Global disparities in maternal morbidity and mortality

The disparity in maternal mortality for African American women remains one of the greatest public health inequities in the United States (US). To better understand approaches toward amelioration of these differences, we examine settings with similar disparities in maternal mortality and “near misses” based on race/ethnicity. This global analysis of disparities in maternal mortality/morbidity will focus on middle- and high-income countries (based on World Bank definitions) with multiethnic populations. Many countries with similar histories of slavery and forced migration demonstrate disparities in health outcomes based on social determinants such as race/ethnicity. We highlight comparisons in the Americas between the US and Brazil—two countries with the largest populations of African descent brought to the Americas primarily through the transatlantic slave trade. We also address the need to capture race/ethnicity/country of origin in a meaningful way in order to facilitate transnational comparisons and potential translatable solutions. Race, class, and gender-based inequities are pervasive, global themes. This approach is human rights—based and consistent with the UN Millennium Development Goals (MDG) and post 2015—sustainable development goals’ aim to place women’s health the context of health equity/women’s rights. Solutions to these issues of inequity in maternal mortality are nation-specific and global.     

Maternal mortality and maternity care from 1990 to 2005: uneven but important gains

Maternal mortality continues to be the major cause of death among women of reproductive age in many countries. Data from published studies and Demographic and Health Surveys show that gains in reducing maternal mortality between 1990 and 2005 have been modest overall. In 2005, there were about 536,000 maternal deaths, and the maternal mortality ratio was estimated at 400 per 100,000 live births, compared to 430 in 1990. Noteworthy declines took place in east Asia (4% per year) and north Africa (3% per year). Maternal deaths and mortality ratios were highest in sub-Saharan Africa and southeast Asia and low in east Asia and Latin America/Caribbean. In 11 of 53 countries with data, fewer than 25% of women had had at least four antenatal visits. About 63% of births were attended by a skilled attendant: from 47% in Africa to 88% in Latin America/Caribbean. In 16 of 23 countries with data, less than 50% of the recommended levels of emergency obstetric care had been fulfilled. Only 61% of women who delivered in a health facility in 30 developing countries received post-partum care, and far fewer who gave birth at home. Countries with maternal mortality ratios of 750+ per 100,000 live births shared problems of high fertility and unplanned pregnancies, poor health infrastructure with limited resources and low availability of health personnel. The task ahead is enormous.     

Mortalidad materna en África

In this report, the authors describe the dramatic situation of maternal health in African countries. According to the most recent estimates, almost 1 million African women die each year (one maternal death per minute) and a significant proportion of these (between 3 and 4 million) have incapacitating genitourinary fistulae. In contrast, in industrialized countries, only 2,500 maternal deaths are registered yearly (0.47% of the total worldwide) with a maternal mortality ratio (MMR) of 20 per 100,000 live births.     

孕产妇危重事件发生率及防控策略研究进展

过去孕产妇死亡率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。2019年美国疾病控制中心收集全国孕产妇死亡信息得出结论:如果采取行动,多达一半的孕产妇死亡是可预防的。随着2000年联合国“千年发展目标”的提出以及各国对孕产妇健康的重视,孕产妇死亡已经成为极低概率事件,而孕产妇危重事件发生率(severe maternal morbidity,SMM)已成为比孕产妇死亡率更常见和有用的产科护理指标。在美国,约50名经历SMM孕产妇中发生1例死亡。虽然孕产妇死亡率历来是孕产妇结局的关键指标,SMM的流行情况却可以为围生期健康提供更全面的信息,也是监测孕产妇结局的一种方法。同时,SMM通常是孕产妇死亡的先兆,作为导致孕产妇死亡的动态过程和前期指标,SMM对强化孕产妇管理、降低孕产妇死亡率有重要意义。许多国家开始将SMM作为评价产科质量的重要指标之一。防控SMM,除了常规策略外,避免医疗相关的延迟,使用孕产妇早期预警触发工具(MEWT)有重要临床价值。     

Perinatal problems in developing countries: lessons learned and future challenges.

Every year, approximately 600,000 women die of pregnancy-related causes--98% of these deaths occur in developing countries. Complications of pregnancy and childbirth are the leading cause of death and disability among women of reproductive age in developing countries. Of all human development indicators, the maternal mortality ratio shows the greatest discrepancy between developed and developing countries. In fact, maternal mortality itself contributes to underdevelopment, because of its severe impact on the lives of young children, the family and society in general. Furthermore, in addition to more than half a million maternal deaths each year 7 million perinatal deaths are recorded and 8 million infants die during the first year of life. Maternal morbidity and mortality as well as perinatal mortality can be reduced through the synergistic effect of combined interventions, without first attaining high levels of economic development. These include: education for all; universal access to basic health services and nutrition before, during and after childbirth; access to family planning services; attendance at birth by professional health workers and access to good quality care in case of complications; and policies that raise women's social and economic status, and their access to property, as well as the labor force.     

Maternal mortality--a world wide problem

Death during pregnancy and delivery is one of the leading causes of death among women in the developing countries. A review of literature, and a comparison of the decline of the maternal mortality in Sweden, concludes that maternal mortality is a sensitive socio-economic index of health in the society, but also that this death cause is one of the few that it is really possible to prevent by the impact of medical services - antenatal and delivery care.     

Current challenges in pregnancy-related mortality

Pregnancy is a normal, healthy state that many women are desirous for. Sadly, this life-affirming process carries serious risks of death and disability for both mother and offspring. It is estimated that 830 women die from preventable pregnancy or pregnancy related complications each day. Almost all of these deaths occur in low and middle income countries (LMICs). Reducing maternal mortality is an ongoing challenge, and care providers, researchers and policy makers must not only identify the key barriers to accessing quality health care, but commit to making maternal health a priority.     

Maternal Mortality and Its Correlates: Practical Implications of Data Analysis Across Multiple Countries

ObjectiveStudies of maternal mortality that use data from multiple countries often identify statistically significant correlates and interpret them as factors relevant to policy. This study was designed to address the fragility of a statistical association between the maternal mortality rate and its main correlates, and to assess the relevance of multi-country data analysis for policy making.MethodsPatterns of variation in the maternal mortality rate associated with the fertility rate, income per capita, primary and secondary school enrolment, institutional quality, women’s participation in politics, and health systems indicators across 111 countries in 2000 and 128 countries in 2005 were investigated using a linear multilevel modelling approach.ResultsThe fertility rate and income per capita were the only robust predictors of the maternal mortality rate. Health systems indicators and school enrolment, after controlling for the effect of the fertility rate, income per capita, and region-specific contextual factors, were found to be unstable direct predictors of the maternal mortality rate.ConclusionAlthough multi-country comparative studies can identify key correlates of the maternal mortality rate, policy recommendations to reduce maternal mortality should be based on causal models that take contextual factors into account.     

The role of professional associations in reducing maternal mortality worldwide.

The death of hundreds of thousands of women due to pregnancy-related complications casts a shadow over the modern obstetrical world. This paper examines the potential roles and responsibilities of professional obstetrical and midwifery associations in addressing this tolerated tragedy of maternal deaths. We examine the successes and challenges of obstetrical and midwifery associations and encourage the growth and development of active associations to address maternal mortality within their own borders. Professional associations can play a vital role in the reduction of maternal mortality worldwide. Their roles include lobbying for women's health and rights, setting standards of practice, raising awareness and team building. Associations from developed countries can influence and strengthen their colleagues within developing countries; for example, the FIGO Save the Mothers initiative. Professional associations should be encouraged to play an active role in reducing maternal mortality within their own country and abroad.     

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.     

Primary obstetrics and gynecology in developing countries: shifting the focus to older women's health

When one thinks of the field of women's health in the developing world, traditionally, one immediately relates it to maternal health and care of those women of reproductive age. Little attention is given to older women's health care. Yet it has been documented that older women with poor access to care have higher age-adjusted mortality. As the abundant existing reproductive-aged women become older, the number of older women in the developing world will increase. In 1994, nearly 312 million of the world's 469 million elderly women resided in developing countries. Currently, out of the 600 million older women worldwide, there are over 400 million older women living in the developing world. It is estimated that by 2020 five out of seven will reside in developing countries, an absolute increase of about 360 million compared to 87 million in developed countries. This article focuses on some of the existing health problems, such as breast and cervical cancer, and their barriers in prevention, diagnosis, and treatment in older women in developing countries. It then discusses the emerging issues from a neglect of the multifaceted problems of older women’s health. Finally, there is a call for a multidisciplinary approach to proposed solutions for future directions in this desperately needed field.     

Maternal mortality at twelve teaching hospitals in Indonesia-an epidemiologic analysis

Records on 36,062 maternity cases admitted to 12 teaching hospitals throughout Indonesia between 1977 and 1980 were analyzed. A hospital maternal mortality rate of 37.4/10,000 cases (39.0/10,000 live births) was derived that was about ten times higher than rates reported from developed countries in the early seventies. Hemorrhage, infection and toxemia accounted for 91.2% of deaths resulting from direct obstetric causes and for 86,1% of total deaths. It is postulated that if all pregnant women received adequate antenatal care, and if all women wanting no additional children were sterilized, maternal mortality would be cut in half. It is recommended that maternal health services in Indonesia be integrated into its successful family planning program.     

A global view of severe maternal morbidity: moving beyond maternal mortality

Background

Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).

Severe maternal morbidity in high-income countries

Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify “high risk” status, delays in diagnosis, and delays in treatment.

Severe maternal morbidity in low and middle income countries

The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.

Effects of SMM on delivery outcomes and infants

Severe maternal morbidity not only puts the woman’s life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.

Conclusion

Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women’s and infants’ health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

     

Promoting safe motherhood in the community: the case for strategies that include men

Although a decade has now passed since the launching of the Safe Motherhood Initiative, maternal mortality continues to be the health indicator showing the greatest disparity between developed and developing countries. Recently revised WHO and UNICEF figures indicate that an estimated 90% of the 585,000 worldwide maternal deaths that occur each year take place in sub-Saharan Africa and Asia. In terms of the lifetime risk of maternal death, this disparity remains striking: 1 in 12 women in parts of sub-Saharan Africa, compared with 1 in 4,000 women in Northern Europe. In addition, for every woman who dies, an estimated 16-17 will suffer from pregnancy-related complications. Research suggests that, in addition to biomedical interventions and the strengthening of health care services, improving awareness of obstetric complications among members of a pregnant woman's immediate and wider social network is an important step in improving her chances of survival when such complications occur. Many of the interventions implemented so far have focused exclusively on improving women's knowledge and practices as they relate to maternal health issues. Nevertheless, it is now increasingly being recognised that the actions required to achieve improvements in reproductive health outcomes in general, and maternal health in particular, should involve communities in the process and encourage men's active participation. Despite this, very few studies on risk perceptions or interventions to raise community awareness of obstetric risk factors, their complications and their consequences have targeted men. The present article argues for the development and testing of risk awareness interventions, which, in addition to women, target men in their familial and social roles within communities and as workers within health care services as a means of improving maternal health outcomes.     

Mortality risk associated with the use of oral contraceptives

In assessing the risk of oral contraceptives the synergistic effects of other risk factors such as smoking, obesity, and hypertension must be considered. Pill users who are nonsmokers are at a much lower risk of heart disease mortality than those who use pills and smoke cigarettes. Most of the data on mortality associated with the use of oral contraceptives come from case-control studies or longitudinal prospective studies carried out in the United Kingdom or the U.S. Cigarette smoking by women is more common there than in most developing countries. To evaluate the risk-benefit ratio involved in the use of oral contraceptives, policymakers msut determine the risk that applies under the conditions of use in their countries. Health benefits must be assessed in a similar manner. In countries where maternal mortality is high, health benefits of controlling fertility will be greater than in countries where deaths from pregnancy and childbirth are relatively rare.     

Current challenges in pregnancy-related mortality

Pregnancy is a normal, healthy state that most women are desirous for at some point in their lives. Sadly, this life-affirming process carries serious risks of death and disability for both mother and offspring. Maternal mortality rates are especially high in resource poor countries, despite the fact that 80% of all maternal deaths are preventable. Although maternal mortality is slowly declining, the goal of reducing maternal deaths to a quarter of the 1990 levels, before 2015, remains a challenging target. To achieve this target, care providers, researchers and policy makers must not only identify the key barriers to accessing quality healthcare, but commit to making maternal health a priority.     

The structure and incidence of the basic causes of maternal mortality

The author treats by the presented scientific publication the structure and frequency of causes for maternal mortality in particular countries and mainly in Bulgaria. Several structure types of maternal mortality are examined--"extragenital", "hemorrhagic", "septic". It has been proven through a close examination of the work of women's consultation cabinets with regard to maternal mortality that a considerable dependence and regularity is determined due to the insufficient coverage of women from housing complexes (only 24.9% have 6-14 visits). For 1995 dead pregnant women, women in delivery and young mothers in particular regions are 0.1 for 1000 from 73,032 checked-up women. Only in Sofia and Montana region the mortality rate is 0.2 for 1000. For 1996 the mortality rate in the presented regions (see Table N1) for pregnant women, women in delivery and young mothers has increases to 7 (0.2 for 1000).     

Capacity to monitor severe maternal morbidity in Australia

Maternal mortality has traditionally been the key element in the monitoring of maternal health and adequacy of obstetric services in Australia and around the world. In developed countries, the ability of maternal mortality to serve this purpose is reduced because of the rarity of maternal mortality, reflected in very low maternal mortality ratios. Internationally, there has been increasing interest in severe maternal morbidity as an indicator to monitor maternal health and maternity services. The aim of this paper is to critically examine the capacity to measure and monitor maternal morbidity in Australia. There is a paucity of reliable maternal morbidity data in Australia; Australia is lagging behind peer countries that are endeavouring to monitor severe maternal morbidity. Dedicated efforts and adequate resources are needed in order to monitor severe maternal morbidity in Australia.     

Intimate partner violence during pregnancy: analysis of prevalence data from 19 countries

We aimed to describe the prevalence of intimate partner violence (IPV) during pregnancy across 19 countries, and examine trends across age groups and UN regions. We conducted a secondary analysis of data from the Demographic and Health Surveys (20 surveys from 15 countries) and the International Violence Against Women Surveys (4 surveys from 4 countries) carried out between 1998 and 2007. Our data suggest that intimate partner violence during a pregnancy is a common experience. The prevalence of IPV during pregnancy ranged from approximately 2.0% in Australia, Cambodia, Denmark and the Philippines to 13.5% in Uganda among ever-pregnant, ever-partnered women; half of the surveys estimated prevalence to be between 3.9 and 8.7%. Prevalence appeared to be higher in African and Latin American countries relative to the European and Asian countries surveyed. In most settings, prevalence was relatively constant in the younger age groups (age 15-35), and then appeared to decline very slightly after age 35. Intimate partner violence during pregnancy is more common than some maternal health conditions routinely screened for in antenatal care. Global initiatives to reduce maternal mortality and improve maternal health must devote increased attention to violence against women, particularly violence during pregnancy.