Table of Contents
Abstract
The neonatal near-miss Assessment Scale (NNMAS) is a specialized clinical evaluation tool designed to identify newborns who experience and survive severe, life-threatening complications during their first 28 days of life. Developed in response to the pressing global health mandate to reduce neonatal mortality, particularly in low-resource settings, this instrument provides a standardized method for capturing near-miss events. By systematically documenting these critical incidents, healthcare systems can better audit the quality of obstetric and neonatal care, moving beyond simple mortality rates to understand the nuances of severe neonatal morbidity.
The development of the NNMAS represents a crucial step in standardizing the near-miss concept for neonatal populations. While maternal near-miss criteria have been well-established for years, neonatal criteria have historically lacked consensus and standardized measurement. This scale operationalizes the concept through a multidimensional framework that captures clinical, laboratory, and pragmatic indicators of severe morbidity. Its validation in Ethiopia highlights its utility in resource-constrained environments where identifying systemic care gaps is essential for improving infant survival trajectories.
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Authors
Purpose
The primary purpose of the NNMAS is to provide clinicians and researchers with a psychometrically sound, contextually appropriate tool for identifying neonatal near-miss cases in low-resource healthcare settings. Historically, the evaluation of neonatal care quality has relied heavily on mortality rates, which fail to capture the broader spectrum of severe, life-threatening morbidities that infants survive. This scale fills a critical gap by offering a standardized set of criteria that do not rely exclusively on advanced technological diagnostics, making it highly applicable in developing nations.
For healthcare administrators and policymakers, the NNMAS serves as a vital quality improvement mechanism. By accurately identifying neonates who nearly died, facilities can conduct targeted clinical audits, investigate the root causes of severe morbidities, and implement systemic changes to prevent future neonatal deaths. It shifts the focus from retrospective mortality reviews to proactive morbidity management.
Construct
The clinical construct measured by the NNMAS is 'neonatal near-miss,' defined as the survival of a newborn following a severe, life-threatening complication within the first month of life. This construct is inherently multidimensional, reflecting the complex physiological systems that can fail during the neonatal period. The theoretical framework posits that severe morbidity can be captured through observable clinical signs, necessary medical interventions, and basic laboratory values.
The scale operationalizes this construct across six distinct domains: cardio-respiratory functioning, sensory and pharmacological interventions, neuro-renal health, hepatic system integrity, laboratory investigations, and pragmatic indicators such as extreme prematurity or very low birth weight. Together, these dimensions provide a holistic profile of neonatal vulnerability, ensuring that life-threatening events are captured regardless of whether they manifest as physiological collapse, the need for intensive resuscitation, or severe metabolic derangement.
Validity
The validation of the NNMAS involved rigorous testing of both convergent and discriminant validity to ensure the instrument accurately measures the near-miss construct. Convergent validity was strongly supported by the data, with average variance extracted (AVE) values ranging from 0.78 to 0.87 across the subscales, well above standard acceptable thresholds. Additionally, the factor loadings for the retained items were robust, falling between 0.52 and 0.86, indicating that the individual items are highly representative of their underlying clinical domains.
Discriminant validity was established using the Fornell-Larcker criterion, which demonstrated that the square root of the AVE for each factor was greater than its correlation with other factors. This confirms that the six dimensions of the scale measure distinct aspects of neonatal morbidity without excessive conceptual overlap. These psychometric properties suggest that the NNMAS meets high academic and clinical standards for construct validity.
Reliability
The NNMAS demonstrates excellent internal consistency, making it a highly reliable tool for clinical assessment. The overall instrument yielded a Cronbach's alpha of 0.80, indicating strong cohesion among the 24 items. This level of reliability is particularly impressive given the diverse, multidimensional nature of the clinical indicators being measured.
At the subscale level, the composite reliability scores were exceptionally high, ranging from 0.87 to 0.95. Furthermore, the item-total correlations were all above the acceptable threshold of 0.25, confirming that each specific clinical indicator meaningfully contributes to the overall assessment of a near-miss event. These findings assure researchers and clinicians that the scale will produce stable and consistent measurements across different patients within similar clinical settings.
Factor Analysis
To uncover the underlying structure of the NNMAS, the researchers conducted an Exploratory Factor Analysis (EFA) using Principal Component Analysis. The suitability of the data for structure detection was confirmed by a Kaiser-Meyer-Olkin (KMO) measure of 0.74 and a highly significant Bartlett's test of sphericity. These preliminary checks ensured that the clinical variables shared sufficient variance to form coherent groupings.
The extraction process revealed a robust six-factor structure that collectively accounted for 54.3% of the total variance in neonatal near-miss cases. The first and most prominent factor, representing cardio-respiratory issues, explained nearly 19% of the variance alone. Subsequent factors captured sensory/drug interventions, neuro-renal complications, hepatic issues, laboratory findings, and pragmatic criteria. The rotated component matrix showed clean item loadings, allowing for clear and clinically meaningful labeling of each domain.
Subscales
| Subscale | Items | Description |
|---|---|---|
| Cardio-respiratory | 7 items | Measures severe respiratory and cardiac distress, including absence of regular breathing, extreme tachypnea/bradycardia, and need for positive pressure ventilation or CPAP. |
| Sensory and drug | 3 items | Captures critical interventions and deficits, such as the use of corticosteroids, vasoactive drugs, and inability to suck within 24 hours. |
| Neuro-renal | 4 items | Assesses severe neurological and renal complications, including neural tube defects, recurrent seizures, central cyanosis, and anuria lasting more than 6 hours. |
| Hepatic | 3 items | Evaluates severe liver-related morbidities, including early jaundice and high bilirubin levels requiring phototherapy within the first 24 hours. |
| Lab-investigation | 3 items | Includes critical laboratory thresholds such as severe anemia (Hgb < 10 g/dl), low white blood cell count, and severe hypoglycemia. |
| Pragmatic | 4 items | Captures overarching vulnerability indicators including early surgery, gestational age under 34 weeks, birth weight under 1750 grams, and severe hypothermia. |
Instrument
| Test Type | Clinician-rated scale |
| Format | 24 items, dichotomous response format (yes/no) |
| Scoring | Items are scored dichotomously based on the presence or absence of specific clinical indicators. The presence of indicators across domains identifies a near-miss case. |
| Language | English |
| Population | Medical patients |
| Age Group | 0-28 days |
| Administration | Clinical observation and medical chart review by trained healthcare providers |
| Completion Time | 20 minutes |
Neonatal Near-miss Assessment Scale Items
Items are currently not available
The individual items of this scale are not publicly available. Researchers interested in using this instrument should contact the original authors directly to request the scale materials.
Sample
465 live-born neonates (53.3% male) admitted to maternity and neonatal wards across four public hospitals in the Amhara region of Northwest Ethiopia. Participants were selected using systematic random sampling.
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Cite this article
Mohammed looti (2026). Neonatal Near-miss Assessment Scale. PSYCHOLOGICAL SCALES. Retrieved from https://scales.arabpsychology.com/s/neonatal-near-miss-assessment-scale/
Mohammed looti. "Neonatal Near-miss Assessment Scale." PSYCHOLOGICAL SCALES, 14 Aug. 2026, https://scales.arabpsychology.com/s/neonatal-near-miss-assessment-scale/.
Mohammed looti. "Neonatal Near-miss Assessment Scale." PSYCHOLOGICAL SCALES, 2026. https://scales.arabpsychology.com/s/neonatal-near-miss-assessment-scale/.
Mohammed looti (2026) 'Neonatal Near-miss Assessment Scale', PSYCHOLOGICAL SCALES. Available at: https://scales.arabpsychology.com/s/neonatal-near-miss-assessment-scale/.
[1] Mohammed looti, "Neonatal Near-miss Assessment Scale," PSYCHOLOGICAL SCALES, vol. X, no. Y, ص Z-Z, August, 2026.
Mohammed looti. Neonatal Near-miss Assessment Scale. PSYCHOLOGICAL SCALES. 2026;vol(issue):pages.