title: Validating the WHO Maternal Near Miss Tool in a high-income country.
abstract: BACKGROUND
  This study was performed to assess the applicability of the WHO Maternal Near Miss Tool (MNM Tool) and the organ dysfunction criteria in a high-income country.
  
  
  METHODS
  The MNM tool was applied to 2552 women who died of pregnancy-related causes or sustained severe acute maternal morbidity between August 2004 and August 2006 in one of the 98 hospitals with a maternity unit in the Netherlands. Fourteen (0.6%) cases had insufficient data for application. Each case was assessed according to the three main "MNM categories" specified in the MNM tool and their subcategory criteria: five disease-, four intervention- and seven organ dysfunction-based criteria. Potentially life-threatening conditions (disease-based inclusions) and life-threatening cases (organ dysfunction-based inclusions) were differentiated according to WHO methodology. Outcomes were incidence of all (sub)categories and case-fatality rates.
  
  
  RESULTS
  Of the 2538 cases, 2308 (90.9%) women fulfilled disease-based, 2116 (83.4%) intervention-based and 1024 (40.3%) organ dysfunction-based criteria. Maternal death occurred in 48 women, of whom 23 (47.9%) fulfilled disease-based, 33 (68.8%) intervention-based and 31 (64.6%) organ dysfunction-based criteria. Case-fatality rates were 23/2308 (1.0%) for cases fulfilling the disease-based criteria, 33/2116 (1.6%) for intervention-based criteria and 31/1024 (3.0%) for women fulfilling the organ dysfunction-based criteria.
  
  
  CONCLUSIONS
  In the Netherlands, where advanced laboratory and clinical monitoring are available, organ dysfunction-based criteria of the MNM tool failed to identify nearly two-thirds of sustained severe acute maternal morbidity cases and more than one-third of maternal deaths. Disease-based criteria remain important, and using only organ dysfunction-based criteria would lead to underestimating severe acute maternal morbidity.
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Tom
authors.identifier: http://orcid.org/0000-0003-1051-9407
authors.initials: T
authors.lastname: Witteveen
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Ilona
authors.identifier: http://orcid.org/0000-0001-6719-3722
authors.initials: I
authors.lastname: de Koning
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Hans
authors.identifier: http://orcid.org/0000-0003-0730-2522
authors.initials: H
authors.lastname: Bezstarosti
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Thomas
authors.identifier: http://orcid.org/0000-0002-9890-9145
authors.initials: T
authors.lastname: van den Akker
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.|Athena Institute, VU University Amsterdam, Amsterdam, the Netherlands.
authors.forename: Jos
authors.identifier: http://orcid.org/0000-0002-6746-3259
authors.initials: J
authors.lastname: van Roosmalen
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Kitty W
authors.identifier: http://orcid.org/0000-0002-1377-4625
authors.initials: KW
authors.lastname: Bloemenkamp
mesh_terms: D000328:Adult; D019049:Developed Countries / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008428:Maternal Mortality; D009102:Multiple Organ Failure / Q000175:diagnosis* / Q000401:mortality; D000067491:Near Miss, Healthcare / Q000706:statistics & numerical data*; D009426:Netherlands / Q000453:epidemiology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis* / Q000401:mortality; D014944:World Health Organization; D055815:Young Adult
keywords: Maternal Near Miss Tool; Severe acute maternal morbidity; World Health Organization; high income country; maternal health; organ dysfunction