title: Maternal near-miss at university hospitals with cesarean overuse: an incident case-control study.
abstract: Cesarean section carries a substantial risk of maternal near-miss morbidity. The aim of this study was to determine the frequency, causes, risk factors, and perinatal outcomes of maternal near-miss at three university hospitals with a high rate of cesarean section in Tehran, Iran.
  
  
  
  An incident case-control study was conducted from March 2012 to May 2014. The modified WHO near-miss criteria were used to identify cases. A control sample of 1024 women delivering at the study hospitals was recruited to represent the source population. Near-miss ratio, crude and adjusted odds ratios with confidence intervals were assessed.
  
  
  
  Among 12 965 live births, 82 mothers developed near-miss morbidities and 12 died. The maternal near-miss ratio was 6.3/1000 live births. Severe postpartum hemorrhage (35%, 29/82), severe preeclampsia (32%, 26/82), and placenta previa/abnormally invasive placenta (10%, 8/82) were the most frequent causes of maternal near-miss. Women with antepartum cesarean section (adjusted odds ratio 7.4, 95% confidence interval 3.7-15.1) and co-morbidity (adjusted odds ratio 2.3, 95% confidence interval 1.4-3.8), uninsured Iranians (adjusted odds ratio 3.4, 95% confidence interval 1.7-7.1) and uninsured Afghans (adjusted odds ratio 4.7, 95% confidence interval 2.4-9.2) had increased risks of near-miss morbidity. Stillbirth and extremely preterm birth were the most prominent adverse perinatal outcomes associated with maternal near-miss.
  
  
  
  Overutilization of cesarean section clearly influenced the causes of maternal near-miss. A lack of health insurance had a measurable impact on near-miss morbidity. Tailored interventions for reducing unnecessary cesarean section and unrestricted insurance cover for emergency obstetric care can potentially improve maternal and perinatal outcomes.
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden.|Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Soheila
authors.identifier: 0000-0003-3394-6444
authors.initials: S
authors.lastname: Mohammadi
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden.
authors.forename: Birgitta
authors.identifier: 0000-0002-2900-2849
authors.initials: B
authors.lastname: Essén
authors.affiliation: Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Masoumeh
authors.initials: M
authors.lastname: Fallahian
authors.affiliation: Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Robabeh
authors.initials: R
authors.lastname: Taheripanah
authors.affiliation: Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Soraya
authors.initials: S
authors.lastname: Saleh Gargari
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden.
authors.forename: Carina
authors.identifier: 0000-0002-3206-6528
authors.initials: C
authors.lastname: Källestål
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D002585:Cesarean Section / Q000009:adverse effects / Q000706:statistics & numerical data*; D005260:Female; D006785:Hospitals, University; D006801:Humans; D015994:Incidence; D007231:Infant, Newborn; D007492:Iran / Q000453:epidemiology; D008428:Maternal Mortality; D017063:Outcome Assessment, Health Care; D054238:Perinatal Mortality; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology* / Q000401:mortality / Q000517:prevention & control; D011295:Prenatal Care; D012307:Risk Factors; D055815:Young Adult
keywords: Afghan migrant; Iran; Maternal near-miss; abnormally invasive placenta; cesarean section; health insurance; placenta previa