Success factors for reducing maternal and child mortality

Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Women’s and Children’s Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula – fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in women’s and children’s health towards 2015 and beyond.     

孕产妇死亡的影响因素及降低孕产妇死亡率的对策

妇女儿童的健康与发展是一个国家和民族生生不息、兴旺发达的基础。随着人类社会的不断进步，国际上将妇女儿童的健康问题放到了重要的位置。妇女儿童作为特殊脆弱人群，保护他们的生存权和健康权是维护人类最基本权利的前提和基础，因此，孕产妇死亡率(以下简称MMR)和婴儿死亡率(以下简称IMR)不仅仅是反映卫生事业发展的重要指标，也是国际上衡量一个国家或地区国民健康素质及社会、经济发展和文明进步的重要指标。     

加强孕产期保健规范化管理降低孕产妇死亡率

哈尔滨市有7个行政区,12个县市。二、三级助产单位107家,乡镇级助产单位101家。2000年以来,孕产妇系统保健工作质量显著提高,孕产妇死亡率呈逐年下降趋势,2004年全市孕产妇总数为57312例,早孕建册率为65.8%,孕产妇系统管理率62.7%,住院分娩率92.0%,高危孕妇住院分娩率为100.0%。孕产妇死亡率为17.9/10万,较1999年下降了48.1%。现将我市加强孕产妇规范化管理,提高产科质量,降低孕产妇死亡率的具体做法总结如下。1加强乡镇卫生院产科建设,适时投入,为提高住院分娩率创造必要条件制定了“哈市乡镇卫生院产科设置标准、人员设备要求及职责范围”…     

The importance of family planning in reducing maternal mortality

Maternal mortality in many developing countries remains at distressingly high levels despite improvements in hospital obstetrics. WHO estimates that 1/2 million maternal deaths occur each year, 99% of which are in developing countries. While many people expect that widespread acceptance of family planning will bring down levels of maternal mortality, some analyses have claimed disappointing reductions, though others were more encouraging. The primary reason for this discrepancy lies in the choice of measure of maternal mortality, compounded somewhat by a confusion in terminology. Maternal mortality can be measured by: 1) the number of maternal deaths; 2) the maternal mortality ratio; 3) the maternal mortality rate; or 4) the lifetime risk of death in childbirth. Family planning use influences the maternal mortality ratio only to the extent that it reduces the proportion of pregnancies to high-risk women. The maternal mortality rate can be substantially influenced by the prevalence of contraception, but it is primarily the reduction in the number of births, per se, that exerts the influence. The choice of measure should be determined by the issue being addressed, and which of the 2 determinants of maternal mortality (obstetric risk or prevalence of pregnancy) is the focus. Current levels of maternal mortality in the developed countries have been achieved only with both good obstetric care and with low fertility. In developing countries today, modern obstetric care is often available only in a few teaching hospitals, but family planning programs are feasible even in remote areas. While implementing family planning programs is not easy, it is more feasible than the implementation of significant improvements in the quality and availability of obstetric care. The contribution of family planning to lower maternal mortality and morbidity should not be underestimated.     

Assessing the role of family planning in reducing maternal mortality

It is widely believed that family planning has important benefits for both maternal and child health. Despite this, little work has been done to quantify the potential effect of family planning in reducing maternal mortality. This paper assesses the impact of family planning in averting maternal deaths, and discusses the overall ability of risk strategies to address the bulk of maternal mortality. The practical difficulties of providing effective contraception to populations with high maternal mortality are addressed, and the need for maternal health care services as an adjunct to useful family planning programs is emphasized. Although family planning cannot by itself cause a substantial reduction in risk of pregnancy, the combined strategies of general fertility reduction, abortion services, and family planning for high-risk groups might effectively address about half of all maternal mortality in the developing world. Pregnancy and delivery care have the potential for saving large numbers of lives with appropriate interventions. It is concluded that reproductive risks can be reduced only by preventing unwanted pregnancies and protecting maternal health during wanted ones.     

Estimates of maternal mortality for 1995

OBJECTIVE: To present estimates of maternal mortality in 188 countries, areas, and territories for 1995 using methodologies that attempt to improve comparability. METHODS: For countries having data directly relevant to the measurement of maternal mortality, a variety of adjustment procedures can be applied depending on the nature of the data used. Estimates for countries lacking relevant data may be made using a statistical model fitted to the information from countries that have data judged to be of good quality. Rather than estimate the Maternal Mortality Ratio (MMRatio) directly, this model estimates the proportion of deaths of women of reproductive age that are due to maternal causes. Estimates of the number of maternal deaths are then obtained by applying this proportion to the best available figure of the total number of deaths among women of reproductive age. FINDINGS: On the basis of this exercise, we have obtained a global estimate of 515,000 maternal deaths in 1995, with a worldwide MMRatio of 397 per 100,000 live births. The differences, by region, were very great, with over half (273,000 maternal deaths) occurring in Africa (MMRatio: > 1000 per 100,000), compared with a total of only 2000 maternal deaths in Europe (MMRatio: 28 per 100,000). Lower and upper uncertainty bounds were also estimated, on the basis of which the global MMRatio was unlikely to be less than 234 or more than 635 per 100,000 live births. These uncertainty bounds and those of national estimates are so wide that comparisons between countries must be made with caution, and no valid conclusions can be drawn about trends over a period of time. CONCLUSION: The MMRatio is thus an imperfect indicator of reproductive health because it is hard to measure precisely. It is preferable to use process indicators for comparing reproductive health between countries or across time periods, and for monitoring and evaluation purposes.     

A framework for analyzing the determinants of maternal mortality.

Hundreds of thousands of women in developing countries die each year from complications of pregnancy, attempted abortion, and childbirth. This article presents a comprehensive and integrated framework for analyzing the cultural, social, economic, behavioral, and biological factors that influence maternal mortality. The development of a comprehensive framework was carried out by reviewing the widely accepted frameworks that have been developed for fertility and child survival, and by reviewing the existing literature on maternal mortality, including the results of research studies and accounts of intervention programs. The principal result of this exercise is the framework itself. One of the main conclusions is that all determinants of maternal mortality (and, hence, all efforts to reduce maternal mortality) must operate through a sequence of only three intermediate outcomes. These efforts must either (1) reduce the likelihood that a woman will become pregnant; (2) reduce the likelihood that a pregnant woman will experience a serious complication of pregnancy or childbirth; or (3) improve the outcomes for women with complications. Several types of interventions are most likely to have substantial and immediate effects on maternal mortality, including family planning programs to prevent pregnancies, safe abortion services to reduce the incidence of complications, and improvements in labor and delivery services to increase the survival of women who do experience complications.     

What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries

The first target of the fifth United Nations Millennium Development Goal is to reduce maternal mortality by 75% between 1990 and 2015. This target is critically off track. Despite difficulties inherent in measuring maternal mortality, interventions aimed at reducing it must be monitored and evaluated to determine the most effective strategies in different contexts. In some contexts, the direct causes of maternal death, such as haemorrhage and sepsis, predominate and can be tackled effectively through providing access to skilled birth attendance and emergency obstetric care. In others, indirect causes of maternal death, such as HIV/AIDS and malaria, make a significant contribution and require alternative interventions. Methods of planning and evaluating maternal health interventions that do not differentiate between direct and indirect maternal deaths may lead to unrealistic expectations of effectiveness or mask progress in tackling specific causes. Furthermore, the need for additional or alternative interventions to tackle the causes of indirect maternal death may not be recognized if all-cause maternal death is used as the sole outcome indicator. This article illustrates the importance of differentiating between direct and indirect maternal deaths by analysing historical data from England and Wales and contemporary data from Ghana, Rwanda and South Africa. The principal aim of the paper is to highlight the need to differentiate deaths in this way when evaluating maternal mortality, particularly when judging progress towards the fifth Millennium Development Goal. It is recommended that the potential effect of maternity services failing to take indirect maternal deaths into account should be modelled.     

A survey study identified global research priorities for decreasing maternal mortality

ObjectivesThe aim of this study was to identify and prioritize research gaps to help decrease maternal mortality.Study Design and SettingWe conducted a two-stage survey. We provided participants (Cochrane Collaboration experts) with a list of 319 problem/population, intervention, comparison, and outcome questions built from 178 Cochrane systematic reviews. Questions were classified according to causes of maternal death. Respondents of the first round refined the research questions and prioritized them by eliminating those that were considered of low priority, according to four criteria. They also included additional questions. In the second round, respondents prioritized 62 questions.ResultsThe overall response rates for the first and second rounds were 47% (73 of 155) and 17% (363 of 2,121), respectively. Participants ranked 62 of the research questions as “very relevant.” Approximately 20% of all questions that were identified in Cochrane reviews and two-third of questions of the second round were considered of “very high priority.” More women (235) than men (128) participated in the survey. We did not find statistically significant differences when comparing the groups of very relevant questions by the type of respondent, income, country, and round.ConclusionWe identified research priorities by mapping and improving the understanding of research needs in low- and middle-income settings internationally.     

Preventing black maternal mortality: A challenge for the 90's

The authors studied maternal mortality in Chicago and Detroit from 1979 through 1984. The death rates for black women were more than four times the national rate for white women. Many of the conditions causing death were preventable. Since the general condition of the mother prior to pregnancy is a major influence on pregnancy outcome, accessible and high-quality prenatal care is a necessary but not sufficient preventive measure. If black maternal mortality is to be prevented, attention must be directed to the protection and promotion of black women's physical, mental and social well-being, and not just to their reproductive health.     

A note on the sisterhood estimator of maternal mortality

This paper comments on the Graham et al. extension of the sibling survival technique of Hill and Trussel to estimate maternal mortality. The basic ideas behind the sisterhood method are described. The Graham et al. thesis is found to be confusing and misleading in that multiple reporting or restricting the sample are viewed erroneously as equally valid alternatives. The sampling frame is confusing. All sisters drawn independently from the same distribution who belong in the sample assures that the 3 sources of error cancel each other exactly. The key assumption of the sisterhood method is independence of mortality experience of adult sisters. A probability model of dying of maternal causes is established and then applied to a numerical example of illustrate the point. An important point is that there should be the possibility that all sisters could be interviewed. When the method uses census rather than survey data, the bias is dependent on sibship size and value of p. The bias for surveys depends on the size of clusters and the extent to which sisters live geographically close by. Multiple reporting is essential for the technique.     

上海市1993至2002年孕产妇死亡情况分析

目的 通过孕产妇死亡资料的分析，总结上海市孕产妇系统管理的经验和教训，为进一步降低孕产妇死亡率提供科学的依据。方法 采用回顾性研究的方法，对1993～2002年来上海市孕产妇死亡的个案及评审情况进行分析。结果 10年来上海市孕产妇死亡率平均为26／10万(223／858 467)，其中本市户籍者为15／10万(100／666 818)。外来户籍者为64．2／10万(123／191 649)；10年中孕产妇前6位死因顺位依次为产科出血、心脏病、妊娠高血压综合征(妊高征)、肝病、异位妊娠和羊水栓塞；通过加强技术培训及健康教育，异位妊娠死亡率从1993～1997年的2．0／10万(9／444 054)降到1998～2002年的1．2／10万(5／414 413)．但值得关注的是近年的异位妊娠死亡又有上升趋势；1993年成立了上海市产科心脏病和肝病诊治中心后，妊娠合并心脏病和肝病的死亡率有了明显下降，从专家评审结果看，本市户籍的孕产妇死亡主要与医疗保健因素尤其是医务人员的知识技能相关，而外来人口中的孕产妇死亡则主要与社会各部门的管理及个人家庭因素尤其是知识水平及经济状况有关。结论 上海本市户籍的孕产妇死亡率已接近一些发达国家的水平，要进一步降低全市孕产妇死亡率，必须加强对外来户籍孕产妇的保健管理。此外，对产科医务人员的队伍建设应提到议事日程。