Abstract:
Background: A maternal near-miss event or severe acute maternal morbidity is defined by the World Health Organization as „a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy‟. Since maternal mortality is a rare event in each health facility, it is important to study maternal nearmiss as a complement to evaluate and improve the quality of obstetric care. Studies addressing the incidence, causes, factors and adverse perinatal outcomes of maternal near-miss are rare in Ethiopia. Thus, the findings of the current study are important to provide a reliable evidence for policy makers, programmers and health practitioners. Objectives: The study aimed to assess the incidence, causes, factors and adverse perinatal outcomes of maternal near-miss. Methods: The study was conducted in five selected public hospitals of Addis Ababa, Ethiopia from May 1, 2015 to April 30, 2016. The hospitals were selected based on the number of deliveries they managed per year. In addition, presence of an Intensive Care Unit, maternity ward, blood transfusion service and availability of cesarean section delivery were considered in the selection of hospitals. A mix of methods was used to address the objectives of the study. A facility-based cross-sectional study was used to determine the incidence and causes of maternal near miss (Objective I). All maternal near-miss cases admitted to the selected hospitals during the study period were prospectively recruited. Maternal near-miss was ascertained using the World Health Organization criteria. A nested case-control design was used for identifying factors associated with maternal near-miss (Objective II). All women who developed maternal near-miss during the study period were included as cases, and those who delivered without any complications within the same day of the near-miss event were enrolled as controls. A total of three controls matched for age and study area were selected for each maternal near-miss case. A prospective cohort study design was used to examine adverse perinatal outcomes of maternal near-miss (Objective III). Women who were admitted to the participating hospitals during the study period and developed maternal near-miss according to the World Health Organization criteria were included as exposed group. Women who delivered without any complications were enrolled as non-exposed group. We followed a total of 828 women admitted for delivery or treatment of pregnancy-related complications along with their singleton newborn babies. The xiv main outcomes of interest were adverse perinatal outcomes and defined with a composite measure. Participants were interviewed by well-trained data collectors using pre-tested questionnaire. Medical records were also reviewed to abstract relevant information. In order to review the participants‟ record, permission was obtained from the participants and administrators of each participating hospital. Univariate analysis was performed to know the underlying and contributing causes of maternal near-miss. The number of maternal near-miss cases over one year per 1000 live births occurring during the same year was calculated to determine the incidence of maternal near-miss. Bivariate and multivariable conditional logistic regressions were performed to identify factors associated with maternal near-miss. Multivariable logistic regressions were also performed to determine the adjusted risk of adverse perinatal outcomes. Stata version 13 was used for the analysis. Results: During a one-year period, a total of 238 maternal near-miss cases and 29,697 live births were reported in the hospitals included in the study, which produced a total maternal near-miss incidence ratio of 8.01 per 1000 live births (95% CI; 7.06 – 9.09). The underlying causes of the majority of maternal near-miss cases were hypertensive disorders and obstetric hemorrhage. Anemia was the major contributing cause reported for maternal near-miss. Most of the maternal near-miss cases occurred before the women‟s arrival at the participating hospitals. The main factors associated with maternal near-miss were: history of chronic hypertension (AOR=10.79, 95% CI; 5.15 – 22.64), rural residence (AOR=10.68, 95% CI; 4.60 – 24.78), history of stillbirth (AOR=6.06, 95% CI; 2.09 – 17.49), no antenatal care attendance (AOR=5.58, 95% CI; 1.82 – 17.05) and history of anemia (AOR=5.16, 95% CI; 2.81 – 9.47). After adjusting for potential confounders, women with maternal near-miss condition had more than five-fold increased odds of adverse perinatal outcomes compared to women without maternal near-miss (AOR=5.69: 95% CI; 3.69 – 8.76). Other risk factors that were independently associated with adverse perinatal outcomes included: rural residence (AOR=2.16: 95% CI; 1.03 – 4.53), history of prior stillbirth (AOR=2.39; 95% CI; 1.12 – 5.10) and primary educational level (AOR=1.89: 95% CI; 1.07 – 3.34). Conclusions and recommendations: The majority of maternal near-miss cases have already occurred on the women‟s arrival at the participating hospitals, implying the need to focus on existing pre-hospital barriers. However, near-miss cases that develop during hospitalization can xv help to measure the quality of obstetric care provided within the health facilities. Efforts made towards improvement in the management of life-threatening obstetric complications could reduce the occurrence of maternal near-miss problems that occur during hospitalization. There is a need for appropriate interventions in order to improve the identified factors of maternal nearmiss. The factors can be modified through a better access to medical and maternity care, scaling up of antenatal care in rural areas, improve in infrastructure to fulfill referral chain from primary level to secondary and tertiary health care level, and, health education to pregnant women. Presence of maternal near-miss in women is an independent risk factor for adverse perinatal outcomes. Hence, interventions rendered at improvement in maternal health can lead to an improvement in perinatal outcomes. The follow-up time used by the World Health Organization to define maternal near-miss has duration of 42 days postpartum. However, because of logistic and feasibility concerns, our follow-up time was limited to only the length of the hospital stay. This might have caused us to underestimate the magnitude of maternal near-miss and hindered us not to investigate the occurrence of other events such as maternal deaths occurred after maternal discharge.