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��ࡱ�>��		����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	���mbjbj$$	E"F|F|�d.���������+++++����+++8O+��,4+���'.Ls.�.�.�.�6��;\=�	�������$D���</�-+�=�6�6�=�=/�++�.�.d\�]C]C]C�=+�.+�.	�]C�=	�]C]C��| ��.����p��Y�k�+�AB<��r�0��G�"�CR"�x��&"�+	���=�=]C�=�=�=�=�=/�/�]C�=�=�=���=�=�=�=��������������������������������������������������������������������"��=�=�=�=�=�=�=�=�=�	�):	Prevalence of maternal near miss and maternal death among pregnancy related complications in Atat hospital, Ethiopia: a retrospective study. 
Babusha Ayele1, Demisew Amenu 2 and Abdisa Gurmessa3
1Department of Emergency Surgery, Jimma University, Jimma, Ethiopia
3Department of Obstetrics & Gynacology, Jimma University, Jimma, Ethiopia
4Department of Statistics, Jimma University, Jimma, Ethiopia
Email:babusha.ayele29@gmail.com/ HYPERLINK "mailto:babusha.ayele@yahoo.com" babusha.ayele@yahoo.com,                              HYPERLINK "mailto:demisame5@gmail.com" demisame5@gmail.com/ HYPERLINK "mailto:demisew.amenu@ju.edu.et" demisew.amenu@ju.edu.et,  HYPERLINK "mailto:abdoko006@yahoo.com/abdisa.gurmessa@ju.edu.et" abdoko006@yahoo.com/abdisa.gurmessa@ju.edu.et
 
  Telephone: +251920510285
                     +251 911 811468
                      +251932285782

                                                                                                                                                               







Abstract
Back ground: The reduction of maternal death is one of the high priorities for the international communities. In the view of millennium development goal to reduce it by 75% by 2015. It arises during pregnancy, delivery and during the post partum period. In Ethiopia as a sub-Saharan country, maternal deaths account 470 per 100,000 live births. 
The increment of maternal mortality in developing country overshadows the severe acute maternal morbidity (near miss) who nearly to die but survive a complication during pregnancy, delivery and postpartum period.
Objective: To identify the prevalence of maternal near miss and maternal mortality cases in Atat hospital, in Ethiopia from January 1/2008 to December 31/2012.
Methodology: Five year retrospective facility based study was carried out in Atat hospital by reviewing patients chart, operation note, admission and discharging book of patients who were managed in the maternity ward of the hospital. Data was analyzed by using SPSS for window version 16.
Result: There were 8686 total deliveries and 8509 live births with 206(89.9%) maternal near miss and 23 (10.04%) maternal deaths. The maternal mortality ratio and maternal near miss ratio is 270 per100,000 live births and 24.2/1,000 live births respectively  with mortality index of 10.04% and severe maternal outcome ratio of 26.9 per 1000 live births. Uterine rupture account for most common events (58.9%) followed by hemorrhage (27.5%) and hypertension disorder (8.7%). 
Conclusion and recommendation: There was high frequency of maternal morbidity and mortality in this facility. Therefore maternal health policy needs to be concerned not only with preventing loss of life but also with preventing maternal near miss events like uterine rupture, hemorrhage, infection, hypertension disorder and others at all health care levels including primary health care.
Key words: prevalence, maternal near miss, maternal death, pregnancy complications 



Back ground
The reduction of maternal death is a high priority for the international community especially in view of the increased attention on millennium development goal. Maternal death arises from the risk attributable to pregnancy and child birth as well as from the poor quality care of health service (1).

Maternal death is death of mother during pregnancy, delivery or within 42 days of termination of pregnancy irrespective of the site and duration of pregnancy from any cause related or aggravated by pregnancy or its management but not from the accidental or the incidental cause and maternal near miss is defined as women who nearly died but survived a complication during pregnancy, delivery or with in 42 days of termination of pregnancy (2).

According to World health organisation statistics released in 2010; every year 358,000 women die of complication during pregnancy or delivery globally. Ninety nine percent of them being in developing countries where 85% of the population lives.  The global maternal mortality ratio of 260 maternal deaths per 100,000 live births which is still high. Each year in Africa 30 million mothers become pregnant and 207,000 of them die of pregnancy related causes. Africa has the highest maternal mortality in the world estimated at an average of about 590 deaths per 100,000 live births. Ethiopia is one of the developing countries that has high maternal mortality ratio of 470 per 100,000 live births. It is found in Africa sub Saharan country where 56% of the global maternal death foun (3).

In Africa, the high maternal mortality ratio combined with the low contraceptive prevalence rate of 13% and the high fertility rate estimated at 5.6 children per woman increase the life time risk of maternal death (4).

According to 2011 EDHS report, in Ethiopia the total fertility rate of mothers are 4.8 with family planning coverage of 28.4% and ante natal care and health facility delivery coverage of 34% and 10% respectively (13). With this low family planning coverage and high fertility rate and high life time risk of maternal death 1 in 40 (3), mothers who starts to have child bearing  at early age will have more children throughout her life with the increment of life time risk of maternal near miss and death. 
 For many years evaluation of maternal health care service aimed at improving the quality of obstetric care has relied on inquiries in to maternal death. More recently review of case at the very sever end of the maternal morbidity spectrum described as �near-miss� (those who nearly died) has been found to be a useful complement to investigation of a maternal mortality. For every maternal death, there are close to 100 women with sever maternal morbidity referred to as maternal near miss. Compared to maternal death audit, assessment of maternal near miss offers several advantage and maternal near misses are more common than maternal death (7).
Review of near miss cases has the potential to high light the deficiencies as well as the positive elements in the provision of obstetric service in any health system. The practical implementation of maternal near miss concept will provide an important contribution to improve quality of obstetric care, to reduce maternal death and to improve maternal health. Assessing and verifying of the prevalence of maternal near miss has an advantage due to its high frequency and is a day to day activity of health professionals  against pregnancy related complications  to prevent maternal near miss and death . (8)
Besides infectious morbidity, the categories of complications responsible for near-misses and maternal deaths followed the same order of decreasing frequency. Hypertensive disorders in pregnancy and haemorrhage were responsible for near-miss cases and maternal deaths. More women died after developing severe morbidity due to uterine rupture and infection. Early pregnancy complications and antepartum haemorrhage had the lowest mortality indices.. (6).
In Ethiopia and other developing countries due to the presence of high maternal mortality, maternal near miss approach is over shadowed and was not applied for assessment of maternal health. Even if there is no literature that found in Ethiopia, some African countries start to study maternal near miss since it is increasingly recognized as a useful approach to examine quality of obstetric care since pregnancy complication occur in 15% of women worldwide (5). 

This study conducted to investigate the prevalence of near miss and maternal death to determine mortality index and maternal near miss ratio and to determine the leading cause of maternal near miss and maternal death in Ethiopia. 
  
Methods and Material 
Study Area
 This study was conducted in Attat hospital, cheha district, Guragie zone, in SNNR (Southern Nation Nationality and Republic ) of  Ethiopia and 187km away to the south west of Addis Ababa and 17 km to east of Wolkite town. The hospital service has been operative since 1969 and is owned by the Ethiopian Catholic Church and managed by medical mission sisters, an international religious congregation.  
Study design
 Five year retrospective hospital based cross sectional descriptive study was carried out in the maternity ward of Attat Hospital from January 1/2008 to December 31/2012.
Data Collection Procedure
The record of all mothers with pregnancy related complication were checked with pre prepared check list to extract sever maternal morbidity and mortality (maternal near miss and maternal death) who were admitted and got service in Atat hospital within a five year period since 2008 to 2012.
All mothers registered with pregnancy related complications that fulfill WHO near miss identification criteria were included. The data was collected using pre structured check list by trained health professional data collectors from the patients chart based on their medical record number from inpatient and operation theater records, admission and discharge books. 
 Training was given to the data collectors before the data collection was started on how to fill the pre prepared checklist and WHO�s criteria of near miss and the importance of the quality of the data. Near miss cases were identified during data collection using WHO near miss identification criteria. Data concerning socio demographic characteristics, diagnosis, outcome and cause of the bad outcome of the patient was extracted. 




Data processing and analysis 
After data collection was completed, the data were checked for errors, coded and entered to Epi-data version 3.1 and then transported to SPSS version 16.0 for further analysis. The socio demographic data was summarized and presented by using tables and other summery measures. 

 Ethical consideration 

Ethical permission to undertake the study was obtained from administrative body of Attat hospital. Letter of cooperation was given to different authorities of the Hospital and as well informed consent was obtained from maternity department of Atat hospital. 




















Result and Discussion 
Socio-demographic characteristics of maternal near miss and maternal death.
 During this study period there were 8989 total deliveries and 8509 live birthes with maternal mortality ratio of 270 maternal deaths per 100,000 live births. 206 maternal near misses (MNM) with mean age of 31.27 year and 23 maternal deaths with mean age of 31.35 year with the total life treatinig condition of 229 in the mean age of 31.28 year and maternal near miss to mortality ratio of 9:1 were found.  In this study, 185 maternal near miss and 22 of the maternal death (MD) were found in the rural side of study area and 197 of the maternal near miss and 20 of the maternal death cases were married (Table 1).
















Table 1: Distribution of sociodemographic characteristics of maternal near miss and maternal death in Atat hospital, Gurage zone, Ethiopia from Jan.1/20008 to Dec.31/2012.





Sociodemographic characteristics  
Moternal outcome

Total 

MNM
MDN (%)N (%)N (%)Age               15-19
                      20-24
                      25-29
                      30-34
                      35-39
                      40-44
                      45-49
                      Total 

Address         Rural
                       Urban
                        Total 

Marital status    single    
                        Maried
                       Missed
                       Total 5(2,4)
27(13.1)
52(25.2)
46(22.3)
62(30.1)
13(6.3)
1(0.5)
206(100)

185(89.8)
21(10.2)
206(100)

1(0.5)
197(95.6)
8(3.9)
206(100)0(-)
3(13.0)
6(26.1)
7(30.4)
5(21.7)
2(8.7}
0(-)
23(100)

22(95.7)
1(4.3)
23(100)

0
20(86.9)
3(13.1)
23(100)5 (2.2)
30 (13.1)
58 (25.3)
53 (23.1)
67 (29.3)
15 (6.6)
1 (0.4)
229 (100)

207 (90.4)
22 (9.6)
229 (100)

1 (0.4)
217(94.8)
11(4.8)
229
  
 From the total maternal near miss cases 115(55.8%) of them have gravidity of greater than or equal to four and 12(52.2%) of the total maternal death cases had gravidity of 1 up to 3. In addition, 126(61.2%) of the maternal near miss cases and 18 (78.3%) of the maternal death cases have parity of one up to four and 186(90.3) of the maternal near miss (MNM) and 21(91.3%) of the maternal death (MD) cases have gestational age of greater than 28 week. From this study 108(52.4%) of the maternal near miss cases and 13(56.5%) of the maternal death cases have no ANC follow up (Table 2)
Table 2: Distribution of obstetric variables with maternal near miss and maternal death cases in Atat hosptal, Gurage Zone, Ethiopia from Jan.1/2008 to DEC.31/2012.



Obstatric variable
                Maternal outcome    MNM     MDTotal   No (%)  No (%)  No (%)Gravidity 
                  1-3
                  e"4
Parity      
                0
             1-4
              >4
Gestational age 
            <14 weeks
             14-28 weeks
             >28 weeks 
ANC   follow up
                 Yes
                  No
                Missing     

206(100)
91(44.2)
115(55.8)
206(100)
22(10.7)
126(61.2)
58(28.1)
206(100)
9(4.4)
11(5.3)
186(90.3)
206(100)
69(33.5)
108(52.4)
29(14.1)23(10.0)
12(52.2)
11(47.8)
23(100)
2(8.7)
18(78.3)
3(13,0)
23(100)
00
2(8.7)
21(91.3)
23(10.0)
4(17.4)
13(56.5)
6(26.1)229(100)
103(45.0)
126(55.0)
229(100.0)
24(10.5)
144(62.9)
61(26.6)
229(100.0)
9(3.9)
13(5.7)
207(90.4)
229(100.0)
73(31.9)
121(52.8)
35(15.3)
Majority of the near miss and maternal death cases were caused by uterine rupture that account 128(62.1%) and 7(30.4%) respectivelly foollowed by puerperal sepsis and eclampsia that account  maternal death of 5(21.7%) and 4(17.4%) respectively (Table 3).
Table 3:  Distribution of maternal near miss and maternal death and its causes in Atat hospital, Gurage zone, Ethiopia from Jan.1/2008 to DEC.31/2012.



Near miss causes            Maternal out comeMNMMDTotal       
No (%)NO (%)No (%)Hemorrhage
       Abortion
       Ectopic pregnancy
      Placenta previa
      Abruptio placenta
      Post partum hemorrhage
Hypertension disorder 
                 Preeclampsia
                 Eclampsia
Dystocia        
                  Utrine rupture
                 OL
Sepsis          
               Puerpral sepsis
Others          
                Malaria
               HIV/AIDS
                Total61(29.6)
17(8.3)
1(0.48)
12(5.8)
10(4.8)
21(10.2)
15(7.3)
4(1.9)
11(5.4)
130(63.1)
128(62.1)
2(0.97)
1(0.48)
1(0.48)
-
-
-
206(100.0)2(8.7)
-
-
-
-
2 (8.7)
5 (21.7)
1(4.3)
4(17.4)
7(30.4)
7(30.4)
-
5(21.7)
5(21.7)
4(17.4)
3(13.0)
1(4.3)
23(100.0)63 (27.5)
17 (7.4)
1 (0.4)
12 (5.2)
10 (4.4)
23 (10.0)
20 (8.7)
5 (2.2)
15 (6.6)
137 (59.8)
135 (58.9)
2 (0.9)
6 (2.6)
6 (2.6)
4 (1.7)
3 (1.3)
1 (0.4)
229 (100.0)















In this study uterine rupture was the leading cause of life treating condition that account 135(58.9%)  and sever maternal out come ratio of  16.1 per 1000 live births and maternal near miss incidence ratio of 15 per 1000 live births with mortality index of  51% . Generally these study results 26.9 per 1000 live births of sever maternal outcome ratio and 24.2 per 1000 live births of maternal near miss incidence ratio and 10.04 % of mortality index in the study area (Table 4).






















    CausesNo 
MNMNo MDWLTCSMOR/ 1000 LBMNMR/ 1000 LBMI %Hemorrhage
       Abortion
       Ectopic pregnancy
      Placenta previa
      Abruptio placenta
     Post partum hemorrhage
Hypertension disorder 
                 Preeclampsia
                 Eclampsia
Distocia        
                  Utrine rupture
                 OL
Sepsis          
               Puerpral sepsis
Others          
                Malaria
               HIV/AIDS
                Total
61(29.6)
17(8.3)
1(0.48)
12(5.8)
10(4.8)
21(10.2)
15(7.3)
4(1.9)
11(5.4)
130(63.1)
128(62.1)
2(0.97)
1(0.48)
1(0.48)
-
-
-
206(100.0)2(8.7)
-
-
-
-
2 (8.7)
5 (21.7)
1(4.3)
4(17.4)
7(30.4)
7(30.4)
-
5(21.7)
5(21.7)
4(17.4)
3(13.0)
1(4.3)
23(100.0)63 (27.5)
17 (7.4)
1 (0.4)
12 (5.2)
10 (4.4)
23 (10.0)
20 (8.7)
5 (2.2)
15 (6.6)
137 (59.8)
135 (58.9)
2 (0.9)
6 (2.6)
6 (2.6)
4 (1.7)
3 (1.3)
1 (0.4)
229 (100.0)7.4
1.99
0.1
1.4
1.2
2.7
2.4
0.6
1.8
16.1
16.1
0.2
0.7
0.7
0.5
0.4
0.1
26.97.1
1.99
0.1
1.4
1.2
2.5
1.8
0.5
1.3
15.3
15.0
0.2
0.1
0.1
-
-
-
24.23.2
-
-
-
-
8.7
25.0
20.0
26.7
51.0
51.8
-
83.3
83.3
-
-
-
10.04Table 4: The mortality index severe maternal outcome ratio and maternal near miss ratio of maternal near miss in Atat hospital, Gurage zone, Ethiopia from Jan.1/2008 to DEC.31/2012.





Discussion
During this study period there were 8989 a total deliveries and 8509 live births with amaternal mortality ratio of 270 per 100,000 live births and there were 206 maternal near misses and 23 maternal deaths with total life threating condition of 229. Among the maternal death cases 19 (82.6%) of them were caused by direct cause of maternal death and 4 (17.4%) of them caused by indirect cause of maternal death. 
Among the total maternal death cases 7 (30.4%) of them belonges to the age group of 30- 34 years followed by 6(26.1%) of them belonges to the age group of 25-29 years and also 13 (56.5%) of maternal death and 108 (52.4%) of maternal nearmiss cases have no anenatal care followup. Where as in Nigeria Sygamu (8) 13(29.5%) of maternal death belongs to the age group of 26-30 years and 9(20.5%) of them belonges to the age group of 21-25 years. Semilarly 62(30.1%) maternal near miss followed by 52(25.5%) of maternal nearmiss belonges to the age group of 35-39 year and 25-29 years respectively.This migh be dueto the high fertility rate in Africa (4) with low contraceptive coverage with high desire of having many children at early age lead mothers to get repited pregnancy and as pregnancy repited life threatening complication will be happen or there might be delayance to seek health care.
During this study period 22(86.9%) of maternal death and 185(89.8%) of the maternal near misses were in the rural side of the study area and 18(78.3%) of maternal death and 144(62.9%) of maternal nearmiss cases belongs to the parity of one to four but in Serya Damasks (9) 40.8% 0f maternal death and 60% of maternal death belonges to parity of one to three. Also 21(91.3%) of the maternal death and 186(90.3%) of maternal nearmiss cases were belonges to the gestational age of greater than 28 week semilarely in Nigeria  Sygamu (8) 81.5% of maternal death and 93.2% of maternal nearmiss cases were belonge to gestational age of greater than 28 week this might be due to not seeking health care at the time of ANC follow up to detect those complication that arise at late pregnancy and failur to get health institution delivery at the time of labor dueto shortage of awarance or inaccesablity of health institution. 
As compared to this study with other country, the maternal mortality ratio of Sudan Kasala hospital (5) was 432 per 100,000 live births which was higher than this study area and the mortality index of this study were 10.04% but in Kasala hospital it was 19.5% on the other hand in Syria Damaskas (9) there were 15 maternal deaths with maternal mortality ratio of 54.8 per 100,000 live births and mortality index of 1.7 %.This might be dueto there was no delyance in obstatric care.  Smilarly study showed in Malawi (11) that had mortality index of 11.9% which is slightly greater than this study area and as compared to other study done in Liberia (12) that was 28 maternal death and mortality index of 18.9%, as compared of in this study area the mortality index is slightly lower it might be becouse of the good obstetric care which is given in this study areal.
In this study period there were 206 maternalmaternal near miss cases with atotal maternal nearmiss ratio of 24.2 per 1000 live births and sever maternal outcome ratio of 26.9 per 1000 live births. Where as the maternal near miss ratio of Kassala hospital (5) was 22.1 per 1000 live births which is slightly lower than this study area and in Seria Damskas (9) the maternal near miss ratio was 32.9 per 1000 live births which was slightly higher than this study area.
The leading cause of maternal nearmiss and maternal death in this study area was utrine rupture that account 128 (62.1%) of maternal near miss and 7 (30.4%) of maternal death followed by post partum hemorrhage that account maternal nearmiss of 21(10.2%) and puerperal sepsis that account maternal death of 5 (21.7%) but in Sudan Kassala (5) hospital the leading cause of maternal nearmiss was hemorrhage that account 93 (40.8%) followed by infection which account 15%  but the leading cause of maternal death was infection that account 14(35%) followed by hemorrhage that account 9 (22.5%).Where as study showed in Nigeria Segamu (8)  the leading cause of maternal near miss and maternal death was hypertensive disorder and hemorrhage that account61.1% and 50% respectivelly.This might be dueto the delayance of seeking health care at ANC follow up and delivery time in health institution becouse of either shortage of awarance or inaccesablity of health institution to the near by. Semilarly the leading cause of maternal death in Ambo hospital (10) were  hemorrhage yhat account 54.8% followed by puerperal sepsis that account 30.1% and in semilar to this study area the leading couse of maternal death were direct cause of maternal death.





Conclusion
This review shows that besides the 23 women who died due to pregnancy-related complications, there were 206 additional women who received critical care during the same period supporting the view that nearmiss appraisal provides a larger sample to assess the threat to maternal life. The overall maternal death to near-miss ratio, however, indicates that a significant proportion of critically ill women died, suggesting a suboptimal level of care for life-threatening complications. With in this study period, this high maternal morbidity and maternal mortality at the level of this facility shows that maternal health policy needs to be concentrated not only with preventing the loss of life, but also with preventing maternal near missevents like hemorrhage, utrine rupture, hypertensive disorder, sepsis and obstructed labor at all health care level including primery health care by developing management protocols. 
Recommendation
The Attat hospital adminesterative body should use separate registeration book for in patient and outpatient of obstetric and Gynacology cases from other medical and surgical cases.
The Attat hospital techenical body should incorporate important socio demographic and obstatric variables and should fulfil all information of ANC follow up chart and should give soportive supervision for health workers.
The Attat hospital techecnical body should use standared national protocols during the management of obstetric complications.
The Guragea zone health disk should give supporting supervision and refershement training for front health workers about the handling and good referal system of obstetric complications.
The national maternal policy maker should incorporate maternanal nearmiss approach as an indicator of maternal health and should prepare national protocol to defernciate maternal nearmiss and its management approach.
  Acknowledgement
We would like to extend our thanks to Jimma university for financial support to cary out this research and to Atat hospital administrative body for their permission to carried out this research in their hospital and letting us to get data for this research.
References
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