Comprehensive post-loss follow-up to identify maternal morbidities and improve quality of care: A case report from a maternal and child health call-in center in Bangladesh

Comprehensive post-loss follow-up to identify maternal morbidities and improve quality of care: A case report from a maternal and child health call-in center in Bangladesh | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Comprehensive post-loss follow-up to identify maternal morbidities and improve quality of care: A case report from a maternal and child health call-in center in Bangladesh Rajib Biswas, Chris A. Rees, Taukir Tanjim, Md. Sabbit Khan, Mst. Lopa Moni, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9165848/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Following perinatal death in low- and middle-income countries, maternal contact with health systems often terminates abruptly, leaving potential pregnancy-related morbidities undetected and untreated. In Bangladesh, where an estimated 48% of women lack postpartum follow-up, critical maternal conditions may remain hidden until subsequent pregnancies, or may never be identified at all. The Bangladesh site of the Child Health and Mortality Prevention Surveillance (CHAMPS) network routinely follows up with mothers following perinatal death through a physician-operated call-in center. We present a case demonstrating how this comprehensive follow-up identified unrecognized maternal morbidity, facilitated clinical re-engagement, and improved the quality of clinical care, resulting in successful illness resolution and a subsequent healthy delivery. Case presentation A 25-year-old woman was admitted to Faridpur Medical College Hospital due to prolonged obstructed labor in her first pregnancy. Subsequently, a stillborn female infant was delivered via an emergency cesarean section. Following informed consent, Minimally Invasive Tissue Sampling (MITS) of the stillborn child was conducted and an expert panel identified the cause of stillbirth was intrauterine hypoxia due to obstructed labor. Three months post-delivery, during a scheduled follow-up call from the CHAMPS call-in center, the mother reported continuous urinary incontinence. Suspecting vesicovaginal fistula (VVF), the call-in center physician facilitated an urgent referral, which led to the confirmation of a 2 cm VVF. The patient conceived seven months post-loss while on the surgical waitlist for repairing the VVF. The CHAMPS team coordinated her antenatal care and informed her high-risk status to hospital obstetricians. She underwent a planned cesarean section at 37 weeks, delivering a healthy male infant. Six weeks later, she underwent successful surgical repair of the VVF. Conclusions This case, representative of successful interventions within CHAMPS Bangladesh, demonstrates how a mortality surveillance system with systematic post-loss follow-up protocols can identify hidden morbidities, improve the quality of clinical care, and mitigate delays in seeking treatment. In settings where primary healthcare access is inconsistent, this model can function as a vital safety net, linking vulnerable populations to clinical care and preventing recurrent adverse outcomes. Perinatal death Maternal morbidity Vesicovaginal fistula Post-loss follow-up Quality of care Bangladesh Case report Background Perinatal mortality remains a persistent public health challenge in low- and middle-income countries. In Bangladesh, perinatal mortality rates are estimated to be as high as 48 per 1,000 pregnancies of ≥ 7 months duration [ 1 ]. Obstructed labor, a major preventable cause of these deaths [ 2 , 3 ], frequently results in severe maternal morbidities, most notably obstetric fistula [ 4 ]. Unless treated, these fistulae can lead to devastating long-term consequences, such as chronic urinary or fecal incontinence [ 4 , 5 ]. In Bangladesh, obstetric fistulae affect as many as 38 per 100,000 women of reproductive age [ 6 ], yet many cases remain undiagnosed and untreated due to stigma and limited utilization of healthcare services [ 7 , 8 ]. Living with an obstetric fistula often makes a woman’s daily life extremely difficult and possibly humiliating as in some cases, family members isolate her, keeping her alone in a separate room [ 9 , 10 ]. Unlike mothers with live infants who engage with the health system for immunization and postnatal care, bereaved mothers following a perinatal death might not return to the facility for postnatal follow-up [ 11 , 12 ]. This leaves them vulnerable to untreated morbidities, including obstetric fistulae that may persist for years or complicate subsequent pregnancies [ 13 – 15 ]. Women entering a future pregnancy with such unresolved physical trauma significantly heighten their clinical risks. The Child Health and Mortality Prevention Surveillance (CHAMPS) network, operational in Bangladesh since 2017, focuses on determining causes of stillbirths and under-5 deaths through minimally invasive tissue sampling (MITS) in order to inform interventions to prevent future deaths [ 16 ]. The CHAMPS Bangladesh site has leveraged its existing infrastructure to create a systematic post-loss follow-up protocol through a physician-operated call-in center. The call-in center follows up mothers whose stillbirths or deceased children were enrolled in CHAMPS, especially focusing on women with perinatal deaths. This protocol extends beyond passive health monitoring to also serve as an active platform to identify hidden maternal morbidities following perinatal loss, facilitating linkage to clinical care, and mitigating risks for subsequent pregnancies. Case presentation In August 2023, a 25-year-old woman in her first pregnancy sought emergency care due to prolonged obstructed labor at Faridpur Medical College Hospital (FMCH), a tertiary referral center in Bangladesh. She had not attended any antenatal care visits. Her stature was short (140 cm), which raised concern that her pelvis might be too small for a safe vaginal delivery. An emergency cesarean section was therefore performed; however, the baby girl was stillborn. Following the delivery, the family consented to MITS, and the mother was enrolled in the CHAMPS post-loss follow-up protocol. The determination of cause of death (DeCoDe) panel, composed of obstetricians, pediatricians, pathologists, and microbiologists, attributed the stillbirth to intrauterine hypoxia secondary to obstructed labor. The panel also recognized that the mother’s short stature posed a significant, non-modifiable risk factor for recurrent obstruction in future pregnancies. Three months post-loss, during systematic follow-up regarding her recovery from the CHAMPS call-in center, the mother reported persistent urinary incontinence. Suspecting vesicovaginal fistula (VVF), the CHAMPS call-in center physician facilitated an urgent referral to FMCH, where examination confirmed a 2 cm VVF at the bladder trigone. As VVF is not a life-threatening condition, the patient was placed on a surgical waitlist for repair. Despite counseling to delay conception, she conceived seven months after the stillbirth delivery, before her surgical repair could be performed. In accordance with the CHAMPS call-in center protocol, her follow-up schedule was immediately intensified from the standard 3-month intervals to monthly follow-up calls. The higher frequency of follow-up allowed the CHAMPS team to immediately coordinate her antenatal care, ensuring that obstetricians at FMCH were aware of her high-risk status and actively managed complications associated with unrepaired VVF, particularly the monitoring and treatment of urinary tract infections. A multidisciplinary team at FMCH planned an elective cesarean section at term to prevent recurrence of obstructed labor and to protect the fistula tract from the mechanical stresses of labor. In January 2025, at 37 weeks of gestation, the patient underwent the planned cesarean section, delivering a healthy male infant weighing 2.8 kg with normal Apgar scores. Six weeks after the birth of her live-born child, she underwent successful surgical repair of her VVF, achieving complete resolution of her urinary symptoms. Discussion and Conclusions This case illustrates how the CHAMPS mortality surveillance infrastructure, when adapted to include structured post-loss follow-up, can function as a vital safety net. The enhanced quality of clinical care and successful resolution of this mother’s complex condition were not merely the result of a referral but the outcome of a holistic intervention built on trust, persistence, and coordinated care. The impact of this model is highlighted through the following key dimensions: Establishing trust through psychosocial support : The foundation of this intervention was the emotional connection and trust established between the call-in center physician and the grieving mother. The call-in center was staffed by two female physicians, specifically trained in grief counseling and maternal health communication, operating on a 24/7 roster system ensuring a flow of care through structured data recording. In a context where obstetric fistula is heavily stigmatized and often leads to social isolation, women are rarely forthcoming about their symptoms [ 9 , 10 ]. By prioritizing grief counseling and emotional support during the initial contact, the physician created a safe environment for the mother. This human-centric approach empowered her to disclose the symptom of urinary incontinence, which she had suffered in silence. Without this rapport, the clinical diagnosis would likely have been missed. Proactive post-loss follow-up : The structured nature of the follow-up protocol directly addressed the three delays model of maternal mortality [ 17 ]. By reaching out to the mother proactively, the system bypassed the first delay (decision to seek care), which was hindered by her lack of awareness and stigma. Furthermore, the active referral to a tertiary facility addressed the second delay (reaching the facility) and the third delay (receiving adequate care) by ensuring she was not just sent to a hospital, but connected to a specific multidisciplinary team prepared for her complex case. Integrated and multidisciplinary approach : The intervention bridged the often-fragmented gap between public health surveillance and clinical service delivery. The CHAMPS team acted as care coordinators, ensuring that the mother’s subsequent pregnancy was monitored with the vigilance required for a fistula patient. The collaboration between the surveillance team, obstetricians, and surgeons ensured that the timing of her delivery and subsequent repair was optimized, preventing further injury and ensuring a live birth. While this report focuses on a single site in Bangladesh, the implications for the broader CHAMPS network and similar surveillance systems are significant. The scalability of this model to other sites only requires leveraging existing research infrastructure to address the immediate needs of participants. In resource-limited settings, where almost half of women receive no postpartum follow-up, the risk of untreated morbidity following perinatal death remains high. This case demonstrates that mortality surveillance systems have a practical opportunity to fill this gap. As countries aim to meet Sustainable Development Goal indicators, integrating compassionate support with clinical vigilance, systematic post-loss follow-up protocols can identify hidden morbidities, in the vulnerable period following perinatal death, thereby restoring maternal health and protecting future generations. Abbreviations CHAMPS Child Health and Mortality Prevention Surveillance FMCH Faridpur Medical College Hospital VVF Vesicovaginal fistula MITS Minimally Invasive Tissue Sampling DeCoDe Determination of Cause of Death Declarations Ethics approval and consent to participate The Child Health and Mortality Prevention Surveillance (CHAMPS) network study protocol was approved by the Institutional Review Board of Emory University (Atlanta, GA, USA) and the Institutional Review Committee (IRC) of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Informed written consent for minimally invasive tissue sampling (MITS) and systematic post-loss follow-up was obtained from the patient and her family at the time of enrollment in CHAMPS. Consent for publication Written informed consent for publication of clinical details and any identifying information was obtained from the patient prior to submission. A copy of the consent form is available for review by the Editor-in-Chief of this journal on request. Competing interests The authors declare that they have no competing interests. Funding The Child Health and Mortality Prevention Surveillance (CHAMPS) network is funded by the Bill & Melinda Gates Foundation. The funder had no role in the design of the study, data collection, analysis, interpretation of data, or writing the manuscript. Authors’ contributions RB and MZH conceptualized the case report. TT, MLM, SAS, MAM, MRM, AA, and DZ were responsible for data acquisition and clinical management of the case. RB drafted the original manuscript. CAR, ESG, SP, SEA, DZ, TT, MSK, MLM, SAS, AA, MRM, and MAM provided critical review and editing for intellectual content. All authors read and approved the final manuscript. Acknowledgements We express our deepest gratitude to the patient and her family for their trust and willingness to share their story. We gratefully acknowledge the dedication of the entire CHAMPS Bangladesh team, whose collective efforts made this intervention possible. We also extend our thanks to the administration and clinical staff of Faridpur Medical College Hospital and the Institute of Epidemiology, Disease Control and Research (IEDCR) for their continued support and collaboration and CHAMPS Program Office (Emory University) for their guidance and supports. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. This is a case report based on clinical observations and structured follow-up records collected as part of the CHAMPS protocol; individual-level data cannot be publicly shared to protect patient privacy and confidentiality. De-identified data may be available from the corresponding author on reasonable request and subject to institutional data sharing agreements. References National Institute of Population Research and Training - NIPORT, ICF (2020) Bangladesh Demographic and Health Survey 2017-18. Dhaka, Bangladesh, and Rockville. NIPORT and ICF, Maryland, USA Yeshitila YG, Daniel B, Desta M, Kassa GM (2022) Obstructed labor and its effect on adverse maternal and fetal outcomes in Ethiopia: a systematic review and meta-analysis. PLoS ONE 17:e0275400 Harrison MS, Ali S, Pasha O, Saleem S, Althabe F, Berrueta M et al (2015) A prospective population-based study of maternal, fetal, and neonatal outcomes in the setting of prolonged labor, obstructed labor and failure to progress in low-and middle-income countries. Reproductive health 12(Suppl 2):S9 Neilson JP, Lavender T, Quenby S, Wray S (2003) Obstructed labour: reducing maternal death and disability during pregnancy. Br Med Bull 67:191–204 McClure EM, Saleem S, Pasha O, Goldenberg RL (2009) Stillbirth in developing countries: a review of causes, risk factors and prevention strategies. J maternal-fetal neonatal Med 22:183–190 Ahmed S, Curtis SL, Jamil K, Nahar Q, Rahman M, Huda SN et al (2022) Obstetric fistula in Bangladesh: estimates from a national survey with clinical validation correction. Lancet Global Health 10:e1347–e1354 Kon K, Imoto A, Rashid SF, Masuda K (2025) Barriers and facilitators for treatment-seeking among women with genital fistula: a facility-based qualitative study in Bangladesh. Trop Med Health 53:34 Baker Z, Bellows B, Bach R, Warren C (2017) Barriers to obstetric fistula treatment in low-income countries: a systematic review. Tropical Med Int Health 22:938–959 Imoto A, Matsuyama A, Ambauen-Berger B, Honda S (2015) Health-related quality of life among women in rural Bangladesh after surgical repair of obstetric fistula. Int J Gynecol Obstet 130:79–83 Ahmed S, Holtz SA (2007) Social and economic consequences of obstetric fistula: life changed forever? Int J Gynecol Obstet 99:S10–S15 Heazell AE, Siassakos D, Blencowe H, Burden C, Bhutta ZA, Cacciatore J et al (2016) Stillbirths: economic and psychosocial consequences. Lancet 387:604–616 Zhuang S, Chen M, Ma X, Jiang J, Xiao G, Zhao Y et al (2023) The needs of women experiencing perinatal loss: A qualitative systematic review and meta-synthesis. Women Birth 36:409–420 Cui N, Wu S, Wang X, Sheng L (2025) Experiences and needs of family members of perinatal infant deaths: A meta-synthesis. Front Public Health 13:1580039 Kuforiji O, Mills TA, Lovell K (2023) Women’s experiences of care and support following perinatal death in high burden countries: A metasynthesis. Women Birth 36:e195–202 Dube K, Marenga F, Ayebare EO, Bedwell C, Chaudhry N, Chilinda I et al (2025) A meta-core outcome set for stillbirth prevention and bereavement care following stillbirth in LMIC. BMJ Global Health 10:e017688 Salzberg NT, Sivalogan K, Bassat Q, Taylor AW, Adedini S, El Arifeen S et al (2019) Mortality Surveillance Methods to Identify and Characterize Deaths in Child Health and Mortality Prevention Surveillance Network Sites. Clin Infect Dis 69(Suppl 4):S262–S273. https://doi.org/10.1093/cid/ciz599 Thaddeus S, Maine D (1994) Too far to walk: maternal mortality in context. Soc Sci Med 38:1091–1110 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9165848","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":608733864,"identity":"a5d38ba9-3bdb-4c8e-b7db-b88fdcfab091","order_by":0,"name":"Rajib Biswas","email":"","orcid":"https://orcid.org/0000-0002-1624-3723","institution":"International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)","correspondingAuthor":false,"prefix":"","firstName":"Rajib","middleName":"","lastName":"Biswas","suffix":""},{"id":608742275,"identity":"955d0caa-c8f9-4a65-90c5-8d8b5d034e26","order_by":1,"name":"Chris A. 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In Bangladesh, perinatal mortality rates are estimated to be as high as 48 per 1,000 pregnancies of \u0026ge;\u0026thinsp;7 months duration [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Obstructed labor, a major preventable cause of these deaths [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], frequently results in severe maternal morbidities, most notably obstetric fistula [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Unless treated, these fistulae can lead to devastating long-term consequences, such as chronic urinary or fecal incontinence [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In Bangladesh, obstetric fistulae affect as many as 38 per 100,000 women of reproductive age [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], yet many cases remain undiagnosed and untreated due to stigma and limited utilization of healthcare services [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Living with an obstetric fistula often makes a woman\u0026rsquo;s daily life extremely difficult and possibly humiliating as in some cases, family members isolate her, keeping her alone in a separate room [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnlike mothers with live infants who engage with the health system for immunization and postnatal care, bereaved mothers following a perinatal death might not return to the facility for postnatal follow-up [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This leaves them vulnerable to untreated morbidities, including obstetric fistulae that may persist for years or complicate subsequent pregnancies [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Women entering a future pregnancy with such unresolved physical trauma significantly heighten their clinical risks.\u003c/p\u003e \u003cp\u003eThe Child Health and Mortality Prevention Surveillance (CHAMPS) network, operational in Bangladesh since 2017, focuses on determining causes of stillbirths and under-5 deaths through minimally invasive tissue sampling (MITS) in order to inform interventions to prevent future deaths [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The CHAMPS Bangladesh site has leveraged its existing infrastructure to create a systematic post-loss follow-up protocol through a physician-operated call-in center. The call-in center follows up mothers whose stillbirths or deceased children were enrolled in CHAMPS, especially focusing on women with perinatal deaths. This protocol extends beyond passive health monitoring to also serve as an active platform to identify hidden maternal morbidities following perinatal loss, facilitating linkage to clinical care, and mitigating risks for subsequent pregnancies.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eIn August 2023, a 25-year-old woman in her first pregnancy sought emergency care due to prolonged obstructed labor at Faridpur Medical College Hospital (FMCH), a tertiary referral center in Bangladesh. She had not attended any antenatal care visits. Her stature was short (140 cm), which raised concern that her pelvis might be too small for a safe vaginal delivery. An emergency cesarean section was therefore performed; however, the baby girl was stillborn.\u003c/p\u003e \u003cp\u003eFollowing the delivery, the family consented to MITS, and the mother was enrolled in the CHAMPS post-loss follow-up protocol. The determination of cause of death (DeCoDe) panel, composed of obstetricians, pediatricians, pathologists, and microbiologists, attributed the stillbirth to intrauterine hypoxia secondary to obstructed labor. The panel also recognized that the mother\u0026rsquo;s short stature posed a significant, non-modifiable risk factor for recurrent obstruction in future pregnancies. Three months post-loss, during systematic follow-up regarding her recovery from the CHAMPS call-in center, the mother reported persistent urinary incontinence. Suspecting vesicovaginal fistula (VVF), the CHAMPS call-in center physician facilitated an urgent referral to FMCH, where examination confirmed a 2 cm VVF at the bladder trigone.\u003c/p\u003e \u003cp\u003eAs VVF is not a life-threatening condition, the patient was placed on a surgical waitlist for repair. Despite counseling to delay conception, she conceived seven months after the stillbirth delivery, before her surgical repair could be performed. In accordance with the CHAMPS call-in center protocol, her follow-up schedule was immediately intensified from the standard 3-month intervals to monthly follow-up calls. The higher frequency of follow-up allowed the CHAMPS team to immediately coordinate her antenatal care, ensuring that obstetricians at FMCH were aware of her high-risk status and actively managed complications associated with unrepaired VVF, particularly the monitoring and treatment of urinary tract infections. A multidisciplinary team at FMCH planned an elective cesarean section at term to prevent recurrence of obstructed labor and to protect the fistula tract from the mechanical stresses of labor. In January 2025, at 37 weeks of gestation, the patient underwent the planned cesarean section, delivering a healthy male infant weighing 2.8 kg with normal Apgar scores. Six weeks after the birth of her live-born child, she underwent successful surgical repair of her VVF, achieving complete resolution of her urinary symptoms.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDiscussion and Conclusions\u003c/h2\u003e \u003cp\u003eThis case illustrates how the CHAMPS mortality surveillance infrastructure, when adapted to include structured post-loss follow-up, can function as a vital safety net. The enhanced quality of clinical care and successful resolution of this mother\u0026rsquo;s complex condition were not merely the result of a referral but the outcome of a holistic intervention built on trust, persistence, and coordinated care. The impact of this model is highlighted through the following key dimensions:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEstablishing trust through psychosocial support\u003c/b\u003e: The foundation of this intervention was the emotional connection and trust established between the call-in center physician and the grieving mother. The call-in center was staffed by two female physicians, specifically trained in grief counseling and maternal health communication, operating on a 24/7 roster system ensuring a flow of care through structured data recording. In a context where obstetric fistula is heavily stigmatized and often leads to social isolation, women are rarely forthcoming about their symptoms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. By prioritizing grief counseling and emotional support during the initial contact, the physician created a safe environment for the mother. This human-centric approach empowered her to disclose the symptom of urinary incontinence, which she had suffered in silence. Without this rapport, the clinical diagnosis would likely have been missed.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eProactive post-loss follow-up\u003c/b\u003e: The structured nature of the follow-up protocol directly addressed the three delays model of maternal mortality [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. By reaching out to the mother proactively, the system bypassed the first delay (decision to seek care), which was hindered by her lack of awareness and stigma. Furthermore, the active referral to a tertiary facility addressed the second delay (reaching the facility) and the third delay (receiving adequate care) by ensuring she was not just sent to a hospital, but connected to a specific multidisciplinary team prepared for her complex case.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eIntegrated and multidisciplinary approach\u003c/b\u003e: The intervention bridged the often-fragmented gap between public health surveillance and clinical service delivery. The CHAMPS team acted as care coordinators, ensuring that the mother\u0026rsquo;s subsequent pregnancy was monitored with the vigilance required for a fistula patient. The collaboration between the surveillance team, obstetricians, and surgeons ensured that the timing of her delivery and subsequent repair was optimized, preventing further injury and ensuring a live birth.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eWhile this report focuses on a single site in Bangladesh, the implications for the broader CHAMPS network and similar surveillance systems are significant. The scalability of this model to other sites only requires leveraging existing research infrastructure to address the immediate needs of participants.\u003c/p\u003e \u003cp\u003eIn resource-limited settings, where almost half of women receive no postpartum follow-up, the risk of untreated morbidity following perinatal death remains high. This case demonstrates that mortality surveillance systems have a practical opportunity to fill this gap. As countries aim to meet Sustainable Development Goal indicators, integrating compassionate support with clinical vigilance, systematic post-loss follow-up protocols can identify hidden morbidities, in the vulnerable period following perinatal death, thereby restoring maternal health and protecting future generations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHAMPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChild Health and Mortality Prevention Surveillance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFMCH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFaridpur Medical College Hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVVF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVesicovaginal fistula\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMITS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinimally Invasive Tissue Sampling\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDeCoDe\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDetermination of Cause of Death\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe Child Health and Mortality Prevention Surveillance (CHAMPS) network study protocol was approved by the Institutional Review Board of Emory University (Atlanta, GA, USA) and the Institutional Review Committee (IRC) of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Informed written consent for minimally invasive tissue sampling (MITS) and systematic post-loss follow-up was obtained from the patient and her family at the time of enrollment in CHAMPS.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e Written informed consent for publication of clinical details and any identifying information was obtained from the patient prior to submission. A copy of the consent form is available for review by the Editor-in-Chief of this journal on request.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe Child Health and Mortality Prevention Surveillance (CHAMPS) network is funded by the Bill \u0026amp; Melinda Gates Foundation. The funder had no role in the design of the study, data collection, analysis, interpretation of data, or writing the manuscript.\u003c/p\u003e\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e \u003cp\u003eRB and MZH conceptualized the case report. TT, MLM, SAS, MAM, MRM, AA, and DZ were responsible for data acquisition and clinical management of the case. RB drafted the original manuscript. CAR, ESG, SP, SEA, DZ, TT, MSK, MLM, SAS, AA, MRM, and MAM provided critical review and editing for intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eWe express our deepest gratitude to the patient and her family for their trust and willingness to share their story. We gratefully acknowledge the dedication of the entire CHAMPS Bangladesh team, whose collective efforts made this intervention possible. We also extend our thanks to the administration and clinical staff of Faridpur Medical College Hospital and the Institute of Epidemiology, Disease Control and Research (IEDCR) for their continued support and collaboration and CHAMPS Program Office (Emory University) for their guidance and supports.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analysed during the current study. This is a case report based on clinical observations and structured follow-up records collected as part of the CHAMPS protocol; individual-level data cannot be publicly shared to protect patient privacy and confidentiality. De-identified data may be available from the corresponding author on reasonable request and subject to institutional data sharing agreements.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNational Institute of Population Research and Training - NIPORT, ICF (2020) Bangladesh Demographic and Health Survey 2017-18. Dhaka, Bangladesh, and Rockville. NIPORT and ICF, Maryland, USA\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYeshitila YG, Daniel B, Desta M, Kassa GM (2022) Obstructed labor and its effect on adverse maternal and fetal outcomes in Ethiopia: a systematic review and meta-analysis. PLoS ONE 17:e0275400\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarrison MS, Ali S, Pasha O, Saleem S, Althabe F, Berrueta M et al (2015) A prospective population-based study of maternal, fetal, and neonatal outcomes in the setting of prolonged labor, obstructed labor and failure to progress in low-and middle-income countries. Reproductive health 12(Suppl 2):S9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeilson JP, Lavender T, Quenby S, Wray S (2003) Obstructed labour: reducing maternal death and disability during pregnancy. Br Med Bull 67:191\u0026ndash;204\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcClure EM, Saleem S, Pasha O, Goldenberg RL (2009) Stillbirth in developing countries: a review of causes, risk factors and prevention strategies. J maternal-fetal neonatal Med 22:183\u0026ndash;190\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed S, Curtis SL, Jamil K, Nahar Q, Rahman M, Huda SN et al (2022) Obstetric fistula in Bangladesh: estimates from a national survey with clinical validation correction. Lancet Global Health 10:e1347\u0026ndash;e1354\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKon K, Imoto A, Rashid SF, Masuda K (2025) Barriers and facilitators for treatment-seeking among women with genital fistula: a facility-based qualitative study in Bangladesh. Trop Med Health 53:34\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaker Z, Bellows B, Bach R, Warren C (2017) Barriers to obstetric fistula treatment in low-income countries: a systematic review. Tropical Med Int Health 22:938\u0026ndash;959\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImoto A, Matsuyama A, Ambauen-Berger B, Honda S (2015) Health-related quality of life among women in rural Bangladesh after surgical repair of obstetric fistula. Int J Gynecol Obstet 130:79\u0026ndash;83\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed S, Holtz SA (2007) Social and economic consequences of obstetric fistula: life changed forever? Int J Gynecol Obstet 99:S10\u0026ndash;S15\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeazell AE, Siassakos D, Blencowe H, Burden C, Bhutta ZA, Cacciatore J et al (2016) Stillbirths: economic and psychosocial consequences. Lancet 387:604\u0026ndash;616\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhuang S, Chen M, Ma X, Jiang J, Xiao G, Zhao Y et al (2023) The needs of women experiencing perinatal loss: A qualitative systematic review and meta-synthesis. Women Birth 36:409\u0026ndash;420\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCui N, Wu S, Wang X, Sheng L (2025) Experiences and needs of family members of perinatal infant deaths: A meta-synthesis. Front Public Health 13:1580039\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuforiji O, Mills TA, Lovell K (2023) Women\u0026rsquo;s experiences of care and support following perinatal death in high burden countries: A metasynthesis. Women Birth 36:e195\u0026ndash;202\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDube K, Marenga F, Ayebare EO, Bedwell C, Chaudhry N, Chilinda I et al (2025) A meta-core outcome set for stillbirth prevention and bereavement care following stillbirth in LMIC. BMJ Global Health 10:e017688\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalzberg NT, Sivalogan K, Bassat Q, Taylor AW, Adedini S, El Arifeen S et al (2019) Mortality Surveillance Methods to Identify and Characterize Deaths in Child Health and Mortality Prevention Surveillance Network Sites. Clin Infect Dis 69(Suppl 4):S262\u0026ndash;S273. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/cid/ciz599\u003c/span\u003e\u003cspan address=\"10.1093/cid/ciz599\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThaddeus S, Maine D (1994) Too far to walk: maternal mortality in context. Soc Sci Med 38:1091\u0026ndash;1110\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Bill \u0026 Melinda Gates Foundation","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Perinatal death, Maternal morbidity, Vesicovaginal fistula, Post-loss follow-up, Quality of care, Bangladesh, Case report","lastPublishedDoi":"10.21203/rs.3.rs-9165848/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9165848/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFollowing perinatal death in low- and middle-income countries, maternal contact with health systems often terminates abruptly, leaving potential pregnancy-related morbidities undetected and untreated. In Bangladesh, where an estimated 48% of women lack postpartum follow-up, critical maternal conditions may remain hidden until subsequent pregnancies, or may never be identified at all. The Bangladesh site of the Child Health and Mortality Prevention Surveillance (CHAMPS) network routinely follows up with mothers following perinatal death through a physician-operated call-in center. We present a case demonstrating how this comprehensive follow-up identified unrecognized maternal morbidity, facilitated clinical re-engagement, and improved the quality of clinical care, resulting in successful illness resolution and a subsequent healthy delivery.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 25-year-old woman was admitted to Faridpur Medical College Hospital due to prolonged obstructed labor in her first pregnancy. Subsequently, a stillborn female infant was delivered via an emergency cesarean section. Following informed consent, Minimally Invasive Tissue Sampling (MITS) of the stillborn child was conducted and an expert panel identified the cause of stillbirth was intrauterine hypoxia due to obstructed labor. Three months post-delivery, during a scheduled follow-up call from the CHAMPS call-in center, the mother reported continuous urinary incontinence. Suspecting vesicovaginal fistula (VVF), the call-in center physician facilitated an urgent referral, which led to the confirmation of a 2 cm VVF. The patient conceived seven months post-loss while on the surgical waitlist for repairing the VVF. The CHAMPS team coordinated her antenatal care and informed her high-risk status to hospital obstetricians. She underwent a planned cesarean section at 37 weeks, delivering a healthy male infant. Six weeks later, she underwent successful surgical repair of the VVF.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis case, representative of successful interventions within CHAMPS Bangladesh, demonstrates how a mortality surveillance system with systematic post-loss follow-up protocols can identify hidden morbidities, improve the quality of clinical care, and mitigate delays in seeking treatment. In settings where primary healthcare access is inconsistent, this model can function as a vital safety net, linking vulnerable populations to clinical care and preventing recurrent adverse outcomes.\u003c/p\u003e","manuscriptTitle":"Comprehensive post-loss follow-up to identify maternal morbidities and improve quality of care: A case report from a maternal and child health call-in center in Bangladesh","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-20 06:55:06","doi":"10.21203/rs.3.rs-9165848/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0faefca8-9700-408a-b1fe-54233c1a72b2","owner":[],"postedDate":"March 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-20T06:55:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-20 06:55:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9165848","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9165848","identity":"rs-9165848","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}