title: Priorities in emergency obstetric care in Bolivia--maternal mortality and near-miss morbidity in metropolitan La Paz.
abstract: OBJECTIVE
  To document the frequency and causes of maternal mortality and severe (near-miss) morbidity in metropolitan La Paz, Bolivia.
  
  
  METHODS
  Facility-based cross-sectional study.
  
  
  METHODS
  Four maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government-subsidised programme.
  
  
  METHODS
  All maternal deaths and women with near-miss morbidity.
  
  
  METHODS
  Inclusion of near-miss using clinical and management-based criteria.
  
  
  METHODS
  Maternal mortality ratio (MMR), severe morbidity ratio (SMR), mortality indices and proportion of near-miss cases at hospital admission.
  
  
  RESULTS
  MMR was 187/100,000 live births and SMR was 50/1000 live births, with a relatively low mortality index of 3.6%. Severe haemorrhage and severe hypertensive disorders were the main causes of near-miss, with 26% of severe haemorrhages occurring in early pregnancy. Sepsis was the most common cause of death. The majority of near-miss cases (74%) were in critical condition at hospital admission and differed from those fulfilling the criteria after admission as to diagnostic categories and socio-demographic variables.
  
  
  CONCLUSIONS
  Pre-hospital barriers remain to be of great importance in a setting of this type, where there is wide availability of free maternal health care. Such barriers, together with haemorrhage in early pregnancy, pre-eclampsia detection and referral patterns, should be priority areas for future research and interventions to improve maternal health. Near-miss upon arrival and near-miss after arrival at hospital should be analysed separately as that provides additional information about factors that contribute to maternal ill-health.
authors.affiliation: International Maternal and Child Health (IMCH), Department of Women's and Children's Health, Uppsala University Hospital, Sweden. mattias.roost@kbh.uu.se
authors.forename: M
authors.initials: M
authors.lastname: Rööst
authors.forename: V C
authors.initials: VC
authors.lastname: Altamirano
authors.forename: J
authors.initials: J
authors.lastname: Liljestrand
authors.forename: B
authors.initials: B
authors.lastname: Essén
mesh_terms: D000328:Adult; D001838:Bolivia / Q000453:epidemiology; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D004638:Emergency Treatment / Q000401:mortality / Q000706:statistics & numerical data; D005260:Female; D006292:Health Priorities; D006760:Hospitalization / Q000706:statistics & numerical data; D006771:Hospitals, Maternity; D006786:Hospitals, Urban; D006801:Humans; D008428:Maternal Mortality; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality* / Q000628:therapy; D011295:Prenatal Care / Q000458:organization & administration*; D012959:Socioeconomic Factors; D014504:Urban Health