The Ethical Obligation to Prevent Maternal Mortality during the COVID-19 Pandemic and Beyond

The United States of America (USA) has the highest maternal mortality rate of all high-income countries, with over 80% found to be preventable. After leveling off around 2015, maternal mortality rates in the USA further increased due to coronavirus disease 2019 (COVID-19) related deaths starting in 2020 by about 20% from about 17-18/100,000 live births to about 24/100,000 live births with about one in seven maternal deaths due to COVID-19 infections. The vast majority of COVID-19-related maternal deaths were among unvaccinated pregnant patients. A total of 11% of postpartum maternal deaths were found to be associated with mental health issues, with the remainder usually due to medical issues such as hemorrhage and hypertension. As physicians, we have the ethical obligation to address perinatal and maternal mortality, especially preventable maternal mortalities, reduce the discrepancy between different races and ethnicities, recommend COVID-19 vaccinations, and develop approaches to address the causes.Copyright © The Author(s). 2023.

Maternal death due to COVID-19, truth or a myth: A narrative review and experience from a teaching hospital in India.

The course of coronavirus disease-2019 (COVID-19) in pregnancy is unpredictable with outcome trends ranging from milder disease with zero mortality to severe forms and deaths in different parts of the world. We did a comprehensive review of the literature to understand maternal deaths due to COVID-19 in detail. The search was conducted in the PubMed, Embase, and Google Scholar databases, using the keywords "maternal mortality", "maternal death", "COVID-19", "septic shock" and "DIC". The search included original articles, review articles, case reports published till date. We found varying case fatality rates ranging from 0.1% to 12.9%. There are various predictors of maternal death, notably the presence of symptoms, comorbidities, severe disease with cytokine storm and multi-organ dysfunction. We also report higher maternal deaths from low-resource regions owing to gaps in expected and delivered maternal care. While reviewing our institutional data, we found 3 maternal deaths related to COVID-19 in pregnancy. We discussed our experience at our institute of three COVID-19 related maternal mortalities to add evidence to the present data. Most maternal deaths occurred in postpartum period. Late referral, loss to follow-up and inadequate care were important determinants of maternal mortality. We concluded that pregnancy cases with or without complications must be considered high risk and addressed judiciously beginning from infection prevention, early diagnosis, disease categorization, and multidisciplinary approach of management to prevent morbidity and mortality. We strongly suggest strengthening the health care delivery system to save pregnant women from dying, particularly in low-resource countries.

The Geographically Weighted Multivariate Poisson Inverse Gaussian Regression Model and Its Applications

This study aims to develop a method for multivariate spatial overdispersion count data with mixed Poisson distribution, namely the Geographically Weighted Multivariate Poisson Inverse Gaussian Regression (GWMPIGR) model. The parameters of the GWMPIGR model are estimated locally using the maximum likelihood estimation (MLE) method by considering spatial effects. Therefore, the significance of the regression parameter differs for each location. In this study, four GWMPIGR models are evaluated based on the exposure variable and the spatial weighting function. We compare the performance of those four models in real-world application using data on the number of infant, under-5 and maternal deaths in East Java in 2019 using five predictor variables. In this study, the GWMPIGR model uses one exposure variable and three exposure variables. Compared to the fixed kernel Gaussian weighting function, the GWMPIGR model with the fixed kernel bisquare weighting function and one exposure variable has a better fit based on the AICc value. Furthermore, according to the best GWMPIGR model, there are several regional groups formed based on predictors that significantly affected each event in East Java in 2019.

Maternal mortality in the covid-19 pandemic: findings from a rapid systematic review.

BACKGROUND: The COVID-19 pandemic is having significant direct and associated effects on many health outcomes, including maternal mortality. As a useful marker of healthcare system functionality, trends in maternal mortality provide a lens to gauge impact and inform mitigation strategies. OBJECTIVE: To report the findings of a rapid systematic review of studies on levels of maternal mortality before and during the COVID-19 pandemic. METHODS: We systematically searched for studies on the 1st March 2021 in MEDLINE and Embase, with additional studies identified through MedRxiv and searches of key websites. We included studies that reported levels of mortality in pregnant and postpartum women in time-periods pre- and during the COVID-19 pandemic. The maternal mortality ratio was calculated for each study as well as the excess mortality. RESULTS: The search yielded 3411 references, of which five studies were included in the review alongside two studies identified from grey literature searches. Five studies used data from national health information systems or death registries (Mexico, Peru, Uganda, South Africa, and Kenya), and two studies from India were record reviews from health facilities. There were increased levels of maternal mortality documented in all studies; however, there was only statistical evidence for a difference in maternal mortality in the COVID-19 era for four of these. Excess maternal mortality ranged from 8.5% in Kenya to 61.5% in Uganda. CONCLUSIONS: Measuring maternal mortality in pandemics presents many challenges, but also essential opportunities to understand and ameliorate adverse impact both for women and their newborns. Our systematic review shows a dearth of studies giving reliable information on levels of maternal mortality, and we call for increased and more systematic reporting of this largely preventable outcome. The findings help to highlight four measurement-related issues which are priorities for continuing research and development.

Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All".

BACKGROUND: This is the concluding paper of our 11-paper supplement, "Community health workers at the dawn of a new era". METHODS: We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes. RESULTS: CHWs are increasingly being recognized as a critical resource for achieving national and global health goals. These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases. CHWs can also play a critical role in responding to current and future pandemics. For these reasons, we argue that CHWs are now at the dawn of a new era. While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems. Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision. We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric. Rigorous monitoring, evaluation, and implementation research are also needed to enable CHW programmes to continuously improve their quality and effectiveness. CONCLUSION: A marked increase in sustainable funding for CHW programmes is needed, and this will require increased domestic political support for prioritizing CHW programmes as economies grow and additional health-related funding becomes available. The paradigm shift called for here will be an important step in accelerating progress in achieving current global health goals and in reaching the goal of Health for All.

Clinical characteristics, outcomes, & mortality in pregnant women with COVID-19 in Maharashtra, India: Results from PregCovid registry.

Background & objectives: The PregCovid registry was established to document the clinical presentations, pregnancy outcomes and mortality of pregnant and post-partum women with COVID-19. Methods: The PregCovid registry prospectively collects information in near-real time on pregnant and post-partum women with a laboratory-confirmed diagnosis of SARS-CoV-2 from 19 medical colleges across the State of Maharashtra, India. Data of 4203 pregnant women collected during the first wave of the COVID-19 pandemic (March 2020-January 2021) was analyzed. Results: There were 3213 live births, 77 miscarriages and 834 undelivered pregnancies. The proportion of pregnancy/foetal loss including stillbirths was six per cent. Five hundred and thirty-four women (13%) were symptomatic, of which 382 (72%) had mild, 112 (21%) had moderate, and 40 (7.5%) had severe disease. The most common complication was preterm delivery (528, 16.3%) and hypertensive disorders in pregnancy (328, 10.1%). A total of 158 (3.8%) pregnant and post-partum women required intensive care, of which 152 (96%) were due to COVID-19 related complications. The overall case fatality rate (CFR) in pregnant and post-partum women with COVID-19 was 0.8 per cent (34/4203). Higher CFR was observed in Pune (9/853, 1.1%), Marathwada (4/351, 1.1%) regions as compared to Vidarbha (9/1155, 0.8%), Mumbai Metropolitan (11/1684, 0.7%), and Khandesh (1/160, 0.6%) regions. Comorbidities of anaemia, tuberculosis and diabetes mellitus were associated with maternal deaths. Interpretation & conclusions: The study demonstrates the adverse outcomes including severe COVID-19 disease, pregnancy loss and maternal death in women with COVID-19 in Maharashtra, India.