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BACKGROUND: Overdose is a leading cause of maternal mortality; in response, maternal mortality review committees have recommended expanding substance use disorder (SUD) screening, improving collaboration between obstetric and SUD treatment providers, and reducing fragmentation in systems of care. We undertook an analysis of the perinatal SUD treatment landscape in Baltimore, Maryland in order to identify barriers to treatment engagement during pregnancy and the postpartum period and guide system improvement efforts. METHODS: We conducted a survey of seven birthing hospitals, 31 prenatal care practices, and 108 SUD treatment providers in Baltimore from April-June 2023. Organizations were asked to quantify care for perinatal patients with opioid use disorder (OUD) as well as about screening, service availability, referral practices, and support needed to improve care. RESULTS: 61% of the 145 contacted organizations responded. Birthing hospitals reported caring for pregnant persons with OUD with greater frequency than prenatal care practices or SUD treatment programs. Most birthing hospitals and prenatal care practices reported screening for OUD at intake, but the minority reported using validated tools. Service availability varied by type of organization and type of service. In general, prenatal care practices offered the fewest number of SUD-related services. Most SUD treatment programs that offered buprenorphine or methadone to the general population also offered these medications to pregnant patients. Withdrawal management for comorbid alcohol/benzodiazepine use disorders during pregnancy was more limited. The majority of birthing hospitals and prenatal care practices reported offering neither direct naloxone distribution nor prescriptions. Few SUD treatment programs offered tailored services for perinatal patients or for parents of young children, and many programs do not permit children onsite. Respondents reported high levels of interest in education and consultative support on SUD treatment in pregnancy within obstetric settings and on pregnancy-related medical concerns within SUD programs. CONCLUSIONS: This project provides a comprehensive picture of services available for treatment of perinatal OUD in a major US city. Results have served as a guide for ongoing citywide system improvement efforts by our project team and offer a model for other jurisdictions hoping to strengthen services for perinatal OUD and reduce maternal mortality.

The effects of the COVID-19 pandemic on comprehensive maternal deaths in Brazil have not been fully explored. Using publicly available data from the Brazilian Mortality Information (SIM) and Information System on Live Births (SINASC) databases, we used two complementary forecasting models to predict estimates of maternal mortality ratios using maternal deaths (MMR) and comprehensive maternal deaths (MMRc) in the years 2020 and 2021 based on data from 2008 to 2019. We calculated national and regional standardized mortality ratio estimates for maternal deaths (SMR) and comprehensive maternal deaths (SMRc) for 2020 and 2021. The observed MMRc in 2021 was more than double the predicted MMRc based on the Holt-Winters and autoregressive integrated moving average models (127.12 versus 60.89 and 59.12 per 100,000 live births, respectively). We found persisting sub-national variation in comprehensive maternal mortality: SMRc ranged from 1.74 (95% confidence interval [CI] 1.64, 1.86) in the Northeast to 2.70 (95% CI 2.45, 2.96) in the South in 2021. The observed national estimates for comprehensive maternal deaths in 2021 were the highest in Brazil in the past three decades. Increased resources for prenatal care, maternal health, and postpartum care may be needed to reverse the national trend in comprehensive maternal deaths.

The National Institutes of Healths (NIH) Pathways to Prevention panel on postpartum health provides a consensus statement on the evidence, research gaps, and future priorities to prevent maternal morbidity and mortality. The panel reviewed an NIH-commissioned evidence review and workshop that included epidemiologic studies, demonstration interventions, and other maternal morbidity and mortality research to create these national recommendations. The panel concludes that a maternal morbidity and mortality crisis reflects a systemic failure of current U.S. health care, research efforts, and social policies. The panel recommends improving maternal health through a maternal morbidity and mortality prevention moonshot that adopts a comprehensive, multilevel life course conceptual framework; strengthens the research methods used within the science of maternal health; establishes and conducts national prevention, treatment, and policy interventions; and reimburses evidence-informed clinical approaches to improve maternal health across the life course. Without a national focus on fundamentally transformative interventions and other initiatives aimed at redressing structural racism and inequities in health care, current interventions and clinical advances in maternal morbidity and mortality prevention will remain tragically insufficient.

Objectives. To compare pregnancy-related mortality ratios (PRMRs) associated with COVID-19 by race/ethnicity, by region of residence, and in states with and without Medicaid expansion. Methods. We used 2020–2021 data from the US Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research in our analysis. We stratified PRMRs by race/ethnicity, census regions, and Medicaid expansion and nonexpansion states. Results. The 2020–2021 PRMR was 40.3 per 100 000 live births. American Indian/ Alaska Native pregnant people had the greatest PRMR, followed by non-Hispanic Blacks and non-Hispanic Native Hawaiians/other Pacific Islanders. PRMRs associated with COVID-19 in the southern region were at least 2 times higher than in other regions and were highest for all pregnant people in the various racial/ethnic groups. PRMRs associated with COVID-19 were lower in Medicaid expansion states than in nonexpansion states. Conclusions. The US COVID-19 epidemic exacerbated racial and ethnic disparities in pregnancy-related mortality. Public Health Implications. The alarming increase in disparities among racial and ethnic pregnant people during the COVID-19 pandemic underscores the need to address social determinants of health at the structural level. (Am J Public Health. 2024;114(S9): S723–S730. https://doi.org/10.2105/AJPH.2024.307814) [ABSTRACT FROM AUTHOR]

Purpose: To synthesise evidence for the incidence of intensive care unit (ICU) admission, characteristics and mortality of pregnant and postpartum women with a focus on differences between high-income countries (HICs) and low-middle-income countries (LMICs) and report changes in reported findings since the last review by Pollock et al. (2010). Methods: We searched Ovid Medline, EMBASE, and CINAHL (2010–2023), following best practice guidelines for abstract screening for large-evidence systematic reviews. Patient and study characteristics of extracted studies were analysed descriptively. Multivariable meta-regression analysis, employing mixed-effects models, was conducted for assessing ICU admission and mortality. Studies reviewed by Pollock et al. were included to perform an overall analysis, including each study period and geographic region in a model. Results: Seventy-one eligible studies reported data on 111,601 women admitted to ICU, with 41,291,168 deliveries reported in 65 studies. Fifty-six studies were retrospective. Case definitions, admission criteria, and causes of mortality reported were heterogeneous. The pooled ICU admission rate was 1.6% (95% confidence interval [CI] 1.28–1.99; I2 = 99.8%), 0.4% (95% CI 0.32–0.48, I2 = 99.9%) in HICs versus 2.8% (95% CI 0.65–6.4, I2 = 99.9%) in LMICs (p < 0.0001). The pooled ICU mortality rate among 140,780 admissions reported in 63 studies was 6.5% (95% CI 5.2–7.9; I2 = 98.7%), with mortality in HICs 1.4% (95% CI 0.8–2.1, I2 = 98.04%) lower than LMICs 12.4% (95% CI 8.1–17.5, I2 = 98.9%) (p < 0.0001). Multivariable meta-regression analysis found a significant association between the ICU admission rates (p = 0.0001) and mortality (p = 0.0003) with geographic region (HIC vs LMIC). Compared to the earlier study of Pollock et al. in 2010, there was an increase in reported studies (71 vs 40 in Pollock et al. study) and reported admissions (111,601 vs 7887 Pollock et al. study), particularly from LMICs'. Conclusions: Mortality for critically ill peripartum women is substantial and the gap in reported ICU admissions and mortality for critically ill peripartum women between HIC and LMICs remains unacceptably high. The reports are often small and heterogeneous using many case definitions. Reporting standards focusing on critical care processes and outcomes and large multinational prospective studies are necessary to better understand and mitigate maternal and child health challenges as sustainable development goals in LMICs and HICs. [ABSTRACT FROM AUTHOR]

Objective: Postpartum hemorrhage is a leading cause of maternal mortality and morbidity around the globe. The novel low-suction vacuum hemorrhage device (VHD) provides an alternative treatment option for cases of postpartum hemorrhage when first-line uterotonic agents fail. This systematic review aims to review current data evaluating the overall efficacy and safety of VHDs in treating postpartum hemorrhage. Methods: We searched CINAHL Ultimate, Academic Search Premier, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE with Full Text, and PubMed and reference lists of retrieved studies for eligible studies that included outcomes of effectiveness, efficacy, or safety. Two independent reviewers used Covidence.org to screen Titles and Abstracts for 69 studies of which six were included in the analysis. Secondary outcomes measured across studies included time to bleeding control, total device deployment time, and adverse effects. Results: Six nonrandomized trials (N = 1018 participants) included studies conducted in Indonesia, the United States, Switzerland, and Canada. The VHDs were found to have 90% effectiveness in achieving bleeding control across the studies. For most patients, this was achieved in <5 min and required a total device deployment time of 3 h. Reported adverse events were not considered life-threatening, including endometritis in 11 patients and red blood cell transfusions in 38% of patients. Conclusion: VHDs have the potential to be used as a rapidly effective means for mechanical intervention of postpartum hemorrhage. The efficacy and safety of VHDs must be further studied at the randomized controlled trial level to determine their clinical usage. [ABSTRACT FROM AUTHOR]

Objectives: There have been significant advances in the medical management of severe postpartum hemorrhage (sPPH) over recent decades, which is reflected in numerous published guidelines. To date, many of the currently available national and international guidelines recommend recombinant factor VIIa (rFVIIa) to be used only at a very late stage in the course of sPPH, as a "last resort", before or after hysterectomy. Based on new safety data, rFVIIa has recently been approved by the European Medicines Agency (EMA) and Swissmedic for use in sPPH, if uterotonics are insufficient to achieve hemostasis, which in fact is significantly earlier in the course of postpartum hemorrhage (PPH). We therefore aimed to develop expert consensus guidance as a step toward standardizing care with the use of rFVIIa for clinicians managing women experiencing life-threatening sPPH. Methods: The consensus process consisted of one face-to-face meeting with a group of nine experts, including eight obstetrician-gynecologists and a hematologist highly experienced in sPPH care in tertiary care perinatal centers. The panel was representative of multidisciplinary expertise in the European obstetrics community and provided consensus opinion in answer to pre-defined questions around clinical practice with rFVIIa in the management of sPPH. Recommendations have been based on current national and international guidelines, extensive clinical experience, and consensus opinion, as well as the availability of efficacy and new safety data. Results: The expert panel developed 17 consensus statements in response to the 13 pre-defined questions on the use of rFVIIa in the management of sPPH including: available efficacy and safety data and the need for interdisciplinary expertise between obstetricians, anesthesiologists, and hematologists in the management of sPPH. Based on novel data, the experts recommend: (1) earlier administration of rFVIIa in patients with sPPH who do not respond to uterotonic administration to optimize the efficacy of rFVIIa; (2) the importance of hematological parameter prerequisites prior to the administration of rFVIIa to maximize efficacy; and (3) continued evaluation or initiation of further invasive procedures according to standard practice. Furthermore, recommendations on the timing of rFVIIa treatment within the sPPH management algorithm are outlined in a range of specified clinical scenarios and settings, including vaginal delivery, cesarean section, and smaller birthing units before transfer to a tertiary care center. The panel agreed that according to available, and new data, as well as real-world experience, there is no evidence that the use of rFVIIa in patients with sPPH increases the risk of thromboembolism. The authors acknowledge that there is still limited clinical effectiveness data, as well as pharmacoeconomic data, on the use of rFVIIa in sPPH, and recommend further clinical trials and efficacy investigation. Conclusions: This expert panel provides consensus guidance based on recently available data, clinical experience, and expert opinion, augmented by the recent approval of rFVIIa for use in sPPH by the EMA. These consensus statements are intended to support clinical care for sPPH and may help to provide the impetus and a starting point for updates to existing clinical practice guidelines. [ABSTRACT FROM AUTHOR]

Introduction: To develop and validate a support tool for healthcare providers, enabling them to make precise and critical decisions regarding intensive care unit (ICU) admissions for high‐risk pregnant women, thus enhancing maternal outcomes. Methods: This retrospective study involves secondary data analysis of information gathered from 9550 pregnant women, who had severe maternal morbidity (any unexpected complication during labor and delivery that leads to substantial short‐term or long‐term health issues for the mother), collected between 2009 and 2010 from the Brazilian Network for Surveillance of Severe Maternal Morbidity, encompassing 27 obstetric reference centers in Brazil. Machine‐learning models, including decision trees, Random Forest, Gradient Boosting Machine (GBM), and Extreme Gradient Boosting (XGBoost), were employed to create a risk prediction tool for ICU admission. Subsequently, sensitivity analysis was conducted to compare the accuracy, predictive power, sensitivity, and specificity of these models, with differences analyzed using the Wilcoxon test. Results: The XGBoost algorithm demonstrated superior efficiency, achieving an accuracy rate of 85%, sensitivity of 42%, specificity of 97%, and an area under the receiver operating characteristic curve of 86.7%. Notably, the estimated prevalence of ICU utilization by the model (11.6%) differed from the prevalence of ICU use from the study (21.52%). Conclusion: The developed risk engine yielded positive results, emphasizing the need to optimize intensive care bed utilization and objectively identify high‐risk pregnant women requiring these services. This approach promises to enhance the effective and efficient management of pregnant women, particularly in resource‐constrained regions worldwide. By streamlining ICU admissions for high‐risk cases, healthcare providers can better allocate critical resources, ultimately contributing to improved maternal health outcomes. Synopsis: The study develops a predictive AI‐based tool for optimizing ICU admissions, aiming to enhance maternal outcomes by efficiently identifying high‐risk pregnant women needing intensive care. [ABSTRACT FROM AUTHOR]

Objective: To determine the trend in adolescent maternal deaths and deliveries over a period of 5 years and 9 months (July 2014–March 2020) at the Ekurhuleni Health District in South Africa. Methods: The present study was a retrospective review and secondary data analysis using data from the District Health Information System and clinical oversight data from the District Clinical Specialist Team. The study population was adolescent pregnant women aged 10–19 years who died at health facilities. Descriptive and inferential statistics were used for analysis. Results: There was a total of 12 559 adolescent deliveries. Adolescent birth rate was lower than that of sub‐Saharan Africa. Adolescent deaths (n = 37) contributed to around 8% of the total maternal deaths. Deliveries (97%) and deaths (98%) were most common among women aged 15–19 years. Six (16%) women had a repeat pregnancy. A total of 21 (57%) had booked for antenatal care. There were few antenatal visits (mean 4 ± SD 2.1). The main three causes of death were hypertension (35%) followed by hemorrhage (24%) and suicide (14%). Postpartum deaths (62%) were significantly (chi‐square test, P = 0.02) higher than antepartum deaths (38%). The majority (73%) of newborns were born alive which was significantly (chi‐square test, P = 0.002) higher than those which were stillborn (27%). Conclusion: The main challenges were the high number of adolescent deliveries, repeat pregnancies, and preventable causes of death. Multidisciplinary collaboration involving obstetricians, midwives, pediatricians, school health services, social workers and psychologists is indispensable for comprehensive management, prioritizing pregnancy prevention among this vulnerable group. SYNOPSIS: Adolescent birth rate and mortality was lower than that of sub‐Saharan Africa. Large numbers of adolescent deliveries, suicidal deaths and repeat pregnancy were important challenges. [ABSTRACT FROM AUTHOR]

Objectives: The New Orleans Maternal Child Health Coalition convenes to support and amplify the work of New Orleans-based individuals and organizations working to reduce disparities and protect the health of birthing families in the New Orleans area. The objectives of this qualitative study were to identify successes, challenges, and areas of growth for the Coalition and develop broadly generalizable recommendations for similar groups seeking to mobilize and advance health equity in their own communities. Methods: Using purposive sampling, we conducted semi-structured interviews with 12 key informants from within and outside of the Coalition. Interviews were transcribed verbatim, and data was analyzed using inductive and deductive coding approaches. Results: We identified themes relating to the barriers and facilitators to the maintenance of the Coalition, as well as opportunities to advance the mission of the Coalition. Some themes included structural- and systemic-level barriers to achieving the mission, varying perspectives on the effectiveness of the Coalition, opportunities to enhance the operations of the Coalition's work, and opportunities to involve other individuals, particularly those with lived experience, and non-MCH related sectors in Coalition's work. Conclusions for Practice: As the maternal health crisis continues, coalitions like the New Orleans MCH Coalition provide a vehicle to amplify the mission-driven work of people and organizations. Recommendations put forth by the Coalition can also be utilized by coalitions in other jurisdictions. Significance: What is Already Known on this Subject?: Black–White disparities in maternal and child health (MCH) have a longstanding history within the United States (US) and these disparities are mirrored in New Orleans, LA. The New Orleans Maternal and Child Health Coalition was founded to support the collective efficacy of numerous individuals and organizations to protect the health of birthing families in the community. What Does this Study Add?: We identified the key barriers and facilitators to achieving the Coalition's mission and building collective power to achieve MCH equity in the greater New Orleans area. Such evidence is a crucial contribution during this time when rates of maternal mortality and morbidity continue to rise throughout the country. This study amplifies the importance of community-driven work to address disparities in MCH and enhance health equity. [ABSTRACT FROM AUTHOR]

Objectives: Maternal mortality remains an unfinished global agenda and postpartum hemorrhage (PPH) remains one of the leading causes. The aims of this study were to describe the incidence, underlying causes, and case fatality rate of PPH in public hospitals in eastern Ethiopia. Methods: This study was part of a larger Ethiopian Obstetric Surveillance System (EthOSS) project — a multicenter surveillance of women admitted to 13 public hospitals in eastern Ethiopia due to any of the five major obstetric conditions: obstetric hemorrhage, eclampsia, uterine rupture, sepsis, and severe anemia – conducted from April 1, 2021 to March 31, 2022. All registers in maternity units of those hospitals were reviewed to identify eligible women and collect data on sociodemographic and obstetric characteristics, management and maternal outcomes at discharge or death. Findings were reported using descriptive statistics. Results: Among 38,782 births registered during the study period, 2043 women were admitted with at least one of the five major obstetric conditions. Of these 2043, 306 women (15%) had PPH corresponding with an incidence rate of 8 (95% CI: 7–9) per 1000 births. Uterine atony was the main underlying cause in 77%; 81% of women with PPH received at least one uterotonic drug, and 72% of women for whom blood was requested received at least one unit. Of the 70 hospital based maternal deaths, 19 (27%) died from PPH, making a case fatality rate of 6 per 100. Conclusions: Although the overall incidence of PPH appeared low, it was still the underlying cause of death in one out of four women who died. The contributing factors might be that one in five women with PPH did not receive any uterotonic drug and the low blood transfusion. Ongoing audit, followed by targeted action, is essential to improve care quality and reduce adverse maternal outcome. The relatively low incidence may reflect under-recording in paper-based records, implying that further research into methods to optimize the surveillance is needed. Significance: What is Already Known on this Subject?: Although PPH remains the leading cause of maternal mortality in many low-resource settings, systems to track progress and effects of interventions to reduce its burden are lacking. Identifying the incidence, underlying contributing factors and management outcomes would assist in devising tailored interventions. What this Study adds?: While an inadequate administration of uterotonics and low blood transfusion could have contributed to PPH causing significant proportion of maternal death in the study settings, audit of care, context specific interventions and improving paper based recording and research to optimize the surveillance need due attention. [ABSTRACT FROM AUTHOR]

We examine the impact of a home visiting program targeting pregnant women in Mexico City on maternal mortality. Using administrative data and taking advantage of the program’s rollout, we estimate a staggered difference-in-differences model. We find that the program substantially reduces the maternal mortality rate by 23 maternal deaths per 100,000 births, leading to a total of 105 lives saved in the study period, which amounts to social welfare gains of 17 million dollars. We complement our analysis using call data from a government telehealth program and show that the program led to more pregnancy-related calls, suggesting that the reduction in maternal mortality was at least partially driven by the type of information provided during the home visits, which increased mothers’ awareness of common pregnancy complications signs and connected pregnant women with the healthcare system. [ABSTRACT FROM AUTHOR]

Objective: Assessment of COVID‐19 vaccine safety in pregnancy using population‐based data. Design: Matched case–control study nested in a retrospective cohort. Setting: April 2021–March 2022, England. Population or Sample: All pregnant individuals aged between 18 and 50 years with valid health records. Methods: Individuals identified from the national Maternity Services Data Set (MSDS) had their records linked to hospital admission, national COVID‐19 vaccine and COVID‐19 testing databases. Matching included participant's age and estimated week of conception. We compared outcomes across multiple COVID‐19 vaccine exposures using conditional multivariable logistic regression, adjusting for demographic and health characteristics. Main Outcome Measures: Adverse pregnancy, maternal and neonatal outcomes. Results: 514 013 individuals were included. We found lower odds of giving birth to a baby who was low birthweight (aOR = 0.86, 95% CI: 0.79–0.93), preterm (aOR = 0.89, 95% CI: 0.85–0.92) or who had an Apgar score < 7 at 5 min of age (aOR = 0.89, 95% CI: 0.80–0.98) for individuals who received at least one dose of COVID‐19 vaccine during pregnancy. The odds of admission to intensive care unit during pregnancy were lower in those vaccinated (aOR = 0.85, 95% CI: 0.76–0.95). There was no association between vaccination in pregnancy and stillbirth, neonatal death, perinatal death and maternal venous thromboembolism in pregnancy. Conclusions: COVID‐19 vaccines are safe to use in pregnancy. Our findings generated important information to communicate to pregnant individuals and health professionals to support COVID‐19 maternal vaccination programmes. [ABSTRACT FROM AUTHOR]

The aim of this document is to provide guidance for the management of women and birthing people with a permanent pacemaker (PPM) or implantable cardioverter defibrillator (ICD). Cardiac devices are becoming more common in obstetric practice and a reference document for contemporary evidence‐based practice is required. Where evidence is limited, expert consensus has established recommendations. The purpose is to improve safety and reduce the risk of adverse events relating to implanted cardiac devices during pregnancy, birth and the postnatal period. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the association of inpatient maternal mortality with variability in healthcare services delivery such as hospital size, urban/rural designation, teaching/non-teaching status, regional location, and insurance coverage. METHODS: This is a pooled, cross-sectional analysis of the National Inpatient Sample (2012–2014). Information on maternal demographics, clinical conditions, and birth outcomes were identified using respective ICD9-CM codes. Bivariate and multivariate analysis using logistic regression models were used to describe maternal characteristics and to calculate the risk of mortality with each independent variable RESULTS: The weighted sample included 12,409,939 hospital records (82.6% are 18–34-year-old and 49.5% are Caucasians). Maternal death during hospitalization occurred in 1310 cases (12/100,000 live birth). Women with cardiovascular disorders, hemorrhage or sepsis were 33.6, 4.7, and 5.4 times more likely to suffer inpatient maternal mortality. Compared to small-sized hospitals, delivery at medium or large size hospitals is associated with higher mortality, adjusted odds ratios (aOR) 1.8 (1.4–2.3), and 2.2 (1.8–2.8), respectively. Adjusted OR for inpatient maternal mortality in urban non-teaching or urban teaching compared to rural hospitals were 2.2 (1.7–3.0) and 2.9 (2.2–3.9), respectively. Women in the South have higher maternal mortality compared to Northeast, aOR 1.7 (1.5–2.1). Women coved with public insurance experience higher inpatient maternal mortality compared to those with private insurance, aOR: 2.6 (2.1–3.2) and 1.9 (1.6–2.1), respectively. CONCLUSION: Factors related to variability in healthcare delivery may play a role in inpatient maternal mortality. Some could be explained by the case mix and the clinical conditions affecting birthing outcomes. A qualitative analysis is needed to explore how these factors relate to increased maternal mortality in certain hospital settings. [ABSTRACT FROM AUTHOR]

The healthcare that a woman receives during pregnancy, at the time of delivery, and soon after delivery is imperative for the well-being and survival of both the mother and her child. Hence, understanding the factors that influence the utilization of healthcare around the period of birth is important for improving the health of the mother and her child as well as reducing maternal mortality. Although numerous studies have examined the factors that influence the utilization of healthcare around the period of birth, no study has considered the role of ethnic heterogeneity. This paper bridges a significant gap in the literature by reporting findings from the first study that examines the effect of ethnic heterogeneity on healthcare utilization in Ghana. The study utilized data from both the Demographic Health Survey and Ghana Population and Housing Census. Our estimates show that a unit increase in a heterogenous ethnic group lowers the likelihood of utilizing healthcare at the time of birth and after delivery via increasing household poverty. [ABSTRACT FROM AUTHOR]

Despite global progress and a marked reduction in maternal mortality ratio worldwide, the burden of maternal death and morbidity remains a huge challenge, especially among low‐ and middle‐income settings. Maternal mortality is determined by multiple components. As a result, sustainable strategies require not only the implementation of effective health policies but also social development. In this narrative review, we discuss strategies to improve the maternal mortality ratio based on recent advances in public health. Primary care plays a key role in identifying background conditions, risk factors and early signs of some major causes of maternal mortality and morbidity. Antenatal care also addresses other conditions that influence outcomes: unwanted pregnancies, nutrition, sexually transmitted illnesses, family planning, immunization, and child health. Therefore, awareness about major causes of maternal mortality, direct and indirect targeted interventions to adequately identify risk factors, implement prophylactic interventions when available and guarantee early diagnosis, can certainly impact outcomes. [ABSTRACT FROM AUTHOR]

In countries without adequate death registration systems, adult mortality is often estimated using orphanhood-based methods. The HIV pandemic breaches several assumptions of these methods, for example, by increasing the correlation between maternal and child survival. Using microsimulations we generated 1,152 populations facing HIV epidemics and evaluated different orphanhood-based estimates against the underlying mortality rates. We regressed survivorship probabilities on proportions of respondents with surviving mothers, adjusting for trends in seroprevalence and coverage of antiretroviral therapy, to obtain new coefficients. We tested the different methods on survey and census data from 16 African countries with high HIV prevalence. We found that the original orphanhood method underestimates mortality during an AIDS epidemic, but better estimates can be obtained using new coefficients applied to synthetic measures of maternal survival. The resulting estimates agree well with those of the United Nations Population Division. Orphanhood-based estimates can fill data gaps in adult mortality, including in countries with high HIV prevalence. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion The pregnancy, delivery, and neonatal outcomes of pregnancies complicated by gout have yet to be evaluated in a population‐based study. We sought to evaluate the obstetric and neonatal outcomes in pregnant patients with gout using a national population database.This is a retrospective population‐based cohort study utilizing the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP‐NIS). All women who delivered or had a maternal death in the USA (2004–2014) were included in the study. Pregnancy, delivery, and neonatal outcomes were compared between women with an ICD‐9 diagnosis of gout to those without.Overall, 9 096 788 women met the inclusion criteria. Of these, 168 women (1.8/100000) had gout. Patients with gout, compared to those without, were more likely to be older and obese and to have chronic hypertension, pregestational diabetes mellitus, and thyroid disease. Pregnant women with gout were more likely to develop gestational diabetes mellitus (aOR 1.78 [95% CI 1.17–2.72], P = 0.008), to require operative vaginal delivery (aOR 3.26 [95% CI 2.03–5.22], P = 0.0001), and to experience venous thromboembolism (aOR 8.47 [95% CI 2.06–34.82], P = 0.003) compared to pregnant patients without gout. Patients with gout were more likely to deliver a neonate with congenital anomalies compared to those without gout (aOR 3.38 [95% CI 1.24–9.20], P = 0.02).Gout in pregnancy, or pregnancies complicated by a history of gout, are associated with increased risk of gestational diabetes mellitus, pulmonary embolism, and neonatal anomalies. [ABSTRACT FROM AUTHOR]

Background: This study explored how gender inequalities in health systems influence women's experiences of obstetric violence in Ghana. Obstetric violence is recognised as a major public health concern and human rights violation. In particular, it reduces women's trust and use of health facilities for childbirth, thereby increasing the risks of maternal and neonatal mortality. In Ghana, obstetric violence is pervasive and normalised; yet, little is known about the gendered dynamics of this phenomenon. Methodology: A qualitative study was conducted in eight public health facilities in Ghana. Specifically, semi-structured interviews were conducted with 30 midwives who work in the maternity units and 35 women who have utilised the obstetric services of the hospitals for childbirth. The midwives and women were selected using the purposive sampling technique. The transcripts of the interviews were coded using NVivo qualitative data analysis software and were thematically analysed. Secondary materials such as existing data on the medical profession in Ghana were utilised to complement the primary data. Results: The study revealed that there are huge structural inequalities that keep women at the lower cadres of the health system. Five major themes depicting how gender inequalities contribute to women's experiences of obstetric violence emerged: gender inequality in the medical profession, unequally and heavily tasked, feminisation of midwifery, patriarchal pressures and ideologies, and gender insensitivity in resource provision. These inequalities impact the kind of care midwives provide, which is often characterised by mistreatment and abuse of women during childbirth. The study also discovered that patriarchal ideologies about women and their bodies lead to power and control in the delivery room and violence has become a major instrument of domination and control. Conclusion: The hierarchical structure of the healthcare profession puts the midwifery profession in a vulnerable position, with negative consequences for maternity care (obstetric violence). The study recommends that gender-responsive approaches that address structural inequalities in health systems, women's empowerment over their bodies and male involvement in women's reproductive care are crucial in dealing with obstetric violence in Ghana. [ABSTRACT FROM AUTHOR]

Many maternal and neonatal deaths can be avoided if quality healthcare is provided. To this end, the South African National Department of Health implemented a quality improvement (QI) programme (2018–2022) to improve maternal and neonatal health services in 21 public health facilities. This study sought to identify good practices aimed at improving QI teams' performance by identifying optimal facility-level contextual factors and implementation processes. We purposively selected 14 facilities of the 21 facilities for a longitudinal qualitative process evaluation. We interviewed 17 team leaders, 47 members, and five QI advisors who provided technical support to the teams. The data were analysed using framework analysis. We choose the Consolidated Framework for Implementation Research as framework given that it explicates contexts and processes that shape programme implementation. Six quality improvement teams were assessed as well-performing, and eight as less well-performing. This research conceptualises a 'life course lens' for setting up and managing a QI team. We identified eight good practices, six related to implementation processes, and two contextual variables that will optimise team performance. The two most impactful practices to improve the performance of a QI team were (i) selecting healthcare workers with quality improvement-specific characteristics, and (ii) appointing advisors whose interpersonal skills match their technical quality improvement competencies. [ABSTRACT FROM AUTHOR]

Background: Maternal and child mortality rates remain a serious public health challenge in Ethiopia. Short interpregnancy intervals are known to negatively impact perinatal and child health; therefore, improving this practice is a key strategy to reduce mortality and adverse outcomes. Objective: This study aimed to evaluate the extent of short intervals between pregnancies and the factors associated with them among women who gave birth at public hospitals in the North Wollo Zone of northeastern Ethiopia in 2023. Design: A facility-based cross-sectional study was conducted in the North Wollo Zone of northeastern Ethiopia in 2023. Methods: This study was conducted on mothers who delivered at public hospitals in the North Wollo Zone of northeastern Ethiopia. The study participants were selected using a systematic random sampling technique between February 1, 2023, and April 1, 2023. Data were collected through an interviewer-administered questionnaire using the Kobo Collect tool and analyzed using SPSS version 27.0. Bivariable and multivariable analyses were performed to determine the relationship between the outcome and predictor variables. A p value of less than 0.05 was considered significant in the multivariable analysis. Results: The study found that 51.5% of participants had short interpregnancy intervals. Several independent factors were associated with a short birth interval, including the status of the last pregnancy (adjusted odds ratio (AOR): 9.51; 95% CI: 3.932–23.0028), educational status of the woman (AOR: 4.545; 95% CI: 1.208–17.108), and use of modern contraceptives in previous pregnancies (AOR: 6.460, 95% CI: 3.882–23.008). Conclusion: Despite the efforts made through public health interventions in Ethiopia, the prevalence of short interpregnancy intervals in this study was high. Therefore, increasing the utilization of modern contraceptives and promoting health education at both health facilities and community levels could contribute to addressing this issue. Plain language summary: The study of interpregnancy intervals was conducted to better understand the magnitude and causes of short interpregnancy intervals among women who delivered at North Wollo Zone public hospitals Why was the study done? This study was conducted to evaluate the prevalence of short intervals between pregnancies and identify the factors associated with them among women who gave birth at public hospitals in the North Wollo Zone of northeastern Ethiopia in 2023. This research aimed to understand the extent of the issue and its determinants to inform strategies and interventions aimed at reducing maternal and child mortality and improving health outcomes in the region. What did the researchers do? This cross-sectional study was conducted in 2023 in the North Wollo Zone of northeastern Ethiopia. They selected mothers who had given birth at public hospitals between February and April 2023 using systematic random sampling. Data were collected through interviews and analyzed to identify factors associated with short birth intervals. What did the researchers find? The researchers found that over half (51.5%) of the participants had short intervals between pregnancies. They discovered significant associations between short birth intervals and factors such as the outcome of the last pregnancy, educational status of the women, and use of modern contraceptives in previous pregnancies. These findings highlight the importance of addressing these factors to improve the maternal and child health outcomes in the region. What do the findings mean? These findings suggest that a considerable proportion of women in the North Wollo Zone of northeastern Ethiopia experienced short intervals between pregnancies. Factors such as the outcome of previous pregnancies, educational status, and use of modern contraceptives play crucial roles in determining the length of birth intervals. Addressing these factors through improved access to modern contraceptives and enhanced health education could potentially reduce the maternal and child health risks associated with short birth intervals in the region. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion To elucidate the demographics, clinical characteristics, and outcomes of patients with postpartum hemorrhage (PPH) who underwent transcatheter arterial embolization (TAE).We conducted a retrospective observational study using the Japanese Diagnosis Procedure Combination inpatient database, which covers roughly 90% of all tertiary emergency hospitals in Japan, between April 2012 to March 2020. We identified patients with PPH who underwent TAE using the Japanese medical procedure status and code, and the device or drug code. We examined the patient characteristics, interventions administered, and clinical outcomes.Among 64 893 patients diagnosed with PPH, we identified 2705 (4.2%) patients with PPH who underwent TAE. The most common cause of PPH was uterine atony (68.7%), followed by disseminated intravascular coagulation after labor (30.0%) and placenta accreta spectrum disorders (23.4%). The proportion of patients who underwent repeat TAE and a hysterectomy was 64 (2.4%) and 188 (7.0%), respectively. Among hysterectomies (n = 188), 26 (13.8%) had the procedure performed before TAE, 73 (38.8%) underwent hysterectomy on the same day as TAE, and 89 (47.4%) had the procedure conducted after TAE. Of those who underwent a hysterectomy after TAE (n = 89), 33 (37%) were performed more than 1‐week after initial TAE. Overall in‐hospital mortality was 14/2705 (0.5%).Even if hemostasis is achieved through TAE, one must be mindful that a hysterectomy may become necessary more than 1 week after the procedure. These results could be helpful in clinical decision making and providing patients with additional treatment options for PPH that preserve patient fertility. [ABSTRACT FROM AUTHOR]

Background Objective Search Strategy Selection Criteria Data Collection and Analysis Main Results Conclusion High maternal mortality rates in sub‐Saharan Africa necessitate the need for aligned research focusing on prevalent causes and neglected conditions in the region.This mapping review aimed to describe the characteristics of longitudinal maternal health studies between 2012 and 2022 in sub‐Saharan Africa and identify gaps in priority conditions or geographical locations.We identified references through a Medline (PubMed) search covering September 2012 to June 2022.We included prospective cohort or clinical trials that enrolled at least 1000 pregnant women, with a study site in sub‐Saharan Africa, and published in English or French.Screening and data extraction were done in duplicate using EPPI‐reviewer software. Descriptive analysis was used to summarize the results, identifying patterns in studies across time, country, study design, topics, and funders.We identified 213 eligible studies, which were covered in 534 publications. We identified studies in 33 of the 48 sub‐Saharan African countries, with the majority in east and southern Africa. The predominant study topics were HIV (36.4%), nutrition (20%), and malaria (16.3%), with very few publications on hypertensive disorders of pregnancy (6.4%), ante/postpartum hemorrhage (3.7%), and sexually transmitted infections (3.2%). More studies were cohorts (115/213; 54%) than clinical trials. The National Institutes of Health (31.5%), Bill and Melinda Gates Foundation (22.1%), and USAID (10.8%) were the largest research funders.Identifying research trends and mismatches between research topics and disease burden provides useful information for guiding future research prioritization. In particular, gaps exist for studies on hypertensive disorders of pregnancy and ante/postpartum hemorrhage, among the top causes of maternal mortality in sub‐Saharan Africa. [ABSTRACT FROM AUTHOR]

Background: Anaemia in pregnancy (AIP) is a public health concern due to its devastating effects on women and their unborn babies, resulting in increased maternal and neonatal deaths in developing countries. Despite several Ghanaian health policies to combat AIP, AIP is still on the rise. It becomes imperative to identify geographic-specific factors for developing appropriate interventions for the management of AIP. However, Kassena Nankana West District (KNWD) in the Upper East Region of Ghana lacks a study on anaemia risk factors, therefore, this study estimated the prevalence and risk factors for anaemia among pregnant women in the district. Methods: A cross-sectional study was conducted from February to March 2023 in the KNWD. Approximately 376 pregnant women in their third trimester were randomly selected from 10 health facilities by utilizing the antenatal register as the sampling frame. Anthropometric, obstetric, sociodemographic, and health facility resource characteristics were collected using structured questionnaires and from antenatal records. Mixed-effect logistic regression was used to identify independent factors of anaemia at 95% confidence interval. Results: Prevalence of AIP was 53.9% (95%CI:48.5%–58.8%). Mild, moderate, and severe anaemia prevalence was 16.9%, 35.3%, and 1.7% respectively. Malaria infection during pregnancy (aOR = 1.64; 95%CI:1.03–2.62) and accessing health facilities without trained laboratory personnel (aOR = 5.49; 95%CI:1.67–18.00) were associated with increased odds of AIP. Belonging to the major ethnic group (aOR = 0.52; 95%CI:0.28–0.85), accessing health facilities without laboratory services (aOR = 0.14; 95%CI:0.04–0.47), and accessing health facilities without sulphadoxine-pyrimethamine drugs (aOR = 0.22; 95%CI:0.06–0.86) in KNWD were also associated with decreased odds of AIP. Conclusion: KNWD has a severe burden of AIP. Maternal and health facility-related factors were associated with AIP in the district. These factors are preventable. Therefore, the provision of functional laboratory services with dedicated technical personnel, regular supply of sulphadoxine-pyrimethamine drugs to the health facilities, and enhanced community education on malaria prevention are recommended for anaemia control in the district. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the health of pregnant women and their unborn babies. Objective: To explore the impact of COVID-19 on intrapartum care in Ethiopia. Design: A concurrent mixed-methods design was employed. Methods: An interrupted time series analysis was implemented using a Poisson regression model to estimate monthly changes in the incidence rates of institutional childbirth, instrumental vaginal birth, caesarean section, stillbirth, institutional neonatal death, institutional maternal death and availability of essential medical supplies before and during COVID-19. The dataset included data from all women who gave birth in 15 public hospitals, and the total number of childbirths in the cohort study before COVID-19 (12 months of data from March 2019 to February 2020) was 24,478, while during COVID-19 (6 months of data from March to August 2020), the total number of childbirths in the cohort study was 11,966, forming a combined final dataset of 36,444. Simultaneously, a descriptive qualitative study using a purposive sampling technique was conducted through in-depth interviews until data saturation was reached, with data were collected from 14 February to 10 May 2022. Data from the interviews were imported into NVivo 12 Plus to perform an inductive thematic analysis. Quantitative and qualitative data were integrated using joint display methods to identify corroboration or contradiction between the different forms of evidence. Results: Our findings indicate that the incidence rates of caesarean sections and instrumental vaginal births significantly increased in the first 6 months of COVID-19. Three themes were identified: ' Barriers to providing intrapartum care during COVID-19 ', ' Delays to provision of intrapartum care during COVID-19 ' and ' Inadequate COVID-19 preventive measures '. Conclusion: In combination, the three themes contributed to a considerable increase in neonatal and maternal deaths. Interventions such as fully equipped labour wards and obstetric triage systems are needed to restore disrupted maternal and perinatal care during the ongoing and future pandemics. In addition, stakeholders should inform the public that blood donations can help the community recover from recent shocks in emergency health and future pandemics. Further research should investigate the long-term impact of COVID-19 on maternity care and maternal and infant outcomes. [ABSTRACT FROM AUTHOR]

Background: In low‐income countries, such as Ethiopia, home birth is the main cause of maternal and neonatal mortality. Several separate studies have been conducted on the prevalence of home birth preference. However, there is no pooled prevalence of home birth preferences. So, this systematic review and meta‐analysis is aimed at assessing the overall preference for home birth and related factors among Ethiopian women. Methods and Materials: The review included only published articles. Medline/PubMed, Web Science, Google Scholar, Scopus, and the Cochrane Library are the main databases. The review includes cross‐sectional studies in English that meet eligibility requirements. The combined prevalence of women's preference for home birth is calculated by random effect models. In addition, Egger's tests and funnel diagrams were used to investigate publication biases. STATA Version 14 is used to perform all statistical analyses. Results: The review included 14 studies with 6631 participants. In Ethiopia, the prevalence of women's preference for home birth was 41.48% (confidence interval (CI): 49.99; 63, 56; I2:98.7%; p ≤ 0.001). In the analysis of the subgroups, the Oromia region had the highest home birth preference rate at 61.40% (55.54%, 67.16), while southern Ethiopia had the lowest value at 20.52% (5.18, 29.75). The probability of preferring home birth was higher for women without education (OR = 0.22, p ≤ 0.001, I2 = 69.7%) and for younger women (ODR = 0.47, p ≤ 0.001, I2 = 84.2%). Conclusion: According to the study, 41% of Ethiopian women prefer home births over institutional births. Age and education of women are statistically important factors in the choice of birthplace. To solve this problem, health professionals and other stakeholders are strongly encouraged to provide women's health education at the community and institutional levels. [ABSTRACT FROM AUTHOR]

Background: The implementation of the maternal perinatal death surveillance and response (MPDSR) policy is among the envisaged strategies to reduce the high global burden of maternal and perinatal mortality and morbidity. However, implementation of this policy across various contexts is inconsistent. Theoretically informed approaches to process evaluation can support assessment the implementation of policy interventions such as MPDSR, particularly in understanding what the actors involved actually do. In this article, we reflect on how the normalisation process theory (NPT) was used to explore implementation of the MPDSR policy in Uganda. NPT is a sociological theory concerned with the social organisation of the work (implementation) of making practices routine elements of everyday life (embedding) and of sustaining embedded practices in their social contexts (integration). Methods: This qualitative multiple case study conducted across eight districts in Uganda and among 10 health facilities (cases) representing four out of the seven levels of the Uganda health care system. NPT was utilised in several ways including informing the study design, structuring the data collection tools (semi-structured interview guides), providing an organising framework for analysis, interpreting and reporting of study findings as well as making recommendations. Study participants were purposely selected to reflect the range of actors involved in the policy implementation process. This included direct care providers located at each of the cases, the Ministry of Health and from agencies and professional associations. Data were collected using semi-structured, in-depth interviews and were inductively and deductively analysed using NPT constructs and subconstructs. Results and conclusion: NPT served useful for process evaluation, particularly in identifying factors that contribute to variations in policy implementation. Considering the NPT focus on the agency of people involved in implementation, additional efforts are required to understand how recipients of the policy intervention influence how the intervention becomes embedded within the various contexts. [ABSTRACT FROM AUTHOR]

Background Aims Materials and methods Results Conclusions Anticoagulant therapy prevents thrombosis and thromboembolic events in patients with mechanical heart valves. Bridging anticoagulation around the time of birth represents a unique challenge. Few retrospective reviews or case series exist examining peripartum outcomes with bridging anticoagulation.Review of peripartum and postpartum anticoagulation management, with a focus on postpartum complications.Design: case series, single centre. Setting: Royal Brisbane and Women's Hospital, Australia between 1 January, 2000, and 1 August, 2022. Population: all pregnant women with mechanical heart valves (any type) who birthed. Main outcome measures: intrapartum and postpartum haemorrhage, thrombosis, thromboembolic complications, cardiac events, readmission, and maternal death.There were 18 women, with 23 births. Sixteen births were via caesarean section (70%). Fourteen women (61%) experienced at least one significant haemorrhagic complication, one woman required a peripartum hysterectomy, one woman experienced atrial fibrillation, and one had a valvular thromboembolic complication. No maternal cerebral thromboses or maternal deaths were recorded.Women with mechanical heart valves who undergo bridging anticoagulation are associated with significant maternal morbidity. Most postpartum haemorrhagic complications were associated with bridging unfractionated heparin infusions in the first postnatal week. Bridging anticoagulation practices varied widely. Ongoing pooled data are required to inform evidence‐based guidelines for postpartum anticoagulation management. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Aim Data Sources Study Eligibility Criteria Methods Results Conclusion Little scientific evidence exists on maternal and fetal outcomes in aplastic anemia (AA) during pregnancy.The review was conducted to assess the maternal and fetal outcomes due to AA during pregnancy.Web of Science, EMBASE, PubMed, Scopus, Cochrane CENTRAL, and registries until May 5, 2024.Studies (prospective, retrospective cohort, cross‐sectional, one arm, survey, follow‐up studies) evaluating AA during pregnancy were searched as per PROSPERO registered protocol (CRD42024506668). Case reports, case series, expert opinion letters, and studies assessing less than or equal to 10 pregnant women were not considered. The primary outcome was the prevalence of preeclampsia in AA pregnancies. The secondary outcomes included spontaneous abortion, preterm premature rupture of membranes, premature rupture of membranes, fetal growth restriction, type of delivery, intrauterine fetal death, maternal and neonatal mortality, and pre and post‐pregnancy remission status comparison.The quality of research was checked using the New Castle‐Ottawa risk‐of‐bias tool. A meta‐analysis model with a random effect distribution, coupled with meta‐regression, sensitivity analysis, and publication bias assessment, was used in the statistical software R. Standard Equator network study reporting guidelines were followed.Seven (one prospective and six retrospective cohort) studies included patients with confirmed AA diagnosis in 248 pregnancies. The pooled prevalence of preeclampsia was 13% (95% CI, 8%–20%). Heterogeneity was low in the present meta‐analysis (I2 = 26%). The secondary outcome evaluation showed a pooled prevalence of 5% (95% CI, 3%–11%) for spontaneous abortion, 4% (95% CI, 1%–11%) for preterm premature rupture of membranes, 10% (95% CI, 3%–28%) for premature rupture of membranes, 6% (95% CI, 3%–11%) for fetal growth restriction, 5% (95% CI, 2%–13%) for intrauterine fetal death, 12% (95% CI, 5%–26%) for post‐partum hemorrhage, 74% (95% CI, 45%–91%) for intrapartum transfusion requirement, and 55% (95% CI, 27%–80%) for the cesarean delivery opting. The maternal mortality in pregnancies with AA was 4% (95% CI, 0.01–0.14), whereas neonatal mortality was 7% (95% CI, 0.03–0.18). The odds of AA complete remission were better in pre‐pregnancy than post‐pregnancy (OR = 0.36; 95% CI = 0.08–1.66), although the results remain insignificant. The leave‐one‐out sensitivity analysis did not change the pooled estimates for the primary outcome.A risk of developing preeclampsia was observed in every eighth pregnant woman with an AA diagnosis. AA remission status might worsen after undergoing pregnancy, considering the significant obstetric morbidity and mortality burden. [ABSTRACT FROM AUTHOR]

Introduction: In 2021, a staggering five million children globally succumbed to mortality before celebrating their fifth birthdays. Alarmingly, children residing in Sub-Saharan African nations faced mortality risks 15 and 19 times higher than their counterparts in Europe and Northern America, as well as the region encompassing Australia and New Zealand, respectively. Ethiopia, situated in Sub-Saharan Africa, shoulders a significant burden of under-five mortality, securing the third position in Africa and the tenth globally. The primary objective of this study was to scrutinize the trends in under-five mortality inequalities based on maternal education in Ethiopia from 2000 to 2016. Method: The analysis utilized data from repeated cross-sectional surveys, drawing upon a pooled total sample of 35,404 children aged 0–59 months. This sample was derived from the Ethiopian Demography and Health Surveys conducted in 2000, 2005, 2011, and 2016. To explore the determinants of under-five mortality among this age group, we employed multilevel binary logistic regression analysis. This approach allowed us to assess the impact of various factors at the individual, household, and community levels. Additionally, we conducted multivariate decomposition, concentration index, and decomposition rate analyses to scrutinize the evolving trends in maternal education-based disparities in under-five mortality. Result: Maternal education emerged as a significant factor influencing under-five mortality in Ethiopia. Notably, approximately one-third (31%) of the observed inequalities in under-five mortality based on maternal education could be accounted for by the effects of observed characteristics. Over the years, there has been a noteworthy reduction in absolute inequalities in under-five mortality. Specifically, a decline of 0.14 was observed between 2000 and 2005, and a more substantial decrease of 0.32 occurred in the period spanning 2000 to 2016, resulting in an overall change of 56.25%. Furthermore, this study revealed that about 43.12% of the reduction in under-five mortality could be attributed to the narrowed gap in maternal education during the survey period. Conclusion: The implications drawn from these findings underscore the importance of directing interventions aimed at reducing early mortality toward the promotion of maternal education. It is evident that addressing maternal education plays a pivotal role in mitigating inequalities in under-five mortality. Additionally, there is a pressing need to revisit and enhance existing population and health policies. Establishing stronger linkages between child survival issues and the education sector is crucial for achieving the targets outlined in the Sustainable Development Goals related to under-five mortality. By aligning policies with these insights, there is a greater likelihood of fostering sustainable improvements in child survival and advancing towards the overarching goal of reducing under-five mortality. [ABSTRACT FROM AUTHOR]

Objective: To determine prevalence of UTI in pregnant women and its associated risk factors at a tertiary care hospital. Study Design: Cross Sectional study. Setting: Department of Gynae & Obstetrics Independent University Hospital, Faisalabad. Period: 1-10-2022 to 31-3-2023. Methods: All pregnant patients visiting gynae OPD (5280) were enrolled for study. Mid-stream urine sample was taken and analyzed. UTI was diagnosed if >10 pus cells / HPF were seen. Inclusion Criteria: All pregnant females attending antenatal clinic during study period. Exclusion Criteria: Women with chronic renal disease. History of antibiotic treatment in last one week, Congenital renal abnormality. Patients on immuno suppressive therapy. Results: The prevalence of UTI in our study was 28%. In this study 593 patients (40%) were <20 years of age, 258(17%) were in 21-30 years age group, 246 (16%) were 31-40 years and 381(26%) were >40 years of age. In our study 526 (35%) were primigravidas, 249(17%) were G2, 272(18%) were G3 and 431 (29%) were G4 or above. In this study 698 (47%) patients were in first trimester, 320(22%) were in second trimester, 460(31%) in third trimester. Among risk factors 245 patients (16%) were anemic and 421(28%) were diabetic. Conclusion: The Prevalence of UTI in pregnant female of independent university hospital Faisalabad is quite high. Anemia and diabetes are major associated risk factors. Owing to its association with a number of complications, UTI needs to be diagnosed and treated promptly to lessen perinatal and maternal morbidity and mortality. [ABSTRACT FROM AUTHOR]

"Those who cannot remember the past are condemned to repeat it." This maxim underscores the importance of historical awareness in medicine, particularly for obstetricians and gynecologists (ObGyns). ObGyns significantly impact societal health through their care for pregnant women, fetuses, and newborns, uniquely positioning them to advocate for health initiatives with lasting societal benefits. Despite its importance, the history of medicine is underrepresented in medical curricula, missing opportunities to foster critical thinking and ethical decision-making. In today's climate of threatened reproductive rights, vaccine misinformation, and harmful ideologies, it is imperative for ObGyns to champion comprehensive historical education. The history of medicine, particularly in relation to societal issues – such as racism, discrimination, genocides, pandemics, and wars – provides valuable context for addressing challenges like maternal mortality, reproductive rights, vaccine hesitancy, and ethical issues. Understanding historical milestones and notable ethical breaches, such as the Tuskegee Study and the thalidomide tragedy, informs better practices and safeguards patient rights. Technological advancements in hygiene, antibiotics, vaccines, and prenatal care have revolutionized the field, yet contemporary ObGyns must remain vigilant about lessons learned from past challenges and successes. Integrating historical knowledge into medical training enhances clinical proficiency and ethical responsibility, fostering innovation and improving health outcomes. By reflecting on historical achievements and their impacts, current and future ObGyns can advance the field, ensuring comprehensive and ethically sound approaches to patient care. This paper highlights the crucial role of historical knowledge in shaping modern ObGyn practices, advocating for its integration into medical education to address contemporary health challenges and ethical considerations. [ABSTRACT FROM AUTHOR]

In 1928, the American Anthropological Association declared that "Anthropology provided no scientific basis for discrimination against any people on the ground of racial inferiority, religious affiliation, or linguistic heritage" (Guthrie, 1976/1998/2004, p. 30). In 1945, Jung denounced race theory as a pseudo‐science. In 1950, UNESCO released its statement denouncing race. Long discredited as scientifically invalid, the race concept still holds uncanny value and significance for Americans and Europeans. In effect, the concept seems to be mysteriously linked to the limited accessibility and the limited economic support that is allotted to people of colour, internationally. This paper will explore the global implications of Jung's expressed attitude towards people of colour prior to 1945, which I identify as an attitude of white supremacy, an attitude that stands in direct contrast to the analytical ethos, as expressed by the International Association for Analytical Psychology (IAAP). This attitude may promote the continuance of racialized beliefs and behaviours within the planning and provision of care to individuals in need of medical and mental health services. It is requested that a written acknowledgment of harm be added to the works of C. G. Jung. [ABSTRACT FROM AUTHOR]

Background: Puerperal infection is one of the four main causes of maternal mortality. A giant intrauterine mass caused by puerperal infection is a rare form of infection. The delay in treatment may result in the removal of the uterus. Case Presentation: We report a case of a large intrauterine mass resulting from puerperal infection, in which the uterus was salvaged through antibiotic treatment and curettage. The patient was a 27-year-old female, who presented with a large intrauterine mass, accompanied by fever and abdominal pain 35 days after vaginal delivery. The large intrauterine mass was ultimately pathologically confirmed to be necrotic smooth muscle tissue instead of residual pregnancy tissue. Conclusion: In most cases, the intrauterine mass after pregnancy is residual pregnancy tissue. Early identification and management are critical to ensure a good prognosis for patients. Obstetricians and pregnant women should be fully aware of the hazards of puerperal infections. [ABSTRACT FROM AUTHOR]

Background. Several disparities exist for Black mothers during the postpartum period, including but not limited to increased maternal mortality and morbidity rates, decreased access to care, and limited access to resources. Given the racial discrepancies in attention to postpartum care, coupled with the critical importance of the postpartum period for preventing adverse maternal health outcomes, research is warranted to explore how mobile health (mHealth) applications may help to alleviate maternal health disparities by optimizing postpartum care and addressing barriers to care for postpartum Black women. Thus, this review examines the perceptions of mHealth applications and their utility in health outcomes among postpartum Black women. Methods. We undertook a comprehensive literature search using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We included peer-reviewed articles published between 2010 and 2022 that were written in English, utilized mHealth as a primary intervention, and focused on postpartum health and access to resources, primarily among Black women in the United States. Results. A total of eight articles were included in our synthesis, encompassing mobile phone-based interventions for Black women. Cultural tailoring was included in five studies. Interventions that incorporated tailored content and fostered interactions reported high rates of follow-up. Conclusions. Tailored mHealth interventions can effectively promote behavior change and improve health care outcomes for Black women. However, there is a critical need for more research to assess user engagement and retention and whether these improvements indicate long-term sustainability. [ABSTRACT FROM AUTHOR]

Background: Maternal mortality is a global clinical and public health crisis. Researchers and leading organizations have highlighted the need for local partnerships to implement evidence-based strategies to mitigate poor outcomes. Alabama has the third highest maternal mortality rate in the nation. Research on the complexity of maternity mortality is strengthening, but poor outcomes in Alabama persist and there is limited data highlighting the perspectives of those on the frontlines of providing and receiving care. Purpose: We conducted a qualitative, statewide, community-informed, maternal and infant health research assessment with physicians, providers, professionals, and birthing persons to identify challenges and solutions to addressing the states' poor perinatal health outcomes. Methods: Data were collected using a four-phase, research design that included semi-structured interviews, focus groups, one state-wide data sharing event, and five regional data sharing events. Data were collected between January 2020 and October 2021. The data were analyzed using consensus coding and thematic analysis. Main Findings: Fifty-nine (N = 59) individuals participated. Three themes emerged: 1) "They were making me feel so overlooked.": A disconnect between perinatal healthcare services and patient needs; 2) "That shouldn't be something you have to ask for.": Limitations to providing respectful perinatal healthcare; and 3) "If they work together, they can have all the tools they need.": Building a case for collaborative care. Conclusions: Participants advocated for a collaborative perinatal healthcare model that focuses on the provision of respectful, quality perinatal healthcare. Our approach can be applied across contexts and used to support the effective implementation of contextually relevant maternity care practices. Significance: Evidence-based perinatal healthcare practices facilitate maternal and infant wellbeing; however, they are often underutilized. Community-based assessments are critical to understanding the landscape of perinatal healthcare and the priorities of those most affected within a specific context. These perspectives are critical to the development of effective evidence-based interventions. This study is the first qualitative assessment of maternal and infant healthcare research needs assessment in Alabama. We describe how perceptions and practices of care, based on the experiences of practitioners and birthing persons, are driven by health system limitations. Creating a culture of respect and expanding access to perinatal care options are critical to improving outcomes. [ABSTRACT FROM AUTHOR]

The health systems fail to provide quality antenatal health services to vulnerable and marginalised pregnant women regardless of their effectiveness in reducing maternal and neonatal mortality. Despite the importance of antenatal care quality during pregnancy, less is known regarding its inequality in developing countries. This paper aims to determine the inequality in antenatal care quality in Zimbabwe and the contribution of women's empowerment. The paper used the 2010/11 and the 2015 Demographic Health Survey data and concentration index and Shapley decomposition. We found that antenatal care quality was pro-rich for blood sample tests, urine sample tests, blood pressure tests, and iron tablets except for tetanus injections, thus the affluent benefit more from better antenatal care quality than the poor. Women's empowerment had a major contribution to inequality in antenatal care quality. Given the paramount importance of antenatal care in improving maternal, birth, and child outcomes, policymakers should consider policies that enhance the women's empowerment and quality of antenatal care services in Zimbabwe, which in turn enhance the attainment of Sustainable Development Goals. [ABSTRACT FROM AUTHOR]

The article discusses the critical need to address maternal sepsis as a prominent cause of maternal morbidity and mortality worldwide. Topics include the background of maternal sepsis, detailing its impact on pregnant and postpartum women; diagnostic approaches to improve early detection and outcomes; and management strategies within obstetric critical care, emphasizing timely intervention and multidisciplinary care.

Objective To compare the risk of severe maternal morbidity (SMM) from the delivery admission to 42 days' postdischarge among persons with sickle cell disease (SCD) to those without SCD. Study Design This retrospective cohort study included deliveries ≥20 weeks' gestation at an urban safety net hospital in Atlanta, GA from 2011 to 2019. The exposure was SCD diagnosis. The outcome was a composite of SMM from the delivery admission to 42 days' postdischarge. SMM indicators as defined by the Centers for Disease Control and Prevention were identified using the International Classification of Diseases, Ninth and Tenth Revisions (ICD-9/10) codes; transfusion of blood products and sickle cell crisis were excluded. Results Of N = 17,354 delivery admissions, n = 92 (0.53%) had SCD. Persons with SCD versus without SCD had an increased risk of composite SMM (15.22 vs. 2.29%, p < 0.001), acute renal failure (6.52 vs. 0.71%, p < 0.001), acute respiratory distress syndrome (4.35 vs. 0.17%, p < 0.001), puerperal cerebrovascular disorders (3.26 vs. 0.10%, p < 0.001), sepsis (4.35 vs. 0.42%, p < 0.01), air and thrombotic embolism (5.43 vs. 0.10%, p < 0.001), and ventilation (2.17 vs. 0.09%, p < 0.01). Ultimately, those with SCD had an approximately 6-fold higher incidence risk ratio of SMM, which remained after adjustment for confounders (adjusted incidence risk ratio [aIRR]: 5.96, 95% confidence interval [CI]: 3.4–9.19, p < 0.001). Persons with SCD in active vaso-occlusive crisis at the delivery admission had an approximately 9-fold higher risk of SMM up to 42 days' postdischarge compared with those with SCD not in crisis at the delivery admission (incidence: 25.71 vs. 8.77%, p < 0.05; aIRR: 8.92, 95% CI: 4.5–10.04, p < 0.05). Among those with SCD, SMM at the delivery admission was primarily related to renal and cerebrovascular events, whereas most postpartum SMM was related to respiratory events or sepsis. Conclusion SCD is significantly associated with an increased risk of SMM during the delivery admission and through 42 days' postdischarge. Active crisis at delivery further increases the risk of SMM. Key Points Sickle cell disease was associated with an approximately 6-fold increased risk of SMM. Active vaso-occlusive crisis at delivery was associated with an approximately 9-fold increased risk of SMM. 48% of SMM events in persons with SCD occurred postpartum and were respiratory- or sepsis-related. [ABSTRACT FROM AUTHOR]

Objective We evaluated if venous thromboembolism (VTE) prophylaxis in the inpatient antepartum period was associated with wound hematomas, VTE occurrence, and other adverse outcomes. Study Design This study is a secondary analysis of a retrospective cohort of patients who delivered at University of Alabama at Birmingham (UAB). Patients receiving outpatient anticoagulation (AC) were excluded. We grouped patients into those who received inpatient antepartum prophylactic AC and those who did not. The primary outcome was wound hematomas from delivery to 6 weeks postpartum (PP). Secondary outcomes included VTE occurrence and select adverse outcomes, including other wound complications, unplanned procedures, mode of anesthesia, and intensive care unit (ICU) admission. Analyses were performed with no AC group as the reference. A sensitivity analysis excluding those who received inpatient PP AC was performed. Results Of 1,035 included patients, only 169 patients received inpatient prophylactic AC. They were older, had higher body mass indices, and more comorbidities. Patients receiving inpatient antepartum AC had higher wound hematomas (adjusted odds ratio [aOR] 23.81; 95% confidence interval [CI] 7.04–80.47). They had similar risk for developing VTE as the control group (aOR 2.68; 95% CI 0.19–37.49) but were more likely to have wound complications (aOR 2.36; 95% CI 1.24–4.47), maternal deaths (p < 0.05), and require PP ICU admission (aOR 13.38; 95% CI 4.79–37.35). When excluding those receiving any PP AC, there was no difference in bleeding complications between the two groups and VTE rates remained unchanged. Rates of maternal deaths and PP ICU admissions remained higher in those who received inpatient antepartum AC prophylaxis. Conclusion In this small cohort study, increased wound hematomas were found in those who received inpatient antepartum AC prophylaxis with no difference in VTE occurrence. While adverse events were increased in the inpatient AC group, this was mostly associated with PP AC prophylaxis. Larger studies should be conducted to describe the true benefits and risks of antepartum AC prophylaxis and determine efficacy of this widely used practice. Key Points Peripartum chemoprophylaxis is associated with increased wound hematomas. VTE is rare, despite its association with significant peripartum morbidity/mortality. Large studies are needed to guide practices that optimize the risk/benefit ratio of chemoprophylaxis. [ABSTRACT FROM AUTHOR]

Hepatitis E virus (HEV) is typically asymptomatic in developed countries but can be more severe in certain populations. We aim to describe the epidemiology of HEV‐associated hospitalisations from 1998 to 2020 in the United States, investigate risk factors for inpatient mortality and describe outcomes in pregnant women. We utilised the National Inpatient Sample and extracted cases of HEV‐associated hospitalisations using ICD‐9/10 diagnostic codes. Demographic, clinical and pregnancy data were extracted and analysed by chi‐square and logistic regression. We identified 3354 cases of HEV‐associated hospitalisations; 1689 (50.4%) were female and 1425 (42.5%) were non‐Hispanic White. The median age was 50 (IQR: 37–59) years. Hospitalisation rates for HEV ranged from 2.5 per 10,000,000 in 2008 to a peak of 9.6 per 10,000,000 people in the general U.S. population in 2004. The mortality rate was 5.2%. Age ≥ 40 years (OR: 7.73; 95% CI: 1.57–38.09; p = 0.012), HIV infection (OR: 4.63; 95% CI: 1.26–16.97; p = 0.021), and coagulopathy (OR: 7.22; 95% CI: 2.81–18.57; p < 0.001) were associated with increased odds of mortality within the HEV cohort. There were 226 pregnant women with HEV. Rates of maternal death, stillbirth and preterm birth were similar between HEV and non‐HEV pregnant cohorts. Hepatitis B and hepatitis C co‐infection were significantly more common in the HEV pregnant cohort (p < 0.05). HEV‐associated hospitalisations are uncommon in the United States, but likely underdiagnosed. Certain risk factors can be used to predict prognosis of these hospitalised patients. Pregnant women with HEV appear to have favourable maternal and fetal outcomes despite hepatitis B and C co‐infection. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to illustrate the outcomes of abnormally invasive placenta (AIP) cases managed in three leading centers in Lebanon. Methods: We conducted a retrospective multicenter cohort study. Patients managed conservatively (cesarean delivery with successful placental separation) or radically (cesarean hysterectomy) were included in the study. Data included patient characteristics, surgical outcomes (blood loss, operative time, transfusion, partial bladder resection), maternal outcomes (death, length of stay, ICU admission, postoperative hemoglobin level) and neonatal outcomes (Apgar score, neonatal weight, admission to neonatal intensive care unit, neonatal death). Results: The study included 189 patients. In the radical treatment subgroup (141/189), patients were para 3 and delivered at 34 4/7 weeks in average, bled 1.5 L and were transfused with three packed red blood cells, with operative time averaging 160 min. A total of 36% were admitted to the ICU and patients stayed on average for 1 week despite partial bladder resection in 19% of cases. Unscheduled radical delivery occurred at a lower gestational age, was associated with more blood loss, higher rate and volume of transfusion, and risk of maternal and neonatal death. In addition, patients delivered in an unscheduled fashion experienced higher rates of partial bladder resection and longer interventions. In the conservative treatment subgroup, on average patients were para 2 and delivered at 36 weeks, bled 800 mL on average with low rates of transfusion (35%) and ICU admission (22.9%). With regard to neonatal outcomes, the average neonatal birth weight was 2.4 kg in the radical subgroup and 2.5 kg in the conservative subgroup. Neonatal death occurred in 5.4% of cases requiring radical management while it occurred in 2% of patients treated conservatively. Conclusion: Through their multidisciplinary approach, the three centers demonstrated that management of AIP in Lebanon has led to excellent outcomes with no maternal mortality occurring in scheduled radical treatment. By comparison of the three leading centers, pitfalls in each center were identified and addressed. Synopsis: Delivering patients with abnormally invasive placenta should occur in tertiary centers, scheduled when possible. Referral pathways should be designed to guarantee access to appropriate care. [ABSTRACT FROM AUTHOR]

Objective: This study examines maternal mortality among Brazilian indigenous women from 2015 to 2021, contrasting their causes of death with non‐indigenous women. Methods: An observational study utilizing Ministry of Health data analyzed maternal deaths' characteristics, comparing indigenous and non‐indigenous groups based on death certificates and live‐birth records. Variables included age, region, location, time, and cause of death. Maternal mortality ratios (MMR) were calculated with linear regression and outliers identified with Grubbs test. Prevalence ratios compared MMR and causes of death. Results: Between 2015 to 2021, Brazil recorded 13 023 maternal deaths. Among these, with 205 among indigenous women (1.60% of total). Indigenous women had higher MMR (115.14/100 000), than non‐ indigenous women (66.92/100 000), consistently across years. Hemorrhagic causes notably contributed to the indigenous women's elevated MMR. Conclusion: Indigenous Brazilian women face elevated maternal mortality rates across all causes, primarily due to hemorrhage, contrasting wih national trends. Synopsis: IBrazilian indigenous women exhibit a heightened maternal mortality risk, primarily attributed to hemorrhage, distinguishing them from the non‐indigenous population. [ABSTRACT FROM AUTHOR]

• Of the 644 eligible patients identified with uterine rupture, 287 underwent uterine repair, while 357 underwent hysterectomy. • This study highlights the differences in clinical aspects between repair and hysterectomy for uterine rupture in contemporary practice. • The study underscores the need for further research to enhance our understanding of the suitability of each surgical technique for uterine rupture. Uterine rupture, though rare, poses significant risks to both mother and child. Its occurrence varies globally, with a noted 0.015% prevalence in Japan. This condition usually requires surgical intervention, either as uterine repair or hysterectomy. Past studies, largely single-center and outdated, offer limited insights into these treatment options. To assess and compare the clinical outcomes of repair and hysterectomy for uterine rupture among patients included in a large inpatient database in Japan. We analyzed the Diagnosis Procedure Combination inpatient database from July 2010 to March 2022. Patients with uterine rupture who underwent uterine repair or hysterectomy were extracted. Patient characteristics, in-hospital care, and outcomes were compared between the uterine repair group and the hysterectomy group. Main outcomes are reoperation during hospitalization, total volume of blood transfusion, complications (bowel injury, urinary tract injury, wound infection, deep vein thrombosis, or pulmonary embolism), maternal mortality, and postoperative length of stay. We identified 644 patients with uterine rupture. Of those, 287 (44.6 %) underwent uterine repair and 357 (55.4 %) underwent hysterectomy. The hysterectomy group was significantly older, had significantly more comorbidities, and had a significantly higher prevalence of consciousness impairment than the uterine repair group. Compared with the uterine repair group, the hysterectomy group required significantly more in-hospital care and had a significantly greater incidence of reoperation (1.0 % versus 6.4 %; P<0.001). Other complications were not significantly different between the groups. The hysterectomy group had significantly more blood transfusions and a significantly longer postoperative length of hospital stay than the uterine repair group. The results remained consistent even after the adjusted analysis. This study highlights the differences between repair and hysterectomy for uterine rupture, providing valuable insights for clinical decision-making in these cases. [ABSTRACT FROM AUTHOR]

Guidelines for conducting surveys by mobile phone calls in low- and middle-income countries suggest keeping interviews short (<20 minutes). The evidence supporting this recommendation is scant, even though limiting interview duration might reduce the amount of data generated by such surveys. We recruited nearly 2,500 mobile phone users in Malawi and randomly allocated them to 10-, 20-, or 30-minute phone interviews, all ending with questions on parental survival. Cooperation was high in all groups, and differences in completion rates were minimal. The extent of item nonresponse, age heaping, and temporal displacement of deaths in data on parental survival generally did not vary between study groups, but reports of maternal age at death were more reliable in longer interviews. Recommendations about the duration of mobile phone interviews might be too restrictive. They should not preclude additional modules, including ones on mortality, in mobile phone surveys conducted in LMICs. [ABSTRACT FROM AUTHOR]

On the eve of Taiwan's National Health Insurance's 30th birthday, this study reviews the policy and performance trajectory of the Taiwanese health system. Taiwan has controlled their health spending well and grown increasingly reliant on private financing. The floating-point global budget payment preferentially rewards outpatient-based services, but this has not affected the hospital-centric market composition, which persists despite several primary-care friendly developments. The outcomes suggest improving health care workforce and resource availability, good patient-centredness, respectable technical efficiency, and impressive patient care satisfaction. However, there are worrisome trends for financial barriers to access and allocative efficiency. Evidence on clinical quality suggests that hospitals are performing well though the primary care setting might not be. Overall, the public remains satisfied despite signs of lagging improvement in health outcomes, worsening maternal mortality rate, and persistently incomplete financial risk protection. Identifying what drives the worsening financial barriers of access and persistent financial risk is necessary for further discussions on potential financing adjustments. Improving allocative efficiency could draw on a combination of supporting the functions and quality of primary care alongside patient-oriented education and incentives. Further data on causes of slow health status improvement and rebounding maternal mortality rate is necessary. [ABSTRACT FROM AUTHOR]

Obstetrics haemorrhage is the third direct leading cause for maternal mortality as highlighted in the last Mothers and Babies: Reducing risk through Audits and Confidential Enquires across the UK (MBRRACE-UK) report published in 2023. Antepartum haemorrhage (APH) can occur at any time between the age of viability until delivery. The most significant causes of APH, though not the most common, are associated with maternal and perinatal morbidity and mortality. These are placenta praevia, placental abruption, placenta accreta, vasa praevia, and uterine rupture. This review will outline the basic management principles of APH and provide an overview for most serious APH causes. [ABSTRACT FROM AUTHOR]