Objective To test the application of a clinical definition of severe acute maternal morbidity.Design A one-year prospective descriptive multi-centre study. Setting Kalafong and Pretoria Academic hospitals, catering for the delivery of indigent women in the Pretoria Health Region.Methods A 'near-miss' describes a patient with an acute organ system dysfunction, which if not treated appropriately, could result in death. The case notes of women fitting this definition and all maternal deaths were analysed and compared.Outcome measure Determine the primary obstetric factors and the organ systems that failed. Identification of episodes of sub-standard care and missed opportunities. Results One hundred and forty-seven near misses and 30 maternal deaths were identified. The commonest reasons for a near-miss were: emergency hysterectomy in 42 women (29%); severe hypotension in 40 (27%); and pulmonary oedema in 24 (16%). The most common initiating obstetric conditions were hypertension in 38 women (26%); haemorrhage in 38 (26%); and abortion or puerperal sepsis in 29 (20%). The primary obstetric factors amongst the maternal deaths were: hypertension (33%); sepsis (27%); and maternal medical diseases (17%) in 10, 8 and 5 women respectively. Sub-standard care was identified in 82 cases. Breakdown in the health care administration was identified in 33, and patient-orientated missed opportunities on 34 occasions. ConclusionsThe definition of severe acute maternal morbidity identified nearly five times as many cases as maternal death. This definition allows for an effective audit system of maternal care because it is clinically based, the definition is robust and the cases identified reflect the pattern of maternal death.

In a randomized controlled trial David van der Ham and colleagues investigate induction of labor versus expectant management for women with preterm prelabor rupture of membranes.

Objective To assess whether severe acute maternal morbidity (SAMM, 'near misses') can be used as a surrogate of an analysis of maternal deaths to describe the pattern of severe maternal disease and avoidable factors related to it. Design Prospective, descriptive study.Setting A SAMM and maternal mortality audit was conducted in three clearly defined geographical areas, consisting of rural and urban settings in South Africa. Population Indigent black African pregnant women.Method Cases of SAMM and maternal deaths were collected in the areas and a comparison was made of the disease profiles and avoidable factors, missed opportunities and substandard care. Main outcome measures The proportion of primary obstetric causes and avoidable factors in women with SAMM and maternal deaths, and the mortality indices of the primary obstetric causes of death and organ system dysfunction. Results A total of 423 women with SAMM and 128 maternal deaths were collected over two years.Demographic factors were similar between the groups except that significantly more maternal deaths had not attended any antenatal care. The primary obstetric causes of SAMM and maternal death did not correlate. The four most common causes of SAMM were complications of hypertension (27.2%), postpartum haemorrhage (18.0%), antepartum haemorrhage (12.8%) and abortion (11.3%), whereas the four most common causes of maternal death were non-pregnancy related sepsis (26.6%), complications of hypertension (23.4%), pre-existing medical disease (14.1%) and abortion (10.9%). The types of avoidable factors were similar between both groups although administrative factors occurred significantly more frequently in the maternal death group as did poor problem identification and monitoring. Conclusion Review of SAMM gives a different disease pattern to that obtained from maternal death audits.However, in diagnosing inadequacies in the health system, similar information was obtained.

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In women with pregnancies complicated by PPROM near term, induction of labor does not reduce neonatal sepsis, whereas costs associated with this strategy are probably higher.

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This study did not demonstrate that chronic oxygen therapy provides any benefits to compromised fetuses between 24 and 30 weeks of gestation. Larger studies with sufficient power are necessary to assess whether oxygen therapy can reduce perinatal mortality by a clinically useful amount in this group of patients.

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