Indirect Maternal Mortality Research Articles

Maternal Pregnancy Outcomes in Women With Cardiomyopathy: A Systematic Review and Meta-analysis

(Am J Obstet Gynecol. 2022;227:582–592) Pregnancy adds increased stress to the cardiovascular system of pregnant women. As a result, 1% to 4% of pregnancies are complicated by maternal cardiac disease, which increases the risk of adverse outcomes. Cardiac disease is a leading cause of indirect maternal mortality worldwide. Despite its prevalence and outcomes, a lack of systematic evidence exists that specify risks. The aim of this study was to determine the impact of cardiomyopathy on maternal pregnancy outcomes.

Factors associated with anemia among pregnant women attended antenatal care: a health facility-based cross-sectional study.

A health facility-based cross-sectional study was conducted from 1 February 2020 to 2 March 2020 among 420 pregnant women. The data were collected by systematic random sampling technique, entered into a computer using EpiData 3.5, and analyzed using the Statistical Package of Social Sciences 23.0 version. Bivariate and multivariable logistic regression analyses were done to estimate the crude and adjusted odds ratio with a CI of 95% and a P-value of less than 0.05 considered statistically significant. Frequency tables, figures, and descriptive summaries were used to describe the study variables. The overall prevalence of anemia was 32.9% (95% CI: 28.6-37.4), and it was higher in rural than urban pregnant women (45 vs. 23%), respectively. In multivariable analysis women who are found in the age group of greater than or equal to 30 years (AOR=3.45, 95% CI=1.22-9.78), rural residency (AOR=3.51, 95% CI=1.92-6.42), low family income (AOR=3.10, 95% CI=1.19-8.08), multiparty (AOR=2.91, 95% CI=1.33-6.38), a short interpregnancy gap (AOR 3.32, 95% CI=1.69-6.53), not taking iron and folate (AOR=4.83, 95% CI=2.62-9.90), third trimester of pregnancy (AOR=3.21, 95% CI=1.25-8.25), poor minimum dietary diversity score (AOR=3.54, 95% CI=1.58-7.95), undernourished (AOR=4.9, 95% CI=2.19-7.64), poor knowledge of anemia (AOR=3.19, 95% CI=1.72-5.93), consumption of coffee always after meal per day (AOR=3.24, 95% CI=1.42-7.42), having a history of irregular menstruation, and antepartum hemorrhage were significantly associated with anemia in pregnant women. This study showed that the prevalence of anemia in pregnant women in this study area was a moderate public health problem. The author suggest emphasizing the education and counseling of women on the advantage of taking the supplemented iron and folic acid. Health care providers should have to advise women to stay for at least 2 years before the next pregnancy to reduce the risk of adverse maternal and infant outcomes. Awareness creation in the community on the utilization of insecticide-treated bed nets is also needed.

Levels, trends, causes, place and time of, care-seeking for, and barriers in preventing indirect maternal deaths in Bangladesh: An analysis of national-level household surveys.

Eclampsia, haemorrhage, and other direct causes are the primary burden of maternal mortality in Bangladesh, often reducing attention given to indirect maternal deaths (IMDs). However, Sustainable Development Goals may not be achieved without actions to prevent IMDs. We examined the levels, trends, specific causes, timing, place, and care-seeking, and explored the barriers to IMD prevention. We used three nationally representative surveys conducted in 2001, 2010, and 2016 to examine levels and trends in IMDs. The analysis of specific causes, timing, and place of IMDs, and care-seeking before the deaths was based on 37 IMDs captured in the 2016 survey. Finally, we used thematic content analysis of the open history from the 2016 survey verbal autopsy (VA) questionnaire to explore barriers to IMD prevention. After increasing from 51 deaths per 100 000 live births in 2001 to 71 in 2010, the indirect maternal mortality ratio (IMMR) dropped to 38 deaths per 100 000 live births in 2016. In 2016, the indirect causes shared one-fifth of the maternal deaths in Bangladesh. Stroke, cancer, heart disease, and asthma accounted for 80% of the IMDs. IMDs were concentrated in the first trimester of pregnancy (27%) and day 8-42 after delivery (32%). Public health facilities were the main places for care-seeking (48%) and death (49%). Thirty-four (92%) women who died from IMDs sought care from a health facility at least once during their terminal illness. However, most women experienced at least one of the "three delays" of health care. Other barriers were financial insolvency, care-seeking from unqualified providers, lack of health counselling, and the tendency of health facilities to avoid responsibilities. IMMR remained unchanged at a high level during the last two decades. The high concentration of IMDs in pregnancy and the large share due to chronic health conditions indicate the need for preconception health check-ups. Awareness of maternal complications, proper care-seeking, and healthy reproductive practices may benefit. Improving regular and emergency maternal service readiness is essential.

Clinical and pathologic features of out-of-hospital cardiac arrest in pregnancy: insights from a state-wide registry

Abstract Background Cardiovascular disease is the most common cause of indirect maternal mortality worldwide, and cardiac arrest occurs in up to 1 in 12,000 pregnancies. Objective To define rates, clinical and pathologic factors of out-of-hospital cardiac arrest (OHCA) in pregnant and post-partum females. Methods A prospective state-wide cardiac arrest registry combining ambulance, hospital and forensic data captured all OHCAs from 2019–2021. Clinical and pathological details for pregnant patients were identified. Results 1,482 OHCAs occurred, including 376 females of child-bearing age of whom eight were pregnant or post-partum. OHCA incidence was lower in pregnant females compared to non-pregnant females of child-bearing age (5.2 OHCAs per 100,000 pregnant females vs 23.1 per 100,000 females of child-bearing age, p<0.0001). Seven patients (87.5%) died, with five (62.5%) having a cardiac cause of OHCA (unascertained = 2, cardiomyopathy = 2 (1 hypertrophic), ischemic heart disease = 1). Two patients had pre-existing cardiac risk factors, but none had a cardiac diagnosis pre-arrest. Compared to in-hospital cardiac arrests (IHCAs) in pregnancy, OHCAs are more likely to have a cardiac cause (odds ratio 3.81) and lower maternal survival (odds ratio 0.09). Conclusion Maternal OHCA affects approximately 1 in 20,000 pregnancies with high maternal mortality rates. OHCA occurs at one-quarter the rate in non-pregnant females of child-bearing age. Approximately two-thirds of maternal OHCAs had an underlying cardiac cause, but low rates of cardiac diagnosis pre-arrest. OHCAs differ markedly from IHCAs in pregnant females, requiring ongoing evaluation as to specific causes and preventability. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): NHMRC, NHF

Maternal mortality in the Slovak Republic in the years 2007-2018.

Analysis of maternal mortality in the Slovak Republic in the years 2007-2018. The analysis of selected maternal mortality data in the years 2007-2018. In the years 2007-2018, 84 women died during pregnancy or within 42 days of the end of pregnancy - maternal mortality ratio was 12.57 per 100,000 live births. Direct maternal mortality ratio in this period was 4.64 (31 maternal deaths), indirect maternal mortality 6.74 (45 maternal deaths) and direct obstetrics death ratio was 11.38 per 100,000 live births. Pregnancy-associated but unrelated maternal death ratio was 1.19 (eight maternal deaths). The Slovak Gynecological and Obstetric Society revealed a 64% underestimation of maternal mortality data in comparison with routine statistical data. Maternal mortality ratio in the Slovak Republic was one of the highest in the European Union and was discordant with a good level of perinatal mortality. In the Slovak Republic, it is necessary to look for ways to reduce maternal mortality and improve data collection.

Prevalence and associated risk factors for anaemia amongst pregnant women attending three antenatal clinics in Eswatini.

BackgroundAnaemia is a global health problem affecting about a third of the world’s population. In pregnancy, it is a public health concern with consequences for mothers and infants, including maternal death and infant mortality. In low-income countries (LICs), 25% indirect maternal mortality and 30% neonatal deaths are due to anaemia in pregnancy.AimThis study aimed to determine the prevalence and risks associated with anaemia amongst pregnant women attending antenatal clinic (ANC) in three health facilities in Eswatini.SettingThis study was conducted in three health facilities in Eswatini, namely Mankayane, Raleigh Fitkin Memorial (RFM) and Mbabane Hospital.MethodsThis cross-sectional study used non-probability sampling in three hospitals of Eswatini, to select 550 pregnant women, aged 15–49 years. Data were collected from January to March 2021, using face-to-face interviews with a structured questionnaire. Logistic regression was used for statistical analysis.ResultsA total of 550 pregnant women were included in the study. Anaemia prevalence amongst pregnant women was 43.1% with mild, moderate and severe cases of 21.3%; 21.1% and 0.7%, respectively. Prevalence was high amongst women aged 15–19 years (53.3%). Factors associated with anaemia included living in urban areas (odds ratio [OR]: 1.8; confidence interval [CI]: 1.19–2.72), having anaemia 6 months before pregnancy (OR: 4.64; CI: 1.15–18.71), and gestational age at first ANC: third trimester (OR = 10.42; CI: 4.27–25.4) and second trimester (OR: 1.62; CI: 1.02–2.60).ConclusionAnaemia remains prevalent amongst pregnant women in Eswatini. A comprehensive anaemia prevention programme would be justified and could lower the country’s burden of anaemia.

An introduction on cerebrovascular aneurysms during pregnancy

A cerebral aneurysm is an abnormal bulge in the cerebral artery that spreads where the blood vessel wall has weakened. Cerebral aneurysms may allow blood to leak into the subcutaneous space around the brain and cause damage to brain cells. Brain aneurysms can also be ruptured and can lead to serious and possibly fatal strokes. A cerebral aneurysm is known as swelling of a blood vessel in the brain. In the definition of these conditions, it is said that it looks like a hanging berry from a stem. In cases where most aneurysms do not rupture or cause health problems, samples that experience such conditions cause bleeding in the brain - hemorrhagic stroke. Intracranial hemorrhages have attracted much attention because of the increasing role of indirect maternal mortality and the importance of rapid diagnosis and treatment in reducing mortality, and since in many cases, they occur due to brain vascular aneurysm. The topic is also essential. When faced with an aneurysm in a pregnant woman, the decision about pregnancy, termination and termination is based on the indications of midwifery and decision-making about the diagnosis and treatment of aneurysm based on neurosurgical indications.

The Role of Tuan Guru on Improving Iron Intake and Minimalizing Food Restriction Behavior among Pregnant Women with Anemia

Introduction: Anemia in pregnancy is an indirect cause maternal mortality. One of causes anemia during pregnancy is deficit of nutrient especially intake of iron. The aim of this study was to know that the role of religious leaders that called “Tuan Guru” as agent of change to improving iron intake among anemia pregnant women.Methods: This study was quasi-experimental with pre and post-test group design. 86 participants pregnant women with anemia have been recruited in this study with purposive sampling technic. They were divided in intervention group (47 participants) and control group (39 participants). This study involved Tuan Guru as main intervention to give health promotion about nutrition during pregnancy. This study used food recall as an instrument tool that it used to measure nutrient intake especially intake of iron both pre and post intervention and also used questonare to measure food restriction behaviour among anemia pregnant women. Statistical test used paired t-testResults: This study show that there were effect of religious leaders to improving the iron intake among pregnant women with anemia with p=0.01. This study also found that the habits of food restriction among pregnant women are decline between before and after intervention with p=0.00.Conclusion: Tuan Guru has a strong influence in helping to increase nutritional intake and is able to minimize the food restriction behaviour among anemia pregnant women. The result of this study can be a basis for government to make a policy related to involvement of religious leaders in health promotion.

Feto-maternal complications and outcomes of pregnant women with valvular heart disease in a tertiary center in Ethiopia

INTRODUCTION: Globally, valvular heart disease (VHD) is a major cause of heart disease and is associated with indirect maternal mortality. Pregnancy associated with VHD results in various feto-maternal complications. The objective of this study was to evaluate the maternal and fetal complications and outcomes of pregnancies complicated by VHD at Jimma University medical center. METHODS: a hospital-based cross-sectional study was conducted among all pregnant mothers with VHD that visited Jimma University Medical center, from September 1, 2018 to July 30, 2019. RESULTS: the prevalence of VHD in pregnant women was 0.6%. Out of a total of 29 pregnant women 28 (96.6%) had rheumatic heart disease. Mitral stenosis (75.9%) was the most frequent mitral valve pathology and 16 (55.2%) had severe mitral stenosis. The commonest maternal complication was new onset or worsening of heart failure in 22 (75.9%). The commonest neonatal complication was preterm delivery (39.3%). There were 2 postpartum maternal deaths (6.9%) and 4 (14.3%) early neonatal deaths. CONCLUSION: majority of pregnant women with VHD had rheumatic heart disease. Adverse feto-maternal complications were common. Expanding access to cardiovascular interventions and feto-maternal medicine services is recommended.

Maternal mortality in Switzerland 2005-2014.

Maternal mortality is an important indicator for quality control in obstetrics. To improve clinical care, maternal mortality should be assessed periodically. In this study, we analysed maternal mortality cases between 2005 and 2014 in Switzerland and compared them with those in earlier periods. The Federal Statistical Office (FSO) provided all death certificates between 2005 and 2014 with an ICD-10 code in the obstetric field (indicated with the letter O). Additionally, we included all death certificates that gave a positive answer about pregnancy or birth within the last 42 days. We also included cases where death occurred within 365 days after delivery. For an analysis of underreporting, cases from the Institute of Forensic Medicine (IRM), Zurich, were included. The cases were classified according to ICD-10 as “direct”, “indirect”, “non-pregnancy-related”, and “late” deaths. The direct maternal mortality rate (MMR), and indirect and combined MMRs were calculated. We received 117 cases from the FSO, and one additional case was found in the archives of the IRM. Ninety-six cases were eligible for detailed evaluation. As 787,025 live births were recorded between 2005 and 2014 in Switzerland, the direct MMR was 3.30/100,000 live births (26 cases). It has decreased by 20.5% compared with the MMR in 1995–2004 (4.15/100,000 live births, 32 cases; p = n.s.) and by 40.4% compared with the MMR in 1985–1994 (5.54/100,000 live births, 45 cases; odds ratio [OR] 0.6, p = 0.04, 95% confidence interval [CI] 0.37–0.97). The leading cause for direct maternal mortality in the current study period was haemorrhage (nine cases), followed by amniotic fluid embolisms and preeclampsia (five cases each). The indirect MMR was 3.68/100,000 live births. In this group, 13 women committed suicide and 8 women died of complications of pre-existing cardiac pathologies. Suicide was the leading cause of maternal deaths, had suicides been classified as direct obstetric cases. The combined MMR (direct and indirect) was 6.61/100,000 live births (52 cases) (OR 4.8–8.4). Of 41 non-pregnancy-related cases, almost half (20 cases) died of cancer within the first year after delivery. Lethality after caesarean section was 0.008‰ (2/231,385). The trend of reducing direct maternal mortality as well as lethality after caesarean section continues. Haemorrhage is still the leading cause of direct maternal mortality; the rate is similar to what it was in the early 1990s. Indirect maternal mortality is increasing and specifically suicides need special attention. Precise documentation of all maternal deaths is essential to improve outcomes for future mothers.

Histopathological Changes of Placenta Associated with Maternal Anaemia in Northeast Ethiopia: A Comparative Study.

Anaemia during pregnancy affects about half of all pregnant mothers in developing countries; it is the major causes of indirect maternal mortality. Anaemia can directly cause poor growth of fetus in utero due to inadequate oxygen flow to the placental tissue or it is indirect indicator of maternal nutritional deficiency. Mal-development of placenta is the leading cause of maternal and perinatal mortality and an important factor of fetal growth retardation. The aim of this study was to compare histopathological changes of placenta associated with maternal anaemia. A comparative cross-sectional study was conducted from May-June, 2018 in Dessie Referral Hospital. A total of 66 placentas (33 anaemic and 33 non-anaemic) were collected after delivery. EPI data version 4.2.0 was used to enter the data while the data were analyzed by using SPSS version 22. Chi-square and one-way ANOVA were used to analyze the data. In pregnancies with maternal anaemia, 75.7% of anaemic placentas terminal villi vessels were increased in number, compared to 15.1% in non-anaemic (p=0.001). Placental calcification was 72.7% in anaemic groups compared to 54% in non-anaemic groups. However, it was insignificant (p=0.12). Intervillous space was wider in anaemic compared to non-anaemic groups (p<0.001). Chorionic villi capillaries were increased in number, and it was dilated in anaemic placenta, compared to non-anaemic. Intervillous space was significantly wider in anaemic placenta.

Histopathological Changes of Placenta Associated with Maternal Anaemia in Northeast Ethiopia: A Comparative Study

BACKGROUND: Anaemia during pregnancy affects about half of all pregnant mothers in developing countries; it is the major causes of indirect maternal mortality. Anaemia can directly cause poor growth of fetus in utero due to inadequate oxygen flow to the placental tissue or it is indirect indicator of maternal nutritional deficiency. Mal-development of placenta is the leading cause of maternal and perinatal mortality and an important factor of fetal growth retardation. The aim of this study was to compare histopathological changes of placenta associated with maternal anaemia.METHODS: A comparative cross-sectional study was conducted from May-June, 2018 in Dessie Referral Hospital. A total of 66 placentas (33 anaemic and 33 non-anaemic) were collected after delivery. EPI data version 4.2.0 was used to enter the data while the data were analyzed by using SPSS version 22. Chi-square and oneway ANOVA were used to analyze the data.RESULTS; In pregnancies with maternal anaemia, 75.7% of anaemic placentas terminal villi vessels were increased in number, compared to 15.1% in non-anaemic (p=0.001). Placental calcification was 72.7% in anaemic groups compared to 54% in non-anaemic groups. However, it was insignificant (p=0.12). Intervillous space was wider in anaemic compared to non-anaemic groups (p&lt;0.001).CONCLUSIONS; Chorionic villi capillaries were increased in number, and it was dilated in anaemic placenta, compared to non-anaemic. Intervillous space was significantly wider in anaemic placenta.

Maternal mortality due to cardiovascular disease in the Netherlands: a 21-year experience

ObjectiveCardiovascular disorders are the leading cause of indirect maternal mortality in Europe. The aim of this study is to present an extensive overview concerning the specific cardiovascular causes of maternal death and to identify avoidable contributing care factors related to these deaths.MethodsWe assessed all cases of maternal death due to cardiovascular disorders collected by a systematic national confidential enquiry of maternal deaths published by the Dutch Maternal Mortality and Morbidity Committee on behalf of the Netherlands Society of Obstetrics and Gynaecology over a 21-year period (1993–2013) in the Netherlands.ResultsThere were 96 maternal cardiovascular deaths (maternal mortality rate due to cardiovascular diseases 2.4/100,000 liveborn children). Causes were aortic dissection (n = 20, 21%), ischaemic heart disease (n = 17, 18%), cardiomyopathies (including peripartum cardiomyopathy and myocarditis, n = 20, 21%) and (unexplained) sudden death (n = 27, 28%). Fifty-five percent of the deaths occurred postpartum (n = 55, 55%). Care factors that may have contributed to the adverse outcome were identified in 27 cases (28%). These factors were patient-related in 40% (pregnancy against medical advice, underestimation of symptoms) and healthcare-provider-related in 60% (symptoms not recognised, delay in diagnosis, delay in referral).ConclusionThe maternal cardiovascular mortality ratio is low in the Netherlands and the main causes of maternal cardiovascular mortality are in line with other European reports. In a minority of cases, care factors that were possibly preventable were identified. Women with cardiovascular disease should be properly counselled about the risks of pregnancy and the symptoms of complications. Education of care providers regarding the incidence, presentation and diagnosis of cardiovascular disease during pregnancy is recommended.

Reducing risks for pregnant women with epilepsy: A qualitative study exploring experiences of using a toolkit at the antenatal booking appointment

PurposeEpilepsy is a high risk neurological disease associated with an increased risk of indirect maternal mortality due to sudden unexpected death in epilepsy. No evidence exists on the antenatal booking risk management process in women with epilepsy. This study therefore aimed to explore the experiences of midwives' in using a maternity epilepsy toolkit designed by the author to assist with this process. Midwives were chosen as the sample as they are predominantly the first health professional to learn of the diagnosis at the antenatal booking appointment. ObjectivesThe objective of this study was to explore the experiences of midwives in using a maternity epilepsy toolkit at the booking appointment. DesignThis is a qualitative study using the principles of hermeneutic phenomenology. SettingThe study setting is in One National Health Service (NHS) Trust in the South of England. ParticipantsThe participants of the study were n = 4 community midwives who used the maternity epilepsy toolkit at the booking appointment. MethodIn-depth semistructured one-to-one interviews were used. MeasurementsAn interview schedule using main questions, probes, and reinforcers was implemented. Audio-recorded interviews were transcribed verbatim. Transcripts were checked against audio recordings for accuracy. AnalysisInductive approach organized by phenomenological framework to identify recurrent codes, patterns, and themes were used for analysis. FindingsThe following three themes clearly emerged: ‘foundations of epilepsy knowledge’, ‘using the toolkit in midwifery practice’, and ‘the toolkits influence on learning’. ConclusionParticipants described lack of epilepsy knowledge and experience prior to using the ‘toolkit’ and how being prepared optimized its use. They articulated how it enabled them to collate the epilepsy and treatment history, share risk management strategies, and expedite referrals appropriately. They discussed how it increased confidence, reduced fear, and inspired motivation toward learning. The results of this study will provide a foundation for future research exploring the impact that the ‘toolkit’ has on multidisciplinary care provision. Implications for practiceThis small study demonstrated the ‘toolkits’ potential as a method of increasing knowledge about epilepsy and risk management. Initiation of its use in early pregnancy is intended to promote effective history taking, facilitate the identification of women at increased risk of morbidity and mortality, and encourage joint working through early multidisciplinary team referral and involvement.This paper is for the Special Issue :Prevent 21: SUDEP Summit - Time to Listen

Cardiac Disorders Complicating Pregnancy

Background: Cardiac disorders complicate 1 to 4% of pregnancies. Women with cardiac disorders have a risk during pregnancy, labor, postpartum. It is essential to prevent cardiac disorders, if not prevented, diagnose and provide timely appropriate management to prevent deaths. Objective: To know the trends and frequency of disorders, feto-maternal outcome in women with cardiac disorders complicating pregnancy in limited resource settings. Material and Methods: Analysis of case records of women with cardiac disorders managed from 1987 and 2016 was done. During this study period, 79868 women delivered, 576 women with cardiac disorders were hospitalized in the Obstetrics department. The analysis was done after getting information related to objectives. Results: Of 576 women who were admitted with cardiac disorders, 56 had an abortion, 20 were lost to follow up. The feto-maternal outcome of 500 cases was analyzed. 376 (75.2%) women had normal delivery, 72 (14.4%) instrumental and 52 (10.4%) women underwent Caesarean Sections (CSs). Perinatal Mortality Rate (PMR) was 40.9 and 16 (2.87%) of 556 women died, contributing to 9.5% indirect maternal mortality during the period of analysis. However, the outcome has been improving over the years. Conclusion: Pregnancy in women with heart disease is associated with significant cardiac and neonatal morbidity. Over the years, it has been found that pregnancy complicated by heart disease can result in a favorable outcome for both mother and fetus, provided meticulous care is taken before and during pregnancy, labor and postpartum period with appropriate therapy.

Maternal mortality in Italy: Results and perspectives of record-linkage analysis.

Accurate estimates and reliable classification of maternal deaths are imperative steps in the chain of actions targeted at reducing avoidable maternal mortality. The aims of this study were to estimate the maternal mortality ratio (MMR) in 10 Italian regions covering 77% of total national births and to identify the most suitable approach to classify the causes of death. Deaths during and within 1year after pregnancy have been identified through linkage between death registry and hospital discharge database. Regional and national data sources from 2006 to 2012 were used. The MMR has been estimated and deaths were classified as direct or indirect and according to their primary causes. A total of 277 maternal deaths within 42days after pregnancy were identified: 149 direct, 102 indirect causes and 26 unclassified-resulting in a MMR of 9.18 per 100000 live births. The under-reporting rate of official MMR figures in the participating regions is 60.3%. Hemorrhage (MMR 1.92), hypertensive disorders of pregnancy and cardiac diseases (MMR 1.06) were the leading causes of deaths occurring within 42days after pregnancy, whereas malignancy (39%) and violent deaths (17%) were the most frequent of the 543 late maternal deaths. Record-linkage is an efficient and reliable method to estimate maternal mortality and to identify causes of maternal deaths. Both the indirect/direct and the classification by primary cause have a role in countries where direct deaths exceed indirect maternal mortality. Building upon linkage data, confidential enquiries further increase the likelihood of reducing maternal mortality.

Medical provision and urban-rural differences in maternal mortality in late nineteenth century Scotland

This paper examines the effect of variable reporting and coding practices on the measurement of maternal mortality in urban and rural Scotland, 1861–1901, using recorded causes of death and women who died within six weeks of childbirth. This setting provides data (n = 604 maternal deaths) to compare maternal mortality identified by cause of death with maternal mortality identified by record linkage and to contrast urban and rural settings with different certification practices. We find that underreporting was most significant for indirect causes, and that indirect causes accounted for a high proportion of maternal mortality where the infectious disease load was high. However, distinguishing between indirect and direct maternal mortality can be problematic even where cause of death reporting appears accurate. Paradoxically, underreporting of maternal deaths was higher in urban areas where deaths were routinely certified by doctors, and we argue that where there are significant differences in medical provision and reported deaths, differences in maternal mortality may reflect certification practices as much as true differences. Better health services might therefore give the impression that maternal mortality was lower than it actually was. We end with reflections on the interpretation of maternal mortality statistics and implications for the concept of the obstetric transition.

Mortalité maternelle par infection, résultats de l’ENCMM, France 2010–2012

Over the period 2010–2012, maternal mortality from infectious causes accounted for 5% of maternal deaths by direct causes and 16% of maternal deaths by indirect causes. Among the 22 deaths caused by infection occurred during this period, 6 deaths were attributed to direct causes from genital tract origin, confirming thus the decrease in direct maternal deaths by infection during the last ten years. On the contrary, indirect maternal deaths by infection, from extragenital origin, doubled during the same period, with 16 deaths in the last triennium, dominated by winter respiratory infections, particularly influenza: the 2009–2010 influenza A (H1N1) virus pandemic was the leading cause of indirect maternal mortality by infection during the studied period. The main infectious agents involved in maternal deaths from direct causes were Streptococcus A, Escherichia Coli and Clostridium perfringens: these bacterias were responsible for toxic shock syndrome, severe sepsis, secondary in some cases to cellulitis or necrotizing fasciitis. Of the 6 deaths due to direct infection, 4 were considered avoidable because of inadequate management: delayed or missed diagnosis, delayed or inadequate initiation of a specific medical and/or surgical treatment. Of the 16 indirect maternal deaths due to infection causes, the most often involved infectious agents were influenza A (H1N1) virus and Streptococcus pneumonia with induced purpura fulminans: the absence of influenza vaccination during pregnancy, delayed diagnosis and emergency initiation of a specific treatment, were the main contributory factors to these deaths and their avoidability in 70% of the cases analyzed.

Maternal sepsis in the era of genomic medicine.

Maternal sepsis remains one of the leading causes of direct and indirect maternal mortality both in high- and low-income environments. In the last two decades, systems biology approaches, based on '-omics' technologies, have started revolutionizing the diagnosis and management of the septic syndrome. The scope of this narrative review is to present an overview of the basic '-omics' technologies, exemplified by cases relevant to maternal sepsis. Narrative review of the new '-omics' technologies based on a detailed review of the literature. After presenting the main 'omics' technologies, we discuss their limitations and the need for integrated approaches that encompass research efforts across multiple '-omics' layers in the '-omics' cascade between the genome and the phenome. Systems biology approaches are revolutionizing the research landscape in maternal sepsis. There is a need for increased awareness, from the side of health practitioners, as a requirement for the effective implementation of the new technologies in the research and clinical practice in maternal sepsis.

Mortalité maternelle par infection, résultats de l’ENCMM, France 2010–2012

Over the period 2010–2012, maternal mortality from infectious causes accounted for 5% of maternal deaths by direct causes and 16% of maternal deaths by indirect causes. Among the 22 deaths caused by infection occurred during this period, 6 deaths were attributed to direct causes from genital tract origin, confirming thus the decrease in direct maternal deaths by infection during the last ten years. On the contrary, indirect maternal deaths by infection, from extragenital origin, doubled during the same period, with 16 deaths in the last triennium, dominated by winter respiratory infections, particularly influenza: the 2009–2010 influenza A (H1N1) virus pandemic was the leading cause of indirect maternal mortality by infection during the studied period. The main infectious agents involved in maternal deaths from direct causes were Streptococcus A, Escherichia Coli and Clostridium perfringens: these bacterias were responsible for toxic shock syndrome, severe sepsis, secondary in some cases to cellulitis or necrotizing fasciitis. Of the 6 deaths due to direct infection, 4 were considered avoidable because of inadequate management: delayed or missed diagnosis, delayed or inadequate initiation of a specific medical and/or surgical treatment. Of the 16 indirect maternal deaths due to infection causes, the most often involved infectious agents were influenza A (H1N1) virus and Streptococcus pneumonia with induced purpura fulminans: the absence of influenza vaccination during pregnancy, delayed diagnosis and emergency initiation of a specific treatment, were the main contributory factors to these deaths and their avoidability in 70% of the cases analyzed.