Determinants of Maternal Near‐Miss in Bahir Dar City Administration, Northwest Ethiopia: Mediation Analysis Using Karlson–Holm–Breen Method

Abstract

ABSTRACT Introduction Maternal near‐miss is a major public health problem, particularly in underdeveloped countries like Ethiopia. However, little is known about how determinants influence maternal near‐miss through mediators in the Ethiopian context. Objectives To identify determinants and their direct and indirect effects on maternal near‐miss among pregnant women in Bahir Dar City, Northwest Ethiopia. Methods A nested case‐control study was conducted among women in Bahir Dar City, Northwest Ethiopia, from 1 May 2023 through 6 March 2024. The study included 165 cases and 658 controls. Data were collected using structured checklists and interview questionnaires. Binary logistic regression was used to identify determinants, and the Karlson–Holm–Breen approach was used for mediation analysis in Stata 17.0. Results Determinants of maternal near‐miss included rural residence (AOR = 2.14, 95% CI: 1.27–3.61), third party decision (AOR = 4.73, 95% CI: 2.30–9.73), genital mutilation (AOR = 3.32, 95% CI: 1.79–6.13), caesarean history (AOR = 4.85, 95% CI: 2.43–9.67), late antenatal care booking (AOR = 2.10, 95% CI: 1.28–3.44), undernutrition (AOR = 3.51, 95% CI: 1.74–7.07), anaemia (AOR = 4.31, 95% CI: 2.55–7.28), hypertension (AOR = 4.43, 95% CI: 2.56–7.69), first delay (AOR = 4.29, 95% CI: 2.99–6.34) and distance (AOR = 6.25, 95% CI: 4.28–9.12). In mediation analysis, 19.1% of the effect of residence was mediated by distance, 7.5% of the effect of distance was mediated by a third‐party decision, 17.4% of decision‐making power was mediated by first delay, 8.4% of antenatal booking time was mediated by first delay, and 34.5% of genital mutilation was mediated by prior caesarean section. Conclusion Easily identifiable factors determined maternal near‐miss. Some factors had direct and indirect effects via mediators, while others had only direct effects. Early identification of these factors during antenatal visits is crucial for prevention.