Modifiable risk factors and care delays driving maternal near-miss in rural Bangladesh: a facility-based case-control study

Background Maternal near-miss (MNM) events, where women survive life-threatening pregnancy complications, provide important insights into severe maternal morbidity and the quality of obstetric care. In a low and middle-income country such as Bangladesh, although the maternal mortality ratio remains higher than the Sustainable Development Goal target, facility-level maternal deaths are often occasional and MNM events can be a more frequent proxy for robust analysis of the contributing factors. This study aimed to identify clinical and care-seeking risk factors for MNM among women from a defined rural cohort, admitted to a tertiary referral hospital in Bangladesh. Methods We conducted a retrospective case-control study at Faridpur Medical College Hospital (FMCH) between January and December 2022. Participants were pregnant and postpartum women admitted to FMCH from Baliakandi subdistrict in Bangladesh, a Child Health and Mortality Prevention Surveillance (CHAMPS) network’s surveillance site. We identified cases using World Health Organization MNM criteria and the remaining admitted women from the cohort served as controls. We extracted data on sociodemographic characteristics, obstetric history, clinical conditions and delay (> 4 hours from symptom onset to arrival at the referral hospital), linking hospital records with data from the CHAMPS health and demographic, and pregnancy surveillance systems. We utilized multivariable logistic regression analysis to identify independent risk factors, adjusting for age, parity, and education. Results Of the 216 study participants, 60 (28%) experienced an MNM event. Significant independent conditions included gestational hypertension (adjusted odds ratio [aOR] 6.9; 95% confidence interval [CI], 2.7–18.6; p < 0.001), anemia (aOR 3.9; 95% CI, 1.3–14.0; p = 0.023), obstetric hemorrhage (aOR 3.1; 95% CI, 1.1–8.9; p = 0.034) and > 4 hours delay from symptom onset to arrival at the tertiary hospital (aOR 5.5; 95% CI, 2.2–14.3; p < 0.001). Compared to controls, MNM cases experienced significantly higher rates of stillbirth (18% vs. 4%; p = 0.002) and early neonatal death (21% vs. 4%; p = 0.022). Conclusions MNM in this rural Bangladesh was strongly associated with potentially preventable clinical conditions and delays in reaching care. Strengthening antenatal care for screening and early management of these conditions, while reducing delays in reaching tertiary facilities, could significantly reduce severe maternal morbidity and improve perinatal outcomes.