This document discusses maternal near miss (MNM), which refers to women who survive severe life-threatening complications during pregnancy, childbirth, or postpartum. MNM is presented as an important tool for evaluating obstetric healthcare beyond just maternal mortality. The document outlines criteria for identifying MNM cases, indicators for assessing healthcare quality using MNM data, advantages of MNM reviews for reducing maternal mortality, and findings from studies on MNM in various hospitals that identified leading complications and opportunities for improvement. MNM reviews are described as complementary to maternal death reviews for gaining insights to reduce preventable morbidity and mortality.

1. MATERNAL
NEAR
MISS
Prof.
Aboubakr
Elnashar
Benha
University
Hospital,
Egypt
elnashar53@hotmail.com
CONTENTS
I.MATERNAL
MORTALITY
1.
Definitions
2.Why
is
not
sufficient?
II.MATERNAL
NEAR
MISS
1.
Concept
2.Definition
3.Criteria
4.Indicators
5.Review
6.Advantages
7.Reduction
of
MM
8.Studies

2. I.
MATERNAL
MORTALITY
1.
DEFINITIONS
Maternal
Death:
MD
The
death
of
a
woman
while
pregnant,
or
within
42
days
of
termination
of
pregnancy,
irrespective
of
the
duration
and
the
site
of
the
pregnancy,
from
any
cause
related
to
or
aggravated
by
the
pregnancy
or
its
management
(from
direct
or
indirect
obstetric
death)
but
not
from
accidental
or
incidental
causes.
❑
Maternal
Mortality
Rate
Vs
Ratio
Many
sources
use
the
maternal
mortality
ratio
and
the
maternal
mortality
rate
interchangeably
to
mean
the
number
of
maternal
deaths
per
100,000
live
births.
WHO,
however,
distinguishes
the
two:

3. ❑
Maternal
mortality
ratio:
The
number
of
maternal
deaths
per
100,000
live
births
a
measure
of
the
risk
of
death
once
a
woman
has
become
pregnant.
In
Egypt:
2016
Number
of
maternal
deaths:
1194
Live
births:
2
600
173
MM
Ratio:
45.9
❑
Maternal
mortality
rate:
▪The
number
of
maternal
deaths
(direct
and
indirect)
in
a
given
period
per
100,000
women
of
reproductive
age
during
the
same
time
period.
2.
WHY
MM
IS
NOT
SUFFICIENT
for
evaluation
of
obstetric
health
1.Maternal
mortality
is
“just
the
tip
of
iceberg”
with
a
huge
base
to
the
iceberg-
maternal
morbidity-which
remains
un-described,
relatively
unevaluated.

4. 2.
MMR
has
declined
globally,
more
so
in
developed
countries.
3.
Absolute
number
of
maternal
deaths
is
low
it
does
not
allow
reliable
quantitative
analysis
of
maternal
health.
In
Egypt
MMR
has
fallen
from
1992:
174
2016:
46

6. Significant
decline
in
the
past
20
years.
▪From
2007
to
2013,
there
is
no
significant
decrease
in
MMR
II.
MATERNAL
NEAR
MISS
1.CONCEPT
Maternal
near
miss
=
Severe
Acute
Maternal
Morbidity
(SAMM)
Women
who
experienced
and
survived
a
severe
life
threatening
condition
during
pregnancy,
child
birth
/
postpartum
cases
share
many
characteristics
with
maternal
deaths

7. ▪
Maternal
near
miss
=
emerged
as
an
adjunct
and
proxy
measure
to
identify
gaps
in
maternal
health
services
complementary
to
maternal
mortality
inform
about
obstacles
that
have
to
be
overcome
after
the
onset
of
an
acute
complication.
Corrective
actions
for
identified
problems:
reduce
related
mortality
and
long-term
morbidity.
2.
DEFINITION
“a
woman
who
nearly
died
but
survived
a
complication
that
occurred
during
pregnancy,
childbirth
or
within
42
days
of
termination
of
pregnancy”
(WHO,2004)
In
practical
terms
Woman
who
survives
life
threatening
conditions
(i.e.
organ
dysfunction)
during
pregnancy,
abortion,
and
childbirth
or
within
42
days
of
pregnancy
termination,
irrespective
of
receiving
emergency
medical/surgical
interventions
(Souza
et
al,
2007)

8. 3.
CRITERIA
FOR
IDENTIFICATION
▪
WHO
recommended
3
approaches
1.Disease
specific
criteria:
▪
severe
preeclampsia/eclampsia
▪
severe
hge,
▪
severe
sepsis
▪
uterine
rupture.
2.Management/Intervention
based:
▪
admission
to
ICU,
▪
obstetric
hysterectomy,
▪
massive
blood
transfusion,
▪
intubation/ventilation.
3.
Organ
dysfunction
based
criteria
–
lab
markers
▪
apparent
clinical
diseases
▪clinical
markers
▪management
needs.
The
aim
▪
correction
of
that
organ
dysfunction
▪arrest
MNM
progression
to
MD.

9. 4.
INDICATORS
▪Useful
for
▪Auditing
quality
of
maternal
health
care
▪
Assessing
deficiencies
and
gaps
between
actual
use
and
optimal
use
of
high
priority
interventions
in
prevention
and
management
of
severe
pregnancy
complications.
1.
Severe
maternal
outcome
ratio
(SMOR)
Number
of
women
with
life-threatening
conditions
(MNM
+
MD)
per
1000
live
births
(LB).
This
gives
an
estimate
of
the
amount
of
care
resources
that
would
be
needed
in
an
area
or
facility
[SMOR=
(MNM
+MD)/LB].

10. 2.
MNM
ratio
(MNMR)
Number
of
maternal
near-miss
cases
per
1000
live
births
(MNMR
=
MNM/LB).
It
gives
an
estimation
of
the
amount
of
care
resources
that
would
be
needed
in
an
area
or
facility.
3.
Maternal
near-miss
mortality
ratio
(MNM:
1
MD)
refers
to
the
ratio
between
maternal
near-miss
cases
and
maternal
deaths.
Higher
ratios
indicate
better
care.
4.
Mortality
index
Number
of
maternal
deaths
divided
by
number
of
women
with
life-threatening
conditions
expressed
as
a
percentage
[MI=
MD/
(MNM
+
MD)].
The
higher
the
index
the
more
women
with
life-threatening
conditions
die
(low
quality
of
care)
The
lower
the
index
the
fewer
women
with
life-threatening
conditions
die
(better
quality
of
care).

11. 5.
WHAT
IS
MNM
REVIEW?
Process
of
MNM
Review
(MNM-R)
involves
the
following
steps:
1.Identification
of
MNM
cases
2.Notification
to
MO/HOD
3.Data
transmission
(institute
district
state)
4.Review
(institutional
and
district
level)
5.Analysis
and
feedback
for
necessary
action
6.
ADVANTAGES
1.
MNM
shares
MM.
same
pathway
and
pathological
processes
as
Normal
pregnancy
Morbidity
severe
morbidity
near
miss
Death
The
major
reasons
and
causes:
valuable
information
regarding
severe
morbidity,
which,
if
untreated
may
lead
to
MM.

12. 2.
Near
miss
cases
are
more
common
than
maternal
deaths:
adequate
information
and
analysis.
statistically
reliable
quantitative
analysis
comprehensive
profile
of
functioning
of
health
care
system.
3.
It
enables
us
to
learn
from
MNM
survivors
as
▪
women
themselves
are
available
for
interview
about
the
care
they
received.
They
can
share
their
experiences
in
ICU,
psychological
devastation
and
trauma
of
being
separated
from
newborn
and
urge
for
breastfeeding,
besides
the
psychological
perspective
of
other
women
who
have
faced
severe
maternal
illness
4.
MNM-R
seems
to
be
less
threatening
to
service
providers.
In
Cases
of
MDR,
▪
health
professionals
and
other
stakeholders
involved
in
service
delivery
are
fearful
that
the
blame
would
fall
on
their
shoulders.
▪
MDR
process
is
considered
as
a
potential
threat
to
expose
them
to
public
enquiry
and
outrage.
MNM-R
▪
less
threatening
to
providers
because
the
woman
survived
▪
fear
of
blame
and
punishment
is
less
▪
are
willing
and
eager
to
share
their
„success‟
stories.
❖
more
valuable
information
can
be
obtained
and
utilized
for
improvement
of
obstetric
health
and
reduction
of
MMR.

13. 5.
MNM-R
provides
valuable
information
about
social
and
family
problems
lack
of
awareness
of
health
care
facilities.
Level
of
delays
can
also
be
identified
where
they
occur.
7.
SIGNIFICANCE
IN
REDUCING
MATERNAL
MORTALITY
▪
MNM-R
relatively
simpler
to
analyze
easier
to
resolve
complementary
to
MDR
in
appraisal
of
maternal
health.
▪
When
used
in
conjunction
with
MDR
1.
Identify
▪
Requirement
of
health
care
facilities
▪
Delays
at
various
levels
can
be
done,
which
lead
to
maternal
morbidity
and
mortality
▪
Modifiable
socio-demographic
factors
responsible
for
maternal
morbidity
and
mortality.

14. 2.
Assists
in
▪
Recognizing
patterns
and
trends
of
mat
morbidity
and
mortality
▪
Identifying
contributory
factors
of
maternal
deaths
so
that
actions
can
be
taken
at
various
levels
▪
Evaluation
of
quality
of
health
care
at
a
facility
and
to
monitor
it.
▪
International
comparisons
in
imparting
optimal
health
care.
Facilitates
detection
of
lacunae
in
existing
system
▪
Setting
up
a
database
to
capture
all
locations
and
facility
details
to
identify
where
an
MNM
case
comes
from;
this
assists
in
focusing
interventions
in
a
particular
location.
8.
STUDIES
❑
Arab
countries
(Bashour
et
al,
2015)
▪
Maternal
mortality
index
▪
Al
Galaa
hospital
Egypt:
8.6
%
▪
Dar
Al
Tawleed
hospital
in
Syria:
14.3
%
▪
Countries
with
a
moderate
maternal
mortality
ratio:
5.6
%
▪
MNM
cases:
▪
hage-related
complications
were
the
most
frequent
conditions
▪
MNM
dysfunction:
coagulation
dysfunctions
cardiovascular
dysfunctions

15. ▪
Kasr
eleny
Hospital
(Almonerary
et
al,
2012)
The
most
common
diagnosis
encountered
was
Eclampsia:
58.7%
Preeclampsia:
17.4%,
APH
and
PPH:
8.7%
Septic
shock:
4.3%
APP
plus
PPH
in
2.2%
▪
Elgalaa
Hospital
(Elshishini
et
al,
2018)
▪
Organ
dysfunction
in
Near-Miss
Women
(N=128)
▪
Near
miss
clinical
audit:
improve
performance
and
quality
of
care
maternal
health
outcome
indicators.
The
Severe
Maternal
outcome
can
be
used
to
monitor
and
assess
the
performance
and

16. ▪
Mansura
university
Hospital
(Mesbach
et
al,
2018)
Number
and
%
of
distribution
of
MNM
and
dead
women
who
experienced
organ
dysfunctions
▪
The
main
life
threatening:
sever
pre-eclampsia,
sever
PPH
▪
CS
was
the
main
delivery
mood
for
the
near
misses
(93%).
▪
Elshatby
university
Hospital
(Sultan
et
al,
2017)
Severe
pre-eclampsia:
40.2%
post-partum
hemorrhage:
23.8%
Mortality
index:
8.5%.

17. CONCLUSION
▪
Investigating
MNM
cases
aids
in
taking
measures
for
further
improvement
of
service
delivery
and
programs
▪
MNM
is
a
vital
tool
that
can
go
a
long
way
in
reducing
maternal
mortality
▪
MNM-R:
an
eminent
adjunctive
strategy
to
help
identify
gaps
in
health
service
provision.
▪
MNM-R
and
MDR
▪
are
complementary
to
each
other
▪
When
used
together,
they
help
in
recognizing
contributory
factors
of
maternal
deaths
so
that
appropriate
actions
can
be
adopted
at
community
and
health
systems
level.