Systematic review

DOI: 10.1111/j.1471-0528.2012.03294.x
www.bjog.org

The prevalence of maternal near miss: a

systematic review
Tuncalp,a MJ Hindin,a JP Souza,b D Chou,b L Sayb
O
a

Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA and
Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
Tuncalp, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public
Correspondence: Dr O
Health. 615 N Wolfe St MD 21205, Baltimore, USA. Email: otuncalp@jhsph.edu
b

Accepted 11 January 2012.

Background Severe maternal morbidity or near miss is a

promising indicator to improve quality of obstetric care.

Objectives To systematically review all available studies on near

miss.
Search strategy Following a pre-defined protocol, our review

covered articles between January 2004 and December 2010. We

used a combination of the following terms: near miss morbidity,
severe maternal morbidity, severe acute maternal morbidity,
obstetric near-miss, maternal near miss, obstetric near miss,
emergency hysterectomy, emergency obstetric hysterectomy,
maternal complications, pregnancy complications, intensive care
unit.
Selection criteria Nearly 4000 articles were screened by title and

abstract, and 153 articles were retrieved for full text evaluation.
There were no language restrictions.
Data collection and analysis Data extraction was performed using

an instrument that included sections on study characteristics,

quality of reporting, prevalence/incidence and the definition and
identification criteria. Univariate analysis and meta-analysis for
sub-groups were performed.
Main results A total of 82 studies from 46 countries were

included. Criteria for identification of cases varied widely.

Prevalence rates varied between 0.6 and 14.98% for diseasespecific criteria, between 0.04 and 4.54% for management-based
criteria and between 0.14 and 0.92% for organ-based dysfunction
based on Mantel criteria. The rates are higher in low-income and
middle-income countries of Asia and Africa. Based on metaanalysis, the estimate of near miss was 0.42% (95% CI 0.40
0.44%) for the Mantel (organ dysfunction) criteria and 0.039%
(95% CI 0.0370.042%) for emergency hysterectomy. Our metaregression results indicate that emergency hysterectomy rates have
been increasing by about 8% per year.
Authors conclusions There is growing interest in the application
of the maternal near-miss concept as an adjunct to maternal
mortality. However, in the literature published before 2011 there
was still important variation in the criteria used to identify
maternal near-miss cases. The World Health Organization recently
published criteria based on markers of management and of
clinical and organ dysfunction which would enable systematic data
collection on near miss and development of summary estimates.
Comparing the rates over time and across regions, it is clear that
different approaches are needed to lower the rates of near miss
and that interventions must be developed with the local context in
mind.
Keywords Global, maternal morbidity, near miss, review.

, Hindin MJ, Souza JP, Chou D, Say L. The prevalence of maternal near miss: a systematic review. BJOG 2012;119:
Please cite this paper as: Tuncalp O
653661.

Introduction
Progress in the reduction of maternal mortality has been
slow. Over 1000 women still die from pregnancy-related
causes every day around the world and the vast majority of
these deaths occur in developing countries.1 Low-income
countries are heavily affected by the burden of maternal
The World Health Organization retains copyright and all other rights in
the manuscript of this article as submitted for publication.

deaths and maternal mortality is still an important public

health problem among middle-income countries. Strengthened health systems and effective maternal health care (particularly to those women experiencing acute pregnancyrelated complications) are considered the key factors for
reducing maternal mortality.2
Many countries are encouraging pregnant women to
deliver in health facilities. On the one hand, this policy
favours the reduction of delays in the identification and
management of peripartum complications. On the other

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653

Tuncalp et al.

hand, such a policy may lead to overloading of health services, which are already insufficient in many of these settings, thereby adversely affecting the quality of care. In this
context, quality of care has been identified as a central element in the United Nations Global Strategy for Women
and Children Health.3
Confidential enquiries into maternal deaths have been
in use for many years in the identification of quality of
care and health systems issues.4 However, in low mortality
settings or at the health service level, the number of maternal deaths is generally insufficient or not representative
enough to allow reliable policy guidance. In the last
20 years, the concept of maternal near miss has been
explored in maternal health as an adjunct to maternal-death
confidential enquiries. Among other positive characteristics,
near-miss cases occur more frequently than maternal deaths
and can directly inform on problems and obstacles that had
to be overcome during the process of health care, providing
more robust conclusions and rapid reporting on maternal
care issues.5,6 Hence, the identification of cases of severe
maternal morbidity has emerged as a promising complementary or alternative strategy to reduce maternal mortality. In particular, near misses have been viewed as a useful
outcome measure for the evaluation and improvement of
maternal health services in developing countries.4
In 2003/04, the World Health Organization (WHO) conducted a systematic review on the prevalence of severe maternal morbidity and maternal near-miss cases. The substantial
heterogeneity observed in the pre-2004 literature led WHO
to establish a technical working group comprising obstetricians, midwives, epidemiologists and public healthcare professionals to develop a standard definition and uniform
identification criteria for maternal near-miss cases.7 In April
2009, a paper was published by the WHO working group
defining maternal near miss morbidity as a woman who
nearly died but survived a complication that occurred during
pregnancy, childbirth or within 42 days of termination of
pregnancy. With a view to achieving a reasonable balance
between the burden of data collection and useful information, the WHO working group targeted the identification of
only very severe casesi.e. primarily those presenting with
features of organ dysfunction.7 The near-miss identification
criteria developed by the technical working group have been
tested and validated as being able to provide robust and reliable data. Detailed information about the near-miss concept
and its development is published elsewhere (Souza JP et al.,
manuscript in preparation).7,8

Methods
A WHO systematic review published in 2004, spanned the
literature on severe maternal morbidity and maternal near
miss from 1997 to 2004.9 The current review provides an

654

update based on a search for new articles between January

2004 and December 2010. We have included the electronic
databases Pubmed, Embase, Lilacs, Popline, IndMed and
WHO regional databases. The regional databases are as follows: Index Medicus for the Eastern Mediterranean Region
(IMEMR), African Index Medicus (AIM), Western Pacific
Region Index Medicus (WPRIM). We have also searched
for relevant articles in the WHO Library by hand, and contacted experts in the field.
We used a similar search strategy to that in the previous
study with a combination of the following terms: near miss
morbidity, severe maternal morbidity, severe acute maternal
morbidity, obstetric near-miss, maternal near miss, obstetric
near miss, emergency hysterectomy, emergency obstetric hysterectomy, maternal complications, pregnancy complications,
intensive care unit. To verify the compatibility between the
current and previous search strategies, we applied this
search strategy to the timeframe covered by the previous
systematic review and compared the results.
The inclusion criteria for the current review were as follows: (1) articles with near-miss incidence or prevalence
data, (2) published between January 2004 and December
2010, (3) included data from 1990 onwards, (4) sample size
200 and (5) clearly described methodology. There were no
language restrictions.
Data extraction was performed using an instrument that
included sections on the general study level characteristics
(such as design, population, setting), quality of data reporting, prevalence/incidence of maternal near miss and the
definition and identification criteria. Authors have also
been contacted in cases where further information or clarification was required. The denominator used was either
deliveries or live births (only five studies used live births as
a denominator).
We describe the included studies with an emphasis on
the different definitions used and criteria for identification
of the cases. We performed univariate analyses and the
ranges of near-miss prevalence are reported based on identification criteria and region. Studies reporting very high
near-miss prevalence that was outside the ranges formed by
most of the studies in the review were identified as outliers.
We also reported on near miss over mortality ratio to
assess the care that near-miss cases receive.
We conducted meta-analysis for the sub-groups management (emergency hysterectomy) and Mantel-based organ
dysfunction criteria, where more homogeneous criteria were
established among the studies. Also we conducted multivariable meta-regression for the emergency hysterectomy group.
We included the studies from the 2004 review in our final
analyses and observed the historical trends.9 Unless indicated
otherwise all of the analyses include the 82 studies from the
current review. We used Stata 10 (StataCorp LP; StataCorp., College Station, TX, USA) for our analyses.

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Prevalence of near miss: systematic review

Table 1. Near-miss rates by identification criteria and region

3943
Title/Abstract
3790 articles excluded
based on the
inclusion criteria

153
Full-text
3 articles included
after complementary
search

74 articles excluded

82

Duplicate datasets, not providing

numbers of near misses and/or
any denominators and using
specific populations or
complications

Inclusion

Figure 1. The flow diagram of identification of studies.

Results
Nearly 4000 articles were initially screened by title and
abstract, and 153 articles were retrieved for full text evaluation. Data have been extracted from 82 articles (Figure 1).
A total of 82 studies from 46 countries were included
in this review. Studies were mainly retrospective crosssectional and except for one study in Brazil,10 all of the
studies used data from facilities, mainly tertiary-care hospitals. A majority of the studies included describe the characteristics of the setting and participants as well as reporting
definitions and procedures of identification of the cases.
More detailed information on each study is presented in
the Table S1. To validate our current strategy, we tested it
on the articles included in the 2004 review and identified
27 out of the 30 articles included in the previous review
strategy. The three articles not found initially were identified after a complementary reference lists search.
Except for the studies reporting on emergency hysterectomies and intensive-care unit (ICU) admissions, a majority of the studies defined near miss as a woman who
almost died but survived through chance or as a result of
good care received. Overall, there were three major
approaches to the identification: (1) disease-specific criteria
(i.e. severe pre-eclampsia, severe postpartum haemorrhage),
(2) management-based criteria (i.e. admission to ICU, need
for a blood transfusion), or (3) organ system dysfunctionbased criteria. The majority used management-based criteria
including 33 studies that used emergency hysterectomies,
and 18 that used ICU admissions to define near miss.
Seven studies used disease-specific criteria, nine of the articles used organ system dysfunction as the criteria for near
miss and 14 used a combination of disease, organ and
management-based criteria.

Near miss by identification criteria

Study-specific near-miss rates differed based on the method
of identification and region (Table 1). Studies using
disease-specific criteria reported a higher percentage of

Identification criteria

Disease-specific
Management-specific
Emergency hysterectomy
ICU sdmission
Organ dysfunction
Mantel or Modified Mantel
criteria
Other
Mixed criteria
Disease/Organ/Management
Disease/Management
Region***
Africa
Asia
Latin America and Caribbean
Europe
North America
Oceania (Australia)

Range of near
misses (%)
0.614.98
0.040.26
0.044.54 (15.8)*
0.142.3
0.140.92 (17.8)**

No. of
studies (n = 81)
7
34
18
8

2.3

0.044.43
0.093.42

7
7

0.0514.98
0.025.07 (17.8)**
0.344.93 (15.8)*
0.040.79
0.071.38
1.25

14
31
9
18
10
1

*Near-miss rate by Amorim et al.17 is reported separately as it is an

outlier in the group.
**Near-miss rate by Adisasmita et al.19 is reported separately as it is
an outlier in the group.
***Regions have been allocated based on UN Classifications.25

near-miss cases, and a wider range of estimates compared

with the other criteria, 0.614.98%. Case identification criteria varied for disease-specific criteria, which included, but
was not limited to, hypertensive disorders, haemorrhage,
uterine rupture, sepsis and anaemia. Most of the studies
established a certain criteria for the degree of severity for
the selected clinical conditions.1116
Near-miss rates identified by management-specific criteria ranged between 0.04 and 4.54%. However, it should be
noted that within this group, studies identifying emergency
hysterectomies reported lower percentages (0.040.26%)
than studies using ICU admissions (0.044.54%). The
Amorim et al.17 study in Brazil reported a near miss rate of
15.8%much higher than the rest of the studies in this
category and considered one of the two outliers identified
in this review. The hospital in this study serves a very large
geographic area as the main maternal ICU unit and therefore a significant proportion of the women admitted to
the ICU did not enter the denominatordeliveries at the
hospital.
Organ dysfunction-based criteria were used in nine studies and the near-miss rate reported ranged between 0.14
and 2.3%. Eight of nine studies used either Mantel or
modified Mantel criteria in this category and reported rates
between 0.14 and 0.92%. These criteria were first introduced in South Africa and combine organ dysfunction and

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Tuncalp et al.

certain management markers such as intensive-care admission, emergency hysterectomy to identify near-miss cases.18
This criterion is arguably the most stable compared with
others in this review. Depending on the level of the facility
and resources available, some studies used a modified version of these criteria.1923 One study by Adisasmita et al.19
in Indonesia reported a near-miss rate of 17.8%much
higher than the other studies in this category and considered the second outlier in this review. This study included
a large number of early pregnancy losses in the numerator
and included a number of clinical diagnoses (eclampsia,
uterine rupture and ectopic pregnancy) in their near-miss
criteria. Using deliveries as the denominator and including
these clinical diagnoses may have inflated the near-miss
rate. However, even if the obstetric-related admissions were
used as the denominator and only near miss cases with
organ dysfunction are included, the near miss rate is
11.3%still very high compared with all the other studies.

The most commonly used criterion was emergency hysterectomies in all regions except North America, and Latin
America and the Caribbean (LAC) (6/14 in Africa, 16/31 in
Asia, 8/17 in Europe, 3/10 in North America and Australia
and 1/11 in LAC). The second most common criterion
across regions was ICU admission, for all regions except
Africa. In North America, several of the studies identified
near misses using criteria combining disease, organ and
management markers, using International Classification of
Disease (ICD) codes and national and regional databases.
Depending on the resources of a facility or a country overall, the criteria used for identification of near misses vary.
For example, in high-income countries where facility deliveries and systematic, national level data are the norm, more
sensitive markers have been used to identify the near-miss
cases, whereas in resource-poor settings, management-based
criteria are more commonly used.
In low and middle-income countries, approximately 1%
of the women experienced a near-miss event before, during
or after delivery as identified by organ dysfunction criteria.
It was around 0.25% in higher-income countries. Management-specific criteria using ICU admissions and emergency
hysterectomies were under 1% across all regions, except the
two studies from the LAC region.17,25 Using mixed criteria
combining different markers, the rate ranges between 2.10
and 4.43% in low-income and middle-income countries
and 0.09 and 1.38% in higher-income countries.

Near miss by region

Based on their income, all African and Asian countries
(where there were near-miss studies) except Saudi Arabia
and Kuwait are considered low-income or middle-income
countries.24 Table 2 shows the near-miss rates in each
region by different identification criteria. The upper nearmiss rate ranged from 4.93% in Latin America and the
Caribbean, through 5.07% in Asia to 14.98% in Africa
(excluding outliers). In contrast, studies from high-income
countries (Europe, North America and Australia) reported
an upper near-miss rate from a low of 0.79% in Europe to
a high of 1.38% in North America: the lowest rates across
all the criteria compared with those from low-income and
middle-income countries.

Historical trends in near miss

In the 6 years since the 2004 WHO review, more articles
have been published focusing on near-miss maternal morbidity; thereby increasing the number of articles included
from 30 to 82 articles. Table 3 shows a comparison of the

Table 2. Near miss rates in each region by different identification criteria (# signifies the number of studies)
Identification criteria

Disease-specific
Management-specific
Emergency hysterectomy
ICU admission
Organ dysfunction
Mantel or Modified Mantel
Other
Mixed Criteria
Disease/Management
Disease/Organ/Management
Total

Africa

Asia

% Near miss

LAC

% Near miss

0.614.98

3.215.07

0.050.41
0.24

6
1

0.020.49
0.120.90

16
9

0.410.84

0.9 (17.8)**
2.3

3.15

0.0514.98

14

3.42

0.025.07

2
1
1

31

% Near miss

Europe

% Near miss

N. America and
Australia
n

% Near miss

4.93

0.79

0.87
0.344.54 (15.8)*

1
3

0.040.20
0.040.73

8
4

0.070.16
0.291.33

3
2

0.63

0.140.35

2
3
11

0.090.72

0.040.79

17

2.103.04
2.124.43
0.344.92

1.25
0.271.38
0.071.38

1
4
10

*Near-miss rate by Amorim et al.17 is reported separately as it is an outlier in the group.

**Near-miss rate by Adisasmita et al.19 is reported separately as it is an outlier in the group.

656

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Prevalence of near miss: systematic review

Table 3. Comparing the rates by criteria and region between 2004

and current review
2011 Review
(N = 82)
Identification criteria
Disease-specific
0.614.98
Management-specific
Emergency
0.040.26
hysterectomy
ICU admission
0.044.54 (15.8)*
Organ dysfunction
Mantel or Modified 0.140.92 (17.8)**
Mantel
Other
2.3
Mixed criteria
0.044.43
Region
Africa
Asia
Latin America and
Caribbean
Europe
North America and
Australia
Oceania

2004 Review
(N = 30)

0.88.23
0.010.21 (2.99)****
0.081.02
0.381.09 (10.61)***

1.34

2011 Review

2004 Review

0.0514.98
0.025.07 (17.8)**
0.344.93 (15.8)*

0.0810.61
0.014.37
0.140.24

0.040.79
0.071.38

0.041.20
0.080.27

1.25

*Near-miss rate by Amorim et al.17 is reported separately as it is an

outlier in this group.
**Near-miss rate by Adisasmita et al.19 is reported separately as it is
an outlier in this group.
***Near-miss rate by Kaye et al.32 is reported separately as it is an
outlier in this group.
****Near-miss rate by Noor et al.33 is reported separately as it is an
outlier in this group.

two reviews based on identification criteria and region. The

ranges of near-miss cases based on different criteria
reported were similar between the two time points. However, it should be noted that in the current review the
ranges are wider for each category, there are more studies
using mixed criteria overall and a larger number of studies
from low-income and middle-income countries report on
organ dysfunction criteria.

Meta-analysis of near miss

Although we could not conduct meta-analysis of near miss
as a comprehensive category because of the variety of identification criteria, we have conducted meta-analyses for the
two categories, emergency hysterectomy and Mantel-based
organ-based dysfunction, where more homogeneous criteria
were used among the studies compared with the other criteria. As mentioned above, Mantel criteria include a set of
organ-based dysfunction and management-based criteria,

the detailed description of indicators by organ system and

degree of severity can be found elsewhere.18 For this analysis, we have also included 2004 review articles. All of the
studies included in this analysis described the characteristics
of the setting, participants, definitions and procedures of
case identification (11 studies for Mantel criteria and 40
studies for emergency hysterectomy). For the Mantel-based
criteria, the estimate of near miss was 0.42% (95% CI 0.40
0.44%). For the emergency hysterectomy criteria, the nearmiss rate was 0.039% (95% CI 0.0370.42%). Despite the
very narrow range of the confidence intervals, the I-squared
was high: 98.3% for the Mantel-based criteria and 95.5%
from the emergency hysterectomy criteria, suggesting significant heterogeneity between studies (Figures 2 and 3).
We explored the heterogeneity in a multivariable metaregression model for near miss identified by emergency
hysterectomy by using median data collection year, study
region and gross national income for the respective median
data collection year (results not shown).26 For this analysis
we combined North America and LAC region, as there was
only one study from LAC. Our analysis showed that emergency hysterectomy rates were higher in more recent years
of data collection (an approximate 8% increase per year,
P = 0.02, 95% CI 0.010.15). Near miss identified by emergency hysterectomy was significantly more common in
North America/LAC compared with Europe, mostly because
of the one study in the LAC region from Mexico.27 We
found that about one-third of the variation between studies
in emergency hysterectomy rates (R2 = 27.96%) could be
explained by these variables.

Discussion
We have included 82 studies in this systematic review. All
of the included studies have used a variety of near-miss criteria ranging from disease-specific to organ dysfunction
and a mix of different systems. The near-miss rates have
not significantly changed between the review in 2004 and
the current 2011 review, although the ranges are wider for
each category in the current review. In the current study,
disease-specific criteria produced higher rates than both
management-specific and organ dysfunction criteria. Under
the management-based criteria, studies using ICU admission produced larger variation than emergency hysterectomy studies.
Studies using management-based criteria were less likely
to specifically include the discussion on maternal near miss;
rather, they focused on emergency obstetric care and the
case series in their facilities. We should underline the fact
that the rates produced by these individual studies do not
include all the near-miss cases in a facility. Admission to
ICU relies on the availability of physical and human
resources as well as the criteria for admission used in

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Tuncalp et al.

Figure 2. Meta-analysis among studies using Mantel-based organ dysfunction criteria (n = 11).

different institutions. For example Amorim et al.17 reported

a very high ICU admission rate because the facility in the
study was a referral institution, therefore it was almost
impossible to identify the right denominator with all the
deliveries.
Definitions of emergency hysterectomy and Mantel criteria were fairly uniform across studies; however, as shown
in our meta-analysis there was very high heterogeneity
between studies, 95.5% and 98.3% respectively. Although
some of this heterogeneity is the result of the year of data
collection, which was statistically significant, gross national
income and region of the country, it can also be explained
by various reasons including several unmeasured variables
such as the capacity of the hospital to identify the cases
within their chosen criteria, availability or the patient load
of the referral institutions in which many of our studies
are conducted and the general structure of the health system. It should be noted that although there is heterogeneity, near miss is a condition of very low prevalence and our
data still show a narrow range in estimates.
This study has some limitations that should be noted.
First, although we searched for unpublished data, it is very
likely that we missed some unpublished studies. Second,
despite the fact that the number of studies included in this
review almost tripled compared with the 2004 review, we
still had relatively sparse data globally. Despite these limitations, the study has a number of strengths. First, it is comprehensive in its scope and we made special efforts to

658

reach out to the authors for further information and clarification. Second, this review is very timely as we move
towards standardised criteria, as it summarises the current
trends in global near-miss rates. Since the 2004 review, the
number of studies examining maternal near miss almost
tripled, underlining the growing emphasis on the issue
globally. Next, we used the previous systematic review data
both to assess our search criteria and to assess changes over
time. Finally, the study adds to the previous systematic
review by including meta-analysis to get overall near-miss
prevalence rates for two of the criteria.
It is our hope that the recent WHO criteria for identifying maternal near-miss cases will stimulate researchers and
clinicians to carry out near-miss assessments around the
world using the same criteria. We are aware of a number
of ongoing studies, including the large multi-country study
that WHO is implementing in 29 countries.28 To use nearmiss cases as a way to improve quality of care in the facilities, WHO has developed a systematised approach to
implement near-miss criterion-based clinical audits.29 For
these types of audits a set of evidence-based, explicit, measurable criteria for case management are agreed that can
then be used to monitor practice and determine if standards of care have been met, by reviewing case notes.30 The
expected results include, among others, understanding local
patterns of maternal mortality and morbidity, strengths
and weaknesses in the referral system, and the use of
clinical and other healthcare interventions. In addition,

2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2012 RCOG

Prevalence of near miss: systematic review

Figure 3. Meta-analysis among studies using emergency hysterectomya management based criteria (N = 40).

implementing a surveillance strategy on women with lifethreatening conditions being managed at the healthcare
facility can foster a culture of early identification of complications and promote better preparedness for acute morbidities. It is necessary to go beyond surveillance and implement
interventions to improve the quality of maternal care, Facility-based interventions can include the implementation of
evidence-based guidelines, the use of reminders, opinion
leaders endorsement, and continued audit and feedback to
achieve behavioural and process changes.29,31 It would also
lead to interventions aimed at increasing the awareness of
danger signs among providers at lower level facilities as well
as community-based providers to minimise the delays in
referrals to prevent both maternal morbidity and mortality.

Conclusions
There is growing interest in the application of the maternal
near-miss concept as an adjunct to maternal mortality.
However, in the literature published before 2011 there was
still important variation in the criteria used to identify
maternal near-misses. An organ-system dysfunction
approach remains as the most epidemiologically sound set
of criteria. WHO recently published criteria based on
markers of management, and clinical and organ dysfunction, which is currently being adopted by researchers and
organisations around the world. By using the uniform
criteria, clear data on near miss can be systematically

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Tuncalp et al.

collected, thereby facilities, countries and regions can

monitor the near-miss rate over time to develop better
interventions to improve the quality of obstetric care. Our
review also suggests that it may be beneficial to explore
why emergency hysterectomy rates are higher in more
recent years of data collection (an approximate 8% increase
per year). Although it is well known, our results indicate
that more resources are needed in low-income and middleincome countries. Comparing the rates over time and
across regions, it is clear that different approaches are
needed to lower the rates of near miss and that interventions must be developed with the local context in mind.

Disclosure of interests
None.

Contribution to authorship
All of the authors participated in the formulation of the
methodology for this review. OT performed the literature
search and reviewed all abstracts and full text articles with
assistance from JPS and DC. OT wrote the first draft of the
manuscript and MJH, JPS, DC and LS assisted in the writing and editing of the manuscript.

Details of ethics approval

This is a systematic review of previously published data
and therefore does not require ethical approval.

Funding
None.

Acknowledgements
The views expressed in this paper are those of the authors
as individuals, and do not necessarily represent the views
of the WHO and its member states.

Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Table S1. Characteristics of included studies (N = 82).
Please note: Wiley-Blackwell is not responsible for the
content or functionality of any supporting information
supplied by the authors. Any queries (other than missing
material) should be directed to the corresponding author. j

References
1 WHO, UNICEF, UNFPA, The WB. Trends in Maternal Mortality:
19902008. Geneva: WHO, 2010.
2 Maine D. Detours and shortcuts on the road to maternal mortality
reduction. Lancet 2007;370:13802.
3 Secretary-General UN. Global Strategy for Womens and Childrens
Health. New York: United Nations, 2010.

660

4 World Health Organization. Beyond the Numbers: Reviewing Maternal Deaths and Complications to Make Pregnancy Safer. Geneva,
Switzerland: WHO, 2004.
5 Borghi J, Hanson K, Acquah CA, Ekanmian G, Filippi V, Ronsmans
C, et al. Costs of near-miss obstetric complications for women and
their families in Benin and Ghana. Health Policy Plan 2003;18:383
90.
6 Pattinson RC, Hall M. Near misses: a useful adjunct to maternal
death enquiries. Br Med Bull 2003;67:23143.
7 Say L, Souza JP, Pattinson RC. Maternal near misstowards a standard tool for monitoring quality of maternal health care. Best Pract
Res Clin Obstet Gynaecol 2009;23:28796.
8 Cecatti JG, Souza JP, Oliveira Neto AF, Parpinelli MA, Sousa MH,
Say L, et al. Pre validation of the WHO organ dysfunction based criteria for identification of maternal near miss. Reprod Health 2011;
8:22.
9 Say L, Pattinson RC, Gulmezoglu AM. WHO systematic review of
maternal morbidity and mortality: the prevalence of severe acute
maternal morbidity (near miss). Reprod Health 2004;1:3.
10 Souza JP, Cecatti JG, Parpinelli MA, Sousa MH, Lago TG, Pacagnella
RC, et al. Maternal morbidity and near miss in the community: findings from the 2006 Brazilian demographic health survey. BJOG
2010;117:158692.
11 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;10:65.
12 Ben Hamouda S, Khoudayer H, Ben Zina H, Masmoudi A, Bouguerra
B, Sfar R. [Severe maternal morbidity]. J Gynecol Obstet Biol Reprod
(Paris) 2007;36:6948.
13 Filippi V, Ronsmans C, Gohou V, Goufodji S, Lardi M, Sahel A, et al.
Maternity wards or emergency obstetric rooms? Incidence of nearmiss events in African hospitals. Acta Obstet Gynecol Scand
2005;84:1116.
14 Mustafa R, Hashmi H. Near-miss obstetrical events and maternal
deaths. J Coll Physicians Surg Pak 2009;19:7815.
15 Oladapo OT, Ariba AJ, Odusoga OL. Changing patterns of emergency obstetric care at a Nigerian University hospital. Int J Gynaecol
Obstet 2007;98:27884.
16 Roost M, Altamirano VC, Liljestrand J, Essen B. Priorities in emergency obstetric care in Boliviamaternal mortality and near-miss
morbidity in metropolitan La Paz. BJOG 2009;116:121017.
17 Amorim MMR, Katz L, Avila MB, Araujo DE, Valenca M, Albuquerque CJM, et al. Admission profile in an obstetrics intensive care unit
in a maternity hospital of Brazil. Revista Brasileira de Saude Materno
Infantil 2006;6:s5562.
18 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;105:98590.
19 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;8:10.
20 Gandhi MN, Welz T, Ronsmans C. Severe acute maternal morbidity
in rural South Africa. Int J Gynaecol Obstet 2004;87:1807.
21 Murphy CM, Murad K, Deane R, Byrne B, Geary MP, McAuliffe FM.
Severe maternal morbidity for 20042005 in the three Dublin maternity hospitals. Eur J Obstet Gynecol Reprod Biol 2009;143:347.
22 Okong P, Byamugisha J, Mirembe F, Byaruhanga R, Bergstrom S.
Audit of severe maternal morbidity in Ugandaimplications for
quality of obstetric care. Acta Obstet Gynecol Scand 2006;85:797
804.
23 Ronsmans C, Scott S, Adisasmita A, Deviany P, Nandiaty F. Estimation of population-based incidence of pregnancy-related illness and

2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2012 RCOG

Prevalence of near miss: systematic review

24
25

26

27

28

mortality (PRIAM) in two districts in West Java, Indonesia. BJOG

2009;116:8290.
World Bank T. Countries and Economies. New York: The World
Bank, 2011.
Oliveira Neto AF, Parpinelli MA, Cecatti JG, Souza JP, Sousa MH.
Factors associated with maternal death in women admitted to an
intensive care unit with severe maternal morbidity. Int J Gynaecol
Obstet 2009;105:2526.
The World Bank. GNI per capita, PPP (current international $). 2011
[cited 13 December 2011]; Available from: http://data.worldbank.org/indicator/NY.GNP.PCAP.PP.CD
Vazquez JA, Rivera GV, Higareda SH, Paez FG, Vega CC, Segura AP.
[Obstetric hysterectomy Incidence, indications and complications].
Ginecol Obstet Mex 2008;76:15660.
Souza JP, Gulmezoglu AM, Carroli G, Lumbiganon P, Qureshi Z,
Research Group W. The World Health Organization multicountry survey on maternal and newborn health: study protocol. BMC Health
Serv Res 2011;11:286.

29 World Health Organization. Evaluating the Quality of Care for Severe

Pregnancy Complications: The Who Near-Miss Approach for Maternal Health. Geneva: WHO, 2011.
30 Graham WJ. Criterion-based clinical audit in obstetrics: bridging
the quality gap? Best Pract Res Clin Obstet Gynaecol 2009;23:375
88.
31 Althabe F, Buekens P, Bergel E, Belizan JM, Campbell MK, Moss N,
et al. A behavioral intervention to improve obstetrical care. N Engl J
Med 2008;358:192940.
32 Kaye D, Mirembe F, Aziga F, Namulema B. Maternal mortality and
associated near-misses among emergency intrapartum obstetric
referrals in Mulago Hospital, Kampala, Uganda. East Afr Med J
2003;80:1449.
33 Noor S, Majid S, Ruby N. An audit of obstetrical hysterectomy. J Coll
Physicians Surg Pak 2001;11:6425.

2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2012 RCOG

661