Every maternal near-miss counts: Need for a national audit in South Africa? A mixed-methods study

Authors

  • A Heitkamp Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa; Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam and Amsterdam Reproduction and Development Research Institute, The Netherlands
  • J Suh Athena Institute, Vrije Universiteit Amsterdam, The Netherlands
  • S Gebhardt Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
  • J van Roosmalen 3 Athena Institute, Vrije Universiteit Amsterdam, The Netherlands; Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
  • L R Murray Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
  • J I de Vries Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam and Amsterdam Reproduction and Development Research Institute, The Netherlands
  • T van den Akker Athena Institute, Vrije Universiteit Amsterdam, The Netherlands; Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
  • G Theron Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa

DOI:

https://doi.org/10.7196/SAMJ.2022.v112.i9.16248

Keywords:

Child birth, Pregnancy

Abstract

Background. To improve maternal health, studies of maternal morbidity are increasingly being used to evaluate the quality of maternity care, in addition to studies of mortality. While South Africa (SA) has a well-established confidential enquiry into maternal deaths, there is currently no structure in place to systematically collect and analyse maternal near-misses (MNMs) at national level.
Objectives. To synthesise MNM indicators and causes in SA by performing a systematic literature search, and to investigate perceived needs for data collection related to MNMs and determine whether the MNM tool from the World Health Organization (WHO-MNM) would require adaptations in order to be implemented.
Methods. The study used a mixed-methods approach. A systematic literature search was conducted to find all published data on MNM
audits in SA. Semi-structured interviews were conducted virtually with maternal health experts throughout the country who had been
involved in studies of MNMs, and main themes arising in the interviews were synthesised. A method for MNM data collection for SA use was discussed with these experts.
Results. The literature search yielded 797 articles, 15 of which met the WHO-MNM or Mantel et al. severe acute maternal morbidity criteria. The median (interquartile range) MNM incidence ratio in SA was 8.4/1 000 (5.6 - 8.7) live births, the median maternal mortality ratio was 130/100 000 (71.4 - 226) live births, and the median mortality index was 16.6% (11.7 - 18.8). The main causes of MNMs were hypertensive disorders of pregnancy and obstetric haemorrhage. Eight maternal health experts were interviewed from May 2020 to February 2021. All participants focused on the challenges of implementing a national MNM audit, yet noted the urgent need for one. Recognition of MNMs as an indicator of quality of maternity care was considered to lead to improved management earlier in the chain of events, thereby possibly preventing mortality. Obtaining qualitative information from women with MNMs was perceived as an important opportunity to improve the maternity care system. Participants suggested that the WHO-MNM tool would have to be adapted into a simplified tool with more clearly defined criteria and a number of specific diagnoses relevant to the SA setting. This ‘Maternal near-miss: Inclusion criteria and data collection form’ is provided as a supplementary file.
Conclusion. Adding MNMs to the existing confidential maternal death enquiry could potentially contribute to a more robust audit
with data that may inform health systems planning. This was perceived by SA experts to be valuable, but would require context-specific
adaptations to the WHO-MNM tool. The available body of evidence is sufficient to justify moving to implementation.

References

World Health Organization. Evaluating the quality of care for severe pregnancy complications: The WHO near-miss approach for maternal health. Geneva: WHO, 2011. https://apps.who.int/ iris/handle/10665/44692 (accessed December 2021).

Say L, Souza JP, Pattinson RC; WHO working group on Maternal Mortality and Morbidity classifications. Maternal near miss – towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009;23(3):287-296. https://doi.org/10.1016/j. bpobgyn.2009.01.007

National Department of Health, South Africa. Saving Mothers 2014 - 2016: Seventh triennial report on confidential inquiries into maternal death in South Africa. 2017. https://www. westerncape.gov.za/assets/departments/health/saving_mothers_2014-16_-_short_report.pdf (accessed December 2021).

Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: A pilot study of a definition for a near-miss. Br J Obstet Gynaecol 1998;105(9):985-990. https://doi. org/10.1111/j.1471-0528.1998.tb10262.x

Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA statement. PLoS Med 2009;6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097

Heitkamp A, Vollmer Murray L, van den Akker T, et al. Great saves or near misses? Severe maternal outcome in Metro East, South Africa: A region-wide population-based case-control study. Int J Gynaecol Obstet 2022;157(1):173-180. https://doi.org/10.1002/ijgo.13739

Iwuh IA, Fawcus S, Schoeman L. Maternal near-miss audit in the Metro West maternity service, Cape Town, South Africa: A retrospective observational study. S Afr Med J 2018;108(3):171-175. https://doi.org/10.7196/SAMJ.2018.v108i3.12876

Soma-Pillay P, Pattinson RC, Langa-Mlambo L, Nkosi BS, Macdonald AP. Maternal near miss and maternal death in the Pretoria Academic Complex, South Africa: A population-based study. S Afr Med J 2015;105(7):578-563. https://doi.org/10.7196/SAMJnew.8038

Nelissen E, Mduma E, Broerse J, et al. Applicability of the WHO maternal near miss criteria in a low-resource setting. PLoS ONE 2013;8(4):e61248. https://doi.org/10.1371/journal.pone.0061248

Tura AK, Stekelenburg J, Scherjon SA, et al. Adaptation of the WHO maternal near miss tool for use in sub-Saharan Africa: An International Delphi study. BMC Pregnancy Childbirth 2017;17:445. https://doi.org/10.1186/s12884-017-1640-x

Vandecruys HI, Pattinson RC, Macdonald AP, Mantel GD. Severe acute maternal morbidity and mortality in the Pretoria Academic Complex: Changing patterns over 4 years. Eur J Obstet Gynecol Reprod Biol 2002;102(1):6-10. https://doi.org/10.1016/s0301-2115(01)00558-9

CochetL,PattinsonRC,MacdonaldAP.Severeacutematernalmorbidityandmaternaldeathaudit– a rapid diagnostic tool for evaluating maternal care. S Afr Med J 2003;93(9):700-702.

PattinsonRC,BuchmannE,MantelG,SchoonM,ReesH.Canenquiriesintosevereacutematernal morbidity act as a surrogate for maternal death enquiries? BJOG 2003;110(10):889-893.

Gandhi MN, Welz T, Ronsmans C. Severe acute maternal morbidity in rural South Africa. Int J Gynaecol Obstet 2004;87(2):180-187. https://doi.org/10.1016/j.ijgo.2004.07.012

Panday M, Mantel GD, Moodley J. Audit of severe acute morbidity in hypertensive pregnancies in a developing country. J Obstet Gynaecol 2004;24(4):387-391. https://doi.org/10.1080/01443610 410001685501

Lombaard H, Pattinson RC, Backer F, Macdonald P. Evaluation of a strict protocol approach in managing women with severe disease due to hypertension in pregnancy: A before and after study. Reprod Health 2005;2:7. https://doi.org/10.1186/1742-4755-2-7

Soma-Pillay P, MacDonald AP, Mathivha TM, Bakker JL, Mackintosh MO. Cardiac disease in pregnancy: A 4-year audit at Pretoria Academic Hospital. S Afr Med J 2008;98(7):553-556.

Lombaard H, Adam S, Makin J, Sebola P. An audit of the initial resuscitation of severely ill patients presenting with septic incomplete miscarriages at a tertiary hospital in South Africa. BMC Pregnancy Childbirth 2015;15:82. https://doi.org/10.1186/s12884015-0510-7

Soma-Pillay P, Pattinson RC. Barriers to obstetric care among maternal near misses. S Afr Med J 2016;106(11):1110-1113. https://doi.org/10.7196/SAMJ.2016.v106i11.10726

Maswime S, Buchmann EJ. Why women bleed and how they are saved: A cross-sectional study of caesarean section near-miss morbidity. BMC Pregnancy Childbirth 2017;17:15. https://doi. org/10.1186/s12884-016-1182-7

Hlabisa MA. A retrospective study to identify the prevalence of severe maternal morbidity or ‘near misses’ in obstetric patients who are admitted to maternity high care and the intensive care unit at King Edward VIII Hospital. Research project. Durban: University of Kwa-Zulu Natal, 2019. https://researchspace.ukzn. ac.za/handle/10413/17723 (accessed December 2021).

Heitkamp A, Meulenbroek A, van Roosmalen J, et al. Maternal mortality: Near-miss events in middle- income countries, a systematic review. Bull World Health Organ 2021;99(10):693-707F. https://doi. org/10.2471/blt.21.285945

Tura AK, Trang TL, van den Akker T, et al. Applicability of the WHO maternal near miss tool in sub- Saharan Africa: A systematic review. BMC Pregnancy Childbirth 2019;19:79. https://doi.org/10.1186/ s12884-019-2225-7

World Bank. Data Bank: Poverty and equity. https://databank.worldbank.org/reports.aspx?source=poverty- and-equity-database (accessed December 2021).

Knight M; INOSS. The International Network of Obstetric Survey Systems (INOSS): Benefits of

multi-country studies of severe and uncommon maternal morbidities. Acta Obstet Gynecol Scand

;93(2):127-131. https://doi.org/10.1111/aogs.12316

United Nations Children’s Fund (UNICEF). National Budget Brief 2018/2019, November 2018.

https://www.unicef.org/esa/sites/unicef.org.esa/files/2018-12/UNICEF-South-Africa-2018- National-Budget-Brief.pdf (accessed December 2021).

Downloads

Published

2022-08-30

Issue

Section

Research

How to Cite

1.
Heitkamp A, Suh J, Gebhardt S, van Roosmalen J, Murray LR, de Vries JI, et al. Every maternal near-miss counts: Need for a national audit in South Africa? A mixed-methods study. S Afr Med J [Internet]. 2022 Aug. 30 [cited 2024 Jun. 15];112(9):769-77. Available from: https://samajournals.co.za/index.php/samj/article/view/129

Similar Articles

1-10 of 53

You may also start an advanced similarity search for this article.