title: Maternal near miss and maternal deaths in Mozambique: a cross-sectional, region-wide study of 635 consecutive cases assisted in health facilities of Maputo province.
abstract: BACKGROUND
  Life-threatening events during pregnancy are currently used as a measure to assess quality of obstetric care. The aim of this study is to assess prevalence of near miss cases and maternal deaths, to elucidate the causes and to analyze avoidable factors based upon the three-delays approach in southern Mozambique.
  
  
  METHODS
  Near miss cases comprised five categories: eclampsia, severe hemorrhage, severe sepsis, uterine rupture and severe malaria. Pregnant women surviving the event were interviewed during a 5-month period within five health facilities offering comprehensive emergency obstetric care in Maputo City and Province. Family members gave additional information and were interviewed in case of the patient's death.
  
  
  RESULTS
  Out of 27,916 live births, 564 near miss cases and 71 maternal deaths were identified, giving a total maternal near miss ratio of 20/1,000 live births and maternal mortality ratio of 254/100,000 live births, respectively. Near miss fatality rate was 11.2%. Among near miss cases hemorrhage accounted for the most common event (58.0%), followed by eclampsia (35.5%); HIV seroprevalence was 22.3%. Inappropriate attendance in antenatal care services (21.1%), late or wrong diagnosis (12.6%), inadequate management immediately after delivery (9.6%), no monitoring of blood pressure and other vital signs (9.2%) were the most prevalent factors contributing to the severe morbidity under study. Third delay was identified in 69.7% of the interviews. In more than one fourth of near miss cases treatment was not started immediately. Lack of blood derivates and unavailable operating room were reported in 42.0% and 35.0%, respectively.
  
  
  CONCLUSIONS
  Near miss cases were frequent and related to delays in reaching and receiving adequate care. First and third type of delay contributed significantly to the number of maternal near miss cases and deaths. Maternal health policies need to be concerned not only with averting the loss of life, but also with ameliorating care of severe maternal complications at all levels including primary care. Sexual and reproductive health services for adolescents should be prioritized to prevent adverse outcomes.
authors.affiliation: Department of Obstetrics and Gynecology, Maputo Central Hospital, Maputo, Mozambique. edavid9959@yahoo.com.
authors.forename: Ernestina
authors.initials: E
authors.lastname: David
authors.affiliation: Department of Obstetrics and Gynecology, Maputo Central Hospital, Maputo, Mozambique. fernanda.machungo@gmail.com.
authors.forename: Fernanda
authors.initials: F
authors.lastname: Machungo
authors.affiliation: Department of Life Science and Reproduction, University of Verona, U.O. di Ginecologia e Ostetricia, Policlinico Borgo Roma, 37134, Verona, Italy. giovanni.zanconato@univr.it.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Zanconato
authors.affiliation: Department of Life Science and Reproduction, University of Verona, U.O. di Ginecologia e Ostetricia, Policlinico Borgo Roma, 37134, Verona, Italy. elena.cavaliere3@gmail.com.
authors.forename: Elena
authors.initials: E
authors.lastname: Cavaliere
authors.affiliation: Department of Obstetrics and Gynecology, Maputo Central Hospital, Maputo, Mozambique. sfiosse@yahoo.com.br.
authors.forename: Sidonia
authors.initials: S
authors.lastname: Fiosse
authors.affiliation: Department of Obstetrics and Gynecology, Maputo Central Hospital, Maputo, Mozambique. celasululu@gmail.com.
authors.forename: Celeste
authors.initials: C
authors.lastname: Sululu
authors.affiliation: Department of Obstetrics and Gynecology, Maputo Central Hospital, Maputo, Mozambique. bmarluz@yahoo.com.br.
authors.forename: Benvinda
authors.initials: B
authors.lastname: Chiluvane
authors.affiliation: Division of Global Health, Karolinska Institutet, Stockholm, Sweden. staffan.bergstrom@ki.se.
authors.forename: Staffan
authors.initials: S
authors.lastname: Bergström
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D015528:HIV Seroprevalence; D006470:Hemorrhage / Q000453:epidemiology; D006801:Humans; D016779:Malaria, Cerebral / Q000453:epidemiology; D008428:Maternal Mortality; D008429:Maternal Welfare; D009073:Mozambique / Q000453:epidemiology; D011181:Postnatal Care; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology*; D011295:Prenatal Care; D011446:Prospective Studies; D018805:Sepsis / Q000453:epidemiology; D061665:Time-to-Treatment; D055815:Young Adult