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Maternal mortality, near-miss and stillbirths in Suriname

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(1)Safe Motherhood. Maternal mortality, near-miss and stillbirths in Suriname Time to respond. Kim Verschueren.

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(6) PROMOTIECOMMISSIE Promotor. Prof. dr. K.W.M. Bloemenkamp. Copromotoren. Dr. J.L. Browne Dr. M.J. Rijken. Beoordelingscommissie. Prof. dr. M.J.N.L. Benders Prof. dr. D.E. Grobbee Prof. dr. M. Knight Prof. dr. A.M. McCaw-Binns Dr. S. Vreden. 4.

(7) Contents 8. Personal justification Chapter 1. General Introduction. 11. Part I - Surveillance Chapter 2. Maternal mortality audit in Suriname between 2010 and 2014,. 31. a reproductive age mortality survey. BMC Pregnancy and Childbirth. 2017;17:275 Chapter 3. Childbirth outcomes and ethnic disparities in Suriname: a. 47. nationwide registry-based study in a middle-income country. BMC Reproductive Health. 2020;17:62 Part II - Global classification systems Chapter 4. Classifying maternal deaths in Suriname using WHO ICD-MM;. 75. different interpretation by physicians, national and international maternal death review committees. BMC Reproductive Health. 2020; in press Chapter 5. Applicability of the WHO maternal near-miss tool: a. 103. nationwide surveillance study in Suriname. Journal of Global Health. 2020;10:2,020429 Chapter 6. Investigation of stillbirth causes in Suriname: application of the. 137. WHO ICD-PM to national-level hospital data. Global Health Action. 2020;13:1,1794105. 5.

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(18) Chapter 1. ^UcT]cWTaTbd[c^U_^[XcXRP[P]STR^]^\XRUPRc^abX\_TSX]VPRRTbbP]SST[XeTah ^UQPbXRbTaeXRTb G. 8] bcPVT 88 cWT <<A Xb [^fTa (((" _Ta  [XeT QXacWb P]S f^\T] \^bc[h SXT SdT c^ SXaTRc ^QbcTcaXR RPdbTb ^U \PcTa]P[ \^acP[Xch P]S R^\\d]XRPQ[TSXbTPbTb0WXVWTa_a^_^acX^]^Uf^\T]aTRTXeT\PcTa]P[RPaT hTccWTX]UaPbcadRcdaTP]ScWTWTP[cWRPaTbhbcT\PaTfTPZCWXbXbcWTaTbd[c^U P[PRZ^UPRRTbbXTUXabcP]SbTR^]SST[PhbP]S_^^a`dP[Xch^URPaTfXcWbTeTaT bW^acPVTb^UbcPUUP]SaTb^daRTb. G. 8]BcPVT888cWT<<A[^fTabc^!(($_Ta [XeTQXacWbP]SUTacX[XchaPcTb Sa^_ CWXb bcPVT Xb R^]bXSTaTS P cX__X]V _^X]c Pb f^\T] VT]TaP[[h aTPRW W^b_XcP[bP]S`dP[Xch^URPaTQTR^\TbcWTZThSTcTa\X]P]c^UWTP[cW^dcR^\Tb XTcWXaSST[PhFWX[TSXaTRcRPdbTbbcX[[RPdbTcWT\PY^aXch^USTPcWbcWTaTXb P]X]RaTPbTX]X]SXaTRcRPdbTbP]S]^]R^\\d]XRPQ[TSXbTPbTb. G. 8] BcPVT 8E cWT <<A Xb +$ _Ta  [XeT QXacWb  8]SXaTRc RPdbTb PaT cWT _aX\PahRPdbT^U\PcTa]P[\^acP[XchP]S]^]R^\\d]XRPQ[TSXbTPbTPbfT[[Pb ^eTa\TSXRP[XiPcX^]T\TaVTPbcWTVaTPcTbccWaTPcc^cWT`dP[XchP]SX\_a^eTS WTP[cW^dcR^\Tb. G. BcPVT E <<A +$ _Ta  [XeT QXacWb Xb \^bc[h Pb_XaPcX^]P[ fXcW ]^ Pe^XSPQ[T\PcTa]P[STPcWb. CW^dVW \PcTa]P[ \^acP[Xch bTT\b c^ QT Pbb^RXPcTS fXcW cWT X]R^\T [TeT[ ^U P R^d]cahcWTX]RaTPbTX]]PcX^]P[X]R^\TS^Tb]^cVdPaP]cTTPSTRaTPbTX]\PcTa]P[ \^acP[Xch  3XUUTaT]RTb X] \PcTa]P[ \^acP[Xch aPcX^b fXcWX] R^d]caXTb PaT VaTPc Tb_TRXP[[h X] \XSS[TX]R^\T R^d]caXTb P]S RP] ^UcT] QT PccaXQdcTS c^ b^RXP[ X]T`dXchfXcWX]cWTR^d]cah ;PcX]0\TaXRPXbcWTf^a[SaTVX^]fXcWcWTWXVWTbc X]R^\TX]T`dP[XchP]SXbP[b^cWTaTVX^]fXcWcWT[PaVTbcWTP[cWSXb_PaXcXTb. ! ". . <PcTa]P[]TPa\Xbb <PcTa]P[ \^acP[Xch Xb ^][h cWT cX_ ^U cWT XRTQTaV 5XVdaT !. # $.  5^a TPRW f^\P]. fW^ SXTb \P]h \^aT bdUUTa Ua^\ [XUTcWaTPcT]X]V R^]SXcX^]b CWTbT f^\T] ]Paa^f[hTbRP_TSTPcWTXcWTaQhRWP]RT^aQTRPdbT^UcWTRPaTcWThaTRTXeTSQdc ^UcT]WPeT[XUT[PbcX]VSXbPQX[XcXTb #. SV 14.

(19) General introduction. 5XVdaT!0aT_aTbT]cPcX^]^UcWT\PcTa]P[\^acP[XchR^]cX]dd\. # $. 1. .              CWT PSeP]cPVT ^U bcdShX]V \PcTa]P[ ]TPa\Xbb <=< ^eTa \PcTa]P[ STPcWb Xb cWPc Xc ^RRdab \^aT UaT`dT]c[h P]S Xb [Tbb cWaTPcT]X]V c^ PdSXc Qh WTP[cW RPaT _a^eXSTab 8] WXVWX]R^\T R^d]caXTb fXcW ^][h UTf \PcTa]P[ STPcWb _Ta hTPa ^a bTccX]VbfXcWP]PQb^[dcT[^f]d\QTa^U\PcTa]P[STPcWbBdaX]P\TU^aTgP\_[T bcdShX]V]TPa\XbbWPbQTT]dbTSPbP_a^ghc^\TPbdaTcWT`dP[Xch^U^QbcTcaXR RPaT %2[X]XRP[PdSXcXbPdbTUd[P__a^PRWc^aTeXTfRPbTbXST]cXUhSTUXRXT]RXTbX] cWT_a^eXbX^]^URPaTP]Sd[cX\PcT[hX\_a^eTcWT`dP[Xch^U^QbcTcaXRRPaT &CWT V[^QP[RWP[[T]VTX]bcdShX]V<=<XbcWTSTUX]XcX^] fWT]c^R^]bXSTaPf^\P]c^ WPeT]Paa^f[hTbRP_TSSTPcW5XVdaT!P]SW^fc^bhbcT\PcXRP[[hXST]cXUhcWTbT f^\T]_PaPVaP_W!. # % '!. . 2^\_[XRPcX^]b SdaX]V _aTV]P]Rh P]S RWX[SQXacW PaT Pbb^RXPcTS fXcW [^]V[PbcX]V PSeTabT _WhbXRP[ P]S _bhRW^b^RXP[ TUUTRcb U^a \^cWTa UP\X[XTb P]S cWTXa ^UUb_aX]V!. !!.  <PcTa]P[ ]TPa\Xbb Xb P[b^ bca^]V[h Pbb^RXPcTS fXcW _TaX]PcP[. \^acP[Xch bcX[[QXacWb P]S TPa[h ]T^]PcP[ STPcWb P]S ^cWTa PSeTabT _TaX]PcP[ ^dcR^\TbXTQXacWPb_WhgXP_aTcTa\QXacW[^fQXacWfTXVWc=T^]PcP[8]cT]bXeT 2PaTD]XcPS\XbbX^]!"!&CWTaTU^aTTUU^acb\PSTc^aTSdRT\PcTa]P[\^acP[XchP]S ]TPa\XbbfX[[[XZT[hP[b^aTSdRTcWT^RRdaaT]RT^UPSeTabT_TaX]PcP[^dcR^\Tb. . SW 15.

(20) Chapter 1. BcX[[QXacWb BcX[[QXacWbU^a\PbT]bXcXeT\PaZTa^UcWTWTP[cWbhbcT\bbcaT]VcW0]TbcX\PcTS !%\X[[X^]bcX[[QXacW^RRdaaTSV[^QP[[hX]! $ '_Ta QXacWb\^bcX];<82 P]SWP[UUa^\_aTeT]cPQ[TRPdbTb!'BcX[[QXacWbPaTP]TV[TRcTSXbbdTTgR[dSTSUa^\ cWT<36bP]SB36bP]SX]eXbXQ[TX]\^bc]PcX^]P[_^[XRXTb"#>]TX\_^acP]caTPb^] cWTbTQPQXTbPaTd]S^Rd\T]cTSXbcWT[PRZ^UaTVXbcaPcX^]^UbcX[[Q^a]QPQXTbQheXcP[ bcPcXbcXRb X] \P]h R^d]caXTb!'!( 2^\_PaTS c^ \PcTa]P[ P]S ]T^]PcP[ \^acP[Xch UTfTabcdSXTbWPeTQTT]R^]SdRcTSP]ScWTaTSdRcX^]^UbcX[[QXacWbWPbQTT]TeT] b[^fTa"" CWT ;P]RTcBTaXTb 4]SX]V?aTeT]cPQ[TBcX[[QXacWRP[[TSU^aPRcX^]P]S TbcPQ[XbWTScWTPX\c^aTSdRTbcX[[QXacWbc^]^\^aTcWP] _Ta c^cP[QXacWbX] TeTahR^d]cahQh!"$!(<^bcR^d]caXTbX]cWTf^a[SX]R[dSX]VBdaX]P\TWPeT]^c T]S^abTScWXbcPaVTcfXcWX]cWTXa]PcX^]P[WTP[cW_[P]"""8\_a^eTSaTVXbcaPcX^] P]SbdaeTX[[P]RT^UbcX[[QXacWbR[PbbXUXRPcX^]^URPdbTbP]SPdSXc\PhR^]caXQdcTc^ XST]cXUhX]V cWT VP_b X] `dP[Xch ^U RPaT fWXRW ]TTS c^ QT cPaVTcTS c^ T[X\X]PcT _aTeT]cPQ[T bcX[[QXacWb P]S SdT c^ cWT X]caXRPcT aT[PcX^]bWX_ fXcW \PcTa]P[ R^]SXcX^]bP[b^aTSdRTbTeTaT\PcTa]P[^dcR^\Tb"" . 2[PbbXUXRPcX^]^USTPcWP]S]TPa\XbbRPdbTb 2[PbbXUXRPcX^]^USXbTPbTbP]Sd]STa[hX]VRPdbTbXbRadRXP[c^T]PQ[TV[^QP[P]S[^RP[ R^\_PaXb^] P]S STeT[^_ cPaVTcTS bcaPcTVXTb CWT F^a[S 7TP[cW >aVP]XiPcX^] F7>STeT[^_TScWT8]cTa]PcX^]P[2[PbbXUXRPcX^]^U3XbTPbTb<PcTa]P[<^acP[Xch 823<< ! ! P]S ?TaX]PcP[ <^acP[Xch 823?< ! %"#"$ 2[PbbXUXRPcX^] RWP[[T]VTbX]R[dSTSXUUXRd[chX]STcTa\X]X]VcWTRPdbTX]P[^]VRWPX]^UTeT]cbP]S W^f c^ STP[ fXcW cWT \P]h d]Z]^f] RPdbTb SdT c^ P [PRZ ^U _^bc\^acT\ X]eTbcXVPcX^]bTb_TRXP[[hX];<82"%"&8]\PcTa]P[]TPa\XbbR[PbbXUXRPcX^]cWTaTXb cWT RWP[[T]VT cWPc cWT STUX]XcX^] [XUTcWaTPcT]X]V SXUUTab _Ta bTccX]Vb CWT F7> STeT[^_TScWT]TPa\Xbbc^^[F7><=<!.  #dbX]V^][h^aVP]ShbUd]RcX^]. RaXcTaXP7^fTeTaQ^cWWXVWP]S[^fX]R^\TR^d]caXTbaT_^acd]STaaT_^acX]VP]S RP[[U^a[^RP[PSP_cPcX^]b^UcWTRaXcTaXP. (!. 2daaT]cR[PbbXUXRPcX^]c^^[b\Ph]^cQT. _TaUTRc hTc aTR^\\T]SPcX^]b U^a X\_a^eT\T]c fX[[ ^][h d]eTX[ cWa^dVW Xcb P__[XRPcX^]. SX 16.

(21) General introduction. @dP[Xch^URPaTP]SRaXcTaX^]QPbTSPdSXc CWT F7> STUX]Tb `dP[Xch ^U RPaT Pb cWT TgcT]c c^ fWXRW WTP[cW RPaT bTaeXRTb _a^eXSTS X\_a^eT STbXaTS WTP[cW ^dcR^\Tb 8] ^aSTa c^ PRWXTeT cWXb WTP[cW RPaT \dbcQTbPUTTUUTRcXeTcX\T[hTUUXRXT]cT`dXcPQ[TP]S_T^_[TRT]caTS"'C^PbbTbb X\_a^eT\T]cb X] `dP[Xch ^U RPaT Xc \dbc QT \TPbdaTS _aTUTaPQ[h X] P bcP]SPaSXiTS U^a\"'"( 2aXcTaX^]QPbTS PdSXc 210 Xb P dbTUd[ \TcW^S U^a TeP[dPcX]V`dP[Xch^URPaTP]SX]e^[eTbbcadRcdaTS_TTaaTeXTffWTaTQhR[X]XRXP]b TgP\X]TcWT_aPRcXRT_PcXT]cb\TSXRP[aTR^aSPVPX]bcPVaTTSbcP]SPaS^UV^^S `dP[Xch RPaT##  CW^dVW ]^c TgcT]bXeT cWT F7> STeT[^_TS P bTc ^U V[^QP[ X]SXRPc^abU^acWTTeP[dPcX^]^U`dP[Xch^U^QbcTcaXRRPaT"(#!C^STUX]T`dP[Xch^U RPaT P]S bcP]SPaSb U^a 210 ]PcX^]P[ VdXST[X]Tb P]S X]cTa]PcX^]P[ aTR^\\T]SPcX^]bRP]QTdbTS]Tgcc^cWTF7>V[^QP[X]SXRPc^ab . ?3B0RhR[T 0 _^fTaUd[ U^dabcT_ P__a^PRW c^ R^]cX]dP[[h X\_a^eT P]S PSP_c _a^RTbbTb fPb STeT[^_TS Qh FX[[XP\ 4SfPaSb 3T\X]V) CWT ?[P]3^BcdSh0Rc ?3B0 RhR[T#" CWT X\_PRc ^U cWT RhR[T Xb ST_T]ST]c ^] P[[ R^\_^]T]cb ]^ bca^]VTa cWP] Xcb fTPZTbc [X]Z#" CWT ?3B0RhR[T RP] P[b^ QT P__[XTS X] cWT PccT\_c c^ aTSdRT \PcTa]P[ \^acP[Xch ]TPa\Xbb P]S bcX[[QXacWb###& 4gP\_[Tb ^U Xcb P__[XRPcX^] PaT fXcWX] cWT <PcTa]P[ 3TPcW BdaeTX[[P]RT P]S ATb_^]bT <3BA###$ 210##  P]S fXcWX] ]PcX^]fXST bdaeTX[[P]RT bcdSXTb#%#& CWT aT_TPcTS[h X\_[T\T]cTS ?3B0 RhR[TX]b_XaP[b^UX]RaTPbX]VZ]^f[TSVTQaX]VTPRWRhR[TR[^bTacWP]cWT_aTeX^db c^ cWT d[cX\PcT V^P[ FT fX[[ P__[h cWXb dbTUd[ P__a^PRW SdaX]V cWT bcdSXTb _aTbT]cTSX]cWXbcWTbXb. . SY 17. 1.

(22) Chapter 1. BdaX]P\T. BTccX]V BdaX]P\TXbP\d[cXTcW]XRd__Ta\XSS[TX]R^\TR^d]cah^]cWT]^acWTPbcR^Pbc ^UB^dcW0\TaXRP8cR^eTabP]PaTP^U %"'!Z\!R^]bXbcb^Uca^_XRP[aPX]U^aTbc U^a(P]S\^bc^UcWT_^_d[PcX^]'[XeTbX]cWT]Paa^fR^PbcP[_[PX]c^cWT R^d]cahb]^acW#'FXcWP]TbcX\PcTS_^_d[PcX^]^U$&%_T^_[T! (XcXb^]T ^UcWT[TPbc_^_d[^dbR^d]caXTbX]cWT0\TaXRPb#'#(. 3XeTabXchP]STcW]XRSXbcaXQdcX^] CWTTcW]XRP[SXbcaXQdcX^]P\^]Vf^\T]X]BdaX]P\TXb)7X]SdbcP]X!'<Pa^^] !"2aT^[T &9PeP]TbT "<XgTS !8]SXVT]^db#P]S>cWTa" X] ! '#'#( 3XeTabXch X] BdaX]P\T Xb P aTU[TRcX^] ^U cWT R^d]cahb WXbc^ah#($! 8]SXVT]^db_T^_[TP[b^Z]^f]Pb0\TaX]SXP]bPaTcWT^aXVX]P[X]WPQXcP]cb^UcWT R^d]cah <Pa^^] P]S 2aT^[Tb PaT 0UaXRP]STbRT]SP]cb fW^ fTaT T]b[PeTS P]S Qa^dVWc c^ BdaX]P\T Qh 4da^_TP]b X] cWT bTeT]cTT]cW P]S TXVWcTT]cW RT]cdah <Pa^^] _T^_[T X] R^]caPbc c^ 2aT^[Tb TbRP_TS X]c^ cWT X]cTaX^a ^U cWT R^d]cah 2aT^[TbVPX]TScWTXaUaTTS^\X] '%"fWT]b[PeTahfPbPQ^[XbWTSX]BdaX]P\TP]S ^UcT] WPeT \XgTS 0UaXRP]  4da^_TP] 3dcRW P]S 1aXcXbW P]RTbcah 0bXP] STbRT]SP]cb) 7X]SdbcP]X Ua^\ 4Pbc8]SXP 9PeP]TbT Ua^\ 8]S^]TbXP cWT] P 3dcRWad[TSR^[^]hP]S2WX]TbT_T^_[TRP\Tc^BdaX]P\TX]cWT[PcT]X]TcTT]cW RT]cdahPbR^]caPRcf^aZTab<XgTS_T^_[TPaTcWTaTbd[c^UX]cTaRWP]VX]VXST]cXcXTb QTcfTT] P[\^bc P[[ TcW]XRXcXTb >cWTa TcW]XRXcXTb X]R[dST \^bc[h 1aPiX[XP]b 2PdRPbXP]bSTbRT]SP]cb^U3dcRWR^[^]XbcbP]SUTf;TQP]TbT$. 4`dXchP]STR^]^\h 8]T`dXcXTb X] WTP[cW TSdRPcX^] P]S TR^]^\XR bcPcdb WPeT QTT] STbRaXQTS P\^]V _T^_[T [XeX]V X] adaP[ aTVX^]b P\^]V cWT _^^a P]S P\^]V cWT 8]SXVT]^db P]S <Pa^^] _T^_[T X] BdaX]P\T""$. $!. FWX[T cWT <d[cXP]]dP[ 3TeT[^_\T]c ?[P]. _a^_^bTSbTeTaP[[PaVTX]eTbc\T]c_a^YTRcbcWTTR^]^\XRaTRTbbX^]bX]RT! $WPb bTeTaT[hPUUTRcTScWTbT_[P]b$"0SSXcX^]P[[hcWT2>E83 (_P]ST\XRfX[[aTbd[cX] P] TeT] f^abT aTRTbbX^] fXcW \PbbXeT WTP[cW b^RXP[ P]S TR^]^\XR bW^RZ$#. SZ 18.

(23) General introduction. 4b_TRXP[[h;PcX]0\TaXRP]P]S2PaXQQTP]R^d]caXTbP]SBdaX]P\TPaTed[]TaPQ[T c^cWTR^]bT`dT]RTb^U2>E83 (SdTc^fTPZb^RXP[_a^cTRcX^]UaPV\T]cTSWTP[cW bhbcT\bP]ScWTaTVX^]bSXbcX]RcXeT[hWXVWP]S_TabXbcT]cX]T`dP[XchTeT]cW^dVW \^bc PaT R[PbbXUXTS Pb \XSS[TX]R^\T$# 1dX[SX]V QPRZ QTccTa fX[[ ST\P]S T`dP[Xch _a^cTRcX^] ^U Ud]SP\T]cP[ aXVWcb d]XeTabP[ fT[UPaT P]S TR^]^\XR aTbX[XT]RT##.  7TP[cWRPaTbhbcT\ CWTaT PaT UXeT W^b_XcP[b U^da ^U fWXRW PaT [^RPcTS X] ?PaP\PaXQ^ 0RPST\XR 7^b_XcP[b;P]Sb7^b_XcP[3XPZ^]TbbT]WdXbBcEX]RT]cXdbP]S^]TX]cWTSXbcaXRc ^U=XRZTaXTBcaTTZiXTZT]WdXb=XRZTaXTPccWTfTbcTa]Q^aSTa?aX\PahWTP[cWRPaT UPRX[XcXTb PaT V^eTa]\T]cbdQbXSXiTS P]S X]R[dST ATVX^]P[ 7TP[cW BTaeXRTb $  _aX\Pah WTP[cW R[X]XRb X] cWT R^PbcP[ PaTP  P]S cWT <TSXRP[ <XbbX^] $# _aX\Pah WTP[cW R[X]XRb X] cWT X]cTaX^a SXbcaXRcb#' 0SSXcX^]P[[h cWTaT PaT _aXePcT _aX\Pah WTP[cWRPaTR[X]XRbP__a^gX\PcT[h!X]cWTR^PbcP[PaTP#'CWT1daTPd^U?dQ[XR 7TP[cW1>63dcRWPRa^]h\1daTPd>_T]QPaT6Ti^]SWTXSbSXT]bcXbaTb_^]bXQ[T U^aP[[_dQ[XRWTP[cW_a^VaP\bX]R[dSX]V\PcTa]P[STPcWbbdaeTX[[P]RT"".  <PcTa]P[WTP[cWX]BdaX]P\T 0__a^gX\PcT[h [XeTQXacWbcPZT_[PRT_TahTPa^UfWXRW(!X]WTP[cWRPaT UPRX[XcXTb'%X]W^b_XcP[bP]S%X]_aX\PahWTP[cWRPaTRT]caTb#PcW^\TP]S #PaTd]Z]^f]#'8]! '('VPeTQXacWfXcWPbZX[[TSQXacWPccT]SP]cP]S'$ aTRTXeTS Pc [TPbc ^]T P]cT]PcP[ RPaT eXbXc#' 8] ! # [TVXb[PcX^] aTVPaSX]V QPbXR WTP[cWRPaTX]bdaP]RTU^aP[[fPbT]PRcTS$$7^fTeTa_a^eXSX]Vd]XeTabP[PRRTbbc^ WTP[cWRPaTU^a\^cWTabP]ScWTXa]TfQ^a]baT\PX]bPRWP[[T]VTP]SSXb_PaXcXTbX] PRRTbbPaT^UcT]aT[PcTSc^VT^VaP_WXR[^RPcX^]P]SX]bdaP]RTR^eTaPVT#'#($ 3dT c^ aTbcaXRcX^]b ^U _dQ[XR WTP[cW X]bdaP]RT R^\_P]XTb X] !  P cWXaS " ^U f^\T]fTaTR^]Ua^]cTSfXcWPSSXcX^]P[_Ph\T]cbU^aP]cT]PcP[bTaeXRTbbdRWPb d[caPb^d]Sb P]S RPcPbca^_WXR ^dc^U_^RZTc R^bcb U^a PSSXcX^]P[ bTaeXRTb Pb W^b_XcP[XiPcX^]^U]TfQ^a]b#'#($%. . S[ 19. 1.

(24) Chapter 1. CWT BPUT <^cWTaW^^S P]S =TfQ^a] 7TP[cW 0RcX^] ?[P]b ^U ! #"! P]S ! ("" T\_WPbXiTScWT[PRZ^Ud]XU^a\XchX]P]cTX]caPP]S_^bc_Pacd\P]ST\TaVT]Rh ^QbcTcaXR RPaT _a^c^R^[b fWXRW [X\XcTS cWT \^]Xc^aX]V ^U cWT `dP[Xch ^U bTaeXRTb 0Q^acX^] bTaeXRTb PaT X[[TVP[ P]S PRcdP[ ]d\QTab PaT ]^c aTVXbcTaTS$  CWT dbT ^U \^STa]R^]caPRT_cXeTbXb#X]bTgdP[[hPRcXeTf^\T]^UaT_a^SdRcXeTPVT!$ X]bTgdP[[hPRcXeTPS^[TbRT]cbP]S"$X]f^\T]PVTS!!$#'2^]caPRT_cX^]dbT WPbWPaS[hX]RaTPbTS^eTacWT_Pbc !hTPabfXcWb^\Tch_Tb^UR^]caPRT_cXeTb]^c ^a^][h_Pac[hR^eTaTSXT8D3X\_[P]cbbcTaX[XiPcX^]#'. <PcTa]P[\^acP[XchX]BdaX]P\T CWT2T]caP[1daTPd^UEXcP[ATVXbcahfPbTbcPQ[XbWTSX] ( &P]SaTVXbcTab('^U P[[[XeTQXacWbX]BdaX]P\T$%BcX[[QXacWbPaT]^caTVXbcTaTS0R^]UXST]cXP[T]`dXah X]c^\PcTa]P[STPcWbXST]cXUhX]VP]hbW^acUP[[bX]cWTRPaT_a^eXSTSP]SSTeXbX]V aTR^\\T]SPcX^]bc^X\_a^eTUdcdaTRPaTfPbR^]SdRcTSX]BdaX]P\TQh<d]VaP Tc P[ QTcfTT] ((  (("$& <d]VaP Tc P[  ((( aT_^acTS P \PcTa]P[ \^acP[Xch aPcX^^U!!%_Ta [XeTQXacWbfWXRWfPbbXgcX\TbWXVWTacWP]aT_^acTSQh eXcP[aTVXbcah$'1h!cWT1>6X]XcXPcTSPRcXeTbdaeTX[[P]RT^U\PcTa]P[STPcWb 8] ! $ 1>6 aT_^acTS P \PcTa]P[ \^acP[Xch aPcX^ ^U " _Ta  [XeT QXacWb fWXRWX\_[XTbPaTSdRcX^]X]\PcTa]P[STPcWb^U#!X]!"hTPab""$ BdaeTX[[P]RT W^fTeTa fPb ]^c T]cXaT[h aT[XPQ[T SdT c^ cWT UPRc cWPc   R^X]RXST]cP[ P]S PRRXST]cP[RPdbTbfTaT]^cTgR[dSTSP]Sb^\T[PcT\PcTa]P[STPcWb\^aTcWP]#! SPhbPUcTaRWX[SQXacWfTaTX]R[dSTSfWXRW\PhWPeT[TSc^P]^eTaTbcX\PcX^]^U cWT \PcTa]P[ \^acP[Xch aPcT* ! ]^ aT_a^SdRcXeT PVT \^acP[Xch bdaeTh fPb R^]SdRcTS fWXRW \Ph WPeT [TS c^ d]STaaT_^acX]V ^U f^\T] fW^ SXTS X] TPa[h _aTV]P]Rh ^a ^] ]^]^QbcTcaXR fPaSb* P]S " ]^ \PcTa]P[ STPcW aTeXTf fPb _TaU^a\TSc^STcTa\X]TcWTd]STa[hX]VRPdbTP]S[Tbb^]b[TPa]TSCWTd]STa[hX]V RPdbTbfTaTTbcPQ[XbWTSQPbTS^]cWTSTPcWRTacXUXRPcTfWXRW[PRZbP_aTV]P]Rh Q^gP]SR^\_[TcTSQhcWTcaTPcX]V_WhbXRXP]^UcT]]^cUP\X[XPafXcW823<<""$  8]! $PccWTbcPac^UcWTbcdSXTb_aTbT]cTSX]cWXbcWTbXbcWTaTfPb]^\PcTa]P[ STPcWaTeXTfR^\\XccTTP]SSPcP^]\PcTa]P[\^acP[Xch\PcTa]P[]TPa\XbbP]S bcX[[QXacWbfPb[PRZX]V. TR 20.

(25) General introduction. CWTbXbVT]TaP[PX\ CWTVT]TaP[PX\^UcWXbcWTbXbXbc^_a^eXSTaTR^\\T]SPcX^]bc^X\_a^eTcWT`dP[Xch ^U^QbcTcaXRRPaTX]BdaX]P\TP]SaTSdRTbTeTaT\PcTa]P[P]S_TaX]PcP[^dcR^\Tb FTfX[[P__[hcWTU^dabcT_?[P]3^BcdSh0Rc?3B0RhR[Tc^cWTbcdSXTbX]cWXb cWTbXb^]\PcTa]P[\^acP[Xch\PcTa]P[]TPa\XbbP]SbcX[[QXacWbcdSXTbUXVdaT" 0UcTa a^Qdbc bdaeTX[[P]RT PbRTacPX]\T]c P]S aTeXTf ^U RPbTb [Tbb^]b fX[[ QT [TPa]TS^]W^fc^X\_a^eTbdaeTX[[P]RTcPaVTcRWX[SQXacWSXb_PaXcXTbT]WP]RTcWT dbT ^U X]cTa]PcX^]P[ R[PbbXUXRPcX^] bhbcT\b U^a d]STa[hX]V RPdbTb P]S UX]P[[h X\_a^eT cWT `dP[Xch ^U \PcTa]P[ WTP[cW RPaT Qh cWT X\_[T\T]cPcX^] ^U X]cTaeT]cX^]b bdRW Pb <PcTa]P[ 3TPcW BdaeTX[[P]RT P]S ATb_^]bT P]S ]PcX^]P[ ^QbcTcaXR VdXST[X]Tb ;Pbc[h fT PX\ c^ _a^eXST aTR^\\T]SPcX^]b U^a cWT fPh U^afPaSaTS^?3B0RhR[T. CWTbXbaTbTPaRW`dTbcX^] 7^fRP]PaTSdRcX^]^UbTeTaT\PcTa]P[^dcR^\Tb\PcTa]P[\^acP[XchP]S]TPa \XbbP]SbcX[[QXacWbQTPRWXTeTSX]BdaX]P\TP]SW^fRP]V[^QP[\PcTa]P[WTP[cW RPaT_a^eXSTabP]S_^[XRh\PZTabR^]caXQdcTc^cWXbX]BdaX]P\TP]S^cWTa\XSS[T X]R^\TR^d]caXTb. 5XVdaT"BTeTaT\PcTa]P[^dcR^\TbbcX[[QXacWbX]BdaX]P\TdbX]VcWT?3B0RhR[T. TS 21. 1.

(26) Chapter 1. B_TRXUXRaTbTPaRW`dTbcX^]bP]ScWTbXbbcadRcdaT ?Pac8)BdaeTX[[P]RT ?a^eXSTP]^eTaeXTf^U\PcTa]P[\^acP[XchP]SRWX[SQXacW^dcR^\TbX]BdaX]P\T FWPcXbcWT]PcX^]P[\PcTa]P[\^acP[XchaPcX^P]ScWTSTVaTT^Ud]STaaT_^acX]V. FWh S^ f^\T] X] BdaX]P\T SXT SdaX]V _aTV]P]Rh RWX[SQXacW P]S X] cWT _dTa_TaXd\. 3^ RWX[SQXacW WTP[cW RPaT SXb_PaXcXTb TgXbc X] BdaX]P\T P]S XU b^ fWXRW f^\T] PaT \^bc Pc aXbZ. FWPc PaT cWT aTR^\\T]SPcX^]b c^ X\_a^eT \PcTa]P[ STPcW bdaeTX[[P]RT P]S aTSdRT d]STaaT_^acX]V. FWPc PaT cWT aTR^\\T]SPcX^]bc^X\_a^eT]PcX^]P[_TaX]PcP[SPcPPR`dXbXcX^].FWPcPaTcWT \^bc X\_^acP]c aTR^\\T]SPcX^]b c^ aTSdRT \PcTa]P[ \^acP[Xch P]S PSeTabT _TaX]PcP[^dcR^\TbX]BdaX]P\T. . ?Pac88)6[^QP[R[PbbXUXRPcX^]bhbcT\b 0bbTbbd]STa[hX]VRPdbTbP]STeP[dPcTV[^QP[R[PbbXUXRPcX^]c^^[b FWPcXbcWTSXUUTaT]RTX]d]STa[hX]VRPdbTb^U\PcTa]P[STPcWbfWT]R^\_PaX]V R[PbbXUXRPcX^] QTcfTT] [^RP[ Tg_Tacb P]S X]cTa]PcX^]P[ Tg_Tacb. FWPc Xb cWT \PcTa]P[]TPa\XbbaPcX^P]SW^fP__[XRPQ[TPaTcWTF7>\PcTa]P[]TPa\Xbb ^aVP]QPbTSRaXcTaXP.FWPcXbcWTbcX[[QXacWaPcTP]SfWPcPaTcWTd]STa[hX]V RPdbTb ^U bcX[[QXacWb. 7^f RP] cWT P__[XRPQX[Xch P]S UTPbXQX[Xch ^U cWT V[^QP[ R[PbbXUXRPcX^]c^^[b823<<F7><=<P]S823?<QTX\_a^eTS. . ?Pac888)1Th^]ScWT]d\QTab 8]ST_cWaTeXTfPdSXc^U\PcTa]P[STPcWbP]S\PcTa]P[]TPa\Xbb FWhS^f^\T]SXT^a]TPa[hSXTSdTc^bTeTaT^QbcTcaXRR^\_[XRPcX^]b\PcTa]P[ bT_bXbTR[P\_bXPP]S\PY^a^QbcTcaXRWPT\^aaWPVTX]BdaX]P\T.7^fRP]UdcdaT ]TPa STPcWb SdT c^ \PcTa]P[ bT_bXb TR[P\_bXP P]S \PY^a ^QbcTcaXR WPT\^aaWPVTQT_aTeT]cTSX]BdaX]P\T. . ?Pac8E)ATb_^]bT 5^a\d[PcTaTR^\\T]SPcX^]bc^X\_[T\T]c]TRTbbPahX]cTaeT]cX^]b FWPc Xb cWT \^bc X\_^acP]c T]PQ[Ta ^U ^QbcTcaXR VdXST[X]T STeT[^_\T]c. 7^f RP] X\_[T\T]cPcX^] ^U <PcTa]P[ 3TPcW BdaeTX[[P]RT P]S ATb_^]bT <3BA QT T]WP]RTS.  TT  22.

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(42) Maternal mortality audit 2010-2014. An expert committee, consisting of different obstetricians, an internal medicine specialist or anaesthesiologist and midwives, audited all pregnancy-related deaths with two authors (LK and KV) presenting and moderating the sessions. When no consensus was achieved, external ex- pert opinion (JR and HK) was sought. The committee reviewed the cases and agreed to a mode of death, under- lying cause, contributing factors and classified each death using WHO guidelines on applications of ICD-MM.12 Substandard care factors were analysed according to an adapted version of the FIGO-LOGIC MDR Grid analysis of clinical case management form.15 Due to lack of guidelines substandard care was defined as a deviation from ‘standard practice’ according to local clinicians.. Data analysis: Data were manually entered into IBM SPSS version 21.0 (Armonk, New York, USA) for analysis. All maternal deaths were individually analysed and cross-linked with registered maternal deaths by civil registration. Causes, contributing factors and substandard care factors were recoded into categorical variables. Figure 2. Flowchart of pregnancy related deaths in Suriname. 37 37. 2.

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(49) Maternal mortality audit 2010-2014. Classification and causes of maternal deaths Of the 65 maternal deaths, 41 (63%) were due to direct causes, 21 (32%) due to indirect causes and three (5%) maternal deaths were classified as unspecified because the cause of death was unknown (figure 3). The two leading causes of maternal mortality were obstetric and non- obstetric sepsis (n = 18, 27%) and obstetric haemorrhage (n=13, 20%). Obstetric haemorrhage was mainly due to postpartum haemorrhage (n=11, 85%) caused by uterine atony (29%), retained placenta (23%), ruptured uterus (15%), vaginal or cervical tear (8%), and unspecified causes (10%). Underlying cause of all antepartum haemorrhage was placental abruption (n=2, 15%). Hypertensive disorders and its complications (e.g. cerebral bleeding, HELLP, eclampsia) accounted for 14% of maternal deaths. However, hypertensive disorders, such as pregnancy induced hypertension and preeclampsia, were diagnosed in 30% of all maternal deaths. Though not the underlying cause of death, they were commonly classified as a contributing factor. Figure 3. Classification of underlying causes of the maternal deaths (n=65) n Direct maternal deaths n Indirect maternal deaths n Unspecified maternal deaths. Infectious 18%. Infectious 9% Obstetric haemorrhage 20%. All-other causes 14%. Unspecified (unknown) 5% All-other obstetric complications 12%. Hypertensive 14% Thromboembolism 5%. Abortion-related 3%. 41 41. 2.

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