International discussions about maternal health in low-income countries tend to focus on maternal deaths. However, there is increasing concern that these deaths are only the tip of the iceberg in terms of the health effects of the poor availability and quality of maternity services. (1) In addition, countries with high maternal mortality also have a large burden of pregnancy-related complications and associated disabilities. It is estimated that "for every woman who dies from a pregnancy-related cause, about 20 more--roughly 7 million women yearly--experience injury, infection, disease or disability." (1) Of growing interest are "near-miss" obstetric complications--complications so severe that they would probably have killed the woman had she not received timely medical care. (2)
In low-income countries, near misses are often considered obstetric successes because ultimately the woman's life was saved by a focused medical intervention. (2,3) However, little is known about long-term outcomes following these complications. (4) Recent studies document a substantial degree of physical and psychological morbidity in their aftermath (5-10) and the high cost of emergency obstetric care has serious social and economic consequences. (11,12) Although women's lives are known to remain at risk for several months beyond the 42-day cut-off used in standard definitions of maternal death (13) few studies have examined survival beyond this period in women who experience severe obstetric complications.
To what extent does surviving a near-miss obstetric complication mean that a maternal death has actually been averted? Our aim was to investigate maternal mortality in the 4 years after hospital discharge following a near-miss complication in Burkina Faso. We used data from a longitudinal, mixed-methods, cohort study to describe patterns of mortality and analysed the medical, social and health-care-related causes of death after near-miss complications. Finally, we considered the implications of our study findings for strategies that promote safe motherhood.
Burkina Faso is an impoverished country in western Africa that is ranked 177th out of 182 countries in terms of human development; 81% of the population live on less than 2 United States dollars a day. (14) The country's scores on reproductive health indicators are among the worst in the world. The fertility rate is 6.2 children per woman. (15) According to the most recent national census, (16) the maternal mortality ratio is 307 per 100 000 live births, and the World Health Organization's estimate is 560 per 100000 live births. (17) Burkina Faso's district health system functions poorly and existing safe motherhood programmes do not address the availability of comprehensive obstetric care. (18) Only 73.2% of births are assisted by a skilled birth attendant--a figure that hides significant regional and socioeconomic disparities. (19) User fees for maternal health care, especially emergency care, are often unaffordable, u In 2007, the health ministry introduced an 80% subsidy for facility-based delivery to reduce out-of-pocket expenditure, (20) but its effect is still unclear. (21,22)
We followed a cohort of 1014 women for 4 years after they were discharged from seven hospitals across Burkina Faso between November 2004 and March 2005. Women were recruited at hospital discharge to avoid exposure misclassification. (23) Of the 1014 women in the cohort, 337 had experienced a near-miss obstetric complication: the pregnancy ended in a live birth in 199 cases, in a perinatal death in 74 and in a miscarriage, ectopic pregnancy or abortion in 64. For each woman who had a near miss, we recruited an average of two unmatched controls from the seven hospitals. Usually the next two women to have an uncomplicated live delivery, as confirmed by medical notes, were selected, though some hospitals recruited more controls than others. …