ISSN: 2376-127X
Journal of Pregnancy and Child Health
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Review Article Open Access

Maternal Near Miss and Still birth in developing countries: A Systematic Review with Meta-Analysis

Ewnetu Firdawek1*, Alemayehu Worku2 and Mesganaw Fantahun3
1Department of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
2Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
3Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
Corresponding Author : Ewnetu Firdawek
Department of Nursing, College of Medicine and
Health Sciences, Arba Minch University, Arba Minch, Ethiopia
Tel: 251-46-8810771
E-mail: ewnetuliyew@gmail.com
Received: November 07, 2015; Accepted: November 27, 2015; Published: December 04, 2015
Citation: Firdawek E, Worku A, Fantahun M (2015) Maternal Near Miss and Still birth in developing countries: A Systematic Review with Meta-Analysis. J Preg Child Health 2: 209. doi:10.4172/2376-127X.1000209
Copyright: © 2015 Firdawek E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

Background: Maternal near miss during pregnancy and delivery are known to increase the odds of still birth. Although the available few studies suggested the association between maternal near miss and still birth, pooled effect of individual studies is not yet known for developing countries. Hence the aim of the Meta-analysis was to quantify the association between maternal near miss and still birth from studies conducted in developing countries.

Method: Electronic data bases like MEDLINE and Embase were used to search for relevant articles. Observational studies which were published in English language, irrespective of publication status were considered. The methodological quality of the studies included in the current review was done using the Newcastle Ottawa assessment scale and British Sociological Association Medical Sociology Group quality indicators. Pooled estimate along with 95% CI were calculated using random effect model. I2 statistics were used to test for heterogeneity. Forest plot were used to present findings. Egger’s and Begg’s test was done to check for presence of publication bias.

Result: Search of electronic data bases identified 265 studies of which five were included for the final analysis. Majority of the studies have a high methodological quality. The result of pooled estimate showed that the odds of still birth was higher in women who developed maternal near miss than those who deliver without complications (Pooled OR=4.67, 95% CI [2.91-7.47], I2=85.0%). Sub group analysis based on the design of the studies indicated that variation in the design was one of the factors responsible for the observed heterogeneity. The presence of publication bias was not observed from Begg’s and Egger’s test. (Begg’s Test p=0.462 and Egger’s test p=0.637)

Conclusion: The study revealed that the odds of still birth are higher in women who developed maternal near miss complications as compared to women without any complications. Hence this evidence will help policy makers in developing countries to design appropriate interventions that will enhance quality of obstetric care for women during pregnancy, delivery and after delivery so as to save the life of babies born from these women.

Keywords
Still birth; Maternal near miss; Developing countries; Systematic review; Meta-analysis
Abbreviations
AFNO: Adverse Fetal and Neonatal Outcome; APGAR: Activity, Pulse, Grimace, Appearance, Respiration; BSA: British Sociological Association; CI: Confidence Interval; ENM: Early Neonatal Mortality; ES: Estimate; HEELP: Hemolysis Elevated Liver enzymes, and Low Platelets; ICU: Intensive Care Unit; NOS: Newcastle Ottawa Assessment Scale; OR: Odds Ratio; RR: Relative Risk; SAMM: Severe Acute Maternal Morbidity; SE: Standard Error; WHO: World Health Organization
Background
A maternal near miss or severe acute maternal morbidity is currently defined by the WHO as ‘a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy [1].’
Until recently, different authors were using a variety of case identification criteria for maternal near miss. Review of literatures around the world found that the following five types of approaches have been used for identification criteria of maternal near misses. These include utilization of disease based or clinical sign and symptoms that were used by Filippi V et al. and Waterstone M et al. such as hemorrhage, severe preeclampsia, Eclampsia, HEELP syndrome [2,3], management based approaches such as admission to intensive care unit ,blood transfusion or hysterectomy [4-6] ,combination of clinical/disease, management and organ dysfunction that was used by Mantel et al. [7] , the new WHO approach [8,9] and modified WHO approaches [10].
Still birth or fetal death is defined as a fetal death in third trimester (>1000 g birth weight or ≥ 28 completed weeks of gestation [11]. Worldwide 3.3 million still births occur each year and majority of the deaths take place in developing countries. Still birth may stem from many causes and inappropriate management of complications during pregnancy and delivery is among those causes. One third to one fourth of all still births are estimated to occur during delivery and the remaining proportion is estimated to happen before delivery as a result of factors related to maternal and fetal origin [11]. Studies showed that excessively high still birth rates were seen among women with severe obstetric complications as compared to women without complication. For instance, a study by Leonam and his friends in their study in Brazil found a higher incidence of still birth among women with maternal near miss. Similarly, another study in Brazil also found a higher rate of fetal death among near miss women [12,13]. A higher rate of still birth was also seen among women of near miss in studies conducted in 8 Latin American countries, Pakistan and Syria [14-16]. In some of the African countries like Gambia, Nigeria and Sudan a higher risk of still birth was also observed among women of near miss when compared to women without near miss [17-20]. Hence, this is indicative of the link between still birth and maternal near miss.
Although the above few studies suggested the impact of maternal near miss on the risk of still birth, pooled effect of individual studies is not yet known in developing countries. Accordingly, robust evidence on the impact of maternal near miss on still birth is needed for policy makers in developing countries to minimize the high perinatal mortality of these countries as still birth account for over half of perinatal deaths [11]. As three quarter of the neonatal deaths happen in the first week of life and is an important component of child survival strategy, any interventions aimed at this stage has its implication to lower the overall child mortality figures for developing countries [21]. Thus the objective of the Meta-analysis was to estimate the pooled effect of maternal near miss on still birth based on studies done in the developing world.
Method
Search strategy
Electronic data bases which include MEDLINE (http://www.ncbi. nlm.nih.gov/sites/entrez?db) and Embase (http://www.embase.com) were used to search for important literatures. In addition, Google was also used to search for Gray literature .Reference list of retrieved articles have been checked to get more literatures. Those literatures which were published starting from 2005 up to 2015 were reviewed. The last search was done in April1, 2015. Key exposure terms used include severe acute maternal morbidity, maternal near miss, obstetric near miss, Eclampsia, preeclampsia, sepsis, infection, life threatening maternal complications, uterine rapture, obstructed labor, dystocia, unsafe abortions, bleeding and hemorrhage. The outcome key terms include perinatal mortality/ death, still birth, fetal birth, pregnancy outcome and perinatal outcome. The exposure and outcome key terms were combined among themselves using Boolean logic ‘OR’ and exposure and outcome were combined using ‘AND’. Review and presentation of this Meta-analysis was done in accordance with the preferred reporting items for systematic reviews and Meta-analysis check list (PRISMA check list) [22].
Inclusion and Exclusion Criteria
Inclusion criteria
Both observational as well as interventional studies were used as inclusion criteria. However, in the current review, only observational studies which include cross sectional, case control and cohort studies were found from the reviewed data bases. Those literatures from developing countries and published after 2005 were included. Only English written literatures were considered.
Exclusion criteria
Studies of adverse perinatal outcome which are associated with maternal morbidity (not the severe one) and those that assess different adverse perinatal outcomes other than still birth like birth weight, prematurity and APGAR score were excluded. Descriptive studies with no or appropriate comparison group were also excluded. Studies were also excluded if there were no data on the exposure or outcome variable. We also excluded those articles for which we fail to get the full document. Those studies that fail to analyze the outcome (in our case still birth) separately were also part of the exclusion criteria. Summary of inclusion and exclusion criteria are presented in Table 1.
Methodological quality
The methodological quality of the included studies were done using the Newcastle Ottawa assessment scale(NOS) for case control and cohort studies while British sociological association (BSA) Medical Sociology Group that were used by Islam et al. [23] were used for cross sectional studies. While using NOS for case control studies, the study was awarded a maximum of one star for each numbered quality assessment items with in the selection and exposure category and a maximum of two stars for comparability. Similarly for cohort study a maximum of one star was awarded for each numbered items with in selection and outcome and a maximum of two stars for comparability. A NOS score of <4 was considered as low quality, 4–5 moderate quality and ≥ 6 as high quality [24]. For cross sectional study, BSA Medical Sociology Group quality indicators comprising seven quality indicators were used. The total score is out of seven and those studies that get 1-2 were regarded as low quality, 3-5 moderate and 6-7 high quality [23]. The summery of quality assessment used in the review using NOS and BSA Medical Sociology Group quality indicators can be found in Additional file 1and 2 respectively.
Data Extraction
The data were extracted by the principal investigator from the studies included in the Meta analysis using a predefined form which include authors name, maternal near miss criteria used, year of publication, country, design, exposure, outcome, sample size, population, quality of study, and OR estimate.
Operational Definitions
Maternal near miss refers to a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy.
Uncomplicated delivery is defined as any delivery which took place through the vagina without any complications.
Still birth or fetal death is defined as a fetal death in third trimester (>1000 g birth weight or ≥ 28 completed weeks of gestation.
Severe maternal outcome A life-threatening condition (i.e. organ dysfunction), including all maternal deaths and maternal near-miss cases.
Statistical Analysis
The statistical analysis was performed using STATA 11 computer software program. Estimate of individual studies as well as pooled estimate from the included studies was performed along with its 95% confidence interval [25]. For cross sectional and case control studies, adjusted OR was used as a measure of effect size while crude OR with corresponding 95% confidence interval was calculated from the original paper using Epi Info software for the cohort study. In order to test the presence of heterogeneity among the studies included in the Meta analysis, I-squared statistics was used. I-squared is a measure of variation in estimate attributable to heterogeneity. The score of heterogeneity is between 0%-100% with 25% low hetrogenity,50% moderate and 75% high [26]. Since the degree of heterogeneity in this study is high (85.0%), random effect model was used to calculate the pooled estimate. To further explore what causes heterogeneity among studies, we performed sub group analysis based on the factor identified to be a potential source of heterogeneity such as study design. To check for the presence of publication bias, a simple graphic test called funnel plot was examined visually. If the plot is asymmetric and skewed ,it shows that the meta analysis missed some studies and presence of publication bias [27].Since its capacity is minimal to detect bias in smaller trials and visual inspection is subjective, a formal statistical test called Egger’s and Begg’s test was also used with p<0.1 indicating a significant asymmetry and presence of bias [27].
Results
Study selection
Initially a total of 262 articles were identified from the electronic data bases. Of these, 220 articles remained after duplicates were removed using End Note software. After the title and abstract have been checked for relevance, only 56 articles were left for further screening using inclusion and exclusion criteria as well as availability of full document. Using the inclusion and exclusion criteria, 44 studies were excluded. Reason of exclusion include, assessed perinatal out come in maternal morbidity (not the severe one), assessed different perinatal outcome (e.g., birth weight and preterm) and those having no data on exposure. The details of articles excluded with their reason of exclusion have been presented in Additional file 3. After reviewing full document, 8 studies have been excluded and reason of exclusion include; incomplete perinatal outcome data, outcome not separately analyzed (analyzed adverse fetal and neonatal out come together), were descriptive and absence of appropriate comparison group. Finally, 5 articles remained for final Meta-analysis which includes 2 cross sectional, 2 case controls and one cohort. Figure 1 below shows the flow of study selection for the Meta-analysis.
Study Characteristics
Overall a total of 5 studies were included in the Meta-analysis. Three of the studies were from Africa and the rest two were from Latin America. Two of the studies were case control [17,28], 1 cohort [15] and the rest two were cross sectional [19,29].The study which was done in Nigeria by Adeoye and his friends used disease specific criteria to identify maternal near miss cases. It was a case control study done on 64 near miss cases and 256 controls. The study tried to compare the risk of still birth among women with maternal near miss case and among those who delivered without complication. The result showed that the odds of still birth was around 5 times higher in those who developed maternal near miss when compared to those who delivered without complication (OR=5.4 95% CI, 2.18-13.40).The quality of this paper was assessed using Newcastle Ottawa assessment scale and was rated as medium quality study.
The second study which was done in Sudan by Ali and his colloquies compared the odds of still birth among women who delivered having severe anemia and no anemia. It was a case control study which was conducted on a total of 909 women. The study indicated that women who delivered having severe anemia is around 4 times higher risk of developing still birth than women who delivered without anemia (OR=4.3,95% CI, 1.9-9.1).The quality of this paper was generally rated to be high.
Study three by Souza and his friends ,which was conducted in 8 Latin America countries used the pragmatic definition(admission to ICU, blood transfusion, hysterectomy, Eclampsia, cardiac or renal complications) to identify maternal near miss cases. In their cohort study, 2952 women exposed to maternal near miss and 94,083 women without any complications were compared for the development of still birth. The result of the study depict that the odds of still birth was around four times in women who delivered with maternal near miss complications as compared to women who delivered without complication (OR=4.22, 95% CI, 3.42-5.20).In this study, the crude OR was calculated from the reported raw data using a two by two table in Epi Info software program. NOS for this study showed to be a high quality study.
The fourth study included in this meta-analysis was conducted in Gambia by Cham and his friends. They used the disease specific and management based approach to identify maternal near miss cases. The study used retrospective review of records on 826 women with maternal near miss case and 2454 women with non near miss cases to see the still birth rates among the two groups. They found that there was an 8 fold increase risk of still birth among women with severe obstetric complications compared to women without complication. BSA Medical Sociology Group quality indicators were used to see the quality of this article and were rated as a high quality.
The last study was a cross sectional study conducted in Brazil. The authors used the WHO criteria to identify maternal near miss cases. They compared still birth risk between those women who developed severe maternal outcome (death plus near miss) and those without severe maternal outcome. The finding showed that still birth was worse in those who developed severe maternal outcome (OR=2.34, 95% CI 1.29–4.24). Summary of the characteristics of the studies included in the Meta analysis has been shown in Table 2.
Association Between Maternal Near Miss and Odds of Still Birth
The result of the overall pooled estimate performed from random effect analysis showed that the odds of still birth was higher in women who developed maternal near miss than those who deliver without complication (Pooled OR=4.67, 95% CI, 2.91-7.47).The I squared statistics showed that there is a higher heterogeneity among the included studies (85.0%). Figure 2 shows the forest plot of studies included in the Meta-analysis.
Sub Group Analysis
Subgroup analysis was performed according to the designs used by the studies. This factor was considered a priori as a potential source of heterogeneity among the studies. The other characteristics of the studies like quality of the study and maternal near miss criteria’s used were not taken in to account for the sub group analysis as the number of studies included was minimal to sub group according to these factors. Hence, the result of sub group analysis based on design used indicated that 93.5% of the observed heterogeneity is due to the cross sectional study. Thus, variation in the design was one of the factors responsible for the observed heterogeneity (Table 3).
Figure 3 below shows the subgroup analysis performed based on the design of the study to asses for the source of heterogeneity.
To check for the presence of publication bias, funnel plot was used and found that it was symmetrical using visual view. Begg’s and Egger’s test was also done to test publication bias and both showed absence of publication bias (Begg’s Test p=0.462 and Egger’s test p=0.637). Figure 4 below is a funnel plot used to check the presence of publication bias.
Discussion
The objective of the Meta-analysis was to quantify the association of still birth with that of maternal near miss. The result of this Metaanalysis showed that the magnitude of still birth is higher among women who developed maternal near miss than those who deliver without complications. The result was consistent with studies conducted elsewhere that tried to investigate the risk of still birth among maternal near miss cases [12,13,20,30]. Possible explanation for this is that, the health of the mother during pregnancy and delivery is closely linked to survival of the newborn and pregnancy complications or maternal diseases are the main cause of still birth [11]. Every year more than 3.3 million babies are still born and one in three of these deaths occur during delivery and the remaining proportion is estimated to happen before delivery as a result of factors related to maternal and fetal origin [11,31]. Since complications associated with pregnancy and delivery is one of the main causes of stillbirth, it is important to prevent severe maternal complications (maternal near miss) during pregnancy and delivery so as to reduce the rate of still birth among these mothers. Studies also showed that developed countries reduced the rate of still birth mainly due to reductions they made during intra-partum period [32,33]. Besides minimizing still birth contribute to lower the perinatal mortality rate as still birth contribute to over half of perinatal deaths [11].This in turn contribute to lower the overall child mortality figures via lowering the infant mortality rate as more than three quarter of infant deaths occur during the first 28 days of life [21]. Hence, as severe complications that happened during pregnancy and child birth contribute to increase the odds of still birth, working on the general health of the mother during pregnancy and delivery period can also save the life of infants born to these women. The policy makers should, therefore, focus on improving the health of the women during this period so that child mortality level of their country will be minimized.
Limitation of the Review
The studies that were included in this Meta-analysis used different identification criteria to define the exposure(maternal near miss).One of the studies used the WHO criteria [29], some used disease based [17,28],the other disease plus management based [19] and the rest used pragmatic definitions [15]. Using different identification criteria to identify maternal near miss cases might have its own impact for the observed heterogeneity of the studies. In addition, the design variations observed among the studies included in the Meta-analysis could be one possible explanation for the observed heterogeneity as seen from the sub group analysis. We found and include only few articles, five in number, which assessed the impact of maternal near miss on still birth. This posed difficulty to perform subgroup analysis for all study characteristics supposed to cause heterogeneity among the included studies. In addition search strategy used only free data bases and it was also difficult to get the full articles of some retrieved papers which might introduce bias in the summery estimate of the Meta-analysis. Use of crude and adjusted OR for the summery estimate might have an impact on the overall pooled effect of the observed association. At last, health system of one country will vary from the other. Hence, still birth risk might be as a result of variation in health system of the country as well as confounded by other factors. So the result should be interpreted with caution.
Conclusion
The Meta-analysis showed that the odd of still birth is higher in women who developed maternal near miss complications during pregnancy and delivery when compared to women without any complications. Hence, to prevent the high still birth rate among these mothers, strategies should be designed so as to enhance the overall quality of care for mothers during pregnancy and delivery.

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Maternal Near Miss and Still birth in developing countries: A Systematic Review with Meta-Analysis
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