Maternal Deaths, Near misses and Great saves
Authors:   , Heitkamp Anke Carla 
Published: March 2023

Surveillance of Severe Maternal Outcome (SMO), which is the combination of Maternal Near Miss (MNM) and Maternal Mortality, in the Metro East health district, Western Cape province, South Africa, has given useful insight into its incidence and contributing factors.
The MNM-ratio in Metro East was 8.6 per 1,000 livebirths in 2014-2015, and the Maternal Mortality Ratio 49.7 per 100,000 live births, resulting in a SMO-ratio of 9.1 per 1,000 live births. This MNM-ratio identified for Metro East is comparable to the median MNM-ratio reported for middle-income countries of 9.6 per 1,000 livebirths, with a median MNM-ratio of 15.9 per 1,000 in lower-middle and 7.8 per 1,000 in upper-middle income countries. The MNM-ratio in Metro East was slightly higher than the ratio in other regions in South Africa, but case fatality among women with MNM was lower, possibly illustrating a relatively higher quality of care.
The main causes of SMO in Metro East were hypertensive disorders of pregnancy and major obstetric haemorrhage, which are similar to the commonest causes of SMO in other middle-income countries, and worldwide. Associated factors were a positive HIV-serostatus, birth by caesarean section, preeclampsia and obesity. The relatively large differences in the incidence of SMO between different regions in South Africa, and between different middle-income countries appear to be at least partly explained by difficulties in applying the MNM-tool as proposed by the World Health Organization. We suggest that the tool is currently mostly valuable for assessments of SMO in the local setting, rather than for comparisons between regions or countries.
Analyses of SMO in Metro East provided useful insights into local causes: obstetric haemorhage relatively frequently due to placental abruption, often in combination with intrauterine fetal death and hypertension. In contrast with most other settings, hysterectomy for maternal sepsis was as common as for peripartum haemorrhage, both associated with cesarean section.
Severe complications of hypertensive disorders of pregnancy were frequent, with pulmonary edema being a particularly common complication leading to maternal death. Early detection and management of preeclampsia, monitoring of fluid balance and cardiac evaluation when pulmonary edema persists, were preventive suggestions.
Audit helped identify lessons learned: for all women with SMO, not attending antenatal care was a woman-related factor and missing the diagnosis or not starting adequate management in time were factors at the level of the health worker. In almost a quarter of cases, different management could have prevented SMO. Life style changes, understanding maternal behavior, but also recognizing SMO in an early stage and adequate multidisciplinary management in a critical care setting could reduce SMO and improve its outcomes.
Health workers found the identification and analysis of MNM a valuable addition to the already existing confidential enquiry into maternal deaths in South Africa. A national MNM audit was recommended to address causes and improve maternal outcomes. A list of diagnosis additional to those mentioned in the existing MNM tool would help identifying local causes of MNM more precisely. Simplification of the tool would be welcomed in this setting.