Applicability of the WHO maternal near-miss tool: A nationwide surveillance study in Suriname

Abstract

Background: Maternal near-miss (MNM) is an important maternal health quality-of-care indicator. To facilitate comparison between countries, the World Health Organization (WHO) developed the "MNM-tool". However, several low- and middle-income countries have proposed adaptations to prevent underreporting, ie, Namibian and Sub-Sahara African (SSA)-criteria. This study aims to assess MNM and associated factors in middle-income country Suriname by applying the three different MNM tools.

Methods: A nationwide prospective population-based cohort study was conducted using the Suriname Obstetric Surveillance System (SurOSS). We included women with MNM-criteria defined by WHO-, Namibian- and SSA-tools during one year (March 2017-February 2018) and used hospital births (86% of total) as a reference group.

Results: There were 9114 hospital live births in Suriname in the one-year study period. SurOSS identified 71 women with WHO-MNM (8/1000 live births, mortality-index 12%), 118 with Namibian-MNM (13/1000 live births, mortality-index 8%), and 242 with SSA-MNM (27/1000 live births, mortality-index 4%). Namibian- and SSA-tools identified all women with WHO-criteria. Blood transfusion thresholds and eclampsia explained the majority of differences in MNM prevalence. Eclampsia was not considered a WHO-MNM in 80% (n = 35/44) of cases. Nevertheless, mortality-index for MNM with hypertensive disorders was 17% and the most frequent underlying cause of maternal deaths (n = 4/10, 40%) and MNM (n = 24/71, 34%). Women of advanced age and maroon ethnicity had twice the odds of WHO-MNM (respectively adjusted odds ratio (aOR) = 2.6, 95% confidence interval (CI) = 1.4-4.8 and aOR = 2.0, 95% CI = 1.2-3.6). The stillbirths rate among women with WHO-MNM was 193/1000births, with six times higher odds than women without MNM (aOR = 6.8, 95%CI = 3.0-15.8). While the prevalence and mortality-index differ between the three MNM tools, the underlying causes of and factors associated with MNM were comparable.

Conclusions: The MNM ratio in Suriname is comparable to other countries in the region. The WHO-tool underestimates the prevalence of MNM (high mortality-index), while the adapted tools may overestimate MNM and compromise global comparability. Contextualized MNM-criteria per obstetric transition stage may improve comparability and reduce underreporting. While MNM studies facilitate international comparison, audit will remain necessary to identify shortfalls in quality-of-care and improve maternal outcomes.

Figure 1

Number of women with maternal near miss according to the different tools.

Figure 2

Number of women per maternal near miss category and tool, reported in events. *Coagulation dysfunction high for SSA-MNM and Namibian-MNM due to transfusion threshold of two units (n = 112) and four units (n = 31) respectively, instead of WHO-MNM threshold of five units of red blood cells (n = 15). †Additional criteria for Namibia-MNM included eclampsia (n = 44), uterine rupture (n = 1) and laparotomy other than for CS or ectopic pregnancy (n = 2). ‡Additional criteria for SSA-MNM included eclampsia (n = 44), uterine rupture (n = 1), severe sepsis (n = 40), pulmonary edema (n = 13), severe complications of abortion (n = 21), severe pre-eclampsia with ICU-admission (n = 103) and laparotomy other than CS (n = 6).

Figure 3

Number of women who received red blood cell (RBC) products and fulfilled WHO MNM-criteria.

Figure 4

Primary underlying causes of maternal deaths and underlying diseases causing MNM according to the different tools. In the case of more than one near-miss event, the primary underlying cause was reported according to the ICD-MM guideline. *Maternal death “other obstetric complications” was caused by amniotic fluid embolism (n = 1), pulmonary embolism (n = 4) and peri-partum cardiomyopathy (n = 1).