Five-year trends in maternal near-miss and its causes in Northeastern Iran: a retrospective multi-center registry-based study

Maternal Near Miss (MNM) serves as a critical indicator for evaluating the quality of obstetric care. This study aimed to analyze the trends, primary causes, and socio-demographic determinants of MNM cases over a five-year period across the affiliated hospital network of Mashhad University of Medical Sciences in Northeastern Iran. This descriptive-analytical study investigated 1,276 MNM cases recorded between 2020 and 2024. Data were extracted from the maternal morbidity surveillance system. Trends in MNM ratios, primary causes (Obstetric Hemorrhage, Hypertensive Disorders, COVID-19, and underlying diseases), maternal age, and seasonal distributions were analyzed using Chi-square test and Poisson regression. A total of 1,276 MNM cases were identified among a total of 411,287 live births (overall MNMR: 3.10 per 1,000 live births), with a fluctuating annual trend peaking in 2024 (n = 427). The most prevalent causes were obstetric hemorrhage (34.4%, n = 438), hypertensive disorders (21.3%, n = 271), and underlying medical diseases (18.7%, n = 238). COVID-19-related MNM peaked in 2021 (n = 76) before declining. A significant association was found between the year of occurrence and the primary cause (χ2 = 149.47, P < 0.001). Women of peak reproductive age (19–35 years) accounted for 63.6% of all near-miss events across the study period, while mothers aged ≥ 36 years constituted the fastest-growing subgroup (33.9%), and the annual MNMR showed a borderline upward trend (IRR = 1.20, 95% CI: 0.99–1.45, P = 0.064). The highest monthly frequency of cases was observed in Aban [Oct–Nov] (n = 146) and Azar [Nov–Dec] (n = 132), indicating a concentration of admissions during the late-autumn and early-winter months. The observed borderline increase in maternal near-miss events across the 5-year period alongside notable annual fluctuations and evolving clinical etiologies underscores the need for adaptive and responsive obstetric care strategies. Severe hemorrhage consistently remains the predominant contributor to near-miss morbidity, while the clinical complexity associated with medical comorbidities and advanced maternal age highlights the growing necessity of multidisciplinary management. The identified temporal variations and age-stratified distribution patterns provide essential baseline evidence to guide targeted clinical vigilance, resource allocation, and preparedness in tertiary maternal health services. Maternal near miss refers to situations in which a woman nearly dies from severe complications during pregnancy, childbirth, or shortly after delivery, but survives due to critical medical care. Studying these cases helps health systems evaluate the quality of emergency obstetric care. In this study, we analyzed maternal near-miss cases recorded across a multi-center network of hospitals affiliated with Mashhad University of Medical Sciences over a five-year period (2020 to 2024) to understand changes over time and identify leading causes of severe maternal complications. We described how the number of cases changed over time, what the main causes were, and how cases were distributed by maternal age and by month of the year. We also examined the impact of COVID-19 during the study period. We found that maternal near miss cases increased over the study period, with the highest number recorded in 2024. The most common causes were obstetric hemorrhage, hypertensive disorders of pregnancy (high blood pressure disorders), underlying medical diseases, and COVID-19, especially in the earlier years of the study. Most cases occurred in women aged 19 to 35 years. When we looked at the timing of cases by month, we observed a relatively higher number of cases in autumn; because this was a descriptive finding, it should be interpreted with caution and not as proof of a seasonal pattern. These findings show that serious pregnancy complications remain an important challenge and that better prevention, early diagnosis, and timely treatment are needed. They also highlight the importance of continued monitoring of maternal health, especially in referral hospitals that care for high-risk pregnancies.