Lost opportunities for effective management of obstetric conditions to reduce maternal mortality and severe maternal morbidity in Argentina and Uruguay

Social determinants and exposure to intimate partner violence in women with severe acute maternal morbidity in the intensive care unit: a systematic review

BACKGROUND

Studying severe acute maternal morbidity in the intensive care unit improves our understanding of potential factors affecting maternal health.

AIM

To review evidence on maternal exposure to intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit.

METHODS

The protocol for this review was registered in PROSPERO (registration number CRD42016037492). A systematic search was performed in MEDLINE, CINAHL, ProQuest, LILACS and SciELO using the search terms "intensive care unit", "intensive care", "critical care" and "critically ill" in combination with "intimate partner violence", "social determinants of health", "severe acute maternal morbidity", pregnancy, postpartum and other similar terms. Eligible studies were (i) quantitative, (ii) published in English and Spanish, (iii) from 2000 to 2021, (iv) with data related to intimate partner violence and/or social determinants of health, and (v) investigating severe acute maternal morbidity (maternity patients treated in the intensive care unit during pregnancy, childbirth or within 42 days of pregnancy termination). Of 52,866 studies initially identified, 1087 full texts were assessed and 156 studies included. Studies were independently assessed by two reviewers for screening, revision, quality assessment and abstracted data. Studies were categorised into high/middle/low-income countries and summarised data were presented using a narrative description, due to heterogenic data as: (i) exposure to intimate partner violence and (ii) social determinants of health.

RESULTS

One study assessed intimate partner violence among mothers with severe acute maternal morbidity in the intensive care unit and found that women exposed to intimate partner violence before and during pregnancy had a nearly four-fold risk of severe acute maternal morbidity requiring ICU admission. Few social determinants of health other than age were reported in most studies.

CONCLUSION

This review identified a significant gap in knowledge concerning intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit, which is essential to better understand the complete picture of the maternal morbidity spectrum and reduce maternal mortality.

The contributions of parental lactation on offspring development: It's not udder nonsense!

The Developmental Origins of Health and Disease (DOHaD) hypothesis describes how maternal stress exposures experienced during critical periods of perinatal life are linked to altered developmental trajectories in offspring. Perinatal stress also induces changes in lactogenesis, milk volume, maternal care, and the nutritive and non-nutritive components of milk, affecting short and long-term developmental outcomes in offspring. For instance, selective early life stressors shape the contents of milk, including macro/micronutrients, immune components, microbiota, enzymes, hormones, milk-derived extracellular vesicles, and milk microRNAs. In this review, we highlight the contributions of parental lactation to offspring development by examining changes in the composition of breast milk in response to three well-characterized maternal stressors: nutritive stress, immune stress, and psychological stress. We discuss recent findings in human, animal, and in vitro models, their clinical relevance, study limitations, and potential therapeutic significance to improving human health and infant survival. We also discuss the benefits of enrichment methods and support tools that can be used to improve milk quality and volume as well as related developmental outcomes in offspring. Lastly, we use evidence-based primary literature to convey that even though select maternal stressors may modulate lactation biology (by influencing milk composition) depending on the severity and length of exposure, exclusive and/or prolonged milk feeding may attenuate the negative in utero effects of early life stressors and promote healthy developmental trajectories. Overall, scientific evidence supports lactation to be protective against nutritive and immune stressors, but the benefits of lactation in response to psychological stressors need further investigation.

Got milk? Maternal immune activation during the mid-lactational period affects nutritional milk quality and adolescent offspring sensory processing in male and female rats

Previous studies have underscored the importance of breastfeeding and parental care on offspring development and behavior. However, their contribution as dynamic variables in animal models of early life stress are often overlooked. In the present study, we investigated how lipopolysaccharide (LPS)-induced maternal immune activation (MIA) on postnatal day (P)10 affects maternal care, milk, and offspring development. MIA was associated with elevated milk corticosterone concentrations on P10, which recovered by P11. In contrast, both milk triglyceride and percent creamatocrit values demonstrated a prolonged decrease following inflammatory challenge. Adolescent MIA offspring were heavier, which is often suggestive of poor early life nutrition. While MIA did not decrease maternal care quality, there was a significant compensatory increase in maternal licking and grooming the day following inflammatory challenge. However, this did not protect against disrupted neonatal huddling or later-life alterations in sensorimotor gating, conditioned fear, mechanical allodynia, or reductions in hippocampal parvalbumin expression in MIA offspring. MIA-associated changes in brain and behavior were likely driven by differences in milk nutritional values and not by direct exposure to LPS or inflammatory molecules as neither LPS binding protein nor interleukin-6 milk levels differed between groups. These findings reflected comparable microbiome and transcriptomic patterns at the genome-wide level. Animal models of early life stress can impact both parents and their offspring. One mechanism that can mediate the effects of such stressors is changes to maternal lactation quality which our data show can confer multifaceted and compounding effects on offspring physiology and behavior.

Abortion-related morbidity in six Latin American and Caribbean countries: findings of the WHO/HRP multi-country survey on abortion (MCS-A)

INTRODUCTION

Abortion-related complications are a significant cause of morbidity and mortality among women in many Latin American and Caribbean (LAC) countries. The objective of this study was to characterise abortion-related complication severity, describe the management of these complications and report women's experiences with abortion care in selected countries of the Americas region.

METHODS

This is a cross-sectional study of 70 health facilities across six countries in the region. We collected data on women's characteristics including socio-demographics, obstetric history, clinical information, management procedures and using Audio Computer-Assisted Self-Interviewing (ACASI) survey the experience of abortion care. Descriptive bivariate analysis was performed for women's characteristics, management of complications and reported experiences of abortion care by severity of complications, organised in five hierarchical mutually exclusive categories based on indicators present at assessment. Generalised linear estimation models were used to assess the association between women's characteristics and severity of complications.

RESULTS

We collected data on 7983 women with abortion-related complications. Complications were classified as mild (46.3%), moderate (49.5%), potentially life-threatening (3.1%), near-miss cases (1.1%) and deaths (0.2%). Being single, having a gestational age of ≥13 weeks and having expelled products of conception before arrival at the facility were significantly associated with experiencing severe maternal outcomes compared with mild complications.Management of abortion-related complications included both uterotonics and uterine evacuation for two-thirds of the women while one-third received uterine evacuation only. Surgical uterine evacuation was performed in 93.2% (7437/7983) of women, being vacuum aspiration the most common one (5007/7437, 67.4%).Of the 327 women who completed the ACASI survey, 16.5% reported having an induced abortion, 12.5% of the women stated that they were not given explanations regarding their care nor were able to ask questions during their examination and treatment with percentages increasing with the severity of morbidity.

CONCLUSIONS

This is one of the first studies using a standardised methodology to measure severity of abortion-related complications and women's experiences with abortion care in LAC. Results aim to inform policies and programmes addressing sexual and reproductive rights and health in the region.

[Foundations for the development and implementation of a women's and perinatal health information model for management in Latin AmericaFundamentos do desenvolvimento e implementação de um modelo de informação em saúde da materna e perinatal orientado à gestão na América Latina]

OBJECTIVE

The Perinatal Information System (SIP) represents a milestone in the use of systematized information in the Region of the Americas. What has been learned from the system has contributed to the development of a model based on a set of core indicators (SCI). The objective of the study was to describe the historical and methodological process involved in the development, implementation, and territorial scaling-up of an SCI to monitor and evaluate women's and perinatal health policies, programs, and services geared to management (SIP-GESTIÓN).

METHODS

The study was conducted in two stages: 1) a four-phase validation of an SCI in a hospital network: a) construction of the theoretical indicator model, b) operations research, c) final selection of the indicators, and d) the definition of reference standards; and 2) territorial scaling-up.

RESULTS

A total of 17 indicator models were identified. The initial model included 177 indicators divided into seven dimensions (context, habits, accessibility, use of services, quality of care, maternal and fetal impact, and maternal and neonatal impact), with 21 indicators remaining after three Delphi rounds. The final model (SIP-GESTIÓN), which included 40 indicators, was then used to study 240,021 (79.1%) of the 303,559 deliveries attended in 122 selected maternity facilities in 24 jurisdictions (100%) in Argentina. The information is presented in national terms and by health region, province, and hospital.

CONCLUSIONS

This model has made it possible to achieve high levels of information coverage and quality and territorial scaling-up and is useful for management, research, and the reorientation of programs and policies.

[Tacit and explicit knowledge: comparative analysis of the prioritization of maternal health problems in Mexico]

OBJECTIVE

To identify coincidences and differences in the identification and prioritization of maternal healthcare service problems in Mexico based on the perspective of tacit knowledge and explicit knowledge that may offer evidence that can contribute to attaining the Sustainable Development Goals.

METHODS

Mixed study performed in three stages: 1) systematization of maternal healthcare service problems identified by tacit knowledge (derived from professional experience); 2) identification of maternal healthcare service problems in Latin America addressed by explicit knowledge (scientific publications); 3) comparison between the problems identified by tacit and explicit knowledge.

RESULTS

The main problems of maternal health services identified by tacit knowledge are related to poor quality of care, while the predominant problems studied in the scientific literature are related to access barriers to health services. Approximately, 70% of the problems identified by tacit knowledge are also mentioned in the explicit knowledge. Conversely, 70% of the problems identified in the literature are also considered by tacit knowledge. Nevertheless, when looking at the problems taken one by one, no statistically significant similarities were found.

CONCLUSIONS

The study discovered that the identification of maternal health service problems by tacit knowledge and explicit knowledge is fairly comparable, according to the comparability index used in the study, and highlights the interest of integrating both approaches in order to improve prioritization and decision making towards the Sustainable Development Goals.

Maternal Mortality Ratio and Causes of Death in IRI Between 2009 and 2012

Objective: The Maternal Mortality Ratio is an important health indicator. We presented the distribution and causes of maternal mortality in Islamic Republic of Iran. Materials and methods: After provision of an electronic Registry system for date entry, a descriptive-retrospective data collection had been performed for all maternal Deaths in March 2009- March 2012. All maternal deaths and their demographic characteristic were identified by using medical registries, death certificates, and relevant codes according to International Classification of Diseases (ICD-9) during pregnancy, labor, and 42 days after parturition. Results: During 3 years, there were 5094317 deliveries and 941 maternal deaths (MMR of 18.5 per 1000000 live births). We had access to pertained data of 896 cases (95.2%) for review in our study. Of 896 reported deaths, 549 were classified as direct, 302 as indirect and 45 as unknown. Hemorrhage was the most common cause of maternal mortality, followed by Preeclampsia, Eclampsia and sepsis. Among all indirect causes, cardio -vascular diseases were responsible for 10% of maternal deaths, followed by thromboembolism, HTN and renal diseases. Conclusion: Although maternal mortality ratio in IRI could be comparable with the developed countries but its pattern is following developing countries and with this study we had provided reliable data for other prospective studies.

["I was like a ticking bomb": Experiences of severe maternal morbidity in the Metropolitan Area of Buenos Aires]

With the objective of recording and analyzing women's experiences with severe maternal morbidity from their perspective, between February and May 2011, 16 semi-structured interviews with women treated in the public hospitals of the Buenos Aires Metropolitan Area who suffered from severe maternal morbidity were carried out. In their testimonies, women report a number of delays in care, such as difficulties in identifying the problem on time, obstacles in accessing health centers and important faults in the management of obstetric emergencies. They describe the event as surprising, distressing and painful, a perception reinforced by the violation of their rights and significant communication problems. These findings are meant as a step towards the holistic and comprehensive study of severe maternal morbidity, as well as to confirm the urgent need for further research from a gender and humans rights perspective.

Lipopolysaccharide-induced sickness behavior in lactating rats decreases ultrasonic vocalizations and exacerbates immune system activity in male offspring

OBJECTIVE

The present study analyzed the effects of lipopolysaccharide (LPS) on maternal behavior during lactation and possible correlations with changes in emotional and immune responses in offspring.

METHODS

Lactating rats received 100 μg/kg LPS, and the control group received saline solution on lactation day (LD) 3. Maternal general activity and maternal behavior were observed on LD5 (i.e. the day that the peak of fever occurred). In male pups, hematological parameters and ultrasonic vocalizations (USVs) were assessed on LD5. At weaning, an additional dose of LPS (50 µg/kg, i.p.) was administered in male pups, and open-field behavior, oxidative burst and phagocytosis were evaluated.

RESULTS

A reduction in the time in which dams retrieved the pups was observed, whereas no effects on maternal aggressive behavior were found. On LD5, a reduction of the frequency of USVs was observed in pups, but no signs of inflammation were found. At weaning, an increase in immune system activity was observed, but no differences in open-field behavior were found.

CONCLUSION

These results indicate that inflammation in lactating mothers disrupted mother/pup interactions and may have produced short- and long-term effects on pup behavior as well as biological pathways that modulate inflammatory responses to bacterial endotoxin challenge in pups.

The epidemiology of life-threatening complications associated with reproductive process in public hospitals in Argentina

OBJECTIVE

To analyse life-threatening obstetric complications that occurred in public hospitals in Argentina.

DESIGN

Multicentre collaborative cross-sectional study.

SETTING

Twenty-five hospitals included in the Perinatal Network of Buenos Aires Metropolitan Area.

POPULATION

Women giving birth in participating hospitals during a 1-year period.

METHODS

All cases of severe maternal morbidity (SMM) and maternal mortality (MM) during pregnancy (including miscarriage and induced abortion), labour and puerperium were included. Data were collected prospectively.

MAIN OUTCOME MEASURES

Identification criteria, main causes and incidence of SMM; case-fatality rates, morbidity-mortality index and effective intervention's use rate.

RESULTS

A total of 552 women with life-threatening conditions were identified: 518 with SMM, 34 with MM. Identification criteria for SMM were case-management (48.9%), organ dysfunction (15.2%) and mixed criteria (35.9%). Incidence of SMM was 0.8% (95% confidence interval [95% CI] 0.73-0.87%) and hospital maternal death ratio was 52.3 per 100 000 live births (95% CI 35.5-69.1). Main causes of MM were abortion complications and puerperal sepsis; main causes of SMM were postpartum haemorrhage and hypertension. Overall case-fatality rate was 6.2% (95% CI 4.4-8.6): the highest due to sepsis (14.8%) and abortion complications (13.3%). Morbidity-mortality index was 15:1 (95% CI 7.5-30.8). Use rate of known effective interventions to prevent or treat main causes of MM and SMM was 52.3% (95% CI 46.9-57.7).

CONCLUSIONS

This study describes the importance of life-threatening obstetric complications that took place in public hospitals with comprehensive obstetric care and the low utilisation of known effective interventions that may decrease rates of SMM and MM. It also provides arguments that justify the need to develop a surveillance system for SMM.

Responsiveness of emergency obstetric care systems in low- and middle-income countries: a critical review of the "third delay"

We reviewed the evidence on the duration, causes and effects of delays in providing emergency obstetric care to women attending health facilities (the third delay) in low- and middle-income countries. We performed a critical literature review using terms related to obstetric care, birth outcome, delays and developing countries. A manual search of reference lists of key articles was also performed. 69 studies met the inclusion criteria. Most studies reported long delays in providing care, and the mean waiting time for women admitted with complications was as much as 24 h before treatment. The three most cited barriers to providing timely care were shortage of treatment materials, surgery facilities and qualified staff. Existing evidence is insufficient to estimate the effect of delays on birth outcomes. Delays in providing emergency obstetric care seem common in resource-constrained settings but further research is necessary to determine the effect of the third delay on birth outcomes.

Maternal morbidity: neglected dimension of safe motherhood in the developing world

In safe motherhood programming in the developing world, insufficient attention has been given to maternal morbidity, which can extend well beyond childbirth. For every woman who dies of pregnancy-related causes, an estimated 20 women experience acute or chronic morbidity. Maternal morbidity adversely affects families, communities and societies. Maternal morbidity has multiple causes, with duration ranging from acute to chronic, severity ranging from transient to permanent and with a range of diagnosis and treatment options. This article addresses six selected relatively neglected aspects of maternal morbidity to illustrate the range of acute and chronic morbidities that can affect women related to pregnancy and childbearing that are prevalent in developing countries: anaemia, maternal depression, infertility, fistula, uterine rupture and scarring and genital and uterine prolapse. Based on this review, recommendations to reduce maternal morbidity include: expand the focus of safe motherhood to explicitly include morbidity; improve data on incidence and prevalence of maternal morbidity; link mortality and morbidity outcomes and programming; increase access to facility- and community-based maternal health care and reproductive health care; and address the antecedents to poor maternal health through a lifecycle approach.

Maternal mortality from preeclampsia/eclampsia

Preeclampsia/eclampsia is one of the 3 leading causes of maternal morbidity and mortality worldwide. During the past 50 years, there has been a significant reduction in the rates of eclampsia, maternal mortality, and maternal morbidity in the developed countries. In contrast, the rates of eclampsia, maternal complications, and maternal mortality remain high in the developing countries. These differences are mainly due to universal access to prenatal care, access to timely care, and proper management of patients with preeclampsia-eclampsia in the developed countries. In contrast, most of maternal deaths and complications are due to lack of prenatal care, lack of access to hospital care, lack of resources, and inappropriate diagnosis and management of patients with preeclampsia-eclampsia in the developing countries. Preeclampsia/eclampsia is associated with substantial maternal complications, both acute and long-term. Clear protocols for early detection and management of hypertension in pregnancy at all levels of health care are required for better maternal as well as perinatal outcome. This is especially important in the developing countries.