Title: Trends in maternal mortality in Latin America and the Caribbean: A joinpoint analysis
Version: 0 Date: 10 Apr 2025
Reviewer's report:
The study aims to assess trends in maternal mortality rates and the maternal mortality ratio
among women of childbearing age across Latin American and Caribbean countries from 1997 to
2020. Despite addressing a relevant topic and being well-written, I believe that the manuscript
has some significant flaws that merit being noted. In what follows, I mention what I believe are
the fundamental flaws of the paper.
Regarding the Impact of the COVID-19 Pandemic:
The authors aim to assess trends in maternal mortality in the period spanning from 1997 to
2020.The manuscript currently does not address the potential influence of the pandemic on the
observed trends in maternal mortality rates and ratios. To provide a more nuanced understanding,
it would be beneficial to:
- Incorporate analyses that exclude 2020 data (e.g., comparing trends from 1997-2019 in Table
1) to isolate the pre-pandemic trends. This would help discern whether the observed changes
between 1997 and 2020 are potentially driven by the pandemic rather than reflecting longer-
term patterns.
- Engage with existing literature in the discussion section regarding the impact of the COVID-19
pandemic on maternal mortality. This would provide context for the findings and acknowledge
a critical factor influencing the 2020 data. For instance, the noted increase in Brazil's MMR
between 1997 and 2020 might be disproportionately influenced by the pandemic, contrasting
with evidence of a pre-pandemic decline. Similar considerations likely apply to other countries
in the analysis.
Regarding the Materials and Methods:
The description of the materials and methods could benefit from further clarification to ensure
reproducibility and a thorough understanding of the analysis. Specific points to address include:
- Age-Standardized Maternal Mortality Rates (ASMR): The manuscript states the calculation of
ASMR per 100,000 person-years using the direct method, restricted to women of reproductive
age (15-49 years). It is unclear how age-standardization was performed when the denominator
was already limited to this specific age group. A more detailed explanation of the standardization
process is needed.
- Data Quality and Bias: The potential impact of misclassification and underreporting of maternal
deaths on the findings should be explicitly addressed in the methodology. Given that these issues
likely vary significantly across the included countries, the authors should clearly state if the
data used incorporates any corrections for these biases and consider including supplementary
analyses using publicly available data that attempts to adjust for these limitations (e.g., data from
the Global Burden of Disease study). While the limitations are acknowledged in the discussion,
addressing them analytically would strengthen the robustness of the conclusions.
- Joinpoint Regression: The manuscript mentions using Joinpoint regression (version 4.7.0)
to analyze trends. To enhance clarity and interpretation, the authors should provide a brief
explanation of what Joinpoint regression is and how its results should be understood in the
context of this study.
- Definition of Time Periods for APCs: The criteria used to define the distinct time periods
(APC1, APC2, APC3, and APC4) presented in Tables 2 and 3 are not clearly articulated.
The manuscript should specify whether these periods were determined arbitrarily or based on
identified structural shifts in the mortality trends. Clarifying this will improve the interpretability
of the APC values.