OBJECTIVES Maternal near-miss audits were initially introduced to evaluate the quality of obstetric care at the time of the event. One of the principle advantages of studying near-misses is that these women are able to adequately report the obstacles and delays they face to assure their continued survival. The primary objective of the study was to compare the long-term health of women who suffered a serious acute morbidity event in pregnancy to a control group of low risk women who have had a normal pregnancy outcome. We wanted to determine whether the insult associated with maternal near-misses makes women more vulnerable to further organ dysfunction. The secondary aim was to determine the spectrum of morbidity in the Pretoria Academic Complex (PAC) and the barriers to obstetric care. METHODS AND MATERIALS This study consists of 6 sub-studies to address the research problem. The first study investigated the epidemiology of the spectrum of morbidity in the PAC. Delivery data related to demographic and reproductive characteristics, pregnancy and childbirth complications were collected on a daily basis from hospitals in the PAC: Steve Biko Academic Hospital, Kalafong Provincial Tertiary Hospital, Tshwane District Hospital, Pretoria West and Mamelodi Hospitals and from Stanza Bopape and Eersterust Midwife Obstetric Units. Daily audit meetings were held at the 2 tertiary hospitals to identify women with potentially life-threatening conditions. We further investigated the delays/barriers in providing obstetric care to women who were classified as a maternal near miss. The “three delays model” was used to identify the phases of delay in the health system. Three studies investigated the long-term complications in women with severe pre-eclampsia in pregnancy. Magnetic resonance imaging, echocardiography, and digital photos of the eye were taken at delivery and 1-year post-partum. In the last study, we compared the quality of life of women classified as a maternal near miss to a group of women with an uncomplicated low-risk pregnancy using the World Health Organisation Quality of Life questionnaire. RESULTS About one in 20 pregnant women in the PAC had a potentially life-threatening condition and 0.5% a life-threatening condition in pregnancy. One or more factors causing a delay in accessing care were identified in 83% of near-miss cases. Near miss women have a poorer quality of life 1-year after delivery than women with uncomplicated pregnancies. Severe pre-eclampsia in pregnancy was found to have the following long-term effects on maternal health: ? Cerebral white matter lesions were demonstrated in 48% of women with severe pre-eclampsia at 1 year postpartum ? Women with early onset pre-eclampsia requiring delivery prior to 34 weeks had an increased risk of cardiac diastolic dysfunction ? Retinal artery and venular calibers in women with pre-eclampsia are smaller than those of normotensive women at 1-year postpartum CONCLUSION Women who experience a severe acute morbidity event in pregnancy must be recognised as a vulnerable group who are require increased postpartum care and surveillance. Ideally all tertiary centres should have near-miss clinics for postpartum care. Any risk factors for future disease should be identified and modified to promote long-term health.