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Afari H, Sheehan M, Reza N. Contemporary Management of Cardiomyopathy and Heart Failure in Pregnancy. Cardiol Ther 2024; 13:17-37. [PMID: 38340291 PMCID: PMC10899150 DOI: 10.1007/s40119-024-00351-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/11/2024] [Indexed: 02/12/2024] Open
Abstract
Cardiovascular disease is the primary cause of pregnancy-related mortality and morbidity in the United States, and maternal mortality has increased over the last decade. Pregnancy and the postpartum period are associated with significant vascular, metabolic, and physiologic adaptations that can unmask new heart failure or exacerbate heart failure symptoms in women with known underlying cardiomyopathy. There are unique management considerations for heart failure in women throughout pregnancy, and it is imperative that clinicians caring for pregnant women understand these important principles. Early involvement of multidisciplinary cardio-obstetrics teams is key to optimizing maternal and fetal outcomes. In this review, we discuss the unique challenges and opportunities in the diagnosis of heart failure in pregnancy, management principles along the continuum of pregnancy, and the safety of heart failure therapies during and after pregnancy.
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Affiliation(s)
- Henrietta Afari
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 11Th Floor South Pavilion, Philadelphia, PA, 19104, USA
| | - Megan Sheehan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 11Th Floor South Pavilion, Philadelphia, PA, 19104, USA.
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Hettiarachchi A, Jayaratne K, De Silva C, Senanayake H, Lokunarangoda N, Agampodi S. Heart disease complicating pregnancy as a leading cause of maternal deaths in LMIC settings: the Sri Lankan experience. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 15:100223. [PMID: 37614353 PMCID: PMC10442957 DOI: 10.1016/j.lansea.2023.100223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 05/13/2023] [Accepted: 05/15/2023] [Indexed: 08/25/2023]
Abstract
Background Heart disease (HD) is one of the leading indirect causes of maternal deaths worldwide, both in high- and low- and middle-income countries (LMICs). This study aims to describe maternal deaths due to cardiovascular disease complicating pregnancy in Sri Lanka. Methods The national Maternal Death Surveillance Response (MDSR) system in Sri Lanka investigates all female deaths during pregnancy and 12 months after delivery. These maternal death investigation records were perused in this analysis. Maternal deaths from 2006 to 2018 with HD complicating pregnancy as the immediate or underlying cause of death were re-coded using the ICD-11 classification. Findings Of the 2855 pregnancy-related deaths reported to the MDSR from 2006 to 2018, 1646 (57.7%) were confirmed as maternal deaths. Of those, 284 (17.25%) were attributed to HD complicating pregnancy. The cause-specific maternal mortality ratio due to heart disease from 2006 to 2018 was 7.24 per 100,000 live births. Rheumatic heart disease was the leading cause of HD (60, 21.1%), while cardiomyopathies (59, 20.7%) and congenital anomalies (34, 12.0%) accounted for a sizeable share. Medically contraindicated pregnancies accounted for 54 (19%) deaths. Application of the 3-delay model identified 186 (65.5%) cases with possible delays. Out of all deaths, 158 (55.6%) cases were categorized as preventable. Interpretation Preventing maternal mortality from HD in LMICs requires a lifecycle approach with situation-specific interventions and highly specialized care. Community awareness, capacity building related to management, and specific infrastructure development will be key strategies. Funding None.
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Affiliation(s)
- Ayesh Hettiarachchi
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, 5008, Sri Lanka
| | - Kapila Jayaratne
- Family Health Bureau, Ministry of Health, No: 231, De Saram Place, Colombo 10, Sri Lanka
| | - Chithramalee De Silva
- Family Health Bureau, Ministry of Health, No: 231, De Saram Place, Colombo 10, Sri Lanka
| | - Hemantha Senanayake
- Faculty of Medicine, University of Colombo, 25, Kynsey Rd, Colombo, 00800, Sri Lanka
| | - Niroshan Lokunarangoda
- Department of Medicine & Mental Health, Faculty of Medicine, University of Moratuwa, Bandaranayake Mawatha, Moratuwa, 10400, Sri Lanka
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Edwards P, Anyaogu C, Mezue K, Baugh D, Goha A, Egbuche O, Nunura F, Madu E. Focused cardiac ultrasound in pregnancy. J Investig Med 2023; 71:81-91. [PMID: 36691704 DOI: 10.1177/10815589221142195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Cardiac disease in pregnancy is an important cause of maternal morbidity and mortality. In many high-income countries, acquired cardiac disease is now the largest cause of maternal mortality. Given its prevalence in low- and middle-income countries (LMICs), rheumatic heart disease is the most common cause of cardiac disease in pregnancy worldwide and is associated with poor maternal outcome. The diagnosis of cardiac disease in pregnancy is often delayed resulting in excess maternal morbidity and mortality. Maternal mortality review committees have suggested that prompt recognition and treatment of heart disease in pregnancy may improve maternal outcome. Given the similarities between symptoms of normal pregnancy and those of cardiac disease, the clinical diagnosis of heart disease in pregnancy is challenging with echocardiography being the primary diagnostic modality. Focused cardiac ultrasound (FOCUS) at the point of care provides supplemental data to the history and physical examination and has been demonstrated to permit early diagnosis and improvement in the management of cardiac disease in emergency medicine, intensive care, and anesthesia. It has also been demonstrated to be useful in surveillance for rheumatic heart disease in LMICs. The use of FOCUS may allow earlier and more accurate diagnosis of cardiac disease in pregnancy with the potential to decrease morbidity and mortality in both developed and developing countries.
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Affiliation(s)
- Paul Edwards
- Heart Institute of the Caribbean, Kingston, Jamaica
| | | | - Kenechukwu Mezue
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Dainia Baugh
- Heart Institute of the Caribbean, Kingston, Jamaica
| | - Ahmed Goha
- Cardiology department, Cardiac Center Hail, Hail, Saudi Arabia
| | - Obiora Egbuche
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Felix Nunura
- Heart Institute of the Caribbean, Kingston, Jamaica
| | - Ernest Madu
- Heart Institute of the Caribbean, Kingston, Jamaica
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Patil H, Kotireddy J, Shitole A, Patil S. Maternal and fetal outcomes among pregnant women with cardiac disease attending a tertiary care hospital: A prospective observational study. INDIAN JOURNAL OF HEALTH SCIENCES AND BIOMEDICAL RESEARCH (KLEU) 2023. [DOI: 10.4103/kleuhsj.kleuhsj_393_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Chhabra ST. Cardio-obstetrics in India: The Mission, the Scope and the Road Ahead. INDIAN JOURNAL OF CARDIOVASCULAR DISEASE IN WOMEN 2022. [DOI: 10.25259/ijcdw_12_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Heemelaar S, Agapitus N, van den Akker T, Stekelenburg J, Mackenzie S, Hugo‐Hamman C, Auala T. Experiences of a dedicated Heart and Maternal Health Service providing multidisciplinary care to pregnant women with cardiac disease in a tertiary centre in Namibia. Trop Med Int Health 2022; 27:803-814. [PMID: 36053884 PMCID: PMC9543594 DOI: 10.1111/tmi.13804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objectives Methods Results Conclusions
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Affiliation(s)
- S. Heemelaar
- Department of Obstetrics & Gynaecology Windhoek Central Hospital Windhoek Namibia
- Department of Obstetrics and Gynaecology Leiden University Medical Center Leiden The Netherlands
| | - N. Agapitus
- Department of Cardiology Windhoek Central Hospital Windhoek Namibia
| | - T. van den Akker
- Department of Obstetrics and Gynaecology Leiden University Medical Center Leiden The Netherlands
- Athena Institute VU University Amsterdam The Netherlands
| | - J. Stekelenburg
- Department of Health Science, Global Health University Medical Center Groningen Groningen The Netherlands
- Department of Obstetrics and Gynaecology Medical Center Leeuwarden Leeuwarden The Netherlands
| | - S. Mackenzie
- Department of Obstetrics & Gynaecology Windhoek Central Hospital Windhoek Namibia
| | - C. Hugo‐Hamman
- Department of Cardiology Windhoek Central Hospital Windhoek Namibia
| | - T. Auala
- Department of Cardiology Windhoek Central Hospital Windhoek Namibia
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Gnanaraj JP, Princy SA, Sliwa-Hahnle K, Sathyendra S, Jeyabalan N, Sethumadhavan R, G S, Sumathi N, S V, P P, Murali V, B S, T G, P M, Jeemon P, Elavarasi E, R R, S V, K K. Tamil Nadu Pregnancy and Heart Disease Registry (TNPHDR): design and methodology. BMC Pregnancy Childbirth 2022; 22:80. [PMID: 35093002 PMCID: PMC8801092 DOI: 10.1186/s12884-021-04305-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/30/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Cardiac disease in pregnancy is a major contributor to maternal mortality in high, middle and low-income countries. Availability of data on outcomes of pregnancy in women with heart disease is important for planning resources to reduce maternal mortality. Prospective data on outcomes and risk predictors of mortality in pregnant women with heart disease (PWWHD) from low- and middle-income countries are scarce.
Methods
The Tamil Nadu Pregnancy and Heart Disease Registry (TNPHDR) is a prospective, multicentric and multidisciplinary registry of PWWHD from 29 participating sites including both public and private sectors, across the state of Tamil Nadu in India. The TNPHDR is aimed to provide data on incidence of maternal and fetal outcomes, adverse outcome predictors, applicability of the modified World Health Organization (mWHO) classification of maternal cardiovascular risk and the International risk scoring systems (ZAHARA and CARPREG I & II) in Indian population and identify possible gaps in the existing management of PWWHD. Pregnancy and heart teams will be formed in all participating sites. Baseline demographic, clinical, laboratory and imaging parameters, data on counselling received, antenatal triage and management, peripartum management and postpartum care will be collected from 2500 eligible participants as part of the TNPHDR. Participants will be followed up at one, three and six-months after delivery/termination of pregnancy to document study outcomes. Predictors of maternal and foetal outcome will be identified.
Discussion
The TNPHDR will be the first representative registry from low- and middle-income countries aimed at providing crucial information on pregnancy outcomes and risk predictors in PWWHD. The results of TNPHDR could help to formulate steps for improved care and to generate a customised and practical guideline for managing pregnancy in women with heart disease in limited resource settings.
Trial registration
The TNPHDR is registered under Clinical Trials Registry-India (CTRI/2020/01/022736).
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Mashak B, Hashemnejad M, Fakehi M, Heidary Z, Mirmajidi R, Ghaemi M. Atypical presentation of cardiomyopathy in a case of maternal mortality that was demonstrated as hypovolemic shock. Clin Case Rep 2021; 9:e05010. [PMID: 34721867 PMCID: PMC8543056 DOI: 10.1002/ccr3.5010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/28/2021] [Accepted: 10/11/2021] [Indexed: 01/19/2023] Open
Abstract
Periconceptional and prenatal care should be continued even during COVID-19 pandemics. Indeed, prevention and intervention programs for managing heart failure with aggressive resuscitation and invasive monitoring help to provide the best outcomes in cardiomyopathies. PPH may be associated with cardiac diseases and the resuscitation measures need modification to prevent maternal mortality.
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Affiliation(s)
- Banfsheh Mashak
- Kamali HospitalSchool of MedicineAlborz University of Medical SciencesKarajIran
| | - Maryam Hashemnejad
- Kamali HospitalSchool of MedicineAlborz University of Medical SciencesKarajIran
| | - Maliheh Fakehi
- Department of Gynecology and ObstetricsShahid Akbarabadi HospitalIran University of Medical SciencesTehranIran
| | - Zohreh Heidary
- Vali‐e‐Asr Reproductive Health Research CenterTehran University of Medical SciencesTehranIran
| | - Roghayyeh Mirmajidi
- Kamali HospitalSchool of MedicineAlborz University of Medical SciencesKarajIran
| | - Marjan Ghaemi
- Vali‐e‐Asr Reproductive Health Research CenterTehran University of Medical SciencesTehranIran
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Keepanasseril A, Pfaller B, Metcalfe A, Siu SC, Davis MB, Silversides CK. Cardiovascular Deaths in Pregnancy: Growing Concerns and Preventive Strategies. Can J Cardiol 2021; 37:1969-1978. [PMID: 34600086 DOI: 10.1016/j.cjca.2021.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Anish Keepanasseril
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - Birgit Pfaller
- Department of Internal Medicine 1, University Hospital of St Pölten, Karl Landsteiner University of Health Sciences, Karl Landsteiner Institute for Nephrology, St Pölten, Austria
| | - Amy Metcalfe
- Department of Obstetrics and Gynecology, Department of Community Health Sciences and Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Samuel C Siu
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, University of Western Ontario, London, Ontario, Canada
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Candice K Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada.
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Mocumbi AO. Women's cardiovascular health: shifting towards equity and justice. Lancet 2021; 397:2315-2317. [PMID: 34010612 DOI: 10.1016/s0140-6736(21)01017-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/27/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Ana Olga Mocumbi
- Instituto Nacional de Saúde, Maputo, 1120 Mozambique; Universidade Eduardo Mondlane, Maputo 1101, Mozambique.
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Afari HA, Davis EF, Sarma AA. Echocardiography for the Pregnant Heart. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021; 23:55. [PMID: 34075291 PMCID: PMC8160078 DOI: 10.1007/s11936-021-00930-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 01/22/2023]
Abstract
Purpose of review Pregnancy is associated with significant hemodynamic changes, making it a potentially high-risk period for women with underlying cardiovascular disease. Echocardiography remains the preferred modality for diagnosis and monitoring of pregnant women with cardiovascular disease as it is widely available and does not require radiation. This paper reviews the role of echocardiography along the continuum of pregnancy in at-risk patients, with a focus on key cardiac disease states in pregnancy. Recent findings In the preconception stage, risk stratification scores such as CARPREG II, ZAHARA and the modified WHO remain central to counseling and planning. As such, echocardiography serves an important role in assessing the severity of pre-existing structural disease. Among women with pre-existing cardiovascular disease who become pregnant-as well as those who develop cardiovascular symptoms during pregnancy-echocardiography is a key imaging tool for assessment of hemodynamic and structural changes and is recommended as the first-line imaging modality when appropriate by both the American College of Obstetricians and Gynecologists (ACOG) and the Food and Drug Administration (FDA). However, routine screening intervals during pregnancy for various cardiac lesions are not well defined, resulting in clinical heterogeneity in care. Summary Echocardiography is the imaging modality of choice for defining, risk stratifying, and monitoring cardiovascular changes throughout pregnancy. Once identified, at-risk patients should receive careful individual counseling and follow-up with a multidisciplinary team. Echocardiography serves as a widely available tool for serial monitoring of pregnant women with cardiovascular disease throughout pregnancy and the postpartum period.
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Affiliation(s)
| | - Esther F. Davis
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA USA
| | - Amy A. Sarma
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
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Kodan LR, Verschueren KJ, Paidin R, Paidin R, Browne JL, Bloemenkamp KW, Rijken MJ. Trends in maternal mortality in Suriname: 3 confidential enquiries in 3 decades. AJOG GLOBAL REPORTS 2021; 1:100004. [PMID: 36275195 PMCID: PMC9563526 DOI: 10.1016/j.xagr.2021.100004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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