Severe acute maternal morbidity: a pilot study of a definition for a near-miss

Objective To test the application of a clinical definition of severe acute maternal morbidity. Design A one-year prospective descriptive multi-centre study. Setting Kalafong and Pretoria Academic hospitals, catering for the delivery of indigent women in the Pretoria Health Region. Methods A 'near-miss' describes a patient with an acute organ system dysfunction, which if not treated appropriately, could result in death. The case notes of women fitting this definition and all maternal deaths were analysed and compared. Outcome measure Determine the primary obstetric factors and the organ systems that failed. Identification of episodes of sub-standard care and missed opportunities. Results One hundred and forty-seven near misses and 30 maternal deaths were identified. The commonest reasons for a near-miss were: emergency hysterectomy in 42 women (29%); severe hypotension in 40 (27%); and pulmonary oedema in 24 (16%). The most common initiating obstetric conditions were hypertension in 38 women (26%); haemorrhage in 38 (26%); and abortion or puerperal sepsis in 29 (20%). The primary obstetric factors amongst the maternal deaths were: hypertension (33%); sepsis (27%); and maternal medical diseases (17%) in 10, 8 and 5 women respectively. Sub-standard care was identified in 82 cases. Breakdown in the health care administration was identified in 33, and patient-orientated missed opportunities on 34 occasions. Conclusions The definition of severe acute maternal morbidity identified nearly five times as many cases as maternal death. This definition allows for an effective audit system of maternal care because it is clinically based, the definition is robust and the cases identified reflect the pattern of maternal death.