Title: Trends in maternal mortality in Latin America and the Caribbean: A joinpoint analysis
Version: 0 Date: 14 Apr 2025
Reviewer:  Paulina Rios-Quituizaca
Reviewer's report:
Reviewer Report – Manuscript Evaluation
The study presents a relevant and engaging approach; however, it primarily focuses on
temporal trends in maternal mortality without providing a clear and consistent methodological
framework for the analysis conducted across countries. The lack of transparency in the analytical
methods used—particularly for certain countries—raises concerns regarding potential bias in
the interpretation of results. This issue becomes more evident given that the analysis was not
conducted for all countries included in the dataset.
Abstract:
Please consider briefly explaining in the methodology or results section how the study
contributes to "providing key insights to address this issue." For instance, it would be valuable
to highlight the specific measures or policies implemented by countries such as Guatemala,
Nicaragua, and Costa Rica that contributed to the reduction in ASMR and MMR, in contrast
to the shared challenges faced by Brazil, Puerto Rico, and Venezuela. This would help
contextualize the concluding statement: “Strengthening access to healthcare, skilled birth
attendance, and prenatal/postnatal care is essential to reduce maternal mortality,” which
currently appears unsupported by a clearly articulated methodological process.
Methodology:
Regarding the official registration of maternal deaths in each country, a mixed methodology is
typically employed. This approach combines case reporting systems with active case finding,
resulting in official annual figures. Since the authors rely on WHO mortality databases, it
is important to clarify whether the estimates of maternal mortality rates and ratios obtained
through the proposed methodology are comparable to or aligned with the official national data
reported by the countries analyzed. Including this comparison would enhance the credibility and
contextual relevance of the findings.
There is an apparent disconnect between the conclusions and the methodological procedures
outlined in the manuscript. The conclusions discuss several factors influencing maternal
mortality trends, but it is unclear how these were identified or analyzed. Clarification is
recommended to ensure alignment between the stated methods and the inferences drawn.
Results:
Figure 1:
It is recommended to reorder the bars chronologically, displaying the year 1997 first, followed
by 2020. This adjustment would facilitate a more intuitive understanding of the temporal trends
presented.
Discussion:
The discussion section does not explicitly reflect or interpret the data presented in the results.
For example, the authors identify Venezuela and the Dominican Republic as the most affected
countries, whereas the abstract lists Brazil, Puerto Rico, and Venezuela. This inconsistency
should be addressed to maintain coherence across the manuscript.
A direct comparison across all countries may not yield the most meaningful insights, as countries
with initially high maternal mortality rates tend to show more pronounced reductions over time,
whereas those with already low rates may exhibit slower or less evident progress. This may be
the case for Nicaragua and Guatemala.
A more informative strategy might involve grouping countries that began with relatively
similar baseline conditions yet achieved markedly different outcomes. Notable examples include
Costa Rica, El Salvador, Mexico, Peru, and Panama, which have demonstrated significant
improvements. Given the well-documented crisis in Venezuela, drawing lessons from these
successful cases—especially those with similar initial conditions—may provide more actionable
insights for countries facing persistent challenges.
For both the discussion and conclusion, I recommend focusing on the temporal changes
supported by the study’s more robust methodological components. An additional valuable
contribution would be to include a critical assessment of countries with low-quality data, as
analyses involving these countries should be interpreted with caution due to potential limitations
in reliability and completeness.