Objective To assess whether severe acute maternal morbidity (SAMM, 'near misses') can be used as a surrogate of an analysis of maternal deaths to describe the pattern of severe maternal disease and avoidable factors related to it. Design Prospective, descriptive study.Setting A SAMM and maternal mortality audit was conducted in three clearly defined geographical areas, consisting of rural and urban settings in South Africa. Population Indigent black African pregnant women.Method Cases of SAMM and maternal deaths were collected in the areas and a comparison was made of the disease profiles and avoidable factors, missed opportunities and substandard care. Main outcome measures The proportion of primary obstetric causes and avoidable factors in women with SAMM and maternal deaths, and the mortality indices of the primary obstetric causes of death and organ system dysfunction. Results A total of 423 women with SAMM and 128 maternal deaths were collected over two years.Demographic factors were similar between the groups except that significantly more maternal deaths had not attended any antenatal care. The primary obstetric causes of SAMM and maternal death did not correlate. The four most common causes of SAMM were complications of hypertension (27.2%), postpartum haemorrhage (18.0%), antepartum haemorrhage (12.8%) and abortion (11.3%), whereas the four most common causes of maternal death were non-pregnancy related sepsis (26.6%), complications of hypertension (23.4%), pre-existing medical disease (14.1%) and abortion (10.9%). The types of avoidable factors were similar between both groups although administrative factors occurred significantly more frequently in the maternal death group as did poor problem identification and monitoring. Conclusion Review of SAMM gives a different disease pattern to that obtained from maternal death audits.However, in diagnosing inadequacies in the health system, similar information was obtained.

Corresponding author : M G Schoon (schoonm@fshealth.gov.za) Aim. In December 2011, having identified inter-facility transport as a problem in the maternity service, the Free State Department of Health procured and issued 48 vehicles including 18 dedicated to maternity care. Subsequently, a sustained reduction in mortality was observed. We probed the role of inter-facility transport in effecting this reduction in mortality. Methods. A before-after analysis was performed of data from 2 separate databases, including the district health information system and the emergency medical and rescue services call-centre database. Data were compared for a 12-month prior-and 10-month post-intervention period using descriptive and correlation statistics. Results. The maternal mortality decreased from 279/100 000 live births during 2011 to 152/100 000 live births during 2012. The mean dispatch interval decreased from 32.01 to 22.47 minutes. The number of vehicles dispatched within 1 hour increased from 84.2% to 90.7% (p<0.0001). Monthly mean dispatch interval curves closely mirrored the maternal mortality curve. Conclusion. Effective and prompt inter-facility transport of patients with pregnancy complications to an appropriate facility resulted in a reduction of maternal mortality. Health authorities should prioritise funding for inter-facility vehicles for maternity services to ensure prompt access of pregnant women to centres with skills available to manage obstetric emergencies.

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