• M Rööst, V C Altamirano, J Liljestrand, and B Essén.
• International Maternal and Child Health (IMCH), Department of Women's and Children's Health, Uppsala University Hospital, Sweden. mattias.roost@kbh.uu.se
• BJOG. 2009 Aug 1; 116 (9): 1210-7.

ObjectiveTo document the frequency and causes of maternal mortality and severe (near-miss) morbidity in metropolitan La Paz, Bolivia.DesignFacility-based cross-sectional study.SettingFour maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government-subsidised programme.PopulationAll maternal deaths and women with near-miss morbidity.MethodsInclusion of near-miss using clinical and management-based criteria.Main Outcome MeasuresMaternal mortality ratio (MMR), severe morbidity ratio (SMR), mortality indices and proportion of near-miss cases at hospital admission.ResultsMMR was 187/100,000 live births and SMR was 50/1000 live births, with a relatively low mortality index of 3.6%. Severe haemorrhage and severe hypertensive disorders were the main causes of near-miss, with 26% of severe haemorrhages occurring in early pregnancy. Sepsis was the most common cause of death. The majority of near-miss cases (74%) were in critical condition at hospital admission and differed from those fulfilling the criteria after admission as to diagnostic categories and socio-demographic variables.ConclusionsPre-hospital barriers remain to be of great importance in a setting of this type, where there is wide availability of free maternal health care. Such barriers, together with haemorrhage in early pregnancy, pre-eclampsia detection and referral patterns, should be priority areas for future research and interventions to improve maternal health. Near-miss upon arrival and near-miss after arrival at hospital should be analysed separately as that provides additional information about factors that contribute to maternal ill-health.

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