Maternal near Miss and Maternal Death in the World Health Organization's 2005 Global Survey on Maternal and Perinatal health/Deces Maternels et Deces Maternels Evites De Justesse Dans le Cadre De L'enquete Mondiale Sur la Sante Maternelle et Perinatale Realisee En 2005 Par l'Organisation Mondiale De la Sante/Cuasieventos Maternos Y Mortalidad Materna En la Encuesta Mundial 2005 De la Organizacion Mundial

Introduction Approximately 15 000 women die every year in Latin America and the Caribbean of causes related to pregnancy. The maternal mortality ratio (MMR) for the region, which is around 130 maternal deaths per 100 000 live births, lies somewhere between the MMRs observed in developed and underdeveloped countries. (1) When maternal deaths are infrequent, the information they provide is not generalizable and they become poor sources of information on which to base measures to improve maternal health. Thus, in this situation severe maternal morbidity, which continues to be a public health problem in Latin America, has been proposed as a proxy for maternal death. (2,3) Women who survive severe complications during pregnancy, childbirth and the postpartum period could serve as surrogates to help us gain a better understanding of the set of conditions and preventable factors that together contribute to a maternal death. (2) This is known as the concept of maternal near miss (4) recently defined by the World Health Organization (WHO), after some controversy, (5) as the near death of a woman from a complication during pregnancy, childbirth or within 42 days after the termination of pregnancy. (6) Assessing maternal near misses for their values as proxies may be especially useful in Latin America, where MMRs are moderately low. In this paper we describe the occurrence of severe maternal morbidity in large hospitals in Latin America and test the usefulness of a pragmatic definition of maternal near miss for predicting maternal deaths. We also checked for associations between a maternal near miss on the one hand, and maternal factors and perinatal outcomes on the other. Methods The WHO Global Survey on Maternal and Perinatal Health, whose methods have been described in detail elsewhere, (7,8) is a multicountry and multicentre study designed by WHO in 2004 to explore the relationship between rates of Caesarean delivery and maternal and perinatal outcomes in selected medical institutions. It has also been used to gather information on severe maternal complications in Africa, Asia and Latin America. Briefly, the WHO Global Survey was implemented through a worldwide network of health institutions that were selected by means of a stratified multistage cluster sampling design. The present study is a secondary analysis, performed in 2005, of the Latin American database. Anonymous maternal and perinatal data were collected from the hospital records of all women admitted for delivery over a period of two to three months to 120 randomly selected hospitals located in eight randomly selected Latin American countries. In each hospital data were collected over two to three months and entered in a MedSciNet AB (Stockholm, Sweden) online data system. Definitions and outcomes In 2005, WHO criteria for maternal near miss had not yet been defined. Nonetheless, we used the information available in the database to establish the predictive value of five factors with respect to maternal death during pregnancy, childbirth and the first week postpartum. The five factors were admission to the intensive care unit (ICU), blood transfusion, hysterectomy, eclampsia, or cardiac and renal complications. We assumed that a combination of factors indicative of severe maternal morbidity would identify those women who, having narrowly escaped maternal death, could be considered maternal near misses. We also examined the association between maternal near miss and certain maternal and institutional characteristics, namely age, marital status, years of schooling, parity, number of antenatal visits, obesity, Caesarean section in the previous pregnancy, and type of health facility in which the delivery took place (public, social security or private). We also looked at the following perinatal outcomes: length of maternal postpartum stay, low and very low birth weight, admission of neonate to ICU, stillbirth, early neonatal death and mode of delivery. …