The Lifetime Risk of Maternal Near Miss morbidity in Asia, Africa, the Middle East, and Latin America: a cross-country systematic analysis

Background Life-threatening maternal near miss (MNM) morbidity can have long-term consequences for women’s physical, psychological, sexual, social, and economic wellbeing. The lifetime risk of MNM (LTR-MNM) quantifies the probability that a 15-year-old girl will experience a near miss before age 50, given current mortality and fertility levels. We compare LTR-MNM globally to reveal inequities in the cumulative burden of severe maternal morbidity across the reproductive life course. Methods We estimate the LTR-MNM for 40 countries with multi-facility, regional, or national data on the prevalence of MNM morbidity measured using World Health Organization (WHO) or modified WHO criteria of organ dysfunction from 2010 onwards (Central and Southern Asia=6, Eastern and South-Eastern Asia=9, Latin America and the Caribbean=10, Northern Africa and Western Asia=2, Sub-Saharan Africa=13). We also calculate the lifetime risk of severe maternal outcome (LTR-SMO) as the lifetime risk of maternal death or MNM. Findings The LTR-MNM ranges from a 1 in 1436 risk in China (2014) to 1 in 6 in Guatemala (2016), with a corresponding LTR-SMO from 1 in 887 to 1 in 5, respectively. The LTR-MNM is a 1 in 20 risk or higher in nine countries, seven of which are in sub-Saharan Africa. The LTR-SMO is a 1 in 20 risk or higher in 11 countries, eight of which are in sub-Saharan Africa. The relative contribution of the LTR-MNM to the LTR-SMO ranges from 42% in Angola to 99% in Japan. Interpretation There exists substantial global and regional inequity in the cumulative burden of severe maternal morbidity across the reproductive life course. The LTR-MNM is an important indicator to advocate for further global commitment to end preventable maternal morbidity. Finally, the LTR-SMO is an important tool to compare heterogeneity in the relative contribution of morbidity to the overall burden of maternal ill-health across the female reproductive life course, depending on countries’ stage in the obstetric transition. Funding This work was supported by U.G.’s PhD studentship from the UK Economic and Social Research Council [ES/P000592/1]. This work was also supported by the European Union Horizon 2020 research and innovation programme Marie Curie Fellowship (to J.M.A.) [grant agreement no. 896821], and Leverhulme Trust Large Centre Grant (to J.M.A. and A.P.). Evidence before this study We searched Embase, MEDLINE, and Global Health for English language studies reporting national, regional, or multi-facility estimates of the prevalence of life-threatening maternal morbidity (i.e., “maternal near miss” events), published from 2010 until 21 November 2023. Search terms included (1) “maternal near miss”/”severe (acute) maternal morbidity”/”life-threatening condition/complications” and (2) “prevalence”/”incidence”/ “ratio”/ “surveillance”. Our search revealed a dearth of population-level estimates: most existing prevalence data derive from (single) facility-based studies without accounting for births that occur outside of the facility. This bias may be substantial where institutional delivery rates are low. Second, existing global comparisons of the maternal near miss ratio indicate differences in the level of obstetric risk associated with an individual pregnancy only. But since women are at risk of experiencing a life-threatening complication with each pregnancy, existing data fail to account for differences in cumulative risk from repeat pregnancy. The lifetime risk of maternal near miss is a new indicator that attempts to address these deficits in the existing evidence base to better understand global inequities in the burden maternal near miss morbidity across women’s reproductive lives. Added value of this study We provide the first cross-country estimates of the lifetime risk of maternal near miss for 40 countries with multi-facility, regional, or national data on the prevalence of maternal near miss. We also calculate how the lifetime risk of maternal near miss compares to the lifetime risk of maternal death for a given country-year, and the relative contribution of morbidity to the lifetime risk of severe maternal outcome (the risk of death or near miss morbidity). This is the first study to do so. Implications of all the available evidence First, there is substantial global inequity in the risk of severe maternal morbidity across women’s reproductive lifetimes. By accounting for the cumulative risk from repeat pregnancy and women’s reproductive age survival, the lifetime risk of maternal near miss presents a clearer picture of cross-country disparities in the burden of near miss morbidity than prevalence data alone might suggest. Second, the composite risk that a girl will either die from a maternal cause or experience near miss morbidity during her lifetime is extremely high in many countries, particularly in sub-Saharan Africa. These findings provide a new lens through which to understand reproductive injustice, and a new opportunity to advocate for increased global commitment to end preventable maternal morbidity and mortality. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by Ursula Gazeley PhD studentship from the UK Economic and Social Research Council [ES/P000592/1]. This work was also supported by the European Union Horizon 2020 research and innovation programme Marie Curie Fellowship (to J.M.A.) [grant agreement no. 896821] and Leverhulme Trust Large Centre Grant (to J.M.A. and A.P.). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics approval was not required to calculate the LTR-MNM as we used population-level data available in the public domain (published data on the MNM ratio and twin birth rate, and open-access fertility and mortality data from the United Nations World Population Prospects). The full list of included MNM estimates are available in the supplementary material. Data on the twin birth rate are available from Monden et al (2021). All fertility and mortality data used in this article are freely available for download from the United Nations World Population Prospects Download Centre: . I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). 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