The quality of maternal healthcare is commonly assessed by studying maternal mortality. But is there a better way to evaluate healthcare for pregnant women? Researchers from the London School of Hygiene and Tropical Medicine argue that life-threatening illnesses or 'near misses' may be a better starting point for investigating and improving maternal healthcare systems.

What are the advantages of studying near misses? They occur more frequently than deaths, survivors can be interviewed and health professionals may be more willing to discuss cases where death was avoided. This approach may be a useful tool for evaluating maternal healthcare if consistent, reliable definitions can be developed.

Death is obviously the most severe outcome of pregnancy. So reviewing the circumstances leading to death is assumed to be the best way to highlight faults both within and beyond the health facility. Drawing on the experience of developed and developing countries, the researchers suggest ways in which severe or life-threatening complications during pregnancy can be used to assess maternal health services.

'Near miss' cases are potentially useful for in-depth case studies because:

• Episodes of severe illness are more common than maternal deaths, allowing stronger quantitative analysis.
• Women with life-threatening illness are often hospitalised, whereas maternal deaths frequently occur in the home. This makes it easier to review the healthcare they received.
• Survivors of life-threatening complications can be interviewed, which may reveal aspects of the episode that are otherwise overlooked.
• When patients have survived, discussion of the case may be less threatening to healthcare providers than when they died.
• Involving health professionals in the definition of severe illness may be the first step towards improving the accuracy of the data and ultimately the quality of care.

Compared to death, however, it can be difficult to define a life-threatening episode, and this complicates comparison across countries and facilities. Definitions of severe illness can be based on the management of the case (for example whether the patient was admitted to intensive care), on clinical symptoms, or on the involvement of organ systems. None of these operational definitions are universally applicable: they fail to take into account the resources available and the management situations in different health systems.

The researchers suggest selecting definitions based on the:

• purpose of the investigation
• resources available where the audit or case review is taking place
• quality of the available data.

Source(s):
'Investigating severe maternal morbidity' by C. Ronsmans and V. Filippi, in Maternal deaths: beyond the numbers, Geneva; World Health Organisation (in press)

id21 Research Highlight: 25 October 2002

Further Information:
Carine Ronsmans
Maternal Health Programme
Infectious Disease Epidemiology Unit
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Tel: +44 (0)20 7927 2190
Fax: +44 (0)20 7299 4720
Contact the contributor: carine.ronsmans@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

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