The Secular Trends of the Maternal Near Miss Ratio in China, 2012-2018

Background: Maternal near miss (MNM) is one of the most vital health indicators reflecting the quality of obstetric care. The aim of this study was to explore the causes and change patterns in the maternal near miss ratio (MNMR) during the era of the two-child policy in Jiangsu Province, China. Methods: A retrospective cross-sectional study of 247,261 women who were pregnant in 11 hospitals in Jiangsu Province between January 2012 and December 2018 was conducted. The study period was divided into 3 stages: baseline, from January 2012 to June 2014; stage 1, from July 2014 (time of selective two-child policy begins to take effect) to June 2016; and stage 2, from July 2016 (time of universal two-child policy begins to take effect) to December 2018. Findings: Over seven years, a total of 883 mothers were identified as maternal near miss (MNM), yielding an overall MNMR of 3·70/1000 live births (LBs) (95% CI, 3·52-4·01). The MNMR slightly fluctuated around a mean of 2·75/1000 LBs at baseline and stage 1, and leveled at an additional 2·67/1000 LBs (95% CI 1·08-4·25, P = 0·001) at stage 2. We further investigated what conventional factors were the main determinants of the increase in the MNMR. Multivariate logistic regression analysis was used to identify the MNM-related risk factors: advanced maternal age (OR=1·55 and 1·82 for aged 30~35 and aged ≥35), multipara (OR=1·24), cesarean section (OR=3·22), abortion (OR=4·42), no antenatal visits (OR=1·99) and multiple births (OR=7·05). Among the identified MNM-related risk factors, the monthly percentage of multiparity pregnancy, advanced maternal age (≥35) and multiple births accumulated over time were positively related to the increasing monthly MNMR (r=0·54, 0·61, 0·31, respectively). We further evaluated that the accumulation of multiparas and mothers with advanced maternal age accounted for 71·75% of the increase in the MNMR. We then revealed that haemorrhagic disorder was the leading cause of MNM (n = 613, 69·42%). The heamorrhage-caused MNMR increased over seven years (Ptrend < 0·001), and the accumulation of multiparas and mothers with advanced maternal age were also main determinants of the increase (75·62%). Interpretation: Overall, the MNMR considerably increased from 2012 to 2018, which was largely driven by the increase of multiparas and advanced age. More attention needs to be paid to the health of mothers with advanced age and multiple pregnancies, including improving the referral system for pregnant women and raising the quality and standard of obstetric care. Funding Statement: This work was supported by grants from the National Key Research and Development Program of China, the Natural Science Foundation of Jiangsu Province, the State Key Program of National Natural Science of China, the National Health and Family Planning Commission of the People’s Republic of China, the National Natural Science Foundation of China, the China Medical Board, WHO, UNICEF, and China Postdoctoral Science Foundation. Declaration of Interests: The authors have declared that no competing interests exist. Ethics Approval Statement: The study was approved by the ethics committee of the West China Second University Hospital (protocol ID, 2012008). Informed consent was obtained for each participant.