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Trends in maternal mortality in Suriname: 3 confidential enquiries in 3 decades

The financial and personal burden of chronic cardiac disease is high. Costs are likely to increase over the next few decades. Promising applications of telehealth have appeared in the diagnosis and management of cardiac disease and there are indications that telehealth services can improve the management of chronic cardiac disease as well as extend services to remote and rural populations. Telehealth has been applied to the capture of symptoms of cardiac disease with electrocardiography and echocardiography, to the management and rehabilitation of recently discharged patients, and in peer-to-peer consultation where remote expertise can facilitate diagnosis. Telehealth promises cost reductions in service delivery, although there is a need for properly controlled cost-effectiveness trials to underpin telehealth with a firm evidence base.

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SummaryAimsCardiac disease is emerging as an important contributor to maternal deaths in both lower-to-middle and higher-income countries. There has been a steady increase in the overall institutional maternal mortality rate in South Africa over the last decade. The objectives of this study were to determine the cardiovascular causes and contributing factors of maternal death in South Africa, and identify avoidable factors, and thus improve the quality of care provided.MethodsData collected via the South African National Confidential Enquiry into Maternal Deaths (NCCEMD) for the period 2011–2013 for cardiovascular disease (CVD) reported as the primary pathology was analysed. Only data for maternal deaths within 42 days post-delivery were recorded, as per statutory requirement. One hundred and sixty-nine cases were reported for this period, with 118 complete hospital case files available for assessment and data analysis.ResultsPeripartum cardiomyopathy (PPCM) (34%) and complications of rheumatic heart disease (RHD) (25.3%) were the most important causes of maternal death. Hypertensive disorders of pregnancy, HIV disease infection and anaemia were important contributing factors identified in women who died of peripartum cardiomyopathy. Mitral stenosis was the most important contributor to death in RHD cases. Of children born alive, 71.8% were born preterm and 64.5% had low birth weight. Seventy-eight per cent of patients received antenatal care, however only 33.7% had a specialist as an antenatal care provider. Avoidable factors contributing to death included delay in patients seeking help (41.5%), lack of expertise of medical staff managing the case (29.7%), delay in referral to the appropriate level of care (26.3%), and delay in appropriate action (36.4%).ConclusionThe pattern of CVD contributing to maternal death in South Africa was dominated by PPCM and complications of RHD, which could, to a large extent, have been avoided. It is likely that there were many CVD deaths that were not reported, such as late maternal mortality (up to one year postpartum). Infrastructural changes, use of appropriate referral algorithm and training of primary, secondary and tertiary staff in CVD complicating pregnancy is likely to improve the outcome. The use of simple screening equipment and point-of-care testing for early-onset heart failure should be explored via research projects.

Background: The global maternal mortality rate (MMR) in 2022 is 91.46 per 100,000 live births with the cause of death being bleeding while the indirect causes of maternal mortality are during pregnancy wheere many pregnant women experience nutritional problems such as Chornic Energi Deficiency ( CHD) and Nutritional Anemia at 8.43% (WHO, 2022). The maternal mortality rate in ASEAN is 235 per 100,000 live births with the majority of causes of death being bleeding (ASEAN Secretariat, 2022). Until now, the maternal mortality rate in Indonesia alone in 2020 was 91.45/100,000 live births. In 2021, maternal mortality will increase to 305/100,000 live births. Meanwhile, in 2022, the maternal mortality rate will decrease by 230/100,000 live births. Within a period of 3 years, the causes of maternal death included Covid 19, bleeding, hypertension in pregnancy, and heart disease (Ministry of Health of the Republic of Indonesia, 2022). The maternal mortality rate in Central Java in 2020 was 84.6/100,000 live births, in 2021 it will be 199/100,000 live births. In 2022 there will be a decrease to 98.6/100,000 live births, hypertension in pregnancy and bleeding are still the cases of death in that year (Central Health Office, 2022). Brebes Regency shows that the maternal mortality rate in 2020 was 62 cases. In 2021 there were 105 cases and in 2022 there was a decrease to 50 cases with the causes of death being bleeding, hypertension, infection and heart disorders (Brebes District Health Office, 2021) Objective: Reduce maternal and infant morbidity and mortality rates in Brebes Regency, especially the Bumiayu Community Health Center area Conclusion: After providing comprehensive midwifery care to Mrs. S aged 32 years with Chronic Energy Deficiency (KEK) at BPM Mrs. The R working area of the Bumiayu Community Health Center from the third trimester of pregnancy, childbirth, newborns, postpartum and family planning is in good condition.

Neurological diseases remain the second most common cause of maternal mortality from indirect causes, according to the last United Kingdom confidential enquiry into maternal death. The maternal mortality rate from epilepsy is reported as 0.61 per 100,000 maternities. The aim of this study was to analyse the trends and causes of maternal death from epilepsy in the UK over the last 30 years. Information on sub-standard care associated with fatalities was also consolidated to inform guidance and clinical care by obstetricians and physicians caring for pregnant women with epilepsy. A retrospective review of 10 triennial confidential enquiry into maternal death reports (1979-2008) was performed, encompassing 21,514,457 maternities. Late and coincidental deaths were not included in the analyses. Between 1979 and 2008, there were 92 maternal deaths from epilepsy. The proportion of total maternal deaths from epilepsy over 30 years is 3.7% (95% CI 3.0-4.5), which showed an increasing trend. Sudden unexpected death in epilepsy remains the single greatest cause of maternal death from epilepsy followed by aspiration of gastric contents during seizures and drowning during bathing. All women with epilepsy should be looked after by specialist combined obstetric and medical or neurological teams in pregnancy to improve maternal and fetal outcomes.

Background: Maternal and perinatal deaths are clustered around delivery and the first 24 hours after birth respectively. Whilst most maternal and perinatal deaths are preventable, women and babies continue to die from these preventable causes. Specific objective: To evaluate maternal and perinatal mortality in Amachara General Hospital, Umuahia South, Abia State. Methods and materials: A retrospective 3-year study was conducted among 4870 mothers and 4834 live babies in Amachara General Hospital, Umuahia South LGA. Data were collected and coded into and analyzed using Statistical Package for Social Science, Version 26.0. Categorical variables were summarized using frequency and proportions, logistic regression models were used to determine association with maternal deaths. Chi-Square test was used to test association at p<0.05 & p<0.001. Result: Of the 4870 babies born at or after 28 weeks of gestation, 136 (2.8%) were stillbirths, maternal mortality ratio was 532.3 per 100,000 live births and perinatal mortality rate was 129.4 per 1000 births. Puerperal sepsis 86 (34.1%) and asphyxia related condition 220 (34.9%) were most common causes of maternal and perinatal deaths respectively. Mothers aged 35 years and older was one of the factors associated with increased risk of perinatal death, p-<0.05 & p<0.001. Conclusion: Maternal mortality ratio and perinatal mortality rate were still high in this study and still far from the Sustainable Development Goals 2030 target. Sepsis and HIV positive were most probable causes of maternal deaths. Asphyxia related conditions were the most common possible cause of perinatal mortality. Mothers aged 35 years and older and Apgar score < 6 at five minutes after delivery were associated with increased risk of perinatal mortality.

Pakistan is the sixth most populous country in the world & is ranked 53^rd in the list of countries contributing towards high maternal mortality ratios. According to a recent maternal mortality survey, the current maternal mortality ratio of Pakistan is 186 per 100,000 live births with high disparities among provinces; Balochistan being the highest contributor with MMR of 298 per 100,000 live births. This study specifically focuses on the causes & contributory factors of high maternal deaths in Balochistan based on the evidence generated by the Maternal and Perinatal Death Surveillance & Response system. MPDSR provides the decision maker with reliable and timely data to take required action and to reduce the preventable maternal deaths. Maternal mortality data was collected from the three pilot tertiary health care facilities and data was analyzed using Statistical Package for Social Sciences version (20.0). Out of 40 notified maternal deaths in the period January 2020 till July 2020 around 39 deaths were reviewed & analyzed. This study found out that of these 39 maternal deaths around 32% were attributed to hemorrhage, and around 15% & 12% resulted from eclampsia and sepsis respectively. Other major causes of maternal deaths included obstructed labour (10%), embolism (10%) and anesthesia complications (2%) respectively. Non-medical causes of these maternal deaths included shortage of human resource (7.7%), lack of medical equipment (7.7%) and failure to recognize the danger signs earlier (5.1%). The major underlying factors of these maternal deaths included low antenatal visits, underutilization of family planning services, poor referral system and delays at all levels in the three delay model. The study concluded that almost all of these maternal deaths can be avoided by undertaking appropriate measures & timely actions.

The latest report from the UK and Ireland Confidential Enquiries into Maternal Deaths, the third in the new annual report format, was published in December,1 and includes surveillance of maternal deaths from 2012 to 2014 and confidential enquiries covering the period 2009−14. Once again the report includes reviews into the care of women who died during or after pregnancy in the Republic of Ireland as well as the UK. Following the annual topic-specific format, this report includes topic-specific reviews of deaths and severe morbidity from cardiac causes, deaths from pre-eclampsia and eclampsia and related causes, deaths in early pregnancy, and messages for critical care. This report would not have been possible without the dedication of clinical staff throughout the UK and Ireland, and in particular the MBRRACE-UK assessors who reviewed all the cases. This report highlighted many instances when pregnant and postpartum women had clear symptoms and signs of cardiac disease, which were not recognised, often because the diagnosis was simply not considered in a young pregnant woman. There was evidence of a focus on excluding, rather than making, a diagnosis in women who presented repeatedly for care. Repeated presentation should be considered a ‘red flag’ by staff caring for pregnant and postpartum women in any setting. Once again, a number of women received fragmented care, and important messages concerning planned care were not passed between teams, highlighting the urgent need for joint, multidisciplinary, maternity and cardiac care. Nonetheless, while it is clear that care in many areas can still be improved, the success of evidence-based quality care for women with hypertensive disorders should be recognised. Now, in the UK and Ireland, less than one woman in every million giving birth dies from a hypertensive disorder of pregnancy; a condition from which more than 100 women still die every day globally. Taking forward the lessons for improving care identified by these Confidential Enquiries will continue this achievement across other causes of maternal death.

Most deaths are now caused by preventable or treatable medical conditions Since the first report of the Confidential Enquiry into Maternal Deaths in 1952, the maternal death rate in the...

This article provides an overview of surveillance methods, levels, and causes of maternal mortality in developed countries, in Europe and the United States, during 2006-2010. Accurate identification of maternal deaths is not always possible, and no two countries in the world use the same surveillance methods for maternal mortality. Despite limitations (e.g. underestimation, misclassification), routine vital registration systems are the backbone of maternal mortality surveillance systems in developed countries. Enhanced surveillance methods involve linkages between deaths of women of reproductive age and births within the preceding year, or the use of additional data sources for maternal deaths. Confidential enquiries into maternal deaths, in place in France, the Netherlands, and the UK are the gold standard in maternal mortality surveillance. Levels of maternal mortality in Europe were the lowest in the world during 2006-2010. While Europe has not seen major changes in maternal mortality in recent years, pregnancy-related mortality increased considerably in the USA, where improvements in the identification of deaths appear to play a part. The triad of infection, hemorrhage, and hypertensive disorders of pregnancy, which in the past accounted for >90% of all maternal deaths, now accounts for 60-70% of such deaths in developed countries. Maternal mortality surveillance provides learning opportunities to prevent future maternal deaths. There is need for integration of linked, multiple data sources into current maternal mortality surveillance systems to improve their utility.

Objective: Describe the clinical and sociodemographic characteristics of maternal deaths that occurred in a hospital in Yucatán, Mexico, as well as propose recommendations to improve the care of pregnant women in order to help reduce in-hospital maternal mortality. Material and methods: Retrospective, cross-sectional study conducted in a second-level care concentration hospital. The hospital database of maternal deaths that occurred during the 2014–2018 period was reviewed, as well as clinical summaries, maternal death reports, maternal death ratification forms, and hospital records. Results: There were 54 maternal deaths, the year with the highest percentage was 2018 with 15 (27.8%) deaths. Most of the women resided in municipalities with low and very low degrees of marginalization 23 (42.6%); 48 (88.9%) were engaged in housework; 13 had a history of previous abortion (24.1%), with prenatal control 18 (33.3%), used some contraceptive method 13 (24.1%); and 21 (38.9%) presented some complication during pregnancy. Direct maternal deaths were mainly hypertensive disorders with 9 (32.1%) deaths. Indirect maternal deaths were mainly due to heart disease and arteriovenous disorders 6 (30.0%). The Hospital Mortality Committee issued 98 (55.1%) recommendations to improve emergency care, of which 32 (32. 6%) were related to the training of health personnel in the first level of care; and 22 (22.5%) for the second level of care. Conclusion: It is important to improve the care of the pregnant woman through the permanent training of health personnel to detect warning signs in the prenatal consultation and care of the obstetric emergency, in order to fully detect the problems that arise in the care chain of patients. Likewise, the training and updating of medical personnel for the correct completion of the basic causes of maternal death according to IDC-10 will be necessary for the correct certification of deaths.

The aim of this study was to assess temporal trends in incidence and underlying causes of maternal deaths from obstetric hemorrhage in France and to describe clinical care before and after implementation of the first national guidelines published in 2004 and updated in 2014. Data from all hemorrhage-related maternal deaths between 2001 and 2015 were extracted from the French Confidential Enquiry into Maternal Deaths. We compared the maternal mortality ratio (MMR), cause of obstetric hemorrhage, and death preventability by triennium. Critical care, transfusion, and obstetric management among women who died were described for 2001 to 2003 and 2013 to 2015. The MMR from obstetric hemorrhage significantly decreased over time from 2.3 of 100,000 livebirths (54 of 2,391,551) in 2001 to 2003 to 0.8 of 100,000 livebirths (19 of 2,412,720) in 2013 to 2015. In 2001 to 2003, uterine atony accounted for 50% (27 of 54) of maternal deaths vs 21% (4 of 19) in 2013 to 2015. As compared to 2001 to 2003, an increased proportion of women had hemodynamic continuous monitoring in 2013 to 2015 (30%, 9 of 30, vs 47%, 8 of 18) and received vasopressor infusion therapy (57%, 17 of 30, vs 72%, 13 of 18), and a smaller proportion was extubated during active hemorrhage (17%, 5 of 30, vs 0 of 18). Transfusion therapy was initiated more frequently and earlier in 2013 to 2015 (71 vs 58 minutes). In 2013 to 2015, 88% of maternal deaths due to hemorrhage remained preventable. The main identified improvable care factors were related to delays in diagnosis and surgical management, particularly after cesarean delivery. Maternal mortality by obstetric hemorrhage decreased dramatically in France between 2001 and 2015, particularly mortality due to uterine atony. Among women who died, we detected fewer instances of substandard transfusion management or critical care. Nevertheless, opportunities for improvement were observed in most of the recent cases.

BackgroundResponse should be a key part of maternal death surveillance and response (MDSR) programmes, which include confidential enquiries into maternal deaths. The programmes investigate avoidable factors in maternal deaths and make recommendations for improving maternity care. There is a gap in information on how these recommendations are transformed into practice.ObjectiveTo explore the methods used to assess the implementation status of recommendations made in confidential enquiries into maternal deaths and other health outcomes.Data sourcesWe searched PubMed, Web of Science, CINAHL, and Google Scholar databases and general web for grey literature using the “Arksey and O’Malley framework” in all major scientific databases and search engines.Study selection and data extractionAn initial screening was followed by extraction of information using a data chart. Variables in the chart were based on the response component of maternal death and surveillance systems.SynthesisInformation collected was summarised using content analysis method.ResultsWe reviewed 13 confidential enquiry systems into maternal deaths. Many confidential enquiries into maternal deaths published reports with their recommendations and dissemination often involved national‐level scientific presentations. Only five reports provided strategies for implementing the recommendations. Follow‐up of previous recommendations was routinely published in only two reports. However, impact assessment of recommendations on other health outcomes was found only in the UK.ConclusionThere is a gap in monitoring the response generated by confidential enquiries into maternal deaths. Actions to develop this are therefore needed.

Management of failed intubation in a septic parturient