Impact of efforts to prevent maternal deaths due to obstetric hemorrhage on trends in epidemiology and management of severe postpartum hemorrhage in Japan: a nationwide retrospective study.

BACKGROUND: The Japan Society of Obstetrics and Gynecology and the Japan Association of Obstetricians and Gynecologists have issued the guidelines and recommendations on postpartum hemorrhage since 2010 and have been conducted widespread educational activities from 2012. The aim of this study was to investigate the impact of these efforts by the Societies to prevent maternal deaths due to obstetric hemorrhage on trends in epidemiology and management of severe postpartum hemorrhage in Japan. METHODS: A national retrospective cohort study was conducted using the national database of health insurance claims for the period 2012 and 2018. The subjects were all insured women who received a blood transfusion for postpartum hemorrhage. The primary endpoints of this study were hysterectomy and maternal mortality. The etiology of hemorrhage, treatment facility, type of procedure, and blood transfusion volume were tabulated. RESULTS: Women with postpartum hemorrhage that underwent transfusion increased from 3.5 to 5.5 per 1000 deliveries between 2012 and 2018. The most common cause of postpartum hemorrhage was atonic hemorrhage. After insurance coverage in 2013, the intrauterine balloon tamponade use increased to 20.3% of postpartum hemorrhages treated with transfusion in 2018, while the proportion of hysterectomy was decreased from 7.6% (2013-2015) to 6.4% (2016-2018) (p < 0.0001). The proportion of postpartum hemorrhage in maternal deaths decreased from 21.1% (2013-2015) to 14.1% (2016-2018) per all maternal deaths cases (p = 0.14). Cases with postpartum hemorrhage managed in large referral hospitals was increased (65.9% in 2012 to 70.4% in 2018) during the study period (p < 0.0001). CONCLUSIONS: The efforts by the Societies to prevent maternal mortality due to obstetric hemorrhage resulted in a significant decrease in the frequency of hysterectomies and a downward trend in maternal mortality due to obstetric hemorrhage.

Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016‒2017.

Objectives. To better understand racial and ethnic disparities in US maternal mortality. Methods. We analyzed 2016-2017 vital statistics mortality data with cause-of-death literals (actual words written on the death certificate) added. We created a subset of confirmed maternal deaths that had pregnancy mentions in the cause-of-death literals. Primary cause of death was identified and recoded using cause-of-death literals. We examined racial and ethnic disparities both overall and by primary cause. Results. The maternal mortality rate for non-Hispanic Black women was 3.55 times that for non-Hispanic White women. Leading causes of maternal death for non-Hispanic Black women were eclampsia and preeclampsia and postpartum cardiomyopathy with rates 5 times those for non-Hispanic White women. Non-Hispanic Black maternal mortality rates from obstetric embolism and obstetric hemorrhage were 2.3 to 2.6 times those for non-Hispanic White women. Together, these 4 causes accounted for 59% of the non-Hispanic Black‒non-Hispanic White maternal mortality disparity. Conclusions. The prominence of cardiovascular-related conditions among the leading causes of confirmed maternal death, particularly for non-Hispanic Black women, necessitates increased vigilance for cardiovascular problems during the pregnant and postpartum period. Many of these deaths are preventable.

Maternal mortality ratio in Jiangsu Province, China: recent trends and associated factors.

BACKGROUND: In recent years, births to older mothers and multiparous mothers have increased rapidly with the change of birth policy in China. And mothers of advanced age are more likely to have maternal complications and poor birth outcomes. We aimed to estimate the recent trends and underlying risk factors of maternal mortality. METHODS: In this systematic assessment, we used data from the National Maternal and Child Health Routine Reporting System (2013-2018), Jiangsu Provincial Maternal Mortality Surveillance System (2017-2018), the Integrated National Mortality Surveillance System (2018), City Statistical Yearbooks (2018), City Health Statistical Yearbooks (2018). The factors associated with maternal mortality ratio (MMR) were explored using the stepwise regression analysis and cluster analysis. RESULTS: The MMR maintained at low levels between 2013 and 2016 and there was a slight increase in maternal mortality after 2016 in Jiangsu province. With the implementation of the China's universal two child policies, the percentage of multiparous mothers ascended from 34.2% (95% confidence interval (CI) = 34.1-34.3%) in 2013 to 51.4% (95% CI = 51.3-51.6%) in 2018 (beta = 3.88, P < 0.001). Consistently, the percentage of advanced maternal age (≥ 35) increased from 8.4% (95% CI = 8.4-8.5%) in 2013 to 10.4% (95% CI = 10.3-10.4%) in 2018 (beta = 0.50, P = 0.012). And we found that the percentage of multiparous mothers and advanced maternal age among maternal deaths were higher than all pregnant women (P < 0.001). In the stepwise regression analysis, four risk factors were significantly associated with maternal mortality ratio (primary industry of gross domestic product (GDP), rate of delivery in maternal and child health hospital, rate of cesarean section and rate of low birth weight). As the results derived from cluster analysis, the relatively developed regions had lower preventable maternal mortality ratio (43.5% (95% CI = 31.2-56.7%) vs. 62.6% (95% CI = 52.3-72.0%), P = 0.027). CONCLUSIONS: Since the universal two child policy has been associated with changes in health related birth characteristics: women giving birth have been more likely to be multiparous, and more likely to be aged 35 and over. This somewhat magnifies the impact of differences in economic development and obstetric services on MMR. The findings based on prefecture level data suggest that interventions must target economic development, the health system and maternal risk factors in synergy. These approaches will be of great benefit to control or diminish environmental factors associated with preventable deaths and will effectively reduce MMR and narrow the gap among the different regions.

Maternal mortality in six low and lower-middle income countries from 2010 to 2018: risk factors and trends.

BACKGROUND: Maternal mortality is a public health problem that disproportionately affects low and lower-middle income countries (LMICs). Appropriate data sources are lacking to effectively track maternal mortality and monitor changes in this health indicator over time. METHODS: We analyzed data from women enrolled in the NICHD Global Network for Women's and Children's Health Research Maternal Newborn Health Registry (MNHR) from 2010 through 2018. Women delivering within research sites in the Democratic Republic of Congo, Guatemala, India (Nagpur and Belagavi), Kenya, Pakistan, and Zambia are included. We evaluated maternal and delivery characteristics using log-binomial models and multivariable models to obtain relative risk estimates for mortality. We used running averages to track maternal mortality ratio (MMR, maternal deaths per 100,000 live births) over time. RESULTS: We evaluated 571,321 pregnancies and 842 maternal deaths. We observed an MMR of 157 / 100,000 live births (95% CI 147, 167) across all sites, with a range of MMRs from 97 (76, 118) in the Guatemala site to 327 (293, 361) in the Pakistan site. When adjusted for maternal risk factors, risks of maternal mortality were higher with maternal age > 35 (RR 1.43 (1.06, 1.92)), no maternal education (RR 3.40 (2.08, 5.55)), lower education (RR 2.46 (1.54, 3.94)), nulliparity (RR 1.24 (1.01, 1.52)) and parity > 2 (RR 1.48 (1.15, 1.89)). Increased risk of maternal mortality was also associated with occurrence of obstructed labor (RR 1.58 (1.14, 2.19)), severe antepartum hemorrhage (RR 2.59 (1.83, 3.66)) and hypertensive disorders (RR 6.87 (5.05, 9.34)). Before and after adjusting for other characteristics, physician attendance at delivery, delivery in hospital and Caesarean delivery were associated with increased risk. We observed variable changes over time in the MMR within sites. CONCLUSIONS: The MNHR is a useful tool for tracking MMRs in these LMICs. We identified maternal and delivery characteristics associated with increased risk of death, some might be confounded by indication. Despite declines in MMR in some sites, all sites had an MMR higher than the Sustainable Development Goals target of below 70 per 100,000 live births by 2030. TRIAL REGISTRATION: The MNHR is registered at NCT01073475 .

Maternal deaths due to eclampsia in teenagers: Lessons from assessment of maternal deaths in South Africa.

BACKGROUND: Eclampsia remains a major cause of maternal mortality, particularly in teenage pregnancies. Healthcare professionals providing antenatal must regard teenagers as a high risk group for the pre-eclampsia-eclampsia syndrome. SETTING: Data extracted from the South African Saving Mothers Report: 2014-2016. AIM: To establish the clinical details in teenage maternal deaths owing to eclampsia. METHOD: Retrospective review of the case records and maternal death assessment forms of teenagers that died due to eclampsia during 2014-2016. RESULTS: There were 47 teenagers (aged 14 to 19 years) who died from eclampsia. Of these 18 out of 47 (38%) deaths occurred in the post-partum period. Forty (85.1%) of the patients had antenatal care. Three (6.4%) had post-partum eclampsia, and of the remaining 44 of the 47 (93.6%), the gestational age at first occurrence of a seizure ranged from 25 to 39 weeks. The blood pressures at the time of seizure ranged from systolic of 131 to 210 mmHg and diastolic of 89 to 130 mmHg. The commonest final causes of death were intracerebral haemorrhage associated with severe hypertension and multi-organ failure. Avoidable factors included transport delays, referral to the wrong levels of health care and poor care by health professionals. CONCLUSION: Teenage pregnancy is a risk factor for eclampsia-related death; awareness of borderline elevations of blood pressure levels from baseline values (prehypertension levels) and taking following national guidelines on the management of hypertensive disorders of pregnancy will decrease deaths from eclampsia.

A qualitative study of community elders' perceptions about the underutilization of formal maternal care and maternal death in rural Nigeria.

BACKGROUND: Underutilization of formal maternal care services and accredited health attendants is a major contributor to the high maternal mortality rates in rural communities in Nigeria. Perceptions of a poor quality of care and inaccessible services in health facilities strongly influence the low use of formal maternal care services. There is therefore a need to understand local perceptions about maternal health services utilization and maternal death. This study thereby aims to explore perceptions and beliefs about the underutilization of formal care and causes of maternal death, as well as to identify potential solutions to improve use and reduce maternal mortality in rural Nigeria. METHODS: Data were collected through 9 community conversations, which were conducted with 158 community elders in 9 rural communities in Edo State, Nigeria. Data from transcripts were analyzed through inductive thematic analysis using NVivo 12 software. RESULTS: Perceived reasons for the underutilization of formal maternal care included poor qualities of care, physical inaccessibility, financial inaccessibility, and lack of community knowledge. Perceived reasons for maternal death were related to medical causes, maternal healthcare services deficiencies, uptake of native maternal care, and poor community awareness and negligence. Elders identified increased access to adequate maternal care, health promotion and education, community support, and supernatural assistance from a deity as solutions for increasing use of formal maternal care and reducing maternal mortality rates. CONCLUSION: Study results revealed that multifaceted approaches that consider community contexts, challenges, and needs are required to develop acceptable, effective and long-lasting positive changes. Interventions aiming to increase use of formal care services and curb maternal mortality rates must target improvements to the technical and interpersonal qualities of care, ease of access, community awareness and knowledge, and allow community members to actively engage in implementation phases.

Monitoring progress in reducing maternal mortality using verbal autopsy methods in vital registration systems: what can we conclude about specific causes of maternal death?

Reducing maternal mortality is a key focus of development strategies and one of the indicators used to measure progress towards achieving the Sustainable Development Goals. In the absence of medical certification of the cause of deaths that occur in the community, verbal autopsy (VA) methods are the only available means to assess levels and trends of maternal deaths that occur outside health facilities. The 2016 World Health Organization VA Instrument facilitates the identification of eight specific causes of maternal death, yet maternal deaths are often unsupervised, leading to sparse and generally poor symptom reporting to inform a reliable diagnosis using VAs. There is little research evidence to support the reliable identification of specific causes of maternal death in the context of routine VAs. We recommend that routine VAs are only used to capture the event of a maternal death and that more detailed follow-up interviews are used to identify the specific causes.

Scaling Up Misoprostol to Prevent Postpartum Hemorrhage at Home Births in Mozambique: A Case Study Applying the ExpandNet/WHO Framework.

BACKGROUND: Mozambique has a high maternal mortality ratio, and postpartum hemorrhage (PPH) is a leading cause of maternal deaths. In 2015, the Mozambican Ministry of Health (MOH) commenced a program to distribute misoprostol at the community level in selected districts as a strategy to reduce PPH. This case study uses the ExpandNet/World Health Organization (WHO) scale-up framework to examine the planning, management, and outcomes of the early expansion phase of the scale-up of misoprostol for the prevention of PPH in 2 provinces in Mozambique. METHODS: Qualitative semistructured interviews were conducted between February and October 2017 in 5 participating districts in 2 provinces. Participants included program stakeholders, health staff, community health workers (CHWs), and traditional birth attendants (TBAs). Interviews were analyzed using the ExpandNet/WHO framework alongside national policy and planning documents and notes from a 2017 national Ministry of Health maternal, newborn, and child health workshop. Outcomes were estimated using misoprostol coverage and access in 2017 for both provinces. RESULTS: The study revealed a number of barriers and facilitators to scale-up. Facilitators included a supportive political and legal environment; a clear, credible, and relevant innovation; early expansion into some Ministry of Health systems and a strong network of CHWs and TBAs. Barriers included a reduction in reach due to a shift from universal distribution to application of eligibility criteria; fear of misdirecting misoprostol for abortion or labor induction; limited communication and understanding of the national PPH prevention strategy; inadequate monitoring and evaluation; challenges with logistics systems; and the inability to engage remote TBAs. Lower coverage was found in Inhambane province than Nampula province, possibly due to NGO support and political champions. CONCLUSION: This study identified the need for a formal review of the misoprostol program to identify adaptations and to develop a systematic scale-up strategy to guide national scale-up.

Population-level factors associated with maternal mortality in the United States, 1997-2012.

BACKGROUND: In contrast to peer nations, the United States is experiencing rapid increases in maternal mortality. Trends in individual and population-level demographic factors and health trends may play a role in this change. METHODS: We analyzed state-level maternal mortality for the years 1997-2012 using multilevel mixed-effects regression grouped by state, using publicly available data including whether a state had adopted the 2003 U.S. Standard Certificate of Death, designed to simplify identification of pregnant and recently pregnant decedents. We calculated the proportion of the increase in maternal mortality attributable to specific factors during the study period. RESULTS: Maternal mortality was associated with higher population prevalence of obesity and high school non-completion among women of childbearing age; these factors explained 31.0% and 5.3% of the attributable increase in maternal mortality during the study period, respectively. Among delivering mothers, prevalence of diabetes (17.0%), attending fewer than 10 prenatal visits (4.9%), and African American race (2.0%) were also associated with higher maternal mortality, as was time-varying state adoption of the 2003 death certificate (31.1%). CONCLUSIONS: Our findings indicate that, in addition to better case ascertainment of maternal deaths, adverse changes in chronic diseases, insufficient healthcare access, and social determinants of health represent identifiable risks for maternal mortality that merit prompt attention in population-directed interventions and health policies.

Optimal profile limits for maternal mortality rate (MMR) in South Sudan.

BACKGROUND: Reducing Maternal Mortality Rate (MMR) is considered by the international community as one of the eight Millennium Development Goals. Based on previous studies, Skilled Assistant at Birth (SAB), General Fertility Rate (GFR) and Gross Domestic Product (GDP) have been identified as the most significant predictors of MMR in South Sudan. This paper aims for the first time to develop profile limits for the MMR in terms of significant predictors SAB, GFR, and GDP. The paper provides the optimal values of SAB and GFR for a given MMR level. METHODS: Logarithmic multi- regression model is used to model MMR in terms of SAB, GFR and GDP. Data from 1986 to 2015 collected from Juba Teaching Hospital was used to develop the model for predicting MMR. Optimization procedures are deployed to attain the optimal level of SAB and GFR for a given MMR level. MATLAB was used to conduct the optimization procedures. The optimized values were then used to develop lower and upper profile limits for yearly MMR, SAB and GFR. RESULTS: The statistical analysis shows that increasing SAB by 1.22% per year would decrease MMR by 1.4% (95% CI (0.4-5%)) decreasing GFR by 1.22% per year would decrease MMR by 1.8% (95% CI (0.5-6.26%)). The results also indicate that to achieve the UN recommended MMR levels of minimum 70 and maximum 140 by 2030, the government should simultaneously reduce GFR from the current value of 175 to 97 and 75, increase SAB from the current value of 19 to 50 and 76. CONCLUSIONS: This study for the first time has deployed optimization procedures to develop lower and upper yearly profile limits for maternal mortality rate targeting the UN recommended lower and upper MMR levels by 2030. The MMR profile limits have been accompanied by the profile limits for optimal yearly values of SAB and GFR levels. Having the optimal level of predictors that significantly influence the maternal mortality rate can effectively aid the government and international organizations to make informed evidence-based decisions on resources allocation and intervention plans to reduce the risk of maternal death.

Factors associated with maternal mortality in Malawi: application of the three delays model.

BACKGROUND: The three delays model proposes that maternal mortality is associated with delays in: 1) deciding to seek care; 2) reaching the healthcare facility; and 3) receiving care. Previously, the majority of women who died were reported to have experienced type 1 and 2 delays. With increased coverage of healthcare services, we sought to explore the relative contribution of each type of delay. METHOD: 151 maternal deaths were identified during a 12-month reproductive age mortality survey (RAMOS) conducted in Malawi; verbal autopsy and facility-based medical record reviews were conducted to obtain details about the circumstances surrounding each death. Using the three delays framework, data were analysed for women who had; 1) died at a healthcare facility, 2) died at home but had previously accessed care and 3) died at home and had not accessed care. RESULTS: 62.2% (94/151) of maternal deaths occurred in a healthcare facility and a further 21.2% (32/151) of mothers died at home after they had accessed care at a healthcare facility. More than half of all women who died at a healthcare facility (52.1%) had experienced more than one type of delay. Type 3 delays were the most significant delay for women who died at a healthcare facility or women who died at home after they had accessed care, and was identified in 96.8% of cases. Type 2 delays were experienced by 59.6% and type 1 delays by 39.7% of all women. Long waiting hours before receiving treatment at a healthcare facility, multiple delays at the time of admission, shortage of drugs, non-availability and incompetence of skilled staff were some of the major causes of type 3 delays. Distance to a healthcare facility was the main problem resulting in type 2 delays. CONCLUSION: The majority of women do try to reach health services when an emergency occurs, but type 3 delays present a major problem. Improving quality of care at healthcare facility level will help reduce maternal mortality.

Analysis of inequality in maternal and child health outcomes and mortality from 2000 to 2013 in China.

BACKGROUND: Inequality in maternal and child health seriously hinders the overall improvement of health, which is a concern in both the United Nations Sustainable Development Goals (SDGs) and Healthy China 2030. However, research on the equality of maternal and child health is scarce. This study longitudinally assessed the equality trends in China's maternal and child health outcomes from 2000 to 2013 based on place of residence and gender to improve the fairness of domestic maternal and child health. METHODS: Data on China's maternal and child health monitoring reports were collected from 2000 to 2013. Horizontal and vertical monitoring were performed on the following maternal and child health outcome indicators: incidence of birth defects (IBD), maternal mortality rate (MMR), under 5 mortality rate (U5MR) and neonatal mortality rate (NMR). The newly developed HD*Calc software by the World Health Organization (WHO) was employed as a tool for the health inequality assessment. The between group variance (BGV) and the Theil index (T) were used to measure disparity between different population groups, and the Slope index was used to analyse the BGV and T trends. RESULTS: The disparity in the MMR, U5MR and NMR for the different places of residence (urban and rural) improved over time. The BGV (Slope BGV = -32.24) and T (Slope T = -7.87) of MMR declined the fastest. The gender differences in the U5MR (Slope BGV = -0.06, Slope T = -0.21) and the NMR (Slope BGV = -0.01, Slope T = 0.23) were relatively stable, but the IBD disparity still showed an upward trend in both the place of residence and gender strata. A decline in urban-rural differences in the cause of maternal death was found for obstetric bleeding (Slope BGV = -14.61, Slope T = -20.84). Improvements were seen in the urban-rural disparity in premature birth and being underweight (PBU) in children under 5 years of age. Although diarrhoea and pneumonia decreased in the U5MR, no obvious gender-based trend in the causes of death was observed. CONCLUSION: We found improvement in the disparity of maternal and child health outcomes in China. However, the improvements still do not meet the requirements proposed by the Healthy China 2030 strategy, particularly regarding the rise in the IBD levels and the decline in equality. This study suggests starting with maternal and child health services and focusing on the disparity in the causes of death in both the place of residence and gender strata. Placing an emphasis on health services may encourage the recovery of the premarital check and measures such as prenatal and postnatal examinations to improve equality.

Obstetric Care Consensus No. 5: Severe Maternal Morbidity: Screening and Review.

This document builds upon recommendations from peer organizations and outlines a process for identifying maternal cases that should be reviewed. Severe maternal morbidity is associated with a high rate of preventability, similar to that of maternal mortality. It also can be considered a near miss for maternal mortality because without identification and treatment, in some cases, these conditions would lead to maternal death. Identifying severe morbidity is, therefore, important for preventing such injuries that lead to mortality and for highlighting opportunities to avoid repeat injuries. The two-step screen and review process described in this document is intended to efficiently detect severe maternal morbidity in women and to ensure that each case undergoes a review to determine whether there were opportunities for improvement in care. Like cases of maternal mortality, cases of severe maternal morbidity merit quality review. In the absence of consensus on a comprehensive list of conditions that represent severe maternal morbidity, institutions and systems should either adopt an existing screening criteria or create their own list of outcomes that merit review.

Management of abortion complications at a rural hospital in Uganda: a quality assessment by a partially completed criterion-based audit.

BACKGROUND: Complications of unsafe abortion are a major contributor to maternal deaths in developing countries. This study aimed to evaluate the clinical assessment for life-threatening complications and the following management in women admitted with complications from abortions at a rural hospital in Uganda. METHODS: A partially completed criterion-based audit was conducted comparing actual to optimal care. The audit criteria cover initial clinical assessment of vital signs and management of common severe complications such as sepsis and haemorrhage. Sepsis shall be managed by immediate evacuation of the uterus and antibiotics in relation to and after surgical management. Shock by aggressive rehydration followed by evacuation. In total 238 women admitted between January 2007 and April 2012 were included. Complications were categorized as incomplete, threatened, inevitable, missed or septic abortion and by trimester. Actual management was compared to the audit criteria and presented by descriptive statistics. RESULTS: Fifty six per cent of the women were in second trimester. Abortion complications were distributed as follows: 53 % incomplete abortions, 28 % threatened abortions, 12 % inevitable abortions, 4 % missed abortions and 3 % septic abortions. Only one of 238 cases met all criteria of optimal clinical assessment and management. Thus, vital signs were measured in 3 %, antibiotic criteria was met in 59 % of the cases, intravenous fluid resuscitation was administered to 35 % of women with hypotension and pain was managed in 87 % of the cases. Sharp curettage was used in 69 % of those surgically evacuated and manual vacuum aspiration in 14 %. In total 3 % of the abortions were categorized as unsafe. Two of eight women with septic abortion had evacuation performed during admission-day, one woman died due to septic abortion and one from severe haemorrhage. CONCLUSIONS: Guidelines were not followed and suboptimal assessment or management was observed in all but one case. This was especially due to missing documentation of vital signs necessary to diagnose life-threatening complications, poor fluid resuscitation at signs of shock, and delayed evacuation of septic abortion.

A profile of women at the highest risk of maternal death in Pakistan.

Traditionally, health interventions implemented in Pakistan have been designed to increase the supply of maternal health services, but have not focused on reaching the poorest women or on providing high-quality services. Demand-side barriers to the utilization of health services are substantial in Pakistan, as are supply-side constraints to the provision of quality health care. This study uses data from the Pakistan Demographic and Health Survey 2006-07 to develop a profile of the poorest women in Pakistan in order to understand demand-side barriers to accessing maternal health care. The study shows stark differences in human capital, material and demographic resources between the poorest women and other women. It illustrates how these differences translate into low levels of service utilization among the poorest women. The purpose of the study is to stimulate a discussion of both the difficulty and the importance of reaching the poorest women with high-quality maternal health interventions. The findings from several pilot projects in Pakistan suggest that the poorest women can be reached at disproportionately higher rates than non-poor women through targeted, community-based, interventions. There is little demonstrable evidence, however, that high-quality care has been provided through these interventions. Evidence-based approaches, which have the potential to overcome financial and sociocultural barriers to service utilization, should be scaled up as soon as possible. However, measures should be taken to ensure that the quality of care provided through these interventions is adequate and able to lead to significant reductions in mortality.

Reasons for persistently high maternal and perinatal mortalities in Ethiopia: Part II-Socio-economic and cultural factors.

BACKGROUND: The major causes of maternal and perinatal deaths are mostly pregnancy related. However, there are several predisposing factors for the increased risk of pregnancy related complications and deaths in developing countries. The objective of this review was to grossly estimate the effect of selected socioeconomic and cultural factors on maternal mortality, stillbirths and neonatal mortality in Ethiopia. METHODS: A comprehensive literature review was conducted focusing on the effect of total fertility rate (TFR), modern contraceptive use, harmful traditional practice, adult literacy rate and level of income on maternal and perinatal mortalities. For the majority of the data, regression analysis and Pearson correlation coefficient were used as a proxy indicator for the association of variables with maternal, fetal and neonatal mortality. RESULTS: Although there were variations in the methods for estimation, the TFR of women in Ethiopia declined from 5.9 to 4.8 in the last fifteen years, which was in the middle as compared with that of other African countries. The preference of injectable contraceptive method has increased by 7-fold, but the unmet contraceptive need was among the highest in Africa. About 50% reduction in female genital cutting (FGC) was reported although some women's attitude was positive towards the practice of FGC. The regression analysis demonstrated increased risk of stillbirths, neonatal and maternal mortality with increased TFR. The increased adult literacy rate was associated with increased antenatal care and skilled person attended delivery. Low adult literacy was also found to have a negative association with stillbirths and neonatal and maternal mortality. A similar trend was also observed with income. CONCLUSION: Maternal mortality ratio, stillbirth rate and neonatal mortality rate had inverse relations with income and adult education. In Ethiopia, the high total fertility rate, low utilization of contraceptive methods, low adult literacy rate, low income and prevalent harmful traditional practices have probably contributed to the high maternal mortality ratio, stillbirth and neonatal mortality rates.

The maternal early warning criteria: a proposal from the national partnership for maternal safety.

Case reviews of maternal death have revealed a concerning pattern of delay in recognition of hemorrhage, hypertensive crisis, sepsis, venous thromboembolism, and heart failure. Early-warning systems have been proposed to facilitate timely recognition, diagnosis, and treatment for women developing critical illness. A multidisciplinary working group convened by the National Partnership for Maternal Safety used a consensus-based approach to define The Maternal Early Warning Criteria, a list of abnormal parameters that indicate the need for urgent bedside evaluation by a clinician with the capacity to escalate care as necessary in order to pursue diagnostic and therapeutic interventions. This commentary reviews the evidence supporting the use of early-warning systems, describes The Maternal Early Warning Criteria, and provides considerations for local implementation.

Guidelines and tools for organizing and conducting maternal death reviews.

Maternal death reviews (MDRs) provide the multidisciplinary maternity care team with a process to conduct in-depth review of the health care and circumstances surrounding maternal deaths. From these reviews, recommendations to improve care in primary, secondary, and tertiary healthcare settings can be made. Practical guidelines and training curricula for MDRs are lacking. To fill this gap, a manual comprising guidelines and tools to help health professionals conduct structured MDRs was developed through the FIGO LOGIC initiative.

Training health professionals in conducting maternal death reviews.

In countries where maternal death review (MDR) sessions are proposed as an intervention to improve quality of obstetric care, training focuses on the theory behind this method. However, experience shows that health staff lack confidence to apply the theory if they have not attended a practical training session. To address this problem, a training curriculum based on the new guidelines from the FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative for preparing and conducting MDR sessions was designed and tested in Cameroon. This curriculum is competency-based and consists primarily of practical individual or group exercises.