Maternal Near Miss - Background

Background

Maternal mortality is a sentinel event to assess the quality of a health care system. The standard indicator is the Maternal Mortality Ratio, defined as the ratio of the number of maternal deaths per 100,000 live births. Due to improved health care the ratio has been declining steadily in developed countries. For example, in the UK 1952-1982 the ratio was halving every 10 years. In the European Union the ratio has now stabilized at around 10 to 20.

The small number of cases makes the evaluation of maternal mortality practically impossible Historically, the study of negative outcomes have been highly successful in preventing their causes, this strategy of prevention therefore faces difficulties when if the number of negative outcome drop to low levels. In the UK, for example, the most dramatic decline in maternal death was achieved in Rochdale, an industrial town in the poorest area of England. In 1928 the town had a Maternal Mortality Ratio of over 900 per 100,000 live births, more than double the national average of the time. An enquiry into the causes of the deaths reduced the ratio to 280 per 100,000 pregnancies by 1934, only six years later, then the lowest in the country.

The very low figures of maternal mortality have therefore stimulated an interest in investigating cases of life threatening obstetric morbidity or maternal near miss. There are several advantages of investigating near miss events over events with fatal outcome

• near miss are more common than maternal deaths
• their review is likely to yield useful information on the same pathways that lead to severe morbidity and death,
• investigating the care received may be less threatening to providers because the woman survived
• one can learn from the women themselves since they can be interviewed about the care they received.
• all near misses should be interpreted as free lessons and opportunities to improve the quality of service provision
• it is also clear that maternal deaths merely are the tip of the iceberg of maternal disability. For every woman who dies, many more will survive but often suffer from lifelong disabilities.

The growing interest is reflected in an increasing number of systematic reviews on the prevalence of near miss. The studies and reviews span

• analytic attempts to define the concept more strictly,
• descriptive efforts to measure and quantify new indicators (prevalence) of near-miss for different geographical regions etc.
• explanatory efforts of the leading cause for morbidity