WHO systematic review of maternal mortality and morbidity: methodological issues and challenges

Incompleteness and misclassification of maternal death recording: a systematic review and meta-analysis

OBJECTIVE

To quantify the extent of incompleteness and misclassification of maternal and pregnancy related deaths, and to identify general and context-specific factors associated with incompleteness and/or misclassification of maternal death data.

METHODS

We conducted a systematic review of incompleteness and/or misclassification of maternal and pregnancy-related deaths. We conducted a narrative synthesis to identify methods used to capture and classify maternal deaths, as well as general and context specific factors affecting the completeness and misclassification of maternal death recording. We conducted a meta-analysis of proportions to obtain estimates of incompleteness and misclassification of maternal death recording, overall and disaggregated by income and surveillance system types.

FINDINGS

Of 2872 title-abstracts identified, 29 were eligible for inclusions in the qualitative synthesis, and 20 in the meta-analysis. Included studies relied principally on record linkage and review for identifying deaths, and on review of medical records and verbal autopsies to correctly classify cause of death. Deaths to women towards the extremes of the reproductive age range, those not classified by a medical examiner or a coroner, and those from minority ethnic groups in their setting were more likely misclassified or unrecorded. In the meta-analysis, we found maternal death recording to be incomplete by 34% (95% CI: 28-48), with 60% sensitivity (95% CI: 31-81.). Overall, we found maternal mortality was under-estimated by 39% (95% CI: 30-48) due to incompleteness and/or misclassification. Reporting of deaths away from the intrapartum, due to indirect causes or occurring at home were less complete than their counterparts. There was substantial between and within group variability across most results.

CONCLUSION

Maternal deaths were under-estimated in almost all contexts, but the extent varied across settings. Countries should aim towards establishing Civil Registration and Vital Statistics systems where they are not instituted. Efforts to improve the completeness and accuracy of maternal cause of death recording, such as Confidential Enquiries into Maternal Deaths, are needed even where CRVS is considered to be well-functioning.

Global, Regional, and National Incidence and Mortality of Neonatal Preterm Birth, 1990-2019

IMPORTANCE

Preterm birth complications are the leading cause of death in children younger than 5 years worldwide. Despite advancing knowledge of risk factors and mechanisms related to preterm labor, the preterm birth rate has risen in most industrialized countries. Moreover, the burden of neonatal preterm birth remains unclear across the world.

OBJECTIVE

To determine the trends in incidence and mortality of neonatal preterm birth at the global, regional, and national levels to quantify its burden from 1990 to 2019 using data from the 2019 Global Burden of Disease study.

DESIGN, SETTING, AND PARTICIPANTS

Annual incident cases, deaths, age-standardized incidence rates (ASIRs), and age-standardized mortality rates (ASMRs) of neonatal preterm birth between 1990 and 2019 were collected from the 2019 Global Burden of Disease study. The percentage of relative changes in incident cases and deaths as well as the estimated annual percentage changes (EAPCs) of ASIRs and ASMRs were calculated to quantify their temporal trends. Correlations of EAPC of ASIRs and ASMRs with sociodemographic index (SDI) and universal health coverage index were evaluated by Pearson correlation analyses.

EXPOSURES

Infants born alive before 37 completed weeks of gestation between 1990 and 2019.

MAIN OUTCOMES AND MEASURES

Incident cases, deaths, ASIRs, and ASMRs of neonatal preterm birth.

RESULTS

Globally, the incident cases of neonatal preterm birth decreased by 5.26% from 16.06 million in 1990 to 15.22 million in 2019, and the deaths decreased by 47.71% from 1.27 million in 1990 to 0.66 million in 2019. The overall ASIR (EAPC = -0.19 [95% CI, -0.27 to -0.11]) and ASMR (EAPC = -2.09 [95% CI, -1.99 to -2.20]) decreased in this period. The ASIR of neonatal preterm birth increased by a mean of 0.25% (95% CI, 0.13%-0.38%) in high-SDI regions from 1990 to 2019. The ASMR of neonatal preterm birth increased by a mean of 2.09% (95% CI, 1.99%-2.20%) in Southern Sub-Saharan Africa in this period. A positive correlation was observed between EAPC of ASIR and SDI or universal health coverage index in 2019, while a negative correlation was observed between EAPC in ASMR and SDI or universal health coverage index in 2019 at national levels.

CONCLUSIONS AND RELEVANCE

Preterm birth remains a crucial issue in children worldwide, with an increasing trend in ASIR in high-SDI regions and in ASMR in Southern Sub-Saharan Africa between 1990 to 2019. Efforts to reduce both the incidence and mortality of preterm births are essential.

Causes of maternal mortality in Sub-Saharan Africa: A systematic review of studies published from 2015 to 2020

Background

Maternal deaths remain high in Sub-Saharan Africa (SSA) and their causes of maternal death must be analysed frequently in this region to guide interventions.

Methods

We conducted a systematic review of studies published from 2015 to 2020 that reported the causes of maternal deaths in 57 SSA countries. The objective was to identify the leading causes of maternal deaths using the international classification of disease - 10^th revision, for maternal mortality (ICD-MM). We searched PubMed, WorldCat Discovery Libraries Worldwide (including Medline, Web of Science, LISTA and CNHAL databases), and Google Scholar databases and citations, using the search words "maternal mortality", "maternal death", "pregnancy-related death", "reproductive age mortality" and "causes" as MeSH terms or keywords. The last date of search from all databases was 21 May 2021. We included original research articles published in English and excluded articles that mentioned SSA country names without study results for those countries, studies that reported death from a single cause or assigned causes of death using computer models or incompletely broke down the causes of death. We exported, de-duplicated and screened the searches electronically in EndNote version 20. We selected the final articles by reading the titles, abstracts and full texts. Two authors searched the articles and assessed the risk of bias using a tool adapted from Montoya and others. Data from the articles were extracted onto an Excel worksheet and the deaths classified into ICD-MM groups. Proportions were calculated with 95% confidence intervals and compared for deaths attributed to each cause and ICD-MM group. We compared the results with WHO and Global Burden of Disease (GDB) estimates.

Results

We identified 38 studies that reported 11 427 maternal and four incidental deaths. Twenty-one of the third-eight studies were retrospective record reviews. The leading causes of death (proportions and 95% confidence intervals (CI)) were obstetric hemorrhage: 28.8% (95% CI = 26.5%-31.2%), hypertensive disorders in pregnancy: 22.1% (95% CI = 19.9%-24.2%), non-obstetric complications: 18.8% (95% CI = 16.4%-21.2%) and pregnancy-related infections: 11.5% (95% CI = 9.8%-13.2%). The studies reported few deaths of unknown/undetermined and incidental causes.

Conclusions

Limitations of this review were the failure to access more data from government reports, but the study results compared well with WHO and GDB estimates. Obstetric hemorrhage, hypertensive disorders in pregnancy, non-obstetric complications, and pregnancy-related infections are the leading causes of maternal deaths in SSA. However, deaths from incidental causes are likely under-reported in this region. SSA countries must continue to invest in health information systems that collect and publishes comprehensive, quality, maternal death causes data. A publicly accessible repository of data sets and government reports for causes of maternal death will be helpful in future reviews. This review received no specific funding and was not registered.

Maternal mortality in the covid-19 pandemic: findings from a rapid systematic review

Background

The COVID-19 pandemic is having significant direct and associated effects on many health outcomes, including maternal mortality. As a useful marker of healthcare system functionality, trends in maternal mortality provide a lens to gauge impact and inform mitigation strategies.

Objective

To report the findings of a rapid systematic review of studies on levels of maternal mortality before and during the COVID-19 pandemic.

Methods

We systematically searched for studies on the 1st March 2021 in MEDLINE and Embase, with additional studies identified through MedRxiv and searches of key websites. We included studies that reported levels of mortality in pregnant and postpartum women in time-periods pre- and during the COVID-19 pandemic. The maternal mortality ratio was calculated for each study as well as the excess mortality.

Results

The search yielded 3411 references, of which five studies were included in the review alongside two studies identified from grey literature searches. Five studies used data from national health information systems or death registries (Mexico, Peru, Uganda, South Africa, and Kenya), and two studies from India were record reviews from health facilities. There were increased levels of maternal mortality documented in all studies; however, there was only statistical evidence for a difference in maternal mortality in the COVID-19 era for four of these. Excess maternal mortality ranged from 8.5% in Kenya to 61.5% in Uganda.

Conclusions

Measuring maternal mortality in pandemics presents many challenges, but also essential opportunities to understand and ameliorate adverse impact both for women and their newborns. Our systematic review shows a dearth of studies giving reliable information on levels of maternal mortality, and we call for increased and more systematic reporting of this largely preventable outcome. The findings help to highlight four measurement-related issues which are priorities for continuing research and development.

Protocol for analysing the epidemiology of maternal mortality in Zimbabwe: A civil registration and vital statistics trend study

BACKGROUND

Sub-Saharan Africa (SSA) carries the highest burden of maternal mortality, yet, the accurate maternal mortality ratios (MMR) are uncertain in most SSA countries. Measuring maternal mortality is challenging in this region, where civil registration and vital statistics (CRVS) systems are weak or non-existent. We describe a protocol designed to explore the use of CRVS to monitor maternal mortality in Zimbabwe-an SSA country.

METHODS

In this study, we will collect deliveries and maternal death data from CRVS (government death registration records) and health facilities for 2007-2008 and 2018-2019 to compare MMRs and causes of death. We will code the causes of death using classifications in the maternal mortality version of the 10th revision to the international classification of diseases. We will compare the proportions of maternal deaths attributed to different causes between the two study periods. We will also analyse missingness and misclassification of maternal deaths in CRVS to assess the validity of their use to measure maternal mortality in Zimbabwe.

DISCUSSION

This study will determine changes in MMR and causes of maternal mortality in Zimbabwe over a decade. It will show whether HIV, which was at its peak in 2007-2008, remains a significant cause of maternal deaths in Zimbabwe. The study will recommend measures to improve the quality of CRVS data for future use to monitor maternal mortality in Zimbabwe and other SSA countries of similar characteristics.

Mental health of adolescents associated with sexual and reproductive outcomes: a systematic review

Objective

To systematically review the literature on the mental health of adolescents associated with sexual and reproductive outcomes, and compare the mental health outcomes with that of other age groups.

Methods

We searched seven databases for relevant peer-reviewed articles published between 1 January 2010 and 25 April 2019. Our inclusion criteria required that the study included age-disaggregated data on adolescents, and focused and assessed mental health outcomes associated with pregnancy or sexually transmitted infections. We extracted data on the specific health event, the mental health outcome and the method of measuring this, and comparisons with other age groups.

Findings

After initially screening 10 818 articles by title and abstract, we included 96 articles in our review. We observed that a wide-ranging prevalence of mental ill-health has been reported for adolescents. However, most studies of mental health during pregnancy did not identify an increased risk of depression or other mental disorders among adolescents compared with other age groups. In contrast, the majority of studies conducted during the postpartum period identified an increased risk of depression in adolescents compared with other age groups. Three studies reported on mental health outcomes following abortion, with varying results. We found no studies of the effect of sexually transmitted infections on mental health among adolescents.

Conclusion

We recommend that sexual and reproductive health services should be accessible to adolescents to address their needs and help to prevent any adverse mental health outcomes.

Assessment of the potential role of atmospheric particulate pollution and airborne transmission in intensifying the first wave pandemic impact of SARS-CoV-2/COVID-19 in Northern Italy

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which exploded in Wuhan (Hebei Region, China) in late 2019, has later spread around the world, causing pandemic effects on humans. During the first wave of the pandemic, Italy, and especially its Northern regions around the Po Valley, faced severe consequences in terms of infected individuals and casualties (more than 31,000 deaths and 255,000 infected people by mid-May 2020). While the spread and effective impact of the virus is primarily related to the lifestyles and social habits of the different human communities, environmental and meteorological factors also play a role. Among these, particulate pollution may directly impact the human respiratory system or act as virus carrier, thus behaving as potential amplifying factor in the pandemic spread of SARS-CoV-2. Enhanced levels of PM2.5 and PM10 particles in Northern Italy were observed over the 2-month period preceding the virus pandemic spread. Threshold levels for PM10 (< 50 μg/m3) were exceeded on 20-35 days over the period January-February 2020 in many areas in the Po Valley, where major effects in terms of infections and casualties occurred, with levels in excess of 80 μg/m3 occasionally observed in the 1-3 weeks preceding the contagious activation around February 25, 2020. Threshold values for PM2.5 indicated in WHO air quality guidelines (< 25 μg/m3) were exceeded on more than 40 days over the period January-February 2020 in large portions of the Po Valley, with levels up to 70 μg/m3 observed in the weeks preceding the contagious activation. In this paper, PM10 particle measurements are compared with epidemiologic parameters' data. Specifically, a statistical analysis is carried out to correlate the infection rate, or incidence of the pathology, the mortality rate, and the case fatality rate with PM concentrations. The study considers epidemiologic data for all 110 Italian provinces, as reported by the Italian Statistics Institute, over the period 20 February-31 March 2020. Corresponding PM10 concentrations covering the period 15-26 February 2020 were collected from the network of air quality monitoring stations run by different regional and provincial environment agencies. The case fatality rate is found to be highly correlated to the average PM10 concentration, with a correlation coefficient of 0.89 and a slope of the regression line of (6.7 ± 0.3) × 10-3 m3/μg, which implies a doubling (from 3 to 6%) of the mortality rate of infected patients for an average PM10 concentration increase from 22 to 27 μg/m3. Infection and mortality rates are also found to be correlated with PM10 concentrations, with correlation coefficients being 0.82 and 0.80, respectively, and the slopes of the regression lines indicating a doubling (from 1 to 2‰) of the infection rate and a tripling (from 0.1 to 0.3‰) of the mortality rate for an average PM10 concentration increase from 25 to 29 μg/m3. Considerations on the exhaled particles' sizes, their concentrations and residence times, the transported viral dose and the minimum infective dose, in combination with PM2.5 and PM10 pollution measurements and an analytical microphysical model, allowed assessing the potential role of airborne transmission through virus-laden PM particles, in addition to droplet and the traditional airborne transmission, in conveying SARS-CoV-2 in the human respiratory system. In specific circumstances which can be found in indoor environments, the number of small potentially infectious particles coalescing on PM2.5 and PM10 particles is estimated to exceed the number of infectious particles needed to activate COVID-19 infection in humans.

Evidence-Based Considerations Exploring Relations between SARS-CoV-2 Pandemic and Air Pollution: Involvement of PM2.5-Mediated Up-Regulation of the Viral Receptor ACE-2

The COVID-19/SARS-CoV-2 pandemic struck health, social and economic systems worldwide, and represents an open challenge for scientists -coping with the high inter-individual variability of COVID-19, and for policy makers -coping with the responsibility to understand environmental factors affecting its severity across different geographical areas. Air pollution has been warned of as a modifiable factor contributing to differential SARS-CoV-2 spread but the biological mechanisms underlying the phenomenon are still unknown. Air quality and COVID-19 epidemiological data from 110 Italian provinces were studied by correlation analysis, to evaluate the association between particulate matter (PM)2.5 concentrations and incidence, mortality rate and case fatality risk of COVID-19 in the period 20 February-31 March 2020. Bioinformatic analysis of the DNA sequence encoding the SARS-CoV-2 cell receptor angiotensin-converting enzyme 2 (ACE-2) was performed to identify consensus motifs for transcription factors mediating cellular response to pollutant insult. Positive correlations between PM2.5 levels and the incidence (r = 0.67, p < 0.0001), the mortality rate (r = 0.65, p < 0.0001) and the case fatality rate (r = 0.7, p < 0.0001) of COVID-19 were found. The bioinformatic analysis of the ACE-2 gene identified nine putative consensus motifs for the aryl hydrocarbon receptor (AHR). Our results confirm the supposed link between air pollution and the rate and outcome of SARS-CoV-2 infection and support the hypothesis that pollution-induced over-expression of ACE-2 on human airways may favor SARS-CoV-2 infectivity.

Outcome of uterine rupture and associated factors in Yirgalem general and teaching hospital, southern Ethiopia: a cross-sectional study

Background

The occurrence of uterine rupture has dropped significantly in high income countries. It continues, however, to be a major public and clinical health problem in low income countries including Ethiopia. Aim of this study was to assess management outcomes of uterine rupture and associated factors in Yirgalem General and Teaching Hospital in South Ethiopia.

Methods

Institution-based cross-sectional study was conducted to examine medical records of women with uterine rupture between January 1, 2012, and Decem”ber 31, 2017. Data were collected based on a checklist. Descriptive statistics and logistic regression analyses were performed.

Results

Incidence of uterine rupture was 345 in 13,500 live births (25.5 in 1000 live births) in the study period. Of these, 331 cases were included. Poor maternal outcome occurred in 224 (67.7%) women. There were 13 (3.7%) maternal deaths and 320 (96.7%) stillbirths. Wound site infection (131; 39.6%) and anemia (129; 39%) were the most common post-operative complications. Prolonged duration of labor (more than 24 h) (adjusted odds ratio (aOR) 3.6; 95% CI 1.7–7.4), women with sepsis on admission (aOR 2.9; 95% CI 1.4–6.1), hemoglobin level < 7 g/dl prior to surgical intervention (aOR 4.5; 95% CI 1.1–17.8), delayed surgical intervention after hospitalization (4 h or more before surgery) (aOR 3.8; 95% CI 1.8–8), women who did not receive blood transfusion (aOR 4.0; 95% CI 2.1–7.9) and prolonged intraoperative time (aOR 5.5; 95% CI 2.8–10.8) were all factors associated with poor maternal outcome of uterine rupture.

Conclusion

Poor maternal outcome of uterine rupture was high in the study area as compared to other studies. Proper management of anemia, prompt surgical treatment, proper labor progress monitoring, surgical skills, improved infection prevention, maximizing blood transfusion availability and improving the quality of maternal healthcare all play a significant role in reducing uterine rupture and enhancing the chance of good outcomes.

Birth-Related Perineal Trauma in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

Introduction Birth-related perineal trauma (BPT) is a common consequence of vaginal births. When poorly managed, BPT can result in increased morbidity and mortality due to infections, haemorrhage, and incontinence. This review aims to collect data on rates of BPT in low- and middle-income countries (LMICs), through a systematic review and meta-analysis. Methods The following databases were searched: Medline, Embase, Latin American and Caribbean Health Sciences Literature (LILACs), and the World Health Organization (WHO) regional databases, from 2004 to 2016. Cross-sectional data on the proportion of vaginal births that resulted in episiotomy, second degree tears or obstetric anal sphincter injuries (OASI) were extracted from studies carried out in LMICs by two independent reviewers. Estimates were meta-analysed using a random effects model; results were presented by type of BPT, parity, and mode of birth. Results Of the 1182 citations reviewed, 74 studies providing data on 334,054 births in 41 countries were included. Five studies reported outcomes of births in the community. In LMICs, the overall rates of BPT were 46% (95% CI 36–55%), 24% (95% CI 17–32%), and 1.4% (95% CI 1.2–1.7%) for episiotomies, second degree tears, and OASI, respectively. Studies were highly heterogeneous with respect to study design and population. The overall reporting quality was inadequate. Discussion Compared to high-income settings, episiotomy rates are high in LMIC medical facilities. There is an urgent need to improve reporting of BPT in LMICs particularly with regards to births taking in community settings.

Monitoring maternal and newborn health outcomes globally: a brief history of key events and initiatives

OBJECTIVE

Over time, we have seen a major evolution of measurement initiatives, indicators and methods, such that today a wide range of maternal and perinatal indicators are monitored and new indicators are under development. Monitoring global progress in maternal and newborn health outcomes and development has been dominated in recent decades by efforts to set, measure and achieve global goals and targets: the Millennium Development Goals followed by the Sustainable Development Goals. This paper aims to review, reflect and learn on accelerated progress towards global goals and events, including universal health coverage, and better tracking of maternal and newborn health outcomes.

METHODS

We searched for literature of key events and global initiatives over recent decades related to maternal and newborn health. The searches were conducted using PubMed/MEDLINE and the World Health Organization Global Index Medicus.

RESULTS

This paper describes global key events and initiatives over recent decades showing how maternal and neonatal mortality and morbidity, and stillbirths, have been viewed, when they have achieved higher priority on the global agenda, and how they have been measured, monitored and reported. Despite substantial improvements, the enormous maternal and newborn health disparities that persist within and between countries indicate the urgent need to renew the focus on reducing inequities.

CONCLUSION

The review has featured the long story of the progress in monitoring improving maternal and newborn health outcomes, but has also underlined current gaps and significant inequities. The many global initiatives described in this paper have highlighted the magnitude of the problems and have built the political momentum over the years for effectively addressing maternal and newborn health and well-being, with particular focus on improved measurement and monitoring.

Associations of systolic blood pressure trajectories during pregnancy and risk of adverse perinatal outcomes

This study aimed to explore the association of systolic blood pressure (SBP) trajectories of pregnant women with the risk of adverse outcomes of pregnant women and their fetuses. A register-based cohort of 63,724 pregnant women and their fetuses from January 2013 to December 2017 was investigated. Demographic characteristics, history of disease and family history of disease for pregnant women and perinatal outcomes were recorded, and blood pressure was measured during the whole pregnancy. SBP trajectories were estimated with latent mixture modeling by Proc Traj in SAS using SBP data from the first antenatal care appointment (8-14 weeks), the highest SBP before admission, the admission SBP and the SBP at 2 h postpartum. A censored normal model (CNORM) was considered appropriate, and model fit was assessed using the Bayesian information criterion (BIC). A logistic regression model was used to examine the association between SBP trajectories and the risk of adverse perinatal outcomes. Four distinct SBP trajectory patterns over the pregnancy period were identified and were labeled as low-stable, moderate-stable, high-decreasing and moderate-increasing. Three maternal and three fetal adverse outcomes were selected as the main outcome measures. After adjusting for confounding factors, compared with pregnant women with the low-stable pattern, those with the high-decreasing pattern had a higher risk of developing poor growth outcomes of fetuses, while those with the moderate-increasing pattern had higher risks of developing both adverse maternal and fetal outcomes. Our study results suggest that pregnant women should pay attention to the control of blood pressure throughout pregnancy.

Does splitting a tablet obtain the accurate dose?: A systematic review protocol

BACKGROUND

Physical manipulation of the manufactured dose form is a common practice, with almost a quarter of all drugs administered in primary care having their dose altered. Splitting a tablet can be advantageous as it facilitates swallowing, allows for dose flexibility and provides cost reductions. However, there are concerns these physical changes can lead to inaccurate portions resulting in significant variations from the prescribed dose. Thus, the review described in this protocol aims to summarise the literature assessing the effect of tablet splitting on dose accuracy.

METHODS

Relevant studies will be identified through electronic searches in databases including EMBASE, MEDLINE, CINAHL, and the Cochrane Library, from the beginning of databases until January 2020. Studies investigating any drug, where the tablet was split, will be potentially eligible. Two reviewers will independently screen studies and extract data using standardised forms. Data extracted will include general study information, characteristics of the study, intervention characteristics and outcomes. Primary outcome is to assess dose accuracy of a split tablet measured by drug content or weight variability. Assessment of risk of bias will be dependent upon study design. If deemed feasible, meta-analysis will be performed.

RESULTS

The study described within this protocol will provide a synthesis of current evidence assessing the effect of tablet splitting on dose accuracy.

CONCLUSION

The conclusion of our study will provide evidence to judge whether splitting a tablet results in an accurate half dose.

ETHICS AND DISSEMINATION

Ethics approval was not required for this study. The results of the systematic review described will be published in a peer-reviewed journal.

REGISTRATION DETAILS

PROSPERO CRD42018106252.

Association between quality and quantity of dietary carbohydrate and pregnancy-induced hypertension: A case-control study

BACKGROUND & AIMS

Pregnancy-induced hypertension (PIH) is a pregnancy-specific disorder that increases maternal and infant mortality and morbidity. The quantity and quality of consumed carbohydrates are probably the main dietary factors affecting blood pressure. The present study aimed to evaluate the association of carbohydrate quality and quantity with PIH.

METHODS

This case-control study was performed on 202 pregnant women with or without PIH. The dietary data were collected using 168-item semi-quantitative food frequency questionnaires. Daily glycemic index (GI) and glycemic load (GL), ratio of whole grains to total grains, ratio of solid carbohydrates to total carbohydrates, dietary fiber and carbohydrate intake, and carbohydrate quality index (CQI) were calculated and their associations with PIH were evaluated using logistic regression. We eliminated collinearity within independent variables using factor analysis and then with evaluating the relationship between extracted factors and PIH.

RESULTS

In pregnant women in whom the daily carbohydrate intake and GL were higher than median increased frequency of PIH compared to whom had lower than median ones (OR = 3.23, 95% CI 1.46-7.17, and P = 0.004; OR = 2.60, 95% CI 1.21-5.56; and P = 0.035, respectively). Furthermore, we showed a significant inverse association between extracted factor that was mostly related to total fiber intake frequency of PIH (OR = 0.45; 95% CI 0.20-0.97, and P = 0.049 when higher than median values compared to lower than ones). The GI, ratio of whole grains to total grains, ratio of solid carbohydrates to total carbohydrates, and CQI did not associate with PIH.

CONCLUSIONS

These findings suggest that carbohydrate intake and GL are related to higher and daily fiber intake to lower frequency of PIH.

The global prevalence of postpartum psychosis: a systematic review

BACKGROUND

Mental health is a significant contributor to global burden of disease and the consequences of perinatal psychiatric morbidity can be substantial. We aimed to obtain global estimates of puerperal psychosis prevalence based on population-based samples and to understand how postpartum psychosis is assessed and captured among included studies.

METHODS

In June 2014, we searched PubMed, CiNAHL, EMBASE, PsycINFO, Sociological Collections, and Global Index Medicus for publications since the year 1990. Criteria for inclusion in the systematic review were: use of primary data relevant to pre-defined mental health conditions, specified dates of data collection, limited to data from 1990 onwards, sample size >200 and a clear description of methodology. Data were extracted from published peer reviewed articles.

RESULTS

The search yielded 24,273 publications, of which six studies met the criteria. Five studies reported incidence of puerperal psychosis (ranging from 0.89 to 2.6 in 1000 women) and one reported prevalence of psychosis (5 in 1000). Due to the heterogeneity of methodologies used across studies in definitions and assessments used to identify cases, data was not pooled to calculate a global estimate of risk.

CONCLUSIONS

This review confirms the relatively low rate of puerperal psychosis; yet given the potential for serious consequences, this morbidity is significant from a global public health perspective. Further attention to consistent detection of puerperal psychosis can help provide appropriate treatment to prevent harmful consequences for both mother and baby.

Consequences of maternal morbidity on health-related functioning: a systematic scoping review

OBJECTIVES

To assess the scope of the published literature on the consequences of maternal morbidity on health-related functioning at the global level and identify key substantive findings as well as research and methodological gaps.

METHODS

We searched for articles published between 2005 and 2014 using Medline, Embase, Popline, CINAHL Plus and three regional bibliographic databases in January 2015.

DESIGN

Systematic scoping review PRIMARY OUTCOME: Health-related functioning RESULTS: After screening 17 706 studies, 136 articles were identified for inclusion. While a substantial number of papers have documented mostly negative effects of morbidity on health-related functioning and well-being, the body of evidence is not spread evenly across conditions, domains or geographical regions. Over 60% of the studies focus on indirect conditions such as depression, diabetes and incontinence. Health-related functioning is often assessed by instruments designed for the general population including the 36-item Short Form or disease-specific tools. The functioning domains most frequently documented are physical and mental; studies that examined physical, mental, social, economic and specifically focused on marital, maternal and sexual functioning are rare. Only 16 studies were conducted in Africa.

CONCLUSIONS

Many assessments have not been comprehensive and have paid little attention to important functioning domains for pregnant and postpartum women. The development of a comprehensive instrument specific to maternal health would greatly advance our understanding of burden of ill health associated with maternal morbidity and help set priorities. The lack of attention to consequences on functioning associated with the main direct obstetric complications is of particular concern.

REVIEW REGISTRATION

CRD42015017774.

Social determinants and maternal exposure to intimate partner violence of obstetric patients with severe maternal morbidity in the intensive care unit: a systematic review protocol

INTRODUCTION

Maternal mortality is a potentially preventable public health issue. Maternal morbidity is increasingly of interest to aid the reduction of maternal mortality. Obstetric patients admitted to the intensive care unit (ICU) are an important part of the global burden of maternal morbidity. Social determinants influence health outcomes of pregnant women. Additionally, intimate partner violence has a great negative impact on women's health and pregnancy outcome. However, little is known about the contextual and social aspects of obstetric patients treated in the ICU. This study aimed to conduct a systematic review of the social determinants and exposure to intimate partner violence of obstetric patients admitted to an ICU.

METHODS AND ANALYSIS

A systematic search will be conducted in MEDLINE, CINAHL, ProQuest, LILACS and SciELO from 2000 to 2016. Studies published in English and Spanish will be identified in relation to data reporting on social determinants of health and/or exposure to intimate partner violence of obstetric women, treated in the ICU during pregnancy, childbirth or within 42 days of the end of pregnancy. Two reviewers will independently screen for study eligibility and data extraction. Risk of bias and assessment of the quality of the included studies will be performed by using the Critical Appraisal Skills Programme (CASP) checklist. Data will be analysed and summarised using a narrative description of the available evidence across studies. This systematic review protocol will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines.

ETHICS AND DISSEMINATION

Since this systematic review will be based on published studies, ethical approval is not required. Findings will be presented at La Trobe University, in Conferences and Congresses, and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

CRD42016037492.

Multiple-bias analysis as a technique to address systematic error in measures of abortion-related mortality

Background

The UN Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs) have brought heightened global attention to the measurement of maternal mortality. It is imperative that new and novel approaches be used to measure maternal mortality and to better understand existing data. In this paper we present one approach: an epidemiologic framework for identifying the identification and quantification of systematic error (multiple-bias analysis), outline the necessary steps for investigators interested in conducting multiple-bias analyses in their own data, and suggest approaches for reporting such analyses in the literature.

Methods

To conceptualize the systematic error present in studies of abortion-related deaths, we propose a bias framework. We posit that selection bias and misclassification are present in both verbal autopsy studies and facility-based studies. The multiple-bias analysis framework provides a relatively simple, quantitative strategy for assessing systematic error and resulting bias in any epidemiologic study.

Results

In our worked example of multiple-bias analysis on a study reporting 20.6 % of maternal deaths to be abortion related, after adjustment for selection bias, misclassification, and random error, the median increased, on average, to 0.308, approximately 20 % greater than the reported proportion of abortion-related deaths.

Conclusions

Reporting results of multiple-bias analyses in estimates of abortion-related mortality, predictors of unsafe abortion, and other reproductive health questions that suffer from similar biases would not only improve reporting practices in the field, but might also provide a more accurate understanding of the range of potential impact of policies and programs that target the underlying causes of unsafe abortion and abortion-related mortality.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-016-0075-3) contains supplementary material, which is available to authorized users.

Non-Life Threatening Maternal Morbidity: Cross Sectional Surveys from Malawi and Pakistan

Background

For more accurate estimation of the global burden of pregnancy associated disease, clarity is needed on definition and assessment of non-severe maternal morbidity. Our study aimed to define maternal morbidity with clear criteria for identification at primary care level and estimate the distribution of and evaluate associations between physical (infective and non-infective) and psychological morbidities in two different low-income countries.

Methods

Cross sectional study with assessment of morbidity in early pregnancy (34%), late pregnancy (35%) and the postnatal period (31%) among 3459 women from two rural communities in Pakistan (1727) and Malawi (1732). Trained health care providers at primary care level used semi-structured questionnaires documenting signs and symptoms, clinical examination and laboratory tests which were bundled to reflect infectious, non-infectious and psychological morbidity.

Results

One in 10 women in Malawi and 1 in 5 in Pakistan reported a previous pregnancy complication with 1 in 10 overall reporting a previous neonatal death or stillbirth. In the index pregnancy, 50.1% of women in Malawi and 53% in Pakistan were assessed to have at least one morbidity (infective or non-infective). Both infective (Pakistan) and non-infective morbidity (Pakistan and Malawi) was lower in the postnatal period than during pregnancy. Multiple morbidities were uncommon (<10%). There were marked differences in psychological morbidity: 26.9% of women in Pakistan 2.6% in Malawi had an Edinburgh Postnatal Depression Score (EPDS) > 9. Complications during a previous pregnancy, infective morbidity (p <0.001), intra or postpartum haemorrhage (p <0.02) were associated with psychological morbidity in both settings.

Conclusions

Our findings highlight the need to strengthen the availability and quality of antenatal and postnatal care packages. We propose to adapt and improve the framework and criteria used in this study, ensuring a basic set of diagnostic tests is available, to ensure more robust assessment of non-severe maternal morbidity.

Global causes of maternal death: a WHO systematic analysis

BACKGROUND

Data for the causes of maternal deaths are needed to inform policies to improve maternal health. We developed and analysed global, regional, and subregional estimates of the causes of maternal death during 2003-09, with a novel method, updating the previous WHO systematic review.

METHODS

We searched specialised and general bibliographic databases for articles published between between Jan 1, 2003, and Dec 31, 2012, for research data, with no language restrictions, and the WHO mortality database for vital registration data. On the basis of prespecified inclusion criteria, we analysed causes of maternal death from datasets. We aggregated country level estimates to report estimates of causes of death by Millennium Development Goal regions and worldwide, for main and subcauses of death categories with a Bayesian hierarchical model.

FINDINGS

We identified 23 eligible studies (published 2003-12). We included 417 datasets from 115 countries comprising 60 799 deaths in the analysis. About 73% (1 771 000 of 2 443 000) of all maternal deaths between 2003 and 2009 were due to direct obstetric causes and deaths due to indirect causes accounted for 27·5% (672 000, 95% UI 19·7-37·5) of all deaths. Haemorrhage accounted for 27·1% (661 000, 19·9-36·2), hypertensive disorders 14·0% (343 000, 11·1-17·4), and sepsis 10·7% (261 000, 5·9-18·6) of maternal deaths. The rest of deaths were due to abortion (7·9% [193 000], 4·7-13·2), embolism (3·2% [78 000], 1·8-5·5), and all other direct causes of death (9·6% [235 000], 6·5-14·3). Regional estimates varied substantially.

INTERPRETATION

Between 2003 and 2009, haemorrhage, hypertensive disorders, and sepsis were responsible for more than half of maternal deaths worldwide. More than a quarter of deaths were attributable to indirect causes. These analyses should inform the prioritisation of health policies, programmes, and funding to reduce maternal deaths at regional and global levels. Further efforts are needed to improve the availability and quality of data related to maternal mortality.

Lived experiences of women who developed uterine rupture following severe obstructed labor in Mulago hospital, Uganda

BACKGROUND

Maternal mortality is a major public health challenge in Uganda. Whereas uterine rupture remains a major cause of maternal morbidity and mortality, there is limited research into what happens to women who survive such severe obstetric complications. Understanding their experiences might delineate strategies to support survivors.

METHODS

This qualitative study used a phenomenological approach to explore lived experiences of women who developed uterine rupture following obstructed labor. In-depth interviews initially conducted during their hospitalization were repeated 3-6 months after the childbirth event to explore their health and meanings they attached to the traumatic events and their outcomes. Data were analyzed using thematic analysis.

RESULTS

The resultant themes included barriers to access healthcare, multiple "losses" and enduring physical, psychosocial and economic consequences. Many women who develop uterine rupture fail to access critical care needed due to failure to recognise danger signs of obstructed labor, late decision making for accessing care, geographical barriers to health facilities, late or failure to diagnose obstructed labor at health facilities, and failure to promptly perform caesarean section. Secondly, the sequel of uterine rupture includes several losses (loss of lives, loss of fertility, loss of body image, poor quality of life and disrupted marital relationships). Thirdly, uterine rupture has grim economic consequences for the survivors (with financial loss and loss of income during and after the calamitous events).

CONCLUSION

Uterine rupture is associated with poor quality of care due to factors that operate at personal, household, family, community and society levels, and results in dire physical, psychosocial and financial consequences for survivors. There is need to improve access to and provision of emergency obstetric care in order to prevent uterine rupture consequent to obstructed labor. There is also critical need to provide counselling and support to survivors to enable them cope with physical, social, psychological and economic consequences.

The impact of postpartum haemorrhage management guidelines implemented in clinical practice: a systematic review of the literature

Postpartum haemorrhage (PPH) is an urgent obstetric condition requiring an immediate response and a multidisciplinary approach. The aim of this study was to review PPH management guidelines implemented in clinical practice, to evaluate their impact regarding prevention, diagnosis and treatment, and to analyze how the numbers of PPH cases changed in the post-intervention period. A systematic search in the PubMed database was performed. The references of all included articles were examined. Studies evaluating the management of PPH and the impact on the numbers of cases of this pathology after the implementation of new or updated guidelines were involved in the analysis. Two reviewers independently examined the titles and abstracts of all identified citations, selected potentially eligible studies, and evaluated their full-text versions. Methodological quality was assessed using a checklist based on the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement. We analyzed seven articles that evaluated the impact of new or updated guidelines for PPH management implemented in clinical practice. In four trials, the numbers of PPH cases declined after the intervention. Guidelines for PPH management can have a positive impact on the reduction of the number of PPH cases.

Perspectives of professionals participating in the Brazilian Network for the Surveillance of Severe Maternal Morbidity regarding the implementation of routine surveillance: a qualitative study

Background

The Brazilian Network for the Surveillance of Severe Maternal Morbidity was developed in Brazil with the participation of 27 centers in different regions of the country. The objective of the network project was to evaluate the frequency of severe maternal morbidity (near-miss and potentially life-threatening conditions) and the factors involved with these clinical conditions. Over the data collection period, this project implemented a surveillance system to identify these cases in the participating institutions. The objective of the present study was to evaluate the perspective of the professionals who participated in this network regarding the surveillance of cases of severe maternal morbidity, the facilities and difficulties encountered in involving colleagues in the process, and participants’ proposals to give continuity to this practice of qualifying maternal healthcare.

Methods

A descriptive study with a qualitative approach was conducted in which coordinators, investigators and managers at all the 27 obstetric units participating in the network were interviewed. Data were collected at 6 and 12 months after implementation of the network during semi-structured telephone interviews that were recorded following verbal informed consent. Thematic content analysis was performed of the responses to the open questions in the interviews.

Results

In the opinion of 60% of the participants, involving their colleagues in the surveillance process proved difficult, principally because these professionals were not very interested in the research project, but also because they found it difficult to review concepts and professional practices, because they had an excessive workload or due to operational and technical difficulties. The great majority considered that support from government agencies providing financial resources would be crucial to enable surveillance to be maintained or expanded and also to train a larger number of professionals and improve work conditions. The majority of participants found it difficult to define the ideal time interval at which surveillance should be conducted.

Conclusion

The investigators, coordinators and managers involved in the Brazilian network project mentioned several problems that had to be confronted during this process; however, in their opinion the project should be maintained and even expanded in view of its potential to contribute towards improving obstetric care.

Factors associated with severe maternal morbidity and near miss in the São Francisco Valley, Brazil: a retrospective, cohort study

Background

Maternal mortality remains a major public health issue worldwide, with persistent high rates prevailing principally in underdeveloped countries. The objective of this study was to determine the risk factors for severe maternal morbidity and near miss (SMM/NM) in pregnant and postpartum women at the maternity ward of the Dom Malan Hospital, Petrolina, in northeastern Brazil.

Methods

A retrospective, cohort study was conducted to evaluate the sociodemographic and obstetric characteristics of the women. Patients who remained hospitalized at the end of the study period were excluded. Risk ratios (RR) and their respective 95% confidence intervals (95% CI) were calculated as a measure of relative risk. Hierarchical multiple logistic regression was also performed. Two-tailed p-values were used for all the tests and the significance level adopted was 5%.

Results

A total of 2,291 pregnant or postpartum women receiving care between May and August, 2011 were included. The frequencies of severe maternal morbidity and near miss were 17.5% and 1.0%, respectively. Following multivariate analysis, the factors that remained significantly associated with an increased risk of SMM/NM were a Cesarean section in the current pregnancy (OR: 2.6; 95% CI: 2.0 – 3.3), clinical comorbidities (OR: 3.4; 95% CI: 2.5 – 4.4), having attended fewer than six prenatal visits (OR: 1.1; 95% CI: 1.01 – 1.69) and the presence of the third delay (i.e. delay in receiving care at the health facility) (OR: 13.3; 95% CI: 6.7 – 26.4).

Conclusions

The risk of SMM/NM was greater in women who had been submitted to a Cesarean section in the current pregnancy, in the presence of clinical comorbidities, fewer prenatal visits and when the third delay was present. All these factors could be minimized by initiating a broad debate on healthcare policies, introducing preventive measures and improving the training of the professionals and services providing obstetric care.

Systematic reviews of bruising in relation to child abuse-what have we learnt: an overview of review updates

BACKGROUND

Dogma has long prevailed regarding the ageing of bruises, and whether certain patterns of bruising are suggestive or diagnostic of child abuse.

OBJECTIVES

We conducted the first Systematic Reviews addressing these two issues, to determine the scientific basis for current clinical practice. There have been seven updates since 2004.

METHODS

An all language literature search was performed across 13 databases, 1951-2004, using >60 key words, supplemented by 'snowballing' techniques. Quality standards included a novel confirmation of abuse scale. Updates used expanded key words, and a higher standard for confirmation of abuse.

RESULTS

Of 1495 potential studies, only three met the inclusion criteria for ageing of bruises in 2004, confirming that it is inaccurate to do so with the naked eye. This was roundly rejected when first reported, generating a wave of new studies attempting to determine a scientifically valid method to age bruises, none of which are applicable in children yet. Regarding patterns of bruising that may be suggestive or diagnostic of abuse, we included 23 of 167 studies reviewed in 2004, although only 2 were comparative studies. Included studies noted that unintentional bruises occur predominantly on the front of the body, over bony prominences and their presence is directly correlated to the child's level of independent mobility. Bruising patterns in abused children, differed in location (most common site being face, neck, ear, head, trunk, buttocks, arms), and tended to be larger. Updates have included a further 14 studies, including bruising in disabled children, defining distinguishing patterns in severely injured abused and non-abused children, and importance of petechiae.

CONCLUSIONS

Systematic Reviews of bruising challenged accepted wisdom regarding ageing of bruises, which had no scientific basis; stimulated higher quality research on patterns of bruises distinguishing abusive and non-abusive bruising patterns, and highlighted the benefits of regular updates of these reviews.

Community Study of maternal mortality in South West Nigeria: how applicable is the sisterhood method

A significant reduction in maternal mortality was witnessed globally in the year 2010, yet, no significant reduction in the maternal mortality ratio (MMR) in Nigeria was recorded. The absence of accurate data on the numbers, causes and local factors influencing adverse maternal outcomes has been identified as a major obstacle hindering appropriate distribution of resources targeted towards improving maternal healthcare. This paper reports the first community based study that measures the incidence of maternal mortality in Ibadan, Nigeria using the indirect sisterhood method and explores the applicability of this method in a community where maternal mortality is not a rare event. A community-based study was conducted in Ibadan using the principles of the sisterhood method developed by Graham et al. for developing countries. Using a multi-stage sampling design with stratification and clustering, 3,028 households were selected. All persons approached agreed to take part in the study (a participation rate of 100%), with 2,877 respondents eligible for analysis. There was a high incidence of maternal mortality in the study setting: 1,324/6,519 (20.3%) sisters of the respondents had died, with 1,139 deaths reportedly related to pregnancy, childbirth or the puerperium. The MMR was 7,778 per 100,000 live births (95% CI 7,326-8,229). Adjusted for a published Total Fertility Rate of 6.0, the MMR was 6,525 per 100,000 live births (95% CI 6,144-6,909). Women in Ibadan were dying more from pregnancy related complications than from other causes. Findings of this study have implications for midwifery education, training and practice and for the first time provide policy makers and planners with information on maternal mortality in the community of Ibadan city and shed light on the causes of maternal mortality in the area.

Global and regional estimates of preeclampsia and eclampsia: a systematic review

Reduction of maternal mortality is a target within the Millennium Development Goals. Data on the incidence of preeclampsia and eclampsia, one of the main causes of maternal deaths, are required at both national and regional levels to inform policies. We conducted a systematic review of the incidence of hypertensive disorders of pregnancy (HDP) with the objective of evaluating its magnitude globally and in different regions and settings. We selected studies using pre-specified criteria, recorded database characteristics and assessed methodological quality of the eligible studies reporting incidence of any HDP during the period 2002-2010. A logistic model was then developed to estimate the global and regional incidence of HDP using pre-specified predictor variables where empiric data were not available. We found 129 studies meeting the inclusion criteria, from which 74 reports with 78 datasets reporting HDP were analysed. This represents nearly 39 million women from 40 countries. When the model was applied, the overall estimates are 4.6% (95% uncertainty range 2.7-8.2), and 1.4% (95% uncertainty range 1.0-2.0) of all deliveries for preeclampsia and eclampsia respectively, with a wide variation across regions. The figures we obtained give a general idea of the magnitude of the problem and suggest that some regional variations might exist. The absence of data in many countries is of concern, however, and efforts should be made to implement data collection and reporting for substantial statistics. The implementation of large scale surveys conducted during a short period of time could provide more reliable and up-to-date estimations to inform policy.

Placenta accreta and maternal morbidity in the Republic of Ireland, 2005-2010

OBJECTIVE

To describe the nationwide prevalence of placenta accreta and to quantify its impact on maternal morbidity.

METHODS

Using discharge data for public hospitals in Ireland, years 2005-2010, deliveries with placenta accreta were identified using ICD-10-AM code for morbidly adherent placenta and compared with deliveries without the condition. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated using logistic regression.

RESULTS

Placenta accreta prevalence increased 34% from 2005 to 2010 (7.9/10 000 deliveries versus 10.6/10 000 deliveries). This condition was associated with a substantial increased risk of hemorrhage (aOR: 16.6, 95% CI: 13.4-20.5), hysterectomy (aOR: 950.6, 95% CI: 632.9-1427.9), procedures to reduce uterine blood flow (aOR: 72.4, 95% CI: 35.1-149.4), transfusion (aOR: 41.8, 95% CI: 33.4-52.2), anemia (aOR 15.1, 95% CI: 10.8-21.0), abdominal organ injury (aOR: 8.2, 95% CI: 5.2-13.1), bladder surgery (aOR: 38.5, 95% CI: 21.8-68.1), mechanical ventilation (aOR: 63.2, 95% CI: 28.4-140.6), intensive care unit admission (aOR: 41.3, 95% CI: 30.0-56.9), and co-existing placenta previa (aOR: 23.2, 95% CI: 16.8-31.8) as well as increased risk of cesarean section, longer hospitalization and stillbirth.

CONCLUSIONS

To our knowledge, this is the first study to use a comparison group of deliveries without placenta accreta and quantitatively illustrate with odds ratios the profound adverse health effects of this condition on the mother.

Obesity and its health impact in Africa: a systematic review

Abstract

Obesity and its association with co-morbidities in Africa are on the rise. This systematic review examines evidence of obesity and its association with co-morbidities within the African continent. Comparative studies conducted in Africa on adults 17 years and older with mean body mass index (BMI) ≥ 28 kg/m² were included. Five electronic databases were searched. Surveys, case–control and cohort studies from January 2000 to July 2010 were evaluated. Of 720 potentially relevant articles, 10 met the inclusion criteria. Prevalence of obesity was higher in urban than rural subjects with significant increases in obesity rates among women. Inflammatory marker levels were significantly elevated among Africans compared with Caucasians. The co-relationship between obesity and chronic diseases was also highlighted. This systematic review demonstrates that while obesity remains an area of significant public health importance to Africans, particularly in urban areas, there is little evidence of proper diagnosis, treatment and/or prevention.

Measuring unsafe abortion-related mortality: a systematic review of the existing methods

BACKGROUND

The WHO estimates that 13% of maternal mortality is due to unsafe abortion, but challenges with measurement and data quality persist. To our knowledge, no systematic assessment of the validity of studies reporting estimates of abortion-related mortality exists.

STUDY DESIGN

To be included in this study, articles had to meet the following criteria: (1) published between September 1(st), 2000-December 1(st), 2011; (2) utilized data from a country where abortion is "considered unsafe"; (3) specified and enumerated causes of maternal death including "abortion"; (4) enumerated ≥100 maternal deaths; (5) a quantitative research study; (6) published in a peer-reviewed journal.

RESULTS

7,438 articles were initially identified. Thirty-six studies were ultimately included. Overall, studies rated "Very Good" found the highest estimates of abortion related mortality (median 16%, range 1-27.4%). Studies rated "Very Poor" found the lowest overall proportion of abortion related deaths (median: 2%, range 1.3-9.4%).

CONCLUSIONS

Improvements in the quality of data collection would facilitate better understanding global abortion-related mortality. Until improved data exist, better reporting of study procedures and standardization of the definition of abortion and abortion-related mortality should be encouraged.

Maternal Health and Care in India: Why a Major Public Health Strategy Is Essential

India has large inequalities in maternal health and high maternal mortality and morbidity rates. A social model of maternal health was used as a framework for a broad review of online published literature to appraise the approaches used by India to address these issues and to examine the potential for reducing the country’s maternal health inequalities.

The review found the following:

• An apparent lack of coordinated economic, social, and health strategy and policies focused on improving maternal health

• No acknowledgment in national health policy of the limitations of the medical model of maternal health and little apparent mention of the social model

• No evident national frameworks for quality assurance in maternity care

• Lack of recognition of the importance of woman-centered care

• No evident comprehensive maternal health needs assessment to underpin coordinated multisector working

• An apparent lack of reliable national data collection for setting inequality targets and monitoring progress

• No apparent performance-focused management system for improving maternity care nationally.

Although India has made large increases in maternal health care provision over recent decades, a pragmatic review of government policies, the reports of international agencies, and the findings of published research studies indicate that major barriers exist to reducing maternal health inequalities and to achieving good quality care for disadvantaged women. The main barrier appears to be the widespread use at all levels, including government, of the medical model of maternal health, which focuses mostly on obstetric interventions and fails to address the wider economic and social determinants of maternal health or to use a woman-centered approach to maternity care.

We recommend that Indian governments adopt instead a “social model” approach to maternal health improvement and urgently employ a public health strategy led by a national multisector task force to reduce inequalities in maternal health.

National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications

BACKGROUND

Preterm birth is the second largest direct cause of child deaths in children younger than 5 years. Yet, data regarding preterm birth (<37 completed weeks of gestation) are not routinely collected by UN agencies, and no systematic country estimates nor time trend analyses have been done. We report worldwide, regional, and national estimates of preterm birth rates for 184 countries in 2010 with time trends for selected countries, and provide a quantitative assessment of the uncertainty surrounding these estimates.

METHODS

We assessed various data sources according to prespecified inclusion criteria. National Registries (563 datapoints, 51 countries), Reproductive Health Surveys (13 datapoints, eight countries), and studies identified through systematic searches and unpublished data (162 datapoints, 40 countries) were included. 55 countries submitted additional data during WHO's country consultation process. For 13 countries with adequate quality and quantity of data, we estimated preterm birth rates using country-level loess regression for 2010. For 171 countries, two regional multilevel statistical models were developed to estimate preterm birth rates for 2010. We estimated time trends from 1990 to 2010 for 65 countries with reliable time trend data and more than 10,000 livebirths per year. We calculated uncertainty ranges for all countries.

FINDINGS

In 2010, an estimated 14·9 million babies (uncertainty range 12·3-18·1 million) were born preterm, 11·1% of all livebirths worldwide, ranging from about 5% in several European countries to 18% in some African countries. More than 60% of preterm babies were born in south Asia and sub-Saharan Africa, where 52% of the global livebirths occur. Preterm birth also affects rich countries, for example, USA has high rates and is one of the ten countries with the highest numbers of preterm births. Of the 65 countries with estimated time trends, only three (Croatia, Ecuador, and Estonia), had reduced preterm birth rates 1990-2010.

INTERPRETATION

The burden of preterm birth is substantial and is increasing in those regions with reliable data. Improved recording of all pregnancy outcomes and standard application of preterm definitions is important. We recommend the addition of a data-quality indicator of the per cent of all live preterm births that are under 28 weeks' gestation. Distinguishing preterm births that are spontaneous from those that are provider-initiated is important to monitor trends associated with increased caesarean sections. Rapid scale up of basic interventions could accelerate progress towards Millennium Development Goal 4 for child survival and beyond.

FUNDING

Bill & Melinda Gates Foundation through grants to Child Health Epidemiology Reference Group (CHERG) and Save the Children's Saving Newborn Lives programme; March of Dimes; the Partnership for Maternal Newborn and Childe Health; and WHO, Department of Reproductive Health and Research.

Association of postpartum maternal morbidities with children's mental, psychomotor and language development in rural Bangladesh

Little is known from developing countries about the effects of maternal morbidities diagnosed in the postpartum period on children's development. The study aimed to document the relationships of such morbidities with care-giving practices by mothers, children's developmental milestones and their language, mental and psychomotor development. Maternal morbidities were identified through physical examination at 6-9 weeks postpartum (n=488). Maternal care-giving practices and postnatal depression were assessed also at 6-9 weeks postpartum. Children's milestones of development were measured at six months, and their mental (MDI) and psychomotor (PDI) development, language comprehension and expression, and quality of psychosocial stimulation at home were assessed at 12 months. Several approaches were used for identifying the relationships among different maternal morbidities, diagnosed by physicians, with children's development. After controlling for the potential confounders, maternal anaemia diagnosed postpartum showed a small but significantly negative effect on children's language expression while the effects on language comprehension did not reach the significance level (p=0.085). Children's development at 12 months was related to psychosocial stimulation at home, nutritional status, education of parents, socioeconomic status, and care-giving practices of mothers at six weeks of age. Only a few mothers experienced each specific morbidity, and with the exception of anaemia, the sample-size was insufficient to make a conclusion regarding each specific morbidity. Further research with a sufficient sample-size of individual morbidities is required to determine the association of postpartum maternal morbidities with children's development.

Occurrence and determinants of postpartum maternal morbidities and disabilities among women in Matlab, Bangladesh

The burden of maternal ill-health includes not only the levels of maternal mortality and complications during pregnancy and around the time of delivery but also extends to the standard postpartum period of 42 days with consequences of obstetric complications and poor management at delivery. There is a dearth of reliable data on these postpartum maternal morbidities and disabilities in developing countries, and more research is warranted to investigate these and further strengthen the existing safe motherhood programmes to respond to these conditions. This study aims at identifying the consequences of pregnancy and delivery in the postpartum period, their association with acute obstetric complications, the sociodemographic characteristics of women, mode and place of delivery, nutritional status of the mother, and outcomes of birth. From among women who delivered between 2007 and 2008 in the icddr,b service area in Matlab, we prospectively recruited all women identified with complicated births (n=295); a perinatal mortality (n=182); and caesarean-section delivery without any maternal indication (n=147). A random sample of 538 women with uncomplicated births, who delivered at home or in a facility, was taken as the control. All subjects were clinically examined at 6-9 weeks for postpartum morbidities and disabilities. Postpartum women who had suffered obstetric complications during birth and delivered in a hospital were more likely to suffer from hypertension [adjusted odds ratio (AOR)=3.44; 95% confidence interval (CI)=1.14-10.36], haemorrhoids (AOR=1.73; 95% CI=1.11-3.09), and moderate to severe anaemia (AOR=7.11; 95% CI=2.03-4.88) than women with uncomplicated normal deliveries. Yet, women who had complicated births were less likely to have perineal tears (AOR=0.05; 95% CI=0.02-0.14) and genital prolapse (AOR=0.22; 95% CI=0.06-0.76) than those with uncomplicated normal deliveries. Genital infections were more common amongst women experiencing a perinatal death than those with uncomplicated normal births (AOR=1.92; 95% CI=1.18-3.14). Perineal tears were significantly higher (AOR=3.53; 95% CI=2.32-5.37) among those who had delivery at home than those giving birth in a hospital. Any woman may suffer a postpartum morbidity or disability. The increased likelihood of having hypertension, haemorrhoids, or anaemia among women with obstetric complications at birth needs specific intervention. A higher quality of maternal healthcare services generally might alleviate the suffering from perineal tears and prolapse amongst those with a normal uncomplicated delivery.

Precision of healthcare systematic review searches in a cross-sectional sample

BACKGROUND

In systematic reviews, search precision is generally traded off against the desire to retrieve all relevant studies; however, there is no published evidence on typical precision values. The objective of this study is to establish typical values for the precision of systematic review searches in healthcare.

METHODS

From an existing cross-sectional sample of 300 MEDLINE-indexed systematic reviews, those that reported the flow of bibliographic records through the review process (n = 109) were examined. Where the ratio of the number of included studies and the number of unique retrievals could be determined, overall and median precision of the search was calculated. Subgroup analyses were conducted by review type (treatment/prevention, diagnosis/prognosis, epidemiology, other), eligible study designs, number of databases searched and for updates of existing systematic reviews.

RESULTS

Precision could be calculated for 94 systematic reviews. The median [interquartile range] precision was 0.029 [0.013, 0.081] with a range of 0.007-0.358. In this sample, precision did not differ significantly in any of the subgroups examined.

IMPLICATIONS

Search precision of approximately 3% was typical in this cross-section of health related systematic reviews. This finding is useful for systematic review teams to gauge review resource needs and for information specialists in evaluating their searches. Copyright © 2011 John Wiley & Sons, Ltd.

Gender difference in snoring and how it changes with age: systematic review and meta-regression

PURPOSE

The aim of this study was to study the interactions among age, gender, and snoring across all age groups

METHODS

All cross-sectional study reporting gender-specific prevalence of snoring in general population published from 1966 through July 2008 were included and were meta-analyzed. The sources of heterogeneity among primary studies were studied by meta-regression.

RESULTS

From a total of 1,593 citations reviewed, 63 were included in the analysis of snoring. These 63 studies were comprised 104,337 and 110,474, respectively. A combined odds ratio of 1.89 with a 95% confidence interval of 1.75-2.03 for male versus female was found. The heterogeneity was significant with an estimated between-study variance, τ (2) being 0.065 and 95% confidence interval of 0.0397-0.0941. Multiple meta-regression showed that age were the significant effect modifier of the relationship between snoring and gender.

CONCLUSION

This study found a consistent male predominance in snoring among the general population, and the heterogeneity in the risk of snoring between two genders can be partly explained by age.

Rationale for a long-term evaluation of the consequences of potentially life-threatening maternal conditions and maternal "near-miss" incidents using a multidimensional approach

Recent advances in health care mean that women survive severe conditions and events related to pregnancy that would previously have resulted in death. Therefore, a greater number of women will experience significant maternal morbidity with significant consequences. Little is known, however, about these long-term consequences. Some investigators have evaluated the repercussions of severe biological or traumatic events, and have reported that survivors are at an increased risk of death in the five years after the event. In addition, they continue to experience both organic and emotional problems such as clinical, cardiac, respiratory, and neurological complications, as well as anxiety and depression, following discharge from hospital. Following a maternal "near-miss" incident, various life domains may be affected (organic, mental, cognitive, and social function), and these must be evaluated in addition to the related economic issues and quality of life. However, because of the diversity of methods and instruments used to evaluate possible repercussions, comparisons between the few studies available on the subject are difficult. An in-depth debate should be initiated to discuss the methodological aspects of such investigation. We propose a conceptual and methodological discussion on the long-term repercussions of severe maternal morbidity based on the evaluation of the following variables: reproductive health, quality of life, posttraumatic stress syndrome, sexual function, postpartum depression, daily functioning, and the physical, neurological, and psychomotor development of the children born after a complicated pregnancy.

Reduction of severe acute maternal morbidity and maternal mortality in Thyolo District, Malawi: the impact of obstetric audit

BACKGROUND

Critical incident audit and feedback are recommended interventions to improve the quality of obstetric care. To evaluate the effect of audit at district level in Thyolo, Malawi, we assessed the incidence of facility-based severe maternal complications (severe acute maternal morbidity (SAMM) and maternal mortality) during two years of audit and feedback.

METHODOLOGY/PRINCIPAL FINDINGS

Between September 2007 and September 2009, we included all cases of maternal mortality and SAMM that occurred in Thyolo District Hospital, the main referral facility in the area, using validated disease-specific criteria. During two- to three-weekly audit sessions, health workers and managers identified substandard care factors. Resulting recommendations were implemented and followed up. Feedback was given during subsequent sessions. A linear regression analysis was performed on facility-based severe maternal complications. During the two-year study period, 386 women were included: 46 died and 340 sustained SAMM, giving a case fatality rate of 11.9%. Forty-five cases out of the 386 inclusions were audited in plenary with hospital staff. There was a reduction of 3.1 women with severe maternal complications per 1000 deliveries in the district health facilities, from 13.5 per 1000 deliveries in the beginning to 10.4 per 1000 deliveries at the end of the study period. The incidence of uterine rupture and major obstetric hemorrhage reduced considerably (from 3.5 to 0.2 and from 5.9 to 2.6 per 1000 facility deliveries respectively).

CONCLUSIONS

Our findings indicate that audit and feedback have the potential to reduce serious maternal complications including maternal mortality. Complications like major hemorrhage and uterine rupture that require relatively straightforward intrapartum emergency management are easier to reduce than those which require uptake of improved antenatal care (eclampsia) or timely intravenous medication or HIV-treatment (peripartum infections).

Joining the dots: a plea for precise estimates of the maternal mortality ratio in sub-Saharan Africa

Monitoring of maternal mortality levels in sub-Saharan Africa (SSA) to assess the achievements of safe motherhood programmes and for MDG-5 has been made difficult because of the lack of precise estimates of the maternal mortality ratio (MMR). Projections based on the slow rate of decline of the MMR indicate that MDG-5 may not be reached before the end of this century in this region. Measurements done using demographical and health surveys, statistical modelling and censuses are imprecise and do not allow trends in individual countries to be established. SSA countries should be encouraged to measure mortality levels from their own resources, using methods that produce precise estimates such as population-based surveys. Establishment of the trends will lead to country-specific program targets. The less frequent but more precise measurements can be afforded by SSA countries, as a case study from Zimbabwe shows.

The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity

OBJECTIVE

To analyse preterm birth rates worldwide to assess the incidence of this public health problem, map the regional distribution of preterm births and gain insight into existing assessment strategies.

METHODS

Data on preterm birth rates worldwide were extracted during a previous systematic review of published and unpublished data on maternal mortality and morbidity reported between 1997 and 2002. Those data were supplemented through a complementary search covering the period 2003-2007. Region-specific multiple regression models were used to estimate the preterm birth rates for countries with no data.

FINDINGS

We estimated that in 2005, 12.9 million births, or 9.6% of all births worldwide, were preterm. Approximately 11 million (85%) of these preterm births were concentrated in Africa and Asia, while about 0.5 million occurred in each of Europe and North America (excluding Mexico) and 0.9 million in Latin America and the Caribbean. The highest rates of preterm birth were in Africa and North America (11.9% and 10.6% of all births, respectively), and the lowest were in Europe (6.2%).

CONCLUSION

Preterm birth is an important perinatal health problem across the globe. Developing countries, especially those in Africa and southern Asia, incur the highest burden in terms of absolute numbers, although a high rate is also observed in North America. A better understanding of the causes of preterm birth and improved estimates of the incidence of preterm birth at the country level are needed to improve access to effective obstetric and neonatal care.

Development and Use of Quality of Care Indicators for Obstetric Care in Women with Preeclampsia, Severe Preeclampsia, and Severe Morbidity

OBJECTIVE

To develop indicators for evaluating the quality of care in managing preeclampsia.

METHODS

An expert group helped to develop and validate the following indicators for evaluating quality of care: availability of intensive care; completeness of laboratory tests; appropriateness of drug treatment at admission and before delivery (antihypertensive drugs, anticonvulsants, and dexamethasone); gestational age at which pregnancy should be interrupted; and type of delivery. By using these indicators, it was possible to evaluate the quality of care in 432 patients with preeclampsia.

RESULTS

A significant percentage of patients with preeclampsia and "near misses" received low quality of care, regardless of disease severity.

CONCLUSION

A number of interventions are needed to increase the quality of care to help avert maternal deaths in patients with preeclampsia.

Safety of ultrasonography in pregnancy: WHO systematic review of the literature and meta-analysis

OBJECTIVE

In the context of the planned International Society of Ultrasound in Obstetrics and Gynecology-World Health Organization multicenter study for the development of fetal growth standards for international application, we conducted a systematic review and meta-analysis to evaluate the safety of human exposure to ultrasonography in pregnancy.

METHODS

A systematic search of electronic databases, reference lists and unpublished literature was conducted for trials and observational studies that assessed short- and long-term effects of exposure to ultrasonography, involving women and their fetuses exposed to ultrasonography, using B-mode or Doppler sonography during any period of pregnancy, for any number of times. The outcome measures were: (1) adverse maternal outcome; (2) adverse perinatal outcome; (3) abnormal childhood growth and neurological development; (4) non-right handedness; (5) childhood malignancy; and (6) intellectual performance and mental disease.

RESULTS

The electronic search identified 6716 citations, and 19 were identified from secondary sources. A total of 61 publications reporting data from 41 different studies were included: 16 controlled trials, 13 cohort and 12 case-control studies. Ultrasonography in pregnancy was not associated with adverse maternal or perinatal outcome, impaired physical or neurological development, increased risk for malignancy in childhood, subnormal intellectual performance or mental diseases. According to the available clinical trials, there was a weak association between exposure to ultrasonography and non-right handedness in boys (odds ratio 1.26; 95% CI, 1.03-1.54).

CONCLUSION

According to the available evidence, exposure to diagnostic ultrasonography during pregnancy appears to be safe.

Prepregnancy BMI and the risk of gestational diabetes: a systematic review of the literature with meta-analysis

The objective of this study is to assess and quantify the risk for gestational diabetes mellitus (GDM) according to prepregnancy maternal body mass index (BMI). The design is a systematic review of observational studies published in the last 30 years. Four electronic databases were searched for publications (1977-2007). BMI was elected as the only measure of obesity, and all diagnostic criteria for GDM were accepted. Studies with selective screening for GDM were excluded. There were no language restrictions. The methodological quality of primary studies was assessed. Some 1745 citations were screened, and 70 studies (two unpublished) involving 671 945 women were included (59 cohorts and 11 case-controls). Most studies were of high or medium quality. Compared with women with a normal BMI, the unadjusted pooled odds ratio (OR) of an underweight woman developing GDM was 0.75 (95% confidence interval [CI] 0.69 to 0.82). The OR for overweight, moderately obese and morbidly obese women were 1.97 (95% CI 1.77 to 2.19), 3.01 (95% CI 2.34 to 3.87) and 5.55 (95% CI 4.27 to 7.21) respectively. For every 1 kg m(-2) increase in BMI, the prevalence of GDM increased by 0.92% (95% CI 0.73 to 1.10). The risk of GDM is positively associated with prepregnancy BMI. This information is important when counselling women planning a pregnancy.

Níveis de retinol e carotenóides séricos e intercorrências gestacionais em puérperas

OBJETIVO: Investigar a associação entre intercorrências gestacionais e níveis de retinol e carotenóides em puérperas atendidas em maternidade pública do Rio de Janeiro. MÉTODOS: A amostra foi constituída por 262 puérperas atendidas na Maternidade Escola da Universidade Federal do Rio de Janeiro. O estado nutricional antropométrico foi avaliado pelo do índice de massa corporal pré-gestacional e pelo ganho ponderal gestacional, e foram coletadas informações sobre intercorrências gestacionais nos registros médicos dos prontuários. Foram adotados os pontos de corte 1,05µmol/L e 80µg/dL para definir inadequação dos níveis de retinol e carotenóides séricos, respectivamente. RESULTADOS: Quarenta e dois vírgula sete por cento da amostra foi acometida por intercorrências gestacionais, destacando-se anemia (29,0%), inadequação dos níveis de retinol (24,4%), e síndromes hipertensivas da gravidez (5,7%). Observou-se maior proporção de obesidade pré-gestacional entre mulheres com síndromes hipertensivas da gravidez, em comparação com as não portadoras de tal intercorrência. Verificou-se menor nível médio de carotenóides séricos entre as que desenvolveram síndromes hipertensivas da gravidez e 91,7% destas apresentaram inadequação destes nutrientes. CONCLUSÃO: Os resultados revelam acometimento importante de mulheres por intercorrências gestacionais e por deficiências nutricionais. Além disso, apontam a obesidade pré-gestacional como um possível fator de risco para o desenvolvimento de síndromes hipertensivas da gravidez e sugerem uma associação entre baixos níveis de carotenóides e tal intercorrência.