Preventable Maternal Mortality Research Articles

Examining expert views on maternal mortality in Turkey: A qualitative study.

Maternal mortality ratio is one of the significant indicators of a country's healthcare quality and development. In recent years, Türkiye has made significant advancements in maternal and child health services. However, it has been discussed that stagnation has been observed in recent years, and the migration from Syria and the COVID-19 pandemic have significantly overshadowed this success. The purpose of this study is to evaluate the current situation of the maternal mortality level in the country based on the experiences and views of experts working in this area. Key informant interviews were conducted with a purposive sample of academics, representatives of public institutions, and NGOs to understand the mechanisms of success in maternal mortality in the 1990s. Thematic analysis was used to understand the reasons for the stagnation of the decline in maternal mortality and to develop recommendations for reducing maternal mortality. Twenty-five key informant interviews were conducted. Positive developments contributing to the success of maternal mortality, problems and obstacles hindering further progress and suggestions/recommendations are the themes of this research. The key informants highlighted the health transformation policies, the lack of data on the impact of COVID-19, recent migration on maternal mortality, inadequate education and training on sexual and reproductive health (SRH), the absence of rights-based policies, and gender equality as critical issues in current policies. The outcomes of this study underline the importance of the availability, accessibility, and quality of SRH services and empowering women, girls, families, and communities to eliminate preventable maternal mortality levels.

Validating the indicator "maternal death review coverage" to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record data.

Understanding causes and contributors to maternal mortality is critical from a quality improvement perspective to inform decision making and monitor progress toward ending preventable maternal mortality. The indicator "maternal death review coverage" is defined as the percentage of maternal deaths occurring in a facility that are audited. Both the numerator and denominator of this indicator are subject to misclassification errors, underreporting, and bias. This study assessed the validity of the indicator by examining both its numerator-the number and quality of death reviews-and denominator-the number of facility-based maternal deaths and comparing estimates of the indicator obtained from facility- versus district-level data. We collected data on the number of maternal deaths and content of death reviews from all health facilities serving as birthing sites in 12 districts in three countries: Argentina, Ghana, and India. Additional data were extracted from health management information systems on the number and dates of maternal deaths and maternal death reviews reported from health facilities to the district-level. We tabulated the percentage of facility deaths with evidence of a review, the percentage of reviews that met the World Health Organization defined standard for maternal and perinatal death surveillance and response. Results were stratified by sociodemographic characteristics of women and facility location and type. We compared these estimates to that obtained using district-level data. and looked at evidence of the review at the district/provincial level. Study teams reviewed facility records at 34 facilities in Argentina, 51 facilities in Ghana, and 282 facilities in India. In total, we found 17 deaths in Argentina, 14 deaths in Ghana, and 58 deaths in India evidenced at facilities. Overall, >80% of deaths had evidence of a review at facilities. In India, a much lower percentage of deaths occurring at secondary-level facilities (61.1%) had evidence of a review compared to deaths in tertiary-level facilities (92.1%). In all three countries, only about half of deaths in each country had complete reviews: 58.8% (n = 10) in Argentina, 57.2% (n = 8) in Ghana, and 41.1% (n = 24) in India. Dramatic reductions in indicator value were seen in several subnational geographic areas, including Gonda and Meerut in India and Sunyani in Ghana. For example, in Gonda only three of the 18 reviews conducted at facilities met the definitional standard (16.7%), which caused the value of the indicator to decrease from 81.8% to 13.6%. Stratification by women's sociodemographic factors suggested systematic differences in completeness of reviews by women's age, place of residence, and timing of death. Our study assessed the validity of an important indicator for ending preventable deaths: the coverage of reviews of maternal deaths occurring in facilities in three study settings. We found discrepancies in deaths recorded at facilities and those reported to districts from facilities. Further, few maternal death reviews met global quality standards for completeness. The value of the calculated indicator masked inaccuracies in counts of both deaths and reviews and gave no indication of completeness, thus undermining the ultimate utility of the measure in achieving an accurate measure of coverage.

Using incident reports to diagnose communication challenges for precision intervention in learning health systems: A methods paper.

Poor communication is a leading root cause of preventable maternal mortality in the United States. Communication challenges are compounded with the presence of biases, including racism. Hospital administrators and clinicians are often aware that communication is a problem, but understanding where to intervene can be difficult to determine. While clinical leadership routinely reviews incident reports and acts on them to improve care, we hypothesized that reviewing incident reports in a systematic way might reveal thematic patterns, providing targeted opportunities to improve communication in direct interaction with patients and within the healthcare team itself. We abstracted incident reports from the Women's Health service and linked them with patient charts to join patient's race/ethnicity, birth outcome, and presence of maternal morbidity and mortality to the incident report. We conducted a qualitative content analysis of incident reports using an inductive and deductive approach to categorizing communication challenges. We then described the intersection of different types of communication challenges with patient race/ethnicity and morbidity outcomes. The use of incident reports to conduct research on communication was new for the health system. Conversations with health system-level stakeholders were important to determine the best way to manage data. We developed a thematic codebook based on prior research in healthcare communication. We found that we needed to add codes that were equity focused, as this was missing from the existing codebook. We also found that clinical and contextual expertise was necessary for conducting the analysis-requiring more resources to conduct coding than initially estimated. We shared our findings back with leadership iteratively during the work. Incident reports represent a promising source of health system data for rapid improvement to transform organizational practice around communication. There are barriers to conducting this work in a rapid manner, however, that require further iteration and innovation.

Accountability for maternal and newborn health: Why measuring and monitoring broader social, political, and health system determinants matters.

This article offers four key lessons learned from a set of seven studies undertaken as part of the collection entitled, "Improving Maternal Health Measurement to Support Efforts toward Ending Preventable Maternal Mortality". These papers were aimed at validating ten of the Ending Preventable Maternal Mortality initiative indicators that capture information on distal causes of maternal mortality. These ten indicators were selected through an inclusive consultative process, and the research designs adhere to global recommendations on conducting indicator validation studies. The findings of these papers are timely and relevant given growing recognition of the role of macro-level social, political, and economic factors in maternal and newborn survival. The four key lessons include: 1) Strengthen efforts to capture maternal and newborn health policies to enable global progress assessments while reducing multiple requests to countries for similar data; 2) Monitor indicator "bundles" to understand degree of policy implementation, inconsistencies between laws and practices, and responsiveness of policies to individual and community needs; 3) Promote regular monitoring of a holistic set of human resource metrics to understand how to effectively strengthen the maternal and newborn health workforce; and 4) Develop and disseminate clear guidance for countries on how to assess health system as well as broader social and political determinants of maternal and newborn health. These lessons are consistent with the Kirkland principles of focus, relevance, innovation, equity, global leadership, and country ownership. They stress the value of indicator sets to understand complex phenomenon related to maternal and newborn health, including small groupings of complementary indicators for measuring policy implementation and health workforce issues. They also stress the fundamental ethos that maternal and newborn health indicators should only be tracked if they can drive actions at global, regional, national, or sub-national levels that improve lives.

Alliance for Innovation on Maternal Health: Evolution of a program to address maternal morbidity and mortality

The Alliance for Innovation on Maternal Health program is a national investment in promoting safe care for every birth in the United States and lowering rates of preventable maternal mortality and severe maternal morbidity. Through its work with state and jurisdiction-based teams on patient safety bundle implementation, the program supports data-driven quality improvement. This paper details key aspects of the Alliance for Innovation on Maternal Health including patient safety bundles, technical assistance, implementation resource development, data support, and partnerships while providing an overview of the program's evolution, reach, impact, and future opportunities.

Recommendations call for screening before, during, and after pregnancy

The most common pregnancy complication, and the leading cause of preventable maternal mortality, are perinatal mental health problems. Sometimes, clinicians don't want to screen for something because they don't know what to do if the results are positive: but in the case of perinatal depression, there are treatments, according to a new study.

РОЛЬ ПЕРИНАТАЛЬНОГО ЦЕНТРА МНОГОПРОФИЛЬНОЙ БОЛЬНИЦЫ В ПРОФИЛАКТИКЕ МАТЕРИНСКОЙ СМЕРТНОСТИ ОТ АКУШЕРСКИХ КРОВОТЕЧЕНИЙ: КАК БЫЛО И КАК СТАЛО

The study aims to evaluate the role of a perinatal center in a multidisciplinary hospital in the prevention of maternal mortality caused by obstetric bleeding. The study used the continuous sampling method to conduct a retrospective analysis of 185 cases of pregnancies and their outcomes in women with obstetric bleeding during pregnancy, labor, and the postpartum period treated at the Perinatal Center in Khanty-Masiysk from 2010 to 2011 and from 2019 to 2020. It was identified that primary risk factors for maternal mortality due to obstetric bleeding include iron deficiency anemia; gestational diabetes mellitus with complications; four or five pregnancies in anamnesis; and one to three scars on a uterus, which are the most significant risk factors for obstetric bleeding. From 2019 to 2020, there was a 1.3-fold increase in cases of premature detachment of normally situated placentas and a 2.5-fold increase in cases of placenta praevia with bleeding and fused placentas in the structure of hemorrhage. Taking into account existing risk factors, identifying a group of near miss cases and timely routing of patients to a level 3 medical facility is a necessary condition for preventing maternal mortality.

Effectiveness of Focused Obstetric Ultrasound Training to Nurses from Remote Health Posts to Improve Pregnancy Outcome and Reduce Morbidity.

A rural ultrasound program was started in Nepal in order to detect complicated pregnancies early in health post where radiologists are not available to provide their services. The study aims to investigate whether focused obstetric ultrasound trained nurses were capable of detecting high risk pregnancy at an early stage in their health post and refer them to higher centre timely so that they are taken care properly. The study site for research were health posts and hospitals where the rural ultrasound program had been conducted in districts of Sudurpashchim province. The referral centres within Sudurpashchim province were assessed for cross verification of diagnosis and pregnancy outcome of referred cases. Quantitative data was collected from health posts and hospitals ultrasound log book where women who had accessed obstetric ultrasound services during pregnancy. Qualitative data was collected from nurses who have completed training. The data was verified from log-book registered in the health post and hospitals. All the quantitative data was entered and analysed. Cross verified data revealed that focused obstetric ultrasound received nurses identified cases been verified same diagnosis in referral hospitals with 66 cases. In-depth interview with 28 nurses revealed that training received by them was effective in minimizing preventable maternal and neonatal mortality and morbidity. Focused obstetric ultrasound in rural and under-resources communities like in Nepal has the potential to improve access and quality of health care services and can result in an increased uptake of antenatal care service utilisation.

Implementing E-MOTIVE for detection and treatment of postpartum haemorrhage in South Africa.

Postpartum haemorrhage is the leading cause of preventable maternal mortality in South Africa. In a significant breakthrough in the management of PPH, the E-MOTIVE trial found that a multifaceted health service intervention reduced severe PPH after vaginal delivery by 60% in 78 hospitals in Nigeria, Kenya, Tanzania and SA. The E-MOTIVE approach comprises objective blood loss measurement monitored every 15 minutes during the first hour after delivery to detect PPH early and trigger a bundle of first-line treatments, including massaging the uterus, oxytocin infusion, tranexamic acid infusion, intravenous crystalloid fluids, examination for the cause, emptying the bladder and, if necessary, escalation of care. E-MOTIVE was integrated into the existing Essential Steps in Managing Obstetric Emergencies algorithm. Certain research-related elements of the trial setting cannot be replicated in routine practice. Therefore, we need to develop local strategies to ensure the essential clinical elements of the intervention are implemented. Potential strategies include incorporating the E-MOTIVE principles into national guidelines, ongoing training strategies and ensuring all facilities are equipped with necessary medication, equipment and delegations. This breakthrough intervention provides hope for women in SA, and requires a purposeful, co-ordinated implementation strategy on a national scale to reach all levels of the health service.

Cost-Effectiveness Analysis of a Community Emergency Transport System for Maternal Care in Northern Ghana

Maternal mortality is a function of economic underdevelopment. Obstetric complications are the major cause of maternal mortality. Early detection, rapid transportation and prompt care utilizing Emergency Obstetric and Newborn Care (EmONC) can help end preventable maternal mortality. However, poor referral transportation limits utilization of lifesaving EmONC in least developed countries. Korea International Cooperation Agency supported Ghana to implement a 5-year Primary Health Care project in Upper East region in 2016. This project had a Community Emergency Transport System (CETS) component. CETS was implemented using customized ‘motorking’ tricycle ambulances to strengthen maternal referral transportation. We conducted cost-effectiveness analysis to determine CETS’ value-for-money (VfM). The incremental cost-effectiveness ratio (ICER) and incremental net-benefit (INB) were estimated. The study perspective was societal. The comparator was traditional transportation system (TTS). The cost-effectiveness threshold was Ghana’s GDP for 2020 (USD2,254.15/GH₵11,045.34). The study respondents were women with pregnancy experience in 2020 within the project area who utilize a referral transport. Respondents were randomly selected from CETS and TTS areas. Primary and secondary data were collected at households and health facilities respectively. Data was analyzed with STATA 15.0. The ICER computed was GH₵559.69 (USD114.22). CETS was deemed cost-effective because ICER was below the cost-effectiveness threshold. The net-benefit was GH₵31,456.96 (USD6,419.79). The INB was less than zero (-2002.61) implying CETS was not cost-effective. There was a conflict between ICER and INB on VfM of CETS. Affordability should be considered in Policy adoption. Keywords: Community emergency transport system, Cost-effectiveness, Ending preventable maternal mortality, Northern Ghana, Traditional transport system.

Knowledge of obstetric danger signs and associated factors among pregnant women attending antenatal care services at Thai community hospital.

To decrease preventable maternal mortality, providing health education to all parties is mandatory. Good knowledge, including awareness of pregnant women regarding obstetric danger signs (ODS), leads to appropriate practices and services. The knowledge of ODS varies among countries and regions. Since the data in rural regions of Thailand remains unavailable, this study aimed to identify the prevalence of good ODS knowledge and associated factors among pregnant women attending antenatal services at a Thai community hospital. We performed a cross-sectional, analytical study in 415 singleton pregnant women who visited the antenatal clinic at Wang Saphung Hospital, Loei, Thailand. A well-trained research assistant interviewed all participants using the data record form containing twenty items on the demographic and obstetric data and sixteen items on ODS knowledge. An ODS score of at least 75% (12 points) was considered a good level of knowledge. A total of 275 participants (66.27%) had good knowledge of ODS. The most recognized ODS was vaginal bleeding whereas the least recognized ODS during pregnancy was convulsion; the least recognized ODS during labor and delivery was retained placenta. Multivariate regression analysis showed that the predictive factors of good OBS knowledge included a higher education level, maternal age of at least 20 years, and having medical personnel as a source of knowledge. In a rural setting of Thailand, two-thirds of pregnant women had good ODS knowledge. Identifying those at risk for fair and poor ODS knowledge and prompt management for the vulnerable subgroups might help decrease maternal mortality.

Effect of Short, Animated Video Storytelling on Maternal Knowledge and Satisfaction in the Perinatal Period in South Africa: Randomized Controlled Trial.

Innovative mobile health (mHealth) interventions can improve maternal knowledge, thereby supporting national efforts to reduce preventable maternal and child mortality in South Africa. Studies have documented a potential role for mobile video content to support perinatal health messaging, enhance maternal satisfaction, and overcome literacy barriers. Short, animated storytelling (SAS) is an innovative, emerging approach to mHealth messaging. We aimed to measure the effect of SAS videos on maternal knowledge and user satisfaction for mothers enrolled in antenatal care programs at 2 public health facilities in the Tshwane District of South Africa. We used a randomized controlled trial with a nested evaluation of user satisfaction. Participants were randomized 1:1 into Standard-of-Care (SOC) Control, and SAS Intervention groups. The intervention videos were delivered through WhatsApp, and 1 month later, participants responded to telephone surveys assessing their knowledge. The intervention group then participated in a nested evaluation of user satisfaction. We surveyed 204 participants. Of them, 49.5% (101/204) were aged between 25 and 34 years. Almost all participants self-identified as Black, with the majority (190/204, 93.2%) having completed secondary school. The mean overall knowledge score was 21.92/28. We observed a slight increase of 0.28 (95% uncertainty interval [UI] -0.58 to 1.16) in the overall knowledge score in the intervention arm. We found that those with secondary education or above scored higher than those with only primary education by 2.24 (95% UI 0.76-4.01). Participants aged 35 years or older also scored higher than the youngest age group (18-24 years) by 1.83 (95% CI 0.39-3.33). Finally, the nested user satisfaction evaluation revealed high maternal satisfaction (4.71/5) with the SAS video series. While the SAS videos resulted in high user satisfaction, measured knowledge gains were small within a participant population that was already receiving perinatal health messages through antenatal clinics. The higher knowledge scores observed in older participants with higher education levels suggest that boosting maternal knowledge in younger mothers with lower education levels should continue to be a public health priority in South Africa. Given the high maternal satisfaction among the SAS video-users in this study, policy makers should consider integrating similar approaches into existing, broad-reaching perinatal health programs, such as MomConnect, to boost satisfaction and potentially enhance maternal engagement. While previous studies have shown the promise of animated video health education, most of this research has been conducted in high-income countries. More research in underresourced settings is urgently needed, especially as access to mobile technology increases in the Global South. Future studies should explore the effect of SAS videos on maternal knowledge in hard-to-reach populations with limited access to antenatal care, although real-world logistical challenges persist when implementing studies in underresourced South African populations. Pan African Clinical Trials Registry PACTR202203673222680; https://tinyurl.com/362cpuny.

Addressing the Public Health Crisis of Maternal Mortality

This Viewpoint discusses the National Institutes of Health initiative that focuses on research that reduces preventable maternal mortality, decreases severe maternal morbidity, and promotes health equity.

Antenatal Care Services Utilization among the Antenatal and Postnatal Women in a Rural Area of South India: A Cross-Sectional Study

Introduction: Timely and quality antenatal care is a crucial determinant towards the prevention of maternal mortality, which is a significant developmental goal for developing countries, which contributes to more than 99% of maternal deaths worldwide. However, the lack of equitable access to quality ANC is a major challenge in resource-limited settings, particularly in developing countries like India. Objectives: To assess the utilization rates of antenatal care services among antenatal women and postnatal women and to determine the factors responsible forunder or non-utilization of antenatal care services (ANC). Method: The present study was conducted for a period offour months among antenatal and postnatal women in a rural area of South India. All antenatal and postnatal women except those who were not willing to participate and those who had MTP/abortion during the present pregnancy were included for the study. A pre tested semi structured questionnaire was used for collecting information regarding ANC utilization. Data was entered in Microsoft Excel and analyzed for descriptive and inferential statistics. Results: A total of 175 (125 antenatal and 50 postnatal) women were interviewed. Among them, 90.3% (92% antenatal and 86% postnatal) women had completely utilized ANC services. Among the postnatal women, those who had completely utilized ANC services, 11.6% had complications at the time of their delivery and those who had incompletely utilized ANC services, 57.1% had complications.The difference was found to be statistically significant (p<0.05).Only 87.4% women were covered in home visits and 28.6% of them were not given any prenatal advice.IFA tablets were taken adequately only by 57.7% women. Conclusion: The present study revealed that most of the women were aware about the antenatal services available and had registered their pregnancy early. Td immunization was done at right time. However antenatal home visits were not effectively implemented.

Help a mother out: The impact of acute care surgeon response in postpartum hemorrhage

IntroductionA Code White (CW) activation is a hospital-wide alert for postpartum hemorrhage (PPH) and acute care surgeons (ACS) were added to the response team to assist in resuscitation. A multidisciplinary training program was also implemented. This study aimed to evaluate the impact of ACS involvement and training on maternal outcomes. MethodsA retrospective review was performed on all CW activations from 1/1/2015–8/31/2022. Three groups—pre-ACS response, ACS response, and ACS response ​+ ​training (R&T)—were compared. Results218 patients had CW activations. ACS response increased MTP activations (50.0%vs76.5%vs76.2%, p ​= ​0.014) and TXA administration (50.0%vs96.5%vs93.3%, p ​< ​0.0001). The ACS R&T had the highest ACS presence (53.6%vs72.9%vs96.2%, p ​< ​0.0001), shortest operation (99 vs 67 vs 53min, p ​= ​0.002), lowest crystalloid use (2000 vs 1110 vs 800 ​ml, p ​= ​0.003), and lowest transfusion requirements. Mortality decreased from 17.9% in pre-ACS to 2.4% in ACS response and 0% in ACS R&T (p ​< ​0.0001). ConclusionACS assistance in CW activations and multidisciplinary PPH education led to the prevention of maternal mortality. ACS are a valuable resource in this unique population.

Knowledge of obstetric danger signs and associated factors among pregnant women attending antenatal care services at Thai community hospital

Background: To decrease preventable maternal mortality, providing health education to all parties is mandatory. Good knowledge, including awareness of pregnant women regarding obstetric danger signs (ODS), leads to appropriate practices and services. The knowledge of ODS varies among countries and regions. Since the data in rural regions of Thailand remains unavailable, this study aimed to identify the prevalence of good ODS knowledge and associated factors among pregnant women attending antenatal services at a Thai community hospital. Methods: We performed a cross-sectional, analytical study in 415 singleton pregnant women who visited the antenatal clinic at Wang Saphung Hospital, Loei, Thailand. A well-trained research assistant interviewed all participants using the data record form containing twenty items on the demographic and obstetric data and sixteen items on ODS knowledge. An ODS score of at least 75% (12 points) was considered a good level of knowledge. Results: A total of 275 participants (66.27%) had good knowledge of ODS. The most recognized ODS was vaginal bleeding whereas the least recognized ODS during pregnancy was convulsion; the least recognized ODS during labor and delivery was retained placenta. Multivariate regression analysis showed that the predictive factors of good OBS knowledge included a higher education level, maternal age of at least 20 years, and having medical personnel as a source of knowledge. Conclusions: In a rural setting of Thailand, two-thirds of pregnant women had good ODS knowledge. Identifying those at risk for fair and poor ODS knowledge and prompt management for the vulnerable subgroups might help decrease maternal mortality.

"I hope to all the world they don't forget women of Afghanistan": An interrupted survey among doctors in Afghanistan.

To assess current access to essential sexual and reproductive health (SRHR) services in Afghanistan and how access has changed with the transition of power. This is a cross-sectional study based on data from an anonymous survey among doctors in Afghanistan in May 2022, analyzed using descriptive statistics. The survey recorded subjective estimates of access to SRHR services, barriers to access, extent of maternal mortality or near miss due to preventable factors, and the effect of the regime change on access. The data collection was interrupted after 60 responses. A majority of providers responded that their population went hungry often or always. According to our criteria for "access", that 75% or more of the population was estimated to have it, no respondents (0%) assessed that access existed for services for gender-based violence. The corresponding proportion responding that access existed was 3.4% for services after rape, 12.6% for legal abortion, 13.3% for antenatal care, and 20% for labor care. According to 41.7% of respondents, untreated postpartum hemorrhage accounted for a large or very large proportion of preventable maternal mortality or near miss. Almost half of respondents (47.4%) reported the same for lack of skilled providers, 66.2% reported it for the concept "too many pregnancies", and 55% reported it for malnutrition and poor health. According to 43.3% of respondents, the regime change had reduced access to labor care to a large extent, 33.9% of respondents said this in relation to access to contraceptives, and 43.1% for overall access for internally displaced persons. Interim data suggest that women in some settings in Afghanistan have no access to SRHR services, that preventable factors account for a large portion of maternal deaths or near miss, and that access has deteriorated since the transition of power.

Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countries

Maternal mortality, stillbirths, and neonatal mortality account for almost 5 million deaths a year and are often analysed separately, despite having overlapping causes and interventions. We propose a comprehensive five-phase mortality transition model to improve analyses of progress and inform strategic planning. In this empirical data-driven study to develop a model transition, we used UN estimates for 151 countries to assess changes in maternal mortality, stillbirths, and neonatal deaths. On the basis of ratios of maternal to stillbirth and neonatal mortality, we identified five phases of transition, in which phase 1 has the highest mortality and phase 5 has the lowest. We used global databases to examine phase-specific characteristics during 2000-20 for causes of death, fertility rates, abortion policies, health workforce and financing, and socioeconomic indicators. We analysed 326 national surveys to assess service coverage and inequalities by transition phase. Among 116 countries in phases 1 to 4 in 2000, 73 (63%) progressed at least one phase by 2020, six advanced two phases, and three regressed. The ratio of stillbirth and neonatal deaths to maternal deaths increased from less than 10 in phase 1 to well over 50 in phase 4 and phase 5. Progression was associated with a declining proportion of deaths caused by infectious diseases and peripartum complications, declining total and adolescent fertility rates, changes in health-workforce densities and skills mix (ie, ratio of nurses or midwives to physicians) from phase 3 onwards, increasing per-capita health spending, and reducing shares of out-of-pocket health expenditures. From phase 1 to 5, the median coverage of first antenatal care visits increased from 66% to 98%, four or more antenatal care visits from 44% to 94%, institutional births from 36% to 99%, and caesarean section rates from 2% to 25%. The transition out of high-mortality phases involved a major increase in institutional births, primarily in lower-level health facilities, whereas subsequent progress was characterised by rapid increases in hospital births. Wealth-related inequalities reduced strongly for institutional birth coverage from phase 3 onwards. The five-phase maternal mortality, stillbirth, and neonatal mortality transition model can be used to benchmark the current indicators in comparison to typical patterns in the transition at national or sub-national level, identify outliers to better assess drivers of progress, and inform strategic planning and investments towards Sustainable Development Goal targets. It can also facilitate programming for integrated strategies to end preventable maternal mortality and neonatal mortality and stillbirths. Bill & Melinda Gates Foundation.

Exploring the intersection between country context and priority setting to prevent maternal mortality: A multi-methods study comparing expected vs observed priorities in five countries to validate the obstetric transition model.

The obstetric transition model suggests that, as countries economically develop, the primary causes of maternal mortality change. Countries are assigned to one of five stages based on their maternal mortality ratio to identify priorities for reducing maternal deaths based on predominant determinants of mortality at each stage. We aim to validate the obstetric transition model using data from six diverse low- and middle-income countries representing self-identified priorities for improving maternal health and measurement compiled in a multi-stakeholder process. We used multiple data sources from Bangladesh, Cote d'Ivoire, India, Mexico, Nigeria, and Pakistan, which included secondary data on country context and primary data derived from two sources: the content of multi-stakeholder meetings, called National Dialogues, which were organised around the 11 key themes identified in the World Health Organization's "Strategies toward ending preventable maternal mortality" (EPMM) and follow-up key informant interviews conducted in five of the seven countries. We conducted the analysis in four phases examining, the country's contextual profile, mapping the key themes and indicators to the model, exploring stakeholder prioritisation, and examining reasons for divergence from the model. Our results suggest that the stages of the obstetric transition generally align with the social, epidemiological, and health systems characteristics that the model predicts to be associated with countries at each stage, with some deviation related to health system deficiencies and barriers to access. Stakeholder priorities in maternal health generally align with those predicted by the model. Equity and women's rights emerged as a priority throughout all stages, not only within countries that are more advanced in the transition, as predicted by the model. Deviations between the model's predictions and country-level prioritisation were often explained by context-specific challenges. This study is one of the first to validate the obstetric transition model using real data. Our findings support the validity of the obstetric transition model as a useful guide to aid decisionmakers in prioritising attention towards addressing maternal mortality. Country context, including equity, remains important to further inform priority-setting.

Measuring maternal improvement through multi-stakeholder engagement: Documenting developments in the dynamic programmatic context of the global COVID-19 pandemic through outcome harvesting.

To bolster country efforts towards meeting the targets and strategies laid out in WHO's report "Strategies toward ending preventable maternal mortality" (EPMM), a series of seven consultations, known as National Dialogues, were conducted to better understand national priority areas for the improvement of maternal health and to support the adoption and use of EPMM indicators at the national level. The last Dialogue was conducted in March 2020, as the COVID-19 pandemic was beginning to have global impacts. We aimed to explore the circumstantial challenges and opportunities that countries have encountered in meeting the specific stakeholder commitments made in each country by National Dialogue participants during the COVID-19 pandemic. We based our study methodology on outcome harvesting, a qualitative approach that examines how incremental change contributes towards achieving a specified outcome. It collects evidence on what has changed and then works backwards to determine whether and how a programme or intervention led to the observed changes. We collected data from 20 participants in five countries (Bangladesh, India, Mexico, Nigeria, and Pakistan) through key informant interviews and focus group discussions. We analysed the data through inductive coding focused on emergent themes. The onset of the global COVID pandemic overturned plans and upended health systems, bringing new opportunities in some countries and halting progress towards the agenda outlined in the National Dialogue elsewhere. Participants identified adaptations that facilitated continued progress, such as shifting the locus of advocacy and activity from national to sub-national focal areas, catalytic changes in response to the crisis (including the development and improvement of digital communication and data technology), and increased awareness of the importance of identified priorities (including a human rights approach to maternal health). Our data suggest that the priorities for maternal health system performance to drive improvement toward ending preventable maternal deaths and the advocacy commitments designed to increase the relevance of upstream policy and health system-level determinants of maternal health and survival have retained their urgency during the COVID-19 pandemic.