Thirty Years of United Nations Inter-Agency Working Group's Global, Regional, and National Maternal Mortality Estimates Revisited.

Over the last three decades, the United Nations interagency working group series of model-based maternal mortality estimation showed a significant reduction in maternal mortality ratio (MMR) at global, regional, and national levels. However, the contribution of sub-Saharan Africa for the global maternal deaths in 2020 was nearly two-fold higher than before, and the top five countries with high burden of maternal deaths remained unchanged after four decades. In this commentary, we argue that not all countries with high maternal deaths had high MMR; the lower MMR was noted as shadowing the large number of maternal deaths in countries with high rates of total births. We critically appraised the changes and challenges in maternal mortality measurements. We recommend the use of multiple indicators and categorizing the absolute number of maternal deaths to assess individual countries' maternal health status. As the majority of maternal deaths are preventable and all maternal deaths are catastrophic to the family, estimating the absolute number of maternal deaths should be given equal weight in future research undertakings.

Political Ideology Direction of Policy Agendas and Maternal Mortality Outcomes in the U.S., 1915-2007.

OBJECTIVES: The causes for persistently high and increasing maternal mortality rates in the United States have been elusive. METHODS: We use the shift in the ideological direction of the Republican and the Democratic parties in the 1960s, to test the hypothesis that fluctuations in overall and race-specific maternal mortality rates (MMR) follow the power shifts between the parties before and after the Political Realignment (PR) of the 1960s. RESULTS: Using time-series data analysis methods, we find that, net of trend, overall and race-specific MMRs were higher under Democratic administrations than Republican ones before the PR (1915-1965)-i.e., when the Democratic Party was a protector of the Jim Crow system. This pattern, however, changed after the PR (1966-2007), with Republican administrations underperforming Democratic ones-i.e., during the period when the Republican Party shifted toward a more economically and socially conservative agenda. The pre-post PR partisan shifts in MMRs were larger for Black (9.5%, p < . 01 ) relative to White mothers (7.4%, p < . 05 ) during the study period. CONCLUSIONS FOR PRACTICE: These findings imply that parties and the ideological direction of their agendas substantively affect the social determinants of maternal health and produce politized health outcomes.

Prenatal hypertension as the risk of eclampsia, HELLP syndrome, and critical obstetric hemorrhage.

Critical bleeding is a common cause of maternal mortality in obstetric patients. However, the non-obstetric factors underlying critical obstetric bleeding remain uncertain. Therefore, this study aimed to clarify the impact of chronic hypertension on obstetric hemorrhage by evaluating a nationwide administrative database in Japan. Women who gave birth between 2018 and 2022 were enrolled. The primary outcome was critical hemorrhage requiring massive red blood cell (RBC) transfusion during childbirth. In total, 354, 299 eligible women were selected from the database. The maternal mortality rate was >1.0% among those who received a massive RBC transfusion (≥4000 cc), and this amount was used as the cutoff of the outcome. Critical hemorrhage was less frequent with elective Caesarean section (CS) compared with vaginal childbirth or emergent CS (odds ratio [OR], 0.38; 95% confidence interval, 0.30-0.47). Multiple logistic regression analysis adjusting for these obstetric risks revealed that a higher maternal age (adjusted OR [aOR] per 1 year, 1.07 [1.05-1.09]); oral medications with prednisolone (aOR, 2.5 [1.4-4.4]), anti-coagulants (aOR, 10 [5.4-19]), and anti-platelets (aOR, 2.9 [1.3-6.4]); and a prenatal history of hypertension (aOR, 2.5 [1.5-4.4]) and hypoproteinemia (aOR, 5.8 [1.7-20]) are the risks underlying critical obstetric hemorrhage. Prenatal history of hypertension was significantly associated with obstetric disseminated intravascular coagulation (OR, 1.9 [1.5-2.4]); Hemolysis, Elevated Liver enzymes, and Low platelet count (HELLP) syndrome (OR, 3.3 [2.7-4.2]); and eclampsia (OR, 6.1 [4.6-8.1]). In conclusion, a maternal prenatal history of hypertension is associated with the development of HELLP syndrome, eclampsia, and resultant critical hemorrhage. The incidence of HELLP syndrome and eclampsia increased more than fivefold in the presence of prenatal hypertension. However, the likelihood of subsequently developing DIC or experiencing critical bleeding did not change by the presence of prenatal hypertension.

Analysis of maternal mortality in Berlin, Germany - discrepancy between reported maternal mortality and comprehensive death certificate exploration.

OBJECTIVES: The Organisation for Economic Cooperation and Development (OECD) estimates an average maternal mortality rate (MMR) of around 3.4 maternal deaths per 100,000 live births for 2019-2021, based on relevant diagnoses on death certificates. However, Germany does not currently have a registry for recording the number of maternal deaths. The aim of this study is to identify the actual number of maternal deaths in Berlin between 2019 and 2022, as well as sources of underreporting and causes of death. METHODS: Potential maternal mortality cases were identified through a search at the Berlin Central Archive for Death Certificates, inquiring women aged 15-50 years with indications of present or recent pregnancy on the death certificate. To cross match the database, an additional search at the Charité University Hospital Berlin was carried out, checking each individual file for pregnancy-association. RESULTS: The data search resulted in 2,316 women, 18 of which presented an association to pregnancy. Of these, 12 could be classified as maternal mortality cases (MMR 7.8/100,000). The additional search in a university setting revealed two further maternal mortality cases without prior indication of pregnancy on the death certificate. This results in a total MMR of 9.1/100,000 live births, which is over double the official estimate by the OECD. CONCLUSIONS: Based on our findings in Berlin, it can be estimated that there is significant underreporting regarding maternal death cases in Germany. A more comprehensive recording system is needed to more accurately portray maternal mortality.

Trends, influencing factors and prediction analysis of under-five and maternal mortality rates in China from 1991 to 2020.

Introduction: Under-five mortality rate (U5MR) and maternal mortality rate (MMR) are important indicators for evaluating the quality of perinatal health and child health services in a country or region, and are research priorities for promoting maternal and infant safety and maternal and child health. This paper aimed to analysis and predict the trends of U5MR and MMR in China, to explore the impact of social health services and economic factors on U5MR and MMR, and to provide a basis for relevant departments to formulate relevant policies and measures. Methods: The JoinPoint regression model was established to conduct time trend analysis and describe the trend of neonatal mortality rate (NMR), infant mortality rate (IMR), U5MR and MMR in China from 1991 to 2020. The linear mixed effect model was used to assess the fixed effects of maternal health care services and socioeconomic factors on U5MR and MMR were explored, with year as a random effect to minimize the effect of collinearity. Auto regressive integrated moving average models (ARIMA) were built to predict U5MR and MMR from 2021 to 2025. Results: The NMR, IMR, U5MR and MMR from 1991 to 2020 in China among national, urban and rural areas showed continuous downward trends. The NMR, IMR, U5MR and MMR were significantly negatively correlated with gross domestic product (GDP), the proportion of the total health expenditure (THE) to GDP, system management rate, prenatal care rate, post-natal visit rate and hospital delivery rate. The predicted values of national U5MR from 2021 to 2025 were 7.3 ‰, 7.2 ‰, 7.1 ‰, 7.1 ‰ and 7.2 ‰ and the predicted values of national MMR were 13.8/100000, 12.1/100000, 10.6/100000, 9.6/100000 and 8.3/100000. Conclusion: China has made great achievements in reducing the U5MR and MMR. It is necessary for achieving the goals of Healthy China 2030 by promoting the equalization of basic public health services and further optimizing the allocation of government health resources. China's experience in reducing U5MR and MMR can be used as a reference for developing countries to realize the SDGs.

Trends, Projections, and Regional Disparities of Maternal Mortality in Africa (1990-2030): An ARIMA Forecasting Approach.

With the United Nations Sustainable Development Goals (SDG) (2015-2030) focused on the reduction in maternal mortality, monitoring and forecasting maternal mortality rates (MMRs) in regions like Africa is crucial for health strategy planning by policymakers, international organizations, and NGOs. We collected maternal mortality rates per 100,000 births from the World Bank database between 1990 and 2015. Joinpoint regression was applied to assess trends, and the autoregressive integrated moving average (ARIMA) model was used on 1990-2015 data to forecast the MMRs for the next 15 years. We also used the Holt method and the machine-learning Prophet Forecasting Model. The study found a decline in MMRs in Africa with an average annual percentage change (APC) of -2.6% (95% CI -2.7; -2.5). North Africa reported the lowest MMR, while East Africa experienced the sharpest decline. The region-specific ARIMA models predict that the maternal mortality rate (MMR) in 2030 will vary across regions, ranging from 161 deaths per 100,000 births in North Africa to 302 deaths per 100,000 births in Central Africa, averaging 182 per 100,000 births for the continent. Despite the observed decreasing trend in maternal mortality rate (MMR), the MMR in Africa remains relatively high. The results indicate that MMR in Africa will continue to decrease by 2030. However, no region of Africa will likely reach the SDG target.

Maternal Mortality in Africa: Regional Trends (2000-2017).

BACKGROUND: United Nations Sustainable Development Goals state that by 2030, the global maternal mortality rate (MMR) should be lower than 70 per 100,000 live births. MMR is still one of Africa's leading causes of death among women. The leading causes of maternal mortality in Africa are hemorrhage and eclampsia. This research aims to study regional trends in maternal mortality (MM) in Africa. METHODS: We extracted data for maternal mortality rates per 100,000 births from the United Nations Children's Fund (UNICEF) databank from 2000 to 2017, 2017 being the last date available. Joinpoint regression was used to study the trends and estimate the annual percent change (APC). RESULTS: Maternal mortality has decreased in Africa over the study period by an average APC of -3.0% (95% CI -2.9; -3,2%). All regions showed significant downward trends, with the greatest decreases in the South. Only the North African region is close to the United Nations' sustainable development goals for Maternal mortality. The remaining Sub-Saharan African regions are still far from achieving the goals. CONCLUSIONS: Maternal mortality has decreased in Africa, especially in the South African region. The only region close to the United Nations' target is the North African region. The remaining Sub-Saharan African regions are still far from achieving the goals. The West African region needs more extraordinary efforts to achieve the goals of the United Nations. Policies should ensure that all pregnant women have antenatal visits and give birth in a health facility staffed by specialized personnel.

Maternal mortality and its prominence in the Syrian Arab Republic: Challenges, efforts, and recommendations.

WHO has brought to light how the Maternal Mortality Ratio is alarmingly high in countries like Syria because women lack basic necessities such as access to proper healthcare, resources, and information. With the ongoing war, COVID-19 pandemic, and other resultant factors are converging to further exacerbate Syria's current collapsing situation. Leading to an increasing number of maternal mortality cases, with the country's economy and its disparities making it nearly impossible for Syria to recover. In the wake of these problems piling up, Syria requires immediate preventative measure to be put into place to avoid further crises complications, and mortalities.

Prevalence of high-risk pregnancy among pregnant women enrolled under Pradhan Mantri Surakshit Matritva Abhiyan in government health facilities of district Etawah, Uttar Pradesh: A cross-sectional study.

Background: According to the Sample Registration System report, India has reduced the maternal mortality rate from 130 per 100,000 live births in 2014-2016 to 113 per 100,000 live births in 2016-2018. The main purpose of antenatal care is to identify "high-risk" cases as early as possible from a large group of antenatal mothers and provide them skilled and appropriate care. Objective: To determine the prevalence of high-risk pregnancy (HRP) in pregnant females availing services under pradhan mantri surakshit matritva abhiyan (PMSMA) and to assess awareness of pregnant mothers about services provided under PMSMA in district Etawah of Uttar Pradesh. Material and Methods: Community-based cross-sectional study was carried out among 400 female beneficiaries who were registered under the PMSMA scheme and delivered their baby at any government health facility during one year of study period. Results: It was observed that from all the antenatal women visiting the community health center for HRP day under the PMSMA scheme, 162 (40.5%) were categorized as HRPs and 238 (59.6%) of them were nonhigh-risk pregnancies. A statistically significant association was observed (P-value = 0.005 at 95% CI) between the difference in the proportion of HRPs and the educational status of the pregnant mothers. Out of 400 beneficiaries, 167 (41.75%) were aware of the PMSMA scheme. Conclusion: Regular antenatal care (ANC) check-ups, early identification of HRP, health education, and timely screening are needed to reduce maternal mortality.

Achieving effectiveness of antenatal outcomes: A qualitative study in Mutasa district, Zimbabwe.

Achieving the effectiveness of antenatal outcomes depends on the utilization of antenatal care services. The purpose of the study was to explore the utilization of antenatal care in Mutasa District, Zimbabwe. A qualitative research approach using explorative and descriptive design was utilized. Purposive and snowball sampling techniques were used to sample pregnant women and women whose children were under the age of one year. In-depth interviews were conducted using the Shona language. Data were analyzed using thematic content analysis where themes and sub-themes emerged; namely; factors influencing the perceptions of women on antenatal care services uptake. We certify that all applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during this research. Multiple obstacles to adherence were identified, including a low level of education, low socio-demographic factors such as age, low income, distance traveled to the clinic, high parity, and acceptability of antenatal care by rural women. Awareness should be made by the Zimbabwean Ministry of Health and Child Care through better education of the target groups such as young mothers, people from low socio-economic groups, and childbearing women for better utilization.

Geographically weighted bivariate zero inflated generalized Poisson regression model and its application.

This study discusses the development of Zero Inflated Generalized Poisson Regression (ZIGPR) with two response variables, that is Bivariate ZIGPR (BZIGPR). The extension of the ZIGPR model by considering spatial factor called Geographically Weighted Zero Inflated Generalized Poisson Regression (GWBZIGPR). The GWBZIGPR produces a local parameter estimator for each location of observation. The parameter estimation using the Maximum Likelihood Estimation (MLE) method obtained an equation that did not closed-form so that the numerical iteration of Berndt Hall Hall Hausman (BHHH) is used. The data used in this study are the number of pregnant maternal mortality and postpartum maternal mortality data in 91 sub-districts in Pekalongan Residency, Central Java Province. The results showed that the Akaike Information Criterion Corrected (AICc) value in the GWBZIGPR model is smaller than BZIGPR, so it means that the GWBZIGPR is better than the BZIGPR for modeling the number of pregnant maternal mortality and postpartum maternal mortality in Pekalongan Residency. The results of this study will assist local governments in anticipating the causes of maternal mortality.

Management of reproductive health in patients with pulmonary hypertension.

Pulmonary hypertension is characterized by elevated pulmonary artery pressure caused by several clinical conditions that affect pulmonary vasculature. Morbidity and death in this condition are related to the development of right ventricular failure. Normal physiologic changes that occur in pregnancy to support the growing fetus can pose hemodynamic challenges to the pregnant patient with pulmonary hypertension that results in increased morbidity and mortality rates. Current guidelines recommend that patients with known pulmonary hypertension be counseled against pregnancy. This review aims to provide clinicians with guidelines for preconception counseling, medication management, and delivery planning.

Cultural Factors Contributing to Maternal Mortality Rate in Rural Villages of Limpopo Province, South Africa.

INTRODUCTION: The understanding of the link between cultural affairs and maternal health is critical to save the lives of women. The South African maternal mortality rate (MMR) target for 2015 was 38/100,000 live births. In 2017, South Africa had 1,222 maternal deaths. The purpose was to determine the perceived cultural factors contributing to MMR in rural villages in Mopani District. METHODS: This qualitative research and non-probability purposive sampling was used to select participants who met the inclusion criteria. Thirty women, age 40 years and above childbearing age, who had given birth in their lifetime, were sampled. Data were collected through in-depth individual interviews at the women's homes. Probing to elicit more information was conducted focusing on hemorrhage, hypertension and risk of contracting human immunodeficiency virus (HIV). Data were analyzed through open coding methods. Trustworthiness was ensured by Guba and Lincoln's criteria, credibility, dependability, confirmability, and transferability. RESULTS: From the study three themes emerged from the data as cultural factors relating to heavy, red post-delivery bleeding perceived as cleaning-out of the womb. With hypertension, gaining weight rapidly before the 20th week of gestation not reported as a pregnancy was still culturally concealed. Contracting HIV, women were exposed to unsafe sex practices due to cultural expectations of having children as a sign of femininity. DISCUSSION: The formulation of culture congruent interventions to promote good and acceptable cultural practices that cannot harm the physical and mental status of women was recommended to reduce unplanned deaths among them.

Leaving half the population behind-the continued fight to cover America's mothers: a call to action.

For the last century, healthcare coverage in the United States has been a debated topic. The passage of the Social Security Act Amendments and the Patient Protection and Affordable Care Act has improved the available coverage of vulnerable populations, but access to healthcare is still fraught with barriers. This is particularly true for women in the postpartum period. It is widely accepted that the postpartum period is the optimal time to address health issues that developed during pregnancy or predated pregnancy. With more than half of maternal deaths occurring in the year after a birth and disproportionately affecting women of color, the postpartum time period is critical. The United States is the only industrialized country with a rising maternal mortality rate and therefore must take advantage of the 12 months postpartum, or "fourth trimester," to aid in addressing this national health crisis. As an incentivized provision, most states have expanded Medicaid since the signing of the Patient Protection and Affordable Care Act. However, pregnancy-related coverage still ceases after 60 days postpartum. Although states can apply for a waiver to extend this coverage, this process is unnecessarily laborious. The time has far passed for the federal government to act. Presently, there are numerous pieces of legislation before Congress to provide Medicaid coverage for pregnant patients through 365 days postpartum. Insurance coverage alone will not reverse the rising maternal mortality rate in this country, but it is a crucial first step.

Trends and causes of maternal mortality in a tertiary care hospital over five years: 2013-2017.

BACKGROUND AND OBJECTIVE: Maternal death measurement is essential to a country's wellbeing and development status. In emerging countries like Pakistan, it remains an intimidating and failed public health challenge. Objectives of our audit were to estimate trends and causes of maternal demise in Lady Reading Hospital, Peshawar, Pakistan. METHODS: Between January 2013 to December 2017, a retrospective study was carried out at Medical Teaching Institute, Lady Reading Hospital, Peshawar. A structured proforma was used to collect data from the medical records. To detect trends in mother demise maternal mortality ratio was calculated for each year and for all five years, Spss version 23 was used for data analysis. RESULTS: In the five-year periods 134 deaths were recorded. The maternal mortality during the study period was 431/100,000 live births. An unstable trend in mortality with two crowning periods in 2013 and 2017 was observed. Hemorrhage persisted as the foremost cause of maternal death over the five years period, accounting for 47.76% deaths followed by hypertension, accounting for 25.37% deaths. An increased risk of 35.08% was observed among women aged 25-29 years, followed by 26.11% in 20-24 years and 23.88% in >30 years. CONCLUSION: There is a decreasing trend of maternal death from 2013 to 2016 but a slight increase was noted in 2017. Hemorrhage was the top cause responsible for the maternal death.

Addressing Maternal Mortality in Selected Districts of Madhya Pradesh, India - A Human Rights-based Approach.

BACKGROUND: Maternal mortality is an indicator of state of maternal health services, status of women, women's health, and above all developments of nation. OBJECTIVES: The objectives of the study were to identify the patterns and causes, medical as well as sociocultural, of maternal death as well as consider and list out the rights realization perspective of the mothers, their immediate families and the community at large. MATERIALS AND METHODS: A cross-sectional study was conducted in three districts of Madhya Pradesh, India, for 1 year. One hundred and two maternal deaths were covered, and verbal autopsy was conducted. Human right perspective was assessed using questionnaire. RESULTS: Majority (64.7%) of maternal deaths occurred between 18 and 25 years of age. About 50.9% were primigravida, and postpartum hemorrhage was the most common cause. Nearly 53.9% had visited more than one facility before death. CONCLUSION: Poor antenatal care and lack of human resources posed major reasons for death in all facilities. Rights realization among the beneficiaries was found to be very poor.

Optimal profile limits for maternal mortality rate (MMR) in South Sudan.

BACKGROUND: Reducing Maternal Mortality Rate (MMR) is considered by the international community as one of the eight Millennium Development Goals. Based on previous studies, Skilled Assistant at Birth (SAB), General Fertility Rate (GFR) and Gross Domestic Product (GDP) have been identified as the most significant predictors of MMR in South Sudan. This paper aims for the first time to develop profile limits for the MMR in terms of significant predictors SAB, GFR, and GDP. The paper provides the optimal values of SAB and GFR for a given MMR level. METHODS: Logarithmic multi- regression model is used to model MMR in terms of SAB, GFR and GDP. Data from 1986 to 2015 collected from Juba Teaching Hospital was used to develop the model for predicting MMR. Optimization procedures are deployed to attain the optimal level of SAB and GFR for a given MMR level. MATLAB was used to conduct the optimization procedures. The optimized values were then used to develop lower and upper profile limits for yearly MMR, SAB and GFR. RESULTS: The statistical analysis shows that increasing SAB by 1.22% per year would decrease MMR by 1.4% (95% CI (0.4-5%)) decreasing GFR by 1.22% per year would decrease MMR by 1.8% (95% CI (0.5-6.26%)). The results also indicate that to achieve the UN recommended MMR levels of minimum 70 and maximum 140 by 2030, the government should simultaneously reduce GFR from the current value of 175 to 97 and 75, increase SAB from the current value of 19 to 50 and 76. CONCLUSIONS: This study for the first time has deployed optimization procedures to develop lower and upper yearly profile limits for maternal mortality rate targeting the UN recommended lower and upper MMR levels by 2030. The MMR profile limits have been accompanied by the profile limits for optimal yearly values of SAB and GFR levels. Having the optimal level of predictors that significantly influence the maternal mortality rate can effectively aid the government and international organizations to make informed evidence-based decisions on resources allocation and intervention plans to reduce the risk of maternal death.

Disparities in health system input between minority and non-minority counties and their effects on maternal mortality in Sichuan province of western China.

BACKGROUND: The maternal mortality rate (MMR) markedly decreased in China, but there has been a significant imbalance among different geographic regions (east, central and west regions), and the mortality in the western region remains high. This study aims to examine how much disparity in the health system and MMR between ethnic minority and non-minority counties exists in Sichuan province of western China and measures conceivable commitments of the health system determinants of the disparity in MMR. METHODS: The MMR and health system data of 67 minority and 116 non-minority counties were taken from Sichuan provincial official sources. The 2-level Poisson regression model was used to identify health system determinants. A series of nested models with different health system factors were fitted to decide contribution of each factor to the disparity in MMR. RESULTS: The MMR decreased over the last decade, with the fastest declining rate from 2006 to 2010. The minority counties experienced higher raw MMR in 2002 than non-minority counties (94.4 VS. 58.2), which still remained higher in 2014 (35.7 VS. 14.3), but the disparity of raw MMR between minority and non-minority counties decreased from 36.2 to 21.4. The better socio-economic condition, more health human resources and higher maternal health care services rate were associated with lower MMR. Hospital delivery rate alone explained 74.5% of the difference in MMR between minority and non-minority counties. All health system indicators together explained 97.6% of the ethnic difference in MMR, 59.8% in the change trend, and 66.3% county level variation respectively. CONCLUSIONS: Hospital delivery rate mainly determined disparity in MMR between minority and non-minority counties in Sichuan province. Increasing hospital birth rates among ethnic minority counties may narrow the disparity in MMR by more than two-thirds of the current level.

Amniotic fluid embolism mortality rate.

AIM: The objective of this study was to determine the mortality rate of amniotic fluid embolism (AFE) using population-based studies and case series. METHODS: A literature search was conducted using the two key words: 'amniotic fluid embolism (AFE)' AND 'mortality rate'. Thirteen population-based studies were evaluated, as well as 36 case series including at least two patients. RESULTS: The mortality rate from population-based studies varied from 11% to 44%. When nine population-based studies with over 17 000 000 live births were aggregated, the maternal mortality rate was 20.4%. In contrast, the mortality rate of AFE in case series varies from 0% to 100% with numerous rates in between. CONCLUSION: The AFE mortality rate in population-based studies varied from 11% to 44% with the best available evidence supporting an overall mortality rate of 20.4%. Data from case series should no longer be used as a basis for describing the lethality of AFE.

Recommendations for saving mothers' lives in Japan: Report from the Maternal Death Exploratory Committee (2010-2014).

To make recommendations for saving mothers' lives, issues related to maternal deaths including diseases, causes, treatments, and hospital and regional systems are analyzed by the Maternal Death Exploratory Committee in Japan. In this report, we present ten clinical important recommendations based on the analysis of maternal deaths between 2010 and 2014 in Japan.