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Depuis 2015, la mortalité maternelle n’a cessé d’augmenter dans la Région des Amériques, ce qui souligne la nécessité urgente d’agir. Le rapport de mortalité maternelle (RMM) est revenu en 2020 au même niveau que celui observé au début des années 2000, soit un recul de 20 ans. Entre 2015 et 2020, le RMM a augmenté de 17 % dans la Région des Amériques, pour atteindre le nombre de 25 décès maternels par jour en 2020. Par rapport aux autres régions de l’Organisation mondiale de la Santé, la Région des Amériques a enregistré la plus forte augmentation du RMM au niveau mondial. En 2020, 98 % des naissances dans la Région ont été assistées par du personnel de santé qualifié, néanmoins le RMM était de 68 décès pour 100 000 naissances vivantes. Selon les estimations, le RMM se maintient à ce même niveau élevé dans la Région depuis 2020.

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Desde 2015, a mortalidade materna tem aumentado constantemente na Região das Américas, o que destaca a necessidade de ações urgentes. Em 2020, a razão de mortalidade materna (RMM) voltou ao mesmo nível do início dos anos 2000, marcando um retrocesso de 20 anos. Entre 2015 e 2020, a RMM cresceu 17% na Região, chegando a 25 mortes maternas por dia em 2020. Em comparação com outras regiões da Organização Mundial da Saúde, a Região das Américas registrou o maior aumento mundial da RMM. Embora 98% dos partos tenham sido assistidos por pessoal de saúde qualificado em 2020, nesse mesmo ano a RMM na Região foi de 68 mortes por 100 mil nascidos vivos. Estima-se que, desde 2020, a RMM tenha permanecido nesse mesmo nível elevado em toda a Região.

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We carried out the health situation analysis in the Legal Amazon through morbidity and mortality indicators and the comparison between intra and inter-state federation of the region and Brazil. Analysis of the health situation, trends, and identification of clusters in the Brazilian Amazon, for the period from 2010 to 2021, using secondary data available in official health information systems. Circulatory diseases were the main cause of death, representing 23% of deaths. External causes and respiratory diseases contributed 16% and 9% of deaths, respectively; 52.6% of infant deaths occurred in the early neonatal period, and the infant mortality rate remained above the national average. The ratio of maternal mortality was also high and above the national average between 2010 and 2021. The dengue incidence rate remained below the national average with a drop trend of -59.50%. However, rates of Chagas disease, AIDS, Hansen's disease, American cutaneous leishmaniasis and tuberculosis remained above average rates in the country. It was concluded that the population of the Brazilian Amazon faces health challenges. The findings facilitate the identification of territorial priorities for the implementation of actions that impact morbidity and mortality reduction in the region.

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OBJECTIVE: To analyze the temporal and territorial relationship between health system financing fragmentation and maternal mortality in the last two decades in Mexico. METHODS: We conducted an ecological-longitudinal study of the maternal mortality ratio (MMR) in the 32 states of Mexico during the period 2000-2022. Annual MMRs were estimated at the national and state levels according to health insurance. We compared the distribution of individual attributes and place of residence between deceased women with and without social security to identify overrepresented demographic profiles. Finally, we mapped state disparities in MMR by health insurance for the last four political administrations. FINDINGS: MMR in Mexico decreased from 59.3 maternal deaths per hundred thousand live births in 2000 to 47.3 in 2018. However, from 2019 onwards, MMR increased from 48.7 in 2019 to 72.4 in 2022. Seven out of ten maternal deaths occurred in the population without social security from 2000 to 2018, then decreasing to six out of ten from 2020. Maternal deaths in the population without social security were more frequent among younger women, with less schooling, unmarried, and residing in rural areas, with higher Indigenous presence and greater social marginalization. From 2019 onwards, the MMR was higher in the population with social security. CONCLUSION: The results of this study confirm the close relationship between maternal mortality and social inequalities, and suggest that affiliation with social security has ceased to be a differentiating factor in recent years. Understanding the evolution of maternal mortality between the population with and without social security in Mexico allows us to quantify the gap in maternal deaths attributed to inequalities in access to maternal health services, which can contribute to the design of policies that mitigate these gaps.

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Desde el 2015, la mortalidad materna ha aumentado de manera constante en la Región de las Américas, lo que pone de relieve la necesidad de tomar medidas urgentes. En el 2020, la razón de mortalidad materna (RMM) volvió al mismo nivel observado a principios de los años 2000, lo que supone un retroceso de veinte años. Entre el 2015 y el 2020 aumentó un 17%, lo que se traduce en 25 muertes maternas por día en el 2020. En comparación con otras regiones de la Organización Mundial de la Salud, la Región de las Américas ha registrado el mayor aumento de la RMM a nivel mundial. A pesar de que en el 2020 el 98% de los partos los atendió personal de salud calificado, la RMM en la Región correspondiente a ese año fue de 68 muertes por 100 000 nacidos vivos y se estima que desde entonces se sigue manteniendo en el mismo nivel elevado. Esta situación ha puesto de relieve la fragilidad del progreso en la Región, donde es necesario reducir la RMM para alcanzar la meta regional de 30 muertes por 100 000 nacidos vivos establecida para el 2030 en la Agenda de Salud Sostenible para las Américas 2018-2030 (ASSA2030) de la Organización Panamericana de la Salud (OPS), así como la meta 3.1 de los Objetivos de Desarrollo Sostenible.

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Introduction: Maternal mortality remains a significant challenge for public health globally, particularly in developing areas such as Ica, Peru. This study aims to analyze the risk factors contributing to maternal mortality in reference hospitals in Ica during the period of 2010 to 2020. Methods: A case-control study was conducted, including 49 cases of maternal deaths and 98 controls, applying multivariate logistic regression to analyze data collected from hospital records. Results: The absence of a partner (adjusted OR: 12.3; 95% CI: 2.6 to 58.8), history of anemia (adjusted OR: 5.8; 95% CI: 1.5 to 21.3), delays of more than two hours in accessing medical care (adjusted OR: 10.2; 95% CI: 2.0 to 51.1), and lack of knowledge of warning signs such as unrecognized vaginal bleeding by companions (adjusted OR: 7.4; 95% CI: 1.2 to 46.7) were associated with an increased risk of maternal mortality. Conclusions: The identification of these factors highlights the urgent need to develop comprehensive strategies that optimize access to maternal health services and strengthen education on warning signs. To reduce preventable maternal mortality, it is essential to collaborate between the Ministry of Health of Peru and regional governments, aiming to expand coverage and improve the quality of prenatal care. Additionally, awareness should be increased and transportation availability ensured 24 hours a day for women experiencing obstetric complications. The main limitation of this study is the generalization of results due to the regional focus and exclusive use of hospital data.

Introducción: La mortalidad materna sigue siendo un reto considerable para la salud pública a nivel mundial, particularmente en áreas en desarrollo como Ica, Perú. Este estudio tiene como finalidad analizar los factores de riesgo que contribuyen a la mortalidad materna en hospitales de referencia en Ica durante el período de 2010 a 2020. Métodos: Se realizó un estudio de casos y controles, incluyendo 49 casos de muertes maternas y 98 controles, aplicando regresión logística multivariante para analizar datos recopilados de historias clínicas y registros hospitalarios. Resultados: Los factores significativamente asociados con un aumento en el riesgo de mortalidad materna incluyen la ausencia de pareja (odds ratio ajustado [OR]: 12,3; IC 95%: 2,6 a 58,8), antecedentes de anemia (OR ajustado: 5,8; IC 95%: 1,5 a 21,3), demoras superiores a dos horas en acceder a atención médica (OR ajustado: 10,2; IC 95%: 2,0 a 51,1), y el desconocimiento de signos de alarma como el sangrado vaginal no reconocido por los acompañantes (OR ajustado: 7,4; IC 95%: 1,2 a 46,7). Conclusiones: La identificación de estos factores subraya la necesidad urgente de desarrollar estrategias integrales que optimicen el acceso a los servicios de salud materna y fortalezcan la educación sobre los signos de alarma. Para disminuir la mortalidad materna evitable, es esencial la colaboración entre el Ministerio de Salud del Perú y los gobiernos regionales, con el objetivo de ampliar la cobertura y mejorar la calidad de la atención prenatal. Además, se debe aumentar la concienciación y asegurar la disponibilidad de transporte las 24 horas para mujeres que enfrenten complicaciones obstétricas. La principal limitación es la generalización restringida por el enfoque regional y el uso exclusivo de datos hospitalarios.

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A carga da mortalidade infantil representa uma dolorosa realidade que resulta em uma imensa perda de vidas. A meta 3.2 dos Objetivos de Desenvolvimento Sustentável estabelece um compromisso com o fim das mortes evitáveis de recém-nascidos até 2030. O estudo apresentado neste artigo teve por objetivo desenvolver, validar e avaliar um serious game para a prevenção da mortalidade neonatal precoce, voltado para enfermeiros da Atenção Primária à Saúde. Trata-se de uma pesquisa metodológica realizada em cinco etapas: exploratória; validação de conteúdo; desenvolvimento do serious game; avaliação semântica; avaliação de ludicidade. O serious game @-feto busca sensibilizar os enfermeiros quanto à identificação precoce de fatores de risco e condutas frente ao transtorno materno hipertensivo, à insuficiência istmocervical e à infecção do trato urinário na gestação. Possui índices de validade considerados excelentes: conteúdo: 0,98; semântica: 1; ludicidade: 0,98. O serious game @-feto constitui-se uma tecnologia para aprimorar conhecimentos na área materno-infantil de forma lúdica e motivacional.

The burden of infant mortality represents a painful reality that results in an immense loss of lives. The goal 3.2 of the Sustainable Development Goals establishes a commitment to ending avoidable deaths of newborns by 2030. The study presented in this article aimed to develop, validate, and evaluate a serious game for the prevention of early neonatal mortality, designed for Primary Health Care nurses. It is a methodological research conducted in five stages: exploratory, content validation, serious game development, semantic evaluation, and playfulness assessment. The serious game @-feto seeks to sensitise nurses to the early identification of risk factors and management of maternal hypertensive disorder, isthmo-cervical insufficiency, and urinary tract infection during pregnancy. It holds validity indices considered excellent: content: 0.98; semantics: 1; playfulness: 0.98. The serious game @-feto constitutes a technology to enhance knowledge in the maternal-child field in a playful and motivational manner.

La carga de la mortalidad infantil representa una dolorosa realidad que resulta en una inmensa pérdida de vidas. La meta 3.2 de los Objetivos de Desarrollo Sostenible establece un compromiso con el fin de las muertes evitables de recién nacidos hasta 2030. El estudio presentado en este artículo tuvo como objetivo desarrollar, validar y evaluar un serious game para la prevención de la mortalidad neonatal precoz, para enfermeros de la Atención Primaria de Salud. Se trata de una investigación metodológica realizada en cinco etapas: exploratoria; validación de contenido; desarrollo del serious game; evaluación semántica; evaluación de la capacidad lúdica. El serious game @-feto busca sensibilizar a los enfermeros sobre la identificación temprana de factores de riesgo y para conductas ante el trastorno materno hipertensivo, la insuficiencia istmocervical y la infección del tracto urinario durante el embarazo. Posee índices de validez considerados excelentes: contenido: 0,98; semántica: 1; capacidad lúdica: 0,98. El serious game @-feto se constituye una tecnología para mejorar los conocimientos en el área materno-infantil de manera lúdica y motivacional.

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La vigilancia y respuesta efectiva frente a la morbilidad y mortalidad materna, perinatal, neonatal, infantil y de la niñez son esenciales para prevenir estas tragedias. La vigilancia permite no solo identificar los factores de riesgo y las causas subyacentes de esas muertes, sino también monitorear la eficacia de las intervenciones implementadas. Por otro lado, una respuesta eficaz garantiza que las mujeres y los niños en situación de riesgo reciban atención adecuada y oportuna, lo que puede marcar la diferencia entre la vida y la muerte. El presente documento pretende estandarizar la vigilancia de la morbi mortalidad materna y de la niñez, a través de actividades que identifiquen, registren, notifiquen, investiguen, analicen, formulen recomendaciones y evalúen resultados en el Sistema Nacional Integrado de Salud (SNIS). En esta línea, las instituciones que forman parte de dicho sistema, deben establecer estrategias sistemáticas y basadas en evidencias para la vigilancia y respuesta ante estos eventos críticos

Surveillance and effective response to maternal, perinatal, neonatal, infant and child morbidity and mortality are essential to prevent these tragedies. Surveillance makes it possible not only to identify the risk factors and underlying causes of these deaths, but also to monitor the effectiveness of the interventions implemented. On the other hand, an effective response ensures that women and children at risk receive adequate and timely care, which can make the difference between life and death. This document aims to standardize the surveillance of maternal and child morbidity and mortality through activities that identify, register, report, investigate, analyze, formulate recommendations and evaluate results in the National Integrated Health System (SNIS). Along these lines, the institutions that are part of this system should establish systematic and evidence-based strategies for surveillance and response to these critical events

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INTRODUCTION: Postpartum haemorrhage (PPH) remains the leading cause of maternal death. Yet there is a lack of clarity around what research is needed to determine what works and how best to deliver proven PPH interventions. This article describes a WHO-led effort to develop a global PPH research agenda for 2023-2030, to reinvigorate research and innovation while avoiding duplication and waste. METHODS: Potential questions were culled from evidence gaps in a forthcoming Lancet PPH series, a pipeline analysis on PPH medicines and devices, international PPH guidelines, previous research prioritisation efforts and submissions from a reference group of PPH experts and stakeholders. Questions were deduplicated and consolidated, categorised into three tracks (innovation, implementation and cross-cutting) and subjected to an online prioritisation survey. Survey participants (n=120) assessed these questions using five criteria (answerability, effectiveness, deliverability, maximum potential for disease burden reduction and equity) following the Child Health and Nutrition Research Initiative methodology. The outcome of this exercise was complemented by an in-person consensus meeting (Global PPH Summit from 7 March 2023 to 10 March 2023 in Dubai, United Arab Emirates) to finalise the research agenda. RESULTS: Fifteen research questions (five per track) were identified as top priority. The top question per track called for research on the comparative effectiveness and safety of alternative routes of administration (other than the intravenous route) of tranexamic acid in the treatment of PPH (innovation); identifying barriers and facilitators affecting the adoption and use of evidence-based recommendations for PPH management (implementation) and the effectiveness of a strategy of early detection and first response treatment using a bundle of recommended interventions for improving PPH-related outcomes (cross-cutting). CONCLUSION: This shared research agenda should guide future investments into PPH studies with high potential to transform policy and clinical practice in the near term to medium term. Funding for the new research priorities is urgently needed.

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OBJECTIVE: To analyze the impact of the Covid-19 pandemic on the Maternal Mortality Ratio in Brazil from 2018 to 2021. METHOD: Ecological time series study, which analyzed the trend and spatial distribution of maternal deaths from 2018 to 2021, with data obtained from the Mortality and Live Birth Information System. The Maternal Mortality Ratio values were subjected to Prais-Winsten linear regression analysis using Stata program, version 14.0. The evolution of the Maternal Mortality Ratio in the regions was presented on maps created using the TabWin software. RESULTS: A total of 8,229 maternal deaths were recorded in the period. The year 2021 recorded the highest Maternal Mortality Ratio (113.1 maternal deaths per 100,000 live births). Brazil showed a stationary trend, while the North region had a higher Maternal Mortality Ratio across the four years, showing an increasing trend, along with the Northeast, while the Central-West, South and Southeast showed a stationary trend. CONCLUSION: Despite the stationary trend in most Brazilian regions, the Maternal Mortality Ratio increased, especially in 2020 and 2021, years of the Covid-19 pandemic, which demonstrates the need for constant monitoring of vulnerabilities among women during the pregnancy-puerperal cycle to prevent maternal deaths.

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Magnesium sulfate marks 100 years in the medical management of eclampsia. Lazard, starting in May 1924 at the Los Angeles General Hospital, collected clinical evidence of its benefits on the mortality associated with pregnancy convulsions. Doses, regimens, and dilutions were analyzed, revealing therapeutic safety for both mother and fetus. By the end of the 20th century, randomized clinical trials demonstrated the clinical utility of magnesium for the following indications: treatment of eclampsia, prevention of eclampsia, and neurological protection of the brain in preterm infants less than 32 weeks of gestation, among others. This journey has been controversial among many authorities; however, the National University of Colombia and its Department of Obstetrics and Gynecology have defended the Zuspan regimen as the ideal approach for managing these patients since 1982. Through this review, we aim to present all the evidence that has established magnesium as an essential drug for reducing maternal mortality worldwide, especially in developing countries.

El Sulfato de Magnesio completa 100 años en el manejo médico de la eclampsia. Lazard, a partir de mayo de 1924, en el Hospital General de los Ángeles, recogió las evidencias clínicas de sus beneficios sobre la mortalidad de la enfermedad convulsiva del embarazo. Se analizaron dosis, esquemas, diluciones, se encontró seguridad terapéutica para la madre y el feto, y finalizando el siglo XX, se realizaron experimentos clínicos aleatorizados que demostraron la utilidad clínica del magnesio para las siguientes indicaciones: tratamiento de la eclampsia, prevención de la eclampsia, protección neurológica del cerebro del prematuro menor de 32 semanas, entre otras. Todo este camino ha sido controvertido por muchas autoridades; sin embargo, la Universidad Nacional de Colombia y su Departamento de Obstetricia y Ginecología han defendido desde 1982 el esquema Zuspan como el ideal en el manejo de estas pacientes. Con esta revisión queremos mostrar todas las evidencias que han convertido al magnesio en un fármaco indispensable para disminuir la mortalidad materna en todo el mundo, especialmente en los países subdesarrollados.

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[ABSTRACT]. Objective. To examine maternal mortality in Panama, analyzing its direct obstetric deaths, indirect obstetric deaths, and contributory conditions. Methods. This cohort study used publicly available data from the National Institute of Statistics and Census to present a 25-year retrospective analysis of maternal deaths in the Republic of Panama from 1998 to 2022. Public data were sourced from the National Institute of Statistics and Census website of Panama. Relevant codes from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD) were used. The maternal mortality ratio (MMR) was defined as the number of maternal deaths per 100 000 live births. Trendline reliability with R2 was performed to analyze the data. Results. A total of 1 026 maternal deaths occurred in Panama from 1998 through 2022, of which 61.2% were attributed to direct obstetric causes; 23.9%, indirect obstetric causes; 13.6%, contributory conditions; and 1.4% were unknown or undetermined. The average MMR was 60.1. The trendline reliability resulted in R2 = 0.1 (y = –0.5147x + 1094.7), which is not statistically significant but meets the 2030 Sustainable Development Goals. The specific primary causes of direct obstetric deaths were: 12.9% due to postpartum hemorrhage (ICD O72); 9.2%, eclampsia (ICD O15); 6.7%, puerperal sepsis (ICD O85); and 6.3%, pre-eclampsia (ICD O14). For indirect obstetric deaths, the primary causes were: 14.9% due to other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth, and the puerperium (ICD O99); and 7.3%, maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth, and the puerperium (ICD O98). Conclusions. The findings of this study confirmed that there were substantially more direct obstetric causes (61.2%) than indirect obstetric causes (23.9%), contributory causes (13.6%), or unknown/undetermined causes (1.4%) of maternal mortality, despite being highly preventable. Although Panama is right on track to fulfill the target of 70 MMR by 2030, these results highlight the lack of health care access due to the absence of obstetrician-gynecologists per 100 000 population in indigenous comarcas, where 30.8% of the maternal mortalities occur. Furthermore, the health system in Panama is not immune to pandemics and crises. From 1998 to 2022, there were 5 years when the MMR in Panama exceeded 70: 2001, 2002, 2006, 2011, and 2020. These findings also underscore the dichotomy between statistics and health policy. While the trendline reliability was insignificant (R2 = 0.1), the MMR satisfies requirements for the 2030 Sustainable Development Goals. Future studies should consider factors related to indirect obstetrics and contributory causes of deaths, health care access, COVID-19, cesarean section and natural birth, age, economic income, prenatal and postpartum care, as well as the quality of private and public health facilities in the Americas.

[RESUMEN]. Objetivo. Examinar la mortalidad materna en Panamá mediante el análisis de las muertes obstétricas directas e indirectas y las debidas a afecciones que contribuyen a producirlas. Métodos. Para este estudio de cohorte se utilizaron datos de acceso público del Instituto Nacional de Estadística y Censo, con el fin de presentar un análisis retrospectivo de 25 años de la mortalidad materna en República de Panamá entre 1998 y el 2022. Los datos públicos se obtuvieron del sitio web del Instituto Nacional de Estadística y Censo de Panamá. Se utilizaron los códigos pertinentes de la Clasificación Estadística Internacional de Enfermedades y Problemas Relacionados con la Salud, décima revisión (CIE-10). Se definió la razón de mortalidad materna (RMM) como el número de muertes maternas por cada 100 000 nacidos vivos. Los datos se analizaron mediante la fiabilidad de la línea de tendencia con el cálculo de R2. Resultados. Entre 1998 y el 2022 se registraron en Panamá 1026 muertes maternas, de las cuales el 61,2% se atribuyó a causas obstétricas directas; el 23,9% a causas obstétricas indirectas; el 13,6% a afecciones que contribuyen a producirlas; y el 1,4% a causas desconocidas o indeterminadas. La RMM media fue de 60,1. La fiabilidad de la línea de tendencia mostró un valor de R2 = 0,1 (y = –0,5147x + 1094,7), que no alcanza significación estadística, pero cumple con los Objetivos de Desarrollo Sostenible para el 2030. Las principales causas específicas de las muertes obstétricas directas fueron: un 12,9% por hemorragia posparto (CIE O72); un 9,2%, por eclampsia (CIE O15); un 6,7%, por sepsis puerperal (CIE O85); y un 6,3%, por preeclampsia (CIE O14). En el caso de las muertes obstétricas indirectas, las causas principales fueron: un 14,9% por enfermedades maternas clasificadas bajo otro concepto pero que complican el embarazo, parto y puerperio (CIE O99); y un 7,3%, por enfermedades infecciosas y parasitarias maternas clasificadas bajo otro concepto pero que complican el embarazo, parto y puerperio (CIE O98). Conclusiones. Los resultados de este estudio confirmaron que, a pesar de ser en gran parte prevenible, la mortalidad materna se debió en mayor medida a las causas obstétricas directas (61,2%) que a las indirectas (23,9%), las afecciones que contribuyen a producirla (13,6%) o a las causas desconocidas o indeterminadas (1,4%). Aunque Panamá está en camino de cumplir con el objetivo de una RMM de 70 para el 2030, estos resultados ponen de manifiesto la falta de acceso a la atención de salud en las comarcas indígenas, donde se produce el 30,8% de la mortalidad materna, debido al reducido número de obstetras y ginecólogos por cada 100 000 habitantes. Además, el sistema de salud de Panamá no es inmune a las pandemias y las crisis. Entre 1998 y el 2022, hubo cinco años en los que la RMM fue superior a 70: 2001, 2002, 2006, 2011 y 2020. Estos resultados también subrayan la dicotomía existente entre las estadísticas y las políticas de salud. Si bien la fiabilidad de la línea de tendencia no fue significativa (R2 = 0,1), su valor cumple con los requisitos de los Objetivos de Desarrollo Sostenible para el 2030. En estudios futuros se deberán tener en cuenta los factores relacionados con la mortalidad debida a causas obstétricas indirectas y afecciones que contribuyen a producirla, el acceso a la atención de salud, la COVID-19, las cesáreas y los partos naturales, la edad, los ingresos económicos, la atención prenatal y puerperal, así como la calidad de los establecimientos de salud privados y públicos de la Región de las Américas.

[RESUMO]. Objetivo. Examinar a mortalidade materna no Panamá por meio de uma análise das mortes obstétricas diretas, mortes obstétricas indiretas e fatores contribuintes. Métodos. Este estudo de coorte usa dados publicamente disponíveis do Instituto Nacional de Estatística e Censo do Panamá para apresentar uma análise retrospectiva de um período de 25 anos de mortes maternas na República do Panamá, de 1998 a 2022. Os dados públicos foram obtidos no site do Instituto Nacional de Estatística e Censo. Foram usados códigos relevantes da Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde, Décima Revisão (CID). A razão de mortalidade materna (RMM) foi definida como o número de mortes maternas por 100 mil nascidos vivos. Para analisar os dados, determinou-se a confiabilidade da linha de tendência usando R2. Resultados. Houve 1 026 mortes maternas no Panamá de 1998 a 2022. Dessas, 61,2% foram atribuídas a causas obstétricas diretas; 23,9%, a causas obstétricas indiretas; 13,6%, a fatores contribuintes; e 1,4% tinham causa desconhecida ou indeterminada. A RMM média foi de 60,1. Na análise da confiabilidade da linha de tendência, obteve-se R2 = 0,1 (y = -0,5147x + 1094,7), o que não é estatisticamente significante, mas atende aos Objetivos de Desenvolvimento Sustentável para 2030. As causas primárias específicas de mortes obstétricas diretas foram: 12,9% devido a hemorragia pós-parto (CID O72); 9,2%, eclâmpsia (CID O15); 6,7%, infecção puerperal (CID O85); e 6,3%, pré-eclâmpsia (CID O14). No caso das mortes obstétricas indiretas, as principais causas foram: 14,9% devido a outras doenças da mãe, classificadas em outra parte mas que complicam a gravidez, o parto e o puerpério (CID O99); e 7,3%, doenças infecciosas e parasitárias maternas classificáveis em outra parte, mas que compliquem a gravidez, o parto e o puerpério (CID O98). Conclusões. Os achados deste estudo confirmaram que houve um número substancialmente maior de causas obstétricas diretas (61,2%) que de causas obstétricas indiretas (23,9%), fatores contribuintes (13,6%) ou causas desconhecidas ou indeterminadas (1,4%) de mortalidade materna, apesar de essas causas serem altamente preveníveis. Embora o Panamá esteja no rumo certo para cumprir a meta de RMM de 70 até 2030, esses resultados destacam a falta de acesso à atenção à saúde devido ao déficit de ginecologistas-obstetras por 100 mil habitantes nas comarcas indígenas, onde se concentram 30,8% das mortes maternas. Além disso, o sistema de saúde do Panamá não é imune a pandemias e crises. Entre 1998 e 2022, houve cinco anos em que a RMM no Panamá passou de 70: 2001, 2002, 2006, 2011 e 2020. Estes achados também realçam a dicotomia entre as estatísticas e as políticas de saúde. Embora a confiabilidade da linha de tendência não tenha sido significante (R2 = 0,1), a RMM cumpre os requisitos dos Objetivos de Desenvolvimento Sustentável para 2030. Futuros estudos devem considerar fatores relacionados às causas obstétricas indiretas e contribuintes das mortes, acesso à atenção à saúde, COVID-19, cesariana e parto natural, idade, renda econômica e assistência pré-natal e pós-parto, bem como a qualidade dos estabelecimentos de saúde públicos e privados na Região das Américas.

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In low and middle-income countries such as Brazil, most maternal deaths are related to hypertensive complications. Preeclampsia is the leading cause of maternal mortality and morbidity. Significant proportion is associated with the following factors: lack of identification of high-risk women, lack of adequate prevention, difficulty in maintaining a high-risk prenatal follow-up, delayed diagnosis, insecurity and low use of magnesium sulphate, delayed pregnancy interruption and lack of postpartum follow-up of these high-risk cases. Four major actions are proposed to minimize this alarming clinical picture and reduce the mortality rates due to preeclampsia, called the "4 P Rule" (Adequate Prevention - Vigilant Prenatal Care - Timely Delivery (Parturition) - Safe Postpartum). From this simple "rule" we can open a range of important processes and reminders that may help in the guidance of preeclampsia management.

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The effects of the COVID-19 pandemic on comprehensive maternal deaths in Brazil have not been fully explored. Using publicly available data from the Brazilian Mortality Information (SIM) and Information System on Live Births (SINASC) databases, we used two complementary forecasting models to predict estimates of maternal mortality ratios using maternal deaths (MMR) and comprehensive maternal deaths (MMRc) in the years 2020 and 2021 based on data from 2008 to 2019. We calculated national and regional standardized mortality ratio estimates for maternal deaths (SMR) and comprehensive maternal deaths (SMRc) for 2020 and 2021. The observed MMRc in 2021 was more than double the predicted MMRc based on the Holt-Winters and autoregressive integrated moving average models (127.12 versus 60.89 and 59.12 per 100,000 live births, respectively). We found persisting sub-national variation in comprehensive maternal mortality: SMRc ranged from 1.74 (95% confidence interval [CI] 1.64, 1.86) in the Northeast to 2.70 (95% CI 2.45, 2.96) in the South in 2021. The observed national estimates for comprehensive maternal deaths in 2021 were the highest in Brazil in the past three decades. Increased resources for prenatal care, maternal health, and postpartum care may be needed to reverse the national trend in comprehensive maternal deaths.

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BACKGROUND: Eclampsia and pre-eclampsia rank as the third leading causes of maternal death in Ecuador, following pre-existing chronic diseases and postpartum haemorrhage, as reported by the Ecuadorian National Institute of Statistics and Census (INEC). In contrast, HELLP (Haemolysis, Elevated Liver enzymes, Low Platelet count) syndrome remains underexplored epidemiologically, not only in Latin America but globally. This study marks the first population-based investigation into HELLP syndrome incidence and mortality in Ecuador, examining geographical variations, altitude influences and ethnic backgrounds. METHODS: Conducted as a retrospective population-based cohort study from 2015 to 2017, this research delves into the incidence, risk factors and maternal mortality associated with HELLP syndrome in Ecuador. Utilising data from INEC and the Ecuadorian Ministry of Health, we identified HELLP syndrome cases through ICD-10 (International Classification of Diseases, tenth revision) coding in hospitalised individuals. Logistic regression analysis was employed to explore association, whilst geospatial statistical analysis focused on cantons to identify significant spatial clusters. Primary outcome measures include HELLP syndrome incidence and maternal mortality, supplying crucial insights into the syndrome's impact on maternal health in Ecuador. RESULTS: The incidence of HELLP syndrome is 0.76 (0.69-0.84)/ 1000 deliveries. Afro-Ecuadorian communities have a higher risk (Odds Ratio (OR) = 2.18 (1.03-4.63)) compared to Indigenous Ecuadorian communities. Living at mid-level or high altitude is a significant risk factor OR of 2.79 (2.19-3.55) and an OR 3.61 (2.58-5.03), respectively. Being an older mother was also identified as a risk factor. Women living more than 20 km from the obstetric unit have an OR of 2.55 (2.05-3.18). Moreover, we found that cantons with higher crude HELLP syndrome incidence also have lower numbers of physicians (R = 0.503, p-value < 0.001). The mortality incidence of women with HELLP syndrome is 21.22 (12.05-20.59)/1000 deliveries with HELLP syndrome diagnoses. CONCLUSIONS: High altitude, advanced maternal age and geographical distance between residence and health centres are risk factors for HELLP syndrome. Maternal mortality in women with HELLP syndrome is higher than pre-eclampsia and eclampsia but comparable with previous reports in other countries.

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This article aims to analyze spatial and temporal patterns of maternal mortality in Brazil during the period 2010-2020 and identify related socioeconomic indicators. We conducted an ecological study of the maternal mortality ratio (MMR) in Brazil's municipalities using secondary data. Temporal analysis was performed using the joinpoint method. Bayesian statistics, spatial autocorrelation, the Getis Ord Gi* technique and the scan statistic were used to identify spatial clusters, and multiple non-spatial and spatial regression models were used to assess the association between factors and the MMR. There was an increase in the MMR in 2020 and an increase in deaths in the North and Southeast. Clusters were found in Amazonas, Tocantins, Piauí, Maranhão, Bahia and Mato Grosso do Sul. The following indicators were negatively associated with the MMR: cesarean section rate, Municipal Human Development Index, and per capita household income of people who are vulnerable to poverty. The MMR was stable up to 2019, followed by a sharp rise in 2020 coinciding with the onset of the Covid-19 pandemic in the country. It is essential that efforts to reduce maternal mortality in Brazil extend beyond the promotion of improvements in antenatal, childbirth and postpartum care to address the social determinants of the problem.

O objetivo do artigo é analisar o padrão espacial e temporal e identificar indicadores socioeconômicos relacionados à razão de mortalidade materna (RMM) no Brasil de 2010 a 2020. Estudo ecológico que analisou a RMM nos municípios do Brasil, utilizando dados secundários. Para análise temporal, utilizou-se o método joinpoint. Para a identificação de aglomerados espaciais, utilizou-se estatística bayesiana, autocorrelação espacial, a técnica Getis Ord Gi* e a varredura scan. Para a identificação dos fatores associados à RMM, foram adotados modelos múltiplos de regressão não espacial e espacial. Observou-se aumento da RMM de 2019 para 2020. Houve crescimento de óbitos nas regiões Norte e Sudeste. Os clusters foram encontrados no Amazonas, Tocantins, Piauí, Maranhão, Bahia e Mato Grosso do Sul. Estão negativamente relacionados à RMM os seguintes indicadores: taxa de parto cesáreo, índice de desenvolvimento humano municipal e renda domiciliar per capita dos vulneráveis à pobreza. Embora a tendência temporal tenha se mostrado constante até 2019, a RMM apresentou crescimento no ano de início da pandemia de COVID-19 no país. A redução da MM no Brasil vai além da promoção de melhorias na assistência gravídico-puerperal, sendo fundamental focar também nos determinantes sociais do problema.

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More than half of births among Indigenous women in Guatemala are still being attended at home by providers with no formal training. We describe the incorporation of comadronas (traditional midwives) into casas maternas (birthing centers) in the rural highlands of western Guatemala. Although there was initial resistance to the casa, comadronas and clients have become increasingly enthusiastic about them. The casas provide the opportunity for comadronas to continue the cultural traditions of prayers, massages, and other practices that honor the vital spiritual dimension of childbirth close to home in a home-like environment with extended family support while at the same time providing a safer childbirth experience in which complications can be detected by trained personnel at the casa, managed locally, or promptly referred to a higher-level facility. Given the growing acceptance of this innovation in an environment in which geographical, financial, and cultural barriers to deliveries at higher-level facilities lead most women to deliver at home, casas maternas represent a feasible option for reducing the high level of maternal mortality in Guatemala.This article provides an update on the growing utilization of casas and provides new insights into the role of comadronas as birthing team members and enthusiastic promotors of casas maternas as a preferable alternative to home births. Through the end of 2023, these casas maternas had cared for 4,322 women giving birth. No maternal deaths occurred at a casa, but 4 died after referral.The Ministry of Health of Guatemala has recently adopted this approach and has begun to implement it in other rural areas where home births still predominate. This approach deserves consideration as a viable and feasible option for reducing maternal mortality throughout the world where home births are still common, while at the same time providing women with respectful and culturally appropriate care.

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Objective: Eclampsia is a hypertensive disorder that occurs during pregnancy and can lead to death. The literature has gaps by not providing comprehensive data on the epidemiology of the disease, restricting analysis to limited temporal intervals and geographical locations. This study aims to characterize the epidemiological profile of women who died from eclampsia in Brazil from 2000 to 2021. Methods: The maternal mortality data were obtained from the Sistema de Informações sobre Mortalidade, with the following variables of interest selected: "Federative Unit," "Year," "Age Range," "Race/Color," and "Education Level." The collection of the number of live births for data normalization was conducted in the Sistema de Informações sobre Nascidos Vivos. Statistical analyses were performed using GraphPad Prism, calculating odds ratio for variables and fixing number of deaths per 100,000 live births for calculating maternal mortality ratio (MMR). Results: There was a downward trend in maternal mortality rate during the study period. Maranhão stood out as the federative unit with the highest MMR (17 deaths per 100.000 live births). Mothers aged between 40 and 49 years (OR = 3.55, CI: 3.11-4.05) presents higher MMR. Additionally, black women showed the highest MMR (OR = 4.67, CI: 4.18-5.22), as well as mothers with no educational background (OR = 5.83, CI: 4.82-7.06). Conclusion: The epidemiological profile studied is predominantly composed of mothers with little or no formal education, self-declared as Black, residing in needy states and with advanced aged. These data are useful for formulating public policies aimed at combating the issue.

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To analyze the temporal trend of the late maternal mortality ratio (LMMR) in Brazil and its geographic regions in the period from 2010 to 2019, an ecological time series study was conducted. Data related to late maternal mortality from information systems of the Brazilian Ministry of Health were used. Statistical analysis used Prais-Winsten autoregressive models. A total of 1,470 late maternal deaths were reported in Brazil, resulting in an LMMR of 5 deaths per 100,000 live births. The late maternal mortality records revealed regional disparities, with the lowest index in the North (3.5/100,000 live births) and the highest in the South (8.3/100,000 live births). The LMMR showed an increasing trend in the country, with a general increase in the LMMR in the period and a mean annual percentage variation of 9.79% (95%CI: 4.32; 15.54). The Central-West region led this increase, with a mean annual percentage change of 26.06% (95%CI: 16.36; 36.56), followed by the North and Northeast regions, with 23.5% (95%CI: 13.93; 33.88). About 83% of the reported late maternal deaths were investigated, and 65.6% were corrected by the Maternal Mortality Committees. These findings highlight the relevance of late maternal mortality as an important indicator for maternal health, which is often invisible. The increase in the LMMR result from the improvement in the quality of the registration of these deaths in recent years in Brazil, and especially from the work of investigating deaths. The fragility of reporting with regional disparities points to the need for a more comprehensive approach that promotes equity and prevention of avoidable late maternal mortality.

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Esta revisão rápida apresenta as recomendações de 18 guias de prática clínica, relativas ao diagnóstico, prevenção e manejo das seguintes causas obstétricas diretas de mortalidade materna: abortamento, gravidez ectópica, hemorragia puerperal, hipertensão arterial, infecção puerperal e tromboembolismo venoso.

This rapid review presents the recommendations of 18 clinical practice guidelines, relating to the diagnosis, prevention and management of the following direct obstetric causes of maternal mortality: abortion, ectopic pregnancy, puerperal hemorrhage, arterial hypertension, puerperal infection and venous thromboembolism.