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Aboulatta L, Kowalec K, Leong C, Delaney JA, Falk J, Alessi-Severini S, Chateau D, Tan Q, Kearns K, Raimondi C, Vaccaro C, Lavu A, Haidar L, Peymani P, Eltonsy S. Preterm birth and stillbirth rates associated with socioeconomic disparities during COVID-19 pandemic: a population-based cross-sectional study. BMJ Paediatr Open 2023; 7:e001686. [PMID: 36806202 PMCID: PMC9943698 DOI: 10.1136/bmjpo-2022-001686] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Conflicting evidence exists on the impact of the COVID-19 pandemic restrictions on preterm birth (PTB) and stillbirth rates. We aimed to evaluate changes in PTB and stillbirth rates before and during the pandemic period and assess the potential effect modification of socioeconomic status (SES). METHODS Using the linked administrative health databases from Manitoba, Canada, we conducted a cross-sectional study among all pregnant women, comparing 3.5 years pre-pandemic (1 October 2016 to 29 February 2020) to the first year of the pandemic (1 March 2020 to 31 March 2021). We used generalised linear models to assess the quarterly rates of PTB (<37 weeks) and stillbirths. We calculated the predicted trends based on pre-pandemic period data. Finally, we evaluated the PTB and stillbirth rates among lower and higher SES pregnant women (average annual household income) using subgroup analysis and interaction models. RESULTS We examined 70 931 pregnancies in Manitoba during the study period. The risk of PTB increased by 7.7% (95%CI 1.01 to 1.13) and stillbirths by 33% (95% CI 1.08 to 1.64) during the pandemic period. Following COVID-19 restrictions implemented in March 2020, there were increases in the quarterly rates of both PTB (immediate increase (β2)=1.37; p=0.0247) and stillbirths (immediate increase (β2)=0.12; p=0.4434). Among the lower income groups, the pandemic restrictions resulted in an immediate relative increase in PTB and stillbirth rates by 20.12% (immediate increase (β2)=3.17; p=0.0057) and 27.19% (immediate increase (β2)=0.48; p=0.0852). However, over the pandemic, the overall PTB rate significantly decreased as a rebound effect by 0.85% per quarter (p=0.0004), whereas the overall stillbirth rate did not decrease significantly (slope decrease (β3) =-0.01; p=0.8296) compared with the pre-pandemic period. The quarterly rates during the pandemic among the higher income group decreased by 0.39% (p=0.1296) for PTB and increased by 0.07% (p=0.1565) for stillbirth. We observed an effect modification by SES for PTB rates (p=0.047). CONCLUSION While the onset of COVID-19 pandemic restrictions was not associated with significant effects on stillbirth rates, we observed an immediate and rebound effect on PTB rates. The impact of COVID-19 on preterm birth was dependent on SES, with higher influence on families with lower SES. Further studies are needed to detect future trend changes during pandemic waves after 2021 and assess potential underlying mechanisms.
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Affiliation(s)
- Laila Aboulatta
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kaarina Kowalec
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Christine Leong
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Psychiatry, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joseph A Delaney
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Jamie Falk
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Silvia Alessi-Severini
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dan Chateau
- College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Qier Tan
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Katherine Kearns
- Department of Family Medicine, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Christina Raimondi
- Department of Family Medicine, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Christine Vaccaro
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alekhya Lavu
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lara Haidar
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Payam Peymani
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sherif Eltonsy
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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Sánchez-Barricarte JJ, Sánchez-Arlegui A. Relationship between historical developments in the percentages of low birthweight and fetal mortality in Spain. GACETA SANITARIA 2022:S0213-9111(22)00164-9. [PMID: 36599717 DOI: 10.1016/j.gaceta.2022.102268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To document the differences in low birthweight in different population subgroups and to analyze its possible relationship with fetal mortality rates in Spain. METHOD We used the microdata on live births and stillbirths since 1975 to 2020 from the Spanish National Statistics Institute to examine differentials in delivering a low birthweight controlling for different sociodemographic variables and to determine the relationship between low birthweight and fetal mortality. No statistical analysis was necessary beyond the calculation of percentages and rates. RESULTS The data at our disposal for Spain confirm the historical increase in the incidence of low birthweight and allow us to link trends in low birthweight with a decrease in the fetal mortality rate. When fetal mortality is high, the incidence of low birthweight is low, given that a natural selection effect takes place. CONCLUSIONS The surprising historical increase in the incidence of low birthweight in Spain can be explained by the improvement in mortality rates. As more fetuses of lower gestational age are born alive, cases of low birthweight also increase.
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Silva MO, Macedo VC, Canuto IMB, Silva MC, da Costa HVV, do Bonfim CV. Spatial dynamics of fetal mortality and the relationship with social vulnerability. J Perinat Med 2022; 50:645-652. [PMID: 34883002 DOI: 10.1515/jpm-2021-0444] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/29/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To analyze the spatial-temporal patterns of fetal mortality according to its relationship with social vulnerability, identifying priority areas for intervention. METHODS Ecological study conducted in the state of Pernambuco, Northeast region of Brazil, from 2011 to 2018. The mean fetal mortality rate per city was calculated for the studied period. A cluster analysis was performed to select cities with homogeneous characteristics regarding fetal mortality and social vulnerability, then the Attribute Weighting Algorithm and Pearson correlation techniques were employed. In the spatial analysis it was used the local empirical Bayesian modeling and global and local Moran statistics. RESULTS Twelve thousand nine hundred and twelve thousand fetal deaths were registered. The fetal mortality rate for the period was 11.44 fetal deaths per 1,000 births. The number of groups formed was 7, in which correlation was identified between fetal mortality and dimensions, highlighting the correlations between fetal mortality rate and the Index of Social Vulnerability urban infrastructure for the municipalities in group 1 and 5, the values of the correlations found were 0.478 and 0.674 respectively. The spatial analysis identified areas of higher risk for fetal mortality distributed in regions of medium, high and very high social vulnerability. CONCLUSIONS The study allowed observing the existing correlations between fetal mortality and social vulnerability and identifying priority areas for intervention, with a view to reducing fetal mortality in the state.
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Affiliation(s)
- Myllena O Silva
- Social Research Department, Joaquim Nabuco Foundation, Recife, Pernambuco, Brazil
| | - Vilma C Macedo
- Department of Nursing, Health Sciences Center, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Indianara M B Canuto
- Graduate Program in Public Health, Aggeu Magalhães Institute, Oswaldo Cruz Foundation, Recife, Pernambuco, Brazil
| | - Mayara C Silva
- Social Research Department, Joaquim Nabuco Foundation, Recife, Pernambuco, Brazil
| | - Heitor V V da Costa
- Computer Science Center, Graduate Program in Computer Science, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Cristine V do Bonfim
- Social Research Department, Joaquim Nabuco Foundation, Recife, Pernambuco, Brazil
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Perfil epidemiológico, padrões espaciais e evitabilidade da mortalidade fetal em Pernambuco. ACTA PAUL ENFERM 2021. [DOI: 10.37689/actaape/2021ao001355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Grant ID, Giussani DA, Aiken CE. Blood pressure and hypertensive disorders of pregnancy at high altitude: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2021; 3:100400. [PMID: 34023533 DOI: 10.1016/j.ajogmf.2021.100400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/06/2021] [Accepted: 05/15/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Exposure to high altitude (≥2500 m) is associated with increased arterial blood pressure. During pregnancy, even a mild elevation of maternal blood pressure is associated with reduced birthweight and increased prevalence of pregnancy complications. This study aimed to systematically assess the impact of altitude on maternal blood pressure at term and on the prevalence of hypertensive disorders of pregnancy. DATA SOURCES PubMed, Ovid Embase, Cochrane Library, Medline, Web of Science, and ClinicalTrials.gov were searched (inception to November 11, 2020). STUDY APPRAISAL AND SYNTHESIS METHODS Observational, cohort, or case-control studies were included if they reported a high-altitude and appropriate control pregnant population. Studies published >50 years ago were excluded; 2 reviewers independently assessed articles for eligibility and risk of bias. RESULTS At high altitude, maternal systolic and diastolic blood pressure at term was higher than at low altitude (4.8±1.6 mm Hg; P<.001; 4.0±0.8 mm Hg; P<.001, respectively). Hypertensive disorders of pregnancy were more common at high altitude (odds ratio, 1.31 [1.03-1.65]; P<.05). The prevalence of gestational hypertension was nearly twice as high at high altitude (odds ratio, 1.92 [1.15-3.22]; P<.05) but the prevalence of preeclampsia was half as high (odds ratio, 0.57 [0.46-0.70]; P<.001). The likelihood of stillbirth was increased by 63% in pregnancies at high altitude compared with low altitude (odds ratio, 1.63 [1.12-2.35]; P<.01). CONCLUSION Maternal blood pressure is higher at term in pregnancies at high altitude than low altitude, accompanied with an increased risk of gestational hypertension but not preeclampsia. Risk of stillbirth at high altitude is also increased. With a growing population residing at high altitude worldwide, it is essential to clearly define the associated risk of adverse pregnancy outcomes.
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Affiliation(s)
- Imogen D Grant
- Department of Obstetrics and Gynaecology (Ms Grant and Dr Aiken); NIHR Cambridge Biomedical Research Centre, Cambridge, United Kingdom (Ms Grant and Dr Aiken).
| | - Dino A Giussani
- Department of Physiology, Development and Neuroscience (Dr Giussani), University of Cambridge, Cambridge, United Kingdom
| | - Catherine E Aiken
- Department of Obstetrics and Gynaecology (Ms Grant and Dr Aiken); NIHR Cambridge Biomedical Research Centre, Cambridge, United Kingdom (Ms Grant and Dr Aiken)
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La Parra-Casado D, Arza-Porras J, Estévez JF. Health indicators of the National Roma Integration Strategy in Spain in the years 2006 and 2014. Eur J Public Health 2021; 30:906-910. [PMID: 32385497 DOI: 10.1093/eurpub/ckaa070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In 2011, the European Commission adopted the European framework for the National Roma Integration Strategies (NRISs) 2020, which focussed on four areas: education, employment, health and housing. In 2012 Spain approved its Strategy 2012-20, one of the central aims of which is to reduce social inequalities in health that affect the Roma population. Our objective was to analyze changes in health inequalities between the Roma population and the general population in Spain in the years 2006 and 2014. METHODS The Spanish National Health Surveys (NHSs) 2006 (n = 29 478) and 2012 (n = 20 884) and the NHS of the Spanish Roma Population 2006 (n = 933) and 2014 (n = 1155) were compared. This study considered the variables included in NRIS 2012-20: self-perceived health, tobacco use in men, traffic accidents in men and women, obesity in women and gynaecological visits. RESULTS Despite the adoption of the NRIS 2012-20, there were no observed improvements in health between 2006 and 2014 in the Roma population. Nor was there a reduction in inequalities in health concerning the general population in Spain. Also, there was no reduction in the health inequalities by gender for the two populations. CONCLUSIONS Health is determined in part by social factors including education, employment, housing and also by anti-Roma discourses and discrimination. Improving the health of the Roma population requires a multi-sectoral approach with a gender perspective.
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Affiliation(s)
- Daniel La Parra-Casado
- Department of Sociology II, Interuniversity Institute of International Economics, University of Alicante, Alicante, Spain
| | - Javier Arza-Porras
- Department of Sociology and Social Work, Public University of Navarra, Pamplona-Iruña, Spain
| | - Jesús Francisco Estévez
- Department of Sociology II, Interuniversity Institute of International Economics, University of Alicante, Alicante, Spain
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Canuto IMDB, Macêdo VCD, Frias PGD, Oliveira CMD, Costa HVVD, Portugal JL, Bonfim CVD. Spatial patterns of avoidable fetal mortality and social deprivation. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2021; 24:e210007. [PMID: 33886880 DOI: 10.1590/1980-549720210007.supl.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/03/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To develop a social need index for stratification of municipalities and identification of priority areas for reducing fetal mortality. METHODS ecological study, carried out in the state of Pernambuco, between 2010 and 2017. The technique of factor analysis by main components was used for the elaboration of the social need index. In the spatial analysis, the local empirical Bayesian estimator was applied and Moran's spatial autocorrelation was verified. RESULTS The social deprivation index selected two factors that, together, explained 77.63% of the total variance. The preventable fetal mortality rate increased among strata of social need, with rates of 8.0 per thousand births (low deprivation), 8.1 per thousand (medium deprivation), 8.8 per thousand (high deprivation), and 10.7 per thousand (very high social deprivation). Some municipalities in the São Francisco and Sertão Mesoregions had both high fetal and preventable fetal mortality, in addition to a very high social deprivation rate. Conclusion: The spatial analysis identified areas with the highest risk for fetal mortality. The social deprivation index listed some determinants of fetal deaths in areas with worse living conditions. Priority areas for intervention in public policies to reduce fetal mortality and its determinants were detected.
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Kale PL, Fonseca SC, Oliveira PWMD, Brito ADS. Fetal and infant mortality trends according to the avoidability of causes of death and maternal education. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2021; 24:e210008. [PMID: 33886881 DOI: 10.1590/1980-549720210008.supl.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 11/30/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To estimate trends of fetal (FMR) and neonatal (NMR) mortality rates due to avoidable causes and maternal education in the city of Rio de Janeiro (2000-2018). METHODS Ecological time series study. Mortality and Live Birth Information System Data. The List of Avoidable Causes of Death Due to Interventions of the Brazilian Health System was used for neonatal deaths and an adaptation for fetal deaths, according to maternal education indicators (low <4 and high ≥12, years of study). Joinpoint regression models were used to estimate trends in FMR, based on one thousand births, and NMR, based on one thousand live births. RESULTS FMR decreased from 11.0 to 9.3% and NMR from 11.3 to 7.8% (2000/2018). In 2006, FMR (10.5%) exceeded NMR (9.0%), remaining higher. From 2000 to 2018, the annual decrease of FMR was 0.8% (2000 to 2018) and of NMR, 3.8% until 2007, decreasing to 1.1% by 2011; from then on, it remained stable. Avoidable causes, especially those reducible by adequate prenatal care, showed higher rates. Both FMR and NMR for low-education women were higher than those for the high-education level, the difference being much more pronounced for FMR, and at the end of the period: low- and high-education FMR were respectively 16.4 and 4.5% (2000) and 48.5 and 3.9% (2018), and for NMR, 18.2 and 6.7% (2000) and 28.4 and 5.0% (2018). CONCLUSION The favorable trend of decreasing mortality was not observed for children of mothers with low education, revealing inequalities. The causes were mostly avoidable, being related to prenatal care and childbirth.
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Affiliation(s)
- Pauline Lorena Kale
- Institute of Collective Health Studies, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil
| | - Sandra Costa Fonseca
- Institute of Collective Health, Universidade Federal Fluminense, Niterói (RJ), Brazil
| | | | - Alexandre Dos Santos Brito
- Institute of Collective Health Studies, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil
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Risk of Stillbirth Among Foreign-Born Mothers in the United States. J Immigr Minor Health 2021; 24:318-326. [PMID: 33710447 DOI: 10.1007/s10903-021-01164-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 10/21/2022]
Abstract
The objective of this study is to assess the impact of maternal nativity on stillbirth in the US. We utilized the US Birth Data and Fetal Death Data for the years 2014-2017. Our analysis was restricted to live and stillbirths (N= of 14,867,880) that occurred within the gestational age of 20-42 weeks. The fetuses-at risk approach was used to generate stillbirth trends by gestational age. Adjusted Cox proportional hazards regression model was utilized to estimate the association between maternal nativity and stillbirth. Overall, the gestational week-specific prospective risk of stillbirth was consistently higher for native-born than their foreign-born mothers. Foreign-born mothers were 20% less likely to experience stillbirth than their native-born counterparts (AHR = 0.80; 95% CI = 0.78-0.81). Delineating the factors influencing the observed effect of maternal nativity on birth outcomes should be a research priority to inform strategies to address adverse birth outcomes in the US.
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García-Tizón Larroca S, Amor Valera F, Ayuso Herrera E, Cueto Hernandez I, Cuñarro Lopez Y, De Leon-Luis J. Human Development Index of the maternal country of origin and its relationship with maternal near miss: A systematic review of the literature. BMC Pregnancy Childbirth 2020; 20:224. [PMID: 32299375 PMCID: PMC7164222 DOI: 10.1186/s12884-020-02901-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 03/27/2020] [Indexed: 01/09/2023] Open
Abstract
Background The reduction in maternal mortality worldwide has increased the interest in studying more frequent severe events such as maternal near miss. The Human Development Index is a sociodemographic country-specific variable that includes key human development indicators such as living a long and healthy life, acquiring knowledge, and enjoying a decent standard of living, allowing differentiation between countries. In a globalised environment, it is necessary to study whether the Human Development Index of each patient's country of origin can be associated with the maternal near-miss rate and thus classify the risk of maternal morbidity and mortality. Methods A systematic review of the literature published between 2008 and 2019 was conducted, including all articles that reported data about maternal near miss in their sample of pregnant women, in addition to describing the study countries of their sample population. The Human Development Index of the study country, the maternal near-miss rate, the maternal mortality rate, and other maternal-perinatal variables related to morbidity and mortality were used. Results After the systematic review, eighty two articles from over thirty countries were included, for a total of 3,699,697 live births, 37,191 near miss cases, and 4029 mortality cases. A statistically significant (p <0.05) inversely proportional relationship was observed between the Human Development Index of the study country and the maternal near-miss and mortality rates. The most common cause of maternal near miss was haemorrhage, with an overall rate of 38.5%, followed by hypertensive disorders of pregnancy (34.2%), sepsis (7.5%), and other undefined causes (20.9%). Conclusions The Human Development Index of the maternal country of origin is a sociodemographic variable allowing differentiation and classification of the risk of maternal mortality and near miss in pregnant women. The most common cause of maternal near miss published in the literature was haemorrhage. Trial registration PROSPERO ID: CRD 42019133464
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Affiliation(s)
- Santiago García-Tizón Larroca
- Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, HGUGM, Calle O' Donnell, 48, Planta 0, 28009, Madrid, Spain.
| | - Francisco Amor Valera
- Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, HGUGM, Calle O' Donnell, 48, Planta 0, 28009, Madrid, Spain
| | - Esther Ayuso Herrera
- Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, HGUGM, Calle O' Donnell, 48, Planta 0, 28009, Madrid, Spain
| | - Ignacio Cueto Hernandez
- Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, HGUGM, Calle O' Donnell, 48, Planta 0, 28009, Madrid, Spain
| | - Yolanda Cuñarro Lopez
- Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, HGUGM, Calle O' Donnell, 48, Planta 0, 28009, Madrid, Spain
| | - Juan De Leon-Luis
- Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, HGUGM, Calle O' Donnell, 48, Planta 0, 28009, Madrid, Spain.,Department of Public and Maternal-Infant Health, Complutense University, Madrid, Spain
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