The global use of the International Classification of Diseases to Perinatal Mortality (ICD-PM): A systematic review.

Background: The World Health Organization launched the International Classification of Diseases for Perinatal Mortality (ICD-PM) in 2016 to uniformly report on the causes of perinatal deaths. In this systematic review, we aim to describe the global use of the ICD-PM by reporting causes of perinatal mortality and summarizing challenges and suggested amendments. Methods: We systematically searched MEDLINE, Embase, Global Health, and CINAHL databases using key terms related to perinatal mortality and the classification for causes of death. We included studies that applied the ICD-PM and were published between January 2016 and June 2021. The ICD-PM data were extracted and a qualitative analysis was performed to summarize the challenges of the ICD-PM. We applied the PRISMA guidelines, registered our protocol at PROSPERO [CRD42020203466], and used the Appraisal tool for Cross-Sectional Studies (AXIS) as a framework to evaluate the quality of evidence. Results: The search retrieved 6599 reports. Of these, we included 15 studies that applied the ICD-PM to 44 900 perinatal deaths. Most causes varied widely; for example, "antepartum hypoxia" was the cause of stillbirths in 0% to 46% (median = 12%, n = 95) in low-income settings, 0% to 62% (median = 6%, n = 1159) in middle-income settings and 0% to 55% (median = 5%, n = 249) in high-income settings. Five studies reported challenges and suggested amendments to the ICD-PM. The most frequently reported challenges included the high proportion of antepartum deaths of unspecified cause (five studies), the inability to determine the cause of death when the timing of death is unknown (three studies), and the challenge of assigning one cause in case of multiple contributing conditions (three studies). Conclusions: The ICD-PM is increasingly being used across the globe and gives health care providers insight into the causes of perinatal death in different settings. However, there is wide variation in reported causes of perinatal death across comparable settings, which suggests that the ICD-PM is applied inconsistently. We summarized the suggested amendments and made additional recommendations to improve the use of the ICD-PM and help strengthen its consistency. Registration: PROSPERO [CRD42020203466].

From Passive Surveillance to Response: Suriname's Efforts to Implement Maternal Death Surveillance and Response.

Implementation of maternal death surveillance and response (MDSR) is crucial to reduce maternal deaths. In Suriname, MDSR was not implemented until 2015. We describe the process of MDSR implementation in Suriname and share the "lessons learned," as experienced by the health care providers, national maternal death review committee members, and public health experts. Before 2015, maternal deaths were identified using death certificates and by active surveillance in the hospitals. Based on the recommendations from a 2010-2014 Reproductive Age Mortality Survey in Suriname, a maternal death review committee has improved the identification of maternal deaths and has audited every death since 2015. Although this review committee initiated several actions to implement MDSR together with health care providers, the involvement of the Ministry of Health (MOH) was crucial. Therefore, the Maternal Health Steering Committee was recently installed as a direct working arm of MOH to guide MDSR implementation. One of the main barriers to implementing MDSR in Suriname has been the lack of action following recommendations. Delineating roles and responsibilities for action, establishing accountability mechanisms, and influencing stakeholders in a position to act are critical to ensure a response to the recommendations. To implement MDSR, the 5 Cs-commitment, "no blame, no shame" culture, coordination, collaboration, and communication-are crucial.

Classifying maternal deaths in Suriname using WHO ICD-MM: different interpretation by Physicians, National and International Maternal Death Review Committees.

The World Health Organization (WHO) provides a framework (ICD-MM) to classify pregnancy-related deaths systematically, which enables global comparison among countries. We compared the classification of pregnancy-related deaths in Suriname by the attending physician and by the national maternal death review (MDR) committee and among the MDR committees of Suriname, Jamaica and the Netherlands. There were 89 possible pregnancy-related deaths in Suriname between 2010 and 2014. Nearly half (47%) were classified differently by the Surinamese MDR committee as compared to the classification of the attending physicians. All three MDR committees agreed that 18% (n = 16/89) of the cases were no maternal deaths. Out of the remaining 73 cases, there was disagreement regarding whether 15% (n = 11) were maternal deaths. The Surinamese and Jamaican MDR committees achieved greater consensus in classification than the Surinamese and the Netherlands MDR committees. The Netherlands MDR committee classified more deaths as unspecified than Surinamese and the Jamaican MDR committees. Underlying causes that achieved a high level of agreement among the three committees were abortive outcomes and obstetric hemorrhage, while little agreement was reported for unspecified and other direct causes. The issues encountered during maternal death classification using the ICD-MM guidelines included classification of suicide during early pregnancy; when to assume pregnancy without objective evidence; how to count maternal deaths occurring outside the country of residence; the relevance of direct or indirect cause attribution; and how to select the underlying cause when direct and indirect conditions or multiple comorbidities co-occur. Addressing these classification barriers in future revisions of the ICD-MM guidelines could enhance the feasibility of maternal death classification and facilitate global comparison. BACKGROUND: Insight into the underlying causes of pregnancy-related deaths is essential to develop policies to avert preventable deaths. The WHO International Classification of Diseases-Maternal Mortality (ICD-MM) guidelines provide a framework to standardize maternal death classifications and enable comparison in and among countries over time. However, despite the implementation of these guidelines, differences in classification remain. We evaluated consensus on maternal death classification using the ICD-MM guidelines. METHODS: The classification of pregnancy-related deaths in Suriname during 2010-2014 was compared in the country (between the attending physician and the national maternal death review (MDR) committee), and among the MDR committees from Suriname, Jamaica and the Netherlands. All reviewers applied the ICD-MM guidelines. The inter-rater reliability (Fleiss kappa [κ]) was used to measure agreement. RESULTS: Out of the 89 cases certified by attending physicians, 47% (n = 42) were classified differently by the Surinamese MDR committee. The three MDR committees agreed that 18% (n = 16/89) of these cases were no maternal deaths, and, therefore, excluded from further analyses. However, opinions differed whether 15% (n = 11) of the remaining 73 cases were maternal deaths. The MDR committees achieved moderate agreement classifying the deaths into type (direct, indirect and unspecified) (κ = 0.53) and underlying cause group (κ = 0.52). The Netherlands MDR committee classified more maternal deaths as unspecified (19%), than the Jamaican (7%) and Surinamese (4%) committees did. The mutual agreement between the Surinamese and Jamaican MDR committees (κ = 0.69 vs κ = 0.63) was better than between the Surinamese and the Netherlands MDR committees (κ = 0.48 vs κ = 0.49) for classification into type and underlying cause group, respectively. Agreement on the underlying cause category was excellent for abortive outcomes (κ = 0.85) and obstetric hemorrhage (κ = 0.74) and fair for unspecified (κ = 0.29) and other direct causes (κ = 0.32). CONCLUSIONS: Maternal death classification differs in Suriname and among MDR committees from different countries, despite using the ICD-MM guidelines on similar cases. Specific challenges in applying these guidelines included attribution of underlying cause when comorbidities occurred, the inclusion of deaths from suicides, and maternal deaths that occurred outside the country of residence.

Trends in maternal mortality in Suriname: 3 confidential enquiries in 3 decades.

BACKGROUND: The Sustainable Development Goal target 3.1 aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births. Great disparities reported in maternal mortality ratio between and within countries make this target unachievable. To gain more insight into such disparities and to monitor and describe trends, confidential enquiries into maternal deaths are crucial. OBJECTIVE: We aimed to study the trend in maternal mortality ratio, causes, delay in access and quality of care, and "lessons learned" in Suriname, over almost 3 decades with 3 confidential enquiries into maternal deaths and provide recommendations to prevent maternal deaths. STUDY DESIGN: The third national confidential enquiry into maternal deaths was conducted between 2015 and 2019 in Suriname by prospective, population-based surveillance and multidisciplinary systematic maternal death review. Subsequently, a comparative analysis with previous confidential enquiry into maternal deaths was performed: confidential enquiry into maternal deaths I (a prospective study, 1991-1993) and confidential enquiry into maternal deaths II (a retrospective study, 2010-2014). RESULTS: We identified 62 maternal deaths and recorded 48,881 live births (maternal mortality ratio, 127/100,000 live births) between 2015-2019. Of the women who died, 14 of 62 (23%) were in poor condition when entering a health facility, whereas 11 of 62 (18%) died at home or during transportation. The maternal mortality ratio decreased over the years, (226 [n=64]; 130 [n=65]; and 127 [n=62]), with underreporting rates of 62%, 26%, and 24%, respectively in confidential enquiry into maternal deaths I, II and III. Of the women deceased, 36 (56%), 37 (57%), and 40 (63%) were of African descent; 46 (72%), 45 (69%), and 47 (76%) died after birth; and 47 (73%), 55 (84%), and 48 (77%) died in the hospital, respectively, in confidential enquiries into maternal deaths I, II, and III. Significantly more women were uninsured in confidential enquiry into maternal deaths III (15 of 59 [25%,]) than in confidential enquiry into maternal deaths II (0%) and I (6 of 64 [9%]). Obstetrical hemorrhage was less often the underlying cause of death over the years (19 of 64 [30%], vs 13 of 65 [20%], vs 7 of 62 [11%]), whereas all other obstetrical causes occurred more often in confidential enquiry into maternal deaths III (eg, suicide [0; 1 of 65 (2%); 5 of 62 (8%)]) and unspecified deaths (1 of 64 [2%]; 3 of 65 [5%]; and 11 of 62 [18%] in confidential enquiry into maternal deaths I, II and III respectively). Maternal deaths were preventable in nearly half of the cases in confidential enquiry into maternal deaths II (28 of 65) and III (29 of 62). Delay in quality of care occurred in at least two-thirds of cases (41 of 62 [65%], 47 of 59 [80%], and 47 of 61 [77%]) over the years. CONCLUSION: Suriname's maternal mortality rate has decreased throughout the past 3 decades, yet the trend is too slow to achieve the Sustainable Development Goal 3.1. Preventable maternal deaths can be reduced by ensuring high-quality facility-based obstetrical and postpartum care, universal access to care especially for vulnerable women (of African descent and low socioeconomic class), and by addressing specific underlying causes of maternal deaths.

The burden of severe hypertensive disorders of pregnancy on perinatal outcomes: a nationwide case-control study in Suriname.

BACKGROUND: Latin America and the Caribbean is the region with the highest prevalence of hypertensive disorders of pregnancy worldwide. In Suriname, where the stillbirth rate is the second highest in the region, it is not yet known which maternal factors contribute most substantially. OBJECTIVE: The aims of this study in Suriname were to (1) study the impact of different types of maternal morbidity on adverse perinatal outcomes and (2) study perinatal birth outcomes among women with severe hypertensive disorders of pregnancy. STUDY DESIGN: A case-control study was conducted between March 2017 and February 2018 during which time all hospital births (86% of total) in Suriname were included. We identified babies with adverse perinatal outcomes (perinatal death or neonatal near miss) and women with severe maternal morbidity (according to the World Health Organization Near Miss tool). Stillbirths and early neonatal deaths (<7 days) were considered perinatal death. We defined a neonatal near miss as a birthweight below 1750 g, gestational age <33 weeks, 5-minute Apgar score <7, and preterm intrauterine growth restriction

Postpartum hemorrhage in Suriname: A national descriptive study of hospital births and an audit of case management.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of direct maternal mortality globally and in Suriname. We aimed to study the prevalence, risk indicators, causes, and management of PPH to identify opportunities for PPH reduction. METHODS: A nationwide retrospective descriptive study of all hospital deliveries in Suriname in 2017 was performed. Logistic regression analysis was applied to identify risk indicators for PPH (≥ 500ml blood loss). Management of severe PPH (blood loss ≥1,000ml or ≥500ml with hypotension or at least three transfusions) was evaluated via a criteria-based audit using the national guideline. RESULTS: In 2017, the prevalence of PPH and severe PPH in Suriname was 9.2% (n = 808/8,747) and 2.5% (n = 220/8,747), respectively. PPH varied from 5.8% to 15.8% across the hospitals. Risk indicators associated with severe PPH included being of African descent (Maroon aOR 2.1[95%CI 1.3-3.3], Creole aOR 1.8[95%CI 1.1-3.0]), multiple pregnancy (aOR 3.4[95%CI 1.7-7.1]), delivery in Hospital D (aOR 2.4[95%CI 1.7-3.4]), cesarean section (aOR 3.9[95%CI 2.9-5.3]), stillbirth (aOR 6.4 [95%CI 3.4-12.2]), preterm birth (aOR 2.1[95%CI 1.3-3.2]), and macrosomia (aOR 2.8 [95%CI 1.5-5.0]). Uterine atony (56.7%, n = 102/180[missing 40]) and retained placenta (19.4%, n = 35/180[missing 40]), were the main causes of severe PPH. A criteria-based audit revealed that women with severe PPH received prophylactic oxytocin in 61.3% (n = 95/155[missing 65]), oxytocin treatment in 68.8% (n = 106/154[missing 66]), and tranexamic acid in 4.9% (n = 5/103[missing 117]). CONCLUSIONS: PPH prevalence and risk indicators in Suriname were similar to international and regional reports. Inconsistent blood loss measurement, varied maternal and perinatal characteristics, and variable guideline adherence contributed to interhospital prevalence variation. PPH reduction in Suriname can be achieved through prevention by practicing active management of the third stage of labor in every birth and considering risk factors, early recognition by objective and consistent blood loss measurement, and prompt treatment by adequate administration of oxytocin and tranexamic acid according to national guidelines.

Applicability of the WHO maternal near-miss tool: A nationwide surveillance study in Suriname.

BACKGROUND: Maternal near-miss (MNM) is an important maternal health quality-of-care indicator. To facilitate comparison between countries, the World Health Organization (WHO) developed the "MNM-tool". However, several low- and middle-income countries have proposed adaptations to prevent underreporting, ie, Namibian and Sub-Sahara African (SSA)-criteria. This study aims to assess MNM and associated factors in middle-income country Suriname by applying the three different MNM tools. METHODS: A nationwide prospective population-based cohort study was conducted using the Suriname Obstetric Surveillance System (SurOSS). We included women with MNM-criteria defined by WHO-, Namibian- and SSA-tools during one year (March 2017-February 2018) and used hospital births (86% of total) as a reference group. RESULTS: There were 9114 hospital live births in Suriname in the one-year study period. SurOSS identified 71 women with WHO-MNM (8/1000 live births, mortality-index 12%), 118 with Namibian-MNM (13/1000 live births, mortality-index 8%), and 242 with SSA-MNM (27/1000 live births, mortality-index 4%). Namibian- and SSA-tools identified all women with WHO-criteria. Blood transfusion thresholds and eclampsia explained the majority of differences in MNM prevalence. Eclampsia was not considered a WHO-MNM in 80% (n = 35/44) of cases. Nevertheless, mortality-index for MNM with hypertensive disorders was 17% and the most frequent underlying cause of maternal deaths (n = 4/10, 40%) and MNM (n = 24/71, 34%). Women of advanced age and maroon ethnicity had twice the odds of WHO-MNM (respectively adjusted odds ratio (aOR) = 2.6, 95% confidence interval (CI) = 1.4-4.8 and aOR = 2.0, 95% CI = 1.2-3.6). The stillbirths rate among women with WHO-MNM was 193/1000births, with six times higher odds than women without MNM (aOR = 6.8, 95%CI = 3.0-15.8). While the prevalence and mortality-index differ between the three MNM tools, the underlying causes of and factors associated with MNM were comparable. CONCLUSIONS: The MNM ratio in Suriname is comparable to other countries in the region. The WHO-tool underestimates the prevalence of MNM (high mortality-index), while the adapted tools may overestimate MNM and compromise global comparability. Contextualized MNM-criteria per obstetric transition stage may improve comparability and reduce underreporting. While MNM studies facilitate international comparison, audit will remain necessary to identify shortfalls in quality-of-care and improve maternal outcomes.

Why magnesium sulfate 'coverage' only is not enough to reduce eclampsia: Lessons learned in a middle-income country.

OBJECTIVES: Determine the eclampsia prevalence and factors associated with eclampsia and recurrent seizures in Suriname and evaluate quality-of-care indicator 'magnesium sulfate (MgSO4) coverage'. STUDY DESIGN: A two-year prospective nationwide cohort study was conducted in Suriname and included women with eclampsia at home or in a healthcare facility. MAIN OUTCOME MEASURES: We calculated the prevalence by the number of live births obtained from vital registration. Risk factor denominator data concerned hospital births. Descriptive statistics and multivariate regression analysis were performed. RESULTS: Seventy-two women with eclampsia (37/10.000 live births) were identified, including two maternal deaths (case-fatality 2.8%). Nulliparity, African-descent and adolescence were associated with eclampsia. Adolescents with eclampsia had significantly lower BPs (150/100 mmHg) than adult women (168/105 mmHg). The first seizure occurred antepartum in 54% (n = 39/72), intrapartum in 19% (n = 14/72) and postpartum in 26% (n = 19/72). Recurrent seizures were observed in 60% (n = 43/72). MgSO4 was administered to 99% (n = 69/70) of women; however 26% received no loading dosage and, in 22% of cases MgSO4 duration was <24 h, i.e. guideline adherence existed in only 43%. MgSO4 was ceased during CS in all women (n = 40). Stable BP was achieved before CS in 46%. The median seizure-to-delivery interval was 27 h, and ranged from four to 36 h. CONCLUSION: Solely 'MgSO4 coverage' is not a reliable quality-of-care indicator, as it conceals inadequate MgSO4 dosage and timing, discontinuation during CS, stabilization before delivery, and seizure-to-delivery interval. These other quality-of-care indicators need attention from the international community in order to reduce the prevalence of eclampsia.

Investigation of stillbirth causes in Suriname: application of the WHO ICD-PM tool to national-level hospital data.

BACKGROUND: Suriname has one of the highest stillbirth rates in Latin America and the Caribbean. To facilitate data comparison of perinatal deaths, the World Health Organization developed the International Classification of Diseases-10 Perinatal Mortality (ICD-PM). OBJECTIVE: We aimed to (1) assess characteristics and risk indicators of women with a stillbirth, (2) determine the timing and causes of stillbirths according to the ICD-PM with critical evaluation of its application and (3) propose recommendations for the reduction of stillbirths in Suriname. METHODS: A hospital-based, nation-wide, cross-sectional study was conducted in all hospitals within Suriname during one-year (2017). The medical files of stillbirths (gestation ≥28 weeks/birth weight ≥1000 grams) were reviewed and classified using ICD-PM. We used descriptive statistics and multiple logistic regression analyses. RESULTS: The stillbirth rate in Suriname was 14.4/1000 births (n=131 stillbirths, n=9089 total births). Medical files were available for 86% (n=113/131) of stillbirths. Women of African descent had the highest stillbirth rate and two times the odds of stillbirth (OR 2.1, 95%CI 1.4-3.1) compared to women of other ethnicities. One third (33%, n=37/113) of stillbirths occurred after hospital admission. The timing was antepartum in 85% (n=96/113), intrapartum in 11% (n=12/113) and unknown in 4% (n=5/113). Antepartum stillbirths were caused by hypoxia in 46% (n=44/96). In 41% (n=39/96) the cause was unspecified. Maternal medical and surgical conditions were present in 50% (n=57/113), mostly hypertensive disorders. CONCLUSION: Stillbirth reduction strategies in Suriname call for targeting ethnic disparities, improving antenatal services, implementing perinatal death audits and improving diagnostic post-mortem investigations. ICD-PM limited the formulation of recommendations due to many stillbirths of 'unspecified' causes. Based on our study findings, we also recommend addressing some challenges with applying the ICD-PM. ABBREVIATIONS: CTG: Cardiotocography; ENAP: Every Newborn Action Plan (ENAP); ICD-PM: The WHO application of ICD-10 to deaths during the perinatal period - perinatal mortality; SBR: Stillbirth rate; SGA: Small for gestational age; WHO: World Health Organization; LMIC: Low- and middle-income countries; FHR: foetal heart rate.

Childbirth outcomes and ethnic disparities in Suriname: a nationwide registry-based study in a middle-income country.

BACKGROUND: Our study aims to evaluate the current perinatal registry, analyze national childbirth outcomes and study ethnic disparities in middle-income country Suriname, South America. METHODS: A nationwide birth registry study was conducted in Suriname. Data were collected for 2016 and 2017 from the childbirth books of all five hospital maternity wards, covering 86% of all births in the country. Multinomial regression analyses were used to assess ethnic disparities in outcomes of maternal deaths, stillbirths, teenage pregnancy, cesarean delivery, low birth weight and preterm birth with Hindustani women as reference group. RESULTS: 18.290 women gave birth to 18.118 (98%) live born children in the five hospitals. Hospital-based maternal mortality ratio was 112 per 100.000 live births. Hospital-based late stillbirth rate was 16 per 1000 births. Stillbirth rate was highest among Maroon (African-descendent) women (25 per 1000 births, aOR 2.0 (95%CI 1.3-2.8) and lowest among Javanese women (6 stillbirths per 1000 births, aOR 0.5, 95%CI 0.2-1.2). Preterm birth and low birthweight occurred in 14 and 15% of all births. Teenage pregnancy accounted for 14% of all births and was higher in Maroon women (18%) compared to Hindustani women (10%, aOR 2.1, 95%CI 1.8-2.4). The national cesarean section rate was 24% and was lower in Maroon (17%) than in Hindustani (32%) women (aOR 0.5 (95%CI 0.5-0.6)). Cesarean section rates varied between the hospitals from 17 to 36%. CONCLUSION: This is the first nationwide comprehensive overview of maternal and perinatal health in a middle income country. Disaggregated perinatal health data in Suriname shows substantial inequities in outcomes by ethnicity which need to be targetted by health professionals, researchers and policy makers.

Bottom-up development of national obstetric guidelines in middle-income country Suriname.

BACKGROUND: Obstetric guidelines are useful to improve the quality of care. Availability of international guidelines has rapidly increased, however the contextualization to enhance feasibility of implementation in health facilities in low and middle-income settings has only been described in literature in a few instances. This study describes the approach and lessons learned from the 'bottom-up' development process of context-tailored national obstetric guidelines in middle-income country Suriname. METHODS: Local obstetric health care providers initiated the guideline development process in Suriname in August 2016 for two common obstetric conditions: hypertensive disorders of pregnancy (HDP) and post partum haemorrhage (PPH). RESULTS: The process consisted of six steps: (1) determination of how and why women died, (2) interviews and observations of local clinical practice, (3) review of international guidelines, (4) development of a primary set of guidelines, (5) initiation of a national discussion on the guidelines content and (6) establishment of the final guidelines based on consensus. Maternal enquiry of HDP- and PPH-related maternal deaths revealed substandard care in 90 and 95% of cases, respectively. An assessment of the management through interviews and labour observations identified gaps in quality of the provided care and large discrepancies in the management of HDP and PPH between the hospitals. International recommendations were considered unfeasible and were inconsistent when compared to each other. Local health care providers and stakeholders convened to create national context-tailored guidelines based on adapted international recommendations. The guidelines were developed within four months and locally implemented. CONCLUSION: Development of national context-tailored guidelines is achievable in a middle-income country when using a 'bottom-up' approach that involves all obstetric health care providers and stakeholders in the earliest phase. We hope the descriptive process of guideline development is helpful for other countries in need of nationwide guidelines.

The golden hour of sepsis: An in-depth analysis of sepsis-related maternal mortality in middle-income country Suriname.

BACKGROUND: Sepsis was the main cause of maternal mortality in Suriname, a middle-income country. Objective of this study was to perform a qualitative analysis of the clinical and management aspects of sepsis-related maternal deaths with a focus on the 'golden hour' principle of antibiotic therapy. METHODS: A nationwide reproductive age mortality survey was performed from 2010 to 2014 to identify and audit all maternal deaths in Suriname. All sepsis-related deaths were reviewed by a local expert committee to assess socio-demographic characteristics, clinical aspects and substandard care. RESULTS: Of all 65 maternal deaths in Suriname 29 (45%) were sepsis-related. These women were mostly of low socio-economic class (n = 23, 82%), of Maroon ethnicity (n = 14, 48%) and most deaths occurred postpartum (n = 21, 72%). Underlying causes were pneumonia (n = 14, 48%), wound infections (n = 3, 10%) and endometritis (n = 3, 10%). Bacterial growth was detected in 10 (50%) of the 20 available blood cultures. None of the women with sepsis as underlying cause of death received antibiotic treatment within the first hour, although most women fulfilled the diagnostic criteria of sepsis upon admission. In 27 (93%) of the 29 women from which sufficient information was available, substandard care factors were identified: delay in monitoring in 16 (59%) women, in diagnosis in 17 (63%) and in treatment in 21 (78%). CONCLUSION: In Suriname, a middle-income country, maternal mortality could be reduced by improving early recognition and timely diagnosis of sepsis, vital signs monitoring and immediate antibiotic infusion (within the golden hour).

Maternal mortality audit in Suriname between 2010 and 2014, a reproductive age mortality survey.

BACKGROUND: The fifth Millennium Development Goal (MDG-5) aimed to improve maternal health, targeting a maternal mortality ratio (MMR) reduction of 75% between 1990 and 2015. The objective of this study was to identify all maternal deaths in Suriname, determine the extent of underreporting, estimate the reduction, audit the maternal deaths and assess underlying causes and substandard care factors. METHODS: A reproductive age mortality survey was conducted in Suriname (South-American upper-middle income country) between 2010 and 2014 to identify all maternal deaths in the country. MMR was compared to vital statistics and a previous confidential enquiry from 1991 to 1993 with a MMR 226. A maternal mortality committee audited the maternal deaths and identified underlying causes and substandard care factors. RESULTS: In the study period 65 maternal deaths were identified in 50,051 live births, indicating a MMR of 130 per 100.000 live births and implicating a 42% reduction of maternal deaths in the past 25 years. Vital registration indicated a MMR of 96, which marks underreporting of 26%. Maternal deaths mostly occurred in the urban hospitals (84%) and the causes were classified as direct (63%), indirect (32%) or unspecified (5%). Major underlying causes were obstetric and non-obstetric sepsis (27%) and haemorrhage (20%). Substandard care factors (95%) were mostly health professional related (80%) due to delay in diagnosis (59%), delay or wrong treatment (78%) or inadequate monitoring (59%). Substandard care factors most likely led to death in 47% of the cases. CONCLUSION: Despite the reduction in maternal mortality, Suriname did not reach MDG-5 in 2015. Steps to reach the Sustainable Development Goal in 2030 (MMR ≤ 70 per 100.000 live births) and eliminate preventable deaths include improving data surveillance, installing a maternal death review committee, and implementing national guidelines for prevention and management of major complications of pregnancy, childbirth and puerperium.