Study protocol: a mixed-methods study of the implementation of doula care to address racial health equity in six state Medicaid programs.

BACKGROUND: Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity. METHODS: We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes. DISCUSSION: Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity. Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).

Diversity, Equity, and Inclusion: Obstetrics and Gynecologist Hospitalists' Impact on Maternal Mortality.

Obstetrics and gynecology hospitalists play a vital role in reducing maternal morbidity and mortality by providing immediate access to obstetric care, especially in emergencies. Their presence in hospitals ensures timely interventions and expert management, contributing to better outcomes for mothers and babies. This proactive approach can extend beyond hospital walls through education, advocacy, and community outreach initiatives aimed at improving maternal health across diverse settings.

Recent Amendment in the Medical Termination of Pregnancy Act in India: Empowering Women's Health.

SUMMARY: In 1971, the Medical Termination of Pregnancy (MTP) Act was implemented to deal with unsafe abortions, fetal complications, and maternal mortality. In India, it is estimated that more than half of all abortions are unsafe leading to infection, hemorrhages, injury to internal organs, and sometimes maternal death. To address these issues, the MTP Act was amended in 2021 to promote uniformity, accessibility, availability, affordability, and quality of MTP services with appropriate management in case of any adverse event.

Can Obstetrics and Gynecology Hospitalists Reduce Severe Maternal Morbidity?

Maternal mortality in the United States has risen steadily over the past 20 years. Several interventions including maternal mortality committees and safety bundles have been introduced to decrease the trend. Severe maternal morbidity is a more frequent occurrence related to maternal mortality and can be used to track interventions. Within safety bundles, the presence of well-trained on-site staff such as obstetrics and gynecology (OB/GYN) hospitalists is key to correct implementation. In this article, the authors review the role of OB/GYN hospitalists in specific diagnoses and the evidence present to date on OB/GYN hospitalists' role in decreasing severe maternal morbidity.

Mortalidade materna por causas obstétricas diretas: revisão rápida de guias de prática clínica / Maternal mortality from direct obstetric causes: rapid review of clinical practice guidelines

Esta revisão rápida apresenta as recomendações de 18 guias de prática clínica, relativas ao diagnóstico, prevenção e manejo das seguintes causas obstétricas diretas de mortalidade materna: abortamento, gravidez ectópica, hemorragia puerperal, hipertensão arterial, infecção puerperal e tromboembolismo venoso.

This rapid review presents the recommendations of 18 clinical practice guidelines, relating to the diagnosis, prevention and management of the following direct obstetric causes of maternal mortality: abortion, ectopic pregnancy, puerperal hemorrhage, arterial hypertension, puerperal infection and venous thromboembolism.

Fetomaternal Outcome in Antepartum Hemorrhage After 34 Weeks of Gestation.

BACKGROUND: Antepartum hemorrhage is defined as any bleeding from or into the genital tract during pregnancy, after the period of viability until delivery of the fetus. APH complicates 2-5% of pregnancies and is a primary cause of perinatal and maternal mortality globally. Aim of this study is to evaluate maternal and perinatal outcome in patients with APH at a tertiary care hospital. METHODS: The present study was a cross sectional study conducted in Obstetrics and Gynaecology department of Paropakar Maternity and Women's Hospital, during a period of 5 months from December 2022 to April 2023. 50 cases of APH were enrolled with gestational age ≥ 34 weeks of gestation. RESULTS: Incidence of APH after 34 weeks of gestation was 0.51%. The most common type of APH was abruption placenta (44%) followed by placenta previa (32%) and undetermined (24%). The age range of 26 to 30 years old accounted for the highest number of APH patients i.e., 21(42%). In placenta previa, 75% and in abruption placenta 63.64% were multigravida. APH was presented mostly between 37-40 weeks. Around 26% of the patients had anemia at the time of admission. Most common mode of delivery was cesarean section (82%). Most common maternal complications were PPH (40%), blood transfusion (28%), DIC (4%), cesarean hysterectomy (4%). Low birth weight and preterm were the most common causes of fetal complications. Maternal mortality was 2% and perinatal mortality was 18% overall. CONCLUSIONS: APH is primary cause of maternal and perinatal morbidity and mortality. In our study, an abruption placenta was the most frequent cause of APH. Cesarean section was the most commonly used mode of delivery. PPH with blood transfusion was the most prevalent maternal complication, while fetal complications included low birth weight and preterm..

A Critical Analysis of Safe Abortion Road Map in Nepal.

BACKGROUND: Abortion was legalized by the 2002 Muluki Ain to combat the surging rates of maternal mortality and morbidity. By 2021, the Maternal Mortality Rate plummeted to 151 from 539 in 1996. The decline in the abortion-related maternal mortality attributes to the implication of progressive abortion policies that includes expanded safe abortion services introduction of medical abortion, constitutional recognition of abortion, the mandates by Safe Motherhood and Reproductive Health Rights Act, and free-of-cost abortion services in government health facilities. This review study delves into exploring the contemporary abortion policies and its implications on women's access to safe abortion services as well as the factors that affect the access. METHODS: This study incorporates findings from extensive desk review of abortion services in Nepal. RESULTS: The 2021 safe abortion services Program Implementation Guideline aims to expand safe abortion sites; however, the Nepal's challenging geography ensues its inequitable distribution, especially in mountainous area. Policy provisions on information and financial accessibility to abortion are well navigated by the Safe Motherhood and Reproductive Health Rights Act and regulation but consistent to sporadic gaps in its implementation were comprehended in this study. This paper further discussed the Safe Motherhood and Reproductive Health Rights Act's regressive mandate of 28-week gestational limit at any condition and the role of gender in abortion decision-making under the pretext of factors influencing safe abortion services. CONCLUSIONS: The review study recommends strategies: improving capacity for abortion services under federalism, combating stigma, improving the private sector's readiness, and building a resilient health system.

Cost of mate choice: Changing patterns of global age disparity in marriage and their consequences to women's health including maternal mortality and menopause.

BACKGROUND: Consistent across cultures and throughout time is the male preference for younger females. Given its prevalence, the mate choice theory proposes that age-disparate relationships may have contributed to the evolution of maternal mortality and menopause. OBJECTIVES: The objective is to document evidence for age disparity in marriage from past and present populations and evaluate their relevance to maternal mortality and menopause. DESIGN: Cross-sectional data were collected from various regions and time points, ranging from the Roman era to the current decade. METHODS: To analyze both the age disparity in marriage and age at marriage, data were collected from Ancestry.ca for Quebec, Massachusetts, India, South Africa, and England and Wales. Additional data were taken from the United Nations as a more recent and comprehensive source. To analyze the relationships between age disparity in marriage and different social factors, data on gross domestic product, maternal mortality rates, fertility, primary school enrollment, child marriage rates, and percentage of women in the total labor force were collected from the World Health Organization, World Bank, and United Nations International Children's Emergency Fund. RESULTS: The results showed that males were significantly older than females at first marriage in all populations and time frames sampled, supporting the assumption underlying the mate choice theory. Maternal mortality rates were strongly associated with age-disparate relationships, increasing by 275 per 100,000 live births for each additional year in the age disparity. CONCLUSION: The results from this study provide support for the assumption underlying the mate choice theory of maternal mortality and menopause.

Changing patterns of global age disparity in marriage provide support for the mate choice theory of menopause, raising the possibility of a gradual shift in delayed reproduction and delayed menopause. Living things have inherent capacity to survive and reproduce until they die, with one exception: humans. Women go through menopause while men remain fertile. Among the many explanations offered for the origin of menopause, grandmother hypothesis is the leading one. Being too old to reproduce, it is argued, grandmothers stop reproducing and make up for the loss of fitness through helping (grand mothering) their grand offspring. There are two problems with this theory: first, grand mothering and menopause need not be connected, and second, grandmothers cannot be simultaneously too old to reproduce and not too old to be able to gather resources to make up for their loss of fitness. We proposed a mate choice theory of menopause which posits that human mating system is non-random, that is, males have preference for younger females, depriving older females from reproduction and allowing deleterious fertility mutations to accumulate giving rise to menopause. Male preference for younger females is consistent across cultures and dominates all social relations affecting mate choice including monogamy, serial monogamy, widowers remarrying, polygamy, harem, and others. In this study, we wanted to test if male preference for younger females has been widespread through time. We collected data on age disparity in marriage from past and present populations, from Roman era to the current decade, and evaluated their relevance to the origin of maternal mortality and menopause. The results showed that males were significantly older than females at first marriage in all populations and time frames sampled, supporting the assumption underlying the mate choice theory of menopause. Maternal mortality rates were strongly associated with age­disparate relationships, increasing by 275 per 100,000 live births for each additional year in the age disparity. Through repeated cycles of widowers marring younger women, maternal mortality would have functioned as a reinforcer of the origin of menopause.

Delivery and postnatal care among women in 71 low- and middle-income countries: analyzing coverage gaps using household surveys.

BACKGROUND: High levels of maternal morbidity and mortality persist in low- and middle-income countries, despite increases in coverage of facility delivery and skilled assistance at delivery. We compared levels of facility birth to a summary delivery care measure and quantified gaps. METHODS: We approximated a delivery care score from type of delivery (home, lower-level facility, or hospital), skilled attendant at delivery, a stay of 24-or-more-hours after delivery, and a health check within 48-h after delivery. Data were obtained from 333,316 women aged 15-49 who had a live birth in the previous 2 years, and from 71 countries with nationally representative surveys between 2013 and 2020. We computed facility delivery and delivery care coverage estimates to assess the gap. We stratified the analysis by country characteristics, including the national maternal mortality ratio (MMR), to assess the size of coverage gaps, and we assessed missed opportunities through coverage cascades. We looked at the association between MMR and delivery care coverage. RESULTS: Delivery care coverage varied by country, ranging from 24% in Sudan to 100% in Cuba. Median coverage was 70% with an interquartile range of 30 percentage points (55% and 85%). The cascade showed that while 76% of women delivered in a facility, only 41% received all four interventions. Coverage gaps exist across all MMR levels. Gaps between highest and lowest wealth quintiles were greatest in countries with MMR levels of 100 or higher, and the gap narrowed in countries with MMR levels below 100. The delivery care indicator had a negative association with MMR. CONCLUSIONS: In addition to providing high-quality evidenced-based care to women during birth and the postpartum period, there is also a need to address gaps in delivery care, which occur within and between countries, wealth quintiles, and MMR phases.

Structural barriers to maternity care in Cameroon: a qualitative study.

BACKGROUND: The maternal mortality and perinatal mortality rate in Cameroon are among the highest worldwide. To improve these outcomes, we conducted a formative qualitative assessment to inform the adaptation of a mobile provider-to-provider intervention in Cameroon. We explored the complex interplay of structural barriers on maternity care in this low-resourced nation. The study aimed to identify structural barriers to maternal care during the early adaptation of the mobile Medical Information Service via Telephone (mMIST) program in Cameroon. METHODS: We conducted in-depth interviews and focus groups with 56 key stakeholders including previously and currently pregnant women, primary healthcare providers, administrators, and representatives of the Ministry of Health, recruited by purposive sampling. Thematic coding and analysis via modified grounded theory approach were conducted using NVivo12 software. RESULTS: Three main structural barriers emerged: (1) civil unrest (conflict between Ambazonian militant groups and the Cameroonian government in the Northwest), (2) limitations of the healthcare system, (3) inadequate physical infrastructure. Civil unrest impacted personal security, transportation safety, and disrupted medical transport system. Limitations of healthcare system involved critical shortages of skilled personnel and medical equipment, low commitment to evidence-based care, poor reputation, ineffective health system communication, incentives affecting care, and inadequate data collection. Inadequate physical infrastructure included frequent power outages and geographic distribution of healthcare facilities leading to logistical challenges. CONCLUSION: Dynamic inter-relations among structural level factors create barriers to maternity care in Cameroon. Implementation of policies and intervention programs addressing structural barriers are necessary to facilitate timely access and utilization of high-quality maternity care.

Increasing the number of midwives is necessary but not sufficient: using global data to support the case for investment in both midwife availability and the enabling work environment in low- and middle-income countries.

BACKGROUND: Most countries are off-track to achieve global maternal and newborn health goals. Global stakeholders agree that investment in midwifery is an important element of the solution. During a global shortage of health workers, strategic decisions must be made about how to configure services to achieve the best possible outcomes with the available resources. This paper aims to assess the relationship between the strength of low- and middle-income countries' (LMICs') midwifery profession and key maternal and newborn health outcomes, and thus to prompt policy dialogue about service configuration. METHODS: Using the most recent available data from publicly available global databases for the period 2000-2020, we conducted an ecological study to examine the association between the number of midwives per 10,000 population and: (i) maternal mortality, (ii) neonatal mortality, and (iii) caesarean birth rate in LMICs. We developed a composite measure of the strength of the midwifery profession, and examined its relationship with maternal mortality. RESULTS: In LMICs (especially low-income countries), higher availability of midwives is associated with lower maternal and neonatal mortality. In upper-middle-income countries, higher availability of midwives is associated with caesarean birth rates close to 10-15%. However, some countries achieved good outcomes without increasing midwife availability, and some have increased midwife availability and not achieved good outcomes. Similarly, while stronger midwifery service structures are associated with greater reductions in maternal mortality, this is not true in every country. CONCLUSIONS: A complex web of health system factors and social determinants contribute to maternal and newborn health outcomes, but there is enough evidence from this and other studies to indicate that midwives can be a highly cost-effective element of national strategies to improve these outcomes.

Resilience in the time of crisis: A review of the maternal, perinatal and reproductive health effects of COVID-19 in South Africa.

BACKGROUND: The COVID-19 pandemic had a profound effect on the health sector globally and in South Africa (SA). OBJECTIVE: To review the effects of COVID-19 on maternal, perinatal and reproductive health outcomes and service utilisation in SA. METHODS: Three routine national data collection systems were sourced: the District Health Information System, the Saving Mothers reports of the National Committee on Confidential Enquiry into Maternal Deaths and the Saving Babies reports from the National Perinatal Morbidity and Mortality Committee using data from the Perinatal Problem Identification Program. RESULTS: There were 35% and 8% increases in maternal and stillbirth mortality rates, respectively, in 2020 and 2021, which correlated with the COVID-19 waves. However, in 2022, rates returned to pre-COVID levels. Antenatal visits and facility births showed little change, but there was a shift to more rural provinces. The use of oral and injectable contraceptives and termination of pregnancy services decreased markedly in 2020 and 2021, with a sustained shift to long-acting reversible contraceptives. The increase in maternal deaths was predominantly due to COVID-19 respiratory complications, but also an increase in obstetric haemorrhage. Stillbirths increased significantly (10%) for birthweights between 2 000 g and 2 499 g, categorised mostly as unexplained stillbirths or preterm labour, but no increase in neonatal deaths was observed. Administrative avoidable factors increased by 24% in the 2020 - 2022 triennium, but there was no increase in patient/community level or healthcare provider-related avoidable factors during the pandemic years. CONCLUSION: COVID-19 caused a marked increase in maternal death and stillbirth rates in 2020 and 2021 due to both direct effects of the virus and indirect effects on functioning of the health system. The continued, although modified, health-seeking behaviour of women and the rapid return to pre-COVID-19 mortality rates demonstrates enormous resilience in women and the health system.

Global Financing Facility investments for vulnerable populations: content analysis regarding maternal and newborn health and stillbirths in 11 African countries, 2015 to 2019.

BACKGROUND: The Global Financing Facility (GFF) was launched in 2015 to catalyse increased domestic and external financing for reproductive, maternal, newborn, child, adolescent health, and nutrition. Half of the deaths along this continuum are neonatal deaths, stillbirths or maternal deaths; yet these topics receive the least aid financing across the continuum. OBJECTIVES: To conduct a policy content analysis of maternal and newborn health (MNH), including stillbirths, in GFF country planning documents, and assess the mortality burden related to the investment. METHODS: Content analysis was conducted on 24 GFF policy documents, investment cases and project appraisal documents (PADs), from 11 African countries. We used a systematic data extraction approach and applied a framework for analysis considering mindset, measures, and money for MNH interventions and mentions of mortality outcomes. We compared PAD investments to MNH-related deaths by country. RESULTS: For these 11 countries, USD$1,894 million of new funds were allocated through the PADs, including USD$303 million (16%) from GFF. All documents had strong content on MNH, with particular focus on pregnancy and childbirth interventions. The investment cases commonly included comprehensive results frameworks, and PADs generally had less technical content and fewer indicators. Mortality outcomes were mentioned, especially for maternal. Stillbirths were rarely included as targets. Countries had differing approaches to funding descriptions. PAD allocations are commensurate with the burden. CONCLUSIONS: The GFF country plans present a promising start in addressing MNH. Emphasising links between investments and burden, explicitly including stillbirth, and highlighting high-impact packages, as appropriate, could potentially increase impact.

Main finding: Maternal and newborn health care packages are strongly included in the Global Financing Facility policy documents for 11 African countries, especially regarding pregnancy and childbirth, though less for stillbirth, or postnatal care, or small and sick newborn care.Added knowledge: This study is the first independent content analysis of Global Financing Facility investment cases and related project appraisal documents, revealing mostly consistent content for maternal and newborn health across documents and overall correlation between national mortality burden and investments committed.Global health impact for policy and action: The Global Financing Facility have demonstrated promising initial investments for maternal and newborn health, although there are also missed opportunities for strengthening, especially for some neonatal high-impact packages and counting impact on stillbirths.

The Association Between State-Level Prenatal Substance Use Policies and Rates of Maternal Mortality in the United States: A Legal Epidemiology Study.

Little research has explored relationships between prenatal substance use policies and rates of maternal mortality across all 50 states, despite evidence that prenatal substance use elevates risk of maternal death. This study, utilizing publicly available data, revealed that state-level mandated testing laws predicted maternal mortality after controlling for population characteristics.

Implementation of maternal and perinatal death surveillance and response and related death review interventions in humanitarian settings: A scoping review.

Background: The global population impacted by humanitarian crises continues to break records each year, leaving strained and fractured health systems reliant upon humanitarian assistance in more than 60 countries. Yet little is known about implementation of maternal and perinatal death surveillance and response (MPDSR) within crisis-affected contexts. This scoping review aimed to synthesise evidence on the implementation of MPDSR and related death review interventions in humanitarian settings. Methods: We searched for peer-reviewed and grey literature in English and French published in 2016-22 that reported on MPDSR and related death review interventions within humanitarian settings. We screened and reviewed 1405 records, among which we identified 25 peer-reviewed articles and 11 reports. We then used content and thematic analysis to understand the adoption, appropriateness, fidelity, penetration, and sustainability of these interventions. Results: Across the 36 records, 33 unique programmes reported on 37 interventions within humanitarian contexts in 27 countries, representing 69% of the countries with a 2023 United Nations humanitarian appeal. Most identified programmes focussed on maternal death interventions; were in the pilot or early-mid implementation phases (1-5 years); and had limited integration within health systems. While we identified substantive documentation of MPDSR and related death review interventions, extensive gaps in evidence remain pertaining to the adoption, fidelity, penetration, and sustainability of these interventions. Across humanitarian contexts, implementation was influenced by severe resource limitations, variable leadership, pervasive blame culture, and mistrust within communities. Conclusions: Emergent MPDSR implementation dynamics show a complex interplay between humanitarian actors, communities, and health systems, worthy of in-depth investigation. Future mixed methods research evaluating the gamut of identified MPDSR programmes in humanitarian contexts will greatly bolster the evidence base. Investment in comparative health systems research to understand how best to adapt MPDSR and related death review interventions to humanitarian contexts is a crucial next step.

Racial disparities and maternal mortality in Brazil: findings from a national database.

OBJECTIVE: To assess maternal mortality (MM) in Brazilian Black, Pardo, and White women. METHODS: We evaluated the maternal mortality rate (MMR) using data from the Brazilian Ministry of Health public databases from 2017 to 2022. We compared MMR among Black, Pardo, and White women according to the region of the country, age, and cause. For statistical analysis, the Q2 test prevalence ratio (PR) and confidence interval (CI) were calculated. RESULTS: From 2017 to 2022, the general MMR was 68.0/100,000 live births (LB). The MMR was almost twice as high among Black women compared to White (125.81 vs 64.15, PR = 1.96, 95%CI:1.84-2.08) and Pardo women (125.8 vs 64.0, PR = 1.96, 95%CI: 1.85-2.09). MMR was higher among Black women in all geographical regions, and the Southeast region reached the highest difference among Black and White women (115.5 versus 60.8, PR = 2.48, 95%CI: 2.03-3.03). During the covid-19 pandemic, MMR increased in all groups of women (Black 144.1, Pardo 74.8 and White 80.5/100.000 LB), and the differences between Black and White (PR = 1.79, 95%CI: 1.64-1.95) and Black and Pardo (PR = 1.92, 95%CI: 1.77-2.09) remained. MMR was significantly higher among Black women than among White or Pardo women in all age ranges and for all causes. CONCLUSION: Black women presented higher MMR in all years, in all geographic regions, age groups, and causes. In Brazil, Black skin color is a key MM determinant. Reducing MM requires reducing racial disparities.

Obstetrics care in Indonesia: Determinants of maternal mortality and stillbirth rates.

PROBLEM: The Indonesian Healthcare Program starting in 2014 enabled access to healthcare delivery for large population groups. Guidance of usage, infrastructure and healthcare process development were the most challenging tasks during the implementation period. Due to the high social impact obstetric care and related quality assurance require evidence-based developmental strategies. This study aims for analysis of outcome and maternal health care utilization, as well as differences related to demographic and economic subgroups. METHODS: For univariate group comparison ANOVA method was applied and combined with Scheffé procedure and Bonferoni correction for post-hoc tests. Meanwhile, multivariate approaches through regression analysis based on insurance reimbursement data antenatal, perinatal and postnatal care were performed at the province level. Maternal mortality (MMR) and stillbirth rates were used for outcome. Demographic characteristics, availability of obstetricians (SPOG), midwifes and healthcare infrastructure were included for their determinants. RESULTS: Specialized hospital facilities (type A/B) for advanced care covered a large part of uncomplicated cases (~35%). Differences between insurance membership groups (poor, non-poor) were not seen. Availability of human resources (SPOG, midwifes) (R2 = 0.728; p<0.001) and rural setting (R2 = 0.288; p = 0.001) are correlated with reduced insufficient referral. Their presence within provinces was related to lower occurrence of complicated cases (R2 = 0.294; p = 0.001). However, higher SPOG rates within provinces were also related to high C-section rates (p<0.001). MMR and stillbirth rates can be predicted by availability of human resources and C-section rates explaining 49.0% of variance. CONCLUSIONS: Improvement of perinatal outcome should focus on sufficient referral processes, availability of SPOG in provinces dominated by rural/remote demography and avoidance of overtreatment by high C-section rates. It is very important to regulate the education of obstetricians and gynecologists in Indonesia as well as distribution arrangements regarding to solve the problems with pregnancy complications in remote and rural areas.

Trends and causes of maternal mortality in Indonesia: a systematic review.

BACKGROUND: The maternal mortality ratio (MMR) in Indonesia is among the highest in Southeast Asia. We aim to describe trends in the MMR and causes of maternal deaths in Indonesia over the past decades, regionally and nationally. METHODS: We performed a systematic review and conducted a search using PubMed, Embase, Global Health, CINAHL, Cochrane, Portal Garuda, and Google Scholar from the inception of the database to April 2023. We included all studies on the incidence and/or the causes of maternal deaths in Indonesia. The MMR was defined as the number of maternal deaths per 100,000 live births. Maternal death causes were assessed and reclassified according to the WHO International Classification of Disease Maternal Mortality (ICD-MM). RESULTS: We included 63 studies that reported the MMR (54 studies) and/or the causes of maternal deaths (44 studies) in Indonesia from 1970 to 2022, with a total of 254,796 maternal deaths. The national MMR declined from 450 to 249 (45%) between 1990 and 2020. Great differences in MMR exist across the country, with the lowest in Java-Bali and the highest (more than twice the national MMR) in Sulawesi and Eastern Indonesia. Between 1990 and 2022, the proportion of deaths due to hemorrhage and sepsis decreased, respectively from 48 to 18% and 15-5%, while the share of deaths due to hypertensive disorders and non-obstetric causes increased, respectively from 8 to 19% and 10-49%. CONCLUSION: Despite the steady decline of maternal deaths in Indonesia, it remains one of the highest in Southeast Asia, with enormous disparities within the country. Hypertensive disorders and non-communicable diseases make up a growing share of maternal deaths, making maternal death reduction strategies increasingly challenging. National Maternal Death Surveillance and Response needs to be prioritized to eliminate preventable maternal deaths in Indonesia. REGISTRATION OF SYSTEMATIC REVIEWS: PROSPERO, CRD42022320213.