Volume 51, Issue 2 - Special Issue: Maternal Mortality; Issue Editors: Asim Kurjak, Milan Stanojević and Joachim W. Dudenhausen

Approximately 800 women die from pregnancy or childbirth-related complications around the world every day, 99% of which occur in developing countries. In majority of cases deaths are related to pre-eclampsia and eclampsia. The purpose of new adjusted and simplified IAPM guidelines is specifically lowering maternal mortality by decreasing preventable deaths in developing countries (particularly in remote rural areas) by using rather cheap medicines used to control chronic and gestational hypertension, prevent pre-eclampsia in high-risk pregnancies and treat severe pre-eclampsia and eclampsia. IAPM guidelines should be implemented and evaluated in each developing country respecting specific problems, needs and resources. It is of essential importance to: 1. Identify specific high-risk pregnancies, 2. Commence timely appropriate ASA and calcium supplementation, 3. Organize basic antenatal care and adequate referral of pregnancies with early onset of pre-eclampsia to the appropriate institutions and ensure induction of labour in well-equipped delivery facility for women with near-term and term pre-eclampsia 4. Ensure magnesium sulphate availability to prevent severe pre-eclampsia and eclampsia-related maternal deaths, and 5. Identify specific barriers for implementation of these guidelines and correct them accordingly. Only by systematic implementations of these guidelines, we may have a chance to decrease the mortality of pre-eclampsia an its complications as a killer number one of mothers in developing countries.

Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management. Maternal mortality (MM) and morbidity are a public health issue, with scarce knowledge on their levels and causes in low-income (LIC) countries. The data on MM and morbidity should rely on population-based studies which are non-existent. Therefore, maternal mortality ratio (MMR) estimates are based mostly on the mathematical models. MMR declined from 430 per 100,000 live births (LB) in 1990 to 211 in 2017. Absolute numbers of maternal deaths were 585,000 in 1990, 514,500 in 1995 and less than 300,000 nowadays. Regardless of reduction, MM remains neglected tragedy especially in LIC. Millennium Development Goals (MDGs) declared reduction MMR by three quarters between 2000 and 2015, which failed. Target of Sustainable Development Goals (SDGs) was to decrease MMR to 70 per 100,000 LB. Based on the data from the country report on SDGs in 10 countries with the highest absolute number of maternal deaths it can be concluded that the progress has not been made in reaching the targeted MMR. To reduce MMR, inequalities in access to and quality of reproductive, maternal, and newborn health care services should be addressed, together with strengthening health systems to respond to the needs and priorities of women and girls, ensuring accountability to improve quality of care and equity.

Objectives The fifth of the United Nations’ Millennium Development Goals proposed for 2000–2015 was to improve maternal health, which has only partially been achieved. Worldwide, the maternal mortality ratio is currently estimated at 216/100.000 livebirths, compared to 380/100,000 in 1990. As yet, there has been no published comprehensive analysis of maternal mortality data as it pertains to Berlin and by extension Germany. Aim of the study was to evaluate and analyze the maternal mortality rate of Berlin as a result of shortcomings in healthcare provision and identify possible solutions. Methods The Institute for Quality and Transparency in the Healthcare Sector sourced external quality control from the Qualitätsbüro Berlin to provide maternal mortality data from Berlin hospitals from 2007 to 2020. Results Nineteen maternal deaths were registered between 2007 and 2020 in total. Case analysis shows that two main events occur: thrombosis and hemorrhage at 31.6%, respectively, followed by hypertensive disorder (15.8%), and sepsis (15.8%). After detailed analysis of each case report, we determined 8/19 (42.1%) maternal deaths as being potentially preventable given slightly altered circumstances. Conclusions The system of registration of perinatal data in Germany does not allow for a comprehensive recording of maternal death and requires alteration to provide a more accurate picture of the phenomenon of maternal mortality; presumably, there exist twice as many unreported cases. Symptoms, risks, and primary prevention tactics of thromboembolism during pregnancy and birth should be imparted to every licensed professional in individual hospital settings, along with evidence-based simulation training for the event of obstetric or prepartum hemorrhage.

Objectives The United States maternal mortality (MM) rate is the highest amid developed/industrialized nations, and New Jersey’s rate is among the highest. Healthcare professionals, public health officials, and policy makers are working to understand drivers of MM. An interactive data visualization tool for MM and health-related information (New Jersey Maternal Mortality Dashboard [NJMMD]) was recently developed. Methods NJMMD is an open-source application that uses data from publicly available state/federal government sources to provide a cross-sectional, high-level depiction of potential relationships between MM and demographic, social, and public health factors. Results MM rates or ratios (maternal deaths/1,000 women aged 15–49 years or 100,000 live births, respectively) are available by year (2005–2017), age (5-year [15–49] periods), and race/ethnicity (non-Hispanic White, Black, or Asian; Hispanic; or other), and by contextual social determinants of health (percent insured; percent covered by Medicaid; difference in nulliparous, term, singleton, vertex Cesarian birth rate from New Jersey goal; number of obstetrician/gynecologists or midwives per capita; and poverty rate). Bar graphs also can be produced with these variables. Conclusions NJMMD is the first publicly available, interactive, state-focused MM tool that takes into account the intersection of social and demographic determinants of health, which play important roles in health outcomes. Trends and patterns in variables associated with MM and health can be identified for New Jersey and each of its 11 counties, and inform areas of focus for further analysis. Outputs may enable researchers, policy makers, and others to develop appropriate interventions and be better positioned to set benchmarks, allocate resources, and evaluate outcomes.

Objectives Sub-Saharan African countries account for nearly half of maternal deaths, and Southern Asian countries are second in the 85% of deaths that occur worldwide. Despite this fact, there is a rapid enhancement in the number of skilled health workers. There has been a sharp increase of 53% in 1990 and 61% in 2007 in trained birth attendant utilization shows that attention is being paid to the management of labor services. But surprisingly, still, the births take place without the assistance of trained health personnel in Southern Asian countries and Sub-Saharan Africa. The objective of this study is the assessment of barriers to health care facility utilization and its management concerning labor problems in urban North India. Methods A sample of “300” pregnant urban women was taken for study and analysis. A convenience sampling method was used. The factor analysis was applied for the interpretation and analysis of the data. Results It was found that there were inadequacies in services as well as unawareness of services in almost all urban areas among pregnant women. Conclusions The tremendous increase in the cost of services and corrupt behavior among the service providers rampantly found in the urban locations, inaccessibility of proper means of communication and also economic backwardness and low literacy became the impediment to the utilization of maternal healthcare services in North-India.

Maternal mortality is nowadays more of a problem of developing countries especially those in Sub-Saharan Africa (SSA). Maternal mortality has to large extent been eliminated in developed countries and has drastically been reduced in many other regions of the world. The maternal mortality rate (MMR) available in the literature from Africa is not a true reflection of the actual MMR as it is derived from institutional studies. The causes of maternal mortality in SSA are the same as those in developed countries. The means of addressing maternal mortality used in developed countries are the same as those used in developing countries, however, the success levels are not the same. There are various impediments to reducing maternal mortality with roots in cultural, social, economic and systemic factors prevalent in SSA. An in-depth study of these factors will give an insight as to why maternal mortality reduction has remained an enigma in SSA. Analyzing these factors will guide us to design and implement measures that will in the long run lead to significant maternal mortality reduction in SSA. The aim of this review is to identify impediments to maternal mortality reduction in SSA and highlight measures that can lead to maternal mortality reduction.

Objectives Maternal mortality is one of the major Sustainable Development Goals (SDGs) of the global health community. The aim of the SDG 3.1 is to reduce global maternal mortality ratio considerably by 2030. The objective of this study was to document the epidemiological trends in maternal mortality for Mpilo Central Hospital. Methods This was a 10 year retrospective study using readily available data from the maternity registers. The International Classification of Diseases-Maternal Mortality (ICD-MM) coding system for maternal deaths was used. Results The maternal mortality ratio (MMR) declined from 655 per 100,000 live births in 2011 to 203 per 100,000 live births by 2020. The commonest groups of maternal mortality during the period 2011–2020 were hypertensive disorders, obstetric haemorrhage, pregnancy-related infection, and pregnancies with abortive outcomes. There were 273 maternal deaths recorded in the period 2011–2015, and 168 maternal deaths in the period 2016–2020. There was also a decline in maternal deaths due to obstetric haemorrhage (53 vs. 34). Maternal deaths due to pregnancy-related infection also declined (46 vs. 22), as well as pregnancies with abortive outcomes (40 vs. 26). Conclusions There was a 69% decline in the MMR over the 10 year period. The introduction of government interventions such as malarial control, the adoption of life-long Option B+ antiretroviral treatment for the pregnant women, the training courses of staff, and the introduction of strong clinical leadership and accountability were all associated with a significant decline in the causes of maternal deaths.

Venous thromboembolism (VTE) is one of the leading causes of direct maternal deaths. It has been estimated that approximately 50% of these deaths are potentially preventable. The UK Confidential Enquiries into Maternal Deaths and the National Partnership for Maternal Safety have proposed strategies for the prevention of maternal deaths from VTE based on current guideline recommendations. The main strategies include: – Early recognition and comprehensive assessment of risk factors for VTE at different times from the beginning of pregnancy until patient’s discharge from hospital. – Appropriate risk stratification using standardized VTE risk assessment tools (e.g. the Royal College Scoring System). – Risk–based antenatal and postnatal heparin thromboprophylaxis adjusting the heparin dosage and the duration of prophylaxis to the individual patient’s risk. – Adequate management of heparin prophylaxis before and after delivery. – Preference of universal rather than selective post-cesarean heparin thromboprophylaxis and application of perioperative mechanical prophylaxis. – Avoidance of gaps in the postpartum prescription of heparin. – Good communication and cooperation between primary and secondary care including community midwifery staff in the postpartum period. – Immediate intravenous administration of (unfractionated) heparin, if pulmonary embolism is suspected. – Critical analysis of all thromboembolic events, particularly in association with maternal death to learn from failures and to realize, if and where improvement is needed. Adequate pharmacological thromboprophylaxis has the potential to reduce the risk of VTE by 60–70% in pregnant women at increased risk.

Objectives To determine whether the maternal plasma concentrations of cytokines are higher in pregnant women with postpartum hemorrhage (PPH) compared to pregnant women without PPH. Methods A retrospective case-control study included 36 women with PPH and 72 matched controls. Cases and controls were matched for gestational age at delivery, labor status, delivery route, parity, and year of sample collection. Maternal plasma samples were collected up to 3 days prior to delivery. Comparison of the plasma concentrations of 29 cytokines was performed by using linear mixed-effects models and included adjustment for covariates and multiple testing. A false discovery rate adjusted p-value <0.1 was used to infer significance. Random forest models with evaluation by leave-one-out and 9-fold cross-validation were used to assess the combined value of the proteins in predicting PPH. Results Concentrations of interleukin (IL)-16, IL-6, IL-12/IL-23p40, monocyte chemotactic protein 1 (MCP-1), and IL-1β were significantly higher in PPH than in the control group. This difference remained significant after adjustment for maternal age, clinical chorioamnionitis, and preeclampsia. Multi-protein random forest proteomics models had moderate cross-validated accuracy for prediction of PPH [area under the ROC curve, 0.69 (0.58–0.81) by leave-one-out cross validation and 0.73 (0.65–0.81) by 9-fold cross-validation], and the inclusion of clinical and demographic information did not increase the prediction performance. Conclusions Pregnant women with severe PPH had higher median maternal plasma concentrations of IL-16, IL-6, IL-12/IL-23p40, MCP-1, and IL-1β than patients without PPH. These cytokines could serve as biomarkers or their pathways may be therapeutic targets. Highlights – Pregnant women with severe PPH had higher maternal plasma concentrations of IL-16, IL-6, IL-12/IL-23p40, MCP-1, and IL-1β than patients without PPH. – Maternal plasma cytokines could serve as biomarkers, or their pathways may be therapeutic targets in PPH.

Maternal mortality represents a major issue for every health system, especially in developed countries that aim on creating protocols to retain a declining pattern. With the appropriate medical supplies and training, some of these countries have made a remarkable progress in preventing maternal morbidity and mortality. On the contrary, developing countries have still made little or even no progress. Identifying determinants and designing strategies is of great importance in order to overcome such difficulties. The aim of this study is to identify the main causes of maternal mortality in the different societies.

Maternal and neonatal health is one of the main global health challenges. Every day, approximately 800 women and 7,000 newborns die due to complications during pregnancy, delivery, and neonatal period. The leading causes of maternal death in sub-Saharan Africa are obstetric hemorrhage (28.8%), hypertensive disorders in pregnancy (22.1%), non-obstetric complications (18.8%), and pregnancy-related infections (11.5%). Diagnostic ultrasound examinations can be used in a variety of specific circumstances during pregnancy. Because adverse outcomes may also arise in low-risk pregnancies, it is assumed that routine ultrasound in all pregnancies will enable earlier detection and improved management of pregnancy complications. The World Health Organization (WHO) estimated in 1997 that 50% of developing countries had no access to ultrasound imaging, and available equipment was outdated or broken. Unfortunately, besides all the exceptional benefits of ultrasound in obstetrics, its inappropriate use and abuse are reported. Using ultrasound to view, take a picture, or determine the sex of a fetus without a medical indication can be considered ethically unjustifiable. Ultrasound assessment when indicated should be every woman’s right in the new era. However, it is still only a privilege in some parts of the world. Investment in both equipment and human resources has been clearly shown to be cost-effective and should be an obligatory step in the improvement of health care. Well-developed health systems should guide developing countries, creating principles for the organization of the health system with an accent on the correct, legal, and ethical use of diagnostic ultrasound in pregnancy to avoid its misuse. The aim of the article is to present the importance of correct and appropriate use of ultrasound in obstetrics and gynecology with reference to developing countries.

Although the maternal mortality rate has decreased and significant improvements have been made in maternal care, maternal death remains one of the substantial problems of our society. The leading causes of maternal death are postpartum hemorrhage, the most important cause of death in developing countries, and preeclampsia and venous thromboembolism, which are more prevalent in developed countries. To treat these conditions, a variety of therapeutic approaches, including pharmacologic agents and surgical techniques, have been adopted. However, a certain number of pregnant women do not respond to any of these options. That is the main reason for developing new therapeutic approaches. Biological medications are isolated from natural sources or produced by biotechnology methods. Heparin is already successfully used in the therapy of deep venous thrombosis and pulmonary embolism. Blood derivatives, used in an autologous or allogenic manner, have proven to be efficacious in achieving hemostasis in postpartum hemorrhage. Mesenchymal stem cells, alpha-1-microglobulin, and antithrombin exhibit promising results in the treatment of preeclampsia in experimental models. However, it is essential to evaluate these novel approaches’ efficacy and safety profile throughout clinical trials before they can become a standard part of patient care.

Hypertensive syndrome in pregnancy complicates up to 15% of pregnancies, and preeclampsia (PE) occurs in about 3–10% of pregnant women. Inadequate prenatal care is associated with higher mortality from PE, possibly due to reduced monitoring, detection, and missed opportunities for early intervention. The imperative of the clinician’s work is to monitor the symptoms and clinical signs of PE, and stratification of patients in relation to the risk of PE is essential. PE represents a multisystem inflammatory response, and the consequences can be expected in all organs. The question of the effect of PE on long-term maternal health is raised. The aim of the paper is to present the effect of PE on the patient’s health through the prism of low-income countries.

Objectives This study aimed to compare pregnant and non-pregnant women infected with SARS-CoV-2 disease (COVID-19) in terms of in-hospital mortality. Methods This historical cohort study was conducted on hospitalized women of reproductive ages (15–49 years) infected with SARS-CoV-2 in Fars province, Iran during 15 March 2019–10 May 2021. Results Out of the 5,322 patients, 330 were pregnant. The fatality rate of SARS-CoV-2 was 1.2% amongst pregnant women and 3.5% amongst non-pregnant ones. Pregnant and non-pregnant women reported the same history of smoking, opium use, previous COVID-19 infection, vaccination against SARS-CoV-2, and COVID-19 symptoms (p>0.05 for all). However, the pregnant women were younger and had fewer underlying diseases (p<0.001 for both). The results revealed no significant difference between the two groups regarding in-hospital clinical manifestations including the number of days after the onset of COVID-19 symptoms, mechanical ventilation, and long involvement (cRR; 95% CI=0.99 (0.96–1.02), 1.18 (0.72–2.02), and 0.95 (0.88–1.02), respectively). Nonetheless, Intensive Care Unit (ICU) admission was significantly higher in pregnant women (cRR; 95% CI=2.37(1.85–3.02)). After adjusting for age, history of underlying diseases, and ICU admission, pregnant women showed lower in-hospital mortality due to COVID-19 compared to non-pregnant women (aRR; 95% CI=0.32 (0.12–0.87)). Conclusions Based on the current study findings, pregnant women showed lower in-hospital mortality due to COVID-19 compared to non-pregnant ones. Nevertheless, they should follow the same recommendations as non-pregnant women, avoiding exposure to the virus and receiving medical treatment and vaccination. Further studies are recommended to address the follow-up of recovered pregnant women, their babies, and puerperium.

Objectives In this article, we aimed to evaluate the most recent information on the impact of the COVID-19 pandemic on the health of mothers and their babies. Methods We conducted a literature search by utilizing online sources. Scientific papers that were written in English on the effects of COVID-19 on both mother and their newborn were assessed. Results COVID-19 can be fatal, especially in pregnant women with accompanying chronic diseases. The timing and mode of delivery should be decided by the status of the mother and fetus instead of SARS-CoV-2 positivity in pregnant women. At the nursery, routine separation of SARS-CoV-2 positive mothers and their infants is not recommended. However, it is important to take preventive measures to reduce the risk of transmission. The advantages of breastfeeding seem to outweigh the potential dangers of viral transmission. Neonatal COVID-19 infections may cause different clinical pictures from asymptomatic infections to life-threatening diseases. International health authorities specifically recommend that pregnant and lactating women get vaccinated to diminish the risk of transmission of the virus to the mother and fetus, not giving preference to a certain vaccine. It is prudent to apply universal screening only in populations with a high prevalence of COVID-19. Conclusions Healthcare professionals should carefully manage the perinatal period during the COVID-19 outbreak, using the most up-to-date information to protect and promote maternal and newborn health. Further scientific studies are needed to clarify the early and long-term effects of the COVID-19 pandemic on maternal-neonatal morbidity and mortality.