Reduction of maternal mortality due to preeclampsia in Colombia-an interrupted time-series analysis

PubMed Central

Herrera-Medina, Rodolfo; Herrera-Escobar, Juan Pablo; Nieto-Díaz, Aníbal

2014-01-01

Introduction: Preeclampsia is the most important cause of maternal mortality in developing countries. A comprehensive prenatal care program including bio-psychosocial components was developed and introduced at a national level in Colombia. We report on the trends in maternal mortality rates and their related causes before and after implementation of this program. Methods: General and specific maternal mortality rates were monitored for nine years (1998-2006). An interrupted time-series analysis was performed with monthly data on cases of maternal mortality that compared trends and changes in national mortality rates and the impact of these changes attributable to the introduction of a bio-psychosocial model. Multivariate analyses were performed to evaluate correlations between the interventions. Results: Five years after (2002 - 2006) its introduction the general maternal mortality rate was significantly reduced to 23% (OR=0.77, CI 95% 0.71-0.82).The implementation of BPSM also reduced the incidence of preeclampsia in 22% (OR= 0.78, CI 95% 0.67-0.88), as also the labor complications by hemorrhage in 25% (OR=0.75, CI 95% 0.59-0.90) associated with the implementation of red code. The other causes of maternal mortality did not reveal significant changes. Biomedical, nutritional, psychosocial assessments, and other individual interventions in prenatal care were not correlated to maternal mortality (p= 0.112); however, together as a model we observed a significant association (p= 0.042). Conclusions: General maternal mortality was reduced after the implementation of a comprehensive national prenatal care program. Is important the evaluation of this program in others populations. PMID:24970956

Alternative strategies to reduce maternal mortality in India: a cost-effectiveness analysis.

PubMed

Goldie, Sue J; Sweet, Steve; Carvalho, Natalie; Natchu, Uma Chandra Mouli; Hu, Delphine

2010-04-20

Approximately one-quarter of all pregnancy- and delivery-related maternal deaths worldwide occur in India. Taking into account the costs, feasibility, and operational complexity of alternative interventions, we estimate the clinical and population-level benefits associated with strategies to improve the safety of pregnancy and childbirth in India. Country- and region-specific data were synthesized using a computer-based model that simulates the natural history of pregnancy (both planned and unintended) and pregnancy- and childbirth-associated complications in individual women; and considers delivery location, attendant, and facility level. Model outcomes included clinical events, population measures, costs, and cost-effectiveness ratios. Separate models were adapted to urban and rural India using survey-based data (e.g., unmet need for birth spacing/limiting, facility births, skilled birth attendants). Model validation compared projected maternal indicators with empiric data. Strategies consisted of improving coverage of effective interventions that could be provided individually or packaged as integrated services, could reduce the incidence of a complication or its case fatality rate, and could include improved logistics such as reliable transport to an appropriate referral facility as well as recognition of referral need and quality of care. Increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality. If over the next 5 y the unmet need for spacing and limiting births was met, more than 150,000 maternal deaths would be prevented; more than US$1 billion saved; and at least one of every two abortion-related deaths averted. Still, reductions in maternal mortality reached a threshold ( approximately 23%-35%) without including strategies that ensured reliable access to intrapartum and emergency obstetrical care (EmOC). An integrated and stepwise approach was identified that would ultimately prevent four of five

Alternative Strategies to Reduce Maternal Mortality in India: A Cost-Effectiveness Analysis

PubMed Central

Goldie, Sue J.; Sweet, Steve; Carvalho, Natalie; Natchu, Uma Chandra Mouli; Hu, Delphine

2010-01-01

Background Approximately one-quarter of all pregnancy- and delivery-related maternal deaths worldwide occur in India. Taking into account the costs, feasibility, and operational complexity of alternative interventions, we estimate the clinical and population-level benefits associated with strategies to improve the safety of pregnancy and childbirth in India. Methods and Findings Country- and region-specific data were synthesized using a computer-based model that simulates the natural history of pregnancy (both planned and unintended) and pregnancy- and childbirth-associated complications in individual women; and considers delivery location, attendant, and facility level. Model outcomes included clinical events, population measures, costs, and cost-effectiveness ratios. Separate models were adapted to urban and rural India using survey-based data (e.g., unmet need for birth spacing/limiting, facility births, skilled birth attendants). Model validation compared projected maternal indicators with empiric data. Strategies consisted of improving coverage of effective interventions that could be provided individually or packaged as integrated services, could reduce the incidence of a complication or its case fatality rate, and could include improved logistics such as reliable transport to an appropriate referral facility as well as recognition of referral need and quality of care. Increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality. If over the next 5 y the unmet need for spacing and limiting births was met, more than 150,000 maternal deaths would be prevented; more than US$1 billion saved; and at least one of every two abortion-related deaths averted. Still, reductions in maternal mortality reached a threshold (∼23%–35%) without including strategies that ensured reliable access to intrapartum and emergency obstetrical care (EmOC). An integrated and stepwise approach was identified that would ultimately

Maternal mortality in developing countries.

PubMed

Harrison, K A

1989-01-01

A commentary on the state of maternal mortality is developing countries is presented. Of the estimated half million maternal deaths worldwide yearly, 150,000 occur in Africa, 282,000 in Southern and South Eastern Asia, 26,000 in Western and East Asia, 34,000 in tropical South America, 1,000 in temperate South America, and 2,000 in Oceania. 494,000 maternal deaths occur in developing countries, with 6,000 in all developing countries. Maternal death rates are highest in developing countries due primarily to flaws in the social, economic, and political conditions of the countries involved, combined with a grossly inadequate quantity and quality of available health care services. Here, major causes of maternal death include abortion, anemia, eclampsia, infection, hemorrhage, and obstructed labor and its accompanying complications. Attempts at lowering maternal mortality should include health intervention policies on a global scale, utilizing the intervention of developing countries with their necessary financial and technological support. Universal formal education appears to be the most effective weapon against maternal death. This approach is an effort to modernize most developing societies. Still, a few obstacles remain. These include: discarding cherished traditional customs of health care in favor of modernized techniques, restricting existing health services, and providing faster and more efficient operative intervention procedures. Family planning is also stressed as an important initiative. The most contentious of all methods to lower maternal death rates is the retraining of illiterate traditional birth attendants (TBAs). Activities of TBAs should be viewed cautiously as results of the techniques - in areas such as the Sudan, Africa, and Asia, - have proven to be of little consequence in lowering maternal mortality. Attention to retraining TBAs should be replaced with sufficient training and proper utilization of midwives. The Royal College of Obstetricians

Janani Suraksha Yojana: the conditional cash transfer scheme to reduce maternal mortality in India - a need for reassessment.

PubMed

Rai, Rajesh Kumar; Singh, Prashant Kumar

2012-01-01

Alongside endorsing Millennium Development Goal 5 in 2000, India launched its National Population Policy in 2000 and the National Health Policy in 2002. However, these have failed thus far to reduce the maternal mortality ratio (MMR) by the targeted 5.5% per annum. Under the banner of the National Rural Health Mission, the Government of India launched a national conditional cash transfer (CCT) scheme in 2005 called Janani Suraksha Yojana (JSY), aimed to encourage women to give birth in health facilities which, in turn, should reduce maternal deaths. Poor prenatal care in general, and postnatal care in particular, could be considered the causes of the high number of maternal deaths in India (the highest in the world). Undoubtedly, institutional delivery in India has increased and MMR has reduced over time as a result of socioeconomic development coupled with advancement in health care including improved women's education, awareness and availability of health services. However, in the light of its performance, we argue that the JSY scheme was not well enough designed to be considered as an effective pathway to reduce MMR. We propose that the service-based CCT is not the solution to avoid/reduce maternal deaths and that policy-makers and programme managers should reconsider the 'package' of continuum of care and maternal health services to ensure that they start from adolescence and the pre-pregnancy period, and extend to delivery, postnatal and continued maternal health care.

Abortion and maternal mortality in the developing world.

PubMed

Okonofua, Friday

2006-11-01

Unsafe abortion is an important public health problem, accounting for 13% of maternal mortality in developing countries. Of an estimated annual 70,000 deaths from unsafe abortion worldwide, over 99% occur in the developing countries of sub-Saharan Africa, Central and Southeast Asia, and Latin America and the Caribbean. Factors associated with increased maternal mortality from unsafe abortion in developing countries include inadequate delivery systems for contraception needed to prevent unwanted pregnancies, restrictive abortion laws, pervading negative cultural and religious attitudes towards induced abortion, and poor health infrastructures for the management of abortion complications. The application of a public health approach based on primary, secondary, and tertiary prevention can reduce morbidity and mortality associated with unsafe abortion in developing countries. Primary prevention includes the promotion of increased use of contraception by women (and by men) at risk for unwanted pregnancy; secondary prevention involves the liberalization of abortion laws and the development of programs to increase access to safe abortion care in developing countries. In contrast, tertiary prevention includes the integration and institutionalization of post-abortion care for incomplete abortion and the early and appropriate treatment of more severe complications of abortion. Efforts to address these problems will contribute both to reducing maternal mortality associated with induced abortion and to achieving the Millennium Development Goals in developing countries.

Maternal mortality in Vietnam in 1994-95.

PubMed

Hieu, D T; Hanenberg, R; Vach, T H; Vinh, D Q; Sokal, D

1999-12-01

This report presents the first population-based estimates of maternal mortality in Vietnam. All the deaths of women aged 15-49 in 1994-95 in three provinces of Vietnam were identified and classified by cause. Maternal mortality was the fifth most frequent cause of death. The maternal mortality ratio was 155 deaths per 100,000 live births. This ratio compares with the World Health Organization's estimates of 430 such deaths globally and 390 for Asia. The maternal mortality ratio in the delta regions of these provinces was half that of the mountainous and semimountainous regions. Because a larger proportion of the Vietnamese population live in delta regions than elsewhere, the maternal mortality ratio for Vietnam as a whole may be lower than that of the three provinces studied. Maternal mortality is low in Vietnam primarily because a relatively high proportion of deliveries take place in clinics and hospitals, where few women die in childbirth. Also, few women die of the consequences of induced abortion in Vietnam because the procedure is legal and easily available.

Safer Muslim motherhood: Social conditions and maternal mortality in the Muslim world.

PubMed

Liese, Kylea Laina; Maeder, Angela B

2018-05-01

The greatest variation in maternal mortality is among poor countries and wealthy countries that rely on emergency obstetric technology to save a woman's life during childbirth. However, substantial variation in maternal mortality ratios (MMRs) exists within and among poor countries with uneven access to advanced obstetric services. This article examines MMRs across the Muslim world and compares the impact of national wealth, female education, and skilled birth attendants on maternal mortality. Understanding how poor countries have lowered MMRs without access to expensive obstetric technologies suggests that certain social variables may act protectively to reduce the maternal risk for life-threatening obstetric complications that would require emergency obstetric care.

A review of cultural influence on maternal mortality in the developing world.

PubMed

Evans, Emily C

2013-05-01

identify research examining the effect of culture on maternal mortality rates. literature review of CINAHL, Cochrane, PsychInfo, OVID Medline and Web of Science databases. developing countries with typically higher rates of maternal mortality. women, birth attendants, family members, nurse midwives, health-care workers, and community members. reviews, qualitative and mixed-methods research have identified components of culture that have a direct impact on maternal mortality. Examples of culture are given in the text and categorised according to the way in which they impact maternal mortality. cultural customs, practices, beliefs and values profoundly influence women's behaviours during the perinatal period and in some cases increase the likelihood of maternal death in childbirth. The four ways in which culture may increase MMR are as follows: directly harmful acts, inaction, use of care and social status. understanding the specifics of how the culture surrounding childbirth contributes to maternal mortality can assist nurses, midwives and other health-care workers in providing culturally competent care and designing effective programs to help decrease MMR, especially in the developing world. Interventions designed without accounting for these cultural factors are likely to be less effective in reducing maternal mortality. Copyright © 2012 Elsevier Ltd. All rights reserved.

"Safe motherhood", family planning and maternal mortality: an Indonesian case study.

PubMed

Smyth, I

1994-06-01

This case study in Indonesia examined some assumptions about the outcome of family planning services. Safe Motherhood programs were flawed, because of the misplaced emphasis on family planning as a strategy to reduce maternal mortality. Family planning programs reduce the exposure to the risks of child-bearing, but they do not reduce the actual risks. Reproductive health should not be linked so tightly to demographic concerns and family planning. That cost saving occurs from family planning is insufficient to justify inattention to the needs of high quality obstetric care. Family planning should be viewed as just one component of a larger, comprehensive set of measures designed to assure the health of women at all stages in the life cycle: as citizens and workers, as mothers, and as adolescents. Interventions must begin before childbearing and include growth in economic, educational, and health opportunities. The aim of reducing maternal mortality by 50% by the year 2000 was included in Indonesia's five-year development plan: Repelita V. The example of Indonesia was important, because of its achievements in reducing poverty and increasing the standard of living of the population, and because of its large population size. Estimated maternal mortality in Indonesia was 450/100,000 live births in 1989, up from 390/100,000 in 1982. There was evidence from other studies that maternal mortality has increased. Criticism has been directed to the misplaced emphasis on family planning and the top-down delivery of professional services for ignoring local health-enhancing practices and the role of families, fathers, and communities as health providers. The realized cost effectiveness of family planning is an abstraction. Fertility has declined with an increase in family planning from 5.6 children to 3.0 children in 1990, but, for example, Bali has both high levels of contraception use and high maternal mortality. Integrated programs and the high risk approach have not been

National and sub-national analysis of the health benefits and cost-effectiveness of strategies to reduce maternal mortality in Afghanistan.

PubMed

Carvalho, Natalie; Salehi, Ahmad Shah; Goldie, Sue J

2013-01-01

Afghanistan has one of the highest rates of maternal mortality in the world. We assess the health outcomes and cost-effectiveness of strategies to improve the safety of pregnancy and childbirth in Afghanistan. Using national and sub-national data, we adapted a previously validated model that simulates the natural history of pregnancy and pregnancy-related complications. We incorporated data on antenatal care, family planning, skilled birth attendance and information about access to transport, referral facilities and quality of care. We evaluated single interventions (e.g. family planning) and strategies that combined several interventions packaged as integrated services (transport, intrapartum care). Outcomes included pregnancy-related complications, maternal deaths, maternal mortality ratios, costs and cost-effectiveness ratios. Model-projected reduction in maternal deaths between 1999-2002 and 2007-08 approximated 20%. Increasing family planning was the most effective individual intervention to further reduce maternal mortality; up to 1 in 3 pregnancy-related deaths could be prevented if contraception use approached 60%. Nevertheless, reductions in maternal mortality reached a threshold (∼30% to 40%) without strategies that assured women access to emergency obstetrical care. A stepwise approach that coupled improved family planning with incremental improvements in skilled attendance, transport, referral and appropriate intrapartum care and high-quality facilities prevented 3 of 4 maternal deaths. Such an approach would cost less than US$200 per year of life saved at the national level, well below Afghanistan's per capita gross domestic product (GDP), a common benchmark for cost-effectiveness. Similar results were noted sub-nationally. Our findings reinforce the importance of early intensive efforts to increase family planning for spacing and limiting births and to provide control of fertility choices. While significant improvements in health delivery

Estimation of maternal and neonatal mortality at the subnational level in Liberia.

PubMed

Moseson, Heidi; Massaquoi, Moses; Bawo, Luke; Birch, Linda; Dahn, Bernice; Zolia, Yah; Barreix, Maria; Gerdts, Caitlin

2014-11-01

To establish representative local-area baseline estimates of maternal and neonatal mortality using a novel adjusted sisterhood method. The status of maternal and neonatal health in Bomi County, Liberia, was investigated in June 2013 using a population-based survey (n=1985). The standard direct sisterhood method was modified to account for place and time of maternal death to enable calculation of subnational estimates. The modified method of measuring maternal mortality successfully enabled the calculation of area-specific estimates. Of 71 reported deaths of sisters, 18 (25.4%) were due to pregnancy-related causes and had occurred in the past 3 years in Bomi County. The estimated maternal mortality ratio was 890 maternal deaths for every 100 000 live births (95% CI, 497-1301]. The neonatal mortality rate was estimated to be 47 deaths for every 1000 live births (95% CI, 42-52). In total, 322 (16.9%) of 1900 women with accurate age data reported having had a stillbirth. The modified direct sisterhood method may be useful to other countries seeking a more regionally nuanced understanding of areas in which neonatal and maternal mortality levels still need to be reduced to meet Millennium Development Goals. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group.

PubMed

Alkema, Leontine; Chou, Doris; Hogan, Daniel; Zhang, Sanqian; Moller, Ann-Beth; Gemmill, Alison; Fat, Doris Ma; Boerma, Ties; Temmerman, Marleen; Mathers, Colin; Say, Lale

2016-01-30

Millennium Development Goal 5 calls for a 75% reduction in the maternal mortality ratio (MMR) between 1990 and 2015. We estimated levels and trends in maternal mortality for 183 countries to assess progress made. Based on MMR estimates for 2015, we constructed projections to show the requirements for the Sustainable Development Goal (SDG) of less than 70 maternal deaths per 100,000 livebirths globally by 2030. We updated the UN Maternal Mortality Estimation Inter-Agency Group (MMEIG) database with more than 200 additional records (vital statistics from civil registration systems, surveys, studies, or reports). We generated estimates of maternal mortality and related indicators with 80% uncertainty intervals (UIs) using a Bayesian model. The model combines the rate of change implied by a multilevel regression model with a time-series model to capture data-driven changes in country-specific MMRs, and includes a data model to adjust for systematic and random errors associated with different data sources. We had data for 171 of 183 countries. The global MMR fell from 385 deaths per 100,000 livebirths (80% UI 359-427) in 1990, to 216 (207-249) in 2015, corresponding to a relative decline of 43·9% (34·0-48·7), with 303,000 (291,000-349,000) maternal deaths worldwide in 2015. Regional progress in reducing the MMR since 1990 ranged from an annual rate of reduction of 1·8% (0·0-3·1) in the Caribbean to 5·0% (4·0-6·0) in eastern Asia. Regional MMRs for 2015 ranged from 12 deaths per 100,000 livebirths (11-14) for high-income regions to 546 (511-652) for sub-Saharan Africa. Accelerated progress will be needed to achieve the SDG goal; countries will need to reduce their MMRs at an annual rate of reduction of at least 7·5%. Despite global progress in reducing maternal mortality, immediate action is needed to meet the ambitious SDG 2030 target, and ultimately eliminate preventable maternal mortality. Although the rates of reduction that are needed to achieve country

Abortion in the Structure of Causes of Maternal Mortality.

PubMed

Volkov, Valery G; Granatovich, Nina N; Survillo, Elena V; Pichugina, Leontina V; Achilgova, Zarina S

2018-06-12

 To study the structure of maternal mortality caused by abortion in the Tula region.  The medical records of deceased pregnant women, childbirth, and postpartum from January 01, 2001, to December 31, 2015, were analyzed.  Overall, 204,095 abortion cases were recorded in the Tula region for over 15 years. The frequency of abortion was reduced 4-fold, with 18,200 in 2001 to 4,538 in 2015. The rate of abortions per 1,000 women (age 15-44 years) for 15 years decreased by 40.5%, that is, from 46.53 (2001) to 18.84 (2015), and that of abortions per 100 live births and stillbirths was 29.5%, that is, from 161.7 (2001) to 41.5 (2015). Five women died from abortion complications that began outside of the hospital, which accounted for 0.01% of the total number. In the structure of causes of maternal mortality for 15 years, abortion represented 14.3% of the cases. Lethality mainly occurred in the period from 2001 to 2005 (4 cases). Among the maternal deaths, many women died in rural areas after pregnancy termination at 18 to 20 weeks of gestation ( n  = 4). In addition, three women died from sepsis and two from bleeding.  The introduction of modern, effective technologies of family planning has reduced maternal mortality due to abortion. Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil.

The Decline in Maternal Mortality in Sweden

PubMed Central

Högberg, Ulf

2004-01-01

The maternal mortality rate in Sweden in the early 20th century was one third that in the United States. This rate was recognized by American visitors as an achievement of Swedish maternity care, in which highly competent midwives attend home deliveries. The 19th century decline in maternal mortality was largely caused by improvements in obstetric care, but was also helped along by the national health strategy of giving midwives and doctors complementary roles in maternity care, as well as equal involvement in setting public health policy. The 20th century decline in maternal mortality, seen in all Western countries, was made possible by the emergence of modern medicine. However, the contribution of the mobilization of human resources should not be underestimated, nor should key developments in public health policy. PMID:15284032

Intergenerational impacts of maternal mortality: Qualitative findings from rural Malawi

PubMed Central

2015-01-01

Background Maternal mortality, although largely preventable, remains unacceptably high in developing countries such as Malawi and creates a number of intergenerational impacts. Few studies have investigated the far-reaching impacts of maternal death beyond infant survival. This study demonstrates the short- and long-term impacts of maternal death on children, families, and the community in order to raise awareness of the true costs of maternal mortality and poor maternal health care in Neno, a rural and remote district in Malawi. Methods Qualitative in-depth interviews were conducted to assess the impact of maternal mortality on child, family, and community well-being. We conducted 20 key informant interviews, 20 stakeholder interviews, and six sex-stratified focus group discussions in the seven health centers that cover the district. Transcripts were translated, coded, and analyzed in NVivo 10. Results Participants noted a number of far-reaching impacts on orphaned children, their new caretakers, and extended families following a maternal death. Female relatives typically took on caregiving responsibilities for orphaned children, regardless of the accompanying financial hardship and frequent lack of familial or governmental support. Maternal death exacerbated children’s vulnerabilities to long-term health and social impacts related to nutrition, education, employment, early partnership, pregnancy, and caretaking. Impacts were particularly salient for female children who were often forced to take on the majority of the household responsibilities. Participants cited a number of barriers to accessing quality child health care or support services, and many were unaware of programming available to assist them in raising orphaned children or how to access these services. Conclusions In order to both reduce preventable maternal mortality and diminish the impacts on children, extended families, and communities, our findings highlight the importance of financing and

State Medicaid Coverage of Medically Necessary Abortions and Severe Maternal Morbidity and Maternal Mortality

PubMed Central

Jarlenski, Marian; Hutcheon, Jennifer A; Bodnar, Lisa M; Simhan, Hyagriv N

2017-01-01

Objective To estimate the association between state Medicaid coverage of medically necessary abortion and severe maternal morbidity and in-hospital maternal mortality in the U.S. Methods We used data on pregnancy-related hospitalizations from the Nationwide Inpatient Sample from 2000 to 2011 (weighted n=38,016,845). State-level Medicaid coverage of medically necessary abortion for each year was determined from Guttmacher Institute reports. We used multivariable logistic regression to examine the association between state Medicaid coverage of abortion and severe maternal morbidity and in-hospital maternal mortality, overall and stratified by payer. Results The unadjusted rate of severe maternal morbidity was lower among Medicaid-paid hospitalizations in states with Medicaid coverage of medically necessary abortion, relative to those in states without such coverage (62.4 vs. 69.3 per 10,000). Among Medicaid-paid hospitalizations in states with Medicaid coverage of medically necessary abortion, there were 8.5 per 10,000 fewer cases (95% CI 4.0,16.5) of severe maternal morbidity in adjusted analyses, relative to those in states without such Medicaid coverage. Similarly, there were 10.3 per 10,000 fewer cases (95% CI 3.5,17.2) of severe maternal morbidity in adjusted analyses among private insurance-paid hospitalizations in states with Medicaid coverage of medically necessary abortion, relative to those in states without such Medicaid coverage. The adjusted rate of in-hospital maternal mortality was not different for Medicaid-paid hospitalizations in states with and without Medicaid coverage of medically necessary abortion (9.2 and 9.0 per 100,000, respectively), nor for private-insurance paid hospitalizations (5.6 and 6.1 per 100,000, respectively). Conclusions State Medicaid coverage of medically necessary abortion was associated with an average 16% decreased risk of severe maternal morbidity. An association between state Medicaid coverage of medically necessary

State Medicaid Coverage of Medically Necessary Abortions and Severe Maternal Morbidity and Maternal Mortality.

PubMed

Jarlenski, Marian; Hutcheon, Jennifer A; Bodnar, Lisa M; Simhan, Hyagriv N

2017-05-01

To estimate the association between state Medicaid coverage of medically necessary abortion and severe maternal morbidity and in-hospital maternal mortality in the United States. We used data on pregnancy-related hospitalizations from the Nationwide Inpatient Sample from 2000 to 2011 (weighted n=38,016,845). State-level Medicaid coverage of medically necessary abortion for each year was determined from Guttmacher Institute reports. We used multivariable logistic regression to examine the association between state Medicaid coverage of abortion and severe maternal morbidity and in-hospital maternal mortality, overall and stratified by payer. The unadjusted rate of severe maternal morbidity was lower among Medicaid-paid hospitalizations in states with Medicaid coverage of medically necessary abortion relative to those in states without such coverage (62.4 compared with 69.3 per 10,000). Among Medicaid-paid hospitalizations in states with Medicaid coverage of medically necessary abortion, there were 8.5 per 10,000 fewer cases (95% confidence interval [CI] 4.0-16.5) of severe maternal morbidity in adjusted analyses relative to those in states without such Medicaid coverage. Similarly, there were 10.3 per 10,000 fewer cases (95% CI 3.5-17.2) of severe maternal morbidity in adjusted analyses among private insurance-paid hospitalizations in states with Medicaid coverage of medically necessary abortion relative to those in states without such Medicaid coverage. The adjusted rate of in-hospital maternal mortality was not different for Medicaid-paid hospitalizations in states with and without Medicaid coverage of medically necessary abortion (9.2 and 9.0 per 100,000, respectively) nor for private insurance-paid hospitalizations (5.6 and 6.1 per 100,000, respectively). State Medicaid coverage of medically necessary abortion was associated with an average 16% decreased risk of severe maternal morbidity. An association between state Medicaid coverage of medically necessary

The cost effectiveness of a quality improvement program to reduce maternal and fetal mortality in a regional referral hospital in Accra, Ghana.

PubMed

Goodman, David M; Ramaswamy, Rohit; Jeuland, Marc; Srofenyoh, Emmanuel K; Engmann, Cyril M; Olufolabi, Adeyemi J; Owen, Medge D

2017-01-01

To evaluate the cost-effectiveness of a quality improvement intervention aimed at reducing maternal and fetal mortality in Accra, Ghana. Quasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis. Data were collected on the cost and outcomes of a 5-year Kybele-Ghana Health Service Quality Improvement (QI) intervention conducted at Ridge Regional Hospital, a tertiary referral center in Accra, Ghana, focused on systems, personnel, and communication. Maternal deaths prevented were estimated comparing observed rates with counterfactual projections of maternal mortality and case-fatality rates for hypertensive disorders of pregnancy and obstetric hemorrhage. Stillbirths prevented were estimated based on counterfactual estimates of stillbirth rates. Cost-effectiveness was then calculated using estimated disability-adjusted life years averted and subjected to Monte Carlo and one-way sensitivity analyses to test the importance of assumptions inherent in the calculations. Incremental Cost-effectiveness ratio (ICER), which represents the cost per disability-adjusted life-year (DALY) averted by the intervention compared to a model counterfactual. From 2007-2011, 39,234 deliveries were affected by the QI intervention implemented at Ridge Regional Hospital. The total budget for the program was $2,363,100. Based on program estimates, 236 (±5) maternal deaths and 129 (±13) intrapartum stillbirths were averted (14,876 DALYs), implying an ICER of $158 ($129-$195) USD. This value is well below the highly cost-effective threshold of $1268 USD. Sensitivity analysis considered DALY calculation methods, and yearly prevalence of risk factors and case fatality rates. In each of these analyses, the program remained highly cost-effective with an ICER ranging from $97-$218. QI interventions to reduce maternal and fetal mortality in low resource settings can be highly cost effective. Cost-effectiveness analysis is feasible and should regularly be conducted to

[Obstetric care in Mali: effect of organization on in-hospital maternal mortality].

PubMed

Zongo, A; Traoré, M; Faye, A; Gueye, M; Fournier, P; Dumont, A

2012-08-01

Maternal mortality is still too high in sub-Saharan Africa, particularly in referral hospitals. Solutions exist but their implementation is a great issue in the poor-resources settings. The objective of this study is to assess the effect of the organization of obstetric care services on maternal mortality in referral hospitals in Mali. This is a multicentric observational survey in 22 referral hospitals. Clinical data on 42,929 women delivering in the 22 hospitals within the 2007 to 2008 study period were collected. Organization evaluation was based on explicit criteria defined by an expert committee. The effect of the organization on in-hospital mortality adjusted on individual and institutional characteristics was estimated using multi-level logistic regression models. The results show that an optimal organization of obstetric care services based on eight explicit criteria reduced in-hospital maternal mortality by 41% compared with women delivering in a referral hospital with sub-optimal organization defined as non-compliance with at least one of the eight criteria (ORa=0.59; 95% CI=0.34-0.92). Furthermore, local policies that improved financial access to emergency obstetric care had a significant impact on maternal outcome. Criteria for optimal organization include the management of labor and childbirth by qualified personnel, an organization of human resources that allows timely management of obstetric emergencies, routine use of partography for all patients and availability of guidelines for the management of complications. These conditions could be easily implemented in the context of Mali to reduce in-hospital maternal mortality. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Evaluating the impact a proposed family planning model would have on maternal and infant mortality in Afghanistan.

PubMed

Rahmani, Ahmad Masoud; Wade, Benjamin; Riley, William

2015-01-01

This study aimed to assess the potential impact a proposed family planning model would have on reducing maternal and infant mortality in Afghanistan. Afghanistan has a high total fertility rate, high infant mortality rate, and high maternal mortality rate. Afghanistan also has tremendous socio-cultural barriers to and misconceptions about family planning services. We applied predictive statistical models to a proposed family planning model for Afghanistan to better understand the impact increased family planning can have on Afghanistan's maternal mortality rate and infant mortality rate. We further developed a sensitivity analysis that illustrates the number of maternal and infant deaths that can be averted over 5 years according to different increases in contraceptive prevalence rates. Incrementally increasing contraceptive prevalence rates in Afghanistan from 10% to 60% over the course of 5 years could prevent 11,653 maternal deaths and 317,084 infant deaths, a total of 328,737 maternal and infant deaths averted. Achieving goals in reducing maternal and infant mortality rates in Afghanistan requires a culturally relevant approach to family planning that will be supported by the population. The family planning model for Afghanistan presents such a solution and holds the potential to prevent hundreds of thousands of deaths. Copyright © 2013 John Wiley & Sons, Ltd.

Models of care that have reduced maternal mortality and morbidity in Sri Lanka.

PubMed

Haththotuwa, Rohana; Senanayake, Lakshmen; Senarath, Upul; Attygalle, Deepika

2012-10-01

Sri Lanka, a non-industrialized country with limited resources, has been able to achieve a maternal mortality ratio that is markedly lower than the ratios of similar countries. Many factors have contributed to Sri Lanka's success story. A political commitment to the cause and implementation of clear policies through well-structured and organized community-based and institutional healthcare services--expanded to cover the whole country and provided free of charge--have been the foundation of maternal and child health (MCH) services in the country. The healthcare programs have been well accepted and utilized by the people as the literacy rate is more than 90% for both men and women. Public health midwives form the backbone of MCH services and provide frontline reproductive health care. More than 98% of deliveries occur in hospitals and are attended by midwives. Furthermore, 85% of women in Sri Lanka deliver in facilities served by specialist obstetricians/gynecologists. The Sri Lanka College of Obstetricians and Gynecologists plays a leading role by assisting the Family Health Bureau in making policies and guidelines, training staff, and acting as team leaders for maternity care services. This was evident after the tsunami in December 2004. National maternal mortality reviews, monitoring and evaluation of MCH activities, and relatively high contraceptive prevalence rates have also contributed to the success in Sri Lanka, which could serve as a model for other countries. Copyright © 2012. Published by Elsevier Ireland Ltd.

Strategies to reduce disparities in maternal morbidity and mortality: Patient and provider education.

PubMed

Jain, Joses; Moroz, Leslie

2017-08-01

A reduction in racial disparities in maternal morbidity and mortality requires effective education of both patients and providers. Although providers seem to recognize that disparities exist, there is a widespread need for improving our understanding differences in health care and outcomes and the factors that contribute to them. There are increasingly more educational materials available for the purpose of augmenting disparities education among patients and providers. However, it is important to incorporate contemporary learning methodologies and technologies to address our current knowledge deficit. Collaborative educational models with a multi-disciplinary approach to patient education will be essential. Ultimately, the comprehensive education of providers and patients will require efforts on the part of numerous stakeholders within patient care delivery models. Further investigation will be necessary to determine how best to disseminate this information to maximize the impact of patient and provider educations with the goal of eliminating disparities in maternal morbidity and mortality. Copyright © 2017 Elsevier Inc. All rights reserved.

Obstetric near-miss and maternal mortality in maternity university hospital, Damascus, Syria: a retrospective study

PubMed Central

2010-01-01

Background Investigating severe maternal morbidity (near-miss) is a newly recognised tool that identifies women at highest risk of maternal death and helps allocate resources especially in low income countries. This study aims to i. document the frequency and nature of maternal near-miss at hospital level in Damascus, Capital of Syria, ii. evaluate the level of care at maternal life-saving emergency services by comparatively analysing near-misses and maternal mortalities. Methods Retrospective facility-based review of cases of near-miss and maternal mortality that took place in the years 2006-2007 at Damascus Maternity University Hospital, Syria. Near-miss cases were defined based on disease-specific criteria (Filippi 2005) including: haemorrhage, hypertensive disorders in pregnancy, dystocia, infection and anaemia. Main outcomes included maternal mortality ratio (MMR), maternal near miss ratio (MNMR), mortality indices and proportion of near-miss cases and mortality cases to hospital admissions. Results There were 28 025 deliveries, 15 maternal deaths and 901 near-miss cases. The study showed a MNMR of 32.9/1000 live births, a MMR of 54.8/100 000 live births and a relatively low mortality index of 1.7%. Hypertensive disorders (52%) and haemorrhage (34%) were the top causes of near-misses. Late pregnancy haemorrhage was the leading cause of maternal mortality (60%) while sepsis had the highest mortality index (7.4%). Most cases (93%) were referred in critical conditions from other facilities; namely traditional birth attendants homes (67%), primary (5%) and secondary (10%) healthcare unites and private practices (11%). 26% of near-miss cases were admitted to Intensive Care Unit (ICU). Conclusion Near-miss analyses provide valuable information on obstetric care. The study highlights the need to improve antenatal care which would help early identification of high risk pregnancies. It also emphasises the importance of both: developing protocols to prevent/manage post

[Maternal diabetes--normalized perinatal mortality, but still high fetal growth].

PubMed

Hellesen, H B; Vikane, E; Lie, R T; Irgens, L M

1996-11-30

Studies suggest that maternal diabetes can cause both placental insufficiency and exaggerated foetal growth. Pregnant mothers with diabetes have suffered high risk of losing their child. Data from the Medical Birth Registry of Norway show a decrease in the still birth rate from 16th week of gestation from 115.7 per 1,000 in 1967-75 to 12.8 in 1986-92 in the diabetes groups. The relative risks were 7.8 and 1.4 respectively for the two time periods. The early neonatal mortality rate decreased correspondingly. The proportion of Caesarean sections in mothers with diabetes, and the proportion of children with low birth weight or born prematurely also increased in the diabetes group. However, children in the diabetes group were on average still as big at gestational age in the most recent period as in the first period. Our data suggest that the improved metabolic control of maternal diabetes has reduced the occurrence and degree of placental insufficiency, with inherent decreases in mortality and risk of complications, but without reducing the foetal growth-stimulating effect of maternal diabetes.

Scaling Up Family Planning to Reduce Maternal and Child Mortality: The Potential Costs and Benefits of Modern Contraceptive Use in South Africa

PubMed Central

Chola, Lumbwe; McGee, Shelley; Tugendhaft, Aviva; Buchmann, Eckhart; Hofman, Karen

2015-01-01

Introduction Family planning contributes significantly to the prevention of maternal and child mortality. However, many women still do not use modern contraception and the numbers of unintended pregnancies, abortions and subsequent deaths are high. In this paper, we estimate the service delivery costs of scaling up modern contraception, and the potential impact on maternal, newborn and child survival in South Africa. Methods The Family Planning model in Spectrum was used to project the impact of modern contraception on pregnancies, abortions and births in South Africa (2015-2030). The contraceptive prevalence rate (CPR) was increased annually by 0.68 percentage points. The Lives Saved Tool was used to estimate maternal and child deaths, with coverage of essential maternal and child health interventions increasing by 5% annually. A scenario analysis was done to test impacts when: the change in CPR was 0.1% annually; and intervention coverage increased linearly to 99% in 2030. Results If CPR increased by 0.68% annually, the number of pregnancies would reduce from 1.3 million in 2014 to one million in 2030. Unintended pregnancies, abortions and births decrease by approximately 20%. Family planning can avert approximately 7,000 newborn and child and 600 maternal deaths. The total annual costs of providing modern contraception in 2030 are estimated to be US$33 million and the cost per user of modern contraception is US$7 per year. The incremental cost per life year gained is US$40 for children and US$1,000 for mothers. Conclusion Maternal and child mortality remain high in South Africa, and scaling up family planning together with optimal maternal, newborn and child care is crucial. A huge impact can be made on maternal and child mortality, with a minimal investment per user of modern contraception. PMID:26076482

Scaling Up Family Planning to Reduce Maternal and Child Mortality: The Potential Costs and Benefits of Modern Contraceptive Use in South Africa.

PubMed

Chola, Lumbwe; McGee, Shelley; Tugendhaft, Aviva; Buchmann, Eckhart; Hofman, Karen

2015-01-01

Family planning contributes significantly to the prevention of maternal and child mortality. However, many women still do not use modern contraception and the numbers of unintended pregnancies, abortions and subsequent deaths are high. In this paper, we estimate the service delivery costs of scaling up modern contraception, and the potential impact on maternal, newborn and child survival in South Africa. The Family Planning model in Spectrum was used to project the impact of modern contraception on pregnancies, abortions and births in South Africa (2015-2030). The contraceptive prevalence rate (CPR) was increased annually by 0.68 percentage points. The Lives Saved Tool was used to estimate maternal and child deaths, with coverage of essential maternal and child health interventions increasing by 5% annually. A scenario analysis was done to test impacts when: the change in CPR was 0.1% annually; and intervention coverage increased linearly to 99% in 2030. If CPR increased by 0.68% annually, the number of pregnancies would reduce from 1.3 million in 2014 to one million in 2030. Unintended pregnancies, abortions and births decrease by approximately 20%. Family planning can avert approximately 7,000 newborn and child and 600 maternal deaths. The total annual costs of providing modern contraception in 2030 are estimated to be US$33 million and the cost per user of modern contraception is US$7 per year. The incremental cost per life year gained is US$40 for children and US$1,000 for mothers. Maternal and child mortality remain high in South Africa, and scaling up family planning together with optimal maternal, newborn and child care is crucial. A huge impact can be made on maternal and child mortality, with a minimal investment per user of modern contraception.

Maternal mortality and morbidity. Zimbabwe's birth force.

PubMed

Jacobson, J L

1991-01-01

. Disruptions in medical supplies handicap TBAs in carrying out their work. Some of the solutions are to utilize bicycles for transporting supplies to remote areas, or mobile clinics which provide supplies and training. If more countries followed Zimbabwe's lead, other countries would benefit from reduced birth rates and improved infant and maternal mortality in a cost effective and culturally compatible way.

Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 study.

PubMed

2017-08-03

Assessing the burden of maternal mortality is important for tracking progress and identifying public health gaps. This paper provides an overview of the burden of maternal mortality in the Eastern Mediterranean Region (EMR) by underlying cause and age from 1990 to 2015. We used the results of the Global Burden of Disease 2015 study to explore maternal mortality in the EMR countries. The maternal mortality ratio in the EMR decreased 16.3% from 283 (241-328) maternal deaths per 100,000 live births in 1990 to 237 (188-293) in 2015. Maternal mortality ratio was strongly correlated with socio-demographic status, where the lowest-income countries contributed the most to the burden of maternal mortality in the region. Progress in reducing maternal mortality in the EMR has accelerated in the past 15 years, but the burden remains high. Coordinated and rigorous efforts are needed to make sure that adequate and timely services and interventions are available for women at each stage of reproductive life.

A systematic review of micro correlates of maternal mortality.

PubMed

Yakubu, Yahaya; Mohamed Nor, Norashidah; Abidin, Emilia Zainal

2018-05-05

In the year 2000, the World Health Organization launched the Millennium Development Goals (MDGs) which were to be achieved in 2015. Though most of the goals were not achieved, a follow-up post 2015 development agenda, the Sustainable Development Goals (SDGs) was launched in 2015, which are to be achieved by 2030. Maternal mortality reduction is a focal goal in both the MDGs and SDGs. Achieving the maternal mortality target in the SDGs requires multiple approaches, particularly in developing countries with high maternal mortality. Low-income developing countries rely to a great extent on macro determinants such as public health expenditure, which are spent mostly on curative health and health facilities, to improve population health. To complement the macro determinants, this study employs the systematic review technique to reveal significant micro correlates of maternal mortality. The study searched MEDLINE, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Science Direct, and Global Index Medicus of the World Health Organization. Our search was time framed from the 1st January, 2000 to the 30th September, 2016. In the overall search result, 6758 articles were identified, out of which 33 were found to be eligible for the review. The outcome of the systematic search for relevant literature revealed a concentration of literature on the micro factors and maternal mortality in developing countries. This shows that maternal mortality and micro factors are a major issue in developing countries. The studies reviewed support the significant relationship between the micro factors and maternal mortality. This study therefore suggests that more effort should be channelled to improving the micro factors in developing countries to pave the way for the timely achievement of the SDGs' maternal mortality ratio (MMR) target.

The use of audit to identify maternal mortality in different settings: is it just a difference between the rich and the poor?

PubMed

van Dillen, Jeroen; Stekelenburg, Jelle; Schutte, Joke; Walraven, Gijs; van Roosmalen, Jos

2007-01-01

To illustrate how maternal mortality audit identifies different causes of and contributing factors to maternal deaths in different settings in low- and high-income countries and how this can lead to local solutions in reducing maternal deaths. Descriptive study of maternal mortality from different settings and review of data on the history of reducing maternal mortality in what are now high-income countries. Kalabo district in Zambia, Farafenni division in The Gambia, Onandjokwe district in Namibia, and the Netherlands. Population of rural areas in Zambia and The Gambia, peri-urban population in Namibia and nationwide data from the Netherlands. Data from facility-based maternal mortality audits from three African hospitals and data from the latest confidential enquiry in the Netherlands. Maternal mortality ratio (MMR), causes (direct and indirect) and characteristics. MMR ranged from 10 per 100,000 (the Netherlands) to 1,540 per 100,000 (The Gambia). Differences in causes of deaths were characterized by HIV/AIDS in Namibia, sepsis and HIV/AIDS in Zambia, (pre-)eclampsia in The Netherlands and obstructed labour in The Gambia. Differences in maternal mortality are more than just differences between the rich and poor. Acknowledging the magnitude of maternal mortality and harnessing a strong political will to tackle the issues are important factors. However, there is no single, general solution to reduce maternal mortality, and identification of problems needs to be promoted through audit, both national and local.

Reexamining the effects of gestational age, fetal growth, and maternal smoking on neonatal mortality

PubMed Central

Ananth, Cande V; Platt, Robert W

2004-01-01

Background Low birth weight (<2,500 g) is a strong predictor of infant mortality. Yet low birth weight, in isolation, is uninformative since it is comprised of two intertwined components: preterm delivery and reduced fetal growth. Through nonparametric logistic regression models, we examine the effects of gestational age, fetal growth, and maternal smoking on neonatal mortality. Methods We derived data on over 10 million singleton live births delivered at ≥ 24 weeks from the 1998–2000 U.S. natality data files. Nonparametric multivariable logistic regression based on generalized additive models was used to examine neonatal mortality (deaths within the first 28 days) in relation to fetal growth (gestational age-specific standardized birth weight), gestational age, and number of cigarettes smoked per day. All analyses were further adjusted for the confounding effects due to maternal age and gravidity. Results The relationship between standardized birth weight and neonatal mortality is nonlinear; mortality is high at low z-score birth weights, drops precipitously with increasing z-score birth weight, and begins to flatten for heavier infants. Gestational age is also strongly associated with mortality, with patterns similar to those of z-score birth weight. Although the direct effect of smoking on neonatal mortality is weak, its effects (on mortality) appear to be largely mediated through reduced fetal growth and, to a lesser extent, through shortened gestation. In fact, the association between smoking and reduced fetal growth gets stronger as pregnancies approach term. Conclusions Our study provides important insights regarding the combined effects of fetal growth, gestational age, and smoking on neonatal mortality. The findings suggest that the effect of maternal smoking on neonatal mortality is largely mediated through reduced fetal growth. PMID:15574192

Maternal mortality in Denmark, 1985-1994.

PubMed

Andersen, Betina Ristorp; Westergaard, Hanne Brix; Bødker, Birgit; Weber, Tom; Møller, Margrete; Sørensen, Jette Led

2009-02-01

In Denmark, maternal mortality has been reported over the last century, both locally through hospital reports and in national registries. The purpose of this study was to analyze data from national medical registries of pregnancy-related deaths in Denmark 1985-1994 and to classify them according to the UK Confidential Enquiry into Maternal Deaths (CEMD). All deaths of women with a registered pregnancy within 12 months prior to the death were identified by comparing the Danish medical registries, death certificates, and relevant codes according to International Classification of Diseases (ICD-10). All cases were classified using the UK CEMD classification. Cases of maternal death were further evaluated by an audit group. 311 cases were classified. 92 deaths (29.6%) occurred 42 days), 1 woman died from a direct obstetric cause, 46 from indirect causes, and 172 from fortuitous causes. Hypertensive disorders of pregnancy were the major cause of direct maternal deaths. The rate of maternal deaths constituted 9.8/100,000 maternities (i.e. the number of women delivering registrable live births at any gestation or stillbirths at 24 weeks of gestation or later). This is the first systematic report on deaths in Denmark based on data from national registries. The maternal mortality rate in Denmark is comparable to the rates in other developed countries. Fortunately, statistics are low, but each case represents potential learning. Obstetric care has changed and classification methods differ between countries. Prospective registration and registry linkage seem to be a way to ensure completion. This retrospective study has provided the background for a prospective study on registration and evaluation of maternal mortality in Denmark.

'Big push' to reduce maternal mortality in Uganda and Zambia enhanced health systems but lacked a sustainability plan.

PubMed

Kruk, Margaret E; Rabkin, Miriam; Grépin, Karen Ann; Austin-Evelyn, Katherine; Greeson, Dana; Masvawure, Tsitsi Beatrice; Sacks, Emma Rose; Vail, Daniel; Galea, Sandro

2014-06-01

In the past decade, "big push" global health initiatives financed by international donors have aimed to rapidly reach ambitious health targets in low-income countries. The health system impacts of these efforts are infrequently assessed. Saving Mothers, Giving Life is a global public-private partnership that aims to reduce maternal mortality dramatically in one year in eight districts in Uganda and Zambia. We evaluated the first six to twelve months of the program's implementation, its ownership by national ministries of health, and its effects on health systems. The project's impact on maternal mortality is not reported here. We found that the Saving Mothers, Giving Life initiative delivered a large "dose" of intervention quickly by capitalizing on existing US international health assistance platforms, such as the President's Emergency Plan for AIDS Relief. Early benefits to the broader health system included greater policy attention to maternal and child health, new health care infrastructure, and new models for collaborating with the private sector and communities. However, the rapid pace, external design, and lack of a long-term financing plan hindered integration into the health system and local ownership. Sustaining and scaling up early gains of similar big push initiatives requires longer-term commitments and a clear plan for transition to national control. Project HOPE—The People-to-People Health Foundation, Inc.

National, regional, and global levels and trends in maternal mortality between 1990 and 2015 with scenario-based projections to 2030: a systematic analysis by the United Nations Maternal Mortality Estimation Inter-Agency Group

PubMed Central

Alkema, Leontine; Chou, Doris; Hogan, Daniel; Zhang, Sanqian; Moller, Ann-Beth; Gemmill, Alison; Fat, Doris Ma; Boerma, Ties; Temmerman, Marleen; Mathers, Colin; Say, Lale; Ahmed, Saifuddin; Ali, Mohamed; Amouzou, Agbessi; Braunholtz, David; Byass, Peter; Carvajal-Velez, Liliana; Gaigbe-Togbe, Victor; Gerland, Patrick; Loaiza, Edilberto; Mills, Samuel; Mutombo, Namuunda; Newby, Holly; Pullum, Thomas W.; Suzuki, Emi

2017-01-01

Summary Background Millennium Development Goal (MDG) 5 calls for a reduction of 75% in the maternal mortality ratio (MMR) between 1990 and 2015. We estimated levels and trends in maternal mortality for 183 countries to assess progress made. Based on MMR estimates for 2015, we constructed scenario-based projections to highlight the accelerations needed to accomplish the Sustainable Development Goal (SDG) global target of less than 70 maternal deaths per 100,000 live births globally by 2030. Methods We updated the open access UN Maternal Mortality Estimation Inter-agency Group (MMEIG) database. Based upon nationally-representative data for 171 countries, we generated estimates of maternal mortality and related indicators with uncertainty intervals using a Bayesian model, which extends and refines the previous UN MMEIG estimation approach. The model combines the rate of change implied by a multilevel regression model with a time series model to capture data-driven changes in country-specific MMRs, and includes a data model to adjust for systematic and random errors associated with different data sources. Results The global MMR declined from 385 deaths per 100,000 live births (80% uncertainty interval ranges from 359 to 427) in 1990 to 216 (207 to 249) in 2015, corresponding to a relative decline of 43.9% (34.0 to 48.7) during the 25-year period, with 303,000 (291,000 to 349,000) maternal deaths globally in 2015. Regional progress in reducing the MMR since 1990 ranged from an annual rate of reduction of 1.8% (0 to 3.1) in the Caribbean to 5.0% (4.0 to 6.0) for Eastern Asia. Regional MMRs for 2015 range from 12 (11 to 14) for developed regions to 546 (511 to 652) for sub-Saharan Africa. Accelerated progress will be needed to achieve the SDG goal; countries will need to reduce their MMRs at an annual rate of reduction of at least 7.5%. Interpretation Despite global progress in reducing maternal mortality, immediate action is required to begin making progress towards the

Knowledge gaps in scientific literature on maternal mortality: a systematic review.

PubMed Central

Gil-González, Diana; Carrasco-Portiño, Mercedes; Ruiz, Maria Teresa

2006-01-01

Issues related to maternal mortality have generated a lot of empirical and theoretical information. However, despite the amount of work published on the topic, maternal mortality continues to occur at high rates and solutions to the problem are still not clear. Scientific research on maternal mortality is focused mainly on clinical factors. However, this approach may not be the most useful if we are to understand the problem of maternal mortality as a whole and appreciate the importance of economical, political and social macrostructural factors. In this paper, we report the number of scientific studies published between 2000 and 2004 about the main causes of maternal death, as identified by WHO, and compare the proportion of papers on each cause with the corresponding burden of each cause. Secondly, we systematically review the characteristics and quality of the papers on the macrostructural determinants of maternal mortality. In view of their burden, obstructed labour, unsafe abortion and haemorrhage are proportionally underrepresented in the scientific literature. In our review, most studies analysed were cross-sectional, and were carried out by developed countries without the participation of researchers in the developing countries where maternal mortality was studied. The main macrostructural factors mentioned were socioeconomic variables. Overall, there is a lack of published information about the cultural and political determinants of maternal mortality. We believe that a high-quality scientific approach must be taken in studies of maternal mortality in order to obtain robust comparative data and that study design should be improved to allow causality between macrostructural determinants and maternal mortality to be shown. PMID:17143465

Maternal mortality in India: current status and strategies for reduction.

PubMed

Prakash, A; Swain, S; Seth, A

1991-12-01

The causes (medical, reproductive factors, health care delivery system, and socioeconomic factors) of maternal mortality in India and strategies for reducing maternal mortality are presented. Maternal mortality rates (MMR) are very high in Asia and Africa compared with Northern Europe's 4/100,000 live births. An Indian hospital study found the MMR to be 4.21/1000 live births. 50-98% of maternal deaths are caused by direct obstetric causes (hemorrhage, infection, and hypertensive disorders, ruptured uterus, hepatitis, and anemia). 50% of maternal deaths due to sepsis are related to illegal induced abortion. MMR in India has not declined significantly in the past 15 years. Age, primi and grande multiparity, unplanned pregnancy, and related illegal abortion are the reproductive causes. In 1985 WHO reported that 63-80% of maternal deaths due to direct obstetric causes and 88-98% of all maternal deaths could probably have been prevented with proper handling. In India, coordination between levels in the delivery system and fragmentation of care account for the poor quality of maternal health care. Mass illiteracy is another cause. Effective strategies for reducing the MMR are 1) to place a high priority on maternal and child health (MCH) services and integrate vertical programs (e.g., family planning) related to MCH; 2) to give attention to care during labor and delivery, which is the most critical period for complications; 3) to provide community-based delivery huts which can provide a clean and safe delivery place close to home, and maternity waiting rooms in hospitals for high risk mothers; 4) to improve the quality of MCH care at the rural community level (proper history taking, palpation, blood pressure and fetal heart screening, risk factor screening, and referral); 5) to improve quality of care at the primary health care level (emergency care and proper referral); 6) to include in the postpartum program MCH and family planning services; 7) to examine the

Causes of maternal mortality decline in Matlab, Bangladesh.

PubMed

Chowdhury, Mahbub Elahi; Ahmed, Anisuddin; Kalim, Nahid; Koblinsky, Marge

2009-04-01

Bangladesh is distinct among developing countries in achieving a low maternal mortality ratio (MMR) of 322 per 100,000 livebirths despite the very low use of skilled care at delivery (13% nationally). This variation has also been observed in Matlab, a rural area in Bangladesh, where longitudinal data on maternal mortality are available since the mid-1970s. The current study investigated the possible causes of the maternal mortality decline in Matlab. The study analyzed 769 maternal deaths and 215,779 pregnancy records from the Health and Demographic Surveillance System (HDSS) and other sources of safe motherhood data in the ICDDR,B and government service areas in Matlab during 1976-2005. The major interventions that took place in both the areas since the early 1980s were the family-planning programme plus safe menstrual regulation services and safe motherhood interventions (midwives for normal delivery in the ICDDR,B service area from the late 1980s and equal access to comprehensive emergency obstetric care [EmOC] in public facilities for women from both the areas). National programmes for social development and empowerment of women through education and microcredit programmes were implemented in both the areas. The quantitative findings were supplemented by a qualitative study by interviewing local community care providers for their change in practices for maternal healthcare over time. After the introduction of the safe motherhood programme, reduction in maternal mortality was higher in the ICDDR,B service area (68.6%) than in the government service area (50.4%) during 1986-1989 and 2001-2005. Reduction in the number of maternal deaths due to the fertility decline was higher in the government service area (30%) than in the ICDDR,B service area (23%) during 1979-2005. In each area, there has been substantial reduction in abortion-related mortality--86.7% and 78.3%--in the ICDDR,B and government service areas respectively. Education of women was a strong predictor

Abortion: its contribution to maternal mortality.

PubMed

Kwast, B E

1992-03-01

Every year between 100,000 and 200,000 women die from illicit abortion. In this paper the magnitude of the problem is described, those most at risk are identified and methods of preventing unwanted pregnancy are suggested. It is argued that midwives have a major role to play in family planning counselling and the provision of contraceptive services. Midwives can also reduce maternal mortality by resuscitating women when emergencies arise from incomplete abortion. This paper is based on one originally given at the ICM/WHO/UNICEF pre-congress workshop is Kobe, Japan, October 1990.

Impact of training traditional birth attendants on maternal mortality and morbidity in Sub-Saharan Africa.

PubMed

Kayombo, Edmund J

2013-04-01

This paper presents discussion on impact of training traditional birth attendants (TBAs) on overall improvement of reproductive health care with focus on reducing the high rate of maternal and new-born mortality in rural settings in sub-Saharan Africa. The importance of TBAs for years has been denied by professional western trained health practitioners and other scientists until during the late 1980s, when World Health Organization through Safe motherhood 1987 found TBAs have a significant role in reducing maternal and new-born mortality. Trained TBAs in sub-Sahara Africa can have positive impact on reducing maternal and new-born mortality if the programme is well implemented with systematic follow-up after training. This could be done through joint meeting between health workers and TBAs as feed and learning experience from problem encountered in process of providing child delivery services. TBAs can help to break socio-cultural barriers on intervention on reproductive health programmes. However projects targeting TBAs should not be of hit and run; but gradually familiarize with the target group, build trust, transparency, and tolerance, willing to learn and creating rappour with them. In this paper, some case studies are described on how trained TBAs can be fully utilized in reducing maternal and new-born mortality rate in rural areas. What is needed is to identify TBAs, map their distribution and train them on basic primary healthcare related to child deliveries and complications which need to be referred to conventional health facilities immediately.

An analysis of the determinants of maternal mortality in sub-Saharan Africa.

PubMed

Buor, Daniel; Bream, Kent

2004-10-01

To establish what population characteristics affect the high maternal mortality rate in the sub-Saharan Africa region and to propose possible solutions to reduce this rate. This study is a secondary analysis of existing data sources from the World Bank, the World Health Organization (WHO), as well as direct and indirect sources from UNAIDS, the United Nations, Demographic and Health Surveys (DHS), Macro International, and national statistical offices. Instead of looking at continentwide or individual nation models, it develops a regional model. Sociodemographic population variables are used as independent variables to predict the dependent variable, maternal mortality. Additionally, a new country-specific political stability independent variable is introduced into the model. Data from 28 sub-Saharan African countries are used. Bivariate correlations are used to establish associations among the variables, whereas cross-tabulations, using Kendall's tau-c values, and regression lines are used to establish impacts. In the sub-Saharan Africa region, births attended by skilled health personnel and life expectancy at birth strongly correlate with maternal mortality. Gross national product (GNP) per capita and health expenditure per capita also have strong association with maternal mortality. The availability of skilled delivery personnel, life expectancy, national economic wealth, and health expenditure per capita predict the maternal mortality rate of a country. Based on these findings, it is recommended that structural arrangements be made to train skilled health personnel to take care of maternal health problems. In view of the high cost of training physicians, middle-level health personnel may offer an affordable alternative to handle emergency obstetrical cases to address the shortage of physicians. In addition, the allocation of adequate resources to the health sector could improve maternal mortality. The economic wealth of a country and life expectancy at birth are

A new challenge for Africa: to reduce maternal mortality by half over the next decade.

PubMed

Ladjali, M

1989-04-01

This publication reviews the 1989 conference on safe motherhood in Niamey, Niger. Statistics regarding the situation in Africa reveal that 150,000 of the 1/2 million yearly maternal deaths worldwide occur in Africa, and 1 woman in 20 risks dying of pregnancy-related causes. Other maternal deaths are distributed as follows: 300,000 in South and West Asia, 34,000 in Latin America, 12,000 in East Asia and 6000 in all developed countries. The main causes of maternal deaths in Africa were identified as medical factors, among them lack of access to family planning, and socioeconomic and cultural factors, such as sexual discrimination against women and inferior social status. African girls are weaned earlier, receive a lower caloric intake, and work 4 times as long as boys. African women work 2490 hours per year, compared to 1400 hours for men. In a discussion of traditional practices related to maternal and child health, early marriage and genital mutilation, which are perpetuated by illiteracy, were deemed dangerous. The need for non-medical strategies and actions to improve the status of women, recognize their economic role and give them equal opportunities was acknowledged. Fertility control was identified as a determining factor in helping to reinforce these strategies, as unwanted pregnancies increase the risk of maternal death through abortion attempts. An important aspect of the conference was the identification of women as full-time partners of the health services rather than passive beneficiaries. Participants called for a reduction in women's domestic workload and the abolition of genital mutilation. They also agreed to promote exchange of information between African governments on research and positive developments. The World Bank called for more incisive efforts to reduce infant mortality and for population issues to be included in the economic debate.

Effect of maternal death reviews and training on maternal mortality among cesarean delivery: post-hoc analysis of a cluster-randomized controlled trial.

PubMed

Zongo, Augustin; Dumont, Alexandre; Fournier, Pierre; Traore, Mamadou; Kouanda, Séni; Sondo, Blaise

2015-02-01

To explore the differential effect of a multifaceted intervention on hospital-based maternal mortality between patients with cesarean and vaginal delivery in low-resource settings. We reanalyzed the data from a major cluster-randomized controlled trial, QUARITE (Quality of care, Risk management and technology in obstetrics). These subgroup analyses were not pre-specified and were treated as exploratory. The intervention consisted of an initial interactive workshop and quarterly educational clinically oriented and evidence-based outreach visits focused on maternal death reviews (MDR) and best practices implementation. The trial originally recruited 191,167 patients who delivered in each of the 46 participating hospitals in Mali and Senegal, between 2007 and 2011. The primary endpoint was hospital-based maternal mortality. Subgroup-specific Odds Ratios (ORs) of maternal mortality were computed and tested for differential intervention effect using generalized linear mixed model between two subgroups (cesarean: 40,975; and vaginal delivery: 150,192). The test for homogeneity of intervention effects on hospital-based maternal mortality among the two delivery mode subgroups was statistically significant (p-value: 0.0201). Compared to the control, the adjusted OR of maternal mortality was 0.71 (95% CI: 0.58-0.82, p=0.0034) among women with cesarean delivery. The intervention had no significant effect among women with vaginal delivery (adjusted OR 0.87, 95% CI 0.69-1.11, p=0.6213). This differential effect was particularly marked for district hospitals. Maternal deaths reviews and on-site training on emergency obstetric care may be more effective in reducing maternal mortality among high-risk women who need a cesarean section than among low-risk women with vaginal delivery. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Causes of Maternal Mortality Decline in Matlab, Bangladesh

PubMed Central

Ahmed, Anisuddin; Kalim, Nahid; Koblinsky, Marge

2009-01-01

Bangladesh is distinct among developing countries in achieving a low maternal mortality ratio (MMR) of 322 per 100,000 livebirths despite the very low use of skilled care at delivery (13% nationally). This variation has also been observed in Matlab, a rural area in Bangladesh, where longitudinal data on maternal mortality are available since the mid-1970s. The current study investigated the possible causes of the maternal mortality decline in Matlab. The study analyzed 769 maternal deaths and 215,779 pregnancy records from the Health and Demographic Surveillance System (HDSS) and other sources of safe motherhood data in the ICDDR,B and government service areas in Matlab during 1976-2005. The major interventions that took place in both the areas since the early 1980s were the family-planning programme plus safe menstrual regulation services and safe motherhood interventions (midwives for normal delivery in the ICDDR,B service area from the late 1980s and equal access to comprehensive emergency obstetric care [EmOC] in public facilities for women from both the areas). National programmes for social development and empowerment of women through education and microcredit programmes were implemented in both the areas. The quantitative findings were supplemented by a qualitative study by interviewing local community care providers for their change in practices for maternal healthcare over time. After the introduction of the safe motherhood programme, reduction in maternal mortality was higher in the ICDDR,B service area (68.6%) than in the government service area (50.4%) during 1986-1989 and 2001-2005. Reduction in the number of maternal deaths due to the fertility decline was higher in the government service area (30%) than in the ICDDR,B service area (23%) during 1979-2005. In each area, there has been substantial reduction in abortion-related mortality—86.7% and 78.3%—in the ICDDR,B and government service areas respectively. Education of women was a strong

Maternal obesity and infant mortality: a meta-analysis.

PubMed

Meehan, Sean; Beck, Charles R; Mair-Jenkins, John; Leonardi-Bee, Jo; Puleston, Richard

2014-05-01

Despite numerous studies reporting an elevated risk of infant mortality among women who are obese, the magnitude of the association is unclear. A systematic review and meta-analysis was undertaken to assess the association between maternal overweight or obesity and infant mortality. Four health care databases and gray literature sources were searched and screened against the protocol eligibility criteria. Observational studies reporting on the relationship between maternal overweight and obesity and infant mortality were included. Data extraction and risk of bias assessments were performed. Twenty-four records were included from 783 screened. Obese mothers (BMI ≥30) had greater odds of having an infant death (odds ratio 1.42; 95% confidence interval, 1.24-1.63; P < .001; 11 studies); these odds were greatest for the most obese (BMI >35) (odds ratio 2.03; 95% confidence interval, 1.61-2.56; P < .001; 3 studies). Our results suggest that the odds of having an infant death are greater for obese mothers and that this risk may increase with greater maternal BMI or weight; however, residual confounding may explain these findings. Given the rising prevalence of maternal obesity, additional high-quality epidemiologic studies to elucidate the actual influence of elevated maternal mass or weight on infant mortality are needed. If a causal link is determined and the biological basis explained, public health strategies to address the issue of maternal obesity will be needed. Copyright © 2014 by the American Academy of Pediatrics.

Can cash transfers improve determinants of maternal mortality? Evidence from the household and community programs in Indonesia.

PubMed

Kusuma, Dian; Cohen, Jessica; McConnell, Margaret; Berman, Peter

2016-08-01

Despite global efforts in maternal health, 303,000 maternal deaths still occurred globally in 2015. One explanation is a considerable inequality in maternal mortality and the sources such as nutritional status and health utilization. One strategy to fight health inequality due to poverty is conditional cash transfer (CCT). Taking advantage of two large clustered-randomized trials in Indonesia from 2007 to 2009, this paper provides evidence on the effects of household cash transfers (PKH) and community cash transfers (Generasi) on determinants of maternal mortality. The sample sizes are 14,000 households for PKH and 12,000 households for Generasi. After two years of implementation, difference-in-differences (DID) analyses show that the two programs can improve determinants of maternal mortality with Generasi provides positive impact in some aspects of determinants, but PKH does not. Generasi improves maternal health knowledge, reduces financial barriers to accessing health services and improves utilization of health services, increases utilization among higher-risk women, improves posyandu equipment, and increases nutritional intake. As for PKH, evidence shows its strongest effects only on utilization of health services. Both programs, however, are unlikely to have a large effect on maternal mortality due to design and implementation issues that might significantly reduce program effectiveness. While the programs improved utilization, they did so at community-based facilities not equipped with emergency obstetric care. In the midst of popularity of household cash transfer, our results show that community cash transfer offers a viable policy alternative to improve the determinants of maternal mortality by allowing more flexibility in activities and at lower cost by monitoring at community level. Copyright © 2016 Elsevier Ltd. All rights reserved.

Addressing the human resources crisis: a case study of Cambodia’s efforts to reduce maternal mortality (1980–2012)

PubMed Central

Fujita, Noriko; Abe, Kimiko; Rotem, Arie; Tung, Rathavy; Keat, Phuong; Robins, Ann; Zwi, Anthony B

2013-01-01

Objective To identify factors that have contributed to the systematic development of the Cambodian human resources for health (HRH) system with a focus on midwifery services in response to high maternal mortality in fragile resource-constrained countries. Design Qualitative case study. Review of the published and grey literature and in-depth interviews with key informants and stakeholders using an HRH system conceptual framework developed by the authors (‘House Model’; Fujita et al, 2011). Interviews focused on the perceptions of respondents regarding their contributions to strengthening midwifery services and the other external influences which may have influenced the HRH system and reduction in the maternal mortality ratio (MMR). Setting Three rounds of interviews were conducted with senior and mid-level managers of the Ministries of Health (MoH) and Education, educational institutes and development partners. Participants A total of 49 interviewees, who were identified through a snowball sampling technique. Main outcome measures Scaling up the availability of 24 h maternal health services at all health centres contributing to MMR reduction. Results The incremental development of the Cambodian HRH system since 2005 focused on the production, deployment and retention of midwives in rural areas as part of a systematic strategy to reduce maternal mortality. The improved availability and access to midwifery services contributed to significant MMR reduction. Other contributing factors included improved mechanisms for decision-making and implementation; political commitment backed up with necessary resources; leadership from the top along with a growing capacity of mid-level managers; increased MoH capacity to plan and coordinate; and supportive development partners in the context of a conducive external environment. Conclusions Lessons from this case study point to the importance of a systemic and comprehensive approach to health and HRH system strengthening and

Maternal mortality ratio in Lebanon in 2008: a hospital-based reproductive age mortality study (RAMOS).

PubMed

Hobeika, Elie; Abi Chaker, Samer; Harb, Hilda; Rahbany Saad, Rita; Ammar, Walid; Adib, Salim

2014-01-01

International agencies have recently assigned Lebanon to the group H of countries with "no national data on maternal mortality," and estimated a corresponding maternal mortality ratio (MMR) of 150 per 100,000 live births. The Ministry of Public Health addressed the discrepancy perceived between the reality of the maternal mortality ratio experience in Lebanon and the international report by facilitating a hospital-based reproductive age mortality study, sponsored by the World Health Organization Representative Office in Lebanon, aiming at providing an accurate estimate of a maternal mortality ratio for 2008. The survey allowed a detailed analysis of maternal causes of deaths. Reproductive age deaths (15-49 years) were initially identified through hospital records. A trained MD traveled to each hospital to ascertain whether recorded deaths were in fact maternal deaths or not. ICD10 codes were provided by the medical controller for each confirmed maternal deaths. There were 384 RA death cases, of which 13 were confirmed maternal deaths (339%) (numerator). In 2008, there were 84823 live births in Lebanon (denominator). The MMR in Lebanon in 2008 was thus officially estimated at 23/100,000 live births, with an "uncertainty range" from 153 to 30.6. Hemorrhage was the leading cause of death, with double the frequency of all other causes (pregnancy-induced hypertension, eclampsia, infection, and embolism). This specific enquiry responded to a punctual need to correct a clearly inadequate report, and it should be relayed by an on-going valid surveillance system. Results indicate that special attention has to be devoted to the management of peri-partum hemorrhage cases. Arab, postpartum hemorrhage, development, pregnancy management, verbal autopsy

Distribution of causes of maternal mortality among different socio-demographic groups in Ghana; a descriptive study.

PubMed

Asamoah, Benedict O; Moussa, Kontie M; Stafström, Martin; Musinguzi, Geofrey

2011-03-10

Ghana's maternal mortality ratio remains high despite efforts made to meet Millennium Development Goal 5. A number of studies have been conducted on maternal mortality in Ghana; however, little is known about how the causes of maternal mortality are distributed in different socio-demographic subgroups. Therefore the aim of this study was to assess and analyse the causes of maternal mortality according to socio-demographic factors in Ghana. The causes of maternal deaths were assessed with respect to age, educational level, rural/urban residence status and marital status. Data from a five year retrospective survey was used. The data was obtained from Ghana Maternal Health Survey 2007 acquired from the database of Ghana Statistical Service. A total of 605 maternal deaths within the age group 12-49 years were analysed using frequency tables, cross-tabulations and logistic regression. Haemorrhage was the highest cause of maternal mortality (22.8%). Married women had a significantly higher risk of dying from haemorrhage, compared with single women (adjusted OR = 2.7, 95%CI = 1.2-5.7). On the contrary, married women showed a significantly reduced risk of dying from abortion compared to single women (adjusted OR = 0.2, 95%CI = 0.1-0.4). Women aged 35-39 years had a significantly higher risk of dying from haemorrhage (aOR 2.6, 95%CI = 1.4-4.9), whereas they were at a lower risk of dying from abortion (aOR 0.3, 95% CI = 0.1-0.7) compared to their younger counterparts. The risk of maternal death from infectious diseases decreased with increasing maternal age, whereas the risk of dying from miscellaneous causes increased with increasing age. The study shows evidence of variations in the causes of maternal mortality among different socio-demographic subgroups in Ghana that should not be overlooked. It is therefore recommended that interventions aimed at combating the high maternal mortality in Ghana should be both cause-specific as well as target-specific.

Improving the maternal mortality ratio in Zhejiang Province, China, 1988-2008.

PubMed

Qiu, Liqian; Lin, Jun; Ma, Yuanying; Wu, Weiwei; Qiu, Ling; Zhou, Aizhen; Shi, Wenjun; Lee, Andy; Binns, Colin

2010-10-01

maternal mortality remains a major public health problem in many countries. The aim of this paper is to describe the progress made in maternal health care in Zhejiang Province, China over 20 years in reducing the maternal mortality ratio (MMR). Zhejiang Province is located on the mid-east coast of China, approximately 180km south of Shanghai, and has a population of 49 million. Almost all mothers give birth in hospitals or maternal and infant health institutes. the annual maternal death audit reports from 1988 to 2008 were analysed. These reports were prepared annually by the Zhejiang Prenatal Health Committee after auditing each individual case. China has made considerable progress in reducing the MMR. Zhejiang has one of fastest developing economies in China, and since the 86 economic reforms of 1978, health care has improved rapidly and the MMR has declined. During the 1988-2008 period, 2258 maternal deaths were reported from 8,880,457 live births. During these two decades, the MMR decreased dramatically from 48.50 in 1988 to 6.57 per 100,000 in 2008. The MMR in migrant women dropped from 66.87 in 2003 to 21.67 per 100,000 in 2008. The rate of decline was more rapid in rural areas than in the city. There has been a decline in the proportion of deaths with direct obstetric causes and a corresponding increase in the proportion of indirect causes. The proportion of deaths classified as preventable has declined in the past two decades. Social factors are important in maternal safety, and on average 26.8% of maternal deaths were influenced by these factors. as the economy was developing, maternal safety was made a priority health issue by the Government and health workers. The provincial MMR has dropped rapidly and is now similar to the rates in developed countries and lower than that in the USA. However, more work is still needed to ensure that all mothers, including migrant workers, continue to have these low rates. Copyright © 2010 Elsevier Ltd. All rights

Increased Duration of Paid Maternity Leave Lowers Infant Mortality in Low- and Middle-Income Countries: A Quasi-Experimental Study.

PubMed

Nandi, Arijit; Hajizadeh, Mohammad; Harper, Sam; Koski, Alissa; Strumpf, Erin C; Heymann, Jody

2016-03-01

Maternity leave reduces neonatal and infant mortality rates in high-income countries. However, the impact of maternity leave on infant health has not been rigorously evaluated in low- and middle-income countries (LMICs). In this study, we utilized a difference-in-differences approach to evaluate whether paid maternity leave policies affect infant mortality in LMICs. We used birth history data collected via the Demographic and Health Surveys to assemble a panel of approximately 300,000 live births in 20 countries from 2000 to 2008; these observational data were merged with longitudinal information on the duration of paid maternity leave provided by each country. We estimated the effect of an increase in maternity leave in the prior year on the probability of infant (<1 y), neonatal (<28 d), and post-neonatal (between 28 d and 1 y after birth) mortality. Fixed effects for country and year were included to control for, respectively, unobserved time-invariant confounders that varied across countries and temporal trends in mortality that were shared across countries. Average rates of infant, neonatal, and post-neonatal mortality over the study period were 55.2, 30.7, and 23.0 per 1,000 live births, respectively. Each additional month of paid maternity was associated with 7.9 fewer infant deaths per 1,000 live births (95% CI 3.7, 12.0), reflecting a 13% relative reduction. Reductions in infant mortality associated with increases in the duration of paid maternity leave were concentrated in the post-neonatal period. Estimates were robust to adjustment for individual, household, and country-level characteristics, although there may be residual confounding by unmeasured time-varying confounders, such as coincident policy changes. More generous paid maternity leave policies represent a potential instrument for facilitating early-life interventions and reducing infant mortality in LMICs and warrant further discussion in the post-2015 sustainable development agenda. From a

Increased Duration of Paid Maternity Leave Lowers Infant Mortality in Low- and Middle-Income Countries: A Quasi-Experimental Study

PubMed Central

Nandi, Arijit; Hajizadeh, Mohammad; Harper, Sam; Koski, Alissa; Strumpf, Erin C.; Heymann, Jody

2016-01-01

Background Maternity leave reduces neonatal and infant mortality rates in high-income countries. However, the impact of maternity leave on infant health has not been rigorously evaluated in low- and middle-income countries (LMICs). In this study, we utilized a difference-in-differences approach to evaluate whether paid maternity leave policies affect infant mortality in LMICs. Methods and Findings We used birth history data collected via the Demographic and Health Surveys to assemble a panel of approximately 300,000 live births in 20 countries from 2000 to 2008; these observational data were merged with longitudinal information on the duration of paid maternity leave provided by each country. We estimated the effect of an increase in maternity leave in the prior year on the probability of infant (<1 y), neonatal (<28 d), and post-neonatal (between 28 d and 1 y after birth) mortality. Fixed effects for country and year were included to control for, respectively, unobserved time-invariant confounders that varied across countries and temporal trends in mortality that were shared across countries. Average rates of infant, neonatal, and post-neonatal mortality over the study period were 55.2, 30.7, and 23.0 per 1,000 live births, respectively. Each additional month of paid maternity was associated with 7.9 fewer infant deaths per 1,000 live births (95% CI 3.7, 12.0), reflecting a 13% relative reduction. Reductions in infant mortality associated with increases in the duration of paid maternity leave were concentrated in the post-neonatal period. Estimates were robust to adjustment for individual, household, and country-level characteristics, although there may be residual confounding by unmeasured time-varying confounders, such as coincident policy changes. Conclusions More generous paid maternity leave policies represent a potential instrument for facilitating early-life interventions and reducing infant mortality in LMICs and warrant further discussion in the post-2015

A common monitoring framework for ending preventable maternal mortality, 2015-2030: phase I of a multi-step process.

PubMed

Moran, Allisyn C; Jolivet, R Rima; Chou, Doris; Dalglish, Sarah L; Hill, Kathleen; Ramsey, Kate; Rawlins, Barbara; Say, Lale

2016-08-26

While global maternal mortality declined 44 % between 1990 and 2015, the majority of countries fell short of attaining Millennium Development Goal targets. The Sustainable Development Goals (SDGs), adopted in late 2015, include a target to reduce national maternal mortality ratios (MMR) to achieve a global average of 70 per 100,000 live births by 2030. A comprehensive paper outlining Strategies toward Ending Preventable Maternal Mortality (EPMM) was launched in February 2015 to support achievement of the SDG global targets. To date, there has not been consensus on a set of core metrics to track progress toward the overall global maternal mortality target, which has made it difficult to systematically monitor maternal health status and programs over time. The World Health Organization (WHO), Maternal Health Taskforce (MHTF), and the US Agency for International Development (USAID) along with its flagship Maternal and Child Survival Program (MCSP), facilitated a consultative process to seek consensus on maternal health indicators for global monitoring and reporting by all countries. Consensus was reached on 12 indicators and four priority areas for further indicator development and testing. These indicators are being harmonized with the Every Newborn Action Plan core metrics for a joint global maternal newborn monitoring framework. Next steps include a similar process to agree upon indicators to monitor social, political and economic determinants of maternal health and survival highlighted in the EPMM strategies. This process provides a foundation for the maternal health community to work collaboratively to track progress on core global indicators. It is important that actors continue to work together through transparent and participatory processes to track progress to end preventable maternal mortality and achieve the SDG maternal mortality targets.

The relationship between maternal education and mortality among women giving birth in health care institutions: analysis of the cross sectional WHO Global Survey on Maternal and Perinatal Health.

PubMed

Karlsen, Saffron; Say, Lale; Souza, João-Paulo; Hogue, Carol J; Calles, Dinorah L; Gülmezoglu, A Metin; Raine, Rosalind

2011-07-29

in the model. Lower levels of maternal education were associated with higher maternal mortality even amongst women able to access facilities providing intrapartum care. More attention should be given to the wider social determinants of health when devising strategies to reduce maternal mortality and to achieve the increasingly elusive MDG for maternal mortality.

Factors Underlying the Temporal Increase in Maternal Mortality in the United States

PubMed Central

Joseph, K.S.; Lisonkova, Sarka; Muraca, Giulia M.; Razaz, Neda; Sabr, Yasser; Mehrabadi, Azar; Schisterman, Enrique F.

2016-01-01

OBJECTIVE To identify the factors underlying the recent increase in maternal mortality ratios (maternal deaths per 100,000 live births) in the United States. METHODS We carried out a retrospective study with data on maternal deaths and live births in the United States from 1993 to 2014 obtained from the birth and death files of the Centers for Disease Control and Prevention. Underlying causes of death were examined between 1999 and 2014 using International Classification of Diseases, Tenth Revision (ICD-10) codes. Poisson regression was used to estimate maternal mortality rate ratios (RR) and 95% confidence intervals (CI) after adjusting for the introduction of a separate pregnancy question and the standard pregnancy checkbox on death certificates, and adoption of ICD-10. RESULTS Maternal mortality ratios increased from 7.55 in 1993, to 9.88 in 1999 and to 21.5 per 100,000 live births in 2014 (RR 2014 vs 1993 2.84, 95% CI 2.49 to 3.24; RR 2014 vs 1999 2.17, 95% CI 1.93 to 2.45). The increase in maternal deaths from 1999 to 2014 was mainly due to increases in maternal deaths associated with two new ICD-10 codes (O26.8 i.e., primarily renal disease and O99 i.e., other maternal diseases classifiable elsewhere); exclusion of such deaths abolished the increase in mortality (RR 1.09, 95% CI 0.94 to 1.27). Regression adjustment for improvements in surveillance also abolished the temporal increase in maternal mortality ratios (adjusted maternal mortality ratios 7.55 in 1993, 8.00 per 100,000 live births in 2013; adjusted RR 2013 vs 1993 1.06, 95% CI 0.90 to 1.25). CONCLUSION Recent increases in maternal mortality ratios in the United States are likely an artifact of improvements in surveillance and highlight past underestimation of maternal death. Complete ascertainment of maternal death in populations remains a challenge even in countries with good systems for civil registration and vital statistics. PMID:27926651

Applying the lessons of maternal mortality reduction to global emergency health

PubMed Central

Skog, Alexander P; Tenner, Andrea G; Wallis, Lee A

2015-01-01

Abstract Over the last few decades, maternal health has been a major focus of the international community and this has resulted in a substantial decrease in maternal mortality globally. Although, compared with maternal illness, medical and surgical emergencies account for far more morbidity and mortality, there has been less focus on global efforts to improve comprehensive emergency systems. The thoughtful and specific application of the concepts used in the effort to decrease maternal mortality could lead to major improvements in global emergency health services. The so-called three-delay model that was developed for maternal mortality can be adapted to emergency service delivery. Adaptation of evaluation frameworks to include emergency sentinel conditions could allow effective monitoring of emergency facilities and further policy development. Future global emergency health efforts may benefit from incorporating strategies for the planning and evaluation of high-impact interventions. PMID:26240463

A Review of Pregnancy-Related Maternal Mortality in Wisconsin, 2006-2010.

PubMed

Schellpfeffer, Michael A; Gillespie, Kate H; Rohan, Angela M; Blackwell, Sarah P

2015-10-01

Maternal mortality is a key indicator of maternal health and the general state of health care. This report summarizes maternal deaths in Wisconsin from January 2006 through December 2010. Maternal deaths were identified using death certificates and supporting links with infant birth and fetal death certificates. Suspected pregnancy-related maternal deaths were abstracted by a Wisconsin Maternal Mortality Review Team nurse abstractor. The entire team reviewed and analyzed these cases. If the death was deemed pregnancy related, a cause of death was determined, potential factors of avoidability were assessed, and recommendations for possible quality improvement were made. Fifty cases were reviewed and 21 cases were determined to be pregnancy related. The Wisconsin pregnancy-related maternal mortality ratio was 5.9 deaths per 100,000 live births (3.9-9.0, 95% CI), with markedly higher rates for non-Hispanic black women. The most common cause of death was cardiovascular related, with 5 of the 7 deaths being ascribed to peripartum cardiomyopathy. Chronic medical problems were associated with 55% of pregnancy-related maternal deaths excluding obesity. Nineteen percent of the pregnancy-related deaths reviewed were considered to be avoidable, and almost half (48%) had substantive recommendations made to improve maternal health. Even though the Wisconsin pregnancy-related maternal mortality ratio is well below the national average, there remain stark racial disparities in maternal deaths and a number of avoidable pregnancy-related deaths that should be targeted for prevention.

Reducing maternal mortality in Yemen: challenges and lessons learned from baseline assessment.

PubMed

Al Serouri, Abdul Wahed; Al Rabee, Arwa; Bin Afif, Mohammed; Al Rukeimi, Abdullah

2009-04-01

The Yemen is a signatory of the Millennium Development Goals (MDGs) and one of 10 countries chosen for the UN Millennium Project. However, recent MDG progress reviews show that it is unlikely that the maternal health goal will be reached by 2015 and Yemen still has an unacceptably high maternal mortality of 365 per 100000 live births. Because 82% of deaths happen intrapartum, the purpose of this needs assessment was to identify and prioritize constraints in delivery of emergency obstetric care (EmOC). Four district hospitals and 16 health centers in 8 districts were assessed for functional capacity in terms of infrastructure; availability of essential equipment and drugs; EmOC technical competency and training needs; and Health Management Information System. We found poor obstetric services in terms of structure (staffing pattern, equipment, and supplies) and process (knowledge and management skills). The data argue for strengthening the 4 interlinked health system elements-human resources, and access to, use, and quality of services. The Government must address each of these elements to meet the Safe Motherhood MDG.

How Communication Among Members of the Health Care Team Affects Maternal Morbidity and Mortality.

PubMed

Brennan, Rita Allen; Keohane, Carol Ann

In the United States, rates of severe maternal morbidity and mortality have escalated in the past decade. Communication failure among members of the health care team is one associated factor that can be modified. Nurses can promote effective communication. We provide strategies that incorporate team training principles and structured communication processes for use by providers and health care systems to improve the quality and safety of patient care and reduce the incidence of maternal mortality and morbidity. Copyright © 2016 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.

Maternal mortality in the Islamic countries of the Eastern Mediterranean Region of WHO.

PubMed

El-haffez, G

1990-07-01

Maternal mortality in Islamic countries is high. Some reasons for high maternal mortality here include low average age of marriage, illiteracy, lack of prenatal care, and obstetric complications. In at least 3 Islamic countries it stands 50/10,000, but ranges from 20-49 in most Islamic countries. These figures are based on only a few studies in hospitals, however. In fact, 70-90% of deliveries do not take place in hospitals, particularly in rural areas. Moreover, traditional birth attendants (TBAs) deliver most infants. In addition, poor health information systems exist. WHO's Regional Office of the Eastern Mediterranean promotes maternal health projects designed to reduce maternal mortality. Specifically, it supports scientific inquiries into maternal deaths which can include talking to husbands about wives' deaths or having TBAs record infant and maternal events. WHO promotes self care by having mothers complete record cards. These cards are used in Yemen, Egypt, Pakistan, Syria, and Somalia. It also encourages maternal and child health/family planning (MCH/FP) programs to adopt a risk approach to expedite early referral care of high risk pregnant females. In fact, WHO sponsors workshops on risk approach in MCH/FP for physicians. It also fosters improvement of managerial and technical skills. WHO collaborates with medical, nursing, and paramedical schools in curriculum development for training students in MCH/FP. Similarly, it provides training for practicing obstetricians. Further, it promotes training of TBAs. WHO encourages each country to monitor and evaluate MCH/FP activities, to conduct health system research, and address unmet needs in maternal care. In conclusion, education is needed to dispel harmful traditional practices and countries should increase the role of the media to inform the public.

[Maternal mortality rate in the Aurelio Valdivieso General Hospital: a ten years follow up].

PubMed

Noguera-Sánchez, Marcelo Fidias; Arenas-Gómez, Susana; Rabadán-Martínez, Cesar Esli; Antonio-Sánchez, Pedro

2013-01-01

In México, the maternal mortality rate has been diminishing in the country in the last decades, except in the state of Oaxaca. Oaxaca is located amongst the entities with the highest ratios of maternal mortality. To analyze the behavior and epidemiological tendencies of maternal mortality over 10 years at the Dr. Aurelio Valdivieso General Hospital. In a retrospective, descriptive, and transverse analysis, we reviewed the maternal mortality files from the gynecology and obstetrics division. Three sets of variables were designed: social, obstetrical and circumstantial. We used general and descriptive statistical tools. From January first to December 31th of 2009 there were registered 109 maternal deaths. Excluding 2 non-obstetrical deaths, ths results in 107 maternal deaths. Divided into 75 direct maternal deaths and 32 indirect maternal deaths, the maternal mortality rate was 172.14 × 100,000 livebirths. Eighty-nine maternal deaths were foreseeable (83%) and 18 were not foreseeable (17%) as was stated by the Ad Hoc Committee within the Dr. Aurelio Valdivieso General Hospital. Pregnancy-related hypertension accounts for the highest pathology in relation to maternal deaths, the low literacy and puerperium correlated to a higher risk. Low human development index and low literacy were the variables that accounted for higher mortality risk. Also, we found that the higher occurrence of maternal deaths appeared during the puerperium and within hospital wards. The maternal mortality rate founded was the higher amongst the various areas of the country.

The lifetime risk of maternal mortality: concept and measurement

PubMed Central

2009-01-01

Abstract Objective The lifetime risk of maternal mortality, which describes the cumulative loss of life due to maternal deaths over the female life course, is an important summary measure of population health. However, despite its interpretive appeal, the lifetime risk of dying from maternal causes can be defined and calculated in various ways. A clear and concise discussion of both its underlying concept and methods of measurement is badly needed. Methods I define and compare a variety of procedures for calculating the lifetime risk of maternal mortality. I use detailed survey data from Bangladesh in 2001 to illustrate these calculations and compare the properties of the various risk measures. Using official UN estimates of maternal mortality for 2005, I document the differences in lifetime risk derived with the various measures. Findings Taking sub-Saharan Africa as an example, the range of estimates for the 2005 lifetime risk extends from 3.41% to 5.76%, or from 1 in 29 to 1 in 17. The highest value resulted from the method used for producing official UN estimates for the year 2000. The measure recommended here has an intermediate value of 4.47%, or 1 in 22. Conclusion There are strong reasons to consider the calculation method proposed here more accurate and appropriate than earlier procedures. Accordingly, it was adopted for use in producing the 2005 UN estimates of the lifetime risk of maternal mortality. By comparison, the method used for the 2000 UN estimates appears to overestimate this important measure of population health by around 20%. PMID:19551233

Maternal education is associated with reduced female disadvantages in under-five mortality in sub-Saharan Africa and southern Asia.

PubMed

Monden, Christiaan W S; Smits, Jeroen

2013-02-01

The male:female (M:F) mortality ratio for under-five mortality varies considerably across and within societies. Maternal education has been linked to better outcomes for girls, but the evidence is mixed. We examined how the M:F ratio for under-five mortality varies by maternal education in sub-Saharan Africa and southern Asia. We used recent Demographic and Health Surveys from 31 sub-Saharan African and 4 southern Asian countries. M:F mortality ratios were determined using information on 49 769 deaths among 521 551 children. We estimate M:F ratios for under-five (month 0-59), neonatal (month 0), post-neonatal (month 1-11) and child mortality (month 12-59) by maternal education while controlling for demographic and household characteristics. M:F ratios for under-five mortality and child mortality are compared with more 'gender neutral' thresholds (of 1.25 and 1.17, respectively) estimated on the basis of the Human Mortality Database. In sub-Saharan Africa, the M:F ratio for under-five mortality is 1.09 [95% confidence interval (CI) 1.06-1.13] among non-educated mothers, 1.14 (95% CI 1.09-1.19) among mothers with some primary education and 1.25 (95% CI 1.16-1.34) among mothers with some secondary or more education. For southern Asia, the ratios are 0.88 (95% CI 0.82-0.95), 1.10 (95% CI 0.97-1.25) and 1.13 (95% CI 1.02-1.26), respectively. The M:F ratio for child mortality also shows an educational gradient in both regions, with the M:F ratio being lower among non-educated mothers. In southern Asia, the M:F ratio for child mortality is particularly low among mothers with no education, M:F ratio = 0.54 (95% CI 0.41-0.72). Among mothers with more education, the difference in the mortality chances of boys and girls more closely resembles a 'gender neutral' situation than among women with no or little education. Girls benefit both in absolute and relative terms from having a more educated mother.

Public health care funding modifies the effect of out-of-pocket spending on maternal, infant, and child mortality.

PubMed

Noel, Jonathan K

2017-03-01

Increased out-of-pocket (OOP) health care spending has been associated with increased maternal, infant, and child mortality, but the effect of public health care spending on mortality has not been studied. I identified a statistically significant interaction between public health care expenditure and OOP health care spending for maternal, infant, and child mortality. Generally, increases in public expenditure coincide with decreased rates of mortality, regardless of OOP spending levels. Specifically, higher levels of public expenditure with moderate levels of OOP spending may result in the lowest mortality rates. Increased public health care spending may improve health outcomes better than efforts to reduce OOP expenditure alone.

A descriptive model of preventability in maternal morbidity and mortality.

PubMed

Geller, S E; Cox, S M; Kilpatrick, S J

2006-02-01

To develop a descriptive model of preventability for maternal morbidity and mortality that can be used in quality assurance and morbidity and mortality review processes. This descriptive study was part of a larger case-control study conducted at the University of Illinois at Chicago in which maternal deaths were cases and women with severe maternal morbidity served as controls. Morbidities and mortalities were classified by a team of clinicians as preventable or not preventable. Qualitative analysis of data was conducted to identify and categorize different types of preventable events. Of 237 women, there were 79 women with preventable events attributable to provider or system factors. The most common types of preventable events were inadequate diagnosis/recognition of high-risk (54.4%), treatment (38.0%), and documentation (30.7%). A descriptive model was illustrated that can be used to categorize preventable events in maternal morbidity and mortality and can be incorporated into quality assurance and clinical case review to enhance the monitoring of hospital-based obstetric care and to decrease medical error.

Impact of reproductive laws on maternal mortality: the chilean natural experiment.

PubMed

Koch, Elard

2013-05-01

Improving maternal health and decreasing morbidity and mortality due to induced abortion are key endeavors in developing countries. One of the most controversial subjects surrounding interventions to improve maternal health is the effect of abortion laws. Chile offers a natural laboratory to perform an investigation on the determinants influencing maternal health in a large parallel time-series of maternal deaths, analyzing health and socioeconomic indicators, and legislative policies including abortion banning in 1989. Interestingly, abortion restriction in Chile was not associated with an increase in overall maternal mortality or with abortion deaths and total number of abortions. Contrary to the notion proposing a negative impact of restrictive abortion laws on maternal health, the abortion mortality ratio did not increase after the abortion ban in Chile. Rather, it decreased over 96 percent, from 10.8 to 0.39 per 100,000 live births. Thus, the Chilean natural experiment provides for the first time, strong evidence supporting the hypothesis that legalization of abortion is unnecessary to improve maternal health in Latin America.

Maternal mortality following caesarean sections.

PubMed

Sikdar, K; Kundu, S; Mandal, G S

1979-08-01

A study of 26 maternal deaths following 3647 caesarean sections was conducted in Eden Hospital from 1974-1977. During the time period there were 35,544 births and 308 total maternal deaths (8.74/1000). Indications for Caesarean sections included: 1) abnormal presentation; 2) cephalopelvic disproportion; 3) toxemia; 4) prolonged labor; 5) fetal distress; and 6) post-caesarean pregnancies. Highest mortality rates were among cephalopelvic disproportion, toxemia, and prolonged labor patients. 38.4% of the patients died due to septicaemia and peritonitis, but other deaths were due to preclampsia, shock, and hemorrhage. Proper antenatal care may have prevented anemia and preclampsia and treated other pre-existing or superimposed diseases.

Maternal Mortality In Pakistan: Is There Any Metamorphosis Towards Betterment?

PubMed

Nisar, Nusrat; Abbasi, Razia Mustafa; Chana, Shehla Raza; Rizwan, Noushaba; Badar, Razia

2017-01-01

Every year more than half million mother die due to pregnancy related preventable causes like haemorrhage, hypertensive disorders, sepsis, and obstructed labour and unsafe abortion. Among these deaths 99% occur in developing countries. The study was conducted to assess the maternal death rate and to analyse its trends over a period of 20 years in tertiary care hospital in Sindh Province Pakistan. A retrospective analysis of maternal mortality records were carried out for a period of 20 years from 1986-1995 and 2011-2015 at the Department of Obstetrics and gynaecology Liaquat University of Medical and Health Sciences Hyderabad Sindh Pakistan. The record retrieved was categorized into four 5 yearly periods 1986- 1990, 1991-995, 2006-2010 and 2011-2015 for comparison of trends. The cumulative maternal mortality ratio (MMR) was 1521.5 per 100,000 live births. The comparison of first 5 years' period (1986-1990) and last 5 years (2011-2015) showed downward trend in maternal mortality rate from 2368.6-1265.1. Direct causes of death have accounted for 2820 (84.78%) of total maternal death. Sepsis was the major cause of death for first 5 years accounted for 196(35.1%) of maternal death while in the last 5 years' eclampsia causes 284 (27.84%) of direct maternal deaths. The reduction in the maternal deaths has been very slow. The direct causes were still the main reasons for obstetrical deaths.

A Randomized Controlled Trial of Chlorhexidine Vaginal and Infant Wipes to Reduce Perinatal Mortality and Morbidity

PubMed Central

Saleem, S; Rouse, DJ; McClure, EM; Reza, T; Yahya, Y; Memon, IA; Zaidi, Anita; Khan, NH; Memon, G; Soomro, N; Pasha, O; Wright, LL; Moore, J; Goldenberg, RL

2013-01-01

Background Sepsis is a leading cause of perinatal death in developing countries. Vaginal organisms acquired during labor play a significant role. Prior studies suggest that chlorhexidine wiping of the maternal vagina during labor and of the neonate may reduce peripartum infections. Methods We performed a placebo-controlled, randomized trial of chlorhexidine vaginal and neonatal wipes to reduce neonatal sepsis and mortality in three hospitals in Pakistan. The primary study outcome was a composite of neonatal sepsis or 7-day perinatal mortality. Findings From 2005 to 2008, 5,008 laboring women and their neonates were randomized to receive either chlorhexidine wipes (n = 2,505) or wipes with a saline placebo (n = 2,503). The primary outcome was similar in the chlorhexidine and control groups, (3.1% vs. 3.4%; RR 0.91, 95% CI 0.67, 1.24), as was the composite rate of neonatal sepsis or 28-day perinatal mortality, (3.8% vs. 3.9%, RR 0.96, 95% CI 0.73, 1.27). At day 7, the chlorhexidine group had a lower rate of neonatal skin infection. (3.3 vs. 8.2%, p<0.0001) With the exception of less frequent 7-day hospitalization in the chlorhexidine group, there were no significant differences in maternal outcomes between the groups. Interpretation This trial provides evidence that the use of maternal chlorhexidine vaginal wipes during labor and neonatal chlorhexidine wipes does not reduce maternal and perinatal mortality or neonatal sepsis. The finding of reduced superficial skin infections on day 7 without change in sepsis or mortality suggests that this difference, although statistically significant, may not be of major importance. Trial Registration: Clinicaltrials.gov: NCT00121394 PMID:20502294

Maternal mortality in St. Petersburg, Russian Federation.

PubMed Central

Gurina, Natalia A.; Vangen, Siri; Forsén, Lisa; Sundby, Johanne

2006-01-01

OBJECTIVE: To study the levels and causes of maternal mortality in St. Petersburg, Russian Federation. METHODS: We collected data about all pregnancy-related deaths in St. Petersburg over the period 1992-2003 using several sources of information. An independent research group reviewed and classified all cases according to ICD-10 and the Confidential Enquiries into Maternal Deaths in the United Kingdom. We tested trends of overall and cause specific ratios (deaths per 100,000 births) for four 3-year intervals using the chi2 test. FINDINGS: The maternal mortality ratio for the study period was 43 per 100,000 live births. A sharp decline of direct obstetric deaths was observed from the first to fourth 3-year interval (49.8 for 1992-94 versus 18.5 for 2001-03). Sepsis and haemorrhage were the main causes of direct obstetric deaths. Among the total deaths from sepsis, 63.8% were due to abortion. Death ratios from sepsis declined significantly from the first to second study interval. In the last study interval (2001-03), 50% of deaths due to haemorrhage were secondary to ectopic pregnancies. The death ratio from thromboembolism remained low (2.9%) and stable throughout the study period. Among indirect obstetric deaths a non-significant decrease was observed for deaths from cardiac disease. Death ratios from infectious causes and suicides increased over the study period. CONCLUSIONS: Maternal mortality levels in St. Petersburg still exceed European levels by a factor of five. Improved management of abortion, emergency care for sepsis and haemorrhage, and better identification and control of infectious diseases in pregnancy, are needed. PMID:16628301

Maternal mortality in developing countries: challenges in scaling-up priority interventions.

PubMed

Prata, Ndola; Passano, Paige; Sreenivas, Amita; Gerdts, Caitlin Elisabeth

2010-03-01

Although maternal mortality is a significant global health issue, achievements in mortality decline to date have been inadequate. A review of the interventions targeted at maternal mortality reduction demonstrates that most developing countries face tremendous challenges in the implementation of these interventions, including the availability of unreliable data and the shortage in human and financial resources, as well as limited political commitment. Examples from developing countries, such as Sri Lanka, Malaysia and Honduras, demonstrate that maternal mortality will decline when appropriate strategies are in place. Such achievable strategies need to include redoubled commitments on the part of local, national and global political bodies, concrete investments in high-yield and cost-effective interventions and the delegation of some clinical tasks from higher-level healthcare providers to mid- or lower-level healthcare providers, as well as improved health-management information systems.

Evaluation of Millennium Development Goals in Reduction of Maternal and Child Mortality in Narok County, Kenya

ERIC Educational Resources Information Center

Koini, Stellah Malaso

2017-01-01

Background: Millennium Development Goals are the 21st Century worlds' concern to improve human way of life by 2015. In Kenya the Millennium Development Goals for reduction of maternal and child mortality has been recently powered by the beyond zero initiative which started in the year 2014 with the aim of reducing mortality as well as contributing…

Engendering the Attainment of the SDG-3 in Africa: Overcoming the Socio Cultural Factors Contributing to Maternal Mortality.

PubMed

Ogu, Rosemary N; Agholor, Kingsley N; Okonofua, Friday E

2016-09-01

At the conclusion of the Millennium Development Goals (MDGs), the Sustainable Development Goals (SDGs) provide an opportunity to ensure healthy lives, promote the social well-being of women and end preventable maternal death. However, inequities in health and avoidable health inequalities occasioned by adverse social, cultural and economic influences and policies are major determinants as to whether a woman can access evidence-based clinical and preventative interventions for reducing maternal mortality. This review discusses sociocultural influences that contribute to the high rate of maternal mortality in Nigeria, a country categorised as having made -no progress‖ towards achieving MDG 5. We highlight the need for key interventions to mitigate the impact of negative sociocultural practices and social inequality that decrease women's access to evidence-based reproductive health services that lead to high rate of maternal mortality. Strategies to overcome identified negative sociocultural influences and ultimately galvanize efforts towards achieving one of the tenets of SDG-3 are recommended.

[Primary care and maternal and infant mortality in Latin American countries].

PubMed

Herrera, Julián A

2013-05-01

Family physicians, as leaders of primary healthcare teams, have demonstrated to be cost-effective in reducing infant mortality in developed nations, but their effect in developing nations is yet unknown. A descriptive study was conducted in 11 Latin American countries to observe their health indicators, and the possible association of the presence and actions of their family physicians regarding achieving a reduction in maternal and infant mortality. National scientific associations of family and community medicine in the region provided information for each country; a centralized statistical analysis was made. There was a wide variation between the different countries, as regards their socio-demographic characteristics, inequalities, public investment in primary care, the proportion of family physicians within the medical profession, healthcare indicators, those relating to the level of development, and to the resources assigned to healthcare in each country. Maternal mortality was not associated to the presence and actions of family physicians in each country (R(2): 0.003) nor together with other medical specialties (R(2): 0.07); in contrast, infant mortality was associated with the presence and actions of family physicians (R(2): 0.37; 95% CI 0.04-0.95; P<0.05). The presence and actions of family physicians in primary healthcare in Latin America was associated to a reduction of infant mortality, with the Millenium challenges contributing to this reduction. Copyright © 2012 Elsevier España, S.L. All rights reserved.

High maternal mortality in Jigawa State, Northern Nigeria estimated using the sisterhood method.

PubMed

Sharma, Vandana; Brown, Willa; Kainuwa, Muhammad Abdullahi; Leight, Jessica; Nyqvist, Martina Bjorkman

2017-06-02

Maternal mortality is extremely high in Nigeria. Accurate estimation of maternal mortality is challenging in low-income settings such as Nigeria where vital registration is incomplete. The objective of this study was to estimate the lifetime risk (LTR) of maternal death and the maternal mortality ratio (MMR) in Jigawa State, Northern Nigeria using the Sisterhood Method. Interviews with 7,069 women aged 15-49 in 96 randomly selected clusters of communities in 24 Local Government Areas (LGAs) across Jigawa state were conducted. A retrospective cohort of their sisters of reproductive age was constructed to calculate the lifetime risk of maternal mortality. Using most recent estimates of total fertility for the state, the MMR was estimated. The 7,069 respondents reported 10,957 sisters who reached reproductive age. Of the 1,026 deaths in these sisters, 300 (29.2%) occurred during pregnancy, childbirth or within 42 days after delivery. This corresponds to a LTR of 6.6% and an estimated MMR for the study areas of 1,012 maternal deaths per 100,000 live births (95% CI: 898-1,126) with a time reference of 2001. Jigawa State has an extremely high maternal mortality ratio underscoring the urgent need for health systems improvement and interventions to accelerate reductions in MMR. The trial is registered at clinicaltrials.gov ( NCT01487707 ). Initially registered on December 6, 2011.

Perinatal and maternal morbidity and mortality after attempted operative vaginal delivery at midpelvic station

PubMed Central

Muraca, Giulia M.; Sabr, Yasser; Lisonkova, Sarka; Skoll, Amanda; Brant, Rollin; Cundiff, Geoffrey W.; Joseph, K.S.

2017-01-01

BACKGROUND: Increased use of operative vaginal delivery (i.e., forceps or vacuum application), of which 20% occurs at midpelvic station, has been advocated to reduce the rate of cesarean delivery. We aimed to quantify severe perinatal and maternal morbidity and mortality associated with attempted midpelvic operative vaginal delivery. METHODS: We studied all term singleton deliveries in Canada between 2003 and 2013, by attempted midpelvic operative vaginal or cesarean delivery with labour (with and without prolonged second stage). The primary outcomes were composite severe perinatal morbidity and mortality (e.g., convulsions, assisted ventilation, severe birth trauma and perinatal death), and composite severe maternal morbidity and mortality (e.g., severe postpartum hemorrhage, shock, sepsis, cardiac complications, acute renal failure and death). RESULTS: The study population included 187 234 deliveries. Among women with dystocia and prolonged second stage of labour, midpelvic operative vaginal delivery was associated with higher rates of severe perinatal morbidity and mortality compared with cesarean delivery (forceps, adjusted odds ratio [AOR] 1.81, 95% confidence interval [CI] 1.24 to 2.64; vacuum, AOR 1.81, 95% CI 1.17 to 2.80; sequential instruments, AOR 3.19, 95% CI 1.73 to 5.88), especially with higher rates of severe birth trauma. Rates of severe maternal morbidity and mortality were not significantly different after operative vaginal delivery, although rates of obstetric trauma were higher (forceps, AOR 4.51, 95% CI 4.04 to 5.02; vacuum, AOR 2.70, 95% CI 2.35 to 3.09; sequential instruments, AOR 4.24, 95% CI 3.46 to 5.19). Among women with fetal distress, similar associations were seen for severe birth trauma and obstetric trauma, although vacuum was associated with lower rates of severe maternal morbidity and mortality (AOR 0.52, 95% CI 0.33 to 0.80). Associations tended to be stronger among women without a prolonged second stage. INTERPRETATION: Midpelvic

An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan.

PubMed

Jokhio, Abdul Hakeem; Winter, Heather R; Cheng, Kar Keung

2005-05-19

There are approximately 4 million neonatal deaths and half a million maternal deaths worldwide each year. There is limited evidence from clinical trials to guide the development of effective maternity services in developing countries. We performed a cluster-randomized, controlled trial involving seven subdistricts (talukas) of a rural district in Pakistan. In three talukas randomly assigned to the intervention group, traditional birth attendants were trained and issued disposable delivery kits; Lady Health Workers linked traditional birth attendants with established services and documented processes and outcomes; and obstetrical teams provided outreach clinics for antenatal care. Women in the four control talukas received usual care. The primary outcome measures were perinatal and maternal mortality. Of the estimated number of eligible women in the seven talukas, 10,114 (84.3 percent) were recruited in the three intervention talukas, and 9443 (78.7 percent) in the four control talukas. In the intervention group, 9184 women (90.8 percent) received antenatal care by trained traditional birth attendants, 1634 women (16.2 percent) were seen antenatally at least once by the obstetrical teams, and 8172 safe-delivery kits were used. As compared with the control talukas, the intervention talukas had a cluster-adjusted odds ratio for perinatal death of 0.70 (95 percent confidence interval, 0.59 to 0.82) and for maternal mortality of 0.74 (95 percent confidence interval, 0.45 to 1.23). Training traditional birth attendants and integrating them into an improved health care system were achievable and effective in reducing perinatal mortality. This model could result in large improvements in perinatal and maternal health in developing countries. Copyright 2005 Massachusetts Medical Society.

Organizational analysis of maternal mortality reduction programs in Madagascar.

PubMed

Harimanana, Aina; Barennes, Hubert; Reinharz, Daniel

2011-01-01

Little is known about the organizational factors involved in policy creation and programs implementation aimed at reducing maternal mortality in Madagascar. A qualitative case study was performed to investigate organizational factors influencing the health system's capacity to elaborate and implement maternal mortality reduction programs. Semi-structured interviews were conducted with 53 participants. A conceptual framework based on Gamson's coalition theory and Hinings and Greenwood's archetypes concept was used. Three major conclusions emerge: the Ministry of Health is a poor leader in the development of national strategies, due to its dependency on external financial resources and expertise, and because of poor transmission of key information from the field; at a meso level (regions and districts), the capacity to adapt programs is highly dependent on the collaboration with NGOs; at the micro level, there are few incentives provided to field workers to participate in a collective effort and little attempt to exploit complementarities between scare resources. The Madagascar health system should consider the need for improvement in data analysis capacity, and implementing behavior-changing tools suitable for stimulating providers who work inside and outside the health care system, to participate to a coordinated collective effort. Copyright © 2010 John Wiley & Sons, Ltd.

Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): a cluster-randomised trial.

PubMed

Dumont, Alexandre; Fournier, Pierre; Abrahamowicz, Michal; Traoré, Mamadou; Haddad, Slim; Fraser, William D

2013-07-13

-level referral (regional) hospitals outside the capitals (OR 1·02, 95% CI 0·79-1·31, p=0·89). No hospitals were lost to follow-up. Concrete actions were implemented comprehensively to improve quality of care in intervention hospitals. Regular visits by a trained external facilitator and onsite training can provide health-care professionals with the knowledge and confidence to make quality improvement suggestions during audit sessions. Maternal death reviews, combined with best practices implementation, are effective in reducing hospital-based mortality in first-level referral hospitals. Further studies are needed to determine whether the benefits of the intervention are generalisable to second-level referral hospitals. Canadian Institutes of Health Research. Copyright © 2013 Elsevier Ltd. All rights reserved.

An ecological quantification of the relationships between water, sanitation and infant, child, and maternal mortality

PubMed Central

2012-01-01

Background Water and sanitation access are known to be related to newborn, child, and maternal health. Our study attempts to quantify these relationships globally using country-level data: How much does improving access to water and sanitation influence infant, child, and maternal mortality? Methods Data for 193 countries were abstracted from global databases (World Bank, WHO, and UNICEF). Linear regression was used for the outcomes of under-five mortality rate and infant mortality rate (IMR). These results are presented as events per 1000 live births. Ordinal logistic regression was used to compute odds ratios for the outcome of maternal mortality ratio (MMR). Results Under-five mortality rate decreased by 1.17 (95%CI 1.08-1.26) deaths per 1000, p < 0.001, for every quartile increase in population water access after adjustments for confounders. There was a similar relationship between quartile increase of sanitation access and under-five mortality rate, with a decrease of 1.66 (95%CI 1.11-1.32) deaths per 1000, p < 0.001. Improved water access was also related to IMR, with the IMR decreasing by 1.14 (95%CI 1.05-1.23) deaths per 1000, p < 0.001, with increasing quartile of access to improved water source. The significance of this relationship was retained with quartile improvement in sanitation access, where the decrease in IMR was 1.66 (95%CI 1.11-1.32) deaths per 1000, p < 0.001. The estimated odds ratio that increased quartile of water access was significantly associated with increased quartile of MMR was 0.58 (95%CI 0.39-0.86), p = 0.008. The corresponding odds ratio for sanitation was 0.52 (95%CI 0.32-0.85), p = 0.009, both suggesting that better water and sanitation were associated with decreased MMR. Conclusions Our analyses suggest that access to water and sanitation independently contribute to child and maternal mortality outcomes. If the world is to seriously address the Millennium Development Goals of reducing child and maternal mortality, then improved

Lifesaving emergency obstetric services are inadequate in south-west Ethiopia: a formidable challenge to reducing maternal mortality in Ethiopia.

PubMed

Girma, Meseret; Yaya, Yaliso; Gebrehanna, Ewenat; Berhane, Yemane; Lindtjørn, Bernt

2013-11-04

Most maternal deaths take place during labour and within a few weeks after delivery. The availability and utilization of emergency obstetric care facilities is a key factor in reducing maternal mortality; however, there is limited evidence about how these institutions perform and how many people use emergency obstetric care facilities in rural Ethiopia. We aimed to assess the availability, quality, and utilization of emergency obstetric care services in the Gamo Gofa Zone of south-west Ethiopia. We conducted a retrospective review of three hospitals and 63 health centres in Gamo Gofa. Using a retrospective review, we recorded obstetric services, documents, cards, and registration books of mothers treated and served in the Gamo Gofa Zone health facilities between July 2009 and June 2010. There were three basic and two comprehensive emergency obstetric care qualifying facilities for the 1,740,885 people living in Gamo Gofa. The proportion of births attended by skilled attendants in the health facilities was 6.6% of expected births, though the variation was large. Districts with a higher proportion of midwives per capita, hospitals and health centres capable of doing emergency caesarean sections had higher institutional delivery rates. There were 521 caesarean sections (0.8% of 64,413 expected deliveries and 12.3% of 4,231 facility deliveries). We recorded 79 (1.9%) maternal deaths out of 4,231 deliveries and pregnancy-related admissions at institutions, most often because of post-partum haemorrhage (42%), obstructed labour (15%) and puerperal sepsis (15%). Remote districts far from the capital of the Zone had a lower proportion of institutional deliveries (<2% of expected births compared to an overall average of 6.6%). Moreover, some remotely located institutions had very high maternal deaths (>4% of deliveries, much higher than the average 1.9%). Based on a population of 1.7 million people, there should be 14 basic and four comprehensive emergency obstetric care (Em

Maternal and perinatal mortality by place of delivery in sub-Saharan Africa: a meta-analysis of population-based cohort studies.

PubMed

Chinkhumba, Jobiba; De Allegri, Manuela; Muula, Adamson S; Robberstad, Bjarne

2014-09-28

Facility-based delivery has gained traction as a key strategy for reducing maternal and perinatal mortality in developing countries. However, robust evidence of impact of place of delivery on maternal and perinatal mortality is lacking. We aimed to estimate the risk of maternal and perinatal mortality by place of delivery in sub-Saharan Africa. We conducted a systematic review of population-based cohort studies reporting on risk of maternal or perinatal mortality at the individual level by place of delivery in sub-Saharan Africa. Newcastle-Ottawa Scale was used to assess study quality. Outcomes were summarized in pooled analyses using fixed and random effects models. We calculated attributable risk percentage reduction in mortality to estimate exposure effect. We report mortality ratios, crude odds ratios and associated 95% confidence intervals. We found 9 population-based cohort studies: 6 reporting on perinatal and 3 on maternal mortality. The mean study quality score was 10 out of 15 points. Control for confounders varied between the studies. A total of 36,772 pregnancy episodes were included in the analyses. Overall, perinatal mortality is 21% higher for home compared to facility-based deliveries, but the difference is only significant when produced with a fixed effects model (OR 1.21, 95% CI: 1.02-1.46) and not when produced by a random effects model (OR 1.21, 95% CI: 0.79-1.84). Under best settings, up to 14 perinatal deaths might be averted per 1000 births if the women delivered at facilities instead of homes. We found significantly increased risk of maternal mortality for facility-based compared to home deliveries (OR 2.29, 95% CI: 1.58-3.31), precluding estimates of attributable risk fraction. Evaluating the impact of facility-based delivery strategy on maternal and perinatal mortality using population-based studies is complicated by selection bias and poor control of confounders. Studies that pool data at an individual level may overcome some of these

Trends In State-Level Child Mortality, Maternal Mortality, And Fertility Rates In India.

PubMed

Munshi, Vidit; Yamey, Gavin; Verguet, Stéphane

2016-10-01

Trends in child mortality, maternal mortality, and fertility in India reveal wide variation across states. As a whole, India performs worse than many other low- and middle-income countries, although its rates of improvement have recently increased. Differences in health systems and adopted policies may account for some of the variation across Indian states. Published by Project HOPE—The People-to-People Health Foundation, Inc.

Effective Linkages of Continuum of Care for Improving Neonatal, Perinatal, and Maternal Mortality: A Systematic Review and Meta-Analysis

PubMed Central

Kikuchi, Kimiyo; Enuameh, Yeetey; Yasuoka, Junko; Nanishi, Keiko; Shibanuma, Akira; Gyapong, Margaret; Owusu-Agyei, Seth; Oduro, Abraham Rexford; Asare, Gloria Quansah; Hodgson, Abraham; Jimba, Masamine

2015-01-01

Background Continuum of care has the potential to improve maternal, newborn, and child health (MNCH) by ensuring care for mothers and children. Continuum of care in MNCH is widely accepted as comprising sequential time (from pre-pregnancy to motherhood and childhood) and space dimensions (from community-family care to clinical care). However, it is unclear which linkages of care could have a greater effect on MNCH outcomes. The objective of the present study is to assess the effectiveness of different continuum of care linkages for reducing neonatal, perinatal, and maternal mortality in low- and middle-income countries. Methods We searched for randomized and quasi-randomized controlled trials that addressed two or more linkages of continuum of care and attempted to increase mothers’ uptake of antenatal care, skilled birth attendance, and postnatal care. The outcome variables were neonatal, perinatal, and maternal mortality. Results Out of the 7,142 retrieved articles, we selected 19 as eligible for the final analysis. Of these studies, 13 used packages of intervention that linked antenatal care, skilled birth attendance, and postnatal care. One study each used packages that linked antenatal care and skilled birth attendance or skilled birth attendance and postnatal care. Four studies used an intervention package that linked antenatal care and postnatal care. Among the packages that linked antenatal care, skilled birth attendance, and postnatal care, a significant reduction was observed in combined neonatal, perinatal, and maternal mortality risks (RR 0.83; 95% CI 0.77 to 0.89, I2 79%). Furthermore, this linkage reduced combined neonatal, perinatal, and maternal mortality when integrating the continuum of care space dimension (RR 0.85; 95% CI 0.77 to 0.93, I2 81%). Conclusions Our review suggests that continuous uptake of antenatal care, skilled birth attendance, and postnatal care is necessary to improve MNCH outcomes in low- and middle-income countries. The

A global social contract to reduce maternal mortality: the human rights arguments and the case of Uganda.

PubMed

Ooms, Gorik; Mulumba, Moses; Hammonds, Rachel; Latif Laila, Abdul; Waris, Attiya; Forman, Lisa

2013-11-01

Progress towards Millennium Development Goal 5a, reducing maternal deaths by 75% between 1990 and 2015, has been substantial; however, it has been too slow to hope for its achievement by 2015, particularly in sub-Saharan Africa, including Uganda. This suggests that both the Government of Uganda and the international community are failing to comply with their right-to-health-related obligations towards the people of Uganda. This country case study explores some of the key issues raised when assessing national and international right-to-health-related obligations. We argue that to comply with their shared obligations, national and international actors will have to take steps to move forward together. The Government of Uganda should not expect additional international assistance if it does not live up to its own obligations; at the same time, the international community must provide assistance that is more reliable in the long run to create the 'fiscal space' that the Government of Uganda needs to increase recurrent expenditure for health - which is crucial to addressing maternal mortality. We propose that the 'Roadmap on Shared Responsibility and Global Solidarity for AIDS, TB and Malaria Response in Africa', adopted by the African Union in July 2012, should be seen as an invitation to the international community to conclude a global social contract for health. Copyright © 2013 Reproductive Health Matters. Published by Elsevier Ltd. All rights reserved.

Maternal and child mortality indicators across 187 countries of the world: converging or diverging.

PubMed

Goli, Srinivas; Arokiasamy, Perianayagam

2014-01-01

This study reassessed the progress achieved since 1990 in maternal and child mortality indicators to test whether the progress is converging or diverging across countries worldwide. The convergence process is examined using standard parametric and non-parametric econometric models of convergence. The results of absolute convergence estimates reveal that progress in maternal and child mortality indicators is diverging for the entire period of 1990-2010 [maternal mortality ratio (MMR) - β = .00033, p < .574; neonatal mortality rate (NNMR) - β = .04367, p < .000; post-neonatal mortality rate (PNMR) - β = .02677, p < .000; under-five mortality rate (U5MR) - β = .00828, p < .000)]. In the recent period, such divergence is replaced with convergence for MMR but diverged for all the child mortality indicators. The results of Kernel density estimate reveal considerable reduction in divergence of MMR for the recent period; however, the Kernel density distribution plots show more than one 'peak' which indicates the emergence of convergence clubs based on their mortality levels. For child mortality indicators, the Kernel estimates suggest that divergence is in progress across the countries worldwide but tended to converge for countries with low mortality levels. A mere progress in global averages of maternal and child mortality indicators among a global cross-section of countries does not warranty convergence unless there is a considerable reduction in variance, skewness and range of change.

Maternal mortality in Mexico, beyond millennial development objectives: An age-period-cohort model.

PubMed

Rodríguez-Aguilar, Román

2018-01-01

The maternal mortality situation is analyzed in México as an indicator that reflects the social development level of the country and was one of the millennial development objectives. The effect of a maternal death in the related social group has multiplier effects, since it involves family dislocation, economic impact and disruption of the orphans' normal social development. Two perspectives that causes of maternal mortality were analyzed, on one hand, their relationship with social determinants and on the other, factors directly related to the health system. Evidence shows that comparing populations based on group of selected variables according to social conditions and health care access, statistically significant differences prevail according to education and marginalization levels, and access to medical care. In addition, the Age-Period-Cohort model raised, shows significant progress in terms of a downward trend in maternal mortality in a generational level. Those women born before 1980 had a greater probability of maternal death in relation to recent generations, which is a reflection of the improvement in social determinants and in the Health System. The age effect shows a problem in maternal mortality in women under 15 years old, so teen pregnancy is a priority in health and must be addressed in short term. There is no clear evidence of a period effect.

Progress and inequities in maternal mortality in Afghanistan (RAMOS-II): a retrospective observational study.

PubMed

Bartlett, Linda; LeFevre, Amnesty; Zimmerman, Linnea; Saeedzai, Sayed Ataullah; Turkmani, Sabera; Zabih, Weeda; Tappis, Hannah; Becker, Stan; Winch, Peter; Koblinsky, Marge; Rahmanzai, Ahmed Javed

2017-05-01

The risk of maternal death in Afghanistan is among the highest in the world; however, the risks within the country are poorly understood. Subnational maternal mortality estimates are needed along with a broader understanding of determinants to guide future maternal health programmes. Here we aimed to study maternal mortality risk and causes, care-seeking patterns, and costs within the country. We did a household survey (RAMOS-II) in the urban area of Kabul city and the rural area of Ragh, Badakshan. Questionnaires were administered to senior female household members and data were collected by a team of female interviewers with secondary school education. Information was collected about all deaths, livebirths, stillbirths, health-care access and costs, household income, and assets. Births were documented using a pregnancy history. We investigated all deaths in women of reproductive age (12-49 years) since January, 2008, using verbal autopsy. Community members; service providers; and district, provincial, and national officials in each district were interviewed to elicit perceptions of changes in maternal mortality risk and health service provision, along with programme and policy documentation of maternal care coverage. Data were collected between March 2, 2011, and Oct 16, 2011, from 130 688 participants: 63 329 in Kabul and 67 359 in Ragh. The maternal mortality ratio in Ragh was quadruple that in Kabul (713 per 100 000 livebirths, 95% CI 553-873 in Ragh vs 166, 63-270 in Kabul). We recorded similar patterns for all other maternal death indicators, including the maternal mortality rate (1·7 per 1000 women of reproductive age, 95% CI 1·3-2·1 in Ragh vs 0·2, 0·1-0·3 in Kabul). Infant mortality also differed significantly between the two areas (115·5 per 1000 livebirths, 95% CI 108·6-122·3 in Ragh vs 24·8, 20·5-29·0 in Kabul). In Kabul, 5594 (82%) of 6789 women reported a skilled attendant during recent deliveries compared with 381 (3%) of 11�

The influence of the war on perinatal and maternal mortality in Bosnia and Herzegovina.

PubMed

Fatusić, Z; Kurjak, A; Grgić, G; Tulumović, A

2005-10-01

To investigate the influence of the war on perinatal and maternal mortality during the war conflict in Bosnia and Herzegovina. In a retrospective study we analysed perinatal and maternal mortality in the pre-war period (1988-1991), the war period (1992-1995) and the post-war period (1996-2003). We also analysed the number of deliveries, the perinatal and maternal mortality rates and their causes. During the analysed period we had a range of 3337-6912 deliveries per year, with a decreased number in the war period. During the war period and immediately after the war, the perinatal mortality rate increased to 20.9-26.3% (average 24.28%). After the war the rate decreased to 8.01% in 2003 (p < 0.05). Maternal mortality before the war was 39/100,000 deliveries, during the war it increased to 65/100,000 and after the war it decreased to 12/100,000 deliveries (p < 0.05). The increase in maternal mortality during the war was because of an increased number of uterine ruptures, sepsis and bleeding due to shell injury of pregnant women. During the war we could expect a decreased number of deliveries, and an increased rate of perinatal and maternal mortality and preterm deliveries due to: inadequate nutrition, stress factors (life in refugee's centers, bombing, deaths of relatives, uncertain future...), and break down of the perinatal care system (lack of medical staff, impossibility of collecting valid health records, particularly perinatal information, and the destruction of medical buildings).

The Associations between Types of Ambient PM2.5 and Under-Five and Maternal Mortality in Africa.

PubMed

Owili, Patrick Opiyo; Lien, Wei-Hung; Muga, Miriam Adoyo; Lin, Tang-Huang

2017-03-30

Exploring the effects of different types of PM 2.5 is necessary to reduce associated deaths, especially in low- and middle-income countries (LMICs). Hence we determined types of ambient PM 2.5 before exploring their effects on under-five and maternal mortality in Africa. The spectral derivate of aerosol optical depth (AOD) from Moderate Resolution Imaging Spectroradiometer (MODIS) products from 2000 to 2015 were employed to determine the aerosol types before using Generalized Linear and Additive Mixed-Effect models with Poisson link function to explore the associations and penalized spline for dose-response relationships. Four types of PM 2.5 were identified in terms of mineral dust, anthropogenic pollutant, biomass burning and mixture aerosols. The results demonstrate that biomass PM 2.5 increased the rate of under-five mortality in Western and Central Africa, each by 2%, and maternal mortality in Central Africa by 19%. Anthropogenic PM 2.5 increased under-five and maternal deaths in Northern Africa by 5% and 10%, respectively, and maternal deaths by 4% in Eastern Africa. Dust PM 2.5 increased under-five deaths in Northern, Western, and Central Africa by 3%, 1%, and 10%, respectively. Mixture PM 2.5 only increased under-five deaths and maternal deaths in Western (incidence rate ratio = 1.01, p < 0.10) and Eastern Africa (incidence rate ratio = 1.06, p < 0.01), respectively. The findings indicate the types of ambient PM 2.5 are significantly associated with under-five and maternal mortality in Africa where the exposure level usually exceeds the World Health Organization's (WHO) standards. Appropriate policy actions on protective and control measures are therefore suggested and should be developed and implemented accordingly.

Financial incentives to influence maternal mortality in a low-income setting: making available 'money to transport' - experiences from Amarpatan, India.

PubMed

De Costa, Ayesha; Patil, Rajkumar; Kushwah, Surgiv Singh; Diwan, Vinod Kumar

2009-03-18

Only 40.7% women in India deliver in an institution; leaving many vulnerable to maternal morbidity and mortality (India has 22% of global maternal deaths). While limited accessibility to functioning institutions may account in part, a common reason why women deliver at home is poverty. A lack of readily available financial resources for families to draw upon at the time of labor to transport the mother to an institution, is often observed. This paper reports a yearlong collaborative intervention (between the University and Department of Health) to study if providing readily available and easily accessible funds for emergency transportation would reduce maternal deaths in a rural, low income, and high maternal mortality setting in central India. It aimed to obviate a deterrent to emergency obstetric care; the non-availability of resources with mothers when most needed. Issues in implementation are also discussed. Maternal deaths were actively identified in block Amarpatan (0.2 million population) over a 2-year period. The project, with participation from local government and other groups, trained 482 local health care providers (public and private) to provide antenatal care. Emergency transport money (in cash) was placed with one provider in each village. Maternal mortality in the adjacent block (Maihar) was followed (as a 'control' block). Maternal deaths in Amarpatan decreased during the project year relative to the previous year, or in the control block the same year. Issues in implementation of the cash incentive scheme are discussed. Although the intervention reduced maternal deaths in this low-income setting, chronic poverty and malnutrition are underlying structural problems that need to be addressed.

Reflections on the maternal mortality millennium goal.

PubMed

Lawson, Gerald W; Keirse, Marc J N C

2013-06-01

Nearly every 2 minutes, somewhere in the world, a woman dies because of complications of pregnancy and childbirth. Every such death is an overwhelming catastrophe for everyone confronted with it. Most deaths occur in developing countries, especially in Africa and southern Asia, but a significant number also occur in the developed world. We examined the available data on the progress and the challenges to the United Nations' fifth Millennium Development Goal of achieving a 75 percent worldwide reduction in the maternal mortality by 2015 from what it was in 1990. Some countries, such as Belarus, Egypt, Estonia, Honduras, Iran, Lithuania, Malaysia, Romania, Sri Lanka and Thailand, are likely to meet the target by 2015. Many poor countries with weak health infrastructures and high fertility rates are unlikely to meet the goal. Some, such as Botswana, Cameroon, Chad, Congo, Guyana, Lesotho, Namibia, Somalia, South Africa, Swaziland and Zimbabwe, had worse maternal mortality ratios in 2010 than in 1990, partially because of wars and civil strife. Worldwide, the leading causes of maternal death are still hemorrhage, hypertension, sepsis, obstructed labor, and unsafe abortions, while indirect causes are gaining in importance in developed countries. Maternal death is especially distressing if it was potentially preventable. However, as there is no single cause, there is no silver bullet to correct the problem. Many countries also face new challenges as their childbearing population is growing in age and in weight. Much remains to be done to make safe motherhood a reality. © 2013, Copyright the Authors, Journal compilation © 2013, Wiley Periodicals, Inc.

Fetal, Infant, and Maternal Mortality During Periods of Economic Instability

ERIC Educational Resources Information Center

Brenner, M. H.

1973-01-01

One of the most sensitive indicators of the general socioeconomic level of a nation is the infant mortality rate. Evidence indicates that economic recessions and upswings have played a significant role in fetal, infant, and maternal mortality in the last 45 years. (RJ)

Acknowledging HIV and malaria as major causes of maternal mortality in Mozambique

PubMed Central

Singh, Kavita; Moran, Allisyn; Story, William; Bailey, Patricia; Chavane, Leonardo

2014-01-01

Objective To review national data on HIV and malaria as causes of maternal death and to determine the importance of looking at maternal mortality at a subnational level in Mozambique. Methods Three national data surveys were used to document HIV and malaria as causes of maternal mortality and to assess HIV and malaria prevention services for pregnant women. Data were collected between 2007 and 2011, and included population-level verbal autopsy data and household survey data. Results Verbal autopsy data indicated that 18.2% of maternal deaths were due to HIV and 23.1% were due to malaria. Only 19.6% of recently pregnant women received at least two doses of sulfadoxine-pyrimethamine for intermittent preventive treatment, and only 42.3% of pregnant women were sleeping under an insecticide-treated net. Only 37.5% of recently pregnant women had been counseled, tested, and received an HIV test result. Coverage of prevention services varied substantially by province. Conclusion Triangulation of information on cause of death and coverage of interventions can enable appropriate targeting of maternal health interventions. Such information could also help countries in Sub-Saharan Africa to recognize and take action against malaria and HIV in an effort to decrease maternal mortality. PMID:24981974

[Maternal mortality in Spain, 1980-1992. Relationship with birth distributions according to the mother's age].

PubMed

Valero Juan, L F; Sáenz González, M C

1997-11-01

The maternal mortality evolution in Spain during the 1980-1992 period is reported. The influence of birth distribution according to maternal age is analyzed. The information was gathered from vital statistics published by Instituto Nacional de Estadística. The mortality rates have stabilized since 1985 (4.8 per 10(5) for 1992) associated with the increase in the proportion of births in women aged > or = 30 years (40.6% for 1992). Birth distributions according to maternal age account for 13.1% of the deaths observed. The predictions point to an increase in maternal mortality for the year 2000.

Optimal breastfeeding durations for HIV-exposed infants: the impact of maternal ART use, infant mortality and replacement feeding risk.

PubMed

Mallampati, Divya; MacLean, Rachel L; Shapiro, Roger; Dabis, Francois; Engelsmann, Barbara; Freedberg, Kenneth A; Leroy, Valeriane; Lockman, Shahin; Walensky, Rochelle; Rollins, Nigel; Ciaranello, Andrea

2018-04-01

In 2010, the WHO recommended women living with HIV breastfeed for 12 months while taking antiretroviral therapy (ART) to balance breastfeeding benefits against HIV transmission risks. To inform the 2016 WHO guidelines, we updated prior research on the impact of breastfeeding duration on HIV-free infant survival (HFS) by incorporating maternal ART duration, infant/child mortality and mother-to-child transmission data. Using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Infant model, we simulated the impact of breastfeeding duration on 24-month HFS among HIV-exposed, uninfected infants. We defined "optimal" breastfeeding durations as those maximizing 24-month HFS. We varied maternal ART duration, mortality rates among breastfed infants/children, and relative risk of mortality associated with replacement feeding ("RRRF"), modelled as a multiplier on all-cause mortality for replacement-fed infants/children (range: 1 [no additional risk] to 6). The base-case simulated RRRF = 3, median infant mortality, and 24-month maternal ART duration. In the base-case, HFS ranged from 83.1% (no breastfeeding) to 90.2% (12-months breastfeeding). Optimal breastfeeding durations increased with higher RRRF values and longer maternal ART durations, but did not change substantially with variation in infant mortality rates. Optimal breastfeeding durations often exceeded the previous WHO recommendation of 12 months. In settings with high RRRF and long maternal ART durations, HFS is maximized when mothers breastfeed longer than the previously-recommended 12 months. In settings with low RRRF or short maternal ART durations, shorter breastfeeding durations optimize HFS. If mothers are supported to use ART for longer periods of time, it is possible to reduce transmission risks and gain the benefits of longer breastfeeding durations. © 2018 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.

Maternal mortality in Mexico, beyond millennial development objectives: An age-period-cohort model

PubMed Central

2018-01-01

The maternal mortality situation is analyzed in México as an indicator that reflects the social development level of the country and was one of the millennial development objectives. The effect of a maternal death in the related social group has multiplier effects, since it involves family dislocation, economic impact and disruption of the orphans' normal social development. Two perspectives that causes of maternal mortality were analyzed, on one hand, their relationship with social determinants and on the other, factors directly related to the health system. Evidence shows that comparing populations based on group of selected variables according to social conditions and health care access, statistically significant differences prevail according to education and marginalization levels, and access to medical care. In addition, the Age-Period-Cohort model raised, shows significant progress in terms of a downward trend in maternal mortality in a generational level. Those women born before 1980 had a greater probability of maternal death in relation to recent generations, which is a reflection of the improvement in social determinants and in the Health System. The age effect shows a problem in maternal mortality in women under 15 years old, so teen pregnancy is a priority in health and must be addressed in short term. There is no clear evidence of a period effect. PMID:29561878

Maternal education, birth weight, and infant mortality in the United States.

PubMed

Gage, Timothy B; Fang, Fu; O'Neill, Erin; Dirienzo, Greg

2013-04-01

This research determines whether the observed decline in infant mortality with socioeconomic level, operationalized as maternal education (dichotomized as college or more, versus high school or less), is due to its "indirect" effect (operating through birth weight) and/or to its "direct" effect (independent of birth weight). The data used are the 2001 U.S. national African American, Mexican American, and European American birth cohorts by sex. The analysis explores the birth outcomes of infants undergoing normal and compromised fetal development separately by using covariate density defined mixture of logistic regressions (CDDmlr). Among normal births, mean birth weight increases significantly (by 27-108 g) with higher maternal education. Mortality declines significantly (by a factor of 0.40-0.96) through the direct effect of education. The indirect effect of education among normal births is small but significant in three cohorts. Furthermore, the indirect effect of maternal education tends to increase mortality despite improved birth weight. Among compromised births, education has small and inconsistent effects on birth weight and infant mortality. Overall, our results are consistent with the view that the decrease in infant death by socioeconomic level is not mediated by improved birth weight. Interventions targeting birth weight may not result in lower infant mortality.

[Analysis of maternal morbidity and mortality in Slovak Republic in the years 2007-2012].

PubMed

Korbeľ, M; Krištúfková, A; Dugátová, M; Daniš, J; Némethová, B; Kaščák, P; Nižňanská, Z

Analysis of maternal morbidity and mortality in Slovak Republic (SR) in the years 2007-2012. Epidemiological perinatological nation-wide. 1st Department of Gynaecology and Obstetrics School of Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic. The analysis of selected maternal morbidity and mortality data prospective collected in the years 2007-2012 from all obstetrics hospitals in the Slovak Republic. Caesarean section rate progressively increased from 24.1% in the year 2007 up to 30.3% in the year 2012. In the year 2012 the frequency of vacuum-extraction was 1.4%, forceps 0.6%, perineal tears 3th and 4th degree 0.49% and episiotomy 65%. Incidence of total severe acute maternal morbidity was 6.34 per 1,000 births. Incidence (per 1,000 births) of transport to anaesthesiology department/intensive care unit was 2.32, postpartum hysterectomy 0.72, HELLP syndrome 0.63, eclampsia 0.29, abnormal placental invasion 0.37, uterine rupture 0.27, severe sepsis in pregnancy and puerperium 0.21. In the years 2007-2012 frequency of fatal amniotic fluid embolism was 2.46/100,000 maternities or 2.43/100,000 live-births. Maternal mortality ratio in this period was 14 per 100,000 live births and pregnancy-related deaths ratio was 11.9 per 100,000 live births. In the year 2012 Slovakia reached the highest caesarean section rate in her own history - 30.3%. Incidence of severe acute maternal morbidity was 6.34 per 1,000 births. Maternal mortality ratio in Slovakia was one of the highest in European Union. Decreasing of caesarean section rate and episiotomy, incidence of severe acute maternal morbidity and maternal mortality still need to be improved in Slovak Republic.

Maternal mortality in Syria: causes, contributing factors and preventability.

PubMed

Bashour, Hyam; Abdulsalam, Asmaa; Jabr, Aisha; Cheikha, Salah; Tabbaa, Mohammed; Lahham, Moataz; Dihman, Reem; Khadra, Mazen; Campbell, Oona M R

2009-09-01

To describe the biomedical and other causes of maternal death in Syria and to assess their preventability. A reproductive age mortality study (RAMOS) design was used to identify pregnancy related deaths. All deaths among women aged 15-49 reported to the national civil register for 2003 were investigated through home interviews. Verbal autopsies were used to ascertain the cause of death among pregnancy related maternal deaths, and causes and preventability of deaths were assessed by a panel of doctors. A total of 129 maternal deaths were identified and reviewed. Direct medical causes accounted for 88%, and haemorrhage was the main cause of death (65%). Sixty nine deaths (54%) occurred during labour or delivery. Poor clinical skills and lack of clinical competency were behind 54% of maternal deaths. Ninety one percent of maternal deaths were preventable. The causes of maternal death in Syria and their contributing factors reflect serious defects in the quality of maternal care that need to be urgently rectified.

Reducing rural maternal mortality and the equity gap in northern Nigeria: the public health evidence for the Community Communication Emergency Referral strategy.

PubMed

Aradeon, Susan B; Doctor, Henry V

2016-01-01

The Sustainable Development Goal (SDG) maternal mortality target risks being underachieved like its Millennium Development Goal (MDG) predecessor. The MDG skilled birth attendant (SBA) strategy proved inadequate to end preventable maternal deaths for the millions of rural women living in resource-constrained settings. This equity gap has been successfully addressed by integrating a community-based emergency obstetric care strategy into the intrapartum care SBA delivery strategy in a large scale, northern Nigerian health systems strengthening project. The Community Communication Emergency Referral (CCER) strategy catalyzes community capacity for timely evacuations to emergency obstetric care facilities instead of promoting SBA deliveries in environments where SBA availability and accessibility will remain inadequate for the near and medium term. Community Communication is an innovative, efficient, equitable, and culturally appropriate community mobilization approach that empowers low- and nonliterate community members to become the communicators. For the CCER strategy, this community mobilization approach was used to establish and maintain emergency maternal care support structures. Public health evidence demonstrates the success of integrating the CCER strategy into the SBA strategy and the practicability of this combined strategy at scale. In intervention sites, the maternal mortality ratio reduced by 16.8% from extremely high levels within 4 years. Significantly, the CCER strategy contributed to saving one-third of the lives saved in the project sites, thereby maximizing the effectiveness of the SBAs and upgraded emergency obstetric care facilities. Pre- and postimplementation Knowledge, Attitude, and Practice Survey results and qualitative assessments support the CCER theory of change. This theory of change rests on a set of implementation steps that rely on three innovative components: Community Communication, Rapid Imitation Practice, and CCER support

Reducing rural maternal mortality and the equity gap in northern Nigeria: the public health evidence for the Community Communication Emergency Referral strategy

PubMed Central

Aradeon, Susan B; Doctor, Henry V

2016-01-01

The Sustainable Development Goal (SDG) maternal mortality target risks being underachieved like its Millennium Development Goal (MDG) predecessor. The MDG skilled birth attendant (SBA) strategy proved inadequate to end preventable maternal deaths for the millions of rural women living in resource-constrained settings. This equity gap has been successfully addressed by integrating a community-based emergency obstetric care strategy into the intrapartum care SBA delivery strategy in a large scale, northern Nigerian health systems strengthening project. The Community Communication Emergency Referral (CCER) strategy catalyzes community capacity for timely evacuations to emergency obstetric care facilities instead of promoting SBA deliveries in environments where SBA availability and accessibility will remain inadequate for the near and medium term. Community Communication is an innovative, efficient, equitable, and culturally appropriate community mobilization approach that empowers low- and nonliterate community members to become the communicators. For the CCER strategy, this community mobilization approach was used to establish and maintain emergency maternal care support structures. Public health evidence demonstrates the success of integrating the CCER strategy into the SBA strategy and the practicability of this combined strategy at scale. In intervention sites, the maternal mortality ratio reduced by 16.8% from extremely high levels within 4 years. Significantly, the CCER strategy contributed to saving one-third of the lives saved in the project sites, thereby maximizing the effectiveness of the SBAs and upgraded emergency obstetric care facilities. Pre- and postimplementation Knowledge, Attitude, and Practice Survey results and qualitative assessments support the CCER theory of change. This theory of change rests on a set of implementation steps that rely on three innovative components: Community Communication, Rapid Imitation Practice, and CCER support

Personal accounts of 'near-miss' maternal mortalities in Kampala, Uganda.

PubMed

Weeks, Andrew; Lavender, Tina; Nazziwa, Enid; Mirembe, Florence

2005-09-01

To explore the socio-economic determinants of maternal mortality in Uganda through interviews with women who had 'near-misses'. Observational study using qualitative research methods. The postnatal and gynaecology wards of a large government hospital in Kampala, Uganda. Thirty women who had narrowly avoided maternal deaths with diagnoses of obstructed labour (7), severe pre-eclampsia/eclampsia (3), post caesarean infection (6), haemorrhage (5), ectopic pregnancy (5) and septic abortion (4). The semi-structured interviews were conducted in the local language by a woman unconnected to the hospital, and were recorded before being translated and transcribed. Analysis was conducted in duplicate using commercial software. The predominant theme was powerlessness, which occurred both within and outside the hospital. It was evident in the women's attempts to get both practical and financial help from those around them as well as in their failure to gain rapid access to care. Financial barriers and problems with transport primarily governed health-seeking behaviour. Medical mistakes and delays in referral were evident in many interviews, especially in rural health centres. Women were appreciative of the care they received from the central government hospital, although there were reports of overcrowding, long delays, shortages and inhumane care. There were no reports of bribery. Women with near-miss maternal mortalities experience institutional and social powerlessness: these factors may be a major contributor to maternal mortality.

The Associations between Types of Ambient PM2.5 and Under-Five and Maternal Mortality in Africa

PubMed Central

Owili, Patrick Opiyo; Lien, Wei-Hung; Muga, Miriam Adoyo; Lin, Tang-Huang

2017-01-01

Exploring the effects of different types of PM2.5 is necessary to reduce associated deaths, especially in low- and middle-income countries (LMICs). Hence we determined types of ambient PM2.5 before exploring their effects on under-five and maternal mortality in Africa. The spectral derivate of aerosol optical depth (AOD) from Moderate Resolution Imaging Spectroradiometer (MODIS) products from 2000 to 2015 were employed to determine the aerosol types before using Generalized Linear and Additive Mixed-Effect models with Poisson link function to explore the associations and penalized spline for dose-response relationships. Four types of PM2.5 were identified in terms of mineral dust, anthropogenic pollutant, biomass burning and mixture aerosols. The results demonstrate that biomass PM2.5 increased the rate of under-five mortality in Western and Central Africa, each by 2%, and maternal mortality in Central Africa by 19%. Anthropogenic PM2.5 increased under-five and maternal deaths in Northern Africa by 5% and 10%, respectively, and maternal deaths by 4% in Eastern Africa. Dust PM2.5 increased under-five deaths in Northern, Western, and Central Africa by 3%, 1%, and 10%, respectively. Mixture PM2.5 only increased under-five deaths and maternal deaths in Western (incidence rate ratio = 1.01, p < 0.10) and Eastern Africa (incidence rate ratio = 1.06, p < 0.01), respectively. The findings indicate the types of ambient PM2.5 are significantly associated with under-five and maternal mortality in Africa where the exposure level usually exceeds the World Health Organization’s (WHO) standards. Appropriate policy actions on protective and control measures are therefore suggested and should be developed and implemented accordingly. PMID:28358348

Action plan to reduce perinatal mortality.

PubMed

Bhakoo, O N; Kumar, R

1990-01-01

The government of India has set a goal of reducing perinatal mortality from its current rate of 48/1000 to 30-35/1000 by the year 2000. Perinatal deaths result from maternal malnutrition, inadequate prenatal care, complications of delivery, and infections in the postpartum period. Since reductions in perinatal mortality require attention to social, economic, and behavioral factors, as well as improvements in the health care delivery system, a comprehensive strategy is required. Social measures, such as raising the age at marriage to 18 years for females, improving the nutritional status of adolescent girls, reducing the strenuousness of work during pregnancy, improving female literacy, raising women's status in the society and thus in the family, and poverty alleviation programs, would all help eliminate the extent of complications of pregnancy. Measures required to enhance infant survival include improved prenatal care, prenatal tetanus toxoid immunization, use of sterile disposable cord care kits, the provision of mucus extractors and resuscitation materials to birth attendants, the creation of neonatal care units in health facilities, and more efficient referral of high-risk newborns and mothers. Since 90% of births in rural India take place at home priority must be given to training traditional birth attendants in the identification of high risk factors during pregnancy, delivery, and the newborn period.

Linking high parity and maternal and child mortality: what is the impact of lower health services coverage among higher order births?

PubMed

Sonneveldt, Emily; DeCormier Plosky, Willyanne; Stover, John

2013-01-01

A number of data sets show that high parity births are associated with higher child mortality than low parity births. The reasons for this relationship are not clear. In this paper we investigate whether high parity is associated with lower coverage of key health interventions that might lead to increased mortality. We used DHS data from 10 high fertility countries to examine the relationship between parity and coverage for 8 child health intervention and 9 maternal health interventions. We also used the LiST model to estimate the effect on maternal and child mortality of the lower coverage associated with high parity births. Our results show a significant relationship between coverage of maternal and child health services and birth order, even when controlling for poverty. The association between coverage and parity for maternal health interventions was more consistently significant across countries all countries, while for child health interventions there were fewer overall significant relationships and more variation both between and within countries. The differences in coverage between children of parity 3 and those of parity 6 are large enough to account for a 12% difference in the under-five mortality rate and a 22% difference in maternal mortality ratio in the countries studied. This study shows that coverage of key health interventions is lower for high parity children and the pattern is consistent across countries. This could be a partial explanation for the higher mortality rates associated with high parity. Actions to address this gap could help reduce the higher mortality experienced by high parity birth.

One in Five Maternal Deaths in Bangladesh Associated with Acute Jaundice: Results from a National Maternal Mortality Survey

PubMed Central

Shah, Rupal; Nahar, Quamrun; Gurley, Emily S.

2016-01-01

We estimated the proportion of maternal deaths in Bangladesh associated with acute onset of jaundice. We used verbal autopsy data from a nationally representative maternal mortality survey to calculate the proportion of maternal deaths associated with jaundice and compared it to previously published estimates. Of all maternal deaths between 2008 and 2010, 23% were associated with jaundice, compared with 19% from 1998 to 2001. Approximately one of five maternal deaths was preceded by jaundice, unchanged in 10 years. Our findings highlight the need to better understand the etiology of these maternal deaths in Bangladesh. PMID:26755563

One in Five Maternal Deaths in Bangladesh Associated with Acute Jaundice: Results from a National Maternal Mortality Survey.

PubMed

Shah, Rupal; Nahar, Quamrun; Gurley, Emily S

2016-03-01

We estimated the proportion of maternal deaths in Bangladesh associated with acute onset of jaundice. We used verbal autopsy data from a nationally representative maternal mortality survey to calculate the proportion of maternal deaths associated with jaundice and compared it to previously published estimates. Of all maternal deaths between 2008 and 2010, 23% were associated with jaundice, compared with 19% from 1998 to 2001. Approximately one of five maternal deaths was preceded by jaundice, unchanged in 10 years. Our findings highlight the need to better understand the etiology of these maternal deaths in Bangladesh. © The American Society of Tropical Medicine and Hygiene.

The Effects of Maternal Mortality on Infant and Child Survival in Rural Tanzania: A Cohort Study.

PubMed

Finlay, Jocelyn E; Moucheraud, Corrina; Goshev, Simo; Levira, Francis; Mrema, Sigilbert; Canning, David; Masanja, Honorati; Yamin, Alicia Ely

2015-11-01

The full impact of a maternal death includes consequences faced by orphaned children. This analysis adds evidence to a literature on the magnitude of the association between a woman's death during or shortly after childbirth, and survival outcomes for her children. The Ifakara and Rufiji Health and Demographic Surveillance Sites in rural Tanzania conduct longitudinal, frequent data collection of key demographic events at the household level. Using a subset of the data from these sites (1996-2012), this survival analysis compared outcomes for children who experienced a maternal death (42 and 365 days definitions) during or near birth to those children whose mothers survived. There were 111 maternal deaths (or 229 late maternal deaths) during the study period, and 46.28 % of the index children also subsequently died (40.73 % of children in the late maternal death group) before their tenth birthday-a much higher prevalence of child mortality than in the population of children whose mothers survived (7.88 %, p value <0.001). Children orphaned by early maternal deaths had a 51.54 % chance of surviving to their first birthday, compared to a 94.42 % probability for children of surviving mothers. A significant, but lesser, child survival effect was also found for paternal deaths in this study period. The death of a mother compromises the survival of index children. Reducing maternal mortality through improved health care-especially provision of high-quality skilled birth attendance, emergency obstetric services and neonatal care-will also help save children's lives.

Maternal stress and infant mortality: The importance of the preconception period

PubMed Central

Class, Quetzal A.; Khashan, Ali S.; Lichtenstein, Paul; Långström, Niklas; D’Onofrio, Brian M.

2013-01-01

Although preconception and prenatal maternal stress are associated with adverse birth and childhood outcomes, the relation to infant mortality remains uncertain. We used logistic regression to study infant mortality risk following maternal stress within a population-based sample of offspring born in Sweden from 1973 to 2008 (N= 3,055,361). Preconception (6-0 months before conception) and prenatal (conception to birth) stress was defined as death of a first-degree relative of the mother. A total of 20,651 offspring were exposed to preconception stress, 26,731 to prenatal stress, and 8,398 cases of infant mortality were identified. Preconception stress increased the risk of infant mortality independent of measured covariates (adjusted OR=1.53; 95% CI=1.25–1.88) and the association was timing-specific and robust across low-risk groups. Prenatal stress did not increase risk of infant mortality (adjusted OR=1.05; 95% CI=0.84–1.30). The period immediately before conception may be a sensitive developmental period influencing risk for infant mortality. PMID:23653129

Inequality in Maternal Mortality in Iran: An Ecologic Study

PubMed Central

Tajik, Parvin; Nedjat, Saharnaz; Afshar, Nozhat Emami; Changizi, Nasrin; Yazdizadeh, Bahareh; Azemikhah, Arash; Aamrolalaei, Sima; Majdzadeh, Reza

2012-01-01

Background: Maternal mortality (MM) is an avoidable death and there is national, international and political commitment to reduce it. The objective of this study is to examine the relation of MM to socioeconomic factors and its inequality in Iran's provinces at an ecologic level. Methods: The overall MM from each province was considered for 3 years from 2004 to 2006. The five independent variables whose relations were studied included the literacy rate among men and women in each province, mean annual household income per capita, Gini coefficients in each province, and Human Development Index (HDI). The correlation of Maternal Mortality Ratio (MMR) to the above five variables was evaluated through Pearson's correlation coefficient (simple and weighted for each province's population) and linear regression – by considering MMR as the dependent variable and the Gini coefficient, HDI, and difference in literacy rate among men and women as the independent variables. Results: The mean MMR in the years 2004–2006 was 24.7 in 100,000 live births. The correlation coefficients between MMR and literacy rate among women, literacy rate among men, the mean annual household income per capita, Gini coefficient and HDI were 0.82, 0.90, –0.61, 0.52 and –0.77, respectively. Based on multivariate regression, MMR was significantly associated with HDI (standardized B=–0.93) and difference in literacy rate among men and women (standardized B=–0.47). However, MMR was not significantly associated with the Gini coefficient. Conclusion: This study shows the association between socioeconomic variables and their inequalities with MMR in Iran's provinces at an ecologic level. In addition to the other direct interventions performed to reduce MM, it seems essential to especially focus on more distal factors influencing MMR. PMID:22347608

“Without a mother”: caregivers and community members’ views about the impacts of maternal mortality on families in KwaZulu-Natal, South Africa

PubMed Central

2015-01-01

Background Maternal mortality in South Africa is high and a cause for concern especially because the bulk of deaths from maternal causes are preventable. One of the proposed reasons for persistently high maternal mortality is HIV which causes death both indirectly and directly. While there is some evidence for the impact of maternal death on children and families in South Africa, few studies have explored the impacts of maternal mortality on the well-being of the surviving infants, older children and family. This study provides qualitative insight into the consequences of maternal mortality for child and family well-being throughout the life-course. Methods This qualitative study was conducted in rural and peri-urban communities in Vulindlela, KwaZulu-Natal. The sample included 22 families directly affected by maternal mortality, 15 community stakeholders and 7 community focus group discussions. These provided unique and diverse perspectives about the causes, experiences and impacts of maternal mortality. Results and discussion Children left behind were primarily cared for by female family members, even where a father was alive and involved. The financial burden for care and children’s basic needs were largely met through government grants (direct and indirectly targeted at children) and/or through an obligation for the father or his family to assist. The repercussions of losing a mother were felt more by older children for whom it was harder for caregivers to provide educational supervision and emotional or psychological support. Respondents expressed concerns about adolescent’s educational attainment, general behaviour and particularly girl’s sexual risk. Conclusion These results illuminate the high costs to surviving children and their families of failing to reduce maternal mortality in South Africa. Ensuring social protection and community support is important for remaining children and families. Additional qualitative evidence is needed to explore

An examination of the maternal social determinants influencing under-5 mortality in Nigeria: Evidence from the 2013 Nigeria Demographic Health Survey.

PubMed

Blackstone, Sarah R; Nwaozuru, Ucheoma; Iwelunmor, Juliet

2017-06-01

Nigeria is the second largest contributor to child (under-5) mortality in the world, with an average of 128 child deaths per 1000 live births, and is not on track to meet the Millennium Development Goals of reducing childhood mortality rates to 64 per 1000. Data from the 2013 Nigeria Demographic and Health Survey (NDHS) report were analysed to explore the relationship between structural and intermediary maternal characteristics and likelihood of childhood mortality. Binary logistic regressions for the first three reported births were conducted with childhood mortality (e.g. death before 59 months of age) as a dependent variable. Maternal characteristics investigated included age, education, region, antenatal care, and breastfeeding. Significant factors for birth 1 included region of residence, breastfeeding, literacy, wealth, number of children, and antenatal care. For second birth, not breastfeeding and attending antenatal care with a nurse were negatively associated with survival. For third birth, wealth and number of children were positively associated with survival. The results point to some maternal characteristics that may be influential in childhood mortality. However, community and systems level factors should be accounted for in interventions, as maternal characteristics do not offer a full explanation for why children are dying so young in Nigeria.

Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

PubMed Central

2017-01-01

Summary Background In transitioning from the Millennium Development Goal to the Sustainable Development Goal era, it is imperative to comprehensively assess progress toward reducing maternal mortality to identify areas of success, remaining challenges, and frame policy discussions. We aimed to quantify maternal mortality throughout the world by underlying cause and age from 1990 to 2015. Methods We estimated maternal mortality at the global, regional, and national levels from 1990 to 2015 for ages 10–54 years by systematically compiling and processing all available data sources from 186 of 195 countries and territories, 11 of which were analysed at the subnational level. We quantified eight underlying causes of maternal death and four timing categories, improving estimation methods since GBD 2013 for adult all-cause mortality, HIV-related maternal mortality, and late maternal death. Secondary analyses then allowed systematic examination of drivers of trends, including the relation between maternal mortality and coverage of specific reproductive health-care services as well as assessment of observed versus expected maternal mortality as a function of Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Findings Only ten countries achieved MDG 5, but 122 of 195 countries have already met SDG 3.1. Geographical disparities widened between 1990 and 2015 and, in 2015, 24 countries still had a maternal mortality ratio greater than 400. The proportion of all maternal deaths occurring in the bottom two SDI quintiles, where haemorrhage is the dominant cause of maternal death, increased from roughly 68% in 1990 to more than 80% in 2015. The middle SDI quintile improved the most from 1990 to 2015, but also has the most complicated causal profile. Maternal mortality in the highest SDI quintile is mostly due to other direct maternal disorders, indirect maternal disorders, and abortion, ectopic

Maternal health care initiatives: Causes of morbidities and mortalities in two rural districts of Upper West Region, Ghana.

PubMed

Sumankuuro, Joshua; Crockett, Judith; Wang, Shaoyu

2017-01-01

Maternal and neonatal morbidities and mortalities have received much attention over the years in sub-Saharan Africa; yet addressing them remains a profound challenge, no more so than in the nation of Ghana. This study focuses on finding explanations to the conditions which lead to maternal and neonatal morbidities and mortalities in rural Ghana, particularly the Upper West Region. Mixed methods approach was adopted to investigate the medical and non-medical causes of maternal and neonatal morbidities and mortalities in two rural districts of the Upper West Region of Ghana. Survey questionnaires, in-depth interviews and focus group discussions were employed to collect data from: a) 80 expectant mothers (who were in their second and third trimesters, excluding those in their ninth month), b) 240 community residents and c) 13 healthcare providers (2 district directors of health services, 8 heads of health facilities and 3 nurses). Morbidity and mortality during pregnancy is attributed to direct causes such urinary tract infection (48%), hypertensive disorders (4%), mental health conditions (7%), nausea (4%) and indirect related sicknesses such as anaemia (11%), malaria, HIV/AIDS, oedema and hepatitis B (26%). Socioeconomic and cultural factors are identified as significant underlying causes of these complications and to morbidity and mortality during labour and the postnatal period. Birth asphyxia and traditional beliefs and practices were major causes of neonatal deaths. These findings provide focused targets and open a window of opportunity for the community-based health services run by Ghana Health Service to intensify health education and promotion programmes directed at reducing risky economic activities and other cultural beliefs and practices affecting maternal and neonatal morbidity and mortality.

Changing epidemiology of maternal mortality in rural India: time to reset strategies for MDG-5.

PubMed

Shah, Pankaj; Shah, Shobha; Kutty, Raman V; Modi, Dhiren

2014-05-01

To understand changes in epidemiology of maternal mortality in rural India in the context of increasing institutional deliveries and implementation of community-based interventions that can inform policies to reach MDG-5. This study is a secondary analysis of prospectively collected community-based data of every pregnancy and its outcomes from 2002 to 2011 in a rural, tribal area of Gujarat, India as part of safe-motherhood programme implemented by voluntary organisation, SEWA Rural. The programme consisted of community-based interventions supported by a first referral unit, and promotion of institutional deliveries. For every maternal death, a verbal autopsy was conducted. The incidence rates for maternal mortality according to place, cause and timing of maternal deaths in relation to pregnancy were computed. Annual incidence rate ratios (IRR) and 95% confidence intervals, adjusted for caste and maternal education, were estimated using Poisson regression to test for linear trend in reduction in mortality during the study period. Thirty-two thousand eight hundred and ninety-three pregnancies, 29,817 live births and 80 maternal deaths were recorded. Maternal mortality ratio improved from 607 (19 deaths) in 2002-2003 to 161 (five deaths) in 2010-2011. The institutional delivery rate increased from 23% to 65%. The trend of falling maternal deaths was significant over time, with an annual reduction of 17% (adjusted IRR 0.83 CI 0.75-0.91, P-value <0.001). There were significant reductions in adjusted incidence rate of maternal deaths due to direct causes, during intrapartum and post-partum periods, and those which occurred at home. However, reductions in incidence of maternal deaths due to indirect causes, at hospital and during antepartum period were not statistically significant. Most maternal deaths are now occurring at hospitals and due to indirect causes. Gains in institutional deliveries and community-based interventions resulting in fewer maternal deaths due to

Maternal education and child mortality in Zimbabwe.

PubMed

Grépin, Karen A; Bharadwaj, Prashant

2015-12-01

In 1980, Zimbabwe rapidly expanded access to secondary schools, providing a natural experiment to estimate the impact of increased maternal secondary education on child mortality. Exploiting age specific exposure to these reforms, we find that children born to mothers most likely to have benefited from the policies were about 21% less likely to die than children born to slightly older mothers. We also find that increased education leads to delayed age at marriage, sexual debut, and first birth and that increased education leads to better economic opportunities for women. We find little evidence supporting other channels through which increased education might affect child mortality. Expanding access to secondary schools may greatly accelerate declines in child mortality in the developing world today. Copyright © 2015 Elsevier B.V. All rights reserved.

Kinship, maternal effects, and management: Juvenile mortality and survival in captive African painted dogs, Lycaon pictus.

PubMed

Yordy, Jennifer; Mossotti, Regina H

2016-09-01

In 77 African painted dog (Lycaon pictus) litters born in North American zoos since 1998, pup mortality at 30 days was 53% (n = 478). More alarmingly, 52% of those 77 litters had zero pups surviving at 30 days. Many variables may have the potential to affect pup mortality in captivity, including kinship, maternal age, prior maternal breeding experience, and numerous social and husbandry factors. Data on these variables were obtained from the North American Regional Studbook, with supplemental information compiled from a survey sent to painted dog breeding facilities in North America. Survival curve analysis revealed significant effects for maternal age and kinship, with kinship being most significant (χ 2 , df = 19.71, 1; P < 0.0001). Pups born to unrelated parents had a median age at death two orders of magnitude higher than pups born to parents who were related to each other. Pup mortality was also lower for experienced mothers and for females under 2.5 years or between 4.5 and 6.5 years old. Follow-up analyses of these findings indicated that among first-time mothers, the youngest females achieved the lowest juvenile mortality, while juvenile mortality for experienced mothers was relatively low in all age classes until 6.5 years old. Regression analysis indicated that chances of survival are improved for pups born to younger mothers, unrelated parents, and in packs of >2 individuals. Enclosure size and area per animal may also be important factors. Our findings indicate that specific characteristics can be used to predict and potentially reduce pup mortality in captive African painted dogs. Zoo Biol. 35:367-377, 2016. © Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Infant mortality in India: use of maternal and child health services in relation to literacy status.

PubMed

Gokhale, Medha K; Rao, Shobha S; Garole, Varsha R

2002-06-01

Slow reduction in infant mortality rate in the last couple of decades is a major concern in India. State-level aggregate data from the National Family Health Survey 1992 and micro-level data on rural mothers (n=317) were used for examining the influence of female literacy on reduction of infant mortality through increased use of maternal and child health (MCH) services. Illiteracy of females was strongly associated with all variables relating to maternal care and also with infant mortality rate. States were grouped into best, medium, and worst on the basis of female illiteracy (about 11%, 48.5%, and 75% respectively). Infant mortality rate (per 1,000 livebirths) was significantly (p<0.01) higher among the worst group (90.99) than that among the medium (64.2) and the best (24.0) groups. Use of maternal health services increased in the worst to become the best groups for tetanus toxoid (from 48.0% to 84.4%), iron and folic acid tablets (36.6% to 76.2%), hospitalized deliveries (14.2% to 69.7%), and childcare services, such as vaccination (23.8% to 64.9%). Illiteracy of females had a more detrimental impact on rural than on urban areas. In the event of high female illiteracy, male literacy was beneficial for improving the use of services for reducing infant mortality rate. The micro-level study supported all major findings obtained for the national-level aggregate data. Programmes, like providing free education to girls, will yield long-term health benefits.

Where does distance matter? Distance to the closest maternity unit and risk of foetal and neonatal mortality in France.

PubMed

Pilkington, Hugo; Blondel, Béatrice; Drewniak, Nicolas; Zeitlin, Jennifer

2014-12-01

The number of maternity units has declined in France, raising concerns about the possible impact of increasing travel distances on perinatal health outcomes. We investigated impact of distance to closest maternity unit on perinatal mortality. Data from the French National Vital Statistics Registry were used to construct foetal and neonatal mortality rates over 2001-08 by distance from mother's municipality of residence and the closest municipality with a maternity unit. Data from French neonatal mortality certificates were used to compute neonatal death rates after out-of-hospital birth. Relative risks by distance were estimated, adjusting for individual and municipal-level characteristics. Seven percent of births occurred to women residing at ≥30 km from a maternity unit and 1% at ≥45 km. Foetal and neonatal mortality rates were highest for women living at <5 km from a maternity unit. For foetal mortality, rates increased at ≥45 km compared with 5-45 km. In adjusted models, long distance to a maternity unit had no impact on overall mortality but women living closer to a maternity unit had a higher risk of neonatal mortality. Neonatal deaths associated with out-of-hospital birth were rare but more frequent at longer distances. At the municipal-level, higher percentages of unemployment and foreign-born residents were associated with increased mortality. Overall mortality was not associated with living far from a maternity unit. Mortality was elevated in municipalities with social risk factors and located closest to a maternity unit, reflecting the location of maternity units in deprived areas with risk factors for poor outcome. © The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association.

Reasons for Persistently High Maternal and Perinatal Mortalities in Ethiopia: Part II-Socio-Economic and Cultural Factors

PubMed Central

Berhan, Yifru; Berhan, Asres

2014-01-01

Background The major causes of maternal and perinatal deaths are mostly pregnancy related. However, there are several predisposing factors for the increased risk of pregnancy related complications and deaths in developing countries. The objective of this review was to grossly estimate the effect of selected socioeconomic and cultural factors on maternal mortality, stillbirths and neonatal mortality in Ethiopia. Methods A comprehensive literature review was conducted focusing on the effect of total fertility rate (TFR), modern contraceptive use, harmful traditional practice, adult literacy rate and level of income on maternal and perinatal mortalities. For the majority of the data, regression analysis and Pearson correlation coefficient were used as a proxy indicator for the association of variables with maternal, fetal and neonatal mortality. Results Although there were variations in the methods for estimation, the TFR of women in Ethiopia declined from 5.9 to 4.8 in the last fifteen years, which was in the middle as compared with that of other African countries. The preference of injectable contraceptive method has increased by 7-fold, but the unmet contraceptive need was among the highest in Africa. About 50% reduction in female genital cutting (FGC) was reported although some women's attitude was positive towards the practice of FGC. The regression analysis demonstrated increased risk of stillbirths, neonatal and maternal mortality with increased TFR. The increased adult literacy rate was associated with increased antenatal care and skilled person attended delivery. Low adult literacy was also found to have a negative association with stillbirths and neonatal and maternal mortality. A similar trend was also observed with income. Conclusion Maternal mortality ratio, stillbirth rate and neonatal mortality rate had inverse relations with income and adult education. In Ethiopia, the high total fertility rate, low utilization of contraceptive methods, low adult

Assessing health and economic outcomes of interventions to reduce pregnancy-related mortality in Nigeria.

PubMed

Erim, Daniel O; Resch, Stephen C; Goldie, Sue J

2012-09-14

Women in Nigeria face some of the highest maternal mortality risks in the world. We explore the benefits and cost-effectiveness of individual and integrated packages of interventions to prevent pregnancy-related deaths. We adapt a previously validated maternal mortality model to Nigeria. Model outcomes included clinical events, population measures, costs, and cost-effectiveness ratios. Separate models were adapted to Southwest and Northeast zones using survey-based data. Strategies consisted of improving coverage of effective interventions, and could include improved logistics. Increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality, was cost saving in the Southwest zone and cost-effective elsewhere, and prevented nearly 1 in 5 abortion-related deaths. However, with a singular focus on family planning and safe abortion, mortality reduction would plateau below MDG 5. Strategies that could prevent 4 out of 5 maternal deaths included an integrated and stepwise approach that includes increased skilled deliveries, facility births, access to antenatal/postpartum care, improved recognition of referral need, transport, and availability quality of EmOC in addition to family planning and safe abortion. The economic benefits of these strategies ranged from being cost-saving to having incremental cost-effectiveness ratios less than $500 per YLS, well below Nigeria's per capita GDP. Early intensive efforts to improve family planning and control of fertility choices, accompanied by a stepwise effort to scale-up capacity for integrated maternal health services over several years, will save lives and provide equal or greater value than many public health interventions we consider among the most cost-effective (e.g., childhood immunization).

Effects of nutritional stress and socio-economic status on maternal mortality in six German villages, 1766-1863.

PubMed

Scalone, Francesco

2014-01-01

We examined the effects of nutritional stress on maternal mortality arising from short-term economic crises in eighteenth-century and nineteenth-century Germany, and how these effects might have been mitigated by socio-economic status. Historical data from six German villages were used to assess how socio-economic conditions and short-term economic crises following poor harvests may have affected maternal mortality. The results show that 1 year after an increase in grain prices the risk of maternal death increased significantly amongst the wives of those working outside the agricultural sector, and more so than for the wives of those working on farms. Nutritional crises seem to have had a significantly stronger impact on maternal mortality in the period 2-6 weeks after childbirth, when mothers were most prone to infections and indirect, obstetrical causes of maternal death. The findings indicate that both nutritional stress and socio-economic factors contributed to maternal mortality.

Praying until Death: Apostolicism, Delays and Maternal Mortality in Zimbabwe

PubMed Central

2016-01-01

Religion affects people’s daily lives by solving social problems, although it creates others. Female sexual and reproductive health are among the issues most affected by religion. Apostolic sect members in Zimbabwe have been associated with higher maternal mortality. We explored apostolic beliefs and practices on maternal health using 15 key informant interviews in 5 purposively selected districts of Zimbabwe. Results show that apostolicism promotes high fertility, early marriage, non-use of contraceptives and low or non-use of hospital care. It causes delays in recognizing danger signs, deciding to seek care, reaching and receiving appropriate health care. The existence of a customized spiritual maternal health system demonstrates a huge desire for positive maternal health outcomes among apostolics. We conclude that apostolic beliefs and practices exacerbate delays between onset of maternal complications and receiving help, thus increasing maternal risk. We recommend complementary and adaptive approaches that address the maternal health needs of apostolics in a religiously sensitive manner. PMID:27509018

Composite measures of women's empowerment and their association with maternal mortality in low-income countries.

PubMed

Lan, Chiao-Wen; Tavrow, Paula

2017-11-08

Maternal mortality has declined significantly since 1990. While better access to emergency obstetrical care is partially responsible, women's empowerment might also be a contributing factor. Gender equality composite measures generally include various dimensions of women's advancement, including educational parity, formal employment, and political participation. In this paper, we compare several composite measures to assess which, if any, are associated with maternal mortality ratios (MMRs) in low-income countries, after controlling for other macro-level and direct determinants. Using data from 44 low-income countries (half in Africa), we assessed the correlation of three composite measures - the Gender Gap Index, the Gender Equity Index (GEI), and the Social Institutions and Gender Index (SIGI) - with MMRs. We also examined two recognized contributors to reduce maternal mortality (skilled birth attendance (SBA) and total fertility rate (TFR)) as well as several economic and political variables (such as the Corruption Index) to see which tracked most closely with MMRs. We examined the countries altogether, and disaggregated by region. We then performed multivariate analysis to determine which measures were predictive. Two gender measures (GEI and SIGI) and GDP per capita were significantly correlated with MMRs for all countries. For African countries, the SIGI, TFR, and Corruption Index were significant, whereas the GEI, SBA, and TFR were significant in non-African countries. After controlling for all measures, SBA emerged as a predictor of log MMR for non-African countries (β = -0.04, P = 0.01). However, for African countries, only the Corruption Index was a predictor (β = -0.04, P = 0.04). No gender measure was significant. In African countries, corruption is undermining the quality of maternal care, the availability of critical drugs and equipment, and pregnant women's motivation to deliver in a hospital setting. Improving gender equality and

Independent and combined effects of maternal smoking and solid fuel on infant and child mortality in sub-Saharan Africa.

PubMed

Akinyemi, Joshua O; Adedini, Sunday A; Wandera, Stephen O; Odimegwu, Clifford O

2016-12-01

To estimate the independent and combined risks of infant and child mortality associated with maternal smoking and use of solid fuel in sub-Saharan Africa. Pooled weighted data on 143 602 under-five children in the most recent demographic and health surveys for 15 sub-Saharan African countries were analysed. The synthetic cohort life table technique and Cox proportional hazard models were employed to investigate the effect of maternal smoking and solid cooking fuel on infant (age 0-11 months) and child (age 12-59 months) mortality. Socio-economic and other confounding variables were included as controls. The distribution of the main explanatory variable in households was as follows: smoking + solid fuel - 4.6%; smoking + non-solid fuel - 0.22%; no smoking + solid fuel - 86.9%; and no smoking + non-solid fuel - 8.2%. The highest infant mortality rate was recorded among children exposed to maternal smoking + solid fuel (72 per 1000 live births); the child mortality rate was estimated to be 54 per 1000 for this group. In full multivariate models, the risk of infant death was 71% higher among those exposed to maternal smoking + solid fuel (HR = 1.71, CI: 1.29-2.28). For ages 12 to 59 months, the risk of death was 99% higher (HR = 1.99, CI: 1.28-3.08). Combined exposures to cigarette smoke and solid fuel increase the risks of infant and child mortality. Mothers of under-five children need to be educated about the danger of smoking while innovative approaches are needed to reduce the mortality risks associated with solid cooking fuel. © 2016 John Wiley & Sons Ltd.

A Needs Assessment of Health Issues Related to Maternal Mortality Rates in Afghanistan: A Pilot Study.

PubMed

Naim, Ali; Feldman, Robert; Sawyer, Robin

2015-01-01

Maternal death rates in Afghanistan were among the highest in the world during the reign of the Taliban. Although these figures have improved, current rates are still alarming. The aim of this pilot study was to develop a needs assessment of the major health issues related to the high maternal mortality rates in Afghanistan. In-depth interviews were conducted with managerial midwives, clinical midwives, and mothers. Results of the interviews indicate that the improvement in the maternal mortality rate may be attributed to the increase in the involvement of midwives in the birthing process. However, barriers to decreasing maternal mortality still exist. These include transportation, access to care, and sociocultural factors such as the influence of the husband and mother-in-law in preventing access to midwives. Therefore, any programs to decrease maternal mortality need to address infrastructure issues (making health care more accessible) and sociocultural factors (including husbands and mother-in-laws in maternal health education). However, it should be noted that these findings are based on a small pilot study to help develop a larger scale need assessment. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

[Maternal mortality: the demographic aspects].

PubMed

Sanogo, D

1989-10-01

The World Health Organization (WHO) has defined maternal mortality (MM) as a death following a delivery or during the 42 day period following a prolonged or complicated delivery. This definition is ambiguous because it does not take into account the institutional causes (deficiencies) that lead to MM in Sub-Saharan Africa (SSA) nor does it reflect all the reasons leading to MM because of the lack of nationwide health information systems and the lack of accurate statistics. While developed countries can depend on the state to provide accurate statistics, developing countries depend on hospitals, health training centers and special surveys to provide such data which often leads to 25-50% gross underestimations of MM. The most recent WHO data (1989) shows that SSA has the highest MM rates worldwide, ranging from 500- 700/100,000 as compared to Asia with 55-650; Latin America with 110-210 and the developed countries with 10-48. The data for SSA doesn't reflect the true situation in the rural areas where MM rates are over 1000/1000,000. MM is a symptom of poor countries where women contribute to their own deaths through repeated pregnancies, causing significant socioeconomic losses to society. UNICEF (1988) has categorized the demographic factors as high risk for women based on: 1) the age of the mother, and 2) the number of pregnancies. Family planning (FP) reduces MM by preventing illegal abortions; it reduces the number of unwanted pregnancies and increases the earnings of a community by reducing the number of pregnant women. The experience of developed countries demonstrates how women have avoided high-risk and unwanted pregnancies.

Maternal mortality in Bangladesh: a Countdown to 2015 country case study.

PubMed

El Arifeen, Shams; Hill, Kenneth; Ahsan, Karar Zunaid; Jamil, Kanta; Nahar, Quamrun; Streatfield, Peter Kim

2014-10-11

Bangladesh is one of the only nine Countdown countries that are on track to achieve the primary target of Millennium Development Goal (MDG) 5 by 2015. It is also the only low-income or middle-income country with two large, nationally-representative, high-quality household surveys focused on the measurement of maternal mortality and service use. We use data from the 2001 and 2010 Bangladesh Maternal Mortality Surveys to measure change in the maternal mortality ratio (MMR) and from these and six Bangladesh Demographic and Health Surveys to measure changes in factors potentially related to such change. We estimate the changes in risk of maternal death between the two surveys using Poisson regression. The MMR fell from 322 deaths per 100,000 livebirths (95% CI 253-391) in 1998-2001 to 194 deaths per 100,000 livebirths (149-238) in 2007-10, an annual rate of decrease of 5·6%. This decrease rate is slightly higher than that required (5·5%) to achieve the MDG target between 1990 and 2015. The key contribution to this decrease was a drop in mortality risk mainly due to improved access to and use of health facilities. Additionally, a number of favourable changes occurred during this period: fertility decreased and the proportion of births associated with high risk to the mother fell; income per head increased sharply and the poverty rate fell; and the education levels of women of reproductive age improved substantially. We estimate that 52% of maternal deaths that would have occurred in 2010 in view of 2001 rates were averted because of decreases in fertility and risk of maternal death. The decrease in MMR in Bangladesh seems to have been the result of factors both within and outside the health sector. This finding holds important lessons for other countries as the world discusses and decides on the post-MDG goals and strategies. For Bangladesh, this case study provides a strong rationale for the pursuit of a broader developmental agenda alongside increased and

Increasing women's access to skilled pregnancy care to reduce maternal and perinatal mortality in rural Edo State, Nigeria: a randomized controlled trial.

PubMed

Yaya, Sanni; Okonofua, Friday; Ntoimo, Lorretta; Kadio, Bernard; Deuboue, Rodrigue; Imongan, Wilson; Balami, Wapada

2018-01-01

Nigeria presently has the second highest absolute number of maternal deaths and perinatal deaths (stillbirth and neonatal deaths) in the world. The country accounts for up to 14% of global maternal deaths and is second only to India in the number of women who die during childbirth. Although all parts of the country are worsened by these staggering statistics, several lines of evidence show that most maternal, and perinatal deaths occur in the north-east and north-west geo-political zones where women have limited access to evidence-based maternal and neonatal health services. The proposed project intends to identify the demand and supply factors that prevent women from using PHCs for maternal and early new-born care in Nigeria, and to test innovative and community relevant interventions for improving women's access to PHC services, and thus, ultimately, to prevent maternal and perinatal deaths. An open-labelled, randomized controlled trial will is carried out in two local government areas selected based on three criteria (i) maternal mortality rates (ii) PHC utilization rates and (iii) and geographic localization. The study will be conducted over 54-months in six communities, with PHCs in six communities of similar status serving as control sites. Surveys about quality of care and maternal health services utilization will be carried out at baseline, at midterm and at end of the project to test the effectiveness of the intervention, alongside conventional epidemiological measures of maternal and perinatal mortality. Ethical approval for the study has been granted (reference no. NHREC/01/01/2007). The findings will be published in compliance with reporting guidelines for randomized controlled trials. The current Federal Government in Nigeria has identified PHC as its main strategy for increasing access to health in Nigeria. However, despite numerous efforts, there are persisting concerns that there is currently no scientific evidence on which to base the improvement

What is the cause of the decline in maternal mortality in India? Evidence from time series and cross-sectional analyses.

PubMed

Goli, Srinivas; Jaleel, Abdul C P

2014-05-01

Summary Studies on the causes of maternal mortality in India have focused on institutional deliveries, and the association of socioeconomic and demographic factors with the decline in maternal mortality has not been sufficiently investigated. By using both time series and cross-sectional data, this paper examines the factors associated with the decline in maternal mortality in India. Relative effects estimated by OLS regression analysis reveal that per capita state net domestic product (-1.49611, p<0.05), poverty ratio (0.02426, p<0.05), female literacy rate (-0.05905, p<0.10), infant mortality rate and total fertility rate (0.11755, p<0.05) show statistically significant association with the decline in the maternal mortality ratio in India. The Barro-regression estimate reveals that improvements in economic and demographic conditions such as growth in state income (β=0.35020, p<0.05) and reduction in poverty (β=0.01867, p<0.01) and fertility (β=0.02598, p<0.05) have a greater association with the decline in the maternal mortality ratio in India than institutional deliveries (β=0.00305). The negative β-coefficient (β=-0.69578, p<0.05), showing the effect of the initial maternal mortality ratio on change in maternal mortality ratio in the Barro-regression model, indicates a greater decline in maternal mortality ratio in laggard states compared with advanced states. Overall, comparing the estimates of relative effects, the socioeconomic and demographic factors have a stronger statistically significant association with the maternal mortality ratio than institutional deliveries. Interestingly, the weak association between 'increase in institutional deliveries' and 'decline in maternal mortality ratio' suggests that merely increasing deliveries alone will not help in ensuring maternal survival in India. Quality of services provided by the health facility, birth preparedness and avoiding delay in reaching health facility are also important. Deliveries in health

Information management in Iranian Maternal Mortality Surveillance System.

PubMed

Sadoughi, Farahnaz; Karimi, Afsaneh; Erfannia, Leila

2017-07-01

Maternal mortality is preventable by proper information management and is the main target of the Maternal Mortality Surveillance System (MMSS). This study aimed to determine the status of information management in the Iranian Maternal Mortality Surveillance System (IMMSS). The population of this descriptive and analytical study, which was conducted in 2016, included 96 administrative staff of health and treatment deputies of universities of medical sciences and the Ministry of Health in Iran. Data were gathered by a five-part questionnaire with confirmed validity and reliability. A total of 76 questionnaires were completed, and data were analyzed using SPSS software, version 19, by descriptive and inferential statistics. The relationship between variables "organizational unit" and the four studied axes was studied using Kendall's correlation coefficient test. The status of information management in IMMSS was desirable. Data gathering and storage axis and data processing and compilation axis achieved the highest (2.7±0.46) and the lowest (2.4±0.49) mean scores, respectively. The data-gathering method, control of a sample of women deaths in reproductive age in the universities of medical sciences, use of international classification of disease, and use of this system information by management teams to set resources allocation achieved the lowest mean scores in studied axes. Treatment deputy staff had a more positive attitude toward the status of information management of IMMSS than the health deputy staff (p=0.004). Although the status of information management in IMMSS was desirable, it could be improved by modification of the data-gathering method; creating communication links between different data resources; a periodic sample control of women deaths in reproductive age in the universities of medical sciences; and implementing ICD-MM and integration of its rules on a unified system of death.

Gender inequality, health expenditure and maternal mortality in sub-Saharan Africa: A secondary data analysis

PubMed Central

Atwood, Stephen; Van der Putten, Marc

2013-01-01

Abstract Background This article provided an analysis of gender inequality, health expenditure and its relationship to maternal mortality. Objective The objective of this article was to explore gender inequality and its relationship with health expenditure and maternal mortality in sub-Saharan Africa (SSA). A unique analysis was used to correlate the Gender Inequality Index (GII), Health Expenditure and Maternal Mortality Ratio (MMR). The GII captured inequalities across three dimensions – Reproductive health, Women empowerment and Labour force participation between men and women. The GII is a composite index introduced by the UNDP in 2010 and corrects for the disadavanatges of the other gender indices. Although the GII incorporates MMR in its calculation, it should not be taken as a substitute for, but rather as complementary to, the MMR. Method An exploratory and descriptive design to a secondary documentary review using quantitative data and qualitative information was used. The article referred to sub-Saharan Africa, but seven countries were purposively selected for an in-depth analysis based on the availability of data. The countries selected were Angola, Botswana, Malawi, Mozambique, South Africa, Zambia and Zimbabwe. Results Countries with high gender inequality captured by the gender inequality index were associated with high maternal mortality ratios as compared with countries with lower gender inequality, whilst countries that spend less on health were associated with higher maternal deaths than countries that spend more. Conclusion A potential relationship exists between gender inequality, health expenditure, and maternal mortality. Gender inequalities are systematic and occur at the macro, societal and household levels.

[Maternal mortality in the Hospital General de Matamoros Dr. Alfredo Pumarejo Lafaurie for a period of 10 years].

PubMed

González-Rosales, Ricardo; Ayala-Leal, Isabel; Cerda-López, Jorge Alejandro; Cerón-Saldaña, Miguel Angel

2010-04-01

In Mexico, maternal mortality has fallen substantially in recent decades. Although according to the Secretaria de Salud, in Tamaulipas the maternal mortality rate has increased in recent years. Despite these facts, Tamaulipas ranks among the ten institutions with the lowest level of maternal mortality. To describe the basic elements of epidemiologic behavior of maternal mortality during a period of ten years at the Gynecology and Obstetrics department of the Hospital General de Matamoros Dr. Alfredo Pumarejo Lafaurie in Tamaulipas, Mexico. A descriptive, transverse, retrospective and a cases series research was carried out at the Gynecology and Obstetrics department of the Hospital General de Matamoros Dr. Alfredo Pumarejo Lafaurie in Tamaulipas, Mexico. There was a revision of the expedients of direct and indirect obstetric maternal deaths occurred from January 1, 1998 to December 31, 2007. We used descriptive statistics with central trend measurements and standard deviation. 30 obstetric maternal deaths were registered. Maternal death ratio was 87.2 x 100,000 live births during the 10 years. The average age of patients was 25.1 +/- 7.8 years old. 54% were in their first pregnancy. Only 20% had adequate prenatal control. Direct obstetric causes were 60% and indirect obstetric causes 40%. The main causes of maternal deaths were preeclampsia/eclampsia (27%), obstetric hemorrhage (20%) and gravid-puerperal sepsis (13%). 83% was foreseeable. It was noted a clear trend towards the reduction in the maternal mortality ratio in the decade from 1998 to 2007. Preeclampsia-eclampsia and obstetric hemorrhage remain the main causes of maternal death. The maternal mortality ratio tended to invest when comparing the first five years with the last five years of the study, which talks about improvements in management and direct obstetric causes prevention.

Impacts of maternal mortality on living children and families: A qualitative study from Butajira, Ethiopia.

PubMed

Molla, Mitike; Mitiku, Israel; Worku, Alemayehu; Yamin, Alicia

2015-05-06

The consequences of maternal mortality on orphaned children and the family members who support them are dramatic, especially in countries that have high maternal mortality like Ethiopia. As part of a four country, mixed-methods study (Ethiopia, Malawi, South Africa, and Tanzania) qualitative data were collected in Butajira, Ethiopia with the aim of exploring the far reaching consequences of maternal deaths on families and children. We conducted interviews with 28 adult family members of women who died from maternal causes, as well as 13 stakeholders (government officials, civil society, and a UN agency); and held 10 focus group discussions with 87 community members. Data were analyzed using NVivo10 software for qualitative analysis. We found that newborns and children whose mothers died from maternal causes face nutrition deficits, and are less likely to access needed health care than children with living mothers. Older children drop out of school to care for younger siblings and contribute to household and farm labor which may be beyond their capacity and age, and often choose migration in search of better opportunities. Family fragmentation is common following maternal death, leading to tenuous relationships within a household with the births and prioritization of additional children further stretching limited financial resources. Currently, there is no formal standardized support system for families caring for vulnerable children in Ethiopia. Impacts of maternal mortality on children are far-reaching and have the potential to last into adulthood. Coordinated, multi-sectorial efforts towards mitigating the impacts on children and families following a maternal death are lacking. In order to prevent impacts on children and families, efforts targeting maternal mortality must address inequalities in access to care at the community, facility, and policy levels.

An assessment study of maternal mortality ratio databank in five districts of North Western Frontier Province Pakistan.

PubMed

Farooq, Nasir; Jadoon, Huma; Masood, Tayyeb Imran; Wazir, M Saleem; Farooq, Umer; Lodhi, Mohammad Saqib

2006-01-01

Maternal mortality ratio is an indicator to measure the summary of information about mother and child health. It is estimated that about 500 maternal deaths occur per 100,000 live births each year in Pakistan. It is a well known fact that all health statistics coming out of the developing countries are calculated "guesstimates" some are perhaps more close to the real figures than the others. There is a dire need to help generate information that can be used by health professionals, health care planners and managers to save women's lives by improving the quality of care provided to turn away maternal mortality. The maternal mortality ratio for Pakistan as well as for NWFP is projected as 533/100,000 live births for the year 1990-91 produced by National Institute of Population Studies, Pakistan. This was a retrospective cross-sectional quantitative study for the period (2001-2002) conducted in five districts of (NWFP) North Western Frontier Province, Pakistan. National HMIS data opened the maternal mortality ratio for; Haripur as 0.168 and 0.173, Mansehra 00 and 00, Battagram 00 and 00, Swat 0.051. and 0.524 and Swabi 00 and 0.968 per/1000 live births, respectively. The small part exercise outcome (the study) endorsed more shadowy side of the actual maternal mortality ratio for the same period in the same districts. In our country there is a urgent need to institute an efficient mode of operation to get accurate maternal mortality database. Verbal Autopsy method is cost effective and feasible approach for implementation in a country like Pakistan.

An assessment of the impact of the JSY cash transfer program on maternal mortality reduction in Madhya Pradesh, India

PubMed Central

Ng, Marie; Misra, Archana; Diwan, Vishal; Agnani, Manohar; Levin-Rector, Alison; De Costa, Ayesha

2014-01-01

Background The Indian Janani Suraksha Yojana (JSY) program is a demand-side program in which the state pays women a cash incentive to deliver in an institution, with the aim of reducing maternal mortality. The JSY has had 54 million beneficiaries since inception 7 years ago. Although a number of studies have demonstrated the effect of JSY on coverage, few have examined the direct impact of the program on maternal mortality. Objective To study the impact of JSY on maternal mortality in Madhya Pradesh (MP), one of India's largest provinces. Design By synthesizing data from various sources, district-level maternal mortality ratios (MMR) from 2005 to 2010 were estimated using a Bayesian spatio-temporal model. Based on these, a mixed effects multilevel regression model was applied to assess the impact of JSY. Specifically, the association between JSY intensity, as reflected by 1) proportion of JSY-supported institutional deliveries, 2) total annual JSY expenditure, and 3) MMR, was examined. Results The proportion of all institutional deliveries increased from 23.9% in 2005 to 55.9% in 2010 province-wide. The proportion of JSY-supported institutional deliveries rose from 14% (2005) to 80% (2010). MMR declines in the districts varied from 2 to 35% over this period. Despite the marked increase in JSY-supported delivery, our multilevel models did not detect a significant association between JSY-supported delivery proportions and changes in MMR in the districts. The results from the analysis examining the association between MMR and JSY expenditure are similar. Conclusions Our analysis was unable to detect an association between maternal mortality reduction and the JSY in MP. The high proportion of institutional delivery under the program does not seem to have converted to lower mortality outcomes. The lack of significant impact could be related to supply-side constraints. Demand-side programs like JSY will have a limited effect if the supply side is unable to deliver care

A low-cost uterine balloon tamponade for management of postpartum hemorrhage: modeling the potential impact on maternal mortality and morbidity in sub-Saharan Africa.

PubMed

Herrick, Tara; Mvundura, Mercy; Burke, Thomas F; Abu-Haydar, Elizabeth

2017-11-13

Postpartum hemorrhage (PPH) is the leading cause of maternal deaths worldwide. This study sought to quantify the potential health impact (morbidity and mortality reductions) that a low-cost uterine balloon tamponade (UBT) could have on women suffering from uncontrolled PPH due to uterine atony in sub-Saharan Africa. The Maternal and Neonatal Directed Assessment of Technology (MANDATE) model was used to estimate maternal deaths, surgeries averted, and cases of severe anemia prevented through UBT use among women with PPH who receive a uterotonic drug but fail this therapy in a health facility. Estimates were generated for the year 2018. The main outcome measures were lives saved, surgeries averted, and severe anemia prevented. The base case model estimated that widespread use of a low-cost UBT in clinics and hospitals could save 6547 lives (an 11% reduction in maternal deaths), avert 10,823 surgeries, and prevent 634 severe anemia cases in sub-Saharan Africa annually. A low-cost UBT has a strong potential to save lives and reduce morbidity. It can also potentially reduce costly downstream interventions for women who give birth in a health care facility. This technology may be especially useful for meeting global targets for reducing maternal mortality as identified in Sustainable Development Goal 3.

[Prenatal care and hospital maternal mortality in Tijuana, Baja California, Mexico].

PubMed

Gonzaga-Soriano, María Rode; Zonana-Nacach, Abraham; Anzaldo-Campos, María Cecilia; Olazarán-Gutiérrez, Asbeidi

2014-01-01

To describe the prenatal care (PC) received in women with maternal hospital deaths from 2005 to 2011 in Tijuana, Baja California, Mexico. Were reviewed the medical chars and registrations of the maternal deaths by the local Committees of Maternal Mortality. There were 44 maternal hospital deaths. Thirty (68%) women assisted to PC appointments during pregnancy, the average number of PC visits was 3.8 and 18 (41%) had an adequate PC (≥ 5 visits). Six (14%) women didn't know they were pregnant; 19 (43%), 21 (48%) y 4 (9%) maternal deaths were due to direct, indirect obstetric cause or non-obstetric causes. Eighteen (18%), 2 (4 %) and 34 (77%) of the maternal deaths occurred during pregnancy, delivery or puerperium. It is necessary pregnancy women have an early, periodic and systematic PC to identify opportunely risk factors associated with pregnancy complications.

Tackling Health Inequities in Chile: Maternal, Newborn, Infant, and Child Mortality Between 1990 and 2004

PubMed Central

Requejo, Jennifer Harris; Nien, Jyh Kae; Merialdi, Mario; Bustreo, Flavia; Betran, Ana Pilar

2009-01-01

Objectives. We analyzed trends in maternal, newborn, and child mortality in Chile between 1990 and 2004, after the introduction of national interventions and reforms, and examined associations between trends and interventions. Methods. Data were provided by the Chilean Ministry of Health on all pregnancies between 1990 and 2004 (approximately 4 000 000). We calculated yearly maternal mortality ratios, stillbirth rates, and mortality rates for neonates, infants (aged > 28 days and < 1 year), and children aged 1 to 4 years. We also calculated these statistics by 5-year intervals for Chile's poorest to richest district quintiles. Results. During the study period, the maternal mortality ratio decreased from 42.1 to 18.5 per 100 000 live births. The mortality rate for neonates decreased from 9.0 to 5.7 per 1000 births, for infants from 7.8 to 3.1 per 1000 births, and for young children from 3.1 to 1.7 per 1000 live births. The stillbirth rate declined from 6.0 to 5.0 per 1000 births. Disparities in these mortality statistics between the poorest and richest district quintiles also decreased, with the largest mortality reductions in the poorest quintile. Conclusions. During a period of socioeconomic development and health sector reforms, Chile experienced significant mortality and inequity reductions. PMID:19443831

Determinants of maternal mortality in Eastern Mediterranean region: A panel data analysis

PubMed Central

Bayati, Mohsen; Vahedi, Sajad; Esmaeilzadeh, Firooz; Kavosi, Zahra; Jamali, Zahra; Rajabi, Abdolhalim; Alimohamadi, Yousef

2016-01-01

Background: As one of the main criteria of health outcomes, maternal mortality indicates the socioeconomic development level of countries. The present study aimed at identifying and analyzing the effective factors on maternal mortality in Eastern Mediterranean Region (EMR) of the World Health Organization (WHO). Methods: Analytical model was developed based on the literature review. Panel data of 2004-2011 periods for 22 EMR countries was used. Required data were collected from WHO online database. Based on results of diagnostic tests for panel data model, parameters of model were estimated by fixed effects method. Results: Descriptive statistics demonstrated the large disparities in social, economic, and health indicators among EMRO countries. Findings obtained from evaluating the model showed a negative, significant relationship between GDP per capita (β=-0.869, p<0.01), health expenditure) β=-0.525, p<0.01 (female literacy rate) β=-1.045, <0.01 (skilled birth attendance) β=-0.899, p<0.05) and maternal mortality rate. Conclusion: Improved income and economic development, increased resources allocated to the health sector, improved delivery services particularly the increased use of trained staff in the delivery, improve quality of primary care centers, mitigating the risks of marginalization and its dangers, and especially improving the level of women's education and knowledge are the key factors in policy making related to maternal health promotion. PMID:27453890

Shifting visions: "delegation" policies and the building of a "rights-based" approach to maternal mortality.

PubMed

Freedman, Lynn P

2002-01-01

"Rights-based" approaches fold human rights principles into the ongoing work of health policy making and programming. The example of delegation of anesthesia provision for emergency obstetric care is used to demonstrate how a rights-based approach, applied to this problem in the context of high-mortality countries, requires decision makers to shift from an individual, ethics-based, clinical perspective to a structural, rights-based, public health perspective. This fluid and context-sensitive approach to human rights also applies at the international level, where the direction of overall maternal mortality reduction strategy is set. By contrasting family planning programs and maternal mortality programs, this commentary argues for choosing the human rights approach that speaks most effectively to the power dynamics underlying the particular health problem being addressed. In the case of maternal death in high-mortality countries, this means a strategic focus on the health care system itself.

The causes of maternal mortality in adolescents in low and middle income countries: a systematic review of the literature.

PubMed

Neal, Sarah; Mahendra, Shanti; Bose, Krishna; Camacho, Alma Virginia; Mathai, Matthews; Nove, Andrea; Santana, Felipe; Matthews, Zoë

2016-11-11

While the main causes of maternal mortality in low and middle income countries are well understood, less is known about whether patterns for causes of maternal deaths among adolescents are the same as for older women. This study systematically reviews the literature on cause of maternal death in adolescence. Where possible we compare the main causes for adolescents with those for older women to ascertain differences and similarity in mortality patterns. An initial search for papers and grey literature in English, Spanish and Portuguese was carried out using a number of electronic databases based on a pre-determined search strategy. The outcome of interest was the proportion of maternal deaths amongst adolescents by cause of death. A total of 15 papers met the inclusion criteria established in the study protocol. The main causes of maternal mortality in adolescents are similar to those of older women: hypertensive disorders, haemorrhage, abortion and sepsis. However some studies indicated country or regional differences in the relative magnitudes of specific causes of adolescent maternal mortality. When compared with causes of death for older women, hypertensive disorders were found to be a more important cause of mortality for adolescents in a number of studies in a range of settings. In terms of indirect causes of death, there are indications that malaria is a particularly important cause of adolescent maternal mortality in some countries. The main causes of maternal mortality in adolescents are broadly similar to those for older women, although the findings suggest some heterogeneity between countries and regions. However there is evidence that the relative importance of specific causes may differ for this younger age group compared to women over the age of 20 years. In particular hypertensive conditions make up a larger share of maternal deaths in adolescents than older women. Further, large scale studies are needed to investigate this question further.

Comparing two survey methods for estimating maternal and perinatal mortality in rural Cambodia.

PubMed

Chandy, Hoeuy; Heng, Yang Van; Samol, Ha; Husum, Hans

2008-03-01

We need solid estimates of maternal mortality rates (MMR) to monitor the impact of maternal care programs. Cambodian health authorities and WHO report the MMR in Cambodia at 450 per 100,000 live births. The figure is drawn from surveys where information is obtained by interviewing respondents about the survival of all their adult sisters (sisterhood method). The estimate is statistically imprecise, 95% confidence intervals ranging from 260 to 620/100,000. The MMR estimate is also uncertain due to under-reporting; where 80-90% of women deliver at home maternal fatalities may go undetected especially where mortality is highest, in remote rural areas. The aim of this study was to attain more reliable MMR estimates by using survey methods other than the sisterhood method prior to an intervention targeting obstetric rural emergencies. The study was carried out in rural Northwestern Cambodia where access to health services is poor and poverty, endemic diseases, and land mines are endemic. Two survey methods were applied in two separate sectors: a community-based survey gathering data from public sources and a household survey gathering data direct from primary sources. There was no statistically significant difference between the two survey results for maternal deaths, both types of survey reported mortality rates around the public figure. The household survey reported a significantly higher perinatal mortality rate as compared to the community-based survey, 8.6% versus 5.0%. Also the household survey gave qualitative data important for a better understanding of the many problems faced by mothers giving birth in the remote villages. There are detection failures in both surveys; the failure rate may be as high as 30-40%. PRINCIPLE CONCLUSION: Both survey methods are inaccurate, therefore inappropriate for evaluation of short-term changes of mortality rates. Surveys based on primary informants yield qualitative information about mothers' hardships important for the design

Gender gap matters in maternal mortality in low and lower-middle-income countries: A study of the global Gender Gap Index.

PubMed

Choe, Seung-Ah; Cho, Sung-Il; Kim, Hongsoo

2017-09-01

Reducing maternal mortality has been a crucial part of the global development agenda. According to modernisation theory, the effect of gender equality on maternal health may differ depending on a country's economic development status. We explored the correlation between the Global Gender Gap Index (GGI) provided by the World Economic Forum and the maternal mortality ratio (MMR) obtained from the World Development Indicators database of the World Bank. The relationships between each score in the GGI, including its four sub-indices (measuring gender gaps in economic participation, educational attainment, health and survival, and political empowerment), and the MMR were analysed. When the countries were stratified by gross national income per capita, the low and lower-middle-income countries had lower scores in the GGI, and lower scores in the economic participation, educational attainment, and political empowerment sub-indices than the high-income group. Among the four sub-indices, the educational attainment sub-index showed a significant inverse correlation with the MMR in low and lower-middle-income countries when controlling for the proportion of skilled birth attendance and public share of health expenditure. This finding suggests that strategic efforts to reduce the gender gap in educational attainment could lead to improvements in maternal health in low and lower-middle-income countries.

Spatial-temporal dynamics and structural determinants of child and maternal mortality in a rural, high HIV burdened South African population, 2000-2014: a study protocol.

PubMed

Tlou, B; Sartorius, B; Tanser, F

2016-07-15

Child (infant and under-5) and maternal mortality rates are key indicators for assessing the health status of populations. South Africa's maternal and child mortality rates are high, and the country mirrors the continental trend of slow progress towards its Millennium Development Goals. Rural areas are often more affected regarding child and maternal mortalities, specifically in areas with a high HIV burden. This study aims to understand the factors affecting child and maternal mortality in the Africa Centre Demographic Surveillance Area (DSA) from 2003 to 2014 towards developing tailored interventions to reduce the deaths in resource poor settings. This will be done by identifying child and maternal mortality 'hotspots' and their associated risk factors. This retrospective study will use data for 2003-2014 from the Africa Centre Demographic Information System (ACDIS) in rural KwaZulu-Natal Province, South Africa. All homesteads in the study area have been mapped to an accuracy of <2 m, all deaths recorded and the assigned cause of death established using a verbal autopsy interview. Advanced spatial-temporal clustering techniques (both regular (Kulldorff) and irregular (FleXScan)) will be used to identify mortality 'hotspots'. Various advanced statistical modelling approaches will be tested and used to identify significant risk factors for child and maternal mortality. Differences in attributability and risk factors profiles in identified 'hotspots' will be assessed to enable tailored intervention guidance/development. This multicomponent study will enable a refined intervention model to be developed for typical rural populations with a high HIV burden. Ethical approval was received from the Biomedical Research Ethics Committee (BREC) of the University of KwaZulu-Natal (BE 169/15). Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Do New Mothers Understand the Risk Factors for Maternal Mortality?

PubMed

Logsdon, M Cynthia; Davis, Deborah Winders; Myers, John A; Masterson, Katlin M; Rushton, Jeffrey A; Lauf, Adrian P

2018-03-16

The purpose of this study was to describe new mothers' knowledge related to maternal mortality. Using a cross-sectional design, new mothers were recruited from a postpartum unit of an academic health sciences center where the population was predominately low-income women. Before hospital discharge, they answered questions on their knowledge of potential postpartum complications that could lead to maternal mortality. Questions were based on recommendations from an expert nursing panel. Descriptive statistics were used for data analysis. One hundred twenty new mothers participated. Results indicated that most new mothers knew that they should watch for heavy bleeding, a severe headache, and swelling after hospital discharge. However, fewer participants knew that a new mother could experience feelings that she could harm herself or her baby, have blood clots larger than a baby's hand, a temperature of 100.4 °F or more, and odor with vaginal discharge. Courses of action new mothers would take if experiencing any of the warning signs included 18% of mothers would take no action, 76.7% would tell their boyfriend/husband/partner, 72.5% would inform their mother. Only 60% who would call the labor and delivery unit. Only 38% of the sample knew that pregnancy-related complications can occur for up to 1 year after birth, and 13% of mothers reported not knowing that complications can occur for up to 6 weeks postpartum. Our findings provide a foundation to enhance postpartum education for new mothers and their families and to potentially decrease rates of maternal mortality in the United States.

Why are women so intelligent? The effect of maternal IQ on childhood mortality may be a relevant evolutionary factor.

PubMed

Charlton, Bruce G

2010-03-01

Humans are an unusual species because they exhibit an economic division of labour. Most theories concerning the evolution of specifically human intelligence have focused either on economic problems or sexual selection mechanisms, both of which apply more to men than women. Yet while there is evidence for men having a slightly higher average IQ, the sexual dimorphism of intelligence is not obvious (except at unusually high and low levels). However, a more female-specific selection mechanism concerns the distinctive maternal role in child care during the offspring's early years. It has been reported that increasing maternal intelligence is associated with reducing child mortality. This would lead to a greater level of reproductive success for intelligent women, and since intelligence is substantially heritable, this is a plausible mechanism by which natural selection might tend to increase female intelligence in humans. Any effect of maternal intelligence on improving child survival would likely be amplified by assortative mating for IQ by which people tend to marry others of similar intelligence - combining female maternal and male economic or sexual selection factors. Furthermore, since general intelligence seems to have the functional attribute of general purpose problem-solving and more rapid learning, the advantages of maternal IQ are likely to be greater as the environment for child-rearing is more different from the African hunter-gatherer society and savannah environment in which ancestral humans probably evolved. However, the effect of maternal IQ on child mortality would probably only be of major evolutionary significance in environments where childhood mortality rates were high. The modern situation is that population growth is determined mostly by birth rates; so in modern conditions, maternal intelligence may no longer have a significant effect on reproductive success; the effect of female IQ on reproductive success is often negative. Nonetheless, in the

Effect of Early Detection and Treatment on Malaria Related Maternal Mortality on the North-Western Border of Thailand 1986–2010

PubMed Central

McGready, Rose; Boel, Machteld; Rijken, Marcus J.; Ashley, Elizabeth A.; Cho, Thein; Moo, Oh; Paw, Moo Koh; Pimanpanarak, Mupawjay; Hkirijareon, Lily; Carrara, Verena I.; Lwin, Khin Maung; Phyo, Aung Pyae; Turner, Claudia; Chu, Cindy S.; van Vugt, Michele; Price, Richard N.; Luxemburger, Christine; ter Kuile, Feiko O.; Tan, Saw Oo; Proux, Stephane; Singhasivanon, Pratap; White, Nicholas J.; Nosten, François H.

2012-01-01

Introduction Maternal mortality is high in developing countries, but there are few data in high-risk groups such as migrants and refugees in malaria-endemic areas. Trends in maternal mortality were followed over 25 years in antenatal clinics prospectively established in an area with low seasonal transmission on the north-western border of Thailand. Methods and Findings All medical records from women who attended the Shoklo Malaria Research Unit antenatal clinics from 12th May 1986 to 31st December 2010 were reviewed, and maternal death records were analyzed for causality. There were 71 pregnancy-related deaths recorded amongst 50,981 women who attended antenatal care at least once. Three were suicide and excluded from the analysis as incidental deaths. The estimated maternal mortality ratio (MMR) overall was 184 (95%CI 150–230) per 100,000 live births. In camps for displaced persons there has been a six-fold decline in the MMR from 499 (95%CI 200–780) in 1986–90 to 79 (40–170) in 2006–10, p<0.05. In migrants from adjacent Myanmar the decline in MMR was less significant: 588 (100–3260) to 252 (150–430) from 1996–2000 to 2006–2010. Mortality from P.falciparum malaria in pregnancy dropped sharply with the introduction of systematic screening and treatment and continued to decline with the reduction in the incidence of malaria in the communities. P.vivax was not a cause of maternal death in this population. Infection (non-puerperal sepsis and P.falciparum malaria) accounted for 39.7 (27/68) % of all deaths. Conclusions Frequent antenatal clinic screening allows early detection and treatment of falciparum malaria and substantially reduces maternal mortality from P.falciparum malaria. No significant decline has been observed in deaths from sepsis or other causes in refugee and migrant women on the Thai–Myanmar border. PMID:22815732

'Tweaking' the model for understanding and preventing maternal and neonatal morbidity and mortality in Low Income Countries: "inserting new ideas into a timeless wine skin".

PubMed

Mwaniki, Michael K; Baya, Evaline J; Mwangi-Powell, Faith; Sidebotham, Peter

2016-01-25

Maternal and neonatal morbidity and mortality in Low Income Countries, especially in sub-Saharan Africa involves numerous interrelated causes. The three-delay model/framework was advanced to better understand the causes and associated Contextual factors. It continues to inform many aspects of programming and research on combating maternal and child morbidity and mortality in the said countries. Although this model addresses some of the core areas that can be targeted to drastically reduce maternal and neonatal morbidity and mortality, it potentially omits other critical facets especially around primary prevention, and pre- and post-hospitalization continuum of care. The final causes of Maternal and Neonatal mortality and morbidity maybe limited to a few themes largely centering on infections, preterm births, and pregnancy and childbirth related complications. However, to effectively tackle these causes of morbidity and mortality, a broad based approach is required. Some of the core issues that need to be addressed include:-i) prevention of vertically transmitted infections, intra-partum related adverse events and broad primary prevention strategies, ii) overall health care seeking behavior and delays therein, iii) quality of care at point of service delivery, and iv) post-insult treatment follow up and rehabilitation. In this article we propose a five-pronged framework that takes all the above into consideration. This frameworks further builds on the three-delay model and offers a more comprehensive approach to understanding and preventing maternal and neonatal morbidity and mortality in Low Income Countries In shaping the post 2015 agenda, the scope of engagement in maternal and newborn health need to be widened if further gains are to be realized and sustained. Our proposed five pronged approach incorporates the need for continued investment in tackling the recognized three delays, but broadens this to also address earlier aspects of primary prevention, and the

Family planning issues relating to maternal and infant mortality in the United States.

PubMed

Puffer, R R

1993-01-01

Both maternal and infant death rates in the United States are much higher than in many developed countries. The interrelationships between abortions and maternal and infant mortality have been analyzed on the basis of data from the 1970s and 1980s. The legalization of abortions in 1973 resulted in a marked increase in legal abortions and marked reductions in maternal and infant mortality over the course of the 1970s. However, a wide variation in abortion rates and in the number of abortion facilities indicates that such facilities were not readily available to all segments of the population in some areas. This probably accounts in part for higher maternal and infant death rates in such areas. Smoking, small weight gain, use of alcohol and drugs in pregnancy, and excessive maternal youth or age affected the outcome of pregnancy and contributed to high rates of infant death. Infant death rates were especially high among newborns of teenagers and young adult mothers; relatively high proportions of these newborns had low birthweights; a large share of the pregnancies involved were unintended; and slightly over half of the unintended pregnancies in teenagers and young women resulted in abortion. Comparisons with findings in Sweden reveal that the rates of unplanned pregnancy, abortion, and infant mortality were all much higher in the United States than in Sweden. The differences are attributed to better contraceptive services, which were made available free or very inexpensively in Sweden. Also, the frequency of low weight births was much lower in Sweden.

What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe.

PubMed

Bouvier-Colle, M-H; Mohangoo, A D; Gissler, M; Novak-Antolic, Z; Vutuc, C; Szamotulska, K; Zeitlin, J

2012-06-01

To assess capacity to develop routine monitoring of maternal health in the European Union using indicators of maternal mortality and severe morbidity. Analysis of aggregate data from routine statistical systems compiled by the EURO-PERISTAT project and comparison with data from national enquiries. Twenty-five countries in the European Union and Norway. Women giving birth in participating countries in 2003 and 2004. Application of a common collection of data by selecting specific International Classification of Disease codes from the 'Pregnancy, childbirth and the puerperium' chapter. External validity was assessed by reviewing the results of national confidential enquiries and linkage studies. Maternal mortality ratio, with distribution of specific obstetric causes, and severe acute maternal morbidity, which included: eclampsia, surgery and blood transfusion for obstetric haemorrhage, and intensive-care unit admission. In 22 countries that provided data, the maternal mortality ratio was 6.3 per 100,000 live births overall and ranged from 0 to 29.6. Under-ascertainment was evident from comparisons with studies that use enhanced identification of deaths. Furthermore, routine cause of death registration systems in countries with specific systems for audit reported higher maternal mortality ratio than those in countries without audits. For severe acute maternal morbidity, 16 countries provided data about at least one category of morbidity, and only three provided data for all categories. Reported values ranged widely (from 0.2 to 1.6 women with eclampsia per 1000 women giving birth and from 0.2 to 1.0 hysterectomies per 1000 women). Currently available data on maternal mortality and morbidity are insufficient for monitoring trends over time in Europe and for comparison between countries. Confidential enquiries into maternal deaths are recommended. © 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.

What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe

PubMed Central

Bouvier-Colle, M-H; Mohangoo, AD; Gissler, M; Novak-Antolic, Z; Vutuc, C; Szamotulska, K; Zeitlin, J

2012-01-01

Objective To assess capacity to develop routine monitoring of maternal health in the European Union using indicators of maternal mortality and severe morbidity. Design Analysis of aggregate data from routine statistical systems compiled by the EURO-PERISTAT project and comparison with data from national enquiries. Setting Twenty-five countries in the European Union and Norway. Population Women giving birth in participating countries in 2003 and 2004. Methods Application of a common collection of data by selecting specific International Classification of Disease codes from the ‘Pregnancy, childbirth and the puerperium’ chapter. External validity was assessed by reviewing the results of national confidential enquiries and linkage studies. Main outcome measures Maternal mortality ratio, with distribution of specific obstetric causes, and severe acute maternal morbidity, which included: eclampsia, surgery and blood transfusion for obstetric haemorrhage, and intensive-care unit admission. Results In 22 countries that provided data, the maternal mortality ratio was 6.3 per 100 000 live births overall and ranged from 0 to 29.6. Under-ascertainment was evident from comparisons with studies that use enhanced identification of deaths. Furthermore, routine cause of death registration systems in countries with specific systems for audit reported higher maternal mortality ratio than those in countries without audits. For severe acute maternal morbidity, 16 countries provided data about at least one category of morbidity, and only three provided data for all categories. Reported values ranged widely (from 0.2 to 1.6 women with eclampsia per 1000 women giving birth and from 0.2 to 1.0 hysterectomies per 1000 women). Conclusions Currently available data on maternal mortality and morbidity are insufficient for monitoring trends over time in Europe and for comparison between countries. Confidential enquiries into maternal deaths are recommended. PMID:22571748

Lessons from 150 years of UK maternal hemorrhage deaths.

PubMed

Kerr, Robert Stuart; Weeks, Andrew David

2015-06-01

We have reviewed maternal hemorrhage death rates in the UK over the past 150 years in order to draw lessons from this material for current attempts to reduce global maternal mortality. Mortality rates from data in the UK Annual Reports from the Registrar General were entered into a database. Charts were created to display trends in hemorrhage mortality, allowing comparison with historical medical advances. Hemorrhage death rates fell steadily before the 1930s; between 1874 and 1926 they fell by 56%. In contrast, there was no consistent reduction in overall maternal mortality rates until the 1930s; from 1932 to 1952 they fell by 85%, primarily due to a reduction in sepsis deaths. In conclusion the majority of maternal hemorrhage mortality reductions in the UK occurred prior to the availability of effective oxytocics, antibiotics, and blood transfusion. Improving access to and standards of maternal care is key to addressing global maternal mortality today. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology.

Unmasking inequalities: Sub-national maternal and child mortality data from two urban slums in Lagos, Nigeria tells the story.

PubMed

Anastasi, Erin; Ekanem, Ekanem; Hill, Olivia; Adebayo Oluwakemi, Agnes; Abayomi, Oluwatosin; Bernasconi, Andrea

2017-01-01

Nigeria has one of the highest maternal mortality ratios in the world as well as high perinatal mortality. Unfortunately, the country does not have the resources to assess this critical indicator with the conventional health information system and measuring its progress toward the goal of ending preventable maternal deaths is almost impossible. Médecins Sans Frontières (MSF) conducted a cross-sectional study to assess maternal and perinatal mortality in Makoko Riverine and Badia East, two of the most vulnerable slums of Lagos. The study was a cross-sectional, community-based household survey. Nearly 4,000 households were surveyed. The sisterhood method was utilized to estimate maternal mortality and the preceding births technique was used to estimate newborn and child mortality. Questions regarding health seeking behavior were posed to female interviewees and self-reported data were collected. Data was collected from 3963 respondents for a total of 7018 sisters ever married. The maternal mortality ratio was calculated at 1,050/100,000 live births (95% CI: 894-1215), and the lifetime risk of maternal death at 1:18. The neonatal mortality rate was extracted from 1967 pregnancies reported and was estimated at 28.4/1,000; infant mortality at 43.8/1,000 and under-five mortality at 103/1,000. Living in Badia, giving birth at home and belonging to the Egun ethnic group were associated with higher perinatal mortality. Half of the last pregnancies were reportedly delivered in private health facilities. Proximity to home was the main influencing factor (32.4%) associated with delivery at the health facility. The maternal mortality ratio found in these urban slum populations within Lagos is extremely high, compared to the figure estimated for Lagos State of 545 per 100,000 live births. Urgent attention is required to address these neglected and vulnerable neighborhoods. Efforts should be invested in obtaining data from poor, marginalized, and hard-to-reach populations in

Distribution of causes of maternal mortality during delivery and post-partum: results of an African multicentre hospital-based study.

PubMed

Thonneau, Patrick F; Matsudai, Tomohiro; Alihonou, Eusèbe; De Souza, Jose; Faye, Ousseynou; Moreau, Jean-Charles; Djanhan, Yao; Welffens-Ekra, Christiane; Goyaux, Nathalie

2004-06-15

To assess the maternal mortality ratio in maternity units of reference hospitals in large west African cities, and to describe the distribution of complications and causes of maternal deaths. Prospective descriptive study in twelve reference maternities located in three African countries (Benin, Ivory Coast, Senegal). Data (clinical findings at hospital entry, medical history, complications, type of surgery, vital status of the women at discharge) were collected from obstetrical and surgical files and from admission hospital registers. All cases of maternal deaths were systematically reviewed by African and European staff. Of a total of 10,515 women, 1495 presented a major obstetric complication with dystocia or inappropriate management of the labour phase as the leading cause. Eighty-five maternal deaths were reported, giving a global hospital-based maternal mortality ratio of 800/100,000. Hypertensive disorders were involved in 25/85 cases (29%) and post-partum haemorrhage in 13/85 cases (15%). Relatively few cases (14) of major sepsis were reported, leading to three maternal deaths. The results of this multicentre study confirm the high rates of maternal mortality in maternity units of reference hospitals in large African cities, and in addition to dystocia the contribution of hypertensive disorders and post-partum haemorrhage to maternal deaths.

Reducing maternal deaths in a low resource setting in Nigeria.

PubMed

Ezugwu, E C; Agu, P U; Nwoke, M O; Ezugwu, F O

2014-01-01

To assess the impact of the adoption of evidence based guidelines on maternal mortality reduction at Enugu State University Teaching Hospital, Nigeria. A retrospective review of all maternal deaths between 1 st January, 2005 and 31 st December, 2010 was carried out. Evidence based management guidelines for eclampsia and post-partum hemorrhage were adopted. These interventions strategy were carried out from 1 st January, 2008-31 st December, 2010 and the result compared with that before the interventions (2005-2007). Maternal mortality ratio (MMR) and case fatality rates. There were 9150 live births and 59 maternal deaths during the study period, giving an MMR of 645/100 000 live births. Pregnant women who had no antenatal care had almost 10 times higher MMR. There was 43.5% reduction in the MMR with the interventions (488 vs. 864/100 000 live births P = 0.039, odds ratio = 1.77). There was also significant reduction in case fatality rate for both eclampsia (15.8% vs. 2.7%; P = 0.024, odds ratio = 5.84 and Post partum hemorrhage (PPH) (13.6% vs. 2.5% P value = 0.023, odds ratio = 5.5. Obstetric hemorrhage was the most common cause of death (23.73%), followed by the eclampsia. Administration of evidence based intervention is possible in low resource settings and could contribute to a significant reduction in the maternal deaths.

Knowledge of safe motherhood among women in rural communities in northern Nigeria: implications for maternal mortality reduction

PubMed Central

2013-01-01

Background Most developed countries have made considerable progress in addressing maternal mortality, but it appears that countries with high maternal mortality burdens like Nigeria have made little progress in improving maternal health outcomes despite emphasis by the Millennium Development Goals (MDGs). Knowledge about safe motherhood practices could help reduce pregnancy related health risks. This study examines knowledge of safe motherhood among women in selected rural communities in northern Nigeria. Methods This was a cross-sectional study carried out in two states (Kaduna and Kano States) within northern Nigeria. Pretested, interviewer-administered questionnaires were applied by female data collectors to 540 randomly selected women who had recently delivered within the study site. Chi-square tests were used to determine possible association between variables during bivariate analysis. Variables significant in the bivariate analysis were subsequently entered into a multivariate logistic regression analysis. The degree of association was estimated by odds ratio (OR) and 95% confidence interval (CI) between knowledge of maternal danger signs and independent socio-demographic as well as obstetric history variables which indicated significance at p< 0.05. Results Over 90% of respondents in both states showed poor knowledge of the benefits of health facility delivery by a skilled birth attendant. More than 80% of respondents in both states displayed poor knowledge of the benefits of ANC visits. More than half of the respondents across both states had poor knowledge of maternal danger signs. According to multivariate regression analysis, ever attending school by a respondent increased the likelihood of knowing maternal danger signs by threefold (OR 2.63, 95% CI: 1.2-5.8) among respondents in Kaduna State. While attendance at ANC visits during most recent pregnancy increased the likelihood of knowing maternal danger signs by twofold among respondents in Kano State

TulaSalud: An m-health system for maternal and infant mortality reduction in Guatemala.

PubMed

Martínez-Fernández, Andrés; Lobos-Medina, Isabel; Díaz-Molina, Cesar Augusto; Chen-Cruz, Moisés Faraón; Prieto-Egido, Ignacio

2015-07-01

The Guatemalan NGO (Non-Governmental Organization) TulaSalud has implemented an m-health project in the Department of Alta Verapaz. This Department has 1.2 million inhabitants (78% living in rural areas and 89% from indigenous communities) and in 2012, had a maternal mortality rate of 273 for every 100,000 live births. This m-health initiative is based on the provision of a cell phone to community facilitators (CFs). The CFs are volunteers in rural communities who perform health prevention, promotion and care. Thanks to the cell phone, the CFs have become tele-CFs who able to carry out consultations when they have questions; send full epidemiological and clinical information related to the cases they attend to; receive continuous training; and perform activities for the prevention and promotion of community health through distance learning sessions in the Q'eqchí and/or Poqomchi' languages. In this study, rural populations served by tele-CFs were selected as the intervention group while the control group was composed of the rural population served by CFs without Information and Communication Technology (ICT) tools. As well as the achievement of important process results (116,275 medical consultations, monitoring of 6,783 pregnant women, and coordination of 2,014 emergency transfers), the project has demonstrated a statistically significant decrease in maternal mortality (p < 0.05) and in child mortality (p = 0.054) in the intervention group compared with rates in the control group. As a result of the telemedicine initiative, the intervention areas, which were selected for their high maternal and infant mortality rates, currently show maternal and child mortality indicators that are not only lower than the indicators in the control area, but also lower than the provincial average (which includes urban areas). © The Author(s) 2015.

Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the 'migration three delays' model.

PubMed

Esscher, Annika; Binder-Finnema, Pauline; Bødker, Birgit; Högberg, Ulf; Mulic-Lutvica, Ajlana; Essén, Birgitta

2014-04-12

Several European countries report differences in risk of maternal mortality between immigrants from low- and middle-income countries and host country women. The present study identified suboptimal factors related to care-seeking, accessibility, and quality of care for maternal deaths that occurred in Sweden from 1988-2010. A subset of maternal death records (n = 75) among foreign-born women from low- and middle-income countries and Swedish-born women were audited using structured implicit review. One case of foreign-born maternal death was matched with two native born Swedish cases of maternal death. An assessment protocol was developed that applied both the 'migration three delays' framework and a modified version of the Confidential Enquiry from the United Kingdom. The main outcomes were major and minor suboptimal factors associated with maternal death in this high-income, low-maternal mortality context. Major and minor suboptimal factors were associated with a majority of maternal deaths and significantly more often to foreign-born women (p = 0.01). The main delays to care-seeking were non-compliance among foreign-born women and communication barriers, such as incongruent language and suboptimal interpreter system or usage. Inadequate care occurred more often among the foreign-born (p = 0.04), whereas delays in consultation/referral and miscommunication between health care providers where equally common between the two groups. Suboptimal care factors, major and minor, were present in more than 2/3 of maternal deaths in this high-income setting. Those related to migration were associated to miscommunication, lack of professional interpreters, and limited knowledge about rare diseases and pregnancy complications. Increased insight into a migration perspective is advocated for maternity clinicians who provide care to foreign-born women.

Preconception maternal bereavement and infant and childhood mortality: A Danish population-based study

PubMed Central

Class, Quetzal A.; Mortensen, Preben B.; Henriksen, Tine B.; Dalman, Christina; D’Onofrio, Brian M.; Khashan, Ali S.

2015-01-01

Objectives Preconception maternal bereavement may be associated with an increased risk for infant mortality, though these previously reported findings have not been replicated. We sought to examine if the association could be replicated and explore if risk extended into childhood. Methods Using a Danish population-based sample of offspring born 1979–2009 (N=1,865,454), we predicted neonatal (0–28 days), post-neonatal infant (29–364 days), and early childhood (1–5 years) mortality following maternal bereavement in the preconception (6–0 months before pregnancy) and prenatal (between conception and birth) periods. Maternal bereavement was defined as death of a first degree relative of the mother. Analyses were conducted using logistic and log-linear Poisson regression that were adjusted for offspring, mother, and father sociodemographic and health factors. Results We identified 6,541 (0.004%) neonates, 3,538 (0.002%) post-neonates, and 2,132 (0.001%) children between the ages of 1 to 5 years who died. After adjusting for covariates, bereavement during the preconception period was associated with an increased odds of neonatal (adjusted odds ratio [aOR] = 1.87, 95% CI: 1.53–2.30) and post-neonatal infant mortality (aOR=1.52, 95% CI: 1.15–2.02). Associations were timing-specific (6 months prior to pregnancy only) and consistent across sensitivity analyses. Bereavement during the prenatal period was not consistently associated with increased risk of offspring mortality, however this may reflect relatively low statistical power. Conclusions Results support and extend previous findings linking bereavement during the preconception period with increased odds of early offspring mortality. The period immediately prior to pregnancy may be a sensitive period with potential etiological implications and ramifications for offspring mortality. PMID:26374948

Unmasking inequalities: Sub-national maternal and child mortality data from two urban slums in Lagos, Nigeria tells the story

PubMed Central

Adebayo Oluwakemi, Agnes; Abayomi, Oluwatosin

2017-01-01

Introduction Nigeria has one of the highest maternal mortality ratios in the world as well as high perinatal mortality. Unfortunately, the country does not have the resources to assess this critical indicator with the conventional health information system and measuring its progress toward the goal of ending preventable maternal deaths is almost impossible. Médecins Sans Frontières (MSF) conducted a cross-sectional study to assess maternal and perinatal mortality in Makoko Riverine and Badia East, two of the most vulnerable slums of Lagos. Materials and methods The study was a cross-sectional, community-based household survey. Nearly 4,000 households were surveyed. The sisterhood method was utilized to estimate maternal mortality and the preceding births technique was used to estimate newborn and child mortality. Questions regarding health seeking behavior were posed to female interviewees and self-reported data were collected. Results Data was collected from 3963 respondents for a total of 7018 sisters ever married. The maternal mortality ratio was calculated at 1,050/100,000 live births (95% CI: 894–1215), and the lifetime risk of maternal death at 1:18. The neonatal mortality rate was extracted from 1967 pregnancies reported and was estimated at 28.4/1,000; infant mortality at 43.8/1,000 and under-five mortality at 103/1,000. Living in Badia, giving birth at home and belonging to the Egun ethnic group were associated with higher perinatal mortality. Half of the last pregnancies were reportedly delivered in private health facilities. Proximity to home was the main influencing factor (32.4%) associated with delivery at the health facility. Discussion The maternal mortality ratio found in these urban slum populations within Lagos is extremely high, compared to the figure estimated for Lagos State of 545 per 100,000 live births. Urgent attention is required to address these neglected and vulnerable neighborhoods. Efforts should be invested in obtaining data from

Mediational pathways connecting secondary education and age at marriage to maternal mortality: A comparison between developing and developed countries.

PubMed

Hagues, Rachel Joy; Bae, DaYoung; Wickrama, Kandauda K A S

2017-02-01

While studies have shown that maternal mortality rates have been improving worldwide, rates are still high across developing nations. In general, poor health of women is associated with higher maternal mortality rates in developing countries. Understanding country-level risk factors can inform intervention and prevention efforts that could bring high maternal mortality rates down. Specifically, the authors were interested in investigating whether: (1) secondary education participation (SEP) or age at marriage (AM) of women were related to maternal mortality rates, and (2) adolescent birth rate and contraceptive use (CU) acted as mediators of this association. The authors add to the literature with this current article by showing the relation of SEP and AM to maternal mortality rates globally (both directly and indirectly through mediators) and then by comparing differences between developed and developing/least developed countries. Path analysis was used to test the hypothesized model using country level longitudinal data from 2000 to 2010 obtained from United Nations publications, World Health Organization materials, and World Bank development reports. Findings include a significant correlation between SEP and AM for developing countries; for developed countries the relation was not significant. As well, SEP in developing countries was associated with increased CU. Women in developing countries who finish school before marriage may have important social capital gains.

Temporal evolution and spatial distribution of maternal death

PubMed Central

Carreno, Ioná; Bonilha, Ana Lúcia de Lourenzi; da Costa, Juvenal Soares Dias

2014-01-01

OBJECTIVE To analyze the temporal evolution of maternal mortality and its spatial distribution. METHODS Ecological study with a sample made up of 845 maternal deaths in women between 10 and 49 years, registered from 1999 to 2008 in the state of Rio Grande do Sul, Southern Brazil. Data were obtained from Information System on Mortality of Ministry of Health. The maternal mortality ratio and the specific maternal mortality ratio were calculated from records, and analyzed by the Poisson regression model. In the spatial distribution, three maps of the state were built with the rates in the geographical macro-regions, in 1999, 2003, and 2008. RESULTS There was an increase of 2.0% in the period of ten years (95%CI 1.00;1.04; p = 0.01), with no significant change in the magnitude of the maternal mortality ratio. The Serra macro-region presented the highest maternal mortality ratio (1.15, 95%CI 1.08;1.21; p < 0.001). Most deaths in Rio Grande do Sul were of white women over 40 years, with a lower level of education. The time of delivery/abortion and postpartum are times of increased maternal risk, with a greater negative impact of direct causes such as hypertension and bleeding. CONCLUSIONS The lack of improvement in maternal mortality ratio indicates that public policies had no impact on women’s reproductive and maternal health. It is needed to qualify the attention to women’s health, especially in the prenatal period, seeking to identify and prevent risk factors, as a strategy of reducing maternal death. PMID:25210825

The value of customised centiles in assessing perinatal mortality risk associated with parity and maternal size.

PubMed

Gardosi, J; Clausson, B; Francis, A

2009-09-01

We wanted to compare customised and population standards for defining smallness for gestational age (SGA) in the assessment of perinatal mortality risk associated with parity and maternal size. Population-based cohort study. Sweden. Swedish Birth Registry database 1992-1995 with 354 205 complete records. Coefficients were derived and applied to determine SGA by the fully customised method, or by adjustment for fetal sex only, and using the same fetal weight standard. Perinatal deaths and rates of small for gestational age (SGA) babies within subgroups stratified by parity, body mass index (BMI) and maternal size within the BMI range of 20.0-24.9. Perinatal mortality rates (PMR) had a U-shaped distribution in parity groups, increased proportionately with maternal BMI, and had no association with maternal size within the normal BMI range. For each of these subgroups, SGA rates determined by the customised method showed strong association with the PMR. In contrast, SGA based on uncustomised, population-based centiles had poor correlation with perinatal mortality. The increased perinatal mortality risk in pregnancies of obese mothers was associated with an increased risk of SGA using customised centiles, and a decreased risk of SGA using population-based centiles. The use of customised centiles to determine SGA improves the identification of pregnancies which are at increased risk of perinatal death.

[Human rights, maternal mortality and reproductive health].

PubMed

Cook, R J

1993-06-01

This work examines reproductive health within the framework of human rights assured by various international conventions, and analyzes the high maternal mortality rates of developing countries as a violation of several guaranteed rights. The 1st of 3 main sections of the report discusses the failure of governments to make protection of women's reproductive health a priority. Historically, women's principal role has been to bear children, and no recognition was given to the cost in health of accomplishing this duty. Women's reproductive health has created controversies in many traditional juridical systems because of its relation to human sexuality and morals. WHO has estimated that some 500,000 maternal deaths occur each year, with 25-50% resulting from unsafe abortions. The causes of maternal mortality often have their roots in the poor nutrition or inadequate health care provided to the woman long before the 1st pregnancy. Early and frequent pregnancies and heavy physical labor are among the many factors that contribute to maternal death. Laws to protect women's health may be lacking or may not be applied. For example, many countries have no legal minimum age for marriage. To combat the traditional negligence, a new viewpoint is emerging which views women's reproductive health as a condition in which childbearing occurs in a state of physical, mental, and social wellbeing. It implies that women have the capacity to reproduce, regulate their fertility, and enjoy sexual relations. Laws that deny access to reproductive health services or place obstacles or conditions in the way are coming under question as violations of basic human rights of women protected by international conventions. The main such convention discussed in this article is the Convention on the Elimination of All Forms of Discrimination Against Women, although several other conventions are relevant to protecting women's reproductive health. If international law on human rights is to become truly

Does the Use of Diagnostic Technology Reduce Fetal Mortality?

PubMed

Grytten, Jostein; Skau, Irene; Sørensen, Rune; Eskild, Anne

2018-01-19

To examine the effect that the introduction of new diagnostic technology in obstetric care has had on fetal death. The Medical Birth Registry of Norway provided detailed medical information for approximately 1.2 million deliveries from 1967 to 1995. Information about diagnostic technology was collected directly from the maternity units, using a questionnaire. The data were analyzed using a hospital fixed-effects regression with fetal mortality as the outcome measure. The key independent variables were the introduction of ultrasound and electronic fetal monitoring at each maternity ward. Hospital-specific trends and risk factors of the mother were included as control variables. The richness of the data allowed us to perform several robustness tests. The introduction of ultrasound caused a significant drop in fetal mortality rate, while the introduction of electronic fetal monitoring had no effect on the rate. In the population as a whole, ultrasound contributed to a reduction in fetal deaths of nearly 20 percent. For post-term deliveries, the reduction was well over 50 percent. The introduction of ultrasound made a major contribution to the decline in fetal mortality at the end of the last century. © Health Research and Educational Trust.

Exploring Child Mortality Risks Associated with Diverse Patterns of Maternal Migration in Haiti

PubMed Central

Smith-Greenaway, Emily; Thomas, Kevin

2014-01-01

Internal migration is a salient dimension of adulthood in Haiti, particularly among women. Despite the prevalence of migration in Haiti, it remains unknown whether Haitian women’s diverse patterns of migration influence their children’s health and survival. In this paper, we introduce the concept of lateral (i.e., rural-to-rural, urban-to-urban) versus nonlateral (i.e., rural-to-urban, urban-to-rural) migration to describe how some patterns of mothers’ internal migration may be associated with particularly high mortality among children. We use the 2006 Haitian Demographic and Health Survey to estimate a series of discrete-time hazard models among 7,409 rural children and 3,864 urban children. We find that, compared with their peers with nonmigrant mothers, children born to lateral migrants generally experience lower mortality whereas those born to nonlateral migrants generally experience higher mortality. Although there are important distinctions across Haiti’s rural and urban contexts, these associations remain net of socioeconomic factors, suggesting they are not entirely attributable to migrant selection. Considering the timing of maternal migration uncovers even more variation in the child health implications of maternal migration; however, the results counter the standard disruption and adaptation perspective. Although future work is needed to identify the processes underlying the differential risk of child mortality across lateral versus nonlateral migrants, the study demonstrates that looking beyond rural-to-urban migration and considering the timing of maternal migration can provide a fuller, more complex understanding of migration’s association with child health. PMID:25506111

Pitfalls of national routine death statistics for maternal mortality study.

PubMed

Saucedo, Monica; Bouvier-Colle, Marie-Hélène; Chantry, Anne A; Lamarche-Vadel, Agathe; Rey, Grégoire; Deneux-Tharaux, Catherine

2014-11-01

The lessons learned from the study of maternal deaths depend on the accuracy of data. Our objective was to assess time trends in the underestimation of maternal mortality (MM) in the national routine death statistics in France and to evaluate their current accuracy for the selection and causes of maternal deaths. National data obtained by enhanced methods in 1989, 1999, and 2007-09 were used as the gold standard to assess time trends in the underestimation of MM ratios (MMRs) in death statistics. Enhanced data and death statistics for 2007-09 were further compared by characterising false negatives (FNs) and false positives (FPs). The distribution of cause-specific MMRs, as assessed by each system, was described. Underestimation of MM in death statistics decreased from 55.6% in 1989 to 11.4% in 2007-09 (P < 0.001). In 2007-09, of 787 pregnancy-associated deaths, 254 were classified as maternal by the enhanced system and 211 by the death statistics; 34% of maternal deaths in the enhanced system were FNs in the death statistics, and 20% of maternal deaths in the death statistics were FPs. The hierarchy of causes of MM differed between the two systems. The discordances were mainly explained by the lack of precision in the drafting of death certificates by clinicians. Although the underestimation of MM in routine death statistics has decreased substantially over time, one third of maternal deaths remain unidentified, and the main causes of death are incorrectly identified in these data. Defining relevant priorities in maternal health requires the use of enhanced methods for MM study. © 2014 John Wiley & Sons Ltd.

Standardized severe maternal morbidity review: rationale and process.

PubMed

Kilpatrick, Sarah J; Berg, Cynthia; Bernstein, Peter; Bingham, Debra; Delgado, Ana; Callaghan, William M; Harris, Karen; Lanni, Susan; Mahoney, Jeanne; Main, Elliot; Nacht, Amy; Schellpfeffer, Michael; Westover, Thomas; Harper, Margaret

2014-08-01

Severe maternal morbidity and mortality have been rising in the United States. To begin a national effort to reduce morbidity, a specific call to identify all pregnant and postpartum women experiencing admission to an intensive care unit or receipt of 4 or more units of blood for routine review has been made. While advocating for review of these cases, no specific guidance for the review process was provided. Therefore, the aim of this expert opinion is to present guidelines for a standardized severe maternal morbidity interdisciplinary review process to identify systems, professional, and facility factors that can be ameliorated, with the overall goal of improving institutional obstetric safety and reducing severe morbidity and mortality among pregnant and recently pregnant women. This opinion was developed by a multidisciplinary working group that included general obstetrician-gynecologists, maternal-fetal medicine subspecialists, certified nurse-midwives, and registered nurses all with experience in maternal mortality reviews. A process for standardized review of severe maternal morbidity addressing committee organization, review process, medical record abstraction and assessment, review culture, data management, review timing, and review confidentiality is presented. Reference is made to a sample severe maternal morbidity abstraction and assessment form.

Maternal tetanus toxoid vaccination and neonatal mortality in rural north India.

PubMed

Singh, Abhishek; Pallikadavath, Saseendran; Ogollah, Reuben; Stones, William

2012-01-01

Preventable neonatal mortality due to tetanus infection remains common. We aimed to examine antenatal vaccination impact in a context of continuing high neonatal mortality in rural northern India. Using the third round of the Indian National Family Health Survey (NFHS) 2005-06, mortality of most recent singleton births was analysed in discrete-time logistic model with maternal tetanus vaccination, together with antenatal care utilisation and supplementation with iron and folic acid. 59% of mothers reported receiving antenatal care, 48% reported receiving iron and folic acid supplementation and 68% reported receiving two or more doses of tetanus toxoid (TT) vaccination. The odds of all-cause neonatal death were reduced following one or more antenatal dose of TT with odds ratios (OR) of 0.46 (95% CI 0.26 to 0.78) after one dose and 0.45 (95% CI 0.31 to 0.66) after two or more doses. Reported utilisation of antenatal care and iron-folic acid supplementation did not influence neonatal mortality. In the statistical model, 16% (95% CI 5% to 27%) of neonatal deaths could be attributed to a lack of at least two doses of TT vaccination during pregnancy, representing an estimated 78,632 neonatal deaths in absolute terms. Substantial gains in newborn survival could be achieved in rural North India through increased coverage of antenatal TT vaccination. The apparent substantial protective effect of a single antenatal dose of TT requires further study. It may reflect greater population vaccination coverage and indicates that health programming should prioritise universal antenatal coverage with at least one dose.

What Pertussis Mortality Rates Make Maternal Acellular Pertussis Immunization Cost-Effective in Low- and Middle-Income Countries? A Decision Analysis

PubMed Central

Russell, Louise B.; Pentakota, Sri Ram; Toscano, Cristiana Maria; Cosgriff, Ben; Sinha, Anushua

2016-01-01

Background. Despite longstanding infant vaccination programs in low- and middle-income countries (LMICs), pertussis continues to cause deaths in the youngest infants. A maternal monovalent acellular pertussis (aP) vaccine, in development, could prevent many of these deaths. We estimated infant pertussis mortality rates at which maternal vaccination would be a cost-effective use of public health resources in LMICs. Methods. We developed a decision model to evaluate the cost-effectiveness of maternal aP immunization plus routine infant vaccination vs routine infant vaccination alone in Bangladesh, Nigeria, and Brazil. For a range of maternal aP vaccine prices, one-way sensitivity analyses identified the infant pertussis mortality rates required to make maternal immunization cost-effective by alternative benchmarks ($100, 0.5 gross domestic product [GDP] per capita, and GDP per capita per disability-adjusted life-year [DALY]). Probabilistic sensitivity analysis provided uncertainty intervals for these mortality rates. Results. Infant pertussis mortality rates necessary to make maternal aP immunization cost-effective exceed the rates suggested by current evidence except at low vaccine prices and/or cost-effectiveness benchmarks at the high end of those considered in this report. For example, at a vaccine price of $0.50/dose, pertussis mortality would need to be 0.051 per 1000 infants in Bangladesh, and 0.018 per 1000 in Nigeria, to cost 0.5 per capita GDP per DALY. In Brazil, a middle-income country, at a vaccine price of $4/dose, infant pertussis mortality would need to be 0.043 per 1000 to cost 0.5 per capita GDP per DALY. Conclusions. For commonly used cost-effectiveness benchmarks, maternal aP immunization would be cost-effective in many LMICs only if the vaccine were offered at less than $1–$2/dose. PMID:27838677

Maternal care receptivity and its relation to perinatal and neonatal mortality. A rural study.

PubMed

Bhardwaj, N; Hasan, S B; Zaheer, M

1995-04-01

A longitudinal study was conducted on 212 pregnant women from May 1987 to April 1988. Maternal Care Receptivity (MCR) "an innovative approach" was adopted for the assessment of maternal care services provided to pregnant mothers at their door steps. During follow-up, scores were allotted to each of the services rendered and antenatal status of pregnant women. Depending on the score--MCR was classified as high (11 to 8), moderate (7 to 4) or poor (3 to 0). Perinatal and neonatal deaths were recorded and an inverse relationship between MCR and perinatal and mortalities was observed (z = 5.46, p < 0.0001). Significantly, no perinatal or neonatal deaths occurred in women with high MCR. One of the most important cause of high PNMR and neonatal mortality rate in developing countries is poor MCR, i.e., under utilization of even the existing maternal health services. The main reasons for this under utilization appear to be poverty, illiteracy, ignorance and lack of faith in modern medicine.

Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model

PubMed Central

2014-01-01

Background Several European countries report differences in risk of maternal mortality between immigrants from low- and middle-income countries and host country women. The present study identified suboptimal factors related to care-seeking, accessibility, and quality of care for maternal deaths that occurred in Sweden from 1988–2010. Methods A subset of maternal death records (n = 75) among foreign-born women from low- and middle-income countries and Swedish-born women were audited using structured implicit review. One case of foreign-born maternal death was matched with two native born Swedish cases of maternal death. An assessment protocol was developed that applied both the ‘migration three delays’ framework and a modified version of the Confidential Enquiry from the United Kingdom. The main outcomes were major and minor suboptimal factors associated with maternal death in this high-income, low-maternal mortality context. Results Major and minor suboptimal factors were associated with a majority of maternal deaths and significantly more often to foreign-born women (p = 0.01). The main delays to care-seeking were non-compliance among foreign-born women and communication barriers, such as incongruent language and suboptimal interpreter system or usage. Inadequate care occurred more often among the foreign-born (p = 0.04), whereas delays in consultation/referral and miscommunication between health care providers where equally common between the two groups. Conclusions Suboptimal care factors, major and minor, were present in more than 2/3 of maternal deaths in this high-income setting. Those related to migration were associated to miscommunication, lack of professional interpreters, and limited knowledge about rare diseases and pregnancy complications. Increased insight into a migration perspective is advocated for maternity clinicians who provide care to foreign-born women. PMID:24725307

Using human rights in maternal mortality programs: from analysis to strategy.

PubMed

Freedman, L P

2001-10-01

This article describes an approach to maternal mortality reduction that uses human rights not simply to denounce the injustice of death in pregnancy and childbirth, but also to guide the design and implementation of maternal mortality policies and programs. As a first principle, programs and policies need to prioritize measures that promote universal access to high quality emergency obstetric care services, which we know from health research are essential to saving women's lives. With that priority, human rights principles can be integrated into programs at the clinical, facility management, and national policy levels. For example, a human rights 'audit' can help identify ways to encourage respectful, non-discriminatory treatment of patients, providers and staff in the clinical setting. Human rights principles of entitlement and accountability can inform mechanisms of community participation designed to improve responsiveness and functioning of health facilities. Human rights principles can inform analysis of health sector reform and its impact on access to emergency obstetric care. Whether applied to the intricacies of human relationships within a facility or to the impact of international financial institutions on health systems, the ultimate role of human rights is to identify the workings of power that keep unacceptable levels of maternal morality as they are and to use the human rights vision of dignity and social justice to work for the re-arrangements of power necessary for change.

Health system determinants of infant, child and maternal mortality: A cross-sectional study of UN member countries

PubMed Central

2011-01-01

Objective Few studies have examined the link between health system strength and important public health outcomes across nations. We examined the association between health system indicators and mortality rates. Methods We used mixed effects linear regression models to investigate the strength of association between outcome and explanatory variables, while accounting for geographic clustering of countries. We modelled infant mortality rate (IMR), child mortality rate (CMR), and maternal mortality rate (MMR) using 13 explanatory variables as outlined by the World Health Organization. Results Significant protective health system determinants related to IMR included higher physician density (adjusted rate ratio [aRR] 0.81; 95% Confidence Interval [CI] 0.71-0.91), higher sustainable access to water and sanitation (aRR 0.85; 95% CI 0.78-0.93), and having a less corrupt government (aRR 0.57; 95% CI 0.40-0.80). Out-of-pocket expenditures on health (aRR 1.29; 95% CI 1.03-1.62) were a risk factor. The same four variables were significantly related to CMR after controlling for other variables. Protective determinants of MMR included access to water and sanitation (aRR 0.88; 95% CI 0.82-0.94), having a less corrupt government (aRR 0.49; 95%; CI 0.36-0.66), and higher total expenditures on health per capita (aRR 0.84; 95% CI 0.77-0.92). Higher fertility rates (aRR 2.85; 95% CI: 2.02-4.00) were found to be a significant risk factor for MMR. Conclusion Several key measures of a health system predict mortality in infants, children, and maternal mortality rates at the national level. Improving access to water and sanitation and reducing corruption within the health sector should become priorities. PMID:22023970

Direct and maternal additive effects are not the main determinants of Iberian piglet perinatal mortality.

PubMed

Muñoz, M; Rodríguez, M C; García-Cortes, L A; González, A; García-Casco, J M; Silió, L

2017-12-01

Data of 127,800 Iberian piglets were used to study genetic parameters of mortality at birth at the piglet level. These records proceed from three data sets: 4,987 litter of 2,156 sows of a dam line, 2,768 litter of 817 sows of a complete diallel cross between four Iberian strains and 7,153 litter of 2,113 sows of the Torbiscal composite line. Perinatal mortality was considered as a binary trait, and Bayesian threshold animal models were fitted to separately analyse the three data sets. The posterior means of direct heritability were 0.010, 0.004 and 0.003, and those of maternal heritability were 0.034, 0.011 and 0.014 for dam line, diallel cross and Torbiscal line, respectively. Important effects of litter size and parity order were inferred in the three data sets, of within-breed cross-breeding parameters in the diallel cross and of sex and sow handling in the Torbiscal line Therefore, the inclusion of perinatal mortality in the objective of selection is questionable in this breed and strategies for reducing piglet mortality successful in other breeds should be considered. © 2017 Blackwell Verlag GmbH.

Association between Maternal Mortality and Cesarean Section: Turkey Experience

PubMed Central

Uzuncakmak, Cihangir; Ozcam, Hasene

2016-01-01

Background To investigate the cesarean Section (C/S) rates and maternal mortality (MM) causes and its relation between 2002 and 2013. Methods Data were gathered from Turkish Ministry of Health and Istanbul Health Administration. The Annual Clinical Reports for 2002–2013 were reviewed and analyzed: C/Ss and maternal deaths in women who gave birth ≥20 weeks between January 1, 2002, and December 31, 2013, in any hospital in Turkey and Istanbul. Results The major causes of MM were hemorrhage (20%), hypertensive disorders (18.2%), embolism (10.3%), cardiovascular conditions (9%), infection (8.5%), and other causes (10.4%). Overall, the average annual CS delivery rate was 46.4% in Istanbul and 36.6% in Turkey. There was a significant increase in the CS rates in Istanbul and Turkey from 2008 to 2013 relative to those from 2002 to 2007 (p = 0.004). There was a statistically significant and inverse relationship (97.2%) between the MMR and CS rate from 2002 to 2013 in Turkey (p = 0.001). However, no significant relationship was detected between the MMR and CS rate from 2002 to 2013 in Istanbul (p > 0.05). There was a significant inverse correlation (66.3%) between the CS rate and peripartumhemorrhage in Turkey (p = 0.019) and there was a significant inverse correlation (66.5%) between the CS rate and peripartumhemorrhage(p = 0.018) in Istanbul between 2007 to 2013. There were no significant differences in ante-intrapartum haemorrhage bleeding (p > 0.05) or postpartum hemorrhage (p > 0.05) from 2007 to 2013. Conclusions This study demonstrates that there was a inverse correlation between increased CS and maternal mortality rates during the previous decade in Turkey. Although cesarean rates increase excessively, it appears that improved health care facilities have a positive effect on MMRs in Turkey. PMID:27880841

Association between Maternal Mortality and Cesarean Section: Turkey Experience.

PubMed

Uzuncakmak, Cihangir; Ozcam, Hasene

2016-01-01

To investigate the cesarean Section (C/S) rates and maternal mortality (MM) causes and its relation between 2002 and 2013. Data were gathered from Turkish Ministry of Health and Istanbul Health Administration. The Annual Clinical Reports for 2002-2013 were reviewed and analyzed: C/Ss and maternal deaths in women who gave birth ≥20 weeks between January 1, 2002, and December 31, 2013, in any hospital in Turkey and Istanbul. The major causes of MM were hemorrhage (20%), hypertensive disorders (18.2%), embolism (10.3%), cardiovascular conditions (9%), infection (8.5%), and other causes (10.4%). Overall, the average annual CS delivery rate was 46.4% in Istanbul and 36.6% in Turkey. There was a significant increase in the CS rates in Istanbul and Turkey from 2008 to 2013 relative to those from 2002 to 2007 (p = 0.004). There was a statistically significant and inverse relationship (97.2%) between the MMR and CS rate from 2002 to 2013 in Turkey (p = 0.001). However, no significant relationship was detected between the MMR and CS rate from 2002 to 2013 in Istanbul (p > 0.05). There was a significant inverse correlation (66.3%) between the CS rate and peripartumhemorrhage in Turkey (p = 0.019) and there was a significant inverse correlation (66.5%) between the CS rate and peripartumhemorrhage(p = 0.018) in Istanbul between 2007 to 2013. There were no significant differences in ante-intrapartum haemorrhage bleeding (p > 0.05) or postpartum hemorrhage (p > 0.05) from 2007 to 2013. This study demonstrates that there was a inverse correlation between increased CS and maternal mortality rates during the previous decade in Turkey. Although cesarean rates increase excessively, it appears that improved health care facilities have a positive effect on MMRs in Turkey.

Maternal Mortality in Colombia in 2011: A Two Level Ecological Study

PubMed Central

Cárdenas-Cárdenas, Luz Mery; Cotes-Cantillo, Karol; Chaparro-Narváez, Pablo Enrique; Fernández-Niño, Julián Alfredo; Paternina-Caicedo, Angel; Castañeda-Orjuela, Carlos; De la Hoz-Restrepo, Fernando

2015-01-01

Objective Maternal mortality reduction is a Millennium Development Goal. In Colombia, there is a large disparity in the maternal mortality ratio (MMR) between and into departments (states) and also between municipalities. We examined socioeconomics variables at the municipal and departmental levels which could be associated to the municipal maternal mortality in Colombia. Methods A multilevel ecology study was carried out using different national data sources in Colombia. The outcome variable was the MMR at municipal level in 2011 with multidimensional poverty at municipal and department level as the principal independent variables and other measures of the social and economic characteristics at municipal and departmental level were also considered explicative variables (overall fertility municipal rate, percentage of local rural population, health insurance coverage, per capita territorial participation allocated to the health sector, transparency index and Gini coefficient). The association between MMR and socioeconomic contextual conditions at municipal and departmental level was assessed using a multilevel Poisson regression model. Results The MMR in the Colombian municipalities was associated significantly with the multidimensional poverty (relative ratio of MMR: 3.52; CI 95%: 1.09-11.38). This association was stronger in municipalities from departments with the highest poverty (relative ratio of MMR: 7.14; CI 95%: 2.01-25.35). Additionally, the MMR at municipal level was marginally associated with municipally health insurance coverage (relative ratio of MMR: 0.99; CI 95%: 0.98-1.00), and significantly with transparency index at departmental level (relative ratio of MMR: 0.98; CI 95%: 0.97-0.99). Conclusion Poverty and transparency in a contextual level were associated with the increase of the municipal MMR in Colombia. The results of this study are useful evidence for informing the public policies discussion and formulation processes with a differential

Maternal mortality in Colombia in 2011: a two level ecological study.

PubMed

Cárdenas-Cárdenas, Luz Mery; Cotes-Cantillo, Karol; Chaparro-Narváez, Pablo Enrique; Fernández-Niño, Julián Alfredo; Paternina-Caicedo, Angel; Castañeda-Orjuela, Carlos; De la Hoz-Restrepo, Fernando

2015-01-01

Maternal mortality reduction is a Millennium Development Goal. In Colombia, there is a large disparity in the maternal mortality ratio (MMR) between and into departments (states) and also between municipalities. We examined socioeconomics variables at the municipal and departmental levels which could be associated to the municipal maternal mortality in Colombia. A multilevel ecology study was carried out using different national data sources in Colombia. The outcome variable was the MMR at municipal level in 2011 with multidimensional poverty at municipal and department level as the principal independent variables and other measures of the social and economic characteristics at municipal and departmental level were also considered explicative variables (overall fertility municipal rate, percentage of local rural population, health insurance coverage, per capita territorial participation allocated to the health sector, transparency index and Gini coefficient). The association between MMR and socioeconomic contextual conditions at municipal and departmental level was assessed using a multilevel Poisson regression model. The MMR in the Colombian municipalities was associated significantly with the multidimensional poverty (relative ratio of MMR: 3.52; CI 95%: 1.09-11.38). This association was stronger in municipalities from departments with the highest poverty (relative ratio of MMR: 7.14; CI 95%: 2.01-25.35). Additionally, the MMR at municipal level was marginally associated with municipally health insurance coverage (relative ratio of MMR: 0.99; CI 95%: 0.98-1.00), and significantly with transparency index at departmental level (relative ratio of MMR: 0.98; CI 95%: 0.97-0.99). Poverty and transparency in a contextual level were associated with the increase of the municipal MMR in Colombia. The results of this study are useful evidence for informing the public policies discussion and formulation processes with a differential approach.

Reduction of maternal and perinatal mortality in rural and peri-urban settings: what works?

PubMed

Kwast, B E

1996-10-01

The purpose of this article is two-fold: (i) to lay out conceptual frameworks for programming in the fields of maternal and neonatal health for the reduction of maternal and peri/neonatal mortality; (ii) to describe selected MotherCare demonstration projects in the first 5 years between 1989 and 1993 in Bolivia, Guatemala, Indonesia and Nigeria. In Inquisivi, Bolivia, Save the Children/Bolivia, worked with 50 women's groups in remote rural villages in the Andean mountains. Through a participatory research process, the 'autodiagnosis', actions identified by women's groups included among others: provision of family planning through a local non-governmental organization (NGO), training of community birth attendants, income generating projects. In Quetzaltenango, Guatemala, access was improved through training of traditional birth attendants (TBAs) in timely recognition and referral of pregnancy/delivery/neonatal complications, while quality of care in health facilities was improved through modifying health professionals' attitude towards TBAs and clients, and implementation of management protocols. In Indonesia, the University of Padjadjaran addressed issues of referral and emergency obstetric care in the West-Java subdistrict of Tanjunsari. Birthing homes with radios were established in ten of the 27 villages in the district, where trained nurse/midwives provided maternity care on a regular basis. In Nigeria professional midwives were trained in interpersonal communication and lifesaving obstetric skills, while referral hospitals were refurbished and equipped. While reduction in maternal mortality after such a short implementation period is difficult to demonstrate, all projects showed improvements in referral and in reduction in perinatal mortality.

Maternal Tetanus Toxoid Vaccination and Neonatal Mortality in Rural North India

PubMed Central

Singh, Abhishek; Pallikadavath, Saseendran; Ogollah, Reuben; Stones, William

2012-01-01

Objectives Preventable neonatal mortality due to tetanus infection remains common. We aimed to examine antenatal vaccination impact in a context of continuing high neonatal mortality in rural northern India. Methods and Findings Using the third round of the Indian National Family Health Survey (NFHS) 2005–06, mortality of most recent singleton births was analysed in discrete-time logistic model with maternal tetanus vaccination, together with antenatal care utilisation and supplementation with iron and folic acid. 59% of mothers reported receiving antenatal care, 48% reported receiving iron and folic acid supplementation and 68% reported receiving two or more doses of tetanus toxoid (TT) vaccination. The odds of all-cause neonatal death were reduced following one or more antenatal dose of TT with odds ratios (OR) of 0.46 (95% CI 0.26 to 0.78) after one dose and 0.45 (95% CI 0.31 to 0.66) after two or more doses. Reported utilisation of antenatal care and iron-folic acid supplementation did not influence neonatal mortality. In the statistical model, 16% (95% CI 5% to 27%) of neonatal deaths could be attributed to a lack of at least two doses of TT vaccination during pregnancy, representing an estimated 78,632 neonatal deaths in absolute terms. Conclusions Substantial gains in newborn survival could be achieved in rural North India through increased coverage of antenatal TT vaccination. The apparent substantial protective effect of a single antenatal dose of TT requires further study. It may reflect greater population vaccination coverage and indicates that health programming should prioritise universal antenatal coverage with at least one dose. PMID:23152814

Association between maternal nutritional extremes and offspring mortality: A population-based cross-sectional study, Brazil, Demographic Health Survey 2006.

PubMed

Felisbino-Mendes, Mariana Santos; Moreira, Alexandra Dias; Velasquez-Melendez, Gustavo

2015-09-01

to estimate the association between maternal nutritional extremes and offspring mortality in the Brazilian population. this cross-sectional study used secondary data from Brazilian women of reproductive age obtained from the National Demographic and Health Survey 2006. Maternal anthropometric indices were used: height, body mass index (BMI), and waist circumference. Logistic regression modelling was used to evaluate the relationship between obesity and offspring mortality. The data analysis was appropriate for the complex sample design. children of mothers of short stature were at greater risk of death in the postnatal period than children of mothers of normal height, even after adjusting for sociodemographic characteristics [odds ratio (OR) 4.54, 95% confidence interval (CI) 1.31-15.77]. Maternal obesity was associated with mortality, and children whose mothers were abdominally obese were at greater risk of dying in the neonatal period (OR 3.19, 95% CI 1.23-8.27). Children of mothers who were overweight or obese (BMI≥25kg/m(2)) were at greater risk of dying in the neonatal period (OR 2.41, 95% CI 1.12-5.16), and children of malnourished mothers (BMI<18.5kg/m(2)) were at greater risk of dying during the postneonatal period (OR 9.47, 95% CI 2.07-43.41). maternal obesity is a risk factor for neonatal death, maternal malnutrition is a risk factor for postneonatal death, and maternal short stature is a risk factor for mortality among Brazilian children. Copyright © 2015 Elsevier Ltd. All rights reserved.

Causes of maternal and child mortality among Cambodian sex workers and their children: a cross sectional study.

PubMed

Willis, Brian; Onda, Saki; Stoklosa, Hanni Marie

2016-11-21

To reach global and national goals for maternal and child mortality, countries must identify vulnerable populations, which includes sex workers and their children. The objective of this study was to identify and describe maternal deaths of female sex workers in Cambodia and causes of death among their children. A convenience sample of female sex workers were recruited by local NGOs that provide support to sex workers. We modified the maternal mortality section of the 2010 Cambodia Demographic and Health Survey and collected reports of all deaths of female sex workers. For each death we ask the 'sisterhood' methodology questions to identify maternal deaths. For child deaths we asked each mother who reported the death of a child about the cause of death. We also asked all participants about the cause of deaths of children of other female sex workers. We interviewed 271 female sex workers in the four largest Cambodian cities between May and September 2013. Participants reported 32 deaths of other female sex workers that met criteria for maternal death. The most common reported causes of maternal deaths were abortion (n = 13;40%) and HIV (n = 5;16%). Participants report deaths of 8 of their children and 50 deaths of children of other female sex workers. HIV was the reported cause of death for 13 (36%) children under age five. This is the first report of maternal deaths of sex workers in Cambodia or any other country. This modification of the sisterhood methodology has not been validated and did not allow us to calculate maternal mortality rates so the results are not generalizable, however these deaths may represent unrecognized maternal deaths in Cambodia. The results also indicate that children of sex workers in Cambodia are at risk of HIV and may not be accessing treatment. These issues require additional studies but in the meantime we must assure that sex workers in Cambodia and their children have access to quality health services.

Perinatal Maternal Mortality in Sickle Cell Anemia: Two Case Reports and Review of the Literature.

PubMed

Rizk, Sanaa; Pulte, Elizabeth D; Axelrod, David; Ballas, Samir K

As outcomes of patients with sickle cell anemia improve and survival into adulthood with good quality of life and expectation of long-term survival becomes more common, challenges have developed, including issues related to reproduction. Pregnancy is frequently complicated in patients with sickle cell anemia with mortality up to 4.0%. Here we report maternal perinatal mortality in two women with sickle cell anemia who died post-partum due to acute chest syndrome (ACS), caused by bone marrow fat embolism and review the literature pertinent to this subject. Patient A was a 28-year-old woman with sickle cell anemia with multiple complications. At 30 weeks' gestation she developed hemolysis associated with poor placental function necessitating delivery by C-section. The fetus was delivered successfully but she died due to multi organ failure after delivery. Autopsy showed pulmonary and amniotic fluid embolization. Patient B was a 37-year-old woman with uncomplicated sickle cell anemia who presented with pre term labor and crisis, then ACS and fetal distress. The infant was delivered successfully but the patient died after cardiovascular collapse. Autopsy results showed fat and bone marrow embolization as the cause of death. Pregnancy continues to be high risk for patients with sickle cell anemia including those with mild disease. Maternal perinatal mortality could be unpredictable due to serious complications of sickle cell disease. More studies to assess maternal perinatal mortality are needed.

The effect of economic downturns on maternal mortality among pregnancies with abortive outcomes in 81 countries, 1981-2010.

PubMed

Ng, Ka Ying Bonnie; Maruthappu, Mahiben; Farrukh, Jawaad; Williams, Callum; Atun, Rifat; Zeltner, Thomas

2015-08-01

To determine the association between economic downturns and abortion-related maternal mortality in multiple countries over 30 years. In a retrospective study, WHO data were obtained for maternal deaths among pregnancies with abortive outcomes between January 1, 1981, and December 31, 2010. Economic data for the same period were obtained from The World Bank. An economic downturn was defined as an annual decline in gross domestic product per head. Multivariate regression-controlling for country-specific differences in infrastructure, population size, and demographic structure-and 5-year lag analyses were performed. Data were available for 81 countries. Abortion-related maternal mortality was significantly increased in years of economic downturns (R=0.0708; 95% confidence interval [CI] 0.0264-0.1151; P=0.0018). The association was sustained for 4 years after an economic downturn (year 1: R=0.0709 [95% CI 0.0231-0.1187], P=0.0037; year 2: R=0.0634 [0.0178-0.1089], P=0.0065; year 3: R=0.0554 [0.0105-0.1004], P=0.0157; year 4: R=0.0593 [0.0148-0.1037], P=0.009). There was an annual 36% increase in deaths associated with unsafe abortion during economic downturn years. Economic downturns were associated with increased abortion-related maternal mortality, possibly due to changes in government healthcare spending and service provision. A global economic downturn could impede a reduction in maternal mortality. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Major Determinants of Maternal Near-Miss and Mortality at the Maternity Teaching Hospital, Erbil city, Iraq

PubMed Central

Akrawi, Vian Sabri; Al-Hadithi, Tariq Salman; Al-Tawil, Namir Ghanim

2017-01-01

Objectives To find out the major determinants of maternal near-miss (NM)and maternal deaths (MDs) in Erbil city, Iraq, by comparative analysis of maternal NMs and MDs. Methods We conducted a hospital-based cross-sectional study in the Maternity Teaching Hospital in Erbil city from 1 June to 31 December 2013. All MDs and NMs that occurred in the hospital during the study period were included in the study. Systematic identification of all eligible women was done. This identification included a baseline assessment of the severe pregnancy-related complications using the World Health Organization NM criteria. Results Severe preeclampsia and postpartum hemorrhage (PPH) constituted the highest proportions of complications in women with potentially life-threatening conditions (PLTCs) (30.5% and 30.0%, respectively). The highest mortality indexes were those for ruptured uterus (16.7) and severe complications of placenta previa (14.2). Factors that were significantly associated with MD (compared to NM) were hepatic dysfunction (p = 0.046), multiple/unspecified disorders (p = 0.003), arrival as an emergency condition by ambulance (p = 0.015), and history of previous cesarean section (p = 0.013). Conclusions Severe preeclampsia and PPH are the main complications that lead to PLTCs. Factors found to be associated with MDs are hepatic dysfunction, multiple/unspecified disorders, arrival as an emergency condition by ambulance, and history of a previous cesarean section. PMID:29026470

Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: meta-analysis.

PubMed

Wilson, Amie; Gallos, Ioannis D; Plana, Nieves; Lissauer, David; Khan, Khalid S; Zamora, Javier; MacArthur, Christine; Coomarasamy, Arri

2011-12-01

To assess the effectiveness of strategies incorporating training and support of traditional birth attendants on the outcomes of perinatal, neonatal, and maternal death in developing countries. Systematic review with meta-analysis. Medline, Embase, the Allied and Complementary Medicine database, British Nursing Index, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, BioMed Central, PsycINFO, Latin American and Caribbean Health Sciences Literature database, African Index Medicus, Web of Science, Reproductive Health Library, and Science Citation Index (from inception to April 2011), without language restrictions. Search terms were "birth attend*", "traditional midwife", "lay birth attendant", "dais", and "comadronas". Review methods We selected randomised and non-randomised controlled studies with outcomes of perinatal, neonatal, and maternal mortality. Two independent reviewers undertook data extraction. We pooled relative risks separately for the randomised and non-randomised controlled studies, using a random effects model. We identified six cluster randomised controlled trials (n=138 549) and seven non-randomised controlled studies (n=72 225) that investigated strategies incorporating training and support of traditional birth attendants. All six randomised controlled trials found a reduction in adverse perinatal outcomes; our meta-analysis showed significant reductions in perinatal death (relative risk 0.76, 95% confidence interval 0.64 to 0.88, P<0.001; number needed to treat 35, 24 to 70) and neonatal death (0.79, 0.69 to 0.88, P<0.001; 98, 66 to 170). Meta-analysis of the non-randomised studies also showed a significant reduction in perinatal mortality (0.70, 0.57 to 0.84, p<0.001; 48, 32 to 96) and neonatal mortality (0.61, 0.48 to 0.75, P<0.001; 96, 65 to 168). Six studies reported on maternal mortality and our meta-analysis showed a non-significant reduction (three randomised trials, relative risk 0.79, 0.53 to 1.05, P=0

Determinants of maternal mortality: a hospital based study from south India.

PubMed

Rajaram, P; Agrawal, A; Swain, S

1995-01-01

During 1981-1986, 86 maternal deaths transpired at the obstetrics department of the Jawaharlal Institute of Postgraduate Medical Education and Research in Pondicherry, India. The maternal mortality rate stood at 5.8/1000 births. 31.4% were primigravidae. The percentage of maternal deaths characterized as gravidae 2-4, 5, and multigravidae was 42.9%, 9.3%, and 16.4%, respectively. The leading causes of death were sepsis (41.9%), especially septic abortion (30.2%); eclampsia-severe preeclampsia (10.5%); ruptured uterus (9.3%); and hemorrhage and prolonged labor (8.1% each). Direct obstetric causes of death accounted for 81.4% of all maternal deaths. Indirect obstetric causes of death were hepatitis (5.8%), heart disease (4.7%), and severe anemia (2.3%). Most of the women who died were illiterate (97.6%), poor (98.8%), and had received no prenatal care (94.2%). 47.7% traveled more than 60 km to the hospital. Quacks or untrained traditional birth attendants had excessively interfered with about 33% before they reached the hospital, especially the septic induced abortion, obstructed labor, and ruptured uterus cases. Among the 48 women who delivered before dying, there were 24 live births (5 of whom died during the early neonatal period) and 24 still births. These findings indicate a need for a cooperative effort to improve and expand maternal and child health care in the community.

Data do count! Collection and use of maternal mortality data in Peru, 1990-2005, and improvements since 2005.

PubMed

Iguiñiz-Romero, Ruth; Palomino, Nancy

2012-06-01

This paper reports on a qualitative, exploratory study in 2005, based on interviews with 15 key decision-makers from the Peruvian Ministry of Health responsible for maternal mortality prevention and officials responsible for national data and information on maternal deaths. The main aims were to find out the sources of data and information used by Ministry of Health officials for programme planning and decision-making, whether policies and programmes were informed by the data available, and data flows among central decision-makers within the Ministry and between Ministry and regional and local health centres. Information systems require staff and systems capable of collecting, processing, analysing and sharing data. In Peru, none of these conditions was fulfilled in a homogeneous way. Vertical programmes in the poorest regions had funds for information systems and infrastructure, but limited technical and human resources. Public health workers were overwhelmed with provision of services and not always trained in data collection or informatics. Thus, quality of data collection and analysis varied greatly across regions. Data collection and usage since the study have been improved, reflected in a fall in maternal mortality ratios and women's increased use of maternity services, but efforts to maintain and improve data quality must continue to ensure that initiatives to prevent maternal mortality can be monitored and services improved. Copyright © 2012 Reproductive Health Matters. Published by Elsevier Ltd. All rights reserved.

Maternal mortality in New York--Looking back, looking forward.

PubMed

Chazotte, Cynthia; D'Alton, Mary E

2016-03-01

New York City was ahead of its time in recognizing the issue of maternal death and the need for proper statistics. New York has also documented since the 1950s the enormous public health challenge of racial disparities in maternal mortality. This paper addresses the history of the first Safe Motherhood Initiative (SMI), a voluntary program in New York State to review reported cases of maternal deaths in hospitals. Review teams found that timely recognition and intervention in patients with serious morbidity could have prevented many of the deaths reviewed. Unfortunately the program was defunded by New York State. The paper then focuses on the revitalization of the SMI in 2013 to establish three safety bundles across the state to be used in the recognition and treatment of obstetric hemorrhage, severe hypertension in pregnancy, and the prevention of venous thromboembolism; and their introduction into 118 hospitals across the state. The paper concludes with a look to the future of the coordinated efforts needed by various organizations involved in women's healthcare in New York City and State to achieve the goal of a review of all maternal deaths in the state by a multidisciplinary team in a timely manner so that appropriate feedback to the clinical team can be given and care can be modified and improved as needed. It is the authors' opinion that we owe this type of review to the women of New York who entrust their care to us. Copyright © 2016 Elsevier Inc. All rights reserved.

[Coverage for birth care in Mexico and its interpretation within the context of maternal mortality].

PubMed

Lazcano-Ponce, Eduardo; Schiavon, Raffaela; Uribe-Zúñiga, Patricia; Walker, Dilys; Suárez-López, Leticia; Luna-Gordillo, Rufino; Ulloa-Aguirre, Alfredo

2013-01-01

To evaluate health coverage for birth care in Mexico within the frame of maternal mortality reduction. Two information sources were used: 1) The comparison between the results yield by the Mexican National Health and Nutrition Surveys 2006 and 2012 (ENSANUT 2006 and 2012), and 2) the databases monitoring maternal deaths during 2012 (up to December 26), and live births (LB) in Mexico as estimated by the Mexican National Population Council (Conapo). The national coverage for birth care by medical units is nearly 94.4% at the national level, but in some federal entities such as Chiapas (60.5%), Nayarit (87.8%), Guerrero (91.2%), Durango (92.5%), Oaxaca (92.6%), and Puebla (93.4%), coverage remains below the national average. In women belonging to any social security system (eg. IMSS, IMSS Oportunidades, ISSSTE), coverage is almost 99%, whereas in those affiliated to the Mexican Popular Health Insurance (which depends directly from the Federal Ministry of Health), coverage reached 92.9%. In terms of Maternal Mortality Ratio (MMR), there are still large disparities among federal states in Mexico, with a national average of 47.0 per 100 000 LB (preliminary data for 2012, up to December 26). The MMR estimation has been updated using the most recent population projections. There is no correlation between the level of institutional birth care and the MMR in Mexico. It is thus necessary not only to guarantee universal birth care by health professionals, but also to provide obstetric care by qualified personnel in functional health services networks, to strengthen the quality of obstetric care, family planning programs, and to promote the implementation of new and innovative health policies that include intersectoral actions and human rights-based approaches targeted to reduce the enormous social inequity still prevailing in Mexico.

Regionalization and Local Hospital Closure in Norwegian Maternity Care—The Effect on Neonatal and Infant Mortality

PubMed Central

Grytten, Jostein; Monkerud, Lars; Skau, Irene; Sørensen, Rune

2014-01-01

Objective To study whether neonatal and infant mortality, after adjustments for differences in case mix, were independent of the type of hospital in which the delivery was carried out. Data The Medical Birth Registry of Norway provided detailed medical information for all births in Norway. Study Design Hospitals were classified into two groups: local hospitals/maternity clinics versus central/regional hospitals. Outcomes were neonatal and infant mortality. The data were analyzed using propensity score weighting to make adjustments for differences in case mix between the two groups of hospitals. This analysis was supplemented with analyses of 13 local hospitals that were closed. Using a difference-in-difference approach, the effects that these closures had on neonatal and infant mortality were estimated. Principal Finding Neonatal and infant mortality were not affected by the type of hospital where the delivery took place. Conclusion A regionalized maternity service does not lead to increased neonatal and infant mortality. This is mainly because high-risk deliveries were identified well in advance of the birth, and referred to a larger hospital with sufficient perinatal resources to deal with these deliveries. PMID:24476021

Social inequalities in maternal mortality among the provinces of Ecuador.

PubMed

Sanhueza, Antonio; Roldán, Jakeline Calle; Ríos-Quituizaca, Paulina; Acuña, Maria Cecilia; Espinosa, Isabel

2017-06-08

This study set out to describe the association between the maternal mortality ratio (MMR) estimates and a set of socioeconomic indicators and compute the MMR inequalities among the provinces of Ecuador. A cross-sectional ecological study was conducted, using data for 2014 from the country's 24 provinces. The MMR estimate was calculated for each province, as well as the association and its strength between MMR and specific socioeconomic indicators. For the indicators that were found to be significantly associated with MMR, inequality measurements were computed. Despite a relatively low MMR for Ecuador overall, ratios differed substantially among the provinces. Five socioeconomic indicators proved to be statistically significantly associated with MMR: total fertility rate, the percentage of indigenous population, the percentage of households with children who do not attend school, gross domestic product, and the percentage of houses with electrical service. Of these five, only three had MMR inequalities that were significant: total fertility rate, gross domestic product, and the percentage of households with electricity. This study supports research arguing that national averages can be misleading, as they often hide differences among subgroups at the local level. The findings also suggest that MMR is significantly associated with some socioeconomic indicators, including ones linked with significant health outcome inequalities. In order to reduce health inequities, it is crucial that countries look beyond national averages and identify the subgroups being left behind, explore the particular social determinants that generate these health inequalities, and examine the specific barriers and other factors affecting the subgroups most vulnerable to maternal health inequalities.

The untold story: how the health care systems in developing countries contribute to maternal mortality.

PubMed

Sundari, T K

1992-01-01

This article attempts to put together evidence from maternal mortality studies in developing countries of how an inadequate health care system characterized by misplaced priorities contributes to high maternal mortality rates. Inaccessibility of essential health information to the women most affected, and the physical as well as economic and sociocultural distance separating health services from the vast majority of women, are only part of the problem. Even when the woman reaches a health facility, there are a number of obstacles to her receiving adequate and appropriate care. These are a result of failures in the health services delivery system: the lack of minimal life-saving equipment at the first referral level; the lack of equipment, personnel, and know-how even in referral hospitals; and worst of all, faulty patient management. Prevention of maternal deaths requires fundamental changes not only in resource allocation, but in the very structures of health services delivery. These will have to be fought for as part of a wider struggle for equity and social justice.

Paid maternity and paternity leave: rights and choices.

PubMed

Jordan, Claire

2007-01-01

From April 2007 onwards, maternity leave will be raised to nine months Paid maternity leave is associated with significant health benefits for babies, including reduced infant mortality The Government proposes to increase paid maternity leave to one year and introduce additional paternity leave by around 2009 The U.K's provision for maternity leave and child care is more generous than the U.S.A. or Australia but less than in the Scandinavian countries

Biocultural perspectives on maternal mortality and obstetrical death from the past to the present.

PubMed

Stone, Pamela K

2016-01-01

Global efforts to improve maternal health are the fifth focus goal of the Millennium Development Goals adopted by the international community in 2000. While maternal mortality is an epidemic, and the death of a woman in childbirth is tragic, certain assumptions that frame the risk of death for reproductive aged women continue to hinge on the anthropological theory of the "obstetric dilemma." According to this theory, a cost of hominin selection to bipedalism is the reduction of the pelvic girdle; in tension with increasing encephalization, this reduction results in cephalopelvic disproportion, creating an assumed fragile relationship between a woman, her reproductive body, and the neonates she gives birth to. This theory, conceived in the 19th century, gained traction in the paleoanthropological literature in the mid-20th century. Supported by biomedical discourses, it was cited as the definitive reason for difficulties in human birth. Bioarchaeological research supported this narrative by utilizing demographic parameters that depict the death of young women from reproductive complications. But the roles of biomedical and cultural practices that place women at higher risk for morbidity and early mortality are often not considered. This review argues that reinforcing the obstetrical dilemma by framing reproductive complications as the direct result of evolutionary forces conceals the larger health disparities and risks that women face globally. The obstetrical dilemma theory shifts the focus away from other physiological and cultural components that have evolved in concert with bipedalism to ensure the safe delivery of mother and child. It also sets the stage for a framework of biological determinism and structural violence in which the reproductive aged female is a product of her pathologized reproductive body. But what puts reproductive aged women at risk for higher rates of morbidity and mortality goes far beyond the reproductive body. Moving beyond reproduction

Behind the Slow Road to Progress: Addressing Myriad Causes of the Persistence of Relatively High Maternal Mortality in Brebes Regency after the Post EMAS Program

NASA Astrophysics Data System (ADS)

Kusumo Habsari, Sri; Sofiah, Sofiah; Sumardiyono, Sumardiyono

2018-02-01

The purpose of this article is to discuss the restricting factors which hinder the Brebes regency’s goal of reducing maternal and new born mortality, especially in the aspects of communication strategy which has been applied by the local district government. The location of the research was Bulakamba sub-district which has applied the system of “desa siaga madya" (mid-size alert village) but unfortunately has the highest maternal mortality in Brebes regency. Through analyzing data which have been collected by making observation, doing interviews, conducting focus group discussion and studying documents using an interactive data analysis technique, the results show that there are some complex obstacles which hinder the success of the program. Although the local government has attempted to produce health regulations as an intervention, to improve the quality of the health services and to develop special communication strategy, the rate of maternal mortality is still relatively high in this sub-district. However, the cultural change as the impact of modernization and cultural mobility, especially in the coastal area of the regency could not be blamed as one of the myriad causes of the persistence. It still needs a special address from the government to intervene, especially to prepare the society to face the modern life with all of its complexities.

A study on maternal mortality in Mexico through a qualitative approach.

PubMed

Castro, R; Campero, L; Hernández, B; Langer, A

2000-01-01

This report presents the main qualitative results of a verbal autopsy study carried out in three states of Mexico, which aimed at identifying the factors associated with maternal mortality that could be subject to modifications through concrete interventions. By reviewing death certificates issued in 1995, it was possible to identify 164 households where a maternal death had occurred. One hundred forty-five of these households were visited, and a precoded questionnaire was completed to explore socioeconomic and living conditions, as well as causes of death. An open-ended question to prompt the relatives to narrate all the facts that led to the maternal deaths was included in the questionnaire. This study presents an analysis of that question, focusing on the delays in the care-seeking process and organized according to the model of the three delays: in deciding to seek care, in reaching a care facility, and in actually receiving care after arrival. Additionally, problems related to quality of care are examined. For analysis of the accounts, structural, interactional/community, and subjective variables were identified that allowed refining of our understanding of the problem of maternal deaths. Finally, based on the findings of the study, this article presents a series of recommendations, highlighting that interventions should address the early stages of a complication and focus on decreasing the various forms of inequality (gender and socioeconomic) associated with the occurrence of maternal deaths.

Severe maternal morbidity and near misses in tertiary hospitals, Kelantan, Malaysia: a cross-sectional study.

PubMed

Norhayati, Mohd Noor; Nik Hazlina, Nik Hussain; Sulaiman, Zaharah; Azman, Mohd Yacob

2016-03-05

Severe maternal conditions have increasingly been used as alternative measurements of the quality of maternal care and as alternative strategies to reduce maternal mortality. We aimed to study severe maternal morbidity and maternal near miss among women in two tertiary hospitals in Kota Bharu, Kelantan, Malaysia. A cross-sectional study with record review was conducted in 2014. Severe maternal morbidity and maternal near miss were classified using the new World Health Organization criteria. Health indicators for obstetric care were calculated and descriptive analyses were performed using SPSS version 22.0. In total, 21,579 live births, 395 women with severe maternal morbidity, 47 women with maternal near miss and two maternal deaths were analysed. The severe maternal morbidity incidence ratio was 18.3 per 1000 live births and the maternal near miss incidence ratio was 2.2 per 1000 live births. The maternal near miss mortality ratio was 23.5 and the mortality index was 4.1 %. The process indicators for essential interventions were almost 100.0 %. Haemorrhagic disorders were the most common event for severe maternal morbidity (68.6 %) and maternal near miss (80.9 %) and management-based criteria accounted for 85.1 %. Comprehensive emergency care and intensive care as well as overall improvements in the quality of maternal health care need to be achieved to substantial reduce maternal death.

Signal functions for emergency obstetric care as an intervention for reducing maternal mortality: a survey of public and private health facilities in Lusaka District, Zambia.

PubMed

Tembo, Tannia; Chongwe, Gershom; Vwalika, Bellington; Sitali, Lungowe

2017-09-06

Zambia's maternal mortality ratio was estimated at 398/100,000 live births in 2014. Successful aversion of deaths is dependent on availability and usability of signal functions for emergency obstetric and neonatal care. Evidence of availability, usability and quality of signal functions in urban settings in Zambia is minimal as previous research has evaluated their distribution in rural settings. This survey evaluated the availability and usability of signal functions in private and public health facilities in Lusaka District of Zambia. A descriptive cross sectional study was conducted between November 2014 and February 2015 at 35 public and private health facilities. The Service Availability and Readiness Assessment tool was adapted and administered to overall in-charges, hospital administrators or maternity ward supervisors at health facilities providing maternal and newborn health services. The survey quantified infrastructure, human resources, equipment, essential drugs and supplies and used the UN process indicators to determine availability, accessibility and quality of signal functions. Data on deliveries and complications were collected from registers for periods between June 2013 and May 2014. Of the 35 (25.7% private and 74.2% public) health facilities assessed, only 22 (62.8%) were staffed 24 h a day, 7 days a week and had provided obstetric care 3 months prior to the survey. Pre-eclampsia/ eclampsia and obstructed labor accounted for most direct complications while postpartum hemorrhage was the leading cause of maternal deaths. Overall, 3 (8.6%) and 5 (14.3%) of the health facilities had provided Basic and Comprehensive EmONC services, respectively. All facilities obtained blood products from the only blood bank at a government referral hospital. The UN process indicators can be adequately used to monitor progress towards maternal mortality reduction. Lusaka district had an unmet need for BEmONC as health facilities fell below the minimum UN standard

Factors Contributing to Maternal and Child Mortality Reductions in 146 Low- and Middle-Income Countries between 1990 and 2010.

PubMed

Bishai, David M; Cohen, Robert; Alfonso, Y Natalia; Adam, Taghreed; Kuruvilla, Shyama; Schweitzer, Julian

2016-01-01

From 1990-2010, worldwide child mortality declined by 43%, and maternal mortality declined by 40%. This paper compares two sources of progress: improvements in societal coverage of health determinants versus improvements in the impact of health determinants as a result of technical change. This paper decomposes the progress made by 146 low- and middle-income countries (LMICs) in lowering childhood and maternal mortality into one component due to better health determinants like literacy, income, and health coverage and a second component due to changes in the impact of these health determinants. Health determinants were selected from eight distinct health-impacting sectors. Health determinants were selected from eight distinct health-impacting sectors. Regression models are used to estimate impact size in 1990 and again in 2010. Changes in the levels of health determinants were measured using secondary data. The model shows that respectively 100% and 89% of the reductions in maternal and child mortality since 1990 were due to improvements in nationwide coverage of health determinants. The relative share of overall improvement attributable to any single determinant varies by country and by model specification. However, in aggregate, approximately 50% of the mortality reductions were due to improvements in the health sector, and the other 50% of the mortality reductions were due to gains outside the health sector. Overall, countries improved maternal and child health (MCH) from 1990 to 2010 mainly through improvements in the societal coverage of a broad array of health system, social, economic and environmental determinants of child health. These findings vindicate efforts by the global community to obtain such improvements, and align with the post-2015 development agenda that builds on the lessons from the MDGs and highlights the importance of promoting health and sustainable development in a more integrated manner across sectors.

Empowering members of a rural southern community in Nigeria to plan to take action to prevent maternal mortality: A participatory action research project.

PubMed

Esienumoh, Ekpoanwan E; Allotey, Janette; Waterman, Heather

2018-04-01

To facilitate the empowerment of members of a rural community to plan to take action to prevent maternal mortality. Globally, about 300,000 maternal deaths occur yearly. Sub-Saharan Africa and Southern Asia regions account for almost all the deaths. Within those regions, India and Nigeria account for over a third of the global maternal deaths. Problem of maternal mortality in Nigeria is multifaceted. About 80% of maternal deaths are avoidable, given strategies which include skilled attendants, emergency obstetric care and community mobilisation. In this article, a strategy of community empowerment to plan to take action to prevent maternal mortality is discussed. Participatory action research was used. Twelve volunteers were recruited as coresearchers into the study through purposive and snowball sampling who, following an orientation workshop, undertook participatory qualitative data collection with an additional 29 community members. Participatory thematic analysis of the data was undertaken which formed the basis of the plan of action. Community members attributed maternal morbidities and deaths to superstitious causes, delayed referrals by traditional birth attendants, poor transportation and poor resourcing of health facilities. Following critical reflection, actions were planned to empower the people to prevent maternal deaths through community education and advocacy meetings with stakeholders to improve health and transportation infrastructures; training of existing traditional birth attendants in the interim and initiating their collaboration with skilled birth attendants. The community is a resource which if mobilised through the process of participatory action research can be empowered to plan to take action in collaboration with skilled birth attendants to prevent maternal mortality. Interventions to prevent maternal deaths should include community empowerment to have better understanding of their circumstances as well as their collaboration with health

Effects of quality improvement in health facilities and community mobilization through women's groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial.

PubMed

Colbourn, Tim; Nambiar, Bejoy; Bondo, Austin; Makwenda, Charles; Tsetekani, Eric; Makonda-Ridley, Agnes; Msukwa, Martin; Barker, Pierre; Kotagal, Uma; Williams, Cassie; Davies, Ros; Webb, Dale; Flatman, Dorothy; Lewycka, Sonia; Rosato, Mikey; Kachale, Fannie; Mwansambo, Charles; Costello, Anthony

2013-09-01

Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi. We evaluated a rural participatory women's group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14,576 and 20,576 births were recorded during baseline (June 2007-September 2008) and intervention (October 2008-December 2010) periods. For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60-1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72-0.97). We did not observe any intervention effects on maternal mortality. Despite implementation problems, a combined community and facility approach using participatory women's groups and quality improvement at health centres reduced newborn mortality in rural Malawi.

Next generation maternal health: external shocks and health-system innovations.

PubMed

Kruk, Margaret E; Kujawski, Stephanie; Moyer, Cheryl A; Adanu, Richard M; Afsana, Kaosar; Cohen, Jessica; Glassman, Amanda; Labrique, Alain; Reddy, K Srinath; Yamey, Gavin

2016-11-05

In this Series we document the substantial progress in the reduction of maternal mortality and discuss the current state of science in reducing maternal mortality. However, maternal health is also powerfully influenced by the structures and resources of societies, communities, and health systems. We discuss the shocks from outside of the field of maternal health that will influence maternal survival including economic growth in low-income and middle-income countries, urbanisation, and health crises due to disease outbreaks, extreme weather, and conflict. Policy and technological innovations, such as universal health coverage, behavioural economics, mobile health, and the data revolution, are changing health systems and ushering in new approaches to affect the health of mothers. Research and policy will need to reflect the changing maternal health landscape. Copyright © 2016 Elsevier Ltd. All rights reserved.

Next generation maternal health: external shocks and health-system innovations

PubMed Central

Kruk, Margaret E; Kujawski, Stephanie; Moyer, Cheryl A; Adanu, Richard M; Afsana, Kaosar; Cohen, Jessica; Glassman, Amanda; Labrique, Alain; Reddy, K Srinath; Yamey, Gavin

2016-01-01

In this Series we document the substantial progress in the reduction of maternal mortality and discuss the current state of science in reducing maternal mortality. However, maternal health is also powerfully influenced by the structures and resources of societies, communities, and health systems. We discuss the shocks from outside of the field of maternal health that will influence maternal survival including economic growth in low-income and middle-income countries, urbanisation, and health crises due to disease outbreaks, extreme weather, and conflict. Policy and technological innovations, such as universal health coverage, behavioural economics, mobile health, and the data revolution, are changing health systems and ushering in new approaches to affect the health of mothers. Research and policy will need to reflect the changing maternal health landscape. PMID:27642020

The impact of economic recession on maternal and infant mortality: lessons from history.

PubMed

Ensor, Tim; Cooper, Stephanie; Davidson, Lisa; Fitzmaurice, Ann; Graham, Wendy J

2010-11-24

The effect of the recent world recession on population health has featured heavily in recent international meetings. Maternal health is a particular concern given that many countries were already falling short of their MDG targets for 2015. We utilise 20th century time series data from 14 high and middle income countries to investigate associations between previous economic recession and boom periods on maternal and infant outcomes (1936 to 2005). A first difference logarithmic model is used to investigate the association between short run fluctuations in GDP per capita (individual incomes) and changes in health outcomes. Separate models are estimated for four separate time periods. The results suggest a modest but significant association between maternal and infant mortality and economic growth for early periods (1936 to 1965) but not more recent periods. Individual country data display markedly different patterns of response to economic changes. Japan and Canada were vulnerable to economic shocks in the post war period. In contrast, mortality rates in countries such as the UK and Italy and particularly the US appear little affected by economic fluctuations. The data presented suggest that recessions do have a negative association with maternal and infant outcomes particularly in earlier stages of a country's development although the effects vary widely across different systems. Almost all of the 20 least wealthy countries have suffered a reduction of 10% or more in GDP per capita in at least one of the last five decades. The challenge for today's policy makers is the design and implementation of mechanisms that protect vulnerable populations from the effects of fluctuating national income.

Impact of family planning programs in reducing high-risk births due to younger and older maternal age, short birth intervals, and high parity.

PubMed

Brown, Win; Ahmed, Saifuddin; Roche, Neil; Sonneveldt, Emily; Darmstadt, Gary L

2015-08-01

Several studies show that maternal and neonatal/infant mortality risks increase with younger and older maternal age (<18 and >34 years), high parity (birth order >3), and short birth intervals (<24 months). Family planning programs are widely viewed as having contributed to substantial maternal and neonatal mortality decline through contraceptive use--both by reducing unwanted births and by reducing the burden of these high-risk births. However, beyond averting births, the empirical evidence for the role of family planning in reducing high-risk births at population level is limited. We examined data from 205 Demographic and Health Surveys (DHS), conducted between 1985 and 2013, to describe the trends in high-risk births and their association with the pace of progress in modern contraceptive prevalence rate (yearly increase in rate of MCPR) in 57 developing countries. Using Blinder-Oaxaca decomposition technique, we then examine the contributions of family planning program, economic development (GDP per capita), and educational improvement (secondary school completion rate) on the progress of MCPR in order to link the net contribution of family planning program to the reduction of high-risk births mediated through contraceptive use. Countries that had the fastest progress in improving MCPR experienced the greatest declines in high-risk births due to short birth intervals (<24 months), high parity births (birth order >3), and older maternal age (>35 years). Births among younger women <18 years, however, did not decline significantly during this period. The decomposition analysis suggests that 63% of the increase in MCPR was due to family planning program efforts, 21% due to economic development, and 17% due to social advancement through women's education. Improvement in MCPR, predominately due to family planning programs, is a major driver of the decline in the burden of high-risk births due to high parity, shorter birth intervals, and older maternal age in

The difficulties of conducting maternal death reviews in Malawi.

PubMed

Kongnyuy, Eugene J; van den Broek, Nynke

2008-09-11

Maternal death reviews is a tool widely recommended to improve the quality of obstetric care and reduce maternal mortality. Our aim was to explore the challenges encountered in the process of facility-based maternal death review in Malawi, and to suggest sustainable and logically sound solutions to these challenges. SWOT (strengths, weaknesses, opportunities and threats) analysis of the process of maternal death review during a workshop in Malawi. Strengths: Availability of data from case notes, support from hospital management, and having maternal death review forms. Weaknesses: fear of blame, lack of knowledge and skills to properly conduct death reviews, inadequate resources and missing documentation. Opportunities: technical assistance from expatriates, support from the Ministry of Health, national protocols and high maternal mortality which serves as motivation factor. Threats: Cultural practices, potential lawsuit, demotivation due to the high maternal mortality and poor planning at the district level. Solutions: proper documentation, conducting maternal death review in a blame-free manner, good leadership, motivation of staff, using guidelines, proper stock inventory and community involvement. Challenges encountered during facility-based maternal death review are provider-related, administrative, client related and community related. Countries with similar socioeconomic profiles to Malawi will have similar 'pull-and-push' factors on the process of facility-based maternal death reviews, and therefore we will expect these countries to have similar potential solutions.

Etiology, clinical profile, and outcome of liver disease in pregnancy with predictors of maternal mortality: A prospective study from Western India.

PubMed

Solanke, Dattatray; Rathi, Chetan; Pandey, Vikas; Patil, Mallanagoud; Phadke, Aniruddha; Sawant, Prabha

2016-11-01

The aim of this study is to study the etiology, clinical profile, and prognostic factors related to maternal and fetal health in pregnant patients with liver disease in Western India. This study included 103 consecutive pregnant patients with liver dysfunction from August 2013 to July 2015, who underwent regular biochemical tests, viral markers, ultrasound of abdomen, etc. and were followed up for 6 weeks postpartum or until death. Pregnancy-specific causes of liver dysfunction were found in 39 % (40/103) patients. Liver diseases were most frequent in third trimester 69.9 % (72/103). Etiologies in third trimester were viral hepatitis 36.1 % (26/72), pregnancy induced hypertension (PIH) 30.5 % (22/72), intrahepatic cholestasis of pregnancy 11.1 % (8/72), acute fatty liver of pregnancy (2/72), etc. Hepatitis E was the commonest agent among viral hepatitis 71.8 % (28/39). Causes of maternal mortality (n = 25) were hepatitis E 40 % (10/25), PIH 32 % (8/25), and tropical diseases 20 % (5/25). Fetal mortality (n = 31) was 38.7 % (12/31) in hepatitis E. Maternal mortality was significantly associated with presence of jaundice, fever, abdominal pain, oliguria, anemia, leukocytosis, and coagulopathy. Model for end-stage liver disease (MELD) score >21 predicted maternal mortality with 80 % sensitivity and 91 % specificity (area under the receiver operating characteristic curve = 0.878 and p < 0.001). Liver disease was most common in the third trimester of pregnancy. Hepatitis E was the most common cause of liver disease in pregnant women in western India with significant maternal mortality, predicted by high MELD score.

Maternal mortality as a Millennium Development Goal of the United Nations: a systematic assessment and analysis of available data in threshold countries using Indonesia as example

PubMed Central

Reinke, Evelyn; Supriyatiningsih; Haier, Jörg

2017-01-01

Background In 2015 the proposed period ended for achieving the Millennium Development Goals (MDG) of the United Nations targeting to lower maternal mortality worldwide by ~ 75%. 99% of these cases appear in developing and threshold countries; but reports mostly rely on incomplete or unrepresentative data. Using Indonesia as example, currently available data sets for maternal mortality were systematically reviewed. Methods Besides analysis of international and national data resources, a systematic review was carried out according to Cochrane methodology to identify all data and assessments regarding maternal mortality. Results Overall, primary data on maternal mortality differed significantly and were hardly comparable. For 1990 results varied between 253/100 000 and 446/100 000. In 2013 data appeared more conclusive (140–199/100 000). An annual reduction rate (ARR) of –2.8% can be calculated. Conclusion Reported data quality of maternal mortality in Indonesia is very limited regarding comprehensive availability and methodology. This limitation appears to be of general importance for the targeted countries of the MDG. Primary data are rare, not uniformly obtained and not evaluated by comparable methods resulting in very limited comparability. Continuous small data set registration should have high priority for analysis of maternal health activities. PMID:28400953

Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: meta-analysis

PubMed Central

Wilson, Amie; Gallos, Ioannis D; Plana, Nieves; Lissauer, David; Khan, Khalid S; Zamora, Javier; MacArthur, Christine

2011-01-01

Objective To assess the effectiveness of strategies incorporating training and support of traditional birth attendants on the outcomes of perinatal, neonatal, and maternal death in developing countries. Design Systematic review with meta-analysis. Data sources Medline, Embase, the Allied and Complementary Medicine database, British Nursing Index, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, BioMed Central, PsycINFO, Latin American and Caribbean Health Sciences Literature database, African Index Medicus, Web of Science, Reproductive Health Library, and Science Citation Index (from inception to April 2011), without language restrictions. Search terms were “birth attend*”, “traditional midwife”, “lay birth attendant”, “dais”, and “comadronas”. Review methods We selected randomised and non-randomised controlled studies with outcomes of perinatal, neonatal, and maternal mortality. Two independent reviewers undertook data extraction. We pooled relative risks separately for the randomised and non-randomised controlled studies, using a random effects model. Results We identified six cluster randomised controlled trials (n=138 549) and seven non-randomised controlled studies (n=72 225) that investigated strategies incorporating training and support of traditional birth attendants. All six randomised controlled trials found a reduction in adverse perinatal outcomes; our meta-analysis showed significant reductions in perinatal death (relative risk 0.76, 95% confidence interval 0.64 to 0.88, P<0.001; number needed to treat 35, 24 to 70) and neonatal death (0.79, 0.69 to 0.88, P<0.001; 98, 66 to 170). Meta-analysis of the non-randomised studies also showed a significant reduction in perinatal mortality (0.70, 0.57 to 0.84, p<0.001; 48, 32 to 96) and neonatal mortality (0.61, 0.48 to 0.75, P<0.001; 96, 65 to 168). Six studies reported on maternal mortality and our meta-analysis showed a non-significant reduction (three

Maternal mortality and derivations from the WHO near-miss tool: An institutional experience over a decade in Southern India.

PubMed

Halder, Ajay; Jose, Ruby; Vijayselvi, Reeta

2014-01-01

Preceding the use of World Health Organization (WHO) near-miss approach in our institute for the surveillance of Severe Maternal Outcome (SMO), we pilot-tested the tool on maternal death cases that took place over the last 10 years in order to establish its feasibility and usefulness at the institutional level. This was a retrospective review of maternal deaths in Christian Medical College Vellore, India, over a decade. Cases were recorded and analyzed using the WHO near-miss tool. The International Classification of Diseases, 10(th) Revision was used to define and classify maternal mortality. There were 98,139 total births and 212 recorded maternal deaths. Direct causes of mortality constituted 46.96% of total maternal deaths, indirect causes constituted 51.40%, and unknown cases constituted 1.9%. Nonobstetrical cause (48.11%) is the single largest group. Infections (19.8%) other than puerperal sepsis remain an important group, with pulmonary tuberculosis, scrub typhus, and malaria being the leading ones. According to the WHO near-miss criteria, cardiovascular and respiratory dysfunctions are the most frequent organ dysfunctions. Incidence of coagulation dysfunction is seen highest in obstetrical hemorrhage (64%). All women who died had at least one organ dysfunction; 90.54% mothers had two- and 38.52% had four- or more organ involvement. The screening questions of the WHO near-miss tool are particularly instrumental in obtaining a comprehensive assessment of the problem beyond the International Classification of Diseases-Maternal Mortality and establish the need for laboratory-based identification of organ dysfunctions and prompt availability of critical care facilities. The process indicators, on the other hand, inquire about the basic interventions that are more or less widely practiced and therefore give no added information at the institutional level.

Indirect cost of maternal deaths in the WHO African Region in 2010.

PubMed

Kirigia, Joses Muthuri; Mwabu, Germano Mwige; Orem, Juliet Nabyonga; Muthuri, Rosenabi Deborah Karimi

2014-08-31

An estimated 147,741 maternal deaths occurred in 2010 in 45 of the 47 countries in the African Region of the World Health Organization (WHO). The objective of this study was to estimate the indirect cost of maternal deaths in the Region to provide data for use in advocacy for increased domestic and external investment in multisectoral policy interventions to curb maternal mortality. This study used the cost-of-illness method to estimate the indirect cost of maternal mortality, i.e. the loss in non-health gross domestic product (GDP) attributable to maternal deaths. Estimates on maternal mortality for 2010 from Trends in maternal mortality: 1990 to 2010 published by WHO, UNICEF, UNFPA and the World Bank were used in these calculations. Values for future non-health GDP lost were converted into their present values by applying a 3% discount rate. One-way sensitivity analysis at 5% and 10% discount rates assessed the impact on non-health GDP loss. Indirect cost analysis was undertaken for the countries, categorized under three income groups. Group 1 consisted of nine high and upper middle income countries, Group 2 of 12 lower middle income countries, and Group 3 of 26 low income countries. Estimates for Seychelles in Group 1 and South Sudan in Group 3 were not provided in the source used. The 147,741 maternal deaths that occurred in 45 countries in the African Region in 2010 resulted in a total non-health GDP loss of Int$ 4.5 billion (PPP). About 24.5% of the loss was in Group 1 countries, 44.9% in Group 2 countries and 30.6% in Group 3 countries. This translated into losses in non-health GDP of Int$ 139,219, Int$ 35,440 and Int$ 16,397 per maternal death, respectively, for the three groups. Using discount rates of 5% and 10% reduced the total non-health GDP loss by 19.1% and 47.7%, respectively. Maternal mortality is responsible for a noteworthy level of non-health GDP loss among the countries in the African Region. There is urgent need, therefore, to increase

Effects of quality improvement in health facilities and community mobilization through women’s groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial

PubMed Central

Colbourn, Tim; Nambiar, Bejoy; Bondo, Austin; Makwenda, Charles; Tsetekani, Eric; Makonda-Ridley, Agnes; Msukwa, Martin; Barker, Pierre; Kotagal, Uma; Williams, Cassie; Davies, Ros; Webb, Dale; Flatman, Dorothy; Lewycka, Sonia; Rosato, Mikey; Kachale, Fannie; Mwansambo, Charles; Costello, Anthony

2016-01-01

Background Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi. Methods We evaluated a rural participatory women’s group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14 576 and 20 576 births were recorded during baseline (June 2007–September 2008) and intervention (October 2008–December 2010) periods. Results For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60–1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72–0.97). We did not observe any intervention effects on maternal mortality. Conclusions Despite implementation problems, a combined community and facility approach using participatory women’s groups and quality improvement at health centres reduced newborn mortality in rural Malawi. PMID:24030269

Maternal health in Gujarat, India: a case study.

PubMed

Mavalankar, Dileep V; Vora, Kranti S; Ramani, K V; Raman, Parvathy; Sharma, Bharati; Upadhyaya, Mudita

2009-04-01

Gujarat state of India has come a long way in improving the health indicators since independence, but progress in reducing maternal mortality has been slow and largely unmeasured or documented. This case study identified several challenges for reducing the maternal mortality ratio, including lack of the managerial capacity, shortage of skilled human resources, non-availability of blood in rural areas, and infrastructural and supply bottlenecks. The Gujarat Government has taken several initiatives to improve maternal health services, such as partnership with private obstetricians to provide delivery care to poor women, a relatively-short training of medical officers and nurses to provide emergency obstetric care (EmOC), and an improved emergency transport system. However, several challenges still remain. Recommendations are made for expanding the management capacity for maternal health, operationalization of health facilities, and ensuring EmOC on 24/7 (24 hours a day, seven days a week) basis by posting nurse-midwives and trained medical officers for skilled care, ensuring availability of blood, and improving the registration and auditing of all maternal deaths. However, all these interventions can only take place if there are substantially-increased political will and social awareness.

Maternal Health in Gujarat, India: A Case Study

PubMed Central

Vora, Kranti S.; Ramani, K.V.; Raman, Parvathy; Sharma, Bharati; Upadhyaya, Mudita

2009-01-01

Gujarat state of India has come a long way in improving the health indicators since independence, but progress in reducing maternal mortality has been slow and largely unmeasured or documented. This case study identified several challenges for reducing the maternal mortality ratio, including lack of the managerial capacity, shortage of skilled human resources, non-availability of blood in rural areas, and infrastructural and supply bottlenecks. The Gujarat Government has taken several initiatives to improve maternal health services, such as partnership with private obstetricians to provide delivery care to poor women, a relatively-short training of medical officers and nurses to provide emergency obstetric care (EmOC), and an improved emergency transport system. However, several challenges still remain. Recommendations are made for expanding the management capacity for maternal health, operationalization of health facilities, and ensuring EmOC on 24/7 (24 hours a day, seven days a week) basis by posting nurse-midwives and trained medical officers for skilled care, ensuring availability of blood, and improving the registration and auditing of all maternal deaths. However, all these interventions can only take place if there are substantially-increased political will and social awareness. PMID:19489418

[Is abortion a serious public health problem in Chile in the field of maternal-perinatal health?

PubMed

Valenzuela, María Teresa; San-Martín P, Pamela; Cavada, Gabriel

2017-08-01

The World Health Organization, by 2014, estimates that approximately 22 million unsafe abortions take place every year in the world, almost all of them in developing countries. The Millennium Goals, as part of the fifth compendium, focused on maternal health by proposing that member states should reduce maternal mortality to 75% by 2015. To determine, using maternal health indicators, if abortion in Chile is a priority health problem. Data about maternal mortality and its causes between 1982 and 2014, was obtained from the databases available at the Chilean Ministry of Health. Trend analyzes were carried out using linear autoregressive models. Between 1982 and 2012, maternal mortality rates decreased from 51.8 to 18.3 per 100,000 live births. Complications of pregnancy, childbirth and puerperium were the first three causes and the last one is abortion. The proportion of abortions due to unspecified causes, including induced abortion, decreased from 36.6% to 26.1% between 2001 and 2012. Abortion is not a public health problem in Chile. To continue reducing maternal mortality, programs for the early detection of risks such as diabetes, obesity and hypertension should be implemented.

Maternal dietary zinc supplementation enhances the epigenetic-activated antioxidant ability of chick embryos from maternal normal and high temperatures.

PubMed

Zhu, Yongwen; Liao, Xiudong; Lu, Lin; Li, Wenxiang; Zhang, Liyang; Ji, Cheng; Lin, Xi; Liu, Hsiao-Ching; Odle, Jack; Luo, Xugang

2017-03-21

The role of maternal dietary zinc supplementation in protecting the embryos from maternal hyperthermia-induced negative effects via epigenetic mechanisms was examined using an avian model (Gallus gallus). Broiler breeder hens were exposed to two maternal temperatures (21°C and 32°C) × three maternal dietary zinc treatments (zinc-unsupplemented control diet, the control diet + 110 mg zinc/kg inorganic or organic zinc) for 8 weeks. Maternal hyperthermia increased the embryonic mortality and induced oxidative damage evidenced by the elevated mRNA expressions of heat shock protein genes. Maternal dietary zinc deficiency damaged the embryonic development associated with the global DNA hypomethylation and histone 3 lysine 9 hyperacetylation in the embryonic liver. Supplementation of zinc in maternal diets effectively eliminated the embryonic mortality induced by maternal hyperthermia and enhanced antioxidant ability with the increased mRNA and protein expressions of metallothionein IV in the embryonic liver. The increased metallothionein IV mRNA expression was due to the reduced DNA methylation and increased histone 3 lysine 9 acetylation of the metallothionein IV promoter regardless of zinc source. These data demonstrate that maternal dietary zinc addition as an epigenetic modifier could protect the offspring embryonic development against maternal heat stress via enhancing the epigenetic-activated antioxidant ability.

Inequalities in institutional delivery uptake and maternal mortality reduction in the context of cash incentive program, Janani Suraksha Yojana: results from nine states in India.

PubMed

Randive, Bharat; San Sebastian, Miguel; De Costa, Ayesha; Lindholm, Lars

2014-12-01

Proportion of women giving birth in health institutions has increased sharply in India since the introduction of cash incentive program, Janani Suraksha Yojana (JSY) in 2005. JSY was intended to benefit disadvantaged population who had poor access to institutional care for childbirth and who bore the brunt of maternal deaths. Increase in institutional deliveries following the implementation of JSY needs to be analysed from an equity perspective. We analysed data from nine Indian states to examine the change in socioeconomic inequality in institutional deliveries five years after the implementation of JSY using the concentration curve and concentration index (CI). The CI was then decomposed in order to understand pathways through which observed inequalities occurred. Disparities in access to emergency obstetric care (EmOC) and in maternal mortality reduction among different socioeconomic groups were also assessed. Slope and relative index of inequality were used to estimate absolute and relative inequalities in maternal mortality ratio (MMR). Results shows that although inequality in access to institutional delivery care persists, it has reduced since the introduction of JSY. Nearly 70% of the present inequality was explained by differences in male literacy, EmOC availability in public facilities and poverty. EmOC in public facilities was grossly unavailable. Compared to richest division in nine states, poorest division has 135 more maternal deaths per 100,000 live births in 2010. While MMR has decreased in all areas since JSY, it has declined four times faster in richest areas compared to the poorest, resulting in increased inequalities. These findings suggest that in order for the cash incentive to succeed in reducing the inequalities in maternal health outcomes, it needs to be supported by the provision of quality health care services including EmOC. Improved targeting of disadvantaged populations for the cash incentive program could be considered. Copyright �

Analysis of inequality in maternal and child health outcomes and mortality from 2000 to 2013 in China.

PubMed

Li, Yanting; Zhang, Yimin; Fang, Shuai; Liu, Shanshan; Liu, Xinyu; Li, Ming; Liang, Hong; Fu, Hua

2017-04-20

Inequality in maternal and child health seriously hinders the overall improvement of health, which is a concern in both the United Nations Sustainable Development Goals (SDGs) and Healthy China 2030. However, research on the equality of maternal and child health is scarce. This study longitudinally assessed the equality trends in China's maternal and child health outcomes from 2000 to 2013 based on place of residence and gender to improve the fairness of domestic maternal and child health. Data on China's maternal and child health monitoring reports were collected from 2000 to 2013. Horizontal and vertical monitoring were performed on the following maternal and child health outcome indicators: incidence of birth defects (IBD), maternal mortality rate (MMR), under 5 mortality rate (U5MR) and neonatal mortality rate (NMR). The newly developed HD*Calc software by the World Health Organization (WHO) was employed as a tool for the health inequality assessment. The between group variance (BGV) and the Theil index (T) were used to measure disparity between different population groups, and the Slope index was used to analyse the BGV and T trends. The disparity in the MMR, U5MR and NMR for the different places of residence (urban and rural) improved over time. The BGV (Slope BGV = -32.24) and T (Slope T = -7.87) of MMR declined the fastest. The gender differences in the U5MR (Slope BGV = -0.06, Slope T = -0.21) and the NMR (Slope BGV = -0.01, Slope T = 0.23) were relatively stable, but the IBD disparity still showed an upward trend in both the place of residence and gender strata. A decline in urban-rural differences in the cause of maternal death was found for obstetric bleeding (Slope BGV = -14.61, Slope T = -20.84). Improvements were seen in the urban-rural disparity in premature birth and being underweight (PBU) in children under 5 years of age. Although diarrhoea and pneumonia decreased in the U5MR, no obvious gender-based trend in the causes of death was observed. We

Risk factors for early infant mortality in Sarlahi district, Nepal.

PubMed Central

Katz, Joanne; West, Keith P.; Khatry, Subarna K.; Christian, Parul; LeClerq, Steven C.; Pradhan, Elizabeth Kimbrough; Shrestha, Sharada Ram

2003-01-01

OBJECTIVES: Early infant mortality has not declined as rapidly as child mortality in many countries. Identification of risk factors for early infant mortality may help inform the design of intervention strategies. METHODS: Over the period 1994-97, 15,469 live-born, singleton infants in rural Nepal were followed to 24 weeks of age to identify risk factors for mortality within 0-7 days, 8-28 days, and 4-24 weeks after the birth. FINDINGS: In multivariate models, maternal and paternal education reduced mortality between 4 and 24 weeks only: odds ratios (OR) 0.28 (95% confidence interval (CI) = 0.12-0.66) and 0.63 (95% CI = 0.44-0.88), respectively. Miscarriage in the previous pregnancy predicted mortality in the first week of life (OR = 1.98, 95% CI = 1.37-2.87), whereas prior child deaths increased the risk of post-neonatal death (OR = 1.85, 95% CI 1.24-2.75). A larger maternal mid-upper arm circumference reduced the risk of infant death during the first week of life (OR = 0.88, 95% CI = 0.81-0.95). Infants of women who did not receive any tetanus vaccinations during pregnancy or who had severe illness during the third trimester were more likely to die in the neonatal period. Maternal mortality was strongly associated with infant mortality (OR = 6.43, 95% CI = 2.35-17.56 at 0-7 days; OR = 11.73, 95% CI = 3.82-36.00 at 8-28 days; and OR = 51.68, 95% CI = 20.26-131.80 at 4-24 weeks). CONCLUSION: Risk factors for early infant mortality varied with the age of the infant. Factors amenable to intervention included efforts aimed at maternal morbidity and mortality and increased arm circumference during pregnancy. PMID:14758431

Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data.

PubMed

Ye, J; Zhang, J; Mikolajczyk, R; Torloni, M R; Gülmezoglu, A M; Betran, A P

2016-04-01

Caesarean section was initially performed to save the lives of the mother and/or her baby. Caesarean section rates have risen substantially worldwide over the past decades. In this study, we set out to compile all available caesarean section rates worldwide at the country level, and to identify the appropriate caesarean section rate at the population level associated with the minimal maternal and neonatal mortality. Ecological study using longitudinal data. Worldwide country-level data. A total of 159 countries were included in the analyses, representing 98.0% of global live births (2005). Nationally representative caesarean section rates from 2000 to 2012 were compiled. We assessed the relationship between caesarean section rates and mortality outcomes, adjusting for socio-economic development by means of human development index (HDI) using fractional polynomial regression models. Maternal mortality ratio and neonatal mortality rate. Most countries have experienced increases in caesarean section rate during the study period. In the unadjusted analysis, there was a negative association between caesarean section rates and mortality outcomes for low caesarean section rates, especially among the least developed countries. After adjusting for HDI, this effect was much smaller and was only observed below a caesarean section rate of 5-10%. No important association between the caesarean section rate and maternal and neonatal mortality was observed when the caesarean section rate exceeded 10%. Although caesarean section is an effective intervention to save maternal and infant lives, based on the available ecological evidence, caesarean section rates higher than around 10% at the population level are not associated with decreases in maternal and neonatal mortality rates, and thus may not be necessary to achieve the lowest maternal and neonatal mortality. The caesarean section rate of around 10% may be the optimal rate to achieve the lowest mortality. © 2015 The Authors

International health policy and stagnating maternal mortality: is there a causal link?

PubMed

Unger, Jean-Pierre; Van Dessel, Patrick; Sen, Kasturi; De Paepe, Pierre

2009-05-01

This paper examines why progress towards Millennium Development Goal 5 on maternal health appears to have stagnated in much of the global south. We contend that besides the widely recognised existence of weak health systems, including weak services, low staffing levels, managerial weaknesses, and lack of infrastructure and information, this stagnation relates to the inability of most countries to meet two essential conditions: to develop access to publicly funded, comprehensive health care, and to provide the not-for-profit sector with needed political, technical and financial support. This paper offers a critical perspective on the past 15 years of international health policies as a possible cofactor of high maternal mortality, because of their emphasis on disease control in public health services at the expense of access to comprehensive health care, and failures of contracting out and public-private partnerships in health care. Health care delivery cannot be an issue both of trade and of right. Without policies to make health systems in the global south more publicly-oriented and accountable, the current standards of maternal and child health care are likely to remain poor, and maternal deaths will continue to affect women and their families at an intolerably high level.

Low levels of maternal education and the proximate determinants of childhood mortality: a little learning is not a dangerous thing.

PubMed

Basu, Alaka Malwade; Stephenson, Rob

2005-05-01

This paper examines the impact of 'low' levels of maternal education on the proximate determinants of child mortality using data from the 1992/93 Indian National Family Health Survey. Twenty-two outcomes are investigated, representing child mortality and morbidity, illness management, service utilization and health behaviours. Maternal education is a significant correlate of each of the outcomes, and even low levels of education increase child survival prospects and health-related behaviours, except for neonatal mortality and the effective management of diarrhoea. We speculate on some of the possible mechanisms behind such impressive findings and suggest that rather than female autonomy, it may be the 'hidden curriculum' values of discipline and obedience of authority that account for them.

“Guilty until proven innocent”: the contested use of maternal mortality indicators in global health

PubMed Central

Storeng, Katerini T.; Béhague, Dominique P.

2017-01-01

Abstract The MMR – maternal mortality ratio – has risen from obscurity to become a major global health indicator, even appearing as an indicator of progress towards the global Sustainable Development Goals. This has happened despite intractable challenges relating to the measurement of maternal mortality. Even after three decades of measurement innovation, maternal mortality data are widely presumed to be of poor quality, or, as one leading measurement expert has put it, ‘guilty until proven innocent’. This paper explores how and why leading epidemiologists, demographers and statisticians have devoted the better part of the last three decades to producing ever more sophisticated and expensive surveys and mathematical models of globally comparable MMR estimates. The development of better metrics is publicly justified by the need to know which interventions save lives and at what cost. We show, however, that measurement experts’ work has also been driven by the need to secure political priority for safe motherhood and by donors’ need to justify and monitor the results of investment flows. We explore the many effects and consequences of this measurement work, including the eclipsing of attention to strengthening much-needed national health information systems. We analyse this measurement work in relation to broader political and economic changes affecting the global health field, not least the incursion of neoliberal, business-oriented donors such as the World Bank and the Bill and Melinda Gates Foundation whose institutional structures have introduced new forms of administrative oversight and accountability that depend on indicators. PMID:28392630

Space-time patterns in maternal and mother mortality in a rural South African population with high HIV prevalence (2000-2014): results from a population-based cohort.

PubMed

Tlou, B; Sartorius, B; Tanser, F

2017-06-03

International organs such as, the African Union and the South African Government view maternal health as a dominant health prerogative. Even though most countries are making progress, maternal mortality in South Africa (SA) significantly increased between 1990 and 2015, and prevented the country from achieving Millennium Development Goal 5. Elucidating the space-time patterns and risk factors of maternal mortality in a rural South African population could help target limited resources and policy guidelines to high-risk areas for the greatest impact, as more generalized interventions are costly and often less effective. Population-based mortality data from 2000 to 2014 for women aged 15-49 years from the Africa Centre Demographic Information System located in the Umkhanyakude district of KwaZulu-Natal Province, South Africa were analysed. Our outcome was classified into two definitions: Maternal mortality; the death of a woman while pregnant or within 42 days of cessation of pregnancy, regardless of the duration and site of the pregnancy, from any cause related to or exacerbated by the pregnancy or its management but not from unexpected or incidental causes; and 'Mother death'; death of a mother whilst child is less than 5 years of age. Both the Kulldorff and Tango spatial scan statistics for regular and irregular shaped cluster detection respectively were used to identify clusters of maternal mortality events in both space and time. The overall maternal mortality ratio was 650 per 100,000 live births, and 1204 mothers died while their child was less than or equal to 5 years of age, of a mortality rate of 370 per 100,000 children. Maternal mortality declined over the study period from approximately 600 per 100,000 live births in 2000 to 400 per 100,000 live births in 2014. There was no strong evidence of spatial clustering for maternal mortality in this rural population. However, the study identified a significant spatial cluster of mother deaths in childhood (p

Addressing the Child and Maternal Mortality Crisis in Haiti through a Central Referral Hospital Providing Countrywide Care

PubMed Central

Jacobs, Lee D; Judd, Thomas M; Bhutta, Zulfiqar A

2016-01-01

The neonatal, infant, child, and maternal mortality rates in Haiti are the highest in the Western Hemisphere, with rates similar to those found in Afghanistan and several African countries. We identify several factors that have perpetuated this health care crisis and summarize the literature highlighting the most cost-effective, evidence-based interventions proved to decrease these mortality rates in low- and middle-income countries. To create a major change in Haiti’s health care infrastructure, we are implementing two strategies that are unique for low-income countries: development of a countrywide network of geographic “community care grids” to facilitate implementation of frontline interventions, and the construction of a centrally located referral and teaching hospital to provide specialty care for communities throughout the country. This hospital strategy will leverage the proximity of Haiti to North America by mobilizing large numbers of North American medical volunteers to provide one-on-one mentoring for the Haitian medical staff. The first phase of this strategy will address the child and maternal health crisis. We have begun implementation of these evidence-based strategies that we believe will fast-track improvement in the child and maternal mortality rates throughout the country. We anticipate that, as we partner with private and public groups already working in Haiti, one day Haiti’s health care system will be among the leaders in that region. PMID:26934625

Addressing the Child and Maternal Mortality Crisis in Haiti through a Central Referral Hospital Providing Countrywide Care.

PubMed

Jacobs, Lee D; Judd, Thomas M; Bhutta, Zulfiqar A

2016-01-01

The neonatal, infant, child, and maternal mortality rates in Haiti are the highest in the Western Hemisphere, with rates similar to those found in Afghanistan and several African countries. We identify several factors that have perpetuated this health care crisis and summarize the literature highlighting the most cost-effective, evidence-based interventions proved to decrease these mortality rates in low- and middle-income countries.To create a major change in Haiti's health care infrastructure, we are implementing two strategies that are unique for low-income countries: development of a countrywide network of geographic "community care grids" to facilitate implementation of frontline interventions, and the construction of a centrally located referral and teaching hospital to provide specialty care for communities throughout the country. This hospital strategy will leverage the proximity of Haiti to North America by mobilizing large numbers of North American medical volunteers to provide one-on-one mentoring for the Haitian medical staff. The first phase of this strategy will address the child and maternal health crisis.We have begun implementation of these evidence-based strategies that we believe will fast-track improvement in the child and maternal mortality rates throughout the country. We anticipate that, as we partner with private and public groups already working in Haiti, one day Haiti's health care system will be among the leaders in that region.

Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on Maternal and Newborn Health.

PubMed

Vogel, J P; Souza, J P; Mori, R; Morisaki, N; Lumbiganon, P; Laopaiboon, M; Ortiz-Panozo, E; Hernandez, B; Pérez-Cuevas, R; Roy, M; Mittal, S; Cecatti, J G; Tunçalp, Ö; Gülmezoglu, A M

2014-03-01

We aimed to determine the prevalence and risks of late fetal deaths (LFDs) and early neonatal deaths (ENDs) in women with medical and obstetric complications. Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS). A total of 359 participating facilities in 29 countries. A total of 308 392 singleton deliveries. We reported on perinatal indicators and determined risks of perinatal death in the presence of severe maternal complications (haemorrhagic, infectious, and hypertensive disorders, and other medical conditions). Fresh and macerated LFDs (defined as stillbirths ≥ 1000 g and/or ≥28 weeks of gestation) and ENDs. The LFD rate was 17.7 per 1000 births; 64.8% were fresh stillbirths. The END rate was 8.4 per 1000 liveborns; 67.1% occurred by day 3 of life. Maternal complications were present in 22.9, 27.7, and 21.2% [corrected] of macerated LFDs, fresh LFDs, and ENDs, respectively. The risks of all three perinatal mortality outcomes were significantly increased with placental abruption, ruptured uterus, systemic infections/sepsis, pre-eclampsia, eclampsia, and severe anaemia. Preventing intrapartum-related perinatal deaths requires a comprehensive approach to quality intrapartum care, beyond the provision of caesarean section. Early identification and management of women with complications could improve maternal and perinatal outcomes. © 2014 RCOG The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

The Alliance for Innovation in Maternal Health Care: A Way Forward.

PubMed

Mahoney, Jeanne

2018-06-01

The Alliance for Innovation in Maternal Health is a program supported by the Health Services Resource Administration to reduce maternal mortality and severe maternal morbidity in the United States. This program develops bundles of evidence based action steps for birth facilities to adapt. Progress is monitored at the facility, state and national levels to foster data-driven quality improvement efforts.

Meeting the community halfway to reduce maternal deaths? Evidence from a community-based maternal death review in Uttar Pradesh, India

PubMed Central

Raj, Sunil Saksena; Maine, Deborah; Sahoo, Pratap Kumar; Manthri, Suneedh; Chauhan, Kavita

2013-01-01

ABSTRACT Background: Uttar Pradesh (UP) is the most populous state in India with the second highest reported maternal mortality ratio in the country. In an effort to analyze the reasons for maternal deaths and implement appropriate interventions, the Government of India introduced Maternal Death Review guidelines in 2010. Methods: We assessed causes of and factors leading to maternal deaths in Unnao District, UP, through 2 methods. First, we conducted a facility gap assessment in 15 of the 16 block-level and district health facilities to collect information on the performance of the facilities in terms of treating obstetric complications. Second, teams of trained physicians conducted community-based maternal death reviews (verbal autopsies) in a sample of maternal deaths occurring between June 1, 2009, and May 31, 2010. Results: Of the 248 maternal deaths that would be expected in this district in a year, we identified 153 (62%) through community workers and conducted verbal autopsies with families of 57 of them. Verbal autopsies indicated that 23% and 30% of these maternal deaths occurred at home and on the way to a health facility, respectively. Most of the women who died had been taken to at least 2 health facilities. The facility assessment revealed that only the district hospital met the recommended criteria for either basic or comprehensive emergency obstetric and neonatal care. Conclusions: Life-saving treatment of obstetric complications was not offered at the appropriate level of government facilities in a representative district in UP, and an inadequate referral system provided fatal delays. Expensive transportation costs to get pregnant women to a functioning medical facility also contributed to maternal death. The maternal death review, coupled with the facility gap assessment, is a useful tool to address the adequacy of emergency obstetric and neonatal care services to prevent further maternal deaths. PMID:25276519

Effect of maternal height on caesarean section and neonatal mortality rates in sub-Saharan Africa: An analysis of 34 national datasets.

PubMed

Arendt, Esther; Singh, Neha S; Campbell, Oona M R

2018-01-01

The lifecycle perspective reminds us that the roots of adult ill-health may start in-utero or in early childhood. Nutritional and infectious disease insults in early life, the critical first 1000 days, are associated with stunting in childhood, and subsequent short adult stature. There is limited or no opportunity for stunted children above 2 years of age to experience catch-up growth. Some previous research has shown short maternal height to lead to adverse birth outcomes. In this paper, we document the association between maternal height and caesarean section, and between maternal height and neonatal mortality in 34 sub-Saharan African countries. We also explore the appropriate height cut-offs to use. Our paper contributes arguments to support a focus on preventing non-communicable risk factors, namely early childhood under-nutrition, as part of the fight to reduce caesarean section rates and other adverse maternal and newborn health outcomes, particularly neonatal mortality. We focus on the Sub-Saharan Africa region because it carries the highest burden of maternal and neonatal ill-health. We used the most recent Demographic and Health Survey for 34 sub-Saharan African countries. The distribution of heights of women who had given birth in the 5 years before the survey was explored. We adopted the following cut-offs: Very Short (<145.0cm), Short (145.0-149.9cm), Short-average (150.0-154.9cm), Average (155.0-159.9cm), Average-tall (160.0-169.9cm) and Tall (≥170.0cm). Multivariate logistic regression was used to assess the contribution of maternal stature to the odds ratio of caesarean section delivery, adjusting for other exposures, such as age at index birth, residence, maternal BMI, maternal education, wealth index quintile, previous caesarean section, multiple birth, birth order and country of survey. We also look at its contribution to neonatal mortality adjusting for age at index birth, residence, maternal BMI, maternal education, wealth index quintile

Cochrane systematic reviews are useful to map research gaps for decreasing maternal mortality.

PubMed

Chapman, Evelina; Reveiz, Ludovic; Chambliss, Amy; Sangalang, Stephanie; Bonfill, Xavier

2013-01-01

To use an "evidence-mapping" approach to assess the usefulness of Cochrane reviews in identifying research gaps in the maternal health. The article describes the general mapping, prioritizing, reconciling, and updating approach: (1) identifying gaps in the maternal health research using published systematic reviews and formulating research questions, (2) prioritizing questions using Delphi method, (3) reconciling identified research priorities with the existing literature (i.e., searching of ongoing trials in trials registries), (4) updating the process. A comprehensive search of Cochrane systematic reviews published or updated from January 2006 to March 2011 was performed. We evaluated the "Implications for Research" section to identify gaps in the research. Our search strategy identified 695 references; 178 systematic reviews identifying at least one research gap were used. We formulated 319 research questions, which were classified into 11 different categories based on the direct and indirect causes of maternal mortality: postpartum hemorrhage, abortion, hypertensive disorders, infection/sepsis, caesarean section, diabetes, pregnancy prevention, preterm labor, other direct causes, indirect causes, and health policies and systems. Most research questions concerned the effectiveness of clinical interventions, including drugs (42.6%), nonpharmacologic interventions (16.3%), and health system (14.7%). It is possible to identify gaps in the maternal health research by using this approach. Copyright © 2013 Elsevier Inc. All rights reserved.

Mortality associated with phaeochromocytoma.

PubMed

Prejbisz, A; Lenders, J W M; Eisenhofer, G; Januszewicz, A

2013-02-01

Two major categories of mortality are distinguished in patients with phaeochromocytoma. First, the effects of excessive circulating catecholamines may result in lethal complications if the disease is not diagnosed and/or treated timely. The second category of mortality is related to development of metastatic disease or other neoplasms. Improvements in disease recognition and diagnosis over the past few decades have reduced mortality from undiagnosed tumours. Nevertheless, many tumours remain unrecognised until they cause severe complications. Death resulting from unrecognised or untreated tumour is caused by cardiovascular complications. There are also numerous drugs and diagnostic or therapeutic manipulations that can cause fatal complications in patients with phaeochromocytoma. Previously it has been reported that operative mortality was as high as 50% in unprepared patients with phaeochromocytoma who were operated and in whom the diagnosis was unsuspected. Today mortality during surgery in medically prepared patients with the tumour is minimal. Phaeochromocytomas may be malignant at presentation or metastases may develop later, but both scenarios are associated with a potentially lethal outcome. Patients with phaeochromocytoma run an increased risk to develop other tumours, resulting in an increased mortality risk compared to the general population. Phaeochromocytoma during pregnancy represents a condition with potentially high maternal and foetal mortality. However, today phaeochromocytoma in pregnancy is recognised earlier and in conjunction with improved medical management, maternal mortality has decreased to less than 5%. © Georg Thieme Verlag KG Stuttgart · New York.

Perinatal Outcomes, Including Mother-to-Child Transmission of HIV, and Child Mortality and Their Association with Maternal Vitamin D Status in Tanzania

PubMed Central

Mehta, Saurabh; Hunter, David J.; Mugusi, Ferdinand M.; Spiegelman, Donna; Manji, Karim P.; Giovannucci, Edward L.; Hertzmark, Ellen; Msamanga, Gernard I.; Fawzi, Wafaie W.

2009-01-01

Background Vitamin D is a strong immunomodulator and may protect against adverse pregnancy outcomes, mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV), and child mortality. Methods A total of 884 HIV-infected pregnant women who were participating in a vitamin supplementation trial in Tanzania were monitored to assess pregnancy outcomes and child mortality. The association of these outcomes with maternal vitamin D status at enrollment was examined in an observational analysis. Results No association was observed between maternal vitamin D status and adverse pregnancy outcomes, including low birth weight and preterm birth. In multivariate models, a low maternal vitamin D level (<32 ng/mL) was associated with a 50% higher risk (95% confidence interval [CI], 2%–120%) of MTCT of HIV at 6 weeks, a 2-fold higher risk of MTCT of HIV through breast-feeding among children who were HIV uninfected at 6 weeks (95% CI, 1.08–3.82), and a 46% higher overall risk of HIV infection (95% CI, 11%–91%). Children born to women with a low vitamin D level had a 61% higher risk of dying during follow-up (95% CI, 25%–107%). Conclusions If found to be efficacious in randomized trials, vitamin D supplementation could prove to be an inexpensive method of reducing the burden of HIV infection and death among children, particularly in resource-limited settings. PMID:19673647

Using community informants to estimate maternal mortality in a rural district in Pakistan: a feasibility study.

PubMed

Mir, Ali Mohammad; Shaikh, Mohammad Saleem; Qomariyah, Siti Nurul; Rashida, Gul; Khan, Mumraiz; Masood, Irfan

2015-01-01

We aimed to assess the feasibility of using community-based informants' networks to identify maternal deaths that were followed up through verbal autopsies (MADE-IN MADE-FOR technique) to estimate maternal mortality in a rural district in Pakistan. We used 4 community networks to identify deaths in women of reproductive age in the past 2 years in Chakwal district, Pakistan. The deaths recorded by the informants were followed up through verbal autopsies. In total 1,143 Lady Health Workers (government employees who provide primary health care), 1577 religious leaders, 20 female lady councilors (elected representatives), and 130 nikah registrars (persons who register marriages) identified 2001 deaths in women of reproductive age. 1424 deaths were followed up with verbal autopsies conducted with the relatives of the deceased. 169 pregnancy-related deaths were identified from all reported deaths. Through the capture-recapture technique probability of capturing pregnancy-related deaths by LHWs was 0.73 and for religious leaders 0.49. Maternal mortality in Chakwal district was estimated at 309 per 100,000 live births. It is feasible and economical to use community informants to identify recent deaths in women of reproductive age and, if followed up through verbal autopsies, obviate the need for conducting large scale surveys.

Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce neonatal mortality

PubMed Central

2013-01-01

Background Nepal has made substantial progress in reducing under-five mortality and is on track to achieve Millennium Development Goal 4, but advances in neonatal health are less encouraging. The objectives of this study were to assess relative and absolute inequalities in neonatal mortality over time, and to review experience with major programs to promote neonatal health. Methods Using four nationally representative surveys conducted in 1996, 2001, 2006 and 2011, we calculated neonatal mortality rates for Nepal and for population groups based on child sex, geographical and socio-economic variables using a true cohort log probability approach. Inequalities based on different variables and years were assessed using rate differences (rd) and rate ratios (rr); time trends in neonatal mortality were measured using the annual rate of reduction. Through literature searches and expert consultation, information on Nepalese policies and programs implemented since 1990 and directly or indirectly attempting to reduce neonatal mortality was compiled. Data on timeline, coverage and effectiveness were extracted for major programs. Results The annual rate of reduction for neonatal mortality between 1996 and 2011 (2.8 percent per annum) greatly lags behind the achievements in under-five and infant mortality, and varies across population groups. For the year 2011, stark absolute and relative inequalities in neonatal mortality exist in relation to wealth status (rd = 21.4, rr = 2.2); these are less pronounced for other measures of socio-economic status, child sex and urban–rural residence, ecological and development region. Among many efforts to promote child and maternal health, three established programs and two pilot programs emerged as particularly relevant to reducing neonatal mortality. While these were designed based on national and international evidence, information about coverage of different population groups and effectiveness is limited. Conclusion Neonatal

Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce neonatal mortality.

PubMed

Paudel, Deepak; Shrestha, Ishwar B; Siebeck, Matthias; Rehfuess, Eva A

2013-12-28

Nepal has made substantial progress in reducing under-five mortality and is on track to achieve Millennium Development Goal 4, but advances in neonatal health are less encouraging. The objectives of this study were to assess relative and absolute inequalities in neonatal mortality over time, and to review experience with major programs to promote neonatal health. Using four nationally representative surveys conducted in 1996, 2001, 2006 and 2011, we calculated neonatal mortality rates for Nepal and for population groups based on child sex, geographical and socio-economic variables using a true cohort log probability approach. Inequalities based on different variables and years were assessed using rate differences (rd) and rate ratios (rr); time trends in neonatal mortality were measured using the annual rate of reduction. Through literature searches and expert consultation, information on Nepalese policies and programs implemented since 1990 and directly or indirectly attempting to reduce neonatal mortality was compiled. Data on timeline, coverage and effectiveness were extracted for major programs. The annual rate of reduction for neonatal mortality between 1996 and 2011 (2.8 percent per annum) greatly lags behind the achievements in under-five and infant mortality, and varies across population groups. For the year 2011, stark absolute and relative inequalities in neonatal mortality exist in relation to wealth status (rd = 21.4, rr = 2.2); these are less pronounced for other measures of socio-economic status, child sex and urban-rural residence, ecological and development region. Among many efforts to promote child and maternal health, three established programs and two pilot programs emerged as particularly relevant to reducing neonatal mortality. While these were designed based on national and international evidence, information about coverage of different population groups and effectiveness is limited. Neonatal mortality varies greatly by socio

A qualitative study of conceptions and attitudes regarding maternal mortality among traditional birth attendants in rural Guatemala.

PubMed

Rööst, Mattias; Johnsdotter, Sara; Liljestrand, Jerker; Essén, Birgitta

2004-12-01

To explore conceptions of obstetric emergency care among traditional birth attendants in rural Guatemala, elucidating social and cultural factors. design Qualitative in-depth interview study. Rural Guatemala. Thirteen traditional birth attendants from 11 villages around San Miguel Ixtahuacán, Guatemala. Interviews with semi-structured, thematic, open-ended questions. Interview topics were: traditional birth attendants' experiences and conceptions as to the causes of complications, attitudes towards hospital care and referral of obstetric complications. Conceptions of obstetric complications, hospital referrals and maternal mortality among traditional birth attendants. Pregnant women rather than traditional birth attendants appear to make the decision on how to handle a complication, based on moralistically and fatalistically influenced thoughts about the nature of complications, in combination with a fear of caesarean section, maltreatment and discrimination at a hospital level. There is a discrepancy between what traditional birth attendants consider appropriate in cases of complications, and the actions they implement to handle them. Parameters in the referral system, such as logistics and socio-economic factors, are sometimes subordinated to cultural values by the target group. To have an impact on maternal mortality, bilateral culture-sensitive education should be included in maternal health programs.

Paternal levels of DNA damage in spermatozoa and maternal parity influence offspring mortality in an endangered ungulate.

PubMed

Ruiz-López, María José; Espeso, Gerardo; Evenson, Donald P; Roldan, Eduardo R S; Gomendio, Montserrat

2010-08-22

Understanding which factors influence offspring mortality rates is a major challenge since it influences population dynamics and may constrain the chances of recovery among endangered species. Most studies have focused on the effects of maternal and environmental factors, but little is known about paternal factors. Among most polygynous mammals, males only contribute the haploid genome to their offspring, but the possibility that sperm DNA integrity may influence offspring survival has not been explored. We examined several maternal, paternal and individual factors that may influence offspring survival in an endangered species (Gazella cuvieri). Levels of sperm DNA damage had the largest impact upon offspring mortality rates, followed by maternal parity. In addition, there was a significant interaction between these two variables, so that offspring born to primiparous mothers were more likely to die if their father had high levels of sperm DNA damage, but this was not the case among multiparous mothers. Thus, multiparous mothers seem to protect their offspring from the deleterious effects of sperm DNA damage. Since levels of sperm DNA damage seem to be higher among endangered species, more attention should be paid to the impact of this largely ignored factor among the viability of endangered species.

Examining the impact of introducing ICD-MM on observed trends in maternal mortality rates in the UK 2003-13.

PubMed

Knight, Marian; Nair, Manisha; Brocklehurst, Peter; Kenyon, Sara; Neilson, James; Shakespeare, Judy; Tuffnell, Derek; Kurinczuk, Jennifer J

2016-07-20

The causes of maternal death are now classified internationally according to ICD-MM. One significant change with the introduction of ICD-MM in 2012 was the reclassification of maternal suicide from the indirect group to the direct group. This has led to concerns about the impact of this reclassification on calculated mortality rates. The aim of this analysis was to examine the trends in maternal deaths in the UK over the past 10 years, and to investigate the impact of reclassification using ICD-MM on the observed rates. Data about all maternal deaths between 2003-13 in the UK were included in this analysis. Data about maternal deaths occurring prior to 2009 were obtained from previously published reports. The deaths of women from 2009-13 during or after pregnancy were identified through the MBRRACE-UK Confidential Enquiry into Maternal Deaths. The underlying causes of maternal death were reclassified from a disease-based system to ICD-MM. Maternal mortality rates with 95 % confidence intervals were calculated using national data on the number of maternities as the denominator. Rate ratios with 95 % CI were calculated to compare the change in rates of maternal death as per ICD-MM relative to the old classification system. There was a decrease in the maternal death rate between 2003-05 and 2011-13 (rate ratio (RR) 0.65; 95 % CI 0.54-0.77 comparing 2003-5 with 2011-13; p = 0.005 for trend over time). The direct maternal death rate calculated using the old classification decreased with a RR of 0.47 (95 % CI 0.34-0.63) when comparing 2011-13 with 2003-05; p = 0.005 for trend over time. Reclassification using ICD-MM made little material difference to the observed trend in direct maternal death rates, RR = 0.51 (95 % CI 0.39-0.68) when comparing 2003-5 with 2011-13; p = 0.005 for trend over time. The impact of reclassifying maternal deaths according to ICD-MM in the UK was minimal. However, such reclassification raises awareness of maternal suicides

Towards an Inclusive and Evidence-Based Definition of the Maternal Mortality Ratio: An Analysis of the Distribution of Time after Delivery of Maternal Deaths in Mexico, 2010-2013

PubMed Central

Fritz, Jimena; Olvera, Marisela; Torres, Luis M.; Lozano, Rafael

2016-01-01

Progress towards the Millennium Development Goal No. 5 was measured by an indicator that excluded women who died due to pregnancy and childbirth after 42 days from the date of delivery. These women suffered from what are defined as late deaths and sequelae-related deaths (O96 and O97 respectively, according to the International Classification of Diseases, 10th revision). Such deaths end up not being part of the numerator in the calculation of the Maternal Mortality Ratio (MMR), the indicator that governments and international agencies use for reporting. The issue is not trivial since these deaths account for a sizeable fraction of all maternal deaths in the world and show an upward trend over time in many countries. The aim of this study was to analyze empirical data on maternal deaths that occurred between 2010 and 2013 in Mexico, linking databases of the Deliberate Search and Reclassification of Maternal Deaths (BIRMM) and the Birth Information Subsystem (SINAC) of the Ministry of Health. Data were analyzed by negative binomial regression, survival analysis and multiple cause analysis. While the reported MMR decreased by 5% per year between 2010 and 2013, the MMR due to late and sequelae-related deaths doubled from 3.5 to 7 per 100,000 live-births in 2013 (p <0.01). A survival analysis of all maternal deaths revealed nothing particular around the 42 day threshold, other than the exclusion of 18% of women who died due to childbirth in 2013. The multiple cause analysis showed a strong association between the excluded deaths and obstetric causes. It is suggested to review the construction of the MMR to make it a more inclusive and dignified measurement of maternal mortality by including all deaths due to pregnancy and childbirth into the Maternal Death definition. PMID:27310260

Maternal ethanol ingestion: effect on maternal and neonatal glucose balance

DOE Office of Scientific and Technical Information (OSTI.GOV)

Witek-Janusek, L.

1986-08-01

Liver glycogen availability in the newborn is of major importance for the maintenance of postnatal blood glucose levels. This study examined the effect of maternal ethanol ingestion on maternal and neonatal glucose balance in the rate. Female rats were placed on 1) the Lieber-DeCarli liquid ethanol diet, 2) an isocaloric liquid pair-diet, or 3) an ad libitum rat chow diet at 3 wk before mating and throughout gestation. Blood and livers were obtained from dams and rat pups on gestational days 21 and 22. The pups were studied up to 6 h in the fasted state and up to 24more » h in the fed state. Maternal ethanol ingestion significantly decreased litter size, birth weight, and growth. A significantly higher mortality during the early postnatal period was seen in the prenatal ethanol exposed pups. Ethanol significantly decreased fed maternal liver glycogen stores but not maternal plasma glucose levels. The newborn rats from ethanol ingesting dams also had significantly decreased liver glycogen stores. Despite mobilizing their available glycogen, these prenatal ethanol exposed pups became hypoglycemic by 6 h postnatal. This was more marked in the fasted pups. Ethanol did not affect maternal nor neonatal plasma insulin levels. Thus maternal ethanol ingestion reduces maternal and neonatal liver glycogen stores and leads to postnatal hypoglycemia in the newborn rat.« less

Inequalities in Maternal Health Care Utilization in Sub-Saharan African Countries: A Multiyear and Multi-Country Analysis

PubMed Central

Alam, Nazmul; Hajizadeh, Mohammad; Dumont, Alexandre; Fournier, Pierre

2015-01-01

To assess social inequalities in the use of antenatal care (ANC), facility based delivery (FBD), and modern contraception (MC) in two contrasting groups of countries in sub-Saharan Africa divided based on their progress towards maternal mortality reduction. Six countries were included in this study. Three countries (Ethiopia, Madagascar, and Uganda) had <350 MMR in 2010 with >4.5% average annual reduction rate while another three (Cameroon, Zambia, and Zimbabwe) had >550 MMR in 2010 with only <1.5% average annual reduction rate. All of these countries had at least three rounds of Demographic and Health Surveys (DHS) before 2012. We measured rate ratios and differences, as well as relative and absolute concentration indices in order to examine within-country geographical and wealth-based inequalities in the utilization of ANC, FBD, and MC. In the countries which have made sufficient progress (i.e. Ethiopia, Madagascar, and Uganda), ANC use increased by 8.7, 9.3 and 5.7 percent, respectively, while the utilization of FBD increased by 4.7, 0.7 and 20.2 percent, respectively, over the last decade. By contrast, utilization of these services either plateaued or decreased in countries which did not make progress towards reducing maternal mortality, with the exception of Cameroon. Utilization of MC increased in all six countries but remained very low, with a high of 40.5% in Zimbabwe and low of 16.1% in Cameroon as of 2011. In general, relative measures of inequalities were found to have declined overtime in countries making progress towards reducing maternal mortality. In countries with insufficient progress towards maternal mortality reduction, these indicators remained stagnant or increased. Absolute measures for geographical and wealth-based inequalities remained high invariably in all six countries. The increasing trend in the utilization of maternal care services was found to concur with a steady decline in maternal mortality. Relative inequality declined overtime in

78 FR 37553 - Maternal Health Town Hall Listening Session; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-06-21

...-served basis. To register for this meeting please go to: http://learning.mchb.hrsa.gov/LiveWebcastDetail... share and discuss proposed strategies and to solicit ideas in support of the National Maternal Health... public on HRSA's strategic thinking around a national strategy to reduce maternal morbidity and mortality...

The Potential Impact of Changes in Fertility on Infant, Child, and Maternal Mortality. World Bank Staff Working Papers No. 698 and Population and Development Series No. 23.

ERIC Educational Resources Information Center

Trussell, James; Pebley, Anne R.

The relationship between changes in the timing and quantity of fertility, such as those that might result from an effective family planning program in developing countries, and changes in child and maternal mortality is examined. Results from five multivariate studies estimate the changes in mortality that might occur from altering maternal age,…

Maternal psychological stress-induced developmental disability, neonatal mortality and stillbirth in the offspring of Wistar albino rats

PubMed Central

Govindaraj, Sakthivel; Shanmuganathan, Annadurai; Rajan, Ravindran

2017-01-01

Background Stress is an inevitable part of life, and maternal stress during the gestational period has dramatic effects in the early programming of the physiology and behavior of offspring. The developmental period is crucial for the well-being of the offspring. Prenatal stress influences the developmental outcomes of the fetus, in part because the developing brain is particularly vulnerable to stress. The etiology of birth defects of the offspring is reported to be 30–40% genetic and 7–10% multifactorial, with the remaining 50% still unknown and also there is no clear cause for neonatal mortality and still-birth. Objective The present study explores the association of maternal psychological stress on mother and the offspring’s incidence of birth defects, stillbirth, and neonatal mortality. Study design Pregnant animals were restrained to induce psychological stress (3 times per day, 45 minutes per session). Except control group, other animals were exposed to restraint stress during the gestational period: early gestational stress (EGS, stress exposure during 1st day to 10th days of gestational period), late gestational stress (LGS, stress exposure during 11th day to till parturition), and full term gestational stress (FGS, stress exposure to the whole gestational period). The effects of maternal stress on the mother and their offspring were analyzed. Results Expectant female rats exposed to stress by physical restraint showed decreased body weight gain, food intake, and fecal pellet levels. Specifically, the offspring of female rats subjected to late gestational and full term gestational restraint stress showed more deleterious effects, such as physical impairment (LGS 24.44%, FGS 10%), neonatal mortality (EGS 2.56%, LGS 24.44%, FGS 17.5%), stillbirths (FGS 27.5%), low birth weight (EGS 5.42g, LGS 4.40g, FGS 4.12g), preterm births (EGS 539 Hrs, LGS 514 Hrs, FGS 520.6 Hrs), and delayed eyelid opening (EGS 15.16 Days, LGS 17 Days, FGS 17.67 Days). Conclusion

[Hospital maternal mortality: causes and consistency between clinical and autopsy diagnosis at the Northeastern Medical Center of the IMSS, Mexico].

PubMed

Calderón-Garcidueñas, Ana Laura; Martínez-Salazar, Griselda; Fernández-Díaz, Héctor; Cerda-Flores, Ricardo M

2002-02-01

The aim was to study the causes of maternal mortality (MM) and the percent of concordance between the clinical diagnosis and the autopsy findings. The autopsies of maternal death (1980-1999) from the Hospital de Especialidades, Centro Médico del Noreste, IMSS in Monterrey, México, were analyzed. The cases were classified in directly obstetric maternal mortality (DOM) and indirectly obstetric maternal mortality (IOM), the causes were studied and the percent of concordance between pre- and post-mortem diagnosis was determined. There were 124 deaths. Autopsy was performed in 61 (49.1%) women. In 55 cases the clinical file and the autopsy protocol were available. This was our sample for study. Sixty percent of the cases were DO. Causes of DOM were: specific hypertensive pregnancy disease (SHPD) (51.6%), sepsis (35.5%), hypovolemic shock (9.7%), anesthetic accidents (3%); causes of IOM were: sepsis (41.7%), malignancies (16.7%), hematological diseases (12.5%), cardiopathy and systemic arterial hypertension (12.5%), hepatic disorders (12.5%), and Superior Longitudinal Sinus thrombosis (4%). A 100% clinical-pathological concordance was observed in DOM cases, while only a 41.6% was found in IOM cases. In those cases of sepsis (IOM), the etiologic agents were identified only in 20% before death. The early detection and treatment of SHPD and the prevention of sepsis should decrease the MM. This study showed some weakness in the Health Services that should be improved.

The role of human rights litigation in improving access to reproductive health care and achieving reductions in maternal mortality.

PubMed

Dunn, Jennifer Templeton; Lesyna, Katherine; Zaret, Anna

2017-11-08

Improving maternal health, reducing global maternal mortality, and working toward universal access to reproductive health care are global priorities for United Nations agencies, national governments, and civil society organizations. Human rights lawyers have joined this global movement, using international law and domestic constitutions to hold nations accountable for preventable maternal death and for failing to provide access to reproductive health care services. This article discusses three decisions in which international treaty bodies find the nations of Brazil and Peru responsible for violations of the Convention on the Elimination of All Forms of Discrimination Against Women and the International Covenant on Civil and Political Rights and also two domestic decisions alleging constitutional violations in India and Uganda. The authors analyze the impact of these decisions on access to maternal and other reproductive health services in Brazil, Peru, India, and Uganda and conclude that litigation is most effective when aligned with ongoing efforts by the public health community and civil society organizations. In filing these complaints and cases on behalf of individual women and their families, legal advocates highlight health system failures and challenge the historical structures and hierarchies that discriminate against and devalue women. These international and domestic decisions empower women and their communities and inspire nations and other stakeholders to commit to broader social, economic, and political change. Human rights litigation brings attention to existing public health campaigns and supports the development of local and global movements and coalitions to improve women's health.

Hospitals by day, dispensaries by night: Hourly fluctuations of maternal mortality within Mexican health institutions, 2010-2014.

PubMed

Lamadrid-Figueroa, Hector; Montoya, Alejandra; Fritz, Jimena; Ortiz-Panozo, Eduardo; González-Hernández, Dolores; Suárez-López, Leticia; Lozano, Rafael

2018-01-01

Quality of obstetric care may not be constant within clinics and hospitals. Night shifts and weekends experience understaffing and other organizational hurdles in comparison with the weekday morning shifts, and this may influence the risk of maternal deaths. To analyze the hourly variation of maternal mortality within Mexican health institutions. We performed a cross-sectional multivariate analysis of 3,908 maternal deaths and 10,589,444 births that occurred within health facilities in Mexico during the 2010-2014 period, using data from the Health Information Systems of the Mexican Ministry of Health. We fitted negative binomial regression models with covariate adjustment to all data, as well as similar models by basic cause of death and by weekdays/weekends. The outcome was the Maternal Mortality Ratio (MMR), defined as the number of deaths occurred per 100,000 live births. Hour of day was the main predictor; covariates were day of the week, c-section, marginalization, age, education, and number of pregnancies. Risk rises during early morning, reaching 52.5 deaths per 100,000 live births at 6:00 (95% UI: 46.3, 62.2). This is almost twice the lowest risk, which occurred at noon (27.1 deaths per 100,000 live births [95% U.I.: 23.0, 32.0]). Risk shows peaks coinciding with shift changes, at 07:00, and 14:00 and was significantly higher on weekends and holidays. Evidence suggests strong hourly fluctuations in the risk of maternal death with during early morning hours and around the afternoon shift change. These results may reflect institutional management problems that cause an uneven quality of obstetric care.

Vitamin A supplementation during pregnancy for maternal and newborn outcomes.

PubMed

McCauley, Mary E; van den Broek, Nynke; Dou, Lixia; Othman, Mohammad

2015-10-27

The World Health Organization recommends routine vitamin A supplementation during pregnancy or lactation in areas with endemic vitamin A deficiency (where night blindness occurs), based on the expectation that supplementation will improve maternal and newborn outcomes including mortality, morbidity and prevention of anaemia or infection.   To review the effects of supplementation of vitamin A, or one of its derivatives, during pregnancy, alone or in combination with other vitamins and micronutrients, on maternal and newborn clinical outcomes. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2015) and reference lists of retrieved studies. All randomised or quasi-randomised trials, including cluster-randomised trials, evaluating the effect of vitamin A supplementation in pregnant women. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We reviewed 106 reports of 35 trials, published between 1931 and 2015. We included 19 trials including over 310,000 women, excluded 15 trials and one is ongoing. Overall, seven trials were judged to be of low risk of bias, three were high risk of bias and for nine it was unclear. 1) Vitamin A alone versus placebo or no treatmentOverall, when trial results are pooled, vitamin A supplementation does not affect the risk of maternal mortality (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.65 to 1.20; four trials Ghana, Nepal, Bangladesh, UK, high quality evidence), perinatal mortality (RR 1.01, 95% CI 0.95 to 1.07; one study, high quality evidence), neonatal mortality, stillbirth, neonatal anaemia, preterm birth (RR 0.98, 95% CI 0.94 to 1.01, five studies, high quality evidence), or the risk of having a low birthweight baby.Vitamin A supplementation reduces the risk of maternal night blindness (RR 0.79, 95% CI 0.64 to 0.98; two trials). There is evidence that vitamin A supplements may reduce maternal clinical infection

Girl child marriage and its association with national rates of HIV, maternal health, and infant mortality across 97 countries.

PubMed

Raj, Anita; Boehmer, Ulrike

2013-04-01

This study was designed to assess associations between national rates of girl child marriage and national rates of HIV and maternal and child health (MCH) concerns, using national indicator data from 2009 United Nations reports. Current analyses were limited to the N = 97 nations (of 188 nations) for which girl child marriage data were available. Regression analyses adjusted for development and world region demonstrate that nations with higher rates of girl child marriage are significantly more likely to contend with higher rates of maternal and infant mortality and nonutilization of maternal health services, but not HIV.

Effect of home visiting by nurses on maternal and child mortality: results of a 2-decade follow-up of a randomized clinical trial.

PubMed

Olds, David L; Kitzman, Harriet; Knudtson, Michael D; Anson, Elizabeth; Smith, Joyce A; Cole, Robert

2014-09-01

Mothers and children living in adverse contexts are at risk of premature death. To determine the effect of prenatal and infant/toddler nurse home visiting on maternal and child mortality during a 2-decade period (1990-2011). A randomized clinical trial was designed originally to assess the home visiting program's effect on pregnancy outcomes and maternal and child health through child age 2 years. The study was conducted in a public system of obstetric and pediatric care in Memphis, Tennessee. Participants included primarily African American women and their first live-born children living in highly disadvantaged urban neighborhoods, who were assigned to 1 of 4 treatment groups: treatment 1 (transportation for prenatal care [n = 166]), treatment 2 (transportation plus developmental screening for infants and toddlers [n = 514]), treatment 3 (transportation plus prenatal/postpartum home visiting [n = 230]), and treatment 4 (transportation, screening, and prenatal, postpartum, and infant/toddler home visiting [n = 228]). Treatments 1 and 3 were included originally to increase statistical power for testing pregnancy outcomes. For determining mortality, background information was available for all 1138 mothers assigned to all 4 treatments and all but 2 live-born children in treatments 2 and 4 (n = 704). Inclusion of children in treatments 1 and 3 was not possible because background information was missing on too many children. Nurses sought to improve the outcomes of pregnancy, children's health and development, and mothers' health and life-course with home visits beginning during pregnancy and continuing through child age 2 years. All-cause mortality in mothers and preventable-cause mortality in children (sudden infant death syndrome, unintentional injury, and homicide) derived from the National Death Index. The mean (SE) 21-year maternal all-cause mortality rate was 3.7% (0.74%) in the combined control group (treatments 1 and 2), 0.4% (0.43%) in treatment 3, and 2

Prioritizing investments in innovations to protect women from the leading causes of maternal death.

PubMed

Herrick, Tara M; Harner-Jay, Claudia M; Levisay, Alice M; Coffey, Patricia S; Free, Michael J; LaBarre, Paul D

2014-01-09

PATH, an international nonprofit organization, assessed nearly 40 technologies for their potential to reduce maternal mortality from postpartum hemorrhage and preeclampsia and eclampsia in low-resource settings. The evaluation used a new Excel-based prioritization tool covering 22 criteria developed by PATH, the Maternal and Neonatal Directed Assessment of Technology (MANDATE) model, and consultations with experts. It identified five innovations with especially high potential: technologies to improve use of oxytocin, a uterine balloon tamponade, simplified dosing of magnesium sulfate, an improved proteinuria test, and better blood pressure measurement devices. Investments are needed to realize the potential of these technologies to reduce mortality.

Reducing Infant Mortality. KIDS COUNT Indicator Brief

ERIC Educational Resources Information Center

Shore, Rima; Shore, Barbara

2009-01-01

Despite the wide range of expertise that has been brought to bear on reducing infant mortality across the nation, the first year of life remains a time of considerable risk for many babies. Although the U.S. spends more on health care than any other country, its infant mortality rate remains higher than that of most other industrialized nations.…

Socio-cultural and service delivery dimensions of maternal mortality in rural central India: a qualitative exploration using a human rights lens

PubMed Central

Jat, Tej Ram; Deo, Prakash R.; Goicolea, Isabel; Hurtig, Anna-Karin; San Sebastian, Miguel

2015-01-01

Background Despite the avoidable nature of maternal mortality, unacceptably high numbers of maternal deaths occur in developing countries. Considering its preventability, maternal mortality is being increasingly recognised as a human rights issue. Integration of a human rights perspective in maternal health programmes could contribute positively in eliminating avertable maternal deaths. This study was conducted to explore socio-cultural and service delivery–related dimensions of maternal deaths in rural central India using a human rights lens. Design Social autopsies were conducted for 22 maternal deaths during 2011 in Khargone district in central India. The data were analysed using thematic analysis. The factors associated with maternal deaths were classified by using the ‘three delays’ framework and were examined by using a human rights lens. Results All 22 women tried to access medical assistance, but various factors delayed their access to appropriate care. The underestimation of the severity of complications by family members, gender inequity, and perceptions of low-quality delivery services delayed decisions to seek care. Transportation problems and care seeking at multiple facilities delayed reaching appropriate health facilities. Negligence by health staff and unavailability of blood and emergency obstetric care services delayed receiving adequate care after reaching a health facility. Conclusions The study highlighted various socio-cultural and service delivery–related factors which are violating women's human rights and resulting in maternal deaths in rural central India. This study highlights that, despite the health system's conscious effort to improve maternal health, normative elements of a human rights approach to maternal health (i.e. availability, accessibility, acceptability, and quality of maternal health services) were not upheld. The data and analysis suggest that the deceased women and their relatives were unable to claim their

Socio-cultural and service delivery dimensions of maternal mortality in rural central India: a qualitative exploration using a human rights lens.

PubMed

Jat, Tej Ram; Deo, Prakash R; Goicolea, Isabel; Hurtig, Anna-Karin; San Sebastian, Miguel

2015-01-01

Despite the avoidable nature of maternal mortality, unacceptably high numbers of maternal deaths occur in developing countries. Considering its preventability, maternal mortality is being increasingly recognised as a human rights issue. Integration of a human rights perspective in maternal health programmes could contribute positively in eliminating avertable maternal deaths. This study was conducted to explore socio-cultural and service delivery-related dimensions of maternal deaths in rural central India using a human rights lens. Social autopsies were conducted for 22 maternal deaths during 2011 in Khargone district in central India. The data were analysed using thematic analysis. The factors associated with maternal deaths were classified by using the 'three delays' framework and were examined by using a human rights lens. All 22 women tried to access medical assistance, but various factors delayed their access to appropriate care. The underestimation of the severity of complications by family members, gender inequity, and perceptions of low-quality delivery services delayed decisions to seek care. Transportation problems and care seeking at multiple facilities delayed reaching appropriate health facilities. Negligence by health staff and unavailability of blood and emergency obstetric care services delayed receiving adequate care after reaching a health facility. The study highlighted various socio-cultural and service delivery-related factors which are violating women's human rights and resulting in maternal deaths in rural central India. This study highlights that, despite the health system's conscious effort to improve maternal health, normative elements of a human rights approach to maternal health (i.e. availability, accessibility, acceptability, and quality of maternal health services) were not upheld. The data and analysis suggest that the deceased women and their relatives were unable to claim their entitlements and that the duty bearers were not

The effect of maternal child marriage on morbidity and mortality of children under 5 in India: cross sectional study of a nationally representative sample

PubMed Central

Saggurti, Niranjan; Winter, Michael; Labonte, Alan; Decker, Michele R; Balaiah, Donta; Silverman, Jay G

2010-01-01

Objective To assess associations between maternal child marriage (marriage before age 18) and morbidity and mortality of infants and children under 5 in India. Design Cross-sectional analyses of nationally representative household sample. Generalised estimating equation models constructed to assess associations. Adjusted models included maternal and child demographics and maternal body mass index as covariates. Setting India. Population Women aged 15-49 years (n=124 385); data collected in 2005-6 through National Family Health Survey-3. Data about child morbidity and mortality reported by participants. Analyses restricted to births in past five years reported by ever married women aged 15-24 years (n=19 302 births to 13 396 mothers). Main outcome measures In under 5s: mortality related infectious diseases in the past two weeks (acute respiratory infection, diarrhoea); malnutrition (stunting, wasting, underweight); infant (age <1 year) and child (1-5 years) mortality; low birth weight (<2500 kg). Results The majority of births (73%; 13 042/19 302) were to mothers married as minors. Although bivariate analyses showed significant associations between maternal child marriage and infant and child diarrhoea, malnutrition (stunted, wasted, underweight), low birth weight, and mortality, only stunting (adjusted odds ratio 1.22, 95% CI 1.12 to 1.33) and underweight (1.24, 1.14 to 1.36) remained significant in adjusted analyses. We noted no effect of maternal child marriage on health of boys versus girls. Conclusions The risk of malnutrition is higher in young children born to mothers married as minors than in those born to women married at a majority age. Further research should examine how early marriage affects food distribution and access for children in India. PMID:20093277

Maternal singing during kangaroo care led to autonomic stability in preterm infants and reduced maternal anxiety.

PubMed

Arnon, Shmuel; Diamant, Chagit; Bauer, Sofia; Regev, Rivka; Sirota, Gisela; Litmanovitz, Ita

2014-10-01

Kangaroo care (KC) and maternal singing benefit preterm infants, and we investigated whether combining these benefitted infants and mothers. A prospective randomised, within-subject, crossover, repeated-measures study design was used, with participants acting as their own controls. We evaluated the heart rate variability (HRV) of stable preterm infants receiving KC, with and without maternal singing. This included low frequency (LF), high frequency (HF) and the LF/HF ratio during baseline (10 min), singing or quiet phases (20 min) and recovery (10 min). Physiological parameters, maternal anxiety and the infants' behavioural state were measured. We included 86 stable preterm infants, with a postmenstrual age of 32-36 weeks. A significant change in LF and HF, and lower LF/HF ratio, was observed during KC with maternal singing during the intervention and recovery phases, compared with just KC and baseline (all p-values <0.05). Maternal anxiety was lower during singing than just KC (p = 0.04). No differences in the infants' behavioural states or physiological parameters were found, with or without singing. Maternal singing during KC reduces maternal anxiety and leads to autonomic stability in stable preterm infants. This effect is not detected in behavioural state or physiological parameters commonly used to monitor preterm infants. ©2014 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.

Maternally derived anti-fibroblast growth factor 23 antibody as new tool to reduce phosphorus requirement of chicks.

PubMed

Ren, Zhouzheng; Bütz, Daniel E; Sand, Jordan M; Cook, Mark E

2017-04-01

Novel means to reduce phosphate input into poultry feeds and increase its retention would preserve world phosphate reserves and reduce environmental impact of poultry production. Here we show that a maternally derived antibody to a fibroblast growth factor-23 (FGF-23) peptide (GMNPPPYS) alleviated phosphorus deficiency in chicks fed low non-phytate phosphorus (nPP) diets. White Leghorn laying hens were vaccinated with either an adjuvant control or the synthetic FGF-23 peptide, and chicks with control or anti-FGF-23 maternal antibodies were fed a diet containing either 0.13 or 0.45% nPP (experiment 1), and 0.20 or 0.45% nPP (experiment 2) for 14 d. In both experiments, decreasing nPP from 0.45 to 0.13 or 0.20% decreased BW gain, G:F, excreta phosphorus, plasma phosphate, and plasma FGF-23 at all time periods examined (nPP main effect, P < 0.05). In experiment 1, chicks with maternal anti-FGF-23 antibody had increased tibiotarsi ash (d 14), and decreased excreta phosphate (d 7, 14) and plasma intact parathyroid hormone (d 7) when compared to chicks with control antibody (antibody main effect, P < 0.05). Mortality (d 7 to 14, 1 to 14), posture scores (d 7, 14) and bone lesion scores (d 14) decreased and plasma phosphate (d 14) increased in anti-FGF-23 chicks fed 0.13% nPP, compared to those with control antibody on the same diet (P < 0.05). In experiment 2, chicks with maternal anti-FGF-23 antibody had increased tibiotarsi ash (d 14), and plasma phosphate (d 14) and 1,25(OH)2D3 (d 14) levels, compared to chicks with control antibody (antibody main effect, P < 0.05). BW gain and G:F were increased in chicks with anti-FGF-23 antibody fed 0.20% nPP, compared to control antibody chicks on the same diet, at all time periods examined (P < 0.05). In conclusion, maternally-derived anti-FGF-23 antibody increased phosphorus retention in chicks fed diets containing either 0.13 or 0.20% nPP and thereby, reduced signs of phosphorus deficiency. © 2016 Poultry Science Association

What can Pakistan do to address maternal and child health over the next decade?

PubMed

Bhutta, Zulfiqar A; Hafeez, Assad

2015-11-25

Pakistan faces huge challenges in meeting its international obligations and agreed Millennium Development Goal targets for reducing maternal and child mortality. While there have been reductions in maternal and under-5 child mortality, overall rates are barely above secular trends and neonatal mortality has not reduced much. Progress in addressing basic determinants, such as poverty, undernutrition, safe water, and sound sanitary conditions as well as female education, is unsatisfactory and, not surprisingly, population growth hampers economic growth and development across the country. The devolution of health to the provinces has created challenges as well as opportunities for action. This paper presents a range of actions needed for change within the health and social sectors, including primary care, social determinants, strategies to reach the unreached, and accountability.

A comparison of sisterhood information on causes of maternal death with the registration causes of maternal death in Matlab, Bangladesh.

PubMed

Shahidullah, M

1995-10-01

To explore whether causes of maternal death can be investigated using the sisterhood method, an indirect method for providing a community-based estimate of the level of maternal mortality, this study compares the sisterhood causes of maternal death with the Matlab Demographic Surveillance System's (DSS) causes of maternal death. Data for this study came from the Matlab DSS, which has been in operation since 1966 as a field site of the International Centre for Diarrhoeal Disease Research, Bangladesh. The maternal deaths that occurred during the 15-year period from 1976 to 1990 in the Matlab DSS area are the basis of this study. A sisterhood survey was conducted in Matlab in November and December 1991 to collect information on conditions, events and symptoms that preceded death. The collected information was evaluated to assign a most likely cause of maternal death. The sisterhood survey cause of maternal death was then compared with the DSS cause of maternal death. Cause of death could not be assigned with reasonable confidence for 34 (11%) of the 305 maternal deaths for which information was collected. For the remaining deaths, the agreement between the two classification systems was generally high for most cause-of-death categories considered. Though cause-of-death information obtained by the sisterhood method will always be subject to some error, it can provide an indication of an overall distribution of causes of maternal deaths. This data can be used for the planning of programmes aimed at reducing maternal mortality and for the evaluation of such programmes over time.

Human resources for maternal health: multi-purpose or specialists?

PubMed Central

Fauveau, Vincent; Sherratt, Della R; de Bernis, Luc

2008-01-01

A crucial question in the aim to attain MDG5 is whether it can be achieved faster with the scaling up of multi-purpose health workers operating in the community or with the scaling up of professional skilled birth attendants working in health facilities. Most advisers concerned with maternal mortality reduction concur to promote births in facilities with professional attendants as the ultimate strategy. The evidence, however, is scarce on what it takes to progress in this path, and on the 'interim solutions' for situations where the majority of women still deliver at home. These questions are particularly relevant as we have reached the twentieth anniversary of the safe motherhood initiative without much progress made. In this paper we review the current situation of human resources for maternal health as well as the problems that they face. We propose seven key areas of work that must be addressed when planning for scaling up human resources for maternal health in light of MDG5, and finally we indicate some advances recently made in selected countries and the lessons learned from these experiences. Whilst the focus of this paper is on maternal health, it is acknowledged that the interventions to reduce maternal mortality will also contribute to significantly reducing newborn mortality. Addressing each of the seven key areas of work – recommended by the first International Forum on 'Midwifery in the Community', Tunis, December 2006 – is essential for the success of any MDG5 programme. We hypothesize that a great deal of the stagnation of maternal health programmes has been the result of confusion and careless choices in scaling up between a limited number of truly skilled birth attendants and large quantities of multi-purpose workers with short training, fewer skills, limited authority and no career pathways. We conclude from the lessons learnt that no significant progress in maternal mortality reduction can be achieved without a strong political decision to

Maternal factors contributing to under-five mortality at birth order 1 to 5 in India: a comprehensive multivariate study.

PubMed

Singh, Rajvir; Tripathi, Vrijesh

2013-01-01

The objective of the study is to assess maternal factors contributing to under-five mortality at birth order 1 to 5 in India. Data for this study was derived from the children's record of the 2007 India National Family Health Survey, which is a nationally representative cross-sectional household survey. Data is segregated according to birth order 1 to 5 to assess mother's occupation, Mother's education, child's gender, Mother's age, place of residence, wealth index, mother's anaemia level, prenatal care, assistance at delivery , antenatal care, place of delivery and other maternal factors contributing to under-five mortality. Out of total 51555 births, analysis is restricted to 16567 children of first birth order, 14409 of second birth order, 8318 of third birth order, 5021 of fourth birth order and 3034 of fifth birth order covering 92% of the total births taken place 0-59 months prior to survey. Mother's average age in years for birth orders 1 to 5 are 23.7, 25.8, 27.4, 29 and 31 years, respectively. Most mothers whose children died are Hindu, with no formal education, severely anaemic and working in the agricultural sector. In multivariate logistic models, maternal education, wealth index and breastfeeding are protective factors across all birth orders. In birth order model 1 and 2, mother's occupation is a significant risk factor. In birth order models 2 to 5, previous birth interval of lesser than 24 months is a risk factor. Child's gender is a risk factor in birth order 1 and 5. Information regarding complications in pregnancy and prenatal care act as protective factors in birth order 1, place of delivery and immunization in birth order 2, and child size at birth in birth order 4. Prediction models demonstrate high discrimination that indicates that our models fit the data. The study has policy implications such as enhancing the Information, Education and Communication network for mothers, especially at higher birth orders, in order to reduce under

Comparing local perspectives on women’s health with statistics on maternal mortality: an ethnobotanical study in Bénin and Gabon

PubMed Central

2014-01-01

Background According to the World Health Organization (WHO), reproductive health problems are the leading cause of morbidity and mortality for women in Africa. In spite of this scenario and the importance of plants in African health care, limited research has been conducted linking maternal health and plant-based medicine. The objective of our research was to examine how closely Beninese and Gabonese women’s health perspectives, medicinal plant knowledge, and plant use practices reflect the statistical causes of maternal mortality. Methods In Bénin (2011) and Gabon (2012), we conducted 87 ethnobotanical questionnaires with the corresponding collection of 800 botanical specimens. We used free-listing analysis, citation frequency and species counts to determine women’s top health concerns. We also interviewed 18 biomedical healthcare providers in national hospitals and local clinics. Results Informants’ perceptions of the main causes of maternal suffering included malaria, infertility, and menstruation and pregnancy concerns. Women were knowledgeable on plants to treat the top causes of maternal morbidity, but knew more plants for conditions such as anemia, infertility, breast milk production, and the maintenance of menstruation and pregnancy. The biomedical staff recognized the role of traditional medicine in their patients’ lives and expressed concern for herbal remedies to facilitate birth, but were restricted by national policies on advising on medicinal plant use. Conclusions Plants serve as an entry point to understanding Beninese and Gabonese women’s perceptions of common health concerns and local health management strategies. Plant use practices in both countries did not closely parallel the top statistical causes of maternal mortality, but highlighted key issues such as menstruation and infertility as salient health concerns for women. More research is needed on the role of plants in women's gynecological healthcare. PMID:24679004

A Performance Analysis of Public Expenditure on Maternal Health in Mexico.

PubMed

Servan-Mori, Edson; Avila-Burgos, Leticia; Nigenda, Gustavo; Lozano, Rafael

2016-01-01

We explore the relationship between public expenditure, coverage of adequate ANC (including timing, frequent and content), and the maternal mortality ratio--adjusted by coverage of adequate ANC--observed in Mexico in 2012 at the State level. Additionally, we examine the inequalities and concentration of public expenditure between populations with and without Social Security. Results suggest that in the 2003-2011 period, the public expenditure gap between women with and without Social Security decreased 74%, however, the distribution is less equitable among women without Social Security, across the States. Despite high levels of coverage on each dimension of ANC explored, coverage of adequate ANC was lower among Social Security than non-Social Security women. This variability results in differences up to 1.5 times in State-adjusted maternal mortality rate at the same level of expense and maternal mortality rate, respectively. The increase in the economic resources is only a necessary condition for achieving improved health outcomes. Providing adequate health services and achieving efficient, effective and transparent use of resources in health, are critical elements for health systems performance. The attainment of universal effective coverage of maternal health and reducing maternal mortality in Mexico, requires the adjustment of policy innovations including the rules of allocation and execution of health resources. Health policies should be designed on a more holistic view promoting a balance between accessibility, effective implementation and rigorous stewardship.

Puerperal sepsis, the leading cause of maternal deaths at a Tertiary University Teaching Hospital in Uganda.

PubMed

Ngonzi, Joseph; Tornes, Yarine Fajardo; Mukasa, Peter Kivunike; Salongo, Wasswa; Kabakyenga, Jerome; Sezalio, Masembe; Wouters, Kristien; Jacqueym, Yves; Van Geertruyden, Jean-Pierre

2016-08-05

Maternal mortality is highest in sub-Saharan Africa. In Uganda, the WHO- MDG 5 (aimed at reducing maternal mortality by 75 % between 1990 and 2015) has not been attained. The current maternal mortality ratio (MMR) in Uganda is 438 per 100,000 live births coming from 550 per 100,000 in 1990. This study sets out to find causes and predictors of maternal deaths in a tertiary University teaching Hospital in Uganda. The study was a retrospective unmatched case control study which was carried out at the maternity unit of Mbarara Regional Referral Hospital (MRRH). The sample included pregnant women aged 15-49 years admitted to the Maternity unit between January 2011 and November 2014. Data from patient charts of 139 maternal deaths (cases) and 417 controls was collected using a standard audit/data extraction form. Multivariable logistic regression analysis was used to assess for the factors associated with maternal mortality. Direct causes of mortality accounted for 77.7 % while indirect causes contributed 22.3 %. The most frequent cause of maternal mortality was puerperal sepsis (30.9 %), followed by obstetric hemorrhage (21.6 %), hypertensive disorders in pregnancy (14.4 %), abortion complications (10.8 %). Malaria was the commonest indirect cause of mortality accounting for 8.92 %. On multivariable logistic regression analysis, the factors associated with maternal mortality were: primary or no education (OR 1.9; 95 % CI, 1.0-3.3); HIV positive sero-status (OR, 3.6; 95 % CI, 1.9-7.0); no antenatal care attendance (OR 3.6; 95 % CI, 1.8-7.0); rural dwellers (OR, 4.5; 95 % CI, 2.5-8.3); having been referred from another health facility (OR 5.0; 95 % CI, 2.9-10.0); delay to seek health care (delay-1) (OR 36.9; 95 % CI, 16.2-84.4). Most maternal deaths occur among mothers from rural areas, uneducated, HIV positive, unbooked mothers (lack of antenatal care), referred mothers in critical conditions and mothers delaying to seek health care. Puerperal sepsis is

Social Welfare Expenditures and Infant Mortality.

PubMed

Shim, Joyce

2015-01-01

This study examines the effects of social welfare expenditures on infant mortality (deaths younger than age 1 per 1,000 live births) across 19 Organisation for Economic Co-operation and Development (OECD) countries from 1980 to 2010. Data are obtained from various sources including the OECD, World Health Organization, and World Bank. The findings indicate that among three social welfare expenditure measures for families, the expenditures on family cash allowances are predicted to reduce infant mortality. However, the other two measures-the expenditures on parental and maternity leave and expenditures on family services-have no significant effects on infant mortality.

The effect of maternal and child health and family planning services on mortality: is prevention enough?

PubMed Central

Fauveau, V; Wojtyniak, B; Chakraborty, J; Sarder, A M; Briend, A

1990-01-01

OBJECTIVE--To examine the impact on mortality of a child survival strategy, mostly based on preventive interventions. DESIGN--Cross sectional comparison of cause specific mortality in two communities differing in the type, coverage, and quality of maternal and child health and family planning services. In the intervention area the services were mainly preventive, community based, and home delivered. SUBJECTS--Neonates, infants, children, and mothers in two contiguous areas of rural Bangladesh. INTERVENTIONS--In the intervention area community health workers provided advice on contraception and on feeding and weaning babies; distributed oral rehydration solution, vitamin A tablets for children under 5, and ferrous fumarate and folic acid during pregnancy; immunised children; trained birth attendants in safe delivery and when to refer; treated minor ailments; and referred seriously ill people and malnourished children to a central clinic. MAIN OUTCOME MEASURES--Overall and age and cause specific death rates, obtained by a multiple step "verbal autopsy" process. RESULTS--During the two years covered by the study overall mortality was 17% lower among neonates, 9% lower among infants aged 1-5 months, 30% lower among children aged 6-35 months, and 19% lower among women living in the study area than in those living in the control area. These differences were mainly due to fewer deaths from neonatal tetanus, measles, persistent diarrhoea with severe malnutrition among children, and fewer abortions among women. CONCLUSIONS--The programme was effective in preventing some deaths. In addition to preventive components such as tetanus and measles immunisation, health and nutrition education, and family planning, curative services are needed to reduce mortality further. PMID:2390566

Effectiveness of an intervention on uptake of maternal care in four counties in Ningxia, China.

PubMed

Zhou, Hong; Zhao, Chun-Xia; Wang, Xiao-Li; Xv, Yi-Chong; Shi, Ling; Wang, Yan

2012-12-01

To understand the utilisation of prenatal care and hospitalised delivery among pregnant Muslim women in Ningxia, China, and to explore the effectiveness of the integrated interventions to reduce maternal mortality. Cross-sectional surveys before and after the intervention were carried out. Using multistage sampling, 1215 mothers of children <5 years old were recruited: 583 in the pre-intervention survey and 632 in the post-intervention study. Data on prenatal care and delivery were collected from face-to-face interviews. Maternal mortality ratio (MMR) data were obtained from the local Maternal and Child Mortality Report System. After the intervention, the MMR significantly decreased (45.5 deaths per 100,000 live births to 32.7 deaths). Fewer children were born at home after the intervention than before the intervention (OR, 0.11; 95% CI, 0.08-0.15). The proportion of women who attended prenatal care at least once increased from 78.2% to 98.9% (OR, 24.55; 95% CI, 11.37-53.12). The proportion of women who had prenatal visit(s) in the first trimester of pregnancy increased from 35.1% to 82.6% (OR, 8.77; 95% CI, 6.58-11.69). The quality of prenatal care was greatly improved. Effects of the intervention on the utilisation of maternal care remained significant after adjusting for education level and household possessions. The findings suggest that integrated strategies can effectively reduce maternal mortality. © 2012 Blackwell Publishing Ltd.

What interventions are effective on reducing inequalities in maternal and child health in low- and middle-income settings? A systematic review.

PubMed

Yuan, Beibei; Målqvist, Mats; Trygg, Nadja; Qian, Xu; Ng, Nawi; Thomsen, Sarah

2014-06-21

The deadline for achieving Millennium Development Goals 4 and 5 is approaching, but inequalities between disadvantaged and other populations is a significant barrier for progress towards achieving these goals. This systematic review aims to collect evidence about the differential effects of interventions on different sociodemographic groups in order to identify interventions that were effective in reducing maternal or child health inequalities. We searched the PubMed, EMBASE and other relevant databases. The reference lists of included reviews were also screened to find more eligible studies. We included experimental or observational studies that assessed the effects of interventions on maternal and child health, but only studies that report quantitative inequality outcomes were finally included for analysis. 22 articles about the effectiveness of interventions on equity in maternal and child health were finally included. These studies covered five kinds of interventions: immunization campaigns, nutrition supplement programs, health care provision improvement interventions, demand side interventions, and mixed interventions. The outcome indicators covered all MDG 4 and three MDG 5 outcomes. None of the included studies looked at equity in maternal mortality, adolescent birth rate and unmet need for family planning. The included studies reported inequalities based on gender, income, education level or comprehensive socioeconomic status. Stronger or moderate evidence showed that all kinds of the included interventions may be more effective in improving maternal or child health for those from disadvantaged groups. Studies about the effectiveness of interventions on equity in maternal or child health are limited. The limited evidence showed that the interventions that were effective in reducing inequity included the improvement of health care delivery by outreach methods, using human resources in local areas or provided at the community level nearest to residents and

Prioritizing investments in innovations to protect women from the leading causes of maternal death

PubMed Central

2014-01-01

PATH, an international nonprofit organization, assessed nearly 40 technologies for their potential to reduce maternal mortality from postpartum hemorrhage and preeclampsia and eclampsia in low-resource settings. The evaluation used a new Excel-based prioritization tool covering 22 criteria developed by PATH, the Maternal and Neonatal Directed Assessment of Technology (MANDATE) model, and consultations with experts. It identified five innovations with especially high potential: technologies to improve use of oxytocin, a uterine balloon tamponade, simplified dosing of magnesium sulfate, an improved proteinuria test, and better blood pressure measurement devices. Investments are needed to realize the potential of these technologies to reduce mortality. PMID:24405972

National surgical mortality audit may be associated with reduced mortality after emergency admission.

PubMed

Kiermeier, Andreas; Babidge, Wendy J; McCulloch, Glenn A J; Maddern, Guy J; Watters, David A; Aitken, R James

2017-10-01

The Western Australian Audit of Surgical Mortality was established in 2002. A 10-year analysis suggested it was the primary driver in the subsequent fall in surgeon-related mortality. Between 2004 and 2010 the Royal Australasian College of Surgeons established mortality audits in other states. The aim of this study was to examine national data from the Australian Institute of Health and Welfare (AIHW) to determine if a similar fall in mortality was observed across Australia. The AIHW collects procedure and outcome data for all surgical admissions. AIHW data from 2005/2006 to 2012/2013 was used to assess changes in surgical mortality. Over the 8 years surgical admissions increased by 23%, while mortality fell by 18% and the mortality per admission fell by 33% (P < 0.0001). A similar decrease was seen in all regions. The mortality reduction was overwhelmingly observed in elderly patients admitted as an emergency. The commencement of this nation-wide mortality audit was associated with a sharp decline in perioperative mortality. In the absence of any influences from other changes in clinical governance or new quality programmes it is probable it had a causal effect. The reduced mortality was most evident in high-risk patients. This study adds to the evidence that national audits are associated with improved outcomes. © 2017 Royal Australasian College of Surgeons.

Extremes of maternal age and child mortality: analysis between 2000 and 2009☆

PubMed Central

Ribeiro, Fanciele Dinis; Ferrari, Rosângela Aparecida Pimenta; Sant'Anna, Flávia Lopes; Dalmas, José Carlos; Girotto, Edmarlon

2014-01-01

OBJECTIVE: To analyze the characteristics of infant mortality at the extremes of maternal age. METHOD: Retrospective, cross-sectional quantitative study using data from Live Birth Certificates, Death Certificates and from Child Death Investigation records in Londrina, Paraná, in the years of 2000-2009. RESULTS: During the 10-year study period , there were 176 infant deaths among mothers up to 19 years of age, and 113 deaths among mothers aged 35 years or more. The infant mortality rate among young mothers was 14.4 deaths per thousand births, compared to 12.9 deaths in the other age group. For adolescent mothers, the following conditions prevailed: lack of a stable partner (p<0.001), lack of a paid job (p<0.001), late start of prenatal care in the second trimester of pregnancy (p<0.001), fewer prenatal visits (p<0.001) and urinary tract infections (p<0.001). On the other hand, women aged 35 or more had a higher occurrence of hypertension during pregnancy (p<0.001), and of surgical delivery (p<0.001). Regarding the underlying cause of infant death, congenital anomalies prevailed in the group of older mothers (p=0.002), and external causes were predominant in the group of young mothers (p=0.019). CONCLUSION: Both age groups deserve the attention of social services for maternal and child health, especially adolescent mothers, who presented a higher combination of factors deemed hazardous to the child's health. PMID:25511003

The Chilean infant mortality decline: improvement for whom? Socioeconomic and geographic inequalities in infant mortality, 1990-2005.

PubMed

Hertel-Fernandez, Alexander Warren; Giusti, Alejandro Esteban; Sotelo, Juan Manuel

2007-10-01

To measure socioeconomic inequalities and differential risk in infant mortality on national and regional levels in Chile from 1990 to 2005, and propose new policy targets. The study analysed Chilean vital events registries from 1990 to 2005 for infant mortality by maternal education, head of household occupational status, cause, age and location of death. Annual infant mortality rates and relative risk were calculated by maternal education and head of household occupational status for each cause and age of death. Socioeconomic inequalities were then mapped to 29 regional health services. Reductions in the national infant mortality rate were driven by reductions among highly educated mothers, while recent stagnation in the national rate is caused by high levels of infant mortality among uneducated mothers. These vulnerable households are particularly prone to infant mortality risk due to infectious disease and trauma. We also identify clustering of high socioeconomic inequalities in infant mortality throughout the poorer north, indigenous south and densely populated metropolitan centre of Santiago. Finally, we report large inequities in vital statistics coverage, with infant deaths among vulnerable households much more likely to be inadequately defined than in the remaining population. These results indicate that the socioeconomically disadvantaged in Chile are at a significantly higher risk for infant mortality by infectious diseases and trauma during the first month of life. Efforts to reduce national infant mortality in Chile and other countries must involve policies that target child survival for at-risk populations for specific diseases, ages and locations.

From identification and review to action--maternal mortality review in the United States.

PubMed

Berg, Cynthia J

2012-02-01

The maternal mortality review process is an ongoing quality improvement cycle with 5 steps: identification of maternal deaths, collection of medical and other data on the events surrounding the death, review and synthesis of the data to identify potentially alterable factors, the development and implementation of interventions to decrease the risk of future deaths, and evaluation of the results. The most important step is utilization of the data to identify and implement evidence-based actions; without this step, the rest of the work will not have an impact. The review committee ideally is based in the health department of a state (or large city) as a core public health function. This provides stability for the process as well as facilitates implementation of the review committees' recommendations. The review committee should be multidisciplinary, with its members being official representatives of their organizations or departments, again to improve buy-in of the stakeholders. Published by Elsevier Inc.

Reducing Inequities in Neonatal Mortality through Adequate Supply of Health Workers: Evidence from Newborn Health in Brazil

PubMed Central

Sousa, Angelica; Dal Poz, Mario R.; Boschi-Pinto, Cynthia

2013-01-01

Introduction Progress towards the MDG targets on maternal and child mortality is hindered worldwide by large differentials between poor and rich populations. Using the case of Brazil, we investigate the extent to which policies and interventions seeking to increase the accessibility of health services among the poor have been effective in decreasing neonatal mortality. Methods With a panel data set for the 4,267 Minimum Comparable Areas (MCA) in Brazil in 1991 and 2000, we use a fixed effect regression model to evaluate the effect of the provision of physicians, nurse professionals, nurse associates and community health workers on neonatal mortality for poor and non-poor areas. We additionally forecasted the neonatal mortality rate in 2005. Results We find that the provision of health workers is particularly important for neonatal mortality in poor areas. Physicians and especially nurse professionals have been essential in decreasing neonatal mortality: an increase of one nurse professional per 1000 population is associated with a 3.8% reduction in neonatal mortality while an increase of one physician per 1000 population is associated with a 2.3% reduction in neonatal mortality. We also find that nurse associates are less important for neonatal mortality (estimated reduction effect of 1.2% ) and that community health workers are not important particularly among the poor. Differences in the provision of health workers explain a large proportion of neonatal mortality. Discussion In this paper, we show new evidence to inform decision making on maternal and newborn health. Reductions in neonatal mortality in Brazil have been hampered by the unequal distribution of health workers between poor and non-poor areas. Thus, special attention to a more equitable health system is required to allocate the resources in order to improve the health of poor and ensure equitable access to health services to the entire population. PMID:24073222

Reducing inequities in neonatal mortality through adequate supply of health workers: evidence from newborn health in Brazil.

PubMed

Sousa, Angelica; Dal Poz, Mario R; Boschi-Pinto, Cynthia

2013-01-01

Progress towards the MDG targets on maternal and child mortality is hindered worldwide by large differentials between poor and rich populations. Using the case of Brazil, we investigate the extent to which policies and interventions seeking to increase the accessibility of health services among the poor have been effective in decreasing neonatal mortality. With a panel data set for the 4,267 Minimum Comparable Areas (MCA) in Brazil in 1991 and 2000, we use a fixed effect regression model to evaluate the effect of the provision of physicians, nurse professionals, nurse associates and community health workers on neonatal mortality for poor and non-poor areas. We additionally forecasted the neonatal mortality rate in 2005. We find that the provision of health workers is particularly important for neonatal mortality in poor areas. Physicians and especially nurse professionals have been essential in decreasing neonatal mortality: an increase of one nurse professional per 1000 population is associated with a 3.8% reduction in neonatal mortality while an increase of one physician per 1000 population is associated with a 2.3% reduction in neonatal mortality. We also find that nurse associates are less important for neonatal mortality (estimated reduction effect of 1.2% ) and that community health workers are not important particularly among the poor. Differences in the provision of health workers explain a large proportion of neonatal mortality. In this paper, we show new evidence to inform decision making on maternal and newborn health. Reductions in neonatal mortality in Brazil have been hampered by the unequal distribution of health workers between poor and non-poor areas. Thus, special attention to a more equitable health system is required to allocate the resources in order to improve the health of poor and ensure equitable access to health services to the entire population.

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

PubMed

D'Alton, Mary E; Friedman, Alexander M; Smiley, Richard M; Montgomery, Douglas M; Paidas, Michael J; D'Oria, Robyn; Frost, Jennifer L; Hameed, Afshan B; Karsnitz, Deborah; Levy, Barbara S; Clark, Steven L

2016-10-01

Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.

Effect of Facilitation of Local Maternal-and-Newborn Stakeholder Groups on Neonatal Mortality: Cluster-Randomized Controlled Trial

PubMed Central

Persson, Lars Åke; Nga, Nguyen T.; Målqvist, Mats; Thi Phuong Hoa, Dinh; Eriksson, Leif; Wallin, Lars; Selling, Katarina; Huy, Tran Q.; Duc, Duong M.; Tiep, Tran V.; Thi Thu Thuy, Vu; Ewald, Uwe

2013-01-01

Background Facilitation of local women's groups may reportedly reduce neonatal mortality. It is not known whether facilitation of groups composed of local health care staff and politicians can improve perinatal outcomes. We hypothesised that facilitation of local stakeholder groups would reduce neonatal mortality (primary outcome) and improve maternal, delivery, and newborn care indicators (secondary outcomes) in Quang Ninh province, Vietnam. Methods and Findings In a cluster-randomized design 44 communes were allocated to intervention and 46 to control. Laywomen facilitated monthly meetings during 3 years in groups composed of health care staff and key persons in the communes. A problem-solving approach was employed. Births and neonatal deaths were monitored, and interviews were performed in households of neonatal deaths and of randomly selected surviving infants. A latent period before effect is expected in this type of intervention, but this timeframe was not pre-specified. Neonatal mortality rate (NMR) from July 2008 to June 2011 was 16.5/1,000 (195 deaths per 11,818 live births) in the intervention communes and 18.4/1,000 (194 per 10,559 live births) in control communes (adjusted odds ratio [OR] 0.96 [95% CI 0.73–1.25]). There was a significant downward time trend of NMR in intervention communes (p = 0.003) but not in control communes (p = 0.184). No significant difference in NMR was observed during the first two years (July 2008 to June 2010) while the third year (July 2010 to June 2011) had significantly lower NMR in intervention arm: adjusted OR 0.51 (95% CI 0.30–0.89). Women in intervention communes more frequently attended antenatal care (adjusted OR 2.27 [95% CI 1.07–4.8]). Conclusions A randomized facilitation intervention with local stakeholder groups composed of primary care staff and local politicians working for three years with a perinatal problem-solving approach resulted in increased attendance to antenatal care and reduced neonatal

Using human rights to improve maternal and neonatal health: history, connections and a proposed practical approach.

PubMed

Gruskin, Sofia; Cottingham, Jane; Hilber, Adriane Martin; Kismodi, Eszter; Lincetto, Ornella; Roseman, Mindy Jane

2008-08-01

We describe the historical development of how maternal and neonatal mortality in the developing world came to be seen as a public-health concern, a human rights concern, and ultimately as both, leading to the development of approaches using human rights concepts and methods to advance maternal and neonatal health. We describe the different contributions of the international community, women's health advocates and human rights activists. We briefly present a recent effort, developed by WHO with the Harvard Program on International Health and Human Rights, that applies a human rights framework to reinforce current efforts to reduce maternal and neonatal mortality.

The quality of the maternal health system in Eritrea.

PubMed

Sharan, Mona; Ahmed, Saifuddin; Ghebrehiwet, Mismay; Rogo, Khama

2011-12-01

To examine the quality of the maternal health system in Eritrea to understand system deficiencies and its relevance to maternal mortality within the context of Millennium Development Goal (MDG) 5. A sample of 118 health facilities was surveyed. Data were collected on 5 dimensions of health system quality: availability; accessibility; management; infrastructure; and process indicators. Data on the causes of hospital admissions for obstetric patients and maternal deaths were extracted from medical records. Eritrea has only 11 comprehensive emergency obstetric care (CEmOC) facilities, all of which are grossly understaffed. There is considerable pressure on the infrastructure and health providers at hospitals. Compliance with clinical care standards and availability of supplies were optimal. As a result, the case fatality rate of 0.65% was low. In total, 45.6% of obstetric admissions and 19.5% of maternal deaths were attributed to abortion complications. In Eritrea, critical gaps in the health system-especially those related to human resources-will impede progress toward MDG 5, and it will not be possible to reduce maternal mortality without addressing the high burden of abortion. Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

A Performance Analysis of Public Expenditure on Maternal Health in Mexico

PubMed Central

Servan-Mori, Edson; Avila-Burgos, Leticia; Nigenda, Gustavo; Lozano, Rafael

2016-01-01

We explore the relationship between public expenditure, coverage of adequate ANC (including timing, frequent and content), and the maternal mortality ratio -adjusted by coverage of adequate ANC- observed in Mexico in 2012 at the State level. Additionally, we examine the inequalities and concentration of public expenditure between populations with and without Social Security. Results suggest that in the 2003–2011 period, the public expenditure gap between women with and without Social Security decreased 74%, however, the distribution is less equitable among women without Social Security, across the States. Despite high levels of coverage on each dimension of ANC explored, coverage of adequate ANC was lower among Social Security than non-Social Security women. This variability results in differences up to 1.5 times in State-adjusted maternal mortality rate at the same level of expense and maternal mortality rate, respectively. The increase in the economic resources is only a necessary condition for achieving improved health outcomes. Providing adequate health services and achieving efficient, effective and transparent use of resources in health, are critical elements for health systems performance. The attainment of universal effective coverage of maternal health and reducing maternal mortality in Mexico, requires the adjustment of policy innovations including the rules of allocation and execution of health resources. Health policies should be designed on a more holistic view promoting a balance between accessibility, effective implementation and rigorous stewardship. PMID:27043819

Maternal health and survival in Pakistan: issues and options.

PubMed

Khan, Yasir P; Bhutta, Shereen Z; Munim, Shama; Bhutta, Zulfiqar A

2009-10-01

Although its measurement may be difficult, the maternal mortality ratio (MMR) is a key indicator of maternal health globally. In Pakistan each year over five million women become pregnant, and of these 700,000 (15% of all pregnant women) are likely to experience some obstetrical and medical complications. An estimated 30,000 women die each year from pregnancy-related causes, and the most recent estimates indicate that the MMR is 276 per 100,000 births annually. In this review, we describe the status of maternal health and survival in Pakistan and place it in its wider context of key determinants. We draw attention to the economic and social vulnerability of pregnant women, and stress the importance of concomitant broader strategies, including poverty reduction and women's empowerment. Undernutrition for girls, early marriage, and high fertility rates coupled with unmet needs for contraception are important determinants of maternal ill health in Pakistan. Our review also examines factors influencing the under-utilization of maternal health services among Pakistani women, such as the lack of availability of skilled care providers and poor quality services. Notwithstanding these observations, there are evidence-based interventions available that, if implemented at scale, could make important contributions towards reducing the burden of maternal mortality in Pakistan.

Reduced Poliovirus vaccine neutralising-antibody titres in infants with maternal HIV-exposure.

PubMed

Sanz-Ramos, Marta; Manno, Daniela; Kapambwe, Mirriam; Ndumba, Ida; Musonda, Kunda G; Bates, Matthew; Chibumbya, Julia; Siame, Joshua; Monze, Mwaka; Filteau, Suzanne; Gompels, Ursula A

2013-04-12

Maternally HIV-exposed (mHIV-EU) infants have poor health even without HIV-1 infection. The responses to vaccination are less well defined. Immunity to oral Poliovirus vaccine (OPV) was studied in Zambian infants participating in a randomised controlled trial of micronutrient fortification to improve child health. Maternally HIV-unexposed and mHIV-EU infants were recruited at 6 months age and randomised to basal or enriched micronutrient-fortified diets for 12 months. HIV-exposed mother-infant pairs had received perinatal nevirapine to prevent mother-to-child-transmission. In the cohort of 597 infants, neutralising-antibody titres to OPV were analysed at 18 months with respect to micronutrient fortification, maternal or infant HIV-1 infection, and human cytomegalovirus (HCMV) infection detected by antibodies and viraemia (serum DNA). Vaccine protection was defined as log2 titre>3. Compared to uninfected children, HIV-1-infected children had reduced neutralising antibody titres to OPV, irrespective of diet: log2 titre difference (95% confidence interval) -3.44 (-2.41; -4.46), P<0.01. OPV antibody titres were lower in HIV-infected children with HCMV viraemia compared to those without viraemia at 18 months, but did not reach significance: difference -2.55 (-6.10; 1.01), P=0.14. Breast-feeding duration was independently associated with increasing OPV titre (P-value<0.01). In mHIV-EU children there were reduced neutralising antibody titres to Poliovirus compared with maternally HIV-unexposed, irrespective of diet, maternal education and socioeconomic status: log2 titre difference (95% confidence interval) -0.56 (-0.98; -0.15), P<0.01. This difference was noticeably decreased after adjusting for breast-feeding duration, suggesting that in our study population less breast-feeding by HIV-positive mothers could explain the reduced OPV titres in mHIV-EU infants. The mHIV-EU infants had reduced polio vaccine antibody titres which were associated with reduced breast

Easier said than done!: methodological challenges with conducting maternal death review research in Malawi.

PubMed

Combs Thorsen, Viva; Sundby, Johanne; Meguid, Tarek; Malata, Address

2014-02-21

Maternal death auditing is widely used to ascertain in-depth information on the clinical, social, cultural, and other contributing factors that result in a maternal death. As the 2015 deadline for Millennium Development Goal 5 of reducing maternal mortality by three quarters between 1990 and 2015 draws near, this information becomes even more critical for informing intensified maternal mortality reduction strategies. Studies using maternal death audit methodologies are widely available, but few discuss the challenges in their implementation. The purpose of this paper is to discuss the methodological issues that arose while conducting maternal death review research in Lilongwe, Malawi. Critical reflections were based on a recently conducted maternal mortality study in Lilongwe, Malawi in which a facility-based maternal death review approach was used. The five-step maternal mortality surveillance cycle provided the framework for discussion. The steps included: 1) identification of cases, 2) data collection, 3) data analysis, 4) recommendations, and 5) evaluation. Challenges experienced were related to the first three steps of the surveillance cycle. They included: 1) identification of cases: conflicting maternal death numbers, and missing medical charts, 2) data collection: poor record keeping, poor quality of documentation, difficulties in identifying and locating appropriate healthcare workers for interviews, the potential introduction of bias through the use of an interpreter, and difficulties with locating family and community members and recall bias; and 3) data analysis: determining the causes of death and clinical diagnoses. Conducting facility-based maternal death reviews for the purpose of research has several challenges. This paper illustrated that performing such an activity, particularly the data collection phase, was not as easy as conveyed in international guidelines and in published studies. However, these challenges are not insurmountable. If they are

Effectiveness of the facility-based maternal near-miss case reviews in improving maternal and newborn quality of care in low-income and middle-income countries: a systematic review

PubMed Central

Lazzerini, Marzia; Richardson, Sonia; Ciardelli, Valentina; Erenbourg, Anna

2018-01-01

Objectives The maternal near-miss case review (NMCR) has been promoted by WHO as an approach to improve quality of care (QoC) at facility level. This systematic review synthesises evidence on the effectiveness of the NMCR on QoC and maternal and perinatal health outcomes in low-income and middle-income countries (LMICs). Methods Studies were searched for in six electronic databases (MEDLINE, Index Medicus, Web of Science, the Cochrane library, Embase, LILACS), with no language restrictions. Two authors independently screened papers and selected them for inclusion and independently extracted data. Maternal mortality was the primary outcome. Secondary outcomes included any outcome informing on any of the six dimensions of QoC: efficacy, safety, efficiency, equity, accessibility and timely care, acceptability and patient-centred care. Results Out of 24 822 papers retrieved, 17 studies from 11 countries were included. Maternal mortality measured before and after the implementation of the NMCR cycle significantly decreased (OR 0.77, 95% CI 0.61 to 0.98, eight studies, 55 573 043 women; I2=39%). A statistically significant reduction in the incidence of uterine rupture, postpartum haemorrhage and maternal sepsis was observed in three out of six studies. Ten studies reporting on maternal care process all showed some significant improvement when measured against predefined standards. All studies reported that the NMCR resulted in some amelioration of the facility structure (physical structure, staffing, equipment, training, organisation of care). Newborn outcomes were overall poorly reported; four studies showed no significant difference in perinatal mortality. Patient satisfaction and equity were also poorly reported. Conclusions Policy makers may consider implementing the maternal NMCR cycle approach among strategies aiming at improving QoC and reducing maternal mortality and morbidity in LMIC. Future studies should better document the effectiveness of the NMCR cycle

The effectiveness of the TBA programme in reducing maternal mortality and morbidity in Malawi.

PubMed

Bisika, Thomas

2008-08-01

The main objective of this study was to assess the role of TBAs and the quality of their services in contributing to the reduction of maternal deaths in Malawi. This study used a qualitative research methodology involving key informant and in-depth interviews, observation and focus group interviews. The study found that most of the people rely on traditional birth attendants although the quality of their services is poor due to illiteracy, their ailing age, lack of supplies and equipment and general absence of supervision. The study fiuther observed that although the hospital sees many pregnant women during antenatal care, very few women actually come back to the hospital for delivery. The study also found that there was high awareness among TBAs about what they were supposed to do but that their actual practices did not reflect compliance with their roles as assigned by the formal health system. The study concludes that TBAs are an important source of maternal care especially in rural areas and that they need to be empowered to comply with the requirement of ensuring infection free deliveries. This entails adequate supervision and provision of supplies. The study further observed that the utilization levels of TBAs is far much greater that presently acknowledged suggesting severe inadequacies within the formal health system.

Accelerating Maternal and Child Health Gains in Papua New Guinea: Modelled Predictions from Closing the Equity Gap Using LiST.

PubMed

Byrne, Abbey; Hodge, Andrew; Jimenez-Soto, Eliana

2015-11-01

Many priority countries in the countdown to the millennium development goals deadline are lagging in progress towards maternal and child health (MCH) targets. Papua New Guinea (PNG) is one such country beset by challenges of geographical inaccessibility, inequity and health system weakness. Several countries, however, have made progress through focused initiatives which align with the burden of disease and overcome specific inequities. This study identifies the potential impact on maternal and child mortality through increased coverage of prioritised interventions within the PNG health system. The burden of disease and health system environment of PNG was documented to inform prioritised MCH interventions at community, outreach, and clinical levels. Potential reductions in maternal and child mortality through increased intervention coverage to close the geographical equity gap were estimated with the lives saved tool. A set community-level interventions, with highest feasibility, would yield significant reductions in newborn and child mortality. Adding the outreach group delivers gains for maternal mortality, particularly through family planning. The clinical services group of interventions demands greater investment but are essential to reach MCH targets. Cumulatively, the increased coverage is estimated to reduce the rates of under-five mortality by 19 %, neonatal mortality by 26 %, maternal mortality ratio by 10 % and maternal mortality by 33 %. Modest investments in health systems focused on disadvantaged populations can accelerate progress in maternal and child survival even in fragile health systems like PNG. The critical approach may be to target interventions and implementation appropriately to the sensitive context of lagging countries.

Maternal HIV-1 envelope–specific antibody responses and reduced risk of perinatal transmission

PubMed Central

Permar, Sallie R.; Fong, Youyi; Vandergrift, Nathan; Fouda, Genevieve G.; Gilbert, Peter; Parks, Robert; Jaeger, Frederick H.; Pollara, Justin; Martelli, Amanda; Liebl, Brooke E.; Lloyd, Krissey; Yates, Nicole L.; Overman, R. Glenn; Shen, Xiaoying; Whitaker, Kaylan; Chen, Haiyan; Pritchett, Jamie; Solomon, Erika; Friberg, Emma; Marshall, Dawn J.; Whitesides, John F.; Gurley, Thaddeus C.; Von Holle, Tarra; Martinez, David R.; Cai, Fangping; Kumar, Amit; Xia, Shi-Mao; Lu, Xiaozhi; Louzao, Raul; Wilkes, Samantha; Datta, Saheli; Sarzotti-Kelsoe, Marcella; Liao, Hua-Xin; Ferrari, Guido; Alam, S. Munir; Montefiori, David C.; Denny, Thomas N.; Moody, M. Anthony; Tomaras, Georgia D.; Gao, Feng; Haynes, Barton F.

2015-01-01

Despite the wide availability of antiretroviral drugs, more than 250,000 infants are vertically infected with HIV-1 annually, emphasizing the need for additional interventions to eliminate pediatric HIV-1 infections. Here, we aimed to define humoral immune correlates of risk of mother-to-child transmission (MTCT) of HIV-1, including responses associated with protection in the RV144 vaccine trial. Eighty-three untreated, HIV-1–transmitting mothers and 165 propensity score–matched nontransmitting mothers were selected from the Women and Infants Transmission Study (WITS) of US nonbreastfeeding, HIV-1–infected mothers. In a multivariable logistic regression model, the magnitude of the maternal IgG responses specific for the third variable loop (V3) of the HIV-1 envelope was predictive of a reduced risk of MTCT. Neutralizing Ab responses against easy-to-neutralize (tier 1) HIV-1 strains also predicted a reduced risk of peripartum transmission in secondary analyses. Moreover, recombinant maternal V3–specific IgG mAbs mediated neutralization of autologous HIV-1 isolates. Thus, common V3-specific Ab responses in maternal plasma predicted a reduced risk of MTCT and mediated autologous virus neutralization, suggesting that boosting these maternal Ab responses may further reduce HIV-1 MTCT. PMID:26053661

Disadvantaged populations in maternal health in China who and why?

PubMed Central

Yuan, Beibei; Qian, Xu; Thomsen, Sarah

2013-01-01

Background China has made impressive progress towards the Millennium Development Goal (MDG) for maternal and reproductive health, but ensuring that progress reaches all segments of the population remains a challenge for policy makers. The aim of this review is to map disadvantaged populations in terms of maternal health in China, and to explain the causes of these inequities to promote policy action. Methods We searched PUBMED, Popline, Proquest and WanFang and included primary studies conducted in mainland China. Experts were also contacted to identify additional studies. Disadvantaged populations in terms of MDG 5 and the reasons for this disadvantage explored by authors were identified and coded based on the conceptual framework developed by the WHO Commission on the Social Determinants of Health. Results In China, differences in maternal health service utilization and the maternal mortality ratio among different income groups, and among regions with different socio-economic development still exist, although these differences are narrowing. Groups with low levels of education and ethnic minorities utilize maternal health care less frequently and experience higher maternal mortality, although we could not determine whether these differences have changed in the last decade. Rural-to-urban migrants use maternal health care and contraception to a lower extent than permanent residents of cities, and differential maternal mortality shows a widening trend among these groups. Gender inequity also contributes to the disadvantaged position of women. Intermediary factors that explain these inequities include material circumstances such as long distances to health facilities for women living in remote areas, behavioral factors such as traditional beliefs that result in reduced care seeking among ethnic minorities, and health system determinants such as out-of-pocket payments posing financial barriers for the poor. Conclusions Inequity in maternal health continues to be an

Disadvantaged populations in maternal health in China who and why?

PubMed

Yuan, Beibei; Qian, Xu; Thomsen, Sarah

2013-04-03

China has made impressive progress towards the Millennium Development Goal (MDG) for maternal and reproductive health, but ensuring that progress reaches all segments of the population remains a challenge for policy makers. The aim of this review is to map disadvantaged populations in terms of maternal health in China, and to explain the causes of these inequities to promote policy action. We searched PUBMED, Popline, Proquest and WanFang and included primary studies conducted in mainland China. Experts were also contacted to identify additional studies. Disadvantaged populations in terms of MDG 5 and the reasons for this disadvantage explored by authors were identified and coded based on the conceptual framework developed by the WHO Commission on the Social Determinants of Health. In China, differences in maternal health service utilization and the maternal mortality ratio among different income groups, and among regions with different socio-economic development still exist, although these differences are narrowing. Groups with low levels of education and ethnic minorities utilize maternal health care less frequently and experience higher maternal mortality, although we could not determine whether these differences have changed in the last decade. Rural-to-urban migrants use maternal health care and contraception to a lower extent than permanent residents of cities, and differential maternal mortality shows a widening trend among these groups. Gender inequity also contributes to the disadvantaged position of women. Intermediary factors that explain these inequities include material circumstances such as long distances to health facilities for women living in remote areas, behavioral factors such as traditional beliefs that result in reduced care seeking among ethnic minorities, and health system determinants such as out-of-pocket payments posing financial barriers for the poor. Inequity in maternal health continues to be an issue worthy of greater programmatic and

[Safe illegal abortion would make an important contribution to decreasing maternal mortality and female suffering].

PubMed

Kleiverda, G

2008-03-01

Unsafe abortion is a major public health concern in many developing countries, contributing to a substantial proportion of maternal deaths. Increased legal access to abortion services is associated with improvement in mortality and morbidity. Safe illegal abortion by means of drugs is another possible way to prevent this unnecessary harm to women. The Dutch government, however, is now proposing legal changes that will diminish the access to medical abortion by general practitioners.

Social autopsy: a potential health-promotion tool for preventing maternal mortality in low-income countries.

PubMed

Mahato, Preeti K; Waithaka, Elizabeth; van Teijlingen, Edwin; Pant, Puspa Raj; Biswas, Animesh

2018-04-01

Despite significant global improvements, maternal mortality in low-income countries remains unacceptably high. Increasing attention in recent years has focused on how social factors, such as family and peer influences, the community context, health services, legal and policy environments, and cultural and social values, can shape and influence maternal outcomes. Whereas verbal autopsy is used to attribute a clinical cause to a maternal death, the aim of social autopsy is to determine the non-clinical contributing factors. A social autopsy of a maternal death is a group interaction with the family of the deceased woman and her wider local community, where facilitators explore the social causes of the death and identify improvements needed. Although still relatively new, the process has proved useful to capture data for policy-makers on the social determinants of maternal deaths. This article highlights a second aspect of social autopsy - its potential role in health promotion. A social autopsy facilitates "community self-diagnosis" and identification of modifiable social and cultural factors that are attributable to the death. Social autopsy therefore has the potential not only for increasing awareness among community members, but also for promoting behavioural change at the individual and community level. There has been little formal assessment of social autopsy as a tool for health promotion. Rigorous research is now needed to assess the effectiveness and cost effectiveness of social autopsy as a preventive community-based intervention, especially with respect to effects on social determinants. There is also a need to document how communities can take ownership of such activities and achieve a sustainable impact on preventable maternal deaths.

Co-causation of reduced newborn size by maternal undernutrition, infections, and inflammation.

PubMed

Ashorn, Per; Hallamaa, Lotta; Allen, Lindsay H; Ashorn, Ulla; Chandrasiri, Upeksha; Deitchler, Megan; Doyle, Ronan; Harjunmaa, Ulla; Jorgensen, Josh M; Kamiza, Steve; Klein, Nigel; Maleta, Kenneth; Nkhoma, Minyanga; Oaks, Brietta M; Poelman, Basho; Rogerson, Stephen J; Stewart, Christine P; Zeilani, Mamane; Dewey, Kathryn G

2018-01-08

More than 20 million babies are born with low birthweight annually. Small newborns have an increased risk for mortality, growth failure, and other adverse outcomes. Numerous antenatal risk factors for small newborn size have been identified, but individual interventions addressing them have not markedly improved the health outcomes of interest. We tested a hypothesis that in low-income settings, newborn size is influenced jointly by multiple maternal exposures and characterized pathways associating these exposures with newborn size. This was a prospective cohort study of pregnant women and their offspring nested in an intervention trial in rural Malawi. We collected information on maternal and placental characteristics and used regression analyses, structural equation modelling, and random forest models to build pathway maps for direct and indirect associations between these characteristics and newborn weight-for-age Z-score and length-for-age Z-score. We used multiple imputation to infer values for any missing data. Among 1,179 pregnant women and their babies, newborn weight-for-age Z-score was directly predicted by maternal primiparity, body mass index, and plasma alpha-1-acid glycoprotein concentration before 20 weeks of gestation, gestational weight gain, duration of pregnancy, placental weight, and newborn length-for-age Z-score (p < .05). The latter 5 variables were interconnected and were predicted by several more distal determinants. In low-income conditions like rural Malawi, maternal infections, inflammation, nutrition, and certain constitutional factors jointly influence newborn size. Because of this complex network, comprehensive interventions that concurrently address multiple adverse exposures are more likely to increase mean newborn size than focused interventions targeting only maternal nutrition or specific infections. © 2018 The Authors. Maternal & Child Nutrition published by John Wiley & Sons, Ltd.

Growing a Best Babies Zone: Lessons Learned from the Pilot Phase of a Multi-Sector, Place-Based Initiative to Reduce Infant Mortality.

PubMed

Pies, Cheri; Barr, Monica; Strouse, Carly; Kotelchuck, Milton

2016-05-01

Infant mortality reduction in the U.S. has been addressed predominantly through clinical approaches. While these efforts have reduced the infant mortality rate overall, they have not reduced disparities between different racial/socioeconomic groups. To address the interrelated social, economic and environmental factors contributing to infant mortality, a place-based approach is needed to complement existing initiatives and clinical practices. Best Babies Zone (BBZ) is an early attempt to put life course theory into practice, taking a place-based approach to reducing infant mortality by aligning resources, building community leadership, and transforming educational opportunities, economic development, and community systems in concentrated neighborhoods. BBZ is currently in three neighborhoods: Price Hill (Cincinnati, OH), Hollygrove (New Orleans, LA), and Castlemont (Oakland, CA). Assessment In its first 4 years, each BBZ crafted resident-driven strategies for decreasing the root causes of toxic stress and poor birth outcomes. To address resident priorities, BBZ sites experimented with tools from other fields (like design thinking and health impact assessment), and emphasized existing MCH strategies like leadership development. Early challenges, including shifting from traditional MCH interventions and addressing health equity, point to areas of growth in implementing this approach in the maternal and child health field. BBZ aims to elevate local voice and mobilize multiple sectors in order to address the social determinants of infant mortality, and other initiatives working to improve MCH outcomes can learn from the successes and challenges of the first 4 years of BBZ in order to bring life course theory into practice.

Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of northern Nigeria.

PubMed

Wall, L L

1998-12-01

Northern Nigeria has a maternal mortality ratio greater than 1,000 maternal deaths per 100,000 live births. Serious maternal morbidity (for example, vesico-vaginal fistula) is also common. Among the most important factors contributing to this tragic situation are: an Islamic culture that undervalues women; a perceived social need for women's reproductive capacities to be under strict male control; the practice of purdah (wife seclusion), which restricts women's access to medical care; almost universal female illiteracy; marriage at an early age and pregnancy often occurring before maternal pelvic growth is complete; a high rate of obstructed labor; directly harmful traditional medical beliefs and practices; inadequate facilities to deal with obstetric emergencies; a deteriorating economy; and a political culture marked by rampant corruption and inefficiency. The convergence of all of these factors has resulted in one of the worst records of female reproductive health existing anywhere in the world.

Working toward decreasing infant mortality in developing countries through change in the medical curriculum

PubMed Central

2011-01-01

Background High infant and maternal mortality rates are one of the biggest health issues in Pakistan. Although these rates are given high priority at the national level (Millennium Development Goals 4 and 5, respectively), there has been no significant decrease in them so far. We hypothesize that this lack of success is because the undergraduate curriculum in Pakistan does not match local needs. Currently, the Pakistani medical curriculum deals with issues in maternal and child morbidity and mortality according to Western textbooks. Moreover, these are taught disjointedly through various departments. We undertook curriculum revision to sensitize medical students to maternal and infant mortality issues important in the Pakistani context and educate them about ways to reduce the same through an integrated teaching approach. Methods The major determinants of infant mortality in underdeveloped countries were identified through a literature review covering international research produced over the last 10 years and the Pakistan Demographic Health Survey 2006-07. An interdisciplinary maternal and child health module team was created by the Medical Education Department at Shifa College of Medicine. The curriculum was developed based on the role of identified determinants in infant and maternal mortality. It was delivered by an integrated team without any subject boundaries. Students' knowledge, skills, and attitudes were assessed by multiple modalities and the module itself by student feedback using questionnaires and focus group discussions. Results Assessment and feedback demonstrated that the students had developed a thorough understanding of the complexity of factors that contribute to infant mortality. Students also demonstrated knowledge and skill in counseling, antenatal care, and care of newborns and infants. Conclusions A carefully designed integrated curriculum can help sensitize undergraduate medical students and equip them to identify and address complex issues

The associations of parity and maternal age with small-for-gestational-age, preterm, and neonatal and infant mortality: a meta-analysis

PubMed Central

2013-01-01

Background Previous studies have reported on adverse neonatal outcomes associated with parity and maternal age. Many of these studies have relied on cross-sectional data, from which drawing causal inference is complex. We explore the associations between parity/maternal age and adverse neonatal outcomes using data from cohort studies conducted in low- and middle-income countries (LMIC). Methods Data from 14 cohort studies were included. Parity (nulliparous, parity 1-2, parity ≥3) and maternal age (<18 years, 18-<35 years, ≥35 years) categories were matched with each other to create exposure categories, with those who are parity 1-2 and age 18-<35 years as the reference. Outcomes included small-for-gestational-age (SGA), preterm, neonatal and infant mortality. Adjusted odds ratios (aOR) were calculated per study and meta-analyzed. Results Nulliparous, age <18 year women, compared with women who were parity 1-2 and age 18-<35 years had the highest odds of SGA (pooled adjusted OR: 1.80), preterm (pooled aOR: 1.52), neonatal mortality (pooled aOR: 2.07), and infant mortality (pooled aOR: 1.49). Increased odds were also noted for SGA and neonatal mortality for nulliparous/age 18-<35 years, preterm, neonatal, and infant mortality for parity ≥3/age 18-<35 years, and preterm and neonatal mortality for parity ≥3/≥35 years. Conclusions Nulliparous women <18 years of age have the highest odds of adverse neonatal outcomes. Family planning has traditionally been the least successful in addressing young age as a risk factor; a renewed focus must be placed on finding effective interventions that delay age at first birth. Higher odds of adverse outcomes are also seen among parity ≥3 / age ≥35 mothers, suggesting that reproductive health interventions need to address the entirety of a woman’s reproductive period. Funding Funding was provided by the Bill & Melinda Gates Foundation (810-2054) by a grant to the US Fund for UNICEF to support the activities of the Child

The Dublin Declaration on Maternal Health Care and Anti-Abortion Activism

PubMed Central

2017-01-01

Abstract The Dublin Declaration on Maternal Healthcare—issued by self-declared pro-life activists in Ireland in 2012—states unequivocally that abortion is never medically necessary, even to save the life of a pregnant woman. This article examines the influence of the Dublin Declaration on abortion politics in Latin America, especially El Salvador and Chile, where it has recently been used in pro-life organizing to cast doubt on the notion that legalizing abortion will reduce maternal mortality. Its framers argue that legalizing abortion will not improve maternal mortality rates, but reproductive rights advocates respond that the Dublin Declaration is junk science designed to preserve the world’s most restrictive abortion laws. Analyzing the strategy and impact of the Dublin Declaration brings to light one of the tactics used in anti-abortion organizing. PMID:28630540

Reduced placental amino acid transport in response to maternal nutrient restriction in the baboon.

PubMed

Pantham, Priyadarshini; Rosario, Fredrick J; Nijland, Mark; Cheung, Alex; Nathanielsz, Peter W; Powell, Theresa L; Galan, Henry L; Li, Cun; Jansson, Thomas

2015-10-01

Intrauterine growth restriction increases the risk of perinatal complications and predisposes the infant to diabetes and cardiovascular disease in later life. Mechanisms by which maternal nutrient restriction (MNR) reduces fetal growth are poorly understood. We hypothesized that MNR decreases placental amino acid (AA) transporter activity, leading to reduced transplacental transfer of AAs. Pregnant baboons were fed either a control (ad libitum, n = 7), or MNR diet (70% of control diet, n = 7) from gestational day (GD) 30. At GD 165 (0.9 gestation), placentas (n = 7 in each group) were collected, and microvillous plasma membrane vesicles (MVM) isolated. MVM system A and system L AA transport was determined in vitro using radiolabeled substrates and rapid filtration techniques. In vivo transplacental AA transport was assessed by infusing nine (13)C- or (2)H-labeled essential AA as a bolus into the maternal circulation (n = 5 control, n = 4 MNR) at cesarean section. A fetal vein-to-maternal artery mole percent excess ratio for each essential AA was calculated. Fetal and placental weights were significantly reduced in the MNR group compared with controls (P < 0.01). The activity of system A and system L was markedly reduced by 73 and 84%, respectively, in MVM isolated from baboon placentas at GD 165 following MNR (P < 0.01). In vivo, the fetal vein-to-maternal artery mole percent excess ratio was significantly reduced for leucine, isoleucine, methionine, phenylalanine, threonine, and tryptophan in MNR baboons (P < 0.05). This is the first study to investigate placental AA transport in a nonhuman primate model of MNR. We demonstrate that the downregulation of system A and system L activity in syncytiotrophoblast MVM in MNR leads to decreased transplacental AA transport and, consequently, reduced circulating fetal AA concentrations, a potential mechanism linking maternal undernutrition to reduced fetal growth. Copyright © 2015 the American Physiological Society.

Maternal deaths in the Nordic countries.

PubMed

Vangen, Siri; Bødker, Birgit; Ellingsen, Liv; Saltvedt, Sissel; Gissler, Mika; Geirsson, Reynir T; Nyfløt, Lill T

2017-09-01

Despite the seriousness of the event, maternal deaths are substantially underreported. There is often a missed opportunity to learn from such tragedies. The aim of the study was to identify maternal deaths in the five Nordic countries, to classify causes of death based on internationally acknowledged criteria, and to identify areas that would benefit from further teaching, training or research to possibly reduce the number of maternal deaths. We present data for the years 2005-2013. National audit groups collected data by linkage of registers and direct reporting from hospitals. Each case was then assessed to determine the cause of death, and level of care provided. Potential improvements to care were evaluated. We registered 168 maternal deaths, 90 direct and 78 indirect cases. The maternal mortality ratio was 7.2/100 000 live births ranging from 6.8 to 8.1 between the countries. Cardiac disease (n = 29) was the most frequent cause of death, followed by preeclampsia (n = 24), thromboembolism (n = 20) and suicide (n = 20). Improvements to care which could potentially have made a difference to the outcome were identified in one-third of the deaths, i.e. in as many as 60% of preeclamptic, 45% of thromboembolic, and 32% of the deaths from cardiac disease. Direct deaths exceeded indirect maternal deaths in the Nordic countries. To reduce maternal deaths, increased efforts to better implement existing clinical guidelines seem warranted, particularly for preeclampsia, thromboembolism and cardiac disease. More knowledge is also needed about what contributes to suicidal maternal deaths. © 2017 Nordic Federation of Societies of Obstetrics and Gynecology.

The joint effect of maternal malnutrition and cold weather on neonatal mortality in nineteenth-century Venice: an assessment of the hypothermia hypothesis.

PubMed

Derosas, Renzo

2009-11-01

Recent studies stress the key role played by neonatal mortality in the demographic regime of north-eastern Italy. In particular, during the period 1700-1830 this area experienced a dramatic upsurge in winter neonatal deaths, pushing overall neonatal and infant mortality rates to the highest in Italy and most of Europe. Scholars have argued that this trend was caused by a general pauperization leading to widespread maternal malnutrition, low birth weight, and an increased frequency of winter neonatal deaths caused by the higher sensitivity of low-birth-weight infants to the cold. The study presented here tested this hypothesis using a large mid-nineteenth-century longitudinal sample of the Venetian population. Two alternative measures of maternal malnutrition were applied: chronic undernourishment and temporary nutritional stress during late gestation. Only the second condition is significantly associated with higher neonatal mortality when outside temperatures were low. This is consistent with mechanisms of neonatal thermoregulation but casts doubt on the pauperization hypothesis suggested by other studies.

Maternal Health Situation in India: A Case Study

PubMed Central

Mavalankar, Dileep V.; Ramani, K.V.; Upadhyaya, Mudita; Sharma, Bharati; Iyengar, Sharad; Gupta, Vikram; Iyengar, Kirti

2009-01-01

Since the beginning of the Safe Motherhood Initiative, India has accounted for at least a quarter of maternal deaths reported globally. India's goal is to lower maternal mortality to less than 100 per 100,000 livebirths but that is still far away despite its programmatic efforts and rapid economic progress over the past two decades. Geographical vastness and sociocultural diversity mean that maternal mortality varies across the states, and uniform implementation of health-sector reforms is not possible. The case study analyzes the trends in maternal mortality nationally, the maternal healthcare-delivery system at different levels, and the implementation of national maternal health programmes, including recent innovative strategies. It identifies the causes for limited success in improving maternal health and suggests measures to rectify them. It recommends better reporting of maternal deaths and implementation of evidence-based, focused strategies along with effective monitoring for rapid progress. It also stresses the need for regulation of the private sector and encourages further public-private partnerships and policies, along with a strong political will and improved management capacity for improving maternal health. PMID:19489415

Foetal mortality, infant mortality, and age of parents. An overview.

PubMed

Gourbin, C

2005-11-01

This review article examines the relationship between late foetal and infant mortality, and age of parents. The highest risks are observed at older maternal ages for foetal mortality and at both extremes of reproductive ages for infant mortality. For infant morbidity, the role of intermediate variables is discussed. Increasing paternal age seems to be related to higher foetal and neonatal mortality.

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

PubMed

Kassebaum, Nicholas J; Bertozzi-Villa, Amelia; Coggeshall, Megan S; Shackelford, Katya A; Steiner, Caitlyn; Heuton, Kyle R; Gonzalez-Medina, Diego; Barber, Ryan; Huynh, Chantal; Dicker, Daniel; Templin, Tara; Wolock, Timothy M; Ozgoren, Ayse Abbasoglu; Abd-Allah, Foad; Abera, Semaw Ferede; Abubakar, Ibrahim; Achoki, Tom; Adelekan, Ademola; Ademi, Zanfina; Adou, Arsène Kouablan; Adsuar, José C; Agardh, Emilie E; Akena, Dickens; Alasfoor, Deena; Alemu, Zewdie Aderaw; Alfonso-Cristancho, Rafael; Alhabib, Samia; Ali, Raghib; Al Kahbouri, Mazin J; Alla, François; Allen, Peter J; AlMazroa, Mohammad A; Alsharif, Ubai; Alvarez, Elena; Alvis-Guzmán, Nelson; Amankwaa, Adansi A; Amare, Azmeraw T; Amini, Hassan; Ammar, Walid; Antonio, Carl A T; Anwari, Palwasha; Arnlöv, Johan; Arsenijevic, Valentina S Arsic; Artaman, Ali; Asad, Majed Masoud; Asghar, Rana J; Assadi, Reza; Atkins, Lydia S; Badawi, Alaa; Balakrishnan, Kalpana; Basu, Arindam; Basu, Sanjay; Beardsley, Justin; Bedi, Neeraj; Bekele, Tolesa; Bell, Michelle L; Bernabe, Eduardo; Beyene, Tariku J; Bhutta, Zulfiqar; Bin Abdulhak, Aref; Blore, Jed D; Basara, Berrak Bora; Bose, Dipan; Breitborde, Nicholas; Cárdenas, Rosario; Castañeda-Orjuela, Carlos A; Castro, Ruben Estanislao; Catalá-López, Ferrán; Cavlin, Alanur; Chang, Jung-Chen; Che, Xuan; Christophi, Costas A; Chugh, Sumeet S; Cirillo, Massimo; Colquhoun, Samantha M; Cooper, Leslie Trumbull; Cooper, Cyrus; da Costa Leite, Iuri; Dandona, Lalit; Dandona, Rakhi; Davis, Adrian; Dayama, Anand; Degenhardt, Louisa; De Leo, Diego; del Pozo-Cruz, Borja; Deribe, Kebede; Dessalegn, Muluken; deVeber, Gabrielle A; Dharmaratne, Samath D; Dilmen, Uğur; Ding, Eric L; Dorrington, Rob E; Driscoll, Tim R; Ermakov, Sergei Petrovich; Esteghamati, Alireza; Faraon, Emerito Jose A; Farzadfar, Farshad; Felicio, Manuela Mendonca; Fereshtehnejad, Seyed-Mohammad; de Lima, Graça Maria Ferreira; Forouzanfar, Mohammad H; França, Elisabeth B; Gaffikin, Lynne; Gambashidze, Ketevan; Gankpé, Fortuné Gbètoho; Garcia, Ana C; Geleijnse, Johanna M; Gibney, Katherine B; Giroud, Maurice; Glaser, Elizabeth L; Goginashvili, Ketevan; Gona, Philimon; González-Castell, Dinorah; Goto, Atsushi; Gouda, Hebe N; Gugnani, Harish Chander; Gupta, Rahul; Gupta, Rajeev; Hafezi-Nejad, Nima; Hamadeh, Randah Ribhi; Hammami, Mouhanad; Hankey, Graeme J; Harb, Hilda L; Havmoeller, Rasmus; Hay, Simon I; Pi, Ileana B Heredia; Hoek, Hans W; Hosgood, H Dean; Hoy, Damian G; Husseini, Abdullatif; Idrisov, Bulat T; Innos, Kaire; Inoue, Manami; Jacobsen, Kathryn H; Jahangir, Eiman; Jee, Sun Ha; Jensen, Paul N; Jha, Vivekanand; Jiang, Guohong; Jonas, Jost B; Juel, Knud; Kabagambe, Edmond Kato; Kan, Haidong; Karam, Nadim E; Karch, André; Karema, Corine Kakizi; Kaul, Anil; Kawakami, Norito; Kazanjan, Konstantin; Kazi, Dhruv S; Kemp, Andrew H; Kengne, Andre Pascal; Kereselidze, Maia; Khader, Yousef Saleh; Khalifa, Shams Eldin Ali Hassan; Khan, Ejaz Ahmed; Khang, Young-Ho; Knibbs, Luke; Kokubo, Yoshihiro; Kosen, Soewarta; Defo, Barthelemy Kuate; Kulkarni, Chanda; Kulkarni, Veena S; Kumar, G Anil; Kumar, Kaushalendra; Kumar, Ravi B; Kwan, Gene; Lai, Taavi; Lalloo, Ratilal; Lam, Hilton; Lansingh, Van C; Larsson, Anders; Lee, Jong-Tae; Leigh, James; Leinsalu, Mall; Leung, Ricky; Li, Xiaohong; Li, Yichong; Li, Yongmei; Liang, Juan; Liang, Xiaofeng; Lim, Stephen S; Lin, Hsien-Ho; Lipshultz, Steven E; Liu, Shiwei; Liu, Yang; Lloyd, Belinda K; London, Stephanie J; Lotufo, Paulo A; Ma, Jixiang; Ma, Stefan; Machado, Vasco Manuel Pedro; Mainoo, Nana Kwaku; Majdan, Marek; Mapoma, Christopher Chabila; Marcenes, Wagner; Marzan, Melvin Barrientos; Mason-Jones, Amanda J; Mehndiratta, Man Mohan; Mejia-Rodriguez, Fabiola; Memish, Ziad A; Mendoza, Walter; Miller, Ted R; Mills, Edward J; Mokdad, Ali H; Mola, Glen Liddell; Monasta, Lorenzo; de la Cruz Monis, Jonathan; Hernandez, Julio Cesar Montañez; Moore, Ami R; Moradi-Lakeh, Maziar; Mori, Rintaro; Mueller, Ulrich O; Mukaigawara, Mitsuru; Naheed, Aliya; Naidoo, Kovin S; Nand, Devina; Nangia, Vinay; Nash, Denis; Nejjari, Chakib; Nelson, Robert G; Neupane, Sudan Prasad; Newton, Charles R; Ng, Marie; Nieuwenhuijsen, Mark J; Nisar, Muhammad Imran; Nolte, Sandra; Norheim, Ole F; Nyakarahuka, Luke; Oh, In-Hwan; Ohkubo, Takayoshi; Olusanya, Bolajoko O; Omer, Saad B; Opio, John Nelson; Orisakwe, Orish Ebere; Pandian, Jeyaraj D; Papachristou, Christina; Park, Jae-Hyun; Caicedo, Angel J Paternina; Patten, Scott B; Paul, Vinod K; Pavlin, Boris Igor; Pearce, Neil; Pereira, David M; Pesudovs, Konrad; Petzold, Max; Poenaru, Dan; Polanczyk, Guilherme V; Polinder, Suzanne; Pope, Dan; Pourmalek, Farshad; Qato, Dima; Quistberg, D Alex; Rafay, Anwar; Rahimi, Kazem; Rahimi-Movaghar, Vafa; ur Rahman, Sajjad; Raju, Murugesan; Rana, Saleem M; Refaat, Amany; Ronfani, Luca; Roy, Nobhojit; Pimienta, Tania Georgina Sánchez; Sahraian, Mohammad Ali; Salomon, Joshua A; Sampson, Uchechukwu; Santos, Itamar S; Sawhney, Monika; Sayinzoga, Felix; Schneider, Ione J C; Schumacher, Austin; Schwebel, David C; Seedat, Soraya; Sepanlou, Sadaf G; Servan-Mori, Edson E; Shakh-Nazarova, Marina; Sheikhbahaei, Sara; Shibuya, Kenji; Shin, Hwashin Hyun; Shiue, Ivy; Sigfusdottir, Inga Dora; Silberberg, Donald H; Silva, Andrea P; Singh, Jasvinder A; Skirbekk, Vegard; Sliwa, Karen; Soshnikov, Sergey S; Sposato, Luciano A; Sreeramareddy, Chandrashekhar T; Stroumpoulis, Konstantinos; Sturua, Lela; Sykes, Bryan L; Tabb, Karen M; Talongwa, Roberto Tchio; Tan, Feng; Teixeira, Carolina Maria; Tenkorang, Eric Yeboah; Terkawi, Abdullah Sulieman; Thorne-Lyman, Andrew L; Tirschwell, David L; Towbin, Jeffrey A; Tran, Bach X; Tsilimbaris, Miltiadis; Uchendu, Uche S; Ukwaja, Kingsley N; Undurraga, Eduardo A; Uzun, Selen Begüm; Vallely, Andrew J; van Gool, Coen H; Vasankari, Tommi J; Vavilala, Monica S; Venketasubramanian, N; Villalpando, Salvador; Violante, Francesco S; Vlassov, Vasiliy Victorovich; Vos, Theo; Waller, Stephen; Wang, Haidong; Wang, Linhong; Wang, XiaoRong; Wang, Yanping; Weichenthal, Scott; Weiderpass, Elisabete; Weintraub, Robert G; Westerman, Ronny; Wilkinson, James D; Woldeyohannes, Solomon Meseret; Wong, John Q; Wordofa, Muluemebet Abera; Xu, Gelin; Yang, Yang C; Yano, Yuichiro; Yentur, Gokalp Kadri; Yip, Paul; Yonemoto, Naohiro; Yoon, Seok-Jun; Younis, Mustafa Z; Yu, Chuanhua; Jin, Kim Yun; El Sayed Zaki, Maysaa; Zhao, Yong; Zheng, Yingfeng; Zhou, Maigeng; Zhu, Jun; Zou, Xiao Nong; Lopez, Alan D; Naghavi, Mohsen; Murray, Christopher J L; Lozano, Rafael

2014-09-13

The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery. We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values. 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most

Maternal cerebrovascular accidents in pregnancy: incidence and outcomes.

PubMed

Walsh, Jennifer; Murphy, Cliona; Murray, Aoife; O'Laoide, Risteard; McAuliffe, Fionnuala M

2010-12-01

Stroke occurring during pregnancy and the postnatal period is a rare but potentially catastrophic event. The aim of this study was to examine the incidence and outcomes of pregnancies complicated by maternal stroke in a single centre. This is a prospective study of over 35,000 consecutive pregnancies over a four-year period at the National Maternity Hospital in Dublin from 2004 to 2008; in addition we also retrospectively examined all cases of maternal mortality at our institution over a 50-year period from 1959 to 2009. We prospectively identified eight cases of strokes complicating pregnancy and the postnatal period giving an overall incidence of 22.34 per 100,000 pregnancies or 24.74 per 100,000 deliveries. There were no stroke-related mortalities during that time. Retrospective analysis of maternal mortality revealed 102 maternal deaths over a 50-year period, 19 (18.6%) of which were due to cerebrovascular accidents. In conclusion, strokes complicating pregnancy and the puerperium remain a rare event and though there appears to be evidence that the incidence is increasing, the associated maternal mortality appears to be falling.

Maternal education and age: inequalities in neonatal death.

PubMed

Fonseca, Sandra Costa; Flores, Patricia Viana Guimarães; Camargo, Kenneth Rochel; Pinheiro, Rejane Sobrino; Coeli, Claudia Medina

2017-11-17

Evaluate the interaction between maternal age and education level in neonatal mortality, as well as investigate the temporal evolution of neonatal mortality in each stratum formed by the combination of these two risk factors. A nonconcurrent cohort study, resulting from a probabilistic relationship between the Mortality Information System and the Live Birth Information System. To investigate the risk of neonatal death we performed a logistic regression, with an odds ratio estimate for the combined variable of maternal education and age, as well as the evaluation of additive and multiplicative interaction. The neonatal mortality rate time series, according to maternal education and age, was estimated by the Joinpoint Regression program. The neonatal mortality rate in the period was 8.09‰ and it was higher in newborns of mothers with low education levels: 12.7‰ (adolescent mothers) and 12.4‰ (mother 35 years old or older). Low level of education, without the age effect, increased the chance of neonatal death by 25% (OR = 1.25, 95%CI 1.14-1.36). The isolated effect of age on neonatal death was higher for adolescent mothers (OR = 1.39, 95%CI 1.33-1.46) than for mothers aged ≥ 35 years (OR = 1.16, 95%CI 1.09-1.23). In the time-trend analysis, no age group of women with low education levels presented a reduction in the neonatal mortality rate for the period, as opposed to women with intermediate or high levels of education, where the reduction was significant, around 4% annually. Two more vulnerable groups - adolescents with low levels of education and older women with low levels of education - were identified in relation to the risk of neonatal death and inequality in reducing the mortality rate.

Maternal education and age: inequalities in neonatal death

PubMed Central

Fonseca, Sandra Costa; Flores, Patricia Viana Guimarães; Camargo, Kenneth Rochel; Pinheiro, Rejane Sobrino; Coeli, Claudia Medina

2017-01-01

ABSTRACT OBJECTIVE Evaluate the interaction between maternal age and education level in neonatal mortality, as well as investigate the temporal evolution of neonatal mortality in each stratum formed by the combination of these two risk factors. METHODS A nonconcurrent cohort study, resulting from a probabilistic relationship between the Mortality Information System and the Live Birth Information System. To investigate the risk of neonatal death we performed a logistic regression, with an odds ratio estimate for the combined variable of maternal education and age, as well as the evaluation of additive and multiplicative interaction. The neonatal mortality rate time series, according to maternal education and age, was estimated by the Joinpoint Regression program. RESULTS The neonatal mortality rate in the period was 8.09‰ and it was higher in newborns of mothers with low education levels: 12.7‰ (adolescent mothers) and 12.4‰ (mother 35 years old or older). Low level of education, without the age effect, increased the chance of neonatal death by 25% (OR = 1.25, 95%CI 1.14–1.36). The isolated effect of age on neonatal death was higher for adolescent mothers (OR = 1.39, 95%CI 1.33–1.46) than for mothers aged ≥ 35 years (OR = 1.16, 95%CI 1.09–1.23). In the time-trend analysis, no age group of women with low education levels presented a reduction in the neonatal mortality rate for the period, as opposed to women with intermediate or high levels of education, where the reduction was significant, around 4% annually. CONCLUSIONS Two more vulnerable groups – adolescents with low levels of education and older women with low levels of education – were identified in relation to the risk of neonatal death and inequality in reducing the mortality rate. PMID:29166446

Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors.

PubMed

Mahmood, Mohammad Afzal; Mufidah, Ismi; Scroggs, Steven; Siddiqui, Amna Rehana; Raheel, Hafsa; Wibdarminto, Koentijo; Dirgantoro, Bernardus; Vercruyssen, Jorien; Wahabi, Hayfaa A

2018-01-01

Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays. The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals. There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped.

Free markets and dead mothers: the social ecology of maternal mortality in post-socialist Mongolia.

PubMed

Janes, Craig R; Chuluundorj, Oyuntsetseg

2004-06-01

Beginning in 1990, Mongolia, a former client state of what was then the Soviet Union, undertook liberal economic reforms. These came as a great shock to Mongolia and Mongolians, and resulted in food shortages, reports of famine, widespread unemployment, and a collapse of public health and health care. Although economic conditions have stabilized in recent years, unemployment and poverty are still at disturbingly high levels. One important consequence of the transition has been the transformation of the rural, primarily pastoral, economy. With de-collectivization, herding households have been thrown into a highly insecure subsistence mode of production, and, as a consequence, have become vulnerable to local fluctuations in rainfall and availability and quality of forage, and many now lack access to traded staples and essential commodities. Household food insecurity, malnutrition, and migration of impoverished households to provincial centers and the capital of Ulaanbaatar are one result. Reductions to investments in the health sector have also eroded the quality of services in rural areas, and restricted access to those services still functioning. Evidence suggests that women are particularly vulnerable to these political-ecological changes, and that this vulnerability is manifested in increasing rates of poor reproductive health and maternal mortality. Drawing on case-study ethnographic and epidemiological data, this article explores the links between neoliberal economic reform and maternal mortality in Mongolia.

Maintaining rigor in research: flaws in a recent study and a reanalysis of the relationship between state abortion laws and maternal mortality in Mexico.

PubMed

Darney, Blair G; Saavedra-Avendano, Biani; Lozano, Rafael

2017-01-01

A recent publication [Koch E, Chireau M, Pliego F, Stanford J, Haddad S, Calhoun B, Aracena P, Bravo M, Gatica S, Thorp J. Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states. BMJ Open 2015;5(2):e006013] claimed that Mexican states with more restrictive abortion laws had lower levels of maternal mortality. Our objectives are to replicate the analysis, reanalyze the data and offer a critique of the key flaws of the Koch study. We used corrected maternal mortality data (2006-2013), live births, and state-level indicators of poverty. We replicate the published analysis. We then reclassified state-level exposure to abortion on demand based on actual availability of abortion (Mexico City versus the other 31 states) and test the association of abortion access and the maternal mortality ratio (MMR) using descriptives over time, pooled chi-square tests and regression models. We included 256 state-year observations. We did not find significant differences in MMR between Mexico City (MMR=49.1) and the 31 states (MMR=44.6; p=.44). Using Koch's classification of states, we replicated published differences of higher MMR where abortion is more available. We found a significant, negative association between MMR and availability of abortion in the same multivariable models as Koch, but using our state classification (beta=-22.49, 95% CI=-38.9; -5.99). State-level poverty remains highly correlated with MMR. Koch makes errors in methodology and interpretation, making false causal claims about abortion law and MMR. MMR is falling most rapidly in Mexico City, but our main study limitation is an inability to draw causal inference about abortion law or access and maternal mortality. We need rigorous evidence about the health impacts of increasing access to safe abortion worldwide. Transparency and integrity in research is crucial, as well as perhaps even more in

Reducing mortality risk by targeting specific air pollution sources: Suva, Fiji.

PubMed

Isley, C F; Nelson, P F; Taylor, M P; Stelcer, E; Atanacio, A J; Cohen, D D; Mani, F S; Maata, M

2018-01-15

Health implications of air pollution vary dependent upon pollutant sources. This work determines the value, in terms of reduced mortality, of reducing ambient particulate matter (PM 2.5 : effective aerodynamic diameter 2.5μm or less) concentration due to different emission sources. Suva, a Pacific Island city with substantial input from combustion sources, is used as a case-study. Elemental concentration was determined, by ion beam analysis, for PM 2.5 samples from Suva, spanning one year. Sources of PM 2.5 have been quantified by positive matrix factorisation. A review of recent literature has been carried out to delineate the mortality risk associated with these sources. Risk factors have then been applied for Suva, to calculate the possible mortality reduction that may be achieved through reduction in pollutant levels. Higher risk ratios for black carbon and sulphur resulted in mortality predictions for PM 2.5 from fossil fuel combustion, road vehicle emissions and waste burning that surpass predictions for these sources based on health risk of PM 2.5 mass alone. Predicted mortality for Suva from fossil fuel smoke exceeds the national toll from road accidents in Fiji. The greatest benefit for Suva, in terms of reduced mortality, is likely to be accomplished by reducing emissions from fossil fuel combustion (diesel), vehicles and waste burning. Copyright © 2017. Published by Elsevier B.V.

Misclassified maternal deaths among East African immigrants in Sweden.

PubMed

Elebro, Karin; Rööst, Mattias; Moussa, Kontie; Johnsdotter, Sara; Essén, Birgitta

2007-11-01

Western countries have reported an increased risk of maternal mortality among African immigrants. This study aimed to identify cases of maternal mortality among immigrants from the Horn of Africa living in Sweden using snowball sampling, and verify whether they had been classified as maternal deaths in the Cause of Death Registry. Three "locators" contacted immigrants from Somalia, Eritrea, and Ethiopia to identify possible cases of maternal mortality. Suspected deaths were scrutinised through verbal autopsy and medical records. Confirmed instances, linked by country of birth, were compared with Registry statistics. We identified seven possible maternal deaths of which four were confirmed in medical records, yet only one case had been classified as such in the Cause of Death Registry. At least two cases, a significant number, seemed to be misclassified. The challenges of both cultural and medical competence for European midwives and obstetricians caring for non-European immigrant mothers should be given more attention, and the chain of information regarding maternal deaths should be strengthened. We propose a practice similar to the British confidential enquiry into maternal deaths. In Sweden, snowball sampling was valuable for contacting immigrant communities for research on maternal mortality; by strengthening statistical validity, it can contribute to better maternal health policy in a multi-ethnic society.

Infant mortality and family welfare: policy implications for Indonesia.

PubMed

Poerwanto, S; Stevenson, M; de Klerk, N

2003-07-01

To examine the effect of family welfare index (FWI) and maternal education on the probability of infant death. A population based multistage stratified clustered survey. Women of reproductive age in Indonesia between 1983-1997. The 1997 Indonesian Demographic and Health Survey. Infant mortality was associated with FWI and maternal education. Relative to families of high FWI, the risk of infant death was almost twice among families of low FWI (aOR=1.7, 95%CI=0.9 to 3.3), and three times for families of medium FWI (aOR=3.3,95%CI=1.7 to 6.5). Also, the risk of infant death was threefold higher (aOR=3.4, 95% CI=1.6 to 7.1) among mothers who had fewer than seven years of formal education compared with mothers with more than seven years of education. Fertility related indicators such as young maternal age, absence from contraception, birth intervals, and prenatal care, seem to exert significant effect on the increased probability of infant death. The increased probability of infant mortality attributable to family income inequality and low maternal education seems to work through pathways of material deprivation and chronic psychological stress that affect a person's health damaging behaviours. The policies that are likely to significantly reduce the family's socioeconomic inequality in infant mortality are implicated.

Treating HIV infected mothers reduces mortality in children under 5 years of age to levels seen in children of HIV uninfected mothers: evidence from rural South Africa

PubMed Central

Ndirangu, James; Newell, Marie-Louise; Thorne, Claire; Bland, Ruth

2012-01-01

Background Maternal and child survival are highly correlated, but the contribution of HIV infection on this relationship, and in particular the impact of HIV treatment has not been quantified. We estimate the association between maternal HIV and treatment and under-5 child mortality in a rural population in South Africa. Methods All children born between January 2000-January 2007 in the Africa Centre Demographic Surveillance Area were included. Maternal HIV status information was available from HIV surveillance; maternal antiretroviral treatment (ART) from the HIV Treatment Programme database and linked to surveillance data. Mortality rates were computed as deaths per 1000 person-years observed. Time-varying maternal HIV effect (positive, negative, ART) on U5MR was assessed in Cox regression, adjusting for other factors associated with under-5 mortality. Results 9,068 mothers delivered 12,052 children, of whom 947 (7.9%) died before age 5. Infant mortality rate (IMR) declined by 49% from 69.0 in 2000 to 35.5 in 2006 deaths per 1000 person-years observed; a significantly decline was observed post-ART (2004-2006). The estimated proportion of deaths across all age groups were higher among the children born to the HIV-positive and HIV-not reported status women than among children of HIV-negative women. Multivariably, mortality in children of mothers on ART was not significantly different from children of HIV-negative mothers (aHR 1.29, 0.53-3.17; p=0.572). Conclusions These findings highlight the importance of maternal HIV treatment with direct benefits of improved survival among all children under-5. Timely HIV treatment for eligible women is required to benefit both mothers and children. PMID:22267472

Lactoferrin reduces mortality in preweaned calves with diarrhea.

PubMed

Habing, G; Harris, K; Schuenemann, G M; Piñeiro, J M; Lakritz, J; Clavijo, X Alcaraz

2017-05-01

Calf diarrhea is the most common reason for mortality and antimicrobial therapy in preweaned calves on dairy farms in the United States. Conventional and organic livestock producers require alternative therapies for calf diarrhea to reduce the necessity of conventional antimicrobials. Alternatives administered for mild cases or early in the disease course may be useful to mitigate disease progression and reduce the likelihood of septicemia and negative sequelae. Lactoferrin is a bioactive protein naturally found in colostrum that has been shown to prevent septicemia in high-risk infants. Among organic producers, garlic extract is widely used for the treatment of disease and perceived to be efficacious. The objectives of the study were to determine the effectiveness of lactoferrin and garlic extract to reduce mortality and culling, improve weight gain, and reduce the duration of disease in preweaned calves with the first diagnosis of diarrhea. In total, 628 calves with diarrhea from a single commercial dairy were enrolled in a blinded, randomized field trial. Calves diagnosed with diarrhea (fecal score ≥3), were randomized to 3 consecutive days of oral garlic extract, lactoferrin, or water (control). Calves were clinically evaluated for up to 10 d. Body weight was measured at enrollment and 10 d later. For calves receiving garlic extract, the risk of death or culling was not significantly different than calves in the control group; however, calves that received lactoferrin had approximately half the risk of death or culling in the 120 d following diagnosis. Additionally, the relative risk of death or culling in the 60 d following diagnosis was significantly lower for the subset of calves with severe diarrhea at enrollment. Neither garlic nor lactoferrin had a significant effect on disease duration or average weight gain during the 10-d period. Lactoferrin significantly reduced mortality and culling when administered to preweaned calves with the first diagnosis of

Variation in embryonic mortality and maternal transcript expression among Atlantic cod (Gadus morhua) broodstock: a functional genomics study.

PubMed

Rise, Matthew L; Nash, Gordon W; Hall, Jennifer R; Booman, Marije; Hori, Tiago S; Trippel, Edward A; Gamperl, A Kurt

2014-12-01

Early life stage mortality is an important issue for Atlantic cod aquaculture, yet the impact of the cod maternal (egg) transcriptome on egg quality and mortality during embryonic development is poorly understood. In the present work, we studied embryonic mortality and maternal transcript expression using eggs from 15 females. Total mortality at 7days post-fertilization (7 dpf, segmentation stage) was used as an indice of egg quality. A 20,000 probe (20K) microarray experiment compared the 7hours post-fertilization (7 hpf, ~2-cell stage) egg transcriptome of the two lowest quality females (>90% mortality at 7 dpf) to that of the highest quality female (~16% mortality at 7 dpf). Forty-three microarray probes were consistently differentially expressed in both low versus high quality egg comparisons (25 higher expressed in low quality eggs, and 18 higher expressed in high quality eggs). The microarray experiment also identified many immune-relevant genes [e.g. interferon (IFN) pathway genes ifngr1 and ifrd1)] that were highly expressed in eggs of all 3 females regardless of quality. Twelve of the 43 candidate egg quality-associated genes, and ifngr1, ifrd1 and irf7, were included in a qPCR study with 7 hpf eggs from all 15 females. Then, the genes that were confirmed by qPCR to be greater than 2-fold differentially expressed between 7 hpf eggs from the lowest and highest quality females (dcbld1, ddc, and acy3 more highly expressed in the 2 lowest quality females; kpna7 and hacd1 more highly expressed in the highest quality female), and the 3 IFN pathway genes, were included in a second qPCR study with unfertilized eggs. While some maternal transcripts included in these qPCR studies were associated with extremes in egg quality, there was little correlation between egg quality and gene expression when all females were considered. Both dcbld1 and ddc showed greater than 100-fold differences in transcript expression between females and were potentially influenced by

The triple threat of pregnancy, HIV infection and malaria: reported causes of maternal mortality in two nationwide health facility assessments in Mozambique, 2007 and 2012.

PubMed

Bailey, Patricia E; Keyes, Emily; Moran, Allisyn C; Singh, Kavita; Chavane, Leonardo; Chilundo, Baltazar

2015-11-09

The paper's primary purpose is to determine changes in magnitude and causes of institutional maternal mortality in Mozambique. We also describe shifts in the location of institutional deaths and changes in availability of prevention and treatment measures for malaria and HIV infection. Two national cross-sectional assessments of health facilities with childbirth services were conducted in 2007 and 2012. Each collected retrospective data on deliveries and maternal deaths and their causes. In 2007, 2,199 cases of maternal deaths were documented over a 12 month period; in 2012, 459 cases were identified over a three month period. In 2007, data collection also included reviews of maternal deaths when records were available (n = 712). Institutional maternal mortality declined from 541 to 284/100,000 births from 2007 to 2012. The rate of decline among women dying of direct causes was 66% compared to 26% among women dying of indirect causes. Cause-specific mortality ratios fell for all direct causes. Patterns among indirect causes were less conclusive given differences in cause-of-death recording. In absolute numbers, the combination of antepartum and postpartum hemorrhage was the leading direct cause of death each year and HIV and malaria the main non-obstetric causes. Based on maternal death reviews, evidence of HIV infection, malaria or anemia was found in more than 40% of maternal deaths due to abortion, ectopic pregnancy and sepsis. Almost half (49%) of all institutional maternal deaths took place in the largest hospitals in 2007 while in 2012, only 24% occurred in these hospitals. The availability of antiretrovirals and antimalarials increased in all types of facilities, but increases were most dramatic in health centers. The rate at which women died of direct causes in Mozambique's health facilities appears to have declined significantly. Despite a clear improvement in access to antiretrovirals and antimalarials, especially at lower levels of health care

Maternal peanut exposure during pregnancy and lactation reduces peanut allergy risk in offspring.

PubMed

López-Expósito, Iván; Song, Ying; Järvinen, Kirsi M; Srivastava, Kamal; Li, Xiu-Min

2009-11-01

Maternal allergy is believed to be a risk factor for peanut allergy (PNA) in children. However, there is no direct evidence of maternal transmission of PNA susceptibility, and it is unknown whether maternal peanut exposure affects the development of PNA in offspring. To investigate the influence of maternal PNA on offspring reactions to the first peanut exposure, and whether maternal low-dose peanut exposure during pregnancy and lactation influences these reactions and peanut sensitization in a murine model. Five-week-old offspring of PNA C3H/HeJ mothers (PNA-Ms) were challenged intragastrically with peanut (first exposure), and reactions were determined. In a subset of the experiment, PNA-Ms were fed a low dose of peanut (PNA-M/PN) or not fed peanut (PNA-M/none) during pregnancy and lactation. Their 5-week-old offspring were challenged intragastrically with peanut, and reactions were determined. In another subset of the experiment, offspring of PNA-M/PN or PNA-M/none were sensitized with peanut intragastrically for 6 weeks, and serum peanut-specific antibodies were determined. PNA-M offspring exhibited anaphylactic reactions at first exposure to peanut that were associated with peanut-specific IgG(1) levels and prevented by a platelet activation factor antagonist. In a subset experiment, PNA-M/PN offspring showed significantly reduced first-exposure peanut reactions, increased IgG(2a), and reduced mitogen-stimulated splenocyte cytokine production compared with PNA-M/none offspring. In an additional experiment, PNA-M/PN offspring showed reduction of peanut-specific IgE to active peanut sensitization. We show for the first time maternal transmission of susceptibility to first-exposure peanut reactions and active peanut sensitization. Low-dose peanut exposure during pregnancy and lactation reduced this risk.

Associations between maternal experiences of intimate partner violence and child nutrition and mortality: findings from Demographic and Health Surveys in Egypt, Honduras, Kenya, Malawi and Rwanda.

PubMed

Rico, Emily; Fenn, Bridget; Abramsky, Tanya; Watts, Charlotte

2011-04-01

If effective interventions are to be used to address child mortality and malnutrition, then it is important that we understand the different pathways operating within the framework of child health. More attention needs to be given to understanding the contribution of social influences such as intimate partner violence (IPV). To investigate the relationship between maternal exposure to IPV and child mortality and malnutrition using data from five developing countries. Population data from Egypt, Honduras, Kenya, Malawi and Rwanda were analysed. Logistic regression analysis was used to generate odds ratios of the associations between several categories of maternal exposure to IPV since the age of 15 and three child outcomes: under-2-year-old (U2) mortality and moderate and severe stunting (<-2 Z-score height-for-age and <-3 Z-score height-for-age) in 6-59-month-old children. Analyses were adjusted for potential confounders, and the role of mediating factors was explored. The prevalence of physical and/or sexual IPV since the age of 15 years ranged from 15.5% (Honduras) to 46.2% (Kenya). For child stunting, prevalence ranged from 25.4% (Egypt) to 58.0% (Malawi) and for U2 mortality from 3.6% (Honduras) to 15.2% (Rwanda). In Kenya, maternal exposure to IPV was associated with higher U2 mortality (adjusted odds ratio (OR)=1.42, 95% CI 1.18 to 1.71) and child stunting (adjusted OR=1.36, 95% CI 1.16 to 1.61). In Malawi and Honduras, marginal associations were observed between IPV and severe stunting and U2 mortality, respectively, with strength of associations varying by type of violence. The relationship between IPV and U2 mortality and stunting in Kenya, Honduras and Malawi suggests that, in these countries, IPV plays a role in child malnutrition and mortality. This contributes to a growing body of evidence that broader public health benefits may be incurred if efforts to address IPV are incorporated into a wider range of maternal and child health programmes

Pakistan and the Millennium Development Goals for Maternal and Child Health: progress and the way forward.

PubMed

Rizvi, Arjumand; Bhatti, Zaid; Das, Jai K; Bhutta, Zulfiqar A

2015-04-03

The world has made substantial progress in reducing maternal and child mortality, but many countries are projected to fall short of achieving their Millennium Development Goals (MDGs) 4 and 5 targets. The major objective of this paper is to examine progress in Pakistan in reducing maternal and child mortality and malnutrition over the last two decades. Data from recent national and international surveys suggest that Pakistan lags behind on all of its MDGs related to maternal and child health and, for some indicators especially related to nutrition, the situation has worsened from the baseline of 1990. Progress in addressing key social determinants such as poverty, female education and empowerment has also been slow and unregulated population growth has further compromised progress. There is a need to integrate the various different sectors and programmes to achieve the desired results effectively and efficiently as many of the determinants and influencing factors are outside the health sector. Pakistan has to accelerate improvement of access to maternal health services, particularly contraception, emergency obstetric care and skilled birth attendance; the need to improve maternal and child nutrition cannot be over-emphasised.

Measles vaccination in the presence or absence of maternal measles antibody: impact on child survival.

PubMed

Aaby, Peter; Martins, Cesário L; Garly, May-Lill; Andersen, Andreas; Fisker, Ane B; Claesson, Mogens H; Ravn, Henrik; Rodrigues, Amabelia; Whittle, Hilton C; Benn, Christine S

2014-08-15

Measles vaccine (MV) has a greater effect on child survival when administered in early infancy, when maternal antibody may still be present. To test whether MV has a greater effect on overall survival if given in the presence of maternal measles antibody, we reanalyzed data from 2 previously published randomized trials of a 2-dose schedule with MV given at 4-6 months and at 9 months of age. In both trials antibody levels had been measured before early measles vaccination. In trial I (1993-1995), the mortality rate was 0.0 per 1000 person-years among children vaccinated with MV in the presence of maternal antibody and 32.3 per 1000 person-years without maternal antibody (mortality rate ratio [MRR], 0.0; 95% confidence interval [CI], 0-.52). In trial II (2003-2007), the mortality rate was 4.2 per 1000 person-years among children vaccinated in presence of maternal measles antibody and 14.5 per 1000 person-years without measles antibody (MRR, 0.29; 95% CI, .09-.91). Possible confounding factors did not explain the difference. In a combined analysis, children who had measles antibody detected when they received their first dose of MV at 4-6 months of age had lower mortality than children with no maternal antibody, the MRR being 0.22 (95% CI, .07-.64) between 4-6 months and 5 years. Child mortality in low-income countries may be reduced by vaccinating against measles in the presence of maternal antibody, using a 2-dose schedule with the first dose at 4-6 months (earlier than currently recommended) and a booster dose at 9-12 months of age. NCT00168558. © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America.

Measles Vaccination in the Presence or Absence of Maternal Measles Antibody: Impact on Child Survival

PubMed Central

Aaby, Peter; Martins, Cesário L.; Garly, May-Lill; Andersen, Andreas; Fisker, Ane B.; Claesson, Mogens H.; Ravn, Henrik; Rodrigues, Amabelia; Whittle, Hilton C.; Benn, Christine S.

2014-01-01

Background. Measles vaccine (MV) has a greater effect on child survival when administered in early infancy, when maternal antibody may still be present. Methods. To test whether MV has a greater effect on overall survival if given in the presence of maternal measles antibody, we reanalyzed data from 2 previously published randomized trials of a 2-dose schedule with MV given at 4–6 months and at 9 months of age. In both trials antibody levels had been measured before early measles vaccination. Results. In trial I (1993–1995), the mortality rate was 0.0 per 1000 person-years among children vaccinated with MV in the presence of maternal antibody and 32.3 per 1000 person-years without maternal antibody (mortality rate ratio [MRR], 0.0; 95% confidence interval [CI], 0–.52). In trial II (2003–2007), the mortality rate was 4.2 per 1000 person-years among children vaccinated in presence of maternal measles antibody and 14.5 per 1000 person-years without measles antibody (MRR, 0.29; 95% CI, .09–.91). Possible confounding factors did not explain the difference. In a combined analysis, children who had measles antibody detected when they received their first dose of MV at 4–6 months of age had lower mortality than children with no maternal antibody, the MRR being 0.22 (95% CI, .07–.64) between 4–6 months and 5 years. Conclusions. Child mortality in low-income countries may be reduced by vaccinating against measles in the presence of maternal antibody, using a 2-dose schedule with the first dose at 4–6 months (earlier than currently recommended) and a booster dose at 9–12 months of age. Clinical Trials Registration. NCT00168558. PMID:24829213

Pregnancy termination in Matlab, Bangladesh: maternal mortality risks associated with menstrual regulation and abortion.

PubMed

Rahman, Mizanur; DaVanzo, Julie; Razzaque, Abdur

2014-09-01

In Bangladesh, both menstrual regulation (MR), which is thought to be a relatively safe method, and abortion, which in this setting is often performed using unsafe methods, are used to terminate pregnancies (known or suspected). However, little is known about changes over time in the use of these methods or their relative mortality risks. Data from the Demographic Surveillance System in Matlab, Bangladesh, on 110,152 pregnancy outcomes between 1989 and 2008 were used to assess changes in mortality risks associated with MR (and a small number of dilation and curettage procedures), abortion and live birth. Tabulation and logistic regression analyses were used to compare outcomes in two areas of Matlab--the comparison area, which receives standard government health and family planning services, and the Maternal and Child Health-Family Planning (MCH-FP) area, which receives enhanced health and family planning services. In Matlab as a whole, the proportion of pregnancies ending in MR increased from 1.9% in 1989-1999 to 4.2% in 2000-2008, while the proportion ending in abortion decreased from 1.6% to 1.1%. The odds of mortality from MR were 4.1 times those from live birth in 1989-1999, but were no longer elevated in 2000-2008. The odds of mortality from abortion were 12.0 and 4.9 times those of live birth in 1989-1999 and 2000-2008, respectively. Reduction in mortality risk was greater in the MCH-FP area than the comparison area (90% vs. 75%). MR is no longer associated with higher mortality risk than live birth in Bangladesh, but abortion is.

Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013