Priorities in emergency obstetric care in Bolivia--maternal mortality and near-miss morbidity in metropolitan La Paz

Objective To document the frequency and causes of maternal mortality and severe (near-miss) morbidity in metropolitan La Paz, Bolivia. Design Facility-based cross-sectional study. Setting Four maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government-subsidised programme. Population All maternal deaths and women with near-miss morbidity. Methods Inclusion of near-miss using clinical and management-based criteria. Main outcome measures Maternal mortality ratio (MMR), severe morbidity ratio (SMR), mortality indices and proportion of near-miss cases at hospital admission. Results MMR 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. Conclusions Pre-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.