Maternal health remains a crucial indicator of the quality and accessibility of healthcare services in any country. While global efforts have significantly reduced maternal mortality, maternal morbidity continues to be a pressing concern—especially in developing nations.(1,2) A Maternal Near Miss (MNM) refers to a woman who nearly dies but survives a complication occurring during pregnancy, childbirth, or within 42 days of termination of pregnancy. These cases offer valuable insights into the gaps in healthcare systems and provide an opportunity to improve service delivery without the finality of death. (3)

The World Health Organization (WHO) and the National Health Mission (NHM), India, have developed specific criteria to identify MNM cases, emphasizing the need to monitor not just maternal deaths but also severe maternal outcomes. Studying MNM is vital because it highlights both the failures and successes in maternal healthcare delivery.(4)

 Among the various causes of MNM, obstetric haemorrhage remains the most common and preventable contributor to severe maternal morbidity and mortality. It encompasses postpartum haemorrhage (PPH), antepartum haemorrhage (APH), haemorrhage in early pregnancy (such as ectopic pregnancy and abortion), and rarer but serious conditions like ruptured uterus. In resource-limited settings, delayed referrals, inadequate blood transfusion services, and lack of timely surgical intervention often exacerbate the outcomes of haemorrhagic complications.(5)

Tertiary care hospitals often act as referral centers for high-risk pregnancies and obstetric emergencies. As a result, these centers provide a unique window to assess the burden and clinical spectrum of maternal near miss events.(6)

This study was conducted with the aim of identifying the frequency, causes, and associated risk factors of maternal near miss cases, with a specific focus on haemorrhagic complications in a tertiary care hospital setting. The findings of this study aim to inform clinical practices and strengthen maternal healthcare systems for better outcomes.(5,6).

The objective of this study was to assess maternal near miss cases, focusing on the identification of their etiology and associated risk factors. This prospective observational study was conducted in the Department of Obstetrics and Gynaecology at Mahatma Gandhi Memorial Medical College & Maharaja Yashwant Rao Hospital, Indore, from March 2023 to March 2024.

Sample Size & Inclusion Criteria

• 130 MNM cases fulfilling National Health Mission MNM criteria.

Exclusion Criteria

• Women unwilling to participate.
• Lost to follow-up.

Data Collection & Analysis

• Clinical history, obstetric examination, and investigations were recorded.
• Chi-square test, Student’s t-test, and ANOVA were used for analysis.

A total of 130 maternal near miss (MNM) cases were identified during the study period. The leading cause was obstetric haemorrhage, observed in 71 cases (54.6%), with postpartum haemorrhage (PPH) accounting for 39 cases (30%), followed by antepartum haemorrhage (APH) in 17 cases (13%) and ruptured ectopic pregnancy in 15 cases (11.5%). One case of abortion-related haemorrhage was also noted.

 All haemorrhagic cases required blood transfusion, and several underwent surgical interventions, including cesarean hysterectomy. Hypertensive disorders were the second most common cause, seen in 35 cases (26.9%)—including 25 cases of eclampsia, 6 of severe preeclampsia, and 4 of HELLP syndrome. Four cases (3.1%) were attributed to sepsis, including three due to retained placenta and one postoperative wound infection. Other critical conditions included cardiac dysfunction (2 cases), hepatic dysfunction (3 cases), and ARDS (1 case). Most patients (86.2%) required blood transfusions, 40% needed ICU admission, and 13% were managed with ventilatory or inotropic support. The maternal near miss to mortality ratio was 5.2:1, indicating that for every maternal death, over five women survived a life-threatening complication.

 Demographic analysis showed that most women were between 21–30 years of age (63.8%), with 36.9% being primigravida. The majority (43.1%) presented at a gestational age of more than 36 weeks. Notably, 78.5% were unbooked, 69.2% were illiterate, and 70.8% were homemakers. Regarding referral status, 53.1% were self-referred while 46.9% were referred from other facilities, indicating both delayed health-seeking behavior and gaps in timely referral systems.

Table 1: Socio-demographic variables, parity and gestational age of participants

Table 2: Distribution of cases on the basis of causes of maternal near miss

Table 3: Distribution of cases on the basis of Medical Interventions

In this study, blood transfusion was the most frequently administered intervention, with 85.4% of patients requiring it, indicating a high incidence of hemorrhagic complications. Inotropic support was needed in 46.1% of cases, reflecting significant cardiovascular instability. Ventilatory support was provided to 24.6% of patients, highlighting respiratory issues, often related to sepsis or organ dysfunction. Dialysis was the least common intervention, used in only 7.7% of cases, suggesting that renal dysfunction was less prevalent in this group

This study highlights that haemorrhage remains the leading cause of maternal near miss (MNM) in a tertiary care setting, accounting for more than half (54.6%) of all MNM cases. Among haemorrhagic events, postpartum haemorrhage (PPH) was the most frequent, followed by antepartum haemorrhage (APH) and ruptured ectopic pregnancy. These findings are consistent with other studies conducted in similar settings, including those by Lovepreet Kaur et al. (2018)(7) and Chandrakanta Prasad et al. (2022)(8), where haemorrhage was also a dominant cause of MNM. The high incidence of PPH observed in our study may be attributed to dHypertensive disorders, particularly eclampsia, were the second most common cause of MNM (26.9%), which is higher than the rates of pregnancy-induced hypertension (PIH) observed in comparable studies. This suggests that many women in our study population presented late, in more severe conditions, due to limited access to early antenatal care or lack of proper screening and referral. The predominance of unbooked cases (78.5%) further supports the conclusion that a majority of patients did not receive regular antenatal supervision, which is crucial for identifying and managing high-risk pregnancies.(7,8)

Sepsis and organ dysfunction (cardiac, hepatic, and respiratory) were less frequently observed but remain important contributors to maternal morbidity. All patients with sepsis required intensive management and antibiotic therapy, and outcomes were favorable due to timely intervention. The maternal near miss to mortality ratio in this study was 5.2:1, indicating that for every maternal death, five women survived a life-threatening obstetric complication. This ratio reflects not only the severity of cases referred to our center but also the effectiveness of timely interventions, surgical management, ICU support, and blood transfusion services in preventing maternal deaths.(9)

Sociodemographic factors played a significant role in MNM events. A majority of patients were young (21–30 years), illiterate, unbooked, and from low socioeconomic backgrounds. Additionally, the high rate of self-referral (53.1%) suggests that many women bypassed lower-level healthcare facilities or were not adequately referred, leading to delayed presentation and advanced complications upon arrival.(10)

This study highlights the critical role of medical interventions in managing maternal near miss (MNM) cases. The high incidence of blood transfusions (85.4%) reflects severe hemorrhagic complications, while inotropic (46.1%) and ventilatory support (24.6%) indicate widespread cardiovascular and respiratory instability, often due to sepsis or blood loss. The lower need for dialysis (7.7%) suggests less renal dysfunction. These findings emphasize the importance of timely access to emergency care, blood banks, and intensive support to mitigate severe maternal outcomes.(9,11)

These findings underscore the need for strengthening maternal health services at the community and primary care levels. Early booking, routine antenatal check-ups, and identification of high-risk pregnancies are essential steps to reduce severe maternal outcomes. Moreover, improving referral systems, training healthcare providers at peripheral centers, and ensuring the availability of emergency obstetric care—including blood banks and intensive care—are critical for reducing both maternal near miss and mortality rates.

This study reaffirms that haemorrhage—particularly postpartum haemorrhage—is the leading cause of maternal near miss in tertiary care settings, followed closely by hypertensive disorders like eclampsia. The majority of affected women were unbooked, illiterate, and presented late, often in critical condition, underscoring the importance of early antenatal registration and effective referral systems.

Timely interventions such as surgical management, blood transfusions, and critical care support were pivotal in improving outcomes. The maternal near miss to mortality ratio of 5.2:1 reflects both the severity of complications and the effectiveness of emergency obstetric care provided.

To reduce maternal morbidity and mortality, there is an urgent need to strengthen primary-level care, ensure the availability of skilled birth attendants, and establish robust referral mechanisms. Focused community awareness, improved antenatal coverage, and protocol-driven emergency management at all levels of healthcare can significantly enhance maternal health outcomes.

ACKNOWLEDGEMENT
We express our heartfelt gratitude to the Department of Obstetrics and Gynaecology at Mahatma Gandhi Memorial Medical College & Maharaja Yashwant Rao Hospital, Indore, for their continuous support and guidance throughout this study. We sincerely thank all the medical and paramedical staff involved in the care of the patients, whose cooperation made data collection and analysis possible. We are especially grateful to the women who consented to participate in this research, allowing us to gain insights that can help improve maternal health outcomes. Lastly, we acknowledge the contribution of the National Health Mission (NHM) for providing the criteria that formed the basis of this study.

Funding: No funding sources

Conflict of interest: None declared.

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