title: The WHO maternal near-miss approach and the maternal severity index model (MSI): tools for assessing the management of severe maternal morbidity.
abstract: OBJECTIVE
  To validate the WHO maternal near-miss criteria and develop a benchmark tool for severe maternal morbidity assessments.
  
  
  METHODS
  In a multicenter cross-sectional study implemented in 27 referral maternity hospitals in Brazil, a one-year prospective surveillance on severe maternal morbidity and data collection was carried out. Diagnostic accuracy tests were used to assess the validity of the WHO maternal near-miss criteria. Binary logistic regression was used to model the death probability among women with severe maternal complications and benchmark the management of severe maternal morbidity.
  
  
  RESULTS
  Of the 82,388 women having deliveries in the participating health facilities, 9,555 women presented pregnancy-related complications, including 140 maternal deaths and 770 maternal near misses. The WHO maternal near-miss criteria were found to be accurate and highly associated with maternal deaths (Positive likelihood ratio 106.8 (95% CI 99.56-114.6)). The maternal severity index (MSI) model was developed and found to able to describe the relationship between life-threatening conditions and mortality (Area under the ROC curve: 0.951 (95% CI 0.909-0.993)).
  
  
  CONCLUSIONS
  The identification of maternal near-miss cases using the WHO list of pregnancy-related life-threatening conditions was validated. The MSI model can be used as a tool for benchmarking the performance of health services managing women with severe maternal complications and provide case-mix adjustment.
authors.affiliation: UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland. souzaj@who.int
authors.forename: Joao Paulo
authors.initials: JP
authors.lastname: Souza
authors.forename: Jose Guilherme
authors.initials: JG
authors.lastname: Cecatti
authors.forename: Samira M
authors.initials: SM
authors.lastname: Haddad
authors.forename: Mary Angela
authors.initials: MA
authors.lastname: Parpinelli
authors.forename: Maria Laura
authors.initials: ML
authors.lastname: Costa
authors.forename: Leila
authors.initials: L
authors.lastname: Katz
authors.forename: Lale
authors.initials: L
authors.lastname: Say
mesh_terms: D015415:Biomarkers / Q000378:metabolism; D001938:Brazil / Q000453:epidemiology; D005260:Female; D006801:Humans; D063130:Maternal Death / Q000706:statistics & numerical data; D008954:Models, Biological; D009017:Morbidity; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology* / Q000401:mortality; D014944:World Health Organization
chemical_list: D015415:Biomarkers