Late maternal deaths: a neglected responsibility

Outcome reporting in studies on pregnant women with cardiac disease: a systematic review: Outcomes in studies on pregnancy and heart disease

BACKGROUND

Although considerable variation in the reporting and definition of outcomes in cardio-obstetric studies is known, the extent of this variation has not been documented. The primary objective of this systematic review was to highlight this variation and inform the development of a Core Outcome Set for studies on Cardiac disease in Pregnancy (COSCarP).

METHODS

Medline, Embase, Web of Science and Cochrane Central databases were searched from 1980 to 2018 to identify all English-language publications on pregnancy and heart disease. Title/abstract screening and data extraction which included details on the study, patient population, and all reported outcomes, was performed in duplicate by two reviewers. As the aim of the review was to identify variation in outcome reporting, risk-of-bias assessment was not performed. The study protocol was registered on PROSPERO (CRD42016038218).

RESULTS

The final analysis included 422 cardio-obstetric studies. Maternal mortality or survival were reported in 232/422 studies, with inconsistency in terms of cause of death [all-cause (n=65), cardiac (n=55) or obstetric (n=10)] or timeframe (ranging from in-hospital mortality (n=11) to mortality 5 years following pregnancy). In 95/232 studies (41%), the cause and timeframe were not specified. Similar inconsistencies in reporting and definitions were noted for outcomes such as heart failure (n=298), perinatal loss (n=296), fetal growth (n=221), bleeding (n=205), arrhythmias (n=202), preterm birth (n=191), thromboembolism (n=153) and hypertensive disorders (n=122). Functioning / life-impact and adverse effects of treatment were sparingly reported in cardio-obstetric studies.

CONCLUSIONS

This systematic review hopes to create awareness among cardio-obstetric teams about the inconsistencies in reporting and defining outcomes which makes it difficult to compare studies and perform meta-analyses. COSCarP which is being developed through international consensus between patients and care-providers will provide cardio-obstetrics teams with a minimal set of outcomes to be reported in future cardio-obstetric studies.

The global burden of maternal disorders attributable to iron deficiency related sub-disorders in 204 countries and territories: an analysis for the Global Burden of Disease study

Background

Pregnancy-related anemia presents a significant health concern for approximately 500 million women of reproductive age worldwide. To better prevent maternal disorders, it is essential to understand the impact of iron deficiency across different maternal disorders, regions, age groups, and subcategories.

Methods

Based on the comprehensive maternal disorders data sourced from the 2019 Global Burden of Disease study, an investigation was carried out focusing on Disability-Adjusted Life Years (DALYs) associated with iron deficiency spanning the period from 1990 to 2019. In addition, Estimated Annual Percentage Changes (EAPCs) were computed for the duration of the study.

Results

Our study indicates decreasing mortality rates and years of life lost due to maternal conditions related to iron deficiency, such as maternal hemorrhage, miscarriage, abortion, hypertensive disorders, and infections. However, mortality rates and years of life lost due to indirect and late maternal deaths, as well as deaths aggravated by HIV/AIDS, have increased in high socio-demographic index (SDI) regions, especially in North America. Moreover, the proportion of maternal deaths aggravated by HIV/AIDS due to iron deficiency is rising globally, especially in Southern Sub-Saharan Africa, Oceania, and Georgia. In addition, in the Maldives, the age-standardized DALYs for maternal disorders attributable to iron deficiency exhibited a notable decreasing trend, encompassing a range of conditions. Furthermore, there was a significant decrease in Disability-Adjusted Life Years rate for miscarriages and preterm births among women aged 15-49, with hypertensive disorders posing the highest burden among women aged 15-39.

Conclusion

The burden of maternal disorders caused by iron deficiency is decreasing in most regions and subtypes, except for deaths aggravated by HIV/AIDS. By thoroughly understanding the details of how iron deficiency impacts the health of pregnant women, health policymakers, healthcare professionals, and researchers can more effectively pinpoint and address the root causes of inequalities in maternal health.

Time series analysis: trend in late maternal mortality in Brazil, 2010-2019

To analyze the temporal trend of the late maternal mortality ratio (LMMR) in Brazil and its geographic regions in the period from 2010 to 2019, an ecological time series study was conducted. Data related to late maternal mortality from information systems of the Brazilian Ministry of Health were used. Statistical analysis used Prais-Winsten autoregressive models. A total of 1,470 late maternal deaths were reported in Brazil, resulting in an LMMR of 5 deaths per 100,000 live births. The late maternal mortality records revealed regional disparities, with the lowest index in the North (3.5/100,000 live births) and the highest in the South (8.3/100,000 live births). The LMMR showed an increasing trend in the country, with a general increase in the LMMR in the period and a mean annual percentage variation of 9.79% (95%CI: 4.32; 15.54). The Central-West region led this increase, with a mean annual percentage change of 26.06% (95%CI: 16.36; 36.56), followed by the North and Northeast regions, with 23.5% (95%CI: 13.93; 33.88). About 83% of the reported late maternal deaths were investigated, and 65.6% were corrected by the Maternal Mortality Committees. These findings highlight the relevance of late maternal mortality as an important indicator for maternal health, which is often invisible. The increase in the LMMR result from the improvement in the quality of the registration of these deaths in recent years in Brazil, and especially from the work of investigating deaths. The fragility of reporting with regional disparities points to the need for a more comprehensive approach that promotes equity and prevention of avoidable late maternal mortality.

Global burden of maternal disorders attributable to malnutrition from 1990 to 2019 and predictions to 2035: worsening or improving?

Background and aims

Maternal malnutrition is a major global public health problem that can lead to serious maternal diseases. This study aimed to analyze and predict the spatio-temporal trends in the burden of maternal disorders attributable to malnutrition, and to provide a basis for scientific improvement of maternal malnutrition and targeted prevention of maternal disorders.

Methods

Data on maternal disorders attributable to malnutrition, including number of deaths, disability-adjusted life years (DALYs), population attributable fractions (PAFs), age-standardized mortality rates (ASMRs), and age-standardized DALY rates (ASDRs) were obtained from the Global Burden of Disease Study 2019 to describe their epidemiological characteristics by age, region, year, and type of disease. A log-linear regression model was used to calculate the annual percentage change (AAPC) of ASMR or ASDR to reflect their temporal trends. Bayesian age-period-cohort model was used to predict the number of deaths and mortality rates to 2035.

Results

Global number of deaths and DALYs for maternal disorders attributable to malnutrition declined by 42.35 and 41.61% from 1990 to 2019, with an AAPC of -3.09 (95% CI: -3.31, -2.88) and -2.98 (95% CI: -3.20, -2.77) for ASMR and ASDR, respectively. The burden was higher among younger pregnant women (20-29 years) in low and low-middle socio-demographic index (SDI) regions, whereas it was higher among older pregnant women (30-39 years) in high SDI region. Both ASMR and ASDR showed a significant decreasing trend with increasing SDI. Maternal hemorrhage had the highest burden of all diseases. Global deaths are predicted to decline from 42,350 in 2019 to 38,461 in 2035, with the ASMR declining from 1.08 (95% UI: 0.38, 1.79) to 0.89 (95% UI: 0.47, 1.31).

Conclusion

Maternal malnutrition is improving globally, but in the context of the global food crisis, attention needs to be paid to malnutrition in low SDI regions, especially among young pregnant women, and corresponding measures need to be taken to effectively reduce the burden of disease.

Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa: an analysis of verbal autopsy data from six countries

OBJECTIVE

To compare the causes of death for women who died during pregnancy and within the first 42 days postpartum with those of women who died between >42 days and within 1 year postpartum.

DESIGN

Open population cohort (Health and Demographic Surveillance Systems).

SETTING

Ten Health and Demographic Surveillance Systems (HDSS) in The Gambia, Kenya, Malawi, Tanzania, Ethiopia and South Africa.

POPULATION

2114 deaths which occurred within 1 year of the end of pregnancy where a verbal autopsy interview was conducted from 2000 to 2019.

METHODS

InterVA5 and InSilicoVA verbal autopsy algorithms were used to attribute the most likely underlying cause of death, which were grouped according to adapted International Classification of Diseases-Maternal Mortality categories. Multinomial regression was used to compare differences in causes of deaths within 42 days versus 43-365 days postpartum adjusting for HDSS and time period (2000-2009 and 2010-2019).

MAIN OUTCOME MEASURES

Cause of death and the verbal autopsy Circumstances of Mortality Categories (COMCATs).

RESULTS

Of 2114 deaths, 1212 deaths occurred within 42 days postpartum and 902 between 43 and 365 days postpartum. Compared with deaths within 42 days, deaths from HIV and TB, other infectious diseases, and non-communicable diseases constituted a significantly larger proportion of late pregnancy-related deaths beyond 42 days postpartum, and health system failures were important in the circumstances of those deaths. The contribution of HIV and TB to deaths beyond 42 days postpartum was greatest in Southern Africa. The causes of pregnancy-related mortality within and beyond 42 days postpartum did not change significantly between 2000-2009 and 2010-2019.

CONCLUSIONS

Cause of death data from the extended postpartum period are critical to inform prevention. The dominance of HIV and TB, other infectious and non-communicable diseases to (late) pregnancy-related mortality highlights the need for better integration of non-obstetric care with ante-, intra- and postpartum care in high-burden settings.

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

OBJECTIVE

To assess the impact of maternal near-miss on late maternal death and the prevalence of hypertension or chronic kidney disease (CKD) and mental health problems at 12 months of follow up.

METHODS

This prospective cohort study was conducted in a tertiary hospital in the southeastern region of India from May 2018 to August 2019, enrolling those with maternal near-miss and with follow up for 12 months. The primary outcomes were incidence of late maternal deaths and prevalence of hypertension and CKD during follow up.

RESULTS

Incidence of maternal near miss was 6.7 per 1000 live births. Among those who had a near miss, late maternal deaths occurred in 7.2% (95% confidence interval [CI] 3.1%-11.3%); prevalence of CKD was 23.0% (95% CI 16.2%-29.8%), and of hypertension was 56.2% (95% CI 50.5%-66.5%) and only two women had depression on follow up. After adjusting for age, parity, socioeconomic status, gestational age at delivery, hemoglobin levels, and perinatal loss, only serum creatinine was independently associated with late maternal death and CKD on follow up.

CONCLUSIONS

Women who survive a life-threatening complication during pregnancy and childbirth are at increased risk of mortality and one or more long-term sequelae contributing to the non-communicable disease burden. A policy shift to increase postpartum follow-up duration, following a high-risk targeted approach after a near-miss event, is needed.

Left Behind: Medicaid Immigrant Exclusions and Access to Maternal Health Care Across the Reproductive-Perinatal Continuum

Noncitizen immigrants are often excluded from accessing critical safety-net programs, such as Medicaid. Access to health care plays a central role in current policy debates on maternal health. Yet, immigrant exclusions are rarely considered in maternal health policy research. Through open-ended interviews with 31 policymakers, researchers, and program administrators, we examined state variations in approaches to providing care for pregnant, post, and intrapartum immigrant women. We found four themes: (a) a patchwork safety-net exists that provides some access to immigrants ineligible for Medicaid; (b) patchwork coverage leads to patchwork care, which can contribute to maternal health inequities; (c) immigrant Medicaid policy is assembled along a hierarchy of deservingness based on documentation status; (d) Trump-era public charge rules and political climate may have a substantial chilling effect on benefit uptake regardless of eligibility. We discuss implications for efforts to expand Medicaid postpartum and address the maternal health crisis.

Peripartum cardiomyopathy: risk factors and predictors of outcome

PURPOSE OF REVIEW

Peripartum cardiomyopathy (PPCM) contributes significantly to maternal morbidity and mortality worldwide. In this review, we describe the present-day epidemiology and current understanding of the pathogenesis of PPCM. We provide an updated approach to diagnosis and management of PPCM, and discuss risk factors and predictors of outcome.

RECENT FINDINGS

The highest incidences of PPCM have been reported in African, Asian, and Caribbean populations. Contemporary literature supports a 'two-hit' hypothesis, whereby the 'first hit' implies a predisposition, and the 'second hit' refers to an imbalanced peripartal hormonal milieu that results in cardiomyopathy. Whereas a half of patients will have left ventricular (LV) recovery, a tenth do not survive. Clinical findings and special investigations (ECG, echocardiography, cardiac MRI, biomarkers) can be used for risk stratification. Frequent prescription of guideline-directed medical therapy is associated with improved outcomes.

SUMMARY

Despite advances in elucidating the pathogenesis of PPCM, it remains unclear why only certain women develop the disease. Moreover, even with better diagnostic work-up and management, it remains unknown why some patients with PPCM have persistent LV dysfunction or die. Future research should be aimed at better understanding of the mechanisms of disease and finding new therapies that could improve survival and LV recovery.

Characteristics of Maternal Mortality Missed by Vital Statistics in Hong Kong, 2000-2019

IMPORTANCE

Reducing maternal mortality is a global objective. The maternal mortality ratio (MMR) is low in Hong Kong, China, but there has been no local confidential enquiry into maternal death, and underreporting is likely.

OBJECTIVE

To determine the causes and timing of maternal death in Hong Kong and identify deaths and their causes that were missed by the Hong Kong vital statistics database.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted among all 8 public maternity hospitals in Hong Kong. Maternal deaths were identified using prespecified search criteria, including a registered delivery episode between 2000 to 2019 and a registered death episode within 365 days after delivery. Cases as reported by the vital statistics were then compared with the deaths found in the hospital-based cohort. Data were analyzed from June to July 2022.

MAIN OUTCOMES AND MEASURES

The outcomes of interest were maternal mortality, defined as death during pregnancy or within 42 days after ending the pregnancy, and late maternal death, defined as death more than 42 days but less than 1 year after end of the pregnancy.

RESULTS

A total of 173 maternal deaths (median [IQR] age at childbirth, 33 [29-36] years) were found, including 74 maternal mortality events (45 direct deaths and 29 indirect deaths) and 99 late maternal deaths. Of 173 maternal deaths, 66 women (38.2%) of individuals had preexisting medical conditions. For maternal mortality, the MMR ranged from 1.63 to 16.78 deaths per 100 000 live births. Suicide was the leading cause of direct death (15 of 45 deaths [33.3%]). Stroke and cancer deaths were the most common causes of indirect death (8 of 29 deaths [27.6%] each). A total of 63 individuals (85.1%) died during the postpartum period. In the theme-based approach analysis, the leading causes of death were suicide (15 of 74 deaths [20.3%]) and hypertensive disorders (10 of 74 deaths [13.5%]). The vital statistics in Hong Kong missed 67 maternal mortality events (90.5%). All suicides and amniotic fluid embolisms, 90.0% of hypertensive disorders, 50.0% of obstetric hemorrhages, and 96.6% of indirect deaths were missed by the vital statistics. The late maternal death ratio ranged from 0 to 16.36 deaths per 100 000 live births. The leading causes of late maternal death were cancer (40 of 99 deaths [40.4%]) and suicide (22 of 99 deaths [22.2%]).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of maternal mortality in Hong Kong, suicide and hypertensive disorder were the dominant causes of death. The current vital statistics methods were unable to capture most of the maternal mortality events found in this hospital-based cohort. Adding a pregnancy checkbox to death certificates and setting up a confidential enquiry into maternal death could be possible solutions to reveal the hidden deaths.

A systematic review of individual and ecological determinants of maternal mortality in the world based on the income level of countries

BACKGROUND

This systematic review was conducted to map the literature on all the existing evidence regarding individual and ecological determinants of maternal mortality in the world and to classify them based on the income level of countries. Such a systematic review had not been conducted before.

METHODS

We conducted an electronic search for primary and review articles using "Maternal Mortality" and "Determinant" as keywords or MeSH terms in their Title or Abstract, indexed in Scopus, PubMed, and Google with no time or geographical limitation and also hand searching was performed for most relevant journals. STROBE and Glasgow university critical appraisal checklists were used for quality assessment of the included studies. Data of the determinants were extracted and classified into individual or ecological categories based on income level of the countries according to World Bank classification.

RESULTS

In this review, 109 original studies and 12 review articles from 33 countries or at global level met the inclusion criteria. Most studies were published after 2013. Most literature studied determinants of low and lower-middle-income countries. The most important individual determinants in low and lower-middle-income countries were location of birth, maternal education, any delays in health services seeking, prenatal care and skilled birth attendance. Household-related determinants in low-income countries included improved water source and sanitation system, region of residence, house condition, wealth of household, and husband education. Additionally, ecological determinants including human resources, access to medical equipment and facilities, total fertility rate, health financing system, country income, poverty rate, governance, education, employment, social protection, gender inequality, and human development index were found to be important contributors in maternal mortality. A few factors were more important in higher-income countries than lower-income countries including parity, IVF births, older mothers, and type of delivery.

CONCLUSION

A comprehensive list of factors associated with maternal death was gathered through this systematic review, most of which were related to lower-income countries. It seems that the income level of the countries makes a significant difference in determinants of maternal mortality in the world.

Women's risk of death beyond 42 days post partum: a pooled analysis of longitudinal Health and Demographic Surveillance System data in sub-Saharan Africa

BACKGROUND

WHO's standard definitions of pregnancy-related and maternal deaths only include deaths that occur within 42 days of delivery, termination, or abortion, with major implications for post-partum care and maternal mortality surveillance. We therefore estimated post-partum survival from childbirth up to 1 year post partum to evaluate the empirical justification for the 42-day post-partum threshold.

METHODS

We used prospective, longitudinal Health and Demographic Surveillance System (HDSS) data from 30 sites across 12 sub-Saharan African countries to estimate women's risk of death from childbirth until 1 year post partum from all causes. Observations were included if the childbirth occurred from 1991 onwards in the HDSS site and maternal age was 10-54 years. We calculated person-years as the time between childbirth and next birth, outmigration, death, or the end of the first year post partum, whichever occurred first. For six post-partum risk intervals (0-1 days, 2-6 days, 7-13 days, 14-41 days, 42-122 days, and 4-11 months), we calculated the adjusted rate ratios of death relative to a baseline risk of 12-17 months post partum.

FINDINGS

Between Jan 1, 1991, and Feb 24, 2020, 647 104 births occurred in the HDSS sites, contributing to 602 170 person-years of exposure time and 1967 deaths within 1 year of delivery. After adjustment for confounding, mortality was 38·82 (95% CI 33·21-45·29) times higher than baseline on days 0-1 after childbirth, 4·97 (3·94-6·21) times higher for days 2-6, 3·35 (2·64-4·20) times higher for days 7-13, and 2·06 (1·74-2·44) times higher for days 14-41. From 42 days to 4 months post partum, mortality was still 1·20 (1·03-1·39) times higher (ie, a 20% higher risk), but deaths in this interval would be excluded from measurement of pregnancy-related mortality. Extending the WHO 42-day post-partum threshold up to 4 months would increase the post-partum pregnancy-related mortality ratio by 40%.

INTERPRETATION

This multicountry study has implications for measurement and clinical practice. It makes the case for WHO to extend the 42-day post-partum threshold to capture the full duration of risk of pregnancy-related deaths. There is a need for a new indicator to track late pregnancy-related deaths that occur beyond 42 days, which are otherwise excluded from global maternal health surveillance efforts. Our results also emphasise the need for international agencies to disaggregate estimates by antepartum, intrapartum, postpartum, and extended post-partum periods. Additionally, the schedule and content of postnatal care packages should reflect the extended duration of post-partum risk.

FUNDING

The UK Economic and Social Research Council.

The 2021 Zika outbreak in Uttar Pradesh state of India: Tackling the emerging public health threat

Zika virus is an RNA virus belonging to the Flavivirus family that is chiefly transmitted by the female Aedes mosquito. The Zika virus first infected humans in Uganda and Tanzania in 1952. Since, it has spread to several parts of the world causing outbreaks of variable extent. In India, these outbreaks have been reported from Gujarat, Tamil Nadu, Madhya Pradesh, Rajasthan, Kerala, and Maharashtra. The most recent outbreak is from the most populous state of India, Uttar Pradesh, where the climate is conducive to the breeding and transmission of other arboviral infections such as Dengue, Chikungunya, and Malaria. These infections also happen to share similar incubation periods and overlapping clinical manifestations with Zika virus (ZIKV) infection, leading to misdiagnoses or delayed diagnosis. We aim to provide an account of the outbreak, its repercussions, errors made in attempting to contain the spread of the disease, and, measures to be taken in the future.

Rationale, design and protocol of a cross-sectional study on pregnancy-related cardiovascular diseases in Tanzania (PRECARDT): burden, characterisation and prognostic significance at delivery

INTRODUCTION

The paucity of data describing cardiovascular disease (CVD) in pregnancy in many parts of Africa including Tanzania has given rise to challenges in proper management by the healthcare providers. This study is set out to (1) determine the prevalence of a range of CVDs during pregnancy in women attending antenatal clinics in Tanzania and (2) determine the impact of these CVDs on maternal and fetal outcomes at delivery.

METHODS AND ANALYSIS

This is a cross-sectional study with a prospective component to be conducted in two referral hospitals in Tanzania. Pregnant women aged ≥18 years diagnosed with a CVD during the antenatal period are being identified and extensively characterised by performing clinical assessment, modified WHO staging, electrocardiography, echocardiography and laboratory tests. Patients identified with CVDs (exposed) and a subset without (unexposed) will be followed up to determine maternal and fetal outcomes at delivery. A minimum sample of 1560 will be sufficient to estimate the prevalence of CVDs with a 95% CI of 2.75% to 5.25%.

ETHICS AND DISSEMINATION

The study is being conducted in accordance with the Helsinki declaration on studies involving human subjects. Ethical approvals have been obtained from Muhimbili University (reference number DA.282/298/01.C/) and Bugando Medical Centre (reference number CREC/330/2019) Ethics Committees. Informed consent is sought from all potential participants before any interview or investigations are performed. Study findings will be disseminated to the scientific community through different methods. Results will also be communicated to policymakers and to the public, as appropriate.

Cardiovascular Deaths in Pregnancy: Growing Concerns and Preventive Strategies

There has been an increase in maternal deaths from cardiovascular disease in many countries. In high-income countries, cardiovascular deaths secondary to cardiomyopathies, ischemic heart disease, sudden arrhythmic deaths, aortic dissection, and valve disease are responsible for up to one-third of all pregnancy-related maternal deaths. In low- and middle-income countries, rheumatic heart disease is a much more common cause of cardiac death during pregnancy. Although deaths occur in women with known heart conditions or cardiovascular risk factors such as hypertension, many women present for the first time in pregnancy with unrecognised heart disease or with de novo cardiovascular conditions such as preeclampsia, peripartum cardiomyopathy, spontaneous coronary artery dissection. Not only has maternal cardiovascular mortality increased, but serious cardiac morbidity, or "near misses," during pregnancy also have increased in frequency. Although maternal morbidity and mortality are often preventable, many health professionals remain unaware of the impact of cardiovascular disease in this population, and the lack of awareness contributes to inappropriate care and preventable deaths. In this review, we discuss the maternal mortality from cardiovascular causes in both high- and low- and middle-income countries and strategies to improve outcomes.

Incidence and disability-adjusted life years of maternal disorders at the global, regional, and national levels from 2007 to 2017: A systematic analysis for the Global Burden of Disease Study 2017

OBJECTIVE

To report the global burden of maternal disorders and their main subcategories in 195 countries and territories between 2007 and 2017.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 estimated maternal disease burden at global, regional, and country levels. Maternal disorders were disaggregated into 10 categories, and estimated incidence and disability-adjusted life years (DALYs) of maternal disorders were reported separately. Indicators were estimated in different geographic settings and different sociodemographic index (SDI) regions. Based on GBD 2017 estimates, we systematically examined the incidence and DALYs of maternal disorders and their main subcategories at the global, regional, and national levels during the period from 2007 to 2017 by age and SDI.

RESULTS

Globally, a total of 7.98 million maternal disorders occurred in 2017, with a 4.33% (95% uncertainty interval [UI] 3.24%-5.60%) decrease in age-standardized incidence rate and a more significant decrease (30.26%) in the age-standardized rate of DALYs. Most incidences and DALYs were found in low-income and middle-income countries, especially in the sub-Saharan region. The greatest incidence of maternal disorders was found to be in maternal abortion and miscarriage (2.00 million), and the highest disease burden was in maternal hemorrhage (2.23 million).

CONCLUSION

A slight increase in the incidence of maternal disorders and substantial reductions in DALYs of overall maternal disorders and their main subcategories were found from 2007 to 2017, especially in low-income countries and the sub-Saharan region. Maternal hemorrhage, hypertensive disorders, and indirect maternal death were the top three causes of maternal disorders disease burden.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Time for cardiac care in pregnancy: beyond 42 days post-partum

[first paragraph of article]Avoidable deaths from pregnancy complications occur on a global scale, with the greatest burden of mortality among women in low-to-middle income countries [1]. Most countries record maternal death only up to 42 days postpartum because of the assumption that avoidable death in pregnant women occurs during pregnancy or shortly thereafter. Although limited, the available data suggest otherwise.

Risk stratification and management of women with cardiomyopathy/heart failure planning pregnancy or presenting during/after pregnancy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy

This position paper focusses on the pathophysiology, diagnosis and management of women diagnosed with a cardiomyopathy, or at risk of heart failure (HF), who are planning to conceive or present with (de novo or previously unknown) HF during or after pregnancy. This includes the heterogeneous group of heart muscle diseases such as hypertrophic, dilated, arrhythmogenic right ventricular and non-classified cardiomyopathies, left ventricular non-compaction, peripartum cardiomyopathy, Takotsubo syndrome, adult congenital heart disease with HF, and patients with right HF. Also, patients with a history of chemo-/radiotherapy for cancer or haematological malignancies need specific pre-, during and post-pregnancy assessment and counselling. We summarize the current knowledge about pathophysiological mechanisms, including gene mutations, clinical presentation, diagnosis, and medical and device management, as well as risk stratification. Women with a known diagnosis of a cardiomyopathy will often require continuation of drug therapy, which has the potential to exert negative effects on the foetus. This position paper assists in balancing benefits and detrimental effects.

The impact of cardiovascular diseases on maternal deaths in the Nordic countries

INTRODUCTION

Cardiovascular diseases have become increasingly important as a cause of maternal death in the Nordic countries. This is likely to be associated with a rising incidence of pregnant women with congenital and acquired cardiac diseases. Through audits, we aim to prevent future maternal deaths by identifying causes of death and suboptimal factors in the clinical management.

MATERIAL AND METHODS

Maternal deaths in the Nordic countries from 2005 to 2017 were identified through linked registers. The national audit groups performed case assessments based on hospital records, classified the cause of death, and evaluated the standards of clinical care provided. Key messages were prepared to improve treatment.

RESULTS

We identified 227 maternal deaths, giving a maternal mortality rate of 5.98 deaths per 100 000 live births. The most common cause of death was cardiovascular disease (n = 36 deaths). Aortic dissection/rupture, myocardial disease, and ischemic heart disease were the most common diagnoses. In nearly 60% of the cases, the disease was not recognized before death. In more than half of the deaths, substandard care was identified (59%). In 11 deaths (31%), improvements to care that may have made a difference to the outcome were identified.

CONCLUSIONS

Between 2005 and 2017, cardiovascular diseases were the most common causes of maternal deaths in the Nordic countries. There appears to be a clear potential for a further reduction in these maternal deaths. Increased awareness of cardiac symptoms in pregnant women seems warranted.

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

BACKGROUND

The Sustainable Development Goal target 3.1 aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births. Great disparities reported in maternal mortality ratio between and within countries make this target unachievable. To gain more insight into such disparities and to monitor and describe trends, confidential enquiries into maternal deaths are crucial.

OBJECTIVE

We aimed to study the trend in maternal mortality ratio, causes, delay in access and quality of care, and “lessons learned” in Suriname, over almost 3 decades with 3 confidential enquiries into maternal deaths and provide recommendations to prevent maternal deaths.

STUDY DESIGN

The third national confidential enquiry into maternal deaths was conducted between 2015 and 2019 in Suriname by prospective, population-based surveillance and multidisciplinary systematic maternal death review. Subsequently, a comparative analysis with previous confidential enquiry into maternal deaths was performed: confidential enquiry into maternal deaths I (a prospective study, 1991–1993) and confidential enquiry into maternal deaths II (a retrospective study, 2010–2014).

RESULTS

We identified 62 maternal deaths and recorded 48,881 live births (maternal mortality ratio, 127/100,000 live births) between 2015-2019. Of the women who died, 14 of 62 (23%) were in poor condition when entering a health facility, whereas 11 of 62 (18%) died at home or during transportation. The maternal mortality ratio decreased over the years, (226 [n=64]; 130 [n=65]; and 127 [n=62]), with underreporting rates of 62%, 26%, and 24%, respectively in confidential enquiry into maternal deaths I, II and III. Of the women deceased, 36 (56%), 37 (57%), and 40 (63%) were of African descent; 46 (72%), 45 (69%), and 47 (76%) died after birth; and 47 (73%), 55 (84%), and 48 (77%) died in the hospital, respectively, in confidential enquiries into maternal deaths I, II, and III. Significantly more women were uninsured in confidential enquiry into maternal deaths III (15 of 59 [25%,]) than in confidential enquiry into maternal deaths II (0%) and I (6 of 64 [9%]). Obstetrical hemorrhage was less often the underlying cause of death over the years (19 of 64 [30%], vs 13 of 65 [20%], vs 7 of 62 [11%]), whereas all other obstetrical causes occurred more often in confidential enquiry into maternal deaths III (eg, suicide [0; 1 of 65 (2%); 5 of 62 (8%)]) and unspecified deaths (1 of 64 [2%]; 3 of 65 [5%]; and 11 of 62 [18%] in confidential enquiry into maternal deaths I, II and III respectively). Maternal deaths were preventable in nearly half of the cases in confidential enquiry into maternal deaths II (28 of 65) and III (29 of 62). Delay in quality of care occurred in at least two-thirds of cases (41 of 62 [65%], 47 of 59 [80%], and 47 of 61 [77%]) over the years.

CONCLUSION

Suriname's maternal mortality rate has decreased throughout the past 3 decades, yet the trend is too slow to achieve the Sustainable Development Goal 3.1. Preventable maternal deaths can be reduced by ensuring high-quality facility-based obstetrical and postpartum care, universal access to care especially for vulnerable women (of African descent and low socioeconomic class), and by addressing specific underlying causes of maternal deaths.

Electrocardiographic features and their echocardiographic correlates in peripartum cardiomyopathy: results from the ESC EORP PPCM registry

AIMS

In peripartum cardiomyopathy (PPCM), electrocardiography (ECG) and its relationship to echocardiography have not yet been investigated in large multi-centre and multi-ethnic studies. We aimed to identify ECG abnormalities associated with PPCM, including regional and ethnic differences, and their correlation with echocardiographic features.

METHODS AND RESULTS

We studied 411 patients from the EURObservational PPCM registry. Baseline demographic, clinical, and echocardiographic data were collected. ECGs were analysed for rate, rhythm, QRS width and morphology, and QTc interval. The median age was 31 [interquartile range (IQR) 26-35] years. The ECG was abnormal in > 95% of PPCM patients. Sinus tachycardia (heart rate > 100 b.p.m.) was common (51%), but atrial fibrillation was rare (2.27%). Median QRS width was 82 ms [IQR 80-97]. Left bundle branch block (LBBB) was reported in 9.30%. Left ventricular (LV) hypertrophy (LVH), as per ECG criteria, was more prevalent amongst Africans (59.62%) and Asians (23.17%) than Caucasians (7.63%, P < 0.001) but did not correlate with LVH on echocardiography. Median LV end-diastolic diameter (LVEDD) was 60 mm [IQR 55-65] and LV ejection fraction (LVEF) 32.5% [IQR 25-39], with no significant regional or ethnic differences. Sinus tachycardia was associated with an LVEF < 35% (OR 1.85 [95% CI 1.20-2.85], P = 0.006). ECG features that predicted an LVEDD > 55 mm included a QRS complex > 120 ms (OR 11.32 [95% CI 1.52-84.84], P = 0.018), LBBB (OR 4.35 [95% CI 1.30-14.53], P = 0.017), and LVH (OR 2.03 [95% CI 1.13-3.64], P = 0.017).

CONCLUSIONS

PPCM patients often have ECG abnormalities. Sinus tachycardia predicted poor systolic function, whereas wide QRS, LBBB, and LVH were associated with LV dilatation.

Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement From the American Heart Association

The global burden of rheumatic heart disease continues to be significant although it is largely limited to poor and marginalized populations. In most endemic regions, affected patients present with heart failure. This statement will seek to examine the current state-of-the-art recommendations and to identify gaps in diagnosis and treatment globally that can inform strategies for reducing disease burden. Echocardiography screening based on World Heart Federation echocardiographic criteria holds promise to identify patients earlier, when prophylaxis is more likely to be effective; however, several important questions need to be answered before this can translate into public policy. Population-based registries effectively enable optimal care and secondary penicillin prophylaxis within available resources. Benzathine penicillin injections remain the cornerstone of secondary prevention. Challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues. Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves are vital therapeutic adjuncts. Management of health of women with unoperated and operated rheumatic heart disease before, during, and after pregnancy is a significant challenge that requires a multidisciplinary team effort. Patients with isolated mitral stenosis often benefit from percutaneous balloon mitral valvuloplasty. Timely heart valve surgery can mitigate the progression to heart failure, disability, and death. Valve repair is preferable over replacement for rheumatic mitral regurgitation but is not available to the vast majority of patients in endemic regions. This body of work forms a foundation on which a companion document on advocacy for rheumatic heart disease has been developed. Ultimately, the combination of expanded treatment options, research, and advocacy built on existing knowledge and science provides the best opportunity to address the burden of rheumatic heart disease.

Update on Prevention and Management of Rheumatic Heart Disease

Rheumatic heart disease (RHD) remains the most common cause of cardiovascular morbidity and mortality globally in children and young adults. This article focuses on prevention and management of RHD. Pregnancy can unmask previously undiagnosed RHD and poses high risk for mother and fetus. Management of anticoagulation is important. Definitive catheter and surgical intervention are the only treatments that can improve outcomes of patients with moderate or severe RHD. Access to intervention remains very limited in RHD endemic regions. There are ongoing global efforts to increase awareness, public policy adoption, and greater access to treatment.

Quality gap in maternal and newborn healthcare: a cross-sectional study in Myanmar

Introduction

Access to maternal and newborn healthcare has improved in Myanmar. However, regular contact with skilled care providers does not necessarily result in quality care. We assessed adequate contact made by women and newborns with skilled care providers, reception of high-quality care and quality-adjusted contacts during antenatal care (ANC), peripartum care (PPC) and postnatal care (PNC) in Myanmar.

Methods

This cross-sectional study was conducted in a predominantly urban township of Yangon and a predominantly rural township of Ayeyawady in March 2016. We collected data from 1500 women. We measured quality-adjusted contact, which refers to adequate contact with high-quality care, as follows: ≥4 ANC contacts and receiving 11–14 of 14 intervention items; facility-based delivery assisted by skilled care providers, receiving 7 of 7 PPC intervention items; and receiving the first PNC contact ≤24 hours postpartum and ≥2 additional contacts, and receiving 16–17 of 17 intervention items. Using multilevel logistic regression analysis with a random intercept at cluster level, we identified factors associated with adequate contact and high-quality ANC, PPC and PNC.

Results

The percentage of crude adequate contact was 60.9% for ANC, 61.3% for PPC and 11.5% for PNC. However, the percentage of quality-adjusted contact was 14.6% for ANC, 15.2% for PPC and 3.6% for PNC. Adequate contact was associated with receiving high-quality care at ANC, PPC and PNC. Being a teenager, low educational level, multiparity and low level in the household wealth index were negatively associated with adequate contact with healthcare providers for ANC and PPC. Receiving a maternal and child health handbook was positively associated with adequate contact for ANC and PPC, and with receiving high-quality ANC, PPC and PNC.

Conclusion

Women and newborns do not receive quality care during contact with skilled care providers in Myanmar. Continuity and quality of maternal and newborn care programmes must be improved.

Determinants and causes of maternal mortality in Iran based on ICD-MM: a systematic review

Background

No systematic review has explored the causes of and factors associated with maternal mortality in the context of Iran. This study reviewed determinants and causes of maternal mortalities during pregnancy, delivery and the puerperium using the International Classification of Diseases-Maternal Mortality (ICD-MM), introduced by the World Health Organization.

Methods

A systematic electronic search of all the studies that identified causes and/or determinants of maternal deaths in any part of Iran or in the whole country were included, without any restriction of time or language of studies. To identify the studies to include in this study, a combination of hand searching and bibliographies was also conducted. These sources and citations yielded a total of 653 articles; nevertheless, only 29 articles met the inclusion criteria, hence, required data were extracted, summarized, and grouped together from these papers and are reported in the tables.

Results

Amongst the 29 studies published between 2003 and 2017 in Iran, 24 studies were cross-sectional. Overall, 4633 deaths were reviewed, and 2655 (58%) of the cases included the data on the causes of death generally. According to the ICD-MM, a total of 69.9, 20.6, and 5.2% of the mortalities were due to direct, indirect and unspecified causes respectively and 4.3% of the causes were not clear in several studies. The leading direct and indirect causes of death were identified as hemorrhage (30.7%) and hypertensive disorders (17.1%) and circulatory system diseases (8.1%) respectively. Several factors including gravidity, type of delivery, socio-economic status of mothers, locations of birth, death and maternity care venues were found in the original studies as the most important determinant of maternal mortalities in Iran.

Conclusions

This study, provided an updated summary of evidences on the causes and determinants of maternal death in Iran, which is critically important for the development of interventions and reduction of the burden of maternal mortality and morbidities.

A review of maternal mortality and quality of care in the USA

Objective: The purpose of this study was to review studies and reports examining maternal mortality and quality of maternal health care in the USA, which has the highest maternal mortality rate among its peers.Methods: Electronic search of current literature on maternal mortality and quality of care in the USA and Europe was conducted. Findings were summarized according to the Donabedian's structure-process-outcomes conceptual model.Results: Standards and protocols, effective communication and hospitalist care indicated positive maternal outcomes, including a reduction in maternal mortality. However, lack of coordination of care among providers for pregnant women with chronic disease, fragmentation, or substandard of care and late prenatal care initiation are among the domain of processes of care that were noted to negatively influence maternal health outcomes. Further, the absence of a national forum committee to gather and systematically use research findings and data to guide change constitutes a serious obstacle in improving quality of care in the obstetric field.Conclusions: Providing good quality of care and eliminating health disparities in obstetrics and gynecology are important elements in preventing maternal deaths. Future research regarding patient-centered care and health disparities in maternal health will provide guidance to policymakers in our efforts to reduce maternal mortality.

The prognostic significance of the 12-lead ECG in peripartum cardiomyopathy

BACKGROUND

Peripartum cardiomyopathy (PPCM) is an important cause of pregnancy-associated heart failure, which appears in previously healthy women towards the end of pregnancy or within five months following delivery. Although the ECG is widely used in clinical practice, its prognostic value has not been established in PPCM.

METHODS

We analysed 12-lead ECGs of patients with PPCM, taken at index presentation and follow-up visits at 6 and 12 months. Poor outcome was determined by the composite endpoint of death, readmission, NYHA functional class III/IV or left ventricular ejection fraction (LVEF) of ≤35% at follow-up.

RESULTS

This cohort of 66 patients had a median age of 28.59 (IQR 25.43-32.19). The median LVEF at presentation (33%, IQR 25-40) improved significantly at follow-up (LVEF 49%, IQR 38-55, P < 0.001 at 6 months; 52% IQR 38-57, P = 0.001 at 12 months). Poor outcome occurred in 27.91% at 6 months and 41.18% at 1 year. Whereas sinus tachycardia at baseline was an independent predictor of poor outcome at 12 months (OR 6.56, 95% CI 1.17-20.41, P = 0.030), sinus arrhythmia was associated with event free survival (log rank P = 0.013). T wave inversion was associated with an LVEF ≤35% at presentation (P = 0.038), but did not predict poor outcome. A prolonged QTc interval at presentation (found in almost half of the cohort) was an independent predictor of poor outcome at 6 months (OR 6.34, 95% CI 1.06-37.80, P = 0.043).

CONCLUSION(S)

A prolonged QTc and sinus tachycardia at baseline were independent predictors of poor outcome in PPCM at 6 months and 1 year respectively.

Time to tackle rheumatic heart disease: Data needed to drive global policy dialogues

Rheumatic heart disease (RHD) is an avoidable disease of poverty that persists predominantly in low resource settings and among Indigenous and other high-risk populations in some high-income nations. Following a period of relative global policy inertia on RHD, recent years have seen a resurgence of research, policy and civil society activity to tackle RHD; this has culminated in growing momentum at the highest levels of global health diplomacy to definitively address this disease of disadvantage. RHD is inextricably entangled with the global development agenda, and effective RHD action requires concerted efforts both within and beyond the health policy sphere. This report provides an update on the contemporary global and regional policy landscapes relevant to RHD, and highlights the fundamental importance of good data to inform these policy dialogues, monitor systems responses and ensure that no one is left behind.

Reducing late maternal death due to cardiovascular disease - A pragmatic pilot study

BACKGROUND

Late maternal mortality (up-to 1-year postpartum) is poorly reported globally and is commonly due to cardiovascular disease (CVD). We investigated targeted interventions aiming at reducing peripartum heart failure admission and late maternal death.

METHODS AND RESULTS

Prospective single-centre study of 269 peripartum women presenting with CVD in pregnancy, or within 6-months postpartum. Both cardiac disease maternity (CDM) Group-I and Group-II were treated by a dedicated cardiac-obstetric team. CDM Group-II received additional interventions: 1. Early (2-6 weeks) postpartum follow-up at the CDM clinic and immediate referral to dedicated CVD specialist clinics. 2. Beta-blocker therapy was continued in women with LVEF<45% while pregnant, or immediately started postpartum. Of 269 consecutive women (mean age 28.6 ± 5.9), 213 presented prepartum, 22% in NYHA groups III-IV and 79% in modified WHO groups III-IV. Patients were diagnosed with congenital heart disease (30%), valvular heart disease (25%) and cardiomyopathy (31%). The groups were similar in age, diagnosis, NYHA, modified WHO, BP and HIV, but Group-II had a higher rate of previously known CVD (p < 0.001) and a lower rate of being nulliparous (p < 0.0005). Of Group-I patients 9 died within the 12-month follow-up period versus one death in Group-II (p = 0.047). Heart failure leading to admission was 32% in Group-I versus 14% in Group-II (p = 0.0008), with Group-II having a higher beta-blocker use peripartum (p = 0.009). Perinatal mortality rate was 22/1000 live births with no differences between groups.

CONCLUSION

Early follow-up in a dedicated CDM clinic with targeted pharmacological interventions led to a significant reduction in peripartum heart failure admission and mortality.

The evolving contribution of non-communicable diseases to maternal mortality in Jamaica, 1998-2015: a population-based study

OBJECTIVE

To describe trends in indirect cause-specific pregnancy-related mortality from 1998 to 2015.

DESIGN

Secondary analysis of annual, national cross-sectional database of maternal and late maternal deaths, identified through active surveillance of deaths among women aged 10-50 years.

SETTING

Jamaica, a middle-income Caribbean country.

POPULATION

Maternal and late maternal deaths.

METHODS

Descriptive trend analyses of demographic and cause-specific maternal and pregnancy-related mortality ratios undertaken comparing the periods 1998-2003, 2004-2009 and 2010-2015. Multivariate logistic regression was used to confirm changes in risk of indirect death.

MAIN OUTCOME MEASURES

Maternal, pregnancy-related, direct, indirect and cause-specific mortality ratios (deaths/100 000 live births).

RESULTS

Maternal deaths from indirect conditions increased between the first two periods (P = 0.004) and stabilised in the third (P = 0.085). Associated with upward movement in cardiovascular deaths (P_[trend] = 0.003), women under 25 years were at elevated risk (odds ratio 1.44, 95% CI 1.00-2.08; P = 0.052). Haematological/immunological conditions (69% sickle cell disease) ranked second but did not vary with time. Health service utilisation was similar across age, parity, health region and major cause categories (non-communicable diseases, non-obstetric infections, direct), however women with indirect conditions spent more time in hospital (median 5 days versus 3 days) and more often died after the puerperium.

CONCLUSIONS

Medical conditions, especially cardiovascular disease, are increasingly associated with maternal and late maternal mortality. Middle-income countries need to simultaneously improve management of indirect conditions, while redoubling efforts to reduce direct deaths. Postpuerperal medical services should be integrated into routine infant health services to improve continuity of care during this high-risk period.

TWEETABLE ABSTRACT

Maternal survival (SDG 3.1) in LMICs requires better care for women with both non-communicable diseases and obstetric conditions.

Long-term prognosis, subsequent pregnancy, contraception and overall management of peripartum cardiomyopathy: practical guidance paper from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy

Peripartum cardiomyopathy is an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause for heart failure is identified. Outcome varies from full recovery to residual left ventricular systolic dysfunction and even death. Many women return to their physician to acquire information on their long-term prognosis, to seek medical advice regarding contraception, or when planning a subsequent pregnancy. This position paper summarizes current evidence for long-term outcome, risk stratification of further pregnancies and overall management. Based on the best available evidence, as well as the clinical experience of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy members, a consensus on pre- and postpartum management algorithms for women undergoing a subsequent pregnancy is presented.

Indirect maternal deaths: UK and global perspectives

Indirect maternal deaths outnumber direct deaths due to obstetric causes in many high-income countries, and there has been a significant increase in the proportion of maternal deaths due to indirect medical causes in low- to middle-income countries. This review presents a detailed analysis of indirect maternal deaths in the UK and a perspective on the causes and trends in indirect maternal deaths and issues related to care in low- to middle-income countries. There has been no significant decrease in the rate of indirect maternal deaths in the UK since 2003. In 2011-2013, 68% of all maternal deaths were due to indirect causes, and cardiac disease was the single largest cause. The major issues identified in care of women who died from an indirect cause was a lack of clarity about which medical professional should take responsibility for care and overall management. Under-reporting and misclassification result in underestimation of the rate of indirect maternal deaths in low- to middle-income countries. Causes of indirect death include a range of communicable diseases, non-communicable diseases and nutritional disorders. There has been evidence of a shift in incidence from direct to indirect maternal deaths in many low- to middle-income countries due to an increase in non-communicable diseases among women in the reproductive age. The gaps in care identified include poor access to health services, lack of healthcare providers, delay in diagnosis or misdiagnosis and inadequate follow-up during the postnatal period. Irrespective of the significant gains made in reducing maternal mortality in many countries worldwide, there is evidence of a steady increase in the rate of indirect deaths due to pre-existing medical conditions. This heightens the need for research to generate evidence about the risk factors, management and outcomes of specific medical comorbidities during pregnancy in order to provide appropriate evidence-based multidisciplinary care across the entire pathway: pre-pregnancy, during pregnancy and delivery, and postpartum.

The heart of Africa: succeeding against the odds

South Africa and other areas of sub-Saharan Africa have in the past 20 years undergone rapid demographical changes, largely due to urbanisation and changes in lifestyle. This rapid change has led to a marked increase in specific cardiac conditions, such as hypertensive heart disease and coronary artery disease (with the highest prevalence in the middle-aged population), in conjunction with a range of other heart diseases, which are historically common in Africa-eg, rheumatic heart disease, cardiomyopathies, and unoperated congenital heart disease. The short supply of well-equipped screening facilities, late diagnosis, and inadequate care at primary, secondary, and tertiary levels have led to a large burden of patients with poorly treated heart failure. Excellent progress has been made in the understanding of the epidemiology, sociodemographical factors, effect of urbanisation, and pathophysiology of cardiac conditions, such as peripartum cardiomyopathy, rheumatic heart disease, and tuberculous pericarditis, which are common in sub-Saharan Africa. This progress has been achieved largely through several studies, such as the Heart of Soweto, THESUS, REMEDY, BA-HEF, Abeokuta-HF, and the PAPUCO studies. Studies on the suitable therapeutic management of several heart conditions have also been done or are underway. In this Lecture, I provide a personal perspective on the evolving burden of cardiac disease, as witnessed since my appointment at Chris Hani Baragwanath Hospital, in Soweto, South Africa, in 1992, which was also the year that the referendum to end apartheid in South Africa was held. Subsequently, a network of cardiologists was formed under the umbrella of the Heart of Africa Studies and the Pan African Cardiac Society. Furthermore, I summarise the major gaps in the health-care system dealing with the colliding epidemic of communicable and non-communicable heart diseases, including cardiac diseases common in peripartum women. I also touch on the fantastic opportunities available for doing meaningful research with enthusiastic colleagues and, thereby, having a large effect, despite the need to be highly innovative in finding much needed funding support.

Late Maternal Deaths and Deaths from Sequelae of Obstetric Causes in the Americas from 1999 to 2013: A Trend Analysis

BACKGROUND

Data on maternal deaths occurring after the 42 days postpartum reference time is scarce; the objective of this analysis is to explore the trend and magnitude of late maternal deaths and deaths from sequelae of obstetric causes in the Americas between 1999 and 2013, and to recommend including these deaths in the monitoring of the Sustainable Development Goals (SDGs).

METHODS

Exploratory data analysis enabled analyzing the magnitude and trend of late maternal deaths and deaths from sequelae of obstetric causes for seven countries of the Americas: Argentina, Brazil, Canada, Colombia, Cuba, Mexico and the United States. A Poisson regression model was developed to compare trends of late maternal deaths and deaths from sequelae of obstetric causes between two periods of time: 1999 to 2005 and 2006 to 2013; and to estimate the relative increase of these deaths in the two periods of time.

FINDINGS

The proportion of late maternal deaths and deaths from sequelae of obstetric causes ranged between 2.40% (CI 0.85% - 5.48%) and 18.68% (CI 17.06% - 20.47%) in the seven countries. The ratio of late maternal deaths and deaths from sequelae of obstetric causes per 100,000 live births has increased by two times in the region of the Americas in the period 2006-2013 compared to the period 1999-2005. The regional relative increase of late maternal death was 2.46 (p<0.0001) times higher in the second period compared to the first.

INTERPRETATION

Ascertainment of late maternal deaths and deaths from sequelae of obstetric causes has improved in the Americas since the early 2000's due to improvements in the quality of information and the obstetric transition. Late and obstetric sequelae maternal deaths should be included in the monitoring of the SDGs as well as in the revision of the International Classification of Diseases' 11th version (ICD-11).