AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 35 ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | Comparing two maternal near miss criteria in an academic hospital in Johannesburg, South Africa: A retrospective cross-sectional study ABSTRACT Background: Given the rarity of maternal deaths, auditing maternal near misses has been proposed as a complementary tool to maternal death audits. This is because near misses often share similar causes with maternal deaths. As a result, near misses can offer valuable insights into the underlying causes and contributing factors of maternal deaths. Such information could assist countries, particularly low- and middle-income countries (LMICs) with high maternal mortality rates, in achieving the United Nations 2030 Sustainable Development Goal (SDG) 3.1. There is currently no universally agreed-upon criteria for identifying maternal near misses, highlighting the necessity for contextually appropriate near- miss criteria. Objective: The aim of this study was to compare maternal near misses and associated factors using two near miss criteria, following the update of the previous criteria to align with World Health Organisation standards, in an academic hospital in Johannesburg, South Africa, with the hope of identifying the most useful near miss criteria. The old and new criteria were adapted from the Mantel and WHO criteria, respectively. Study design: This is a retrospective review of patient clinical records comparing two near miss periods (before and after the updated maternal near miss criteria). Data on maternal demographics and pregnancy characteristics, near misses, underlying causes, and outcomes were collected and analysed using Stata 15.0® (StataCorp, 4905 Lakeway Drive, College Station, Texas 77845, USA). The chi-squared test with a p-value of <0.05 was employed to assess the presence of significant differences between the two study groups. Results: Live births were comparable between the two study periods, with just over 9,000 each year. However, there were more deaths recorded during the first period (under the old criteria) compared to the second period (under the new criteria), despite a higher number of near misses identified in the latter. Furthermore, the mortality index was lower in the second period (7%) compared to the first period (17%). Conclusion: More near misses and fewer maternal deaths were identified using the new criteria compared to the old criteria. We postulate that, with the implementation of the new criteria, more near misses were identified sooner, enabling timely intervention that prevented additional maternal deaths. Therefore, we recommend that the new near miss criteria be considered for use in the study setting. INTRODUCTION Maternal deaths (MD) are rare events, maternal near misses can be used to assess the quality of maternal health and healthcare services because the two occurrences share similar underlying causes and risk factors. [1,2] Reducing maternal deaths is one of the of the United Nations’ 2030 Sustainable Development Goals (SDG). According to the World Health Organisation (WHO) a maternal near miss (MNM) refers to a woman who nearly died, but survived a complication during pregnancy, childbirth or within 42 days of the termination of pregnancy. [3] There is currently no agreed universal criteria for maternal near misses. This has created a need for a near miss criteria that is context appropriate. The aim of the study was to describe maternal near misses and associated factors at an academic hospital in Johannesburg, a year prior and a year after the updated near miss criteria with hope of identifying the near miss criteria that is most suitable for our context. In 2018, South Africa changed its near miss criteria in most state hospitals to be closer to the WHO maternal near miss criteria. This change was also updated in this Johannesburg Academic hospital. The old and the new criterion were adapted from Mantel et al [4] and WHO criteria respectively. [5,6] The old criteria included pulmonary oedema, cardiac arrest, hypovolaemia, ICU admission, emergency hysterectomy, immune system failure, intubation not related to surgery, oxygen saturation <90%, FaO2/FiO2 ≤3, oliguria, urea >15mmol/l, creatinine >400mmol/l, jaundice in the presence of hypertension, diabetic ketoacidosis, thyroid crisis, platelet transfusion, coma >12 hours, sub arachnoid haemorrhage or intracranial bleeds, severe hypotension related to anaesthesia and failed tracheal intubation. Massive transfusion was not included, even though we are aware that massive blood loss is a major cause of MNM and MM. The new criteria that was implemented in August 2019 at CMJAH, was closer to the WHO criteria with four changes. [3] The changed criteria, which was updated from what WHO near miss criteria published in 2009, included: Under laboratory-based criteria, it stated loss of consciousness or coma, without needing the presence of glucosuria and ketoacids in urine. Also, low platelets of <50 x109/l was added, irrespective of the cause of the low platelets. The other changes were found under management-based criteria: ICU admission and repeat intervention, such as relook laparotomies or a laparotomy after an evacuation of the uterus, as well as a massive blood transfusion of ≥4 packed red cells. Repeat interventions were added because of the associated increase in morbidity and mortality. MATERIALS AND METHODS A two-year retrospective review of pregnant women's clinical records, stratified according to two near miss reporting GM Balie 1 , L Chauke 1 Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa CORRESPONDENCE: GM Balie | Email: Gaynor.balie16@gmail.com Comparing two maternal near miss criteria in an academic hospital in Johannesburg, South Africa: A retrospective cross-sectional study