Published in PLOS One on 2026-04-15, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Thwala Siphiwe Bridget Pearl, Blaauw Duane, Buchmann Eckhart, Ssengooba Freddie
Source: PLOS One • DOI 10.1371/journal.pone.0346119
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
A persistently high maternal mortality ratio (MMR) from direct pregnancy causes of maternal deaths in a district of the Gauteng Province prompted a detailed audit to identify clinical factors associated with severe maternal outcomes (SMOs).
A cross-sectional matched case control study design was used to identify clinical factors associated with severe maternal outcomes in two regional hospitals in an urban district in Gauteng. 175 sequential SMO cases (near misses and maternal deaths) were matched to two different controls each. The first control was of women with complications while the second control was of women without complications. Data on individual and clinical obstetric characteristics of cases and controls was extracted from clinical case files. A Firth penalised conditional logistic regression was used to identify the clinical factors associated with severe maternal outcomes.
The overall SMO incidence ratio and MMR were 34.7 per 1000 live births and 130.8 per 100 000 live births respectively. Haemorrhage (48.8%) and hypertension (46.9%) were the most common underlying causes of SMOs. The SMO incidence ratio was 39.0 and 30.2 per 1000 live births for Hospital 1 and 2 respectively. Not receiving antenatal care was the most significant risk for SMOs (p < 0.001). In women with complications, not initiating ANC attendance (AOR = 11.0; CI = 2.6–46.0) or having less than 4 ANC visits (AOR = 2.2; CI = 1.2–4.2) had the highest risk for SMOs (p < 0.001). In women without complications, anaemia (AORs = 3.0; CI = 1.4–6.6; p < 0.01), and hypertension (AORs = 71; CI = 4.2−1,196.2), significantly increased the odds of SMOs.
The severe maternal incidence was high in both hospitals. Obstetric haemorrhage and hypertension were significantly associated with most SMOs. Not attending ANC and having few ANC visits were important factors that showed significant association with poor maternal outcomes.
Introduction
Emergency obstetric care (EmOC) is a set of interventions that have been proven effective in addressing the direct causes of maternal deaths [1,2]. However, unacceptably high maternal mortality persists in many countries [2]. Maternal near misses occur more frequently than maternal deaths, and near miss audits are useful for identifying factors that contribute to severe maternal outcomes (SMOs) [3,4]. Routine near miss audits have also been associated with reductions in maternal and neonatal deaths [5]. However, only few published near miss studies have included control groups in their design particularly in low and middle income countries [6–10]. The absence of a comparison group provides limited evidence that identified risk factors are actually responsible for near misses, and means that it is not possible to quantify the size of effects. Previous South African near miss studies [3,11–13] have also mainly been descriptive studies without controls.
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider research & evidence desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Thwala Siphiwe Bridget Pearl, Blaauw Duane, Buchmann Eckhart, Ssengooba Freddie. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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- Evidence brief: Addressing risk factors for hypertensive disorders in pregnancy: A case study of a quality improvement program in two states in Nigeria
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- Evidence brief: Maternal outcomes at mid-altitudes in anemic pregnant women: Evidence from the WOMAN-2 trial
