Factors associated with maternal mortality in Sub-Saharan Africa: an ecological study

Background  

Maternal health is one of the major worldwide health challenges. Currently, the unacceptably high levels of maternal mortality are a common subject in global health and development discussions. Although some countries have made remarkable progress, half of the maternal deaths in the world still take place in Sub-Saharan Africa where little or no progress has been made. There is no single simple, straightforward intervention that will significantly decrease maternal mortality alone; however, there is a consensus on the importance of a strong health system, skilled delivery attendants, and women's rights for maternal health. Our objective was to describe and determine different factors associated with the maternal mortality ratio in Sub-Saharan countries.     

Time trends and regional differences in maternal mortality in China from 2000 to 2005

Objective

To examine trends and variations in maternal mortality in China between 2000 and 2005.

Methods

We used Poisson regression analysis of data from the Chinese National Maternal and Child Health Routine Reporting System between 2000 and 2005 to identify time trends in the maternal mortality ratio (MMR) by province and region.

Findings

The MMR declined by an average of 5% per year (crude relative risk, RR: 0.95; 95% confidence interval, CI: 0.94–0.97). There was no interaction between region and year (P = 0.2311). Mortality declined by 5% per year in the eastern region (crude RR: 0.95; 95% CI: 0.92–0.97), by 5% per year in the central region (crude RR; 0.95; 95% CI: 0.94–0.96), and by 4% per year in the western region (crude RR: 0.96; 95% CI: 0.94–0.98). The absolute difference in MMR between the western and eastern regions declined from 65.4 deaths per 100 000 live births in 2000 to 49.4 per 100 000 live births in 2005.

Conclusion

China is making good progress towards achieving the fifth Millennium Development Goal, and there is no evidence of a widening gap between better-off and economically more deprived provinces.     

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

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 water and sanitation accesses are key strategies.

     

1996-2010年全国孕产妇死亡率变化趋势

目的 了解1996-2010年全国孕产妇死亡率和主要死亡原因的变化趋势及地区的差异变化。方法 采用以人群为基础的全国孕产妇死亡监测网的数据,1996-2005年覆盖了内地31个省、自治区、直辖市的176个监测区（县）,2006年后扩大至336个区（县）,统计1996-2010年全国不同时间、不同地区孕产妇死亡率、死因别死亡率、下降幅度和年平均下降速率。应用Cochran-Armitage趋势检验及Poisson检验,对1996-2010年的孕产妇死亡率、死因构成及地区间差异的变化趋势进行分析。结果 全国孕产妇死亡率从1996年的64.7/10万下降到2010年的30.0/10万,下降53.2％;2010年农村孕产妇死亡率（30.1/10万）高于城市（29.7/10万）,西部（46.1/10万）高于中部（29.1/10万）及东部地区（17.8/10万）。东、中、西部地区孕产妇死亡率下降幅度分别为37.76％、57.02％和66.27％。地区间差异在逐渐减少,2006-2010年间,农村孕产妇死亡率下降为城市的1.82倍,西部地区为东部地区的3.0倍。产科出血死亡的构成比从1996年的47.9％下降到2010年的27.8％,但仍是导致全国孕产妇死亡的首要因素。结论 全国孕产妇死亡率呈下降趋势,地区间孕产妇死亡率仍存在差异,但差异逐年减小,农村和西部地区仍是孕产妇死亡干预的重点;产科出血仍是各地区的主要死亡原因。     

危重孕产妇管理与孕产妇死亡防控

孕产妇死亡率(MMR)是衡量一个国家或地区妇女健康状况和社会经济发展的重要指标之一。随着社会经济的发展与孕产妇健康水平的提高,孕产妇死亡已成为极低概率事件,尤其是在发达国家,仅仅使用孕产妇死亡及MMR作为终末指标,已无法全面评价和反映孕产妇医疗保健过程的质量和妇幼健康事业的发展现状,难以为改善孕产妇医疗保健政策及策略的制订,提供有效参考信息。对于将危重孕产妇的临床管理作为导致孕产妇死亡的动态过程和前期指标,这对强化危重孕产妇管理,进而降低MMR,具有重要临床意义。笔者拟就全球近年危重孕产妇管理、救治现状及其最新研究进展进行阐述,旨在为促进我国危重孕产妇应急管理及救治体系的建设和完善提供参考,从而有效提高危重孕产妇急救效率和质量,切实降低MMR。     

Maternal mortality in South Africa in 2001: From demographic census to epidemiological investigation

Background

Maternal mortality remains poorly researched in Africa, and is likely to worsen dramatically as a consequence of HIV/AIDS.

Methods

The 2001 census of South Africa included a question on deaths in the previous 12 months, and two questions on external causes and maternal mortality, defined as "pregnancy-related deaths". A microdata sample from the census permits researchers to assess levels and differentials in maternal mortality, in a country severely affected by high death rates from HIV/AIDS and from external causes.

Results

After correcting for several minor biases, our estimate of the Maternal Mortality Ratio (MMR) in 2001 was 542 per 100,000 live births. This level is much higher than previous estimates dating from pre-HIV/AIDS times. This high level occurred despite a relatively low proportion of maternal deaths (6.4%) among deaths of women aged 15–49 years, and was due to the astonishingly high level of adult mortality, some 4.7 times higher than expected from mortality below age 15 or above age 50. The main reasons for these excessive levels were HIV/AIDS and external causes of deaths. Our regional estimates of MMR were found to be consistent with other findings in the Cape Town area, and with the Agincourt DSS. The differentials in MMR were considerable: 1 to 9.2 for population groups (race), 1 to 3.2 for provinces, and 1 to 2.4 for levels of education. Relationship with income and wealth were complex, with highest values for middle income and middle wealth index. The effect of urbanization was small, and reversed in a multivariate analysis. Higher risks in provinces were not necessarily associated with lower income, lower education or higher proportions of home delivery, but correlated primarily with the prevalence of HIV/AIDS.

Conclusion

Demographic census microdata offer the opportunity to conduct an epidemiologic analysis of maternal mortality. In the case of South Africa, the level of MMR increased dramatically over the past 10 years, most likely because of HIV/AIDS. Indirect causes of maternal deaths appear much more important than direct obstetric causes. The MMR appears no longer to be a reliable measure of the quality of obstetric care or a measure of safe motherhood.     

中国2000--2005年孕产妇死亡趋势分析

目的 了解2000-2005年中国孕产妇死亡发生的主要特征、死亡率变化趋势、主要死亡原因及其变化.方法 在全国31个省、自治区、直辖市孕产妇死亡监测网内采用以人群为基础的流行病学调查方法.结果 2000-2005年中国农村孕产妇死亡率高于城市,边远地区高于内地、沿海;全国孕产妇死亡率由53.0/10万下降到47.6/10万,农村由67.2/10万下降到59.2/10万,城市由28.8/10万下降到27.6/10万,下降幅度分别为10.2%、11.9%和4.2%.2000年全国孕产妇死亡前3位死因为产科出血、妊娠期高血压和羊水栓塞,2005年前3位是产科出血、心脏病和妊娠期高血压,但产科出血始终是第一死因,导致产科出血的主要原因是胎盘滞留、宫缩乏力和子宫破裂.结论 2000-2005年全国孕产妇死亡率无趋势变化,主要死因是产科出血.降低农村及边远地区孕产妇死亡率和提高诊治产科出血基本技能是实现<中国妇女发展纲要(2000-2010年)>降低孕产妇死亡率目标的关键.     

Country estimates of maternal mortality: an alternative model.

Ever since the publication of country level estimates of maternal mortality for 1990 by WHO and UNICEF, there has been some degree of controversy about these estimates. The recent publication of a 1995 revision, based on the modification of the multivariate model used for 1990, has not managed to put this controversy to rest. Countries with national estimates of their own have generally protested against the higher figures resulting from the multivariate modelling approach used by WHO and UNICEF, but some experts have also objected to the model itself. As a result of earlier discussions with the WHO/UNICEF team, some adjustments were incorporated into their model, notably the age standardization of maternal mortality ratios (MMRs) and proportions maternal among deaths of females of reproductive age (PMDF) of demographic and health surveys (DHS) direct sisterhood data, as the use of unstandardized values was shown to cause systematic biases. However, a model feature that continued to be controversial was the use of the PMDF as the dependent variable. As will be shown in this paper, the use of this dependent variable has a number of conceptual and practical disadvantages, such as its dependence on non-maternal deaths and the need for separate projections of births and deaths of women of reproductive age, in order to convert the estimated PMDF into a more conventional MMR. The latter greatly increases the uncertainty of the resulting MMR estimates, even though this additional variance is ignored in the WHO/UNICEF estimates of confidence intervals. On balance, the MMR, while also subject to some legitimate objections, is still considered preferable as an independent variable. This paper therefore derives alternative country estimates for 1995 based on a multivariate model of the MMR. The model is shown to lead to smaller root mean square relative errors of the MMR estimates. While the overall number of maternal deaths estimated worldwide is very similar to the number reached by WHO/UNICEF, there are major disagreements with respect to particular countries. Finally, a discussion is included on the appropriate way to incorporate the DHS direct sisterhood data, as this affects the results substantially.     

Risk factors for maternal death in the highlands of rural northern Tanzania: a case-control study

Background  

Tanzania has one of the highest maternal mortality ratios in sub-Saharan Africa. Due to the paucity of epidemiological information on maternal deaths, and the high maternal mortality estimates found earlier in the study area, our objective was to assess determinants of maternal deaths in a rural setting in the highlands of northern Tanzania by comparing the women dying of maternal causes with women from the same population who had attended antenatal clinics in the same time period.     

中国孕产妇死亡状况的国际比较

目的:分析中国孕产妇死亡率在世界各国中的相对位置。方法:收集1990、2005年中国以及世界有可利用数据的172个国家孕产妇死亡率、死亡数,以及相关国情数据。计算死亡率平均年下降速率,并与和中国有相似国情的国家进行比较。结果:2005年世界孕产妇死亡率为386.75/10万,1990～2005年世界孕产妇死亡率平均年下降速率为0.95%;2005年中国孕产妇死亡率为45.00/10万,1990～2005年中国孕产妇死亡率平均年下降速率为4.86%,两项均位居172个有可利用数据国家的第109位。结论:1990～2005年世界孕产妇死亡率整体呈下降趋势,中国2005年孕产妇死亡率低于世界平均水平,1990～2005年孕产妇死亡率平均年下降速率高于世界平均水平。     

北京市孕产妇与流动人口孕产妇1995-2004年死亡分析

目的 分析北京市孕产妇与流动人口孕产妇死亡资料，为制定干预措施提供依据。方法 采用回顾性调查方法。对北京市1995—2004年孕产妇死亡病例及评审资料进行分析。结果该期间北京市户籍孕产妇死亡率为17．9／10万，流动人口死亡率为51．3／10万。北京市孕产妇死因依次为栓塞（21．2％）、妊高征（18．3％）、产科出血（14．4％）和心脏病／异位妊娠（9．6％）。流动人口孕产妇死因依次为产科出血（25．2％）、栓塞（19．7％）、妊高征（17．3％）和肝病（9．5％）。孕产妇可避免死亡占18．9％，创造条件可避免死亡占37．7％，不可避免死亡占43．4％。结论 北京市户籍孕产妇死亡率已接近发达国家水平，流动人口孕产妇保健管理亟待加强。取缔非法接生、加强医务人员的培训及人才培养、提高医疗机构处理妊娠合并症及异位妊娠的急救抢救能力，是今后干预的重点。     

Nutrition and maternal morbidity and mortality

Nearly 600 000 women die every year from pregnancy related conditions and the maternal mortality rates (MMR = deaths per 100 000 live births) in developing countries may be as high as 1000 compared with less than ten in industrialised countries. In the light of the striking impact of deficiencies of micronutrients such as vitamin A and zinc on immune function, morbidity and mortality in children it seems reasonable to suggest that such deficiencies might play a contributing role in the high rates of morbidity and mortality in mothers. Hitherto, there has been rather little published on the contribution of malnutrition to maternal morbidity or mortality but recent results of micronutrient supplementation show a major effect of vitamin A or beta carotene supplementation on maternal mortality in Nepal and an impressive effect of a multiple micronutrient mixture on pregnancy outcome in Tanzania. There is now data showing that subclinical mastitis, a potential risk factor for mother to child transmission of HIV by increasing levels of virus in breast milk, is influenced by maternal diet in Tanzania and feeding patterns in South Africa. Considering the massive tragedy of maternal mortality the recent data provides opportunities for new, innovative nutritional interventions for the reduction of the global burden of maternal morbidity and mortality.     

Magnitude,trends and causes of maternal mortality among reproductive aged women in Kersa health and demographic surveillance system,eastern Ethiopia

Background

Despite efforts at curbing maternal morbidity and mortality, developing countries are still burdened with high rates of maternal morbidity and mortality. Ethiopia is not an exception and has one of the world’s highest rates of maternal deaths. Reducing the huge burden of maternal mortality remains the single most serious challenge in Ethiopia. There is a paucity of information with regards to the local level magnitude and causes of maternal mortality. We assessed the magnitude, trends and causes of maternal mortality using surveillance data from the Kersa Health and Demographic Surveillance System (HDSS), in Eastern Ethiopia.

Method

The analysis used surveillance data extracted from the Kersa HDSS database for the duration of 2008 to 2014. Data on maternal deaths and live births during the seven year period were used to determine the maternal mortality ratio in the study. The data were mainly extracted from a verbal autopsy database. The sample was comprised of all reproductive aged women who died during pregnancy, childbirth or 42?days after delivery. Chi-squared test for linear trend was used to examine the significance of change in rates over time.

Results

Out of the total 311 deaths of reproductive aged women during the study period, 72 (23.2%) died during pregnancy or within 42?days of delivery. The overall estimated maternal mortality ratio was 324 per 100,000 live births (95% CI: 256, 384). The observed maternal mortality ratio has shown a declining trend over the seven years period though there is no statistical significance for the reduction (χ²?=?0.56, P?=?0.57). The estimated pregnancy related mortality ratio was 543 per 100,000 live births (95% CI: 437, 663). Out of those who died due to pregnancy and related causes, only 26% attended at least one antenatal care service. The most common cause of maternal death was postpartum haemorrhage (46.5%) followed by hypertensive disorders of pregnancy (16.3%).

Conclusion

The magnitude of maternal mortality is considerably high but has shown a decreasing trend. Community-based initiatives that aim to improve maternal health should be strengthened further to reduce the prevailing maternal mortality. Targeted information education and communication should be provided.

     

Causes of neonatal and maternal deaths in Dhaka slums: Implications for service delivery

Background  

Bangladesh has about 5.7 million people living in urban slums that are characterized by adverse living conditions, poor access to healthcare services and health outcomes. In an attempt to ensure safe maternal, neonatal and child health services in the slums BRAC started a programme, MANOSHI, in 2007. This paper reports the causes of maternal and neonatal deaths in slums and discusses the implications of those deaths for Maternal Neonatal and Child Health service delivery.     

National estimates for maternal mortality: an analysis based on the WHO systematic review of maternal mortality and morbidity

Background  

Despite the worldwide commitment to improving maternal health, measuring, monitoring and comparing maternal mortality estimates remain a challenge. Due to lack of data, international agencies have to rely on mathematical models to assess its global burden. In order to assist in mapping the burden of reproductive ill-health, we conducted a systematic review of incidence/prevalence of maternal mortality and morbidity.     

Health expenditure,child and maternal mortality nexus: a comparative global analysis

Background

This paper provides empirical evidence on how the relationship between health expenditure and health outcomes varies across countries at different income levels.

Method

Heterogeneity and cross-section dependence were controlled for in the panel data which consist of 161 countries over the period 1995–2014. Infant, under-five and maternal mortality along with life expectancy at birth were selected as health outcome measures. Cross-sectional augmented IPS unit root, panel autoregressive distributed lag, Dumitrescu-Hurlin and Toda-Yamamoto approach to Granger causality tests were used to investigate the relationship across four income groups. An impulse response function modelled the impact on health outcomes of negative shocks to health expenditure.

Results

The results indicate that the health expenditure and health outcome link is stronger for low-income compared to high-income countries. Moreover, rising health expenditure can reduce child mortality but has an insignificant relationship with maternal mortality at all income levels. Lower-income countries are more at risk of adverse impact on health because of negative shocks to health expenditure. Variations in child mortality are better explained by rising health expenditure than maternal mortality. However, the estimated results showed dissimilarity when different assumptions and methods were used.

Conclusion

The influence of health expenditure on health outcome varies significantly across different income levels except for maternal health. Policymakers should recognize that increasing spending has a minute potential to improve maternal health. Lastly, the results vary significantly due to income level, choice of assumptions (homogeneity, cross-section independence) and estimation techniques used. Therefore, findings of the cross-country panel studies should be interpreted with cautions.

     

New paradigm old thinking: the case for emergency obstetric care in the prevention of maternal mortality in Nigeria

Background  

The continuing burden of maternal mortality, especially in developing countries has prompted a shift in paradigm from the traditional risk assessment approach to the provision of access to emergency obstetric care services for all women who are pregnant. This study assessed the knowledge of maternity unit operatives at the primary and secondary levels of care about the concept of emergency obstetric care (EmOC) and investigated the contents of antenatal care (ANC) counseling services they delivered to clients. It also described the operatives' preferred strategies and practices for promoting safe motherhood and averting maternal mortality in South-west Nigeria.     

1999-2018年深圳市宝安区孕产妇死亡情况分析

目的 了解1999-2018年深圳市宝安区的孕产妇死亡情况及其变化趋势.方法 从原始登记表和深圳市妇幼保健管理系统获取宝安区近20年孕产妇死亡个案资料进行整理,统计分析孕产妇死亡率、死亡变化趋势、死亡特征及死亡原因.结果 1999-2018年宝安区年平均孕产妇死亡率为18.86/10万;总体呈下降趋势,从1999-20...     

Survey on maternal mortality in Swaziland using the sisterhood method

Monitoring and evaluating maternal mortality in African countries is impossible without specific and reliable data and indicators. This study of maternal mortality using the 'Sisterhood Method' was undertaken in Swaziland. The crude data on 'sisterhood mortality' were obtained from the 1993-94 Multi-Purpose Household Survey carried out by the Central Statistics Office and Ministry of Health of Swaziland. A total fertility rate of 6.36, as given in the 1986 Swaziland census, was used in estimating these indicators. Prior to this study, the maternal mortality rate (MMR) in Swaziland (based only on health facility data) was considered to lie within the range of 107-125 maternal deaths per 100 000 live births. Use of the 'Sisterhood Method' allowed a more precise estimate of maternal mortality for the general population of Swaziland. The study revealed the estimated MMR to be 229 and the life-time risk of maternal death to be 1 in 69. These values were most probably stable throughout the 6- to 7-year period before the survey.