The WHO maternal near-miss approach and the maternal severity index model (MSI): tools for assessing the management of severe maternal morbidity

PLoS One. 2012;7(8):e44129. doi: 10.1371/journal.pone.0044129. Epub 2012 Aug 29.


Objectives: To validate the WHO maternal near-miss criteria and develop a benchmark tool for severe maternal morbidity assessments.

Methods: 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.

Results: 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)).

Conclusion: 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.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Biomarkers / metabolism
  • Brazil / epidemiology
  • Female
  • Humans
  • Maternal Death / statistics & numerical data
  • Models, Biological*
  • Morbidity
  • Pregnancy
  • Pregnancy Complications / epidemiology*
  • Pregnancy Complications / mortality
  • World Health Organization*


  • Biomarkers

Grant support

The Brazilian Network for Surveillance of Severe Maternal Morbidity was financially supported by CNPq/DECIT (The Brazilian National Research Council and the Department of Science and Technology of the Brazilian Ministry of Health), grant number 402702/2008-5. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.