Indicators for maternal near miss: an observational study, India.

Objective: To compare the incidence of maternal near miss using the World Health Organization (WHO) near-miss tool and six other criteria sets, including criteria designed for low-resource settings or specifically for India. Methods: In a cohort study we used WHO severity indicators to identify women with potentially life-threatening conditions during pregnancy or childbirth admitted to a referral hospital in Puducherry, India, from May 2018 to April 2021. We analysed sociodemographic, clinical and laboratory data for each woman and calculated the incidence of maternal near miss and other process indicators for each set of criteria. Findings: We analysed data on 37 590 live births; 1833 (4.9%) women were identified with potentially life-threatening conditions, 380 women had severe maternal outcomes and 57 died. Applying the different sets of criteria to the same data, we found the incidence of maternal near miss ranged from 7.6 to 15.6 per 1000 live births. Only the Global Network criteria (which exclude laboratory data that may not be available in low-resource settings) and the WHO criteria could identify all women who died. Applying the criterion of any number of units of blood transfusion increased the overall number of women identified with near miss. Conclusion: The WHO and Global Network criteria may be used to detect maternal near miss in low-resource settings. Future studies could assess the usefulness of blood transfusion as an indicator for maternal near miss, especially in low- to middle-income countries where the indicator may not reflect severe maternal morbidity if the number of units received is not specified.

Impact of near-miss event during pregnancy and childbirth on maternal health at 12 months.

OBJECTIVE: To assess the impact of maternal near-miss on late maternal death and the prevalence of hypertension or chronic kidney disease (CKD) and mental health problems at 12 months of follow up. METHODS: This prospective cohort study was conducted in a tertiary hospital in the southeastern region of India from May 2018 to August 2019, enrolling those with maternal near-miss and with follow up for 12 months. The primary outcomes were incidence of late maternal deaths and prevalence of hypertension and CKD during follow up. RESULTS: Incidence of maternal near miss was 6.7 per 1000 live births. Among those who had a near miss, late maternal deaths occurred in 7.2% (95% confidence interval [CI] 3.1%-11.3%); prevalence of CKD was 23.0% (95% CI 16.2%-29.8%), and of hypertension was 56.2% (95% CI 50.5%-66.5%) and only two women had depression on follow up. After adjusting for age, parity, socioeconomic status, gestational age at delivery, hemoglobin levels, and perinatal loss, only serum creatinine was independently associated with late maternal death and CKD on follow up. CONCLUSIONS: Women who survive a life-threatening complication during pregnancy and childbirth are at increased risk of mortality and one or more long-term sequelae contributing to the non-communicable disease burden. A policy shift to increase postpartum follow-up duration, following a high-risk targeted approach after a near-miss event, is needed.

Postpartum depression and its risk factors in women with a potentially life-threatening complication.

OBJECTIVE: To assess the incidence of postpartum depression (PPD) and its risk factors in women with potentially life-threatening complications. METHODS: Eight hundred and ninety women admitted to a tertiary center in South India with potentially life-threatening complications were recruited for the study. Within seven days of delivery, women underwent mental health assessments using the EPDS and PHQ-9 scale. Counseling was provided and follow-up assessment carried out at 3 months postpartum. Bivariate and multivariate analysis was done to assess the association of risk factors to depression. RESULTS: PPD was observed in 21% of the study cohort. Women with no formal education (OR -2.66, 95% CI: 1.10- 6.40) and those who had a stillbirth (OR 2.48, 95%CI: 1.57-3.93) were found to be associated with PPD after adjusting for other factors. Occurrence of an obstetric near-miss event did not increase the risk of depression. Most women recovered with postnatal counseling, with only three requiring medication at the end of 3 months. CONCLUSION: One in five women who develop potentially life-threatening complications developed PPD. A strategy of screening focused on this high-risk group, especially in low resource settings, can lead to early recognition and treatment. This in turn can lead to a reduction in the long-term morbidity associated with PPD.