Title: Trends in maternal mortality in Latin America and the Caribbean: A joinpoint analysis
Version: 1 Date: 23 May 2025
Reviewer:  Paulina Rios-Quituizaca
Reviewer's report:
Reviewer #5:
Manuscript Title: "Trends in maternal mortality in Latin America and the Caribbean: A joinpoint
analysis"
I commend the authors for the substantial improvements made in response to the initial
round of comments. The revised manuscript (R1) demonstrates greater conceptual clarity,
methodological transparency, and alignment between the study objectives, analytical approach,
and conclusions. Below I provide specific observations based on the revised version:
Abstract and Results
The authors have adequately addressed the comments raised in the first round. The results are
now more clearly presented and aligned with the overall narrative of the paper. However, I
recommend further refinement of the Abstract to incorporate key elements from the improved
Discussion section—particularly the contextual explanations related to policy interventions,
socioeconomic factors, and disparities in maternal outcomes. It would also be pertinent
to briefly underscore that national averages can mask significant subnational inequalities,
as demonstrated by various studies in Latin America (https://pmc.ncbi.nlm.nih.gov/articles/
PMC6660870/#B11 ) . Acknowledging this limitation would enhance the interpretive value of
the Abstract and align it more closely with the manuscript’s conclusions.
Methodology
The methodological clarifications have been satisfactorily addressed. The revised manuscript
now explicitly states the origin of the data, sourced from WHO databases, and clearly describes
how the data were selected and incorporated into the analysis.
Importantly, the authors now delineate that the primary objective of the study was to evaluate
temporal trends in maternal mortality using Joinpoint regression analysis, without attempting
to infer causality. The mention of contextual factors—such as improvements in health systems
or socioeconomic instability—in the Discussion and Conclusions sections has been reframed
appropriately. These are now presented as interpretive insights rather than outcomes of
direct statistical testing. This revision has significantly improved the conceptual precision and
transparency of the study.
Discussion
The Discussion section has been considerably enhanced and now better articulates the
differences in maternal mortality trends across countries in the region. The magnitude and
direction of change are presented more clearly and supported with contextual analysis.
However, I suggest an additional improvement: the manuscript would benefit from a brief review
of specific policy interventions or public health strategies implemented in countries with the
most favorable trends. Likewise, in the case of countries with worsening indicators, a concise
exploration of potential political or economic contributors would strengthen the analysis.
Furthermore, I encourage the authors to emphasize more clearly that national averages may
obscure profound within-country disparities. Highlighting the need for disaggregated data and
the identification of underserved subgroups will reinforce the manuscript’s contribution to the
health equity discourse.