The Prevalence and Risk Factors for Severe Maternal Morbidities: A Systematic Review and Meta-Analysis

Vaginal Microbiome and Pregnancy Complications: A Review

Background/Objectives: There are indications that the microbial composition of the maternal mucosal surfaces is associated with adverse events during pregnancy. The aim of this review is to investigate the link between vaginal microbiome alterations and gestational complication risk. Methods: This comprehensive literature review was performed using Medline and Scopus databases. The following search algorithm was used, "Pregnancy Complications" [Mesh] AND (Vagin*), and after the literature screening, 44 studies were included in the final review. Results: The studies that were included investigated the association between vaginal microbial composition and preterm birth, miscarriage, preeclampsia, ectopic pregnancy, gestational diabetes mellitus, chorioamnionitis, and preterm premature rupture of membranes. In most of the studies, it was well established that increased microbial diversity is associated with these conditions. Also, the depletion of Lactobacillus species is linked to most of the gestational complications, while the increased relative abundance and especially Lactobacillus crispatus may exert a protective effect in favor of the pregnant woman. Several pathogenic taxa including Gardnerella, Prevotella, Sneathia, Bacterial Vaginosis-Associated Bacteria-2, Atopobium, and Megasphera seem to be correlated to higher maternal morbidity. Conclusions: Vaginal microbiome aberrations seem to have an association with pregnancy-related adverse events, but more high-quality homogenous studies are necessary to reliably verify this link.

Risk factors for maternal near-miss in an undeveloped province in south-central China, 2012-2022

OBJECTIVE

To explore the risk factors for maternal near-miss (MNM) using the WHO near-miss approach.

METHODS

Data were obtained from the Maternal Near-Miss Surveillance System in Hunan Province, China, 2012-2022. Multivariate logistic regression analysis (method: Forward, Wald, α = 0.05) and adjusted odds ratios (aORs) were used to identify risk factors for MNM.

RESULTS

Our study included 780,359 women with 731,185 live births, a total of 2461 (0.32%) MNMs, 777,846 (99.68%) non-MNMs, and 52 (0.006%) maternal deaths were identified. The MNM ratio was 3.37‰ (95%CI: 3.23-3.50). Coagulation/hematological dysfunction was the most common cause of MNM (75.66%). Results of multivariate logistic regression analysis showed risk factors for MNM: maternal age > = 30 years old (aOR > 1, P < 0.05), unmarried women (aOR = 2.21, 95%CI: 1.71-2.85), number of pregnancies > = 2 (aOR > 1, P < 0.05), nulliparity (aOR = 1.51, 95%CI: 1.32-1.72) or parity > = 3 (aOR = 1.95, 95%CI: 1.50-2.55), prenatal examinations < 5 times (aOR = 1.13, 95%CI: 1.01-1.27), and number of cesarean sections was 1 (aOR = 1.83, 95%CI: 1.64-2.04) or > = 2 (aOR = 2.48, 95%CI: 1.99-3.09).

CONCLUSION

The MNM ratio was relatively low in Hunan Province. Advanced maternal age, unmarried status, a high number of pregnancies, nulliparity or high parity, a low number of prenatal examinations, and cesarean sections were risk factors for MNM. Our study is essential for improving the quality of maternal health care and preventing MNM.

Impact of social determinants of health on progression from potentially life-threatening complications to near miss events and death during pregnancy and post partum in a middle-income setting: an observational study

OBJECTIVE

To assess the potential associations between social determinants of health (SDH) and severe maternal outcomes (SMO), to better understand the social structural framework and the contributory, non-clinical mechanisms associated with SMO.

STUDY DESIGN

Prospective observational study.

STUDY SETTING

Tertiary referral centre in south-eastern region of India.

PARTICIPANTS

One thousand and thirty-three women with potentially life-threatening complications (PLTC) were identified using WHO criteria.

RISK FACTORS ASSESSED

Social Determinants of Health (SDH).

PRIMARY OUTCOMES

Severe maternal outcomes, which include maternal near-miss and maternal death.

STATISTICAL ANALYSIS

Logistic regression to assess the association between SDH and clinical factors on SMO, expressed as adjusted ORs (aOR) with a 95% CI.

RESULTS

Of the 37 590 live births, 1833 (4.9%) sustained PLTC, and 380 (20.7%) developed SMO. Risk of SMO was higher with increasing maternal age (adjusted OR (aOR) 1.04 (95% CI 1.01 to 1.07)), multiparity (aOR 1.44 (1.10 to 1.90)), medical comorbidities (aOR 1.50 (1.11 to 2.02)), obstetric haemorrhage (aOR 4.63 (3.10 to 6.91)), infection (aOR 2.93 (1.83 to 4.70)), delays in seeking care (aOR 3.30 (2.08 to 5.23)), and admissions following a referral (aOR 2.95 (2.21 to 3.93)). SMO was lower in patients from socially backward community (aOR 0.45 (0.33 to 0.61)), those staying more than 10 km from hospital (aOR 0.56 (0.36 to 0.78)), those attending at least four antenatal visits (aOR=0.53 (0.36 to 0.78)) and those referred from resource-limited facilities (aOR=0.62 (0.46 to 0.84)).

CONCLUSION

This study demonstrates the independent contribution of SDH to SMO among those sustaining PLTC in a middle-income setting, highlighting the need to formulate preventive strategies beyond clinical considerations.

Risk Factors for Severe Maternal Morbidity Among Women Enrolled in Mississippi Medicaid

Importance

Mississippi has one of the highest rates of severe maternal morbidity (SMM) in the US, and SMMs have been reported to be more frequent among Medicaid-insured women. A substantial proportion of pregnant women in Mississippi are covered by Medicaid; hence, there is a need to identify potential risk factors for SMM in this population.

Objective

To examine the associations of health care access and clinical and sociodemographic characteristics with SMM events among Mississippi Medicaid-enrolled women who had a live birth.

Design, Setting, and Participants

A nested case-control study was conducted using 2018 to 2021 Mississippi Medicaid administrative claims database. The study included Medicaid beneficiaries aged 12 to 55 years who had a live birth and were continuously enrolled throughout their pregnancy period and 12 months after delivery. Individuals in the case group had SMM events and were matched to controls on their delivery date using incidence density sampling. Data analysis was performed from June to September 2022.

Exposure

Risk factors examined in the study included sociodemographic factors (age and race), health care access (distance from delivery center, social vulnerability index, and level of maternity care), and clinical factors (maternal comorbidity index, first-trimester pregnancy-related visits, and postpartum care).

Main Outcomes and Measures

The main outcome of the study was an SMM event. Adjusted odds ratio (aORs) and 95% CIs were calculated using conditional logistic regression.

Results

Among 13 485 Mississippi Medicaid-enrolled women (mean [SD] age, 25.0 [5.6] years; 8601 [63.8%] Black; 4419 [32.8%] White; 465 [3.4%] other race [American Indian, Asian, Hispanic, multiracial, and unknown]) who had a live birth, 410 (3.0%) were in the case group (mean [SD] age, 26.8 [6.4] years; 289 [70.5%] Black; 112 [27.3%] White; 9 [2.2%] other race) and 820 were in the matched control group (mean [SD] age, 24.9 [5.7] years; 518 [63.2%] Black; 282 [34.4%] White; 20 [2.4%] other race). Black individuals (aOR, 1.44; 95% CI, 1.08-1.93) and those with higher maternal comorbidity index (aOR, 1.27; 95% CI, 1.16-1.40) had higher odds of experiencing SMM compared with White individuals and those with lower maternal comorbidity index, respectively. Likewise, an increase of 100 miles (160 km) in distance between beneficiaries' residence to the delivery center was associated with higher odds of experiencing SMM (aOR, 1.14; 95% CI, 1.07-1.20).

Conclusions and Relevance

The study findings hold substantial implications for identifying high-risk individuals within Medicaid programs and call for the development of targeted multicomponent, multilevel interventions for improving maternal health outcomes in this highly vulnerable population.

The impact of maternal morbidity on cesarean section rates: exploring a Latin American network of sentinel facilities using the Robson's Ten Group Classification System

BACKGROUND

Latin America has the highest Cesarean Section Rates (CSR) in the world. Robson's Ten Group Classification System (RTGCS) was developed to enable understanding the CSR in different groups of women, classified according to obstetric characteristics into one of ten groups. The size of each CS group may provide helpful data on quality of care in a determined region or setting. Data can potentially be used to compare the impact of conditions such as maternal morbidity on CSR. The objective of this study is to understand the impact of Severe Maternal Morbidity (SMM) on CSR in ten different groups of RTGCS.

METHODS

Secondary analysis of childbirth information from 2018 to 2021, including 8 health facilities from 5 Latin American and Caribbean countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic), using a surveillance database (SIP-Perinatal Information System, in Spanish) implemented in different settings across Latin America. Women were classified into one of RTGCS. The frequency of each group and its respective CSR were described. Furthermore, the sample was divided into two groups, according to maternal outcomes: women without SMM and those who experienced SMM, considering Potentially Life-threatening Conditions, Maternal Near Miss and Maternal Death as the continuum of morbidity.

RESULTS

Available data were obtained from 92,688 deliveries using the Robson Classification. Overall CSR was around 38%. Group 5 was responsible for almost one-third of cesarean sections. SMM occurred in 6.7% of cases. Among these cases, the overall CSR was almost 70% in this group. Group 10 had a major role (preterm deliveries). Group 5 (previous Cesarean section) had a very high CSR within the group, regardless of the occurrence of maternal morbidity (over 80%).

CONCLUSION

Cesarean section rate was higher in women experiencing SMM than in those without SMM in Latin America. SMM was associated with higher Cesarean section rates, especially in groups 1 and 3. Nevertheless, group 5 was the major contributor to the overall CSR.

Prevalence and determinants of maternal near miss in Ethiopia: a systematic review and meta-analysis, 2015-2023

BACKGROUND

One of the most challenging problems in developing countries including Ethiopia is improving maternal health. About 303,000 mothers die globally, and one in every 180 is at risk from maternal causes. Developing regions account for 99% of maternal deaths. Maternal near miss (MNM) resulted in long-term consequences. A systematic review and meta-analysis was performed to assess the prevalence and predictors of maternal near miss in Ethiopia from January 2015 to March 2023.

METHODS

A systematic review and meta-analysis cover both published and unpublished studies from different databases (PubMed, CINHAL, Scopus, Science Direct, and the Cochrane Library) to search for published studies whilst searches for unpublished studies were conducted using Google Scholar and Google searches. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Duplicated studies were removed using Endnote X8. The paper quality was also assessed based on the JBI checklist. Finally, 21 studies were included in the study. Data synthesis and statistical analysis were conducted using STATA Version 17 software. Forest plots were used to present the pooled prevalence using the random effect model. Heterogeneity and publication bias was evaluated using Cochran's Q test, (Q) and I squared test (I²). Subgroup analysis based on study region and year of publication was performed.

RESULT

From a total of 705 obtained studies, twenty-one studies involving 701,997 pregnant or postpartum mothers were included in the final analysis. The national pooled prevalence of MNM in Ethiopia was 140/1000 [95% CI: 80, 190]. Lack of formal education [AOR = 2.10, 95% CI: 1.09, 3.10], Lack of antenatal care [AOR = 2.18, 95% CI: 1.33, 3.03], history of cesarean section [AOR = 4.07, 95% CI: 2.91, 5.24], anemia [AOR = 4.86, 95% CI: 3.24, 6.47], and having chronic medical disorder [AOR = 2.41, 95% CI: 1.53, 3.29] were among the predictors of maternal near misses from the pooled estimate.

CONCLUSION

The national prevalence of maternal near miss was still substantial. Antenatal care is found to be protective against maternal near miss. Emphasizing antenatal care to prevent anemia and modifying other chronic medical conditions is recommended as prevention strategies. Avoiding primary cesarean section is recommended unless a clear indication is present. Finally, the country should place more emphasis on strategies for reducing MNM and its consequences, with the hope of improving women's health.

Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity

Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.