Maternal mortality at the Korle Bu Teaching Hospital, Accra, Ghana: A five-year review.

Maternal death is a major global health issue with the highest impact in low-income countries. Despite some modest decline in the maternal mortality rates in Ghana since the 1990's, this has been below expectation. The aim of this study was to describe the trends and contributory factors to maternal mortality at the Korle Bu Teaching Hospital (KBTH), Accra, Ghana. We performed a retrospective chart review of all maternal deaths at KBTH from 2015 to 2019. Data were analyzed using SPSS version 23. A p-value of <0.05 was considered statistically significant. Over the period, there were 45,676 live births, 276 maternal deaths and a maternal mortality ratio of 604/100,000 live births (95% CI: 590/100,000 - 739/100,000). The leading causes of maternal death were hypertensive disorders (37.3%), hemorrhage (20.6%), Sickle cell disease (8.3%), sepsis (8.3%), and pulmonary embolism (8.0%). Significant factors associated with maternal mortalities at the KBTH were: women with no formal education [AOR 3.23 (CI: 1.73- 7.61)], women who had less than four antenatal visits [AOR 1.93(CI: 1.23-3.03)], and emergency cesarean section [AOR 3.87(CI: 2.51-5.98)]. Hypertensive disorders remain the commonest cause of the high maternal mortality at KBTH. Formal education and improvement in antenatal visits may help prevent these deaths.

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.

Postpartum hemorrhage outcomes and race.

BACKGROUND: How race is associated with adverse outcomes in the setting of postpartum hemorrhage is not well characterized. OBJECTIVE: The objective of this study was to assess how race is associated with adverse maternal outcomes in the setting of postpartum hemorrhage. STUDY DESIGN: This retrospective cohort study utilized the National (Nationwide) Inpatient Sample (NIS) from the Agency for Healthcare Research and Quality for the years 2012-2014. Women aged 15-54 years with a diagnosis of postpartum hemorrhage were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. Overall risk for severe morbidity based on Centers for Disease Control and Prevention criteria was analyzed along with risk for specific outcomes such as disseminated intravascular coagulation, hysterectomy, transfusion, and maternal death. Risk for severe morbidity was stratified by comorbid risk and compared by race. Weights were applied to create population estimates. Log-linear regression models were created to assess risk for severe morbidity with risk ratios and associated 95% confidence intervals as measures of effect. RESULTS: A total of 360,370 women with postpartum hemorrhage from 2012 to 2014 were included in this analysis. Risk for severe morbidity was significantly higher among non-Hispanic black women (26.6%) than non-Hispanic white, Hispanic, or Asian or Pacific Islander women (20.7%, 22.5%, and 21.4%, respectively, P < .01). For non-Hispanic black compared with non-Hispanic white, Hispanic, and Asian or Pacific Islander women risk was higher for disseminated intravascular coagulation (8.4% vs 7.1%, 6.8%, and 6.8%, respectively, P < .01) and transfusion (19.4% vs 13.9%, 16.1%, and 15.8%, respectively, P < .01). Black women were also more likely than non-Hispanic white women to undergo hysterectomy (2.4% vs 1.9%, P < .01), although Asian or Pacific Islander women were at highest risk (2.9%). Adjusting for comorbidity, black women remained at higher risk for severe morbidity (P < .01). Risk for death for non-Hispanic black women was significantly higher than for nonblack women (121.8 per 100,000 deliveries, 95% confidence interval, 94.7-156.8 vs 24.1 per 100,000 deliveries, 95% confidence interval, 19.2-30.2, respectively, P < .01). CONCLUSION: Black women were at higher risk for severe morbidity and mortality associated with postpartum hemorrhage.

Associated Factors and Quality of Care Received among Maternal Deaths at a Regional Hospital in Ghana: Maternal Death Audit Review.

Maternal death audits are crucial to the reduction of maternal deaths. The aim of this study was to identity factors contributing to maternal deaths at Eastern Regional Hospital of Ghana. Quantitative and qualitative methods were used. Quantitative data on all the maternal deaths from January to December 2012 was extracted from completed audit forms and patients records using a standardized questionnaire. The data were analyzed in Epi-info. Qualitative data was collected through in-depth interviews and focus group discussions with health staff to assess care received and factors leading to death. A total of 43 maternal deaths occurred out of which 37 (86%) were audited. Major causes of deaths were pregnancy induced hypertension (27%) and abortion (21%). Late referrals, poor supervision of junior staff, inadequate numbers of senior clinicians, lack of intensive care facility as well as unavailability and insufficient blood and blood products were the main contributory factors to the deaths. Tertiary health institutions should be adequately equipped, staffed, and funded to address these causes of maternal death.

[Analysis of maternal deaths in Shanghai from 1996 to 2015].

Objective: To analyze the trend of maternal mortality ratio (MMR) and cause of death in Shanghai from 1996 to 2015. Methods: To collect the material about the maternal death and the maternal death audit from 1996 to 2015, and to analyze the MMR, the cause of death and the result of the maternal death audit of Shanghai from 1996 to 2015 retrospectively. Results: (1) The change of MMR: the MMR in Shanghai decreased from 28.84 per 100 000 live births in 1996 to 6.66 per 100 000 live births in 2015. (2) The characteristic of maternal death: the proportion of Shanghai citizens was 27.4%(121/441) and the proportion of migrant women was 72.6%(320/441). The women with advanced maternal age was 8.2% (20/243) since 1996 to 2005, and increased to 16.7% (33/198) since 2006 to 2015. Maternal deaths during pregnancy increased from 27.6%(67/243) in the first 10 years (1996-2005) to 35.4%(70/198) in the recent 10 years (2006-2015) . The intrapartum maternal deaths was 6.2%(15/243) in the first 10 years and in the recent 10 years it was zero. The proportion of postpartum deaths in the first 10 years and in the recent 10 years were 66.3% (161/243) and 64.6%(128/198) respectively. (3) The cause of maternal death: During the recent 10 years, indirect obstetric causes [63.1%(125/198)] was more than direct obstetric causes [36.9% (73/198) ] for the first time. The death causes changed significantly. Postpartum hemorrhage remained the leading cause of maternal deaths, but the specific mortality rate (SMR) of postpartum hemorrhage decreased significantly from 7.42 per 100 000 live births in the first 10 years to 1.51 per 100 000 live births in the recent 10 years. The maternal deaths because of heart disease and cerebrovascular disease rose to the second and the forth reasons. (4) Maternal death audit: the avoidable maternal death ratio decreased from 3.66 per 100 000 live births in the first 10 years to 1.86 per 100 000 live births in the recent 10 years. Conclusions: During the past 20 years, the MMR of Shanghai decreased significantly and was close to the level of developed countries. In recent years, the causes of maternal death become more complicated. With the implementation of the second child policy, women with high risk factors increase, so government investment, policy support should be strengthened to optimize the management.

Biocultural perspectives on maternal mortality and obstetrical death from the past to the present.

Global efforts to improve maternal health are the fifth focus goal of the Millennium Development Goals adopted by the international community in 2000. While maternal mortality is an epidemic, and the death of a woman in childbirth is tragic, certain assumptions that frame the risk of death for reproductive aged women continue to hinge on the anthropological theory of the "obstetric dilemma." According to this theory, a cost of hominin selection to bipedalism is the reduction of the pelvic girdle; in tension with increasing encephalization, this reduction results in cephalopelvic disproportion, creating an assumed fragile relationship between a woman, her reproductive body, and the neonates she gives birth to. This theory, conceived in the 19th century, gained traction in the paleoanthropological literature in the mid-20th century. Supported by biomedical discourses, it was cited as the definitive reason for difficulties in human birth. Bioarchaeological research supported this narrative by utilizing demographic parameters that depict the death of young women from reproductive complications. But the roles of biomedical and cultural practices that place women at higher risk for morbidity and early mortality are often not considered. This review argues that reinforcing the obstetrical dilemma by framing reproductive complications as the direct result of evolutionary forces conceals the larger health disparities and risks that women face globally. The obstetrical dilemma theory shifts the focus away from other physiological and cultural components that have evolved in concert with bipedalism to ensure the safe delivery of mother and child. It also sets the stage for a framework of biological determinism and structural violence in which the reproductive aged female is a product of her pathologized reproductive body. But what puts reproductive aged women at risk for higher rates of morbidity and mortality goes far beyond the reproductive body. Moving beyond reproduction as the root causes of health inequalities reveals gendered-based oppression and inequality in health analyses. In this new model, maternal mortality can be seen as a sensitive indicator of inequality and social development, and can be explored for what it is telling us about women's health and lives. This article reviews the research in pelvic architecture and cephalopelvic relationships from the subfields of evolutionary biology, paleoanthropology, bioarchaeology, medical anthropology, and medicine, juxtaposing it with historical, ethnographic, and global maternal health analyses to offer a biocultural examination of maternal mortality and reproductive risk management. It reveals the structural violence against reproductive aged women inherent in the biomedical management of birth. By reframing birth as normal, not pathological, global health initiatives can consider new policies that focus on larger issues of disparity (e.g., poverty, lack of education, and poor nutrition) and support better health outcomes across the spectrum of life for women globally.

Community based maternal death review: lessons learned from ten districts in Andhra Pradesh, India.

Maternal death is as much a social phenomenon as a medical event. Maternal death review (MDR), a strategy for monitoring maternal deaths, provides information on medical, social and health system factors that should be addressed to redress gaps in service provision or utilisation. To strengthen MDR implementation in the state of Andhra Pradesh, India. The project involved development of state specific guidelines, technical assistance in operationalization and analysing processes and findings of MDR in ten districts. 284 deaths were recorded over 6 months (April-September 2012) of which 193 (75.4 %) could be reviewed. Post-partum haemorrhage (24 %) and hypertensive disorders (27.4 %) followed by puerperal sepsis in the post-partum period (16.8 %) were the leading causes of maternal deaths. 68.3 % deaths occurred at health facilities. 67 % of mothers dying during the natal or post-natal period, delivered at home, though the death occurred in a health facility. Type 1 delay (58.9 %) was the most common underlying cause of death, followed by type 3 delay (33.3 %). Under or nil reporting from the facilities was observed. Program staff could identify broad areas of intervention but lacked capacity to monitor, analyse, interpret and utilize the generated information to develop feasible actionable plans. Information gathered was incomplete and inaccurate in many cases. Challenges observed showed that it will require more time and continuous committed efforts of health staff for implementation of high quality MDR. Successful implementation will improve the response of the health system and contribute to improved maternal health.

Perceptions to Overcoming Barriers to Prenatal Care in African American Women.

Pregnancy-related deaths affect African American women at a rate four to five times higher than White women. These deaths occur during pregnancy or up to 1 year after childbirth. Inadequate or delayed prenatal care is a factor associated with poor maternal health outcomes in African American women. Identifying factors that pose as facilitators and barriers to prenatal care is essential in developing interventions aimed at improving maternal health outcomes.

Years of life lost due to unintentional drug overdose among perinatal individuals in the United States.

BACKGROUND: The United States has one of the highest maternal mortality rates of developing countries, but the contribution of perinatal drug overdose is not known. Communities of color also have higher rates of maternal morbidity and mortality when compared to White communities, however the contribution due to overdose has not yet been examined in this population. OBJECTIVES: To quantify the years of life lost due to unintentional overdose in perinatal individuals from 2010 to 2019 and assess for disparity by race. STUDY DESIGN: This was a cross-sectional retrospective study with summary-level mortality statistics for the years 2010-2019 obtained from the Centers for Disease Control (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) mortality file. A total of 1,586 individuals of childbearing age (15-44 years) who died during pregnancy or six weeks postpartum (perinatal) from unintentional overdose in the United States from January 1, 2010 to December 31, 2019 were included. Total years of life lost (YLL) was calculated and summated for White, Black, Hispanic, Asian/Pacific Islander, and American Indian/Native Alaska women. Additionally, the top three overall causes of death were also identified for women in this age group for comparison. RESULTS: Unintentional drug overdose accounted for 1,586 deaths and 83,969.78 YLL in perinatal individuals from 2010 to 2019 in the United States. Perinatal American Indian/Native American individuals had a disproportionate amount of YLL when compared to other ethnic groups, with 2.39% of YLL due to overdose, while only making up 0.80% of the population. During the last two years of the study, only American Indian/Native American and Black individuals had increased rates of mortality when compared to other races. During the ten-year study period, when including the top three causes of mortality, unintentional drug overdoses made up 11.98% of the YLL overall and 46.39% of accidents. For the years 2016-2019, YLL due to unintentional overdose was the third leading cause of YLL overall for this population. CONCLUSIONS: Unintentional drug overdose is a leading cause of death for perinatal individuals in the United States, claiming nearly 84,000 years of life over a ten-year period. When examining by race, American Indian/Native American women are most disproportionately affected.

Racial and Ethnic Disparities in Death Associated With Severe Maternal Morbidity in the United States: Failure to Rescue.

OBJECTIVE: To analyze racial and ethnic disparities in failure to rescue (ie, death) associated with severe maternal morbidity and describe temporal trends. METHODS: This was a retrospective cohort study using administrative data. Data for delivery hospitalizations with severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, were abstracted from the 1999-2017 National Inpatient Sample. Race and ethnicity were categorized into non-Hispanic White (reference), non-Hispanic Black, Hispanic, other, and missing. The outcome was failure to rescue from severe maternal morbidity. Disparities were assessed using the failure-to-rescue rate ratio (ratio of the failure-to-rescue rate in the racial and minority group to the failure-to-rescue rate in White women), adjusted for patient and hospital characteristics. Temporal trends in severe maternal morbidity and failure to rescue were assessed. RESULTS: During the study period, 73,934,559 delivery hospitalizations were identified, including 993,864 with severe maternal morbidity (13.4/1,000; 95% CI 13.3-13.5). Among women with severe maternal morbidity, 4,328 died (4.3/1,000; 95% CI 4.2-4.5). The adjusted failure-to-rescue rate ratio was 1.79 (95% CI 1.77-1.81) for Black women, 1.39 (95% CI 1.37-1.41) for women of other race and ethnicity, 1.43 (95% CI 1.42-1.45) for women with missing race and ethnicity data, and 1.08 (95% CI 1.06-1.09) for Hispanic women. During the study period, the severe maternal morbidity rate increased significantly in each of the five racial and ethnic groups but started declining in 2012. Meanwhile, the failure-to-rescue rate decreased significantly during the entire study period. CONCLUSION: Despite improvement over time, failure to rescue from severe maternal morbidity remains a major contributing factor to excess maternal mortality in racial and ethnic minority women.

Maternal Death: Audit in a Tertiary Hospital.

Maternal death audit in a tertiary hospital was conducted to improve the quality of maternal health care. In this descriptive type cross sectional study, maternal deaths were reviewed and factors responsible for maternal death were identified and noted in Rajshahi Medical College Hospital from July 2008 to June 2009. During the study period total 63 maternal deaths recorded among 7560 deliveries. Almost 43% deceased mother was less than 25 years of age. 39.7% mother died during their first pregnancy. Among the delivery group 46% cases delivered vaginally. Regarding time interval 33.3% of death occurred within six hours of admission to hospital. The main causes of death were eclampsia (46%), PPH (17.5%), septic abortion (12.7%). One or more Institutional factors were identified and among them lack of obstetric ICU facility was related to73% cases. Delayed or lack of blood transfusion was responsible for 46% cases and delayed attendance by senior doctors were related to 30% cases. Substantial number of maternal death occurred at or <25 years of age. Eclampsia, hemorrhage, septic abortions along with substandard care was identified as the major cause of maternal death.

Maternal deaths and deaths of women of childbearing age in the indigenous population, Pernambuco, Brazil, 2006-2012. / Mortes maternas e de mulheres em idade reprodutiva na população indígena, Pernambuco, 2006-2012.

OBJECTIVE: to describe maternal deaths and deaths of women of childbearing age in the indigenous population in the state of Pernambuco, Brazil, from 2006 to 2012. METHOD: this is a descriptive study based on linkage of data from the Mortality Information System (SIM) and its investigation module (SIM-Web); causes of death were considered in accordance with the International Statistical Classification of Diseases and Health Related Problems - 10th Revision (ICD-10). RESULTS: linkage provided a database comprised of 115 records, of which only 58.3% were recorded on SIM as indigenous; the main causes of death were diseases of the circulatory system (27.0%), external causes (14.8%), neoplasms (13.0%), and maternal factors (8.7%). CONCLUSION: deaths of indigenous women of childbearing age were underreported; the main cause of these deaths were diseases of the circulatory system, although maternal deaths still represent an important cause of death in the population studied.

Epidemiology of racial/ethnic disparities in severe maternal morbidity and mortality.

The literature abounds with examples of racial/ethnic disparities in both obstetric outcomes and care. Disparities in maternal mortality are well documented with non-Hispanic blacks carrying the burden of the highest maternal mortality rates. Maternal deaths likely represent only the "tip of the iceberg" with respect to pregnancy complications, leading many to explore risk factors and disparities in severe maternal morbidity, a more common precursor to maternal mortality. This review article explores commonly cited indicators of severe maternal morbidity and includes a review of the epidemiological literature supporting or refuting disparities among each indicator.

Improving hospital quality to reduce disparities in severe maternal morbidity and mortality.

Significant racial/ethnic disparities in maternal morbidity and mortality exist in the United States. Black women are 3-4 times more likely to die a pregnancy-related death as compared with white women. Growing research suggests that hospital quality may be a critical lever for improving outcomes and narrowing disparities. This overview reviews the evidence demonstrating that hospital quality is related to maternal mortality and morbidity, discusses the pathways through which these associations between quality and severe maternal morbidity generate disparities, and concludes with a discussion of possible levers for action to reduce disparities by improving hospital quality.

Going 'Beyond the Numbers': Maternal Death Reviews in India.

This essay discusses the Indian government's implementation of maternal death reviews (MDR) across the country in response to a global WHO strategy called 'Beyond the Numbers.' India's MDR process attempts to better count and assess maternal deaths across the country, yet considerable challenges remain. Existing studies of the MDR process in India still reveal systemic failures including poor quality of obstetric care, as well as omissions or delays of care that are covered up or denied. An ethnographic case study suggests ways that ethnographic sensibilities or techniques could be used to harness community stakeholders or lay perspectives by privileging ambiguity, multiplicity, and conflicting views in order to reveal these systemic omissions or failures of accountability. It concludes by suggesting how ethnographic ways of knowing might elicit lay concerns or critiques that threaten the very medical privileges that the MDR process inadvertently shores up.

Escenarios ocultos de la muerte materna: desde la mirada de mujeres sobrevivientes / Hidden scenarios of maternal death: from the gaze of surviving women

El propósito: develar los escenarios ocultos de la muerte materna ocurrida en los micromundos poco abordados en el estado Aragua durante el quinquenio 2011 ­2015.La muerte materna constituye un complejo problema de salud pública, un importante indicador de desarrollo humano, que muestra las más grandes inequidades entre países de diferentes niveles de desarrollo. El enfoque integrador transcomplejo, constituye un camino epistemológico para develar lo que poco se dice y se evidencia, partiendo de referentes multidimensionales que se explican en una dialógica de saberes que no se aplanan unos a los otros sino que se interceptan para hacer tangible las determinaciones socioculturales poco abordadas en las explicaciones de la muerte materna. Desde esta perspectiva epistemológica se hace posible evidenciar las tramas ocultas del discurso de la vida de las mujeres sobrevivientes a la muerte materna, debido a la posibilidad que esta visión de pensamiento brinda para identificar distintos tipos de discurso y las hipertrofias de los mismos, develadas desde interpretaciones que no solo son parte de los micromundos estudiados de las mujeres sino desde la maya de saberes que se imbrican para la comprensión de los testimonios de las informantes. Mediante la hermenéutica como metódica y la historia de vida, se desarrolló un proceso de interpretación y comprensión de los significados de la muerte materna, fundamentadas en sus puntos de encuentro, permitiendo visibilizar lo invisible, desde una postura intersubjetiva. Con técnica de observación, entrevistas enfocadas a: dos mujeres que sobrevivieron a la muerte materna, se obtuvieron las vivencias, lo percibido y recordado, logrando la retención de esa experiencia vivida, que fueron procesadas, encontrando algunos hallazgos como: inadecuada praxis en salud; violencia obstétrica, violencia de género, violencia institucional; creencias socioculturales y representaciones sociales en relación con el embarazo; cargas sociales, emocionales y de trabajo durante el embarazo.

The purpose: to reveal the hidden scenarios of maternal death that occurred in the little-addressed micro-worlds in the state of Aragua during the five-years period 2011 -2015. Maternal death constitutes a complex public health problem, an important indicator of human development, which shows the most great inequities between countries of different levels of development. The integrative cross-complex approach constitutes an epistemological path to reveal what little is said and evidenced, starting from multidimensional references that are explained in a dialogic of knowledge that do not flatten each other but are intercepted to make sociocultural determinations tangible. little addressed in the explanations of maternal death. From this epistemological perspective, it is possible to reveal the hidden plots of the discourse of the lives of women survivors of maternal death, due to the possibility that this vision of thought offers to identify different types of discourse and their hypertrophy, revealed from interpretations that are not only part of the studied microworlds of the women but also from the Mayan knowledge that overlap for the understanding of the informants' testimonies. Through hermeneutics as a method and life history, a process of interpretation and understanding of the meanings of maternal death was developed, based on their meeting points, allowing the invisible to be made visible, from an intersubjective position. With observation technique, interviews focused on: two women who survived maternal death, the experiences were obtained, what was perceived and remembered, achieving the retention of that lived experience, which were processed, finding some findings such as: inadequate health praxis; obstetric violence, gender violence, institutional violence; sociocultural beliefs and social representations in relation to pregnancy; social, emotional and work burdens during pregnancy.