Analysis of cases of near misses in obstetric-gynaecological practice

Abstract

Purpose

The purpose of this study was to identify and determine the frequency and nature of near misses in pregnant women and in the postpartum period.

Methods

In the Turkestan region (Kazakhstan), a retrospective review of cases of critical situations and cases of maternal mortality that occurred during the 12 months of 2022 was conducted. 201 cases of critical conditions in obstetric-gynaecological practice that occurred in 22 regional institutions of all three levels of perinatal care were analysed.

Results

The causes of cases of near misses in the provision of medical care to pregnant women, maternity women, and women in labour were determined. 0.3% of maternal near misses from the total number of births were registered in the region, of which obstetric causes accounted for 58.2% and extragenital—41.8%.

Conclusion

It was found that cases of maternal near misses were 1.2 times more often recorded in the postpartum period compared to the antenatal period. A difficult situation regarding the management of the postpartum period has developed in institutions of the second level of perinatal care, where 62% of maternal near misses were observed in the postpartum period.

Introduction

According to the definition of the World Health Organisation (WHO), a maternal near miss in obstetric-gynaecological practice is a situation in which a woman has experienced a complication that occurred during pregnancy and/or childbirth, as well as within 42 days after the termination of pregnancy [1]. In most cases, maternal near miss occurs when women have any chronic extragenital diseases or those that have arisen in connection with the development of pregnancy [2–9]. According to Zh. A. Abdirasulova et al. [10], professional perinatal monitoring can reduce the risk of pregnancy complications. The availability of medical monitoring and assistance is of high importance in reducing maternal near misses and mortality [11–18]. In developing countries, rates of maternal mortality and near misses are quite high. Almost every woman who had an acute or chronic pathology associated with pregnancy could die in the absence of professional medical care [19–25]. In the study by D. D. Mirzakhmetova et al. [26], the dynamics of the main indicators of perinatal care in a region with a high birth rate was determined. Thus, in southern Kazakhstan, extragenital diseases predominate in the structure of causes of maternal mortality (66%). In the structure of maternal near misses, extragenital diseases are also in the first place (46.2%), followed by preeclampsia (20%), bleeding (16.4%), and septic complications (11.7%).

Despite large-scale state programmes to improve and reorganise the obstetric-gynaecological service, maternal mortality and near miss rates in Kazakhstan are still high [27–30]. Thus, for example, G. Zh. Bodykov and A. M. Kurmanova, [31–33] and G. Zh. Bodykov et al. [32] state that in the structure of maternal mortality and maternal near misses, obstetric bleeding (34.7%) is the largest, extragenital diseases (27.8%) and preeclampsia (19.4%) are in second place, followed by purulent-septic diseases (12.5%). The most significant risk factors for bleeding are anaemia and an increase in the number of caesarean section operations. Due to the significant level of morbidity of women of reproductive age, the perinatal service needs to be improved: improving the dispensary monitoring of pregnant women at risk to detect extragenital diseases in advance. A number of legislative acts have been adopted with the aim of improving the qualifications of medical staff, improving the provision of obstetric-gynaecological care to the population and reducing maternal mortality and maternal near miss rates. For example, the Order of the Minister of Health of the Republic of Kazakhstan dated August 26, 2021, No. KR DSM-92 “On approval of the standard for organising the provision of obstetric-gynaecological care in the Republic of Kazakhstan” [7] has detailed all the important points at each stage of accompanying women in medical institutions of the Republic. An important point is that the hospitalisation of pregnant women is carried out depending on the indications for the levels of regionalisation of perinatal care.

Women enter 1st-level medical institutions after 37 weeks of pregnancy with various pregnancy-related disorders, but not life-threatening. Women are hospitalised in 2nd-level medical institutions starting from 32 weeks of pregnancy. Women’s diagnoses are more serious and higher-level professional help is required. Women starting from 22 weeks of pregnancy with complex obstetric diagnoses and various decompensated extragenital pathologies are admitted to medical institutions of the 3rd level. In the study by A.K. Ayazbekov et al. [34], the fact is mentioned that 154 patients with COVID-19 were treated in the 3rd-level medical institution of perinatal care (Regional Perinatal Center No. 3, Turkestan) in August 2020. This experience required knowledge in the field of crisis management from the administration of medical institutions. Only a professional multidisciplinary team consisting of obstetricians-gynaecologists, anaesthesiologists-resuscitators, neonatologists, infectious disease specialists, epidemiologists, and other specifics of nursing staff and technical support can cope with such global problems [35–38].

The purpose of the study was to search for and assess the causes of life-threatening cases in obstetric-gynaecological practice, to improve the provision of medical care in the Turkestan region, and the possibility of introducing annual monitoring of cases of maternal near misses and maternal mortality to determine effective preventive measures of perinatal care. The paper aims to highlight the significance of maternal near misses, which are critical conditions where women survive severe complications during pregnancy, childbirth, or within 42 days postpartum, thanks to timely medical intervention to emphasize the importance of professional perinatal monitoring in reducing maternal mortality and morbidity. In this study, a maternal near miss is defined as a woman who experienced severe life-threatening complications during pregnancy, childbirth, or within 42 days postpartum but survived due to timely and adequate medical care. This definition aligns with the WHO's criteria for identifying cases where women nearly died but were saved through medical intervention.

Materials and methods

The study was conducted in 22 medical institutions of obstetric-gynaecological services and neonatology services of all three levels of perinatal care in the Turkestan region of Kazakhstan. The case histories of all patients for 12 months of 2022 were analysed. A retrospective review was conducted with a thorough analysis of the medical records of 57,581 women who gave birth, regardless of the gestation period. The study group of women included all pregnant women aged 15–49 years. Among the total number of deliveries in 2022, 201 cases of critical conditions were identified. These women were hospitalised in intensive care units in institutions of the Turkestan region. The level of perinatal care, the causes of critical conditions, and the management of pregnancy and childbirth were analysed, according to protocols, obstetric and extragenital diseases and their connection with maternal near misses were identified. Moreover, the fact of the presence of coronavirus infection in pregnant women and their correlation with critical conditions was of no small importance. The fact of hospitalisation of pregnant women in a medical institution of the appropriate level of perinatal care was checked. Indications for hospitalisation of pregnant women were compared with the level of regionalisation of perinatal care.

For example, 14,038 (24%) births were attended at the first level. Women were admitted to 1st-level medical institutions after 37 weeks of pregnancy with various indications. Among the diagnoses were false contractions, urgent labour, premature rupture of the foetal membranes, various respiratory disorders associated with pregnancy, but not life-threatening, minor anaemia, moderate controlled hypertension, congenital foetal defects that cannot be cured, pelvic presentation of the foetus, planned caesarean section, antenatal foetal death. 22,444 (39%) women were hospitalised in 2nd-level medical institutions, starting from 32 weeks of pregnancy. The diagnoses were different, but more serious and women needed professional help of a higher level. False contractions were diagnosed at 32 weeks of pregnancy, premature birth at 32–36 weeks, premature rupture of foetal membranes, gestational hypertension and chronic hypertension of the second degree at more than 32 weeks, severe anaemia, preeclampsia at 32 weeks, diabetes mellitus, pelvic presentation of the foetus, and various extragenital pathologies. Moreover, antenatal foetal death, foetal development abnormalities with the possibility of surgical treatment, caesarean section operations with concomitant pathology, benign uterine neoplasms, Rh-immunisation of the foetus, and multiple pregnancy were observed.

21,099 women (37%) were hospitalised in 3rd-level medical institutions, starting from 22 weeks of pregnancy, having such diagnoses as false contractions at 22 weeks of pregnancy, premature birth at 22–32 weeks, premature rupture of foetal membranes, gestational hypertension and chronic hypertension of the second-third degree, preeclampsia at up to 32 weeks and eclampsia up to 32 weeks, various decompensated extragenital pathologies. In addition, Rh-immunisation with signs of haemolytic disease of the foetus, placenta praevia, multiple pregnancy with violation of the foetal state of foetuses, and congenital malformations of the foetus requiring surgery and intensive therapy were observed.

Results

Obstetric-gynaecological care for women differs from general therapeutic care in both therapeutic and preventive ways. Obstetricians and gynaecologists must reduce maternal, perinatal, and new-born mortality. Unfortunately, improper pregnancy treatment and medical neglect worsen pregnancy difficulties at birth. WHO reports that postpartum haemorrhage, infection, and uncontrolled high blood pressure cause 75% of maternal fatalities in developing countries [28]. In Kazakhstan, as in other developing countries, the maternal mortality rate was high. However, due to legislative innovations, Order No. 746 “On regionalisation of perinatal care in the Republic of Kazakhstan” was issued on December 21, 2007. At the state level, a decision was made on regionalisation, that is, on the distribution of medical institutions of obstetric-gynaecological services and neonatology services into three different levels, according to the degree of risk of pregnancy and childbirth. The distribution considered the resources and facilities, sufficient human resources and the level of professionalism, geographical location, and logistical capabilities.

The 1st level of perinatal care accepts women with uncomplicated pregnancies and only physiological deliveries above 37 weeks. Kazakhstan has 177 1st-level perinatal care hospitals. 2nd-level medical institutions should provide obstetric-gynaecological treatment to uncomplicated pregnant women, moderate-risk pregnant women with planned childbirth, and premature births beyond 32 weeks. Kazakhstan has 30 2nd-level perinatal hospitals. Pregnant women at high risk of perinatal pathology, possible severe complicated childbirth, premature birth at less than 32 weeks, and new-borns in need of specialized care are treated at the 3rd level of the perinatal service. 3rd-level medical institutions should have extensive equipment, enough professional staff, and the structure of a complex problem-solving institution, including intensive care units for women, full-term, and premature new-borns, a 24-h neonatal post, and an express laboratory. Kazakhstan has 13 3rd-level perinatal medical institutes and 2 scientific medical institutions that provide highly specialized care.

The maternal death rate dropped from 46.8 to 25.3% over the 3 years of the Kazakhstan obstetric-gynaecological service's activity from 2007 to 2010, when perinatal care was redistributed to 3 levels. It was shown that regionalizing perinatal care in Kazakhstan has improved obstetric care and healthcare system efficiency. The study retrospectively analysed the case histories of 57,581 patients who gave birth in 2022 in all 22 Turkestan medical maternity institutes of the 1st, 2nd, and 3rd levels. Analysis of women's histories revealed an average age of 25.6 ± 7.2 years. Figure 1 shows maternal care redistribution by medical institution level.

Fig. 1.

Percentage redistribution of maternity care in medical institutions of the Turkestan region, according to the levels of perinatal care*. Note: *the level of statistical significance p = 0.005 (the results are highly significant).

Source: compiled by the author

The 1st level of perinatal care delivered 24% (14,038) of the total number of births (57,581), the 2nd level delivered 39% (22,444), and the 3rd – 37% (21,099). Among the total number of births during the analysed period of time in the Turkestan region, a total of 201 cases of critical life-threatening conditions were registered in 22 medical institutions of different levels of perinatal care, which amounted to 0.3% of the total number of obstetrics performed (57,581). The maternal near miss rate was 3.4 per 1,000 live-born infants in the Turkestan region for 12 months of 2022, that is, a critical situation during pregnancy or childbirth and in the postpartum period was observed in every 286 patients, which does not exceed the coefficient of other developing countries. The distribution of the frequency of maternal near misses, depending on the level of perinatal care, revealed a significant difference. Thus, at the first level, out of 14,038 deliveries admitted, the situation was critical in 37 (0.2%) cases and maternal near misses were observed in every 379 patients. The frequency of near misses at the second level was every 477 women, namely 47 (0.2%) cases out of a total of 22,444 births. At the third level, the frequency of maternal near misses was significantly higher and occurred in every 180 patients, accounting for 117 (0.5%) cases out of 21,099 delivered births (Table 1).

Table 1.

Comparative data on the number of obstetrics and maternal near misses at different levels of perinatal care*

No	Indicator	Level 1 (number of births – 37)	Level 2 (number of births – 47)	Level 3 (number of births – 117)
1	% of the total number of births in the region	24.3	39	36.7
2	% of the total amount of maternal near misses	18.4	23.3	58.3
3	Frequency of cases of maternal near misses	379	477	180

^*the level of statistical significance p = 0.005 (the results are highly significant)

Source: compiled by the author

In the Turkestan region during the analysed period, on average, maternal near misses were observed in every 286 patients. This indicator does not exceed the level in other developing countries, however, with a more detailed analysis of the situation in medical institutions by the level of perinatal care, the frequency of near misses in 3rd-level medical institutions is much higher than at levels 1 and 2. Moreover, it looks quite alarming that the amount of maternal near misses at the 1st level is 1.2 times higher than at the 2nd. The causes that provoked critical conditions in women, for the study period of 2022, in 58.2% of cases were obstetric and 42% were extragenital from the total number of births performed. Figure 2 shows in detail the correlation between the causes of maternal near misses and the distribution by levels of perinatal care.

Fig. 2.

Ratio of the causes of critical cases by levels of perinatal care in %*. Note: *the level of statistical significance p = 0.005 (the results are highly significant).

Source: compiled by the author

From the statistical data obtained, it can be seen that there is no significant difference between the level of the medical institution and the causes of the development of critical conditions. Obstetric causes are leading at all levels of perinatal care, which in general does not represent a very favourable picture of providing the population with high-quality obstetric-gynaecological care. A detailed analysis of obstetric causes of critical conditions identified the following nosologies: preeclampsia and eclampsia premature detachment of a normally located placenta (PDNLP), postpartum purulent-septic infections (PSI) and endometritis, postpartum bleeding, and obstetric haematomas. Figure 3 shows the nosologies of obstetric causes of critical conditions as a percentage of the total number of maternity services in the Turkestan region for 12 months of 2022.

Fig. 3.

Structure of obstetric causes of maternal near misses in % ratio*. Note: *the level of statistical significance p = 0.005 (the results are highly significant).

Source: compiled by the author

The most common pathology that develops during pregnancy is preeclampsia and eclampsia, according to the study was 37%. This condition of a pregnant woman develops against the background of diseases of the cardiovascular system, hypertensive disorders, and diseases of the urinary system. However, these conditions can be controlled with proper management of pregnancy. 15% of cases of purulent septic infections and endometritis directly depend on the level of quality assurance of obstetric care and management of the postpartum period, as well as 12% of cases of postpartum bleeding. Obstetric bleeding, haematomas, and birth canal injuries are still one of the main and critically important complications that depend on the level of professionalism of doctors. A thorough analysis of extragenital pathology, which led to the critical condition of women in labour and maternity, revealed the following nosologies (Fig. 4).

Fig. 4.

Structure of extragenital causes of critical situations in % ratio*. Note: *the level of statistical significance p = 0.005 (the results are highly significant).

Source: compiled by the author

It is obvious that respiratory diseases occupy a leading position in the structure of extragenital pathology. In the Turkestan region in 2022, there was a significant increase in the incidence of coronavirus infection in the period from June to September. Table 2 provides detailed data on the number and period of maternal near misses in institutions of various levels.

Table 2.

The number and period of maternal near misses in institutions of various levels*

No	Indicator (total of 201 critical cases)	Level 1 (number of births – 37)	Level 2 (number of births – 47)	Level 3 (number of births – 117)
1	During pregnancy	21 (56.7%)	18 (38.2%)	52 (44.4%)
2	In the postpartum period	16 (43.3%)	29 (61.7%)	65 (55.5%)

^*the level of statistical significance p = 0.005 (the results are highly significant)

Source: compiled by the author

Based on statistical data, it can be concluded that the most difficult situation for the management of the postpartum period is in second-level institutions. 62% of women in critical condition in the postpartum period is a rather high and negative indicator from the standpoint of the organisation of obstetric-gynaecological services in the Turkestan region. Figure 5 summarises the statistical data of medical institutions of three levels of perinatal pathology, from which it can be seen that 54.7% of critical situations occur in the postpartum period, and 45.3% during pregnancy.

Fig. 5.

Maternal near misses in different periods in % ratio*. Note: *the level of statistical significance p = 0.005 (the results are highly significant).

Source: compiled by the author

When analysing the case histories, it was revealed that out of 201 cases of maternal near misses, 3 cases (1.4%). passed into the category of maternal mortality. This means that for 12 months of 2022 in the region, every 67 critical cases passed into the maternal mortality group. In the structure of maternal mortality, 66.7% (2 women) died due to extragenital diseases, and obstetric causes accounted for 33% (1 woman). This study was conducted for the possible correction of problem areas in the system of obstetric-gynaecological care in the Turkestan region, which allowed assessing the current situation with the amount of maternal near misses and finding the main causes leading to maternal mortality.

Discussion

To date, there are a large number of scientific papers that analyse the causes of maternal mortality in order to prevent and control the factors that lead to it. Thus, maternal near miss is a condition of women in which they could have died, but survived due to timely professional medical care or without it [39]. Maternal mortality and maternal near misses have the same causes, and their level is quite high today [40]. Each maternal mortality covers 20 women with a near miss, according to V. Verma et al. [14] and M. Kalhan et al. [29]. The audit of critical conditions of pregnant women enables researchers to study the causes that are similar to the causes of maternal death. Such an analysis provides concrete evidence of the shortcomings of medical care that can lead to maternal mortality. Analysis and compilation of preventive protocols can improve the effectiveness of perinatal care and reduce maternal morbidity and mortality.

A. Heitkamp et al. [11] conducted a scientific review, which included 69 scientific papers from 26 countries, which included 12 developing countries and 14 developed countries. It was found that the average number of maternal near misses per 1000 live births was 15.9 in developing countries and 7.8 in developed countries. In Italy, an observational retrospective study was conducted by S. Donati et al. [12], which involved pregnant women aged 15–49 years with hospitalisations in intensive care units in the period from 2004 to 2005. 1259 near misses were detected and the coefficient was 2 per 1000 births. The leading factors of critical conditions in women were obstetric bleeding, disseminated intravascular coagulation, and hypertensive pregnancy disorders.

D.O. Selo-Ojeme et al. [15] included a total of 33 women, both pregnant and in the postpartum period, who were treated in the intensive care unit at a tertiary hospital in the period January 1, 1993–December 31, 2003. The main indications for hospitalisation were obstetric bleeding (36.4%) and hypertensive disorders (39.4%). In both studies, the majority of women 75–80% were admitted in the postpartum period. Y. Lin et al. [19] conducted a retrospective review in hospitals in Beijing for 5 years and found that the most common obstetric reasons for hospital admission were massive postpartum haemorrhage and pregnancy-related hypertension. A. Habte and M. Wondimu [25] conducted in the period from February 1 to June 1, 2020, in five 3rd-level hospitals in central-southern Ethiopia with the participation of 322 women demonstrated that severe postpartum bleeding (50.6%) and sepsis (23.4%) were frequent causes of hospitalisation.

H.N. Teshome et al. [22] conducted a study in the period from February to April 2020, which involved 264 women admitted to public hospitals in the North Sheva district, Ethiopia). Severe preeclampsia (49.5%) and postpartum bleeding (28.3%) were the main reasons for hospitalisation. The study by E.R. Declercq et al. [17] consisted in the fact that in a retrospective cohort analysis of 594,056 births of women in Massachusetts (USA), the greatest number of perinatal and postpartum near misses occurs in cases of sepsis. A huge number of studies confirm the fact that the most common causes of maternal near misses and maternal mortality are bleeding, eclampsia and preeclampsia, and sepsis. There are differences in the percentage ratio between these critical conditions in a particular country, but the reasons remain the same regardless of the level of development of the country. For example, a greater percentage of bleeding and septic complications are observed in developing countries, while eclampsia and preeclampsia prevail in a larger percentage in developed countries. When analysed in detail by the level of perinatal care, the retrospective observational study by I.A. Iwuh et al. [18], conducted for 6 months in 2014 in South Africa, 112 cases of maternal near misses and 13 cases of maternal death were detected. As in other studies, the main causes were arterial hypertension, bleeding, and postpartum sepsis. 56.3% of maternal near misses occurred in a primary healthcare facility, 33.9% occurred in a secondary-level hospital, and 9.8% in a tertiary-level medical facility.

E.I. Baranovskaya [28] suggests that maternal mortality has now increased significantly in the context of the COVID-19 pandemic. The share of maternal near misses caused by problems with the pulmonary system and respiratory diseases has increased to 32%, when until 2019 it was only 5.6%. Ensuring safe motherhood and early childhood is crucial for the development of the nation and the world as a whole. Considering the causes of maternal mortality and near misses, according to E.J. Conrey et al. [23] and S.E. Geller et al. [27], the maternal mortality rate has not significantly decreased. This means that most pregnancy-related deaths could have been prevented through patient monitoring, effective disease prevention, and timely professional care. The attitude of the country’s authorities to this problem is of great importance. The possibilities of providing professional personnel and technical resources in developing countries are still not at the proper level.

In conclusion, the analysis of maternal near misses is established in various countries, including both developed and developing nations. For instance, studies in Italy, the USA, Ethiopia, Mexico, and India have examined the causes and frequency of maternal near misses to improve perinatal care and reduce maternal mortality. These countries have implemented protocols to monitor and analyse near misses, providing valuable insights into the quality of obstetric care and identifying areas for improvement.

Conclusions

From analysing critical conditions in perinatal practice, valuable information about the causes of maternal near misses and maternal mortality can be obtained. Based on the data obtained, problems in the effectiveness of obstetric-gynaecological and neonatology services have been identified. Maternal mortality remains high in developing countries, and Kazakhstan is no exception. However, due to the legislative innovations of December 21, 2007, “On the regionalisation of perinatal care in the Republic of Kazakhstan”, a decision was made at the state level on the distribution of medical institutions of obstetric-gynaecological services and neonatology services at three different levels, according to the degree of risk of pregnancy and childbirth. Only during the three years of operation of the perinatal service in Kazakhstan, in the period from 2007 to 2010, it was noted that the maternal mortality rate decreased from 46.8% to 25.3%. These data showed that the regionalisation of obstetric-gynaecological services in the Republic of Kazakhstan has led to an increase in the quality of care of obstetric institutions and greater efficiency of the healthcare system as a whole. Research work was carried out and the current situation with the number of maternal near misses and maternal mortality in the Turkestan region was assessed.

Based on the revealed statistical data, the most difficult situation for the management of the postpartum period has developed in institutions of the 2nd level of perinatal care. 62% of maternal near misses in the postpartum period is a fairly high and negative indicator from the standpoint of the organisation of obstetric-gynaecological services. However, a significant increase in the incidence of coronavirus infection made a significant contribution to the structure of extragenital pathology leading to critical conditions for pregnant women in the Turkestan region in 2022. In the Turkestan region, maternal near misses were observed in every 286 patients for 12 months of 2022, namely, 3.4 per 1000 live-born babies, which does not exceed the coefficient of other developing countries. Based on this study, the current situation with the amount of maternal near misses was assessed and the main causes leading to maternal mortality in the Turkestan region were found, which in the future will facilitate the correction of problem areas in the system of obstetric-gynaecological care.

Author contributions

Conceptualization, Alima Ayazbekova, Saltanat Kulbayeva, Ardak Ayazbekov; methodology, Aigul Terlikbayeva, Gulzhaukhar Taskynova; software, Saltanat Kulbayeva, Gulzhaukhar Taskynova; investigation, Ardak Ayazbekov, Aigul Terlikbayeva, Alima Ayazbekova; resources, Saltanat Kulbayeva, Gulzhaukhar Taskynova; data curation, Ardak Ayazbekov, Alima Ayazbekova; writing—original draft preparation, Ardak Ayazbekov, Alima Ayazbekova, Saltanat Kulbayeva, Aigul Terlikbayeva, Gulzhaukhar Taskynova; writing—review and editing, Ardak Ayazbekov, Alima Ayazbekova, Saltanat Kulbayeva, Aigul Terlikbayeva, Gulzhaukhar Taskynova; visualization, Alima Ayazbekova, Saltanat Kulbayeva.

Funding

The authors have not disclosed any funding.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author.

Declarations

Conflict of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.