Maternal mortality by socio-demographic characteristics and cause of death in South Africa: 2007-2015.

BACKGROUND: South Africa's maternal mortality ratio remains high although it has substantially declined in the past few years. Numerous studies undertaken in South Africa on maternal mortality have not paid much attention to how the causes are distributed in different socio-demographic groups. This study assesses and analyses the causes of maternal mortality according to sociodemographic factors in South Africa. METHODS: The causes of maternal deaths were assessed with respect to age, province, place of death, occupation, education and marital status. Data were obtained from the vital registration database of Statistics South Africa. About 14,892 maternal deaths of women from 9 to 55 years of age were analysed using frequency tables, cross-tabulations and logistic regression. Maternal mortality ratio (MMR), by year, age group, and province for the years 2007-2015 was calculated. RESULTS: The 2007-2015 MMR was 139.3 deaths per 100,000 live births (10,687,687 total live births). The year 2009 had the highest MMR during this period. Specific province MMR for three triennia (2007-2009; 2010-2012; 2013-2015) shows that the Free State province had the highest MMR (297.9/100000 live births; 214.6/100000 live births; 159/100000 live births) throughout this period. MMR increased with age. Although the contribution of the direct causes of death (10603) was more than double the contribution of indirect causes (4289) maternal mortality showed a steady decline during this period. CONCLUSIONS: The study shows evidence of variations in the causes of death among different socio-demographic subgroups. These variations indicate that more attention has to be given to the role played by socio-demographic factors in maternal mortality.

Changing the conversation: applying a health equity framework to maternal mortality reviews.

The risk of maternal death in the United States is higher than peer nations and is rising and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual's risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death and, when appropriate, to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the community vital signs, the social and community context in which women live, work, and seek health care, maternal mortality review committees may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.

Causes and contributory factors of maternal mortality: evidence from maternal and perinatal death surveillance and response in Ogun state, Southwest Nigeria.

BACKGROUND: Nigeria still ranks second globally in the number of maternal deaths. Most maternal death reviews in Nigeria are isolated research based reports from a single health facility. This study determined causes and contributory factors of maternal mortality in Ogun statefollowing a periodic State-widematernal and perinatal deaths surveillance and response (MPDSR) review. METHODS: We carried out a retrospective analysis of cases of maternal deaths notified (n = 77) and reviewed (n = 45) in health facilities in Ogun State from 2015 to 2016selected using total sampling method. Using the national MPDSR structured and validated data collection tools or questionnaire, collected data was extracted from existing MPDSR data base, andanalyzed using the Statistical Package for Social Sciences (SPSS) software 20.0. We obtained approval from the State Ministry of Health for this study. RESULTS: Average age at maternal death was 30.8 ± 5.7 years. Haemorrhageand pre-eclampsia or eclampsia account for 43.4 and 36.9% of causes respectively. Leading contributory factors ofmaternal deaths include inadequate human resource for health, delay in seeking care, inadequate equipment, lack of ambulance transportation, and delay in referrals services. 51.1%of the women had antenatal care while a significant proportion of the women were referred from Traditional Births Attendants (TBAs) and mission houses. CONCLUSION: We concluded that many of the contributory factors of maternal mortality could be avoided if preventive measures were taken and adequate care available. MPDSR provides a platform for critical evidence of where the main problems lie, and can provide valuable information on strategies which maternal mortality prevention programs should focus on. The implementation and institutionalization of MPDSR programme is on course in Ogun State. MPDSR is feasible and should be institutionalized in all states of Nigeria. A commitment to act upon the findings of MPDSR is a key prerequisite for success.

Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study.

OBJECTIVE: To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities. METHODS: We conducted a repeated cross-sectional study using the 2006-2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe new cases, cause distributions and the reclassification of maternal mortality cases by the BIRMM process. We used statistical tests to analyse differences in sociodemographic characteristics between direct and indirect deaths and differences in the proportion of overall direct and indirect deaths, by year and by municipality poverty level. FINDINGS: A total of 9043 maternal deaths were subjected to the review process. There was a 13% increase (from 7829 to 9043) in overall identified maternal deaths and a threefold increase in the proportion of maternal deaths classified as late maternal deaths (from 2.1% to 6.9%). Over the study period direct obstetric deaths declined, while there was no change in deaths from indirect obstetric causes. Direct deaths were concentrated in women who lived in the poorest municipalities. When compared to those dying of direct causes, women dying of indirect causes had fewer pregnancies and were slightly younger, better educated and more likely to live in wealthier municipalities. CONCLUSION: The BIRMM is one approach to correct maternal death statistics in settings with poor resources. The approach could help the health system to rethink its strategy to reduce maternal deaths from indirect obstetric causes, including prevention of unwanted pregnancies and improvement of antenatal and post-obstetric care.

Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology.

BACKGROUND: Because of the lack of large obstetric anesthesia databases, the incidences of serious complications related to obstetric anesthesia remain unknown. The Society for Obstetric Anesthesia and Perinatology developed the Serious Complication Repository Project to establish the incidence of serious complications related to obstetric anesthesia and to identify risk factors associated with each. METHODS: Serious complications were defined by the Society for Obstetric Anesthesia and Perinatology Research Committee which also coordinated the study. Thirty institutions participated in the approximately 5-yr study period. Data were collected as part of institutional quality assurance and sent to the central project coordinator quarterly. RESULTS: Data were captured on more than 257,000 anesthetics, including 5,000 general anesthetics for cesarean delivery. There were 157 total serious complications reported, 85 of which were anesthesia related. High neuraxial block, respiratory arrest in labor and delivery, and unrecognized spinal catheter were the most frequent complications encountered. A serious complication occurs in approximately 1:3,000 (1:2,443 to 1:3,782) obstetric anesthetics. CONCLUSIONS: The Serious Complication Repository Project establishes the incidence of serious complications in obstetric anesthesia. Because serious complications related to obstetric anesthesia are rare, there were too few complications in each category to identify risk factors associated with each. However, because many of these complications can lead to catastrophic outcomes, it is recommended that the anesthesia provider remains vigilant and be prepared to rapidly diagnose and treat any complication.

Why do pregnant women die? A review of maternal deaths from 1990 to 2010 at the University of Alabama at Birmingham.

BACKGROUND: The number of reported pregnancy-related deaths in the United States steadily increased from 7.2 deaths per 100,000 live births in 1987 to a high of 17.8 deaths per 100,000 live births in 2009. Compared to Caucasian women, African American women were nearly 4 times as likely to die from childbirth. To better understand the reason for this trend, we conducted a case-control study at University of Alabama at Birmingham (UAB) Hospital. Our primary study hypothesis was that women who died at UAB were more likely to be African American than women in a control group who delivered an infant at UAB and did not die. We expected to find a difference in race proportions and other patient characteristics that would further help to elucidate the cause of a racial disparity in maternal deaths. METHODS: We reviewed all maternal deaths (cases) at UAB Hospital from January 1990 through December 2010 identified based on electronic uniform billing data and ICD-9 codes. Each maternal death was matched 2:1 with women who delivered at a time that most closely coincided with the time of the maternal death in 2-step selection process (electronic identification and manual confirmation). Maternal variables obtained were comorbidities, duration of hospital stay, cause of death, race, distance from home to hospital, income, prenatal care, body mass index, parity, insurance type, mode of delivery, and marital status. The strength of univariate associations of maternal variables and case/control status was calculated. The association of case/control status and race was also examined after controlling for residential distance from the hospital. RESULTS: There was insufficient evidence to suggest racial disparity in maternal death. The proportion of African American women was 57% (42 of 77) in the maternal death group and 61% (94 of 154) in the control group (P = 0.23). The univariate odds ratio for maternal death for African American to Caucasian race was 0.66 (95% confidence interval [CI], 0.37-1.19); the adjusted odds ratio was 1.46 (95% CI, 0.73-3.01). Longer compared with shorter distance of residence to the hospital was a highly significant predictor (P < 0.001) of maternal death. CONCLUSIONS: We did not observe a racial disparity in maternal deaths at UAB Hospital. We suggest that the next step toward understanding racial differences in maternal deaths reported in the United States should be directed at the health care delivery outside the tertiary care hospital setting, particularly at eliminating access barriers to health care for all women.

California Pregnancy-Associated Mortality Review: mixed methods approach for improved case identification, cause of death analyses and translation of findings.

After several decades of declining rates, maternal mortality climbed in California from a three-year moving average of 9.4 deaths per 100,000 live births in 1999-2001 to a high of 14.0 deaths per 100,000 live births in 2006-2008 (p < 0.001). The Maternal, Child and Adolescent Health Division of the California Department of Public Health developed a mixed method approach to identify and investigate maternal deaths to inform prevention strategies. This paper describes the methodology of the California Pregnancy-Associated Mortality Review (CA-PAMR) and its advantages for improved surveillance, cause of death analysis, and translation of findings. From 2002 to 2004, 1,598,792 live births occurred in California and 555 women died while pregnant or within one year of pregnancy. A screening algorithm identified cases for review that were likely to be pregnancy-related. Medical records were then abstracted and reviewed by a multidisciplinary committee to determine cause of death, contributing factors, and opportunities for quality improvement. Mixed methods were used to analyze, synthesize and translate Committee recommendations for improved care. Of 211 cases selected for review, 145 deaths were determined to be pregnancy-related. CA-PAMR methods corrected misclassification of cases and more accurately identified the leading causes of death. Cardiovascular disease emerged as the leading cause of pregnancy-related deaths (20%), and African-American women were disproportionately represented among cardiovascular deaths. Overall, the chance to prevent the fatal outcome appeared good or strong in 40% of cases reviewed. The CA-PAMR methodology resulted in additional case finding, improved accuracy of the causes of pregnancy-related deaths, and evidence to guide development of prevention and quality improvement efforts.

Reducing maternal deaths in a low resource setting in Nigeria.

OBJECTIVE: To assess the impact of the adoption of evidence based guidelines on maternal mortality reduction at Enugu State University Teaching Hospital, Nigeria. MATERIALS AND METHODS: A retrospective review of all maternal deaths between 1 st January, 2005 and 31 st December, 2010 was carried out. Evidence based management guidelines for eclampsia and post-partum hemorrhage were adopted. These interventions strategy were carried out from 1 st January, 2008-31 st December, 2010 and the result compared with that before the interventions (2005-2007). MAIN OUTCOME MEASURE: Maternal mortality ratio (MMR) and case fatality rates. RESULTS: There were 9150 live births and 59 maternal deaths during the study period, giving an MMR of 645/100 000 live births. Pregnant women who had no antenatal care had almost 10 times higher MMR. There was 43.5% reduction in the MMR with the interventions (488 vs. 864/100 000 live births P = 0.039, odds ratio = 1.77). There was also significant reduction in case fatality rate for both eclampsia (15.8% vs. 2.7%; P = 0.024, odds ratio = 5.84 and Post partum hemorrhage (PPH) (13.6% vs. 2.5% P value = 0.023, odds ratio = 5.5. Obstetric hemorrhage was the most common cause of death (23.73%), followed by the eclampsia. CONCLUSION: Administration of evidence based intervention is possible in low resource settings and could contribute to a significant reduction in the maternal deaths.

Progress in health-related millennium development goals in the WHO South-East Asia Region.

Home to 25% of the world's population and bearing 30% of the Global disease burden, the South-East Asia Region [1] of the World Health Organization has an important role in the progress of global health. Three of the eight million development goal (MDG) goals that relate to health are MDG 4, 5, and 6. There is progress in all three goals within the countries of the region, although the progress varies across countries and even within countries. With concerted and accelerated efforts in some countries and certain specific areas, the region will achieve the targets of the three health MDGs. The key challenges are in sustainable scaling up of evidence-based interventions to improve maternal and child health and controlling communicable diseases. This will require continued focus and investments in strengthening health systems that provide individual and family centered comprehensive package of interventions with equitable reach and that which is provided free at the point of service delivery. Important lessons that have been learnt in implementing the MDG agenda in the past two decades will inform setting up of the post MDG global health agenda. This article provides a snap shot of progress thus far, key challenges and opportunities in WHO South-East Asia Region and lays down the way forward for the global health agenda post 2015.

Deaths preventable by actions of the Unified Health System in the population of the Brazilian Southeast Region. / Mortes evitáveis por ações do Sistema Único de Saúde na população da Região Sudeste do Brasil.

This paper aims to analyze the mortality trend in the population aged 5-69 years residing in the Southeast and Federal Units (UF), using the "Brazilian List of Preventable Deaths Causes". An ecological study on time series of the standardized mortality rate from preventable and non-preventable causes, with adjustments for ill-defined causes and underreporting of notified deaths, from 2000 to 2013. A declining mortality rate from preventable (2.4% per year) and non-preventable causes (1.5% per year) was found in the population aged 5-69 years living in the Southeast in the period 2000-2013. A drop in all groups of preventable deaths causes and stability in the maternal death causes was observed. Deaths from noncommunicable diseases fell 2.7% annually and were higher in the age group of 60-69 years in 2013 (211.8/100,000 inhabitants for deaths from ischemic heart disease, 146.3/100,000 inhabitants for cerebrovascular diseases and 96.5/100,000 inhabitants for diabetes). The highest preventable death rates are from chronic noncommunicable diseases and external causes, both of which are sensitive to health promotion and intersectoral interventions, which reinforces the need for integrated health policies.

O objetivo deste artigo é analisar a tendência da mortalidade na população de 5 a 69 anos, residente na região Sudeste e Unidades Federadas (UF), utilizando-se a "Lista Brasileira de Causas de Mortes Evitáveis". Estudo ecológico de séries temporais da taxa de mortalidade padronizada por causas evitáveis e não evitáveis, com correções para as causas mal definidas e o sub-registro de óbitos informados, no período de 2000 a 2013. Evidenciou-se o declínio da taxa de mortalidade na população de 5 a 69 anos residente na região Sudeste por causas evitáveis (2,4% ao ano) e não evitáveis (1,5% ao ano) no período 2000-2013. Houve queda em todos os grupos de causas de mortes evitáveis e estabilidade nas causas de morte materna. As mortes por doenças não transmissíveis reduziram 2,7% ao ano e foram mais elevadas na faixa etária de 60 a 69 anos em 2013 (211,8/100.000 hab. para as mortes por doenças isquêmicas do coração; 146,3/100.000 hab. para as doenças cerebrovasculares; e 96,5/100.000 hab. para diabetes). As taxas de mortes evitáveis mais elevadas são por doenças crônicas não transmissíveis e causas externas, ambas sensíveis às intervenções de promoção da saúde e intersetoriais, o que reforça a necessidade de políticas de saúde integradas.

Reducing maternal deaths by skills-and-drills training in managing obstetric emergencies: A before-and-after observational study.

BACKGROUND: The institutional maternal mortality ratio (iMMR) in South Africa (SA) is still unacceptably high. A key recommendation from the National Committee on Confidential Enquiries into Maternal Deaths has been to improve the availability and quality of care for women suffering obstetric emergencies. OBJECTIVES: To determine whether there was a change in the number of maternal deaths and in the iMMR over time that could be attributed to the training of >80% of healthcare professionals by means of a specifically designed emergency obstetric care (EmOC) training programme. METHODS: A before-and-after study was conducted in 12 healthcare districts in SA, with the remaining 40 districts serving as a comparison group. Twelve 'most-in-need' healthcare districts in SA were selected using a composite scoring system. Multiprofessional skills-and-drills workshops were held off-site using the Essential Steps in Managing Obstetric Emergencies and Emergency Obstetric Simulation Training programme. Eighty percent or more of healthcare professionals providing maternity care in each district were trained between October 2012 and March 2015. Institutional births and maternal deaths were assessed for the period January 2011 - December 2016 and a before-and-after-training comparison was made. The number of maternal deaths and the iMMR were used as outcome measures. RESULTS: A total of 3 237 healthcare professionals were trained at 346 workshops. In all, 1 248 333 live births and 2 212 maternal deaths were identified and reviewed for cause of death as part of the SA confidential enquiries. During the same period there were 5 961 maternal deaths and 5 439 870 live births in the remaining 40 districts. Significant reductions of 29.3% in the number of maternal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.66 - 0.77) and 17.5% in the number of maternal deaths from direct obstetric causes (RR 0.825, 95% CI 0.73 - 0.93) were recorded. When comparing the percentage change in iMMR for equivalent before-and-after periods, there was a greater reduction in all categories of causes of maternal death in the intervention districts than in the comparison districts. CONCLUSIONS: Implementing a skills-and-drills EmOC training package was associated with a significant reduction in maternal deaths.

Pregnancy-Related Acute Kidney Injury in Preeclampsia: Risk Factors and Renal Outcomes.

Preeclampsia is a common cause of acute kidney injury (AKI) in low- and middle-income countries, but AKI incidence in preeclampsia, its risk factors, and renal outcomes are unknown. A prospective observational multicenter study of women admitted with preeclampsia in South Africa was conducted. Creatinine concentrations were extracted from national laboratory databases for women with maximum creatinine of ≥90 µmol/L (≥1.02 mg/dL). Renal injury and recovery were defined by Kidney Disease Improving Global Outcomes creatinine criteria. Predefined risk factors, maternal outcomes, and neonatal outcomes were compared between AKI stages. Of 1547 women admitted with preeclampsia 237 (15.3%) met AKI criteria: 6.9% (n=107) stage 1, 4.3% (n=67) stage 2, and 4.1% (n=63) stage 3. There was a higher risk of maternal death (n=7; relative risk, 4.3; 95% CI, 1.6-11.4) and stillbirth (n=80; relative risk, 2.2; 95% CI, 1.8-2.8) in women with AKI compared with those without. Perinatal mortality was also increased (89 of 240; 37.1%). Hypertension in a previous pregnancy was the strongest predictor of AKI stage 2 or 3 (odds ratio, 2.24; 95% CI, 1.21-4.17). Renal recovery rate reduced with increasing AKI stage. A third of surviving women (76 of 230 [33.0%]) had not recovered baseline renal function by discharge. Approximately half (39 of 76; 51.3%) of these women had no further creatinine testing post-discharge. In summary, AKI was common in women with preeclampsia and had high rates of associated maternal and perinatal mortality. Only two-thirds of women had confirmed renal recovery. History of a previous hypertensive pregnancy was an important risk factor.

Epidemiological analysis of maternal deaths in Hunan province in China between 2009 and 2014.

BACKGROUND: The control of maternal deaths continues to be a significant public health issue and commands an enormous amount of attention, especially under the future family planning policy. Here, we describe the epidemiology and trends of maternal deaths in Hunan province, and give several policy implications. METHODS: Maternal deaths in Hunan province between 2009 and 2014 were retrospectively reviewed and analyzed. Cochran-Armitage trend test was used to assess the time trends of maternal mortality rates. Binary logistic regression analyses were undertaken to identify the factors that were associated with unavoidable maternal deaths. RESULTS: In total, there were 987 maternal deaths, with the overall MMR declining by 45.24%. The most common causes of maternal death during this period were pregnancy complications (28.37%), obstetric hemorrhage (25.33%), and amniotic fluid embolism (15.70%). Obstetric hemorrhage (28.14%) was higher in rural areas, while pregnancy complications were higher (29.27%) in urban areas. In all, 627 (63.5%) deaths were avoidable. The risk factors associated with unavoidable maternal deaths was above 35 years (aOR = 1.80 95%CI: 1.27-2.55), without prenatal examination (aOR = 8.97 95%CI: 1.11-7.78), low household incomes (aOR = 1.15 95%CI: 1.02-1.29), without adopting the new way to deliver (aOR = 5.15 95%CI: 3.20-8.31), and death location (aOR = 1.09 95%CI: 1.02-1.18). The most frequent and important factors associated with avoidable deaths was improper knowledge and skills of the county medical institutions. CONCLUSIONS: Moderate progress was made in reducing the MMR in Hunan province. The government should aim to improve the basic midwifery skills in rural areas and the obstetric emergency rescue service for critically ill pregnant women in urban areas, and strengthen training to improve knowledge and skills in medical institutions in counties.

Impact of relaxation of the one-child policy on maternal mortality in Guangzhou, China.

OBJECTIVE: To assess the impact of the one-child policy in China on maternal mortality. METHODS: The present retrospective study included maternal death data from Guangdong, China, from January 1, 2006, to December 31, 2015; data from 2013 were excluded because they were not available. Maternal deaths were divided into legal and illegal pregnancies based on adherence to the one-child policy. The maternal mortality ratio (MMR) was compared between the groups, temporal trends in the MMR were examined, and comparisons were made of the causes of death and access to maternity care. RESULTS: The final analysis included 847 520 live deliveries and 383 maternal deaths. The MMR among legal pregnancies declined moderately from 18.5 deaths per 100 000 live deliveries in 2006 to 12.2 deaths per 100 000 live deliveries in 2015 (P=0.029), whereas the MMR among illegal pregnancies declined dramatically from 1268.4 deaths per 100 000 live deliveries to 177.5 deaths per 100 000 live deliveries (P<0.001). The proportion of avoidable maternal deaths decreased and access to quality maternity care improved among illegal pregnancies during the study period. CONCLUSIONS: Maternal mortality among illegal pregnancies declined with relaxation of the one-child policy in China.

Underlying determinants of maternal mortality in a rural South African population with high HIV prevalence (2000-2014): A population-based cohort analysis.

INTRODUCTION: Maternal mortality is one of the significant health indicators of any country and it's a frequent subject in many global heath discussions. Even though the global trends have shown a decrease on maternal mortality, many countries in sub-Saharan Africa failed to achieve the MDG 5 target in 2015.There is no specific single solution for reducing maternal mortality but there is unanimity that a reliable health system with skilled personal is vital for addressing maternal mortality. This study therefore seeks to identify the risk factors for maternal mortality in typical rural sub-Saharan African countries. METHOD: A longitudinal population based cohort study was conducted using data from 2000-2014 in Africa Health Research Institute (AHRI).The Cox regression method was used to assess the influence of selected risk factors using the Mosley-Chen model on maternal mortality. A total of 20701 women aged 15-49 years were included in the study. RESULTS: The study found 212 maternal deaths from 32,620 live births with a maternal mortality ratio (MMR) of 650 per 100,000 live births. The main causes of death were Communicable diseases (38.2%), Aids and TB (31%) and Unknown causes (11.8%). An increased risk of death was identified on, poor wealth index (HR 3.92[1.01, 15.3]), period of death 2000-2006(HR32.1 [3.79, 71.5]) and number of deliveries (6.76[2.70, 16.9]) were associated with a high risk of maternal mortality after adjusting for other independent variables included in the study. CONCLUSION: Socio-economic status, number of deliveries and period of death were found to be associated with maternal death in rural South Africa.

Reducing late maternal death due to cardiovascular disease - A pragmatic pilot study.

BACKGROUND: Late maternal mortality (up-to 1-year postpartum) is poorly reported globally and is commonly due to cardiovascular disease (CVD). We investigated targeted interventions aiming at reducing peripartum heart failure admission and late maternal death. METHODS AND RESULTS: Prospective single-centre study of 269 peripartum women presenting with CVD in pregnancy, or within 6-months postpartum. Both cardiac disease maternity (CDM) Group-I and Group-II were treated by a dedicated cardiac-obstetric team. CDM Group-II received additional interventions: 1. Early (2-6 weeks) postpartum follow-up at the CDM clinic and immediate referral to dedicated CVD specialist clinics. 2. Beta-blocker therapy was continued in women with LVEF<45% while pregnant, or immediately started postpartum. Of 269 consecutive women (mean age 28.6 ±â€¯5.9), 213 presented prepartum, 22% in NYHA groups III-IV and 79% in modified WHO groups III-IV. Patients were diagnosed with congenital heart disease (30%), valvular heart disease (25%) and cardiomyopathy (31%). The groups were similar in age, diagnosis, NYHA, modified WHO, BP and HIV, but Group-II had a higher rate of previously known CVD (p < 0.001) and a lower rate of being nulliparous (p < 0.0005). Of Group-I patients 9 died within the 12-month follow-up period versus one death in Group-II (p = 0.047). Heart failure leading to admission was 32% in Group-I versus 14% in Group-II (p = 0.0008), with Group-II having a higher beta-blocker use peripartum (p = 0.009). Perinatal mortality rate was 22/1000 live births with no differences between groups. CONCLUSION: Early follow-up in a dedicated CDM clinic with targeted pharmacological interventions led to a significant reduction in peripartum heart failure admission and mortality.

Systematic review of obstetric care from a women-centered perspective in Nigeria since 2000.

BACKGROUND: A women-centered approach can improve the quality of patient care. OBJECTIVE: To review issues in the provision of obstetric care from a patient-centered care perspective in Nigeria. SEARCH STRATEGY: Using terms related to maternal and perinatal mortality, in combination with "Nigeria", MEDLINE, Embase, CINAHL, Web of Knowledge, and African Journal Online were searched, between December 1, 2013 and January 31, 2014, for articles in any language. SELECTION CRITERIA: Articles published in a Nigerian setting after 2000 that investigated causes of and circumstance surrounding maternal deaths and complications, or clinical practice related to maternal care were included. DATA COLLECTION AND ANALYSIS: Data were extracted by two reviewers using a standardized abstraction form and were analyzed from a patient-centered perspective. MAIN RESULTS: The analysis included 57 studies. Clandestine induced abortions, lack of prenatal care, delays in seeking care, and the use of spiritual churches for delivery were found to contribute to adverse pregnancy outcomes. CONCLUSIONS: Healthcare systems respond inadequately to patients' needs in terms of abortion care, information sharing, transitioning between prenatal and obstetric care, and patients' non-medical needs. Data from clinician-led maternal death audits provided insights into how women-centered care can be provided; nonetheless, more-focused studies from a primarily patient-centered perspective are warranted.