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Pregnancy complications associated with maternal near-miss in an undeveloped province in south-central China, 2012鈥�2022

樱花视频 volume听24, Article听number:听3466 (2024) Cite this article

Abstract

Objective

To explore the relationship between pregnancy complications and maternal near-miss (MNM).

Methods

Data were obtained from the Maternal Near-Miss Surveillance System in Hunan Province, China, 2012鈥�2022. The MNM ratio refers to the number of MNM per 1000 live births, and maternal mortality refers to the number of maternal deaths per 100,000 live births. Chi-square trend tests (蠂2trend) were used to determine trends in proportions by year. Multivariate logistic regression analysis (method: Forward, Wald, 伪鈥�=鈥�0.05) and adjusted odds ratios (aORs) were used to identify risk factors for MNM.

Results

Our study included 780,359 women with 731,185 live births, a total of 2461 MNMs, and 52 maternal deaths were identified. The MNM ratio was 3.37鈥� (95%CI: 3.23鈥�3.50), and the maternal mortality was 7.11 per 100,000 live births (95%CI: 5.18鈥�9.04). Coagulation/hematological dysfunction was the most common cause of MNM (75.66%). From 2012 to 2022, the proportion of coagulation/hematological dysfunction among MNM increased from 49.14% in 2012 to 86.39% in 2022, which was the only cause of MNM that showed an increased trend (蠂2trend鈥�=鈥�7.43, P鈥�=鈥�0.01). Results of multivariate logistic regression analysis showed that 10 pregnancy complications were risk factors for MNM: hemorrhage disorder (aOR鈥�=鈥�21.50, 95%CI: 19.64鈥�23.54), infections (aOR鈥�=鈥�1.91, 95%CI: 1.64鈥�2.22), hypertension (aOR鈥�=鈥�4.50, 95%CI: 4.08鈥�4.98), heart disease (aOR鈥�=鈥�14.96, 95%CI: 11.51鈥�19.44), embolic disease (aOR鈥�=鈥�171.70, 95%CI: 94.08-313.36), liver disease (aOR鈥�=鈥�1.54, 95%CI: 1.25鈥�1.90), anaemia (aOR鈥�=鈥�4.72, 95%CI: 4.29鈥�5.19), renal disease (aOR鈥�=鈥�5.44, 95%CI: 4.00-7.40), pulmonary disease (aOR鈥�=鈥�14.85, 95%CI: 8.33鈥�26.50), and connective tissue disease (aOR鈥�=鈥�5.15, 95%CI: 3.06鈥�8.66).

Conclusion

The MNM ratio was relatively low in Hunan Province. Several pregnancy complications increased the risk of MNM. It is helpful for clinical counseling and public health policies, which may contribute to preventing MNM.

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Introduction

Maternal mortality is commonly used as an indicator of the quality of maternity care, with almost 95% of maternal deaths occurring in low and lower-middle-income countries, and the majority of these deaths are preventable [1]. With the rapid decline in maternal mortality [2,3,4], an increasing number of healthcare workers, program managers, and policy-makers responsible for the quality of maternal healthcare are focusing on maternal near-miss (MNM) to prevent MNM from developing into maternal deaths [5,6,7,8,9]. In 2009, WHO published the report 鈥淓valuating The Quality of Care for Severe Pregnancy Complications - The WHO Near-miss Approach for Maternal Health鈥� for healthcare workers, program managers, and policy-makers responsible for the quality of maternal healthcare worldwide [10].

Since WHO published the report, many researchers have conducted studies on MNM. For example, many studies on MNM have been conducted in low- to middle-income countries, and their primary objectives included analyzing the incidence, demographic characteristics, clinical profile, causes, profile, outcomes, burden, and frequency of pregnancy complications of MNM and related indicators [7, 11]. China is a developing country with a wide area and a large population. However, there are few studies on MNM in China, many of which had samples from the relatively economically developed eastern regions or are based on limited data [12,13,14,15,16].

Hunan Province is located in south-central China and has a population of approximately 65 million. Compared with eastern China, Hunan Province is relatively underdeveloped [17]. In 2023, we conducted a study on the epidemiological risk factors for MNM in Hunan Province (2012鈥�2022), in which we analyzed the prevalence and epidemiological risk factors for MNM [18].

In this study, we explored the relationship between pregnancy complications and MNM using multivariate logistic regression analysis in Hunan Province, 2012鈥�2022. It may make an important contribution to the field. First, few studies on MNM in China exist, especially in undeveloped areas. Second, pregnancy complications are important for the diagnosis and intervention of MNM. However, few studies have specifically explored the relationship between pregnancy complications and MNM. Third, many pregnancy complications of MNM may occur simultaneously or interact with each other. However, to the best of our knowledge, few studies have analyzed them by conducting a multivariate analysis.

Methods

Data sources

This study used data from the Maternal Near-Miss Surveillance System in Hunan Province, China, 2012鈥�2022. This system uses the WHO near-miss approach [10] in 18 representative registered hospitals in Hunan Province and is run by the Hunan Provincial Health Commission and the China Ministry of Health. Detailed information about the data collection process has been reported elsewhere [18, 19]. In all 18 hospitals, data were collected for all pregnant and post-partum women using an especially designed data collection form. The definition of indicators and collection of information complied with WHO standards [10, 20]. In this study, the main indicator analyzed was pregnancy complications associated with MNM.

The following are definitions of MNM indicators according to the WHO near-miss approach [10]. Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy or its management, but not from accidental or incidental causes. MNM refers to a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy. Non-MNM refers to a woman who is not a maternal death or MNM case. A live birth refers to the birth of an offspring that breathes or shows evidence of life. MNM ratio refers to the number of MNM per 1000 live births. Maternal mortality refers to the number of maternal deaths per 100,000 live births.

Ethics approval and consent to participate

The Hunan Provincial Health Commission routinely collected the surveillance data, and the government has developed the 鈥淣ational Maternal Near Miss Surveillance Working Manual鈥� to collect those data. Therefore, there is no additional written informed consent. The Medical Ethics Committee of Hunan Provincial Maternal and Child Health Care Hospital approved the study. (NO: 2023-S011). It is a retrospective study of medical records; all data were fully anonymized before we accessed them. Moreover, we de-identified the patient records before analysis. We confirmed that all operations were following relevant guidelines and regulations.

Data quality control

The Hunan Provincial Health Commission developed the 鈥淢aternal Near Miss Surveillance Working Manual鈥� for surveillance. Data were collected and reported by experienced and trained doctors and nurses. To ensure data consistency and accuracy, all collectors must be trained and qualified before starting work. The Hunan Provincial Health Commission asks the technical guidance departments to conduct comprehensive quality control yearly to reduce surveillance data integrity and information error rates.

Statistical analysis

MNM ratios with 95% confidence intervals (CI) were calculated by the log-binomial method [21]. Chi-square trend tests (蠂2trend) were used to determine trends in proportions (cause of MNM) by year. Univariate analysis and unadjusted odds ratios (uORs) were used to examine the association of each pregnancy complication with MNM. Multivariate logistic regression analysis (method: Forward, Wald, 伪鈥�=鈥�0.05) and adjusted odds ratios (aORs) were used to identify risk factors for MNM. We used the presence or absence of MNM as the dependent variable, and the variables assessed significantly in univariate analysis were entered as independent variables in multivariate logistic regression analysis.

Statistical analyses were performed using SPSS 18.0 (IBM Corp., NY, USA).

Results

Basic information on surveillance data

Our study included 780359 women with 731185 live births, a total of 2461 MNMs, and 52 maternal deaths were identified. The MNM ratio was 3.37鈥� (95%CI: 3.23鈥�3.50), and the maternal mortality was 7.11 per 100000 live births (95%CI: 5.18鈥�9.04). Table 1 shows the details of basic information on surveillance data and MNM ratios by year (Fig. 1; Table 1).

Fig. 1
figure 1

Basic information on surveillance data in Hunan Province, China, 2012-2022

Full size image
Table 1 Basic information on surveillance data in Hunan Province, China, 2012鈥�2022
Full size table

Causes of MNM

Coagulation/hematological dysfunction was the most common cause of MNM (75.66%), followed by cardiovascular dysfunction (23.41%). From 2012 to 2022, the proportion of coagulation/hematological dysfunction among MNM showed an increased trend from 49.14% in 2012 to 86.39% in 2022, while cardiovascular dysfunction (from 28.00% in 2012 to 16.57% in 2022), respiratory dysfunction (from 11.43% in 2012 to 3.55% in 2022), renal dysfunction (from 4.57% in 2012 to 1.78% in 2022), neurological dysfunction (from 29.14% in 2012 to 4.14% in 2022), and uterine dysfunction (from 21.71% in 2012 to 2.96% in 2022) showed decreased trends (P鈥�<鈥�0.05). There was no significant trend in hepatic dysfunction (P鈥�>鈥�0.05). Table 2 shows the details of causes of MNM by year (Table 2).

Table 2 Causes of MNM in Hunan Province, China, 2012鈥�2022
Full size table

Results of univariate analysis and multivariate logistic regression analysis for pregnancy complications associated with MNM

In the univariate analysis, all pregnancy complications were associated with MNM. Table 3 shows the details of the results of univariate analysis for pregnancy complications associated with MNM. Therefore, all variables in Table 3 were entered as independent variables in the multivariate logistic regression analysis, including hemorrhage disorder, infections, hypertension, heart disease, embolic disease, liver disease, anaemia, diabetes mellitus, renal disease, pulmonary disease, connective tissue disease, cancer, and other (Table 3).

Table 3 Unadjusted association between different types of pregnancy complications and MNM
Full size table

In the multivariate logistic regression analysis, all pregnancy complications in Table 3 were associated with MNM except for diabetes mellitus and cancer. The following 10 pregnancy complications increased the risk of MNM: hemorrhage disorder (aOR鈥�=鈥�21.50, 95%CI: 19.64鈥�23.54), infections (aOR鈥�=鈥�1.91, 95%CI: 1.64鈥�2.22), hypertension (aOR鈥�=鈥�4.50, 95%CI: 4.08鈥�4.98), heart disease (aOR鈥�=鈥�14.96, 95%CI: 11.51鈥�19.44), embolic disease (aOR鈥�=鈥�171.70, 95%CI: 94.08-313.36), liver disease (aOR鈥�=鈥�1.54, 95%CI: 1.25鈥�1.90), anaemia (aOR鈥�=鈥�4.72, 95%CI: 4.29鈥�5.19), renal disease (aOR鈥�=鈥�5.44, 95%CI: 4.00-7.40), pulmonary disease (aOR鈥�=鈥�14.85, 95%CI: 8.33鈥�26.50), and connective tissue disease (aOR鈥�=鈥�5.15, 95%CI: 3.06鈥�8.66) (Table 4).

Table 4 Adjusted association between different types of pregnancy complications and MNM
Full size table

Discussion

Overall, we identified 10 pregnancy complications that may increase the risk of MNM, including hemorrhage disorder, infections, hypertension, heart disease, embolic disease, liver disease, anaemia, renal disease, pulmonary disease, and connective tissue disease. It was the first study to explore the relationship between pregnancy complications and MNM in undeveloped areas in China through a multivariate analysis, which may make an important contribution to the field.

In this study, the MNM ratio was 3.37鈥�. In 2021, Anke et al. conducted a systematic review of MNM in middle-income countries (including 69 studies in 26 countries and 3 in China). The median MNM ratios were 15.9鈥� (interquartile range: 8.9鈥�34.7) and 7.8鈥� (interquartile range: 5.0-9.6) for lower-middle- and upper-middle-income countries, respectively [7]. It was higher than the present study. In China, some studies reported MNM ratios. For example, the MNM ratio was 5.9鈥� in Zhejiang Province (2012鈥�2017) [12], and 3.81鈥� in in Kowloon Hospita in Suzhou City, Jiangsu Province (2008鈥�2012) [22]. It was also higher than the present study. The above results indicate that the quality of maternal health care in Hunan Province is relatively high. In addition, in this study, the maternal mortality was 7.11 per 100000 live births, higher than in some developed regions in China or some developed countries [18]. It indicates that there is still room for improvement in the quality of maternal health care in Hunan Province.

This study analyzed the causes of MNM. The causes of MNM were discussed in detail in one of our previous studies [18]. In this study, we analyzed trends in the proportion of causes of MNM. To the best of our knowledge, it has not been addressed in previous studies. We found that coagulation/hematological dysfunction was the only cause that showed an increased trend in proportion and has been the determinant cause of MNM. Chen et al. found that obstetric hemorrhage was the main cause of maternal deaths; however, the proportion of maternal deaths due to obstetric hemorrhage decreased from 40.83% in 1990 to 16.85% in 2019 (China, 1990鈥�2019) [4]. It indicates that although coagulation/hematological dysfunction is the main cause of MNM, with the improvement of medical conditions, the prevention and control of coagulation/hematological dysfunction have been gradually improved, and most MNMs caused by coagulation/hematological dysfunction do not develop into maternal deaths.

The most important finding of this study was the identification of pregnancy complications associated with MNM by multivariate analysis. Some of the findings of this study were similar to previous studies [7, 23,24,25,26]. However, to the best of our knowledge, multivariate analysis has not been addressed in previous studies. Moreover, some pregnancy complications, such as renal disease, pulmonary disease, and connective tissue disease, were rarely addressed in previous studies. Previous studies have shown that diabetes mellitus increases the risk of MNM and maternal deaths [15, 27,28,29]. It is inconsistent with this study. There are several possible explanations for this difference. On the one hand, most previous studies did not conduct multivariate analysis, which may have confounding results. On the other hand, diabetes mellitus may be primarily associated with other pregnancy complications [30], and different intensities of glycaemic control for pregnant women with diabetes mellitus can have a significant impact on pregnancy outcomes [31]. To our knowledge, most of the pregnant women with diabetes mellitus in this study were treated, and most had good blood glucose control. Multivariate analysis showed that cancer was not associated with MNM, which has been rarely addressed in previous studies. Sundermann et al. found that patients with cancer increased the risk of severe maternal morbidity and maternal deaths [32, 33]. In the present study, the number of patients with both cancer and MNM was small, which may have significantly biased the results. It may be the main reason for this difference.

In addition, we obtained the aOR for each pregnancy complication associated with MNM through multivariate analysis. Theoretically, a larger aOR value indicates that a higher proportion of pregnancy complications occurred in the case group than in the control group. Conversely, we can approximately consider that the higher the aOR for a pregnancy complication, the greater the likelihood that a pregnant woman will develop MNM if she has that pregnancy complication. These findings have important implications for clinical counseling and public health policies. For example, for pregnant women with high-risk pregnancy complications, doctors should convince them to receive treatment to avoid MNM; the government can implement public health programs to screen pregnant women who are at high risk of MNM, and provide free treatment to reduce the incidence and economic burden of MNM.

This study could improve some things. First, the associations between pregnancy complications and MNM showed only correlations and may not be causal. Further in-depth studies are needed. Second, there may be the risk of under-reporting MNMs in the surveillance system, especially at some county-level surveillance sites.

Conclusion

The MNM ratio was relatively low in Hunan Province. Several pregnancy complications increased the risk of MNM. It is helpful for clinical counseling and public health policies, which may contribute to preventing MNM.

Data availability

All data generated or analyzed during this study are included in this published article.

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Acknowledgements

The authors thank the staff working for the Maternal Near-Miss Surveillance System in Hunan Province, China, 2012鈥�2022.

Funding

National Key Clinical Specialty Scientific Research Project (grant number: Z2023106).

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Authors and Affiliations

  1. Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan Province, China

    Xu Zhou,听Yinglan Wu,听Jie Gao,听Xiaoying Chen,听Aihua Wang听&听Junqun Fang

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Contributions

X.Z., Y.W., J.G., X.C., J.F., and A.W. contributed to data collection. X.Z. and Y.W. analyzed the data and prepared the manuscript. All authors contributed to the study conception and design and read and approved the final manuscript.

Corresponding author

Correspondence to Yinglan Wu.

Ethics declarations

Ethics approval and consent to participate

The Hunan Provincial Health Commission routinely collected the surveillance data, and the government has developed the 鈥淣ational Maternal Near Miss Surveillance Working Manual鈥� to collect those data. Therefore, there is no additional written informed consent. The Medical Ethics Committee of Hunan Provincial Maternal and Child Health Care Hospital approved the study. (NO: 2023-S011). It is a retrospective study of medical records; all data were fully anonymized before we accessed them. Moreover, we de-identified the patient records before analysis. We confirmed that all operations were following relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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Zhou, X., Wu, Y., Gao, J. et al. Pregnancy complications associated with maternal near-miss in an undeveloped province in south-central China, 2012鈥�2022. 樱花视频 24, 3466 (2024). https://doi.org/10.1186/s12889-024-20989-6

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  • DOI: https://doi.org/10.1186/s12889-024-20989-6

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ISSN: 1471-2458

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