Human resources for health and maternal mortality in Latin America and the Caribbean over the last three decades: a systemic-perspective reflections.

BACKGROUND: The role of human resources for health in the operation of health systems is crucial. However, training and incorporating them into institutions is a complex process due to the continuous misalignment between the supply and demand of health personnel. Taking the case of the Latin American and Caribbean region countries, this comment discusses the relationship between the availability of human resources for health and the maternal mortality ratio for the period 1990-2021. It proposes the need to resume planning exercises from a systemic perspective that involves all areas of government and the private sector linked to the training and employment of health workers. MAIN TEXT: We used secondary data from a global source to show patterns in the relationship between these two aspects and identify gaps in the Latin American and Caribbean regions. The results show enormous heterogeneity in the response of regional health systems to the challenge of maternal mortality in the region. Although most countries articulated specific programs to achieve the reduction committed by all countries through the Millennium Development Goals, not all had the same capacity to reduce it, and practically none met the target. In addition, in the English Caribbean countries, we found significant increases in the number of health personnel that do not explain the increases in the maternal mortality rate during the period. CONCLUSIONS: The great lesson from the data shown is that some countries could articulate responses to the problem using available resources through effective strategies, considering the specific needs of their populations. Although variations in maternal mortality rate cannot be explained solely through the provision of health personnel, it is important to consider that it is critical to find new modalities on how human resources for health could integrate and create synergies with other resources to increase systems capacity to deliver care according to conditions in each country.

Infection Prevention and Control: Baseline Knowledge and Practices of TBAs in Rural Kano, Northwestern Nigeria.

BACKGROUND: Maternal infections remain a significant contributor to maternal mortality worldwide. Majority of births in northern Nigeria occur at home and are attended by Traditional Birth Attendants (TBAs). Little has been documented about their knowledge and practice on infection prevention and control practices in Kano, northern Nigeria. OBJECTIVES: This study evaluated the level as well as factors associated with TBAs' infection prevention and control knowledge and practices. METHODS: The study is the baseline phase of a quasi-experimental study, conducted in a rural LGA in Kano State, Nigeria. Using an adapted tool, 163 eligible TBAs were surveyed. Knowledge and practice of IPC were scored, aggregated, and dichotomized into good or poor. Binary logistic regression analysis was used to predict knowledge and practice of IPC. RESULTS: Majority (79.1%) of the TBAs exhibited poor IPC knowledge but many (78.5%) reported good practice. Good knowledge of IPC was predicted by the TBAs' age: a six-fold increased likelihood (AOR=6.25, 95% CI: 1.02- 38.53) and almost five-fold increased likelihood (AOR=4.75, 95% CI: 1.39- 16.24) for those in their second and fourth decades of life. TBAs who reported poor practice of IPC were 83% less likely (AOR=0.17, 95% CI: 0.03- 0.92) to have good knowledge of IPC. TBAs' practice was only linked to previous training (AOR=0.17, 95% CI: 0.04- 0.76). CONCLUSION: TBAs knowledge of IPC was low although reported practice was good. The need for tailored training interventions to enhance knowledge and skills for safe delivery care is paramount to improve maternal and neonatal outcomes.

CONTEXTE: Les infections maternelles restent une contribution significative à la mortalité maternelle dans le monde. La majorité des accouchements dans le nord du Nigeria ont lieu à domicile et sont assistés par des TBA. Peu de choses ont été documentées sur leurs connaissances et leurs pratiques en matière de prévention et de contrôle des infections à Kano, dans le nord du Nigeria. OBJECTIFS: Cette étude a évalué le niveau de connaissances et de pratiques des TBA en matière de prévention et de contrôle des infections, ainsi que les facteurs associés. MÉTHODES: L'étude est la phase de base d'une étude quasiexpérimentale, menée dans une LGA rurale de l'État de Kano, au Nigeria. En utilisant un outil adapté, 163 TBA éligibles ont été interrogés. Les connaissances et les pratiques en matière de PCI ont été évaluées, agrégées et dichotomisées en bonnes ou mauvaises. Une analyse de régression logistique binaire a été utilisée pour prédire les connaissances et les pratiques en matière de PCI. RÉSULTATS: La majorité (79,1 %) des TBA présentaient des connaissances médiocres en PCI, mais beaucoup (78,5 %) ont déclaré avoir de bonnes pratiques. De bonnes connaissances en PCI étaient prédites par l'âge des TBA : une probabilité multipliée par six (AOR=6,25, IC à 95 % : 1,02-38,53) et presque multipliée par cinq (AOR=4,75, IC à 95 % : 1,39-16,24) pour ceux dans leur deuxième et quatrième décennies de vie. Les TBA qui ont déclaré une mauvaise pratique de la PCI étaient 83 % moins susceptibles (AOR=0,17, IC à 95 % : 0,03-0,92) d'avoir de bonnes connaissances en PCI. La pratique des TBA était uniquement liée à une formation antérieure (AOR=0,17, IC à 95 % : 0,04­0,76). CONCLUSION: Les connaissances des TBA en matière de PCI étaient faibles bien que les pratiques déclarées étaient bonnes. La nécessité d'interventions de formation sur mesure pour améliorer les connaissances et les compétences en matière de soins de l'accouchement sécurisés est primordiale pour améliorer les résultats maternels et néonatals. MOTS-CLÉS: Accoucheuses Traditionnelles, Mortalité Maternelle, Infection Maternelle, Nigeria.

Using the WHO individual near miss case review (NMCR) cycle to improve quality of emergency obstetric care and maternal outcome in Keren hospital, Eritrea: an interrupted time series analysis.

BACKGROUND: In 2016, the WHO regional office for Europe prepared a manual for conducting routine facility based individual near miss case review cycle. This study evaluates the effectiveness of the individual near miss case review (NMCR) cycle in improving quality of emergency obstetric care and maternal outcome in Keren hospital. METHODS: An interrupted time series design was used to achieve the objectives of this study. Monthly data on women with potentially life-threatening conditions (PLTCs) admitted between April 2018 and October 2022 (i.e. 33 months pre-implementation and 22 months post-implementation) were collected from medical records. Segmented regression analysis was used to assess the intervention's effect on three process and outcome measures, namely, SMO, delayed care, and substandard care. The intervention was expected a priori to show immediate improvements without time-lag followed by gradual increment in slope. Segmented regression analyses were performed using the "itsa' command in STATA. RESULTS: During the entire study period, 4365 women with potentially life threatening conditions were identified. There was a significant reduction in the post-implementation period in the proportion of mothers with PLTC who experienced SMO (- 8.86; p <  0.001), delayed care (- 8.76; p <  0.001) and substandard care (- 5.58; p <  0.001) compared to pre-implementation period. Results from the segmented regression analysis revealed that the percentage of women with SMO showed a significant 4.75% (95% CI: - 6.95 to - 2.54, p <  0.001) reduction in level followed by 0.28 percentage points monthly (95% CI: - 0.37 to - 0.14, p <  0.001) drop in trend. Similarly, a significant drop of 3.50% (95% CI: - 4.74 to - 2.26, p <  0.001) in the level of substandard care along with a significant decrease of 0.21 percentage points (95% CI: - 0.28 to - 0.14, p < 0.001) in the slope of the regression line was observed. The proportion of women who received delayed care also showed a significant 7% (95% CI: - 9.28 to - 4.68, p < 0.001) reduction in post-implementation level without significant change in slope. CONCLUSIONS: Our findings suggest that the WHO individual NMCR cycle was associated with substantial improvements in quality of emergency obstetric care and maternal outcome. The intervention also bears a great potential for scaling-up following the guidance provided in the WHO NMCR manual.

Maternal mortality and COVID-19: A nationwide ecological analysis from Ecuador.

BACKGROUND: During the COVID-19 pandemic, distinct population subsets, including pregnant women, have been differentially affected. While over 90% of COVID-19-infected pregnant women experience a benign course, a subset demonstrates marked clinical exacerbation. Symptomatic pregnant individuals, in particular, present a heightened risk of severe disease in comparison to their non-pregnant counterparts. OBJECTIVE: The objective of this study is to systematically evaluate the epidemiological characteristics of COVID-19 in pregnant women, assess related maternal mortalities, ascertain the case fatality rate, and delineate associated risk factors. DESIGN: This is a comprehensive population-based ecological study. METHODOLOGY: A population-based study was conducted to investigate the epidemiological patterns of COVID-19-associated morbidity and mortality in pregnant women in Ecuador from 27 February 2020 to 14 May 2021. RESULTS: A total of 3274 positive COVID-19 cases were identified among pregnant women, with 22 official fatalities, yielding a case fatality rate of 0.67%. The majority of cases were of Mestizo ethnicity (92.66%); however, the highest case fatality rate was noted among indigenous pregnant women (case fatality rate = 1.25%), those aged between 40 and 44 years (case fatality rate = 2.68%), and those with a history of comorbidities (2.08%). Pregnant women residing at lower altitudes (<2500 m) exhibited a higher incidence rate (0.20/100,000) compared to those at higher altitudes (>2500 m), which stood at 0.17/100,000. CONCLUSION: The COVID-19 pandemic has profoundly impacted pregnant women in Ecuador during the first 14 months, particularly those with comorbidities, older age, and of indigenous ethnicity. These factors have heightened their vulnerability and susceptibility to severe COVID-19 infection and subsequent mortality. This underscores the urgency for comprehensive protective measures, including prioritization for vaccination. Further studies are needed to inform tailored prevention strategies and therapeutic interventions for these high-risk groups.

Maternal mortality in the United States: are the high and rising rates due to changes in obstetrical factors, maternal medical conditions, or maternal mortality surveillance?

BACKGROUND: National Vital Statistics System reports show that maternal mortality rates in the United States have nearly doubled, from 17.4 in 2018 to 32.9 per 100,000 live births in 2021. However, these high and rising rates could reflect issues unrelated to obstetrical factors, such as changes in maternal medical conditions or maternal mortality surveillance (eg, due to introduction of the pregnancy checkbox). OBJECTIVE: This study aimed to assess if the high and rising rates of maternal mortality in the United States reflect changes in obstetrical factors, maternal medical conditions, or maternal mortality surveillance. STUDY DESIGN: The study was based on all deaths in the United States from 1999 to 2021. Maternal deaths were identified using the following 2 approaches: (1) per National Vital Statistics System methodology, as deaths in pregnancy or in the postpartum period, including deaths identified solely because of a positive pregnancy checkbox, and (2) under an alternative formulation, as deaths in pregnancy or in the postpartum period, with at least 1 mention of pregnancy among the multiple causes of death on the death certificate. The frequencies of major cause-of-death categories among deaths of female patients aged 15 to 44 years, maternal deaths, deaths due to obstetrical causes (ie, direct obstetrical deaths), and deaths due to maternal medical conditions aggravated by pregnancy or its management (ie, indirect obstetrical deaths) were quantified. RESULTS: Maternal deaths, per National Vital Statistics System methodology, increased by 144% (95% confidence interval, 130-159) from 9.65 in 1999-2002 (n=1550) to 23.6 per 100,000 live births in 2018-2021 (n=3489), with increases occurring among all race and ethnicity groups. Direct obstetrical deaths increased from 8.41 in 1999-2002 to 14.1 per 100,000 live births in 2018-2021, whereas indirect obstetrical deaths increased from 1.24 to 9.41 per 100,000 live births: 38% of direct obstetrical deaths and 87% of indirect obstetrical deaths in 2018-2021 were identified because of a positive pregnancy checkbox. The pregnancy checkbox was associated with increases in less specific and incidental causes of death. For example, maternal deaths with malignant neoplasms listed as a multiple cause of death increased 46-fold from 0.03 in 1999-2002 to 1.42 per 100,000 live births in 2018-2021. Under the alternative formulation, the maternal mortality rate was 10.2 in 1999-2002 and 10.4 per 100,000 live births in 2018-2021; deaths from direct obstetrical causes decreased from 7.05 to 5.82 per 100,000 live births. Deaths due to preeclampsia, eclampsia, postpartum hemorrhage, puerperal sepsis, venous complications, and embolism decreased, whereas deaths due to adherent placenta, renal and unspecified causes, cardiomyopathy, and preexisting hypertension increased. Maternal mortality increased among non-Hispanic White women and decreased among non-Hispanic Black and Hispanic women. However, rates were disproportionately higher among non-Hispanic Black women, with large disparities evident in several causes of death (eg, cardiomyopathy). CONCLUSION: The high and rising rates of maternal mortality in the United States are a consequence of changes in maternal mortality surveillance, with reliance on the pregnancy checkbox leading to an increase in misclassified maternal deaths. Identifying maternal deaths by requiring mention of pregnancy among the multiple causes of death shows lower, stable maternal mortality rates and declines in maternal deaths from direct obstetrical causes.

Effect of a mother-baby delivery pack on institutional deliveries: A community intervention trial to address maternal mortality in rural Zambia.

OBJECTIVES: To test the effect of providing additional health education during antenatal care (ANC) and a mother-baby delivery pack on institutional deliveries in Monze, Zambia. SETTING: 16 primary health facilities conducting deliveries in the district. PARTICIPANT: A total of 5000 pregnant women at any gestation and age attending antenatal care (ANC) services in selected health facilities were eligible for enrolment into the study. Out of these, 4,500 (90%) were enrolled into and completed the study. A total of 3,882 (77.6%) were included in the analysis; 12.4% were not included in the analysis due to incomplete data. INTERVENTION: A three-year study (2012 to 2014) analysing baseline delivery data for 2012 and 2013 followed by a community intervention trial was conducted from January to December 2014. Health facilities on the western side were assigned to the intervention arm; those on the eastern side were in the control. In addition to the health education provided during routine ANC visits, participants in the intervention arm received health education and a mother-baby delivery pack when they arrived at the health facility for delivery. Participants in the control arm continued with routine ANC services. OUTCOME MEASURES: The primary measure was the number of institutional deliveries in both arms over the one-year period. Secondary measures were utilisation of ANC, post-natal care (PNC) and under-five clinic services. Descriptive statistics (frequencies, proportions, means and standard deviation) were computed to summarise participant characteristics. Chi-square and Independent T-tests were used to make comparisons between the two arms. One way analysis of variance (ANOVA) was used to test the effect of the intervention after one year (p-value<0.05). Analysis was conducted using R-studio statistical software version 4.2.1. The p-value<0.05 was considered significant. RESULTS: Analysis showed a 15.9% increase in the number of institutional deliveries and a significant difference in the mean number of deliveries between intervention and control arms after one year (F(1,46) = 18.85, p<0.001). Post hoc analysis showed a significant difference in the mean number of deliveries between the intervention and control arms for 2014 (p<0.001). Compared to the control arm, participants in the intervention arm returned earlier for PNC clinic visit, brought their children back and started the under-five clinic visits earlier. CONCLUSION: These findings provide evidence for the effectiveness of the mother-baby delivery pack and additional health education sessions on increasing institutional deliveries, PNC and under-five children's clinic utilisation in rural Zambia. TRIAL REGISTRATION: ISRCTN Registry (ISRCTN15439813 DOI 10.1186/ISRCTN15439813); Pan African Clinical Trial Registry (PACTR202212611709509).

[Maternal mortality due to obstetric haemorrhage in France 2016-2018]. / Mortalité maternelle par hémorragie obstétricale en France 2016­2018.

Between 2016 and 2018, 20 maternal deaths were related to obstetric haemorrhage, excluding haemorrhage in the first trimester of pregnancy, representing a mortality ratio of 0.87 per 100,000 live births (95% CI 0.5 -1.3). Obstetric haemorrhage is the cause of 7.4% of all maternal deaths up to 1 year, 10% of maternal deaths within 42days, and 21% of deaths directly related to pregnancy (direct causes). Between 2001 and 2018, maternal mortality from obstetric haemorrhage has been considerably reduced, from 2.2deaths per 100,000 live births in 2001-2003 to 0.87 in the period presented here. Nevertheless, obstetric haemorrhage is still one of the main direct causes of maternal death, and remains the cause with the highest proportion of deaths considered probably (53%) or possibly (42%) preventable according to the CNEMM's collegial assessment (see chapter 3). The preventable factors reported are related to inadequate content of care in 94% of cases and/or organisation of care in 44% of cases. In this triennium, maternal death due to haemorrhage occurred mainly in the context of caesarean delivery (65% of cases, i.e. 13/20), and mostly in the context of emergency care (12/13). The main causes of obstetric haemorrhage were uterine rupture (6/20) in unscarred uterus or in association with placenta accreta, and surgical injury during the caesarean delivery (5/20). Every maternity hospital, whatever its resources and/or technical facilities, must be able to plan any obstetric haemorrhage situation that threatens the mother's vital prognosis. Intraperitoneal occult haemorrhage following caesarean section and uterine rupture require immediate surgery with the help of skilled surgeon resources with early and appropriate administration of blood products.

[Maternal mortality by stroke in France 2016-2018]. / Mortalité maternelle par accident vasculaire cérébral en France 2016­2018.

Between 2016 and 2018, twenty maternal deaths were associated with a stroke. The 20 deaths whose main cause was stroke represent 7.4% of all maternal deaths, i.e. a maternal mortality ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3). Among the 20 stroke deaths, it was hemorrhagic in 17 cases (85%), ischemic in 2 cases, and due to thrombophlebitis in 1 case. Stroke occurred during pregnancy in 8 women (40%) - one case before 12 weeks, 3 cases between 28 and 32 weeks, and 4 cases between 34 and 40 weeks; in 3 cases the stroke occurred intrapartum, and for the other 9 cases (45%) the stroke occurred postpartum between Day 1 and Day 15. Care was assessed as non-optimal in 10/19 (56%) of cases but mortality as possibly avoidable in 24% of cases (4/17 cases with conclusion established by the CNEMM) and not established in two cases. The potentially improvable elements identified were a delay in carrying out initial brain imaging in three cases (one case antepartum, two cases postpartum) and insufficient hemodynamic monitoring in intensive care in one case.

[Maternal mortality and health care organization in France 2016-2018]. / Mortalité maternelle et organisation des soins en France 2016­2018.

Organization of care is one of the elements examined when assessing cases. Organization of care is a factor, which is considered in addition to the content of care when assessing mortality cases. The factors related to the organization of care concern the suitability of the place of care, the completion of a necessary transfer, the adequacy of human and material resources, and the communication between caregivers. For the 2016-2018 triennium these preventability factors are the subject of a dedicated chapter. Overall, one or more preventability factors linked to the organization of care were reported in 51 cases, i.e. 24% of all assessed cases. The field of communication was the most frequently reported (32/51), followed by inappropriate place of care (20/51), insufficient human resources (13/51), transfers not performed or performed late (11/51) and insufficient material resources (9/51). An overall analysis can be made along two dimensions: organization within the maternity unit, and coordination with other sectors or outpatient medicine. Areas for improvement within the maternity unit relate to the ability to deal with life-threatening emergencies, to organize the call for specialized and/or trained human reinforcements, to organize intensive monitoring of patients in the event of organ failure, and to facilitate good communication between caregivers. Regarding coordination with other units, it is proposed to improve collaboration between the maternity unit's emergency department and the general emergency department, and to improve the transfer of information required by all those involved, including primary care physicians, in the pre-, per- and postpartum period. Finally, the place of care for patients presenting with a psychiatric and somatic pathology is a situation that requires careful consultation.

[Maternal mortality due to cardiovascular diseases in France 2016-2018]. / Mortalité maternelle par pathologies cardiovasculaires en France 2016­2018.

Between 2016 and 2018, cardiovascular diseases were responsible for 41 deaths, making it the leading cause of maternal death within 42 days postpartum in France. The maternal mortality ratio (MMR) for cardiovascular disease is 1.8 per 100,000 NV, a non-significant increase compared with the 2013-2015 triennium (MMR of 1.5 per 100,000 NV). Deaths from cardiac causes accounted for the majority (n=28), with 26 deaths secondary to cardiac disease aggravated by pregnancy (indirect deaths) and 2 deaths related to peripartum cardiomyopathy (direct deaths). Deaths from vascular causes (n=13) corresponded to 9 aortic dissections and 4 ruptures of large vessels, including 3 ruptures of the splenic artery. Preventability of death (possible or probable) was found in 56% of cases compared with 66% in the previous triennium. Care was considered sub-optimal in 57% of cases, down from 72% in the 2013-2015 triennium. In women with known cardiovascular disease, the areas for improvement concern multidisciplinary follow-up, repeated assessment of the cardiovascular risk (WHO grade) and early referral to an expert centre (expert cardiologists, obstetricians, anaesthetists and intensive care). In all pregnant women or women who have recently given birth, a cardiovascular etiology should be considered in the presence of suggestive symptoms (dyspnea, chest or abdominal pain). Ultrasound "point of care" examination (fluid effusions, cardiac dysfunction) and cardiac enzymes assay can help in the diagnosis. Finally, the woman must be involved in her own care.

[Maternal mortality in France, 2016-2018, frequency, causes and women's profile]. / Mortalité maternelle en France, 2016­2018, fréquence, causes et profil des femmes.

OBJECTIVE: To describe, for the 2016-2018 period, the frequency, causes and risk factors of maternal deaths in France. METHOD: Data from the National Confidential Enquiry into Maternal Deaths for 2016-2018. RESULTS: For 2016-2018, 272 maternal deaths occurred in France up to 1 year after the end of pregnancy, i.e a maternal mortality ratio of 11.8 per 100,000 live births (95 % CI 10.4-13.3), and 8.5 (IC 95 % 7.4-9.8) for maternal mortality up to 42 days. Compared to women aged 20-24, the risk of maternal death is multiplied by 2.6 for women aged 35-39, by 5 for women aged 40 and over. Obese women are twice as frequent among maternal deaths (26 %) than in the general population of parturients (11 %). There are territorial disparities -the maternal mortality ratio in the French overseas departments is 2 times higher than in metropolitan France (significant difference but smaller than in 2013-2015)-, and social disparities -the mortality of migrant women remains higher than that of women born in France, particularly for women born in sub-Saharan Africa whose risk is 3 times higher than that of native women. One in three women who died (34 %) had socio-economic vulnerability versus 22 % in the overall population of parturients. Among causes of maternal deaths, the predominant role of psychiatric conditions (mostly suicides) is confirmed for the period 2016-2018, leading cause of maternal mortality considered up to 1 year (17 %), MMR of 1.9/100,000 NV. i.e. approximately one death from psychiatric causes every 3 weeks. Cardiovascular diseases are the second leading cause of maternal mortality up to one year (14 %) and the leading cause up to 42 days (16 %), with 1.3 deaths per 100,000 NV. Amniotic fluid embolism ranks as the third cause (8 %) (2nd cause, 11 %, for MM limited to 42 days), i.e. MMR of 0.9 per 100,000 NV. After a regular decline over the last decade, maternal mortality from obstetric hemorrhage is at a stable level compared to the previous triennium 2013-2015, MMR of 0.9/100,000 NV, i.e 5th cause of MM up to one year (7 %) and 4th cause of MM up to 42 days. CONCLUSION: The overall national maternal mortality ratio does not show a downward trend, even with constant surveillance method. Territorial inequalities persist but change in their magnitude and in the regions concerned. The profile of the causes of maternal mortality up to one year of the pregnancy end shows the leading role of suicides and cardiovascular diseases, which illustrates that the health of pregnant women or those who have recently given birth is not limited to the obstetric domain, and highlights the importance of multidisciplinarity in the management and organization of care for women in this period.

[National confidential enquiry into maternal deaths in France, a 25-year enhanced surveillance system, essential for the reliable characterization of maternal deaths]. / Enquête Nationale Confidentielle sur les Morts Maternelles en France, un système de surveillance améliorée depuis 25 ans, indispensable pour la caractérisation fiable des décès maternels.

Although maternal mortality is rare in wealthy countries, it remains a fundamental indicator of maternal health. It is considered to be a "sentinel event", the occurrence of which indicates dysfunctions, often cumulative, in the healthcare system. In addition to the classic epidemiological surveillance findings - number of deaths, maternal mortality ratio, distribution of medical causes, sub-groups of women at risk - its study, through a precise analysis of the history of each woman who died, enables to highlight areas for improvement in the content or organisation of care, the correction of which will make it possible to prevent not only deaths but also upstream morbid events involving the same mechanisms. To achieve this dual epidemiological and clinical audit objective, an ad hoc "enhanced" system is needed. France has had such a system since 1996, the Enquête Nationale Confidentielle sur la Mortalité Maternelle (ENCMM), under the joint supervision of Santé Publique France and Inserm. The ENCMM method aims to identify maternal deaths exhaustively and reliably up to 1 year after the end of pregnancy, and to document each death as fully as possible. The 1st step is the multi-source identification (direct declaration, death certificates, linkage with birth certificates, hospital stay database) of women who died during pregnancy or in the year following its end. The 2nd step is the collection of detailed information for each death by a pair of clinical assessors. The 3rd step is the review of these anonymised documents by the National Expert Committee on Maternal Mortality, which establishes the maternal nature of the death (causal link with pregnancy) and, with a stated aim of improvement rather than judgement, assesses the adequacy of care and the preventability of the death. The summary of the information gathered for maternal deaths in the 2016-2018 period is presented in the other articles of this special issue.

[Maternal mortality due to Amniotic Fluid Embolism in France 2016-2018]. / Mortalité maternelle par embolie amniotique en France 2016­2018.

Amniotic embolism remains the 3rd leading cause of maternal death in France, with 21 maternal deaths over the 2016-2018 triennium. The women who died were more likely to be obese (25%), to benefit from induction of labor (71%) and be cared in a maternity hospital <1500 deliveries/year (45%), compared with the reference population (ENP 2016). The symptom occurred mainly during labor (95%) and the course was rapid, with a symptom-to-fatality interval of 4hours 45minutes (min: 25minutes - max: 8 days). Preventability was proposed for 35% of the deaths assessed, with areas for improvement identified in terms of technical skills (haemostasis procedures, management of polytransfusion), non-technical skills (communication) and health care organization (human resources, vital emergency plan, wide access to PSL). An autopsy was performed in 38% of deaths.

[Maternal mortality due to hypertensive disorders in France, 2016-2018]. / Mortalité maternelle par complications hypertensives en France, 2016­2018.

Between 2016 and 2018, 13 maternal deaths were due to hypertensive disorders. During this period, the maternal mortality ratio was 0.6/100 000 live births. Hypertensive disorders were responsible for 4.8% of maternal deaths during the first year, 5.1% up to 42 days postpartum and for 13.5% of direct maternal mortality. Maternal deaths due to hypertensive disorders increased close to signification (p=0.09) compared to the last triennium (MMR=0.2/100.000). Classification of the hypertensive disorders was: 5 severe preeclampsia, 3 eclampsia, 4 HELLP syndromes et 1 undefined hypertension. In five cases, a stroke was associated. Mode of delivery was a cesarean section when the hypertensive disorder started before the labour (8/13, 62%). Six women were older than 35years old and 5/12 were nulliparous. Among the 12 cases where place of birth was known, 5 were born foreigners. BMI was over 30 for 46%. Medical care were estimated non optimal in 11/13 of the cases. Among these deaths, 66% (8/12) seemed to be preventable versus 82% for the last period 2013-2015. The main causal factor of suboptimal management was inappropriate management by the obstetrical or anesthetist/intensive care squads, respectively: 3 lack of diagnosis, 8 delays for diagnosis and 5 underestimated severity. Four cases corresponded to inappropriate health care organization. This study offers the opportunity to stress major points to optimize medical management and health care organization facing hypertensive disorders during pregnancy.

[Maternal mortality due to venous thromboembolism in France 2016-2018]. / Mortalité maternelle par thromboembolie veineuse en France 2016­2018.

Pregnancy and the post-partum period represent a thromboembolic risk situation, with pulmonary embolism (PE) remaining one of the leading causes of direct maternal deaths in developed countries. Between 2016 and 2018 in France, twenty maternal deaths were caused by venous thromboembolic complications (VTE), yielding a Maternal Mortality Ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3), with no change compared to the periods 2013-2015 or 2010-2012. Among these 20 deaths, 1 death was related to cerebral thrombophlebitis, and the remaining 19 were due to PE. Regarding the timing of death, 2 deaths occurred after an early termination of pregnancy, 40% (8/20) during an ongoing pregnancy, and 50% (10/20) in the post-partum period. Among the 20 VTE deaths, 20% (4/20) occurred outside of a healthcare facility (at home or in a public place). Among the nineteen cases with documented BMI, seven women had obesity (37%), three times more than in the population of parturients in France (11.8%, ENP 2016). Among the nineteen PE deaths and the case of cerebral thrombophlebitis, eleven were considered preventable, six possibly preventable (35%), two probably preventable (12%), and three preventability undetermined. The identified preventability factors were inadequate care and the patient's failure to interact with the healthcare system. From the case analysis, areas for improvement were identified, including insufficient consideration of major and minor risk factors, the early initiation of appropriate prophylactic treatment, and the absence of fibrinolysis in cases of s refractory cardiac arrest due to suspected PE.

[Indirect causes of maternal deaths (except stroke, cardiovascular diseases and infections) in France 2016-2018]. / Mortalité maternelle de causes indirectes (hors AVC, maladies cardiovasculaires et infections) en France 2016­2018.

Maternal deaths from indirect obstetric cause result from a preexisting condition or a condition that occurred during pregnancy without obstetric causes but was aggravated by the physiological effects of pregnancy. Twenty-nine deaths with an indirect cause related to a preexisting condition, excluding circulatory diseases or infections, were analysed by the expert committee. Pre-pregnancy pathology was documented in 16 women (epilepsy, n=7; amyloid angiopathy, n=1; Dandy-Walker syndrome, n=1; autoimmune diseases, n=3; diffuse infiltrative pneumonitis, n=1; thrombotic thrombocytopenic purpura, n=1; ovarian cancer in fragile X, n=1; major sickle cell disease, n=1). In 13 women, the pathology was unknown before pregnancy (breast cancer, n=9, epilepsy diagnosed during pregnancy, n=1, brain tumours, n=2 meningioma type, macrophagic activation syndrome, n=1). Death was associated with neoplastic or tumour pathology in 13 women (45%). At the same time, epilepsy was responsible for the death of 8 women (27%), making it the most common cause of death. For both neoplasia and epilepsy, about 50% of deaths were preventable, mainly due to undiagnosed and/or delayed treatment in the case of cancer and failure to monitor or adjust treatment in the case of epilepsy. Pre-conception counselling is therefore strongly recommended if a woman has a known chronic medical condition prior to pregnancy. Finally, if there is a family history of breast cancer, a breast examination is strongly recommended from the first visit during pregnancy, and any breast lumps should be investigated as soon as possible to avoid delaying appropriate treatment.

[Maternal mortality among socially vulnerable women in France 2016-2018]. / Mortalité maternelle chez les femmes avec vulnérabilité sociale en France 2016­2018.

Social vulnerability is a known factor in perinatal medical risk, both for the foetus and the mother. As part of the French confidential enquiry into maternal deaths, the introduction in 2015 of specific items relating to social status has made it possible to recreate this composite variable. Over the period 2016-2018, one woman in three who died was in a situation of social vulnerability. Of these 79 deaths, 32 (41%) were related to direct obstetric causes, 26 (33%) to indirect obstetric causes, 12 (15%) to suicides and 8 (10%) of unknown cause. Care was considered sub-optimal in 73% of cases, compared with 64% in the group of maternal deaths with no identified social vulnerability. 43 deaths were judged to be probably (n=12) or possibly (n=31) avoidable, 25 were not avoidable, and 11 were not sufficiently documented for this assessment; i.e. a proportion of 63% of probable or possible avoidability, a higher proportion compared with the 56% of avoidability among women with no identified social vulnerability. In 1/3 of maternal deaths, a lack of interaction between the woman and the healthcare system was involved in the chain of events leading to death, i.e. 2 times more than in the case of socially non-vulnerable women. Improving the interaction of women in socially vulnerable situations with the hospital system and the institutional and voluntary networks providing care, support and assistance is a priority. A specific, responsive medical and social organisation could contribute to this.