GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015

Exploring underutilization of skilled maternal healthcare in rural Edo, Nigeria: A qualitative study

Introduction

Existing studies have acknowledged the underutilization of skilled maternal healthcare services among women in rural Nigeria. Consequently, women in rural areas face a disproportionate risk of poor health outcomes including maternal morbidity and mortality. Addressing the challenge of non-use of skilled maternal healthcare in rural areas necessitates the involvement of multi-stakeholders across different sectors who have vital roles to play in improving maternal health. This study explores the factors contributing to the non-use of maternal healthcare services in rural areas of Edo, Nigeria from the perspectives of community elders and policymakers.

Methods

In this qualitative study, data were collected through 10 community conversations (group discussions) with community elders each consisting of 12 to 21 participants, and six key informant interviews with policymakers in rural areas of Edo State, Nigeria. Participants were purposefully selected. Conversations and interviews occurred in English, Pidgin English and the local language; lasted for an average of 9 minutes; were audio-recorded and transcribed to English. Data were manually coded, and data analysis followed the analytical strategies for qualitative description including an iterative process of inductive and deductive approaches.

Results

Policymakers and community elders attributed the non-use of maternal health services to poor quality of care. Notions of poor quality of care included shortages in skilled healthcare workers, apathy and abusive behaviours from healthcare providers, lack of life-saving equipment, and lack of safe skilled pregnancy care. Non-use was also attributed to women’s complex utilization patterns which involved a combination of different types of healthcare services, including traditional care. Participants also identified affordability and accessibility factors as deterrents to women’s use of skilled maternal healthcare.

Conclusion

The emerging findings on pregnant women’s combined use of different types of care highlight the need to improve the quality, availability, accessibility, and affordability of skilled maternal care for rural women in Nigeria.

Multiscale model of heart growth during pregnancy: integrating mechanical and hormonal signaling

Pregnancy stands at the interface of mechanics and biology. The growing fetus continuously loads the maternal organs as circulating hormone levels surge, leading to significant changes in mechanical and hormonal cues during pregnancy. In response, maternal soft tissues undergo remarkable growth and remodeling to support the mother and baby for a healthy pregnancy. We focus on the maternal left ventricle, which increases its cardiac output and mass during pregnancy. This study develops a multiscale cardiac growth model for pregnancy to understand how mechanical and hormonal cues interact to drive this growth process. We coupled a cell signaling network model that predicts cell-level hypertrophy in response to hormones and stretch to a compartmental model of the rat heart and circulation that predicts organ-level growth in response to hemodynamic changes. We calibrated this multiscale model to data from experimental volume overload and hormonal infusions of angiotensin 2 (AngII), estrogen (E2), and progesterone (P4). We then validated the model's ability to capture interactions between inputs by comparing model predictions against published observations for the combinations of VO + E2 and AngII + E2. Finally, we simulated pregnancy-induced changes in hormones and hemodynamics to predict heart growth during pregnancy. Our model produced growth consistent with experimental data. Overall, our analysis suggests that the rise in P4 during the first half of gestation is an important contributor to heart growth during pregnancy. We conclude with suggestions for future experimental studies that will provide a better understanding of how hormonal and mechanical cues interact to drive pregnancy-induced heart growth.

Leveraging big data for improving the estimation of close to reality travel time to obstetric emergency services in urban low- and middle-income settings

Maternal and perinatal mortality remain huge challenges globally, particularly in low- and middle-income countries (LMICs) where >98% of these deaths occur. Emergency obstetric care (EmOC) provided by skilled health personnel is an evidence-based package of interventions effective in reducing these deaths associated with pregnancy and childbirth. Until recently, pregnant women residing in urban areas have been considered to have good access to care, including EmOC. However, emerging evidence shows that due to rapid urbanization, this so called “urban advantage” is shrinking and in some LMIC settings, it is almost non-existent. This poses a complex challenge for structuring an effective health service delivery system, which tend to have poor spatial planning especially in LMIC settings. To optimize access to EmOC and ultimately reduce preventable maternal deaths within the context of urbanization, it is imperative to accurately locate areas and population groups that are geographically marginalized. Underpinning such assessments is accurately estimating travel time to health facilities that provide EmOC. In this perspective, we discuss strengths and weaknesses of approaches commonly used to estimate travel times to EmOC in LMICs, broadly grouped as reported and modeled approaches, while contextualizing our discussion in urban areas. We then introduce the novel OnTIME project, which seeks to address some of the key limitations in these commonly used approaches by leveraging big data. The perspective concludes with a discussion on anticipated outcomes and potential policy applications of the OnTIME project.

Prediction of Five-Year Cardiovascular Disease Risk in People with Type 2 Diabetes Mellitus: Derivation in Nanjing, China and External Validation in Scotland, UK

Background

To use routinely collected data to develop a five-year cardiovascular disease (CVD) risk prediction model for Chinese adults with type 2 diabetes with validation of its performance in a population of European ancestry.

Methods

People with incident type 2 diabetes and no history of CVD at diagnosis of diabetes between 2008 and 2017 were included in derivation and validation cohorts. The derivation cohort was identified from a pseudonymized research extract of data from the First Affiliated Hospital of Nanjing Medical University (NMU). Five-year risk of CVD was estimated using basic and extended Cox proportional hazards regression models including 6 and 11 predictors respectively. The risk prediction models were internally validated and externally validated in a Scottish population-based cohort with CVD events identified from linked hospital records. Discrimination and calibration were assessed using Harrell's C-statistic and calibration plots, respectively.

Results

Mean age of the derivation and validation cohorts were 58.4 and 59.2 years, respectively, with 53.5% and 56.9% men. During a median follow-up time of 4.75 [2.67, 7.42] years, 18,827 (22.25%) of the 84,630 people in the NMU-Diabetes cohort and 8,763 (7.31%) of the Scottish cohort of 119,891 people developed CVD. The extended model had a C-statistic of 0.723 [0.721-0.724] in internal validation and 0.716 [0.713-0.719] in external validation.

Conclusions

It is possible to generate a risk prediction model with moderate discriminative power in internal and external validation derived from routinely collected Chinese hospital data. The proposed risk score could be used to improve CVD prevention in people with diabetes.

Are Bangladeshi healthcare facilities prepared to provide antenatal care services? Evidence from two nationally representative surveys

Identifying high-risk pregnancies through antenatal care (ANC) is considered the cornerstone to eliminating child deaths and improving maternal health globally. Understanding the factors that influence a healthcare facility's (HCF) preparedness to provide ANC service is essential for assisting maternal and newborn health system progress. We aimed to evaluate the preparedness of HCFs to offer ANC services among childbearing women in Bangladesh and investigate the facility characteristics linked to the preparedness. The data for this study came from two waves of the Bangladesh Health Facilities Survey (BHFS), conducted in 2014 and 2017 using a stratified random sample of facilities. The study samples were 1,508 and 1,506 HCFs from the 2014 and 2017 BHFS, respectively. The outcome variable "ANC services preparedness" was calculated as an index score using a group of tracer indicators. Multinomial logistic regression models were used to identify the significant correlates of ANC service preparedness. We found that private hospitals had a lower chance of having high preparedness than district and upazila public facilities in 2014 (RRR = 0.04, 95% CI: 0.01-0.22, p-value = <0.001) and 2017 (RRR = 0.23, 95% CI: 0.07-0.74, p-value = 0.01), respectively. HCFs from the Khulna division had a 2.84 (RRR = 2.84, CI: 1.25-6.43, p-value = 0.01) and 3.51 (RRR = 3.51, CI: 1.49-8.27, p-value = <0.001) higher likelihood of having medium and high preparedness, respectively, for ANC service compared to the facilities in the Dhaka division in 2017. The facilities that had a medium infection prevention score were 3.10 times (RRR = 3.10, 95% CI: 1.65-5.82; p-value = <0.001) and 1.89 times (RRR = 1.89, 95% CI: 1.09-3.26, p-value = 0.02) more likely to have high preparedness compared to those facilities that had a low infection prevention score in 2014 and 2017 respectively. Facilities without visual aids for client education on pregnancy and ANC were less likely to have high (RRR = 0.29, 95% CI: 0.16-0.53, p-value = <0.001) and (RRR = 0.55, 95% CI: 0.30-0.99, p-value = 0.04) preparedness, respectively, than those with visual aids for client education on pregnancy and ANC in both the surveys. At all two survey time points, facilities that did not maintain individual client cards or records for ANC clients were less likely to have high (RRR = 0.53, 95% CI: 0.31-.92, p-value = 0.02) and (RRR = 0.41, 95% CI: 0.25-0.66, p-value = <0.001) preparedness, respectively, compared to their counterparts. We conclude that most facilities lack adequate indicators for ANC service preparedness. To improve the readiness of ANC services, government authorities could focus on union-level facilities, community clinics, private facilities, and administrative divisions. They could also make sure that infection control items are available, maintain individual client cards or records for ANC clients, and also ensure ANC clients have access to visual aids.

Individual, health facility and wider health system factors contributing to maternal deaths in Africa: A scoping review

The number of women dying during pregnancy and after childbirth remains unacceptably high, with African countries showing the slowest decline. The leading causes of maternal deaths in Africa are preventable direct obstetric causes such as haemorrhage, infection, hypertension, unsafe abortion, and obstructed labour. There is an information gap on factors contributing to maternal deaths in Africa. Our objective was to identify these contributing factors and assess the frequency of their reporting in published literature. We followed the Arksey and O'Malley methodological framework for scoping reviews. We searched six electronic bibliographic databases: MEDLINE, SCOPUS, African Index Medicus, African Journals Online (AJOL), French humanities and social sciences databases, and Web of Science. We included articles published between 1987 and 2021 without language restriction. Our conceptual framework was informed by a combination of the socio-ecological model, the three delays conceptual framework for analysing the determinants of maternal mortality and the signal functions of emergency obstetric care. We included 104 articles from 27 African countries. The most frequently reported contributory factors by level were: (1) Individual-level: Delay in deciding to seek help and in recognition of danger signs (37.5% of articles), (2) Health facility-level: Suboptimal service delivery relating to triage, monitoring, and referral (80.8% of articles) and (3) Wider health system-level: Transport to and between health facilities (84.6% of articles). Our findings indicate that health facility-level factors were the most frequently reported contributing factors to maternal deaths in Africa. There is a lack of data from some African countries, especially those countries with armed conflict currently or in the recent past. Information gaps exist in the following areas: Statistical significance of each contributing factor and whether contributing factors alone adequately explain the variations in maternal mortality ratios (MMR) seen between countries and at sub-national levels.

The trends of maternal mortality ratios and cause pattern in 34 Chinese provinces, 1990-2017

Background

Understanding the trends and causes to the burden of maternal deaths is a key requirement to further reduce the maternal mortality ratio (MMR), and devise targeted intervention policy. We aimed to evaluate the spatiotemporal trends of MMRs and cause patterns across the 34 provinces of China during 1990–2017.

Methods

Using data from the Global Burden of Disease Study 2017, we calculated the levels and trends of total maternal deaths and MMR due to ten different causes through Bayesian multivariable regression model for pregnancies aged 10–54 years, and assessed the age and regional distribution over time.

Results

China has experienced fast decline in MMR, dropped from 95.2 (87.8–102.3) in 1990 to 13.6 (12.5–15.0) in 2017, with an annualised rate of decline of 7.0%. In 1990, the range of MMRs in mainland China was 31.1 in Shanghai, to 323.4 in Tibet. Almost all provinces showed remarkable decline in the last two decades. However, spatial heterogeneity in levels and trends still existed. The annualised rate of decline across provinces from 1990 to 2017 ranged from 0.54% to 10.14%. Decline accelerated between 2005 and 2017 compared with between 1990 and 2005. In 2017, the lowest MMR was 4.2 in Zhejiang; the highest was still in Tibet, but had fallen to 82.7, dropped by 74.4%. MMR was highest in the 40–49 years age group in both 1990 and 2017. In 2017, haemorrhage and hypertensive disorders were the leading two specific causes for maternal deaths.

Conclusions

MMRs have declined rapidly and universally across the provinces of China. Setting of associated interventions in the future will need careful consideration of provinces that still have MMR significantly higher than the national mean level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13770-0.

Health Behaviors and Behavior Change during Pregnancy: Theory-Based Investigation of Predictors and Interrelations

(1) Background: Preventing pregnancy complications and maternal deaths and helping women stay healthy before, during, and after pregnancy by means of sexual health and behavior is imperative. Previous research demonstrated that a lack of social support and perceived discrimination have adverse effects on pregnancy outcomes. These determinants may impact health behavior as an important mediator of pregnancy outcomes. To better understand this relation, the Compensatory Carry-Over Action Model (CCAM) was applied. The research question was: how do predictors of health behavior, specifically intention, planning, self-efficacy, social support, and discrimination, interrelate with different health behaviors during pregnancy? (2) Methods: By means of qualitative interviews with ten pregnant women (20–39 years, mean = 28.6) from different cultural backgrounds, the predictors of health behaviors and experiences with pregnancy, including racial discrimination, were investigated. (3) Results: Not all women changed their unhealthy behaviors even though their higher-level goal was to ensure their baby’s and their own health. This appeared partially due to lack of social support, racial discrimination, and unexpected pregnancy side effects. The women who previously performed health behaviors revealed a healthier pattern with maintaining or even expanding their health behaviors, while those performing no health behavior in the past reported more obstacles with a healthy lifestyle. (4) Conclusions: Pregnant women appear to be having difficulties translating good intentions into behavior. The reasons include lack of support, fear, and insecurity, which impact self-efficacy and planning. Improvements in health behaviors were facilitated by specific circumstances, such as working from home. Policy and practice should take these aspects into account and help mobilize support and overcome discrimination by means of more rights and support for pregnant women while also empowering the individuals.

Racial Disparities in Cardiovascular Risk and Cardiovascular Care in Women

PURPOSE OF REVIEW

Research on sex and gender aspects cardiovascular disease has contributed to a reduction in cardiovascular mortality in women. However, cardiovascular disease remains the leading cause of death of women in the United States. Disparities in cardiovascular risk and outcomes among women overall persist and are amplified for women of certain ethnic and racial subgroups. We review the evidence of racial and ethnic differences in cardiovascular risk and care among women and describe a path forward to achieve equitable cardiovascular care for women of racial and ethnic minority groups.

RECENT FINDINGS

There is a disproportionate effect on cardiovascular outcomes in women and certain racial and ethnic groups in part due to disparities in triage, diagnosis, treatment, which lead to amplification of inequalities in women of minority racial and ethnic background. Data suggest gender and racial bias, underappreciation of nontraditional risk factors, underrepresentation of women in clinical trials and undertreatment of disease contributes to persistent differences in cardiovascular disease outcomes in women of color. Understanding the myriad of factors that contribute to increased cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds is imperative to improving cardiovascular care for this patient population.

Maternal mortality in the Middle East and North Africa region - how could countries move towards obstetric transition stage 5?

BACKGROUND

Maternal mortality in the Middle East and North Africa (MENA) region decreased significantly between 1990 and 2017. This was uneven, however, with some countries faring much better than others.

METHODS

We undertook a trend analysis of Maternal Mortality Ratios (MMRs) of countries in the region in order to understand differences in reduction across countries. Data were extracted from several databases for 23 countries and territories in the region on measures of women's empowerment, availability of vehicles and human resources for health (as a proxy to the three delays model). We identified factors associated with MMR by grouping countries into five different Stages (I-V) of obstetric transition from high to low MMRs.

RESULTS

Among the four Stage II countries, MMR is associated with "antenatal care coverage (% with at least one visit)" and "medical doctors per 10,000 population". Among the eight Stage III countries, MMR is associated with "Gender Parity Index in primary and secondary level school enrolment" and with "nursing and midwifery personnel per 10,000 population". Among the 10 countries and one territory in Stages IV and V, MMR is associated with "GDP per capita", "nursing and midwifery personnel", and "motor vehicle ownership/motorization rate". Two factors were associated with changes in MMR from the period 2006-2010 to 2011-2015: 1) change in adolescent birth rate (r = 0.90, p = 0.005) and 2) Gender Parity Index in primary level school enrolment (r = - 0.51, p = 0.04).

CONCLUSION

Though impressive reductions in MMR have been achieved across countries in the MENA region since 1990, governments should realize that there exists an opportunity to learn from each other to bring MMRs as close to zero as possible. Immediate steps in the right direction would include investment in human resources for health, particularly nurses and midwives; measures to improve adolescent sexual and reproductive health; and greater investments in achieving gender equity in education.

A multilevel assessment of the influence of education on women's uptake of institutional delivery services during childbirth in Bangladesh

OBJECTIVES

Despite a significant decline over time, maternal mortality remains high in Bangladesh. Institutional delivery during childbirth is crucial to reducing maternal mortality, but uptake of institutional delivery services (IDS) remains suboptimal in Bangladesh. Though women's education plays a crucial role in the use of IDS, the educational status of the household head and area-level literacy rate also appear to act as predictors of IDS uptake. This study aims to assess the effect of the educational status of women and household heads as well as district-level adult literacy rates on the use of IDS during childbirth among women in Bangladesh.

DESIGN

This study analyzed nationally representative cross-sectional survey data from the 2019 Bangladesh Multiple Indicator Cluster Survey.

SETTING

Bangladesh.

PARTICIPANTS

9,207 currently married women aged 15-49 years who had at least one live birth in the two years preceding the survey were included in the study. The outcome measure was women's use of IDS during their last childbirth. A multilevel logistic regression model was used to explore the association between education status of women and household heads, and district (i.e., area unit) adult literacy rates and uptake of IDS among women in Bangladesh by controlling for other sociodemographic covariates and clustering.

RESULTS

About 53% of women used IDS during childbirth. Adjusting for other factors and clustering, women with higher educational status, those living in households with higher-educated heads, and those in districts with greater adult literacy rates are more likely to use IDS, after controlling for key sociodemographic variables including wealth.

CONCLUSIONS

Uptake of IDS in Bangladesh remains low, with education playing an important independent role in determining rates. The findings of the study provide empirical evidence for policymakers to design multi-modal educational programs targeted not only at literate women but also at household head (especially male) and communities where literacy (and equally importantly health literacy) may be variable or absent.

Women's Health: Population Patterns and Social Determinants

Women's health, and what we know about it, are influenced by social factors. From the exclusion of women's bodies in medical research, to the silence and stigma of menstruation and menopause, to the racism reflected in maternal mortality, the relevance of social factors is paramount. After a brief history of research on women's health, we review selected patterns, trends, and inequalities in US women's health. These patterns reveal US women's poor and declining longevity relative to those in other high-income countries, gaps in knowledge about painful and debilitating conditions that affect millions of women, and deep inequalities that underscore the need to redress political and structural features of US society that enhance health for some and diminish it for others. We close by describing the challenges and opportunities for future research, and the promise of a social determinants of health approach for advancing a multilevel, intersectional, and biosocial understanding of women's health.

Satisfaction as a Mediator and Its Interaction With Adherence to Labor Analgesia Protocols: A Cross-Sectional Survey of Chinese Medical Personnel

Background

Although the Chinese promotion of labor analgesia began in 2018 to improve maternal health, high-quality medical care is difficult to provide to pregnant women when medical staff cannot implement standard labor analgesia procedures. This study aims to examine medical personnel's adherence to labor analgesia protocols and to explore the relationships among adherence, satisfaction, and other factors.

Methods

The data were from a national cross-sectional dataset (N = 13,944) of the 2020 Chinese Labor Analgesia Pilot Evaluation Project. Mediating and moderating effects analyses were used to examine the role of satisfaction as a mediator between support measures and adherence.

Results

There were differences in adherence between different types of medical personnel. Support measures and satisfaction had a positive association with adherence to labor analgesia protocols. Satisfaction had a significant mediating and moderating effect on the relationship between support measures and adherence to labor analgesia standards. Moderating effects of professional titles and attitudes were also observed.

Conclusion

Primary health care policies worth considering include comprehensive incentives for medical institutions to improve the use of labor analgesia by medical personnel. It is also worth considering providing more training opportunities for the staff in anesthesiology departments.

Spatial Distribution and Associated Factors of Institutional Delivery among Reproductive-Age Women in Ethiopia: The Case of Ethiopia Demographic and Health Survey

Background

Maternal mortality is unacceptably high. About 295,000 women died during and following pregnancy and childbirth in 2017. The vast majority of these deaths (94%) occurred in low-resource settings, and most could have been prevented.

Methods

This research is based on a cross-sectional study using 2016 EDHS data. The analysis included 7,590 women who had given birth in the five years prior to the survey. Clusters with high and low hot spots with institutional delivery were found using SatScan spatial statistical analysis. A multilevel multivariable mixed-effect logistic regression was utilized to discover characteristics associated with institutional delivery.

Result

In this study, 33.25% of women who gave birth in the last 5 years preceding the survey delivered their babies at health institutions. The finding also indicated that the spatial distribution of institutional delivery was nonrandom in the country. Variables achieving statically significant association with utilization of institutional delivery were as follows: at the individual level, richness (AOR = 2.18, 95%CI: 1.39–3.41), higher education (AOR = 3.89, 95%CI: 1.51–10.01), a number of antenatal care visits of four and above (AOR = 6.57, 95%CI: 4.83–8.94), and parity of more than two children (AOR = 0.48, 95%CI: 0.34–0.68); at the community level, higher education (AOR = 1.70, 95%CI: 1.22–2.36) and urban residence (AOR = 5.30, 95%CI: 3.10–9.06) were variables that had achieved statically significant association for utilization of institutional delivery.

Conclusions

This study identified a spatial cluster of institutional delivery with the Somali and Afar region having low utilization rates and Addis Ababa and Tigray regions having the highest utilization rates. The significant individual factors associated with institution delivery were woman antenatal care visits, household wealth index, maternal education, and parity, and the significant community ones were region, place of residence, and educational status. Therefore, to maximize health facility delivery in Ethiopia, the predictors of institutional delivery identified in this study should be given more attention by governmental and nongovernmental stakeholders.

Determinants of obstructed labour and its adverse outcomes among women who gave birth in Hawassa University referral Hospital: A case-control study

Background

Globally, obstructed labour accounted for 22% of maternal morbidities and up to 70% of perinatal deaths. It is one of the most common preventable causes of maternal and perinatal mortality in low-income countries. However, there are limited studies on the determinants of obstructed labor in Ethiopia. Therefore, this study was conducted to assess determinants and outcomes of obstructed labor among women who gave birth in Hawassa University Hospital, Ethiopia.

Methods

A hospital-based case-control study design was conducted in Hawassa University Hospital among 468 women. All women who were diagnosed with obstructed labour and two consecutive controls giving birth on the same day were enrolled in this study. A pretested data extraction tool was used for data collection from the patient charts. Multivariable logistic regression was employed to identify determinants of obstructed labor.

Results

A total of 156 cases and 312 controls were included with an overall response rate of 96.3%. Women who were primipara [AOR 0.19; 95% CI 0.07, 0.52] and multigravida [AOR 0.17; 95% CI 0.07, 0.41] had lower odds of obstructed labour. While contracted pelvis [AOR 3.98; 95% CI 1.68, 9.42], no partograph utilization [AOR 5.19; 95% CI 1.98, 13.6], duration of labour above 24 hours [AOR 7.61; 95% CI 2.98, 19.8] and estimated distance of 10 to 50 kilometers from the hospital [AOR 3.89; 95% CI 1.14, 13.3] had higher odds. Higher percentage of maternal (65.2%) and perinatal (60%) complications occurred among cases (p-value < 0.05). Obstructed labour accounted for 8.3% of maternal deaths and 39.7% of stillbirth. Uterine rupture, post-partum haemorrhage and sepsis were the common adverse outcomes among cases.

Conclusion

Parity, contracted pelvis, non-partograph utilization, longer duration of labour and longer distance from health facilities were determinants of obstructed labour. Maternal and perinatal morbidity and mortality due to obstructed labour are higher. Therefore, improvement of partograph utilization to identify complications early, birth preparedness, complication readiness and provision of timely interventions are recommended to prevent such complications.

Low-dose aspirin for prevention of preeclampsia: Implementation of the NICE guideline in Thailand

AIM

To evaluate the effectiveness of a preeclampsia (PE) screening program using the National Institute for Health and Care Excellence (NICE) guideline in pregnant Thai women.

METHODS

A total of 2552 pregnancies received antenatal care and were delivered at Songklanagarind Hospital between November 2016 and April 2020. PE screening with the NICE guideline was used to identify mothers at risk. In cases of positive screening results, a daily dose of 81 mg aspirin was prescribed. Pregnancy outcomes were compared with 2783 participants who had maternity care before the implementation of the screening program. The effectiveness of aspirin prophylaxis following the NICE guideline was assessed by a logistic regression model to compare the risk of PE development between before and after guidance.

RESULTS

The screening positive rate by NICE was 8.3%. Of these, 77.36% of the participants received aspirin prophylaxis according to the NICE recommendation. After the implementation of the PE screening program, the incidence of PE slightly decreased (from 4.31% to 3.72%, p = 0.274). The chance of PE in pregnancies who had high-risk factors was reduced after using low-dose aspirin prophylaxis, even though the difference was not statistically significant.

CONCLUSIONS

Screening with the NICE guidelines followed by prescription of low-dose aspirin (81 mg/day) was probably not an effective strategy for the prevention of PE in our population. Combining biophysical and biochemical markers to identify pregnant women who subsequently develop PE, concurrently with an increased dose of aspirin prophylaxis, may provide a better outcome in clinical practice.

Applying a gender lens to social norms, couple communication and decision making to increase modern contraceptive use in Ethiopia, a mixed methods study

BACKGROUND

Ethiopia, sub-Saharan Africa's second most populous country has seen improvements in women's reproductive health. The study objectives are (1) using mixed methods research, to identify determinants of contraceptive use in four regions of Ethiopia, and (2) to explore the relationship between social norms, gender equitable norms, couple communication and contraceptive use.

METHODS

The study includes both quantitative and qualitative methods. Researchers interviewed a total of 2770 women of reproductive age (15-49 years) in 2016 using a structured survey covering six health areas. Eligible households were identified using a multi-stage cluster-sampling technique. Using probability proportionate to size sampling, the researchers selected 10% of the proposed target woredas (24 of 240 woredas). The qualitative study included 8 rapid assessments, 16 in-depth interviews, 24 key informant interviews, and 16 focus group discussions. Qualitative data were analyzed using NVivo version 8.

RESULTS

Adjusted odds ratios were estimated for current modern family planning use among married women with logistic regression. The primary influencing factors for contraceptive use are gender equitable norms, high self-efficacy, and weekly exposure to the radio. Qualitative data indicate that the timing of contraceptive use is linked to the social norm of the desired family size of 4-5 children. Gender inequity is evident in couple communication with men controlling decision making even if women initiated conversations on family planning. A key finding based on an inductive analysis of qualitative data indicates that the micro-processes of couple communication and decision making are often dictated by male advantage. The study identified six micro-processes that lead to gender inequity which need to be further examined and researched.

CONCLUSIONS

Barriers to contraceptive use include unequal couple communication and compromised decision making. Inequitable gender norms are also barriers to modern contraceptive use. The study recommends using a gender lens to study couple communication and decision making, with the goal of making both processes more equitable to accelerate the adoption of modern family planning methods in Ethiopia.

Inequalities in antenatal care in Ghana, 1998-2014

Background

In order to effectively and efficiently reduce maternal mortality and ensure optimal outcomes of pregnancy, equity is required in availability and provision of antenatal care. Thus, analysis of trends of socio-economic, demographic, cultural and geographical inequities is imperative to provide a holistic explanation for differences in availability, quality and utilization of antenatal care. We, therefore, investigated the trends in inequalities  in four or more antenatal care visits in Ghana, from 1998 to 2014.

Methods

We used the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) software to analyse data from the 1998 to 2014 Ghana Demographic and Health Surveys. We disaggregated four or more antenatal care visits by four equality stratifiers: economic status, level of education, place of residence, and sub-national region. We measured inequality through summary measures: Difference, Population Attributable Risk (PAR), Ratio, and Population Attributable Fraction (PAF). A 95% uncertainty interval (UI) was constructed for point estimates to measure statistical significance.

Results

The Difference measure of 21.7% (95% UI; 15.2–28.2) and the PAF measure of 12.4% (95% UI 9.6–15.2) indicated significant absolute and relative economic-related disparities in four or more antenatal care visits favouring women in the highest wealth quintile. In the 2014 survey, the Difference measure of 13.1% (95% UI 8.2–19.1) and PAF of 6.5% (95% UI 4.2–8.7) indicate wide disparities in four or more antenatal care visits across education subgroups disfavouring non-educated women. The Difference measure of 9.3% (95% UI 5.8–12.9) and PAF of 5.8% (95% UI 4.7–6.8) suggest considerable relative and absolute urban–rural disparities in four or more antenatal care visits disfavouring rural women. The Difference measure of 20.6% (95% UI 8.8–32.2) and PAF of 7.1% (95% UI 2.9–11.4) in the 2014 survey show significant absolute and relative regional inequality in four or more antenatal care  visits, with significantly higher coverage among regions like Ashanti, compared to the Northern region.

Conclusions

We found a disproportionately lower uptake of four or more antenatal care visits among women who were poor, uneducated and living in rural areas and the Northern region. There is a need for policymakers to design interventions that will enable disadvantaged subpopulations to benefit from four or more antenatal care visits to meet the Sustainable Development Goal  3.1 that aims to reduce the maternal mortality ratio (MMR) to less than  70/100, 000 live births by 2030. Further studies are essential to understand the underlying factors for the  inequalities in antenatal care visits.

Simulation and nurse-mentoring in a statewide nurse mentoring program in Bihar, India: diagnosis of postpartum hemorrhage and intrapartum asphyxia

Background: Mentoring programs that include simulation, bedside mentoring, and didactic components are becoming increasingly popular to improve quality. These programs are designed with little evidence to inform the optimal composition of mentoring activities that would yield the greatest impact on provider skills and patient outcomes. We examined the association of number of maternal and neonatal emergency simulations performed with the diagnosis of postpartum hemorrhage (PPH) and intrapartum asphyxia in real patients. Methods: We used a prospective cohort and births were compared between- and within-facility over time. Setting included 320 public facilities in the state of Bihar, India May 2015 - 2017. The participants were deliveries and livebirths. The interventions carried out were mobile nurse-mentoring program with simulations, teamwork and communication activities, didactic teaching, demonstrations of clinical procedures and bedside mentoring including conducting deliveries. Nurse mentor pairs visited each facility for one week, covering four facilities over a four-week period, for seven to nine consecutive months. The outcome measures were diagnosis of PPH and intrapartum asphyxia. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Conclusions: Findings suggest a complex relationship between performing simulations and opportunities for direct practice with patients, and there may be an optimal balance in performing the two that would maximize diagnosis of PPH and intrapartum asphyxia.

Instituting a Curriculum for Cardio-Obstetrics Subspecialty Fellowship Training

Maternal mortality is rising in the United States, and cardiovascular disease is the leading cause. Adverse pregnancy outcomes such as preeclampsia and gestational diabetes heighten the risk of cardiovascular complications during pregnancy and the peripartum period and are associated with long-term cardiovascular risks. The field of cardio-obstetrics is a subspecialty within adult cardiology that focuses on the management of women with or at high risk for heart disease who are considering pregnancy or have become pregnant. There is growing recognition of the need for more specialists with dedicated expertise in cardio-obstetrics to improve the cardiovascular care of this high-risk patient population. Current recommendations for cardiovascular fellowship training programs accredited by the Accreditation Council for Graduate Medical Education involve establishing core competency in the knowledge of managing heart disease in pregnancy. However, little granular detail is available of what such training should entail, which can lead to knowledge gaps. Additionally, dedicated advanced subspecialty training in this area is not commonly offered. Multidisciplinary collaborative teams have been shown to improve outcomes in cardiac patients during pregnancy, and cardiovascular fellows-in-training interested in cardio-obstetrics should have the opportunity to participate in and contribute to a pregnancy heart team. In this document, we describe a proposed specialized cardio-obstetrics training pathway that could serve to adequately prepare trainees to competently and comprehensively care for women with cardiovascular disease before, during, and after pregnancy.

Enablers and barriers to post-discharge follow-up among women who have undergone a caesarean section: experiences from a prospective cohort in rural Rwanda

Background

Caesarean sections account for roughly one third of all surgical procedures performed in low-income countries. Due to lack of standardised post-discharge follow-up protocols and practices, most of available data are extracted from clinical charts during hospitalization and are thus sub-optimal for answering post-discharge outcomes questions. This study aims to determine enablers and barriers to returning to the hospital after discharge among women who have undergone a c-section at a rural district hospital in Rwanda.

Methods

Women aged ≥ 18 years who underwent c-section at Kirehe District Hospital in rural Rwanda in the period March to October 2017 were prospectively followed. A structured questionnaire was administered to participants and clinical data were extracted from medical files between March and October 2017. At discharge, consenting women were given an appointment to return for follow-up on postoperative day 10 (POD 10) (± 3 days) and provided a voucher to cover transport and compensation for participation to be redeemed on their return. Study participants received a reminder call on the eve of their scheduled appointment. We used a backward stepwise logistic regression, at an α = 0.05 significance level, to identify enablers and barriers associated with post-discharge follow-up return.

Results

Of 586 study participants, the majority (62.6%) were between 21–30 years old and 86.4% had a phone contact number. Of those eligible, 90.4% returned for follow-up. The predictors of return were counselling by a female data collector (OR = 9.85, 95%CI:1.43–37.59) and receiving a reminder call (OR = 16.47, 95%CI:7.07–38.38). Having no insurance reduced the odds of returning to follow-up (OR = 0.03, 95%CI:0.03–0.23), and those who spent more than 10.6 Euro for transport to and from the hospital were less likely to return to follow-up (OR = 0.14, 95%CI:0.04- 0.50).

Conclusion

mHealh interventions using calls or notifications can increase the post-discharge follow-up uptake. The reminder calls to patients and discharge counselling by a gender-matching provider had a positive effect on return to care. Further interventions are needed targeting the uninsured and patients facing transportation hardship. Additionally, association between counselling of women patients by a female data collector and greater return to follow-up needs further exploration to optimize counselling procedures.

Supplementary information

The online version contains supplementary material available at 10.1186/s12913-022-08137-5.

Effect of Intimate Partner Violence on Birth Preparedness and Complication Readiness at Public Health Facilities, Southwest Ethiopia, 2021: Comparative Cross-Sectional Study

Introduction

Birth preparedness and complication readiness (BPCR) strategy is a key to reducing delays of appropriate care for maternal and child health. Women’s autonomy in the decision of receiving care during pregnancy is essential for improvements in maternal health. However, there is a scarcity of information on the effect of intimate partner violence (IPV) on BPCR in Southwest Ethiopia.

Methods

A comparative cross-sectional study was conducted among 688 women (340: women who had experienced IPV and 348: women who had not experienced IPV). A multi-stage sampling technique was used to select study participants. Bivariate and multivariable logistic regression models were done. A P-value <0.05 at a 95% confidence interval was used to declare a statistical significance.

Results

BPCR among IPV women was 30.59%, lower compared with 46.84% women who did not experience IPV. Higher education [AOR=4.00 (1.20, 13.28)], partner did not drink alcohol [AOR=2.53 (1.34, 4.78)], no childhood violence [AOR=2.70 (1.37, 5.32)], partner’s pregnancy desire [AOR=3.61 (1.41, 9.21)], and good knowledge of BPCR [AOR=8.59 (3.56, 20.70)] were more likely to practice BPCR among women who experienced IPV, whereas among women who did not experience IPV, no previous pregnancy complications [AOR=2.22 (1.08, 4.55)], good knowledge of BPCR [AOR=4.90 (2.59, 9.26)] and pregnancy danger signs [AOR=5.23 (1.47, 18.56)] were more likely practice BPCR.

Conclusion

BPCR among IPV women was lower compared with women who did not experience IPV. Likewise, women’s knowledge of BPCR, obstetric danger signs during pregnancy, labor, and postpartum were lower among women who faced IPV. Therefore, minimizing women’s IPV help to improve BPCR.

Fibrinogen concentrate and maternal outcomes in severe postpartum hemorrhage: A population-based cohort study with a propensity score-matched analysis

STUDY OBJECTIVE

Fibrinogen concentrate is used to treat severe postpartum hemorrhage despite limited evidence of its effectiveness in obstetric settings. We aimed to explore the association between its administration and maternal outcomes in women with severe postpartum hemorrhage.

DESIGN, SETTING AND PATIENTS

This secondary analysis of the EPIMOMS prospective population-based study, exploring severe maternal morbidity, as defined by national expert consensus (2012-2013, 182,309 deliveries, France), included all women with severe postpartum hemorrhage and transfused with red blood cells during active bleeding.

MEASUREMENTS

The primary endpoint was maternal near-miss or death, and the secondary endpoint the total number of red blood cells units transfused.

INTERVENTIONS

We studied fibrinogen concentrate administration as a binary variable and then by the timing of its administration. We used multivariable analysis and propensity score matching to account for potential indication bias.

MAIN RESULTS

Among the 730 women with severe postpartum hemorrhage and transfused, 313 (42.9%) received fibrinogen concentrate, and 142 (19.5%) met near-miss criteria or died. The risk of near-miss or death was not significantly lower among the women treated with fibrinogen concentrate than among those not treated, in either the multivariable analysis (adjusted RR = 1.03; 95% CI, 0.72-1.49; P = 0.855) or the propensity score analysis (RR = 0.85; 95% CI, 0.55-1.32; P = 0.477). Among women treated with fibrinogen concentrate, administration more than three hours after red blood cell transfusion started was associated with a higher risk of near-miss or death than administration before or within 30 min after the transfusion began (adjusted RR = 2.07; 95% CI, 1.10-3.89; P = 0.024). Results were similar for the secondary endpoint.

CONCLUSIONS

The use of fibrinogen concentrate in severe postpartum hemorrhage needing red blood cell transfusion during active bleeding is not associated with improved maternal outcomes.

Women's Status and its Association With Home Delivery: A Cross-Sectional Study Conducted in Khyber-Pakhtunkhwa, Pakistan

INTRODUCTION

Home delivery is a predominant driver of maternal and neonatal deaths in developing countries. Despite the efforts of international organizations in Pakistan, home childbirth is common in the remote and rural areas of Khyber Pakhtunkhwa province. We studied women's position within the household (socio-economic dependence, maternal health decision making, and social mobility) and its association with the preference for home delivery.

METHODS

We conducted a cross-sectional household survey among 503 ever-married women of reproductive age (15-49 years), who have had childbirth in the last twelve months or were pregnant (more than 6 months) at the time of the interview. A two-stage cluster sampling technique has been used for recruitment. Descriptive and bivariate analyses have been conducted. A binary logistic regression model was calculated to present odds ratios and corresponding 95% confidence intervals for factor associated with home delivery.

RESULTS

An inferior status of women, restrictions in mobility and limited power in decision making related to household purchases, maternal health care, and outdoor socializing are contributing factors of home delivery. Furthermore, women having faced intimate partner violence were much more likely to deliver at home (OR = 2.66, 95% CI: 1.83.3.86, p < 0.001).

DISCUSSION

We concluded that women are in a position with minimal authority in decision making to access and deliver the baby in any health facility. We recommend that the government should ensure the availability of health facilities in nearby locations to increase institutional deliveries in the study area.

Maternal mortality study in the Eastern Democratic Republic of the Congo

Background

The reduction of maternal mortality in developing countries such as the Democratic Republic of Congo (DRC) still raises many questions. Indeed, this large country in the heart of Africa ranks 4th among the eight countries that alone account for more than 50% of maternal deaths in the world, behind India, Nigeria and Pakistan. However, there is no up-to-date data on maternal mortality in eastern DRC. This study measures the mortality rate rate in health facilities in eastern DRC and identifies the associated risk factors.

Methods

This analytical epidemiological study was based on retrospective data materna deaths recorded in 59 health facilities, in three health zones in the southern part of Maniema province in east DRC. The study was conducted from July 1, 2015 to June 30, 2020. Descriptive, bi and multivariate analyses were used.

Results

The maternal mortality rate was estimated at 620 deaths per 100,000 live births, of which 46% of maternal deaths were related to a parturients’ delayed decision in seeking healthcare in time (first delay). Maternal deaths were significantly associated with extreme ages (≤ 19 years and ≥ 40 years: p =  < 0.001), patient parity (in primigravidas and in large multiparas: p = 0.001), complications such as hemorrhagic, (p =  < 0.001), uterine ruptures:(p =  < 0.001), infections, (p =  < 0.001), and dystocia (p =  < 0.001).

Conclusion

Despite the efforts made by the DRC and its partners in the fight against maternal mortality, women continue to lose their lives when they decide to give birth. The results imply that it is imperative to strengthen both women and health professionals’ knowledge about pregnancy and maternal health and their power to reduce instances of first delay by supporting women in formulating their birth plans.

Maternal race and pre-eclampsia: Cohort study and systematic review with meta-analysis

OBJECTIVES

To examine the association between race and pre-eclampsia and gestational hypertension after adjustment for factors in maternal characteristics and medical history in a screening study from the Fetal Medicine Foundation (FMF) in England, and to perform a systematic review and meta-analysis of studies on pre-eclampsia.

DESIGN

Prospective observational study and systematic review with meta-analysis.

SETTING

Two UK maternity hospitals.

POPULATION

A total of 168 966 women with singleton pregnancies attending for routine ultrasound examination at 11-13 weeks of gestation without major abnormalities delivering at 24 weeks or more of gestation.

METHODS

Regression analysis examined the association between race and pre-eclampsia or gestational hypertension in the FMF data. Literature search to December 2021 was carried out to identify peer-reviewed publications on race and pre-eclampsia.

MAIN OUTCOME MEASURE

Relative risk of pre-eclampsia and gestational hypertension in women of black, South Asian and East Asian race by comparison to white women.

RESULTS

In black women, the respective risks of total-pre-eclampsia and preterm-pre-eclampsia were 2-fold and 2.5-fold higher, respectively, and risk of gestational hypertension was 25% higher; in South Asian women there was a 1.5-fold higher risk of preterm pre-eclampsia but not of total-pre-eclampsia and in East Asian women there was no statistically significant difference in risk of hypertensive disorders. The literature search identified 19 studies that provided data on several million pregnancies, but 17 were at moderate or high-risk of bias and only three provided risks adjusted for some maternal characteristics; consequently, these studies did not provide accurate contributions on different racial groups to the prediction of pre-eclampsia.

CONCLUSION

In women of black and South Asian origin the risk of pre-eclampsia, after adjustment for confounders, is higher than in white women.

Society for Maternal-Fetal Medicine Special Statement: Quality metric for timely postpartum follow-up after severe hypertension

Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality. Because postpartum exacerbation of severe hypertension is common, the American College of Obstetricians and Gynecologists recommends that patients with severe hypertension during the childbirth hospitalization be seen within 72 hours after discharge. In this statement, the Society for Maternal-Fetal Medicine proposes a uniform metric reflecting the rate of timely postpartum follow-up of patients with severe hypertension. The metric is designed to be measured using automated calculations based on billing codes derived from claims data. The metric can be used in quality improvement projects to increase the rate of timely follow-up in patients with severe hypertension during the childbirth hospitalization. Suggested steps for implementing such a project are outlined.

Twin Growth Discordance and Risk of Postpartum Hemorrhage: A Retrospective Cohort Study

Background

In recent years, the incidence of postpartum hemorrhage has increased globally. Multiple pregnancies and cesarean sections are well-known risk factors for postpartum hemorrhage. No studies have evaluated the associations between fetal growth anomalies and postpartum hemorrhage in women with twin pregnancies undergoing cesarean section. This study aimed to identify the relationship between fetal growth anomalies and postpartum hemorrhage in women with twin pregnancies undergoing cesarean section.

Methods

This retrospective single-center study included 3,180 women with twin pregnancies at a tertiary hospital between August 2013 and July 2020. Singleton reference charts were used to assess fetal growth restriction at birth. Discordant growth was defined as an intertwin birth weight difference of ≥20%. Logistic regression analyses were used to evaluate the association between fetal growth anomalies and postpartum hemorrhage. Additionally, sensitivity analysis of abnormal placenta and stratification by twin chorionicity were conducted.

Results

The overall incidence of postpartum hemorrhage was 4.3%. Twin growth discordance, especially with fetal growth restriction, was associated with an increased risk of postpartum hemorrhage (adjusted odds ratio [AOR] = 1.62, 95% confidence interval [CI], 1.05-2.51, P = 0.031; AOR = 1.71; 95% CI, 1.08-2.70, P = 0.022; AOR = 1.98, 95% CI, 1.21-3.25, P = 0.006, respectively). After stratification, this relationship persisted in dichorionic twins (OR = 1.71, 95% CI, 1.04-2.82, P = 0.036; OR = 1.90, 95% CI, 1.13-3.21, P = 0.016; OR = 2.48, 95% CI, 1.41-4.38, P = 0.002, respectively). However, no significant association was observed in monochorionic twin pregnancies.

Conclusion

Growth discordance, especially complicated by fetal growth restriction, was associated with an increased risk of postpartum hemorrhage in women with twin pregnancies undergoing cesarean section, and was more evident in patients with dichorionic twins.

It Takes a Village: Expanding Women's Cardiovascular Care to Include the Community as well as Cardiovascular and Primary Care Teams

Purpose of Review

Our aim is to highlight some of the current issues that prevent women from getting sex-specific and gender-specific cardiovascular care and provide recommendations for new approaches and delivery models to improve cardiovascular care for all women.

Recent Findings

Cardiovascular disease remains the number one cause of death for women in the US. Many women remain unaware of cardiovascular risk factors and many healthcare providers who care for women are also poorly informed and feel ill prepared to assess women for cardiovascular risk. Women’s Heart Centers have tried to bridge the gaps in women’s care between primary care and cardiology. Many of the impediments to care in the current models are lack of comprehensive care and socioeconomic societal limitations.

Summary

New models of care and delivery are essential to change cardiovascular outcomes for all women, especially women at high risk.

Changes in causes of pregnancy-related and maternal mortality in Zimbabwe 2007-08 to 2018-19: findings from two reproductive age mortality surveys

Background

Reducing maternal mortality is a priority of Sustainable Development Goal 3.1 which requires frequent epidemiological analysis of trends and patterns of the causes of maternal deaths. We conducted two reproductive age mortality surveys to analyse the epidemiology of maternal mortality in Zimbabwe and analysed the changes in the causes of deaths between 2007-08 and 2018-19.

Methods

We performed a before and after analysis of the causes of death among women of reproductive ages (WRAs) (12-49 years), and pregnant women from the two surveys implemented in 11 districts, selected using multi-stage cluster sampling from each province of Zimbabwe (n=10); an additional district selected from Harare. We calculated mortality incidence rates and incidence rate ratios per 10000 WRAs and pregnant women (with 95% confidence intervals), in international classification of disease groups, using negative binomial models, and compared them between the two surveys. We also calculated maternal mortality ratios, per 100 000 live births, for selected causes of pregnancy-related deaths.

Results

We identified 6188 deaths among WRAs and 325 PRDs in 2007-08, and 1856 and 137 respectively in 2018-19. Mortality in the WRAs decreased by 82% in diseases of the respiratory system and 81% in certain infectious or parasitic diseases' groups, which include HIV/AIDS and malaria. Pregnancy-related deaths decreased by 84% in the indirect causes group and by 61% in the direct causes group, and HIV/AIDS-related deaths decreased by 91% in pregnant women. Direct causes of death still had a three-fold MMR than indirect causes (151 vs. 51 deaths per 100 000) in 2018-19.

Conclusion

Zimbabwe experienced a decline in both direct and indirect causes of pregnancy-related deaths. Deaths from indirect causes declined mainly due to a reduction in HIV/AIDS-related and malaria mortality, while deaths from direct causes declined because of a reduction in obstetric haemorrhage and pregnancy-related infections. Ongoing interventions ought to improve the coverage and quality of maternal care in Zimbabwe, to further reduce deaths from direct causes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13321-7.

mHealth Phone Intervention to Reduce Maternal Deaths and Morbidity in Cameroon: Protocol for Translational Adaptation

Purpose

The purpose of this NIH-funded protocol is to adapt (Aim 1) and pilot test (Aim 2) an mHealth intervention to improve maternal and child health in Cameroon. We will adapt the 24/7 University of Alabama at Birmingham Medical Information Service via Telephone (MIST) provider support system to mMIST (mobile MIST) for peripheral providers who provide healthcare to pregnant and postpartum women and newborns in Cameroon.

Methods

In Aim 1, we apply qualitative and participatory methods (in-depth interviews and focus groups with key stakeholders) to inform the adaptation of mMIST for use in Cameroon. We use the sequential phases of the ADAPT-ITT framework to iteratively adapt mMIST incorporating qualitative findings and tailoring for local contexts. In Aim 2, we test the adapted intervention for feasibility and acceptability in Ndop, Cameroon.

Results

This study is ongoing at the time that this protocol is published.

Conclusion

The adaptation, refinement, and pilot testing of mMIST will be used to inform a larger-scale stepped wedged cluster randomized controlled effectiveness trial. If successful, this mHealth intervention could be a powerful tool enabling providers in low-resource settings to deliver improved pregnancy care, thereby reducing maternal and fetal deaths.

Trends and causes of maternal death at the Lagos University teaching hospital, Lagos, Nigeria (2007-2019)

Background

Nigeria has one of the worst global maternal mortality ratios (MMR). Institutional audit is invaluable in providing useful information for formulating preventive interventions.

Objective

To evaluate the trends, causes and socio-demographic characteristics of maternal mortality at a tertiary institution in South-western Nigeria over a period of 13 years (2007–2019).

Methodology

Cross sectional and temporal trend analysis of maternal deaths were conducted using chart reviews from 2007 to 2019. Socio-biological characteristics, booking status and ranking of clinical causes of maternal deaths were derived from patients’ chart review (2007–2019). Bivariate analysis and Annual percent change (APC) of the observed trends was respectively conducted using Stata version 17 and Joinpoint version 4.5.0.1 software respectively.

Results

In the period 2007–2019, the mean age at maternal death was 30.8 ± 5.9 years and 88.8% of mortalities occurred among the “unbooked” women. The leading causes of direct maternal mortality were Hypertension (27.0%), Sepsis (20.6%) and haemorrhage (18.7%), while anaemia in pregnancy (3.2%), Human Immunodeficiency Virus (3.2%) and Sickle Cell Disease (2.4%) were the leading indirect causes of maternal mortality Joinpoint estimates showed a statistically significant increase in MMR of about 3.4% per annum from 2211 per 100,000 live births in 2007 to 3555.6 per 100,000 live births in 2019 (APC: +3.4%, P-value < 0.001).

Conclusion

Contrary to some other reports, there was an increase in the institutional MMR between 2007 and 2019 even though the leading causes of death remained similar. Targeted interventions based on accurate data are urgently required in order to achieve the Sustainable Development Goal (SDG) 3.1.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04649-4.

Natural language processing of admission notes to predict severe maternal morbidity during the delivery encounter

BACKGROUND

Severe maternal morbidity and mortality remain public health priorities in the United States, given their high rates relative to other high-income countries and the notable racial and ethnic disparities that exist. In general, accurate risk stratification methods are needed to help patients, providers, hospitals, and health systems plan for and potentially avert adverse outcomes.

OBJECTIVE

Our objective was to understand if machine learning methods with natural language processing of history and physical notes could identify a group of patients at high risk of maternal morbidity on admission for delivery without relying on any additional patient information (eg, demographics and diagnosis codes).

STUDY DESIGN

This was a retrospective study of people admitted for delivery at 2 hospitals (hospitals A and B) in a single healthcare system between July 1, 2016, and June 30, 2020. The primary outcome was severe maternal morbidity, as defined by the Centers for Disease Control and Prevention; furthermore, we examined nontransfusion severe maternal morbidity. Clinician documents designated as history and physical notes were extracted from the electronic health record for processing and analysis. A bag-of-words approach was used for this natural language processing analysis (ie, each history or physical note was converted into a matrix of counts of individual words (or phrases) that occurred within the document). The least absolute shrinkage and selection operator models were used to generate prediction probabilities for severe maternal morbidity and nontransfusion severe maternal morbidity for each note. Model discrimination was assessed via the area under the receiver operating curve. Discrimination was compared between models using the DeLong test. Calibration plots were generated to assess model calibration. Moreover, the natural language processing models with history and physical note texts were compared with validated obstetrical comorbidity risk scores based on diagnosis codes.

RESULTS

There were 13,572 delivery encounters with history and physical notes from hospital A, split between training (A_train, n=10,250) and testing (A_test, n=3,322) datasets for model derivation and internal validation. There were 23,397 delivery encounters with history and physical notes from hospital B (B_valid) used for external validation. For the outcome of severe maternal morbidity, the natural language processing model had an area under the receiver operating curve of 0.67 (95% confidence interval, 0.63-0.72) and 0.72 (95% confidence interval, 0.70-0.74) in the A_test and B_valid datasets, respectively. For the outcome of nontransfusion severe maternal morbidity, the area under the receiver operating curve was 0.72 (95% confidence interval, 0.65-0.80) and 0.76 (95% confidence interval, 0.73-0.79) in the A_test and B_valid datasets, respectively. The calibration plots demonstrated the bag-of-words model's ability to distinguish a group of individuals at a substantially higher risk of severe maternal morbidity and nontransfusion severe maternal morbidity, notably those in the top deciles of predicted risk. Areas under the receiver operating curve in the natural language processing-based models were similar to those generated using a validated, retrospectively derived, diagnosis code-based comorbidity score.

CONCLUSION

In this practical application of machine learning, we demonstrated the capabilities of natural language processing for the prediction of severe maternal morbidity based on provider documentation inherently generated at the time of admission. This work should serve as a catalyst for providers, hospitals, and electronic health record systems to explore ways that artificial intelligence can be incorporated into clinical practice and evaluated rigorously for their ability to improve health.

Population-Based Study on the Maternal-Newborn-Child Health Continuum of Care: Evidence From Lower-Middle-Income Countries in Southeast Asia

This article aimed to assess the relationships within the continuum of care for maternal, neonatal, and child health (MNCH) at four service levels, the utilization distribution, and its contributing factors in six lower-middle-income countries in Southeast Asia. It was based on data from the Demographic and Health Survey, a nationally representative and repeated cross-sectional survey, on 50 619 ever-married women aged 15-49 years. Only 21.9% of women (n = 10 252) obtained all four levels of continuing MNCH services. Women and husbands' education and employment, parity, mass media consumption, and wealth quintiles were the strongest determinants for the continuation of care, apart from access to health care, decision-making autonomy in health care, and women's age. Identifying populations that experience health inequalities, prominent policy intervention, and better health promotion and advocacy systems regarding pregnancy, delivery, and postnatal and immunization care might help to enhance maternal and child health and equity outcomes.

Predictors of health facility childbirth among unmarried and married youth in Uganda

Background

Uganda has a high maternal mortality rate combined with poor use of health facilities at childbirth among youth. Improved use of maternal health services by the youth would help reduce maternal deaths in the country. Predictors of use of health facilities at childbirth among unmarried compared to married youth aged 15–24 years in Uganda between 2006 and 2016 are examined.

Methodology

Binary logistic regression was conducted on the pooled data of the 2006, 2011 and 2016 Uganda Demographic and Health Surveys among youth who had given birth within five years before each survey. This analysis was among a sample of 764 unmarried, compared to 5,176 married youth aged 15–24 years.

Results

Overall, unmarried youth were more likely to have a childbirth within the health facilities (79.3%) compared to married youth (67.6%). Higher odds of use of health facilities at childbirth were observed among youth with at least secondary education (OR = 2.915, 95%CI = 1.747–4.865 for unmarried vs OR = 1.633, 95%CI = 1.348–1.979 for married) and frequent antenatal care of at least four visits (OR = 1.758, 95%CI = 1.153–2.681 for unmarried vs OR = 1.792, 95%CI = 1.573–2.042 for married). Results further showed that youth with parity two or more, those that resided in rural areas and those who were engaged in agriculture had reduced odds of the use of health facilities at childbirth. In addition, among married youth, the odds of using health facilities at childbirth were higher among those with at least middle wealth index, and those with frequent access to the newspapers (OR = 1.699, 95%CI = 1.162–2.486), radio (OR = 1.290, 95%CI = 1.091–1.525) and television (OR = 1.568, 95%CI = 1.149–2.138) compared to those with no access to each of the media, yet these were not significant among unmarried youth.

Conclusion and recommendations

Frequent use of antenatal care and higher education attainment were associated with increased chances of use of health facilities while higher parity, rural residence and being employed in the agriculture sector were negatively associated with use of health facilities at childbirth among both unmarried and married youth. To enhance use of health facilities among youth, there is a need to encourage frequent antenatal care use, especially for higher parity births and for rural residents, and design policies that will improve access to mass media, youth’s education level and their economic status.

Incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia

BACKGROUND

Of the 1010 reported maternal deaths in 2018, just over 65% occurred in hospitals in Ethiopia. However, there is a lack of standardised data about the contributing factors. This study aimed to investigate the incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia.

METHODS

A retrospective cohort design was used; an audit of 1060 maternity care logbooks of adult women post-partum at Felege Hiwot Referral Hospital and University of Gondar Comprehensive Specialized Hospital. The data were abstracted between December 2018 and May 2019 using a systematic random sampling technique. We used the Facility Based Maternal Death Abstraction Form containing sociodemographic characteristics, women's medical history, and partographs. Primary postpartum haemorrhage was defined as the estimated blood loss recorded by the staff greater or equal to 500 ml for vaginal births and 1000 ml for caesarean section births, or the medical doctor diagnosis and recording of the woman as having primary postpartum haemorrhage. The data analysis was undertaken using Stata version 15. Variables with P ≤ 0.10 for significance were selected to run multivariable logistic analyses. Variables that had associations with primary postpartum haemorrhage were identified based on the odds ratio, with 95% confidence interval (CI) and P-value less than 0.05.

RESULTS

The incidence of primary postpartum haemorrhage in the hospitals was 8.8% (95% CI: 7.2, 10.6). Of these, there were 7.4% (95% CI: 2.1, 13.3) maternal deaths. Eight predictor variables were found to be independently associated with primary postpartum haemorrhage, including age ≥35 years (AOR: 2.20; 95% CI: 1.08, 4.46; P = 0.03), longer than 24 hours duration of labour (AOR: 7.18; 95% CI: 2.73, 18.90; P = 0.01), vaginal or cervical lacerations (AOR: 4.95; 95% CI: 2.49, 9.86; P = 0.01), instrumental (forceps or vacuum)-assisted birth (AOR: 2.92; 95% CI: 1.25, 6.81; P = 0.01), retained placenta (AOR: 21.83; 95% CI: 6.33, 75.20; P = 0.01), antepartum haemorrhage in recent pregnancy (AOR: 6.90; 95% CI: 3.43, 13. 84; p = 0.01), women in labour referred from primary health centres (AOR: 2.48; 95% CI: 1.39, 4.42; P = 0.02), and births managed by medical interns (AOR: 2.90; 95% CI: 1.55, 5.37; P = 0.01).

CONCLUSION

We found that while the incidence of primary postpartum haemorrhage appeared to be lower than in other studies in Africa the associated maternal mortality was higher. Although most factors associated with primary postpartum haemorrhage were consistent with those identified in the literature, two additional specific factors, were found to be prevalent among women in Ethiopia; the factors were referred women in labour from primary health facilities and births managed by medical interns. Maternal healthcare providers in these hospitals require training on the management of a birthing emergency.

Nationwide confidential enquiries into maternal deaths because of obstetric hemorrhage in the Netherlands between 2006 and 2019

INTRODUCTION

Obstetric hemorrhage-related deaths are rare in high income countries. Yet, with increasing incidences of obstetric hemorrhage in these countries, it is of utmost importance to learn lessons from each obstetric hemorrhage-related death to improve maternity care. Our objective was to calculate the obstetric hemorrhage-related maternal mortality ratio (MMR), assess causes of obstetric hemorrhage-related deaths, and identify lessons learned.

MATERIAL AND METHODS

Nationwide mixed-methods prospective case-series with confidential enquiries into maternal deaths due to obstetric hemorrhage in the Netherlands from January 1, 2006 to December 31, 2019.

RESULTS

The obstetric hemorrhage-related MMR in the Netherlands in 2006-2019 was 0.7 per 100 000 livebirths and was not statistically significantly different compared with the previous MMR of 1.0 per 100 000 livebirths in 1993-2005 (odds ratio 0.70, 95% confidence interval 0.38-1.30). Leading underlying cause of hemorrhage was retained placenta. Early recognition of persistent bleeding, prompt involvement of a senior clinician and timely management tailored to the cause of hemorrhage with attention to coagulopathy were prominent lessons learned. Also, timely recourse to surgical interventions, including hysterectomy, in case other management options fail to stop bleeding came up as an important lesson in several obstetric hemorrhage-related deaths.

CONCLUSIONS

The obstetric hemorrhage-related MMR in the Netherlands in 2006-2019 has not substantially changed compared to the MMR of the previous enquiry in 1993-2005. Although obstetric hemorrhage is commonly encountered by maternity care professionals, it is important to remain vigilant for possible adverse maternal outcomes and act upon an ongoing bleeding following birth in a more timely and adequate manner. Our confidential enquiries still led to important lessons learned with clinical advice to professionals as how to improve maternity care and avoid maternal deaths. Drawing lessons from maternal deaths should remain a qualitative and moral imperative.

Mortality Rates Among U.S. Women of Reproductive Age, 1999-2019

INTRODUCTION

High and increasing levels of pregnancy-related mortality and morbidity in the U.S. indicate that the underlying health status of reproductive-aged women may be far from optimal, yet few studies have examined mortality trends and disparities exclusively among this population.

METHODS

All-cause and cause-specific mortality data for 1999-2019 were obtained from the Centers for Disease Control and Prevention WONDER Underlying Cause of Death database. Levels and trends in mortality between 1999 and 2019 for women aged 15-44 years stratified by age, race/ethnicity, and state were examined. Given the urgent need to address pregnancy-related health disparities, the correlation between all-cause and pregnancy-related mortality rates across states for the years 2015-2019 was also examined.

RESULTS

Age-adjusted, all-cause mortality rates among women aged 15-44 years improved between 2003 and 2011 but worsened between 2011 and 2019. The recent increase in mortality among this age group was not driven solely by increases in external causes of death. Patterns differed by age, race/ethnicity, and geography, with non-Hispanic American Indian and Alaskan Native women having 2.3 and non-Hispanic Black women having 1.4 times the risk of all-cause mortality in 2019 compared with that of non-Hispanic White women. Age-adjusted all-cause mortality rates and pregnancy-related mortality rates were strongly correlated at the state level (r=0.75).

CONCLUSIONS

Increasing mortality among reproductive-aged women has substantial implications for maternal, women's, and children's health. Given the high correlation between pregnancy-related mortality and all-cause mortality at the state level, addressing the structural factors that shape mortality risks may have the greatest likelihood of improving women's health outcomes across the life course.

Confidential enquiry into maternal deaths in the Netherlands, 2006-2018

INTRODUCTION

To calculate the maternal mortality ratio (MMR) for 2006-2018 in the Netherlands and compare this with 1993-2005, and to describe women's characteristics, causes of death and improvable factors.

MATERIAL AND METHODS

We performed a nationwide, cohort study of all maternal deaths between January 1, 2006 and December 31, 2018 reported to the Audit Committee Maternal Mortality and Morbidity. Main outcome measures were the national MMR and causes of death.

RESULTS

Overall MMR was 6.2 per 100 000 live births, a decrease from 12.1 in 1993-2005 (risk ratio [RR] 0.5). Women with a non-western ethnic background had an increased MMR compared with Dutch women (MMR 6.5 vs. 5.0, RR 1.3). The MMR was increased among women with a background from Surinam/Dutch Antilles (MMR 14.7, RR 2.9). Half of all women had an uncomplicated medical history (79/161, 49.1%). Of 171 pregnancy-related deaths within 1 year postpartum, 102 (60%) had a direct and 69 (40%) an indirect cause of death. Leading causes within 42 days postpartum were cardiac disease (n = 21, 14.9%), hypertensive disorders (n = 20, 14.2%) and thrombosis (n = 19, 13.5%). Up to 1 year postpartum, the most common cause of death was cardiac disease (n = 32, 18.7%). Improvable care factors were identified in 76 (47.5%) of all deaths.

CONCLUSIONS

Maternal mortality halved in 2006-2018 compared with 1993-2005. Cardiac disease became the main cause. In almost half of all deaths, improvable factors were identified and women with a background from Surinam/Dutch Antilles had a threefold increased risk of death compared with Dutch women without a background of migration.

Simulation-based training in asthma exacerbation for medical students: effect of prior exposure to simulation training on performance

OBJECTIVES

To evaluate the effect of prior exposure to simulation-based training on medical students' performance in simulation-based training in asthma exacerbation.

METHODS

Third-year novice medical students, who had no prior experience in simulation education and completed diagnostics and internal medicine courses, were recruited in this prospective observational study and divided into the pre-exposure and unexposed groups. Each group received a four-hour asthma exacerbation simulation-based training. The pre-exposure group was exposed to a myocardial infarction simulation training two weeks prior to the asthma simulation training. The main outcome was the performance scores in clinical skills and abilities. Performance and task checklist completion were recorded during the training. In addition, the knowledge level was tested before and after the simulation training. Students' satisfaction was evaluated using a feedback questionnaire.

RESULTS

In a class of 203 third-year novice medical students, 101 (49.8%) and 102 (50.2%) were assigned to the unexposed and pre-exposure groups, respectively. Scores were higher in the post-simulation test compared with the pre-simulation test. Checklist completion was greater in the pre-exposure group compared with the unexposed group (p < 0.001). Performances in communication and medical humanistic care were better in the pre-exposure group than in the unexposed group (p < 0.001). There were no differences in medical history taking, physical examination, auxiliary examination interpretation and treatment formulation between the two groups (p > 0.001). Totally 73.21% and 26.13% of students strongly agreed and agreed, respectively, that asthma exacerbation simulation-based training was necessary and valuable.

CONCLUSIONS

Prior exposure to simulation training can improve performance in medical students, including communication skills, medical humanistic care and checklist completion in subsequent asthma exacerbation simulation-based training.

A descriptive, cross-sectional study of postpartum education: midwives' self-reported knowledge and teaching of postpartum complications in Ghana

BACKGROUND

Obstetric complications remain the leading causes of maternal deaths. Since it is not always possible to ascertain which women will develop complications and which women will not, all women who have a baby should be educated about warning signs of complications. In this study, we assessed postpartum education provided by midwives, midwives' knowledge to teach patients about complications and their skills to manage postpartum complications.

METHODS

Descriptive, cross-sectional study of 245 midwives in four hospitals in Tamale, Ghana, using an electronic questionnaire. Data analyzed in Stata 16 software using descriptive, bivariate, and multivariate statistics.

RESULTS

Majority of midwives were female (98%). Mean age of midwives was 32 years. Most midwives spent 6 to 15 min teaching patients on warning signs of complications (61.89%). Mode of discharge education was mostly individual (83.13%). Most midwives reported no reference materials given to patients (66.39%). About 93.45% of midwives strongly agreed or agreed it is their responsibility to teach all patients, regardless of risk factors, about warning signs of complications. However, midwives did not always teach patients about complications. The majority of midwives felt they were knowledgeable or very knowledgeable to teach patients about hemorrhage (95.08%), infection (94.67%), preeclampsia/ eclampsia (90.95%), and hypertension (89.35%). Similarly, most midwives felt they had the skills to manage these same four obstetric complications. Unsurprisingly, most midwives were more likely to always educate their patients about hemorrhage, infection, preeclampsia/ eclampsia, and hypertension-the complications they were more knowledgeable about. Many midwives felt not knowledgeable about and not competent to manage postpartum depression, cardiac events, pulmonary embolism, and venous thrombosis. In the same regard, many midwives did not teach patients about the life-threatening complications they were least knowledgeable about.

CONCLUSIONS

Midwives did not always teach patients about complications. Most midwives felt knowledgeable to teach and manage hemorrhage, infection, and preeclampsia/hypertension but not cardiac events, pulmonary embolism, and venous thrombosis. Additional training of midwives on life-threatening complications such as pulmonary embolism and cardiac events is recommended.

Endometriosis does not seem to be an influencing factor of hypertensive disorders of pregnancy in IVF / ICSI cycles

INTRODUCTION

To evaluate whether the incidence of hypertensive disorders of pregnancy (HDP) in pregnant women was related to endometriosis (EM), ovulation and embryo vitrification technology.

METHODS

A retrospective cohort study was conducted on the clinical data of 3674 women who were treated with IVF / ICSI in the Reproductive Medicine Center of the First Affiliated Hospital of Sun Yat-sen University and maintained clinical pregnancy for more than 20 weeks. All pregnancies were followed up until the end of pregnancy. The follow-up consisted of recording the course of pregnancy, pregnancy complications, and basic situation of newborns.

RESULTS

Compared with NC-FET without EM, HRT-FET without EM was found to have a higher incidence of HDP during pregnancy (2.7% V.S. 6.1%, P<0.001); however, no significant difference was found in the incidence of HDP between NC-FET and HRT-FET combined with EM (4.0% V.S. 5.7%, P>0.05). In total frozen-thawed embryo transfer (total-FET), the incidence of HDP in the HRT cycle without ovulation (HRT-FET) was observed to be higher than that in the NC cycle with ovulation (NC-FET) (2.8% V.S. 6.1%, P<0.001). In patients with EM, no significant difference was found in the incidence of HDP between fresh ET and NC-FET (1.2% V.S. 4.0%, P>0.05).

CONCLUSION

EM does not seem to have an effect on the occurrence of HDP in assisted reproductive technology. During the FET cycle, the formation of the corpus luteum may play a protective role in the occurrence and development of HDP. Potential damage to the embryo caused by cryopreservation seems to have no effect on the occurrence of HDP.

Real-time ultrasound-guided stellate ganglion block for migraine: an observational study

Objective

To observe whether ultrasound-guided stellate ganglion block (SGB) can effectively relieve migraine pain and improve the quality of migraine patients’ life.

Methods

81 patients with migraines were enrolled in this study. The patients received SGB with 6 ml of 0.15% ropivacaine once every week for four times. Migraine was assessed with the Migraine Disability Assessment Scale (MIDAS) at baseline and three-months follow-up (Tm). The numerical rating scale (NRS) score at baseline, one day after treatment (Td) and Tm, the frequency of analgesic use in 3 months and the side effects were also recorded at the same time.

Results

The NRS score of migraine subjects decreased significantly from 7.0 (2.0) to 3.0 (1.0) at Td and 2.0 (2.0) at Tm (vs baseline, P < 0.01). The MIDAS total scores were 14.0 (10.5) at baseline and 7.0 (4.5) at Tm (P < 0.001). During the three months, the frequency of analgesic consumption was decreased from 6.2 ± 2.8 to 1.9 ± 1.8. There were no serious side effects.

Conclusions

This study confirmed that ultrasound-guided SGB is an effective method to treat migraines. This technique can reduce pain and disability and then improve the quality of life of patients with migraines.

Centering Equity and Developing the Maternal Health Workforce: Building the National Maternal Health Learning and Innovation Center

Purpose

The purpose of this article is to describe the development of the Maternal Health Learning and Innovation Center (MHLIC), a national initiative designed to enhance workforce capacity of maternal health professionals in the United States.

Description

The mission of the MHLIC is to foster collaboration and learning among diverse stakeholders to accelerate evidence-informed approaches advancing equitable maternal health outcomes through engagement, innovation, and policy. Working to center equity in all efforts, the MHLIC builds workforce capacity through partnership, training, technical assistance, coaching, facilitation of peer learning, and a national resource repository.

Assessment

The MHLIC employed several assessment strategies in its first year, including a baseline learning survey of awardees, a stakeholder survey of potential collaborators in maternal health, and advisory convenings. Internally the MHLIC team assessed its own intercultural development. Assessment results informed internal and external approaches to workforce development.

Conclusions

Telehealth implementation, access to services for rural populations, racial inequities, and data use and dissemination were the primary gaps that awardees and other stakeholders identified. The MHLIC is unique in its collaborative design approach and the centering of equity as foundational to the structure, subject, and culture of its work. The MHLIC utilizes a collaborative approach that capitalizes on academic and practice partners’ extensive expertise in maternal health systems. Key to the success of future maternal health efforts is workforce development that builds the awareness and capacity to advance racial and geographic equity for public health, community, and clinical professionals.

Risk management of pregnant women and the associated low maternal mortality from 2008-2017 in China: a national longitude study

Background

Reducing maternal mortality is one of the key targets of the Sustainable Development Goals (SDGs). In response to the impact of increased birth rate on maternal and child safety following the implementation of the two-child policy in 2013, the Chinese government implemented the risk management strategy (namely Five Strategies for Maternal and Newborn Safety, FSMNS) to reduce maternal mortality ratio (MMR). We aimed to analyze the changes in the proportion of pregnant women at high risk screened before and after the implementation of the risk management strategy and the association with maternal mortality during the two-child policy era in China.

Methods

We conducted a nationwide longitudinal study using data obtained from the National Statistical Yearbook and the National Health Statistics Yearbook for all 31 provinces from 2008–2017 to assess and analyze the changes in the proportion of pregnant women at high risk screened before (2008–2013) and after (2014–2017) the implementation of the risk management strategy during the two-child policy era. We used generalized estimating equation (GEE) models to analyze the relationship between the proportion of pregnant women at high risk and MMR after controlling for sociodemographic factors, health resources, and other maternal healthcare factors.

Results

In the past decade, the number of livebirths in China increased by 32.3%, from 13.3 million in 2008 to 17.6 million in 2017. The median proportion of pregnant women at high risk in 31 provinces increased by 64.8%, from 14.87% in 2008 to 24.50% in 2017. The annual rate of increase in the median proportion of pregnant women at high risk after the implementation of risk management (1.33%) was higher than that before the implementation (0.74%). The median MMR in China decreased by 39.6%, from 21.7 per 100,000 livebirths in 2008 to 13.1 per 100,000 livebirths in 2017. The univariate GEE models showed that MMR decreased by 7.9% per year from 2008–2017 (cRR 0.92, 95% CI 0.91–0.93), and the proportion of pregnant women at high risk was negatively correlated with MMR (cRR 0.97, 95%CI 0.94–0.99; p = 0.001). In the multivariate GEE models, after adjusting for confounders, the proportion of pregnant women at high risk remained negatively correlated with MMR. In the subgroup analysis, the association of MMR with GDP per capita and government health expenditure per capita existed only prior to the implementation of risk management; while high MMR was associated with a low proportion of pregnant women at high risk after the implementation of risk management.

Conclusion

The national risk management strategy contributed to the stable decline of MMR in China during the two-child policy era. Further attention should be focused on pregnant women in China’s central and western regions to ensure reaching SDGs targets and the ‘Healthy China Plan’ by 2030.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07721-z.

Impact of the implementation of the WHO Safe Childbirth Checklist on essential birth practices and adverse events in two Brazilian hospitals: a before and after study

OBJECTIVE

The WHO Safe Childbirth Checklist (SCC) is a promising initiative for safety in childbirth care, but the evidence about its impact on clinical outcomes is limited. This study analysed the impact of SCC on essential birth practices (EBPs), obstetric complications and adverse events (AEs) in hospitals of different profiles.

DESIGN

Quasi-experimental, time-series study and pre/post intervention.

SETTING

Two hospitals in North-East Brazil, one at a tertiary level (H1) and another at a secondary level (H2).

PARTICIPANTS

1440 women and their newborns, excluding those with congenital malformations.

INTERVENTIONS

The implementation of the SCC involved its cross-cultural adaptation, raising awareness with videos and posters, learning sessions about the SCC and auditing and feedback on adherence indicators.

PRIMARY AND SECONDARY OUTCOME MEASURES

Simple and composite indicators related to seven EBPs, 3 complications and 10 AEs were monitored for 1 year, every 2 weeks, totalling 1440 observed deliveries.

RESULTS

The checklist was adopted in 83.3% (n=300) of deliveries in H1 and in 33.6% (n=121) in H2. The hospital with the highest adoption rate for SCC (H1) showed greater adherence to EBPs (improvement of 50.9%;p<0.001) and greater reduction in clinical outcome indicators compared with its baseline: percentage of deliveries with severe complications (reduction of 30.8%;p=0.005); Adverse Outcome Index (reduction of 25.6%;p=0.049); Weighted Adverse Outcome Score (reduction of 39.5%;p<0.001); Severity Index (reduction of 18.4%;p<0.001). In H2, whose adherence to the SCC was lower, there was an improvement of 24.7% compared with before SCC implementation in the composite indicator of EBPs (p=0.002) and a reduction of 49.2% in severe complications (p=0.027), but there was no significant reduction in AEs.

CONCLUSIONS

A multifaceted SCC-based intervention can be effective in improving adherence to EBPs and clinical outcomes in childbirth. The context and adherence to the SCC seem to modulate its impact, working better in a hospital of higher complexity.