Estimating maternal mortality and causes in South Africa: National and provincial levels

Objectives

maternal mortality estimates for South Africa have methodological weaknesses. This study uses the Growth Balance Method to adjust reported household female deaths and pregnancy-related deaths and the relational Gompertz model to adjust reported number of live births and estimate maternal mortality in South Africa at national and provincial level; examines the potential impact of HIV/AIDS prevalence; and investigates the recorded direct causes of maternal mortality.

Design

data from the 2001 Census, 2007 Community Survey and death registrations were utilised. Information on household deaths, including pregnancy-related deaths was collected from the aforementioned census and survey.

Setting

enumerated households in the 2001 Census and a nationally representative sample of 250,348 households in the 2007 Community Survey.

Participants

information about members of households who died in the preceding 12 months was collected, and of these deaths whether there were women aged 15–49 who died while pregnant or within 42 days after childbirth.

Findings

maternal mortality ratio of 764 per 100,000 live births in 2007, ranging from 102 per 100,000 live births in the Western Cape province to 1639 in the Eastern Cape. Maternal infections and parasitic diseases as well as other maternal diseases complicating pregnancy, childbirth and the puerperium are the major causes. The study found a weak correlation between provincial HIVprevalence and maternal mortality ratio.

Conclusion

despite strategies to improve maternal and child health, maternal mortality remains high in South Africa and it is unlikely that the Millennnium Developmemnt Goal of reducing maternal will be achieved.     

National maternal mortality ratio for Jordan, 2007-2008

Objective

To estimate the number of maternal deaths per 100 000 live births during 2007-2008 among Jordanian women; to identify the causes of maternal mortality; and to compare the results with those of the last report for 1995-1996.

Methods

Reproductive-age mortality study of maternal deaths among women aged 15-49 years in Jordan in 2007-2008.

Results

Among 1406 identified deaths of reproductive-aged women, 76 maternal deaths were identified out of 397 588 live births, for a maternal mortality ratio of 19.1 deaths per 100 000 live births. Forty-three (56.6%) deaths were attributable to hemorrhage, thrombosis and thromboembolism, and sepsis. Avoidable factors were present in 53.9% of women, 52.6% had substandard care, and 31.5% had 3 or fewer antenatal visits. Of those with available information on family planning, only 29.4% had ever used any form of contraception.

Conclusions

Maternal deaths in Jordan are declining. The maternal mortality ratio of 19.1 deaths per 100 000 live births reported for 2007-2008 showed a remarkable reduction of 53.9% achieved in the 12 years since the 1995-1996 report (a 4.5% annual reduction), which is approaching the 75% reduction recommended by Millennium Development Goal 5.     

Making EmOC a reality--CARE's experiences in areas of high maternal mortality in Africa.

OBJECTIVE: This paper describes the package of interventions undertaken by the CARE/AMDD program collaboration to increase the availability and quality of emergency obstetric care for 3 high maternal mortality countries in Africa. METHODS: Project implementation over 4 years focused on enhancing the capacity of 10 district hospitals in 3 countries - Tanzania, Rwanda and Ethiopia. Interventions were designed to create functional health facilities with trained and competent staff, working in an enabling environment supporting EmOC service delivery. RESULTS: By keeping a clear focus on EmOC, the project achieved modest improvements in services, even in the face of the considerable constraints of rural district hospitals. Availability and utilization of EmOC increased in Tanzania; the met need for EmOC increased slightly from 14% in year 1 to 19% in year 4, while in Rwanda it increased from 16% to 25% over 4 years. Case fatality rates (CFR) declined by 30-50% in all 3 countries. While still well below UN recommendations, in all 3 countries there was also a progressive increase in the cesarean section rates, a life saving obstetric intervention. CONCLUSIONS: The increases in met need and decreases in case fatality suggest that project interventions improved the quality and use of EmOC, a critical component for saving women's lives.     

孕产妇死亡率下降趋势及其相关因素分析

目的　分析孕产妇死亡率下降趋势及其相关因素 ,以进一步加快孕产妇死亡率的下降速度。　方法　对内蒙古、江西等 8个省的农村贫困地区共 2 32个县的孕产妇死亡情况及相关资料进行影响因素分析。　结果　研究地区的平均孕产妇死亡率自 1995年至 2 0 0 0年下降了 5 1.33% ,下降明显 ,但与全国水平相比仍有差距 ;孕产妇死亡率的下降趋势前中期较中后期下降幅度大 ;孕产妇死亡率的下降速度与经济的增长速度、卫生经费投入的增加及住院分娩率、消毒接生率、产前检查率、产后访视率的增加有关。　结论　建议进一步提高孕产期保健和产科服务质量、改善交通通讯设施以加快孕产妇死亡率的下降速度     

A return to maternal mortality studies: a necessary effort

This report reviews the experience of the Santa Clara County Maternal Mortality Study Committee, which continued its local activity after the termination of California state-supported study groups in 1970. A study of 36 maternal deaths among approximately 262,000 live births was compiled over a 13-year period, between 1971 and 1983, in a population group representative of much of California. Although based on a small population sample, the results indicate an imperative need for such reviews to improve the quality of clinical care and to develop significant statistical information on the incidence and causes of maternal mortality. The historical development of study committees throughout the United States illustrates the necessity of standardized definitions and uniform methodology among study groups in all states and territories. A nationwide study is proposed to obtain a broad-based, cumulative maternal mortality series, directed toward the eventual elimination of preventable maternal deaths. The current effort by a special interest group in the American College of Obstetricians and Gynecologists is commended for beginning this task.     

Obstetric quality assurance to reduce maternal and fetal mortality in Kano and Kaduna State hospitals in Nigeria

Objective

To achieve Millennium Development Goals 4 and 5 in Nigeria, a quality assurance project in obstetrics in 10 hospitals in northern Nigeria was established to improve maternal and fetal outcome.

Methods

The project commenced in January 2008 with assessment and improvement of the structure of the 10 hospitals. Continuous maternal and fetal data collection and analysis were conducted from 2008 to 2009 by means of a maternity record book and structured monthly summary form. The quality of hospital infrastructure and equipment was also assessed.

Results

The mean maternal mortality ratio (MMR) was reduced from 1790 per 100 000 births in the first half of 2008 to 940 per 100 000 births in the second half of 2009. The average fetal mortality ratio (FMR) decreased slightly from 84.9 to 83.5 per 1000 births. There was an inversely proportional relationship between the total number of deliveries in a hospital and MMR and FMR. There was a close correlation between the MMR and the equipment status and hygiene conditions of the hospitals.

Conclusion

Continuous monitoring of quality assurance in maternity units raised the awareness of the quality of obstetric performance and improved the quality of care provided, thereby improving MMR.     

Declining maternal mortality ratio in Uganda: priority interventions to achieve the Millennium Development Goal.

PURPOSE: We conducted a survey to determine availability of emergency obstetric care (EmOC) and to provide data for advocating for improved maternal and newborn health in Uganda. METHODS: The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions, documented maternal deaths and the related causes. Three levels of health facilities were covered. FINDINGS: Few health units had running water; electricity or a functional operating theater. Yet having these items had a protective effect on maternal deaths as follows: theater (OR 0.56, P<0.0001); electricity (OR 0.39, P<0.0001); laboratory (OR 0.71, P<0.0001) and staffing levels (midwives) OR 0.20, P<0.0001. The availability of midwives had the highest protective effect on maternal deaths, reducing the case fatality rate by 80%. Further, most (97.2%) health facilities expected to offer basic EmOC, were not doing so. This is the likely explanation for the high health facility-based maternal death rate of 671/100,000 live births in Uganda. CONCLUSION: Addressing health system issues, especially human resources, and increasingaccess to EmOC could reduce maternal mortality in Uganda and enable the country to achieve the Millennium Development Goal (MDG).     

Universal reporting of maternal mortality: an achievable goal?

This paper aims to highlight the importance of aspiring to achieve universal reporting of maternal deaths as a part of taking responsibility for these avoidable tragedies. The paper first discusses the reasons for reporting maternal deaths, distinguishing between individual case notification and aggregate statistics. This is followed by a summary of the status of reporting at national and international levels, as well as major barriers and facilitators to this process. A new framework is then proposed - the REPORT framework, designed to highlight six factors essential to universal reporting. Malaysia is used to illustrate the relevance of these factors. Finally, the paper makes a Call to Action by FIGO to promote REPORT and to encourage health professionals to play their part in improving the quality of reporting on all maternal deaths - not just those directly in their care.     

Insights into maternal mortality in Madang Province,Papua New Guinea

Objective

To assess the frequency, causes, and reporting of maternal deaths at a provincial referral hospital in coastal Papua New Guinea (PNG), and to describe delays in care.

Methods

In a structured retrospective review of maternal deaths at Modilon General Hospital, Madang, PNG, registers and case notes for the period January 2008 to July 2012 were analyzed to determine causes, characteristics, and management of maternal death cases. Public databases were assessed for underreporting.

Results

During the review period, there were 64 maternal deaths (institutional maternal mortality ratio, 588 deaths per 100 000 live births). Fifty-two cases were analyzed in detail: 71.2% (n = 37) were direct maternal deaths, and hemorrhage (n = 24, 46.2%) and infection (n = 16, 30.8%) were the leading causes of mortality overall. Women frequently did not attend prenatal clinics (n = 34, 65.4%), resided in rural areas (n = 45, 86.5%), and experienced delays in care (n = 45, 86.5%). Maternal deaths were underreported in public databases.

Conclusion

The burden of maternal mortality was found to be high at a provincial hospital in PNG. Most women died of direct causes and experienced delays in care. Strategies to complement current hospital and national policy to reduce maternal mortality and to improve reporting of deaths are needed.     

The continuum of maternal morbidity and mortality: factors associated with severity

OBJECTIVE: The goal of this study was to examine whether sociodemographic, clinical, and other service-related factors, as well as preventability issues affect a woman's progression along the continuum of morbidity and mortality. STUDY DESIGN: This was a case-control study of pregnancy-related deaths, women with near-miss morbidity, and those with other severe, but not life threatening, morbidity. Factors associated with maternal outcome were examined. RESULTS: Provider factors (related to preventability) and clinical diagnosis were significantly associated with progression along the continuum after controlling for sociodemographic characteristics (P < .01 for both associations). CONCLUSION: In order to improve mortality rates, we must understand maternal morbidity and how it may lead to death. This study shows that important initiatives include addressing preventability, in particular, provider factors, which may play a role in moving women along the continuum of morbidity and mortality.     

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

Objective

identify research examining the effect of culture on maternal mortality rates.

Design

literature review of CINAHL, Cochrane, PsychInfo, OVID Medline and Web of Science databases.

Setting

developing countries with typically higher rates of maternal mortality.

Participants

women, birth attendants, family members, nurse midwives, health-care workers, and community members.

Measurements and findings

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.

Key conclusions

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.

Implications for practice

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.     

Frustration from not achieving the expected reduction in maternal mortality

Background Maternal mortality ratio (more commonly cited as maternal mortality rate) is the number of maternal deaths that result from the reproductive process per 100,000 live births. Unfortunately, it is estimated that more than half of maternal deaths are not recorded as such. Worldwide data are probably based upon pregnancy-associated or pregnancy-related deaths only. Persistent efforts are made to assess true mortality rates, though these are considered at most educated guesses. Objective This editorial was aimed to discuss the lately shared opinions regarding global reduction of maternal mortality rates, an unaccomplished goal during the past 20 years. Conclusions Reassessment of resources and means of intervention will hopefully result in narrowing the gap between nations, and perhaps further reducing global maternal mortality subsequently creating a safer world for mothers.     

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

Objective

To establish representative local-area baseline estimates of maternal and neonatal mortality using a novel adjusted sisterhood method.

Methods

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.

Results

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.

Conclusion

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.     

Reduction of maternal mortality: the need for voluntary blood donors.

OBJECTIVE: To explore the relationship between maternal mortality and availability of blood for transfusion at the country level in Latin American and Caribbean countries. METHOD: The association of blood availability with maternal mortality, expressed either as national maternal mortality ratio or proportion of maternal deaths due to hemorrhage, in selected Latin American and Caribbean countries was analyzed by non-parametric methods. RESULT: An inverse correlation was found between blood availability and both maternal mortality ratio (p<0.002) and proportion of deaths due to hemorrhage (p<0.05). CONCLUSION: Limited availability of blood for transfusion in countries with high maternal mortality ratios may hinder comprehensive care of mothers. The results presented here underscore the need for the formation of voluntary blood donors in the pursuit of improved maternal health.     

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

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.