title: Determinants of maternal near-miss in Morocco: too late, too far, too sloppy?
abstract: BACKGROUND
  In Morocco, there is little information on the circumstances surrounding maternal near misses. This study aimed to determine the incidence, characteristics, and determinants of maternal near misses in Morocco.
  
  
  METHODS
  A prospective case-control study was conducted at 3 referral maternity hospitals in the Marrakech region of Morocco between February and July 2012. Near-miss cases included severe hemorrhage, hypertensive disorders, and prolonged obstructed labor. Three unmatched controls were selected for each near-miss case. Three categories of risk factors (sociodemographics, reproductive history, and delays), as well as perinatal outcomes, were assessed, and bivariate and multivariate analyses of the determinants were performed. A sample of 30 near misses and 30 non-near misses was interviewed.
  
  
  RESULTS
  The incidence of near misses was 12‰ of births. Hypertensive disorders during pregnancy (45%) and severe hemorrhage (39%) were the most frequent direct causes of near miss. The main risk factors were illiteracy [OR = 2.35; 95% CI: (1.07-5.15)], lack of antenatal care [OR = 3.97; 95% CI: (1.42-11.09)], complications during pregnancy [OR = 2.81; 95% CI:(1.26-6.29)], and having experienced a first phase delay [OR = 8.71; 95% CI: (3.97-19.12)] and a first phase of third delay [OR = 4.03; 95% CI: (1.75-9.25)]. The main reasons for the first delay were lack of a family authority figure who could make a decision, lack of sufficient financial resources, lack of a vehicle, and fear of health facilities. The majority of near misses demonstrated a third delay with many referrals. The women's perceptions of the quality of their care highlighted the importance of information, good communication, and attitude.
  
  
  CONCLUSIONS
  Women and newborns with serious obstetric complications have a greater chance of successful outcomes if they are immediately directed to a functioning referral hospital and if the providers are responsive.
authors.affiliation: National School of Public Health, Rabat, Morocco; Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium; School of Public Health, Université Libre de Bruxelles, Brussels, Belgium.
authors.forename: Bouchra
authors.initials: B
authors.lastname: Assarag
authors.affiliation: School of Public Health, Université Libre de Bruxelles, Brussels, Belgium.
authors.forename: Bruno
authors.initials: B
authors.lastname: Dujardin
authors.affiliation: Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium; School of Public Health, Université Libre de Bruxelles, Brussels, Belgium; National Centre for Research and Training in Rural Health, Maferinyah, Guinea.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Delamou
authors.affiliation: National School of Public Health, Rabat, Morocco.
authors.forename: Fatima-Zahra
authors.initials: FZ
authors.lastname: Meski
authors.affiliation: Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Vincent
authors.initials: V
authors.lastname: De Brouwere
mesh_terms: D000293:Adolescent; D000328:Adult; D036861:Delivery, Obstetric / Q000009:adverse effects*; D005260:Female; D006801:Humans; D046110:Hypertension, Pregnancy-Induced / Q000453:epidemiology*; D015994:Incidence; D009018:Morocco / Q000453:epidemiology; D006473:Postpartum Hemorrhage / Q000453:epidemiology*; D011247:Pregnancy; D012307:Risk Factors