Outcomes and quality of care for women and their babies after caesarean section in Nigeria.

OBJECTIVE: To describe the outcomes and quality of care for women and their babies after caesarean section (CS) in Nigerian referral-level hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Fifty-four referral-level hospitals. POPULATION: All women giving birth in the participating facilities between 1 September 2019 and 31 August 2020. METHODS: Data for the women were extracted, including sociodemographic data, clinical information, mode of birth, and maternal and perinatal outcomes. A conceptual hierarchical framework was employed to explore the sociodemographic and clinical factors associated with maternal and perinatal death in women who had an emergency CS. MAIN OUTCOME MEASURES: Overall CS rate, outcomes for women who had CS, and factors associated with maternal and perinatal mortality. RESULTS: The overall CS rate was 33.3% (22 838/68 640). The majority of CS deliveries were emergency cases (62.8%) and 8.1% of CS deliveries had complications after delivery, which were more common after an emergency CS. There were 179 (0.8%) maternal deaths in women who had a CS and 29.6% resulted from complications of hypertensive disorders of pregnancy. The overall maternal mortality rate in women who delivered by CS was 778 per 100 000 live births, whereas the perinatal mortality at birth was 51 per 1000 live births. Factors associated with maternal mortality in women who had an emergency CS were being <20 or >35 years of age, having a lower level of education and being referred from another facility or informal setting. CONCLUSIONS: One-third of births were delivered via CS (mostly emergency), with almost one in ten women experiencing a complication after a CS. To improve outcomes, hospitals should invest in care and remove obstacles to accessible quality CS services.

Factors influencing maternal death surveillance and review implementation in Dodoma City, Tanzania. A qualitative case study.

Background: With 295 000 maternal deaths in 2017, 94% in low- and middle-income countries, maternal death is a matter of global public health concern. To address it, Maternal Death Surveillance and Response (MDSR) strategy was introduced in 2013 by the World Health Organization. With a reported maternal mortality ratio of 556:100000 per live births, Tanzania adopted the strategy in 2015. Studies are needed to understand factors influencing the implementation of MDSR in this specific setting. Aims and Objectives: The study aimed to assess the processes influencing MDSR implementation in Dodoma city council. Methods: A qualitative case study was conceptualized according to the Consolidated Framework for Implementation Research, focusing on implementation process domain. Members of MDSR committees were enrolled by purposeful sampling in the five health centres in Dodoma where the strategy was fully implemented and functional. In-depth interviews were conducted with key informants concerning the implementation processes influencing MDSR. Saturation was reached with the 15th respondent. Qualitative inductive content analysis was used to analyse data. Results: The inclusiveness in participatory planning process, stakeholders' readiness and accountability and collective learning were acknowledged as factors positively influencing the implementation of MDSR strategy by respondents. The interaction and alignment of influential factors were essential for successful implementation. Conclusions: MDSR implementation is positively influenced by factors that interact and converge in the building of a learning health system, to increase knowledge through practice and improve practice through knowledge. Further studies are needed to analyse the influence of additional factors at different levels of implementation to fully understand and empower the MDSR implementation network, and to better target the goal of closing the knowledge to practice loop.

Scrub typhus in pregnancy: A report of two cases.

Scrub typhus shows a high prevalence in South-East Asia. In pregnant females, it can cause both maternal and fetal adverse outcomes. We report a case series of two women with scrub typhus and their varied outcomes. A 25-year-old primigravida treated for scrub typhus at 23 weeks' gestation presented at 34 weeks with stage three fetal growth restriction (FGR). Caesarean delivery was performed. The neonate had biliary atresia. A 24-year-old primigravida at 31 weeks' gestation was referred from a local hospital due to scrub typhus induced multi-organ dysfunction. She had FGR stage 1 with oligohydramnios. Emergency caesarean delivery was performed in view of acute fetal bradycardia. There is an emerging need for research to reassess what is already known about scrub typhus in pregnancy and to develop techniques for its treatment inorder to achieve a positive maternal and neonatal outcome in these cases.

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

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

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

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

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

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

[Maternal mortality due to genital tract infection in France, 2016-2018]. / Mortalité maternelle par infection à porte d'entrée génitale en France 2016­2018.

Over the 2016-2018 period, maternal mortality due to direct infectious causes accounted for 13% of maternal deaths by direct causes. The increasing trend in genital-tract infections related-deaths noted in the 2013-2015 report continues for the 2016-2018 period, but this 2010-2018 increase remains at the limit of statistical significance given the low number of cases (p 0.08). The 13 deaths from direct infectious causes for the 2016-2018 period were due to 4 cases of puerperal toxic shock syndrome (Streptococcus A beta hemolyticus or Clostridium group bacilli), 6 sepsis caused by intrauterine infection due to E. Coli and 3 cases of septic shock from intrauterine origin and no documented bacteria. In this 2016-2018 triennium, the quality of care concerning women who died of direct infections was considered non-optimal in 85% (11/13). Death was considered possibly or probably avoidable in 9/13 cases (69%), which made it one of the most avoidable causes of maternal mortality. Preventable factors related to the medical management were the most frequent (9/13), with in particular a diagnostic failure or delayed diagnosis leading to a delay in the introduction of medical treatment. The others contributory factors to these deaths were related to the organization of healthcare (delayed transfer, lack of communication between practitioners) as well as factors related to patient social and/or mental vulnerability.

SARS-CoV-2 infection during pregnancy and the risk of adverse maternal outcomes in the Republic of Georgia: a national birth registry-based cohort study.

BACKGROUND: Georgia experienced an increase in maternal deaths (MD) during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, which warrants further investigation. This study aimed to assess associations between timing of SARS-CoV-2 infection during pregnancy and MD, post-delivery intensive care unit (ICU) admission, and caesarean section (CS) delivery. METHODS: We performed a national birth registry-based cohort study of pregnant women who had completed 22 weeks of gestation and delivered between February 28, 2020, and August 31, 2022. The data were linked to coronavirus disease 2019 (COVID-19) testing, vital, and immunization registries. Pregnant women were classified into three groups: confirmed SARS-CoV-2 infection from conception through 31 days before delivery; confirmed infection within 30 days before or at delivery; and women negative for SARS-CoV-2 infection or without any test results (reference group). Multivariable logistic regression was used to calculate the adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: Among 111,493 pregnant women, 16,751 had confirmed infection during pregnancy, and 7,332 were fully vaccinated against COVID-19 before delivery. Compared to the reference group, those with confirmed infection within 30 days before or at delivery experienced increased odds of MD (aOR: 43.11, 95% CI, 21.99-84.55), post-delivery ICU admission (aOR: 5.20, 95% CI, 4.05-6.67), and CS delivery (aOR: 1.11, 95% CI, 1.03-1.20). CONCLUSIONS: Pregnant women in Georgia with confirmed SARS-CoV-2 infection within 30 days before or at delivery experienced a considerably higher risk of MD and post-delivery ICU admission and a slightly higher risk for CS delivery. Additionally, the results highlighted that most pregnant women were not vaccinated against COVID-19. These findings should alert stakeholders that adherence to public health preventive measures needs to be improved.

Nationwide study of in-hospital maternal mortality in Ecuador, 2015-2022.

Objective: This study aimed to analyze estimates of in-hospital delivery-related maternal mortality and sociodemographic factors influencing this mortality in Ecuador during 2015 to 2022. Methods: Data from publicly accessible registries from the Ecuadorian National Institute of Statistics and Censuses were analyzed. Maternal mortality ratios (MMRs) were calculated, and bivariate and multivariate logistic regression models were used to obtain unadjusted and adjusted odds ratios. Results: There was an increase in in-hospital delivery-related maternal deaths in Ecuador from 2015 to 2022: MMRs increased from 3.70 maternal deaths/100 000 live births in 2015 to 32.22 in 2020 and 18.94 in 2022. Manabí province had the highest rate, at 84.85 maternal deaths/100 000 live births between 2015 and 2022. Women from ethnic minorities had a higher probability of in-hospital delivery-related mortality, with an adjusted odds ratio (AOR) of 9.59 (95% confidence interval [95% CI]: 6.98 to 13.18). More maternal deaths were also observed in private health care facilities (AOR: 1.99, 95% CI: 1.4 to 2.84). Conclusions: Efforts to reduce maternal mortality have stagnated in recent years. During the COVID-19 pandemic in 2020, an increase in maternal deaths in hospital settings was observed in Ecuador. Although the pandemic might have contributed to the stagnation of maternal mortality estimates, socioeconomic, demographic and clinical factors play key roles in the complexity of trends in maternal mortality. The results from this study emphasize the importance of addressing not only the medical aspects of care but also the social determinants of health and disparities in the health care system.

Multi-organ dysfunction and outcomes in pregnancy associated COVID-19 infection - descriptive review of pathological findings.

OBJECTIVE(S): Comparative clinical and morphological characterization of lesions of the vascular and nervous system in cases of maternal death associated with COVID-19. STUDY DESIGN: The study included autopsy in 12 cases of maternal death with a positive intravital result for SARS-CoV-2 by reverse transcription polymerase chain reaction. For histopathology, tissue samples were taken from the internal organs of each patient. Pieces of organs were fixed and stained according to the standard protocol. The relative number of microvessels with vasculitis and fibers of the peripheral nervous system with infiltration by immune cells was studied. All morphological changes were classified depending on the severity of the damage. RESULTS: The average age of patients with a fatal outcome was 35 ± 4.4 years. Time to death after onset of symptoms averaged 16 ± 4.4 days. Dystrophic lesions (necrosis and apoptosis) of the villous and extravillous trophoblast and decidual tissue were observed in the studied placentas. Histopathological signs of mild and severe lesions of the peripheral nervous system in the organs of the gastrointestinal tract were detected in 2 (16.7%) and 10 (83.3%) cases, respectively, in the myocardium in 4 (33.3%) and 8 (66.7%) cases. Histopathological signs of severe damage to the microvascular bed in the organs of the gastrointestinal tract were registered in 9 (75%) cases. CONCLUSION(S): The main clinical feature of this cohort was that death occurred in a long-term period, in most cases with a negative PCR. The histopathological pattern was a non-acute injury with an immune component of the microvascular bed and the autonomic nervous system with predominant damage to the myocardium and intestines. WHAT DOES THIS STUDY ADD TO THE CLINICAL WORK: This study makes it possible to even better study the immunopathological profile in organs and tissues in pregnant women with a fatal outcome when affected by a viral infection, in particular Covid-19. This knowledge can be used when humanity encounters other viral pandemics in the future.

Preeclampsia Prediction Using Machine Learning and Polygenic Risk Scores From Clinical and Genetic Risk Factors in Early and Late Pregnancies.

BACKGROUND: Preeclampsia, a pregnancy-specific condition associated with new-onset hypertension after 20-weeks gestation, is a leading cause of maternal and neonatal morbidity and mortality. Predictive tools to understand which individuals are most at risk are needed. METHODS: We identified a cohort of N=1125 pregnant individuals who delivered between May 2015 and May 2022 at Mass General Brigham Hospitals with available electronic health record data and linked genetic data. Using clinical electronic health record data and systolic blood pressure polygenic risk scores derived from a large genome-wide association study, we developed machine learning (XGBoost) and logistic regression models to predict preeclampsia risk. RESULTS: Pregnant individuals with a systolic blood pressure polygenic risk score in the top quartile had higher blood pressures throughout pregnancy compared with patients within the lowest quartile systolic blood pressure polygenic risk score. In the first trimester, the most predictive model was XGBoost, with an area under the curve of 0.74. In late pregnancy, with data obtained up to the delivery admission, the best-performing model was XGBoost using clinical variables, which achieved an area under the curve of 0.91. Adding the systolic blood pressure polygenic risk score to the models did not improve the performance significantly based on De Long test comparing the area under the curve of models with and without the polygenic score. CONCLUSIONS: Integrating clinical factors into predictive models can inform personalized preeclampsia risk and achieve higher predictive power than the current practice. In the future, personalized tools can be implemented to identify high-risk patients for preventative therapies and timely intervention to improve adverse maternal and neonatal outcomes.

Impact of near-miss event during pregnancy and childbirth on maternal health at 12 months.

OBJECTIVE: To assess the impact of maternal near-miss on late maternal death and the prevalence of hypertension or chronic kidney disease (CKD) and mental health problems at 12 months of follow up. METHODS: This prospective cohort study was conducted in a tertiary hospital in the southeastern region of India from May 2018 to August 2019, enrolling those with maternal near-miss and with follow up for 12 months. The primary outcomes were incidence of late maternal deaths and prevalence of hypertension and CKD during follow up. RESULTS: Incidence of maternal near miss was 6.7 per 1000 live births. Among those who had a near miss, late maternal deaths occurred in 7.2% (95% confidence interval [CI] 3.1%-11.3%); prevalence of CKD was 23.0% (95% CI 16.2%-29.8%), and of hypertension was 56.2% (95% CI 50.5%-66.5%) and only two women had depression on follow up. After adjusting for age, parity, socioeconomic status, gestational age at delivery, hemoglobin levels, and perinatal loss, only serum creatinine was independently associated with late maternal death and CKD on follow up. CONCLUSIONS: Women who survive a life-threatening complication during pregnancy and childbirth are at increased risk of mortality and one or more long-term sequelae contributing to the non-communicable disease burden. A policy shift to increase postpartum follow-up duration, following a high-risk targeted approach after a near-miss event, is needed.

Maternal health surveillance panel: a tool for expanding epidemiological surveillance of women's health and its determinants / Painel de vigilância da saúde materna: uma ferramenta para ampliação da vigilância epidemiológica da saúde das mulheres e seus determinantes

ABSTRACT Objective: To present the methodology used in the development of two products for maternal health surveillance and its determinants and discuss their possible uses. Methods: Based on a theoretical model of the determinants of maternal death and databases of Brazilian health information systems, two free products were developed: an interactive panel "surveillance of maternal health" and an educational material "Aparecida: a story about the vulnerability of Brazilian women to maternal death", both available on the website of the Brazilian Obstetric Observatory. Results: More than 30 indicators were calculated for the period 2012-2020, containing information on socioeconomic conditions and access to health services, reproductive planning, prenatal care, delivery care, conditions of birth and maternal mortality and morbidity. The indicators related to severe maternal morbidity in public hospitalizations stand out, calculated for the first time for the country. The panel allows analysis by municipality or aggregated by health region, state, macro-region and country; historical series analysis; and comparisons across locations and with benchmarks. Information quality data are presented and discussed in an integrated manner with the indicators. In the educational material, visualizations with national and international data are presented, aiming to help in the understanding of the determinants of maternal death and facilitate the interpretation of the indicators. Conclusion: It is expected that the two products have the potential to expand epidemiological surveillance of maternal health and its determinants, contributing to the formulation of health policies and actions that promote women's health and reduce maternal mortality.

RESUME Objetivo: Apresentar a metodologia utilizada no desenvolvimento de dois produtos para a vigilância da saúde materna e seus determinantes e discutir as suas possíveis utilizações. Métodos: A partir de modelo teórico dos determinantes do óbito materno e bases de dados dos sistemas de informação em saúde brasileiros, foram desenvolvidos dois produtos gratuitos: um painel interativo denominado "Vigilância da saúde materna" e um material educativo chamado "Aparecida: uma história sobre a vulnerabilidade da mulher brasileira à morte materna", ambos disponíveis no site do Observatório Obstétrico Brasileiro. Resultados: Foram calculados mais de 30 indicadores para o período 2012-2020, contendo informações sobre condições socioeconômicas e de acesso a serviços de saúde, planejamento reprodutivo, assistência pré-natal, assistência ao parto, condições de nascimento e mortalidade e morbidade materna. Destacam-se os indicadores relacionados à morbidade materna grave em internações públicas, calculados pela primeira vez para o país. O painel permite análises por município ou agregadas por região de saúde, unidade da federação, macrorregião e país; análises de série histórica; e comparações entre localidades e com padrões de referência. Dados de qualidade da informação são apresentados e discutidos de forma integrada aos indicadores. No material educativo, visualizações com dados nacionais e internacionais são apresentadas, visando auxiliar na compreensão dos determinantes do óbito materno e facilitar a interpretação dos indicadores. Conclusão: Espera-se que os produtos tenham o potencial de ampliar a vigilância epidemiológica da saúde materna e seus determinantes, contribuindo para a formulação de políticas e ações de saúde que promovam a saúde das mulheres e reduzam a mortalidade materna.

Nationwide study of in-hospital maternal mortality in Ecuador, 2015-2022 / Estudio a nivel nacional de la mortalidad materna intrahospitalaria en Ecuador, 2015-2022 / Estudo nacional sobre mortalidade materna intra-hospitalar no Equador, 2015-2022

ABSTRACT Objective. This study aimed to analyze estimates of in-hospital delivery-related maternal mortality and sociodemographic factors influencing this mortality in Ecuador during 2015 to 2022. Methods. Data from publicly accessible registries from the Ecuadorian National Institute of Statistics and Censuses were analyzed. Maternal mortality ratios (MMRs) were calculated, and bivariate and multivariate logistic regression models were used to obtain unadjusted and adjusted odds ratios. Results. There was an increase in in-hospital delivery-related maternal deaths in Ecuador from 2015 to 2022: MMRs increased from 3.70 maternal deaths/100 000 live births in 2015 to 32.22 in 2020 and 18.94 in 2022. Manabí province had the highest rate, at 84.85 maternal deaths/100 000 live births between 2015 and 2022. Women from ethnic minorities had a higher probability of in-hospital delivery-related mortality, with an adjusted odds ratio (AOR) of 9.59 (95% confidence interval [95% CI]: 6.98 to 13.18). More maternal deaths were also observed in private health care facilities (AOR: 1.99, 95% CI: 1.4 to 2.84). Conclusions. Efforts to reduce maternal mortality have stagnated in recent years. During the COVID-19 pandemic in 2020, an increase in maternal deaths in hospital settings was observed in Ecuador. Although the pandemic might have contributed to the stagnation of maternal mortality estimates, socioeconomic, demographic and clinical factors play key roles in the complexity of trends in maternal mortality. The results from this study emphasize the importance of addressing not only the medical aspects of care but also the social determinants of health and disparities in the health care system.

RESUMEN Objetivo. El objetivo de este estudio fue analizar las cifras estimadas de mortalidad materna intrahospitalaria asociada al parto y los factores sociodemográficos que influyen en ella en Ecuador en el período 2015-2022. Métodos. Se analizaron datos de los registros de acceso público del Instituto Nacional de Estadística y Censos de Ecuador. Se calcularon las razones de mortalidad materna (RMM) y se utilizaron modelos de regresión logística bivariados y multivariados para obtener los cocientes de posibilidades sin ajustar y ajustados. Resultados. Entre el 2015 y el 2022, se observó un aumento de las muertes maternas intrahospitalarias asociadas al parto en Ecuador: la RMM aumentó de 3,70 muertes maternas por 100 000 nacidos vivos en el 2015 a 32,22 en el 2020 y 18,94 en el 2022. En la provincia de Manabí se registró la cifra más alta, con 84,85 muertes maternas por 100 000 nacidos vivos entre el 2015 y el 2022. Las mujeres pertenecientes a minorías étnicas tuvieron una mayor probabilidad de muerte intrahospitalaria por causas relacionadas con el parto, con un cociente de posibilidades ajustado (aOR, por su sigla en inglés) de 9,59 (intervalo de confianza del 95% [IC del 95%]: 6,98 a 13,18). También se observó una mayor mortalidad materna en los establecimientos de salud privados (aOR: 1,99, IC del 95%: 1,4 a 2,84). Conclusiones. Los esfuerzos para reducir la mortalidad materna se han estancado en los últimos años. Durante la pandemia de COVID-19, se observó un aumento de las muertes maternas en el 2020 en entornos hospitalarios en Ecuador. Si bien la pandemia podría haber contribuido a que las cifras estimadas de mortalidad materna se estancaran, los factores socioeconómicos, demográficos y clínicos desempeñan un papel clave en la complejidad de las tendencias de la mortalidad materna. Los resultados de este estudio destacan la importancia de abordar no solo los aspectos médicos de la atención, sino también los determinantes sociales de la salud y las disparidades en el sistema de atención de salud.

RESUMO Objetivo. O objetivo deste estudo foi analisar estimativas de mortalidade materna relacionada ao parto intra-hospitalar e os fatores sociodemográficos que influenciaram esse tipo de mortalidade no período de 2015 a 2022 no Equador. Métodos. Foram analisados dados de registros de acesso público do Instituto Nacional de Estatísticas e Censos do Equador. Foram calculadas razões de mortalidade materna (RMM), com o uso de regressão logística bivariada e multivariada para obter razões de chance não ajustadas e ajustadas. Resultados. Houve um aumento nas mortes maternas relacionadas ao parto intra-hospitalar no Equador entre 2015 e 2022: as RMM aumentaram de 3,70 mortes maternas/100 mil nascidos vivos em 2015 para 32,22 em 2020 e 18,94 em 2022. A província de Manabí teve a taxa mais alta, com 84,85 mortes maternas/100 mil nascidos vivos entre 2015 e 2022. Mulheres de minorias étnicas tiveram maior probabilidade de mortalidade relacionada ao parto intra-hospitalar, com uma razão de chances ajustada (RCa) de 9,59 (intervalo de confiança de 95% [IC95%]: 6,98 a 13,18). Também foram observadas mais mortes maternas em estabelecimentos de saúde privados (RCa: 1,99, IC95%: 1,4 a 2,84). Conclusões. As inciativas para reduzir a mortalidade materna estagnaram nos últimos anos. Durante a pandemia de COVID-19 em 2020, foi observado um aumento nas mortes maternas em hospitais do Equador. Embora a pandemia possa ter contribuído para a estagnação das estimativas de mortalidade materna, fatores socioeconômicos, demográficos e clínicos desempenharam papéis fundamentais na complexidade das tendências de mortalidade materna. Os resultados deste estudo destacam a importância de abordar não apenas os aspectos clínicos da atenção, mas também os determinantes sociais da saúde e as disparidades do sistema de saúde.

Black/African American Women's Woes: Women's Perspectives of Black/African American Maternal Mortality in the USA.

BACKGROUND: Despite advances in perinatal care in the USA, maternal mortality is on the rise, and maternal death is higher than in any other high-income country. Maternal mortality in the USA is a persistent public health concern. This issue disproportionately affects Black/African American women, with their likelihood of pregnancy-related death being three times more likely compared to White women. This study aimed to explore the resources needed for Black/African American women to address the relatively higher maternal mortality rates recorded for them. METHODS: An anonymous link with demographic and open-ended questions was sent to US women 18 years and older to participate in the study. A total of 140 participants responded to the survey. We retained a final sample of 118 responses after eliminating responses with missing data. Descriptive statistics are reported for closed-ended items. Open-ended responses were analyzed using content analysis procedures, where we coded and categorized the data into themes. RESULTS: Six themes were identified from the study data: (1) Diversity, Equity, and Inclusion (DEI) training for health providers focused on racial bias and discrimination, (2) Advocacy, (3) Provider selection, (4) Researching doctors and delivery hospitals to inform women's birthing decision-making, (5) Women's care-seeking behaviors, and (6) Addressing the Social Determinants of Health. CONCLUSION: Based on the study's findings, we recommend DEI training for healthcare professionals providing direct care to pregnant and postpartum women, advocacy and resource-awareness training for pregnant Black/African American women and their spouses/partners, or a family member, to assist them in their pregnancy and birthing journeys.

Delivery Methods in Twin Gestations: Evaluating Outcomes, Risk Factors, and the Paradigm Shift Towards Elective Cesarean Deliveries.

During the past decade, there has been a consistent rise in the number of twin births and the number of overall cesarean sections (CS) worldwide. This is owed to a variety of social, economic, educational, and scientific factors. More women are opting to advance their professional careers and gain financial stability before having children. Although this approach is understandable, a new set of challenges are faced as a result, the most important of which has been infertility due to advanced maternal age and the subsequent use of assisted fertility treatments, which have been noted to cause multiple gestations. Twin gestations are considered high-risk pregnancies and are associated with an amplitude of potential complications. Arguably, the biggest decision an obstetrician must make when dealing with this population is choosing the most appropriate mode of delivery. Given the lack of clear guidance pertaining to twin deliveries, CSs may often be perceived as safer and are often preferred over vaginal deliveries (VD). In this narrative review, we aimed to compare the outcomes of different delivery methods (CS versus VD) to investigate whether CS is truly superior to VD. Data were collected from the past two decades and analyzed based on the neonatal and maternal outcomes for each delivery mode. Our results indicate that planned VD is just as safe as CS, if not superior, in most uncomplicated twin pregnancies. Thus, it is best to advise and encourage healthy expecting twin carriers to undergo VD and explore any hesitations or fears they might have. Furthermore, a detailed guideline regarding twin delivery is essential to establish and better navigate twin deliveries, lower the rate of unnecessary CSs, and reduce overall twin gestation morbidity and mortality.

Prevalence of maternal mortality causes based on ICD-MM: a systematic review and meta-analysis.

BACKGROUND: Maternal mortality is a universal public health challenge. ICD-Maternal Mortality (ICD-MM) was introduced in 2012 to facilitate the gathering, analysis, and interpretation of data on maternal deaths worldwide. The present study aimed to estimate the global prevalence of maternal death causes through a systematic review and meta-analysis. METHODS: A systematic literature search was conducted using various databases, including Web of Science, PubMed, Scopus, ScienceDirect, Cochrane Library, as well as Persian databases such as MagIran and Scientific Information Database (SID). The search encompassed articles published until August 21, 2022. Thirty-four eligible articles were included in the final analysis. Analysis was performed using a meta-analysis approach. The exact Clopper-Pearson confidence intervals, heterogeneity assessment, and random effects models with Mantel-Haenszel methods were employed using the STATA software version 14.2. RESULTS: The most prevalent causes of maternal deaths, listed in descending order from highest to lowest prevalence, were non-obstetric complications (48.32%), obstetric hemorrhage (17.63%), hypertensive disorders of pregnancy, childbirth, and the puerperium (14.01%), other obstetric complications (7.11%), pregnancy with abortive outcome (5.41%), pregnancy-related infection (5.26%), unanticipated complications of management (2.25%), unknown/undetermined causes (2.01%), and coincidental causes (1.59%), respectively. CONCLUSION: Non-obstetric complications, obstetric hemorrhage, and hypertensive disorders of pregnancy, childbirth, and puerperium were the most common causes of maternal deaths. To reduce the burden of maternal mortality causes, increasing awareness and promoting self-care management among women of reproductive age, and implementing effective screening mechanisms for high-risk mothers during pregnancy, childbirth, and the puerperium can play a significant role. ICD-MM enables the uniform collection and comparison of maternal death information at different levels (local, national, and international) by facilitating the consistent collection, analysis, and interpretation of data on maternal deaths. Our findings can be utilized by policymakers and managers at various levels to facilitate necessary planning aimed at reducing the burden of maternal mortality causes.