AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 39 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 to access maternity healthcare in Johannesburg. [18] The above is also in keeping with a systematic review by Fair et al reported that migrant pregnant women tend to have worse health outcomes compared to the host population. [19] Table 3 compares with Litorp et al, in that after the implementation of the WHO near miss criteria, maternal near miss ratio (MNMR) increased with concomitant decrease in the MMR. [20] Women from neighbouring African countries were disproportionally represented in this study. It could not be established from the study whether this finding was due to difficulties in accessing healthcare services or whether women from other African countries presented with more severe illnesses. However, two different studies reported that migrant pregnant women tend to have worse health outcomes compared to the host population.[ 18,19] Some of the reasons cited revolved around access to healthcare. The initial mortality index was comparable to Soma Pillay et al and the Pretoria Academic Complex, [8] after the updated criteria was used the study decreased by 50% of what the Pretoria Academic Complex MI was. The three leading causes of MNM in both groups were obstetric haemorrhage (first in both groups), hypertensive related and pre-existing medical conditions. These top three causes of maternal near misses in this study are among the top five causes of maternal death reported in the Savings mother report 2017-2020 (including the first year of the Covid-19 pandemic). [1] Obstetric haemorrhage was second, after non-pregnancy related infections. This was on a downward trend in the 2017- 2019 (corrected with 2020 data) saving mother’s report, until the Covid-19 pandemic started, and increased the maternal deaths. [1,21] This observation might be due to delayed access to appropriate care and timeous intervention due a burdened health system during Covid 19 pandemic .[21] The new criteria, which was much closer to the current WHO MNM criteria identified more maternal near misses and there were less maternal deaths during the period making it more attractive for our local setting. Most near misses occurred in women who had a hospital delivery vs a clinic delivery. This is expected, as clinics usually manage low risk women and deliveries. Furthermore, more near misses occurred among women who had caesarean section compared to vaginal delivery (64.9 vs 49.1%). Caesarean sections are associated with higher morbidity and mortality compared to vaginal deliveries. [22] Due to low platelets, there was a statistically significant difference between the two groups with a p-value of 0.04. Although this is statistically significant, it does not appear to have clinical significance. This is because although platelets were reviewed, the average platelets were 141 in the first, compared to 228 in the second group. Surprisingly, the INR was also statistically significant with a p-value of 0.003. However, INR is not part of updated miss criteria but perhaps something that should be investigated. 2. Results in the context of what is known This study adds to the existing knowledge on the importance of auditing maternal near misses, suggesting that similar settings should consider modifying the WHO near miss criteria to suite specific contextual needs. This approach seems to offer more useful information regarding MNN. 3. Clinical implications Increased near misses and decreased maternal deaths illustrate the usefulness of the updated WHO near miss criteria in our setting. Haemorrhage (both ante- and post- partum) and CS complications are a big concern. In the O&G forum, mention is made about preventing the primary CS, by better antenatal management preparation and improved utilisation of assisted vaginal deliveries. [23] A safety checklist needs to be used, to prevent or decrease CS complications. [24] Competency is also required, as well as early recognition of a problem, leading to interventions taking place sooner. [1,24] Decreasing the primary CS rate would decrease CS complications in the index, as well as future pregnancies. [25,26] Antenatally, various methods may be implemented, for example screening and correction of risk factors, such as anaemia and reducing unnecessary CS by interventions such as external cephalic version (ECV) for breech presentation. [26] Better management of labour and the use of the partogram or assisted deliveries will would also decrease The CS complications. [23] Bleeding associated with CS can be better managed by upskilling doctors on performing safe caesarean sections. [24,27] The five main recommendations from the saving mother’s 2017 report are still valid, as management of hypertensive disease in pregnancy and obstetric haemorrhage are still leading causes of maternal near misses. [21] Early identification of hypertension as well as directed therapy is also important to prevent serious complications. [21,28] Prevention of pre-eclampsia by low dose aspirin, as well as calcium supplementation should be implemented as soon as possible in the pregnancy. [29–31] Timely identification and management of abruption placentae is needed by way of training. Pre-existing medical conditions have been on the increase causing maternal near misses. This could be because women are falling pregnant later in life, as well as early intervention for certain conditions allowing women to now bear children. Appropriate management of these women before and during pregnancy, to optimise maternal and foetal outcomes is very important. [21,27] This could be achieved by referring high risk women to Maternal-Foetal Medicine or Obstetric Medicine specialists antenatally, to optimise care and well as plan an appropriate delivery in the correct hospital setting. [32] 4. Research implications Additional studies are needed to look at the contributing factors for the CS related maternal near misses at the study site, including evaluating the safe CS program that has been implemented which includes certification of surgeons’ competency by senior doctors before they are allowed to operate independently. A study by Temlett et al found that the current training for interns in CS has many deficiencies, exposing a lack of adequate training. This includes both surgical and anesthesia. [33] In view of the increased numbers of MNM due to