Low Incidence of Maternal Near-Miss in Zhejiang, a Developed Chinese Province: A Cross-Sectional Study Using the WHO Approach

Figures & data

Figure 1 Flow chart of survey participants and maternal safety outcome.

Abbreviation: MNM, maternal near-miss.

Table 1 Frequency of Organ Dysfunction Related to Pregnancy Among 3208 MNM During 2012–2017

Item		2012, N (%)	2013, N (%)	2014, N (%)	2015, N (%)	2016, N (%)	2017, N (%)	Total, N (%)
MNM		484	512	563	515	554	580	3208
Cardiovascular dysfunction		133 (27.5)	125 (24.4)	123 (21.9)	107 (20.8)	120 (21.7)	109 (18.8)	717 (22.4)
Respiratory dysfunction		59 (12.2)	50 (9.8)	47 (8.4)	29 (5.6)	50 (9.0)	41 (7.1)	276 (8.6)
Renal dysfunction		13 (2.7)	10 (2.0)	4 (0.7)	3 (0.6)	6 (1.1)	5 (0.9)	41 (1.3)
Coagulation/hematological dysfunction		333 (68.8)	375 (73.2)	373 (66.3)	439 (85.2)	466 (84.1)	494 (85.2)	2480 (77.3)
	Clotting failure	74 (15.3)	67 (13.1)	47 (8.4)	80 (15.5)	112 (20.2)	99 (17.1)	479 (14.9)
	Acute thrombocytopenia (less than 50,000 platelets)	121 (25.0)	125 (24.4)	107 (19.0)	135 (26.2)	117 (21.1)	151 (26.0)	756 (23.6)
	Transfusion of $5 units of blood/red cells or more	219 (45.3)	247 (48.2)	291 (51.7)	320 (62.1)	347 (62.6)	345 (59.5)	1769 (55.1)
Hepatic dysfunction	Jaundice in the presence of pre-eclampsia	2 (0.4)	2 (0.4)	2 (0.4)	0 (0.0)	0 (0.0)	2 (0.3)	8 (0.3)
	Bilirubin 100 mmol/l or 6.0 mg/dl	1 (0.2)	9 (1.8)	3 (0.5)	6 (1.2)	6 (1.1)	5 (0.9)	30 (1.0)
Neurological dysfunction		55 (11.4)	50 (9.8)	41 (7.3)	40 (7.8)	29 (5.2)	31 (5.3)	246 (7.7)
Uterine dysfunction		86 (17.8)	80 (15.6)	150 (26.6)	58 (11.3)	41 (7.4)	54 (9.3)	469 (14.6)

Abbreviation: MNM, maternal near-miss.

Table 2 The Difference of Demographic and Obstetric History and Delivery Mode Characteristics of Women with and Without MNM

Item	All Women^a N=612,264 (%)	Women Without MNM^b N=609,022 (%)	Women with MNM N=3208 (%)
Age
≤19	12,165 (2.0)	12,085 (2.0)	80 (2.5)
20–34	511,651 (83.6)	509,323 (83.6)	2304 (71.8)
35–39	59,351 (9.7)	58,866 (9.7)	477 (14.9)
40–45	13,003 (2.1)	12,818 (2.1)	183 (5.7)
≥46	512 (0.1)	500 (0.1)	12 (0.4)
Missing	15,582 (2.5)	15,430 (2.5)	152 (4.7)
Education
College or higher	308,650 (50.4)	307,192 (50.4)	1448 (45.1)
Completed high school	106,082 (17.3)	105,679 (17.4)	398 (12.4)
Completed middle school	150,815 (24.6)	150,038 (24.6)	770 (24.0)
Completed primary school	24,753 (4.0)	24,524 (4.0)	225 (7.0)
None	4189 (0.7)	4135 (0.7)	53 (1.7)
Missing	17,775 (2.9)	17,454 (2.9)	314 (9.8)
Pregnancy
Primipara	350,030 (57.2)	348,468 (57.2)	1546 (48.2)
Multipara	261,605 (42.7)	259,932 (42.7)	1656 (51.6)
Missing	629 (0.1)	622 (0.1)	6 (0.2)
C-section history
0	512,436 (83.7)	510,026 (83.8)	2381 (74.2)
1	95,443 (15.6)	94,679 (15.6)	760 (23.7)
≥2	3735 (0.6)	3681 (0.6)	54 (1.7)
Missing	650 (0.1)	636 (0.1)	13 (0.4)
Prenatal examination
0	10,531 (1.7)	10,387 (1.7)	101 (3.1)
1–4	52,692 (8.6)	52,433 (8.6)	251 (7.8)
5–7	76,288 (12.5)	75,892 (12.5)	391 (12.2)
8–10	156,064 (25.5)	155,506 (25.5)	554 (17.3)
≥11	270,673 (44.2)	269,445 (44.2)	1222 (38.1)
Missing	46,016 (7.5)	45,316 (7.4)	692 (21.6)
Abortion History
0	331,961 (54.2)	330,500 (54.3)	1446 (45.1)
1	164,206 (26.8)	163,328 (26.8)	872 (27.2)
2	75,168 (12.3)	74,632 (12.3)	528 (16.5)
3–5	35,344 (5.8)	35,040 (5.8)	300 (9.4)
≥6	1639 (0.3)	1616 (0.3)	23 (0.7)
Missing	3946 (0.6)	3906 (0.6)	39 (1.2)
Delivery method
Vaginal delivery	310,243 (50.7)	309,619 (50.8)	617 (19.2)
C-section	233,492 (38.1)	231,280 (38.0)	2193 (68.4)
Abortion	16,459 (2.7)	16,411 (2.7)	47 (1.5)
Other	11,923 (2.0)	11,796 (1.9)	124 (3.9)
Missing	40,147 (6.6)	39,916 (6.6)	227 (7.1)
Delivery hospital
Provincial/Municipal hospital	280,784 (45.9)	278,755 (45.8)	2011 (62.7)
County hospital	290,198 (47.4)	289,274 (47.5)	913 (28.5)
Township hospital or home	689 (0.1)	647 (0.1)	40 (1.3)
Other	432 (0.1)	418 (0.1)	14 (0.4)
Missing	40,161 (6.6)	39,928 (6.6)	230 (7.2)

Notes: ^aAll women were 612,264 including women without MNM, MNM and maternal death. ^bWomen without MNM exclude maternal death.

Abbreviation: MNM, maternal near-miss.

Table 3 Comparison of the Frequency of Potentially Life-Threatening Disorder and Other Complications Between Women with MNM and Without

Item			All Women n=612,264 (%)	Women Without MNM N=609,022 (%)	Women With MNM N=3208 (%)
Potentially life-threatening disorder
Hemorrhage disorder
		Placenta praevia	10,173 (1.7)	9433 (1.6)	738 (23.0)
		Abruptio placentae	4062 (0.7)	3868 (0.6)	194 (6.1)
		Placenta accreta	1263 (0.2)	901 (0.2)	361 (11.3)
		Ectopic pregnancy	1330 (0.2)	1280 (0.2)	50 (1.6)
		Postpartum Hemorrhage	21,626 (3.5)	19,155 (3.2)	2447 (76.3)
		Severe Postpartum Hemorrhage	8668 (1.4)	6246 (1.0)	2398 (74.8)
		Ruptured uterus	660 (0.1)	619 (0.1)	41 (1.3)
Hypertension
		Severe Hypertension	4158 (0.7)	3918 (0.6)	237 (7.4)
		Severe pre-eclampsia	7815 (1.3)	7501 (1.2)	310 (9.7)
		Eclampsia	185 (0.0)	1 (0.0)	184 (5.7)
		HELLP syndrome	231 (0.0)	141 (0.0)	89 (2.8)
Severe management indicators
		Blood transfusion	7190 (1.2)	4811 (0.8)	2355 (73.4)
		Hysterectomy	341 (0.1)	4 (0.0)	331 (10.3)
		ICU admission	3123 (0.5)	2033 (0.3)	1071 (33.4)
Other complications
Cardiopathy			2487 (0.4)	2381 (0.4)	98 (3.1)
Embolism			78 (0.0)	33 (0.0)	39 (1.2)
	Air embolism		5 (0.0)	2 (0.0)	2 (0.1)
	Thromboembolism		22 (0.0)	16 (0.0)	4 (0.1)
	Amniotic fluid embolism		53(0.0)	15 (0.0)	35 (1.1)
Hepatopathy			8818 (1.4)	8704 (1.4)	109 (3.4)
Infection			10,816 (1.8)	10,563 (1.7)	246 (7.7)
Diabetes			46,888 (7.7)	46,606 (7.7)	281 (8.8)
Kidney disease			1322 (0.2)	1262 (0.2)	55 (1.7)
Pulmonary disease			271 (0.0)	232 (0.0)	33 (1.0)
Cancer			100 (0.0)	93 (0.0)	7 (0.2)
HIV-positive, AIDS, or HIV wasting syndrome			143 (0.0)	139 (0.0)	4 (0.1)
Connective tissue disease			268 (0.0)	234 (0.0)	34 (1.1)
Anemia			172,547 (28.2)	170,221 (28.0)	2313 (72.1)
		HB≤39 g/l	90 (0.0)	39 (0.0)	49 (1.5)
		40≤HB ≤69 g/l	3814 (0.6)	3095 (0.5)	711 (22.2)
		70≤HB ≤99 g/l	105,369 (17.2)	103,987 (17.1)	1380 (43.0)
		100≤HB ≤109g/l	63,274 (10.3)	63,100 (10.4)	173 (5.4)

Abbreviations: MNM, maternal near-miss; ICU, Intensive Care Unit; HELLP, hemolysis, elevated liver enzymes and low platelet count syndrome; HIV, human immunodeficiency virus; AIDS, Acquired Immune Deficiency Syndrome; HB, haemoglobin.

Table 4 Comparison of Perinatal Outcome Between Women with MNM and Without During 2012–2017

Item	All women	Women Without MNM	Women with MNM	OR (95% CI)
Live birth	543,109	540,477	2611	0.6 [0.5,0.6]
Premature birth
28-36+6weeks’ gestation	41,155 (7.6)	40,086 (7.4)	1061 (40.6)	7.0 [6.5,7.6]
Early preterm birth (28-31+6weeks’ gestation)	5884 (1.1)	5629 (1.0)	253 (9.7)	9.2 [8.1,10.5]
Mid preterm birth (32-33+6weeks’ gestation)	5710 (1.1)	5507 (1.0)	202 (7.7)	7.4 [6.4,8.5]
Late preterm birth (34~36+6weeks’ gestation)	29,561 (5.4)	28,950 (5.4)	606 (23.2)	4.7 [4.3,5.1]
Stillbirth rates^a(‰)	8032(14.8)	8059 (14.8)	221 (84.6)	5.7 [4.9,6.5]
Neonatal mortality^b(‰)	671 (1.2)	672 (1.2)	34 (13.0)	10.2 [7.2,14.5]
Low birth weight incidence
Less than 2500g	35,333 (6.5)	34,387 (6.4)	937 (35.9)	6.9 [6.4,7.5]
1500–2500g (not include 2500g)	26,561 (4.9)	25,934 (4.8)	623 (23.9)	5.4 [5.0,5.9]
Less than 1500 g	8772 (1.6)	8453 (1.6)	314 (12.0)	7.7 [6.9,8.7]
Number of fetuses
1	561,096 (91.6)	558,326 (91.7)	2739 (85.4)	0.5 [0.5,0.6]
>1	10,511 (1.7)	10,286 (1.7)	225 (7.0)	4.4 [3.8,5.0]

Notes: ^aThe WHO definition of third trimester stillbirths per 1000 births includes 28 completed weeks of gestation or longer or 1000 g birth weight or heavier. ^bEarly neonatal deaths within seven days of delivery before discharge per 1000 birth.

Table 5 Risk Factors for MNM in Zhejiang Province During 2012–2017

Name	Crude OR ^a (95% CI)	Adjusted OR ^b (95% CI)
Age
20–34	1	1
≤19	1.4 [1.1,1.8]	1.9 [1.4,2.7]
35–39	1.8 [1.6,2.0]	1.1 [0.9,1.2]
≥40	3.4 [2.8,4.0]	1.4 [1.1,1.7]
Delivery hospital
Provincial/Municipal hospital	1	1
County hospital	0.47 [0.4,0.5]	0.8 [0.7,0.9]
Township hospital or at home	109.5 [51.5,232.9]	12.4 [3.9,39.7]
Delivery method
Vaginal delivery	1	1
C-section	4.5 [4.4,5.0]	3.1 [2.8,3.6]
Abortion	2.2 [0.9,5.4]	3.6 [1.1,11.8]
Prenatal examination
8–10	1	1
0	3.2 [2.4,4.4]	2.2 [1.5,3.4]
1–4	1.4 [1.17,1.57]	1.0 [0.8,1.2]
5–7	1.1 [1.02,1.29]	1.1 [0.9,1.3]
≥10	1.1 [1.0,1.1]	1.2 [1.0,1.3]
Potentially life-threatening disorder
No potentially life-threatening disorder	1	1
Placenta praevia	30.2 [27.4,33.3]	2.0 [1.7,2.3]
Abruptio placentae	10.2 [8.5,12.2]	2.1 [1.7,2.7]
Placenta accreta	112.8 [97.5,130.6]	3.0 [2.4,3.7]
Postpartum hemorrhage	122.0 [109.4,136.1]	41.0 [35.7,47.0]
Ruptured uterus	11.7 [8.0,17.2]	2.5 [1.4,4.4]
Severe Hypertension	13.8 [11.8,16.3]	2.5 [1.9,3.3]
HELLP syndrome	124.0 [90.2,170.5]	8.4 [5.0,14.2]
Cardiopathy	7.7 [5.7,10.3]	2.2 [1.5,3.4]
Embolism	319.3 [194.3,525.3]	46.0 [19.1,110.7]
Hepatopathy	2.4 [1.9,3.1]	1.6 [1.1,2.2]
Infection	5.1 [4.3,6.0]	1.8 [1.4,2.2]
Kidney disease	11.1 [7.9,15.6]	1.8 [1.1,3.1]
Pulmonary disease	32.7 [19.9,53.7]	3.9 [1.7,9.0]
Connective tissue disease	20.7 [10.5,41.0]	9.4 [3.6,24.1]
Anemia (>109 g/l)	1	1
Anemia (HB≤39 g/l)	206.6 [128.1,333.2]	36.6 [16.0,84.1]
Anemia (40 g/l≤HB≤69g/l)	62.0 [55.7,69.0]	6.4 [5.4,7.6]
Anemia (70 g/l≤ HB≤99 g/l])	3.7 [3.4,4.0]	1.7 [1.5,1.9]
Anemia (100 g/l≤ HB≤109 g/l])	0.5 [0.4,0.6]	0.9 [0.7,1.1]

Notes: ^aUnivariate findings by logistic regression. ^bMultivariate findings by adjusting for the age, delivery hospital, delivery method, prenatal examination, maternal complication, anemia.