Original Investigation

Maternal mortality and derivations from the WHO near-miss tool: An institutional experience over a decade in Southern India


  • Ajay Halder
  • Ruby Jose
  • Reeta Vijayselvi

Received Date: 19.04.2014 Accepted Date: 28.09.2014 J Turk Ger Gynecol Assoc 2014;15(4):222-227 PMID: 25584030


Preceding the use of World Health Organization (WHO) near-miss approach in our institute for the surveillance of Severe Maternal Outcome (SMO), we pilot-tested the tool on maternal death cases that took place over the last 10 years in order to establish its feasibility and usefulness at the institutional level.

Material and Methods:

This was a retrospective review of maternal deaths in Christian Medical College Vellore, India, over a decade. Cases were recorded and analyzed using the WHO near-miss tool. The International Classification of Diseases, 10th Revision was used to define and classify maternal mortality.


There were 98,139 total births and 212 recorded maternal deaths. Direct causes of mortality constituted 46.96% of total maternal deaths, indirect causes constituted 51.40%, and unknown cases constituted 1.9%. Nonobstetrical cause (48.11%) is the single largest group. Infections (19.8%) other than puerperal sepsis remain an important group, with pulmonary tuberculosis, scrub typhus, and malaria being the leading ones. According to the WHO near-miss criteria, cardiovascular and respiratory dysfunctions are the most frequent organ dysfunctions. Incidence of coagulation dysfunction is seen highest in obstetrical hemorrhage (64%). All women who died had at least one organ dysfunction; 90.54% mothers had two- and 38.52% had four- or more organ involvement.


The screening questions of the WHO near-miss tool are particularly instrumental in obtaining a comprehensive assessment of the problem beyond the International Classification of Diseases-Maternal Mortality and establish the need for laboratory-based identification of organ dysfunctions and prompt availability of critical care facilities. The process indicators, on the other hand, inquire about the basic interventions that are more or less widely practiced and therefore give no added information at the institutional level.

Keywords: Maternal mortality, who near-miss tool, organ dysfunction