Maternal Near-Miss Events and System Failures at Teaching Hospitals in the South East: A Case-Control Analysis

Maternal near-miss analysis complements maternal mortality review by identifying preventable system failures in women who survive severe acute maternal morbidity, providing actionable quality improvement insights without requiring mortality data. This case-control study analyses maternal near-miss events and associated system failures at teaching hospitals in Imo, Enugu, and Anambra States, South East Nigeria. Cases were women who experienced WHO-defined maternal near-miss events over an 18-month prospective period, with controls selected as women with normal pregnancy outcomes matched for parity and gestational age (2:1 ratio). Clinical, provider, and system factors associated with near-miss occurrence were analysed using conditional logistic regression. Maternal near-miss ratio was 14.7 per 1,000 live births across the three facilities. Severe haemorrhage (38 percent), severe preeclampsia (31 percent), and severe infection (19 percent) were the index conditions. System failures identified in near-miss cases included delayed blood product availability (OR 5.2), insufficient anaesthetic staffing (OR 3.7), and absence of magnesium sulphate at time of need (OR 4.1). Unbooked status doubled near-miss odds. The study provides the first case-control near-miss analysis from the South East zone and demonstrates that supply-side system failures are a greater predictor of near-miss occurrence than patient-level factors. Recommendations include blood bank resilience improvement, 24-hour anaesthetic availability, and drug supply audits. Keywords: maternal near-miss, system failure, South East Nigeria, severe acute maternal morbidity, case-control