title: Applying the maternal near miss approach for the evaluation of quality of obstetric care: a worked example from a Multicenter Surveillance Study.
abstract: OBJECTIVE
  To assess quality of care of women with severe maternal morbidity and to identify associated factors.
  
  
  METHODS
  This is a national multicenter cross-sectional study performing surveillance for severe maternal morbidity, using the World Health Organization criteria. The expected number of maternal deaths was calculated with the maternal severity index (MSI) based on the severity of complication, and the standardized mortality ratio (SMR) for each center was estimated. Analyses on the adequacy of care were performed.
  
  
  RESULTS
  17 hospitals were classified as providing adequate and 10 as nonadequate care. Besides almost twofold increase in maternal mortality ratio, the main factors associated with nonadequate performance were geographic difficulty in accessing health services (P < 0.001), delays related to quality of medical care (P = 0.012), absence of blood derivatives (P = 0.013), difficulties of communication between health services (P = 0.004), and any delay during the whole process (P = 0.039).
  
  
  CONCLUSIONS
  This is an example of how evaluation of the performance of health services is possible, using a benchmarking tool specific to Obstetrics. In this study the MSI was a useful tool for identifying differences in maternal mortality ratios and factors associated with nonadequate performance of care.
authors.affiliation: Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), R. Alexander Fleming 101, P.O. Box 6030, 13083-881 Campinas, SP, Brazil.
authors.forename: Samira Maerrawi
authors.initials: SM
authors.lastname: Haddad
authors.affiliation: Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), R. Alexander Fleming 101, P.O. Box 6030, 13083-881 Campinas, SP, Brazil ; Centre for Research on Reproductive Health of Campinas (Cemicamp), R. Vital Brasil 200, 13083-888 Campinas, SP, Brazil.
authors.forename: Jose Guilherme
authors.identifier: 0000-0003-1285-8445
authors.initials: JG
authors.lastname: Cecatti
authors.affiliation: Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), R. Alexander Fleming 101, P.O. Box 6030, 13083-881 Campinas, SP, Brazil.
authors.forename: Joao Paulo
authors.initials: JP
authors.lastname: Souza
authors.affiliation: Centre for Research on Reproductive Health of Campinas (Cemicamp), R. Vital Brasil 200, 13083-888 Campinas, SP, Brazil.
authors.forename: Maria Helena
authors.initials: MH
authors.lastname: Sousa
authors.affiliation: Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), R. Alexander Fleming 101, P.O. Box 6030, 13083-881 Campinas, SP, Brazil.
authors.forename: Mary Angela
authors.initials: MA
authors.lastname: Parpinelli
authors.affiliation: Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), R. Alexander Fleming 101, P.O. Box 6030, 13083-881 Campinas, SP, Brazil.
authors.forename: Maria Laura
authors.initials: ML
authors.lastname: Costa
authors.affiliation: Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), R. Alexander Fleming 101, P.O. Box 6030, 13083-881 Campinas, SP, Brazil.
authors.forename: Rodolfo C
authors.initials: RC
authors.lastname: Pacagnella
authors.affiliation: Federal University of Amazonas, Manaus, AM, Brazil.
authors.forename: Ione R
authors.initials: IR
authors.lastname: Brum
authors.affiliation: CISAM, School of Medical Sciences, Recife, PE, Brazil.
authors.forename: Olímpio B
authors.initials: OB
authors.lastname: Moraes Filho
authors.affiliation: Federal University of Ceará, Fortaleza, CE, Brazil.
authors.forename: Francisco E
authors.initials: FE
authors.lastname: Feitosa
authors.affiliation: Federal University of Bahia, Salvador, BA, Brazil.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Menezes
authors.affiliation: Hospital Geral Cesar Cals, Fortaleza, CE, Brazil.
authors.forename: Everardo M
authors.initials: EM
authors.lastname: Guanabara
authors.affiliation: Hospital Geral de Fortaleza, Fortaleza, CE, Brazil.
authors.forename: Joaquim L
authors.initials: JL
authors.lastname: Moreira
authors.affiliation: Maternidade Odete Valadares, Belo Horizonte, MG, Brazil.
authors.forename: Frederico A
authors.initials: FA
authors.lastname: Peret
authors.affiliation: Hospital Materno Infantil, Goiania, GO, Brazil.
authors.forename: Luiza E
authors.initials: LE
authors.lastname: Schmaltz
authors.affiliation: IMIP, Recife, PE, Brazil.
authors.forename: Leila
authors.initials: L
authors.lastname: Katz
authors.affiliation: Federal University of Pernambuco, Recife, PE, Brazil.
authors.forename: Antonio C Barbosa
authors.initials: AC
authors.lastname: Lima
authors.affiliation: Federal University of Campina Grande, PB, Brazil.
authors.forename: Melania M
authors.initials: MM
authors.lastname: Amorim
authors.affiliation: Federal University of Maranhão, São Luis, MA, Brazil.
authors.forename: Marilia G
authors.initials: MG
authors.lastname: Martins
authors.affiliation: Federal University of Paraná, Curitiba, PR, Brazil.
authors.forename: Denis J
authors.initials: DJ
authors.lastname: Nascimento
authors.affiliation: Federal University of Paraíba, João Pessoa, PB, Brazil.
authors.forename: Cláudio S
authors.initials: CS
authors.lastname: Paiva
authors.affiliation: Hospital Maternidade Fernando Magalhães, Rio de Janeiro, RJ, Brazil.
authors.forename: Roger D
authors.initials: RD
authors.lastname: Rohloff
authors.affiliation: Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.
authors.forename: Sergio M
authors.initials: SM
authors.lastname: Costa
authors.affiliation: Hospital Maternidade Celso Pierro, Campinas, SP, Brazil.
authors.forename: Adriana G
authors.initials: AG
authors.lastname: Luz
authors.affiliation: Instituto Fernandes Figueira, Rio de Janeiro, RJ, Brazil.
authors.forename: Gustavo
authors.initials: G
authors.lastname: Lobato
authors.affiliation: Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Cordioli
authors.affiliation: University of the State of São Paulo, Botucatu, SP, Brazil.
authors.forename: Jose C
authors.initials: JC
authors.lastname: Peraçoli
authors.affiliation: Jundiaí School of Medicine, Jundiaí, SP, Brazil.
authors.forename: Nelson L
authors.initials: NL
authors.lastname: Maia Filho
authors.affiliation: University of São Paulo, Ribeirão Preto, SP, Brazil.
authors.forename: Silvana M
authors.initials: SM
authors.lastname: Quintana
authors.affiliation: Santa Casa de Limeira, Limeira, SP, Brazil.
authors.forename: Fátima A
authors.initials: FA
authors.lastname: Lotufo
authors.affiliation: Santa Casa de São Carlos, SP, Brazil.
authors.forename: Carla B
authors.identifier: 0000-0002-5590-108X
authors.initials: CB
authors.lastname: Andreucci
authors.affiliation: Maternidade Leonor Mendes de Barros, Sao Paulo, SP, Brazil.
authors.forename: Márcia M
authors.initials: MM
authors.lastname: Aquino
authors.affiliation: Federal University of São Paulo, SP, Brazil.
authors.forename: Rosiane
authors.initials: R
authors.lastname: Mattar
mesh_terms: D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D063130:Maternal Death / Q000706:statistics & numerical data; D008427:Maternal Health Services; D008428:Maternal Mortality; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality* / Q000628:therapy*; D014944:World Health Organization