title: When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country.
abstract: OBJECTIVE
  To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.
  
  
  METHODS
  Nationwide cross-sectional study.
  
  
  METHODS
  Forty-two tertiary hospitals.
  
  
  METHODS
  Women admitted for pregnancy, childbirth and puerperal complications.
  
  
  METHODS
  All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period.
  
  
  METHODS
  Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).
  
  
  RESULTS
  Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care.
  
  
  CONCLUSIONS
  Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care.
  
  
  CONCLUSIONS
  Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.
authors.affiliation: Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland.
authors.forename: O T
authors.initials: OT
authors.lastname: Oladapo
authors.affiliation: Department of Obstetrics and Gynaecology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria.
authors.forename: O O
authors.initials: OO
authors.lastname: Adetoro
authors.affiliation: Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Gwagwalada, Nigeria.
authors.forename: B A
authors.initials: BA
authors.lastname: Ekele
authors.affiliation: Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria.
authors.forename: C
authors.initials: C
authors.lastname: Chama
authors.affiliation: Department of Obstetrics and Gynaecology, University of Calabar Teaching Hospital, Calabar, Nigeria.
authors.forename: S J
authors.initials: SJ
authors.lastname: Etuk
authors.affiliation: Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
authors.forename: A P
authors.initials: AP
authors.lastname: Aboyeji
authors.affiliation: Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Enugu, Nigeria.
authors.forename: H E
authors.initials: HE
authors.lastname: Onah
authors.affiliation: Department of Obstetrics and Gynaecology, University of Uyo Teaching Hospital, Uyo, Nigeria.
authors.forename: A M
authors.initials: AM
authors.lastname: Abasiattai
authors.affiliation: Department of Obstetrics and Gynaecology, Federal Medical Centre, Birnin-Kebbi, Nigeria.
authors.forename: A N
authors.initials: AN
authors.lastname: Adamu
authors.affiliation: Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Idi-Araba, Nigeria.
authors.forename: O
authors.initials: O
authors.lastname: Adegbola
authors.affiliation: Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
authors.forename: A S
authors.initials: AS
authors.lastname: Adeniran
authors.affiliation: Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria.
authors.forename: C O
authors.initials: CO
authors.lastname: Aimakhu
authors.affiliation: Department of Obstetrics and Gynaecology, Federal Medical Centre, Owo, Nigeria.
authors.forename: O
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authors.lastname: Akinsanya
authors.affiliation: Department of Obstetrics and Gynaecology, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria.
authors.forename: L D
authors.initials: LD
authors.lastname: Aliyu
authors.affiliation: Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, Benin-City, Nigeria.
authors.forename: A B
authors.initials: AB
authors.lastname: Ande
authors.affiliation: Department of Obstetrics and Gynaecology, Federal Medical Centre, Birnin-Kudu, Nigeria.
authors.forename: A
authors.initials: A
authors.lastname: Ashimi
authors.affiliation: Department of Obstetrics and Gynaecology, Federal Medical Centre, Nguru, Nigeria.
authors.forename: M
authors.initials: M
authors.lastname: Bwala
authors.affiliation: Department of Obstetrics and Gynaecology, Lagos State University Teaching Hospital, Ikeja, Nigeria.
authors.forename: A
authors.initials: A
authors.lastname: Fabamwo
authors.affiliation: Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria.
authors.forename: A D
authors.initials: AD
authors.lastname: Geidam
authors.affiliation: Department of Obstetrics and Gynaecology, Nnamdi Azikwe University Teaching Hospital, Nnewi, Nigeria.
authors.forename: J I
authors.initials: JI
authors.lastname: Ikechebelu
authors.affiliation: Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria.
authors.forename: J O
authors.initials: JO
authors.lastname: Imaralu
authors.affiliation: Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria.
authors.forename: O
authors.initials: O
authors.lastname: Kuti
authors.affiliation: Department of Obstetrics and Gynaecology, Federal Medical Centre, Bida, Nigeria.
authors.forename: D
authors.initials: D
authors.lastname: Nwachukwu
authors.affiliation: Department of Obstetrics and Gynaecology, Delta State University Teaching Hospital, Abraka, Nigeria.
authors.forename: L
authors.initials: L
authors.lastname: Omo-Aghoja
authors.affiliation: Department of Obstetrics and Gynaecology, Usmanu DanFodiyo University Teaching Hospital, Sokoto, Nigeria.
authors.forename: K
authors.initials: K
authors.lastname: Tunau
authors.affiliation: Department of Obstetrics and Gynaecology, Aminu Kano University Teaching Hospital, Kano, Nigeria.
authors.forename: J
authors.initials: J
authors.lastname: Tukur
authors.affiliation: Department of Obstetrics and Gynaecology, Federal University Teaching Hospital, Abakaliki, Nigeria.
authors.forename: Ouj
authors.initials: O
authors.lastname: Umeora
authors.affiliation: Department of Obstetrics and Gynaecology, National Hospital, Abuja, Nigeria.
authors.forename: A C
authors.initials: AC
authors.lastname: Umezulike
authors.affiliation: Centre for Research in Reproductive Health, Sagamu, Nigeria.
authors.forename: O A
authors.initials: OA
authors.lastname: Dada
authors.affiliation: Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland.
authors.forename: Ӧ
authors.initials: Ӧ
authors.lastname: Tunçalp
authors.affiliation: Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland.
authors.forename: J P
authors.initials: JP
authors.lastname: Vogel
authors.affiliation: Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland.
authors.forename: A M
authors.initials: AM
authors.lastname: Gülmezoglu
mesh_terms: D001771:Blood Banks / Q000600:supply & distribution; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002423:Cause of Death; D003430:Cross-Sectional Studies; D003906:Developing Countries / Q000706:statistics & numerical data*; D004461:Eclampsia / Q000453:epidemiology; D005260:Female; D006779:Hospitals, Public / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008428:Maternal Mortality; D017057:Medically Uninsured / Q000706:statistics & numerical data; D000067491:Near Miss, Healthcare / Q000706:statistics & numerical data*; D009549:Nigeria / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D006473:Postpartum Hemorrhage / Q000453:epidemiology; D011225:Pre-Eclampsia / Q000453:epidemiology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology / Q000401:mortality*; D011446:Prospective Studies; D062606:Tertiary Care Centers / Q000592:standards / Q000706:statistics & numerical data*; D061665:Time-to-Treatment / Q000706:statistics & numerical data
keywords: Clinical audit; WHO near-miss criteria; maternal death; maternal near miss; quality of care; severe acute maternal morbidity