HPP

Health Promotion Perspectives, 2019, 9(4), 255-262

doi: 10.15171/hpp.2019.35 T U MS
Publishing
https://hpp.tbzmed.ac.ir Group

Systematic Review

The global prevalence of maternal near miss: a systematic review

and meta-analysis
ID ID
Sedigheh Abdollahpour1 , Hamid Heidarian Miri2, Talat Khadivzadeh1*
1
Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
2
Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

ARTICLE INFO Abstract

Article History: Background: Improving the maternal health is one of the world’s most challenging problems.
Received: 28 Apr. 2019 Despite significant movements over the past decades, maternal health has been still considered
Accepted: 17 Sep. 2019 as a central goal for sustainable development. Maternal near miss (MNM) cases experience
ePublished: 24 Oct. 2019 long-term physical and psychological effects. To present a clear portrait of the current situation,
we performed a systematic review and meta-analysis with the purpose to assess the worldwide
prevalence of MNM.
Keywords: Methods: We conducted a systematic review on PubMed, Scopus and Web of Science electronic
Maternal near miss, Maternal databases to find published papers in English, before March 2019 and regardless of the type of
health, Prevalence, Systematic study. We, then, assessed the prevalence of MNM according to the World Health Organization
review, Meta-analysis (WHO) criteria. Finally, 49 papers were included in the study. Random effects meta-analysis was
used to pool the available prevalence. The quality of studies was also evaluated.
*Corresponding Author: Results: The weighted pooled worldwide prevalence of MNM, was 18.67/1000 (95% CI: 16.28-
Talat Khadivzadeh, 21.06). Heterogeneity was explored using subgroup analyses based on the continent and the
Nursing and Midwifery Care country. We used meta-regression of MNM on MD which resulted in adjusted R-squared as
Research Center, Mashhad 78.88%.
University of Medical
Conclusion: The prevalence of MNM was considerable. Low- and middle-income countries
Sciences, Mashhad, Iran.
should develop systematic approaches to improve quality of care in the facilities and to reduce
Email:
the risk of MNM events, with the hope to women’s health.
[email protected]

Citation: Abdollahpour S, Heidarian Miri H, Khadivzadeh T. The global prevalence of maternal near miss: a systematic review and meta-
analysis. Health Promot Perspect. 2019;9(4):255-262. doi: 10.15171/hpp.2019.35.

Introduction developing an understanding of why they happen and

In the way of reaching Millennium Development Goals how they can be prevented.2 In recent years the term
to end preventable maternal mortality, it is still regarded “near miss” emerged in the lexicon of maternal health for
as an unfinished agenda and one of the world’s most the evaluation of the quality of obstetric care.2 In April
challenging problems. Despite significant movements 2009, a paper published by the WHO working group
over the past years, it still continued to be as an open defined maternal near miss (MNM) as “a woman who
discussion in the post-2015 framework for sustainable nearly died but survived a complication that occurred
development targets and investment priority.1 According during pregnancy, childbirth or within 42 days after
to the perspective of World Health Organization (WHO), childbirth”.3 In other word, a woman is considered a near
every pregnant woman and newborn should receive miss case if she survives a life-threatening condition (i.e.
qual­ity care throughout pregnancy, childbirth and the organ dysfunction).3 Accordingly, prevalence of near-
postnatal periods.1 Although there was a 45% decrease miss, MNM, started to gradually find its way as a useful
in the worldwide maternal deaths (MD) since 1990, there measurement for the evaluation of safe motherhood
are still 800 deaths per day from highly preventable causes programs in populations.2
before, during, and after the time of childbirth.1 Then, health professionals and administrators have
In 2004, WHO published a manual under the title used MNM to evaluate the facilities for maternal care
“Beyond the Numbers: reviewing maternal death and to reduce the fatality among women with near miss
complications to make pregnancy safer”, that emphasizes complications and to provide a basis on which further
the need for going beyond merely counting deaths to researches are conducted.2 Based on WHO criteria MNM

© 2019 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Abdollahpour et al

ratio (MNMR) mentions to the number of maternal near- adequacy of the sample size, the objectivity and standard
miss cases per 1000 live births (LB).3 This criterion is of the criteria used for measurement of the condition, the
being reviewed to improve the quality of care, because a detailed description of the participants and the setting, the
large number of MNM cases will experience long-term reliability of the condition measurement, the adequacy
physical and psychological effects.3 That due to the lack of the response rate the appropriateness of the statistical
of accurate statistics of psychological complications and analysis, and the appropriate coping with the low response
burden of disease, implementation of supportive care, rate, in case it existed. All the article met the high-quality
screening of traumatic childbirth, and early counseling standard. When the indicators were not mentioned, but
prior to the beginning of post-traumatic stress or contained the necessary information for its calculation,
depression was suggested.4,5 But at present, studies that it was assessed and added to the results in the review.
have examined the global MNM rate are very low or old6,7 Among the results, the following quantitative indicators
and according to WHO criteria, accurate statistics are not were extracted.
available from these mothers. Considering this gap and To explore MNM ratio with WHO approach, the
need for aggregated information for policy and decision number of cases in a thousand LB was considered.3 We
making on reducing maternal morbidity and mortalities, applied a random effects meta-analysis to obtain the
the purpose of this study is to systematically review weighted average prevalence with 95% CIs for studies.
worldwide prevalence of MNM. Heterogeneity was estimated using the Cochran I2 statistic
and its P value.59 Subgroup analysis was accomplished to
Material and Methods analyze MNM as WHO criteria. All statistical analyses
Based on the Preferred Reporting Items for Systematic were conducted using Stata version 14.1(Stata Corp,
Reviews and Meta-analyses (PRISMA) checklist,8 this College Station, TX).
study was designed to review the body of the available
literature on MNM published until March 2019. We have Results
searched the electronic databases including PubMed, The primary search recognized 300 published papers,
Scopus and Web of Science and manually checked including 86 in PubMed, 89 in Web of Science and 104
references of the identified relevant papers. Regarding in Scopus. From those, 164 articles were elimi­ nated
eligibility criteria and regardless of the type of study, we after removal of duplicates. Nearly 135 articles were
include articles that have identified mothers according initially screened by abstract. After excluding those who
to WHO criteria (Including renal, cardiovascular, had inclusion criteria, 67 articles remained for full-text
respiratory, hepatic, coagulation/hematological, uterine screening. Out of these 67 articles, in the next step 18
dysfunction and neurological) 3 as well as articles that were excluded either because they had not followed the
extract the number of MD and the number of live births. WHO definition criteria. Data have been extracted from
We excluded studies targeted certain groups or conditions 49 articles (Figure 1). There was well agreement (88.37%)
such as some ethnic groups, twin pregnancy, post-partum between reviewers on the terminal articles eligible for
hemorrhage, preeclampsia, ectopic pregnancy etc because inclusion.
of lack of generalizability. Depending on the study design, the selected papers
We restricted the search to published articles in English were cross-sectional (n = 34), cohorts (n = 12), case control
language. The search strategy focused on three key words (n = 3). In almost all continents, the prevalence of MNM
or phrases: (“maternal near miss” AND (prevalence or was investigated. No studies were conducted in North
incidence)). The full-text articles were read to confirm America and Australia. The number of articles conducted
eligibility and to collect relevant information from the in Asia, South America, Africa, Europe and Oceania was
selected abstracts. Each article was read by at least two 20, 9, 16, 2, and 2, respectively. Most of these studies were
authors independently for the reading and synthesis conducted in Brazil (n = 7) and India (n = 9). Of the 34
stages. The disagreements between them were solved by articles, both MNM and MD were extracted; out of 15,
consensus. The reasons for exclusion criteria were listed only the prevalence of MNM was extracted. All articles
in the PRISMA flowchart. were conducted since 2012, because the WHO criteria for
The information of studies include author, year, identifying MNM was announced this year. Prevalence
country, continent , design of study, sample size, MNM, of MNM is reported by all the studies ranged from 2.2 to
MD, MNMR and quality score were collected in prepared 287.7 /1000 LB.
a separate page and are summarized in Table 1.9-57 Quality The weighted pooled worldwide prevalence of MNM,
of the studies was evaluated according to the set of was 18.67/1000 (95% CI: 16.28-21.06). There was a large
criteria based on Joanna Briggs Institute (JBI) guidance volume of heterogeneity in the prevalence of MNM (I2
on conducting prevalence and incidence reviews.58 The = 99.8%; Cochran Q-statistic P < 0.0001; Figure 2). The
quality of a paper was assessed based on criteria such subgroup analysis will help to explore heterogeneity in
as the appropriate recruitment of the participants, the the MNM prevalence. Subgroup analysis was conducted
representativeness of the sample, the sufficiency of the based on the continent and the country. Because maternal
coverage of the identified sample by the data analysis, the health indicators are very diverse in countries and

256 Health Promot Perspect, 2019, Volume 9, Issue 4

Abdollahpour et al

Table 1. Specifications of studies about prevalence Maternal Near Miss based on the WHO approach in world

Author Year Country Continent Design Sample (LB) MNM MD MNM/1000 JBI Score
Souza9 2012 Brazil South America Cross-sectional 82 388 770 140 9/34 17
Jabir 10
2013 Iraq Asia Cross-sectional 25 472 129 16 5/06 16
Nelissen11 2013 Tanzania Africa Cross-sectional 9152 216 32 23/6 17
Ps12 2013 India Asia Cross-sectional 7390 131 17/80 18
Rana 13
2013 Nepal Asia Cohort 41 676 157 3/80 15
Tunçalp14 2013 Ghana Africa Cohort 3438 94 37 28/60 17
Setia 15
2013 Indonesia Asia Cross-sectional 14 559 341 23/42 16
Dias16 2014 Brazil South America Cross-sectional 2 300 000 10/21 16
Galvão17 2014 Brazil South America Cross-sectional 16243 77 17 5/80 15
Luexay 18
2014 Laos Asia Cohort 1215 11 2 9/80 15
Pandey19 2014 India Asia Case-control 5273 633 247 120/04 14
Tahira 20
2014 Pakistan Asia Cross-sectional 1000 67 67 17
Bakshi21 2015 India Asia Cross-sectional 688 51 10 5/12 18
Bashour22 2015 Egypt* Africa Cross-sectional 9063 71 6 7/83 17
Madeiro 23
2015 Brazil South America Cohort 5841 56 10 9/60 18
Mazhar24 2015 Pakistan Asia Cross-sectional 13 175 94 38 7/13 15
Menezes 25
2015 Brazil South America Cross-sectional 20 435 77 17 3/76 16
Oliveira26 2015 Brazil South America Cross-sectional 2055 . 12/8 17
Rulisa27 2015 Rwanda Africa Cross-sectional 1739 13 8 14
Tan 28
2015 China Asia Cross-sectional 34 547 8 5 2/3 15
Abha29 2016 India Asia Cohort 13 895 211 102 15/18 17
Cecatti 20
2016 Brazil South America Cross-sectional 82 388 770 140 9/34 17
De Mucio31 2016 Latin America South America Cross-sectional 3196 37 12/3 16
Ghazivakili32 2016 Iran Asia Cross-sectional 38 663 192 7 4/97 16
Kalisa 33
2016 Rwanda Africa Cohort 3994 86 13 21/51 16
Mohammadi34 2016 Iran Asia Case-control 12 965 82 12 6/30 15
Nakimuli 35
2016 Uganda Africa Cohort 25 840 695 130 8/42 15
Nansubuga36 2016 Uganda Africa Cross-sectional 1557 434 287/70 18
Norhayati37 2016 Malaysia Asia Cross-sectional 21 579 395 2 2/20 15
Oladapo 38
2016 Nigeria Africa Cross-sectional 91 724 1451 998 15/81 16
O'Malley39 2016 Ireland Europe Cross-sectional 4502 16 0 3/55 17
Parmar 40
2016 India Asia Cross-sectional 1929 46 18 23/85 18
Rathod41 2016 India Asia Cohort 21 992 161 66 7/56 17
Ray42 2016 India Asia Cross-sectional 4800 220 17 45/83 16
Papua New
Tanimia 43
2016 Oceania Cross-sectional 13 338 122 9 9/1 16
Guinea
Witteveen44 2016 Netherlands Europe Cross-sectional 371 623 1179 3/17 15
Papua New
Bolnga 45
2017 Oceania Cohort 6019 153 10 25/4 16
Guinea
Chandak46 2017 India Asia Cross-sectional 13 186 137 10/38 16
Goldenberg 47
2017 Zambia** Africa Cross-sectional 122 707 4866 39/65 15
Liyew48 2017 Ethiopia Africa Cross-sectional 29 697 238 8/01 15
Mbachu 49
2017 Nigeria Africa Cross-sectional 262 52 5 198 15
Serruya50 2017 Latin America South America Cross-sectional 712 081 21985 1028 31/50 16
Awowole51 2018 Nigeria Africa Case-control 11 242 . 3/8 15
Chikadaya 52
2018 Zimbabwe Africa Cohort 11 871 110 13 9/3 16
Iwuh53 2018 South Africa Africa Case-control 19 222 112 13 5/83 17
Oppong 54
2018 Ghana Africa Cross-sectional 8433 288 62 34/2 17
Woldeyes55 2018 Ethiopia Africa Cross-sectional 2737 138 24 50/42 16
Yang56 2018 China Asia Cohort 14 014 265 18/90 17
Deepti Gupta 57
2018 India Asia Cohort 4533 74 15 16/32 16

Health Promot Perspect, 2019, Volume 9, Issue 4 257

Abdollahpour et al

Identification
Records identified through database Additional records identified through
searching (ISI=89, PubMed=86, Scholar
Scopus=104) (n = 1)
(n = 279)

Records excluded: (specific

groups: Preeclampsia=13
Ethnic different=3
Records after duplicates removed
ART=2
(n =136) PPH=6
CS=6

Screening
EP= 4
Twin=7
ICU=4
Records screened Infection=3
Neonatal=11
(n =136)
Abortion=3)
RCT study=2
Qualitative study=2
Review=3
Full-text articles (n =69 )
assessed for eligibility
Eligibility

(n =67)
Full-text articles
excluded: Not having the
WHO definition criteria
Studies included in (n =18)
qualitative synthesis
(n =49)
Included

Studies included in
quantitative synthesis
(meta-analysis)
(n =49)

Figure 1. PRISMA diagram for the selection process of the articles.

continents. By continents, MNM prevalence ranged from the studies that had been conducted in South America,
3.10/1000 in the Europe to 31.88/1000 LB in the Africa. weighted pooled prevalence of MNM was 11.57 (95%
Among the studies that had been conducted in Asia, CI: 4.68-18.47) with significant heterogeneity between
weighted pooled prevalence of MNM was 16.92 (95% studies (I2 = 99.9%; Cochran Q-statistic P < 0.001).Among
CI: 14.21-19.64) with significant heterogeneity between the studies that had been conducted in Africa, weighted
studies (I2 = 98.9%; Cochran Q-statistic P < 0.001).Among pooled prevalence of MNM was 31.88 [95% CI: 25.14-
38.61] with significant heterogeneity between studies
(I2 = 99.6%; Cochran Q-statistic P = 0.00). Among the
studies that had been conducted in Europe, weighted
pooled prevalence of MNM was 3.10 (95% CI: 2.93-3.28)
with non-significant little heterogeneity between studies
(I2 = 0.0%; Cochran Q-statistic P = 0.61). Among the
studies that had been conducted in Oceania, weighted
pooled prevalence of MNM was 17.14 (95% CI: 1.17-
33.12) with significant heterogeneity between studies
(I2 = 98.2%; Cochran Q-statistic P < 0.001; Figure 3). For
heterogeneous justification, a subgroup analysis was
also conducted based on the country; for example, the
prevalence of MNM in Brazil was 8.36 (95% CI: 6.50-
10.21) with significant heterogeneity between studies
(I2 = 97.9%; Cochran Q-statistic P < 0.001). Among the
studies that had been conducted in India, weighted pooled
prevalence of MNM was 28.22 [95% CI: 19.21-37.22]
with significant heterogeneity between studies (I2 = 99
%; Cochran Q-statistic P < 0.001) and in the Nigeria was
20.87 [95% CI: 8.37-33.37] with significant heterogeneity
between studies (I2 = 99.4 %; Cochran Q-statistic P < 0.001;
Figure 4). The results indicate that the heterogeneity
between studies is significant in a country (Including
Figure 2. Forest plot of the pooling of overall worldwide prevalence Brazil, India and Nigeria).
of MNM. To further assess the source of heterogeneity we used

258 Health Promot Perspect, 2019, Volume 9, Issue 4

Abdollahpour et al

by 0.024. This implies that in order to reduce the risk of

MNM events, it’s helpful to work on the risk factors on
MD. The weighted pooled worldwide prevalence of MD
among 35 studies that had reported it, was 294.75/100 000
LB [95% CI: 244.06-345.44]. A sensitivity analysis using
metainf command which was performed to see whether
the total result is affected by any individual studies showed
that some studies had some impact on the total result but
this impact was not statistically significant. Publication
bias was assessed visually and statistically using funnel
plot and Egger’s and Begg’s test. Regarding the asymmetry
shape of the funnel plot and the P values of Egger’s and
Begg’s test that were 0.160 and 0.000 respectively, it seems
that there could be some sort of publication bias. However,
the results tended to be unchanged after applying Trim
and Fill approach.

Discussion
We found that more than 18.67/1000 LB of the general
population of the world suffered from MNM based on
WHO criteria. So far, two systematic review in 20046 and
20117 have been conducted to determine the prevalence
of maternal mortality globally. In recent years, a review
study conducted to determine the death of mothers based
on WHO criteria, has not been carried out. Therefore,
Figure 3. Forest plot of the pooling of overall continents prevalence
comparing the prevalence’s changes during the passage of
of MNM.
time is relatively difficult. In a review conducted by Say
et al, prevalence’s of MNM ranged from 0.80% to 8.23%
in studies which had disease-specific criteria while it was
from 0.38% to1.09% in studies which had organ-system
based criteria and it was from 0.01% to 2.99% in studies
which had management-based criteria.6
In another review conducted by Tunçalp et al, the
prevalence’s varied between 0.6 and 14.98% in studies
which had disease specific criteria while it varied between
0.14% and 0.92% in studies which had Mantel (organ
dysfunction) criteria and it varied between 0.04% and
4.54% in studies which had management-based criteria.
A meta-analysis in the aforementioned study, estimated
that MNM was 0.42% (95% CI 0.40-0.44%) for the Mantel
(organ dysfunction) criteria.7 In both of these studies, the
reported MNM prevalence is in 100 live birth, but in our
study, according to the WHO definition, the number of
MNM reported in 1000 live births, Which indicates that
the MNM rate has declined in general, and the WHO’s
unit case-identification criteria of MNM and its declare to
Figure 4. Forest plot of the pooling of overall countries prevalence all countries has played a major role in improving quality
of MNM.
care.
Other results of our study were exploring the MNM
meta-regression of MNM on MD which resulted in prevalence in countries. In our study the prevalence
adjusted R-squared as 78.88%. This means that much of the of MNM according to the WHO criteria in Brazil was
observed heterogeneity among studies could be explained 8.36/1000, which is consistent with the systematic review
by maternal death as Pearson correlation coefficient of da Silva et al in Brazil (the MNMR varied from 4.4/1000
between MNM and MD among included studies was also LB).60 The reason for the little statistical difference is the
70.16% (P < 0.001). The coefficient of meta-regression difference in the years of the study as well as various
shows that for each unit increase in MD (per 100 000) definitions in identifying the cases of maternal death. In
the average of MDM (per 1000) is expected to increase the present study the MNM prevalence in middle and low

Health Promot Perspect, 2019, Volume 9, Issue 4 259

Abdollahpour et al

income countries of Asia and Africa to compare to high- Mashhad University of Medical Sciences.
income countries, are higher; which is in line with the study
of Tunçalp et al.7 Of course, in these continents, countries References
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