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Severe maternal morbidity (SMM) rates in the United States more than doubled between 1998 and 2010. Advanced maternal age and chronic comorbidities do not completely explain the increase in SMM or how to effectively address it. The Centers for Disease Control and Prevention and American College of Obstetricians and Gynecologists have called for facility-level multidisciplinary review of SMM for potential preventability and have issued implementation guidelines. Within Illinois, SMM was identified as any intensive or critical care unit admission and/or 4 or more units of packed red blood cells transfused at any time from conception through 42 days postpartum. All cases meeting this definition were counted during statewide surveillance. Cases were selected for review on the basis of their potential to yield insights into factors contributing to preventable SMM or best practices preventing further morbidity or death. If the SMM review committee deemed a case potentially preventable, it identified specific factors associated with missed opportunities and made actionable recommendations for quality improvement. Approximately 1100 cases of SMM were identified from July 1, 2016, to June 30, 2017, yielding a rate of 76 SMM cases per 10 000 pregnancies. Reviews were conducted on 142 SMM cases. Most SMM cases occurred during delivery hospitalization and more than half were delivered by cesarean section. Hemorrhage was the primary cause of SMM (>50% of the cases). Facility-level SMM review was feasible and acceptable in statewide implementation. States that are planning SMM reviews across obstetric facilities should permit ample time for translation of recommendations to practice. Although continued maternal mortality reviews are valuable, they are not sufficient to address the increasing rates of SMM and maternal death. In-depth multidisciplinary review offers the potential to identify factors associated with SMM and interventions to prevent women from moving along the continuum of severity.

Many obstetric fistula patients remain untreated or present late to treatment despite increasing surgical availability in Uganda. We explored women's perceptions of the cause of their obstetric fistula and their treatment seeking behaviours, including barr iers and facilitators to timely care access. In-depth interviews and focus group discussions were conducted from June-August 2014 among 33 women treated for obstetric fistula at Mulago Hospital, Kampala. Data were analysed to describe dimensions and commonalities of themes identified under perceived causes and treatment seeking experiences, and their intersection. Perceived obstetric fistula causes included delays in deciding on hospital delivery, lengthy labour, injury caused by the baby, health worker incompetence, and traditional beliefs. Treatment seeking timing varied. Early treatment seeking was facilitated by awareness of treatment availability through referral, the media, community members, and support by partners and children. Barriers to earl y treatment seeking included inadequate financial and social support, erroneous perceptions about fistula causes and curability, incorrect diagnoses, and delayed or lack of care at health facilities. Our study supports broad educational and awareness activities, facilitation of social and financial support for accessing care, and improving the quality of emergency obstetric care and fistula treatment surgical capacity to reduce women's suffering. (Afr J Reprod Health 2020; 24[2]: 129-140). De nombreux patients atteints de fistule obstétricale restent non traités ou se présentent tardivement au traitement malgré une disponibilité chirurgicale croissante en Ouganda. Nous avons exploré la perception qu'ont les femmes de la cause de leur fistule obstétricale et de leurs comportements de recherche de traitement, y compris les obstacles et les facilitateurs pour un accès rapide aux soins. Des entretiens approfondis et des discussions de groupe ont été menés de juin à août 2014 auprès de 33 femmes traitées pour fistule obstétricale à l'hôpital de Mulago, Kampala. Les données ont été analysées pour décrire les dimensions et les points communs des thèmes identifiés sous les causes perçues et les expériences de recherche de traitement, et leur intersection. Les causes perçues de la fistule obstétricale comprenaient des retards dans les décisions d'accouchement à l'hôpital, un travail prolongé, des blessures causées par le bébé, l'incompétence des agents de santé et les croyances traditionnelles. Le calendrier de recherche du traitement variait. La recherche précoce d'un traitement a été facilitée par la sensibilisation à la disponibili té du traitement grâce à l'aiguillage, aux médias, aux membres de la communauté et au soutien des partenaires et des enfants. Les obstacles à la recherche d'un traitement précoce comprenaient un soutien financier et social inadéquat, des perceptions erronées sur les causes et la curabilité des fistules, des diagnostics incorrects et un retard ou un manque de soins dans les établissements de santé. Notre étude soutient de vastes activités d'éducation et de sensibilisation, la facilitation du soutien social et financier pour l'accès aux soins et l'amélioration de la qualité des soins obstétricaux d'urgence et du traitement chirurgical de la fistule pour réduire la souffrance des femmes. (Afr J Reprod Health 2020; 24[2]:129-140).

Obstetric hemorrhage, with its related complications, remains a significant and often preventable cause of maternal morbidity and mortality. The medical community has made strides in beginning to address the impact of obstetric hemorrhage as a cause of maternal morbidity and mortality with standardized bundles outlining key elements for hospitals to address in order to optimize hemorrhage prevention and management. Changes in definitions, an expansion of the spectrum of causes, variation in interventions and guidelines and lack of innovation are some of the issues that pose ongoing challenges for meaningful risk reduction. Opportunities to support risk reduction include helping to secure necessary resources, building team training and simulation programs, developing interventions targeted at minimizing cognitive biases, and facilitating patient and family support program development.

ObjectivesBlack women face disparities in maternal morbidity and mortality when compared to White women. Multiple factors contribute to these disparities. This study examines the perspectives of Black women who have given birth in the last 5 years, to understand their pregnancy and birth experiences as a means of ascertaining factors that may be contributing to these disparities.MethodsThe Consortium to End Black Maternal Mortality was established as a collaborative table of cross-sector stakeholders and Black mothers to effectively conduct community-based participatory research focused on Black maternal health. Between January and March 2020, Black mothers who had given birth in the last 5 years facilitated Listening Sessions (LS) with other Black mothers in Rochester, NY. Participants reported on details of their pregnancy and delivery, including interaction with providers, personal relationships and their individual experience. The qualitative data captured during these sessions were coded to draw out key themes which were validated with LS participants and the Consortium.ResultsThe key themes that emerged clustered into four groups, including: (1) Mother-Provider Communication; (2) Social Support; (3) Systemic factors and (4) Maternal Emotional & Mental Health. Mother-provider communication was the most salient factor affecting the maternal experience and was found to be influenced primarily by maternal health literacy and provider discriminatory attitudes and behaviors.Conclusions for PracticeAs a result of the Listening Sessions conducted with Black women, we identified mother-provider communication as the most important factor influencing the maternal experience.

In early December 2019 a cluster of cases of pneumonia of unknown cause was identified in Wuhan, a city of 11 million persons in the People’s Republic of China. Further investigation revealed these cases to result from infection with a newly identified coronavirus, initially termed 2019-nCoV and subsequently SARS-CoV-2. The infection moved rapidly through China, spread to Thailand and Japan, extended into adjacent countries through infected persons travelling by air, eventually reaching multiple countries and continents. Similar to such other coronaviruses as those causing the Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS), the new coronavirus was reported to spread via natural aerosols from human-to-human. In the early stages of this epidemic the case fatality rate is estimated to be approximately 2%, with the majority of deaths occurring in special populations. Unfortunately, there is limited experience with coronavirus infections during pregnancy, and it now appears certain that pregnant women have become infected during the present 2019-nCoV epidemic. In order to assess the potential of the Wuhan 2019-nCoV to cause maternal, fetal and neonatal morbidity and other poor obstetrical outcomes, this communication reviews the published data addressing the epidemiological and clinical effects of SARS, MERS, and other coronavirus infections on pregnant women and their infants. Recommendations are also made for the consideration of pregnant women in the design, clinical trials, and implementation of future 2019-nCoV vaccines.

Maternal mortality is rising in the USA. The pregnancy-related maternal mortality ratio increased from 10/100,000 to 17/100,000 live births from the 1990s to 2012. A large proportion of maternal deaths are preventable. This review highlights a national approach to reduce maternal death and morbidity and discusses multiple efforts to reduce maternal morbidity, death and improve obstetric safety. These efforts include communication and collaboration between all stake holders involved in perinatal health, creation of national bundles addressing key maternal care areas such as hemorrhage management, call for all obstetric hospitals to review and analyze all cases of severe maternal morbidity, and access to contraception. Implementation of interventions based on these efforts is a national imperative to improve obstetric safety.

Background Anaemia and depression are common conditions which affect pregnant and postpartum women. Evidence points to associations between anaemia and iron deficiency during pregnancy, and mental health disorders like depression. However, it is unclear the association between improvement in anaemia severity or iron levels during pregnancy and incidence of postpartum depression. Objectives This study examined association between improvement in anaemia severity and iron levels during pregnancy after four weeks of treatment and the incidence of depression at two weeks postpartum. Methods This cohort study nested within a clinical trial in Lagos Nigeria, included 438 anaemic (haemoglobin concentration < 11 g/dL) pregnant women at 20–32 weeks’ gestation without depression followed up until two weeks postpartum. Participants received either intravenous or oral iron treatment at enrolment. Repeat screening for anaemia and iron deficiency (serum ferritin < 30ng/mL) was done at four weeks post-treatment. The outcome, depression (score > 10), was measured at two weeks postpartum using validated Edinburgh Postnatal Depression Scale. Associations between improvement in anaemia severity and iron levels after four weeks post-enrolment versus depression at two weeks postpartum were examined using logistic regression analysis, adjusting for confounders. Results Mean age of women was 29.5 ± 5.6years. Median haemoglobin concentration of 9.3 (IQR: 8.8–9.8)g/dL and median serum ferritin 44.4 (IQR: 22.1–73.7)ng/mL at enrolment. Prevalence of postpartum depression was 5.8% (95%CI: 3.8–8.5%). There was a non-significant association between improvement in anaemia severity at four weeks post-enrolment and postpartum depression, aOR: 0.15 (95%CI: 0.02–1.15). The odds for postpartum depression was nearly five times higher in women who had postpartum haemorrhage, aOR: 4.90 (95%CI: 1.18–20.36). In the subgroup with iron deficiency ( n  = 148), no association was found between an improvement in iron levels four weeks post-enrolment and the odds for postpartum depression, aOR: 1.14 (95%CI: 0.09–3.93). Conclusion Improvement in anaemia severity during late pregnancy was non-significantly associated with lower risk for postpartum depression; no association between improvement in iron levels and postpartum depression. It is likely that an improvement in anaemia severity in early pregnancy will lessen the burden of postpartum depression; however, this study is limited by sample size to draw this conclusion.

PurposeThe purpose of this report from the field is to describe the process by which an multidisciplinary workgroup, selected by the CDC Foundation in partnership with maternal health experts, developed a definition of racism that would be specifically appropriate for inclusion on the Maternal Mortality Review Information Application (MMRIA) form.DescriptionIn the United States Black women are nearly 4 times more likely to experience a pregnancy-related death. Recent evidence points to racism as a fundamental cause of this inequity. Furthermore, the CDC reports that 3 of 5 pregnancy related deaths are preventable. With these startling facts in mind, the CDC created the Maternal Mortality Review Information Application (MMRIA) for use by Maternal Mortality Review Committees (MMRC) to support standardized data abstraction, case narrative development, documentation of committee decisions, and analysis on maternal mortality to inform practices and policies for preventing maternal mortality.AssessmentCharged with the task of defining racism and discrimination as contributors to pregnancy related mortality, the work group established four goals to define their efforts: (1) the desire to create a product that was inclusive of all forms of racism and discrimination experienced by birthing people; (2) an acknowledgement of the legacy of racism in the U.S. and the norms in health care delivery that perpetuate racist ideology; (3) an acknowledgement of the racist narratives surrounding the issue of maternal mortality and morbidity that often leads to victim blaming; and (4) that the product would be user friendly for MMRCs.ConclusionThe working group developed three definitions and a list of recommendations for action to help MMRC members provide suggested interventions to adopt when discrimination or racism were contributing factors to a maternal death. The specification of these definitions will allow the systematic tracking of the contribution of racism to maternal mortality through the MMRIA and allow a greater standardization of its identification across participating jurisdictions with MMRCs that use the form.

Background Twin pregnancy was associated with significantly higher rates of adverse neonatal and perinatal outcomes, especially for the second twin. In addition, the maternal complications (potentially life-threatening conditions-PLTC, maternal near miss-MNM, and maternal mortality-MM) are directly related to twin pregnancy and independently associated with adverse perinatal outcome. The objective of the preset study is to evaluate perinatal outcomes associated with twin pregnancies, stratified by severe maternal morbidity and order of birth. Methods Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), a cross-sectional study implemented in 29 countries. Data from 8568 twin deliveries were compared with 308,127 singleton deliveries. The occurrence of adverse perinatal outcomes and maternal complications were assessed. Factors independently associated with adverse perinatal outcomes were reported with adjusted PR (Prevalence Ratio) and 95%CI. Results The occurrence of severe maternal morbidity and maternal death was significantly higher among twin compared to singleton pregnancies in all regions. Twin deliveries were associated with higher rates of preterm delivery (37.1%), Apgar scores less than 7 at 5th minute (7.8 and 10.1% respectively for first and second twins), low birth weight (53.2% for the first and 61.1% for the second twin), stillbirth (3.6% for the first and 5.7% for the second twin), early neonatal death (3.5% for the first and 5.2% for the second twin), admission to NICU (23.6% for the first and 29.3% for the second twin) and any adverse perinatal outcomes (67% for the first twin and 72.3% for the second). Outcomes were consistently worse for the second twin across all outcomes. Poisson multiple regression analysis identified several factors independently associated with an adverse perinatal outcome, including both maternal complications and twin pregnancy. Conclusion Twin pregnancy is significantly associated with severe maternal morbidity and with worse perinatal outcomes, especially for the second twin.

Cardiotocography (CTG) interpretation is prone to inter-observer variability and may contribute to both missed fetal compromise and potentially avoidable intrapartum intervention. Physiological CTG interpretation (PCI) reframes fetal surveillance around fetal physiology and the intensity of hypoxic stress, but real-world outcome data after unit-wide implementation remain limited. Historical pre-post cohort study with case-mix adjustment at University Hospital Ulm, a tertiary perinatal center in Germany (~3200 births/year). We included term singleton pregnancies (≥37 + 0 weeks) with intended vaginal birth, comparing a pre-implementation period (January 01-December 31, 2018) with a post-implementation period after full adoption (May 01, 2022-April 30, 2023). PCI was introduced as a multicomponent implementation strategy (training, bedside facilitation, documentation changes, and sustainment). composite neonatal morbidity defined as neonatal unit (NNU) transfer plus ≥1 of: umbilical artery pH <7.15, base deficit >16 mmol/L, or 5-min Apgar score <7. umbilical artery acid-base status, Apgar scores, NNU transfer, intrapartum interventions (e.g., oxytocin, tocolysis, fetal scalp blood sampling), mode of birth, and postpartum blood loss. Outcomes were compared using multivariable regression and propensity score matching. A total of 4484 births met the inclusion criteria (2352 pre-implementation; 2132 post-implementation). Composite neonatal morbidity decreased from 4.10% to 2.92% (OR 0.67; 95% CI 0.434-0.958; p = 0.0259). Neonatal acidosis decreased (umbilical artery pH <7.10: 3.87%-2.53%; OR 0.649; 95% CI 0.450-0.919; p = 0.014), and NNU transfers declined (13.18%-9.19%; OR 0.667; 95% CI 0.59-0.808; p < 0.001). Cesarean section rates were not increased after adjustment (OR 0.880; 95% CI 0.722-1.071). Postpartum blood loss was higher post-implementation (438 vs 497 mL; p < 0.001). Unit-wide implementation of PCI was associated with improved neonatal outcomes, including fewer NNU admissions, without an increase in adjusted cesarean section rates. These findings support PCI as a promising framework for intrapartum fetal surveillance, warranting confirmation in multicenter studies and evaluation across different care settings.