Validity of WHO's near-miss approach in a high maternal mortality setting.

Objective: To evaluate the validity of WHO's near-miss approach in a low-resource, high maternal mortality setting.

Design: Prospective cohort study.

Setting: Mnazi Mmoja Hospital, the main referral hospital of Zanzibar, Tanzania, from 1 April 2017 until 31 December 2018.

Population: All women, pregnant or until 42 days after the end of pregnancy, admitted at Mnazi Mmoja Hospital, the tertiary referral hospital in Zanzibar.

Methods: Cases of maternal morbidity and mortality were evaluated according to WHO's near-miss approach. The approach's performance was determined by calculating its accuracy through sensitivity, specificity and positive and negative likelihood ratios. The approach's validity was assessed with Pearson's correlation coefficient between the number of organ dysfunction markers and risk of mortality.

Main Outcomes Measures: Correlation between number of organ dysfunction markers and risk of mortality, sensitivity and specificity.

Results: 26,842 women were included. There were 335 with a severe maternal outcome: 256 maternal near-miss cases and 79 maternal deaths. No signs of organ dysfunction were documented in only 4 of the 79 cases of maternal death. The number of organ dysfunction markers was highly correlated to the risk of mortality with Pearson's correlation coefficient of 0.89.

Conclusions: WHO's near-miss approach adequately identifies women at high risk of maternal mortality in Zanzibar's referral hospital. There is a strong correlation between the number of markers of organ dysfunction and mortality risk.