High Maternal Mortality Research Articles

A Retrospective Analysis of Postpartum Adherence to Follow-up in High-risk Obstetric Patients in Primary Care

Background and Objectives: Texas is a state with a well-documented statistical rate of the nation’s highest maternal mortality rates. Maternal mortality has a multiplicity of risk factors including gestational complications, not limited to diabetes mellitus, hypertension, and preeclampsia. The high-risk obstetrics (HROB) initiative was created at CommuniCare Health Centers in San Antonio, TX, to provide resources to obstetric (OB) patients identified as high risk for perinatal and postpartum complications. The goal of this analysis is to assess the consistency with which HROB patients enrolled present to the first and second OB postpartum follow-up visits and subsequently family medicine follow-up visits. Methods: The patients were enrolled in this initiative based on a criterion for being considered high risk for obstetrical complications including hypertensive disease, preeclampsia, eclampsia, and diabetes mellitus. One hundred ninety-two patient charts were reviewed and 180 were included in this retrospective analysis. Results: A multivariate analysis revealed that an adjusted odds ratio for postpartum follow-up among HROB patients was 1.65 (95% confidence interval = 0.71–3.83). A positive trend was observed for HROB patients’ OB postpartum follow-up visits, whereas a negative trend was observed for family medicine postpartum follow-up visits. Conclusion: Prevention strategies aimed at reducing postpartum loss to follow-up identified in this study could promote better health outcomes among HROB patients in San Antonio, TX.

Risk Factors and Racial Disparities of Maternal and Neonatal Morbidity at Premier Health Maternity Facilities [ID 2683422

INTRODUCTION: Nationally, racial disparities in obstetrical outcomes have proven to be contributing to the high maternal morbidity and mortality rates in the United States when compared to other developed nations. To best approach the inequalities in our community, we sought to determine whether and where obstetrical outcomes were being disproportionately affected by the race of the patient. METHODS: We conducted a retrospective chart review of patients delivering singleton pregnancies at 37 weeks of gestation or greater from January 2019 to July 2021. Using the patient’s self-identified race, regression modeling was used to identify disparities in obstetrical outcomes. A composite of maternal outcomes consisting of third/fourth-degree lacerations, blood transfusion, febrile morbidity, and ICU admission was used to compare morbidities. Neonatal composite morbidity consisted of respiratory distress, sepsis, need for resuscitation, and neonatal intensive care unit (NICU) admission. This study was approved by the Wright State University IRB (protocol number: 07272). RESULTS: There were 13,689 births during the study period. Significantly more non-Caucasian patients experienced cesarean sections than Caucasian patients (30.3% versus 28.5%; P <.01) and on average had a higher maternal composite score (0.5 versus 0.03; P <.01). Black or African American babies were more likely to qualify as small for gestational age, be admitted to the NICU, and have a higher composite score than Caucasian babies (P<.01). CONCLUSION: Within our community, obstetrical and neonatal outcomes were experienced at significantly different rates by different race groups. Next steps include creating standardized protocols to decrease the opportunity for implicit bias to adversely affect patient care.

Contraceptive methods continuation and its determinants among acceptors on repeat visits to a Nigerian University Teaching Hospital: a 10-year review

Background: Family planning is a known reproductive health modality for reducing the high maternal mortality in Nigeria. Contraceptive use and continuation is thus necessary to achieve its benefits. The study aimed to determine the contraceptive options and the factors associated with the continuation of contraceptive choices among women on repeat visits. Methods: This was a 10-year retrospective study of the family planning clinic register of all clients who presented for a repeat visit for contraceptive method continuation at the University of Uyo Teaching Hospital. Results: There were 6939 contraceptive acceptors on repeat visits aged between 14 and 50 years (mean 31.6 years, SD 5.4). The majority were 26 to 30 years (32.9%), had secondary education (54.6%), were multiparous (90.9%) and chose the subdermal implant (34.9%) and the intrauterine contraceptive devices (27.7%) for continuation. There was a significant association between the women`s age (Df=3, F=10.81, p<0.0001), their educational status (Df=6, Χ2=38.5583, p<0.0001), their parity (Df= 15, Χ2 =76.8644, p<0.0001) and the contraceptive method continued. Conclusions: An interest in long-acting reversible contraceptives for continuation was found, and this is significantly associated with their sociodemographic and obstetric characteristics; however, we recommend cross-sectional and focus-group inquiries among clients in the different contraceptive-specific categories for further information on the reasons for their choices at subsequent visits.

Strengthening caesarean birth: Sub-Saharan Africa health system evaluation: Scoping review.

Promoting safe caesarean birth (CB) is a challenge in sub-Saharan Africa (SSA) where maternal and neonatal mortality rates are high due to inadequate maternal health services. Although the CB rate in SSA is lower than the World Health Organization (WHO) recommendation, it is often associated with high maternal and neonatal mortality. The aim of this scoping review was to report on the extent to which SSA health systems deliver safe CB. A systematic search across various databases identified 53 relevant studies, comprising 30 quantitative, 10 qualitative and 16 mixed methods studies. These studies focused on clinical protocols, training, availability, accreditation, staff credentialing, hospital supervision, support infrastructure, risk factors, surgical interventions and complications related to maternal mortality and stillbirth. CB rates in SSA varied significantly, ranging from less than 1% to a high rate of 29.7%. Both very low as well as high rates contributed to significant maternal and neonatal morbidity. Factors influencing maternal and perinatal mortality include poor referral systems, inadequate healthcare facilities, poor quality of CBs, inequalities in access to maternity care and affordable CB intervention. The inadequate distribution of healthcare facilities, and limited access to emergency obstetric care impacted the quality of CBs. Early access to quality maternity services with skilled providers is recommended to improve CB safety.Contributions:This scoping review contributes to the body of knowledge motivating for the prioritization of maternal service across SSA.

Overview of Delivery Complications Using IKAlin Instruments in Bandar Lampung

The maternal mortality rate (MMR) in Lampung Province in 2020 has increased compared to 2019, namely from 110 cases to 115 cases. Bandar Lampung City is one of the regions in Lampung Province with the third highest MMR, 10 cases (8.69%). This research aims to determine the description of childbirth complications experienced by postpartum mothers using the IKAlin instrument (Labour Complications Instrument) in Bandar Lampung in 2023. This type of research uses a descriptive survey method with random sampling. A sample of 222 postpartum mothers with labor complications. This research method involves interviews with postpartum mothers using the IKAlin instrument. The average results of mothers' answers show that the complication of preeclampsia that is felt is high blood pressure, the bleeding complication that is most often felt during labor is experiencing heavy bleeding, and the complication of dystocia that is most often felt is undergoing a prolonged second stage. The advice given is to encourage education about early detection in the community so that people, especially pregnant women, are aware of the importance of monthly pregnancy checks at health facilities to detect birth complications as early as possible.

A network of care to improve the continuity and quality of maternal and perinatal services in Makueni County, Kenya: study protocol

Background Kenya’s high maternal and perinatal mortality rates exceeds its recommended 2030 targets. The lack of effective collaboration between health facilities and workers contributes to delays and uncoordinated provision of care, leading to negative maternal and neonatal health (MNH) outcomes. Network of Care (NOC) is an effective strategy to improve health facility network efficiencies and MNH outcomes. Utilizing NOC to improve health system coordination and MNH outcomes in Kenya has not been studied. We present a study protocol for implementation research to investigate the feasibility and acceptability of establishing a county-level NOC on relationships among health facilities and workers, the feasibility of NOC for the Makueni county health system, and the impact of NOC on the quality of MNH services and emergency referrals within the county health system. Levels of communication, collaboration, and trust between NOC health facilities and levels of preparedness for management of MNH complications are also evaluated. Methods The study employed a mixed methods design with quantitative data from health worker self-administered phone surveys, health facility referral forms, and facility registers collected at baseline, then every three months from September 2021 to July 2023. Health worker focus group discussions and county management key informant interviews were conducted at baseline, midline, and endline. The study purposively selected 60 public and private health facilities in Makueni. These facilities were a sub-sample of 344 facilities with the highest maternity caseloads. A descriptive and thematic analysis of communication, collaboration, and trust between NOC health facilities and workers, and referral system changes will take place. Trend analysis of MNH indicators for Makueni from the Kenya Health Information System will be done. Conclusion This study aims at informing decision-makers locally and globally on whether NOC is feasible and acceptable as a county-level model of care in Kenya with application to similar LMIC settings.

What is the materno-fetal prognosis of adrenal insufficiency and pregnancy in low ressource setting ? A case report

Introduction and importance: Adrenal insufficiency is a rare chronic disease with a prevalence of 39 to 60 cases per million peoples in Europe. However, the prevalence is higher in sub-saharian Africa. The occurrence of pregnancy in adrenal insufficiency is rare but associated with high maternal and perinatal morbidity and mortality. For this reason, the management of pregnancy in adrenal insufficiency patient must be provided by a multidisciplinary team. Case presentation: We report the case of a 34-year-old pregnant woman followed for adrenal insufficiency secondary to prolonged corticosteroid therapy. Treatment consisted to an obstetrical and endocrinological follow-up and corticosteroid replacement therapy with hydrocortisone. A prophylactic caesarean section at 38 weeks resulted in the birth of a newborn male weighing 3395g. Maternal and perinatal prognosis was good. Clinical discussion: Pregnancy in adrenal insufficiency is a therepeutic challange in developing countries. Through this case, we discuss the therapeutic and prognostic aspects of adrenal insufficiency in our setting. Conclusion: With the introduction of gluco-corticosteroid replacement therapy, pregnancy in adrenal insufficiency can progress normally.

Factors influencing delivery-related complications and their consequences in hard-to-reach areas of Bangladesh

Background and objectivesBangladesh's high maternal mortality ratio is exacerbated by delivery-related complications, particularly in hard-to-reach (HtR) areas with limited healthcare access. Despite this, few studies have explored delivery-related complications and factors contributing to these complications among the disadvantaged population. This study aimed to investigate the factors contributing to delivery-related complications and their consequences among the mothers residing in the HtR areas of Bangladesh. MethodsData were collected using a cross-sectional study design from 13 HtR sub-districts of Bangladesh between September 2019 and October 2019. Data from 1,290 recently delivered mothers were analysed. ResultsAround 32% (95% CI: 29.7–34.8) of the mothers reported at least one delivery-related complication. Prolonged labour pain (21%) was the highest reported complication during the delivery, followed by obstructive labour (20%), fever (14%), severe headache (14%). Mothers with higher education, a higher number of antenatal care (ANC) visits, complications during ANC, employed, and first-time mothers had higher odds of reporting delivery-related complications. More than one-half (51%) of these mothers had normal vaginal delivery. Nearly one-fifth (20%) of mothers who reported delivery-related complications were delivered by unskilled health workers at homes. On the other hand, about one-fifth (19%) of the mothers without any complications during delivery had a caesarean delivery. Nine out of ten of these caesarean deliveries were done at the private facilities. ConclusionDelivery-related complications are significantly related to a woman's reproductive history and other background characteristics. Unnecessary caesarean delivery is prominent at private facilities.

Uterine Rupture Factors and Neonatal Outcomes: Sudanese Cases

Background: Uterine rupture is linked to high rates of maternal mortality, especially in developing countries. Thus, this study aimed to evaluate the factors contributing to uterine rupture and the resulting neonatal outcomes in Sudan. Methodology: This study comprised of a series of 26 women presented with uterine rupture to the department of maternity at El-Obeid Teaching Hospital, El-Obeid, North Kordofan state, Sudan. The patients presented within one-year time. Results: In this particular group of patients, the neonatal population exhibited the following distribution: 19.2% (5 out of 26) were classified as Alive and well (WA), 23% (6 out of 26) required admission to the neonatal intensive care unit (NICU), 46.2% (12 out of 26) presented with Fresh Still Birth (FSB), and 11.6% (3 out of 26) displayed manifestations of Macerated Still Birth (MSB). Conclusion: Various factors can impact the outcomes of neonates following uterine rupture, such as the availability of facilities and demographic factors. The majority of newborns delivered showed unfavorable conditions.

The Modification and Psychometric Test of Anemia Complication Prevention Instruments Based on The Health Belief Model

The high maternal mortality rate in middle-income countries is mostly caused by pregnancy complications, one of which is anemia in pregnancy. Behavioral instruments that use the health belief model are osteoporosis prevention, oral hygiene in pregnant women, and disaster preparedness. This instrument needs to be developed because based on previous literature searches it has not shown how the health belief model concept can be used to help pregnant women prevent anemia complications. This research aims to test the construct validity and reliability of the modified questionnaire for preventing anemia complications based on the health belief model. An internal validity test was conducted in Yogyakarta. Five specialists from different health fields - nurses, midwives, nutritionists, health promotion experts, and medical doctors- participated in the study. Some of the things that were done were as follows: 1) defining appropriate concepts and objectives; 2) defining and identifying domains; and 3) defining and creating items. 4) creating the measuring instrument, 5) finalizing the translation with the help of two native English speakers 7) preparing the test instrument for the content validity test, 6) running the validity test with five medical professionals, 7) Applying the Index of Content Validity (I-CVI) to the analyses. 8) Using Cronbach's alpha to conduct a reliability test on thirty pregnant women. The content validity index of the crucial indicator of behavioral prevention of consequences from anemia is one, and the relevance indicator also returns one, resulting in a total score of 0.99. Expert agreement in English has a kappa value of 0.442. Results of reliability using Cronbach's alpha of 0.807. The instrument for preventing anemia issues in pregnant women is valid and reliable, according to the study's findings.

Hubungan Pengetahuan Ibu Dengan Pemakaian Alat Kontrasepsi Suntik 1 Bulan di Puskesmas Lahusa Nias Selatan Tahun 2023

Population growth in Indonesia continues to increase every year. If the rate of population growth in Indonesia is currently stagnant. It is estimated that Indonesia's population will double every 5 years. The increase in population has an impact on issues of food security, meeting energy needs, environmental control, and the low level of Indonesia's Human Development Index (HDI). Meanwhile, in the health sector, the increase in population also has an impact on the high Maternal Mortality Rate (MMR). The aim of the research was to determine the relationship between maternal knowledge and the use of injectable contraceptives for 1 month at the Lahusa South Nias Community Health Center in 2023.The type of research carried out was Descriptive Analytical with a cross sectional approach, the sample in the study was 43 people using a Random Sampling System. The data collected in the research is primary data, namely data obtained directly from respondents. The data analysis used is chi square The results of the cross-tabulation research showed that the majority of mothers' knowledge was good in using contraceptives as many as 12 people (92.3%) with Chi-Square showing a p value of 0.000. So Ho is rejected and Ha is accepted, which means there is a relationship between the mother's knowledge and the use of injectable contraceptives for 1 month at the Lahusa Health Center, South Nias in 2023. The conclusion is that it is hoped that providing a 1-month injectable contraceptive will make it easier and reduce the costs of carrying out contraception at the Lahusa South Nias Community Health Center in 2023.

An Immunocompetent Mongolian Gerbil Model for Hepatitis E Virus Genotype 1 Infection

BACKGROUND & AIMSHepatitis E virus (HEV), primarily genotype 1 (HEV-1), causes approximately 20.1 million infections, 44000 deaths, and 3000 stillbirths annually. Current evidence indicates that HEV-1 is only transmitted in humans. Here, we evaluated whether Mongolian gerbils can serve as animal models for HEV-1 infection. METHODSMongolian gerbils were used for HEV-1 and HEV-3 infection experiments. HEV infection parameters, including detection of HEV RNA and HEV antigen, liver function assessment, and histopathology, were evaluated. RESULTSWe adapted a clinical isolate of HEV-1 for Mongolian gerbils by serial passaging in feces of aged male gerbils. The gerbil-adapted strain obtained at passage 3 induced a robust, acute HEV infection, characterized by stable fecal virus shedding, elevated liver enzymes, histopathological changes in the liver, and seroconversion to anti-HEV. An infectious cDNA clone of the adapted virus was generated. HEV-1-infected pregnant gerbils showed a high rate of maternal mortality and vertical transmission. HEV RNA or antigens were detected in the liver, kidney, intestine, placenta, testis, and fetus liver. Liver and placental transcriptomic analyses indicated activation of host immunity. Tacrolimus prolonged HEV-1 infection, whereas ribavirin cleared infection. The protective efficacy of a licensed HEV vaccine was validated using this model. CONCLUSIONSHEV-1 efficiently infected Mongolian gerbils. This HEV-1 infection model will be valuable for investigating hepatitis E immunopathogenesis and evaluating vaccines and antivirals against HEV.

Equity and Justice in Family Medicine Clinical Care and Teaching Must Incorporate a Reproductive Justice Framework.

Since European settlement, the United States has controlled the reproduction of communities of color through tactics ranging from forced pregnancies, sterilizations, and abortions to immigration policies and policies that separate children from their families. Lesbian, gay, bisexual, transgender, queer (or questioning), asexual, intersex, and gender diverse people (LGBTQIA+) have been persecuted for sexual behavior and gender expression, and also restricted from having children. In response, women of color and LGBTQIA+ communities have organized for Reproductive Justice (RJ) and liberation. The Reproductive Justice framework, conceived in 1994 by the Women of African Descent for Reproductive Justice, addresses the reproductive health needs of Black women and communities from a broad human rights perspective. Since then, the framework has expanded with an intersectional approach to include all communities of color and LGBTQIA+ communities. Notwithstanding, reproductive injustice negatively impacts the health of already marginalized and oppressed communities, which is reflected in higher rates of maternal mortality, infant mortality, infertility, preterm births, and poorer health outcomes associated with race-based stress. While the impact of racial injustice on disparate health outcomes is increasingly addressed in family medicine, Reproductive Justice has not been universally incorporated into care provision or education. Including the RJ framework in family medicine education is critical to understanding how structural, economic, and political factors influence health outcomes to improve health care delivery from a justice and human rights perspective. This commentary describes how an RJ framework can enhance medical education and care provision, and subsequently identifies strategies for incorporating Reproductive Justice teaching into family medicine education.

Designing Indonesian Maternal and Child Health Mobile Applications using User-Centered Design

The high maternal mortality rate in Indonesia has led the Indonesian government to develop a mobile application for maternal and child health (MCH). However, this application received a bad rating on the applications distribution platform, and even some of its features could not function properly. Therefore, this study aims to design the MCH application. This study used the user-centered design (UCD) methodology with three iterations and applied Shneiderman's eight golden rules. Participants involved in the data collection and evaluation process were health workers, health experts, and pregnant women. The first iteration's evaluation will produce a low-fidelity prototype (wireframe), whereas the second and third iteration's evaluations will produce a refined high-fidelity clickable prototype. The resulting prototype has several major features, including notes entry, information and education, reminders, a blood supplement tablet tracker, and monitoring of fetal development. Evaluation in the first iteration utilized interviews to validate the wireframe, whereas the second and third iterations utilized usability testing and system usability scale (SUS). In the second iteration, the final SUS score was 71.2, or "good," while in the third iteration, the final SUS score was 85.4, or "excellent." This research is expected to contribute to two areas: serving as a reference for pregnancy application interface designs, especially for MCH applications, as well as the improvement and development of pregnancy health applications using the UCD methodology.

Appraising LaQshya’s potential in measuring quality of care for mothers and newborns: a comprehensive review of India’s Labor Room Quality Improvement Initiative

BackgroundPoor intrapartum care in India contributes to high maternal and newborn mortality. India’s Labor Room Quality Improvement Initiative (LaQshya) launched in 2017, aims to improve intrapartum care by minimizing complications, enforcing protocols, and promoting respectful maternity care (RMC). However, limited studies pose a challenge to fully examine its potential to assess quality of maternal and newborn care. This study aims to bridge this knowledge gap and reviews LaQshya’s ability to assess maternal and newborn care quality. Findings will guide modifications for enhancing LaQshya’s effectiveness.MethodsWe reviewed LaQshya’s ability to assess the quality of care through a two-step approach: a comprehensive descriptive analysis using document reviews to highlight program attributes, enablers, and challenges affecting LaQshya’s quality assessment capability, and a comparison of its measurement parameters with the 352 quality measures outlined in the WHO Standards for Maternal and Newborn Care. Comparing LaQshya with WHO standards offers insights into how its measurement criteria align with global standards for assessing maternity and newborn care quality.ResultsLaQshya utilizes several proven catalysts to enhance and measure quality- institutional structures, empirical measures, external validation, certification, and performance incentives for high-quality care. The program also embodies contemporary methods like quality circles, rapid improvement cycles, ongoing facility training, and plan-do-check, and act (PDCA) strategies for sustained quality enhancement. Key drivers of LaQshya’s assessment are- leadership, staff mentoring, digital infrastructure and stakeholder engagement from certified facilities. However, governance issues, understaffing, unclear directives, competency gaps, staff reluctance towards new quality improvement approaches inhibit the program, and its capacity to enhance quality of care. LaQshya addresses 76% of WHO’s 352 quality measures for maternal and newborn care but lacks comprehensive assessment of crucial elements: harmful labor practices, mistreatment of mothers or newborns, childbirth support, and effective clinical leadership and supervision.ConclusionLaQshya is a powerful model for evaluating quality of care, surpassing other global assessment tools. To achieve its maximum potential, we suggest strengthening district governance structures and offering tailored training programs for RMC and other new quality processes. Furthermore, expanding its quality measurement metrics to effectively assess provider accountability, patient outcomes, rights, staff supervision, and health facility leadership will increase its ability to assess quality improvements.

Peri-partum Thrombotic thrombocytopenic purpura - A 29 years old pregnant lady presented with convulsion and thrombocytopenia

Thrombotic thrombocytopenic purpura associated with pregnancy is a rare antibody‐mediated thrombotic microangiopathy with high maternal and fetal mortality. We present a 29-year-old Bangladeshi pregnant lady of 32 weeks of gestation who presented to a tertiary care hospital with multiples episodes of generalized convulsion. She was immediately transferred to the operation theatre and after delivery of her baby, she was transferred to ICU. Her reports revealed features of hemolytic anemia, thrombocytopenia and renal failure. She was suspected as a case of Thrombotic thrombocytopenic purpura and received therapeutic plasma exchange. Her condition gradually improved and she was discharged to home in stable condition. Bangladesh Crit Care J March 2024; 12 (1): 68-71

Accessibility andutilization of maternal and child health services among mothers in rural and urban communities of Oyo State

Background: Utilization of maternal and child health services has been linked to the characteristics of the health delivery system like the geographical and economic accessibility (cost) of these services. Low utilization of these services has been implicated in the explanation of high maternal and child mortality worldwide. Early and prompt utilization of maternal and child health care services would have averted most of these deaths. This study assessed the accessibility and utilization of maternal and child health services among mothers in rural and urban communities of Oyo state.Methods: This is a comparative cross-sectional study using a mixed method (quantitative and qualitative) of data collection. A pre-tested interviewer-administered questionnaire was used to collect data from 300 respondents that were recruited using a multistage sampling technique. The qualitative data was obtained through focus group discussions (FGD) with four groups selected using purposive sampling. Data was analyzed using IBM SPSS version 22 at 95% significance level with a p<0.05.Results: This study showed that significant differences existed between the respondents' utilization of maternal and child health services among women of child bearing age in the rural and urban communities (p= 0.013). Few respondents in rural communities (72, 48.0%) have good utilization of maternal and child health services compared to the urban communities where more respondents (119,79.3%) have good utilization of maternal and child health services. Proximity of health facility and affordability of maternal and child health service were found to be statistically significant for respondents in the rural community. This finding is also similar to the FGD findings from the rural discussants.Conclusion: Overall good accessibility and good utilization of maternal and child health services were found to be more for respondents in the urban areas compared their counterparts in the rural communities. It is important for the government to initiate policies on health insurance to favour maternal and child health services especially in the rural communities.

"Black Women Should Not Die Giving Life": The lived experiences of Black women diagnosed with severe maternal morbidity in the United States.

We sought to understand the lived experiences of Black women diagnosed with severe maternal morbidity (SMM) in communities with high maternal mortality to inform practices that reduce obstetric racism and improve patient outcomes. From August 2022 through December 2022, we conducted a phenomenological, qualitative study among Black women who experienced SMM. Participants were recruited via social media and met inclusion criteria if they self-identified as Black cisgender women, were 18-40 years old, had SMM diagnosed, and lived within zip codes in the United States that have the top-five highest maternal mortality rates. Family members participated on behalf of women who were deceased but otherwise met all other criteria. We conducted in-depth interviews (IDIs), and transcripts were analyzed using inductive and deductive methods to explore birth story experiences. Overall, 12 participants completed IDIs; 10 were women who experienced SMM and 2 were mothers of women who died due to SMM. The mean age for women who experienced SMM was 31 years (range 26-36 years) at the time of the IDI or death. Most participants had graduate-level education, and the average annual household income was 123,750 USD. Women were especially interested in study participation because of their high-income status as they did not fit the stereotypical profile of Black women who experience racial discrimination. The average time since SMM diagnosis was 2 years. Participants highlighted concrete examples of communication failures, stereotyping by providers, differential treatment, and medical errors which patients experienced as manifestations of racism. Medical personnel dismissing and ignoring concerns during emergent situations, even when raised through strong self-advocacy, was a key factor in racism experienced during childbirth. Future interventions to reduce racism and improve maternal health outcomes should center on the experiences of Black women and focus on improving patient-provider communication, as well as the quality and effectiveness of responses during emergent situations. Précis statement: This study underscores the need to center Black women's experiences, enhance patient-provider communication, and address emergent concerns to mitigate obstetric racism and enhance maternal health outcomes.

Web-Based Development of Standard Operating Procedures and Midwifery Trainings at Ugandan Birth Clinic in the Framework of Implementing a Quality Improvement System for the MEWU-Midwife Exchange with Uganda.

High maternal and newborn mortality rates in Sub-Saharan Africa indicate the need for global action interventions. Thus, the clinic cooperation midwife exchange with Uganda (MEWU) between Hannover Medical School and Mutolere Hospital, Uganda, was founded. This study, as the first intervention within the MEWU framework, explored whether a web-based approach is suitable for developing, training, and establishing standard operating procedures (SOPs) at Mutolere Hospital. We focused on assessing midwives' confidence in midwifery core competencies. The study was conducted in a prospective, non-controlled intervention design. As a quality improvement tool, the Plan, Do, Check, Act cycle was implemented. SOPs for standard obstetric care were developed and trained in online meetings. Qualitative and quantitative data were collected through a questionnaire completed pre- and post-intervention by participating midwives, evaluations, minutes and video recordings of each case training, and annual analytical reports from Mutolere Hospital containing morbidity and mortality data. The online intervention was successfully implemented. Nine SOPs on basic obstetric care were developed, trained in online case training, and integrated into clinical practice at Mutolere Hospital. An increase in midwives' confidence regarding all surveyed core competencies was observed. There were no significant changes in the hospital's morbidity and mortality rates. The quality management system was implemented to optimize the follow-up projects further. This pilot study shows the potential of web-based interventions as a quality improvement tool in developing countries. The developed SOPs and video database are being used in subsequent studies and extended to further health centers in the Kisoro region.

Successful Management of a Case with Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) is an obstetric emergency with high maternal and fetal mortality and morbidity. The most important factor in determining the prognosis is early diagnosis and treatment. We present a case of amniotic fluid embolism that was successfully treated with early diagnosis and intime management.
 Respiratory arrest developed during labor in a 20-year-old patient who underwent urinoma drainage and cordocentesis for fetal renal anomaly 10 days ago and then profuse bleeding occurred approximately 90 minutes after vaginal delivery. With our definition of AFE, massive blood transfusion, fibrinogen replacement and intrauterine balloon were applied quickly. The diagnosis of AFE was made clinically and excluding differential diagnoses. She was discharged without complications.