To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from cardiovascular disease (CVD) by the California Pregnancy-Associated Mortality Review committee.
Qualitative descriptive design using thematic analysis.
A total of 269 QIOs identified from 87 pregnancy-related deaths from CVD in California from 2002 to 2007.
We coded and thematically organized the 269 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.
The most prevalent theme within the Readiness domain was the care of women in a facility or a department within a facility that was not equipped to handle the severity of their CVD conditions. For Recognition, a common theme was an underappreciation of the severity of illness, including high-risk factors and clinical warning signs, which led to inaccurate diagnoses, such as anxiety or asthma, and missed diagnoses of CVD. The lack of recognition of CVD led to delays in treatment or inaccurate treatment, the leading themes in the Response domain.
Identification of CVD or its risk factors during pregnancy can lead to timely, multidisciplinary approaches to management and birth in facilities that offer appropriately trained health care professionals and appropriate equipment. Maternal mortality can be reduced if signs and symptoms of CVD in women are recognized early and treatment modalities are implemented quickly during pregnancy, childbirth, and the postpartum period.

This article claims to analyze the situation of children born by means of surrogate maternity contract since these babies are one of the most vulnerable parts of this agreement, so their rights and interests could be affected in many ways. In order to study that situation, in the first place, has been accomplished a brief analysis of the concept of the best interest of the child. Afterwards it is examined the possible violation of the best interest of the child in the cases that have already been examined by Doctrine and Jurisprudence, that is, first the case of registration of these children in the country of origin Civil Registry of the intentional parents, and, in second place, the case of maternity benefit for intentional mothers. The article concludes with a reflection about other situations in where the best interest of children can be affected , such as their right to know their biological origins or the cases of identity problems.

BACKGROUND: Preterm birth is a leading cause of perinatal morbidity and mortality worldwide, resulting in a pressing need to identify risk factors leading to effective interventions. Limited evidence suggests potential relationships between maternal sleep or vital exhaustion and preterm birth, yet the literature is generally inconclusive.
METHODS: We examined the relationship between maternal sleep duration and vital exhaustion in the first six months of pregnancy and spontaneous (non-medically indicated) preterm birth among 479 Peruvian women who delivered a preterm singleton infant (<37 weeks gestation) and 480 term controls who delivered a singleton infant at term (≥37 weeks gestation). Maternal nightly sleep and reports of vital exhaustion were ascertained through in-person interviews. Spontaneous preterm birth cases were further categorized as those following either spontaneous preterm labor or preterm premature rupture of membranes. In addition, cases were categorized as very (<32 weeks), moderate (32-33 weeks), and late (34- <37 weeks) preterm birth for additional analyses. Logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).
RESULTS: After adjusting for confounders, we found that short sleep duration (≤6 hours) was significantly associated with preterm birth (aOR = 1.56; 95% CI 1.11-2.19) compared to 7-8 hours of sleep. Vital exhaustion was also associated with increased odds of preterm birth (aOR = 2.41; 95% CI 1.79-3.23) compared to no exhaustion (Ptrend <0.001). These associations remained significant for spontaneous preterm labor and preterm premature rupture of membranes. We also found evidence of joint effects of sleep duration and vital exhaustion on the odds of spontaneous preterm birth.
CONCLUSIONS: The results of this case-control study suggest maternal sleep duration, particularly short sleep duration, and vital exhaustion may be risk factors for spontaneous preterm birth. These findings call for increased clinical attention to maternal sleep and the study of potential intervention strategies to improve sleep in early pregnancy with the aim of decreasing risk of preterm birth.

Despite appropriate guidelines, healthcare services worldwide often fail to deliver high-impact evidence-based care. This case study describes a large-scale programme to improve integrated postpartum care for mothers and newborns in Niger and Mali. As a result of an improvement effort based on common objectives, local ownership and shared learning to accelerate implementation of best practices, 78 facilities demonstrated rapid improvement in compliance with standards for post-partum haemorrhage prevention and Essential Newborn Care as well as a reduction in estimated postpartum haemorrhage. This approach yields rapid results and can be efficiently spread to improve care in low-resource settings.

The Confidential Review of Maternal Deaths (CRMD) in Kerala was started in 2004, with support from the World Health Organization and modelled on the United Kingdom Confidential Enquiries into Maternal Deaths. It is carried out by the Kerala Federation of Obstetrics and Gynaecology with support from the government of Kerala. The leading causes of maternal deaths identified during the period 2004-09 were haemorrhage, hypertension, amniotic fluid embolism, heart disease and sepsis. Follow-up actions in the form of advocating for emergency preparedness, proper transport and standard protocols for management were initiated. Recently the international arm of the United Kingdom National Institute for Health and Clinical Excellence has helped to establish standards to improve obstetric care in Kerala based on the findings of the CRMD Kerala.

OBJECTIVE: Studies in other developed countries have suggested that socioeconomic position may be a risk factor for poorer pregnancy outcomes. This analysis aimed to explore the independent impact of socioeconomic position on selected severe maternal morbidities among women in Australia.
METHODS: A case-control study using data on severe maternal morbidities associated with direct maternal death collected through the Australasian Maternity Outcomes Surveillance System.
METHODS: Australia.
METHODS: 623 cases, 820 controls.
METHODS: Logistic regression analysis to investigate differences in outcomes among different socioeconomic groups, classified by Socio-Economic Indexes for Areas (SEIFA) quintile.
METHODS: Severe maternal morbidity (amniotic fluid embolism, placenta accreta, peripartum hysterectomy, eclampsia or pulmonary embolism).
RESULTS: SEIFA quintile was statistically significantly associated with maternal morbidity, with cases being twice as likely as controls to reside in the most disadvantaged areas (adjusted OR 2.00, 95%CI 1.29-3.10). Maternal age [adjusted odds ratio (aOR) 2.20 for women aged 35 or over compared with women aged 25-29, 95%CI 1.64-3.15] and previous pregnancy complications (aOR 1.30, 95%CI 1.21-1.87) were significantly associated with morbidity. A parity of 1 or 2 was protective (aOR 0.58, 95%CI 0.43-0.79), whereas previous caesarean delivery was associated with maternal morbidity (aOR 2.20 for women with one caesarean delivery, 95%CI 1.44-2.85, compared with women with no caesareans).
CONCLUSIONS: The risk of severe maternal morbidity among women in Australia is significantly increased by social disadvantage. This study suggests that future efforts in improving maternity care provision and maternal outcomes in Australia should include socioeconomic position as an independent risk factor for adverse outcome.

BACKGROUND: Maternal health outcomes in Nigeria, the most populous African nation, are among the worst in the world, and urgent efforts to improve the situation are critical as the deadline (2015) for achieving the Millennium Development Goals draws near.
OBJECTIVE: To evaluate the results of an integrated maternal, newborn, and child health (MNCH) program to improve maternal health outcomes in Northern Nigeria.
METHODS: The intervention model integrated critical health system and community-based improvements aimed at encouraging sustainable MNCH behavior change. Control Local Government Areas received less intense statewide policy changes.
METHODS: We assessed the impact of the intervention on maternal health outcomes in 3 northern Nigerian states by comparing data from 2360 women in 2009 and 4628 women in 2013 who had a birth or pregnancy in the 5 years prior to the survey.
RESULTS: From 2009 to 2013, women with standing permission from their husband to go to the health center doubled (from 40.2% to 82.7%), and health care utilization increased. The proportions of women who delivered with a skilled birth attendant increased from 11.2% to 23.9%, and the proportion of women having at least 1 antenatal care (ANC) visit doubled from 24.9% to 48.8%. ANC was increasingly provided by trained community health extension workers at the primary health center, who provided ANC to 34% of all women with recent pregnancies in 2013. In 2013, 22% of women knew at least 4 maternal danger signs compared with 10% in 2009. Improvements were significantly greater in the intervention communities that received the additional demand-side interventions.
CONCLUSIONS: The improvements between 2009 and 2013 demonstrate the measurable impact on maternal health outcomes of the program through local communities and primary health care services. The significant improvements in communities with the complete intervention show the importance of an integrated approach blending supply- and demand-side interventions.

BACKGROUND: The use of sets of indicators to assess progress has become commonplace in the global health arena. Exploratory research has suggested that indicators used for global monitoring purposes can play a role in national policy-making, however, the mechanisms through which this occurs are poorly understood. This article reports findings from two qualitative studies that aimed to explore national policy-makers\' interpretation and use of indicators from country profiles and reports developed by Countdown to 2015.
METHODS: An initial study aimed at exploring comprehension of Countdown data was conducted at the 2010 joint Women Deliver/Countdown conference. A second study was conducted at the 64th World Health Assembly in 2011, specifically targeting national policy-makers. Semi-structured interviews were carried out with 29 and 22 participants, respectively, at each event. Participants were asked about their understanding of specific graphs and indicators used or proposed for use in Countdown country profiles, and their perception of how such data can inform national policy-making. Responses were categorised using a framework analysis.
RESULTS: Respondents in both studies acknowledged the importance of the profiles for tracking progress on key health indicators in and across countries, noting that they could be used to highlight changes in coverage, possible directions for future policy, for lobbying finance ministers to increase resources for health, and to stimulate competition between neighbouring or socioeconomically similar countries. However, some respondents raised questions about discrepancies between global estimates and data produced by national governments, and some struggled to understand the profile graphs shown in the absence of explanatory text. Some respondents reported that use of Countdown data in national policy-making was constrained by limited awareness of the initiative, insufficient detail in the country profiles to inform policy, and the absence of indicators felt to be more appropriate to their own country contexts.
CONCLUSIONS: The two studies emphasise the need for country consultations to ensure that national policy-makers understand how to interpret and use tools like the Countdown profile for planning purposes. They make clear the value of qualitative research for refining tools used to promote accountability, and the need for country level Countdown-like processes.

OBJECTIVE: A substantial proportion of women in treatment for substance use problems are mothers of dependent children, but only a small number of studies have explored the nature and extent of their child protection involvement with substance-using mothers themselves.
METHODS: A large sample of mothers on the opioid treatment program (OTP) in Sydney, Australia, were interviewed. This paper describes their characteristics, the extent and nature of their involvement with the child protection system, the parenting-related interventions provided and their views of their own parenting.
RESULTS: The 171 mothers were disadvantaged and marginalised and had 302 children under the age of 16 years, 99 of whom were in out-of-home care. Nearly half the children in care (n = 42) had been removed at the time of their birth, and half (n = 49) had been removed from a mother who was on an OTP at the time. Among the younger children (age 1-2 years), higher proportions had been removed at birth than among the older children. None of the 32 mothers who had a child removed at birth and then gave birth subsequently retained care of their new baby. Women often chose to enter treatment (63.6%) for child-related reasons (35%) and attempted to shield their children from their substance use. Few health services were provided to them outside the availability of OTP.
CONCLUSIONS: Entering treatment presents an opportunity for improving outcomes for these women and their children and to reduce future involvement with the child protection system.

BACKGROUND: Maternal health status might have an important effect on breastfeeding, growth, and general health of the infants.
OBJECTIVE: This study was conducted to assess the association between maternal mental health and breastfeeding status of mothers in Kashan province.
METHODS: This case-control study was conducted on 458 mothers in two groups of unsuccessful breastfeeding (case) and successful breastfeeding (control) attending Kashan province health clinics. In this study, the GHQ questionnaire and clinical interview were employed to collect data. The data were statistically analyzed using Chi-square and Fisher\'s exact tests.
RESULTS: It was found that mothers of the case group had a greater susceptibility to depression than those of the control group, that is, breastfeeding status was directly associated with susceptibility to depression (P = 0.001, OR = 5.48). Furthermore, there was a significant association between basic characteristics such as maternal occupational status (P = 0.04) or their educations (P = 0.006) with breastfeeding. Besides, clinical interview revealed that mixed depression and anxiety disorder was the most prevalent type of psychological disorder in the case group.
CONCLUSIONS: Screening depression during pregnancy and postpartum period appeared to be necessary and it should be incorporated into prenatal and postnatal care due to its influence on mothers\' successful breastfeeding.