title: Maternal near misses from two referral hospitals in Uganda: a prospective cohort study on incidence, determinants and prognostic factors.
abstract: BACKGROUND
  Maternal near misses occur more often than maternal deaths and could enable more comprehensive analysis of risk factors, short-term outcomes and prognostic factors of complications during pregnancy and childbirth. The study determined the incidence, determinants and prognostic factors of severe maternal outcomes (near miss or maternal death) in two referral hospitals in Uganda.
  
  
  METHODS
  A prospective cohort study was conducted between March 1, 2013 and February 28, 2014, where cases of severe pregnancy and childbirth complications were included. The clinical conditions included abortion-related complications, obstetric haemorrhage, hypertensive disorders, obstructed labour, infection and pregnancy-specific complications such as febrile illness, anemia and premature rupture of membranes. Near miss cases were defined according to the WHO criteria. Multivariate logistic regression analysis was conducted to identify prognostic factors for severe maternal outcomes.
  
  
  RESULTS
  Of 3100 women with severe obstetric complications, 130 (4.2%) were maternal deaths and 695 (22.7%) were near miss cases. Severe pre-eclampsia was the commonest morbidity (incidence ratio (IR) 7.0%, case-fatality rate (CFR) 2.3%), followed by postpartum haemorrhage (IR 6.7%, CFR 7.2%). Uterine rupture (IR 5.5%) caused the highest CFR (17.9%), followed by eclampsia (IR 0.4%, CFR 17.8%). The three groups (maternal deaths, near misses and non-life-threatening obstetric complications) differed significantly regarding gravidity and education level. The commonest diagnostic criteria for maternal near miss were admission to the high dependency unit (HDU) or to the intensive care unit (ICU). Thrombocytopenia, circulatory collapse, referral to a more specialized unit, intubation unrelated to anaesthesia, and cardiopulmonary resuscitation were predictive of maternal death (p < 0.05). Gravidity (ARR 1.4, 95% C1 1.0-1.2); elevated serum lactate levels (ARR 4.5, 95% CI 2.3-8.7); intubation for conditions unrelated to general anaesthesia (ARR 2.6 (95% CI 1.2-5.7), cardiovascular collapse (ARR 4.9, 95% CI 2.5-9.5); transfusion of 4 or more units of blood (ARR 1.9, 95% CI 1.1-3.1); being an emergency referral (ARR 2.6, 95% CI 1.2-5.6); and need for cardiopulmonary resuscitation (ARR 6.1, 95% CI 3.2-11.7), were prognostic factors.
  
  
  CONCLUSIONS
  The analysis of near misses is a useful tool in the investigation of severe maternal morbidity. The prognostic factors for maternal death, if instituted, might save many women with obstetric complications.
authors.affiliation: Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda.
authors.forename: Annettee
authors.initials: A
authors.lastname: Nakimuli
authors.affiliation: Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda.
authors.forename: Sarah
authors.initials: S
authors.lastname: Nakubulwa
authors.affiliation: Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda.
authors.forename: Othman
authors.initials: O
authors.lastname: Kakaire
authors.affiliation: Department of Obstetrics and Gynecology, Jinja Regional Hospital, Jinja, Uganda.
authors.forename: Michael O
authors.initials: MO
authors.lastname: Osinde
authors.affiliation: Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda.
authors.forename: Scovia N
authors.initials: SN
authors.lastname: Mbalinda
authors.affiliation: Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda.
authors.forename: Rose C
authors.initials: RC
authors.lastname: Nabirye
authors.affiliation: Clinical, Operations and Health Services Research Program, Joint Clinical Research Centre, P. O. Box 10005, Kampala, Uganda.
authors.forename: Nelson
authors.initials: N
authors.lastname: Kakande
authors.affiliation: Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda. dankkaye@yahoo.com.
authors.forename: Dan K
authors.initials: DK
authors.lastname: Kaye
mesh_terms: D000293:Adolescent; D000328:Adult; D004522:Educational Status; D005260:Female; D020073:Gravidity; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D063130:Maternal Death / Q000209:etiology / Q000706:statistics & numerical data*; D008428:Maternal Mortality; D000067491:Near Miss, Healthcare / Q000706:statistics & numerical data*; D007744:Obstetric Labor Complications / Q000209:etiology / Q000401:mortality; D006473:Postpartum Hemorrhage / Q000209:etiology / Q000401:mortality; D011225:Pre-Eclampsia / Q000209:etiology / Q000401:mortality; D011247:Pregnancy; D011248:Pregnancy Complications / Q000209:etiology / Q000401:mortality*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012307:Risk Factors; D014454:Uganda / Q000453:epidemiology; D014597:Uterine Rupture / Q000209:etiology / Q000401:mortality; D055815:Young Adult
references.citation: Br J Obstet Gynaecol. 1998 Sep;105(9):985-90
references.pmid: 9763050
references.citation: BMC Pregnancy Childbirth. 2008 Mar 12;8:10
references.pmid: 18366625
references.citation: Afr J Reprod Health. 2009 Jun;13(2):75-85
references.pmid: 20690251
references.citation: Acta Obstet Gynecol Scand. 2005 Jan;84(1):11-6
references.pmid: 15603561
references.citation: Cochrane Database Syst Rev. 2005 Oct 19;(4):CD002961
references.pmid: 16235307
references.citation: J Obstet Gynaecol. 1998 Sep;18(5):429-30
references.pmid: 15512135
references.citation: Afr J Reprod Health. 1998 Apr;2(1):10-9
references.pmid: 10214424
references.citation: J Intensive Care Med. 2007 May-Jun;22(3):141-56
references.pmid: 17562738
references.citation: BMJ. 2001 May 5;322(7294):1089-93; discussion 1093-4
references.pmid: 11337436
references.citation: PLoS One. 2013 Apr 16;8(4):e61248
references.pmid: 23613821
references.citation: Biomed Res Int. 2014;2014:989815
references.pmid: 25147830
references.citation: Reprod Health. 2011 Aug 02;8:22
references.pmid: 21810265
references.citation: Intensive Care Med. 1999 Jul;25(7):686-96
references.pmid: 10470572
references.citation: Reprod Health. 2005 Nov 01;2:9
references.pmid: 16262901
references.citation: Lancet. 2003 Jan 11;361(9352):180-1
references.pmid: 12531613
references.citation: Bull World Health Organ. 2000;78(5):593-602
references.pmid: 10859853
references.citation: Int J Gynaecol Obstet. 2011 Jul;114(1):84-5
references.pmid: 21570683
references.citation: Acta Obstet Gynecol Scand. 2006;85(7):797-804
references.pmid: 16817076
references.citation: BMC Pregnancy Childbirth. 2013 Jul 04;13:141
references.pmid: 23826935
references.citation: BJOG. 2003 Feb;110(2):128-33
references.pmid: 12618155
references.citation: Reprod Health. 2009 Sep 24;6:15
references.pmid: 19778437
references.citation: Br J Obstet Gynaecol. 1998 Sep;105(9):981-4
references.pmid: 9763049
references.citation: Aust N Z J Obstet Gynaecol. 2011 Oct;51(5):421-5
references.pmid: 21806590
references.citation: Int J Gynaecol Obstet. 2007 Sep;98(3):278-84
references.pmid: 17612545
references.citation: Medicina (Kaunas). 2004;40(4):299-309
references.pmid: 15111741
references.citation: Crit Care Med. 1998 Nov;26(11):1793-800
references.pmid: 9824069
references.citation: Br J Obstet Gynaecol. 1995 Apr;102(4):282-7
references.pmid: 7612509
references.citation: PLoS One. 2012;7(8):e44129
references.pmid: 22952897
references.citation: J Crit Care. 2011 Oct;26(5):535.e1-535.e7
references.pmid: 21106337
references.citation: Best Pract Res Clin Obstet Gynaecol. 2009 Jun;23(3):287-96
references.pmid: 19303368
references.citation: Acta Anaesthesiol Scand. 2008 Apr;52(4):467-78
references.pmid: 18339152
references.citation: Health Trends. 1991;23(1):13-5
references.pmid: 10113878
references.citation: East Afr Med J. 2003 Mar;80(3):144-9
references.pmid: 12762430
references.citation: Int J Gynaecol Obstet. 2004 Nov;87(2):180-7
references.pmid: 15491577
references.citation: Lancet. 1998 Jan 10;351(9096):145-6
references.pmid: 9439527
references.citation: Am J Obstet Gynecol. 2004 Sep;191(3):939-44
references.pmid: 15467568
references.citation: Clinics (Sao Paulo). 2012;67(3):225-30
references.pmid: 22473402
references.citation: Trop Doct. 1998 Oct;28(4):214-7
references.pmid: 9803841
references.citation: BMC Pregnancy Childbirth. 2007 Sep 11;7:20
references.pmid: 17848189
references.citation: Afr J Reprod Health. 2010 Jun;14(2):55-62
references.pmid: 21243919
references.citation: Cad Saude Publica. 2006 Feb;22(2):255-64
references.pmid: 16501738
references.citation: J Clin Diagn Res. 2014 Apr;8(4):OC06-8
references.pmid: 24959481