Examining expert views on maternal mortality in Turkey: A qualitative study.

BACKGROUND: Maternal mortality ratio is one of the significant indicators of a country's healthcare quality and development. In recent years, Türkiye has made significant advancements in maternal and child health services. However, it has been discussed that stagnation has been observed in recent years, and the migration from Syria and the COVID-19 pandemic have significantly overshadowed this success. The purpose of this study is to evaluate the current situation of the maternal mortality level in the country based on the experiences and views of experts working in this area. METHODS: Key informant interviews were conducted with a purposive sample of academics, representatives of public institutions, and NGOs to understand the mechanisms of success in maternal mortality in the 1990s. Thematic analysis was used to understand the reasons for the stagnation of the decline in maternal mortality and to develop recommendations for reducing maternal mortality. RESULTS: Twenty-five key informant interviews were conducted. Positive developments contributing to the success of maternal mortality, problems and obstacles hindering further progress and suggestions/recommendations are the themes of this research. The key informants highlighted the health transformation policies, the lack of data on the impact of COVID-19, recent migration on maternal mortality, inadequate education and training on sexual and reproductive health (SRH), the absence of rights-based policies, and gender equality as critical issues in current policies. CONCLUSION: The outcomes of this study underline the importance of the availability, accessibility, and quality of SRH services and empowering women, girls, families, and communities to eliminate preventable maternal mortality levels.

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

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

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

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

Do black women's lives matter? A study of the hidden impact of the barriers to access maternal healthcare for migrant women in South Africa.

Background: Studies on the barriers migrant women face when trying to access healthcare services in South Africa have emphasized economic factors, fear of deportation, lack of documentation, language barriers, xenophobia, and discrimination in society and in healthcare institutions as factors explaining migrants' reluctance to seek healthcare. Our study aims to visualize some of the outcome effects of these barriers by analyzing data on maternal death and comparing the local population and black African migrant women from the South African Development Countries (SADC) living in South Africa. The heightened maternal mortality of black migrant women in South Africa can be associated with the hidden costs of barriers migrants face, including xenophobic attitudes experienced at public healthcare institutions. Methods: Our analysis is based on data on reported causes of death (COD) from the South African Department of Home Affairs (DHA). Statistics South Africa (Stats SA) processed the data further and coded the cause of death (COD) according to the WHO classification of disease, ICD10. The dataset is available on the StatsSA website (http://nesstar.statssa.gov.za:8282/webview/) for research and statistical purposes. The entire dataset consists of over 10 million records and about 50 variables of registered deaths that occurred in the country between 1997 and 2018. For our analysis, we have used data from 2002 to 2015, the years for which information on citizenship is reliably included on the death certificate. Corresponding benchmark data, in which nationality is recorded, exists only for a 10% sample from the population and housing census of 2011. Mid-year population estimates (MYPE) also exist but are not disaggregated by nationality. For this reason, certain estimates of death proportions by nationality will be relative and will not correspond to crude death rates. Results: The total number of female deaths recorded from the years 2002 to 2015 in the country was 3740.761. Of these, 99.09% (n = 3,707,003) were deaths of South Africans and 0.91% (n = 33,758) were deaths of SADC women citizens. For maternal mortality, we considered the total number of deaths recorded for women between the ages of 15 and 49 years of age and were 1,530,495 deaths. Of these, deaths due to pregnancy-related causes contributed to approximately 1% of deaths. South African women contributed to 17,228 maternal deaths and SADC women to 467 maternal deaths during the period under study. The odds ratio for this comparison was 2.02. In other words, our findings show the odds of a black migrant woman from a SADC country dying of a maternal death were more than twice that of a South African woman. This result is statistically significant as this odds ratio, 2.02, falls within the 95% confidence interval (1.82-2.22). Conclusion: The study is the first to examine and compare maternal death among two groups of women, women from SADC countries and South Africa, based on Stats SA data available for the years 2002-2015. This analysis allows for a better understanding of the differential impact that social determinants of health have on mortality among black migrant women in South Africa and considers access to healthcare as a determinant of health. As we examined maternal death, we inferred that the heightened mortality among black migrant women in South Africa was associated with various determinants of health, such as xenophobic attitudes of healthcare workers toward foreigners during the study period. The negative attitudes of healthcare workers toward migrants have been reported in the literature and the media. Yet, until now, its long-term impact on the health of the foreign population has not been gaged. While a direct association between the heightened death of migrant populations and xenophobia cannot be established in this study, we hope to offer evidence that supports the need to focus on the heightened vulnerability of black migrant women in South Africa. As we argued here, the heightened maternal mortality among migrant women can be considered hidden barriers in which health inequality and the pervasive effects of xenophobia perpetuate the health disparity of SADC migrants in South Africa.

The cost of inaction on preconception health in Nigeria: An economic impact analysis.

A growing body of evidence has shown the effects of poor preconception health on adverse pregnancy outcomes and, subsequently, maternal and child morbidity and mortality. However, the cost of poor preconception health remains relatively unexplored. Using the case of Nigeria, this study provides the first estimate of the disease and economic burden of poor preconception health at a country level. Using data from international databases and the scientific literature, the study used a cost-of-illness approach to quantify the foregone productivity and direct healthcare costs resulting from six preconception risk factors (adolescent pregnancy, short birth interval, overweight and obesity, intimate partner violence, female genital mutilation, folate deficiency). The results indicate that 6.7% of maternal deaths, 10.9% of perinatal deaths, and 10.5% of late neonatal deaths were attributable to the selected preconception risk factors in 2020. The economic burden of poor preconception health in Nigeria was estimated at US$ 3.3 billion in 2020, of which over 90% was generated by premature mortality. If prevalence rates remain constant, total economic losses could amount to US$ 46.2 billion by 2035. This analysis paves the way for further studies investigating the economic costs and benefits of preconception interventions and policies in low and middle-income countries.

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

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

Maternal deaths by suicide and drug overdose in two Canadian provinces; retrospective review.

OBJECTIVE: To identify and review factors associated with maternal deaths by suicide and drug overdose in the Canadian Coroner and Medical Examiners Database (CCMED), from 2017-2019. METHODS: We identified potential maternal deaths in Ontario and British Columbia by searching the CCMED narratives of deaths to females 10 to 60 years old for pregnancy-related terms. Identified narratives were then qualitatively reviewed in quadruplicate to determine if they were maternal deaths by suicide or drug overdose, and to extract information on maternal characteristics, the manner of death, and factors associated with each death. RESULTS: Of the 90 deaths identified in this study, 15 (16.7%) were due to suicide and 20 (22.2%) were due to a drug overdose. These deaths occurred to women of varying ages and across the pregnancy-postpartum period. Among the suicides, 10 were by hanging, and among the overdose-related deaths, 15 had fentanyl detected. Notably, 13 (37.1%) of the 35 deaths to suicide or drug overdose occurred beyond 42 days after pregnancy, 19 (54.3%) followed a miscarriage or induced abortion, and in 23 (65.7%) there was an established history of mental health illness. Substance use disorders were documented in 4 of the 15 suicides (26.7%), and 18 of the 20 overdose-related deaths (90.0%). CONCLUSION: Suicide and drug overdose may contribute more to maternal deaths in Canada than previously realized. Programs are needed to identify women at risk of these outcomes, and to intervene during pregnancy and beyond the conventional postpartum period.

Maternal and perinatal health indicators in Brazil over a decade: assessing the impact of the COVID-19 pandemic and SARS-CoV-2 vaccination through interrupted time series analysis.

Background: Few studies have evaluated the effects of the Coronavirus disease 2019 (COVID-19) pandemic, caused by the SARS-CoV-2 virus, on maternal and perinatal health at a populational level. We investigated maternal and perinatal health indicators in Brazil, focusing on the effects of the COVID-19 pandemic, and SARS-CoV-2 vaccination campaign for pregnant women. Methods: Utilizing interrupted time series analysis (January 2013-December 2022), we examined Maternal Mortality Ratio, Perinatal Mortality Rate, Preterm Birth Rate, Cesarean Section Rate, and other five indicators. Interruptions occurred at the pandemic's onset (March 2020) and pregnant women's vaccination (July 2021). Results were expressed as percent changes on time series' level and slope. Findings: The COVID-19 onset led to immediate spikes in Maternal Mortality Ratio (33.37%) and Perinatal Mortality Rate (3.20%) (p < 0.05). From March 2020 to December 2022, Cesarean Section and Preterm Birth Rates exhibited upward trends, growing monthly at 0.13% and 0.23%, respectively (p < 0.05). Post start of SARS-CoV-2 vaccination (July 2021), Maternal Mortality Ratio (-34.10%) and Cesarean Section Rate (-1.87%) promptly declined (p < 0.05). Subsequently, we observed a monthly decrease of Maternal Mortality Ratio (-9.43%) and increase of Cesarean Section Rate (0.25%) (p < 0.05), while Perinatal Mortality Rate and Preterm Birth Rate showed a stationary pattern. Interpretation: The pandemic worsened all analyzed health indicators. Despite improvements in Maternal Mortality Ratio, following the SARS-CoV-2 vaccination campaign for pregnant women, the other indicators continued to sustain altered patterns from the pre-pandemic period. Funding: No funding.

Factors Predicting Completion of Four or More Antenatal Care Visits in Sarlahi District, Nepal.

Background: A significant number of women die from pregnancy and childbirth complications globally, particularly in low- and middle-income countries (LMICs). Receiving at least four antenatal care (ANC) visits may be important in reducing maternal and perinatal deaths. This study investigates factors associated with attending ≥ 4 ANC visits in Sarlahi district of southern Nepal. Methods: A secondary analysis was conducted on data from the Nepal Oil Massage Study (NOMS), a cluster-randomized, community-based longitudinal pregnancy cohort study encompassing 34 Village Development Committees. We quantified the association between receipt/attendance of ≥ 4 ANC visits and socioeconomic, demographic, morbidity, and pregnancy history factors using logistic regression; Generalized Estimating Equations were used to account for multiple pregnancies per woman. Results: All pregnancies resulting in a live birth (n=31,867) were included in the model and 31.4% of those pregnancies received 4+ ANC visits. Significant positive associations include socioeconomic factors such as participation in non-farming occupations for women (OR=1.52, 95% CI: 1.19, 1.93), higher education (OR=1.79, 95% CI: 1.66, 1.93) and wealth quintile OR=1.44, 95% CI: 1.31, 1.59), nutritional status such as non-short stature (OR=1.17, 95% CI: 1.07, 1.27), obstetric history such as adequate interpregnancy interval (OR=1.31, 95% CI: 1.19, 1.45) and prior pregnancy but no live birth (OR=2.14, 95% CI: 1.57, 2.92), symptoms such as vaginal bleeding (OR=1.35, 95% CI:1.11, 1.65) and awareness of the government's conditional cash transfer ANC program (OR=2.26, 95% CI: 2.01, 2.54). Conversely, belonging to the lower Shudra caste (OR=0.56, 95% CI: 0.47, 0.67), maternal age below 18 or above 35 (OR=0.81, 95% CI:0.74, 0.88; OR=0.77, 95% CI: 0.62, 0.96)), preterm birth (OR=0.41, 95% CI: 0.35, 0.49), parity ≥ 1 (OR=0.66, 95% CI: 0.61, 0.72), and the presence of hypertension during pregnancy (OR=0.79, 95% CI: 0.69, 0.90) were associated with decreased likelihood of attending ≥ 4 ANC visits. Conclusions: These findings underscore the importance of continuing and promoting the government's program and increasing awareness among women. Moreover, understanding these factors can guide interventions aimed at encouraging ANC uptake in the most vulnerable groups, subsequently reducing maternal-related adverse outcomes in LMICs. Trial registration: The clinicaltrial.gov trial registration number for NOMS was #NCT01177111. Registration date was August 6th, 2010.

Maternal periodontitis as a risk factor for preterm birth: A cross-sectional study.

Background: Preterm birth is a heterogeneous condition with multiple underlying causes, and periodontal diseases are one of them. Approximately 900000 preterm births are reported in Pakistan each year. Oral infections such as periodontitis during pregnancy are associated with adverse pregnancy outcomes such as low birth weight and preterm births. However, different studies have reported contradictory findings. We conducted a cross-sectional study to assess the association of preterm birth with oral infection in pregnancy. Methods: We conducted a cross-sectional analytical study on 400 postpartum pregnant women in Khyber Teaching Hospital, Peshawar. Only women within the age bracket of 18‒40 years were recruited. Data were collected by an interview-based structured questionnaire. The extent and severity index were used to assess the periodontal health of participants. Frequency tables were generated, and the chi-squared test was used to determine associations between different categorical variables. Results: The mean age of the participants was 25.8±4.9 years. Approximately 87.5% of the women had generalized periodontitis. Approximately 68% of mothers had moderate severity of periodontitis. The extent index showed no notable difference between the preterm and full-term birth groups. In contrast, the severity index displayed a statistically significant difference between the preterm and full-term birth groups. Conclusion: The majority of women had generalized periodontitis. The severity index demonstrated a significant association between maternal periodontitis and preterm births. There was no association between the age of mothers and preterm births. Complications in pregnancy were not associated with preterm births.

Critical Care Services for Pregnant Patients in Ontario: A Province-Wide Survey.

Critically ill pregnant patients require advanced critical care support, but access to these services is variable. We surveyed active Ontario obstetric facilities regarding critical care access. Responses were received from 44 of 80 obstetric units (55%), 13 (30%) being rural. Transport to another facility was required by 59% (majority >1 hour transport time), and differences were noted in the availability of specialty support services such as anesthesia and internal/obstetric medicine, as well as radiology and laboratory facilities, and use of massive transfusion protocols. Training in early supportive care of obstetric complications and optimized facility transport are areas for potential improvement.

Agnostic identification of plasma biomarkers for postpartum hemorrhage risk.

BACKGROUND: Postpartum hemorrhage is difficult to predict, is associated with significant maternal morbidity, and is the leading cause of maternal mortality worldwide. The identification of maternal biomarkers that can predict increased postpartum hemorrhage risk would enhance clinical care and may uncover mechanisms that lead to postpartum hemorrhage. OBJECTIVE: This retrospective case-control study employed agnostic proteomic profiling of maternal plasma samples to identify differentially abundant proteins in controls and postpartum hemorrhage cases. STUDY DESIGN: Maternal plasma samples were procured from a cohort of >60,000 participants in a single institution's perinatal repository. Postpartum hemorrhage was defined as a decrease in hematocrit of ≥10% or receipt of transfusion within 24 hours after delivery. Postpartum hemorrhage cases (n=30) were matched by maternal age and delivery mode (vaginal or cesarean) with controls (n=56). Mass spectrometry was used to identify differentially abundant proteins using integrated peptide peak areas. Statistically significant differences between groups were defined as P<.05 after controlling for multiple comparisons. RESULTS: By study design, cases and controls did not differ in race, ethnicity, gestational age at delivery, blood type, or predelivery platelet count. Cases had slightly but significantly lower predelivery and postdelivery hematocrit and hemoglobin. Mass spectrometry detected 1140 proteins, including 77 proteins for which relative abundance differed significantly between cases and controls (fold change >1.15, P<.05). Of these differentially abundant plasma proteins, most had likely liver or placental origins. Gene ontology term analysis mapped to protein clusters involved in responses to wound healing, stress response, and host immune defense. Significantly differentially abundant proteins with the highest fold change (prostaglandin D2 synthase, periostin, and several serine protease inhibitors) did not correlate with predelivery hematocrit or hemoglobin but identified postpartum hemorrhage cases with logistic regression modeling revealing good-to-excellent area under the operator receiver characteristic curves (0.802-0.874). Incorporating predelivery hemoglobin with these candidate proteins further improved the identification of postpartum hemorrhage cases. CONCLUSION: Agnostic analysis of maternal plasma samples identified differentially abundant proteins in controls and postpartum hemorrhage cases. Several of these proteins are known to participate in biologically plausible pathways for postpartum hemorrhage risk and have potential value for predicting postpartum hemorrhage. These findings identify candidate protein biomarkers for future validation and mechanistic studies.

Persistent inequities in maternal mortality in Latin America and the Caribbean, 1990-2019.

BACKGROUND: Despite the resources and personnel mobilized in Latin America and the Caribbean to reduce the maternal mortality ratio (MMR, maternal deaths per 100 000 live births) in women aged 10-54 years by 75% between 2000 and 2015, the region failed to meet the Millenium Development Goals (MDGs) due to persistent barriers to access quality reproductive, maternal, and neonatal health services. METHODS: Using 1990-2019 data from the Global Burden of Disease project, we carried out a two-stepwise analysis to (a) identify the differences in the MMR temporal patterns and (b) assess its relationship with selected indicators: government health expenditure (GHE), the GHE as percentage of gross domestic product (GDP), the availability of human resources for health (HRH), the coverage of effective interventions to reduce maternal mortality, and the level of economic development of each country. FINDINGS: In the descriptive analysis, we observed a heterogeneous overall reduction of MMR in the region between 1990 and 2019 and heterogeneous overall increases in the GHE, GHE/GDP, and HRH availability. The correlation analysis showed a close, negative, and dependent association of the economic development level between the MMR and GHE per capita, the percentage of GHE to GDP, the availability of HRH, and the coverage of SBA. We observed the lowest MMRs when GHE as a percentage of GDP was close to 3% or about US$400 GHE per capita, HRH availability of 6 doctors, nurses, and midwives per 1,000 inhabitants, and skilled birth attendance levels above 90%. CONCLUSIONS: Within the framework of the Sustainable Development Goals (SDGs) agenda, health policies aimed at the effective reduction of maternal mortality should consider allocating more resources as a necessary but not sufficient condition to achieve the goals and should prioritize the implementation of new forms of care with a gender and rights approach, as well as strengthening actions focused on vulnerable groups.

Postpartum hemorrhage in electronic health records: risk factors at admission and in-hospital occurrence.

Objective: Postpartum hemorrhage (PPH) is the leading cause of maternal death globally. Therefore, prevention strategies have been created. The study aimed to evaluate the occurrence of PPH and its risk factors after implementing a risk stratification at admission in a teaching hospital. Methods: A retrospective cohort involving a database of SISMATER® electronic medical record. Classification in low, medium, or high risk for PPH was performed through data filled out by the obstetrician-assistant. PPH frequency was calculated, compared among these groups and associated with the risk factors. Results: The prevalence of PPH was 6.8%, 131 among 1,936 women. Sixty-eight (51.9%) of them occurred in the high-risk group, 30 (22.9%) in the medium-risk and 33 (25.2%) in the low-risk group. The adjusted-odds ratio (OR) for PPH were analyzed using a confidence interval (95% CI) and was significantly higher in who presented multiple pregnancy (OR 2.88, 95% CI 1.28 to 6.49), active bleeding on admission (OR 6.12, 95% CI 1.20 to 4.65), non-cephalic presentation (OR 2.36, 95% CI 1.20 to 4.65), retained placenta (OR 9.39, 95% CI 2.90 to 30.46) and placental abruption (OR 6.95, 95% CI 2.06 to 23.48). Vaginal delivery figured out as a protective factor (OR 0.58, 95% CI 0.34 to 0.98). Conclusion: Prediction of PPH is still a challenge since its unpredictable factor arrangements. The fact that the analysis did not demonstrate a relationship between risk category and frequency of PPH could be attributable to the efficacy of the strategy: Women classified as "high-risk" received adequate medical care, consequently.

A Tertiary Center Case Series on Postpartum Rectus Sheath Hematoma: An Unveiled Identity.

Rectus sheath hematoma is a well-recognized, uncommon clinical entity and may not be the initial consideration when evaluating a postpartum patient with abdominal pain or mass. Here, we report three cases of postpartum rectus sheath hematomas (RSH) managed during the last three years. The mean age of the patient was 28 (25-30) years. All patients had a history of cesarean section and presented with pain and distension in the abdomen. The cesarean was performed eight days, one day, and three days in cases 1, 2, and 3, respectively, before presentation to the hospital. Two (Cases 1 and 3) of the three patients received conservative care and were discharged in stable condition. One patient (Case 2) who was operated on for RSH and hemoperitoneum expired due to multiorgan dysfunction syndrome (MODS). Our case series suggests that, depending on the severity of the hematoma and the hemodynamic condition of the patient, RSHs may require medical intervention ranging from conservative management to surgical treatment. Early diagnosis and intervention help prevent hazardous complications and prevent maternal morbidity and mortality.

European Board and College of Obstetrics and Gynaecology position statement on maternal mortality surveillance in Europe.

Maternal mortality data and review are important indicators of the effectiveness of maternity healthcare systems and an impetus for action. Recently, a rising incidence of maternal mortality in high income countries has been reported. Various publications have raised concern about data collection methods at country level, as this usually relies mainly on national vital statistics. It is therefore essential that the collected data are complete and accurate and conform to international definitions and disease classification. Accurate data and review can only be truly available when an Enhanced Obstetric Surveillance System is in place. EBCOG calls for action by national societies to work closely with their respective ministries of health to ensure that high quality surveillance systems are in place.

Adverse maternal outcomes and associated factors among mothers of advanced age delivering at a tertiary hospital, southwestern Uganda: a cross-sectional study.

BACKGROUND: Mothers of advanced age, defined as pregnant women aged ≥ 35 years at the time of giving birth, are traditionally known to be associated with increased risks of adverse maternal outcomes. We determined the prevalence of adverse maternal outcomes and associated factors among mothers of advanced age who delivered at Kabale Regional Referral Hospital (KRRH), in Southwestern Uganda. METHODS: We conducted a cross-sectional study at the Maternity Ward of KRRH from April to September 2023. We consecutively enrolled pregnant women aged ≥ 35 years during their immediate post-delivery period and before discharge. We obtained data on their socio-demographic, obstetric, medical characteristics and their maternal outcomes using interviewer-administered questionnaires. We defined adverse maternal outcome as any complication sustained by the mother that was related to pregnancy, delivery and immediate post-partum events (obstructed labour, antepartum haemorrhage, mode of delivery [cesarean or vacuum extraction], postpartum haemorrhage, hypertensive disorders of pregnancy, preterm or postdate pregnancy, anemia, premature rupture of membranes, multiple pregnancy, and maternal death). A participant was considered to have an adverse outcome if they experienced any one of these complications. We identified factors associated with adverse outcomes using modified Poisson regression. RESULTS: Out of 417 participants, most were aged 35-37 years (n = 206; 49.4%), and had parity ≥ 5 (65.5%). The prevalence of adverse maternal outcomes was 37.6% (n = 157, 95%CI: 33.1-42.4%). Common adverse maternal outcomes included caesarian delivery (23%), and obstructed labour (14.4%). Other complications included anemia in pregnancy (4.5%), chorioamnionitis (4.1%), preterm prelabour rupture of membranes (3.9%), and chronic hypertension and preeclampsia (both 2.4%). Factors associated with adverse maternal outcomes were precipitate labour (adjusted prevalence ratio [aPR] = 1.95, 95%CI: 1.44-2.65), prolonged labour, lasting > 12 h (aPR = 2.86, 95%CI: 1.48-3.16), and chronic hypertension (aPR = 2.01, 95%CI: 1.34-3.9). CONCLUSION: Approximately two-fifth of the advanced-aged mothers surveyed had adverse outcomes. Mothers with prolonged labour, precipitate labour and chronic hypertension were more likely to experience adverse outcomes. We recommend implementation of targeted interventions, emphasizing proper management of labor as well as close monitoring of hypertensive mothers, and those with precipitate or prolonged labor, to mitigate risks of adverse outcomes within this study population.

Midwife-led obstetric triage to increase providers' knowledge and improve timeliness of care: A pre and posttest design.

BACKGROUND: Research in low- and middle-income countries has shown that maternal mortality is directly related to inadequate or absent obstetric (OB) triage systems. Standard triage systems and knowledge on triaging for obstetric emergencies are often absent or lacking in most healthcare systems in Liberia. OBJECTIVE: The objective of this research was to address the third delay defined as receiving adequate, quality care when a facility is reached by increasing knowledge through the establishment of a midwife-led, hospital-based OB triage system to stratify care based on risk and imminence of birth and to improve timely assessment at two district referral hospitals. METHODS: A quasi-experimental study design using a pre/post survey was employed for a midwife-led OB triage training course. Using a train-the-trainer model, five midwives were trained as champions, who in turn trained an additional 62 providers. Test results were analyzed with the R statistical software using paired sample t-test and descriptive statistics. RESULTS: Pretest results revealed a knowledge and practice gap among OB providers on key components of the standard triage package. However, post-test mean scores were significantly higher (M = 79.6, SD = 2.32) than pre-test mean scores (M = 59.0, SD = 2.30) for participants following a 2-day training (p = <0.001). DISCUSSION: Following a structured OB triage training, participants showed significant improvement in post-test OB triage scores. CONCLUSION: Standard OB triage protocols incorporated into the policies and procedures of obstetric wards have the potential to improve knowledge and practice, addressing the third delay and reducing preventable, obstetrics-related deaths.

Efficacy and Safety Analyses of Recombinant Factor VIIa in Severe Post-Partum Hemorrhage.

Background: Despite a range of available treatments, it is still sometimes challenging to treat patients with severe post-partum hemorrhage (sPPH). Objective: This study evaluated the efficacy and safety of recombinant activated factor VIIa (rFVIIa) in sPPH management. Methods: An open-label, multi-center, randomized controlled trial (RCT; NCT00370877) and four observational studies (OS; OS-1 (NCT04723979), OS-2, OS-3, and OS-4) were analyzed regarding efficacy (need for subsequent invasive procedures, including uterine compression sutures, uterine or iliac artery ligations, arterial embolization, or hysterectomy) and safety (incidence of thromboembolic events (TE) and maternal mortality) of rFVIIa for sPPH. The RCT, and OS-1 and OS-2, included a control group of women who did not receive rFVIIa (with propensity score-matching used in OS-1 and OS-2), whereas OS-3 and OS-4 provided descriptive data for rFVIIa-exposed women only. Results: A total of 446 women exposed to rFVIIa and 1717 non-exposed controls were included. In the RCT, fewer rFVIIa-exposed women (50% [21/42]) had an invasive procedure versus non-exposed women (91% [38/42]; odds ratio: 0.11; 95% confidence interval: 0.03-0.35). In OS-1, more rFVIIa-exposed women (58% [22/38]) had an invasive procedure versus non-exposed women (35% [13.3/38]; odds ratio: 2.46; 95% confidence interval: 1.06-5.99). In OS-2, 17% (3/18) of rFVIIa-exposed women and 32% (5.6/17.8) of non-exposed women had an invasive procedure (odds ratio: 0.33; 95% confidence interval: 0.03-1.75). Across all included women, TEs occurred in 1.5% (0.2% arterial and 1.2% venous) of rFVIIa-exposed women and 1.6% (0.2% arterial and 1.4% venous) of non-exposed women with available data. Conclusions: The positive treatment effect of rFVIIa on the RCT was not confirmed in the OS. However, the safety analysis did not show any increased incidence of TEs with rFVIIa treatment.

Vacuum-induced tamponade for managing postpartum hemorrhage: a systematic review.

OBJECTIVE: Postpartum hemorrhage is a leading cause of maternal mortality and morbidity around the globe. The novel low-suction vacuum hemorrhage device (VHD) provides an alternative treatment option for cases of postpartum hemorrhage when first-line uterotonic agents fail. This systematic review aims to review current data evaluating the overall efficacy and safety of VHDs in treating postpartum hemorrhage. METHODS: We searched CINAHL Ultimate, Academic Search Premier, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE with Full Text, and PubMed and reference lists of retrieved studies for eligible studies that included outcomes of effectiveness, efficacy, or safety. Two independent reviewers used Covidence.org to screen Titles and Abstracts for 69 studies of which six were included in the analysis. Secondary outcomes measured across studies included time to bleeding control, total device deployment time, and adverse effects. RESULTS: Six nonrandomized trials (N = 1018 participants) included studies conducted in Indonesia, the United States, Switzerland, and Canada. The VHDs were found to have 90% effectiveness in achieving bleeding control across the studies. For most patients, this was achieved in <5 min and required a total device deployment time of 3 h. Reported adverse events were not considered life-threatening, including endometritis in 11 patients and red blood cell transfusions in 38% of patients. CONCLUSION: VHDs have the potential to be used as a rapidly effective means for mechanical intervention of postpartum hemorrhage. The efficacy and safety of VHDs must be further studied at the randomized controlled trial level to determine their clinical usage.