Maternal mortality remains a major public health problem worldwide. In 2020, almost 800 women a day died from preventable causes related to pregnancy and childbirth; almost 95% of maternal deaths occurred in low- and middle-income countries [1] . This reflects not only the state of healthcare systems, but also social and economic inequalities within populations. In Cameroon, despite the various strategies adopted in the fight against maternal mortality, namely: the introduction of the health voucher [2] , the development of norms and standards in reproductive health [3] , nationwide training in essential and emergency obstetric and neonatal care, the purchase of deliveries from matrons ... The maternal mortality ratio was 406 deaths per 100,000 live births in 2018 according to the Demographic and Health Survey (DHS) [4] . This ratio seems far from achieving Sustainable Development Goal 3.1, which is to bring the global maternal mortality ratio below 70 per 100,000 live births by 2030 [5] . Surveillance of Maternal and Child Deaths is another strategy adopted by Cameroon’s Ministry of Public Health. Since the creation of the SDMR committee and the introduction of maternal death review at the Yaoundé Gyneco-Obstetric and Paediatric Hospital (HGOPY) in 2009, no formal evaluation of results has been carried out. This lack of up-to-date data on maternal deaths limits our understanding of the real impact of these initiatives. Our study therefore aims to present the results of an analysis of reviews of maternal deaths at HGOPY.

Over an 8-year period, from 2016 to 2023, the Yaoundé Gyneco-Obstetric and Paediatric Hospital (YGOPH) recorded 160 cases of maternal death, with a peak in the proportion of maternal deaths recorded in 2021. It should be noted that corona virus disease entered Cameroon in 2020. It was an unknown pathology that scared the population and the medical profession for a long time. Patients were reluctant to go to health facilities for prenatal consultations and even childbirth, for fear of being contaminated. This could explain their late arrival at the maternity ward of the Yaoundé Gyneco-Obstetric and Paediatric Hospital in 2021. The first maternal death reviews at the YGOPH took place in 2018; however, in 2016 and 2017, cases of maternal death had already been notified. This late start to maternal death reviews may be due to the fact that they were not yet part of the mandatory package of activities for health facilities. It was on December 04, 2017 that the Ministry of Public Health signed the regulatory framework for the Maternal and Perinatal Death Surveillance and Response (MPDSR) specifying the general provisions, the organization and operation of the MPDSR and the miscellaneous and final provisions. Although the maternal death review rate in 2021 is 100%, the overall maternal death review rate is 60.6%. This lower result than that of N’DAOU, who found 67% [7] , can be justified by the fact that the review of maternal deaths began 2 years after the start of reporting (i.e. 17 maternal deaths in 2016 and 12 maternal deaths in 2017). With regard to maternal death review reports, the results show a low rate, or even an absence, of availability of said reports. It should be remembered that during a review committee, several deaths are reviewed and a single report is written. But the summary of each case reviewed must be available. As the Yaoundé Gyneco-Obstetric and Paediatric Hospital is a health facility attended by students from several medical faculties, they are sometimes assigned certain tasks, such as writing review reports, but fail to carry them out. The 30 - 35 age group was the most represented at 30.5%. This percentage is higher than that of THIAM, who found 24.7% in the 30 - 34 age bracket [8] , and differs from that of KAMGA, who found 33.1% of maternal deaths in the 20 - 24 age bracket [9] . This difference may be explained by the fact that the KAMGA study population included maternal deaths due to abortion and ectopic pregnancy. These two entities share the risk factor of young age. 50% of the women in our study had at least secondary education. DIASSANA and LHAGADANG found a majority of maternal deaths among women with no schooling (98.8% and 67% respectively) [10] [11] . This may be explained by the fact that our study was carried out in an urban setting, in Yaoundé (the capital of Cameroon), where the school enrolment rate is high. Most deaths occurred in multiparous women who were referred. The fact of having given birth several times might suggest that you can take care of yourself during pregnancy. Multiparous women may neglect prenatal consultations and wait for the last uterine contractions before going to hospital. Yet they are most at risk of malpresentation and post-partum haemorrhage due to uterine atony. YGOPH is a first-class, central-level hospital in the health pyramid. It is therefore a referral hospital for obstetric complications. We reported that 57.7% of women who died were transported in non-medical vehicles (cabs). In contrast, SISSOKO found that 50% of deceased mothers were transported in ambulances [12] . This could be explained by the fact that the reference health centers in Cameroon do not have ambulances, and that Yaoundé has only one Emergency Medical Service, which implies the payment of an additional sum for patient transport (a sum that is often not available to the sick attendants). In our series, 77.8% of women admitted had been seen by a specialist doctor, unlike MALLE who found that 59.52% of women had been seen by obstetricians and midwives [13] . Yaoundé Gyneco-Obstetric and Paediatric Hospital is a university hospital, which permanently welcomes doctors undergoing specialization for their training. The existence of management protocols and the competence of doctors undergoing specialization are probably the factors favoring good patient conditioning on admission, contrary to the results of BERTHE [14] . The majority of women (72.2%) in our study died in the postpartum period. FOUMANE in 2015, in the same hospital, found 32.8% [15] . ALKASSOUN in Niger in 2018, found 70.1% of deaths in the postpartum period [16] . The predominance of maternal deaths during the postpartum period could be linked to the quality of the women in our series, who were multiparous and at risk of postpartum hemorrhage, which is the leading cause of maternal mortality in Cameroon. Direct obstetric causes were by far the most frequent, at 80.6%. As found by KANTA (78%) in 2013 [17] . Postpartum hemorrhage was the most frequent cause of death with 48.3%, followed by hypertension and its complications with 41.3%, and infection with 6.9%. Abortion was a cause of maternal death in only 3.4% of cases. Our results differ from those of FOUMANE, who in 2010 found hypertension to be the leading cause of maternal mortality [15] . Since 2010, YGOPH has been considered a reference center for the management of hypertensive pathology in pregnancy, which is why post-partum hemorrhage ranks first. This is probably due to a lack of awareness of the danger signs and a failure to anticipate the need for blood derivatives. Pneumopathies were the leading indirect obstetric cause, accounting for 42.8%. The advent of the coronavirus pathology in 2021, which is a pneumopathy, should be noted. Most deaths were preventable according to available summary reports, i.e. 69.4%. Our result is higher than those of DIASSANA and BERTHE who found in their study mostly preventable maternal deaths with respectively 39% and 31.71%, and lower than that of LHAGADANG who found a percentage of 84.8%. This percentage can be explained by the fact that the majority of patients came from health centers and arrived at the Yaoundé Gyneco-Obstetric and Paediatric Hospital with serious complications. The factor contributing most to maternal death was delay in the administration of care, at 64%, followed by delay in the decision to seek treatment, at 22%, and finally delay in access to the health service, at 14%. This can be explained by the lack of essential medicines, the lack of blood derivatives, the lack of staff and the low level of staff retraining in the infrastructures.

The study of maternal deaths at the Yaoundé Gyneco-Obstetric and Paediatric Hospital showed that the surveillance of maternal deaths and response is effective in this health facility. Several challenges remain for the management of the 3 delays, mainly that of the intra-hospital management of pregnant women, in labor or in the aftermath of childbirth. It has been established that 69.3% of maternal deaths at the Yaoundé Gyneco-Obstetric and Paediatric Hospital between 2016 and 2023 were avoidable. Hence the need to put the emphasis on implementing the recommendations made during the death reviews in order to make the response effective.

All authors were involved in developing the manuscript, and PME conceptualized and validated the manuscript, PME, JAMN and NKF drafted the first version of this manuscript, PME, JAMN and NKF collected the data, WLT and XJAN did the statistical analysis. All authors have contributed to writing and revising the manuscript.

The authors would like to thank the administrative staff and all the staff at HGOPY, especially those in the archives, who helped us throughout the study. The authors also declare that they received no funding to carry out this study.

Results of maternal death reviews at the Yaoundé Gynaeco-Obstetric and Paediatric Hospital

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