Unravelling the trajectory of a maternal near miss - Need of tying the loose ends: A case report.

This case report examines a maternal near-miss incident case of severe anaemia attributed to health system failures. It highlights the importance of robust health systems in ensuring safe motherhood. A 28-year-old pregnant woman from a tribal community who had availed of multiple antenatal consultations at different community platforms was diagnosed with severe anaemia. The case was appropriately referred to the higher health facility for the management of severe anaemia. However, the non-existence of a formal referral system, the poor linkage between community platforms and referral centres and the lack of awareness led to delayed treatment at the tertiary level. This case report emphasises the need for improved linkage between community platforms and specialised hospitals and timely medical intervention in the healthcare system to avoid preventable delays.