1. Woman’s Health and Midwifery Nursing Dep. Faculty of Nursing
Egypt
Quality of Maternal Health Care: Maternal Near –Misses in a University Hospital , Egypt
Prof. Dr. Amina El-Nemer
Woman’s Health and Midwifery Nursing Dep. Faculty of Nursing

2. Train bridge reflection on the Nile, Mansoura
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Nursing & Healthcare, Nov.17-19,2014, Chicago, USA

3. University Campus, Hospital, Nursing Conference
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4. Introduction and background
Maternal mortality is estimated at women died in 2010.
WHO reports that million women experience sever illness and disabilities
Five percent of maternal deaths occur in Arab countries and women in Middle East are suffering of severe long lasting complications caused be pregnancy and delivery.
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One of the Millennium Development Goals is to reduce maternal mortality ratio by 3/4 by 2015 especially in the sub-Saharan areas where the problem is more tragically.
Recently Maternal Near Miss (MNM) indicator is increasingly being recognized as a potentially useful tool in assessing the quality of healthcare as it reflects the scope of complications during pregnancy and childbirth.
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Maternal Near Miss (MNM) Is “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”. WHO
Nowadays, in addition to studying the maternal deaths, the examination of women who survived a severe complication of pregnancy, childbirth or the puerperium (Near misses)
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Despite all the efforts done by Egyptian government to achieve the Millennium Development goals,
there is a question regarding the quality of care provided to the Egyptian women during pregnancy and delivery.
is still high if compared with other Arab (CIA, World fact book, January 1, 2012).
n Egypt women can develop sever complications during pregnancy and labour. Some of these women die some of them survive. Review the cases of maternal near miss has the potential to highlight both deficiencies and positive elements in the provision of obstetric care which will allow for more rapid reporting, more healthy conclusions and the comparisons made with maternal deaths will reinforce the lessons learnt and can inform the hospital managers and policy makers for establishing requirements for intensive care, comprehensive emergency obstetric care for better maternal outcomes. Maternal mortality has been studied but near miss is not described yet.
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Objective
To identify Maternal Near Miss in a teaching University hospital (MUH). A retrospective descriptive study. 80 women with potential life threatening conditions was reviewed to identify MNM
Methodology: that occurred during pregnancy and immediately after delivery. A total numbers of medical records for women who were admitted during the period of 6 months during a year of 2013 was reviewed and evaluated to identify the Maternal Near Misses by using the WHO Near Miss assessment tool.
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Characteristics of Suspected Women with Potential Life Threatening Conditions.
Mean (Minimum-maximum)
Characteristics
22.8 (19-40)
Women's age
29.2 (18-43)
Gestational age
3 (1-5)
Previous CS (18, 22.5)
Referrals (67, 83.75)
20 (29.6)
Private Obstetricians
30 (44.8)
MOH Hospitals
10 (15.1)
Private Hospitals
7 (10.5)
Others
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10. Time and Types of Morbidity Conditions
Developed after 12 hours
At arrival or within 12 hours
Morbidity conditions % No
1. Women with potentially life-threatening conditions
12.5 10 25 20
Severe postpartum haemorrhage
3.7 3
51.3 41
Severe pre-eclampsia
0.0
5.0 4
Eclampsia
2.5 2
Sepsis or severe systemic infection
Ruptured uterus
16.2 13
83.8 67
Total women with severe complications
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11. Morbid Women Undergoing Critical Interventions% No
2. Women undergoing critical Interventions
43.8 35
Use of blood products
16.3 13
Laparotomy
Admission to intensive care unit (65, 81.25)
53.8
29.2
7.7
6.2
3.1 19 5 4 2
Sever preeclampsia/Eclampsia
Sever PPH
Anemia
Multiple organ dysfunctions
Hystrectomy + Anemia
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12. MNM and dead women who experienced organ dysfunctions.
Near Miss Cases (67)
Organ Dysfunctions % No
29.8 20
Cardiovascular dysfunction
13.4 9
Respiratory dysfunction
7.5 5
Renal dysfunction
11.9 8
Coagulation/haematologic dysfunction
Hepatic dysfunction
Neurologic dysfunction 3 2
Uterine dysfunction/hysterectomy 6 4
Multiple organ dysfunctions/died women
86.6 58
Total
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13. Causes of life-threatening conditions
Near Misses
1. Underlying causes %
No=63
3.2 2
Pregnancy with abortive outcome
31.7 20
Obstetric haemorrhage
55.5 35
Hypertensive disorders
Pregnancy-related infection
7.9 5
Other obstetric disease or complication
19.1 11
Medical/Surgical/Mental disease or complication
Unanticipated complications of management
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14. Previous caesarean section Prolonged / obstructed labour
Contributory Causes
44.4 28
Anemia
23.8 15
Previous caesarean section
7.9 5
Prolonged / obstructed labour
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15. End of pregnancy and pregnancy outcome% No
Pregnancy out comes
3.2 2
Vaginal delivery
93.6 59
Caesarean Section
Complete abortion
1.6 1
Laparotomy for ectopic pregnancy
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16. Process and outcome indicators among MNM
Prevention of PPH
41.3 26
Oxytocina use
58.7 37
Use of any uterotonic (including oxytocin)
TTT of sever PPH (20)
65.0 13
95.0 19
Ergometrine
20.0 4
Misoprostol
Removal of retained products
45.0 9
Artery ligation
10.0 2
Hysterectomy
Anticonvulsants for eclampsia (45)
88.9 40
Magnesium sulfate
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17. Process and outcome indicators among MNM% No
Indicators
Prevention of caesarean section related infection (59)
100 59
Antibiotics
98.4 56
Prophylactic antibiotic during caesarean section
Treatment of sepsis (2) 2
Prenatal therapeutic antibiotics
Preterm birth (6) 6
Corticosteroids for fetal lung maturation
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Conclusion
The main life threatening conditions were severe pre eclampsia, severe hemorrhage, eclampsia and sepsis.
More than 80% of cases went through critical Intervention such as ICU, blood products and laparotomy (87.8).
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Conclusion
79% of cases experienced organs dysfunction.
5% of women with life threatening conditions were died.
Also, study revealed several issues regarding quality of obstetric care that need urgent attention and improvement to reduce maternal morbidity. .
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Recommendations
WHO auditing tool providing a thorough evaluation of the quality of healthcare and suggesting improvements in maternal outcomes.
The results may help establish public healthcare policies and strategies aimed at tackling the issue of maternal morbidity and mortality.
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Qualitative prospective studies should be conducted to acquire further information on the profile of cases and on the risk factors for MNM.
Applying standardized protocols and guidelines in emergency and admission rooms.
Listening to the women who have experienced events severe enough to be classified as SMM or NM will certainly form an important part of future studies.
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Thank you from Egypt P
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Nursing & Healthcare, Nov.17-19,2014, Chicago, USA