Relationship between severity markers (WHO criteria) and maternal deaths.

*<p>N = 82,388 deliveries.</p

The performance of the models I and II and the maternal severity score.

*<p>The Hosmer-Lemeshow test indicates a poor fit if p value is less than 0.05.</p>£<p>The Nagelkerke R² values the proportion of variance in maternal mortality associated with the models’ predictors. Higher R² values, better model performance.</p>@<p>Area under the receiver operating characteristic curve with 95% confidence intervals calculated among women with life-threatening conditions of the subpopulation “B”.</p><p>N.A.: not applicable.</p

Relationship between the number of severity markers (maternal severity score) and mortality^*.

*<p>The Pearson correlation coefficient between the maternal severity score and mortality is 0.96.</p

Main causes of PLTC and proportion of WHO´s Maternal Near Miss criteria identified among women with severe maternal morbidity according to the presence of any cardiac disease.

<p>*χ² test adjusted for cluster effect</p><p>Values in bold mean they are statistically significant.</p><p>Main causes of PLTC and proportion of WHO´s Maternal Near Miss criteria identified among women with severe maternal morbidity according to the presence of any cardiac disease.</p

The Maternal Severity Index (MSI).

*<p>Listed in the <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0044129#pone-0044129-t001" target="_blank">Table 1</a>.</p>#<p>Presence of any of the following conditions: pH <7.1, Use of continuous vasoactive drugs, Cardiac arrest, Cardio-pulmonary resuscitation (CPR).</p>£<p>Presence of any of the following conditions: Gasping, PaO2/FiO2<200 mmHg, Intubation and ventilation not related to anesthesia.</p

The WHO Maternal Near-Miss Approach and the Maternal Severity Index Model (MSI): Tools for Assessing the Management of Severe Maternal Morbidity

<div><h3>Objectives</h3><p>To validate the WHO maternal near-miss criteria and develop a benchmark tool for severe maternal morbidity assessments.</p> <h3>Methods</h3><p>In a multicenter cross-sectional study implemented in 27 referral maternity hospitals in Brazil, a one-year prospective surveillance on severe maternal morbidity and data collection was carried out. Diagnostic accuracy tests were used to assess the validity of the WHO maternal near-miss criteria. Binary logistic regression was used to model the death probability among women with severe maternal complications and benchmark the management of severe maternal morbidity.</p> <h3>Results</h3><p>Of the 82,388 women having deliveries in the participating health facilities, 9,555 women presented pregnancy-related complications, including 140 maternal deaths and 770 maternal near misses. The WHO maternal near-miss criteria were found to be accurate and highly associated with maternal deaths (Positive likelihood ratio 106.8 (95% CI 99.56–114.6)). The maternal severity index (MSI) model was developed and found to able to describe the relationship between life-threatening conditions and mortality (Area under the ROC curve: 0.951 (95% CI 0.909–0.993)).</p> <h3>Conclusion</h3><p>The identification of maternal near-miss cases using the WHO list of pregnancy-related life-threatening conditions was validated. The MSI model can be used as a tool for benchmarking the performance of health services managing women with severe maternal complications and provide case-mix adjustment.</p> </div

Cardiac conditions included in the Brazilian Network for Surveillance of Severe Maternal Morbidity

<p>Cardiac conditions included in the Brazilian Network for Surveillance of Severe Maternal Morbidity</p

Flow chart of women in the study.

<p>Flow chart of women in the study.</p

Accuracy of the WHO set of severity markers in the prediction of maternal deaths among all women and women with pregnancy-related complications ^*.

*<p>In this table maternal near-miss cases are the false positives.</p

Cardiac disease as the main cause of severe maternal morbidity and mortality and corresponding indicators.

<p>* For each group the prevalence ratio, adjusted for cluster effect, was determined for “cardiac disease” versus “non-cardiac disease”.</p><p>PR: Prevalence Ratio; CI: Confidence Interval; MD: Maternal Death; MNM: Maternal Near Miss; PLTC: Potentially Life-Threatening Condition; SMOR: Severe Maternal Outcome Ratio; MMR: Maternal Mortality Ratio; LB: Live Birth. Values in bold mean they are statistically significant.</p><p>Cardiac disease as the main cause of severe maternal morbidity and mortality and corresponding indicators.</p