Maternal Mortality in the Governorate of Tunis between 2017 and 2023: evolution of Maternal Mortality Ratio and the main causes of death

khaoula magdoud; hanene rezigui; Nejla Arifi; Sirine Bayar; Hamza Ben Abdallah; Hassine Saber Abouda; Rim Ben Hmid

doi:10.12688/f1000research.155009.1

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Research Article

Maternal Mortality in the Governorate of Tunis between 2017 and 2023: evolution of Maternal Mortality Ratio and the main causes of death

[version 1; peer review: 2 approved]

khaoula magdoud ^1,2, hanene rezigui³, Nejla Arifi^1,2, [...] Sirine Bayar^1,2, Hamza Ben Abdallah^1,2, Hassine Saber Abouda^1,2, Rim Ben Hmid^1,2

khaoula magdoud ^1,2, hanene rezigui³, [...] Nejla Arifi^1,2, Sirine Bayar^1,2, Hamza Ben Abdallah^1,2, Hassine Saber Abouda^1,2, Rim Ben Hmid^1,2

PUBLISHED 11 Oct 2024

Author details Author details

¹ University Tunis El Manar Tunisia, Faculty of medicine of Tunis, Tunis, Tunisia
² Maternity and Neonatology Center of Tunis, Tunis, Tunisia
³ Regional Health Directorate Of Tunis, Tunis, Tunisia

khaoula magdoud
Roles: Conceptualization, Supervision, Validation, Writing – Original Draft Preparation

hanene rezigui
Roles: Conceptualization, Validation, Writing – Original Draft Preparation

Nejla Arifi
Roles: Conceptualization, Validation, Writing – Original Draft Preparation

Sirine Bayar
Roles: Conceptualization, Validation, Writing – Original Draft Preparation

Hamza Ben Abdallah
Roles: Validation, Writing – Original Draft Preparation

Hassine Saber Abouda
Roles: Conceptualization, Validation

Rim Ben Hmid
Roles: Conceptualization, Validation

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

Maternal mortality is the main indicator of maternal health worldwide. The aims of your study were to determine the Maternal Mortality Ratio (MMR) in the governorate of Tunis and to identify the main causes of maternal death.

Methods

We included all maternal deaths between January 2017 and December 2023, reported to the Tunis Regional Health Directorate. The data collected included the MMR per 100000 live birth, sociodemographic characteristics, causes of death, circumstances of death, autopsy findings, and preventability.

Results

Sixty one maternal deaths were recorded. The average of MMR was 46, 88 per 100000 live births. Two peaks in the MMR were noted in 2017 and 2020. The average age of the patients was 34, 1 years (±5.1). We noted that 43, 75 % of the patients were not residents of the governorate of Tunis. The postpartum period was the most critical. In fact, 83, 33 % of maternal deaths occurred postpartum. Hemorrhage was the main etiology in 20.8% of cases. The second cause was COVID- 19complicationsin 16, 6% of cases.

Conclusion

This study of maternal mortality in Tunis opens the debate on the effectiveness of maternal health policies in Tunisia and the areas for improvement.

Keywords

Maternal mortality, Causes, Hemorrhage, COVID-19, Postpartum period

Corresponding author: khaoula magdoud

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 magdoud k et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: magdoud k, rezigui h, Arifi N et al. Maternal Mortality in the Governorate of Tunis between 2017 and 2023: evolution of Maternal Mortality Ratio and the main causes of death [version 1; peer review: 2 approved]. F1000Research 2024, 13:1218 (https://doi.org/10.12688/f1000research.155009.1) First published: 11 Oct 2024, 13:1218 (https://doi.org/10.12688/f1000research.155009.1) Latest published: 11 Oct 2024, 13:1218 (https://doi.org/10.12688/f1000research.155009.1)

Introduction

Maternal mortality is a major public health problem. It is defined by the World Health Organization (WHO) as: “Regardless of the length or location of the pregnancy, maternal mortality is defined as the death of a woman while she is pregnant or within 42 days after the pregnancy’s termination from any cause connected to or aggravated by the pregnancy or its management, but not from unintentional or incidental causes.”¹

According to WHO data for 2020, maternal mortality is reaching unprecedented levels. Around 287,000 women died during or after pregnancy or childbirth; almost 95% of maternal deaths occurred in low- and middle-income countries.²

The maternal mortality ratio (MMR) in Tunisia has improved from 62 in 2000 to 37 in 2020.¹ The situation in Tunisia shows that maternal mortality has decreased, but insufficiently in relation to the level of effort required and the objectives set.³

Among the direct causes of maternal death are three main pathologies: Hemorrhage, infectious complications and complications linked to pregnancy toxemia. Their frequency and severity reflect the level of development and organization of the healthcare and information system.³

Maternal death is usually avoidable in 80% of cases, even in situations where countries have few resources.³

Hence, the aims of your study are to determine the MMR in the Governorate of Tunis and to identify the main causes of maternal death.

Methods

Study design

This was a retrospective descriptive study focusing on the records of maternal deaths that occurred in public health facilities and were reported to the Regional Health Directorate of Tunis.

Setting

In June 2024, information on maternal death records in the governorate of Tunis from January 2017 to December 2023was collected.

Tunis is the capital of Tunisia. The population of Tunis was 1,078,412 in January 2023, which represents 8, 8% of the general population.⁴

Participants

Inclusion Criteria: We included all deaths of women that occurred during pregnancy or within 42 days after its termination in public health facilities.

Non-Inclusion Criteria: We did not include maternal deaths that occurred due to an accident or trauma, and cases where the records lacked data regarding the circumstances of the death.

Variables

After obtaining approval from the Director of the Regional Health Directorate of Tunis, we collected data from patients’ medical records, the regional committee’s maternal death follow-up reports, and autopsy reports if performed. Indeed, since 1999, Tunisia has set up regional and national committee’s maternal deathfollow-up.⁵ The main roles of these committees are to determine the cause of death and to propose preventive measures.

The data collected included the MMR per 100000LB, sociodemographic characteristics (age, marital status, place of residence), causes of death, circumstances of death (mode of delivery, time of death, place), autopsy findings, and preventability.

The causes of death are subdivided into direct and indirect causes:¹

• Death from direct obstetric cause: these are those resulting from obstetric complications (pregnancy, labor, and postpartum period), interventions, omissions, incorrect treatment, or a chain of events resulting from any of the above factors.
• Death from indirect cause: these are those resulting from a pre-existing disease or a condition that developed during pregnancy without being due to direct obstetric causes but was aggravated by the physiological effects of pregnancy.

Statistical methods

For the entry, analysis, and processing of the collected data, we used Microsoft Office Excel, is available for download at https://www.office.com/?omkt=fr-FR.

Qualitative variables will be described in terms of frequencies and percentages, and quantitative variables in terms of means and standard deviations.

Results

During the seven-year period from January 2017 to December 2023, 61 maternal deaths were recorded (Table 1). In 2017 and 2020, we recorded the highest number of maternal deaths with 13 and 12 cases, respectively.

Table 1. The maternal mortality ratio in Tunis between 2017 and 2023.

Year	Live births	Number of maternal death	MMR
2017	17352	13	74.9
2018	20918	8	38.24
2019	18825	7	37.18
2020	16846	12	71.23
2021	15010	7	46.63
2022	14162	7	49.42
2023	26986	7	25.93
Total	130099	61	46.88

The average MMR was 46, 88 per 100000 LB. The evolution of MMR was marked by two peaks in 2017 and 2020 and a decrease in MMR of 34, 57% between 2017 and 2023 (Figure 1).

Figure 1. Evolution of the maternal mortality ratio (MMR) in Tunis between 2017 and 2023.

Characteristics of the population (Table 2)

Table 2. Sociodemographic and clinical characteristics of maternal deaths in Tunis between 2017 and 2023.

data	Average/number (n=48)	Percentage (%)
Age
- Average age	34.1 years (±5.1)
- Age less than 35 years	30	62,5
- Age greater ≥35 years	18	37,5
Marital status
- Married	48
- Single	0
Place of residence
- Tunis	27	56,25
- Other governorates	21	43,75
Medical history
- No history	40	83,33
- Heart disease	3	6,25
- Hypothyroidism	1	2,08
- Sickle cell disease	1	2,08
- Asthma	1	2,08
- HBP	1	2,08
Obstetric history
- Average parity	2.02
- Number of children ≥ 2	34	70,83
- History of cesarean section	19	39,68
- History of ectopic pregnancy	1	2,08
- Miscarriage	8	16,66
- Voluntary termination of pregnancy	1	2,08
Last pregnancy
- Monitored/Not monitored	29/19	60,41/39,58
- No complications	35	72,91
- HBP	5	10,41
- Gestational diabetes	5	10,41
- Premature rupture of membranes	2	4,16
- Premature birth	1	2,08

During the study period, 61 maternal deaths were recorded, but 13 records lacked data related to the circumstances of the death. Thus, this work focused on 48 records of maternal deaths.

The average age of the patients was 34, 1 years (±5.1), with extremes ranging from 20 to 46years. In 47, 9% of cases, the deceased women were aged between 30 and 34 years. All women were married. We found that 56, 75 % (n=27) resided in Tunis, and 43,75% (n=21) of the patients were not residents of the governorate of Tunis.

A percentage of 83.33% (n=40) of the women had no medical history. Heart disease was the most reported pathology, found in 6.25% (n=3) of studied women.

The average parity of the patients was 2, 02 with extremes from 0 to 5. We noted that 70, 83% (n=34) of the deceased women had two or more children. A history of cesarean delivery was noted in 39, 58% of cases (n=19).

Sixty percent (n=29) of the deceased women had received proper follow-up during their last pregnancy. We noted that 87, 5 % (n=35) of the deceased women had no pathology during the last pregnancy.

Data related to maternal deaths (Table 3)

Table 3. Data related to maternal deaths.

Data	Number (n=48)	Percentage (%)
Time of death
- During pregnancy	5	10,41
- During childbirth	1	2,08
- Post abortion	2	4,16
- Postpartum	40	83,33
Place of maternal death
- Intensive care unit	33	68,75
- Maternity ward	15	31,25
Causes of maternal death
Causes directs	30	62,5
- Hemorrhage	10	20,83
- Pre eclampsia	5	10,41
- Acute hepatic steatosis	5	10,41
- Sepsie	4	8,33
- Pulmonary embolism	3	6,25
- Anesthesia factors	3	6,25
Causes indirects	17	35,41
- SARS-COV-2 infection	8	16,66
- H1N1 infection	3	6,25
- Meningitis	1	2,08
- Heart attack	2	4,16
- Sickle cell crisis	1	2,08
- Peritonitis	2	4,16
unknown	1	2,08

Time of Death: we noted that 83, 33% (n=40) of maternal deaths occurred postpartum, of which 80 % of cases (n=32) were within 24 hours.

Mode of Delivery: For women who died in postpartum (n=40), delivery was by cesarean section in 87, 5% (n=35) of cases.

Place of Maternal Death: Sixty-nine percent of women (n=33) died in an intensive care unit, and 31, 25% (n=15) died in a maternity ward.

Causes of Maternal Death: The causes of maternal death were direct in 62.5% of cases (n=30) and indirect in 35, 4% of cases (n=17). The cause of one maternal death was not identified (Figure 2).

Figure 2. The causes of maternal deaths in Tunis between 2017 and 2023.

Direct Causes: Hemorrhage was the main etiology in 20, 8% of cases (n=10). Preeclampsia and acute fatty liver of pregnancy each accounted for 10.4% of the causes of death (n=5).

Indirect Causes: Indirect causes accounted for 35, 4% (n=17) of the causes of death. A percentage of 16, 6% (n=8) of deaths were related to complications from COVID-19 infection, 6, 25% (n=3) from H1N1 infection, 4, 16% (n=2) following a myocardial infarction, 2% (n=1) peritonitis, 2% (n=1) meningitis of ENT origin, and 2% (n=1) sickle cell crisis.

Autopsy: Autopsy was performed in 8, 5% of cases (n=4). We had only two autopsy results: The first was a woman who died from an anesthetic accident, and the second from a massive pulmonary embolism.

Preventability: In our study, the maternal death follow-up committee deemed the death preventable in 68, 8% of cases (n=33).

Discussion

The maternal mortality rate and its evolution

MMR is the primary indicator of maternal health worldwide. In our study, the average MMR between 2017 and 2023 in the Tunis governorate was 46, 88/100 000 LB. Our study observed two peaks in maternal mortality, with 13 maternal deaths in 2017 and 12 maternal deaths in 2020. Despite the peak in 2020, there was a 34, 57 % drop in MMR between 2017 and 2023

In line with the Millennium Development Goals (MDGs), the objectives were to reduce maternal mortality by three-quarters (MDG 5) and under-five mortality by two-thirds (MDG 4).⁶ Although this objective has been achieved for infant mortality, the objective for reducing maternal mortality has not been met.³

Indeed, following the 2011 Tunisian Revolution, the country faced numerous challenges, including democratic transition, economic difficulties, and demographic shifts.

According to the Tunisian Ministry of Health’s report, one of the main factors contributing to maternal deaths appears to be the dysfunction of the healthcare system, including delays in making the decision to seek medical care and delays in referral to an appropriate healthcare facility.³

According to our findings, 43, 75% (n=21) of the patients were not residents of the governorate of Tunis. Most often, these patients are transferred from other governorates especially the northwest governorates. This explains the delay in transferring patients to an appropriate maternity hospital and, consequently, the delay in care. Indeed, in Tunisia, as in other countries, the disparity in access to care between inland and coastal regions is a public health problem.

According to 2019 data from the Tunisian Ministry of Health, in Greater Tunis (the four governorates: Tunis, Ariana, Ben Arous, and Manouba), there are 4.92 gynecologists-obstetricians per 10,000 women of reproductive age, while in the Northwest regions (the four governorates: Jendouba, Kef, Siliana, and Beja), there are only 1.21 gynecologists-obstetricians per 10,000 women of reproductive age.⁷ Similarly, in terms of facilities, all maternity hospitals with intensive care units for adults and newborns are in coastal regions.

On a global scale, a significant disparity in mortality rates between developed and developing countries has been noticed.⁸ Indeed, according to WHO data from 2020, 99% of maternal deaths occur in developing countries.⁹

In Africa, the average MMR is 415/100000 LB.⁷ This rate differs significantly by country, ranging from 37/100000 LB in Egypt to 1,150/100000 LB in South Sudan.⁸ In Tunisia, the situation is intermediate with a MMR at 37/100000LB in 2020.¹

The causes of maternal death

Since the WHO implemented the ICD-10 for deaths during pregnancy, childbirth and the postpartum period in 2012, the collection, analysis and interpretation of maternal mortality data worldwide has been standardized.^10–12

There are two main causes of maternal death: direct and indirect. Direct causes are the most frequent according to literature data.^13–17

Similarly, in our study, direct causes accounted for 62, 5% of maternal deaths. Hemorrhage was the leading direct cause of death in 20, 8% of cases, followed by complications of hypertensive disorders in 10,4% of cases.

This aligns with the WHO’s findings that approximately three-quarters of all maternal deaths globally are direct, caused by hemorrhage, infection, hypertension during pregnancy, and unsafe abortion.¹⁸

In developing countries, hemorrhage remains the leading cause of maternal mortality, with rates ranging from 28.8% to 43.4%.^17,19,20

Preeclampsia is a common complication of pregnancy, affecting 2-8% of pregnancies.²¹ It can lead to serious maternal health consequences, including eclampsia, haemostasis disorders, HELLP syndrome, kidney failure, and retroplacental hematoma.²²

It is a major direct cause of maternal mortality in both developing and developed countries.^17,18,23,24

Developed countries like the United States and China have witnessed a significant evolution in the causes of maternal mortality. There has been a substantial decline in direct causes, while indirect causes, particularly cardiovascular complications, are increasing.^23,24

In our study, indirect causes accounted for 43% of maternal deaths, with COVID-19 infection being the most common indirect cause, responsible for 8 deaths. This explains the peak in MMR in 2020. Complications of COVID-19 infection were the second leading cause of mortality.

Indeed, pregnant women are considered vulnerable to viral pneumonias, including COVID-19 infection.²⁵

COVID-19 attacks ciliated epithelial cells via the angiotensin-converting enzyme 2 receptor. This receptor is expressed in the cardiovascular, intestinal, pulmonary and renal systems, as well as in the placenta and fetal tissues. Clinical manifestations are due to direct attack on target cells and host response.²⁶

The impact of COVID-19 in pregnant women has been the subject of several studies, but the results are controversial.

Some studies have shown no increase in mortality risk for pregnant women infected with COVID-19.^27–29

However, a Brazilian study published in 2023 found an increased risk of morbidity and mortality among pregnant women infected with COVID-19 compared to a control group. Factors associated with maternal mortality in COVID-19 infected women were cesarean delivery, third-trimester infection, and comorbidities.³⁰ Vaccination was a protective factor.³⁰ Similarly, a meta-analysis involving 11 studies and 13,136 pregnant women found that COVID-19 infection increased maternal mortality regardless of the term of pregnancy.³¹

According to the WHO, during the COVID-19 pandemic, maternal mortality was likely influenced by two mechanisms: deaths due to the direct interaction between pregnancy and COVID-19, and those caused by complications of pregnancy that went untreated due to disruptions in healthcare services.²

The main factors associated with maternal death according to the literature data were advanced maternal age, non-follow-up of the pregnancy and delivery by cesarean section.^24,32

In our series, 87, 5% of patients who died postpartum had delivered by cesarean section.

For years in Tunisia, the rate of cesarean delivery has been increasing with a rate of 43, 2 % in 2018 (46,4 % in urban population).³³

Certainly, cesarean section has improved maternal and neonatal prognosis but at high rates, it can be a factor that increases maternal morbidity and mortality.^34,35

Pending the results of the implementation of the national maternal and neonatal health strategy 2020-2024, it is important to act on two main axes: reduce the cesarean rate and strengthen postpartum monitoring.³⁶

Conclusion

Maternal mortality rates remain high in Tunis. Most maternal deaths occurred postpartum after cesarean section. Hemorrhage continues to be the leading direct cause of maternal mortality, followed by COVID-19 infection.

Ethical statement

This study was examined by the Ethics Review Committee on Maternity and Neonatology Center of Tunis on May 14, 2024. After assessment, the Ethics Review Committee has granted permission to proceed with the study’s conduct after the agreement of the regional health directorate of Tunis. The Ethics Review Committee accorded a waiver of consent participant because the research was conducted exclusively from the use of medical data from records (called data studies) while respecting the anonymity of patients. This study is not considered to be a study “involving the human person.”³⁷ We obtained the agreement of the director of the Regional Health Directorate of Tunis. The final decision of the Ethics Review Committee was obtained on August 14, 2024(Approval number: 15/2024). The confidentiality of data was respected, as was the anonymity of patients, health facilities, and healthcare staff.

Consent to participate

Informed consent waiver was obtained by the Ethics Committee of Maternity and Neonatology Center of Tunis. The patients are deceased so we cannot have their consent. The study is not experimental on cadavers and not considered to be a study “involving the human person.”³⁷

The use of data from the files is permitted while respecting anonymity.

Author contributions

Conceptualization, Khaoula Magdoud, Hanene Rezigui, Sirine Bayar, Hassine Saber Abouda and Rim Ben Hmid; Methodology, Khaoula Magdoud; Validation, Khaoula Magdoud, Hanene Rzigui, Najla Arifi, Sirine Bayar, Hamza Ben Abdallah, Hassine Saber Abouda and Rim Ben Hmid; Writing – original draft, Khaoula Magdoud, Hanene Rzigui, Najla Arifi, Sirine Bayar and Hamza Ben Abdallah.

Key data availability statement

The data are not publicly available in accordance with institutional regulations of the Regional Health Directorate of Tunis. These data relate to deceased patients and are therefore easily identifiable by their ages, places of residence, their history and the circumstances of death. In case of request for scientific or research purposes, access to data is possible by asking the correspondent author Magdoud Khaoula (khoula.magdoud@fmt.utm.tn).

Extended data

Harvard Dataverse: “Maternal Mortality in the Governorate of Tunis between 2017 and 2023: evolution of Maternal Mortality Ratio and the main causes of death” doi: https://doi.org/10.7910/DVN/9CEJ6R.

This project contains the following:

• Questionnaire (in English and French)

Reporting guidelines

This work has been reported in line with the STROBE guidelines.³⁸

Harvard Dataverse: “Maternal Mortality in the Governorate of Tunis between 2017 and 2023: evolution of Maternal Mortality Ratio and the main causes of death” doi: https://doi.org/10.7910/DVN/9CEJ6R.³⁹

This project contains the following:

• STROBE-checklist form

Data are available under the terms of the Creative Commons Zero “No rights reserved’ data waiver (CC0 1.0 Public domain dedication).

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Version 1

VERSION 1 PUBLISHED 11 Oct 2024

Author details Author details

¹ University Tunis El Manar Tunisia, Faculty of medicine of Tunis, Tunis, Tunisia
² Maternity and Neonatology Center of Tunis, Tunis, Tunisia
³ Regional Health Directorate Of Tunis, Tunis, Tunisia

khaoula magdoud
Roles: Conceptualization, Supervision, Validation, Writing – Original Draft Preparation

hanene rezigui
Roles: Conceptualization, Validation, Writing – Original Draft Preparation

Nejla Arifi
Roles: Conceptualization, Validation, Writing – Original Draft Preparation

Sirine Bayar
Roles: Conceptualization, Validation, Writing – Original Draft Preparation

Hamza Ben Abdallah
Roles: Validation, Writing – Original Draft Preparation

Hassine Saber Abouda
Roles: Conceptualization, Validation

Rim Ben Hmid
Roles: Conceptualization, Validation

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

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magdoud k, rezigui h, Arifi N et al. Maternal Mortality in the Governorate of Tunis between 2017 and 2023: evolution of Maternal Mortality Ratio and the main causes of death [version 1; peer review: 2 approved]. F1000Research 2024, 13:1218 (https://doi.org/10.12688/f1000research.155009.1)

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Reviewer Report 18 Sep 2025

Samina Naeem Khalid, MNCH (Maternal, Neonatal and Child Health) Department, Health Services Academy (Ringgold ID: 66692), Islamabad, Pakistan

Junaid Sarfraz Khan, Public Health, Health Services Academy (Ringgold ID: 66692), Islamabad, Pakistan

Approved

https://doi.org/10.5256/f1000research.170122.r411706

An Urgent Call from Tunis: Turning Maternal Mortality Data into Action

Prof. Dr. Samina Naeem Khalid
Email: saminanaeemkhalid@gmail.com, drsamina@hsa.edu.pk
Prof. Dr. Junaid Sarfraz Khan
Email: junaidsarfraz@hsa.edu.pk

The death of ... Continue reading

An Urgent Call from Tunis: Turning Maternal Mortality Data into Action

Prof. Dr. Samina Naeem Khalid
Email: saminanaeemkhalid@gmail.com, drsamina@hsa.edu.pk
Prof. Dr. Junaid Sarfraz Khan
Email: junaidsarfraz@hsa.edu.pk

The death of a woman due to pregnancy or childbirth is not just a statistic; it is a profound tragedy that exposes the very fabric of the health system's weaknesses in the country. The impact of a maternal death ripples outward, first devastating the lives of children, then destabilizing the family structure, and ultimately diminishing the progress of the entire nation. Today, with the medical knowledge and resources available, most of these deaths can be prevented, specifically by strengthening primary care (1).

The recent study by Magdoud and colleagues in F1000Research shows that maternal mortality continues to pose a significant challenge in Tunisia’s capital region, highlighting critical concerns about equity, access, and quality of care (2). This study analyzed 61 maternal deaths in the Governorate of Tunis from 2017 to 2023, yielding findings that are both informative and insightful. An average MMR (Maternal Mortality Ratio) of 46.9 per 100,000 live births was observed, a figure more favorable than some regional benchmarks of the MENA (Middle East and North Africa) region but disproportionately high for a country with Tunisia’s healthcare resources (3). The peaks observed in 2017 and 2020 reflect underlying systemic weaknesses, and in 2020, the additional burden imposed by the COVID-19 pandemic surfaced as the second leading contributor, a stark reminder of how global crises place a disproportionate burden on pregnant women (4).

Three priority areas for intervention emerged clearly from the study’s findings. The first concern is inequitable access to care, with almost 44% of deaths occurring among women referred from underserved regions outside Tunis. These delays are not simple logistical gaps; they are an injustice. No woman’s life should be put at risk because of where she happens to live. It is a stark reminder of the ‘three delays’ identified in the 1990s: seeking help, reaching a facility, and receiving care, that too often turn complications into tragedies (5). The shortage of obstetricians and intensive care facilities outside urban centers in Tunisia is part of a global inequity, one where rural women are left most vulnerable. According to the World Health Organization (WHO), unequal distribution of skilled health providers and emergency obstetric services remains a key contributor to maternal mortality, especially among rural and marginalized groups in low and middle-income countries (6).

The second issue is the high prevalence of cesarean sections, as the national cesarean section rate in Tunisia surpassed 43% in 2018, which is quite concerning. This heavy reliance on surgical delivery carries serious risks that can no longer be overlooked, as 87.5% of postpartum deaths occurred following cesarean deliveries. The findings demand urgent scrutiny of obstetric practices, clinical decision-making, and the systemic forces fueling high cesarean rates. Cesarean sections are undeniably life-saving when medically indicated, but their overuse is dangerous, a concern highlighted by the WHO (7).

Third, analysis of the evolving causes indicates that the hemorrhage persists as the predominant direct cause of maternal mortality, reflecting a global challenge that has shown limited improvement over time. The WHO’s 2023 global report on maternal mortality also highlights the unfinished agenda of addressing preventable causes of hemorrhage and hypertensive disorders. This underscores the urgent need to ensure that pregnant women are central to emergency preparedness and public health strategies (8).

While Tunisia’s MMR of 46.9 per 100,000 live births remains concerning for the country, it is significantly lower than Pakistan’s national average of 186 per 100,000, as documented in the Pakistan Maternal Mortality Survey 2019 (9). Pakistan bears one of the heaviest maternal mortality burdens in South Asia, driven by systemic gaps in emergency obstetric care, limited access to skilled birth attendants, and significant rural and urban disparities. The study by Midhet et al. (2025) provides a valuable long-term perspective on maternal mortality in Pakistan, showing both the persistent burden and the changing pattern of risk factors over the past decade. Their findings are consistent with Magdoud et al. (2024), showing that even moderate national MMRs can mask severe underlying inequities. This is also critically relevant in Pakistan, where structural barriers, economic hardship, and gender inequality disproportionately endanger women (10). Thus, Tunisia's experience demonstrates that reducing overall maternal mortality is not enough unless efforts also focus on addressing disparities and ensuring that neither geography nor poverty determines a woman’s chance of survival.

According to Kumari et al. (2025), global maternal mortality has shown a consistent decline over time, largely driven by stronger health systems, expanded access to skilled birth attendants, and significant progress in obstetric care. However, the findings of Magdoud et al. (2024) highlight that global gains may mask enduring local challenges (11).

A recent study by Nist (2025) emphasizes that, despite overall declines, maternal mortality persists as a critical global health concern, with preventable causes still claiming women’s lives, especially in low- and middle-income countries (12). The report emphasizes the urgent need to ensure equitable access to skilled care, prompt emergency obstetric services, and robust health systems across all settings, reinforced by findings of Magdoud et al. (2024) as a case study.

Dehghani and colleagues (2025) argue that maternal deaths globally are driven by a consistent pattern of clinical causes like hemorrhage and hypertensive disorders, exacerbated by systemic delays. This pattern is clearly illustrated by the findings from Tunisia, reinforcing the urgent need for coordinated interventions, equitable resource distribution, and stronger accountability mechanisms to address these universal failures (13). These two studies show how local surveillance and cause-of-death analyses can inform global strategies, ensuring that efforts to reduce maternal mortality stay relevant to specific contexts while aligning with international frameworks.

The findings of Magdoud et al. function as both a stark warning and a potential roadmap for interventions, demonstrating that a striking 69% of maternal deaths were attributable to preventable causes. Their work reminds us that behind every maternal death, a sentinel event, lies a cascade of systemic failures that abandon women in their most vulnerable moments. Tunisia has made significant progress, yet the work is still not finished. As the world aims to reach the Sustainable Development Goal of reducing maternal mortality to fewer than 70 deaths per 100,000 live births by 2030, Tunis sends a clear message that achieving real progress requires not only clinical excellence but also equity, accountability, and compassion. The women of Tunisia and women across the world deserve care that is equitable, respectful, and capable of saving lives. The challenge now is to turn evidence into policy and practice so that no woman dies while giving life.

Mayrink, J., Costa, M. L., Souza, R. T., Sampaio, L. T., & Cecatti, J. G. (2025). Prevention of maternal mortality with interventions in primary care services: What can we do?. International Journal of Gynecology & Obstetrics, 169(1), 81-88.
Magdoud, K., Rezigui, H., Arifi, N., Bayar, S., Ben Abdallah, H., Abouda, H. S., & Ben Hmid, R. (2024). Maternal Mortality in the Governorate of Tunis between 2017 and 2023: evolution of Maternal Mortality Ratio and the main causes of death. F1000Research, 13, 1218.
Moujahid, C., Turman, J. E., & Amahdar, L. (2024). A scoping review of the social determinants of maternal health in the MENA region. Pan African Medical Journal, 47(1).
BOUNOUH, A. (2021). The devastating impact of COVID-19 on the health system in Tunisia. Moroccan Journal of Public Health, 2(1), 22-44.
Thaddeus, S., & Maine, D. (1994). Too far to walk: maternal mortality in context. Social science & medicine, 38(8), 1091-1110.
Glover, A. L., Brown, D., Holman, C., & Nelson, M. (2025). Obstetric care in rural critical access hospitals: A domestic application of the World Health Organization Emergency Obstetric Care framework in rural communities. The Journal of Rural Health, 41(2), e70037.
Opiyo, N., Kingdon, C., Oladapo, O. T., Souza, J. P., Vogel, J. P., Bonet, M., ... & Betrán, A. P. (2019). Non-clinical interventions to reduce unnecessary caesarean sections: WHO recommendations. Bulletin of the World Health Organization, 98(1), 66.
World Health Organization. (2023). Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. World Health Organization
National Institute of Population Studies-NIPS. Pakistan Maternal Mortality Survey. Islamabad/Pakistan: NIPS/ICF, 2020. (Available from:

https://nips.org.pk/publication/pakistan-maternal-mortality-survey-pmm

Midhet, F., Khalid, S. N., Baqai, S., & Khan, S. A. (2025). Trends in the levels, causes, and risk factors of maternal mortality in Pakistan: A comparative analysis of national surveys of 2007 and 2019. Plos one, 20(1), e0311730.
Kumari, C. K., Anuragamayi, Y., Gundu, V., & Ritika, M. (2025). Declining trends in Maternal Mortality Rate. European Journal of Cardiovascular Medicine, 15, 397-402.
Nist, M. D. (2025). Global Maternal Mortality. MCN: The American Journal of Maternal/Child Nursing, 50(5), 307.
Dehghani, N., Naseri, M., & Kharazmi, H. A. (2025). Reducing Maternal and Infant Mortality: Global Challenges and Integrated Strategies Toward 2030. Health Providers, 5(1), 135-140.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Dr. Samina Naeem Khalid, MBBS, MPhil, PhD, MSPH, CHPE, Fellowship ReproMed (USA), is Head of the Maternal, Neonatal, and Child Health Department (MNCH) at the Health Services Academy, Islamabad. She is a Health Expert with over 30 years of experience in clinical practice, teaching, research, and policy advocacy. She has collaborated with the Ministry of Health, WHO, UNICEF, USAID, UNFPA, and other international partners on reproductive health, family planning, cervical cancer prevention, and safe motherhood initiatives. Dr. Khalid holds advanced training in reproductive medicine and infertility (IVF/ICSI) from the Cleveland Clinic, USA, and has published extensively on maternal mortality, unsafe abortions, and HPV vaccine introduction in Pakistan. A passionate advocate for women’s health, she has trained hundreds of healthcare providers, supervised over 50 postgraduate students, and led national campaigns such as What Women Want, amplifying the voices of more than 250,000 women and girls.

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report 26 Feb 2025

Roger Smith, Mothers and Babies Research Centre, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia

Approved

https://doi.org/10.5256/f1000research.170122.r366690

This paper provides a summary of recent maternal mortality in Tunis. It is well written and highlights the problem of transport from regional centres to the obstetric care facilities in Tunis. It also highlights the high rates of caesarean section. ... Continue reading

This paper provides a summary of recent maternal mortality in Tunis. It is well written and highlights the problem of transport from regional centres to the obstetric care facilities in Tunis. It also highlights the high rates of caesarean section. It does not suggest solutions for regional women to promptly obtain care in the setting of post-partum haemorrhage. Is it possible for the military to provide helicopter evacuation as has been described in Nepal (Sharma et al., AJOG)/

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Maternal Mortality

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Roger Smith, Mothers and Babies Research Centre, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
Samina Naeem Khalid, Health Services Academy (Ringgold ID: 66692), Islamabad, Pakistan

Junaid Sarfraz Khan, Health Services Academy (Ringgold ID: 66692), Islamabad, Pakistan

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18 Sep 2025 | for Version 1

Samina Naeem Khalid, MNCH (Maternal, Neonatal and Child Health) Department, Health Services Academy (Ringgold ID: 66692), Islamabad, Pakistan

Junaid Sarfraz Khan, Public Health, Health Services Academy (Ringgold ID: 66692), Islamabad, Pakistan

5 Views Cite this report Responses(0)

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An Urgent Call from Tunis: Turning Maternal Mortality Data into Action

Prof. Dr. Samina Naeem Khalid
Email: saminanaeemkhalid@gmail.com, drsamina@hsa.edu.pk
Prof. Dr. Junaid Sarfraz Khan
Email: junaidsarfraz@hsa.edu.pk

The death of a woman due to pregnancy or childbirth is not just a statistic; it is a profound tragedy that exposes the very fabric of the health system's weaknesses in the country. The impact of a maternal death ripples outward, first devastating the lives of children, then destabilizing the family structure, and ultimately diminishing the progress of the entire nation. Today, with the medical knowledge and resources available, most of these deaths can be prevented, specifically by strengthening primary care (1).

The recent study by Magdoud and colleagues in F1000Research shows that maternal mortality continues to pose a significant challenge in Tunisia’s capital region, highlighting critical concerns about equity, access, and quality of care (2). This study analyzed 61 maternal deaths in the Governorate of Tunis from 2017 to 2023, yielding findings that are both informative and insightful. An average MMR (Maternal Mortality Ratio) of 46.9 per 100,000 live births was observed, a figure more favorable than some regional benchmarks of the MENA (Middle East and North Africa) region but disproportionately high for a country with Tunisia’s healthcare resources (3). The peaks observed in 2017 and 2020 reflect underlying systemic weaknesses, and in 2020, the additional burden imposed by the COVID-19 pandemic surfaced as the second leading contributor, a stark reminder of how global crises place a disproportionate burden on pregnant women (4).

Three priority areas for intervention emerged clearly from the study’s findings. The first concern is inequitable access to care, with almost 44% of deaths occurring among women referred from underserved regions outside Tunis. These delays are not simple logistical gaps; they are an injustice. No woman’s life should be put at risk because of where she happens to live. It is a stark reminder of the ‘three delays’ identified in the 1990s: seeking help, reaching a facility, and receiving care, that too often turn complications into tragedies (5). The shortage of obstetricians and intensive care facilities outside urban centers in Tunisia is part of a global inequity, one where rural women are left most vulnerable. According to the World Health Organization (WHO), unequal distribution of skilled health providers and emergency obstetric services remains a key contributor to maternal mortality, especially among rural and marginalized groups in low and middle-income countries (6).

The second issue is the high prevalence of cesarean sections, as the national cesarean section rate in Tunisia surpassed 43% in 2018, which is quite concerning. This heavy reliance on surgical delivery carries serious risks that can no longer be overlooked, as 87.5% of postpartum deaths occurred following cesarean deliveries. The findings demand urgent scrutiny of obstetric practices, clinical decision-making, and the systemic forces fueling high cesarean rates. Cesarean sections are undeniably life-saving when medically indicated, but their overuse is dangerous, a concern highlighted by the WHO (7).

Third, analysis of the evolving causes indicates that the hemorrhage persists as the predominant direct cause of maternal mortality, reflecting a global challenge that has shown limited improvement over time. The WHO’s 2023 global report on maternal mortality also highlights the unfinished agenda of addressing preventable causes of hemorrhage and hypertensive disorders. This underscores the urgent need to ensure that pregnant women are central to emergency preparedness and public health strategies (8).

While Tunisia’s MMR of 46.9 per 100,000 live births remains concerning for the country, it is significantly lower than Pakistan’s national average of 186 per 100,000, as documented in the Pakistan Maternal Mortality Survey 2019 (9). Pakistan bears one of the heaviest maternal mortality burdens in South Asia, driven by systemic gaps in emergency obstetric care, limited access to skilled birth attendants, and significant rural and urban disparities. The study by Midhet et al. (2025) provides a valuable long-term perspective on maternal mortality in Pakistan, showing both the persistent burden and the changing pattern of risk factors over the past decade. Their findings are consistent with Magdoud et al. (2024), showing that even moderate national MMRs can mask severe underlying inequities. This is also critically relevant in Pakistan, where structural barriers, economic hardship, and gender inequality disproportionately endanger women (10). Thus, Tunisia's experience demonstrates that reducing overall maternal mortality is not enough unless efforts also focus on addressing disparities and ensuring that neither geography nor poverty determines a woman’s chance of survival.

According to Kumari et al. (2025), global maternal mortality has shown a consistent decline over time, largely driven by stronger health systems, expanded access to skilled birth attendants, and significant progress in obstetric care. However, the findings of Magdoud et al. (2024) highlight that global gains may mask enduring local challenges (11).

A recent study by Nist (2025) emphasizes that, despite overall declines, maternal mortality persists as a critical global health concern, with preventable causes still claiming women’s lives, especially in low- and middle-income countries (12). The report emphasizes the urgent need to ensure equitable access to skilled care, prompt emergency obstetric services, and robust health systems across all settings, reinforced by findings of Magdoud et al. (2024) as a case study.

Dehghani and colleagues (2025) argue that maternal deaths globally are driven by a consistent pattern of clinical causes like hemorrhage and hypertensive disorders, exacerbated by systemic delays. This pattern is clearly illustrated by the findings from Tunisia, reinforcing the urgent need for coordinated interventions, equitable resource distribution, and stronger accountability mechanisms to address these universal failures (13). These two studies show how local surveillance and cause-of-death analyses can inform global strategies, ensuring that efforts to reduce maternal mortality stay relevant to specific contexts while aligning with international frameworks.

The findings of Magdoud et al. function as both a stark warning and a potential roadmap for interventions, demonstrating that a striking 69% of maternal deaths were attributable to preventable causes. Their work reminds us that behind every maternal death, a sentinel event, lies a cascade of systemic failures that abandon women in their most vulnerable moments. Tunisia has made significant progress, yet the work is still not finished. As the world aims to reach the Sustainable Development Goal of reducing maternal mortality to fewer than 70 deaths per 100,000 live births by 2030, Tunis sends a clear message that achieving real progress requires not only clinical excellence but also equity, accountability, and compassion. The women of Tunisia and women across the world deserve care that is equitable, respectful, and capable of saving lives. The challenge now is to turn evidence into policy and practice so that no woman dies while giving life.

Mayrink, J., Costa, M. L., Souza, R. T., Sampaio, L. T., & Cecatti, J. G. (2025). Prevention of maternal mortality with interventions in primary care services: What can we do?. International Journal of Gynecology & Obstetrics, 169(1), 81-88.
Magdoud, K., Rezigui, H., Arifi, N., Bayar, S., Ben Abdallah, H., Abouda, H. S., & Ben Hmid, R. (2024). Maternal Mortality in the Governorate of Tunis between 2017 and 2023: evolution of Maternal Mortality Ratio and the main causes of death. F1000Research, 13, 1218.
Moujahid, C., Turman, J. E., & Amahdar, L. (2024). A scoping review of the social determinants of maternal health in the MENA region. Pan African Medical Journal, 47(1).
BOUNOUH, A. (2021). The devastating impact of COVID-19 on the health system in Tunisia. Moroccan Journal of Public Health, 2(1), 22-44.
Thaddeus, S., & Maine, D. (1994). Too far to walk: maternal mortality in context. Social science & medicine, 38(8), 1091-1110.
Glover, A. L., Brown, D., Holman, C., & Nelson, M. (2025). Obstetric care in rural critical access hospitals: A domestic application of the World Health Organization Emergency Obstetric Care framework in rural communities. The Journal of Rural Health, 41(2), e70037.
Opiyo, N., Kingdon, C., Oladapo, O. T., Souza, J. P., Vogel, J. P., Bonet, M., ... & Betrán, A. P. (2019). Non-clinical interventions to reduce unnecessary caesarean sections: WHO recommendations. Bulletin of the World Health Organization, 98(1), 66.
World Health Organization. (2023). Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. World Health Organization
National Institute of Population Studies-NIPS. Pakistan Maternal Mortality Survey. Islamabad/Pakistan: NIPS/ICF, 2020. (Available from:

https://nips.org.pk/publication/pakistan-maternal-mortality-survey-pmm

Midhet, F., Khalid, S. N., Baqai, S., & Khan, S. A. (2025). Trends in the levels, causes, and risk factors of maternal mortality in Pakistan: A comparative analysis of national surveys of 2007 and 2019. Plos one, 20(1), e0311730.
Kumari, C. K., Anuragamayi, Y., Gundu, V., & Ritika, M. (2025). Declining trends in Maternal Mortality Rate. European Journal of Cardiovascular Medicine, 15, 397-402.
Nist, M. D. (2025). Global Maternal Mortality. MCN: The American Journal of Maternal/Child Nursing, 50(5), 307.
Dehghani, N., Naseri, M., & Kharazmi, H. A. (2025). Reducing Maternal and Infant Mortality: Global Challenges and Integrated Strategies Toward 2030. Health Providers, 5(1), 135-140.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Dr. Samina Naeem Khalid, MBBS, MPhil, PhD, MSPH, CHPE, Fellowship ReproMed (USA), is Head of the Maternal, Neonatal, and Child Health Department (MNCH) at the Health Services Academy, Islamabad. She is a Health Expert with over 30 years of experience in clinical practice, teaching, research, and policy advocacy. She has collaborated with the Ministry of Health, WHO, UNICEF, USAID, UNFPA, and other international partners on reproductive health, family planning, cervical cancer prevention, and safe motherhood initiatives. Dr. Khalid holds advanced training in reproductive medicine and infertility (IVF/ICSI) from the Cleveland Clinic, USA, and has published extensively on maternal mortality, unsafe abortions, and HPV vaccine introduction in Pakistan. A passionate advocate for women’s health, she has trained hundreds of healthcare providers, supervised over 50 postgraduate students, and led national campaigns such as What Women Want, amplifying the voices of more than 250,000 women and girls.

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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7 Views

26 Feb 2025 | for Version 1

Roger Smith, Mothers and Babies Research Centre, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia

7 Views Cite this report Responses(0)

Approved

This paper provides a summary of recent maternal mortality in Tunis. It is well written and highlights the problem of transport from regional centres to the obstetric care facilities in Tunis. It also highlights the high rates of caesarean section. It does not suggest solutions for regional women to promptly obtain care in the setting of post-partum haemorrhage. Is it possible for the military to provide helicopter evacuation as has been described in Nepal (Sharma et al., AJOG)/

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Maternal Mortality

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

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[1] 1. World Health Organization, Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division.2023. Accessed on February 23, 2023.

[2] 2. World Health Organization, Maternal mortality.2024. Accessed on April 26, 2024.

[3] 3. Tunisia’s Ministry of Health, Etat des lieux de la sante maternelle et néonatale en Tunisie.2017. Accessed on September 15, 2017.

[4] 4. National Institute of Statistics of Tunisia, Estimation de la population.1er Janvier 2023: 2023. Accessed on July 27, 2023.

[5] 5. Tej Dellagi R, Ben Salah F, Ben Hamida A, et al.: Le système de surveillance des décès maternels dans la région de Tunis. Arch. Inst. Pasteur Tunis. 2001; 78(1-4): 49–58. PubMed Abstract

[6] 6. World Health Organization (WHO), Millennium Development Goals (MDGs).2018. Accessed on Februry19, 2018.

[7] 7. Tunisia’s Ministry of Health, Démographie Des Professionnels De Santé 2019.2021. Accessed on March 15, 2021.

[8] 8. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al.: Global, regional, and national levels and causes of maternal mortality during 1990–2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014; 384: 980–1004. PubMed Abstract | Publisher Full Text | Free Full Text

[9] 9. World Health Organization, Maternal health|who|regional office for Africa.2020. Accessed on August 03, 2020.

[10] 10. World Health Organization, The WHO Application of ICD-10 to Deaths During Pregnancy, Childbirth and the Puerperium: ICD-MM.2019. Accessed on January28, 2019.

[11] 11. Kodan LR, Verschueren KJ, McCaw-Binns AM, et al.: Classifying maternal deaths in Suriname using WHO ICD-MM: different interpretation by physicians, national and international maternal death review committees. Reprod. Health. 2021; 18(1): 1–11.

[12] 12. Knight M, Nair M, Brocklehurst P, et al.: Examining the impact of introducing ICD-MM on observed trends in maternal mortality rates in the UK 2003–13. BMC Pregnancy Childbirth. 2016; 16(1): 1–8. Publisher Full Text

[13] 13. Maleya A, Kakudji YK, Mwazaz RM, et al.: Maternal and fetal outcomes of unattended pregnancies in Lubumbashi, Democratic Republic of Congo. Pan Afr. Med. J. May 2019; 33(33): 66. Publisher Full Text

[14] 14. Yaya S, Anjorin SS, Adedini SA: Disparities in pregnancy-related deaths: spatial and Bayesian network analyses of maternal mortality ratio in 54 African countries. BMJ Glob. Health. February 2021; 6(2): e004233. PubMed Abstract | Publisher Full Text | Free Full Text

[15] 15. Thiam M: Mortalité Maternelle Au Centre Hospitalier Regional De Thies: Etiologies Et Facteurs Determinants, A Propos De 239 Décès. J SAGO. 2017; 18(1).

[16] 16. Sitaula S, Basnet T, Agrawal A, et al.: Prevalence and risk factors for maternal mortality at a tertiary care centre in Eastern Nepal- retrospective cross sectional study. BMC Pregnancy Childbirth. July 2021; 1; 21(1): 471. PubMed Abstract | Publisher Full Text | Free Full Text

[17] 17. Sageer R, Kongnyuy E, Adebimpe WO, et al.: Causes and contributory factors of maternal mortality: evidence from maternal and perinatal death surveillance and response in Ogun state, Southwest Nigeria. BMC Pregnancy Childbirth. February 2019; 11; 19(1): 63. PubMed Abstract | Publisher Full Text | Free Full Text

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Maternal Mortality in the Governorate of Tunis between 2017 and 2023: evolution of Maternal Mortality Ratio and the main causes of death

Abstract

Background

Methods

Results

Conclusion

Keywords

Introduction

Methods

Study design

Setting

Participants

Variables

Statistical methods

Results

Table 1. The maternal mortality ratio in Tunis between 2017 and 2023.

Figure 1. Evolution of the maternal mortality ratio (MMR) in Tunis between 2017 and 2023.

Characteristics of the population (Table 2)

Table 2. Sociodemographic and clinical characteristics of maternal deaths in Tunis between 2017 and 2023.

Data related to maternal deaths (Table 3)

Table 3. Data related to maternal deaths.

Figure 2. The causes of maternal deaths in Tunis between 2017 and 2023.

Discussion

The maternal mortality rate and its evolution

The causes of maternal death

Conclusion

Ethical statement

Consent to participate

Author contributions

Key data availability statement

Extended data

Reporting guidelines

References

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