow-up time was limited to only the length of the hospital stay instead of up to 42 days of postpartum as WHO recommendation. The short and long-term maternal consequences of near-miss events were also not addressed in the current study.

The common underlying causes of most maternal near miss cases were hypertensive disorders and obstetric hemorrhage. Anemia was the major contributing cause reported for maternal near miss. Giving special emphasis to life-saving interventions, critical care and implementation of prenatal risk identification and prompt referral to the nearby hospitals are essential for reducing delays in provision of appropriate care and improving the overall quality of maternal healthcare.

Findings from this study also showed that while structural quality of care may have improved under PBF program in Borana, the patient process quality of care still needs to improve, suggesting that the quality assessment checklist needs to be revised to include indicators aimed at assessing whether clinical audits are conducted by health facilities in order not to miss and compromise on the procedures for managing complicated deliveries.

Ethical Clearance

Ethical clearance was obtained from Oromia Health Bureau, Health Research Ethical Review Committee and it was in accordance with the principles of the Helsinki II declaration. Ref number: BFO/HBTFH/1-16/416. The anonymity of the participants was respected via the use of MRN rather than the name of the participant. The names of the participants were not reported in the findings of the study to ensure confidentiality.

Availability of data and materials

All the data of this study are available from the corresponding author upon reasonable request.

Funding

This work was financially supported by Catholic Organization for Relief and Development Aid (CORDAID) as part of the “Complimenting Borena PBF program to further improve MCH services” project with ID 201155.

Consent for publication

Not applicable

Competing interest

The authors declared that there is no conflict of interest.

Acknowledgments

We would also like to extend our gratitude to Cordaid Borana field office, Borana Zonal Health Department, the hospital heads, the study participants, and the data collectors for their due cooperation and involvement in the study.

Authors Contributions

All authors have made a substantial contribution to the production of this research output and have been listed in order of level of contribution. Boboh Kamangira, the principal investigator, conceptualized the research and was involved in study design, overall research management and supervision, data analysis, and manuscript drafting and finalization. Gudeta Ayele was involved in the study design, data collection supervision, data management and analysis, and drafting the manuscript. Kaleb Melaku was involved in the study design, data management and analysis, and drafting the manuscript. Abdulbari Abdulkadir has been involved data collection supervision, field logistics management, hospital liaison and manuscript review. Polite Dube and Eubert Vushoma contributed to study protocol and manuscript review and giving final approval for publication.

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No competing interests reported.

Incidence, Causes, and Determinants of Maternal Near-Miss among Women Attending Public Hospitals in Borena Zone of Oromia Region, Ethiopia

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Abstract

Introduction

Material and methods

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

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