Maternal Near-Miss in Tertiary Care: Definition, Indications, Management Typologies, Outcomes and Prospects for Improvement- A Comprehensive Review

Abstract

Maternal near-miss (MNM) cases—women who survive life-threatening complications during pregnancy, childbirth, or within 42 days postpartum—offer valuable insight into the effectiveness and resilience of obstetric services. This review synthesises current definitions, recognition criteria, management strategies, outcomes, and opportunities for improving maternal care in tertiary settings, with emphasis on low- and middle-income countries (LMICs) such as India. Drawing on WHO guidelines, national protocols, and peer-reviewed literature from 2010–2025, key priority areas include postpartum haemorrhage (PPH), hypertensive disorders, and maternal sepsis, supported by evidence from ICU/HDU interventions, early-warning tools, checklists, and simulation-based training. The WHO defines MNM as survival after a life-threatening complication, using organ-dysfunction criteria across cardiovascular, respiratory, renal, hepatic, haematologic, neurologic, and uterine systems, and tracks indicators such as MNM ratio, severe maternal outcome ratio, MNM:maternal death ratio, and mortality index. In Indian tertiary hospitals, MNM ratios typically range from 8–18 per 1,000 live births, MNM:death ratios from 3–6:1, and mortality indices from 15–25%, with variability reflecting referral bias and systemic gaps. Leading causes remain PPH, hypertensive disorders (including pre-eclampsia, eclampsia, and HELLP), and sepsis, with effective bundles involving uterotonics, tranexamic acid, balloon tamponade or compression sutures, massive transfusion protocols, magnesium sulfate with antihypertensives, and prompt antibiotics with source control. Quality-improvement measures such as structured audits, expansion of obstetric critical care capacity, and team-based emergency drills have shown potential to improve recognition, timeliness, and survival. Embedding the WHO near-miss framework into routine tertiary care, supported by readiness in blood supply, critical care infrastructure, and continuous review, can reduce preventable maternal deaths and severe morbidities.