Quality (305) Maternal mortality: near-miss events in middle-income countries, a systematic review

18 October, 2021

Citation, abstract and a comment from me below.

CITATION: Heitkamp A et al. Maternal mortality: near-miss events in middle-income countries, a systematic review

Bull World Health Organ. 2021 Oct 1; 99(10): 693–707F

2021 Aug 30. doi: 10.2471/BLT.21.285945


Objective: To describe the incidence and main causes of maternal near-miss events in middle-income countries using the World Health Organization’s (WHO) maternal near-miss tool and to evaluate its applicability in these settings.

Methods: We did a systematic review of studies on maternal near misses in middle-income countries published over 2009–2020...

Findings: We included 69 studies from 26 countries (12 lower-middle- and 14 upper-middle-income countries)... The most frequent causes of near miss were obstetric haemorrhage in 19/40 studies in lower-middle-income countries and hypertensive disorders in 15/29 studies in upper-middle-income countries...

Conclusion: In several countries, adaptations of the WHO near-miss tool to the local context were suggested, possibly hampering international comparisons, but facilitating locally relevant audits to learn lessons.

COMMENT (Neil): HIFA members may ask, "Why put this in our discussion on Quality?". The point I would like to make here is that papers that look at causes of death (or, in this case, near-miss) almost always consider medical causes of death only. They do not offer insight into social and environmental causes, in particular quality of care and how this might be improved (including appropriate use of reliable healthcare information in the days or weeks leading to the event). How might this be investigated? Perhaps by a variant of social autopsy, which 'are structured, standardised interviews with the caregiver of the deceased which attempt to make a “social diagnosis” of cause of death by identifying its cultural, social and health-systems antecedent'. See for example Merlin Willcox et al's recent study on child death in South Africa, which concludes 'Modifiable factors for preventing deaths during a child’s final illness occur both inside and outside the home. The most important modifiable factors occurring inside the home relate to caregivers’ recognition of illness and appreciation of urgency in response to the severity of the child’s symptoms and signs.' https://eprints.soton.ac.uk/435420/

Social autopsy is a resource-intensive process that is only currently used as an occasional research tool. I hope to see greater use of this approach as I feel it could provide considerable understanding.

Neil Pakenham-Walsh, HIFA Coordinator, neil@hifa.org www.hifa.org