Trends in maternal mortality in Suriname: three confidential enquiries in three decades

Abstract Background The Sustainable Development Goal target 3.1 aims to reduce the global maternal mortality ratio (MMR) to less than 70 per 100.000 live births. Great disparities reported in MMR between and within countries make this target unachievable. To gain more insight into such disparities and to monitor and describe trends, confidential enquiries into maternal deaths (CEMD) are crucial. Objectives We aimed to study the trend in MMR, causes, delay in access and quality of care, and "lessons learned" in Suriname, over almost three decades with three CEMD and provide recommendations to prevent maternal deaths. Study design A national CEMD (CEMD-III) was conducted between 2015 and 2019 in Suriname by prospective, population-based surveillance and multidisciplinary systematic maternal death review. Subsequently, a comparative analysis with previous CEMD was performed [CEMD-I (a prospective study, 1991-1993) and CEMD-II (a retrospective study, 2010-2014)]. Results We identified 62 maternal deaths in CEMD-III and recorded 50.051 live births (MMR 127/100.000 live births). Of the deceased women, 23% (n=14/62) were in poor condition when entering a health facility, while 18% (n=11/62) died at home or during transportation. The MMR declined over the years [CEMD-I 226 (n=64), CEMD-II 130 (n=65), and CEMD-III 127 (n=62)], with underreporting rates of respectively 62%, 26% and 24%. Deceased women were of African-descent in 56% (n=36), 57% (n=37), 63% (n=40), died postpartum in 72% (n=46), 69% (n=45),76% (n=47) and in the hospital in 73% (n=47), 84% (n=55), 77% (n=48), respectively in CEMD-I, II and III. Significantly more women were uninsured in CEMD-III (25%, n=15/59) compared to CEMD-II (0%) and CEMD-I (9%, n=6/64). Obstetric hemorrhage was less often the underlying death cause over the years (CEMD-I 30%, n=19/64 vs CEMD-II 20%, n=13/65 vs CEMD-III 11%, n=7/62), while all other obstetric causes (e.g. suicide [CEMD-I n=0, CEMD-II 2%, n=1/65, CEMD-III 8%, n=5/62]) and unspecified deaths (CEMD-I 2%, n=1/64, CEMD-II 5%, n=3/65, CEMD-III 18%, n=11/62) occurred more often in CEMD-III compared to the previous CEMD. Maternal deaths were preventable in nearly half of the cases in CEMD-II (n=28/65) and CEMD-III (n=29/62). Delay in quality of care occurred in at least two-thirds of cases [65% (n=41/62), 80% (n=47/59), 77% (n=47/61)] over the years. Conclusions Suriname's MMR has declined throughout the past three decades, yet the trend is too slow to achieve the Sustainable Development Goal 3.1. Preventable maternal deaths can be reduced by ensuring high-quality facility-based obstetric and postpartum care, universal access to care especially for vulnerable women (of African descent, and low socioeconomic class), and addressing specific underlying causes of maternal deaths.