DOI: 10.1111/j.1471-0528.2012.03294.

x
Systematic review
www.bjog.org

The prevalence of maternal near miss: a

systematic review
Ö Tunçalp,a MJ Hindin,a JP Souza,b D Chou,b L Sayb
a
Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA and
b
Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
Correspondence: Dr Ö Tunçalp, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public
Health. 615 N Wolfe St MD 21205, Baltimore, USA. Email: otuncalp@jhsph.edu

Accepted 11 January 2012.

Background Severe maternal morbidity or ‘near miss’ is a
promising indicator to improve quality of obstetric care.
Objectives To systematically review all available studies on ‘near
miss’.
Search strategy Following a pre-defined protocol, our review
covered articles between January 2004 and December 2010. We
used a combination of the following terms: near miss morbidity,
severe maternal morbidity, severe acute maternal morbidity,
obstetric near-miss, maternal near miss, obstetric near miss,
emergency hysterectomy, emergency obstetric hysterectomy,
maternal complications, pregnancy complications, intensive care
unit.
Selection criteria Nearly 4000 articles were screened by title and
abstract, and 153 articles were retrieved for full text evaluation.
There were no language restrictions.
Data collection and analysis Data extraction was performed using
an instrument that included sections on study characteristics,
quality of reporting, prevalence/incidence and the definition and
identification criteria. Univariate analysis and meta-analysis for
sub-groups were performed.
Main results A total of 82 studies from 46 countries were
included. Criteria for identification of cases varied widely.
Prevalence rates varied between 0.6 and 14.98% for disease-
specific criteria, between 0.04 and 4.54% for management-based
criteria and between 0.14 and 0.92% for organ-based dysfunction
based on Mantel criteria. The rates are higher in low-income and
middle-income countries of Asia and Africa. Based on meta-
analysis, the estimate of near miss was 0.42% (95% CI 0.40–
0.44%) for the Mantel (organ dysfunction) criteria and 0.039%
(95% CI 0.037–0.042%) for emergency hysterectomy. Our meta-
regression results indicate that emergency hysterectomy rates have
been increasing by about 8% per year.
Authors’ conclusions There is growing interest in the application
of the maternal near-miss concept as an adjunct to maternal
mortality. However, in the literature published before 2011 there
was still important variation in the criteria used to identify
maternal near-miss cases. The World Health Organization recently
published criteria based on markers of management and of
clinical and organ dysfunction which would enable systematic data
collection on near miss and development of summary estimates.
Comparing the rates over time and across regions, it is clear that
different approaches are needed to lower the rates of near miss
and that interventions must be developed with the local context in
mind.
Keywords Global, maternal morbidity, near miss, review.

Please cite this paper as: Tunçalp Ö, Hindin MJ, Souza JP, Chou D, Say L. The prevalence of maternal near miss: a systematic review. BJOG 2012;119:
653–661.

deaths and maternal mortality is still an important public

Introduction
Progress in the reduction of maternal mortality has been
slow. Over 1000 women still die from pregnancy-related
causes every day around the world and the vast majority of
these deaths occur in developing countries.1 Low-income
countries are heavily affected by the burden of maternal
The World Health Organization retains copyright and all other rights in
the manuscript of this article as submitted for publication.
health problem among middle-income countries. Strength-
ened health systems and effective maternal health care (par-
ticularly to those women experiencing acute pregnancy-
related complications) are considered the key factors for
reducing maternal mortality.2
Many countries are encouraging pregnant women to
deliver in health facilities. On the one hand, this policy
favours the reduction of delays in the identification and
management of peripartum complications. On the other

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 653
 Tunçalp et al.
hand, such a policy may lead to overloading of health ser-
vices, which are already insufficient in many of these set-
tings, thereby adversely affecting the quality of care. In this
context, quality of care has been identified as a central ele-
ment in the United Nations Global Strategy for Women
and Children Health.3
Confidential enquiries into maternal deaths have been
in use for many years in the identification of quality of
care and health systems issues.4 However, in low mortality
settings or at the health service level, the number of mater-
nal deaths is generally insufficient or not representative
enough to allow reliable policy guidance. In the last
20 years, the concept of maternal near miss has been
explored in maternal health as an adjunct to maternal-death
confidential enquiries. Among other positive characteristics,
near-miss cases occur more frequently than maternal deaths
and can directly inform on problems and obstacles that had
to be overcome during the process of health care, providing
more robust conclusions and rapid reporting on maternal
care issues.5,6 Hence, the identification of cases of severe
maternal morbidity has emerged as a promising comple-
mentary or alternative strategy to reduce maternal mortal-
ity. In particular, near misses have been viewed as a useful
outcome measure for the evaluation and improvement of
maternal health services in developing countries.4
In 2003/04, the World Health Organization (WHO) con-
ducted a systematic review on the prevalence of severe mater-
nal morbidity and maternal near-miss cases. The substantial
heterogeneity observed in the pre-2004 literature led WHO
to establish a technical working group comprising obstetri-
cians, midwives, epidemiologists and public healthcare pro-
fessionals to develop a standard definition and uniform
identification criteria for maternal near-miss cases.7 In April
2009, a paper was published by the WHO working group
defining maternal near miss morbidity as ‘a woman who
nearly died but survived a complication that occurred during
pregnancy, childbirth or within 42 days of termination of
pregnancy’. With a view to achieving a reasonable balance
between the burden of data collection and useful informa-
tion, the WHO working group targeted the identification of
only very severe cases—i.e. primarily those presenting with
features of organ dysfunction.7 The near-miss identification
criteria developed by the technical working group have been
tested and validated as being able to provide robust and reli-
able data. Detailed information about the near-miss concept
and its development is published elsewhere (Souza JP et al.,
manuscript in preparation).7,8
Methods
A WHO systematic review published in 2004, spanned the
literature on severe maternal morbidity and maternal near
miss from 1997 to 2004.9 The current review provides an
654 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
update based on a search for new articles between January
2004 and December 2010. We have included the electronic
databases Pubmed, Embase, Lilacs, Popline, IndMed and
WHO regional databases. The regional databases are as fol-
lows: Index Medicus for the Eastern Mediterranean Region
(IMEMR), African Index Medicus (AIM), Western Pacific
Region Index Medicus (WPRIM). We have also searched
for relevant articles in the WHO Library by hand, and con-
tacted experts in the field.
We used a similar search strategy to that in the previous
study with a combination of the following terms: near miss
morbidity, severe maternal morbidity, severe acute maternal
morbidity, obstetric near-miss, maternal near miss, obstetric
near miss, emergency hysterectomy, emergency obstetric hys-
terectomy, maternal complications, pregnancy complications,
intensive care unit. To verify the compatibility between the
current and previous search strategies, we applied this
search strategy to the timeframe covered by the previous
systematic review and compared the results.
The inclusion criteria for the current review were as fol-
lows: (1) articles with near-miss incidence or prevalence
data, (2) published between January 2004 and December
2010, (3) included data from 1990 onwards, (4) sample size
‡200 and (5) clearly described methodology. There were no
language restrictions.
Data extraction was performed using an instrument that
included sections on the general study level characteristics
(such as design, population, setting), quality of data report-
ing, prevalence/incidence of maternal near miss and the
definition and identification criteria. Authors have also
been contacted in cases where further information or clari-
fication was required. The denominator used was either
deliveries or live births (only five studies used live births as
a denominator).
We describe the included studies with an emphasis on
the different definitions used and criteria for identification
of the cases. We performed univariate analyses and the
ranges of near-miss prevalence are reported based on iden-
tification criteria and region. Studies reporting very high
near-miss prevalence that was outside the ranges formed by
most of the studies in the review were identified as outliers.
We also reported on near miss over mortality ratio to
assess the care that near-miss cases receive.
We conducted meta-analysis for the sub-groups manage-
ment (emergency hysterectomy) and Mantel-based organ
dysfunction criteria, where more homogeneous criteria were
established among the studies. Also we conducted multivari-
able meta-regression for the emergency hysterectomy group.
We included the studies from the 2004 review in our final
analyses and observed the historical trends.9 Unless indicated
otherwise all of the analyses include the 82 studies from the
current review. We used Stata 10 (StataCorp LP; Stata-
Corp., College Station, TX, USA) for our analyses.
 Prevalence of near miss: systematic review

3943 Table 1. Near-miss rates by identification criteria and region

Title/Abstract
Identification criteria Range of near No. of
3790 articles excluded
based on the misses (%) studies (n = 81)
inclusion criteria

153 Disease-specific 0.6–14.98 7

Full-text Management-specific
3 articles included 74 articles excluded Emergency hysterectomy 0.04–0.26 34
Duplicate datasets, not providing
after complementary numbers of near misses and/or
ICU sdmission 0.04–4.54 (15.8)* 18
search any denominators and using
Organ dysfunction 0.14–2.3
specific populations or
82 complications
Mantel or Modified Mantel 0.14–0.92 (17.8)** 8
Inclusion criteria
Other 2.3 1
Figure 1. The flow diagram of identification of studies. Mixed criteria
Disease/Organ/Management 0.04–4.43 7
Disease/Management 0.09–3.42 7
Results Region***
Africa 0.05–14.98 14
Nearly 4000 articles were initially screened by title and Asia 0.02–5.07 (17.8)** 31
abstract, and 153 articles were retrieved for full text evalua- Latin America and Caribbean 0.34–4.93 (15.8)* 9
tion. Data have been extracted from 82 articles (Figure 1). Europe 0.04–0.79 18
A total of 82 studies from 46 countries were included North America 0.07–1.38 10
in this review. Studies were mainly retrospective cross- Oceania (Australia) 1.25 1

sectional and except for one study in Brazil,10 all of the
studies used data from facilities, mainly tertiary-care hospi-
tals. A majority of the studies included describe the charac-
teristics of the setting and participants as well as reporting
definitions and procedures of identification of the cases.
More detailed information on each study is presented in
the Table S1. To validate our current strategy, we tested it
on the articles included in the 2004 review and identified
27 out of the 30 articles included in the previous review
strategy. The three articles not found initially were identi-
fied after a complementary reference lists search.
Except for the studies reporting on emergency hysterec-
tomies and intensive-care unit (ICU) admissions, a major-
ity of the studies defined near miss as a woman who
almost died but survived through chance or as a result of
good care received. Overall, there were three major
approaches to the identification: (1) disease-specific criteria
(i.e. severe pre-eclampsia, severe postpartum haemorrhage),
(2) management-based criteria (i.e. admission to ICU, need
for a blood transfusion), or (3) organ system dysfunction-
based criteria. The majority used management-based criteria
including 33 studies that used emergency hysterectomies,
and 18 that used ICU admissions to define near miss.
Seven studies used disease-specific criteria, nine of the arti-
cles used organ system dysfunction as the criteria for near
miss and 14 used a combination of disease, organ and
management-based criteria.
Near miss by identification criteria
Study-specific near-miss rates differed based on the method
of identification and region (Table 1). Studies using
disease-specific criteria reported a higher percentage of
*Near-miss rate by Amorim et al.17 is reported separately as it is an
outlier in the group.
**Near-miss rate by Adisasmita et al.19 is reported separately as it is
an outlier in the group.
***Regions have been allocated based on UN Classifications.25
near-miss cases, and a wider range of estimates compared
with the other criteria, 0.6–14.98%. Case identification cri-
teria varied for disease-specific criteria, which included, but
was not limited to, hypertensive disorders, haemorrhage,
uterine rupture, sepsis and anaemia. Most of the studies
established a certain criteria for the degree of severity for
the selected clinical conditions.11–16
Near-miss rates identified by management-specific crite-
ria ranged between 0.04 and 4.54%. However, it should be
noted that within this group, studies identifying emergency
hysterectomies reported lower percentages (0.04–0.26%)
than studies using ICU admissions (0.04–4.54%). The
Amorim et al.17 study in Brazil reported a near miss rate of
15.8%—much higher than the rest of the studies in this
category and considered one of the two outliers identified
in this review. The hospital in this study serves a very large
geographic area as the main maternal ICU unit and there-
fore a significant proportion of the women admitted to
the ICU did not enter the denominator—deliveries at the
hospital.
Organ dysfunction-based criteria were used in nine stud-
ies and the near-miss rate reported ranged between 0.14
and 2.3%. Eight of nine studies used either Mantel or
modified Mantel criteria in this category and reported rates
between 0.14 and 0.92%. These criteria were first intro-
duced in South Africa and combine organ dysfunction and

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 655
 Tunçalp et al.

certain management markers such as intensive-care admis-
sion, emergency hysterectomy to identify near-miss cases.18
This criterion is arguably the most stable compared with
others in this review. Depending on the level of the facility
and resources available, some studies used a modified ver-
sion of these criteria.19–23 One study by Adisasmita et al.19
in Indonesia reported a near-miss rate of 17.8%—much
higher than the other studies in this category and consid-
ered the second outlier in this review. This study included
a large number of early pregnancy losses in the numerator
and included a number of clinical diagnoses (eclampsia,
uterine rupture and ectopic pregnancy) in their near-miss
criteria. Using deliveries as the denominator and including
these clinical diagnoses may have inflated the near-miss
rate. However, even if the obstetric-related admissions were
used as the denominator and only near miss cases with
organ dysfunction are included, the near miss rate is
11.3%—still very high compared with all the other studies.
Near miss by region
Based on their income, all African and Asian countries
(where there were near-miss studies) except Saudi Arabia
and Kuwait are considered low-income or middle-income
countries.24 Table 2 shows the near-miss rates in each
region by different identification criteria. The upper near-
miss rate ranged from 4.93% in Latin America and the
Caribbean, through 5.07% in Asia to 14.98% in Africa
(excluding outliers). In contrast, studies from high-income
countries (Europe, North America and Australia) reported
an upper near-miss rate from a low of 0.79% in Europe to
a high of 1.38% in North America: the lowest rates across
all the criteria compared with those from low-income and
middle-income countries.
The most commonly used criterion was emergency hys-
terectomies in all regions except North America, and Latin
America and the Caribbean (LAC) (6/14 in Africa, 16/31 in
Asia, 8/17 in Europe, 3/10 in North America and Australia
and 1/11 in LAC). The second most common criterion
across regions was ICU admission, for all regions except
Africa. In North America, several of the studies identified
near misses using criteria combining disease, organ and
management markers, using International Classification of
Disease (ICD) codes and national and regional databases.
Depending on the resources of a facility or a country over-
all, the criteria used for identification of near misses vary.
For example, in high-income countries where facility deliv-
eries and systematic, national level data are the norm, more
sensitive markers have been used to identify the near-miss
cases, whereas in resource-poor settings, management-based
criteria are more commonly used.
In low and middle-income countries, approximately 1%
of the women experienced a near-miss event before, during
or after delivery as identified by organ dysfunction criteria.
It was around 0.25% in higher-income countries. Manage-
ment-specific criteria using ICU admissions and emergency
hysterectomies were under 1% across all regions, except the
two studies from the LAC region.17,25 Using mixed criteria
combining different markers, the rate ranges between 2.10
and 4.43% in low-income and middle-income countries
and 0.09 and 1.38% in higher-income countries.
Historical trends in near miss
In the 6 years since the 2004 WHO review, more articles
have been published focusing on near-miss maternal mor-
bidity; thereby increasing the number of articles included
from 30 to 82 articles. Table 3 shows a comparison of the

Table 2. Near miss rates in each region by different identification criteria (# signifies the number of studies)

Identification criteria Africa Asia LAC Europe N. America and

Australia

% Near miss n % Near miss n % Near miss n % Near miss n % Near miss n

Disease-specific 0.6–14.98 3 3.21–5.07 2 4.93 1 0.79 1 – –

Management-specific
Emergency hysterectomy 0.05–0.41 6 0.02–0.49 16 0.87 1 0.04–0.20 8 0.07–0.16 3
ICU admission 0.24 1 0.12–0.90 9 0.34–4.54 (15.8)* 3 0.04–0.73 4 0.29–1.33 2
Organ dysfunction
Mantel or Modified Mantel 0.41–0.84 3 0.9 (17.8)** 2 0.63 1 0.14–0.35 2 – –
Other – – 2.3 1 – – – – – –
Mixed Criteria
Disease/Management 3.15 1 3.42 1 2.10–3.04 2 0.09–0.72 2 1.25 1
Disease/Organ/Management – – – – 2.12–4.43 3 – – 0.27–1.38 4
Total 0.05–14.98 14 0.02–5.07 31 0.34–4.92 11 0.04–0.79 17 0.07–1.38 10

*Near-miss rate by Amorim et al.17 is reported separately as it is an outlier in the group.

**Near-miss rate by Adisasmita et al.19 is reported separately as it is an outlier in the group.

656 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
 Prevalence of near miss: systematic review

Table 3. Comparing the rates by criteria and region between 2004

the detailed description of indicators by organ system and
and current review degree of severity can be found elsewhere.18 For this analy-
sis, we have also included 2004 review articles. All of the
2011 Review 2004 Review studies included in this analysis described the characteristics
(N = 82) (N = 30)
of the setting, participants, definitions and procedures of
case identification (11 studies for Mantel criteria and 40
Identification criteria
studies for emergency hysterectomy). For the Mantel-based
Disease-specific 0.6–14.98 0.8–8.23
criteria, the estimate of near miss was 0.42% (95% CI 0.40–
Management-specific
Emergency 0.04–0.26 0.01–0.21 (2.99)**** 0.44%). For the emergency hysterectomy criteria, the near-
hysterectomy miss rate was 0.039% (95% CI 0.037–0.42%). Despite the
ICU admission 0.04–4.54 (15.8)* 0.08–1.02 very narrow range of the confidence intervals, the I-squared
Organ dysfunction was high: 98.3% for the Mantel-based criteria and 95.5%
Mantel or Modified 0.14–0.92 (17.8)** 0.38–1.09 (10.61)*** from the emergency hysterectomy criteria, suggesting signif-
Mantel
icant heterogeneity between studies (Figures 2 and 3).
Other 2.3
We explored the heterogeneity in a multivariable meta-
Mixed criteria 0.04–4.43 1.34
regression model for near miss identified by emergency
hysterectomy by using median data collection year, study
Region 2011 Review 2004 Review
region and gross national income for the respective median
data collection year (results not shown).26 For this analysis
Africa 0.05–14.98 0.08–10.61
we combined North America and LAC region, as there was
Asia 0.02–5.07 (17.8)** 0.01–4.37
Latin America and 0.34–4.93 (15.8)* 0.14–0.24 only one study from LAC. Our analysis showed that emer-
Caribbean gency hysterectomy rates were higher in more recent years
Europe 0.04–0.79 0.04–1.20 of data collection (an approximate 8% increase per year,
North America and 0.07–1.38 0.08–0.27 P = 0.02, 95% CI 0.01–0.15). Near miss identified by emer-
Australia gency hysterectomy was significantly more common in
Oceania 1.25 –
North America/LAC compared with Europe, mostly because
*Near-miss rate by Amorim et al.17 is reported separately as it is an of the one study in the LAC region from Mexico.27 We
outlier in this group. found that about one-third of the variation between studies
**Near-miss rate by Adisasmita et al.19 is reported separately as it is in emergency hysterectomy rates (R2 = 27.96%) could be
an outlier in this group.
explained by these variables.
***Near-miss rate by Kaye et al.32 is reported separately as it is an
outlier in this group.
****Near-miss rate by Noor et al.33 is reported separately as it is an
Discussion
outlier in this group.
We have included 82 studies in this systematic review. All
of the included studies have used a variety of near-miss cri-
two reviews based on identification criteria and region. The teria ranging from disease-specific to organ dysfunction
ranges of near-miss cases based on different criteria and a mix of different systems. The near-miss rates have
reported were similar between the two time points. How- not significantly changed between the review in 2004 and
ever, it should be noted that in the current review the the current 2011 review, although the ranges are wider for
ranges are wider for each category, there are more studies each category in the current review. In the current study,
using mixed criteria overall and a larger number of studies disease-specific criteria produced higher rates than both
from low-income and middle-income countries report on management-specific and organ dysfunction criteria. Under
organ dysfunction criteria. the management-based criteria, studies using ICU admis-
sion produced larger variation than emergency hysterec-
Meta-analysis of near miss tomy studies.
Although we could not conduct meta-analysis of near miss Studies using management-based criteria were less likely
as a comprehensive category because of the variety of iden- to specifically include the discussion on maternal near miss;
tification criteria, we have conducted meta-analyses for the rather, they focused on emergency obstetric care and the
two categories, emergency hysterectomy and Mantel-based case series in their facilities. We should underline the fact
organ-based dysfunction, where more homogeneous criteria that the rates produced by these individual studies do not
were used among the studies compared with the other crite- include all the near-miss cases in a facility. Admission to
ria. As mentioned above, Mantel criteria include a set of ICU relies on the availability of physical and human
organ-based dysfunction and management-based criteria, resources as well as the criteria for admission used in

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 657
 Tunçalp et al.
Figure 2. Meta-analysis among studies using Mantel-based organ dysfunction criteria (n = 11).
different institutions. For example Amorim et al.17 reported
a very high ICU admission rate because the facility in the
study was a referral institution, therefore it was almost
impossible to identify the right denominator with all the
deliveries.
Definitions of emergency hysterectomy and Mantel crite-
ria were fairly uniform across studies; however, as shown
in our meta-analysis there was very high heterogeneity
between studies, 95.5% and 98.3% respectively. Although
some of this heterogeneity is the result of the year of data
collection, which was statistically significant, gross national
income and region of the country, it can also be explained
by various reasons including several unmeasured variables
such as the capacity of the hospital to identify the cases
within their chosen criteria, availability or the patient load
of the referral institutions in which many of our studies
are conducted and the general structure of the health sys-
tem. It should be noted that although there is heterogene-
ity, near miss is a condition of very low prevalence and our
data still show a narrow range in estimates.
This study has some limitations that should be noted.
First, although we searched for unpublished data, it is very
likely that we missed some unpublished studies. Second,
despite the fact that the number of studies included in this
review almost tripled compared with the 2004 review, we
still had relatively sparse data globally. Despite these limita-
tions, the study has a number of strengths. First, it is com-
prehensive in its scope and we made special efforts to
658 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
reach out to the authors for further information and clari-
fication. Second, this review is very timely as we move
towards standardised criteria, as it summarises the current
trends in global near-miss rates. Since the 2004 review, the
number of studies examining maternal near miss almost
tripled, underlining the growing emphasis on the issue
globally. Next, we used the previous systematic review data
both to assess our search criteria and to assess changes over
time. Finally, the study adds to the previous systematic
review by including meta-analysis to get overall near-miss
prevalence rates for two of the criteria.
It is our hope that the recent WHO criteria for identify-
ing maternal near-miss cases will stimulate researchers and
clinicians to carry out near-miss assessments around the
world using the same criteria. We are aware of a number
of ongoing studies, including the large multi-country study
that WHO is implementing in 29 countries.28 To use near-
miss cases as a way to improve quality of care in the facili-
ties, WHO has developed a systematised approach to
implement near-miss criterion-based clinical audits.29 For
these types of audits a set of evidence-based, explicit, mea-
surable criteria for case management are agreed that can
then be used to monitor practice and determine if stan-
dards of care have been met, by reviewing case notes.30 The
expected results include, among others, understanding local
patterns of maternal mortality and morbidity, strengths
and weaknesses in the referral system, and the use of
clinical and other healthcare interventions. In addition,
 Prevalence of near miss: systematic review

Figure 3. Meta-analysis among studies using emergency hysterectomy—a management based criteria (N = 40).

implementing a surveillance strategy on women with life-

threatening conditions being managed at the healthcare
facility can foster a culture of early identification of compli-
cations and promote better preparedness for acute morbidi-
ties. It is necessary to go beyond surveillance and implement
interventions to improve the quality of maternal care, Facil-
ity-based interventions can include the implementation of
evidence-based guidelines, the use of reminders, opinion
leaders’ endorsement, and continued audit and feedback to
achieve behavioural and process changes.29,31 It would also
lead to interventions aimed at increasing the awareness of
danger signs among providers at lower level facilities as well
as community-based providers to minimise the delays in
referrals to prevent both maternal morbidity and mortality.
Conclusions
There is growing interest in the application of the maternal
near-miss concept as an adjunct to maternal mortality.
However, in the literature published before 2011 there was
still important variation in the criteria used to identify
maternal near-misses. An organ-system dysfunction
approach remains as the most epidemiologically sound set
of criteria. WHO recently published criteria based on
markers of management, and clinical and organ dysfunc-
tion, which is currently being adopted by researchers and
organisations around the world. By using the uniform
criteria, clear data on near miss can be systematically

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 659
 Tunçalp et al.
collected, thereby facilities, countries and regions can
monitor the near-miss rate over time to develop better
interventions to improve the quality of obstetric care. Our
review also suggests that it may be beneficial to explore
why emergency hysterectomy rates are higher in more
recent years of data collection (an approximate 8% increase
per year). Although it is well known, our results indicate
that more resources are needed in low-income and middle-
income countries. Comparing the rates over time and
across regions, it is clear that different approaches are
needed to lower the rates of near miss and that interven-
tions must be developed with the local context in mind.
Disclosure of interests
None.
Contribution to authorship
All of the authors participated in the formulation of the
methodology for this review. OT performed the literature
search and reviewed all abstracts and full text articles with
assistance from JPS and DC. OT wrote the first draft of the
manuscript and MJH, JPS, DC and LS assisted in the writ-
ing and editing of the manuscript.
Details of ethics approval
This is a systematic review of previously published data
and therefore does not require ethical approval.
Funding
None.
Acknowledgements
The views expressed in this paper are those of the authors
as individuals, and do not necessarily represent the views
of the WHO and its member states.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Table S1. Characteristics of included studies (N = 82).
Please note: Wiley-Blackwell is not responsible for the
content or functionality of any supporting information
supplied by the authors. Any queries (other than missing
material) should be directed to the corresponding author. j
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