Maternal and Child Health Journal

, Volume 17, Issue 3, pp 399–404 | Cite as

Severe Acute Maternal Morbidity in a High-Income Developing Multiethnic Country

  • Saad Ghazal-Aswad
  • Padmanabhan Badrinath
  • Islam Sidky
  • Thikra Hassan Safi
  • Husnia Gargash
  • Yousef Abdul-Razak
  • Hisham Mirghani


With declining maternal mortality, the study of severe acute maternal morbidity (SAMM) provides an opportunity to measure the quality of maternal care and to identify ways to improve it. The objective was to study the epidemiology of severe acute maternal morbidity in a high income, rapidly developing, multiethnic country in the Middle East, and to determine the role of ethnicity in maternal morbidity. We included all births occurring in maternal units with more than 500 births a year over a 6 year period in Abu Dhabi emirate, the largest province of the United Arab Emirates. Data on SAMM was collected retrospectively for the first 3 years and prospectively for the later 3 years. A clinical criteria based approach was used to define SAMM. Over the 6 year period there were 122,705 deliveries, and a total of 926 cases of SAMM were identified. The SAMM to births ratio was 7.5/1,000 deliveries. The leading cause of maternal morbidity was hypertensive disorders (59.5 %) followed by hemorrhage (39.6 %). There were clear ethnic differences. Preeclampsia was significantly higher in women from the Indian sub-continent and hemorrhage was more prevalent in UAE women. We have shown that it is possible to use a clinical criteria based approach to study the epidemiology of SAMM. The leading contributors to SAMM were hypertensive disorders and hemorrhage with clear ethnic links supporting earlier reports of a complex interaction between ethnicity, socioeconomic status and maternal health.


Severe acute maternal morbidity Epidemiology Ethnicity United Arab Emirates 


In many parts of the developed world, maternal death has become a rare event. Therefore, the analysis of maternal mortalities might not reflect properly the quality of maternal health care or provide suggestions for improvement [1]. In such situations, severe acute maternal morbidity “(SAMM)” known as “near miss” becomes a better tool to assess maternal care and identify health system failures than maternal mortality [2].

The World Health Organization (WHO) has defined SAMM as the condition of a woman who nearly died, but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy [3].

There is still diversity of opinion as to how to define severe maternal morbidity. There are three main approaches used to identify SAMM. The first uses clinical criteria related to specific diseases, such as severe preeclampsia and eclampsia. The second uses specific interventions such as admission to ICU or the need for intrapartum hysterectomy to define SAMM. The third uses markers for organ dysfunction and organ failure to define SAMM. All have their advantages and disadvantages [4].

The primary obstetrical causes of SAMM differ from those of maternal mortality although avoidable factors might be similar. Therefore, the combination of severe maternal morbidity and maternal mortality provides a better tool to assess success or failure in managing such life-threatening conditions [5].

The United Arab Emirates (UAE) is one of the rapidly growing oil rich nations in the Arabian Peninsula [6]. According to the 2010 midyear estimates by the UAE National Bureau of Statistics, UAE citizens represent less than one sixth of the country’s population [7]. The expatriate population is mainly from the Far East, the Indian subcontinent and the Middle East. The maternal mortality ratio in the UAE was estimated at 21.2/100,000 live births. The leading causes for maternal death were thromboembolic events, hemorrhage and infections [7]. However, there is a paucity of data on the leading causes of SAMM.

The objective of this population-based descriptive study was to ascertain the epidemiology of severe acute maternal morbidity and to determine the impact of ethnicity, if any, in a high-income, rapidly developing, multiethnic country community.

Materials and Methods

This study was conducted over a 6 year period; three retrospective years and a further three prospective years. All four large maternal units, both in the public and private sector, which have more than 500 deliveries per year in the Emirate of Abu Dhabi, were included in the study. Abu Dhabi is the largest Emirate (province) of the UAE where just under half of all UAE women in the country live [7].

Using the clinical criteria approach, several conditions were identified as severe morbidity: eclampsia, severe pre-eclampsia, severe hemorrhage, ruptured uterus, sepsis, HELLP (hemolysis, elevated liver enzymes, and low platelet count), deep venous thrombosis (DVT), and pulmonary embolism (PE).

The Principal Investigator identified a lead clinician for all the maternal units for the study. For the first 3 years, the research nurse identified all the cases retrospectively through the labor & delivery unit, intensive therapy unit (ITU) or high dependency unit (HDU), and operating theatre (OT) registry, for the six identified conditions. The lead clinician then decided whether the case fulfilled the definition of severe morbidity.

For the second half of the study, severe morbidity was identified prospectively.

The identification particulars of the patient, the treating clinician or the hospital involved were not recorded. All relevant related information were collected and recorded by the principle investigator liaising with the lead clinician in the birth units in a pre-defined pro forma. The form covered all relevant clinical data and details related to the antenatal, antepartum, intrapartum and postpartum period.

Severe preeclampsia was defined as blood pressure of 170/110 mmHg on two occasions 4 h apart or >170/110 mmHg once plus ≥0.3 g in 24 h proteinuria or ≥++ on dipstick or Diastolic blood pressure >90 mmHg plus proteinuria (as above) on one occasion, in addition to either oliguria (<30 ml/h for 2 h), visual disturbances (flashing lights or blurred vision), epigatric/right upper quadrant pain or tenderness, thrombocytopenia (<100 × 109/1), or pulmonary edema. Eclampsia was defined as convulsions during pregnancy or in the first 10 days postpartum, together with at least two of the following features within 24 h after convulsions: hypertension (≥170/11 mmHg) Proteinuria (≥+ on random dispstick analysis or ≥0.3 g in 24 h), thrombocytopenia (<100 × 109/1), increased aspartate aminotransferase (≥42 U/1). HELLP Syndrome was diagnosed in the presence of haemoysis (abnormal peripheral smear or raised total bilirubin concentration [≥20.5 micromol/1]), raised liver enzyme activity (raised aspartate aminotransferase (≥70 U/1) or raised gamma- glutamyltransferase (≥70 U/1) and low platelets (<100 × 109/1). The diagnosis of severe hemorrhage was made if the estimated blood loss was >2,000 ml, peripartum fall in hemoglobin concentration was ≥4.0 g/1 or acute transfusion of 4 or more units of blood. Severe sepsis was defined as systematic response to infection manifested by two or more of: temperature >38 or <36 °C (unless after prolonged cesarean), heart rate >100 beats/min, respiratory rate >20/min or PaCO2 <32 mmHg, white cell count >17 × 109/1 or <4 × 109/1 or >10 % immature forms, or bacteremia (that is, positive blood cultures) or positive swab culture. It is also diagnosed if sepsis is associated with either organ dysfunction such as acute renal failure, hypo perfusion evident by lactic acidosis, oliguria or acute alteration in mental state, or hypotension with a systolic blood pressure of less than 90 mmHg or a drop of 40 mmHg or more in the absence of other causes of hypotension. Uterine rupture was defined as acute dehiscence of the uterus leading to the emergency delivery of the infant [8].

This study protocol was approved by the human research ethics committee of the Faculty of Medicine & Health Sciences, UAE University.


There were a total of four maternal units with more than 500 deliveries per year that were included in this study. The total number of deliveries in these units between 1998 and 2003 was 122,705. A total of 926 cases with severe maternal morbidity were identified during the same period. This represents a ratio 7.5 per 1,000 deliveries. The number of maternal deaths during the same period was 26. The SAMM: maternal mortality ratio was 35.6.

The mean maternal age (standard deviation) was 30.1 ± 6.5 years. Of the 926 patients, 627 (67.7 %) patients were between 20 and 34 years, 255 (27.6 %) patients were at 35 years or more, and 44 (4.8 %) patients were younger than 20 years of age. The mean gestational age at which the severe morbidity occurred was 35.4 ± 5.4 weeks. The majority (32.3 %) of patients were from the Indian Subcontinent (Table 1). A total of 222/926 (24.0 %) patients had combined morbidities. Hypertensive disorders were the leading (59.5 %) cause for maternal morbidity (Table 2). The frequency of preeclampsia was significantly higher (p = 0.03) among patients from the Indian subcontinent compared to Arabs. The frequency of hemorrhage was significantly (0.0001) higher among UAE nationals and Arabs compared to patients from the Indian Subcontinent. Severe hemorrhage complicated 367/(39.6 %) pregnancies. Postpartum bleeding was the leading cause (56.7 %) for severe hemorrhage (Table 3).
Table 1

Shows the ethnic distribution of SAMM patients


Frequency (n = 926)


Indian Subcontinent












Table 2

Causes of maternal morbidity


Frequency (n = 926)














Pulmonary embolism \ DVT



Pulmonary edema






HELLP; hemolysis, elevated liver enzymes, and low platelet count, DVT; Deep venous thrombosis

Table 3

Type of hemorrhage among patients with SAMM

Type of hemorrhage

Frequency (n = 367)

















Only 309/926 (33.4 %) patients had a first trimester ultrasound examination. The majority (88.1 %) of patients had their antenatal care at a public hospital, and 481/926 (51.9 %) had their care by a consultant obstetrician. A total of 896 (96.8 %) patients delivered in a public hospital, 29 (3.1 %) patients delivered in a private health facility, and 1 (0.1 %) delivered at home. A consultant (senior physician) was involved in the delivery of 314 (33.9 %) patients, and 78 (8.4 %) patients were not seen by a physician during their labor. Labor was induced in 166 (17.9 %) patients. A total of 692 (74.7 %) patients were delivered by Cesarean section of which 490 (70.9 %) were elective. The mean (±SD) gestational age at delivery was 36.1 (± 4.1) weeks, and mean birth weight was 2,552 (±932) grams. There were 44 (4.7 %) cases of perinatal death. The number of perinatal deaths were significantly (p = 0.0001) higher among patients complicated with hemorrhage (33 deaths) than among pregnancies complicated with preeclampsia (11 deaths).

A total of 543/926 (58.6 %) patients were admitted to the ITU or HDU. A total of 667 (72 %) patients delivered in a hospital with an intensive therapy unit (ITU) facility; however, 455 (49.1 %) were admitted to ITU. Further 716/926 (77.3 %) patients delivered in a health facility with a high dependency unit, and 83 (9 %) were admitted to the HDU. There were no significant differences between the admission rate for preeclampsia and hemorrhage to ITU\HDU. Patients with intrapartum hemorrhage had a significantly higher ITU\HDU admission rate than patients with antepartum (p = 0.01) and postpartum (p = 0.03) hemorrhage. Of the total 926 patients, 803 (86.8 %) patients delivered in a facility with 24 h onsite anesthetists, and 812 (87.7 %) patients delivered in a facility with 24 h blood service.


Categorical variables were compared with Fisher’s exact test when appropriate. The differences between data were considered statistically significant when p < 0.05 (Two-tailed).


In this study, we used mainly the clinical criteria approach, rather than the intervention based or the organ system dysfunction-based approach to define SAMM, because it involved both retrospective and prospective data collection. The use of clinical criteria related to a specific disease entity has the advantage of easy interpretation of information, it allows retrospective data collection, and provides the possibility to assess the quality of care and complication rates of a particular disease. However, it has the disadvantage that some conditions related to direct maternal mortality might be omitted due to a lack of accurate diagnosis, problems associated with retrospective collection of information, including poor documentation and bias, and the difficulty to use data for ongoing audits for all morbidities [5, 8, 9]. Geller et al. [10] suggested a scoring system that includes four factors (ITU admission, surgical intervention, extended intubation, and blood transfusion) that objectively identifies SAMM with high sensitivity and specificity.

The severe maternal morbidity ratio of 7.5 per 1,000 observed in our study is relatively low compared to other reports. A Canadian study that involved 1,336,356 patients, reported a maternal morbidity rate of 13.8 per 1,000 deliveries [11]. Unfortunately, the figures are much higher in the developing countries, reaching as high as 119 per 1,000 deliveries [12, 13, 14]. This reflects the variation in maternal care among these countries. However, the use of different definitions and approaches for maternal morbidity might be contributing factors.

The two main causes for SAMM in our study were preeclampsia and hemorrhage. It is of concern that 12 % of patients with SAMM delivered in a health facility lacking a 24 h blood service. The low utilization (49.1 %) of ITU observed in our study might be due to the variation in the judgment among physicians regarding criteria for ITU admission. However, the availability of HDU might be another important factor as evidenced by the relatively higher utilization of the HDU [15]. The leading causes for SAMM in both developed and developing countries are hemorrhage and hypertensive disorders of pregnancy [16, 17, 18, 19]. However, hemorrhage remains the leading cause for maternal mortality in the developing countries; it is less frequently identified as a cause of death in the developed regions of the world [20, 21]. This is mainly due to the lack of proper antenatal and emergency obstetric care, poor referral systems, and lack of a multidisciplinary team approach in developing countries [22]. In a previous study on the same population, thromboembolic events were the leading (30 %) cause for maternal mortality [7].

The observed variations of causes of SAMM among different ethnic groups in our study, supports reports that suggest that there is complex interaction between ethnicity, socioeconomic status and maternal health [23, 24].

The associated perinatal death indicates the severity of the maternal morbidity condition. Wilson et al. suggested three classes for near-miss events: class I, near miss event with healthy infant; class II, a near miss event with feto-infant morbidity, and class III; a near-miss event with fetal/infant death [18]. We had 44 (4.7 %) cases of perinatal death which were mainly associated with SAMM related to severe hemorrhage.

In our study, hemorrhage was the main pathology in around 40 % of maternal morbidities. It remains a leading cause for obstetrical admission to ICU [16]. Obstetrical hemorrhage is a leading cause of SAMM in both developing and developed countries [25, 26]. Therefore, labor suites should have adequate protocols for the diagnosis and management of obstetrical hemorrhage, and regular training to all health care providers who are involved in maternity care should be provided [27].

Some of the limitations of our study are worth considering here. Due to the rarity of the event under study, we adopted both a prospective and retrospective data collection approach. Our study only included women from the largest province, and due to a lack of resources, we could not cover the whole country. Logistical constraints mandated that we restricted our study subjects to those who attended units with more than 500 deliveries per annum. This enabled us to maintain the quality of the data and increase the validity of the findings. However the possibility remains that the pattern of morbidity in the smaller units not included in the study might be different and this has to be borne in mind while interpreting the results. Finally, as we present in the discussion section, our study is based on the clinical criteria with its own merits and disadvantages.

Conclusions & Recommendations

We have clearly demonstrated the feasibility of using a clinical criteria approach to document maternal morbidity in a country that has not yet fully established systems and processes to collate and analyze maternal data, which is conducted routinely in developed nations. For the first time we document the severe maternal morbidity to be 7.5 per 1,000 deliveries in the United Arab Emirates. Hypertensive disorders and obstetrics hemorrhage are the leading cause of SAMM. The causes of SAMM differed by ethnicity with preeclampsia being significantly higher in women from the Indian subcontinent compared to Arabs. However, hemorrhage was significantly higher among Arab and UAE women compared to those from the subcontinent. In patients with SAMM, perinatal mortality is highly associated with hemorrhage. SAMM was more commonly associated with postpartum hemorrhage than other types of obstetrical bleeding. Nearly 6 in 10 women with SAMM required enhanced care and were admitted to the ITU or HDU. However, less than 50 % of women were admitted to the ITU reflecting variations among clinicians on the threshold for ITU admission.

Based on our study we would like to put forward the following recommendations, both for professionals and policy makers, which we hope would lead to better quality care and further reduce maternal morbidity and mortality. As hemorrhage is one of the main causes of SAMM, it is essential that institutions caring for women with SAMM should have access to a 24 h blood service and this issue needs to be addressed by the health care regulators including the Ministry of Health. As the utilization of ITU services was low in our study, evidence based clinical guidelines need to be drawn up to ensure women requiring ITU care do receive it and also reduce clinical variation in the use of ITU services. As the causes of SAMM vary by ethnicity, professionals caring for a multi ethnic population need to be made aware of this and use this knowledge to anticipate and tackle the causes of SAMM in specific ethnic groups. As our study was the first of its kind, covering a large part of the country, over a 6 year period, we recommend that the health authorities establish longitudinal data collection systems to collate and analyze maternal mortality and morbidity data, in order to take further action to improve the health and health care of women in this part of the world.



This study was funded by grant No: (MRG/10 1999-2000) by Shiek Hamdan Bin Rashid Al Maktoum award for medical sciences. The authors are grateful to Mrs. Flora Dimaculangan, research nurse at the Faculty of Medicine and Health Sciences, United Arab University for her valuable help and organization.


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Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Saad Ghazal-Aswad
    • 1
  • Padmanabhan Badrinath
    • 1
  • Islam Sidky
    • 1
  • Thikra Hassan Safi
    • 1
  • Husnia Gargash
    • 1
  • Yousef Abdul-Razak
    • 1
  • Hisham Mirghani
    • 1
  1. 1.Department Obstetrics and Gynecology, Faculty of Medicine and Health SciencesUnited Arab Emirates UniversityAl-AinUnited Arab Emirates

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