Impact of social determinants of health on progression from potentially life-threatening complications to near miss events and death during pregnancy and post partum in a middle-income setting: an observational study.

OBJECTIVE: To assess the potential associations between social determinants of health (SDH) and severe maternal outcomes (SMO), to better understand the social structural framework and the contributory, non-clinical mechanisms associated with SMO. STUDY DESIGN: Prospective observational study. STUDY SETTING: Tertiary referral centre in south-eastern region of India. PARTICIPANTS: One thousand and thirty-three women with potentially life-threatening complications (PLTC) were identified using WHO criteria. RISK FACTORS ASSESSED: Social Determinants of Health (SDH). PRIMARY OUTCOMES: Severe maternal outcomes, which include maternal near-miss and maternal death. STATISTICAL ANALYSIS: Logistic regression to assess the association between SDH and clinical factors on SMO, expressed as adjusted ORs (aOR) with a 95% CI. RESULTS: Of the 37 590 live births, 1833 (4.9%) sustained PLTC, and 380 (20.7%) developed SMO. Risk of SMO was higher with increasing maternal age (adjusted OR (aOR) 1.04 (95% CI 1.01 to 1.07)), multiparity (aOR 1.44 (1.10 to 1.90)), medical comorbidities (aOR 1.50 (1.11 to 2.02)), obstetric haemorrhage (aOR 4.63 (3.10 to 6.91)), infection (aOR 2.93 (1.83 to 4.70)), delays in seeking care (aOR 3.30 (2.08 to 5.23)), and admissions following a referral (aOR 2.95 (2.21 to 3.93)). SMO was lower in patients from socially backward community (aOR 0.45 (0.33 to 0.61)), those staying more than 10 km from hospital (aOR 0.56 (0.36 to 0.78)), those attending at least four antenatal visits (aOR=0.53 (0.36 to 0.78)) and those referred from resource-limited facilities (aOR=0.62 (0.46 to 0.84)). CONCLUSION: This study demonstrates the independent contribution of SDH to SMO among those sustaining PLTC in a middle-income setting, highlighting the need to formulate preventive strategies beyond clinical considerations.

[Maternal mortality due to obstetric haemorrhage in France 2016-2018]. / Mortalité maternelle par hémorragie obstétricale en France 2016­2018.

Between 2016 and 2018, 20 maternal deaths were related to obstetric haemorrhage, excluding haemorrhage in the first trimester of pregnancy, representing a mortality ratio of 0.87 per 100,000 live births (95% CI 0.5 -1.3). Obstetric haemorrhage is the cause of 7.4% of all maternal deaths up to 1 year, 10% of maternal deaths within 42days, and 21% of deaths directly related to pregnancy (direct causes). Between 2001 and 2018, maternal mortality from obstetric haemorrhage has been considerably reduced, from 2.2deaths per 100,000 live births in 2001-2003 to 0.87 in the period presented here. Nevertheless, obstetric haemorrhage is still one of the main direct causes of maternal death, and remains the cause with the highest proportion of deaths considered probably (53%) or possibly (42%) preventable according to the CNEMM's collegial assessment (see chapter 3). The preventable factors reported are related to inadequate content of care in 94% of cases and/or organisation of care in 44% of cases. In this triennium, maternal death due to haemorrhage occurred mainly in the context of caesarean delivery (65% of cases, i.e. 13/20), and mostly in the context of emergency care (12/13). The main causes of obstetric haemorrhage were uterine rupture (6/20) in unscarred uterus or in association with placenta accreta, and surgical injury during the caesarean delivery (5/20). Every maternity hospital, whatever its resources and/or technical facilities, must be able to plan any obstetric haemorrhage situation that threatens the mother's vital prognosis. Intraperitoneal occult haemorrhage following caesarean section and uterine rupture require immediate surgery with the help of skilled surgeon resources with early and appropriate administration of blood products.

[Maternal mortality by stroke in France 2016-2018]. / Mortalité maternelle par accident vasculaire cérébral en France 2016­2018.

Between 2016 and 2018, twenty maternal deaths were associated with a stroke. The 20 deaths whose main cause was stroke represent 7.4% of all maternal deaths, i.e. a maternal mortality ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3). Among the 20 stroke deaths, it was hemorrhagic in 17 cases (85%), ischemic in 2 cases, and due to thrombophlebitis in 1 case. Stroke occurred during pregnancy in 8 women (40%) - one case before 12 weeks, 3 cases between 28 and 32 weeks, and 4 cases between 34 and 40 weeks; in 3 cases the stroke occurred intrapartum, and for the other 9 cases (45%) the stroke occurred postpartum between Day 1 and Day 15. Care was assessed as non-optimal in 10/19 (56%) of cases but mortality as possibly avoidable in 24% of cases (4/17 cases with conclusion established by the CNEMM) and not established in two cases. The potentially improvable elements identified were a delay in carrying out initial brain imaging in three cases (one case antepartum, two cases postpartum) and insufficient hemodynamic monitoring in intensive care in one case.

[Maternal mortality due to cardiovascular diseases in France 2016-2018]. / Mortalité maternelle par pathologies cardiovasculaires en France 2016­2018.

Between 2016 and 2018, cardiovascular diseases were responsible for 41 deaths, making it the leading cause of maternal death within 42 days postpartum in France. The maternal mortality ratio (MMR) for cardiovascular disease is 1.8 per 100,000 NV, a non-significant increase compared with the 2013-2015 triennium (MMR of 1.5 per 100,000 NV). Deaths from cardiac causes accounted for the majority (n=28), with 26 deaths secondary to cardiac disease aggravated by pregnancy (indirect deaths) and 2 deaths related to peripartum cardiomyopathy (direct deaths). Deaths from vascular causes (n=13) corresponded to 9 aortic dissections and 4 ruptures of large vessels, including 3 ruptures of the splenic artery. Preventability of death (possible or probable) was found in 56% of cases compared with 66% in the previous triennium. Care was considered sub-optimal in 57% of cases, down from 72% in the 2013-2015 triennium. In women with known cardiovascular disease, the areas for improvement concern multidisciplinary follow-up, repeated assessment of the cardiovascular risk (WHO grade) and early referral to an expert centre (expert cardiologists, obstetricians, anaesthetists and intensive care). In all pregnant women or women who have recently given birth, a cardiovascular etiology should be considered in the presence of suggestive symptoms (dyspnea, chest or abdominal pain). Ultrasound "point of care" examination (fluid effusions, cardiac dysfunction) and cardiac enzymes assay can help in the diagnosis. Finally, the woman must be involved in her own care.

[Maternal mortality in France, 2016-2018, frequency, causes and women's profile]. / Mortalité maternelle en France, 2016­2018, fréquence, causes et profil des femmes.

OBJECTIVE: To describe, for the 2016-2018 period, the frequency, causes and risk factors of maternal deaths in France. METHOD: Data from the National Confidential Enquiry into Maternal Deaths for 2016-2018. RESULTS: For 2016-2018, 272 maternal deaths occurred in France up to 1 year after the end of pregnancy, i.e a maternal mortality ratio of 11.8 per 100,000 live births (95 % CI 10.4-13.3), and 8.5 (IC 95 % 7.4-9.8) for maternal mortality up to 42 days. Compared to women aged 20-24, the risk of maternal death is multiplied by 2.6 for women aged 35-39, by 5 for women aged 40 and over. Obese women are twice as frequent among maternal deaths (26 %) than in the general population of parturients (11 %). There are territorial disparities -the maternal mortality ratio in the French overseas departments is 2 times higher than in metropolitan France (significant difference but smaller than in 2013-2015)-, and social disparities -the mortality of migrant women remains higher than that of women born in France, particularly for women born in sub-Saharan Africa whose risk is 3 times higher than that of native women. One in three women who died (34 %) had socio-economic vulnerability versus 22 % in the overall population of parturients. Among causes of maternal deaths, the predominant role of psychiatric conditions (mostly suicides) is confirmed for the period 2016-2018, leading cause of maternal mortality considered up to 1 year (17 %), MMR of 1.9/100,000 NV. i.e. approximately one death from psychiatric causes every 3 weeks. Cardiovascular diseases are the second leading cause of maternal mortality up to one year (14 %) and the leading cause up to 42 days (16 %), with 1.3 deaths per 100,000 NV. Amniotic fluid embolism ranks as the third cause (8 %) (2nd cause, 11 %, for MM limited to 42 days), i.e. MMR of 0.9 per 100,000 NV. After a regular decline over the last decade, maternal mortality from obstetric hemorrhage is at a stable level compared to the previous triennium 2013-2015, MMR of 0.9/100,000 NV, i.e 5th cause of MM up to one year (7 %) and 4th cause of MM up to 42 days. CONCLUSION: The overall national maternal mortality ratio does not show a downward trend, even with constant surveillance method. Territorial inequalities persist but change in their magnitude and in the regions concerned. The profile of the causes of maternal mortality up to one year of the pregnancy end shows the leading role of suicides and cardiovascular diseases, which illustrates that the health of pregnant women or those who have recently given birth is not limited to the obstetric domain, and highlights the importance of multidisciplinarity in the management and organization of care for women in this period.

[National confidential enquiry into maternal deaths in France, a 25-year enhanced surveillance system, essential for the reliable characterization of maternal deaths]. / Enquête Nationale Confidentielle sur les Morts Maternelles en France, un système de surveillance améliorée depuis 25 ans, indispensable pour la caractérisation fiable des décès maternels.

Although maternal mortality is rare in wealthy countries, it remains a fundamental indicator of maternal health. It is considered to be a "sentinel event", the occurrence of which indicates dysfunctions, often cumulative, in the healthcare system. In addition to the classic epidemiological surveillance findings - number of deaths, maternal mortality ratio, distribution of medical causes, sub-groups of women at risk - its study, through a precise analysis of the history of each woman who died, enables to highlight areas for improvement in the content or organisation of care, the correction of which will make it possible to prevent not only deaths but also upstream morbid events involving the same mechanisms. To achieve this dual epidemiological and clinical audit objective, an ad hoc "enhanced" system is needed. France has had such a system since 1996, the Enquête Nationale Confidentielle sur la Mortalité Maternelle (ENCMM), under the joint supervision of Santé Publique France and Inserm. The ENCMM method aims to identify maternal deaths exhaustively and reliably up to 1 year after the end of pregnancy, and to document each death as fully as possible. The 1st step is the multi-source identification (direct declaration, death certificates, linkage with birth certificates, hospital stay database) of women who died during pregnancy or in the year following its end. The 2nd step is the collection of detailed information for each death by a pair of clinical assessors. The 3rd step is the review of these anonymised documents by the National Expert Committee on Maternal Mortality, which establishes the maternal nature of the death (causal link with pregnancy) and, with a stated aim of improvement rather than judgement, assesses the adequacy of care and the preventability of the death. The summary of the information gathered for maternal deaths in the 2016-2018 period is presented in the other articles of this special issue.

[Maternal deaths and management by emergency departments in France 2016-2018]. / Mortalité maternelle et prise en charge par les services d'urgence en France 2016­2018.

In France, 272 maternal deaths occurred during the period 2016-2018, of which 131 were initially treated by healthcare professionals not specialized in obstetric. Fifty-six files were excluded because they did not concern emergency services or because there was insufficient data to allow analysis. Seventy-five cases of maternal deaths initially treated by emergency services (in-hospital emergency department [ED] or emergency medical ambulance [SAMU]) were analyzed. Fifty-six cases were treated by the SAMU and 22 by an ED (both in 3 cases). The causes of death were 20 cardiovascular events, 18 pulmonary embolisms, 9 neurological failures and 8 hemorrhagic shocks. The event occurred during pregnancy in 48 cases (64%) and during per or postpartum period in 27 cases (36%). The motivations for consultation at the ED were mainly pain (n=9), respiratory distress (n=6) or faintness (n=3). The reasons for calling emergency dispatching service (SAMU) were cardiorespiratory arrest in 32 cases (57%) and neurological failure (coma or status epilepticus) in 6 cases (11%). Among the 56 patients treated outside the hospital, 17 died on scene and 39 were transported to a resuscitation room (n=13), a specialized department (n=13), an obstetrics department (n=8) and less often in the ED (n=2). This was considered appropriate in 35 out of 39 cases (90%). Concerning the 75 files analyzed (ED and SAMU), death was considered unavoidable in 37 cases (49%) and potentially avoidable in 29 cases (38%) (maybe=23, probably=6). Avoidability could not be established in 9 cases. Among the 29 potentially avoidable deaths (38%), one of the criteria of avoidability concerned emergency services in 14 cases (ED=9, SAMU/SMUR=5, 18% of the files studied). ED's cares were considered optimal in 11 cases (50%) and non-optimal in 11 cases (50%). SAMU's cares were considered optimal in 45 cases (80%).

[Maternal mortality due to Amniotic Fluid Embolism in France 2016-2018]. / Mortalité maternelle par embolie amniotique en France 2016­2018.

Amniotic embolism remains the 3rd leading cause of maternal death in France, with 21 maternal deaths over the 2016-2018 triennium. The women who died were more likely to be obese (25%), to benefit from induction of labor (71%) and be cared in a maternity hospital <1500 deliveries/year (45%), compared with the reference population (ENP 2016). The symptom occurred mainly during labor (95%) and the course was rapid, with a symptom-to-fatality interval of 4hours 45minutes (min: 25minutes - max: 8 days). Preventability was proposed for 35% of the deaths assessed, with areas for improvement identified in terms of technical skills (haemostasis procedures, management of polytransfusion), non-technical skills (communication) and health care organization (human resources, vital emergency plan, wide access to PSL). An autopsy was performed in 38% of deaths.

[Maternal mortality due to hypertensive disorders in France, 2016-2018]. / Mortalité maternelle par complications hypertensives en France, 2016­2018.

Between 2016 and 2018, 13 maternal deaths were due to hypertensive disorders. During this period, the maternal mortality ratio was 0.6/100 000 live births. Hypertensive disorders were responsible for 4.8% of maternal deaths during the first year, 5.1% up to 42 days postpartum and for 13.5% of direct maternal mortality. Maternal deaths due to hypertensive disorders increased close to signification (p=0.09) compared to the last triennium (MMR=0.2/100.000). Classification of the hypertensive disorders was: 5 severe preeclampsia, 3 eclampsia, 4 HELLP syndromes et 1 undefined hypertension. In five cases, a stroke was associated. Mode of delivery was a cesarean section when the hypertensive disorder started before the labour (8/13, 62%). Six women were older than 35years old and 5/12 were nulliparous. Among the 12 cases where place of birth was known, 5 were born foreigners. BMI was over 30 for 46%. Medical care were estimated non optimal in 11/13 of the cases. Among these deaths, 66% (8/12) seemed to be preventable versus 82% for the last period 2013-2015. The main causal factor of suboptimal management was inappropriate management by the obstetrical or anesthetist/intensive care squads, respectively: 3 lack of diagnosis, 8 delays for diagnosis and 5 underestimated severity. Four cases corresponded to inappropriate health care organization. This study offers the opportunity to stress major points to optimize medical management and health care organization facing hypertensive disorders during pregnancy.

[Maternal mortality due to venous thromboembolism in France 2016-2018]. / Mortalité maternelle par thromboembolie veineuse en France 2016­2018.

Pregnancy and the post-partum period represent a thromboembolic risk situation, with pulmonary embolism (PE) remaining one of the leading causes of direct maternal deaths in developed countries. Between 2016 and 2018 in France, twenty maternal deaths were caused by venous thromboembolic complications (VTE), yielding a Maternal Mortality Ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3), with no change compared to the periods 2013-2015 or 2010-2012. Among these 20 deaths, 1 death was related to cerebral thrombophlebitis, and the remaining 19 were due to PE. Regarding the timing of death, 2 deaths occurred after an early termination of pregnancy, 40% (8/20) during an ongoing pregnancy, and 50% (10/20) in the post-partum period. Among the 20 VTE deaths, 20% (4/20) occurred outside of a healthcare facility (at home or in a public place). Among the nineteen cases with documented BMI, seven women had obesity (37%), three times more than in the population of parturients in France (11.8%, ENP 2016). Among the nineteen PE deaths and the case of cerebral thrombophlebitis, eleven were considered preventable, six possibly preventable (35%), two probably preventable (12%), and three preventability undetermined. The identified preventability factors were inadequate care and the patient's failure to interact with the healthcare system. From the case analysis, areas for improvement were identified, including insufficient consideration of major and minor risk factors, the early initiation of appropriate prophylactic treatment, and the absence of fibrinolysis in cases of s refractory cardiac arrest due to suspected PE.

[Indirect causes of maternal deaths (except stroke, cardiovascular diseases and infections) in France 2016-2018]. / Mortalité maternelle de causes indirectes (hors AVC, maladies cardiovasculaires et infections) en France 2016­2018.

Maternal deaths from indirect obstetric cause result from a preexisting condition or a condition that occurred during pregnancy without obstetric causes but was aggravated by the physiological effects of pregnancy. Twenty-nine deaths with an indirect cause related to a preexisting condition, excluding circulatory diseases or infections, were analysed by the expert committee. Pre-pregnancy pathology was documented in 16 women (epilepsy, n=7; amyloid angiopathy, n=1; Dandy-Walker syndrome, n=1; autoimmune diseases, n=3; diffuse infiltrative pneumonitis, n=1; thrombotic thrombocytopenic purpura, n=1; ovarian cancer in fragile X, n=1; major sickle cell disease, n=1). In 13 women, the pathology was unknown before pregnancy (breast cancer, n=9, epilepsy diagnosed during pregnancy, n=1, brain tumours, n=2 meningioma type, macrophagic activation syndrome, n=1). Death was associated with neoplastic or tumour pathology in 13 women (45%). At the same time, epilepsy was responsible for the death of 8 women (27%), making it the most common cause of death. For both neoplasia and epilepsy, about 50% of deaths were preventable, mainly due to undiagnosed and/or delayed treatment in the case of cancer and failure to monitor or adjust treatment in the case of epilepsy. Pre-conception counselling is therefore strongly recommended if a woman has a known chronic medical condition prior to pregnancy. Finally, if there is a family history of breast cancer, a breast examination is strongly recommended from the first visit during pregnancy, and any breast lumps should be investigated as soon as possible to avoid delaying appropriate treatment.

[Maternal mortality among socially vulnerable women in France 2016-2018]. / Mortalité maternelle chez les femmes avec vulnérabilité sociale en France 2016­2018.

Social vulnerability is a known factor in perinatal medical risk, both for the foetus and the mother. As part of the French confidential enquiry into maternal deaths, the introduction in 2015 of specific items relating to social status has made it possible to recreate this composite variable. Over the period 2016-2018, one woman in three who died was in a situation of social vulnerability. Of these 79 deaths, 32 (41%) were related to direct obstetric causes, 26 (33%) to indirect obstetric causes, 12 (15%) to suicides and 8 (10%) of unknown cause. Care was considered sub-optimal in 73% of cases, compared with 64% in the group of maternal deaths with no identified social vulnerability. 43 deaths were judged to be probably (n=12) or possibly (n=31) avoidable, 25 were not avoidable, and 11 were not sufficiently documented for this assessment; i.e. a proportion of 63% of probable or possible avoidability, a higher proportion compared with the 56% of avoidability among women with no identified social vulnerability. In 1/3 of maternal deaths, a lack of interaction between the woman and the healthcare system was involved in the chain of events leading to death, i.e. 2 times more than in the case of socially non-vulnerable women. Improving the interaction of women in socially vulnerable situations with the hospital system and the institutional and voluntary networks providing care, support and assistance is a priority. A specific, responsive medical and social organisation could contribute to this.

[Maternal mortality due to genital tract infection in France, 2016-2018]. / Mortalité maternelle par infection à porte d'entrée génitale en France 2016­2018.

Over the 2016-2018 period, maternal mortality due to direct infectious causes accounted for 13% of maternal deaths by direct causes. The increasing trend in genital-tract infections related-deaths noted in the 2013-2015 report continues for the 2016-2018 period, but this 2010-2018 increase remains at the limit of statistical significance given the low number of cases (p 0.08). The 13 deaths from direct infectious causes for the 2016-2018 period were due to 4 cases of puerperal toxic shock syndrome (Streptococcus A beta hemolyticus or Clostridium group bacilli), 6 sepsis caused by intrauterine infection due to E. Coli and 3 cases of septic shock from intrauterine origin and no documented bacteria. In this 2016-2018 triennium, the quality of care concerning women who died of direct infections was considered non-optimal in 85% (11/13). Death was considered possibly or probably avoidable in 9/13 cases (69%), which made it one of the most avoidable causes of maternal mortality. Preventable factors related to the medical management were the most frequent (9/13), with in particular a diagnostic failure or delayed diagnosis leading to a delay in the introduction of medical treatment. The others contributory factors to these deaths were related to the organization of healthcare (delayed transfer, lack of communication between practitioners) as well as factors related to patient social and/or mental vulnerability.

[Maternal mortality due to suicide and other psychiatric causes in France 2016-2018]. / Mortalité maternelle par suicide et autres causes psychiatriques en France 2016­2018.

This report, covering the period 2016-2018, confirms that psychiatric causes (largely dominated by suicides) are the leading cause of maternal mortality up to 1year after childbirth, a finding already made in the previous 2013-2015 report. There were 47 deaths from psychiatric causes in 3years, including 45 maternal suicides, giving a maternal mortality ratio (MMR) of 2.1 per 100,000 live births (NV) (95% CI: 1.4-2.6). The median time to suicide was 138days postpartum. This group represents 17.3% (16.5% for suicides) of all maternal deaths for the period. Maternal suicide is linked to an interaction of several risk factors, including a history of personal and family psychiatric disorders not always known to the obstetric team (53% of women), socioeconomic disparities (29% present social vulnerability, and 14% domestic violence), stressful events, and inadequate access to healthcare services. Psychiatric causes are among those in which the proportion of sub-optimal care and preventable deaths, i.e. 79% of cases, are the highest. An analysis of all the women who died in France of psychiatric causes during pregnancy reveals a number of recurring elements that point to the need for improvement, both in terms of the quality and organization of care, and in terms of women's interaction with the healthcare system. Screening for a history of psychiatric disorders and ongoing psychiatric pathologies must be carried out systematically at all stages of pregnancy and postpartum by all those involved, with communication with future parents on the not inconsiderable risk of perinatal depression. Finally, it is important to develop an adapted and graduated response across the country, according to resources, and to strengthen city-hospital collaboration and training for all those involved.

[Maternal mortality, adequation of care and preventability, France 2016-2018]. / Mortalité maternelle, adéquation des soins et évitabilité, France 2016­2018.

OBJECTIVE: To describe, for the 2016-2018 period, the adequacy of care provided to women who died of maternal death in France, as well as the possible preventability of these deaths. METHOD: National data from the Enquête Nationale Confidentielle sur les Morts Maternelles for 2016-2018. For each maternal death identified, the National Expert Committee on Maternal Mortality (CNEMM) assesses the adequacy of the care provided and whether the death was probably, possibly or not preventable. RESULTS: For 2016-2018, 272 maternal deaths (considered up to 1 year after the end of pregnancy) occurred in France. Of these, 265 had sufficient information collected by the confidential survey and could be assessed by the CNEMM. In total, care was judged to be "sub-optimal" for 66% of deaths assessed for all causes, a proportion similar to that for previous periods. In addition to the obstetric and anaesthetic care provided at the time of the acute complication, which was judged to be sub-optimal for 45% (obstetric care) and 38% (anaesthetic care) of maternal deaths, this report highlights the scope for improvement in other types of care, more related to prevention and screening: "sub-optimal" preconception care for 51% of the women who died for whom it was justified, particularly notable for deaths linked to a preexisting condition (52%) and for suicides (67%); prenatal surveillance judged to be "sub-optimal" in 30% of cases, a sub-optimality also more frequent among deaths linked to a preexisting condition (35%) and suicides (34%). In all, 59.7% of maternal deaths assessed were judged to be "probably" (17%) or "possibly" (42.7%) preventable, a profile that remained stable. Suicide and other psychiatric causes, the leading cause of maternal death, were considered to be potentially preventable in 79% of cases. Deaths from haemorrhage remained largely preventable (95%, the highest proportion by cause). The factor most often implicated was inadequate care, and preventability linked to this factor was identified in 53% of deaths, all causes combined. Gap in organization of care was a preventability factor identified in 24% of deaths, and poor interaction between the woman and the healthcare system in 22% of deaths. CONCLUSION: This proportion of more than half of potentially preventable maternal deaths shows that a reduction in maternal mortality in France is still possible and must be achieved, the objective being to prevent all preventable deaths. Analysis of the factors involved, overall and by cause of death, suggests areas for improvement.

Causes of maternal deaths in Sierra Leone from 2016 to 2019: analysis of districts' maternal death surveillance and response data.

INTRODUCTION: Sierra Leone is among the top countries with the highest maternal mortality rates. Although progress has been made in reducing maternal mortality, challenges remain, including limited access to skilled care and regional disparities in accessing quality care. This paper presents the first comprehensive analysis of the burden of different causes of maternal deaths reported in the Maternal Death Surveillance and Response (MDSR) system at the district level from 2016 to 2019. METHODS: The MDSR data are accessed from the Ministry of Health and Sanitation, and the secondary data analysis was done to determine the causes of maternal death in Sierra Leone. The proportions of each leading cause of maternal deaths were estimated by districts. A subgroup analysis of the selected causes of death was also performed. RESULTS: Overall, obstetric haemorrhage was the leading cause of maternal death (39.4%), followed by hypertensive disorders (15.8%) and pregnancy-related infections (10.1%). Within obstetric haemorrhage, postpartum haemorrhage was the leading cause in each district. The burden of death due to obstetric haemorrhage slightly increased over the study period, while hypertensive disorders showed a slightly decreasing trend. Disparities were found among districts for all causes of maternal death, but no clear geographical pattern emerged. Non-obstetric complications were reported in 11.5% of cases. CONCLUSION: The MDSR database provides an opportunity for shared learning and can be used to improve the quality of maternal health services. To improve the accuracy and availability of data, under-reporting must be addressed, and frontline community staff must be trained to accurately capture and report death events.

Impact of near-miss event during pregnancy and childbirth on maternal health at 12 months.

OBJECTIVE: To assess the impact of maternal near-miss on late maternal death and the prevalence of hypertension or chronic kidney disease (CKD) and mental health problems at 12 months of follow up. METHODS: This prospective cohort study was conducted in a tertiary hospital in the southeastern region of India from May 2018 to August 2019, enrolling those with maternal near-miss and with follow up for 12 months. The primary outcomes were incidence of late maternal deaths and prevalence of hypertension and CKD during follow up. RESULTS: Incidence of maternal near miss was 6.7 per 1000 live births. Among those who had a near miss, late maternal deaths occurred in 7.2% (95% confidence interval [CI] 3.1%-11.3%); prevalence of CKD was 23.0% (95% CI 16.2%-29.8%), and of hypertension was 56.2% (95% CI 50.5%-66.5%) and only two women had depression on follow up. After adjusting for age, parity, socioeconomic status, gestational age at delivery, hemoglobin levels, and perinatal loss, only serum creatinine was independently associated with late maternal death and CKD on follow up. CONCLUSIONS: Women who survive a life-threatening complication during pregnancy and childbirth are at increased risk of mortality and one or more long-term sequelae contributing to the non-communicable disease burden. A policy shift to increase postpartum follow-up duration, following a high-risk targeted approach after a near-miss event, is needed.

Prevalence of maternal mortality causes based on ICD-MM: a systematic review and meta-analysis.

BACKGROUND: Maternal mortality is a universal public health challenge. ICD-Maternal Mortality (ICD-MM) was introduced in 2012 to facilitate the gathering, analysis, and interpretation of data on maternal deaths worldwide. The present study aimed to estimate the global prevalence of maternal death causes through a systematic review and meta-analysis. METHODS: A systematic literature search was conducted using various databases, including Web of Science, PubMed, Scopus, ScienceDirect, Cochrane Library, as well as Persian databases such as MagIran and Scientific Information Database (SID). The search encompassed articles published until August 21, 2022. Thirty-four eligible articles were included in the final analysis. Analysis was performed using a meta-analysis approach. The exact Clopper-Pearson confidence intervals, heterogeneity assessment, and random effects models with Mantel-Haenszel methods were employed using the STATA software version 14.2. RESULTS: The most prevalent causes of maternal deaths, listed in descending order from highest to lowest prevalence, were non-obstetric complications (48.32%), obstetric hemorrhage (17.63%), hypertensive disorders of pregnancy, childbirth, and the puerperium (14.01%), other obstetric complications (7.11%), pregnancy with abortive outcome (5.41%), pregnancy-related infection (5.26%), unanticipated complications of management (2.25%), unknown/undetermined causes (2.01%), and coincidental causes (1.59%), respectively. CONCLUSION: Non-obstetric complications, obstetric hemorrhage, and hypertensive disorders of pregnancy, childbirth, and puerperium were the most common causes of maternal deaths. To reduce the burden of maternal mortality causes, increasing awareness and promoting self-care management among women of reproductive age, and implementing effective screening mechanisms for high-risk mothers during pregnancy, childbirth, and the puerperium can play a significant role. ICD-MM enables the uniform collection and comparison of maternal death information at different levels (local, national, and international) by facilitating the consistent collection, analysis, and interpretation of data on maternal deaths. Our findings can be utilized by policymakers and managers at various levels to facilitate necessary planning aimed at reducing the burden of maternal mortality causes.