What is quality in maternal and neonatal health care?

Objective

to review published papers and reports examining quality of care in maternal and newborn health to identify definitions and models of quality of care.

Design

literature review.

Search strategy

electronic search of MEDLINE and organisational databases for literature describing definitions and models of quality used in health care and maternal and newborn health care. Relevant papers and reports were reviewed and summarised.

Findings

there is no universally accepted definition of quality of care. The multi-faceted nature of quality is widely acknowledged. In the literature quality of care is described: from the perspective of health care providers, managers and patients; dimensions within the health care system; using elements such as safety, effectiveness, patient-centeredness, timeliness, equity and efficiency; and through the provision of care and experience of care.

Key conclusions

the importance of ensuring good quality of care for women and newborn babies is well recognised in the literature, however, there is currently no agreed single and comprehensive definition described. Several models were identified, which can be combined to form a comprehensive framework to help define and assess quality of care or lack of quality. Approaches to quality of care that are specifically important for maternal and newborn health were identified and include a rights based approach, adopting care that is evidence-based, consideration of the mother and baby as interdependent and the fact that pregnancy is on the whole a healthy state.

Implications for practice

a model of quality of maternal and newborn health care using perspectives, characteristics, dimensions of the system and elements of quality of care specific to maternal and newborn health is proposed, which can be used as a basis for developing quality improvement strategies and activities, and incorporating quality into existing programmes.     

Maternal death review in Africa

Objective

WHO, UNICEF, and UNFPA with other development partners have supported African Ministries of Health to institutionalize maternal death review (MDR) since 2003. To evaluate the program, its status, lessons learned, and the challenges to success were reviewed in 2007.

Methods

A standard self-administered questionnaire was sent to Ministries of Health in 46 Sub-Saharan African countries in May 2007. Completed questionnaires were returned by e-mail, processed, and analyzed.

Results

Thirty countries completed the survey questionnaire. Maternal death is a notifiable condition in 21 (67%) counties. A national committee has been set up to plan, coordinate, and implement MDR activities in 7 countries. Fifteen countries stated that facility-based MDR is the main method selected for conducting reviews of the causes of maternal death. Fourteen (47%) countries reported that national MDR guidelines had been developed and 12 (40%) had implemented the guidelines. Fifteen (50%) countries reported that maternal deaths were reviewed and analyzed. Only 7 countries reported that the government had allocated a budget for MDR. Implementation of MDR has led to local policy changes and improvement in quality of maternal health services in several countries. Ten of the 15 countries in which analysis has been conducted reported that recommendations have been implemented at least at the health facility level.

Conclusion

Although use of MDR is increasing in African countries, effective coverage is still low. The institutionalization of MDR requires political commitment, legal and administrative back-up, financial support, capacity development, simplified reporting forms and procedures, coordinated support of development partners, involvement of professional bodies, and regular supportive follow-up.     

The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon

Objective

to provide basic information on the distribution (public/private and geographically) and the nature of maternity health provision in Lebanon, including relevant health outcome data at the hospital level in order to compare key features of provision with maternal/neonatal health outcomes.

Design

a self-completion questionnaire was sent to private hospitals by the Syndicate of Private Hospitals in collaboration with the study team and to all public hospitals in Lebanon with a functioning maternity ward by the study team in cooperation with the Ministry of Public Health.

Setting

childbirth in an institutional setting by a trained attendant is almost universal in Lebanon and the predominant model of care is obstetrician-led rather than midwife-led. Yet due to a 15-year-old civil war and a highly privatised health sector, Lebanon lacks systematic or publically available data on the organisation, distribution and quality of maternal health services. An accreditation system for private hospitals was recently initiated to regulate the quality of hospital care in Lebanon.

Participants

in total, 58 (out of 125 eligible) hospitals responded to the survey (46% total response rate). Only hospital-level aggregate data were collected.

Measurements

the survey addressed the volume of services, mode of payment for deliveries, number of health providers, number of labour and childbirth units, availability of neonatal intensive care units, fetal monitors and infusion rate regulation pumps for oxytocin, as well as health outcome data related to childbirth care and stillbirths for the year 2008.

Findings

the study provides the first data on maternal health provision from a survey of all eligible hospitals in Lebanon. More than three-quarters of deliveries occur in private hospitals, but the Ministry of Public Health is the single most important source of payment for childbirth. The reported hospital caesarean section rate is high at 40.8%. Essential equipment for safe maternal and newborn health care is widely available in Lebanon, but over half of the hospitals that responded lack a neonatal intensive care unit. The ratio of reported numbers of midwives to deliveries is three times that of obstetricians to deliveries.

Key conclusions and implications for practice

there is a need for greater interaction between maternal/neonatal health, health system specialists and policy makers on how the health system can support both the adoption of evidence-based interventions and, ultimately, better maternal and perinatal health outcomes.     

A review of cultural influence on maternal mortality in the developing world

Objective

identify research examining the effect of culture on maternal mortality rates.

Design

literature review of CINAHL, Cochrane, PsychInfo, OVID Medline and Web of Science databases.

Setting

developing countries with typically higher rates of maternal mortality.

Participants

women, birth attendants, family members, nurse midwives, health-care workers, and community members.

Measurements and findings

reviews, qualitative and mixed-methods research have identified components of culture that have a direct impact on maternal mortality. Examples of culture are given in the text and categorised according to the way in which they impact maternal mortality.

Key conclusions

cultural customs, practices, beliefs and values profoundly influence women's behaviours during the perinatal period and in some cases increase the likelihood of maternal death in childbirth. The four ways in which culture may increase MMR are as follows: directly harmful acts, inaction, use of care and social status.

Implications for practice

understanding the specifics of how the culture surrounding childbirth contributes to maternal mortality can assist nurses, midwives and other health-care workers in providing culturally competent care and designing effective programs to help decrease MMR, especially in the developing world. Interventions designed without accounting for these cultural factors are likely to be less effective in reducing maternal mortality.     

Estimating maternal mortality and causes in South Africa: National and provincial levels

Objectives

maternal mortality estimates for South Africa have methodological weaknesses. This study uses the Growth Balance Method to adjust reported household female deaths and pregnancy-related deaths and the relational Gompertz model to adjust reported number of live births and estimate maternal mortality in South Africa at national and provincial level; examines the potential impact of HIV/AIDS prevalence; and investigates the recorded direct causes of maternal mortality.

Design

data from the 2001 Census, 2007 Community Survey and death registrations were utilised. Information on household deaths, including pregnancy-related deaths was collected from the aforementioned census and survey.

Setting

enumerated households in the 2001 Census and a nationally representative sample of 250,348 households in the 2007 Community Survey.

Participants

information about members of households who died in the preceding 12 months was collected, and of these deaths whether there were women aged 15–49 who died while pregnant or within 42 days after childbirth.

Findings

maternal mortality ratio of 764 per 100,000 live births in 2007, ranging from 102 per 100,000 live births in the Western Cape province to 1639 in the Eastern Cape. Maternal infections and parasitic diseases as well as other maternal diseases complicating pregnancy, childbirth and the puerperium are the major causes. The study found a weak correlation between provincial HIVprevalence and maternal mortality ratio.

Conclusion

despite strategies to improve maternal and child health, maternal mortality remains high in South Africa and it is unlikely that the Millennnium Developmemnt Goal of reducing maternal will be achieved.     

A community-based participatory research approach to explore community perceptions of the quality of maternal–newborn health services in the Dominican Republic

Objective

to understand both men's and women's beliefs and attitudes regarding public maternity and newborn services, care and quality.

Design

qualitative, cross-sectional, retrospective study with an observation arm, using community-based participatory research as both the mechanism of enquiry and catalyst for change.

Setting

four urban neighbourhoods in the Dominican Republic, selected in collaboration with the Provincial Medical Public Health Director and the partnering local public hospital.

Participants

adolescent women (15–20 years of age), adult women (21–49 years of age) and adult men (>19 years of age) from the four neighbourhoods were recruited to participate in focus sessions, personal interviews and/or antenatal observations. A total number of 137 participants were recruited: 27 males, 51 adolescent females and 59 adult females. The attrition rate was 17% (n=23). Dominican and US midwives and nurses, as well as community leaders, comprised the research team.

Measurements and findings

following informed consent, self-reported demographics and obstetric history were collected. Twelve focus groups and 12 individual interviews were recorded and transcribed, then qualitatively analysed for content and interpretation of salient themes. Antenatal observations were performed by community leaders to identify patterns of antenatal health-care delivery and utilisation. The main over-riding theme uncovered by the research was ‘no me hace caso’, or that women and men accessing the maternal health system did not feel valued. The significant amount of time required to receive care was interpreted by the participants as a lack of respect. Finally, the idea of ‘cuña’ emerged, in which participants noted special treatment for those with social connections to health-care providers. Presentation to the hospital was challenging but resulted in hospital volunteers joining the community volunteer group to collaborate on improving services.

Key conclusions and implications

this study, conducted in the Dominican Republic, illustrates international collaboration between university researchers, maternity service providers and community members. Community-based participatory research may be an effective mechanism to unite community members and health providers in the common mission to improve maternal–newborn health services.     

Disabled women׳s maternal and newborn health care in rural Nepal: A qualitative study

Objective

there is little evidence about disabled women?s access to maternal and newborn health services in low-income countries and few studies consult disabled women themselves to understand their experience of care and care seeking. Our study explores disabled women?s experiences of maternal and newborn care in rural Nepal.

Design

we used a qualitative methodology, using semi-structured interviews.

Setting

rural Makwanpur District of central Nepal.

Participants

we purposively sampled married women with different impairments who had delivered a baby in the past 10 years from different topographical areas of the district. We also interviewed maternal health workers. We compared our findings with a recent qualitative study of non-disabled women in the same district to explore the differences between disabled and non-disabled women.

Findings

married disabled women considered pregnancy and childbirth to be normal and preferred to deliver at home. Issues of quality, cost and lack of family support were as pertinent for disabled women as they were for their non-disabled peers. Health workers felt unprepared to meet the maternal health needs of disabled women.

Key conclusions and implications for practice

integration of disability into existing Skilled Birth Attendant training curricula may improve maternal health care for disabled women. There is a need to monitor progress of interventions that encourage institutional delivery through the use of disaggregated data, to check that disabled women are benefiting equally in efforts to improve access to maternal health care.     

Insights into maternal mortality in Madang Province,Papua New Guinea

Objective

To assess the frequency, causes, and reporting of maternal deaths at a provincial referral hospital in coastal Papua New Guinea (PNG), and to describe delays in care.

Methods

In a structured retrospective review of maternal deaths at Modilon General Hospital, Madang, PNG, registers and case notes for the period January 2008 to July 2012 were analyzed to determine causes, characteristics, and management of maternal death cases. Public databases were assessed for underreporting.

Results

During the review period, there were 64 maternal deaths (institutional maternal mortality ratio, 588 deaths per 100 000 live births). Fifty-two cases were analyzed in detail: 71.2% (n = 37) were direct maternal deaths, and hemorrhage (n = 24, 46.2%) and infection (n = 16, 30.8%) were the leading causes of mortality overall. Women frequently did not attend prenatal clinics (n = 34, 65.4%), resided in rural areas (n = 45, 86.5%), and experienced delays in care (n = 45, 86.5%). Maternal deaths were underreported in public databases.

Conclusion

The burden of maternal mortality was found to be high at a provincial hospital in PNG. Most women died of direct causes and experienced delays in care. Strategies to complement current hospital and national policy to reduce maternal mortality and to improve reporting of deaths are needed.     

The role of faith-based organizations in maternal and newborn health care in Africa

Background

Global disparities in maternal and newborn health represent one of the starkest health inequities of our times. Faith-based organizations (FBOs) have historically played an important role in providing maternal/newborn health services in African countries. However, the contribution of FBOs in service delivery is insufficiently recognized and mapped.

Objectives

A systematic review of the literature to assess available evidence on the role of FBOs in the area of maternal/newborn health care in Africa.

Search strategy

MEDLINE and EMBASE were searched for articles published between 1989 and 2009 on maternal/newborn health and FBOs in Africa.

Results

Six articles met the criteria for inclusion. These articles provided information on 6 different African countries. Maternal/newborn health services provided by FBOs were similar to those offered by governments, but the quality of care received and the satisfaction were reported to be better.

Conclusion

Efforts to document and analyze the contribution of FBOs in maternal/newborn health are necessary to increase the recognition of FBOs and to establish stronger partnerships with them in Africa as an untapped route to achieving Millennium Development Goals 4 and 5.     

A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services

Objective

to synthesise qualitative research on task-shifting to and from midwives to identify barriers and facilitators to successful implementation.

Design

systematic review of qualitative evidence using a 4-stage narrative synthesis approach. We searched the CINAHL, Medline and the Social Science Citation Index databases. Study quality was assessed and evidence was synthesised using a theory-informed comparative case-study approach.

Setting

midwifery services in any setting in low-, middle-, and high-income countries.

Participants

midwives, nurses, doctors, patients, community members, policymakers, programme managers, community health workers, doulas, traditional birth attendants and other stakeholders.

Interventions

task shifting to and from midwives.

Findings

thirty-seven studies were included. Findings were organised under three broad themes: (1) challenges in defining and defending the midwifery model of care during task shifting, (2) training, supervision and support challenges in midwifery task shifting, and (3) teamwork and task shifting.

Key conclusions

this is the first review to report implementation factors associated with midwifery task shifting and optimisation. Though task shifting may serve as a powerful means to address the crisis in human resources for maternal and newborn health, it is also a complex intervention that generally requires careful planning, implementation and ongoing supervision and support to ensure optimal and safe impact. The unique character and history of the midwifery model of care often makes these challenges even greater.

Implications for practice

evidence from the review fed into the World Health Organisation's ‘Recommendations for Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions through Task Shifting’ guideline. It is appropriate to consider task shifting interventions to ensure wider access to safe midwifery care globally. Legal protections and liabilities and the regulatory framework for task shifting should be designed to accommodate new task shifted practices.     

Maternal depression and physical health problems in early pregnancy: Findings of an Australian nulliparous pregnancy cohort study

Objective

to investigate the relationship between physical health problems and depressive symptoms in early pregnancy.

Design

baseline questionnaire, prospective pregnancy cohort study.

Setting

six metropolitan public maternity hospitals in Victoria, Australia.

Participants

1507 nulliparous women recruited in early pregnancy.

Findings

nine per cent of women (131/1500) scored ≥13 on the EPDS indicating probable clinical depression in early pregnancy (mean gestation=15 weeks). The five most commonly reported physical health problems were as follows: exhaustion (86.9%), morning sickness (64.3%), back pain (45.6%), constipation (43.5%) and severe headaches or migraines (29.5%). Women scoring ≥13 on the EPDS reported a mean of six physical health problems compared with a mean of 3.5 among women scoring <13 on the EPDS. Women reporting five or more physical health problems had a three-fold increase in likelihood of reporting depressive symptoms (Adj OR=3.13, 95% CI 2.14–4.58) after adjusting for socio-demographic factors, including maternal age.

Conclusions

the findings from this large multi-centre study show that women experiencing a greater number of physical health problems are at increased risk of reporting depressive symptoms in early pregnancy.

Implications for practice

early detection and support for women experiencing physical and psychological health problems in pregnancy is an important aspect of antenatal care. The extent of co-morbid physical and psychological health problems underlines the need for comprehensive primary health care as an integral component of antenatal care.     

Barriers and solutions for timely initiation of antenatal care in Kigali,Rwanda: Health facility professionals' perspective

Objective

timely initiation of antenatal care (i.e. within the first trimester) is associated with attendance of the full recommended regimen of antenatal visits. This study assessed social and behavioural factors that affect timely initiation of antenatal care in Kigali, Rwanda from the perspective of health facility professionals.

Design

health facility professionals involved in antenatal care provision were interviewed on their perceptions about untimely initiation of antenatal care based on open-ended questions. These one-on-one interviews were tape recorded and transcribed for analysis.

Setting

interviews were performed in June and July 2011 at Muhima Health Center in Kigali, Rwanda.

Participants

17 health facility professionals with a wide range of skills and experience levels were selected from the 36 total staff members of Muhima Health Center based on their participation in and knowledge of antenatal care.

Measurements and findings

inductive content analysis was used to group responses from these qualitative interviews with the goal of creating a conceptual map around barriers and solutions for untimely antenatal care. Qualitative responses were coded to identify the most common themes and sub-themes following a consensus methodology. The health-care professional interviews identified five themes as barriers to timely initiation of antenatal care: (1) lack of knowledge; (2) experience with previous births; (3) issues with male partners not willing/able to attend the clinic; (4) poverty or problems with health insurance; and (5) antenatal care culture. As potential solutions to these hurdles, the following themes were identified: (1) maternal/community education and sensitisation; (2) incentives to attend antenatal care visits; and (3) tracking the content and recommended number of antenatal visits.

Key conclusions

qualitative results indicate that behavioural contextual interventions may help overcome antenatal care barriers. The Rwandan Government and health facilities should work together with target communities to improve antenatal care compliance, taking into account the solutions suggested by the health facility professional interviews.

Implications for practice

study findings suggest that there are specific solutions to increase adherence with timely initiation of antenatal care in Rwanda, including education and sensitisation, modifying couples' HIV testing policies, addressing costs of antenatal care, and tracking the number of recommended antenatal visits.     

Exploring the sustainability of obstetric near-miss case reviews: a qualitative study in the South of Benin

Introduction

near-miss case reviews are one of a number of audit approaches currently being used and evaluated by those with an interest in reducing high rates of maternal mortality in developing countries. Researchers are beginning to take an interest in issues relating to the sustainability of audits.

Objective

to develop an understanding of the barriers and facilitators to the sustainability of obstetric near-miss case reviews in five hospitals in southern Benin.

Design and methods

semi-structured interviews were designed to explore health workers’ and policy makers’ views and experiences of the sustainability of near-miss case reviews aimed to improve quality of care and reduce maternal mortality.

Setting

five hospitals in three regions in the south of Benin.

Participants

two Ministry of Health officials and eight health-care workers involved in a feasibility study conducted in 1998–2001 that introduced near-miss case reviews.

Analysis

framework analysis to identify themes.

Findings

while all participants believed in the importance and value of audit, all hospitals had stopped performing near-miss case reviews within two years of completing the feasibility study. Ten qualitative interviews identified six themes relating to the sustainability of case reviews: clear advantages in ensuring quality of care, fear of blame and punishment, availability of resources, training, supportive hospital work environment, and broader policy issues.

Key conclusions and implications for practice

implementing and sustaining audit is a complex intervention that requires careful planning and consideration. It is important to consider both the content and the context in which audit takes place when developing strategies for sustainability.     

Improving the maternal mortality ratio in Zhejiang Province,China, 1988–2008

Objective

maternal mortality remains a major public health problem in many countries. The aim of this paper is to describe the progress made in maternal health care in Zhejiang Province, China over 20 years in reducing the maternal mortality ratio (MMR).

Setting

Zhejiang Province is located on the mid-east coast of China, approximately 180 km south of Shanghai, and has a population of 49 million. Almost all mothers give birth in hospitals or maternal and infant health institutes.

Method

the annual maternal death audit reports from 1988 to 2008 were analysed. These reports were prepared annually by the Zhejiang Prenatal Health Committee after auditing each individual case.

Measurements and findings

China has made considerable progress in reducing the MMR. Zhejiang has one of fastest developing economies in China, and since the 86 economic reforms of 1978, health care has improved rapidly and the MMR has declined. During the 1988–2008 period, 2258 maternal deaths were reported from 8,880,457 live births. During these two decades, the MMR decreased dramatically from 48.50 in 1988 to 6.57 per 100,000 in 2008. The MMR in migrant women dropped from 66.87 in 2003 to 21.67 per 100,000 in 2008. The rate of decline was more rapid in rural areas than in the city. There has been a decline in the proportion of deaths with direct obstetric causes and a corresponding increase in the proportion of indirect causes. The proportion of deaths classified as preventable has declined in the past two decades. Social factors are important in maternal safety, and on average 26.8% of maternal deaths were influenced by these factors.

Conclusion

as the economy was developing, maternal safety was made a priority health issue by the Government and health workers. The provincial MMR has dropped rapidly and is now similar to the rates in developed countries and lower than that in the USA. However, more work is still needed to ensure that all mothers, including migrant workers, continue to have these low rates.     

A mixed-method study of factors associated with differences in caesarean section rates at community level: The case of rural China

Objective

to assess population-based caesarean section (CS) rates in rural China and explore determinants and reasons for choosing a CS.

Design

cross-sectional study, quantitative and qualitative methods, statistical modelling.

Setting

two rural counties in Anhui province, China.

Participants

(a) household survey participants: 2326 women who gave birth in the two counties from January 2005 to December 2006; (b) qualitative study participants: health providers at township and village level and maternal health-care providers (N=58).

Measurements and findings

the household survey were conducted among 2326 women, collecting data on socio-economic and health status and utilisation of maternal health services. Eleven Focus Group Discussions with health-care providers and users to explore perceptions surrounding CS.the CS rate in the two areas were 46.0% and 64.7%. There were complex and different interactions among social-economic and clinical determinants associated with differences in CS rates. The main determinants that emerged were maternal age, maternal education, yearly income, primiparity, uptake of antenatal care and recorded obstetric complications with complex and differing interactions for each county. Maternal fear of pain, worry about mothers' and infants' safety, not satisfied with doctors' competences and physicians' low confidence in vaginal delivery, and absence of a strong midwifery cadre together contributed to final determination of CS.

Key conclusions

the CS rates were extremely high in the two counties in rural China. Maternal socio-economic, clinic characteristics and health providers' preference contributed together to the high rates of CS.

Implications for practice

evidence-based knowledge and methods to reduce unnecessary CS should be communicated to medical professionals and women. Greater comprehensive attention needs to be paid to a complex pattern of medical, socio-cultural, political and economic contexts of maternity care.     

Longitudinal study of perinatal maternal stress,depressive symptoms and anxiety

Objectives

to understand the trends in, and relationships between, maternal stress, depressive symptoms and anxiety in pregnancy and post partum.

Design

a prospective longitudinal survey study was undertaken to explore maternal psychological distress throughout the perinatal period. The participants were recruited after 24 completed weeks of gestation, and were followed-up monthly until one month post partum (four surveys in total).

Setting

participants were recruited from a single hospital in southern Taiwan, and asked to complete questionnaires in the hospital waiting area.

Participants

inclusion criteria were: age ≥18 years, able to read and write Chinese, ≥24 weeks of gestation, singleton pregnancy and no pregnancy complications (including a diagnosis of antenatal depression or anxiety disorder). In total, 197 women completed all four surveys (response rate 74.62%).

Measurements and findings

stress was measured with the 10-item Perceived Stress Scale, depressive symptoms were measured with the Center for Epidemiologic Studies' Depression scale, and anxiety was measured with the Zung Self-reported Anxiety Scale. Participants were followed-up at four time points: T1 (25–29 gestational weeks), T2 (30–34 gestational weeks), T3 (>34 gestational weeks) and T4 (4–6 weeks post partum). Appointments for data collection were made in accordance with the participants' antenatal and postnatal check-ups. The three types of maternal distress had different courses of change throughout the perinatal period, as levels of depressive symptoms remained unchanged, anxiety levels increased as gestation advanced but declined after birth, and stress decreased gradually during pregnancy but returned to the T1 level after birth. There was a low to high degree of correlation in maternal stress, depressive symptoms and anxiety in pregnancy and post partum.

Key conclusions

around one-quarter of the study participants had depressive symptoms during pregnancy and post partum. Stress and anxiety showed opposing courses during the perinatal period. Regardless of the trend, maternal mental distress returned to the T1 level after birth.

Implications for practice

effective survey questionnaires are suggested for use as primary screening for possible psychological distress among pregnant and post partum women. It is suggested that health care professionals involved in obstetrics and midwifery should pay attention to the psychological needs of pre- and postnatal women, provide women with sufficient information about their mental well-being, and make appropriate and timely referrals to psychiatric or psychological care.     

Assessment of maternal near-miss and quality of care in a hospital-based study in Accra,Ghana

Objective

To assess the baseline incidence of maternal near-miss, process indicators related to facility access, and quality of care at a tertiary care facility in urban Ghana.

Methods

A prospective observational study of all women delivering at the facility, including those with pregnancy-related complications, was conducted between October 2010 and March 2011. Quality of maternal health care was assessed via a newly developed WHO instrument based on near-miss criteria and criterion-based clinical audit methodology.

Results

Among 3438 women, 516 had potentially life-threatening conditions and 131 had severe maternal outcomes (94 near-miss cases and 37 maternal deaths). More than half (64.4%) of the women had been referred to the facility. The incidence of maternal near-miss was 28.6 cases per 1000 live births. Anemia contributed to most cases with a severe maternal outcome. More than half of all women with severe maternal outcomes developed organ dysfunction or died within the first 12 hours of hospital admission. Although preventive measures were prevalent, treatment-related indicators showed mixed results.

Conclusion

The WHO near-miss approach was found to represent a feasible strategy in low-resource countries. Improving referral systems, effective use of critical care, and evidence-based interventions can potentially reduce severe maternal outcomes.