Comparative analysis of maternal near miss incidents in secondary and tertiary healthcare facilities

Abstract

Background

Maternal mortality is a significant global issue, but maternal morbidity, leading to lasting disability, is more prevalent. The World Health Organization (WHO) developed the Maternal Near Miss (MNM) tool to complement maternal mortality measures and improve maternal health outcomes.

Objective

This study compares MNM incidence and magnitude between a secondary health facility and a tertiary health facility in Abuja, Nigeria.

Methods

A 12-month prospective study identified MNM cases using WHO clinical criteria. Data on MNM cases were collected and analyzed using descriptive and comparative statistics. The chi-square test and rate ratio analysis were employed to compare MNM incidences between the facilities.

Result

The secondary health facility had 1,340 live births, 148 MNM cases (110.5 per 1,000 live births), and 2 maternal deaths (mortality index of 1.33%) while the tertiary health facility had 796 live births, 220 MNM cases (276.4 per 1,000 live births), and no maternal deaths (mortality index of 0). Significant differences were observed in the distribution of MNM cases as rate ratio analysis showed women at the tertiary facility were 2.5 times more likely to experience MNM compared to those at the secondary facility [Rate Ratio = 2.53; 95% CI: [1.98–3.24]; p < 0.05].

Discussion

The higher MNM incidence at the tertiary facility likely reflects its role as a referral center for high-risk cases. Despite higher MNM rates, the tertiary facility’s effective management prevented maternal deaths, contrasting with the secondary facility’s mortality outcomes.

Conclusion

This study reveals significant disparities in MNM incidence and distribution between secondary and tertiary healthcare facilities in Abuja, Nigeria. The higher MNM incidence at the tertiary facility underscores its crucial role in managing severe maternal complications and high-risk cases, reflecting the challenges faced by secondary facilities in handling complex maternal health issues.

Background

Maternal mortality remains a global health concern; however, it represents only a fraction of the broader spectrum of maternal morbidity, which can lead to long-term disability [1]. Recognizing this, the World Health Organization (WHO) emphasizes the importance of understanding the root causes of maternal mortality and implementing effective preventive strategies. To complement the measurement of maternal mortality and provide a more comprehensive assessment of maternal health, the WHO developed the Maternal Near Miss (MNM) tool. This tool offers a valuable metric for evaluating severe maternal morbidity and improving maternal health outcomes [2].

Maternal Near Miss (MNM), as defined the by the World Health Organization (WHO), refers to a woman who came close to death but managed to survive a condition that arose during pregnancy, childbirth, or within 42 days after the termination of pregnancy [2]. Maternal near miss is employed as a substitute measure for assessing maternal health, specifically in the context of maternal death, which is a highly distressing occurrence [3]. It serves as a complementary tool for assessing severe maternal outcomes alongside maternal mortality [4]. Given the similarities in characteristics between MNM and maternal mortality, the latter offers valuable insights into the causes, barriers, and strategies for reducing maternal death and long-term consequences [5, 6].

The majority of Maternal Near Miss (MNM) cases require life-saving interventions in hospital settings, making hospital records a primary source of information for identifying and analyzing these events. Utilising a standardised case definition is crucial in order to precisely identify and classify cases of Maternal Near Miss (MNM), hence assuring accuracy in identification and reporting within healthcare facilities [7]. Healthcare systems can effectively determine the occurrence of severe maternal complications and deaths; healthcare providers can identify and track cases of MNM thereby allowing them to understand the frequency and nature of these complications. Monitoring Maternal Near Miss (MNM) cases enables healthcare providers to identify effective interventions and clinical practices for the prevention and management of severe maternal complications, thereby facilitating targeted improvements in care [2, 8].

Hence, MNM surveillance offers an opportunity to evaluate the quality of obstetric care and develop strategies for improving maternal health globally. Compared to auditing maternal deaths alone, analyzing a larger number of MNM cases allows for a more comprehensive understanding of the underlying causes of adverse maternal events and the gaps in clinical management [9]. Interestingly, a significant number of cases involving maternal near miss (MNM) and severe maternal outcomes are observed in secondary healthcare facilities. Secondary facilities, characterized by varying resource capacities, bear the brunt of maternal morbidity, emphasizing the need for targeted interventions at this level. Whereas cases of MNM in tertiary facilities sometimes result from delays in reporting to the institution and lack of early intervention at primary and other centers [10].

Despite the critical roles of both secondary and tertiary healthcare facilities in improving maternal health outcomes, there is notable paucity of comprehensive comparative studies that directly examine MNM in these two levels of care. This gap in the literature limits the ability to systematically assess and contrast maternal health indicators, particularly maternal near miss (MNM) events, across different tiers of the health system. The lack of such comparative evidence constrains understanding of how specific risk factors, delays in care, and socio-demographic variables may differentially impact maternal outcomes at secondary versus tertiary healthcare levels. Therefore, this study aims to address this gap by comparing the incidence and determinants of MNM in a secondary and a tertiary healthcare facility.

Method

Study design

This was a 12-month prospective observational facility-based study conducted between August 2022 and August 2023. The study adhered to the STROBE guidelines for reporting observational studies [11].

Study area/setting

The study was conducted at two publicly owned health facilities in Abuja Municipal Area Council (AMAC), Federal Capital Territory (FCT), Nigeria:

• Asokoro District Hospital (secondary facility): A 135-bed capacity hospital providing medical, surgical, pediatric, obstetric, and gynecological services.

• National Hospital Abuja (tertiary facility): A 400-bed referral hospital that delivers specialized care in all medical areas, including obstetrics, and serves patients from across the West African subregion.

These facilities were selected to enable comparative analysis of maternal near miss (MNM) between secondary and tertiary levels of care within the same geographical and administrative context. In the FCT, there are a total of 906 health facilities, of which 241 (26.6%) are public and 665 (73.4%) are private [12].

Participants

Inclusion and exclusion criteria

The study included all women admitted to Asokoro District Hospital and National Hospital with a life-threatening condition in the antepartum, intrapartum, or postpartum period (within 42 days of delivery) between August 2022 and August 2023 and met the WHO Maternal Near Miss (MNM) criteria (women survived a life-threatening condition that arose during pregnancy, childbirth, or within 42 days after the termination of pregnancy). For this study, cases were identified using the WHO maternal near miss (MNM) operational definition based on clinical or disease-specific criteria [2], which included: (a) Severe postpartum hemorrhage, (b) Severe pre-eclampsia, (c) Eclampsia, (d) Severe systemic infection or sepsis and (e) Uterine Rupture. On the other hand, women whose life-threatening condition was either unrelated to pregnancy, childbirth or postpartum were excluded from the study. The process first involved identifying all women with potentially life-threatening conditions (PLTCs), after which those who fulfilled the WHO MNM clinical criteria were classified as MNM cases. This stepwise approach ensured that both severe obstetric complications and true near-miss events were systematically captured. On the other hand, women whose life-threatening condition was unrelated to pregnancy, childbirth, or the postpartum period were excluded from the study.

Variables and definitions (WHO MNM clinical Criteria)

MNM cases were defined according to the WHO operational definition and clinical criteria [2]. The following disease-specific categories were applied:

Severe Postpartum Hemorrhage: Blood loss of ≥ 1000 mL after childbirth, requiring immediate clinical intervention (e.g., uterotonics, surgery, or blood transfusion). It is a leading cause of maternal death and morbidity globally.

Severe Pre-eclampsia: A pregnancy-specific hypertensive disorder (BP ≥ 140/90 mmHg) after 20 weeks gestation with signs of organ dysfunction (e.g., proteinuria, elevated liver enzymes, low platelets), but without seizures. Requires urgent intervention to prevent progression.

Eclampsia: The occurrence of seizures or coma in a woman with pre-eclampsia that cannot be attributed to other causes. It is a life-threatening emergency often requiring intensive management and delivery of the fetus.

Sepsis or Severe Systemic Infection: A life-threatening condition due to infection, where there is systemic inflammation and organ dysfunction (e.g., fever/hypothermia, tachycardia, hypotension, altered mental status). May arise from genital tract infections, unsafe abortions, or surgical site infections.

Ruptured Uterus: A full-thickness tear of the uterine wall, usually during labor, which may result in fetal expulsion into the abdominal cavity. It causes massive hemorrhage and risk to both mother and fetus, often necessitating emergency laparotomy and hysterectomy.

Other Potentially Life threatening Complications:

Pregnancy-Induced Hypertension (PIH): Recognized as a precursor to preeclampsia/eclampsia: defined as new-onset hypertension (systolic ≥ 140 mmHg and/or diastolic ≥ 90 mmHg) arising after 20 weeks of gestation in a previously normotensive woman, without proteinuria or systemic signs of preeclampsia.

Antepartum Hemorrhage (APH): Defined as genital tract bleeding occurring after 24 weeks of pregnancy and before delivery of the baby.

Placental Abruption: is defined as the premature separation of a normally implanted placenta from the uterine wall before the delivery of the fetus, after 20 weeks of gestation and before the second stage of labor.

Data sources and measurement

Upon obtaining ethical approval and clearance from the Federal Capital Territory Health Research Ethics Committee (FHREC/2022/01/57/07-04-22), the National Hospital Health Research Ethics Committee, and the Asokoro District Hospital Medical Ethics Committee, data were collected from the health registry of each facility. This data, devoid of any participant information was granted a waiver for individual consent by each facility which is in accordance with the ethical principles of Declaration of Helsinki.

MNM cases were identified through routine visits to the labor ward and postnatal ward of both facilities from August 2022 to August 2023. All women were screened from heath facility registry as potential MNM cases were identified and reviewed. Once the WHO MNM clinical criteria were met, information about the occurrence of the pregnancy related complication and severe maternal outcome, mode of delivery, pregnancy outcome for each MNM case was recorded. To ensure data accuracy, at the end of each month, the compiled dataset was cross-verified with ward records to minimize errors or omissions. Any discrepancies were resolved through consultation with the attending midwife, nurse, or resident doctor on duty at the time of the case. In addition, cases with incomplete information were carefully reviewed. Where possible, missing variables were retrieved from additional hospital records (e.g., case notes, theatre logs) or clarified with clinical staff.

Study size

All eligible MNM cases and live births within the 12-month study period were included as part of a facility-based surveillance (design-based census); therefore, no a priori sample size calculation was required.

Bias control

To minimize bias, standardized WHO MNM clinical criteria were applied across both sites, data abstraction was cross-checked monthly, and ambiguous records were clarified with the attending healthcare provider.

Quantitative variables and outcomes

The main outcomes assessed were:

• Incidence of MNM (per 1,000 live births).

• Magnitude and severity of MNM by cause.

• Mortality index (number of maternal deaths ÷ [MNM + maternal deaths] × 100).

Statistical methods

At the end of every month, aggregate of each data was collated and compiled on an excel spreadsheet analyzed using SPSS version 24. Analysis of this data is divided into 2 parts:

• i)Descriptive analysis: Frequencies and proportions of MNM morbidity and maternal near miss indicators were summarized for each facility.
• ii)Comparative analysis:

• Chi-square tests were used to compare distributions of MNM morbidity between the two facilities.

• Rate ratio analysis with 95% confidence intervals compared MNM incidence rates.

• Statistical significance was set at p < 0.05.

Results

During the 12-month period there were a total of 2,670 deliveries and 2,136 live births after screening a total of 368 MNM cases were found in both Asokoro District Hospital (Secondary health facility) and National Hospital (Tertiary health facility).

Descriptive analysis

Asokoro District Hospital (Secondary Facility)

Between August 2022 and August 2023, a total of 1,340 live births were recorded at Asokoro District Hospital. During this period, 148 women with potentially life-threatening conditions (PLTCs) were managed at Asokoro District Hospital and the most common complication was severe pre-eclampsia, accounting for nearly half of the cases (48.6%). This was followed by pregnancy-induced hypertension (16.2%) and severe postpartum hemorrhage (12.2%). Less frequent complications included eclampsia (8.8%), placental abruption (9.5%), and antepartum hemorrhage (4.7%). These findings highlight that hypertensive disorders in pregnancy (PIH, severe preeclampsia, and eclampsia combined) were the predominant contributors to severe maternal morbidity in this facility (Table 1).

Table 1.

Morbidity conditions of women with potentially life-threatening conditions and severe maternal outcomes

Condition	Secondary Facility (Number, %)	Tertiary Facility (Number, %)
Placenta Abruption	14 (9.46%)	22 (10%)
Severe PPH	18 (12.16%)	66 (30%)
APH	7 (4.73%)	13 (5.9%)
Severe Preeclampsia	72 (48.64%)	57 (25.9%)
Eclampsia	13 (8.78%)	24 (10.9%)
PIH	24 (16.2%)	27 (12.3%)
Ruptured Uterus	-	11 (5%)

Out of the 148 women with PLTC, 105 women experienced life-threatening complications, comprising 103 maternal near-miss (MNM) cases and 2 maternal deaths. The MNM incidence ratio was 87.3 per 1,000 live births, while the severe maternal outcome (SMO) ratio was 88.8 per 1,000 live births, indicating a high burden of severe maternal morbidity in the population. The maternal near miss to mortality ratio was 58.5:1, which suggests that for every maternal death, approximately 59 women survived a life-threatening condition—an indication of relatively effective emergency obstetric care. Furthermore, the mortality index of 1.7% (0.0168) is low, meaning that most women with life-threatening conditions survived. This points to comparatively good quality of care within the facilities, although the presence of maternal deaths still signals areas where improvements are needed.

A total of 4 MNM cases were referred into the facility while a total of 5 were referred out of the facility (Table 2).

Table 2.

Severe maternal outcomes and near miss indicators

S/N	OUTCOMES	SECONDARY (Asokoro District Hospital)	TERTIARY (National Hospital)
1	All live births in the population under surveillance	1340	796
2	Maternal deaths	2	0
3	Maternal near miss cases	103	158
4	Women with life threatening conditions	105	158
5	MNM Incidence Ratio (per 1000 live births)	87.3	198.5
6	Severe maternal outcome ratio (per 1000 live births)	88.8	198.5
7	Maternal near miss mortality ratio	58.5:1	Undefined/infinite (no deaths recorded)
8	Mortality index	0.0168	0

National Hospital (Tertiary Facility)

Between August 2022 and August 2023, a total of 796 live births were recorded at the National Hospital and during this period, 220 women with potentially life-threatening conditions were identified. Among the women who developed potentially life-threatening conditions, the most common complication was severe postpartum hemorrhage (30%), followed by severe preeclampsia (25.9%). Other important contributors included pregnancy-induced hypertension (12.3%), eclampsia (10.9%), and placenta abruption (10%), highlighting the significant burden of hypertensive-related complications. Less frequent but still severe were antepartum hemorrhage (5.9%) and ruptured uterus (5%), both of which remain critical obstetric emergencies (Table 1).

Out of the 220 women with potentially life-threatening conditions, there were 158 maternal near miss (MNM) cases and no maternal deaths, giving a total of 158 women with life-threatening conditions (WLTCs). The MNM incidence ratio and the severe maternal outcome ratio (SMOR) were both 198.5 per 1,000 live births, indicating a high burden of severe maternal morbidity in the study population. The MNM mortality ratio was undefined (infinite) since no maternal deaths occurred, meaning all women with life-threatening complications survived. The mortality index was 0%, suggesting effective management of severe complications and good quality of maternal care in the facility during the study period (Table 2).

Comparative analysis

After conducting the statistical analyses and when the incidence of each maternal near miss condition was calculated per 1,000 live births, it was observed that severe postpartum hemorrhage (82.9 vs. 13.4 per 1,000 live births, p < 0.001), eclampsia (30.2 vs. 9.7 per 1,000 live births, p = 0.001), placenta abruption (27.6 vs. 10.4 per 1,000 live births, p = 0.004), antepartum hemorrhage (16.3 vs. 5.2 per 1,000 live births, p = 0.019), and ruptured uterus (13.8 vs. 0 per 1,000 live births, p = 0.001) were significantly more frequent in the tertiary facility compared with the secondary facility. In contrast, the incidence of severe preeclampsia and pregnancy-induced hypertension, although numerically higher in the tertiary facility, did not reach statistical significance. Overall, the tertiary hospital demonstrated a consistently higher burden of severe obstetric complications, highlighting the increased risk profile of women managed at this level of care (Table 3).

Table 3.

Distribution of MNM cases in both secondary and tertiary facilities

Condition	Asokoro District Hospital (Secondary Facility) (n = 148)	National Hospital (Tertiary Facility) (n = 220)	Chi-Square (χ²)	p-value
Severe Preeclampsia	72 (48.64%)	57 (25.9%)	2.47	0.116
PIH	24 (16.2%)	27 (12.3%)	0.76	0.384
Severe PPH	18 (12.16%)	66 (30%)	13.24	0.000*
Placenta Abruption	14 (9.46%)	22 (10%)	0.02	0.890
Eclampsia	13 (8.78%)	24 (10.9%)	0.18	0.671
Antepartum Hemorrhage	7 (4.73%)	13 (5.9%)	0.17	0.679
Ruptured Uterus	0 (0%)	11 (5%)	11.51	0.001*
Total	148	220	51.5	0.001*

*Statistically significant at p < 0.05

The incidence of maternal near miss (MNM) was markedly higher at the National Hospital (198.5 per 1,000 live births) compared with the Asokoro District Hospital (78.4 per 1,000 live births). The calculated rate ratio (RR = 2.53, 95% CI: 1.98–3.24) shows that women delivering at the tertiary facility were more than two and a half times as likely to experience a near miss compared to those at the secondary facility. The confidence interval does not cross 1, indicating that this difference is statistically significant (Table 4).

Table 4.

MNM incidence rate comparison

Facility	Total Live Births	MNM Cases	MNM Incidence Rate per 1,000 Live Births	Rate Ratio (RR)	95% CI for RR
Asokoro District Hospital	1,340	105	78.4
National Hospital	796	158	198.5	2.53	1.98–3.24

Discussion

This study compared the incidence of maternal near miss (MNM) between a secondary and a tertiary healthcare facility. The findings reveal significant differences in the occurrence and distribution of MNM cases between Asokoro District Hospital (secondary level) and the National Hospital Abuja (tertiary level) over 12-months. Due to the research gap, this is the first comparative study of Maternal near miss (MNM) incidence across different levels of the health care system. The MNM incidence rate at the tertiary health facility was significantly higher at 198.5 per 1,000 live births compared to 78.4 per 1,000 live births at the secondary health facility. This indicates that women giving birth at the tertiary health facility are approximately 2.5 times more likely to experience severe maternal complications than those at the secondary health facility. The MNM incidence rate found in this study is quite high compared to those found in other studies conducted at tertiary facilities in low-and middle income countries (LMIC) which ranged from 7.2 per 1000 live births to 178 per 1000 live births over a 12-month period [13–18]. The findings in this study could be attributed to the fact that there are only four tertiary facilities in FCT, Abuja and this tertiary facility receives more referrals of high-risk pregnancies and complicated cases from secondary and primary healthcare centers, thereby contributing to a higher MNM incidence rate.

The chi-square test results indicate statistically significant differences in the distribution of specific MNM cases between the two facilities. The tertiary health facility had significantly higher proportions of Severe PPH (30%), severe preeclampsia (25.9%), and ruptured uterus cases (5%) when compared to the secondary facility which had the highest cases being Severe Preeclampsia (48.64%) and severe PPH (12.14%). This is similar to a study conducted in two tertiary facilities in Zimbabwe where it was found that major causes of maternal near miss were obstetric hemorrhage, hypertensive disorders, and complications of miscarriages [19]. In other studies obstetric hemorrhage and hypertensive disorders were also identified as leading causes of MNM, with the majority of affected women belonging to the 18–25 years age group and being multiparous [16, 20–22]. A separate study in Nigeria highlighted hypertensive disorders as the leading cause of MNM and maternal mortality [23]. The findings of this study may be attributed to the patient population at the tertiary facility, which is likely to have a higher prevalence of risk factors associated with severe maternal outcomes, including pre-existing medical conditions, limited access to adequate antenatal care, and a greater incidence of obstetric complications.

Interestingly, despite the higher MNM incidence at the tertiary health facility, there were no maternal deaths reported, resulting in a mortality index of 0. In contrast, the secondary health facility reported 2 maternal deaths resulting from PPH and eclampsia, leading to a mortality index of 1.68%. This difference underscores the capacity of the tertiary health facility to effectively manage and treat severe maternal complications, preventing mortality even in high-risk cases. The Maternal Near-Miss Mortality Ratio (MNMR) of 58.5:1 at the secondary health facility indicates that for every 59 MNM cases, there was one maternal death. This ratio reflects a need for enhanced emergency obstetric care and timely interventions at the secondary health facility to reduce mortality. In another separate study, a secondary analysis and comparison of severe maternal outcomes (SMOs) data from two facility-based surveys in Nigerian hospitals—the WHO Multi-Country Survey on Maternal and Newborn Health (WHOMCS) and the Nigeria Near-Miss and Maternal Death Survey [24] showed that tertiary-level hospitals in Nigeria experienced unacceptably high maternal mortality rates, while secondary-level facilities had a proportionately higher burden of severe maternal outcomes. The findings of this study differ from those of the WHOMCS and the Nigeria Near-Miss and Maternal Death Survey in several ways. This study found a significantly higher MNM incidence rate at the tertiary health facility compared to previous studies [25, 26], which could be attributed to the tertiary facility’s role as a referral center for high-risk pregnancies and complicated cases from secondary and primary healthcare centers. Additionally, unlike the high maternal mortality rates reported in tertiary facilities in the WHOMCS and the Nigeria Near-Miss and Maternal Death Survey, this study found no maternal deaths at the tertiary facility, indicating effective management of severe maternal complications. However, the specific mortality index and MNMR reported in this study highlight the urgent need for improving emergency obstetric care at the secondary level. Both this study and the previous studies [24–26] emphasize the need to prioritize common conditions with a high mortality index, such as postpartum hemorrhage, eclampsia, and infectious morbidities. In addition, the two maternal deaths observed during the study occurred at different times but shared notable similarities: both women had delivered vaginally and were referred into the facility in critical condition—one due to postpartum hemorrhage and the other due to eclampsia—underscoring the persistent risks of maternal complications post-delivery and the critical role of timely, effective referral systems.

This comparative analysis reveals significant differences in the incidence and distribution of MNM cases between a Secondary health facility and a Tertiary health facility. The tertiary facility’s higher MNM incidence rate and the significant differences in specific morbidity distributions underscore the critical role of tertiary facilities in managing severe maternal complications. Secondary facilities, characterized by varying resource capacities, bear the brunt of maternal morbidity, emphasizing the need for targeted interventions at this level. Despite the critical role that both secondary and tertiary healthcare facilities play in maternal health, there is a noticeable paucity of comprehensive comparative studies directly contrasting these two strata of healthcare settings. The dearth of research directly comparing secondary and tertiary facilities presents a significant gap in our understanding of maternal health dynamics.

Strengths and limitations

This study’s prospective design and continuous data collection over a 12-month period provide a comprehensive overview of maternal near-miss (MNM) cases, capturing detailed information on severe maternal outcomes. By comparing data from both a secondary health facility (Asokoro District Hospital) and a tertiary health facility (National Hospital), the study provides valuable insights into the differences in maternal care and outcomes at different levels of the healthcare system. The use of standardized WHO MNM criteria ensures consistency and comparability with other studies conducted in different settings, enhancing the study’s reliability and validity. The application of chi-square tests and rate ratio analysis adds robustness to the comparative findings, highlighting significant differences in MNM incidence and distribution between the two facilities.

The study is limited to two facilities within the Federal Capital Territory (FCT) of Abuja, which may not be representative of other regions in Nigeria or other low- and middle-income countries (LMICs). The findings of a higher MNM incidence rate at the tertiary facility could be influenced by referral bias, as it receives more high-risk and complicated cases from secondary and primary healthcare centers. The inherent differences in availability of resources, staffing and infrastructure between secondary and tertiary facilities may contribute to variations in MNM rates, complicating direct comparisons. Furthermore, as all eligible cases were included without randomization, unmeasured confounding factors such as socioeconomic status, referral patterns, and severity of illness at presentation may have influenced the observed differences between the secondary and tertiary facilities. Also, although the inclusion of potentially life-threatening conditions (PLTCs) broadened the scope of surveillance in line with WHO and Nigerian MPDSR recommendations, it may have introduced some overlap between categories, thereby complicating strict comparability with studies that used only organ dysfunction-based MNM criteria.

A further limitation relates to the lack of detailed sociodemographic, socioeconomic, and referral-related data. Although both facilities have introduced electronic medical record (EMR) systems, these systems currently operate in a hybrid format, combining electronic and paper-based documentation. During the study period, the incomplete integration of these systems and inconsistent data entry across facilities limited access to reliable sociodemographic and socioeconomic information. In addition, the data collection tools were primarily designed to capture clinical variables necessary for MNM identification and classification according to WHO criteria, rather than baseline characteristics or contextual factors. Consequently, the absence of such data may have constrained the depth of comparative analysis between the two facilities.

Conclusion

This study provides a detailed comparative analysis of maternal near-miss (MNM) cases between a secondary health facility (Asokoro District Hospital) and a tertiary health facility (National Hospital) in the Federal Capital Territory, Abuja, Nigeria. The findings reveal a significantly higher MNM incidence rate at the tertiary facility, highlighting its critical role in managing severe maternal complications, likely due to its function as a referral center for high-risk cases. The results found in this study underscore the urgent need for targeted interventions to improve maternal health outcomes, particularly at the secondary facility level. This includes addressing common conditions with a high mortality index, such as postpartum hemorrhage, eclampsia, and severe preeclampsia. Overall, this study contributes valuable insights into the dynamics of maternal health care at different levels of the healthcare system in Nigeria thereby emphasizing the need for a comprehensive approach to improve maternal health outcomes across both secondary and tertiary facilities. The findings call for enhanced resource allocation, better training for healthcare workers, and improved referral systems to ensure timely and effective care for all women, regardless of the healthcare facility level they access.

Authors’ contributions

The entirety of this research was conceived, undertaken and executed by a single author Abdullahi RH who conceptualized the study design, formulated the research questions, collected and analyzed the data as well as drafted the manuscript from introduction to conclusion. Furthermore, Abdullahi RH undertook the task of preparing tables and ensuring critical revision of the manuscript before submission.

Funding

No funding.

Data availability

All data generated or analysed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

The following ethical approvals were obtained from the following:

1. Federal Capital Territory Health Research Ethics Committee (FCT HREC) Approval Number: FHREC/2022/01/57/07-04-22

2. National Hospital Health Research Ethics Committee Approval number: NHA/ADMIN/236/V.VII/

3. Asokoro District Hospital Medical Ethics Committee Approval number: FCTA/HHSS/HMB/ADH/098/22

The data used in this study were extracted from the health registries of the participating facilities and contained no identifiable patient information. As such, individual informed consent was not required, and a waiver of consent was granted by the respective health research ethics committees.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.