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.

Risk factors for maternal near-miss in an undeveloped province in south-central China, 2012-2022.

OBJECTIVE: To explore the risk factors for maternal near-miss (MNM) using the WHO near-miss approach. METHODS: Data were obtained from the Maternal Near-Miss Surveillance System in Hunan Province, China, 2012-2022. Multivariate logistic regression analysis (method: Forward, Wald, α = 0.05) and adjusted odds ratios (aORs) were used to identify risk factors for MNM. RESULTS: Our study included 780,359 women with 731,185 live births, a total of 2461 (0.32%) MNMs, 777,846 (99.68%) non-MNMs, and 52 (0.006%) maternal deaths were identified. The MNM ratio was 3.37‰ (95%CI: 3.23-3.50). Coagulation/hematological dysfunction was the most common cause of MNM (75.66%). Results of multivariate logistic regression analysis showed risk factors for MNM: maternal age > = 30 years old (aOR > 1, P < 0.05), unmarried women (aOR = 2.21, 95%CI: 1.71-2.85), number of pregnancies > = 2 (aOR > 1, P < 0.05), nulliparity (aOR = 1.51, 95%CI: 1.32-1.72) or parity > = 3 (aOR = 1.95, 95%CI: 1.50-2.55), prenatal examinations < 5 times (aOR = 1.13, 95%CI: 1.01-1.27), and number of cesarean sections was 1 (aOR = 1.83, 95%CI: 1.64-2.04) or > = 2 (aOR = 2.48, 95%CI: 1.99-3.09). CONCLUSION: The MNM ratio was relatively low in Hunan Province. Advanced maternal age, unmarried status, a high number of pregnancies, nulliparity or high parity, a low number of prenatal examinations, and cesarean sections were risk factors for MNM. Our study is essential for improving the quality of maternal health care and preventing MNM.

Individual-level Predictors of Birth Preparedness and Complication Readiness: Urban-Rural Comparison.

INTRODUCTION: Maternal mortality is a major public health problem. Birth preparedness and complication readiness (BP/CR) constitute a veritable strategy for reducing maternal mortality, yet adoption is low with wide urban-rural discrepancies. OBJECTIVES: The objectives of this study were to compare the practice of BP/CR amongst women in rural and urban areas of Rivers State, Nigeria, and determine the individual-level predictors. METHODS: A facility-based cross-sectional comparative study using a multistage sampling method was employed in the selection of 924 (462 urban and 462 rural) women who gave birth within the last 12 months in urban and rural local government areas. Outcome measures were birth preparedness (defined as undergoing antenatal care (ANC) with a skilled birth provider, voluntary counselling and testing for HIV and saving money for childbirth at an agreed place of delivery with a skilled birth attendant) and complication readiness (defined as being knowledgeable about danger signs, identifying decision-maker, a nearest functional institution in case of emergency, emergency means of transport and funds and a suitable blood donor). Bivariate and multivariate analyses were performed at P < 0.05. RESULTS: The proportion of women who were birth prepared was significantly higher amongst women in urban areas (85.9%; 95% confidence interval [CI]: 82.7%-89.1%) versus rural counterparts (56.7%; 95% CI: 52.2%-61.2%), whereas the proportion of complication readiness was significantly higher in rural (31.8%; 95% CI: 27.6%-36.1%) than urban (18.2%; 95% CI: 15.2%-47.8%) groups. Predictors were possession of secondary educational level or higher (adjusted odds ratio [AOR]: 4.9; 95% CI: 1.5-15.5), being employed (AOR: 2.7; 95% CI: 1.5-15.0) and ANC attendance (AOR: 29.2; 95% CI: 8.8-96.9) in urban, whereas amongst the rural, it was ANC attendance (AOR: 20.0; 95% CI: 9.1-43.7). CONCLUSION: In urban areas, more women were birth prepared while fewer women were complication ready compared to the women in rural areas, with predictors such as education, employment and ANC attendance in urban areas and only ANC attendance in rural areas. Measures to promote ANC uptake, maternal education and empowerment could promote BP/CR.

Evaluation of surveillance system and response for maternal and perinatal mortalities in Meda Welabu District, Ethiopia, 2023.

The weekly disease surveillance system (WDSS) serves as a precursor to possible public health emergencies. The Meda Welabu Woreda Bale Zone in Ethiopia has reporting rates of 87% overall timeliness and 88% completeness in 2023, falling short of the 100% objective. Low reporting rates could mean that epidemics in the province are only discovered later. In the Meda Welabu Woreda Bale Zone of Ethiopia, the study was carried out to assess the WDSS maternal and perinatal death surveillance response (MPDSR). Using the most recent Centers for Disease Control (CDC) criteria for assessing public health monitoring systems, we carried out a descriptive cross-sectional analysis. Data from the health workers were gathered through key informant interviews and questionnaires given by the interviewer. Using checklists, the availability of resources was evaluated. Twenty-two health personnel and twelve Health Extension Workers were questioned; of them, 15 (44%) were females. Nurses made up 18 (53%) of the health personnel. Only sixteen (47%) of the respondents were aware of the WDSS goals, compared to thirty-four (53%) who were aware of the deadlines for submitting data to the next level. A total of eight (24%) responders received training in using the WDSS. 26(76%) respondents said they would be willing to continue participating in the WDSS, whereas 6 (18%) respondents said they had analyzed the data from the WDSS. Of the health facilities, seven (50%) reported having issues with the district public health emergency officer. However, low attention to immediately report on maternal and perinatal death (42.9%). It was concluded that the WDSS was adaptable, reasonable, and easy to use. That was erratic and premature, though. We suggest that healthcare professionals in the province receive training on maternal and perinatal death surveillance response. In Meda Welabu Woreda Bale Zone conducted an evaluation in 2023 of the weekly disease surveillance system, maternal and perinatal death surveillance response. Launched in 1998, the system tracks weekly trends of diseases under surveillance to provide an early warning of any dangers to public health, but maternal and perinatal death surveillance were included on 2013. On the other hand, in 2023, the overall completion and timeliness of reports was 88%, falling short of the 100% aim. Low rates of reporting could mean that outbreaks and quality of service in the province were discovered later than expected. Using current centers for disease control criteria and interviewer-administered data, a descriptive cross-sectional study was undertaken.

Extreme weather events and maternal health in low-income and middle-income countries: a scoping review.

BACKGROUND: Despite global efforts to improve maternal health and healthcare, women throughout the world endure poor health during pregnancy. Extreme weather events (EWE) disrupt infrastructure and access to medical services, however little is known about their impact on the health of women during pregnancy in resource-poor settings. OBJECTIVES: This review aims to examine the current literature on the impact of EWE on maternal health to identify the pathways between EWE and maternal health in low-income and middle-income countries to identify gaps. ELIGIBILITY CRITERIA: Studies were eligible for inclusion if they were published before 15 December 2022 and the population of the studies included pregnant and postpartum women (defined at up to 6 weeks postpartum) who were living in low-income and middle-income countries. The exposure of the included study must be related to EWE and the result to maternal health outcomes. SOURCES OF EVIDENCE: We searched the literature using five databases, Medline, Global Health, Embase, Web of Science and CINAHL in December 2022. We assessed the results using predetermined criteria that defined the scope of the population, exposures and outcomes. In total, 15 studies were included. CHARTING METHODS: We identified studies that fit the criteria and extracted key themes. We extracted population demographics and sampling methodologies, assessed the quality of the studies and conducted a narrative synthesis to summarise the key findings. RESULTS: Fifteen studies met the inclusion criteria. The quantitative studies (n=4) and qualitative (n=11) demonstrated an association between EWE and malnutrition, mental health, mortality and access to maternal health services. CONCLUSION: EWE negatively impact maternal health through various mechanisms including access to services, stress and mortality. The results have demonstrated concerning effects, but there is also limited evidence surrounding these broad topics in low-resource settings. Research is necessary to determine the mechanisms by which EWE affect maternal health. PROSPERO REGISTRATION NUMBER: CRD42022352915.

Perinatal mortality, severe maternal morbidity and maternal near miss: protocol of a study integrated with the Birth in Brazil II survey. / Mortalidade perinatal, morbidade materna grave e near miss materno: protocolo de um estudo integrado à pesquisa Nascer no Brasil II.

Brazil presents high maternal and perinatal morbidity and mortality. Cases of severe maternal morbidity, maternal near miss, and perinatal deaths are important health indicators and share the same determinants, being closely related to living conditions and quality of perinatal care. This article aims to present the study protocol to estimate the perinatal mortality rate and the incidence of severe maternal morbidity and maternal near miss in the country, identifying its determinants. Cross-sectional study integrated into the research Birth in Brazil II, conducted from 2021 to 2023. This study will include 155 public, mixed and private maternities, accounting for more than 2,750 births per year, participating in the Birth in Brazil II survey. We will collect retrospective data from maternal and neonatal records of all hospitalizations within a 30-day period in these maternities, applying a screening form to identify cases of maternal morbidity and perinatal deaths. Medical record data of all identified cases will be collected after hospital discharge, using a standardized instrument. Cases of severe maternal morbidity and maternal near miss will be classified based on the definition adopted by the World Health Organization. The perinatal deaths rate and the incidence of severe maternal morbidity and maternal near miss will be estimated. Cases will be compared to controls obtained in the Birth in Brazil II survey, matched by hospital and duration of pregnancy, in order to identify factors associated with negative outcomes. Results are expected to contribute to the knowledge on maternal morbidity and perinatal deaths in Brazil, as well as the development of strategies to improve care.

O Brasil apresenta elevada morbimortalidade materna e perinatal. Casos de morbidade materna grave, near miss materno e óbitos perinatais são indicadores importantes de saúde e compartilham dos mesmos determinantes sociais, tendo estreita relação com as condições de vida e qualidade da assistência perinatal. Este artigo pretende apresentar o protocolo de estudo que visa estimar a taxa de mortalidade perinatal e a incidência de morbidade materna grave e near miss materno no país, assim como identificar seus determinantes. Trata-se de estudo transversal integrado à pesquisa Nascer no Brasil II, realizada entre 2021 e 2023. Serão incluídas neste estudo 155 maternidades públicas, mistas e privadas, com mais de 2.750 partos por ano, participantes do Nascer no Brasil II. Nessas maternidades, será realizada coleta retrospectiva de dados de prontuário materno e neonatal de todas as internações ocorridas num período de 30 dias, com aplicação de uma ficha de triagem para identificação de casos de morbidade materna e de óbito perinatal. Dados de prontuário de todos os casos identificados serão coletados após a alta hospitalar, utilizando instrumento padronizado. Casos de morbidade materna grave e near miss materno serão classificados por meio da definição adotada pela Organização Mundial da Saúde. Será estimada a taxa de mortalidade perinatal e a incidência de morbidade materna grave e near miss materno. Os casos serão comparados a controles obtidos na pesquisa Nascer no Brasil II, pareados por hospital e duração da gestação, visando a identificação de fatores associados aos desfechos negativos. Espera-se que os resultados deste artigo contribuam para o conhecimento sobre a morbidade materna e a mortalidade perinatal no país, bem como para a elaboração de estratégias de melhoria do cuidado.

Brasil tiene una alta morbimortalidad materna y perinatal. Los casos de morbilidad materna severa, maternal near miss y muertes perinatales son importantes indicadores de salud y comparten los mismos determinantes sociales, y tienen una estrecha relación con las condiciones de vida y la calidad de la asistencia perinatal. Este artículo pretende presentar el protocolo de estudio que tiene como objetivo estimar la tasa de mortalidad perinatal y la incidencia de morbilidad materna severa y maternal near miss en el país, así como identificar sus determinantes. Se trata de un estudio transversal integrado a la investigación Nacer en Brasil II, realizada entre el 2021 y el 2023. Este estudio incluirá 155 maternidades públicas, mixtas y privadas, con más de 2.750 partos al año, que participan en el Nacer en Brasil II. En estas maternidades, se realizará una recopilación retrospectiva de datos de las historias clínicas maternas y neonatales de todas las hospitalizaciones ocurridas en un período de 30 días, con la aplicación de un formulario de triaje para identificar casos de morbilidad materna y de muerte perinatal. Los datos de las historias clínicas de todos los casos identificados se recopilarán tras el alta hospitalaria, mediante un instrumento estandarizado. Los casos de morbilidad materna severa y maternal near miss se clasificarán por medio de la definición adoptada por la Organización Mundial de la Salud. Se estimará la tasa de mortalidad perinatal y la incidencia de morbilidad materna severa y maternal near miss. Los casos se compararán con los controles obtenidos en el estudio Nacer en Brasil II, emparejados por hospital y duración del embarazo, para identificar factores asociados con desenlaces negativos. Se espera que los resultados de este artículo contribuyan al conocimiento sobre la morbilidad materna y la mortalidad perinatal en el país, así como a la elaboración de estrategias para mejorar el cuidado.

A novel low-cost uterine balloon tamponade kit to tackle maternal mortality in low-resource settings.

The 3.1 target of the Sustainable Development Goals of the United Nations aims to reduce the global maternal mortality ratio to less than 70 maternal deaths per 100,000 live births by 2030. The last updates on this target show a significant stagnation in the data, thus reducing the chance of meeting it. What makes this negative result even more serious is that these maternal deaths could be avoided through prevention and the wider use of pharmacological strategies and devices to stop postpartum haemorrhage (PPH). PPH is the leading obstetric cause of maternal mortality in low- and middle-income countries (LMICs). Despite low-cost devices based on the uterine balloon tamponade (UBT) technique are already available, they are not safe enough to guarantee the complete stop of the bleeding. When effective, they are too expensive, especially for LMICs. To address this issue, this study presents the design, mechanical characterisation and technology assessment performed to validate a novel low-cost UBT kit, particularly a novel component, i.e., the connector, which guarantees the kit's effectiveness and represents the main novelty. Results proved the device's effectiveness in stopping PPH in a simulated scenario. Moreover, economic and manufacturing evaluations demonstrated its potential to be adopted in LMICs.

Factors associated with the occurrence of maternal deaths in the West Region between 2020 - 2022: case control study.

WHO defines maternal mortality as any death of a woman occurring during pregnancy or within 42 days of its termination or after delivery. Our aim was to study the factors associated with the occurrence of maternal deaths in the West Region of Cameroon between 2020 and 2022. This was a case-control study. Cases consisted of maternal deaths that occurred during the study period. The controls for their part were made up of women who normally gave birth in the same health facilities from which the cases came and during the same period as the cases. The only exposure criterion being the status of death. The data useful for our investigation were collected respectively with the investigation sheets, audit reports and via interviews with the heads of the health facilities where the maternal deaths occurred with a view to considerably reducing information bias. Analysis were done with IBM-SPSS 25 and RStudio 2023.03.0. The West Region of Cameroon recorded 161 maternal deaths between 2020 and 2022. 67% of them were housewives. The most frequently identified causes were haemorrhage (ante-, per- and post-partum), followed far behind by complications and sepsis, with respective 42.2%, 12.4% and 10.6%. Slightly more than one child out of 10 had an abnormal presentation. Nearly 50% had a short labor (less than 10 hours), the partograph was used in 38% of the women, and the GATP practiced in 50.1% of them. Abnormal presentation of the fetus (aOR = 2.7 (95% CI: 1.4 - 5.1), p=0.002), failure to use the partograph (aOR = 4.4 (95% CI: 2 .6 - 7.4), p<0.001), the fact of not having an economic activity (aOR = 1.7 (95% CI: 1.0 - 2.7), p = 0.033), the fact of having taken less than 2 doses of VAT ( aOR = 2.8 (95% CI: 1.8 - 4.4), p<0.001) and the absence of practice of GATP (aOR = 1.6 (CI 95%: 1.0 - 2.6), p=0.040) were identified as factors that significantly favored the occurrence of maternal deaths. Several factors negatively influence the occurrence of maternal deaths in the West Region. Operational strategies such as continuous training of maternity ward staff, and the establishment of systematic maternal death audits and review meetings should be implemented to reduce and control these risk factors.

Obstetric risk profiles and causes of death: Estimating their association with cesarean sections among maternal deaths in Mexico.

BACKGROUND: Maternal mortality is a critical indicator of healthcare quality, and in Mexico, this has become increasingly concerning due to the stagnation in its decline, alongside a concurrent increase in cesarean section (C-section) rates. This study characterizes maternal deaths in Mexico, focusing on estimating the association between obstetric risk profiles, cause of death, and mode of delivery. METHODS: Utilizing a retrospective observational design, 4,561 maternal deaths in Mexico from 2010-2014 were analyzed. Data were sourced from the Deliberate Search and Reclassification of Maternal Deaths database, alongside other national databases. An algorithm was developed to extract the Robson Ten Group Classification System from clinical summaries text, facilitating a nuanced analysis of C-section rates. Information on the reasons for the performance of a C-section was also obtained. Logistic regression and multinomial logistic regression models were used to estimate the relation between obstetric risk factors, mode of delivery and causes of maternal death, adjusting for covariates. RESULTS: Among maternal deaths in Mexico from 2010-2014, 47.1% underwent a C-section, with a significant history of previous C-sections observed in 31.4% of these cases, compared to 17.4% for vaginal deliveries (p<0.001). Early prenatal care in the first trimester was more common in C-section cases (46.8%) than in vaginal deliveries (38.3%, p<0.001). A stark contrast was noted in the place of death, with 82.4% of post-C-section deaths occurring in public institutions versus 69.1% following vaginal births. According to Robson's classification, the highest C-section rates were in Group 4 (67.2%, p<0.001) and Group 8 (66.9%, p<0.001). Logistic regression analysis revealed no significant difference in the odds of receiving a C-section in private versus other settings after adjusting for Robson criteria (OR: 1.21; 95% CI: 0.92, 1.60). A prior C-section significantly increased the likelihood of another (OR: 2.38; CI 95%: 2.01, 2.81). The analysis also indicated C-sections were significantly tied to deaths from hypertensive disorders (RRR = 1.25, 95% CI [1.12, 1.40]). In terms of indications, 6.3% of C-sections were performed under inadequate indications, while the indication was not identifiable in 33.1% of all C-sections. CONCLUSIONS: This study highlights a significant overuse of C-sections among maternal deaths in Mexico (2010-2014), revealed through the Robson classification and ana analysis of the reported indications for the procedure. It underscores the need for revising clinical decision-making to promote evidence-based guidelines and favor vaginal deliveries when possible. High C-section rates, especially noted disparities between private and public sectors, suggest economic and non-clinical factors may be at play. The importance of accurate data systems and further research with control groups to understand C-section practices' impact on maternal health is emphasized.

Validating the indicator "maternal death review coverage" to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record data.

BACKGROUND: Understanding causes and contributors to maternal mortality is critical from a quality improvement perspective to inform decision making and monitor progress toward ending preventable maternal mortality. The indicator "maternal death review coverage" is defined as the percentage of maternal deaths occurring in a facility that are audited. Both the numerator and denominator of this indicator are subject to misclassification errors, underreporting, and bias. This study assessed the validity of the indicator by examining both its numerator-the number and quality of death reviews-and denominator-the number of facility-based maternal deaths and comparing estimates of the indicator obtained from facility- versus district-level data. METHODS AND FINDINGS: We collected data on the number of maternal deaths and content of death reviews from all health facilities serving as birthing sites in 12 districts in three countries: Argentina, Ghana, and India. Additional data were extracted from health management information systems on the number and dates of maternal deaths and maternal death reviews reported from health facilities to the district-level. We tabulated the percentage of facility deaths with evidence of a review, the percentage of reviews that met the World Health Organization defined standard for maternal and perinatal death surveillance and response. Results were stratified by sociodemographic characteristics of women and facility location and type. We compared these estimates to that obtained using district-level data. and looked at evidence of the review at the district/provincial level. Study teams reviewed facility records at 34 facilities in Argentina, 51 facilities in Ghana, and 282 facilities in India. In total, we found 17 deaths in Argentina, 14 deaths in Ghana, and 58 deaths in India evidenced at facilities. Overall, >80% of deaths had evidence of a review at facilities. In India, a much lower percentage of deaths occurring at secondary-level facilities (61.1%) had evidence of a review compared to deaths in tertiary-level facilities (92.1%). In all three countries, only about half of deaths in each country had complete reviews: 58.8% (n = 10) in Argentina, 57.2% (n = 8) in Ghana, and 41.1% (n = 24) in India. Dramatic reductions in indicator value were seen in several subnational geographic areas, including Gonda and Meerut in India and Sunyani in Ghana. For example, in Gonda only three of the 18 reviews conducted at facilities met the definitional standard (16.7%), which caused the value of the indicator to decrease from 81.8% to 13.6%. Stratification by women's sociodemographic factors suggested systematic differences in completeness of reviews by women's age, place of residence, and timing of death. CONCLUSIONS: Our study assessed the validity of an important indicator for ending preventable deaths: the coverage of reviews of maternal deaths occurring in facilities in three study settings. We found discrepancies in deaths recorded at facilities and those reported to districts from facilities. Further, few maternal death reviews met global quality standards for completeness. The value of the calculated indicator masked inaccuracies in counts of both deaths and reviews and gave no indication of completeness, thus undermining the ultimate utility of the measure in achieving an accurate measure of coverage.

Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India.

INTRODUCTION: India's progress in reducing maternal and neonatal mortality since the 1990s was faster than the regional average. We systematically analysed how national health policies, services for maternal and newborn health, and socioeconomic contextual changes, drove these mortality reductions. METHODS: The study's mixed-methods design integrated quantitative trend analyses of mortality, intervention coverage and equity since the 1990s, using the sample registration system and national surveys, with interpretive understandings from policy documents and 13 key informant interviews. RESULTS: India's maternal mortality ratio (MMR) declined from 412 to 103 maternal deaths per 100 000 live births between 1997-1998 and 2017-2019. The neonatal mortality rate (NMR) declined from 46 to 22 per 1000 live births between 1997 and 2019. The average annual rate of mortality reduction increased over time. During this period, coverage of any antenatal care (57%-94%), quality antenatal care (37%-85%) and institutional delivery (34%-90%) increased, as did caesarean section rates among the poorest tertile (2%-9%); these coverage gains occurred primarily in the government (public) sector. The fastest rates for increasing coverage occurred during 2005-2012.The 2005-2012 National Rural Health Mission (which became the National Health Mission in 2012) catalysed bureaucratic innovations, additional resources, pro-poor commitments and accountability. These efforts occurred alongside smaller family sizes and improvements in macroeconomic growth, mobile and road networks, women's empowerment, and nutrition. These together reduced high-risk births and improved healthcare access, particularly among the poor. CONCLUSION: Rapid reduction in NMR and MMR in India was accompanied by increased coverage of maternal and newborn health interventions. Government programmes strengthened public sector services, thereby expanding the reach of these interventions. Simultaneously, socioeconomic and demographic shifts led to fewer high-risk births. The study's integrated methodology is relevant for generating comprehensive knowledge to advance universal health coverage.

Effective multi-sectoral approach for rapid reduction in maternal and neonatal mortality: the exceptional case of Bangladesh.

BACKGROUND: Bangladesh experienced impressive reductions in maternal and neonatal mortality over the past several decades with annual rates of decline surpassing 4% since 2000. We comprehensively assessed health system and non-health factors that drove Bangladesh's success in mortality reduction. METHODS: We operationalised a comprehensive conceptual framework and analysed available household surveys for trends and inequalities in mortality, intervention coverage and quality of care. These include 12 household surveys totalling over 1.3 million births in the 15 years preceding the surveys. Literature and desk reviews permitted a reconstruction of policy and programme development and financing since 1990. These were supplemented with key informant interviews to understand implementation decisions and strategies. RESULTS: Bangladesh prioritised early population policies to manage its rapidly growing population through community-based family planning programmes initiated in mid-1970s. These were followed in the 1990s and 2000s by priority to increase access to health facilities leading to rapid increases in facility delivery, intervention coverage and access to emergency obstetric care, with large contribution from private facilities. A decentralised health system organisation, from communities to the central level, openness to private for-profit sector growth, and efficient financing allocation to maternal and newborn health enabled rapid progress. Other critical levers included poverty reduction, women empowerment, rural development, and culture of data generation and use. However, recent empirical data suggest a slowing down of mortality reductions. CONCLUSION: Bangladesh demonstrated effective multi-sectoral approach and persistent programming, testing and implementation to achieve rapid gains in maternal and neonatal mortality reduction. The slowing down of recent mortality trends suggests that the country will need to revise its strategies to achieve the Sustainable Development Goals. As fertility reached replacement level, further gains in maternal and neonatal mortality will require prioritising universal access to quality facility delivery, and addressing inequalities, including reaching the rural poor.

Learning from success: the main drivers of the maternal and newborn health transition in seven positive-outlier countries and implications for future policies and programmes.

Currently, about 8% of deaths worldwide are maternal or neonatal deaths, or stillbirths. Maternal and neonatal mortality have been a focus of the Millenium Development Goals and the Sustainable Development Goals, and mortality levels have improved since the 1990s. We aim to answer two questions: What were the key drivers of maternal and neonatal mortality reductions seen in seven positive-outlier countries from 2000 to the present? How generalisable are the findings?We identified positive-outlier countries with respect to maternal and neonatal mortality reduction since 2000. We selected seven, and synthesised experience to assess the contribution of the health sector to the mortality reduction, including the roles of access, uptake and quality of services, and of health system strengthening. We explored the wider context by examining the contribution of fertility declines, and the roles of socioeconomic and human development, particularly as they affected service use, the health system and fertility. We analysed government levers, namely policies and programmes implemented, investments in data and evidence, and political commitment and financing, and we examined international inputs. We contextualised these within a mortality transition framework.We found that strategies evolved over time as the contacts women and neonates had with health services increased. The seven countries tended to align with global recommendations but could be distinguished in that they moved progressively towards implementing their goals and in scaling-up services, rather than merely adopting policies. Strategies differed by phase in the transition framework-one size did not fit all.

Learning from Ethiopia's success in reducing maternal and neonatal mortality through a health systems lens.

BACKGROUND: This study aimed to enhance insights into the key characteristics of maternal and neonatal mortality declines in Ethiopia, conducted as part of a seven-country study on Maternal and Newborn Health (MNH) Exemplars. METHODS: We synthesised key indicators for 2000, 2010 and 2020 and contextualised those with typical country values in a global five-phase model for a maternal, stillbirth and neonatal mortality transition. We reviewed health system changes relevant to MNH over the period 2000-2020, focusing on governance, financing, workforce and infrastructure, and assessed trends in mortality, service coverage and systems by region. We analysed data from five national surveys, health facility assessments, global estimates and government databases and reports on health policies, infrastructure and workforce. RESULTS: Ethiopia progressed from the highest mortality phase to the third phase, accompanied by typical changes in terms of fertility decline and health system strengthening, especially health infrastructure and workforce. For health coverage and financing indicators, Ethiopia progressed but remained lower than typical in the transition model. Maternal and neonatal mortality declines and intervention coverage increases were greater after 2010 than during 2000-2010. Similar patterns were observed in most regions of Ethiopia, though regional gaps persisted for many indicators. Ethiopia's progress is characterised by a well-coordinated and government-led system prioritising first maternal and later neonatal health, resulting major increases in access to services by improving infrastructure and workforce from 2008, combined with widespread community actions to generate service demand. CONCLUSION: Ethiopia has achieved one of the fastest declines in mortality in sub-Saharan Africa, with major intervention coverage increases, especially from 2010. Starting from a weak health infrastructure and low coverage, Ethiopia's comprehensive approach provides valuable lessons for other low-income countries. Major increases towards universal coverage of interventions, including emergency care, are critical to further reduce mortality and advance the mortality transition.

Challenges in reducing maternal and neonatal mortality in Niger: an in-depth case study.

INTRODUCTION: Recent modelled estimates suggest that Niger made progress in maternal mortality since 2000. However, neonatal mortality has not declined since 2012 and maternal mortality estimates were based on limited data. We researched the drivers of progress and challenges. METHODS: We reviewed two decades of health policies, analysed mortality trends from United Nations data and six national household surveys between 1998 and 2021 and assessed coverage and inequalities of maternal and newborn health indicators. Quality of care was evaluated from health facility surveys in 2015 and 2019 and emergency obstetric assessments in 2011 and 2017. We determined the impact of intervention coverage on maternal and neonatal lives saved between 2000 and 2020. We interviewed 31 key informants to understand the factors underpinning policy implementation. RESULTS: Empirical maternal mortality ratio declined from 709 to 520 per 100 000 live births during 2000-2011, while neonatal mortality rate declined from 46 to 23 per 1000 live births during 2000-2012 then increased to 43 in 2018. Inequalities in neonatal mortality were reduced across socioeconomic and demographic strata. Key maternal and newborn health indicators improved over 2000-2012, except for caesarean sections, although the overall levels were low. Interventions delivered during childbirth saved most maternal and newborn lives. Progress came from health centre expansion, emergency care and the 2006 fee exemptions policy. During the past decade, challenges included expansion of emergency care, continued high fertility, security issues, financing and health workforce. Social determinants saw minimal change. CONCLUSIONS: Niger reduced maternal and neonatal mortality during 2000-2012, but progress has stalled. Further reductions require strategies targeting comprehensive care, referrals, quality of care, fertility reduction, social determinants and improved security nationwide.

Increased utilisation and quality: a focus on inequality and a learning health system approach-explaining Nepal's success in reducing maternal and newborn mortality 2000-2020.

INTRODUCTION: Maternal mortality in Nepal dropped from 553 to 186 per 100 000 live births during 2000-2017 (66% decline). Neonatal mortality dropped from 40 to 21 per 1000 live births during 2000-2018 (48% decline). Stillbirths dropped from 28 to 18 per 1000 births during 2000-2019 (34% decline). Nepal outperformed other countries in these mortality improvements when adjusted for economic growth, making Nepal a 'success'. Our study describes mechanisms which contributed to these achievements. METHODS: A mixed-method case study was used to identify drivers of mortality decline. Methods used included a literature review, key-informant interviews, focus-group discussions, secondary analysis of datasets, and validation workshops. RESULTS: Despite geographical challenges and periods of political instability, Nepal massively increased the percentage of women delivering in health facilities with skilled birth attendance between 2000 and 2019. Although challenges remain, there was also evidence in improved quality and equity-of-access to antenatal care and childbirth services. The study found policymaking and implementation processes were adaptive, evidence-informed, made use of data and research, and involved participants inside and outside government. There was a consistent focus on reducing inequalities. CONCLUSION: Policies and programmes Nepal implemented between 2000 and 2020 to improve maternal and newborn health outcomes were not unique. In this paper, we argue that Nepal was able to move rapidly from stage 2 to stage 3 in the mortality transition framework not because of what they did, but how they did it. Despite its achievements, Nepal still faces many challenges in ensuring equal access to quality-care for all women and newborns.

A tale of two exemplars: the maternal and newborn mortality transitions of two state clusters in India.

BACKGROUND: India's progress in reducing maternal and newborn mortality since the 1990s has been exemplary across diverse contexts. This paper examines progress in two state clusters: higher mortality states (HMS) with lower per capita income and lower mortality states (LMS) with higher per capita income. METHODS: We characterised state clusters' progress in five characteristics of a mortality transition model (mortality levels, causes, health intervention coverage/equity, fertility and socioeconomic development) and examined health policy and systems changes. We conducted quantitative trend analyses, and qualitative document review, interviews and discussions with national and state experts. RESULTS: Both clusters reduced maternal and neonatal mortality by over two-thirds and half respectively during 2000-2018. Neonatal deaths declined in HMS most on days 3-27, and in LMS on days 0-2. From 2005 to 2018, HMS improved coverage of antenatal care with contents (ANCq), institutional delivery and postnatal care (PNC) by over three-fold. In LMS, ANCq, institutional delivery and PNC rose by 1.4-fold. C-sections among the poorest increased from 1.5% to 7.1% in HMS and 5.6% to 19.4% in LMS.Fewer high-risk births (to mothers <18 or 36+ years, birth interval <2 years, birth order 3+) contributed 15% and 6% to neonatal mortality decline in HMS and LMS, respectively. Socioeconomic development improved in both clusters between 2005 and 2021; HMS saw more rapid increases than LMS in women's literacy (1.5-fold), household electricity (by 2-fold), improved sanitation (3.2-fold) and telephone access (6-fold).India's National (Rural) Health Mission's financial and administrative flexibility allowed states to tailor health system reforms. HMS expanded public health resources and financial schemes, while LMS further improved care at hospitals and among the poorest. CONCLUSION: Two state clusters in India progressed in different mortality transitions, with efforts to maximise coverage at increasingly advanced levels of healthcare, alongside socioeconomic improvements. The transition model characterises progress and guides further advances in maternal and newborn survival.