title: A cross sectional study of maternal 'near-miss' cases in major public hospitals in Egypt, Lebanon, Palestine and Syria.
abstract: BACKGROUND
  The maternal near-miss approach has been increasingly used as a tool to evaluate and improve the quality of care in maternal health. We report findings from the formative stage of a World Health Organization (WHO) funded implementation research study that was undertaken to collect primary data at the facility level on the prevalence, characteristics, and management of maternal near-miss cases in four major public referral hospitals - one each in Egypt, Lebanon, Palestine and Syria.
  
  
  METHODS
  We conducted a cross sectional study of maternal near-miss cases in the four contexts beginning in 2011, where we collected data on severe maternal morbidity in the four study hospitals, using the WHO form (Individual Form HRP A65661). In each hospital, a research team including trained hospital healthcare providers carried out the data collection.
  
  
  RESULTS
  A total of 9,063 live birth deliveries were reported during the data collection period across the four settings, with a total of 77 cases of severe maternal outcomes (71 maternal near-miss cases and 6 maternal deaths). Higher indices for the maternal mortality index were found in both Al Galaa hospital, in Egypt (8.6%) and Dar Al Tawleed hospital in Syria (14.3%), being large referral hospitals, compared to Ramallah hospital in Palestine and Rafik Hariri University hospital in Lebanon. Compared to the WHO's Multicountry Survey using the same data collection tool, our study's mortality indices are higher than the index of 5.6% among countries with a moderate maternal mortality ratio in the WHO Survey. Overall, haemorrhage-related complications were the most frequent conditions among maternal near-miss cases across the four study hospitals. In all hospitals, coagulation dysfunctions (76.1%) were the most prevalent dysfunction among maternal near-miss cases, followed by cardiovascular dysfunctions. The coverage of key evidence-based interventions among women experiencing a near-miss was either universal or very high in the study hospitals.
  
  
  CONCLUSIONS
  Findings from this formative stage confirmed the need for quality improvement interventions. The high reported coverage of the main clinical interventions in the study hospitals would appear to be in contradiction with the above findings as the level of coverage of key evidence-based interventions was high.
authors.affiliation: Faculty of Medicine, Damascus University, Damascus, Syria. hyam1929@gmail.com.
authors.forename: Hyam
authors.initials: H
authors.lastname: Bashour
authors.affiliation: Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon. gs29@aub.edu.lb.
authors.forename: Ghada
authors.initials: G
authors.lastname: Saad-Haddad
authors.affiliation: Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon. jd16@aub.edu.lb.
authors.forename: Jocelyn
authors.initials: J
authors.lastname: DeJong
authors.affiliation: Obstetrics and Gynecology department, Al Galaa Maternity Teaching Hospital, Cairo, Egypt. mshereen57@yahoo.com.
authors.forename: Mohammed Cherine
authors.initials: MC
authors.lastname: Ramadan
authors.affiliation: Institute of Community and Public Health, Birzeit University, Birzeit, Palestine. saharjhassan@gmail.com.
authors.forename: Sahar
authors.initials: S
authors.lastname: Hassan
authors.affiliation: Social Research Center, American University in Cairo, Cairo, Egypt. miralb@gmail.com.
authors.forename: Miral
authors.initials: M
authors.lastname: Breebaart
authors.affiliation: Institute of Community and Public Health, Birzeit University, Ramallah, Palestine. lwick@birzeit.edu.
authors.forename: Laura
authors.initials: L
authors.lastname: Wick
authors.affiliation: Independent, Reproductive Health Consultant, Cairo, Egypt. nvnhassanein@yahoo.com.
authors.forename: Nevine
authors.initials: N
authors.lastname: Hassanein
authors.affiliation: Faculty of Medicine, Damascus University, Damascus, Syria. kharouf.m@hotmail.com.
authors.forename: Mayada
authors.initials: M
authors.lastname: Kharouf
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D004534:Egypt / Q000453:epidemiology; D005260:Female; D006779:Hospitals, Public; D006801:Humans; D007861:Lebanon / Q000453:epidemiology; D050498:Live Birth; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008428:Maternal Mortality; D008877:Middle East / Q000453:epidemiology; D007744:Obstetric Labor Complications / Q000453:epidemiology*; D011247:Pregnancy; D013593:Syria / Q000453:epidemiology; D014944:World Health Organization; D055815:Young Adult