• Soheila Mohammadi, Birgitta Essén, Masoumeh Fallahian, Robabeh Taheripanah, Soraya Saleh Gargari, and Carina Källestål.
• Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden.
• Acta Obstet Gynecol Scand. 2016 Jul 1; 95 (7): 777-86.

IntroductionCesarean section carries a substantial risk of maternal near-miss morbidity. The aim of this study was to determine the frequency, causes, risk factors, and perinatal outcomes of maternal near-miss at three university hospitals with a high rate of cesarean section in Tehran, Iran.Material And MethodsAn incident case-control study was conducted from March 2012 to May 2014. The modified WHO near-miss criteria were used to identify cases. A control sample of 1024 women delivering at the study hospitals was recruited to represent the source population. Near-miss ratio, crude and adjusted odds ratios with confidence intervals were assessed.ResultsAmong 12 965 live births, 82 mothers developed near-miss morbidities and 12 died. The maternal near-miss ratio was 6.3/1000 live births. Severe postpartum hemorrhage (35%, 29/82), severe preeclampsia (32%, 26/82), and placenta previa/abnormally invasive placenta (10%, 8/82) were the most frequent causes of maternal near-miss. Women with antepartum cesarean section (adjusted odds ratio 7.4, 95% confidence interval 3.7-15.1) and co-morbidity (adjusted odds ratio 2.3, 95% confidence interval 1.4-3.8), uninsured Iranians (adjusted odds ratio 3.4, 95% confidence interval 1.7-7.1) and uninsured Afghans (adjusted odds ratio 4.7, 95% confidence interval 2.4-9.2) had increased risks of near-miss morbidity. Stillbirth and extremely preterm birth were the most prominent adverse perinatal outcomes associated with maternal near-miss.ConclusionsOverutilization of cesarean section clearly influenced the causes of maternal near-miss. A lack of health insurance had a measurable impact on near-miss morbidity. Tailored interventions for reducing unnecessary cesarean section and unrestricted insurance cover for emergency obstetric care can potentially improve maternal and perinatal outcomes.© 2016 Nordic Federation of Societies of Obstetrics and Gynecology.

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