ObjectiveTo investigate the burden and causes of life‐threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.DesignNationwide cross‐sectional study.SettingForty‐two tertiary hospitals.PopulationWomen admitted for pregnancy, childbirth and puerperal complications.MethodsAll cases of severe maternal outcome (SMO: maternal near‐miss or maternal death) were prospectively identified using the WHO criteria over a 1‐year period.Main outcome measuresIncidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).ResultsParticipating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near‐misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre‐eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life‐threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21–215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non‐availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care.ConclusionsImproving the chances of maternal survival would not only require timely application of life‐saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care.Tweetable abstractOf 998 maternal deaths and 1451 near‐misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

Objective To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.Design Nationwide cross-sectional study.Setting Forty-two tertiary hospitals.Population Women admitted for pregnancy, childbirth and puerperal complications.Methods All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period.Main outcome measures Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).Results Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were preeclampsia/eclampsia (23.4%) and postpartum haemorrhage †The members of Nigeria Near-miss and Maternal Death Surveillance Network are in Appendix 1.

Gestational age specific values of amniotic fluid index should be used and the 5th and 95th percentiles taken as lower and upper limits of normal, respectively.

One hundred and five consecutive women had transvaginal sonography (TVS) at less than 12 weeks gestation to establish the normal size and shape of the secondary yolk sac (YS) and to assess the YS measurements in predicting pregnancy outcome in the first trimester. A yolk sac diameter more or less than two standard deviation (2SD) from the mean predicted abnormal pregnancy outcome with a sensitivity of 91.4%, specificity of 66% and a positive predictive value of 88.8%. A normal YS size predicted normal pregnancy outcome with a sensitivity of 66%, specificity of 91.4% and a positive predictive value of 95.6%. It is recommended that patients at risk of poor pregnancy outcome should have routine TVS before 12 weeks gestation to assess their YS and those with an abnormal yolk sac should be followed-up closely to exclude fetal abnormalities before 24 weeks gestation.

An intervention to build the capacity of care-providers to use an evidence-based protocol for the treatment of eclampsia in Nigeria was successful in reducing associated case fatality rate. The increased and widespread use of such an intervention in maternity units might contribute to the reduction of maternal mortality in low-income countries.