[Epidemiological characterization of COVID-2019 in Mexican pregnant women: a cohort study]. / Caracterización epidemiológica de la COVID-2019 en población obstétrica mexicana: estudio de cohorte.

Background: COVID-19 in pregnancy can increase the risk of complications due to the cardiorespiratory and immunological changes typical of pregnancy. Objective: To report the epidemiological characterization of COVID-19 in Mexican pregnant women. Material and methods: Cohort study on pregnant women with a positive COVID-19 test, which were followed until delivery and one month later. Results: 758 pregnant women were included in the analysis. Mothers' mean age was 28.8 ± 6.1 years; the majority were workers 497 (65.6%) and with an urban origin (482, 63.6%); the most common blood group was O with 458 (63.0%); 478 (63.0%) were nulliparous women and more than 25% had some comorbidities; the average gestation weeks at infection were 34.4 ± 5.1 weeks; only 170 pregnant women (22.4%) received vaccination; the most frequent vaccine was BioNTech Pfizer (96, 60%); there were no serious adverse events attributed to vaccination. The mean gestational age at delivery was 35.4 ± 5.2 weeks; 85% of pregnancies were cesarean section; the most frequent complication was prematurity (406, 53.5%), followed by preeclampsia (199, 26.2%); there were 5 cases of maternal death and 39 cases of perinatal death. Conclusions: COVID-19 in pregnancy increases the risk of preterm birth, preeclampsia, and maternal death. Vaccination against COVID-19 in this series showed no risk for pregnant women and their newborns.

Introducción: la COVID-19 en el embarazo puede incrementar el riesgo de complicaciones debido a los cambios cardiorrespiratorios e inmunológicos propios de la gestación. Objetivo: reportar la caracterización epidemiológica de la COVID-19 en población obstétrica mexicana. Material y métodos: estudio de cohorte en embarazadas con prueba positiva para COVID-19 que fueron seguidas hasta la resolución del embarazo y un mes después. Resultados: 758 mujeres embarazadas fueron incluidas en el análisis. La media de edad en las madres fue 28.8 ± 6.1 años; la mayoría trabajadoras 497 (65.6%) y de origen urbano (482, 63.6%); el grupo sanguíneo más común fue O 458 (63.0%); 478 (63.0%) fueron primigestas, y más del 25% padecía comorbilidades; las semanas de gestación promedio al contagio fueron 34.4 ± 5.1 semanas; solo 170 gestantes (22.4%) recibieron vacunación; la vacuna más frecuente fue BioNTech Pfizer (96, 60%); no hubo eventos adversos graves atribuibles a la vacunación. La edad gestacional media al nacer fue de 35.4 ± 5.2 semanas; el 85% de los embarazos se interrumpieron por cesárea; la complicación más frecuente fue la prematurez con 406 (53.5%), seguida de preeclampsia con 199 (26.2%); hubo 5 casos de muerte materna y 39 casos de muerte perinatal. Conclusiones: la COVID-19 en el embarazo aumenta el riesgo de parto prematuro, preeclampsia y muerte materna. Al menos en esta serie la vacunación contra COVID-19 no mostró riesgo para las mujeres embarazadas y sus recién nacidos.

Utilization of non-pneumatic anti-shock garment for the management of obstetric hemorrhage among healthcare providers in north Shewa zone, Ethiopia.

Background: Global maternal deaths have either increased or stagnated tragically. Obstetric hemorrhage (OH) remains the major cause of maternal deaths. Non-Pneumatic Anti-Shock Garment (NASG) has several positive results in the management of obstetric hemorrhage in resource-limited settings where getting definitive treatments are difficult and limited. Therefore, this study aimed to assess the proportion and factors associated with the utilization of NASG for the management of obstetric hemorrhage among healthcare providers in the North Shewa zone, Ethiopia. Methods: A cross-sectional study was conducted at health facilities of the north Shewa zone, Ethiopia from June 10th-30th/2021. A simple random sampling (SRS) technique was employed among 360 healthcare providers. Data were collected using a pretested self-administered questionnaire. EpiData version 4.6 and SPSS 25 were used for data entry and analysis, respectively. Binary logistic regression analyses were undertaken to identify associated factors with the outcome variable. The level of significance was decided at a value of p of <0.05. Results: The utilization of NASG for the management of obstetric hemorrhage among healthcare providers was 39% (95%CI: 34-45). Healthcare providers who received training on NASG (AOR = 3.3; 95%CI: 1.46-7.48), availability of NASG in the health facility (AOR = 9.17; 95%CI: 5.10-16.46), diploma (AOR = 2.63; 95%CI: 1.39-3.68), bachelor degree (AOR = 7.89; 95%CI: 3.1-16.29) and those healthcare providers who have a positive attitude toward utilization of NASG (AOR = 1.63; 95%CI: 1.14-2.82) were variables positively associated with the utilization of NASG. Conclusion: In this study, almost two-fifths of healthcare providers used NASG for the management of obstetrics hemorrhage. Arranging educational opportunities and continuous professional development training for healthcare providers, providing in-service and refresher training, and making it available at health facilities may help healthcare providers to effectively use the device, thereby reducing maternal morbidity and mortality.

Evaluation During Postpartum Hemorrhage.

Postpartum hemorrhage is an obstetric emergency that is the leading and the most preventable cause of maternal death that occurs on the day of birth. The treatment of postpartum hemorrhage in a timely fashion is crucial to prevent morbidity and mortality. The accurate assessment of blood loss during delivery and the postpartum period remains a major challenge. Hence, it is imperative to have a standardized evaluation strategy for accurate assessment of blood loss, adequate classification of hemorrhage, and timely initiated interventions. The multidisciplinary evaluation strategy should be in place regardless of the delivery route.

Validating the InterVA-5 cause of death analytical tool: using mortality data from the Comprehensive Health and Epidemiological Surveillance System in Papua New Guinea.

OBJECTIVE: InterVA-5 is a new version of an analytical tool for cause of death (COD) analysis at the population level. This study validates the InterVA-5 against the medical review method, using mortality data in Papua New Guinea (PNG). DESIGN AND SETTING: This study used mortality data collected from January 2018 to December 2020 in eight surveillance sites of the Comprehensive Health and Epidemiological Surveillance System (CHESS), established by the PNG Institute of Medical Research in six major provinces. METHODS: The CHESS demographic team conducted verbal autopsy (VA) interviews with close relatives of the deceased, who died in communities within the catchment areas of CHESS, using the WHO 2016 VA instrument. COD of the deceased was assigned by InterVA-5 tool, and independently certified by the medical team. Consistency, difference and agreement between the InterVA-5 model and medical review were assessed. Sensitivity and positive predictive value (PPV) of the InterVA-5 tool were calculated with reference to the medical review method. RESULTS: Specific COD of 926 deceased people was included in the validation. Agreement between the InterVA-5 tool and medical review was high (kappa test: 0.72; p<0.01). Sensitivity and PPV of the InterVA-5 were 93% and 72% for cardiovascular diseases, 84% and 86% for neoplasms, 65% and 100% for other chronic non-communicable diseases (NCDs), and 78% and 64% for maternal deaths, respectively. For infectious diseases and external CODs, sensitivity and PPV of the InterVA-5 were 94% and 90%, respectively, while the sensitivity and PPV of the medical review method were both 54% for classifying neonatal CODs. CONCLUSION: The InterVA-5 tool works well in the PNG context to assign specific CODs of infectious diseases, cardiovascular diseases, neoplasms and injuries. Further improvements with respect to chronic NCDs, maternal deaths and neonatal deaths are needed.

Levels and trends of maternal death in Baoan district, Shenzhen, China, 1999-2022.

Background: China had achieved impressive success in improving maternal health, while the progress of reducing maternal mortality ratio (MMR) varied across regions. Some studies had reported maternal mortality from national or provincial perspective, but researches of the MMR on long-term period at the city or county level rare been reported. Shenzhen has experienced significant socioeconomic and health changes, reflecting the typical development of China's coastal city. This study mainly introduced the levels and trends of maternal death in Baoan district, Shenzhen from 1999 to 2022. Methods: Maternal mortality data were extracted from registration forms and the Shenzhen Maternal and Child Health Management System. Linear-by-Linear Association tests were used to evaluate the trends of MMR among different groups. The study periods were divided into three stages by 8-year interval and χ2 test or Fisher's test was used to test the difference in maternal deaths of different periods. Results: During 1999-2022, a total of 137 maternal deaths occurred in Baoan, the overall MMR was 15.91 per 100,000 live births, declined by 89.31% with an annualized rate of 9.26%. The MMR declined by 68.15% in migrant population, with an annualized rate of 5.07%, faster than that in permanent population (48.73%, 2.86%). The MMR due to direct and indirect obstetric causes shown a downward trend (P<0.001) and the gap between them narrowed to 14.29% during 2015-2022. The major causes of maternal deaths were obstetric hemorrhage (4.41 per 100,000 live births), amniotic fluid embolism (3.37 per 100,000 live births), medical complications (2.44 per 100,000 live births) and pregnancy-induced hypertension (1.97 per 100,000 live births), the MMR due to the above causes all shown decreasing trends (P < 0.01), pregnancy-induced hypertension became the leading cause of deaths during 2015-2022. The constituent ratio of maternal deaths with advanced age significantly increased by 57.78% in 2015-2022 compared with in 1999-2006. Conclusions: Baoan district had made encouraging progress in improving maternal survival, especially in migrant population. To further reduce the MMR, strengthening professional training to improve the capacity of obstetricians and physicians, increasing the awareness and ability of self-help health care among elderly pregnant women were in urgent need.

Age and Type of Delivery as Risk Indicators for Maternal Mortality.

OBJECTIVE: This study assessed maternal mortality (MM) and related factors in a large-sized municipality in the Southeastern region of Brazil (Campinas, São Paulo) during the period 2000-2015. METHODS: This study consisted of two phases: 1. An analytical nested case-control phase that assessed the impact of individual and contextual variables on MM; and 2. an ecological phase designed to contextualize maternal deaths by means of spatial analysis. The case group consisted of all maternal deaths (n = 87) and the control group consisted of 348 women who gave birth during the same period. Data analysis included descriptive statistics, association, and multiple logistic regression (MLR) tests at p < 0.05 as well as spatial analysis. RESULTS: Maternal Mortality Ratio was 37 deaths per 100.000 live births. Deaths were dispersed throughout the urban territory and no formation of cluster was observed. MLR showed that pregnant women aged ≥ 35 years old (OR = 2.63) or those with cesarean delivery (OR = 2.51) were more prone to maternal death. CONCLUSION: Maternal deaths were distributed dispersedly among the different socioeconomic levels and more prone to occur among older women or those undergoing cesarean deliveries.

OBJETIVO: Esse estudo avaliou a mortalidade materna (MM) e fatores relacionados em um município de grande porte da região sudeste do Brasil (Campinas, São Paulo) no período de 2000-2015. MéTODOS:: Esse estudo consistiu de duas fases: 1. Uma fase analítica de caso-controle que avaliou o impacto de variáveis individuais e contextuais na MM; 2. Uma fase ecológica delineada para contextualizar as mortes maternas por meio de análise espacial. O grupo caso consistiu de 87 mortes maternas e o grupo controle de 348 mulheres que tiveram bebês durante o mesmo período. Os dados foram analisados por estatística descritiva, testes de associação e regressão logística múltipla (RLM) (p < 0,05) assim como análise espacial. RESULTADOS: A taxa de mortalidade materna foi de 37 mortes para cada 100.000 nascidos vivos. As mortes foram dispersas por todo o território urbano e não se observou formação de clusters. Na RLM observou-se que mulheres grávidas com idade ≥ 35 anos (OR = 2,63) ou aquelas que passaram por cesárea (OR = 2,51) foram mais propensas à morte materna. CONCLUSãO:: As mortes maternas foram distribuídas dispersamente entre os diferentes níveis socioeconômicos e mais propensas a ocorrer entre mulheres ≥ 35 anos de idade ou que passaram por cesárea.

Tranexamic Acid to Prevent Obstetrical Hemorrhage after Cesarean Delivery.

BACKGROUND: Prophylactic use of tranexamic acid at the time of cesarean delivery has been shown to decrease the calculated blood loss, but the effect on the need for blood transfusions is unclear. METHODS: We randomly assigned patients undergoing cesarean delivery at 31 U.S. hospitals to receive either tranexamic acid or placebo after umbilical-cord clamping. The primary outcome was a composite of maternal death or blood transfusion by hospital discharge or 7 days post partum, whichever came first. Key secondary outcomes were estimated intraoperative blood loss of more than 1 liter (prespecified as a major secondary outcome), interventions for bleeding and related complications, the preoperative-to-postoperative change in the hemoglobin level, and postpartum infectious complications. Adverse events were assessed. RESULTS: A total of 11,000 participants underwent randomization (5529 to the tranexamic acid group and 5471 to the placebo group); scheduled cesarean delivery accounted for 50.1% and 49.2% of the deliveries in the respective groups. A primary-outcome event occurred in 201 of 5525 participants (3.6%) in the tranexamic acid group and in 233 of 5470 (4.3%) in the placebo group (adjusted relative risk, 0.89; 95.26% confidence interval [CI], 0.74 to 1.07; P = 0.19). Estimated intraoperative blood loss of more than 1 liter occurred in 7.3% of the participants in the tranexamic acid group and in 8.0% of those in the placebo group (relative risk, 0.91; 95% CI, 0.79 to 1.05). Interventions for bleeding complications occurred in 16.1% of the participants in the tranexamic acid group and in 18.0% of those in the placebo group (relative risk, 0.90; 95% CI, 0.82 to 0.97); the change in the hemoglobin level was -1.8 g per deciliter and -1.9 g per deciliter, respectively (mean difference, -0.1 g per deciliter; 95% CI, -0.2 to -0.1); and postpartum infectious complications occurred in 3.2% and 2.5% of the participants, respectively (relative risk, 1.28; 95% CI, 1.02 to 1.61). The frequencies of thromboembolic events and other adverse events were similar in the two groups. CONCLUSIONS: Prophylactic use of tranexamic acid during cesarean delivery did not lead to a significantly lower risk of a composite outcome of maternal death or blood transfusion than placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT03364491.).

Challenges faced by midwives in the implementation of facility-based maternal death reviews in Malawi.

BACKGROUND: Maternal death reviews provide an in-depth understanding of the causes of maternal deaths. Midwives are well positioned to contribute to these reviews. Despite midwives' participation as members of the facility-based maternal death review team, maternal mortality continues to occur, therefore, this study aimed to explore the challenges faced by midwives as they participate in maternal death reviews in the context of the healthcare system in Malawi. METHODS: This was a qualitative exploratory study design. Focus group discussions and individual face-to-face interviews were used to collect data in the study. A total of 40 midwives, who met the inclusion criteria, participated in the study. Data was analyzed manually using a thematic content procedure. RESULTS: Challenges identified were: knowledge and skill gaps; lack of leadership and accountability; lack of institutional political will and inconsistency in conducting FBMDR, impeding midwives' effective contribution to the implementation of maternal death review. The possible solutions and recommendations that emerged were need-based knowledge and skills updates, supportive leadership, effective and efficient interdisciplinary work ethics, and sustained availability of material and human resources. CONCLUSION: Midwives have the highest potential to contribute to the reduction of maternal deaths. Practice development strategies are required to improve their practice in all the areas they are challenged with.

Maternal outcomes of placental abruption with intrauterine fetal death and delivery routes: A nationwide observational study.

INTRODUCTION: Placental abruption is a serious complication, especially when accompanied by intrauterine fetal death. The optimal delivery route for placental abruption with intrauterine fetal death for reducing maternal complications is still unclear. In this study we aimed to compare the maternal outcomes between cesarean delivery and vaginal delivery in women with placental abruption with intrauterine fetal death. MATERIAL AND METHODS: Using the Japan Society of Obstetrics and Gynecology nationwide perinatal registry database, we identified pregnant women with placental abruption with intrauterine fetal death between 2013 and 2019. The following women were excluded: those with multiple pregnancies, placenta previa, placenta accreta spectrum, amniotic fluid embolism, or whose delivery route was missing data. The association between delivery routes (cesarean delivery and vaginal delivery) and the maternal outcome was examined using a linear regression model with inverse probability weighting. The primary outcome was the amount of bleeding during delivery. Missing data were imputed using multiple imputation. RESULTS: The number of women with placental abruption with intrauterine fetal death was 1218/1601932 (0.076%). Of 1134 women analyzed, 608 (53.6%) underwent cesarean delivery. Bleeding during delivery (median [interquartile range]) was 1650.00 (950.00-2450.00) (mL) and 1171.00 (500.00-2196.50) (mL) in cesarean and vaginal delivery, respectively. Bleeding during delivery (mL) was significantly greater in cesarean delivery than in vaginal delivery (regression coefficient, 1086.39; 95% confidence interval, 130.96-2041.81; p = 0.026). Maternal death and uterine rupture occurred in four (0.4%) and five (0.4%) women, respectively. The four maternal deaths were noted in the vaginal delivery group. CONCLUSIONS: Bleeding during delivery was significantly greater in cesarean delivery than that in vaginal delivery in women with placental abruption with intrauterine fetal death. However, severe complications, including maternal death and uterine rupture, occurred in vaginal delivery-related cases. The management of women with placental abruption with intrauterine fetal death should be cautious regardless of the delivery route.

Simulation-based estimates and projections of global, regional and country-level maternal mortality by cause, 1990-2050.

Maternal mortality is a major global health challenge. Although progress has been made globally in reducing maternal deaths, measurement remains challenging given the many causes and frequent underreporting of maternal deaths. We developed the Global Maternal Health microsimulation model for women in 200 countries and territories, accounting for individual fertility preferences and clinical histories. Demographic, epidemiologic, clinical and health system data were synthesized from multiple sources, including the medical literature, Civil Registration Vital Statistics systems and Demographic and Health Survey data. We calibrated the model to empirical data from 1990 to 2015 and assessed the predictive accuracy of our model using indicators from 2016 to 2020. We projected maternal health indicators from 1990 to 2050 for each country and estimate that between 1990 and 2020 annual global maternal deaths declined by over 40% from 587,500 (95% uncertainty intervals (UI) 520,600-714,000) to 337,600 (95% UI 307,900-364,100), and are projected to decrease to 327,400 (95% UI 287,800-360,700) in 2030 and 320,200 (95% UI 267,100-374,600) in 2050. The global maternal mortality ratio is projected to decline to 167 (95% UI 142-188) in 2030, with 58 countries above 140, suggesting that on current trends, maternal mortality Sustainable Development Goal targets are unlikely to be met. Building on the development of our structural model, future research can identify context-specific policy interventions that could allow countries to accelerate reductions in maternal deaths.

From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa.

INTRODUCTION: Maternal and perinatal death surveillance and response (MPDSR), or related forms of maternal and perinatal death audits, can strengthen health systems. We explore the history of initiating, scaling up, and institutionalizing a national perinatal audit program in South Africa. METHODS: Data collection involved 56 individual interviews, a systematic document review, administration of a semistructured questionnaire, and 10 nonparticipant observations of meetings related to the perinatal audit program. Fieldwork and data collection in the subdistricts occurred from September 2019 to March 2020. Data analysis included thematic content analysis and application of a tool to measure subdistrict-level implementation. This study expands on case study research applied to 5 Western Cape subdistricts with long histories of implementation. RESULTS: Although established in the early 1990s, the perinatal audit program was not integrated into national policy and guidelines until 2012 but was then excluded from policy in 2021. A network of national and subnational structures that benefited from a continuity of actors evolved and interacted to support uptake and implementation. Intentional efforts to demonstrate impact and enable local adaptation allowed for more ownership and buy-in. Implementation requires continuous efforts. Even in 5 subdistricts with long histories of practice, we found operational gaps, such as incomplete meeting minutes, signaling a need for strengthening. Nevertheless, the tool used to measure implementation may require revisions, particularly in settings with institutionalized practice. CONCLUSION: This article provides lessons on how to initiate, expand, and strengthen perinatal audit. Despite a long history of implementation, the perinatal audit program in South Africa cannot be assumed to be indefinitely sustainable or final in its current form. To monitor uptake and sustainability of MPDSR, including perinatal audit, we need research approaches that allow exploration of context, local adaptation, and underlying issues that support sustainability, such as relationships, leadership, and trust.

Establishing the Ethiopian Obstetric Surveillance System for Monitoring Maternal Outcomes in Eastern Ethiopia: A Pilot Study.

BACKGROUND: Although the majority of maternal deaths and complications occur in low-resource settings, almost all existing strong registration and confidential enquiry systems are found in high-resource settings. We developed and piloted the Ethiopian Obstetric Surveillance System (EthOSS), based on the successful United Kingdom Obstetric Surveillance System (UKOSS) methodology, in 3 regions in Ethiopia to improve ongoing surveillance and tracking of maternal morbidities and deaths, as well as confidential enquiry, compared to the currently used maternal death surveillance and response program in Ethiopia. METHODS: We launched the EthOSS monthly case notification system in 13 hospitals in eastern Ethiopia in April 2021. Study participants included women admitted to the hospitals from April to September 2021 with major adverse obstetric conditions during pregnancy, childbirth, or within 42 days of termination of pregnancy. Designated clinicians at the hospitals used a simple online system to report the number of cases and maternal deaths monthly to the EthOSS team. We present findings on the incidence and case fatality rates for adverse conditions included in the EthOSS. RESULTS: Over the 6-month pilot period, 904 women with at least 1 EthOSS condition were included in the study, of whom 10 died (case fatality rate, 1.1%). Almost half (46.6%, 421/904) sustained major obstetric hemorrhage, 38.7% (350/904) severe anemia, 29.5% (267/904) eclampsia, 8.8% (80/904) sepsis, and 2.2% (20/904) uterine rupture. To enable care improvement alongside surveillance, the local committee received training on confidential enquiry into maternal deaths from internal and external experts. CONCLUSIONS: In this facility-based project, data on severe adverse obstetric conditions were captured through voluntary reporting by clinicians. Further analysis is essential to assess the robustness of these data, and confidential enquiry into maternal deaths for specific cases is planned to investigate the appropriateness of care.

Verbal autopsy analysis of maternal mortality in Bong County, Liberia: a retrospective mixed methods study.

BACKGROUND: While the medical contributors to maternal mortality are well known, the contextual contributors are less known and understudied. Liberia has one of the highest maternal mortality rates in sub-Saharan Africa, with recent increases in maternal deaths in rural Bong County. The purpose of this study was to better classify the contextual factors leading up to maternal deaths and to develop a list of recommendations to prevent future similar deaths. METHODS: A retrospective mixed method study was conducted examining 35 maternal deaths in Bong County, Liberia using verbal autopsy reports from 2019. An interdisciplinary death audit team reviewed and analysed the maternal deaths to determine the contextual causes of the maternal death. FINDINGS: This study identified three contextual causes: limited resources (materials, transportation, facility, staff), inadequate skills and knowledge (staff, community, family, patient), and ineffective communication (between providers, between health facilities and hospitals, and between provider and patient/family). Of these, inadequate patient education (54.28%), inadequate staff education and training (51.42%), ineffective communication between health facilities and hospitals (31.42%), and inadequate materials (28.57%) were most frequently mentioned. CONCLUSION: Maternal mortality remains an issue in Bong County, Liberia, due to addressable contextual causes. Interventions to ameliorate these preventable deaths include ensuring availability of resources and transportation through improved supply chain and health system accountability. Recurring training should be provided to healthcare workers which involves husbands, families and communities. Innovative means for providers and facilities to communicate clearly and consistently should also be prioritised to prevent future maternal deaths in Bong County, Liberia.

[COVID-19 in maternal, perinatal and neonatal mortality in four locations in Bogotá. Descriptive study.] / COVID-19 en la mortalidad materna, perinatal y neonatal de cuatro localidades de Bogotá. Estudio descriptivo.

OBJECTIVE: The multiple effects of the COVID-19 pandemic are beginning to be seen from the alteration of vital statistics figures. This is summarized in changes in the usual causes of death and excess attributable mortality, which can finally be seen in structural changes in the populations of the countries. For this reason, this research was created with the objective of determining the impact of the COVID-19 pandemic on maternal, perinatal and neonatal mortality in four locations in Bogotá D.C. (Colombia). METHODS: A retrospective longitudinal investigation was carried out in which 217,419 mortality data were analyzed in the towns of Kennedy, Fontibón, Bosa and Puente Aranda in the city of Bogotá - Colombia that occurred between the years 2018 to 2021, of which maternal (54), perinatal (1,370) and neonatal (483) deaths in order to identify a history of SARS-CoV-2 infection that could be related to the excess mortality associated with COVID-19. The data were collected from the open records of vital statistics of the National Statistics Department (DANE), where they were analyzed from frequency measures or central tendency and dispersion according to the types of variables. The specific mortality indicators related to maternal, perinatal and neonatal death events were calculated. RESULTS: A decrease in perinatal and neonatal mortality was evidenced since 2020, which was associated with the progressive decrease in pregnancies in those same years; Additionally, a considerable increase in maternal deaths was observed for 2021 compared to the other years analyzed. The proportion of maternal deaths in 2020 and 2021 by 10% and 17%, respectively, were attributed to COVID-19. CONCLUSIONS: It is observed that the trend of maternal mortality is related to the increase in mortality from COVID-19, maternal deaths associated with COVID-19 occurred specifically in the zonal planning units that registered more than 160 cases of COVID-19 for the year 2021.

OBJETIVO: Los múltiples efectos de la pandemia por la COVID-19 se empiezan a ver a partir de la alteración de las cifras de estadísticas vitales. Esto se resume en cambios en las causas de muertes habituales y el exceso de mortalidad atribuible, lo que finalmente se puede ver en modificaciones estructurales de las poblaciones de los países. Por esta razón se crea esta investigación que tuvo como objetivo determinar el impacto de la pandemia de COVID-19 sobre la mortalidad materna, perinatal y neonatal en cuatro localidades de Bogotá D.C. (Colombia). METODOS: Se realizó una investigación de tipo longitudinal retrospectiva en el que se analizaron 217.419 datos de mortalidades las localidades de Kennedy, Fontibón, Bosa y Puente Aranda de la ciudad de Bogotá - Colombia ocurridas entre los años 2018 a 2021, de los cuales se determinaron las muertes maternas (54), perinatales (1.370) y neonatales (483) a fin de identificar antecedente de infección por SARS-CoV-2 que pudiera estar relacionada con el exceso de mortalidad asociada a la COVID-19. Los datos fueron recopilados de los registros abiertos de estadísticas vitales del Departamento Nacional de Estadística (DANE), en donde fueron analizados a partir de medidas de frecuencias o tendencia central y dispersión de acuerdo con los tipos de variables. Se calcularon los indicadores de mortalidad específicos relacionados con los eventos de muerte materna, perinatal y neonatal. RESULTADOS: Se evidenció una disminución en la mortalidad perinatal y neonatal desde el año 2020, la cual estuvo asociada a la disminución progresiva de embarazos en esos mismos años; de forma adicional se observó un aumento considerable de las muertes maternas para 2021 con respecto a los demás años analizados. La proporción de las muertes maternas en 2020 y 2021 en un 10% y 17%, respectivamente, se atribuyeron a la COVID-19. CONCLUSIONES: Se observa que la tendencia de la mortalidad materna está relacionada con el aumento de la mortalidad por la COVID-19, las muertes maternas asociadas a COVID-19 se presentaron específicamente en las unidades de planeación zonal que registraron más de 160 casos de COVID-19 para el año 2021.

Levels, trends, causes, place and time of, care-seeking for, and barriers in preventing indirect maternal deaths in Bangladesh: An analysis of national-level household surveys.

Background: Eclampsia, haemorrhage, and other direct causes are the primary burden of maternal mortality in Bangladesh, often reducing attention given to indirect maternal deaths (IMDs). However, Sustainable Development Goals may not be achieved without actions to prevent IMDs. We examined the levels, trends, specific causes, timing, place, and care-seeking, and explored the barriers to IMD prevention. Methods: We used three nationally representative surveys conducted in 2001, 2010, and 2016 to examine levels and trends in IMDs. The analysis of specific causes, timing, and place of IMDs, and care-seeking before the deaths was based on 37 IMDs captured in the 2016 survey. Finally, we used thematic content analysis of the open history from the 2016 survey verbal autopsy (VA) questionnaire to explore barriers to IMD prevention. Results: After increasing from 51 deaths per 100 000 live births in 2001 to 71 in 2010, the indirect maternal mortality ratio (IMMR) dropped to 38 deaths per 100 000 live births in 2016. In 2016, the indirect causes shared one-fifth of the maternal deaths in Bangladesh. Stroke, cancer, heart disease, and asthma accounted for 80% of the IMDs. IMDs were concentrated in the first trimester of pregnancy (27%) and day 8-42 after delivery (32%). Public health facilities were the main places for care-seeking (48%) and death (49%). Thirty-four (92%) women who died from IMDs sought care from a health facility at least once during their terminal illness. However, most women experienced at least one of the "three delays" of health care. Other barriers were financial insolvency, care-seeking from unqualified providers, lack of health counselling, and the tendency of health facilities to avoid responsibilities. Conclusions: IMMR remained unchanged at a high level during the last two decades. The high concentration of IMDs in pregnancy and the large share due to chronic health conditions indicate the need for preconception health check-ups. Awareness of maternal complications, proper care-seeking, and healthy reproductive practices may benefit. Improving regular and emergency maternal service readiness is essential.

Tendencias en la mortalidad materna en el departamento de Córdoba – Colombia, 2008 – 2020 / Trends in maternal mortality in the department of Córdoba – Colombia, 2008 - 2020

Introducción: La mortalidad materna es reconocida globalmente como un problema de salud pública, situación que ha sido abordada por la Organización de Naciones Unidas (ONU) incluyendo su reducción dentro del tercer Objetivo de Desarrollo Sostenible. Así mismo, la Organización Mundial de la Salud (OMS) y la Organización Panamericana de la Salud (OPS) se han ocupado de instaurar programas encaminados a promover y mejorar la salud materna. Objetivo: Analizar la evolución de la mortalidad materna en el departamento de Córdoba – Colombia en el periodo 2008 a 2020 e identificar los cambios en la tendencia. Método: Ecológico con información retrospectiva. Se calculó la razón de mortalidad materna para el departamento de Córdoba y para Colombia para el periodo 2008 - 2020. Mediante la regresión joinpoint se estimó el Porcentaje de Cambio Anual (PCA) de la razón y se identificaron puntos de inflexión. Resultados: Los resultados del estudio evidencian para el departamento de Córdoba dos periodos con tendencia creciente: el primero entre el 2008 y 2010 con un PCA de 8,3 (IC95%: -71,3 – 462,6) y el segundo 2018 y 2020 con un PCA de 20,8 (IC95% -63,3 – 297,3). Sin embargo, el valor de p en ambos periodos de tiempo no resulta estadísticamente significativo. Conclusiones: La RMM en el departamento de Córdoba presenta un comportamiento fluctuante con grandes aumentos y repentinos descensos que sugieren deficiencias en el registro de la información y en la notificación del evento. (AU)

Introduction: Maternal mortality is recognized worldwide as a public health issue, a situation that has been addressed by the United Nations (UN) including its reduction within the third objective of sustainable development. Likewise, the World Health Organization (WHO) and the Pan American Health Organization (PAHO) have been in charge of establishing programs focusing on promoting and improving maternal health. Objective: Analyze the evolution of maternal mortality in the department of Córdoba - Colombia in the period 2008 to 2020 and identify changes in the trend. Method: Ecological with retrospective information. The maternal mortality ratio was calculated for the department of Córdoba and for Colombia for the period 2008 - 2020. Using joinpoint regression, the Annual Percentage Change (APC) of the ratio was estimated and inflection points were identified. Results: The results of the study show two periods with an increasing trend for the department of Córdoba: the first between 2008 and 2010 with a PCA of 8.3 (95% CI: -71.3 – 462.6) and the second between 2018 and 2020 with a APC of 20.8 (CI95% -63.3 – 297.3). However, the p value in both time periods is not statistically significant. Conclusions: The MMR in the department of Córdoba presents a fluctuating behavior with large increases and sudden decreases that suggest deficiencies in the recording of information and in the notification of the event. (AU)

Haemorrhage-related maternal mortality in Bangladesh: Levels, trends, time of death, and care-seeking practices based on nationally representative population-based surveys.

Background: Haemorrhage is a major cause of maternal deaths globally, most of which are preventable and predominantly happen in low and middle-income countries, including Bangladesh. We examine the current levels, trends, time of death, and care-seeking practices for haemorrhage-related maternal deaths in Bangladesh. Methods: We conducted a secondary analysis with data from the nationally representative 2001, 2010, and 2016 Bangladesh Maternal Mortality Surveys (BMMS). The cause of death information was collected through verbal autopsy (VA) interviews using a country-adapted version of the standard World Health Organization VA questionnaire. Trained physicians reviewed the VA questionnaire and assigned the cause of death using the International Classification of Diseases (ICD) codes. Results: Haemorrhage accounted for 31% (95% confidence interval (CI) = 24-38) of all maternal deaths in 2016 BMMS, which was 31% (95% CI = 25-41) in 2010 BMMS and 29% (95% CI = 23-36) in 2001 BMMS. The haemorrhage-specific mortality rate remained unchanged between 2010 BMMS (60 per 100 000 live births, uncertainty range (UR) = 37-82) and 2016 BMMS (53 per 100 000 live births, UR = 36-71). Around 70% of haemorrhage-related maternal deaths took place within 24 hours of delivery. Of those who died, 24% did not seek health care outside the home and 15% sought care from more than three places. Approximately two-thirds of the mothers who died due to haemorrhage gave birth at home. Conclusions: Postpartum haemorrhage remains the primary cause of maternal mortality in Bangladesh. To reduce these preventable deaths, the Government of Bangladesh and stakeholders should take steps to ensure community awareness about care-seeking during delivery.

Health system readiness to manage maternal death data and avail evidence for decision-making through the Maternal Death Surveillance System in Ethiopia, 2020.

BACKGROUND: Maternal mortality remains a major health problem in Ethiopia. To generate contextual evidence on the burden and distribution of existing causes and contributing factors for programmatic and individual-level decision-making, the Maternal Death Surveillance and Response System was introduced in 2013. This assessment describes the Ethiopian health system's readiness to avail evidence for decision-making through the MDSR system. METHOD: A cross-sectional study designed using the WHO framework for evaluating surveillance systems was used. By employing a multistage sampling, 631 health facilities and 539 health posts were included. ODK collect data entry software was used to collect data from September 2019 to April 2020. Findings are presented in text descriptions, graphs, maps, and tables. FINDINGS: Four hundred (77.1%) health facilities (332 (74.6%) health centers and 68 (91.9%) hospitals) and 264 (71.5%) health posts reported implementing the MDSR system. Of the implementing health facilities, 349 (87.3%) had a death review committee, and only 42 (12.4%) were functional. About 89.4% of health centers and 79.4% of hospitals had sub-optimal maternal death identification and notification readiness. Only 23 (6.96%) and 18 (26.47%) MDSR-implementing health centers and hospitals had optimal readiness to investigate and review maternal deaths, respectively. Moreover, only 39 (14.0%) health posts had locally translated case definitions and 28 (10.6%) had verbal autopsy format to investigate maternal deaths. Six (1.5%) facility officers and 24 (9.1%) health extension workers were engaged in data analysis and evidence generation at least once during 2019/20. Regional variation is observed in system implementation. CONCLUSIONS AND RECOMMENDATIONS: Sub-optimal MDSR system implementation is recorded. Revitalizing the system by addressing all system components is critical. Having a national-level roadmap for MDSR system implementation and mobilizing all available resources and stakeholders to facilitate this is vital. Establishing a system for routine data quality monitoring and assurance by integrating with the existing PHEM structure, having a system for routine capacity building, advocacy, and monitoring and evaluating the availability and functionality of MDSR committees at health facilities are all critical. Digitalization, designing a system to fit emerging regions' health service delivery, and availing required resources for the system is key.