The Association Between State-Level Prenatal Substance Use Policies and Rates of Maternal Mortality in the United States: A Legal Epidemiology Study.

Little research has explored relationships between prenatal substance use policies and rates of maternal mortality across all 50 states, despite evidence that prenatal substance use elevates risk of maternal death. This study, utilizing publicly available data, revealed that state-level mandated testing laws predicted maternal mortality after controlling for population characteristics.

Trends and causes of maternal mortality in Indonesia: a systematic review.

BACKGROUND: The maternal mortality ratio (MMR) in Indonesia is among the highest in Southeast Asia. We aim to describe trends in the MMR and causes of maternal deaths in Indonesia over the past decades, regionally and nationally. METHODS: We performed a systematic review and conducted a search using PubMed, Embase, Global Health, CINAHL, Cochrane, Portal Garuda, and Google Scholar from the inception of the database to April 2023. We included all studies on the incidence and/or the causes of maternal deaths in Indonesia. The MMR was defined as the number of maternal deaths per 100,000 live births. Maternal death causes were assessed and reclassified according to the WHO International Classification of Disease Maternal Mortality (ICD-MM). RESULTS: We included 63 studies that reported the MMR (54 studies) and/or the causes of maternal deaths (44 studies) in Indonesia from 1970 to 2022, with a total of 254,796 maternal deaths. The national MMR declined from 450 to 249 (45%) between 1990 and 2020. Great differences in MMR exist across the country, with the lowest in Java-Bali and the highest (more than twice the national MMR) in Sulawesi and Eastern Indonesia. Between 1990 and 2022, the proportion of deaths due to hemorrhage and sepsis decreased, respectively from 48 to 18% and 15-5%, while the share of deaths due to hypertensive disorders and non-obstetric causes increased, respectively from 8 to 19% and 10-49%. CONCLUSION: Despite the steady decline of maternal deaths in Indonesia, it remains one of the highest in Southeast Asia, with enormous disparities within the country. Hypertensive disorders and non-communicable diseases make up a growing share of maternal deaths, making maternal death reduction strategies increasingly challenging. National Maternal Death Surveillance and Response needs to be prioritized to eliminate preventable maternal deaths in Indonesia. REGISTRATION OF SYSTEMATIC REVIEWS: PROSPERO, CRD42022320213.

Increasing the number of midwives is necessary but not sufficient: using global data to support the case for investment in both midwife availability and the enabling work environment in low- and middle-income countries.

BACKGROUND: Most countries are off-track to achieve global maternal and newborn health goals. Global stakeholders agree that investment in midwifery is an important element of the solution. During a global shortage of health workers, strategic decisions must be made about how to configure services to achieve the best possible outcomes with the available resources. This paper aims to assess the relationship between the strength of low- and middle-income countries' (LMICs') midwifery profession and key maternal and newborn health outcomes, and thus to prompt policy dialogue about service configuration. METHODS: Using the most recent available data from publicly available global databases for the period 2000-2020, we conducted an ecological study to examine the association between the number of midwives per 10,000 population and: (i) maternal mortality, (ii) neonatal mortality, and (iii) caesarean birth rate in LMICs. We developed a composite measure of the strength of the midwifery profession, and examined its relationship with maternal mortality. RESULTS: In LMICs (especially low-income countries), higher availability of midwives is associated with lower maternal and neonatal mortality. In upper-middle-income countries, higher availability of midwives is associated with caesarean birth rates close to 10-15%. However, some countries achieved good outcomes without increasing midwife availability, and some have increased midwife availability and not achieved good outcomes. Similarly, while stronger midwifery service structures are associated with greater reductions in maternal mortality, this is not true in every country. CONCLUSIONS: A complex web of health system factors and social determinants contribute to maternal and newborn health outcomes, but there is enough evidence from this and other studies to indicate that midwives can be a highly cost-effective element of national strategies to improve these outcomes.

Resilience in the time of crisis: A review of the maternal, perinatal and reproductive health effects of COVID-19 in South Africa.

BACKGROUND: The COVID-19 pandemic had a profound effect on the health sector globally and in South Africa (SA). OBJECTIVE: To review the effects of COVID-19 on maternal, perinatal and reproductive health outcomes and service utilisation in SA. METHODS: Three routine national data collection systems were sourced: the District Health Information System, the Saving Mothers reports of the National Committee on Confidential Enquiry into Maternal Deaths and the Saving Babies reports from the National Perinatal Morbidity and Mortality Committee using data from the Perinatal Problem Identification Program. RESULTS: There were 35% and 8% increases in maternal and stillbirth mortality rates, respectively, in 2020 and 2021, which correlated with the COVID-19 waves. However, in 2022, rates returned to pre-COVID levels. Antenatal visits and facility births showed little change, but there was a shift to more rural provinces. The use of oral and injectable contraceptives and termination of pregnancy services decreased markedly in 2020 and 2021, with a sustained shift to long-acting reversible contraceptives. The increase in maternal deaths was predominantly due to COVID-19 respiratory complications, but also an increase in obstetric haemorrhage. Stillbirths increased significantly (10%) for birthweights between 2 000 g and 2 499 g, categorised mostly as unexplained stillbirths or preterm labour, but no increase in neonatal deaths was observed. Administrative avoidable factors increased by 24% in the 2020 - 2022 triennium, but there was no increase in patient/community level or healthcare provider-related avoidable factors during the pandemic years. CONCLUSION: COVID-19 caused a marked increase in maternal death and stillbirth rates in 2020 and 2021 due to both direct effects of the virus and indirect effects on functioning of the health system. The continued, although modified, health-seeking behaviour of women and the rapid return to pre-COVID-19 mortality rates demonstrates enormous resilience in women and the health system.

Cost of mate choice: Changing patterns of global age disparity in marriage and their consequences to women's health including maternal mortality and menopause.

BACKGROUND: Consistent across cultures and throughout time is the male preference for younger females. Given its prevalence, the mate choice theory proposes that age-disparate relationships may have contributed to the evolution of maternal mortality and menopause. OBJECTIVES: The objective is to document evidence for age disparity in marriage from past and present populations and evaluate their relevance to maternal mortality and menopause. DESIGN: Cross-sectional data were collected from various regions and time points, ranging from the Roman era to the current decade. METHODS: To analyze both the age disparity in marriage and age at marriage, data were collected from Ancestry.ca for Quebec, Massachusetts, India, South Africa, and England and Wales. Additional data were taken from the United Nations as a more recent and comprehensive source. To analyze the relationships between age disparity in marriage and different social factors, data on gross domestic product, maternal mortality rates, fertility, primary school enrollment, child marriage rates, and percentage of women in the total labor force were collected from the World Health Organization, World Bank, and United Nations International Children's Emergency Fund. RESULTS: The results showed that males were significantly older than females at first marriage in all populations and time frames sampled, supporting the assumption underlying the mate choice theory. Maternal mortality rates were strongly associated with age-disparate relationships, increasing by 275 per 100,000 live births for each additional year in the age disparity. CONCLUSION: The results from this study provide support for the assumption underlying the mate choice theory of maternal mortality and menopause.

Changing patterns of global age disparity in marriage provide support for the mate choice theory of menopause, raising the possibility of a gradual shift in delayed reproduction and delayed menopause. Living things have inherent capacity to survive and reproduce until they die, with one exception: humans. Women go through menopause while men remain fertile. Among the many explanations offered for the origin of menopause, grandmother hypothesis is the leading one. Being too old to reproduce, it is argued, grandmothers stop reproducing and make up for the loss of fitness through helping (grand mothering) their grand offspring. There are two problems with this theory: first, grand mothering and menopause need not be connected, and second, grandmothers cannot be simultaneously too old to reproduce and not too old to be able to gather resources to make up for their loss of fitness. We proposed a mate choice theory of menopause which posits that human mating system is non-random, that is, males have preference for younger females, depriving older females from reproduction and allowing deleterious fertility mutations to accumulate giving rise to menopause. Male preference for younger females is consistent across cultures and dominates all social relations affecting mate choice including monogamy, serial monogamy, widowers remarrying, polygamy, harem, and others. In this study, we wanted to test if male preference for younger females has been widespread through time. We collected data on age disparity in marriage from past and present populations, from Roman era to the current decade, and evaluated their relevance to the origin of maternal mortality and menopause. The results showed that males were significantly older than females at first marriage in all populations and time frames sampled, supporting the assumption underlying the mate choice theory of menopause. Maternal mortality rates were strongly associated with age­disparate relationships, increasing by 275 per 100,000 live births for each additional year in the age disparity. Through repeated cycles of widowers marring younger women, maternal mortality would have functioned as a reinforcer of the origin of menopause.

Will South Africa meet the Sustainable Development Goals target for maternal mortality by 2030?

In September 2015, South Africa (SA) and 192 countries adopted Agenda 2030, which included the Sustainable Development Goals. With a mere 6 years to go before 2030, it is useful to understand what progress SA is making towards their attainment. In this short report, we assess progress towards meeting the maternal mortality target, globally and in SA. The maternal mortality ratio that countries are expected to reach is no more than 70 deaths per 100 000 live births. A range of sources is used to show progress, with an emphasis on the reports of the National Committee on Confidential Enquiries into Maternal deaths, which reports on the number of maternal deaths in health facilities, together with reasons for these deaths and recommendations to reduce preventable mortality.

Contributing factors for reduction in maternal mortality ratio in India.

Maternal mortality ratio (MMR) estimates have been studied over time for understanding its variation across the country. However, it is never sufficient without accounting for presence of variability across in terms of space, time, maternal and system level factors. The study endeavours to estimate and quantify the effect of exposures encompassing all maternal health indicators and system level indicators along with space-time effects influencing MMR in India. Using the most recent level of possible -factors of MMR, maternal health indicators from the National Family Health Survey (NFHS: 2019-21) and system level indicators from government reports a heatmap compared the relative performance of all 19 SRS states. Facet plots with a regression line was utilised for studying patterns of MMR for different states in one frame. Using Bayesian Spatio-temporal random effects, evidence for different MMR patterns and quantification of spatial risks among individual states was produced using estimates of MMR from SRS reports (2014-2020). India has witnessed a decline in MMR, and for the majority of the states, this drop is linear. Few states exhibit cyclical trend such as increasing trends for Haryana and West Bengal which was evident from the two analytical models i.e., facet plots and Bayesian spatio- temporal model. Period of major transition in MMR levels which was common to all states is identified as 2009-2013. Bihar and Assam have estimated posterior probabilities for spatial risk that are relatively greater than other SRS states and are classified as hot spots. More than the individual level factors, health system factors account for a greater reduction in MMR. For more robust findings district level reliable estimates are required. As evident from our study the two most strong health system influencers for reducing MMR in India are Institutional delivery and Skilled birth attendance.

Factors associated with maternal mortality in Kazakhstan: a pre- and during-pandemic comparison.

Introduction: The maternal mortality indicator serves as a crucial reflection of a nation's overall healthcare, economic, and social standing. It is necessary to identify the variations in its impacts across diverse populations, especially those at higher risk, to effectively reduce maternal mortality and enhance maternal health. The global healthcare landscape has been significantly reshaped by the COVID-19 pandemic, pressing disparities and stalling progress toward achieving Sustainable Development Goals, particularly in maternal mortality reduction. Methods: This study investigates the determinants of maternal mortality in Kazakhstan from 2019 to 2020 and maternal mortality trends in 17 regions from 2000 to 2020, employing data extracted from national statistical reports. Stepwise linear regression analysis is utilized to explore trends in maternal mortality ratios in relation to socioeconomic factors and healthcare service indicators. Results: The national maternal mortality ratio in Kazakhstan nearly tripled from 13.7 in 2019 to 36.5 per 100,000 live births in 2020. A remarkable decrease was observed from 2000 until around 2015 with rates spiked by 2020. Significant factors associated with maternal mortality include antenatal care coverage and the number of primary healthcare units. Additionally, socioeconomic factors such as secondary education enrollment and cases of domestic violence against women emerged as predictors of MMR. Moreover, the impact of the pandemic was evident in the shift of coefficients for certain predictors, such as antenatal care coverage in our case. In 2020, predictors of MMR continued to include secondary education enrollment and reported cases of domestic violence. Conclusion: Despite Kazakhstan's efforts and commitment toward achieving Sustainable Development Goals, particularly in maternal mortality reduction, the impact of the COVID-19 pandemic poses alarming challenges. Addressing these challenges and strengthening efforts to mitigate maternal mortality remains imperative for advancing maternal health outcomes in Kazakhstan.

Measuring the impact of maternal critical care admission on short- and longer-term maternal and birth outcomes.

PURPOSE: Factors increasing the risk of maternal critical illness are rising in prevalence in maternity populations. Studies of general critical care populations highlight that severe illness is associated with longer-term physical and psychological morbidity. We aimed to compare short- and longer-term outcomes between women who required critical care admission during pregnancy/puerperium and those who did not. METHODS: This is a cohort study including all women delivering in Scottish hospitals between 01/01/2005 and 31/12/2018, using national healthcare databases. The primary exposure was intensive care unit (ICU) admission, while secondary exposures included high dependency unit admission. Outcomes included hospital readmission (1-year post-hospital discharge, 1-year mortality, psychiatric hospital admission, stillbirth, and neonatal critical care admission). Multivariable Cox and logistic regression were used to report hazard ratios (HR) and odds ratios (OR) of association between ICU admission and outcomes. RESULTS: Of 762,918 deliveries, 1449 (0.18%) women were admitted to ICU, most commonly due to post-partum hemorrhage (225, 15.5%) followed by eclampsia/pre-eclampsia (133, 9.2%). Over-half (53.8%) required mechanical ventilation. One-year hospital readmission was more frequent in women admitted to ICU compared with non-ICU populations [24.5% (n = 299) vs 8.9% (n = 68,029)]. This association persisted after confounder adjustment (HR 1.93, 95% confidence interval [CI] 1.33, 2.81, p < 0.001). Furthermore, maternal ICU admission was associated with increased 1-year mortality (HR 40.06, 95% CI 24.04, 66.76, p < 0.001), stillbirth (OR 12.31, 95% CI 7.95,19.08, p < 0.001) and neonatal critical care admission (OR 6.99, 95% CI 5.64,8.67, p < 0.001) after confounder adjustment. CONCLUSION: Critical care admission increases the risk of adverse short-term and long-term maternal, pregnancy and neonatal outcomes. Optimizing long-term post-partum care may benefit maternal critical illness survivors.

Risk factors for maternal near-miss in an undeveloped province in south-central China, 2012-2022.

OBJECTIVE: To explore the risk factors for maternal near-miss (MNM) using the WHO near-miss approach. METHODS: Data were obtained from the Maternal Near-Miss Surveillance System in Hunan Province, China, 2012-2022. Multivariate logistic regression analysis (method: Forward, Wald, α = 0.05) and adjusted odds ratios (aORs) were used to identify risk factors for MNM. RESULTS: Our study included 780,359 women with 731,185 live births, a total of 2461 (0.32%) MNMs, 777,846 (99.68%) non-MNMs, and 52 (0.006%) maternal deaths were identified. The MNM ratio was 3.37‰ (95%CI: 3.23-3.50). Coagulation/hematological dysfunction was the most common cause of MNM (75.66%). Results of multivariate logistic regression analysis showed risk factors for MNM: maternal age > = 30 years old (aOR > 1, P < 0.05), unmarried women (aOR = 2.21, 95%CI: 1.71-2.85), number of pregnancies > = 2 (aOR > 1, P < 0.05), nulliparity (aOR = 1.51, 95%CI: 1.32-1.72) or parity > = 3 (aOR = 1.95, 95%CI: 1.50-2.55), prenatal examinations < 5 times (aOR = 1.13, 95%CI: 1.01-1.27), and number of cesarean sections was 1 (aOR = 1.83, 95%CI: 1.64-2.04) or > = 2 (aOR = 2.48, 95%CI: 1.99-3.09). CONCLUSION: The MNM ratio was relatively low in Hunan Province. Advanced maternal age, unmarried status, a high number of pregnancies, nulliparity or high parity, a low number of prenatal examinations, and cesarean sections were risk factors for MNM. Our study is essential for improving the quality of maternal health care and preventing MNM.

Assessing Racial and Ethnic Disparities in Timing of Pregnancy Related Deaths.

Existing research documents significant racial disparities in pregnancy-related deaths in the United States. Recently, the National Center for Health Statistics (NCHS) identified inconsistencies in maternal mortality data due to irregularities in previous data collection. Yet, corrections of the data still highlight stark differences across racial identity. Additionally, data indicates that while many people die during labor and delivery, a considerable percentage of people die up to a year postpartum. To assess disparities in the timing of pregnancy-related deaths using corrected data, we analyzed aggregated vital statistics data from 2015 to 2018 (n = 4,261). We present relative risk ratios from multinomial logistic regressions to examine the association between race and ethnicity and the timing of pregnancy-related deaths (pregnant at the time of death, 42 days post pregnancy, and 43 days to one-year post pregnancy). Results highlight significant differences in the distribution of timing of pregnancy-related deaths across nativity status and geographic region. Findings document a disproportionate percentage of pregnancy-related deaths among foreign-born people who give birth. Overall, results suggest extending our framing of postpartum care beyond a hospital stay.

Moving from Principle to Practice: A Researcher's Guide to Co-Leading Engaged Research with Community Partners and Patients with Lived Experience to Reduce Maternal Mortality and Morbidity for Maternal Sepsis.

OBJECTIVES: Maternal mortality and morbidity disproportionately affect birthing people from racialized populations. Unfortunately, researchers can often compound these poor outcomes through a lack of authentic community engagement in research beyond the role of the research subject, leading to ineffective strategies for improving care and increasing equity. This article details the real-life strategies utilized to develop a community-engaged research project of a phased federally funded grant employing community engagement principles of co-leadership and co-creation. It also includes reflections from the researchers and advisory board on promising practices and lessons learned for equitably engaging patients and community partners in research. METHODS: This article details the application of principles of community-engaged research in a federally funded phased research project focused on understanding disparities in maternal sepsis to develop better clinical and community interventions. Specifically, it discusses early steps in the research partnership to create a sustainable partnership with a Community Leadership Board guided by the principles of transparency, respect, compensation, and increasing research justice. RESULTS: Based on the authors' experience, recommendations are provided for funders, researchers, and institutions to improve the quality and outcomes of communityengaged research. This work adds to community-based participatory and community-engaged research literature by providing concrete and practical steps for equitably engaging in research partnerships with a variety of collaborators. CONCLUSIONS: In conclusion, integrated patient and community co-leadership enhances research by providing insight, access to communities for education and dissemination of information, and identifying critical areas needing change. This report may help others address fundamental principles in this journey.

Trends in maternal and child health in China and its urban and rural areas from 1991 to 2020: a joinpoint regression model.

The long-term trends in maternal and child health (MCH) in China and the national-level factors that may be associated with these changes have been poorly explored. This study aimed to assess trends in MCH indicators nationally and separately in urban and rural areas and the impact of public policies over a 30‒year period. An ecological study was conducted using data on neonatal mortality rate (NMR), infant mortality rate (IMR), under-five mortality rate (U5MR), and maternal mortality ratio (MMR) nationally and separately in urban and rural areas in China from 1991 to 2020. Joinpoint regression models were used to estimate the annual percentage changes (APC), average annual percentage changes (AAPC) with 95% confidence intervals (CIs), and mortality differences between urban and rural areas. From 1991 to 2020, maternal and child mortalities in China gradually declined (national AAPC [95% CI]: NMRs - 7.7% [- 8.6%, - 6.8%], IMRs - 7.5% [- 8.4%, - 6.6%], U5MRs - 7.5% [- 8.5%, - 6.5%], MMRs - 5.0% [- 5.7%, - 4.4%]). However, the rate of decline nationally in child mortality slowed after 2005, and in maternal mortality after 2013. For all indicators, the decline in mortality was greater in rural areas than in urban areas. The AAPCs in rate differences between rural and urban areas were - 8.5% for NMRs, - 8.6% for IMRs, - 7.7% for U5MRs, and - 9.6% for MMRs. The AAPCs in rate ratios (rural vs. urban) were - 1.2 for NMRs, - 2.1 for IMRs, - 1.7 for U5MRs, and - 1.9 for MMRs. After 2010, urban‒rural disparity in MMR did not diminish and in NMR, IMR, and U5MR, it gradually narrowed but persisted. MCH indicators have declined at the national level as well as separately in urban and rural areas but may have reached a plateau. Urban‒rural disparities in MCH indicators have narrowed but still exist. Regular analyses of temporal trends in MCH are necessary to assess the effectiveness of measures for timely adjustments.

Evolving narratives on signal functions for monitoring maternal and newborn health services: A meta-narrative inspired review.

Emergency obstetric care (EmOC) signal functions are a shortlist of key clinical interventions capable of averting deaths from the five main direct causes of maternal mortality; they have been used since 1997 as a part of an EmOC monitoring framework to track the availability of EmOC services in low- and middle-income settings. Their widespread use and proposed adaptation to include other types of care, such as care for newborns, is testimony to their legacy as part of the measurement architecture within reproductive health. Yet, much has changed in the landscape of maternal and newborn health (MNH) since the initial introduction of EmOC signal functions. As part of a project to revise the EmOC monitoring framework, we carried out a meta-narrative inspired review to reflect on how signal functions have been developed and conceptualised over the past two decades, and how different narratives, which have emerged alongside the evolving MNH landscape, have played a role in the conceptualisation of the signal function measurement. We identified three overarching narrative traditions: 1) clinical 2) health systems and 3) human rights, that dominated the discourse and critique around the use of signal functions. Through an iterative synthesis process including 19 final articles selected for the review, we explored patterns of conciliation and areas of contradiction between the three narrative traditions. We summarised five meta-themes around the use of signal functions: i) framing the boundaries; ii) moving beyond clinical capability; iii) capturing the woods versus the trees; iv) grouping signal functions and v) measurement challenges. We intend for this review to contribute to a better understanding of the discourses around signal functions, and to provide insight for the future roles of this monitoring approach for emergency obstetric and newborn care.

Eight years into the horizon of aspirational maternal and newborn health pledges: a nationwide cross-sectional exploration of the Burundian EmONC network capacity and budget deficits.

OBJECTIVE: The Burundian emergency obstetric and neonatal care (EmONC) programme, which was initiated in 2017 and supported by a specific policy, does not appear to reverse maternal and newborn mortality trends. Our study examined the capacity challenges facing participating EmONC facilities and developed alternative investment proposals to improve their readiness paying particular attention to EmONC professionals, physical infrastructure, and capital equipment. DESIGN: Cross-sectional study. SETTING: Burundian EmONC facilities (n=112). PARTICIPANTS: We examined EmONC policy documents, consulted 12 maternal and newborn health experts and 23 stakeholders and policymakers, surveyed all EmONC facilities (n=112), and collected cost data from the Ministry of Health and local suppliers in Burundi. We developed three context-specific EmONC resource benchmark standards by facility type; the Burundian policy norms and the expert minimum and maximum suggested thresholds; and used these alternatives to estimate EmONC resource gaps. We forecasted three corresponding budget estimates needed to address prevailing deficits taking a government perspective for a 5-year EmONC investment strategy. Additionally, we explored relationships between EmONC professionals and selected measures of service delivery using bivariate analyses and graphically. RESULTS: The lowest EmONC resource benchmark revealed that 95% of basic EmONC and all comprehensive EmONC facilities lack corresponding sets of human resources and 90% of all facilities need additional physical infrastructure and capital equipment. Assessed against the highest benchmark which proposes the most progressive set of standards for the prevailing workloads, Burundi would require 162 more medical doctors, 1005 midwives and nurses, 132 delivery rooms, 191 delivery tables, 678 and 156 maternity and newborn care beds, and 395 incubators amounting to US$32.9 million additional budget for 5 years. CONCLUSION: We demonstrated that Burundian EmONC facilities face enormous capacity challenges equivalent to US$32.9 million funding gap for 5 years; averagely approximating to 5.96% total health budget increase annually.