Introduction Addressing the burden of preventable maternal deaths remains a critical focus of global health efforts in countries like Malawi which still has a high maternal mortality ratio of 381 deaths per 100 000 live births. We investigated the differences in case characteristics, survival and causes of death between pregnant and recently pregnant women who died, following their admission in stable or critical conditions to healthcare facilities in Malawi.Methods We conducted a retrospective analysis of maternal deaths of women from all district and central hospitals of Malawi between August 2020 and August 2022. Data were sourced from the national maternal and newborn health surveillance platform. We performed descriptive analyses, stratified by condition on admission, to identify differences in case characteristics between the two groups, and an exploratory survival analysis, to understand the differences in time to death since admission. Lastly, we performed a principal component analysis to reduce dimensionality to identify the main factors leading to deaths.Results Obstetric haemorrhage was the predominant cause of death among women admitted in stable condition, while those admitted in critical condition primarily died of hypertensive disorders. Most deaths in both categories occurred on the day of admission, corresponding to their primary causes of death. The key factors leading to deaths were mostly healthcare worker factors followed by administrative factors.Conclusion Understanding and responding to the different underlying causes of maternal mortality and contributing factors in the stable and critical cohorts are vital to designing well-targeted and impactful interventions to prevent maternal deaths.

Background Despite strong evidence-based strategies for prevention and management, global efforts to reduce deaths from postpartum haemorrhage (PPH) have failed, and it remains the leading cause of maternal mortality. We conducted a detailed review of all maternal deaths from 33 facilities in Malawi to identify health system weaknesses leading to deaths from PPH.Methods Data were collected regarding every maternal death occurring across all district and central hospitals in Malawi. Deaths occurring from August 2020 to December 2022 were reviewed by multidisciplinary facility-based teams who compiled case narratives from clinical notes and then subsequently reviewed by obstetricians to confirm the cause of death according to international criteria. Data were summarised using proportions/frequencies, comparisons made using χ2 or Wilcoxon rank sum tests, and logistic regression conducted to calculate ORs with CIs.Results PPH was the cause of 20.4% of maternal deaths. Most deaths from PPH occurred within 24 hours of birth (80.0%), among women who had been referred to a higher-level facility (57.0%) and were admitted in stable condition (60.0%). Vacuum births carried an increased risk of death from PPH (OR 4.25 (95% CI 1.15 to 20.13, p=0.039)). Detailed reviews identified that deaths from PPH were more likely to be associated with factors such as ‘lack of obstetric lifesaving skills’ (26.7% vs 10.1%, p<0.001), ‘inadequate monitoring’ (51.5% vs 40.7%, p=0.012) and ‘communication problems between facilities’ (11.5% vs 6.2%, p=0.019) than deaths from other causes.Conclusions Our analysis represents the largest published review of maternal deaths from PPH. We demonstrate that key health system weaknesses are contributing to these preventable maternal deaths. Case reviews conducted by multidisciplinary facility-based teams identified common and recurrent avoidable factors associated with deaths from PPH. Global efforts must now be focused on strategies that address these weaknesses, strengthening health systems and empowering healthcare workers to reduce maternal deaths from PPH.

Climate change poses a significant threat to women's health in sub-Saharan Africa, yet the impact of climate change on maternal health is rarely reported in the region. Using an existing Maternal Surveillance Platform (MATSurvey), we estimated the immediate impact of Cyclone Freddy on maternal health care service indicators in Malawi. We analysed facility-level data for pregnant women up to 42 weeks post-partum using the national MATSurvey database. We compared incidences of service utilisation before (1 January to 19 February 2023) and after (20 February to 30 March 2023) the cyclone using a negative binomial regression approach. Between 1 January and 30 March 2023, a total of 37,445 live births, 50,048 antenatal clinic attendances, 23,250 postnatal clinic attendances, 84 maternal deaths, and 1,166 neonatal deaths were recorded by 33 facilities in the MatSurvey database. There was an immediate reduction in service utilisation in the post-cyclone period, including the postnatal attendance per week (pre-cyclone median: 355.0 [IQR 279.0-552.0], post-cyclone median: 261.0 [IQR 154.3-305.5], RR 0.56 [95% CI 0.44-0.71, p <0.001]) and the antenatal attendance per week (pre-cyclone median: 860.0 [IQR 756.5-1060.0], post-cyclone median: 656.5 [IQR 486.5-803.3], RR 0.66 [95% CI 0.55-0.78, p <0.001]). Stratified analyses by geographical zones revealed a stronger reduction in postnatal clinic attendance in the Southwest (RR 0.50 [95% CI 0.29-0.85, p = 0.010]) and the North (RR 0.29 [95% CI 0.15-0.56, p <0.001]). Cyclone Freddy resulted in an immediate decline in utilisation of maternal health services in cyclone-affected regions in Malawi. We observe evidence of catastrophic climate events impacting on the healthcare of women and their babies. Policymakers, researchers, and health systems need to ensure that essential women's health services are maintained during these events and improve measures to support service resilience in the face of climate change.

Background Caesarean section (CS) is the most common major surgery conducted globally, with rates rising. CS also contributes to maternal morbidity and mortality, with increased risks in low-resource settings. We conducted a detailed review of maternal deaths from 2020 to 2022 in Malawi to determine the burden of deaths related to CS, avoidable health system factors, and causes of death associated with this procedure. Methods Data were collected regarding every maternal death occurring across all district and central hospitals in Malawi, alongside facility-level aggregated birth data. Maternal deaths were reviewed by facility-based multidisciplinary teams with subsequent confirmation of cause of death by obstetricians according to international criteria. Logistic regression was applied to estimate the odds of associations of leading causes of death with CS while adjusting for potential confounders. Results Despite a low national CS rate, most deaths occurred following CS (51.8%, 276/533). Women who delivered by CS were five times (OR 5.60, 95% CI 4.74 to 6.67) more likely to die than women who delivered vaginally. The leading causes of death following CS were postpartum haemorrhage (26.0%, 68/277), eclampsia (15.6%, 41/277) and infection (14.1%, 37/277). Deaths from pregnancy-related infection were more often associated with CS (OR 2.03, 95% CI 1.12 to 3.72). Health system factors more frequently associated with deaths following CS than vaginal birth included ‘prolonged abnormal observations without action’ (p=0.006), ‘delay in starting treatment’ (p=0.006) and ‘lack of blood transfusion’ (p=0.03). Conclusions We found a high burden of maternal death following CS in this low-resource setting. Until now, international attention and many clinical trials have been focused on improving the safety of vaginal birth. Our findings highlight the need to ensure the safe and appropriate use of this potentially life-saving intervention to reduce maternal deaths. To avoid the high burden of death following CS we highlight, there is urgent need to develop and trial CS-specific interventions.

We used national facility-level data from all government hospitals in Malawi to examine the effects of the second and third COVID-19 waves on maternal and neonatal outcomes and access to care during September 6, 2020–October 31, 2021. The COVID-19 pandemic affected maternal and neonatal health not only through direct infections but also through disruption of the health system, which could have wider indirect effects on critical maternal and neonatal outcomes. In an interrupted time series analysis, we noted a cumulative 15.4% relative increase (63 more deaths) in maternal deaths than anticipated across the 2 COVID-19 waves. We observed a 41% decrease in postnatal care visits at the onset of the second COVID-19 wave and 0.2% by the third wave, cumulative to 36,809 fewer visits than anticipated. Our findings demonstrate the need for strengthening health systems, particularly in resource-constrained settings, to prepare for future pandemic threats.

Objective To describe the demographic characteristics, clinical manifestations, and clinical outcomes of hospitalised pregnant and recently pregnant women with COVID-19 in Malawi, a low-income country in Sub-Saharan Africa. This study responds to a critical gap in the global COVID-19 data. Methods A national surveillance platform was established in Malawi by the Ministry of Health to record the impact of COVID-19 on pregnant and recently pregnant women and provide real-time data for decision making. We report this facility-based cohort that includes all pregnant and recently pregnant hospitalised women in Malawi suspected of having COVID-19 between 2nd June 2020 and 1st December 2021. Results 398 women were admitted to hospital with suspected COVID-19 based on presenting symptoms and were tested; 246 (62%) were confirmed to have COVID-19. In women with COVID-19, the mean age was 27 ± 7 years. The most common presenting symptoms were cough (74%), breathlessness (45%), Fever (42%), headache (17%), and joint pain (10%). 53% of the women had COVID-19 symptoms severe enough to warrant admission. 31% (76/246) of women admitted with COVID-19 suffered a severe maternal outcome, 47/246 (19%) died, and 29/246 (12%) had a near-miss event. 9/111 (8%) of recorded births were stillbirths, and 12/101 (12%) of the live births resulted in early neonatal death. Conclusion A national electronic platform providing real-time information on the characteristics and outcomes of pregnant and recently pregnant women with COVID-19 admitted to Malawian government hospitals. These women had much higher rates of adverse outcomes than those suggested in the current global data. These findings may reflect the differences in the severity of disease required for women to present and be admitted to Malawian hospitals, limited access to intensive care and the pandemic’s disruption to the health system. What is already known? What are the new findings? What do the new findings imply? ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was made possible with funding from the Bill and Melinda Gates Foundation (INV001252). Professor David Lissauer is funded by the National Institute for Health Research, as an NIHR Global Health Professor (NIHR300808). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Dr Marc Y.R Henrion is funded in part, by the Wellcome Trust [206545/Z/17/Z]. For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The College of Medicine Research Ethics committee (COMREC) of the Kamuzu University of Health Sciences in Malawi (formerly known as the University of Malawi, College of Medicine) gave ethical approval for this work (COMREC, P.11/20/3186). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Due to confidentiality and sensitivity, the raw data used for this study cannot be publicly shared. This is within the mandate of the Research Ethics Committee approval. Requests to access data can be made by contacting the Malawi Ministry of Health and the Malawi Liverpool Wellcome Clinical Research Program.

BACKGROUND:Outcomes of omicron-associated COVID-19 in pregnancy have not been reported from low-resource settings, and data from sub-Saharan Africa before the emergence of omicron are scarce. Using a national maternal surveillance platform (MATSurvey), we aimed to compare maternal and neonatal outcomes of COVID-19 in Malawi during the omicron wave to the preceding waves of beta and delta. METHODS:All pregnant and recently pregnant patients, up to 42 days following delivery, admitted to 33 health-care facilities throughout Malawi with symptomatic, test-proven COVID-19 during the second (beta [B.1.351]: January to April, 2021), third (delta [B.1.617.2]: June to October, 2021), and fourth (omicron [B.1.1.529]: December 2021 to March, 2022) waves were included, with no age restrictions. Demographic and clinical features, maternal outcomes of interest (severe maternal outcome [a composite of maternal near-miss events and maternal deaths] and maternal death), and neonatal outcomes of interest (stillbirth and death during maternal stay in the health-care facility of enrolment) were compared between the fourth wave and the second and third waves using Fisher's exact test. Adjusted odds ratios (ORs) for maternal outcomes were estimated using mixed-effects logistic regression. FINDINGS:Between Jan 1, 2021, and March 31, 2022, 437 patients admitted to 28 health-care facilities conducting MATSurvey had symptoms of COVID-19. SARS-CoV-2 infection was confirmed in 261 patients; of whom 76 (29%) had a severe maternal outcome and 45 (17%) died. These two outcomes were less common during the fourth wave (omicron dominance) than the second wave (adjusted OR of severe maternal outcome: 3·96 [95% CI 1·22-12·83], p=0·022; adjusted OR of maternal death: 5·65 [1·54-20·69], p=0·0090) and the third wave (adjusted OR: 3·18 [1·03-9·80], p=0·044; adjusted OR: 3·52 [0·98-12·60], p=0·053). Shortness of breath was the only symptom associated with poor maternal outcomes of interest (p<0·0001), and was less frequently reported in the fourth wave (23%) than in the second wave (51%; p=0·0007) or third wave (50%; p=0·0004). The demographic characteristics and medical histories of patients were similar across the three waves. During the second and third waves, 12 (13%) of 92 singleton neonates were stillborn or died during maternal stay in the health-care facility of enrolment, compared with 0 of the 25 born in the fourth wave (p=0·067 vs preceding waves combined). INTERPRETATION:Maternal and neonatal outcomes from COVID-19 were less severe during the fourth wave of the SARS-CoV-2 pandemic in Malawi, during omicron dominance, than during the preceding beta and delta waves. FUNDING:Bill & Melinda Gates Foundation, Wellcome Trust, and the National Institute for Health and Care Research. TRANSLATION:For the Chichewa translation of the abstract see Supplementary Materials section.

Background: Outcomes of Omicron-associated COVID-19 in pregnancy have not been reported from low resource settings, and data from sub-Saharan Africa prior to Omicron emergence is under-represented. Using a national maternal surveillance platform (MATSurvey), we characterise maternal and neonatal outcomes of COVID-19 in Malawi during waves of Beta, Delta and Omicron dominance. Methods: All pregnant and recently pregnant (<42 days) patients admitted to healthcare facilities throughout Malawi with symptomatic test-proven COVID-19 were included. Demographic/clinical features, maternal outcomes (severe maternal outcome and maternal death) and neonatal outcomes (live/stillbirth and survival until maternal discharge) were compared between waves using Fisher’s exact test. Adjusted odds ratios (OR) for maternal outcomes were estimated using mixed-effects logistic regression. Findings: Between 1 January 2021 and 31 March 2022, 265 patients from 28 healthcare facilities met our criteria. 77/265 (29%) had a severe maternal outcome and 46/265 (17%) died. These outcomes were less common during Omicron dominance: the adjusted OR of severe maternal outcome was 3.86 (95% confidence interval [CI] 1.21-12.30, p=0.022) in the second (Beta) and 3.09 (CI 1.76-9.45, p=0.048) in the third (Delta) waves compared to the fourth (Omicron); the adjusted ORs of maternal death were 5.56 (CI 1.53-20.23, p=0.009) and 3.46 (CI 0.97-12.39, p=0.057) respectively. During the second and third waves, 13/104 (13%) of neonates were stillborn or did not survive maternal admission, compared to 0/31 (0%) of neonates born in the fourth wave. Interpretation: Maternal and neonatal outcomes from COVID-19 were better during the fourth wave of the SARS-CoV-2 pandemic in Malawi, during Omicron dominance, compared to preceding Beta and Delta waves. Funding: Bill and Melinda Gates Foundation (BMG618).Declaration of Interest: The Wellcome Trust has provided a Strategic Award to the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (206545/Z/17/Z) that, in part, covers the salary and operational costs of the Statistical Support Unit, headed by MYRH. The authors have no further conflicting interests to declareEthical Approval: Data for this analysis was entirely anonymised and made available to the authors by the authorisation of the Malawi MOH and College of Medicine Research Ethics committee (COMREC: P.11/20/3186). Patients’ confidentiality, and adherence to COMREC’s ethical requirements was maintained throughout all stages of analysis.

ObjectiveTo evaluate whether the implementation of the FAST‐M complex intervention was feasible and improved the recognition and management of maternal sepsis in a low‐resource setting.DesignA before‐and‐after design.SettingFifteen government healthcare facilities in Malawi.PopulationWomen suspected of having maternal sepsis.MethodsThe FAST‐M complex intervention consisted of the following components: the FAST‐M maternal sepsis treatment bundle and the FAST‐M implementation programme. Performance of selected process outcomes was compared between a 2‐month baseline phase and 6‐month intervention phase with compliance used as a proxy measure of feasibility.Main outcome resultCompliance with vital sign recording and use of the FAST‐M maternal sepsis bundle.ResultsFollowing implementation of the FAST‐M intervention, women were more likely to have a complete set of vital signs taken on admission to the wards (0/163 [0%] versus 169/252 [67.1%], P < 0.001). Recognition of suspected maternal sepsis improved with more cases identified following the intervention (12/106 [11.3%] versus 107/166 [64.5%], P < 0.001). Sepsis management improved, with women more likely to receive all components of the FAST‐M treatment bundle within 1 hour of recognition (0/12 [0%] versus 21/107 [19.6%], P = 0.091). In particular, women were more likely to receive antibiotics (3/12 [25.0%] versus 72/107 [67.3%], P = 0.004) within 1 hour of recognition of suspected sepsis.ConclusionImplementation of the FAST‐M complex intervention was feasible and led to the improved recognition and management of suspected maternal sepsis in a low‐resource setting such as Malawi.Tweetable AbstractImplementation of a sepsis care bundle for low‐resources improved recognition & management of maternal sepsis.

ObjectiveTo develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings.DesignModified Delphi process.SettingParticipants from 34 countries.PopulationHealthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group.MethodsWe reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts.Main outcome measureConsensus on bundle items.ResultsConsensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’.ConclusionA clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus.Tweetable abstractA maternal sepsis bundle for low resource settings has been developed by international consensus.