This study showed that cases of maternal near-miss are 24 times more frequent than maternal death, occurring at a ratio of 21.1/1000LB, coinciding with the number from the 2006 National Household Survey, using five criteria to identify maternal morbidity in Brazil . This intervention project also showed that the analysis of unsuccessful perinatal events (near miss, maternal death, and perinatal death) is possible when local and regional surveillance committees' routine is integrated with research initiatives.
Studying these cases was an opportunity to review the wide spectrum of clinical conditions that threaten the life of a pregnant woman, and provided additional data for the members of the municipal and regional committees. Their participation was essential to build capacity on clinical thinking causality and preventability of morbidity and mortality of these unsuccessful perinatal events, with the perspective of health managers at system and hospital level, as reported previously .
The importance of the quality of clinical care was emphasized, including adhesion to clinical protocols, particularly when dealing with hypertensive complications. The widest scope of interventions arose from the analysis of near-miss cases and the total score reflected the potential greater impact of including the revision of near miss cases.
The prevalence of NM identified was greater than expected when criteria only based on organ function are applied, but it is in agreement with the World Health Organization (WHO)'s systematic review (0.01-2.99%) using criteria of case management, and with other systematic reviews [29–31], but lower than in Bolivia (5% or 50.1/10,000) where clinical and management criteria were applied .
The implementation of any intervention and its reevaluation through another process of data collection closes the so-called auditing cycle. There is evidence from systematic reviews of the effectiveness of auditing interventions, particularly when current adhesion to the recommended practices is inadequate . The need to standardize management and to follow protocols was the most frequent recommendation in the discussions of cases by the committees.
The finding that hypertension in pregnancy was the main complication responsible for the adverse perinatal events is in agreement with the WHO systematic review on maternal death in Latin America and a study from Bolivia, but differs from Africa and Asia where hemorrhage is more prevalent. Hypertension was also the single most common cause in developed countries (16.1%), behind all the direct causes together, and ahead of embolia and hemorrhages [31, 32]. This profile shows that the pattern of perinatal morbidity in the Campinas region is similar to developed countries; therefore, strategies and interventions need to be adapted. Adding surveillance of near-miss cases to qualify the system of confidential enquiry and auditing is an important step in this direction.
The finding that 48% of patients were referred from other municipalities as well as from the supplementary health system reflects the need to organize perinatal care regionally, involving public and private healthcare managers, maternity hospitals and staff. To reach this widely encompassing involvement is an enormous challenge. Some professional institutions, and various instances of the National Health System are important catalyzing elements in the process and their involvement must be assured. Among the important elements there are management commissions between hospitals and the Municipal Department of Health, maternity clinical directors, the bipartite committee of the Regional Health Directorate (municipal and state representatives), the State Association of Specialists in Gynecology and Obstetrics, and the Regional Medical Council. This need for a more participative involvement to reduce maternal mortality, particularly from the professional associations, has been emphasized previously by other authors .
One of the difficulties in investigating maternal deaths in Brazil is gaining visibility for the results of the work and, consequently, credibility for the intervention proposals, making their implementation feasible first hand. The current surveillance system has been unable to mobilize health system managers and healthcare professionals working in perinatology as expected. The experience gained in carrying out this study served as training for the members of the committees in the auditing process and motivated them towards carrying out a more purposeful investigation that included many hours of discussion in addition to their regular activities, as observed in other places .
Nevertheless, maintaining a near-miss surveillance system must not be dependent on the motivation of this group of technical staff . It has to depend on the political commitment of the managers and staff of the institutions and on the health system to provide support for revising the events, implementing and evaluating the healing interventions, thereby ensuring full auditing process within the routine clinical activities. The close collaboration between the university and the health services in carrying out this project was essential to ensure its acceptance in the maternity hospitals. The challenge to maintain the involvement of these entities include ample participation on the interventions proposed, many of which including workshops on evidence-based clinical protocols.
There is no widely spread tradition of involving professional medical associations in these qualification processes except through scientific events. This multi-institutional involvement is one of the factors associated with the success of any maternal healthcare qualification proposal . In the United Kingdom, the participation of obstetricians in auditing procedures is a prerequisite of the professional association itself . Collaboration between universities and services may work towards motivating the necessary change.
Interventions that qualify healthcare during delivery and childbirth have been found to be effective, as confirmed by auditing procedures with long-term reevaluation. Mercer et al.  in Northern India, trained teams to use oxytocin and ergometrine to prevent hemorrhage in the third stage of labor, and to introduce partographs to accelerate the decision-making process to transfer cases for Caesarean section during intrapartum care, which in the 7th year of audit had reduced postpartum hemorrhages by 50% and led to more rational decision-making with respect to transfer during labor.
As seen from our data, no delay was incurred in almost 60% of cases. In the remaining cases, the most common finding was a delay in receiving adequate care, often because a particular protocol had not been adopted by that institution. From 2003-5 in United Kingdom, delayed care was recognized as a relevant factor among 17% of women, but substandard care could be pointed in 64% of maternal deaths due to direct causes and 40% due to indirect causes . Similar rates were found for severe maternal morbidity in the Netherlands . Since there is no further information on the criteria used for classification, the rates published may well include less than adequate care, which may not be directly responsible for the near miss or death, as highlighted by Scottish classification . Anyway, this confirms the need to discuss and implement good clinical practice protocols as the most effective measure with the greatest potential impact. Management of hypertensive complications and puerperal hemorrhages emerged as the top clinical conditions priorities for the region.
In this study, the members of the committees had to review the suggestions for improvement in each individual case and the potential impact of these suggestions in reducing the occurrence of a similar adverse event. The exercise of thinking about the causal pathway for the unsuccessful event as a separate exercise from identifying the aspects of substandard care motivated the learning process of the group. This process also contributed towards emphasizing the importance of the knowledge and the publication of the recommendations based on scientifically-based protocols, such as the Manuals for Care during Delivery, Abortion and the Puerperium  and the Ministry of Health's Obstetrical Urgencies and Emergencies Manual , used as reference for this project. The need to incorporate scientific evidence into the audit procedures and to use clinical protocols and training programs to improve the quality of obstetrical care, as experience by the group, has been mentioned before by other authors [39, 40].
This study involved the intensive surveillance of cases in the institutions over a short period of time, and was made possible with supplementary financial support for the data collection teams, and unpaid extra-hour contribution of the members of the committees. Without abandoning the confidential enquiry into all maternal deaths, we suggest the evaluation of near-miss as a sentinel event in perinatal health in a cross-sectional study design, for a short, intensive period of 1-3 months, putting municipal and regional committees together to discuss interventions expected to improve perinatal care. The impact of this program has to undergo reevaluation with the support and articulation of the participating institutions, including the university, and professional organizations.