Levels and Trends of Maternal Mortality and Morbidity by Cause in North Africa and Middle East, 1990 to 2019: An Analysis for the Global Burden of Disease Study 2019

Background: Since 1990, the maternal mortality significantly decreased at global scale as well as the North Africa and Middle East. However, estimates for mortality and morbidity by cause and age at national scale in this region are not available. Method(s): This study is part of the Global Burden of Diseases, Injuries, and Risk Factors study (GBD) 2019. Here we report maternal mortality and morbidity by age and cause across 21 countries in the region from 1990 to 2019. Result(s): Between 1990 and 2019, maternal mortality ratio (MMR) dropped from 148.8 (129.6-171.2) to 94.3 (73.4-121.1) per 100 000 live births in North Africa and Middle East. In 1990, MMR ranged from 6.0 (5.3-6.8) in Kuwait to 502.9 (375.2-655.3) per 100 000 live births in Afghanistan. Respective figures for 2019 were 5.1 (4.0-6.4) in Kuwait to 269.9 (195.8-368.6) in Afghanistan. Percentages of deaths under 25 years was 26.0% in 1990 and 23.8% in 2019. Maternal hemorrhage, indirect maternal deaths, and other maternal disorders rank 1st to 3rd in the entire region. Ultimately, there was an evident decrease in MMR along with increase in socio-demographic index from 1990 to 2019 in all countries in the region and an evident convergence across nations. Conclusion(s): MMR has significantly declined in the region since 1990 and only five countries (Afghanistan, Sudan, Yemen, Morocco, and Algeria) out of 21 nations didn't achieve the Sustainable Development Goal (SDG) target of 70 deaths per 100 000 live births in 2019. Despite the convergence in trends, there are still disparities across countries.Copyright © 2022 Academy of Medical Sciences of I.R. Iran. All rights reserved.

Spatial determinants affected maternal mortality of East Java province during the covid-19 pandemic era, in 2020-2021

Background. Every life aspect and group of the community have changed during the COVID-19 pandemic, including the group of pregnant, childbirth, and postpartum woman. COVID-19 Pandemic occurred in 2020-2021. Maternal mortality in East Java Province was the highest in Indonesia during the pandemic. Objective. This study analyzed the effect of spatial determinants that consist of antenatal, childbirth, and post-partum care on maternal mortality in East Java Province during the Pandemic. Methods. This study used a crossectional method with the unit of analysis in this study was all pregnant, childbirth and postpartum women in 38 districts of East Java Province from 2020 until 2021. Data were analyzed with spatial regression by using Geographically Weighted Regression Software. Results. Maternal mortality in East Java had a spreading pat-tern and negative value of the diff criterion, so we concluded that there was a spatial influence. The variables of antenatal care, accessibility of healthcare service, third postpartum visit, and complication service had significant effects on maternal mortality in all regions (P<0,05). There were four groups of districts that showed a similarity of significant factors. This result showed that each region's diversity of the accessibility of health services affects maternal mortality during the COVID-19 era. Antenatal services, access to health facilities and complication services affected maternal mortality in regions with high maternal mortality rate. Conclusion. Every region has its spatial determinants of maternal mortality. The top government should give authority to local government to have programs to reduce maternal mortality according to the condition in their region. r.Copyright © the Author(s), 2023.

Trends in Postpartum Depression before and during the COVID-19 Pandemic and Correlates of Treatment Choices: A Population-Based Retrospective Cohort Study

Objectives: COVID-19-related stressors - including social distancing, material hardship, increased intimate partner violence, and loss of childcare, among others - may result in a higher prevalence of depression among postpartum individuals. This study examines trends in postpartum depression in the US from 2018 to 2022, as well as correlates of treatment choices among women with postpartum depression. Method(s): 1,108,874 women aged 14-64 in the Komodo Healthcare Map with 1+ live birth between April 2018 and December 2021 and had continuous enrollment 2+ years before and 4+ months after the delivery date were included. Prevalence of depression during postpartum (within 3 months after delivery) was calculated before (April 2018-March 2020) and during (April 2020-March 2022) COVID-19. Multinomial logistic regression was used to investigate correlates of treatment choices (no treatment, medication-only, psychotherapy-only, or both). Result(s): The prevalence of postpartum depression increased from 9.7% pre-pandemic to 12.0% during the pandemic (p < 0.001). Among 119,788 women with postpartum depression in 2018-2022, 47.0% received no treatment, 35.0% received medication-only, 10.0% received psychotherapy-only, and 7.4% received both within one month following their first depression diagnosis. Factors associated with an increase in the odds of receiving medication-psychotherapy treatment (vs. no treatment) included older ages;commercial insurance coverage;lower social vulnerability index;history of anxiety or mood disorder during and before pregnancy;and being diagnosed by a nurse practitioner, physician assistant, or behavioral care practitioner (vs. physician). Similar patterns were observed for medication-only and psychotherapy-only treatments. Conclusion(s): In this large, nationally representative sample of US insured population, the prevalence of postpartum depression increased significantly by 2.3 percentage-points during the pandemic (or a relative increase of 23.7%). Nonetheless, almost half of women with postpartum depression received no treatment, and only 7.5% received both medication and psychotherapy. The study highlighted potential socioeconomic and provider variation in postpartum depression treatment.Copyright © 2023

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.

A novel cystic fibrosis-pregnancy service: Two-year review after introduction of elexacaftor/tezacaftor/ivacaftor

Background: As a quality service improvement response since elexacaftor/ tezacaftor/ivacaftor (ELX/TEZ/IVA) became available and the yearly average number of cystic fibrosis (CF) pregnancies (n = 7 pre-2020, n = 33 in 2021) increased significantly at an adult CF center (~600 people with CF), a monthly multidisciplinary CF-maternal health virtual clinic was established with antenatal virtual CF exercise classes dedicated to providing adaptive, specialist support to this cohort, aswell as outreach guidance and education to local obstetric teams. Method(s): This was a single-center retrospective reviewof Royal Brompton Hospital CF-Maternal Health multidisciplinary team clinic records and a patient survey from March 2020 to March 2022. Result(s): Of 47 pregnancies in 41 women (median age 30;) eligible for ELX/ TEZ/IVA at start of pregnancy, 40% (n = 19) were unplanned, and 19% (n = 9) used assisted conception. Three women with a history of infertility conceived naturally, having required assisted conception for previous pregnancies, and five women had multiple pregnancies during the study period. ELX/TEZ/IVA was continued in 60% (n = 28), delayed in 28% (n = 13), and stopped in 13% (n = 6) of pregnancies through maternal choice and careful clinical counselling. Pre-pregnancy pulmonary status was poorer in women who continued than in those who delayed or stopped (Table 1). Of those who stopped, 85% (n = 5) restarted because of pulmonary deterioration by the third trimester. Prenatal CF complications included at least one episode of minor hemoptysis in 21% (n = 9/41) of women, at least one infective exacerbation in 55% of pregnancies (n = 26/47), and noninvasive ventilation in one woman. Other pregnancy-associated complications included one case of ovarian hyperstimulation syndrome, one case of sub-segmental pulmonary embolism, and two cases of pregnancy-induced hypertension. Excluding 10 first trimester terminations, 10 current pregnancies, and one patient relocation, obstetric outcomes available for 26 pregnancies confirmed a live birth rate of 85% (n = 22/26) and a 15% first-trimester miscarriage rate (n = 4). Obstetric complications included preterm delivery rate of 23% (n = 6/26), including two cases of COVID infection resulting in two neonatal intensive care unit admissions, one case of endometritis after cesarean section, and a fourthdegree perineal tear. There were no ectopic pregnancies, maternal or neonatal deaths, or reports of infant cataracts or congenital malformations. Median gestational age was 37/40 weeks (range 29-40). Mode of delivery was via cesarean section in 45% (n = 10/22, of which twowere emergency) and vaginal in 55% (n = 12/22), of which 83% (n = 10/12) were via induction of labor for diabetes (CF or gestational) indication. Deliveries were supported and occurred equally at local obstetric units and in tertiarycare obstetric hospital settings (50%, n = 11/22). Patient-experience survey responses cited high levels of confidence in health optimization and prioritization during pregnancy and praised excellent inter-health care provider communication and peer-to-peer emotional support provided among expectant mothers in the virtual prenatal exercise groups. Table 1. Baseline demographic and clinical characteristics of elexacaftor/tezacaftor/ivacaftoreligible expectant mothers according to therapeutic decision (Table Presented) Conclusion(s): In the absence of clinical trial safety data, the novel approach of a dedicated CF-maternal health multidisciplinary team clinic with local obstetric outreach support has ensured regular specialist clinical and emotional peer-to-peer support for this cohort of women eligible for ELX/ TEZ/IVA to ensure optimal outcomes and experiences of their pregnancies, where appropriate, close to home.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

Aplasia cutis congenita in dizygotic twin infants

Aplasia cutis congenita (ACC) is often sporadic, but familial cases have been reported. We report a case of a dichorionic diamniotic twin pregnancy in which both the male and female twins had matching areas of aplasia cutis on their scalps. An Irish couple sought fertility treatment using a donor egg and paternal sperm. Successful in vitro fertilization (IVF) and the transfer of two embryos resulted in a diamniotic dichorionic twin pregnancy. Two fetal poles were noted at the 12-week ultrasound (US) scans. The mother suffered from a minor urinary tract infection during the first trimester but had no other history of infection, including herpes simplex virus or COVID- 19. She was known to be varicella immune prior to pregnancy. The twins were born by elective caesarean section owing to breech presentation. Twin one was female and twin two was male. Both infants were born with scarring on the crown of their head, which was consistent with ACC. Cranial US showed no underlying bony abnormality. The rest of the cutaneous examination was normal and there were no other congenital anomalies. ACC is a rare, heterogeneous group of disorders characterized by the congenital absence of skin, which can be focal or widespread. It is thought to affect 1-3 per 10 000 live births. The exact cause of ACC is unclear. Various hypotheses have been suggested, including defective closure of the neural tube or embryonic fusion lines, intrauterine trauma, placental insufficiency, fetus papyraceus, amniotic membrane adhesions, intrauterine infections, teratogens and genetic mutations. The classification of ACC is based on the area affected, type of skin irregularity, associated congenital defects and mode of inheritance. Scalp ACC without multiple anomalies (category 1) is generally associated with an autosomal dominant or sporadic pattern of inheritance. These twins may have an autosomal dominant mutation that led to this phenotype. ACC can also be associated with fetus papyraceus or placental infarct. This is less likely in this case as only two embryos were transferred, and the pregnancy was dichorionic. Most cases of ACC associated with fetus papyraceus occur in monozygotic pregnancies. ACC lesions often heal spontaneously by re-epithelialization resulting in a hairless superficial scar. Twin one had a slightly smaller area affected by ACC and overlying eschar resolved several weeks after birth. Twin two has had no hair growth in the area. This case highlights the difficulties in ascertaining the aetiology of this rare condition in twin pregnancies.

Is The Co-administration of Metformin and Clomiphene Superior to Induce Ovulation in Infertile Patients with Poly Cystic Ovary Syndrome and Confirmed Insulin-resistance: A Double Blind Randomized Clinical Trial

Objective: This study aimed to compare the effects of clomiphene citrate (CC) combined with metformin or placebo on infertile patients with poly cystic ovary syndrome (PCOS) and insulin resistance (IR). Material(s) and Method(s): We included 151 infertile women with PCOS and IR in a university hospital from November 2015 to April 2022 in this prospective, double-blind, randomized, placebo-controlled trial. Patients were randomized into two groups;group A: received CC plus metformin (n = 76) and group B: received CC plus placebo (n = 75). The ovulation rate was the main outcome measure. Clinical pregnancy, ongoing pregnancy, live birth and abortion rates were secondary outcome measures. Result(s): There was no remarkable difference in ovulation rate in two groups. Moreover, no significant changes were observed in clinical pregnancy, ongoing pregnancy, live birth and abortion rates between two groups. A larger proportion of women in group A suffered from side effects of metformin (9.3% versus 1.4%;p=0.064), although this was not significant. Conclusion(s): In IR infertile women with PCOS, metformin pre-treatment did not increase the ovulation, clinical pregnancy and live birth rates in patients on clomiphene citrate.Copyright © 2023 Tehran University of Medical Sciences.

The risk of miscarriage following COVID-19 vaccination: a systematic review and meta-analysis.

STUDY QUESTION: What is the risk of miscarriage among pregnant women who received any of the COVID-19 vaccines? SUMMARY ANSWER: There is no evidence that COVID-19 vaccines are associated with an increased risk of miscarriage. WHAT IS KNOWN ALREADY: In response to the COVID-19 pandemic, the mass roll-out of vaccines helped to boost herd immunity and reduced hospital admissions, morbidity, and mortality. Still, many were concerned about the safety of vaccines for pregnancy, which may have limited their uptake among pregnant women and those planning a pregnancy. STUDY DESIGN, SIZE, DURATION: For this systematic review and meta-analysis, we searched MEDLINE, EMBASE, and Cochrane CENTRAL from inception until June 2022 using a combination of keywords and MeSH terms. PARTICIPANTS/MATERIALS, SETTING, METHODS: We included observational and interventional studies that enrolled pregnant women and evaluated any of the available COVID-19 vaccines compared to placebo or no vaccination. We primarily reported on miscarriage in addition to ongoing pregnancy and/or live birth. MAIN RESULTS AND THE ROLE OF CHANCE: We included data from 21 studies (5 randomized trials and 16 observational studies) reporting on 149 685 women. The pooled rate of miscarriage among women who received a COVID-19 vaccine was 9% (n = 14 749/123 185, 95% CI 0.05-0.14). Compared to those who received a placebo or no vaccination, women who received a COVID-19 vaccine did not have a higher risk of miscarriage (risk ratio (RR) 1.07, 95% CI 0.89-1.28, I2 35.8%) and had comparable rates for ongoing pregnancy or live birth (RR 1.00, 95% CI 0.97-1.03, I2 10.72%). LIMITATIONS, REASONS FOR CAUTION: Our analysis was limited to observational evidence with varied reporting, high heterogeneity and risk of bias across included studies, which may limit the generalizability and confidence in our findings. WIDER IMPLICATIONS OF THE FINDINGS: COVID-19 vaccines are not associated with an increase in the risk of miscarriage or reduced rates of ongoing pregnancy or live birth among women of reproductive age. The current evidence remains limited and larger population studies are needed to further evaluate the effectiveness and safety of COVID-19 vaccination in pregnancy. STUDY FUNDING/COMPETING INTEREST(S): No direct funding was provided to support this work. M.P.R. was funded by the Medical Research Council Centre for Reproductive Health Grant No: MR/N022556/1. B.H.A.W. hold a personal development award from the National Institute of Health Research in the UK. All authors declare no conflict of interest. REGISTRATION NUMBER: CRD42021289098.

An artificial-intelligence-based clinical decision support application reduces the rate of adverse clinical events

Objective: We set to determine if the Medical Brain (MB), an artificial intelligence (AI)-based clinical decision support application designed to improve patient safety, has assisted in reducing the incidence of predefined adverse clinical events (hereinafter referred to as Red Never Events (RNEs). Study Design: MB algorithms had been created based on guidelines and best practices vetted by departmental and hospital leadership. RNEs tracked were lack of admistering antibiotics for group B sterp positive patients in labor, lack of admisterating magnesium sulfate for seizure prophylaxis in pateitns with severe preeclampsia, and not discontinuing Pitocin in laboring patietns with a non reassuring fetal heart rate tracing. A retrospective analysis was then divided into four phases tracking the rate of RNEs: 1) June 2018-June 2019: pre-implementation phase (phase 0). 2) July 2019- Jan 2020: roll-out phase (phase 1). 3) Feburary 2020-June 2020: Covid peak (phase 2), and 4) July 2020-May 2022: Post-Intervention phase (phase 3). The number of RNEs per 1000 live births per month was analyzed by Statistical Process Control (SPC) using Statistical software JMP Pro 16. One-way ANOVA was used to detect a statistically significant difference between the four phases. Result(s): Between June 2018 to May 2022, we had 1,424 RNEs and a total of 28,300 Live births. The average total RNEs per 1000 live births decreased from 117.5 in phase 0 to 10.9 per 1000 live births in phase 3, a 90.7% reduction (Figure 1). The Statistical Process Control (SPC) U-Chart demonstrated no special cause signal during phase 0, indicating random variation. Furthermore, analysis showed a shift in the centerline during phase analysis 1, 2, and 3. The difference was statistically significant among the 4 phases on one-way ANOVA ( p < 0.0001). The LOESS Fit Plot shows a downward trend from the Pre-to-Post-Intervention period (Figure 2). Conclusion(s): The use of an AI-based clinical decision support application successfully reduced the rate of adverse clinical events and has aided in avoiding clinical mishaps in a busy obstetrical unit. [Formula presented] [Formula presented] Copyright © 2022

Effect of inactivated COVID-19 vaccination on pregnancy outcomes following frozen-thawed embryo transfer: A retrospective cohort study.

OBJECTIVE: To investigate the effect of inactivated coronavirus disease 2019 (COVID-19) vaccination on frozen-thawed embryo transfer (FET) outcomes. METHODS: This retrospective cohort study enrolled 1,210 patients undergoing FET cycles in a single university-affiliated hospital between July 1, 2021, and May 1, 2022. Of them, 387 women with two full doses of inactivated SARS-CoV-2 vaccines (CoronaVac or BBIBP-CorV) after oocyte retrieval were assigned to the vaccinated group, while 823 were unvaccinated as controls. Propensity score matching and multiple regression analysis were applied to control for baseline and cycle characteristics (19 covariates in total). RESULTS: There were 265 patients in each group after matching. The rates of clinical pregnancy (58.5% vs. 60.8%; P = 0.595) and live birth (44.4% vs. 48.8%; P = 0.693) were similar between vaccinated and unvaccinated patients, with adjusted odds ratios of 0.89 (95% confidence interval [CI] 0.61-1.29) and 1.31 (95% CI 0.37-4.56), respectively. Consistently, no significant differences were found in serum human chorionic gonadotropin levels as well as biochemical pregnancy, biochemical pregnancy loss, and embryo implantation rates. Based on the time interval from vaccination to FET, vaccinated patients were further subdivided into two categories of ≤2 months and >2 months, and the outcomes remained comparable. CONCLUSION: Our study showed that inactivated COVID-19 vaccination in women did not have measurable detrimental impact on implantation performance and live birth outcome during FET treatment cycles. This finding denies the impairment of endometrial receptivity and trophoblast function by vaccine-induced antibodies at the clinical level.

Inactivated Covid-19 vaccine did not undermine live birth and neonatal outcomes of women with frozen-thawed embryo transfer.

STUDY QUESTION: Does inoculation with inactivated vaccines against coronavirus disease 2019 (Covid-19) before frozen-thawed embryo transfer (FET) affect live birth and neonatal outcomes? SUMMARY ANSWER: Inactivated Covid-19 vaccines did not undermine live birth and neonatal outcomes of women planning for FET. WHAT IS KNOWN ALREADY: Accumulating reports are now available indicating the safe use of mRNA vaccines against Covid-19 in pregnant and lactating women, and a few reports indicate that they are not associated with adverse effects on ovarian stimulation or early pregnancy outcomes following IVF. Evidence about the safety of inactivated Covid-19 vaccines is very limited. STUDY DESIGN, SIZE, DURATION: This is a retrospective cohort analysis from Reproductive Medical Center of a tertiary teaching hospital. Clinical records and vaccination record of 2574 couples with embryos transferred between 1 March 2021 and 30 September 2021 were screened for eligibility of this study. PARTICIPANTS/MATERIALS, SETTING, METHODS: Clinical and vaccination data of infertile couples planning for FET were screened for eligibility of the study. The reproductive and neonatal outcomes of FET women inoculated with inactivated Covid-19 vaccines or not were compared. The primary outcomes were live birth rate per embryo transfer cycle and newborns' birth height and weight. Secondary outcomes included rates of ongoing pregnancy, clinical pregnancy, biochemical pregnancy and spontaneous miscarriage. Multivariate logistical regression and propensity score matching (PSM) analyses were performed to minimize the influence of confounding factors. Subgroup analyses, including single dose versus double dose of the vaccines and the time intervals between the first vaccination and embryo transfer, were also performed. MAIN RESULTS AND THE ROLE OF CHANCE: Vaccinated women have comparable live birth rates (43.6% versus 45.0% before PSM, P = 0.590; and 42.9% versus 43.9% after PSM, P = 0.688), ongoing pregnancy rates (48.2% versus 48.1% before PSM, P = 0.980; and 52.2% versus 52.7% after PSM, P = 0.875) and clinical pregnancy rate (55.0% versus 54.8% before PSM, P = 0.928; and 54.7% versus 54.2% after PSM, P = 0.868) when compared with unvaccinated counterparts. The newborns' birth length (50.0 ± 1.6 versus 49.0 ± 2.9 cm before PSM, P = 0.116; and 49.9 ± 1.7 versus 49.3 ± 2.6 cm after PSM, P = 0.141) and birth weight (3111.2 ± 349.9 versus 3030.3 ± 588.5 g before PSM, P = 0.544; and 3053.8 ± 372.5 versus 3039.2 ± 496.8 g after PSM, P = 0.347) were all similar between the two groups. Neither single dose nor double dose of vaccines, as well as different intervals between vaccination and embryo transfer showed any significant impacts on reproductive and neonatal outcomes. LIMITATIONS, REASONS FOR CAUTION: The main findings might be limited by retrospective design. Besides, inoculations of triple dose of Covid-19 vaccines were not available by the time of data collection, thus the results cannot reflect the safe use of triple dose of inactivated Covid-19 vaccines. Finally, history of Covid-19 infection was based on patients' self-report rather than objective laboratory tests. WIDER IMPLICATIONS OF THE FINDINGS: Eligible individuals of inactivated vaccines against Covid-19 should not postpone vaccination plan because of their embryo transfer schedule, or vice versa. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by the Medical Key Discipline of Guangzhou (2021-2023). All authors had nothing to disclose. TRIAL REGISTRATION NUMBER: N/A.

38th Hybrid Annual Meeting of the European Society of Human Reproduction and Embryology

The proceedings contain 1092 papers. The topics discussed include: semen impairment and occurrence of SARS-COV-2 virus in semen after recovery from COVID-19;the SELECTIMO study - clinical outcomes of uninterrupted embryo culture with or without time-lapse based embryo selection versus interrupted standard culture: a randomized controlled trial;the bias is out of the bag: IVF culture dish well number influences embryo selection decision-making and implantation outcome;reducing inter-observer and intra-observer variability of embryo quality assessment using deep learning;annotation-free embryo score calculated by Idascorecorrelated with live birth and has no correlation with neonatal outcomes after single vitrified-warmed blastocyst transfer;simplifying the complexity of time-lapse decisions with AI: CHLOE (fairtility) can automatically annotate morphokinetics and predict blastulation (at 30HPI), pregnancy and ongoing clinical pregnancy;and controlled ovarian stimulation (COS) protocols for assisted reproduction: a Cochrane systematic review and network meta-analysis.

Multisectoral Factors Associated with Global National Trends in Neonatal Mortality Rates: A Call for Targeted Public Health Intervention, Particularly in Countries Impacted Most by COVID-19

Background: The United Nations' 2030 Sustainable Development Goals (SDGs) target an end to preventable newborn deaths and a reduction in neonatal mortality rate (< 28 d, NMR) to 12/1,000 live births for all countries. Understanding concurrent trends in country-level, multisectoral factors associated with NMR trends may illuminate opportunities for intervention strategies. Our objective was to explore country-specific trends in NMR from 1990-2019 and identify those countries which contribute to the largest percentage of neonatal deaths in order to focus efforts on reducing NMRs in those specific countries. Unfortunately, due to the COVID-19 pandemic, the 2030 SDGs have been severely impacted. Methods: We created a comprehensive global database of NMR and associated variables that were selected based on literature review and categorized into Population Health, Health Systems, Maternal, Neonatal, and Social factors from 1990 to 2019. Data were compiled from publicly available sources including UNICEF, World Bank, WHO, and OECD. Data were collected and analyzed for 195 countries. NMR trends were analyzed from 1990 to 2019 with more targeted analysis of trends in the last 2 decades from 2000 to 2019. We then performed statistical analyses using the selected variables to compare variable means using t-tests, identify bivariate associations, and generate multivariable regression models. Results: In terms of total deaths, 20 countries contributed 75% of the total 2.5 million neonatal deaths. All of these 20 countries showed decreases in NMR since 1990 (Figure 1). However, only China and Egypt accomplished the UN goal of reducing NMR to 12/1,000 live births. We compared variables associated with NMR in our 20 target countries to the remaining countries and found significant differences between the means for most variables (Table 1). Bivariate regression analyses showed statistically significant associations between NMR trends and changes over time in median income, health care spending, literacy level, maternal mortality ratio, and low birthweight rate. Ultimately the variables maternal mortality ratio change and median income change were selected for multivariable analysis based on collinearity. The multivariate regression model generated using NMR, maternal mortality ratio change, median income change resulted in an r-squared value of 0.54, explaining 54% of the variance in NMR trends. Conclusion: Since 20 countries contribute 75% of the neonatal deaths worldwide, we propose that targeting these 20 countries would have the greatest impact on global neonatal deaths. Future research will focus on identification of country specific barriers and evaluating the countries with greatest NMR improvements to propose effective focused strategies for reducing NMRs in high burden countries. The disparate impact that COVID-19 has had on countries with the highest neonatal mortality burden should be a primary focus of continued public health invention efforts, and is a specific focus of our ongoing research.

Mentoring Quality Improvement Teamsin Ethiopia via a Virtual Partnership Between the American Academy of Pediatrics and the Ethiopian Pediatric Society

Background: Despite a marked decline in worldwide under-five mortality over the past 30 years, the largest proportion of these deaths remain neonates. In 2018, 4 million (75% of all under-five deaths) infants died worldwide [1]. The neonatal mortality rate in Ethiopia was 28.1 per 100 live births, compared to 17.7 globally and 27.2 in Africa, ranking 23rd for highest neonatal mortality [2]. The Ethiopian Pediatric Society (EPS), entered a virtual partnership with the American Academy of Pediatrics (AAP) in 2020 to provide educational and practical support to clinicians in Ethiopia to perform quality improvement (QI) research. QI training for clinicians at eight Ethiopian sites is modeled on Project ECHO (Extension for Community Healthcare Outcomes) [3]. ECHO improves capacity for specialists to deliver care to underserved communities via collaboration with local clinicians using video teleconferencing, which has been a particularly advantageous tool to continue global health work during the COVID-19 pandemic. The goal of this project is to support local Ethiopian providers in designing, implementing, and assessing a QI intervention. Methods: We adapt the Project ECHO model to have U.S. neonatology faculty-fellow teams mentor clinicians from 8 hospitals in Ethiopia. Using video conferencing and regular contact through mobile devices, teams work to identify gaps in care, create SMART aim statements, identify key stakeholders and barriers to change, and implement interventions. Interventions are measured with a phone application, Liveborn, which allows instant transmission of data internationally. Sites provide monthly progress updates to the EPS. AAP/EPS leadership, U.S.-based faculty-fellow teams, and QI team leaders meet monthly via video conference for didactic sessions on QI methodology followed by teams presenting their progress, which promotes discussion and collaboration between the sites, AAP/EPS leadership, and U.S. mentorship teams to address any barriers. Results: Teams identified compliance with delayed cord clamping (DCC) and skin-to-skin (STS) after delivery as a gap by independently collecting local data. QI teams are currently still implementing interventions and measuring improvement. Teams have identified several barriers, the most common cited being stakeholder buy-in and logistic challenges in implementation. During monthly meetings, teams continually discuss and brainstorm ways to address barriers overall and among individual sites. Conclusion: Via the ECHO model, the AAP and EPS are supporting Ethiopian QI teams in designing and implementing QI interventions despite the limitations imposed by the COVID-19 pandemic. Challenges to this mentorship process include communication barriers (language, internet network) and perception of lack of need by Ethiopian clinicians for U.S. mentorship. Using the ECHO model, all teams have defined SMART aims, begun to implement interventions, and are now collecting compliance data.

Maternal mortality in modern world

Aim: to analyze the causes and level of global maternal mortality (MM) according to the data published within the last 7 years. Materials and Methods. Search for publications in the PubMed/MEDLINE database was conducted according to the criteria: meta-analysis, free full-text, English, 2015-2021 period. The PICO principle (Patient/Problem, Intervention, Comparison, Outcome) and the keywords "maternal mortality causes", "maternal death causes", "maternal outcomes" were used. The search was finished on October 13, 2021 after retrieving 137 results. Results. The rate of MM and cause pattern has been changing during COVID-19 pandemic. The first weeks of the COVID-19 lockdown showed that in-hospital mortality among pregnant women increased from 0.13 up to 0.20 % (p = 0.01) and in MM the proportion of respiratory diseases elevated up to 32 % versus 5.6%. Certain geographic regions of the world showed that MM due to COVID-19 reached extremely high values extending 3399 per 100,000 live births as well as increased general MM rate. Heart and vascular diseases (pericarditis, myocardial infarction, thromboembolism) have a significant position among the causes of MM. The rate of MM due to cardiovascular disease was inversely related to the population income level. Cardiomyopathy is the cause of death in 4 % (95 % confidence interval (95 % CI) = 2-7) of mothers in developed countries and 14 % (95 % CI = 10-18) in developing countries. The mortality rate 6 weeks after delivery among women with pregnancy-related myocardial infarction was 5.03 % (95 % Cl = 3,78-6,27), whereas it associated with thromboembolism among women with a mechanical heart valve was related to the agent used to prevent thrombosis, ranging from 0.9 (95 % CI = 0.1-1.6) for vitamin K antagonists up to 3.4 (95 % CI = 0-7.7) for unfractionated heparin per 100 pregnancies with a mechanical heart valve. After 2000, the proportion of anesthesia among immediate MМ causes decreased from 3.5 % (95 % CI = 2.9-4.3) down to 2.4 % (95 % CI = 1.9-2.9) in low- and middle-income countries. High MM odds due to maladjusted pregnancy are still observed: OR (odds ratio) = 17 (95 % CI = 9.6-28.8) for hypertension, OR = 3.70 (95 % CI = 1.72-7.99) for HELLP syndrome with acute kidney injury. Severe obstetric complications cause MM in sub-Saharan Africa and South Asia: bleeding (OR = 28.8;95 % CI = 20.3-40.7), preeclampsia or eclampsia (OR = 9.13;95 % CI = 6.10-13.7), maternal infections in antenatal period (OR = 2.80;95 % CI = 1.63-4.80). About 67 % of pregnant women in such countries obtain no antenatal care (OR = 2.80;95% CI = 1.63-4.80), predominantly giving birth at home in sub-Saharan Africa. In Ethiopia, ММ results from obstructed home delivery resulting in maternal death in 17.27 %, where uterine rupture is cause of death in 7.75 % of women. Conclusion. The COVID-19 pandemic contributed a lot to MM. Diseases of the cardiovascular system markedly elevate the MM risk and long-term mortality after delivery. For countries with traditionally home births in the absence of medical care, a high MM remains due to complicated and protracted labor complicated by uterine rupture.

Frequency of Meconium-stained Amniotic Fluid in COVID-positive Term Pregnancies and Perinatal Outcome

Aim: To know the frequency of meconium-stained amniotic fluid (MSAF) among COVID-positive term pregnant mothers and to know perinatal outcomes in these neonates. Materials and methods: A retrospective study was conducted of COVID-positive term pregnancies admitted to Vanivilas hospital, Bangalore Medical College, during the study period of 1 year. The study period was from 1st of July 2020 to 31st of June 2021. High-risk pregnancies that confound the occurrence of MSAF were excluded (obstetric risk factors and medical risk factors complicating pregnancy). Data were collected from medical records of patients and parturition register, which are cross-verified with operation theater records and neonatal intensive care unit (NICU) registers. Results: In total, 200 pregnant women were included in the study. About 65% were delivered by cesarean, 34.5% by the vaginal route, and one vacuum-assisted delivery. In total, 199 live births and one fresh stillbirth are reported. About, 26% had MSAF and 6.5% of newborns had meconium aspiration syndrome. Grade I, II, and III cases were 4.5%, 12.5%, and 9% respectively. Low appearance, pulse, grimace, activity, and respiration (APGAR) scores were correlating with the grade of MSAF, which is statistically significant. There were two neonatal deaths in grade III MSAF cases. Conclusion: The frequency of MSAF is increased among COVID-positive mothers, which translates to low APGAR scores and poor perinatal outcomes. Vigilant intrapartum care is recommended for these pregnancies to reduce the risk of poor neonatal outcomes. Clinical significance: The current study is undertaken to know if coronavirus disease-2019 (COVID-19) is associated with an increased frequency of MSAF among COVID-positive pregnant women. Finding MSAF has implications on operative delivery, cesarean rates, and perinatal outcome. There is a lack of studies about MSAF and perinatal outcomes in COVID-positive mothers. Evidence generated by this study helps to counsel the COVID-positive mothers and guides in the management of COVID-positive laboring women.

Comparison of intraovarian instillation of platelet-rich plasma versus stem-cells for ovarian rejuvenation

Objective: To compare the role of intra-ovarian Platelet-Rich Plasma (PRP) versus marrow derived Stem-Cells (SC) instillation for improvement in ovarian-reserve (AFC,AMH, FSH). Design: A prospective comparative study. Method: 72 infertile females (20-39 years) with poor ovarian reserve (AMH <1.2 ng/ml;AFC < 5) (POSEIDON criterion) were enrolled for study between January 2020 -December 2021. The two comparative groups underwent either intra-ovarian PRP instillation (n = 42) or autologous SC transplantation (n = 30). After the two groups were matched (PRP vs. SC) for baseline characteristics (Age, AMH, AFC, FSH, Estradiol), 30 subjects in each group were compared for change in serum FSH/AMH/Estradiol levels and AFC at 1st month and 3rd month post intervention from the baseline. This was also compared between the two groups using Student t-test. The cost and procedural pain measured using Visual analog scale (VAS) were also compared. Results: After matching for baseline characteristics, significant ∼ 1.8/2 and ∼1.5/1.6fold increase in AFC at 1st/3rd month post intervention (p < 0.001) was observed after PRP instillation and SC transplantation respectively. However, PRP group fared better than SC group at 3rd month post intervention (7.07 vs. 5.60, p = 0.02), while no significant difference existed amongst the two at 1st month of follow up. Levels of Serum FSH, AMH and Estradiol (p > 0.05) did not differ significantly from the baseline at 1st and 3rd month post intervention in both the groups. Similarly, there was no significant difference between the two groups in serum FSH level (7.98 IU/ml vs. 9.62 IU/ml, p = 0.062;8.26 IU/ml vs. 9.50 IU/ml, p = 0.15), AMH level (1.62 ng/ml vs. 1.02 ng/ ml, p = 0.27;1.35 ng/ml vs. 0.95 ng/ml, p = 0.24), Estradiol level (49.12 pg/ml vs. 56.48 pg/ml p = 0.443;54.7 pg/ml vs. 61.12 pg/ml, p = 0.44) at 1st and 3rd month post intervention respectively. PRP is comparatively more cost effective and is associated with lesser pain (32.5 mm vs. 28.13 mm, p = 0.02) then SC group thus showing better compliance and acceptability. Conclusion: Both PRP and SC therapies improves the ovarian reserve markers however, response to PRP is superior to SC. Also, further to note that PRP is minimally invasive and has better compliance and acceptability. The main limitation of this study is small sample size and due to Covid pandemic inability to perform the IVF cycles to show improvement in clinical pregnancies and live births. Therefore, a large randomized trial is required to validate these results.

Assessment of newborn health dynamics after the Russian Federation transition to international criteria for live births and stillbirths

To assess the state of children’s health in obstetric care organizations after Russia transition to international statistics on live births and stillbirths, we studied the main indicators of newborn health in the dynamics from 2013 to 2020. It was found that between 2013 and 2020 the morbidity of newborns decreased by 6.3% (from 337.2‰ to 316.3‰;p<0.05), neonatal mortality by 45.7% (from 3.5‰ to 1.9‰;p<0.05), stillbirth rate by 45.6% (from 10.9‰ to 5.5‰;p<0.05), and hospital mortality of newborns born sick and ill by 40.0% (from 1.0% to 0.6%;p<0.05). Assessment of the distribution of live-born infants by birth weight showed that changes in this parameter of physical development during the period under study had no statistically significant differences (p>0.05). The assessment of the impact of the COVID-19 pandemic on newborn health revealed slight shifts in the distribution of children born alive by birth weight and a 6.8% increase in the stillbirth rate compared to the pre-pandemic level. Thus, in the period from 2013 to 2020 the share of children discharged from obstetric hospitals who were healthy has increased due to the reduction in morbidity and mortality of newborns. The analysis showed that there was an improvement in the health indicators of newborns in the Russian Federation.