Anuj Mundra Moderator – Dr A.M. Mehendale Maternal near-miss reviews: lessons from a pilot programme in India C Purandare, A Bhardwaj, M Malhotra, H Bhushan,

Anuj Mundra Moderator Dr A.M. Mehendale Maternal near-miss reviews: lessons from a pilot programme in India C Purandare, A Bhardwaj, M Malhotra, H Bhushan, S Chhabra, P Shivkumar British Journal of Obstetrics and Gynaecology, 2014

Learning objective To understand the concept of Maternal Near Miss (MNM).

Introduction Significant reduction in MMR has been made in India to reach 178/100000 live births. The 12 th 5yr plan has set an MMR target of 100/100000 to be achieved by 2017. Maternal death review was launched in 2010 which provided information on various factors at different levels to be addressed to reduce maternal deaths. The concept of Maternal Near Miss (MNM) has gained importance and has been considered as a less threatening approach than maternal death to identify factors for improving maternal health care by reducing fear of blame & punishment. Near-miss cases are generally more frequent than maternal deaths and therefore a more reliable quantitative analysis can be carried out, which can give a more comprehensive information about the health care status.

Objectives 1. To agree on the national MNM policy framework and definition of MNM in the Indian context, 2. To agree on the criteria for identifying an MNM, 3. To agree on the tools for recording and reporting an MNM case, 4. To pilot test, and make recommendations for the next steps, including potential scale up across the country.

Key partners and stakeholders Under the guidance of the GoI, key stakeholders were identified and a National Technical Group (NTG) was constituted. The NTG was given the task of fulfilling the key objectives and developing a comprehensive way forward to guide the Govt. for considering national implementation of MNM. The NTG comprised technical experts from the Maternal Health division, MoHFW; Federation of Obstetric and Gynaecological Societies of India, Mahatma Gandhi Institute of Medical Sciences AVNI Health Foundation, Development partners ( UN population Fund, UN Childrens Fund, WHO) Other stakeholders - National Neonatological Forum, Society of Midwives of India, Indian Nursing Council, IAP, NIHFW, State government representatives of 6 states; and National Health Systems Resource Centre The project was implemented in 6 medical colleges in Aligarh, Bhopal, Chennai, Rohtak, Shimla, Sewagram.

Implementation The policy was implemented in 10 phases over a period of 16 months during 2012-13

Implementation The project was implemented in 10 phases over a period of 16 months during 2012-13. The activities carried out in each phase are: PhaseActivities IIdentification of partners for design development & programme management IIDesk research, through which secondary information related to near-miss audit from across the world as well as in India were collected IIINTG was constituted with all programme partners. IV The NTG met and agreed a draft policy framework, case definitions and criteria for the identification of a maternal near-miss and agreed on tools to be used for reporting during the pilot phase. VPilot testing: 6 medical colleges reported their findings. 1 NTG member visited each of the centres for guidance and mentoring. VIMid-term review of the programme at 3 months. Reports review & changes in definition/criteria/tools if required and were implemented VIIRevised policy framework, definition, case selection criteria, tools for reporting used by the pilot institutes VIIIData entry, cleaning, quality checks and data analysis. IX NTG met for the third time and reviewed the final report. Policy framework finalized to be given to the GoI for its release as a national policy for implementation X Report preparation, submission for release of the MNM policy framework, definitions, criteria, and tools, design and development of MNM software.

Definition & Criteria A case of MNM was defined as A women who survives life-threatening condition during pregnancy, termination of pregnancy, childbirth or within 42 days of pregnancy termination, irrespective of receiving emergency medical/surgical interventions or otherwise. For a case to be listed as MNM a min. of 3 criteria in each section, one each from Clinical findings (symptoms/signs) Investigations Interventions to manage the case, OR any single criteria that signifies cardiorespiratory collapse.

Adverse events identified 4 sections of adverse events that could lead to MNM were identified: i. Pregnancy specific disorders- Haemorrhage, sepsis, hypertension ii. Pre-existing disorders aggravated during pregnancy- Anaemia, respiratory dysfunction, cardiac dysfunction, hepatic dysfunction, endocrinal disorders (diabetic ketoacidosis, thyroid crisis), neurological dysfunction, renal dysfunction/failure iii. Pregnancy specific medical disorders- Liver dysfunction/failure, cardiac dysfunction/failure iv. Incidental and accidental causes of maternal death- Accident/ assault/ surgical problems, anaphylaxis, infections, embolism and infarction.

Results Total MNM 264/27433 (0.96%) Mean time reported from onset of illness to admission 48.4 hours

InterventionsNo. (%) Immediate resuscitation65 (24.6) Mechanical Ventilation31 (11.7) Uterine Evacuation27 (10.2) Laparotomy48 (18.2) Hysterectomy39 (14.8) Genital injury repair19 (4.9) Manual removal of placenta3 (1.1) Repositioning of inverted uterus2 (0.8) Internal iliac ligation4 (1.5) Others137 (51.9) Blood transfusion227 (86)

Observations & way forward As a result of the pilot programme, several points were highlighted: "Near-miss" events are more common than maternal deaths and can be more comprehensive and provide additional information, review of "near- miss" events may give more insight into risk factors and possible means of prevention of maternal mortality and morbidity. As the woman survives, near miss reviews are less threatening than death reviews for the teams reporting them. Building the skills of healthcare providers in procedures such as repair of tears, resuscitation, medical & surgical M/m of PPH like B-lynch suturing, stepwise devascularisation and internal iliac ligation and peripartum hysterectomy as well as the management of sepsis and hypertensive disorders of pregnancy remain important.

Women and their families need to be educated regarding birth preparedness and complication readiness because Type 1 delay was still seen to be very high and was associated with severe maternal morbidity in majority of cases. Prevention and timely treatment of anaemia must receive more attention to reduce the risk of mortality from obstetric haemorrhage. The tools developed currently capture the location and facility details and can help to identify where an MNM case has been referred to a higher level health facility. It can help to focus interventions in that particular location.

MNM Data Management software linked to the MCTS and Maternal Death Review software introduced in India has been developed and can be used as soon as MNM review is launched nationally in India. States and Districts will be able to access the reports directly, enabling data sharing, which is more difficult with paper-based reports. As the majority of MNM attend the tertiary facility level and MNM reporting is less difficult in these settings, the focus of MNM implementation will likely initially be at the tertiary level (Medical Colleges/District Hospital converted to Medical Colleges/Hospitals attached to Medical Colleges), then using the Medical College experience and teams, MNM audit can be subsequently scaled up to the District Hospital level. Based on this pilot programme, a report on the benefits of MNM review and the need to implement MNM review was prepared and submitted to the Government of India in October 2013 along with the MNM policy framework.

Other studies on MNM Author YearPlace Findings Roopa PS, Shailja Verma, Lavanya Rai, Pratap Kumar, Murlidhar V. Pai, Jyothi Shetty 2013 Manipal, India 17.9/1000 live birth. Near miss: mortality=5.6:1 Haemorrhage was the leading cause for near miss followed by PIH and Sepsis. Sepsis leading cause for death. Cardiac disease had highest mortality index. Chhbra P, Guleria K, Saini NK, Anjur KT, Vaid NB 2008Delhi Incidence of severe morbidity was 33/1000 live birth. The leading causes were haemorrhage, PIH, and sepsis. More than 50% required caesarean section. Kalra P, kachhwaha CP 2014 Jodhpur, India Near miss incidence was 4.18/1000 live birth. Mortality ratio was 202 per lakh live birth. MNM: mortality was 2.1. Haemorrhage, hypertension and sepsis were major causes. Pandey A, Das V, Agarwal A, Agarwal S, Misra D, Jaiswal N 2014India MNM: mortality= 2.6. the MNM incidence was roughly 12%. Haemorrhage and hypertensive disorders of pregnancy were leading cause of MNM and maternal deaths.

Maternal near-miss indicators Maternal near miss (MNM)- A woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy. Severe maternal outcomes- A life-threatening condition (i.e. organ dysfunction), including all maternal deaths and maternal near-miss cases. Women with life-threatening conditions (WLTC)- All women who either qualified as maternal near-miss cases or those who died (i.e. women presenting a severe maternal outcome). Severe maternal outcome ratio (SMOR)- Number of women with life-threatening conditions per 1000 live births. This indicator gives an estimate of the amount of care and resources that would be needed in an area or facility [SMOR = (MNM + MD)/LB].

Maternal near-miss indicators MNM ratio (MNMR) - the number of maternal near-miss cases per 1000 live births (MNMR = MNM/LB). Maternal near-miss mortality ratio - the ratio between maternal near-miss cases and maternal deaths (MNM : 1 MD). Higher ratios indicate better care. Mortality index- The number of maternal deaths divided by the 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, whereas the lower the index the fewer women with life- threatening conditions die. Perinatal outcome indicators- (e.g. perinatal mortality, neonatal mortality or stillbirth rates) in the context of maternal near-miss could be useful to complement the quality-of-care evaluation.

References Roopa PS, Shailja Verma, Lavanya Rai, Pratap Kumar, Murlidhar V. Pai, and Jyothi Shetty, Near Miss Obstetric Events and Maternal Deaths in a Tertiary Care Hospital: An Audit,Journal of Pregnancy, vol. 2013, Article ID 393758, 5 pages, 2013. doi:10.1155/2013/393758 Chhabra P, Guleria K, Saini NK, Anjur KT, Vaid NB. Pattern of severe maternal morbidity in a tertiary hospital of Delhi, India: a pilot study. Trop Doct. 2008 Oct;38(4):2014. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18820181 Pandey A, Das V, Agarwal A, Agrawal S, Misra D, Jaiswal N. Evaluation of obstetric near miss and maternal deaths in a tertiary care hospital in north India: shifting focus from mortality to morbidity. J Obstet Gynaecol India. 2014 Dec;64(6):3949. Kalra P, Kachhwaha CP. Obstetric near miss morbidity and maternal mortality in a Tertiary Care Centre in Western Rajasthan. Indian J Public Health. 2014 Jan;58(3):199201. World Health Organization. Evaluating the quality of care for severe pregnancy complications:The WHO near-miss approach for maternal health. Geneva; 2011.

Anuj Mundra Moderator – Dr A.M. Mehendale Maternal near-miss reviews: lessons from a pilot programme in India C Purandare, A Bhardwaj, M Malhotra, H Bhushan,

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