BackgroundMaternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).Severe maternal morbidity in high-income countriesSince the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify “high risk” status, delays in diagnosis, and delays in treatment.Severe maternal morbidity in low and middle income countriesThe highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.Effects of SMM on delivery outcomes and infantsSevere maternal morbidity not only puts the woman’s life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.ConclusionIncreasing global maternal morbidity is a failure to achieve broad public health goals of improved women’s and infants’ health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

Background: Human papillomavirus (HPV), the causative agent of cervical cancer, can be screened for using self-collected vaginal samples (self-testing). This may overcome barriers to screening for Māori women who suffer a greater burden of cervical disease than New Zealand European women. Aims:This study aimed to explore the potential acceptability of HPV self-testing for never/under-screened (self-reported no cervical screen in 4+ years, aged 25+) Māori women by Kaupapa Māori (by, with and for Māori) mixed methods, involving hui (focus groups/interviews) and survey. Materials and Methods:Community-based researchers ran hui with women in four regions (N = 106) and supported hui participants to collect survey data (N = 397). Healthcare providers (HCPs) were also interviewed (N = 17). Hui data were thematically analysed. Survey data were analysed by age group, rural/urban, primary health organisation (PHO) enrolment, and time since last cervical screen.Results: Most survey participants were PHO-enrolled (87.15%) and attended regularly (71.79%), but did not attend regular cervical screening. A desire for bodily autonomy, including whakamā (embarrassment/shyness/reticence), was the most frequently cited barrier. Three in four women reported being likely/very likely to do an HPV self-test. Nine in ten women reported being likely/very likely to attend follow up if they receive a positive HPV test result. Women and HCPs in the hui emphasised the importance of health literacy, cultural competence and empathetic support. Conclusion:The findings indicate that with a culturally competent introduction of HPV self-testing, many currently never/under-screened Māori women would be willing to be screened and followed up if necessary. HPV self-testing has the potential to save lives. K E Y W O R D Scervical screening, HPV self-sampling, HPV self-testing, Indigenous health, Kaupapa Māori

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Background Indigenous women in the high‐income countries of Canada, Australia, New Zealand and USA, have a higher incidence and mortality from cervical cancer than non‐Indigenous women. Increasing cervical screening coverage could ultimately decrease cervical cancer disparities. Aims To increase cervical screening for under‐screened/never‐screened Māori women. Materials and Methods This study was a cluster randomised controlled trial. Inclusion criteria were women aged 25–69, last screened ≥4 years ago, in Northland, New Zealand. The intervention arm was the offer of a human papilloma virus (HPV) self‐test and the control arm was the usual offer of standard care – a cervical smear. The primary outcome was rate of cervical screening in the intervention group compared to control in Māori, the Indigenous peoples of New Zealand. Six primary care clinics were randomly allocated to intervention or control. Results Of 500 eligible Māori women in the intervention arm, 295 (59.0%) were screened. Of 431 eligible Māori women in the control arm, 94 (21.8%) were screened. Adjusting for age, time since last screen, deprivation index, Māori women in the intervention arm were 2.8 times more likely to be screened than women in the control arm (95% CI: 2.4–3.1, P‐value <0.0001). Conclusions Offer of HPV self‐testing could potentially halve the number of under‐screened/never‐screened Māori women and decrease cervical morbidity and mortality. These results may be generalisable to benefit Indigenous peoples facing similar barriers in other high‐income countries.

Nick Wilson and colleagues find out how well technology answers questions on sex