{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,12]],"date-time":"2026-06-12T17:59:33Z","timestamp":1781287173171,"version":"3.54.1"},"reference-count":41,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2026,6,12]],"date-time":"2026-06-12T00:00:00Z","timestamp":1781222400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Jiangsu Provincial Key Discipline of Maternal and Child Health","award":["SFY3-JS2021"],"award-info":[{"award-number":["SFY3-JS2021"]}]},{"name":"Wuxi Maternal and Child Health Care Hospital's 'Three Names' Strategy and 'Elite Talent Program'","award":["LJ2023003"],"award-info":[{"award-number":["LJ2023003"]}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Severe maternal morbidity (SMM) is a significant public health concern. This study analyzed the incidence, trends, causes, and pregnancy outcomes of SMM in Wuxi to inform future clinical and public health strategies.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A retrospective analysis was conducted on 315 critical maternal cases identified from 156,435 deliveries in Wuxi between October 1, 2020, and September 30, 2024. Data were extracted from a citywide near-miss maternal surveillance system. Statistical analyses were performed using SPSS 25.0, employing chi-square tests and Cochran-Armitage trend tests to evaluate trends, and chi-square tests for comparisons between groups.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The overall incidence of SMM was 0.20%. Initially, this rate remained stable at 0.19% across the first three cycles (P\u2009&gt;\u20090.05); however, it significantly increased to 0.24% during the cycle from October 2023 to September 2024 (\u03c7\u00b2\u2009=\u20095.24, P\u2009=\u20090.02). This increase was closely associated with a rise in the proportion of women of advanced maternal age (\u226535 years), which reached 26.03% (\u03c7\u00b2\u2009=\u200911.76, P\u2009=\u20090.001). Over time, the distribution of risk levels shifted. Initially, the high-risk group was dominant (63.29%), but in recent cycles, the moderate-risk group became more prominent (64.44%). The moderate-risk group was associated with a higher rate of adverse outcomes (25.00\u201325.71%) compared to the high-risk group (17.11\u201320.69%; \u03c7\u00b2\u2009=\u200910.83, P\u2009=\u20090.01). Direct obstetric factors were the primary causes, accounting for 79.05% of cases, with obstetric hemorrhage being the most prevalent (53.97%). In contrast, the proportion of cases attributable to indirect obstetric factors increased from 17.81% to 26.67%, primarily due to heart disease and infectious diseases.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Improving maternal safety involves dynamic risk assessments, tiered referrals for moderate-risk pregnancies, better multidisciplinary management of complications, optimized emergency responses in primary care, and refined regional referral systems to reduce preventable SMM and mortality.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0351670","type":"journal-article","created":{"date-parts":[[2026,6,12]],"date-time":"2026-06-12T17:47:58Z","timestamp":1781286478000},"page":"e0351670","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Dynamic analysis of critical maternal complications in tertiary hospitals in Wuxi: A study based on four years of monitoring data"],"prefix":"10.1371","volume":"21","author":[{"given":"Ye","family":"Xu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peimin","family":"Hua","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0511-4125","authenticated-orcid":true,"given":"Ye","family":"Shen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,6,12]]},"reference":[{"key":"pone.0351670.ref001","volume-title":"WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division Trends in Maternal Mortality: 1990 to 2015","author":"J Bongaarts","year":"2016"},{"key":"pone.0351670.ref002","volume-title":"Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA\/Population Division","author":"Organization WH","year":"2023"},{"issue":"5","key":"pone.0351670.ref003","doi-asserted-by":"crossref","first-page":"791","DOI":"10.1097\/AOG.0000000000004362","article-title":"Racial and Ethnic Disparities in Death Associated With Severe Maternal Morbidity in the United States: Failure to Rescue","volume":"137","author":"J Guglielminotti","year":"2021","journal-title":"Obstet Gynecol"},{"issue":"3","key":"pone.0351670.ref004","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1097\/AOG.0000000000001556","article-title":"Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues","volume":"128","author":"MF MacDorman","year":"2016","journal-title":"Obstet Gynecol"},{"issue":"11","key":"pone.0351670.ref005","doi-asserted-by":"crossref","DOI":"10.1016\/S2214-109X(24)00322-X","article-title":"The lifetime risk of maternal near miss morbidity in Asia, Africa, the Middle East, and Latin America: a cross-country systematic analysis","volume":"12","author":"U Gazeley","year":"2024","journal-title":"Lancet Glob Health"},{"issue":"9","key":"pone.0351670.ref006","doi-asserted-by":"crossref","first-page":"1890","DOI":"10.1093\/aje\/kwab077","article-title":"Severe Maternal Morbidity: A Comparison of Definitions and Data Sources","volume":"190","author":"JM Snowden","year":"2021","journal-title":"Am J Epidemiol"},{"issue":"3","key":"pone.0351670.ref007","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1016\/j.bpobgyn.2009.01.007","article-title":"Maternal near miss--towards a standard tool for monitoring quality of maternal health care","volume":"23","author":"WHO working group on Maternal Mortality and Morbidity classifications","year":"2009","journal-title":"Best Pract Res Clin Obstet Gynaecol"},{"issue":"4","key":"pone.0351670.ref008","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0061248","article-title":"Applicability of the WHO maternal near miss criteria in a low-resource setting","volume":"8","author":"E Nelissen","year":"2013","journal-title":"PLoS One"},{"issue":"8","key":"pone.0351670.ref009","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0044129","article-title":"The WHO maternal near-miss approach and the maternal severity index model (MSI): tools for assessing the management of severe maternal morbidity","volume":"7","author":"JP Souza","year":"2012","journal-title":"PLoS One"},{"issue":"10","key":"pone.0351670.ref010","doi-asserted-by":"crossref","DOI":"10.2471\/BLT.21.285945","article-title":"Maternal mortality: near-miss events in middle-income countries, a systematic review","volume":"99","author":"A Heitkamp","year":"2021","journal-title":"Bull World Health Organ"},{"key":"pone.0351670.ref011","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1186\/s12978-018-0527-2","article-title":"A global view of severe maternal morbidity: moving beyond maternal mortality","volume":"15","author":"SE Geller","year":"2018","journal-title":"Reprod Health"},{"issue":"2","key":"pone.0351670.ref012","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1016\/j.ijgo.2014.08.023","article-title":"Severe maternal morbidity and near miss due to postpartum hemorrhage in a national multicenter surveillance study","volume":"128","author":"EA Rocha Filho","year":"2015","journal-title":"Int J Gynaecol Obstet"},{"key":"pone.0351670.ref013","article-title":"The WHO maternal near-miss approach and the maternal severity index model (MSI): tools for assessing the management of severe maternal morbidity","author":"JP Souza","year":"2012"},{"issue":"1","key":"pone.0351670.ref014","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1590\/1806-93042018000100002","article-title":"Concepts, prevalence and characteristics of severe maternal morbidity and near miss in Brazil: a systematic review","volume":"18","author":"JMdPd Silva","year":"2018","journal-title":"Rev Bras Saude Mater Infant"},{"issue":"12","key":"pone.0351670.ref015","doi-asserted-by":"crossref","first-page":"2904","DOI":"10.1111\/jan.13791","article-title":"Improving quality of care for perinatal and newborn care at district and subdistrict hospitals in Haryana, India: Implementation research protocol","volume":"74","author":"MK Das","year":"2018","journal-title":"J Adv Nurs"},{"issue":"2","key":"pone.0351670.ref016","doi-asserted-by":"crossref","first-page":"021008","DOI":"10.7189\/jogh.10.0201008","article-title":"Statewide implementation of a quality improvement initiative for reproductive, maternal, newborn and child health and nutritionin Bihar, India","volume":"10","author":"AA Creanga","year":"2020","journal-title":"J Glob Health"},{"issue":"1","key":"pone.0351670.ref017","doi-asserted-by":"crossref","first-page":"1021","DOI":"10.1186\/s12891-024-08122-5","article-title":"Global, regional and national burden of osteoarthritis in 1990-2021: a systematic analysis of the global burden of disease study 2021","volume":"25","author":"Z Wang","year":"2024","journal-title":"BMC Musculoskelet Disord"},{"issue":"1","key":"pone.0351670.ref018","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1186\/s12939-021-01485-4","article-title":"Hukou-based rural-urban disparities in maternal health service utilization and delivery modes in two Chinese cities in Guangdong Province","volume":"20","author":"M Shen","year":"2021","journal-title":"Int J Equity Health"},{"issue":"1","key":"pone.0351670.ref019","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1186\/s12912-022-01071-1","article-title":"Near-miss organizational learning in nursing within a tertiary hospital: a mixed methods study","volume":"21","author":"T Feng","year":"2022","journal-title":"BMC Nurs"},{"key":"pone.0351670.ref020","doi-asserted-by":"crossref","first-page":"405","DOI":"10.2147\/CLEP.S243414","article-title":"Low Incidence of Maternal Near-Miss in Zhejiang, a Developed Chinese Province: A Cross-Sectional Study Using the WHO Approach","volume":"12","author":"Y Ma","year":"2020","journal-title":"Clin Epidemiol"},{"issue":"4","key":"pone.0351670.ref021","doi-asserted-by":"crossref","DOI":"10.1002\/hsr2.407","article-title":"A retrospective study of maternal near miss in the Critical Maternal Care Center in Suqian City, Jiangsu Province, China: A single-center study","volume":"4","author":"S Zhang","year":"2021","journal-title":"Health Sci Rep"},{"issue":"1","key":"pone.0351670.ref022","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1186\/s12913-022-07721-z","article-title":"Risk management of pregnant women and the associated low maternal mortality from 2008-2017 in China: a national longitude study","volume":"22","author":"J Liu","year":"2022","journal-title":"BMC Health Serv Res"},{"issue":"3","key":"pone.0351670.ref023","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0121029","article-title":"Prevalence of gestational diabetes mellitus and its risk factors in Chinese pregnant women: a prospective population-based study in Tianjin, China","volume":"10","author":"J Leng","year":"2015","journal-title":"PLoS One"},{"issue":"10","key":"pone.0351670.ref024","doi-asserted-by":"crossref","first-page":"734","DOI":"10.2471\/BLT.09.071001","article-title":"WHO maternal death and near-miss classifications","volume":"87","author":"WHO Working Group on Maternal Mortality and Morbidity Classifications","year":"2009","journal-title":"Bull World Health Organ"},{"issue":"10","key":"pone.0351670.ref025","article-title":"Advanced maternal age and adverse pregnancy outcomes: A systematic review and meta-analysis","volume":"12","author":"SC Lean","year":"2017","journal-title":"PLoS One"},{"issue":"6","key":"pone.0351670.ref026","doi-asserted-by":"crossref","first-page":"710","DOI":"10.1136\/heart.85.6.710","article-title":"Heart disease and pregnancy","volume":"85","author":"SC Siu","year":"2001","journal-title":"Heart"},{"issue":"2","key":"pone.0351670.ref027","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1016\/S0301-2115(95)02582-0","article-title":"Serial changes in cardiac output during normal pregnancy: a Doppler ultrasound study","volume":"70","author":"TG Hennessy","year":"1996","journal-title":"Eur J Obstet Gynecol Reprod Biol"},{"key":"pone.0351670.ref028","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1016\/j.ijoa.2019.05.010","article-title":"Epidemiology of obstetric critical illness","volume":"40","author":"S Einav","year":"2019","journal-title":"Int J Obstet Anesth"},{"issue":"1","key":"pone.0351670.ref029","first-page":"54","article-title":"Reducing avoidable maternal deaths in China","volume":"36","author":"X Liu","year":"2020","journal-title":"Chin J Pract Gynecol Obstet"},{"issue":"1","key":"pone.0351670.ref030","doi-asserted-by":"crossref","first-page":"3466","DOI":"10.1186\/s12889-024-20989-6","article-title":"Pregnancy complications associated with maternal near-miss in an undeveloped province in south-central China, 2012\u20132022","volume":"24","author":"X Zhou","year":"2024","journal-title":"BMC Public Health"},{"key":"pone.0351670.ref031","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1111\/1471-0528.15623","article-title":"Non-obstetric causes of severe maternal complications: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey","volume":"126","author":"AS Adeniran","year":"2019","journal-title":"BJOG"},{"issue":"5","key":"pone.0351670.ref032","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1056\/NEJMoa1404595","article-title":"Less-tight versus tight control of hypertension in pregnancy","volume":"372","author":"LA Magee","year":"2015","journal-title":"N Engl J Med"},{"issue":"1","key":"pone.0351670.ref033","doi-asserted-by":"crossref","first-page":"844","DOI":"10.1186\/s12884-021-04312-4","article-title":"Correction to: Women with maternal near-miss in the intensive care unit in Yangzhou, China: a 5-year retrospective study","volume":"21","author":"Y Chen","year":"2021","journal-title":"BMC Pregnancy Childbirth"},{"issue":"01","key":"pone.0351670.ref034","first-page":"7","article-title":"Guidelines for pre-pregnancy and pregnancy health care","volume":"53","author":"H Qi","year":"2018","journal-title":"Chinese Journal of Obstetrics and Gynecology"},{"issue":"16","key":"pone.0351670.ref035","doi-asserted-by":"crossref","first-page":"1529","DOI":"10.1056\/NEJMcp1709324","article-title":"Placenta Accreta Spectrum","volume":"378","author":"RM Silver","year":"2018","journal-title":"N Engl J Med"},{"issue":"12","key":"pone.0351670.ref036","doi-asserted-by":"crossref","first-page":"940","DOI":"10.4103\/ija.IJA_537_18","article-title":"Obstetric admissions to tertiary level intensive care unit - Prevalence, clinical characteristics and outcomes","volume":"62","author":"CM Joseph","year":"2018","journal-title":"Indian J Anaesth"},{"issue":"2","key":"pone.0351670.ref037","article-title":"Sofa scoring tool for prediction of outcome in obstetric ICU at a tertiary care centre","author":"N Anand","year":"2020","journal-title":"Siddharth Health Research and Social Welfare Society"},{"issue":"9","key":"pone.0351670.ref038","doi-asserted-by":"crossref","first-page":"947","DOI":"10.1515\/jpm-2019-0125","article-title":"Characteristics of obstetric admissions to intensive care unit: APACHE II, SOFA and the Glasgow Coma Scale","volume":"47","author":"E Fadiloglu","year":"2019","journal-title":"J Perinat Med"},{"key":"pone.0351670.ref039","doi-asserted-by":"crossref","first-page":"1126807","DOI":"10.3389\/fmed.2023.1126807","article-title":"Maternal sepsis in pregnancy and the puerperal periods: a cross-sectional study","volume":"10","author":"P Liu","year":"2023","journal-title":"Front Med (Lausanne)"},{"issue":"9","key":"pone.0351670.ref040","doi-asserted-by":"crossref","first-page":"947","DOI":"10.1515\/jpm-2019-0125","article-title":"Characteristics of obstetric admissions to intensive care unit: APACHE II, SOFA and the Glasgow Coma Scale","volume":"47","author":"E Fadiloglu","year":"2019","journal-title":"J Perinat Med"},{"issue":"3","key":"pone.0351670.ref041","doi-asserted-by":"crossref","first-page":"581","DOI":"10.1213\/ANE.0000000000005578","article-title":"Maternal Intensive Care Unit Admission as an Indicator of Severe Acute Maternal Morbidity: A Population-Based Study","volume":"134","author":"C Godeberge","year":"2022","journal-title":"Anesth Analg"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0351670","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,12]],"date-time":"2026-06-12T17:48:08Z","timestamp":1781286488000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0351670"}},"subtitle":[],"editor":[{"given":"Jingrui","family":"Huang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,6,12]]},"references-count":41,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6,12]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0351670","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,12]]}}}