Maternal death (MD) is the most catastrophic end that could happen to a pregnant woman. It is frequently described as just “the tip of iceberg” and maternal morbidity as the “base”.1–3 Morbidity during pregnancy represents part of a continuum between the extremes of good health and death. Unexpected maternal morbidity that did not result in death but had the potential to do so is classified as a near-miss (NM).4,5 Potentially life-threatening condition (PLTC) has been used as the initial classification of severity in a continuum of severe morbidity, NM, and death. Organ-based dysfunction is used as a golden standard-set criterion for severe maternal outcome (SMO), including all MDs and maternal near-misses (MNMs).6–8 The World Health Organization (WHO) working group on maternal morbidity and mortality classifications established a standard definition to describe severe threats to maternal life.9 This definition is aligned with the International Statistical Classification of Diseases and Related Health Problems (ICD-10).10 MNM was, therefore, defined as women who nearly died but survived a complication that occurred during pregnancy, delivery, or up to 42 days after the end of her pregnancy.6,9

Precise classification of NM morbidity is the first step in analyzing factors that may differentiate survival from death on the continuum from morbidity to mortality.11 Three different methods have been used to identify MNM cases. These approaches are either a set of clinical criteria defining common diagnostic categories, a set of laboratory based criteria, or a set of management based criteria related to specific interventions representing different levels of an organ(s)/system dysfunction and/or failure.7,9,12,13

Although the majority of the deliveries in Iraq occur in public hospitals,14,15 the Maternal Mortality Ratio (MMR) in Iraq and the Kurdistan region in 2012 was 63 deaths/100 000 live births.16,17 In depth study of the MNM cases will play a vital role in identifying any deficiencies as well as strengths in the provision of obstetrical services in the Kurdistan region and will be useful in correcting and strengthening the obstetrical care, hence further reducing MMR. Additionally, epidemiological data on MNM cases are not available in the Kurdistan region.

The objective of this study, therefore, was to determine the major determinants of MNM and mortality events in Erbil city by comparative analysis.

Methods

We conducted a hospital-based cross-sectional study at Erbil Maternity Teaching Hospital. Data collection was done between 1 June and 31 December 2013. This hospital is the only public tertiary care hospital with 313 beds in Erbil governorate, in the Kurdistan region of Iraq. Erbil governorate has a population of around 1 613 223.18 In the previous five years, thousands of displaced Iraqis and Syrian refugees in Erbil increased the population to more than 2 000 000.19 The hospital provides emergency obstetric and gynecological care 24 hours a day.

All MDs and NMs that occurred in the hospital during the study period were included in the study. A systematic identification of the eligible women for the study was done. This identification included a baseline assessment of the severe pregnancy-related complications using the WHO NM criteria.20 However, not all WHO criteria were applicable; therefore, a local modification of the criteria was made. For this reason, the severe forms of the five complications of PLTCs used by the WHO (postpartum hemorrhage (PPH), preeclampsia/hemolysis elevated liver enzymes and low platelet count (HELLP), eclampsia, sepsis or systemic infection, and ruptured uterus) were expanded to include cases of the severe forms of complications of abortion, complications of ectopic pregnancies, complications of abruptio placentae, complications of placenta previa, and other complications associated with SMO.

The operational definitions and indicators used at the hospital are those recommended by the WHO.20 A modified WHO structured questionnaire was filled by direct interview of each woman during her hospital stay. Data on sociodemographic characteristics (including age, education, occupation, and residence), obstetric characteristics, and antenatal care was obtained. The completed questionnaire was double-checked for any missing data. Data not provided by the patient was obtained from their medical record including contributory and associated causes.

The occupation of the women was categorized into three groups: high professionals (medical doctors, dentists, engineers, university teaching staff, lawyers, directors); non-manual skilled or semi-skilled occupations (school teachers, clerks, healthcare workers (excluding doctors, dentists and pharmacists), small business owners); and manual, partly-skilled or unskilled occupations (labor workers, casual workers). Unemployed and retired women were classified according to their previous occupation.21 Housewives and students were categorized into two separate groups.

Critical intervention describes transfusion of three units of blood products or more, laparotomy (including hysterectomy but excluding cesarean section), and admission to the close observation care unit (COCU) for six hours or more as no intensive care unit (ICU) was available. The term prolonged labor refers to abnormal or difficult childbirth or labor for more than 24 hours. Anemia refers to low hemoglobin level (< 6 g/dL) or clinical signs of severe anemia in women without severe hemorrhage, according to Filippi et al.22 The mortality index (MI) was calculated by dividing the number of MDs by the number of women with SMO and is expressed as a percentage.20

Data were analyzed using IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA). Chi-squared test of association was used to compare proportions. A p-value ≤ 0.050 was considered statistically significant.

Results

During the seven-month data collection period, 17 353 live births were registered. A total of 180 women with PLTCs were diagnosed, of which 155 women required critical interventions, and 153 developed SMOs ending with 142 MNMs and 11 MDs.

The mean age±standard deviation of women with PLTCs was 29.0±7.0 years (range 15–49 years), 29.0±6.8 years (range 15–49 years) for women with MNMs, and 29.9±9.3 years (range 15–49 years) for MDs (p = 0.881). Mean gravidity was 3.6±2.8 (range 1–16) for MNM and 4.4±3.5 (range 1–11) for MDs (p = 0.780), and parity was 2.9±2.3 (range 0–13) for MNM and 3.6±3.0 (range 0–9) for MDs (p = 0.570). There were no significant variations in the sociodemographic and obstetric characteristics of the two groups [Table 1].

The mean best estimate gestational age in completed weeks (obstetric/neonatal) was 31.5±10.4 weeks (range 6–42 weeks) for MNM cases and 34.6±6.3 weeks (range 22–40 weeks) for cases of MD (p = 0.999). A statistically significant difference (p = 0.004) was demonstrated between the two categories of dead fetus (stillbirth and early neonatal death). All dead fetuses of MDs were stillbirths while this number was only 36.1% of the MNMs [Table 2].

Severe preeclampsia and PPH constituted the highest proportions of complications in women with PLTCs (30.5% and 30.0%, respectively). The proportions of preeclampsia were 29.5% and 36.3%, while those of severe PPH were 30.9% and 27.2% in MNM and MD cases, respectively. Hypertensive disorder constituted the highest underlying disorder (40.5%) followed by obstetric hemorrhage (34.4%) in women with PLTCs. The proportion of hypertensive disorders were 40.8% and 54.5%, while those of obstetric hemorrhage were 35.2% and 27.2% in MNM and MD cases, respectively. There were no significant differences between the two groups of SMOs in the proportions of severe complications and underlying causes. The highest mortality indexes (MIs) for specified obstetric causes were those for ruptured uterus (16.7%) and severe complications of placenta previa (14.2%) [Table 3].

Cardiovascular, multiple/unspecified, and coagulation/hemorrhage organ/system dysfunctions constituted the majority of organ dysfunctions developed by women with SMOs (60.7%, 60.1%, and 38.5%, respectively). There were significant differences between cases of MNM and MD in developing hepatic dysfunction (p = 0.046) and multiple/unspecified dysfunctions (p = 0.003) only. The MI was 18.2% for uterine dysfunction/hysterectomy, and 16.1% for hepatic dysfunction. Details of organ dysfunctions are shown in Table 4.

Over half (53.0%) of MNM cases developed on arrival to the hospital, compared with 9.0% of MD cases (p = 0.003). Nearly 55.0% of MDs were referred from other health facilities, compared with 39.4% of MNM cases. All referred MDs were referred from a rural hospital, while this number was only 32.1% of MNMs (p = 0.053). Nearly 55.0% of MDs arrived in emergency condition by ambulance, while only 21.1% of MNM cases arrived by ambulance (p = 0.015). Around 86.0% of women with PLTCs underwent critical interventions. Admission to the COCU was significantly higher (p = 0.020) among MNMs cases (90.0%) than MD cases (60.0%). Previous cesarean was the only contributory/associated cause significantly higher (p = 0.013) among MD cases (54.5%) than MNM cases (19.0%) [Table 5].

Discussion

The need for investment in the field of maternity services could be monitored by assessing the quality of obstetric care. Because NM cases are likely to have characteristics in common with cases of MD, a thorough investigation of the determinants and factors that result in MNM can provide more information and highlight areas that need better management.8

This cross-sectional hospital-based investigation of MNM and mortality was conducted for the first time in the Kurdistan region of Iraq. We used a modified WHO near-miss approach and criteria,20 adding certain severe complications that fulfill the clinical, laboratory, and management criteria used to identify a NM. This approach has been used in studies in low-resource setting areas in Malaysia,23 Indonesia,24,25 South Africa,26 Uganda,27 rural Sudan,28 Pakistan,29 Tanzania,30 and Brazil.31,32 The adoption of PLTCs in this study as the initial classification in a continuum of maternal severe morbidity has been adopted in other studies in Tanzania,30 Brazil,31,32 and Iraq (Baghdad).33

We found no significant variations in the sociodemographic and obstetric characteristics of MNM and MD cases, in agreement with studies from Indonesia,24 rural Sudan,28 and Tanzania,30 and the WHO’s 2005 global survey on maternal and perinatal health.34 However, a Turkish study35 reported a significant difference in the gravidity of both groups. The majority of MNM cases and MDs were in their third and forth decades of life, which reflects the usual age of marriage and reproduction. This finding is in agreement with those reported from Indonesia,24 Turkey,35 Brazil,36 the Netherlands,37 and Syria.38 In the WHO’s 2005 global survey,34 NM was significantly associated with higher educational levels. Their finding could be attributed to the tendency of women with higher educational levels to seek early health advice or undergo a cesarean section. In our study, a higher proportion of illiterate women was demonstrated among the MDs group than the MNM cases (non-significant). In agreement with other studies,24,35–38 most MNMs and MDs were in multiparous or multigravida women. A study in India,39 reported that primiparas were slightly more in the MNM group.

In this study, we found no significant variations between MNMs and MDs antenatal care, final mode of delivery or abortion, gestational age, and vital status of the infant. These findings are in agreement with those reported in Tanzania30 and Turkey.35 The proportion of non-attendance to antenatal care among the MDs group was twice that of the MNMs group. A study in Nigeria,40 reported that non-visiting of antenatal care, at least once, was a significant risk factor for MD. Around half of the women with MNMs or MDs delivered by cesarean section, while a study in Baghdad33 reported this as more than 60%. In Brazil,31 cesarean section was a significant protective factor for progression to MNMs and MD. Some authors consider cesarean section delivery as a factor that increased the chance of a woman becoming a NM case by five times; however, this association may be influenced by confounding factors.41 Thus, it is still debatable whether cesarean section is a determinant for NM or is a consequence of this condition.41,42 The WHO recommends cesarean section rates of 15% and identifies higher rates as both potentially harmful and costly to mothers and health care systems.43 Cesarean section has been reported to increase maternal morbidity in Latin America.44

Most MNMs and MDs cases occurred in the third trimester of gestation. This finding is in agreement with those reported from Indonesia,24 Pakistan,29 Tanzania,30 Turkey,35 and Syria.38 In rural Sudan,28 the gestational age of MNMs was significantly higher than that of MDs. The stillbirth rate in MD cases (100%) was significantly higher than that of MNMs (36%). In the WHO’s 2005 global survey,34 and studies in Brazil32,44 and Uganda45 stillbirth was significantly associated with progression of PLTCs to MNMs and MDs.

The main underlying causes and severe complications responsible for NM and MD in our study were severe preeclampsia, severe postpartum hemorrhage, and eclampsia. Other studies revealed similar determinants.24,28,38,40,46,47 There were no significant variations in the underlying causes and severe complications responsible for MNMs and MDs. This finding indicates that NM review of the disease process can be a useful surrogate of MD analysis.22,32,40,48 However, in a study from Turkey,35 significant variations were detected in the proportions of severe complications among the two groups of SMOs. Including the MI for each disease process allows the assessment of the standard of care with respect to common causes of MDs. The highest MI for known severe complications and underlying causes in this study was that of ruptured uterus (16.7%), which constitutes a significant threat to the survival of affected patients and the poorest level of care. Similarly, the level of care provided for pregnancies complicated by severe complications of placenta previa and eclampsia also deserve special attention. These could reflect the lack of adoption of a clear and up-to-date evidence-based protocol for treating these conditions.

In the study from Nigeria,40 ruptured uterus had the highest MI with significant variations between the two groups of SMOs. Sepsis had the highest MI in studies from rural Sudan,28 Brazil,32 Syria,38 India,39 and Bolivia.49

Hypertensive disorders and obstetric hemorrhage were the most common underlying causes of PLTCs. More than half of MD cases developed hypertensive disorders (with a relatively high MI) similar to that revealed by previous studies.38,40,46,47,49,50 In South Africa, hypertensive disorders were the commonest direct cause of MDs.51 In Indonesia,24 rural Sudan,28 and Baghdad33 studies, obstetric hemorrhage constituted the highest cause followed by hypertensive disorders. The highest revealed MI was that for women with unknown causes (20.0%). However, the unknown causes constituted the least frequency (3.3%) of severe complications and underlying causes associated with mortality. These findings could reflect lack of knowledge or incomplete recording and lack of autopsy to evaluate those deaths. In an Indian study in Ahmad Abad,52 medical disorders had the highest MI.

Cardiovascular dysfunction was the commonest organ/system dysfunction reported in this study for MNMs and MD groups followed by multiple or unspecified disorders. Similar findings were reported in Indonesia24 and Baghdad.33 In the mentioned study from Indonesia, the majority (77.3%) of NM cases had one major organ dysfunction, 16.0% had two, 4.6% had three, and 2.0% had four or more. In a study from Baghdad,33 212 women with NM were studied; 16 of the MDs had organ dysfunction (one had unspecified organ dysfunction, and nine had multiple organ dysfunctions).

The highest MI was that for uterine dysfunction/hysterectomy (18.2%), although it constituted the least proportion of organ dysfunction in SMOs (7.1%). This high MI is compatible with that of ruptured uterus, which reflects either a delay in diagnosis and care of obstructed labor and previous scar. Coagulation disorders had the highest MI in the study from Ahmad Abad.52

In this study, a significantly higher proportion of MNMs (over 50%) developed on arrival to the hospital, while around 91% of MDs developed during hospitalization. In the study from Uganda,27 a similar significant association was detected between MD and the timing of complications. In Tanzania,30 half of women who delivered at home were referred to hospital, and all MDs were identified in-hospital.

The high MDs developed during hospitalization could reflect an error in diagnosis and clinical decision-making or lack of medical supplies and staff proficiency in the management of obstetric emergencies. This is further corroborated by the finding that all referred MDs were referred from rural hospitals. It might also reflect late arrival in critical conditions taking into consideration that more than half of MDs arrived by ambulance in an emergency condition. On the other hand, the high proportion of MNMs on arrival could reflect less of a delay in reaching the hospital or in deciding to seek care. A lack of medical supplies and staff proficiency has been reported in previous studies.5,38,49 Studies in rural Sudan,28 Syria,38 Nigeria,40 and Uganda45 reported that most women with PLTCs were referred from other health facilities in critical condition. Similarly, in our study, around two-thirds of women with PLTCs were referred from rural hospital or private clinic in an emergency condition. Most cases of MNMs and MDs arrived in an emergency condition, whether by ambulance or private car, with significant variations between the two groups of SMOs. This finding is similar to that reported in Tanzania.30 In the Syrian study,38 most women have arrived in critical condition by private car.

More than 90% of women with SMOs underwent critical intervention(s) with no significant variations between the two SMO groups. However, a significantly higher rate of admission to the COCU was demonstrated among the MNMs group. A similar finding was reported in Uganda.27 A study from Brazil,32 found a significant association of MNMs and admission to intensive care for more than two days. Transfusion of blood and blood products was the most common intervention in both groups of SMOs with no significant difference, a finding which was similarly reported in Uganda.53 In Tanzania,30 no significant difference in the rate of laparotomy in both groups of SMO was demonstrated, similar to our study. However, in Turkey,35 a significant difference in the laparotomy rate was demonstrated between the two groups of SMO. A significantly higher proportion of MDs had a previous cesarean section than women with MNM. However, studies in Tanzania30 and Brazil,36 revealed no significant variations. In the Nigerian study,40 no significant variation in the proportion of anemia was detected between the two groups of SMO, which was similarly revealed by this study.

Conclusion

Major determinants, including demographic, obstetrics characteristics (antenatal care, final mode of delivery or abortion, gestational age, and vital status of the infant), underlying and associated causes of MNMs and MDs, are similar. Severe preeclampsia and PPH were the main complications leading to PLTCs. Factors found to be associated with MD were hepatic dysfunction, multiple/unspecified disorders, arrival to hospital as an emergency condition by ambulance, and history of previous cesarean section. These findings would guide the hospital administration to issue recommendations that may lead to a decrease in maternal mortalities.

Disclosure

The authors declared no conflicts of interest. No funding was received for this study. The protocol of the study was approved by the Research Ethics Committee of the Kurdistan Board of Medical Specialties. A written informed consent was obtained from each woman (or her guardian) before being enrolled in the study.

Acknowledgements

The authors would like to acknowledge the role of the staff of the Maternity Teaching Hospital in assisting the investigator in completing the data collection.

references

1. 1. Ashford L. Hidden suffering: Disabilities from pregnancy and childbirth in less developed countries. Population Reference Bureau. 2002 [cited 2016 June 24]. Available from: http://www.prb.org/pdf/hiddensufferingeng.pdf.
2. 2. Reichenheim ME, Zylbersztajn F, Moraes CL, Lobato G. Severe acute obstetric morbidity (near-miss): a review of the relative use of its diagnostic indicators. Arch Gynecol Obstet 2009 Sep;280(3):337-343.
3. 3. Paruk F, Moodley J. Severe obstetric morbidity. Curr Opin Obstet Gynecol 2001 Dec;13(6):563-568.
4. 4. Nashef SA. What is a near miss? Lancet 2003 Jan;361(9352):180-181.
5. 5. Stones W, Lim W, Al-Azzawi F, Kelly M. An investigation of maternal morbidity with identification of life-threatening ‘near miss’ episodes. Health Trends 1991;23(1):13-15.
6. 6. Ronsmans C, Filippi V. Reviewing severe maternal morbidity: learning from survivors of life threatening complications. In: WHO: Beyond the numbers: Reviewing maternal deaths and complications to make pregnancy safer. Geneva: WHO; 2004.
7. 7. Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near-miss. Br J Obstet Gynaecol 1998 Sep;105(9):985-990.
8. 8. Tunçalp O, Hindin MJ, Souza JP, Chou D, Say L. The prevalence of maternal near miss: a systematic review. BJOG 2012 May;119(6):653-661.
9. 9. Say L, Souza JP, Pattinson RC; WHO working group on Maternal Mortality and Morbidity classifications. Maternal near miss–towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009 Jun;23(3):287-296.
10. 10. WHO. ICD-10: International statistical classification of diseases and health related problems. 10th revision. Geneva: WHO; 2010.
11. 11. Geller SE, Rosenberg D, Cox SM, Kilpatrick S. Defining a conceptual framework for near-miss maternal morbidity. J Am Med Womens Assoc (1972) 2002;57(3):135-139.
12. 12. Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ 2001 May;322(7294):1089-1093, discussion 1093-1094.
13. 13. Minkauskiene M, Nadisauskiene R, Padaiga Z, Makari S. Systematic review on the incidence and prevalence of severe maternal morbidity. Medicina (Kaunas) 2004;40(4):299-309.
14. 14. Central Statistical Organization (CSO), Kurdistan Regional Statistics Office (KRSO), Ministry of Health (MOH), UNICEF. Iraq multiple indicator cluster survey (MICS-4) 2011: Preliminary report; 2012.
15. 15. Burnham G, Hoe C, Hung YW, Ferati A, Dyer A, Hifi TA, et al. Perceptions and utilization of primary health care services in Iraq: findings from a national household survey. BMC Int Health Hum Rights 2011 Dec;11:15.
16. 16. UNICEF. The state of the World’s Children 2012. Children in an urban world [cited 2016 October 4]. Available from: http://www.unicef.org/sowc/files/SOWC_2012-Main_Report_EN_21Dec2011.pdf.
17. 17. WHO. World health statistics 2012 [cited 2016 October 4]. Available from: http://apps.who.int/iris/bitstream/10665/44844/1/9789241564441_eng.pdf.
18. 18. Iraqi Ministry of Planning / Central Statistical Organization (CSO). Population projections by governorates, social origin for the year 2011 [cited 2016 October 5]. Available from: http://www.cosit.gov.iq/AAS13/population/pop(13).htm.
19. 19. Displacement as a challenge and opportunity: Urban profile of refugees, internally displaced persons and host community. Erbil Governorate, Kurdistan Region of Iraq [cited 2016 October]. Available from: http://www.krso.net/files/articles/010916043642.pdf.
20. 20. WHO. Evaluating the quality of care for severe pregnancy complications: The WHO near-miss approach for maternal health. Geneva: WHO. 2011 [cited 2016 October 5]. Available from: http://apps.who.int/iris/bitstream/10665/44692/1/9789241502221_eng.pdf.
21. 21. Elias P. Social class and standard occupational classification. In: Rose D, editor. Official social classifications in the UK. Social Research Update, issue 9. Surrey: University of Surry; 1995.
22. 22. Filippi V, Ronsmans C, Gohou V, Goufodji S, Lardi M, Sahel A, et al. Maternity wards or emergency obstetric rooms? Incidence of near-miss events in African hospitals. Acta Obstet Gynecol Scand 2005 Jan;84(1):11-16.
23. 23. Nelissen E. Mduma E, Broerse J, Ersdal H, Evjen-Olsen B, van Roosmalen J, et al. Applicability of the WHO maternal near-miss criteria in a low-resource Setting. PLoS One 2013, 8(4): e61248 [cited 2016 October 5]. Available from: http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0061248.
24. 24. Adisasmita A, Deviany PE, Nandiaty F, Stanton C, Ronsmans C. Obstetric near miss and deaths in public and private hospitals in Indonesia. BMC Pregnancy Childbirth 2008 Mar;8:10.
25. 25. Ronsmans C, Scott S, Adisasmita A, Deviany P, Nandiaty F. Estimation of population-based incidence of pregnancy-related illness and mortality (PRIAM) in two districts in West Java, Indonesia. BJOG 2009 Jan;116(1):82-90.
26. 26. Gandhi MN, Welz T, Ronsmans C. Severe acute maternal morbidity in rural South Africa. Int J Gynaecol Obstet 2004 Nov;87(2):180-187.
27. 27. Okong P, Byamugisha J, Mirembe F, Byaruhanga R, Bergstrom S. Audit of severe maternal morbidity in Uganda–implications for quality of obstetric care. Acta Obstet Gynecol Scand 2006;85(7):797-804.
28. 28. Ali AA, Khojali A, Okud A, Adam GK, Adam I. Maternal near-miss in a rural hospital in Sudan. BMC Pregnancy Childbirth 2011 Jun;11:48.
29. 29. Siddiqui SA, Soomro N, Shabih-ul-Hasnain F. Severe obstetric morbidity and its outcome in patients presenting in a tertiary care hospital of Karachi. J Pak Med Assoc 2012 Mar;62(3):226-231.
30. 30. Nelissen EJ, Mduma E, Ersdal HL, Evjen-Olsen B, van Roosmalen JJ, Stekelenburg J. Maternal near miss and mortality in a rural referral hospital in northern Tanzania: a cross-sectional study. BMC Pregnancy Childbirth 2013 Jul;13:141.
31. 31. Lotufo FA, Parpinelli MA, Haddad SM, Surita FG, Cecatti JG. Applying the new concept of maternal near-miss in an intensive care unit. Clinics (Sao Paulo) 2012;67(3):225-230.
32. 32. Zanette E, Parpinelli MA, Surita FG, Costa ML, Haddad SM, Sousa MH, et al. Brazilian Network for Surveillance of Severe Maternal Morbidity Group. Maternal near miss and death among women with severe hypertensive disorders: a Brazilian multicenter surveillance study. Reprod Health 2014 Jan;11(1):4.
33. 33. Jabir M, Abdul-Salam I, Suheil DM. Al-Hilli W, Abul-Hassan S, Al-Zuheiri A, et al. Maternal near miss and quality of maternal health care in Baghdad, Iraq. BMC Pregnancy and Childbirth 2013;13:11.
34. 34. Souza JP, Cecatti JG, Faundes A, Morais SS, Villar J, Carroli G, et al; World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group. Maternal near miss and maternal death in the World Health Organization’s 2005 global survey on maternal and perinatal health. Bull World Health Organ 2010 Feb;88(2):113-119.
35. 35. Simsek Y, Yilmaz E, Celik E, Celik O, Aydogan M, Togal T. The major clinical determinants of maternal death among obstetric near-miss patients: a tertiary centre experience. J Pak Med Assoc 2013;63:988-991.
36. 36. Oliveira FC Jr, Surita FG, Pinto E Silva JL, Cecatti JG, Parpinelli MA, Haddad SM, et al; Brazilian Network for Surveillance of Severe Maternal Morbidity Study Group. Severe maternal morbidity and maternal near miss in the extremes of reproductive age: results from a national cross- sectional multicenter study. BMC Pregnancy Childbirth 2014 Feb;14:77.
37. 37. Zwart JJ, Richters JM, Öry F, de Vries JI, Bloemenkamp KW, van Roosmalen J. Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study of 371,000 pregnancies. BJOG 2008 Jun;115(7):842-850.
38. 38. Almerie Y, Almerie MQ, Matar HE, Shahrour Y, Al Chamat AA, Abdulsalam A. Obstetric near-miss and maternal mortality in maternity university hospital, Damascus, Syria: a retrospective study. BMC Pregnancy Childbirth 2010 Oct;10:65.
39. 39. Roopa PS, Verma S. Rai L, Kumar P, Pai MV, Shetty J. Near Miss obstetric events and maternal deaths in a tertiary care hospital: An audit. Journal of Pregnancy. 2013; Article ID 393758 [cited 2016 October 5]. Available from: https://www.hindawi.com/journals/jp/2013/393758/.
40. 40. Olopada FE, Lawoyin TO. Maternal mortality in a Nigerian maternity hospital. Afr J Biomed Res. 2008;11(3):267-273.
41. 41. van Dillen J, Zwart JJ, Schutte J, Bloemenkamp KW, van Roosmalen J. Severe acute maternal morbidity and mode of delivery in the Netherlands. Acta Obstet Gynecol Scand 2010 Nov;89(11):1460-1465.
42. 42. Morse ML, Fonseca SC, Gottgtroy CL, Waldmann CS, Gueller E. Severe maternal morbidity and near misses in a regional reference hospital. Rev Bras Epidemiol 2011 Jun;14(2):310-322.
43. 43. Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, et al; World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ 2007 Nov;335(7628):1025-1035.
44. 44. Galvão LP, Pereira FA. de Mendonça CM, Menezes FE, do Nascimento Góis KA, Ribeiro Jr RF, et al. The prevalence of severe maternal morbidity and near miss and associated factors in Sergipe, Northeast Brazil. BMC Pregnancy and Childbirth 2014;14:25.
45. 45. Nakimuli A, Mbalinda SN, Nabirye RC, Kakaire O, Nakubulwa S, Osinde MO, et al. Still births, neonatal deaths and neonatal near miss cases attributable to severe obstetric complications: a prospective cohort study in two referral hospitals in Uganda. BMC Pediatr 2015 Apr;15:44.
46. 46. Shrestha NS, Saha R, Karki C. Near miss maternal morbidity and maternal mortality at Kathmandu Medical College Teaching Hospital. Kathmandu Univ Med J (KUMJ) 2010 Apr-Jun;8(30):222-226.
47. 47. Jayaratnam S, De Costa C, Howat P. Developing an assessment tool for maternal morbidity ‘near-miss’- a prospective study in a large Australian regional hospital. Aust N Z J Obstet Gynaecol 2011 Oct;51(5):421-425.
48. 48. Murphy CM, Murad K, Deane R, Byrne B, Geary MP, McAuliffe FM. Severe maternal morbidity for 2004-2005 in the three Dublin maternity hospitals. Eur J Obstet Gynecol Reprod Biol 2009 Mar;143(1):34-37.
49. 49. Rööst M, Altamirano VC, Liljestrand J, Essén B. Priorities in emergency obstetric care in Bolivia–maternal mortality and near-miss morbidity in metropolitan La Paz. BJOG 2009 Aug;116(9):1210-1217.
50. 50. Imam AM, Najjab S, Barghouti W, Abdo SA, Shaar AN, Sarahneh S, et al. Maternal near miss in four governmental hospitals in the West Bank, occupied Palestinian territory in 2010: a retrospective, facility-based survey. Lancet 2012;380:S37-S38.
51. 51. Moodley J; National Committee on Confidential Enquiries into Maternal Deaths, National Department ofHealth, South Africa. Maternal deaths associated with hypertension in South Africa: lessons to learn from the Saving Mothers report, 2005-2007. Cardiovasc J Afr 2011 Jan-Feb;22(1):31-35.
52. 52. Sahijwani DV, Desai A, Kansara V. Analysis of near miss cases as a reflection of emergency obstetric services and need of obstetric ICCU. J South Asian Feder Obstet Gynecol 2013;5(3):99-101.
53. Nakimuli A, Nakubulwa S, Kakaire Q, Osinde MO, Mbalinda SN, Nabirye RC, et al. Maternal near misses from two referral hospitals in Uganda: a prospective cohort study on incidence, determinants and prognostic factors. BMC pregnancy childbirth 2016 Jan 28;16:24.