Validating the WHO maternal near miss tool: Comparing high- and low-resource settings

Tom Witteveen*, Hans Bezstarosti, Ilona de Koning, Ellen Nelissen, Kitty W. Bloemenkamp, Jos van Roosmalen, Thomas van den Akker

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

6 Citations (Scopus)


Background: WHO proposed the WHO Maternal Near Miss (MNM) tool, classifying women according to several (potentially) life-threatening conditions, to monitor and improve quality of obstetric care. The objective of this study is to analyse merged data of one high- and two low-resource settings where this tool was applied and test whether the tool may be suitable for comparing severe maternal outcome (SMO) between these settings. Methods: Using three cohort studies that included SMO cases, during two-year time frames in the Netherlands, Tanzania and Malawi we reassessed all SMO cases (as defined by the original studies) with the WHO MNM tool (five disease-, four intervention- and seven organ dysfunction-based criteria). Main outcome measures were prevalence of MNM criteria and case fatality rates (CFR). Results: A total of 3172 women were studied; 2538 (80.0%) from the Netherlands, 248 (7.8%) from Tanzania and 386 (12.2%) from Malawi. Total SMO detection was 2767 (87.2%) for disease-based criteria, 2504 (78.9%) for intervention-based criteria and 1211 (38.2%) for organ dysfunction-based criteria. Including every woman who received ≥1 unit of blood in low-resource settings as life-threatening, as defined by organ dysfunction criteria, led to more equally distributed populations. In one third of all Dutch and Malawian maternal death cases, organ dysfunction criteria could not be identified from medical records. Conclusions: Applying solely organ dysfunction-based criteria may lead to underreporting of SMO. Therefore, a tool based on defining MNM only upon establishing organ failure is of limited use for comparing settings with varying resources. In low-resource settings, lowering the threshold of transfused units of blood leads to a higher detection rate of MNM. We recommend refined disease-based criteria, accompanied by a limited set of intervention- and organ dysfunction-based criteria to set a measure of severity.

Original languageEnglish
Article number194
JournalBMC Pregnancy and Childbirth
Issue number1
Publication statusPublished - 19 Jun 2017


  • Cohort Studies
  • Female
  • Humans
  • Malawi/epidemiology
  • Maternal Health Services/standards
  • Maternal Mortality
  • Near Miss, Healthcare/standards
  • Netherlands/epidemiology
  • Outcome Assessment (Health Care)/methods
  • Pregnancy
  • Pregnancy Complications/mortality
  • Prevalence
  • Quality Assurance, Health Care/methods
  • Tanzania/epidemiology
  • World Health Organization
  • Resource setting comparison
  • World health organization
  • Maternal near miss
  • Maternal near miss-tool
  • Organ dysfunction
  • Delivery
  • Maternal health
  • Severe acute maternal morbidity


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