Safer maternal health in rural Uttar Pradesh: do primary health services contribute?

India accounts for about one-quarter of maternal deaths world wide, with the most recent statistics showing an average maternal mortality ratio of 407 per 100 000 live births at the national level. The government had hoped to reduce maternal mortality to 200 by 2000, but it is clear that this was not achieved. This paper explores the reasons why the most populous state of Uttar Pradesh continues to have one of the highest reported maternal mortality ratios in India. Data from two districts of Uttar Pradesh on mother and child health-care utilization and the readiness of the public sector to provide antenatal and emergency obstetric services are used to illustrate the reasons why maternal mortality has not declined. While blueprints for safe motherhood programmes exist, the equipment and technical competence to provide services is weak at the present moment. Reductions in maternal mortality would require interventions to improve service delivery as well as community mobilization to improve utilization of services, especially in life-threatening situations.     

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...     

Problem of mortality in women of reproductive age in rural area of Haryana

To learn the extent of mortality among women of reproductive age, data was analyzed on causes of death, as reported by anganwadi workers and heads of households, for all maternal deaths in 1992 in Haryana, India. The community was comprised of 300,907 persons and 58,961 women (19.6%) of reproductive age. 9894 live births were recorded, which is higher than the national average. 219 women died in 1992 from maternal and nonmaternal causes (3.7 per 1000 women). In the study blocks (Rohtak, Chiri, and Kathure) the range of mortality was from 3.4 to 4.1 per 1000. 78.5% (172 deaths) were considered nonmaternal deaths. Mortality was 20.9% among mothers 15-20 years old, 25.6% among mothers 20-25 years old, and 18.6% among mothers 25-30 years old. 65.1% of women died at home. 58.1% sought medical care prior to death. 1.2% of deaths were certified. 36.7% of deaths were to literate women, and the remaining 63.3% were illiterate. Causes of nonmaternal death included accidents, respiratory disorders, poisoning, and digestive disorders. Slightly over 20% of accidental deaths were due to burns and suicide. 21.46% (47 deaths) were maternal deaths (475 per 100,000 live births). Maternal mortality ranged from 46 to 488 in the 3 blocks. Rohtak had the highest maternal mortality. Maternal mortality was highest among women 30-44 years old (996 per 100,000), followed by women 15-20 years old (575 per 100,000). 21.3% died during labor and delivery, and 68% died during the postpartum period. 57.4% died at home, and 25.5% died at the Medical College Hospital. 61.7% used prenatal services. 36.2% did not seek medical care prior to their death. 55.3% of deliveries were by trained birth attendants. 25.5% died with their first births. 51.0% of women with a birth interval under 3 years died. Maternal mortality was distributed by cause as follows: postpartum hemorrhage (17.0%), puerperal sepsis (17.0%), anemia (12.8%), preeclampsia and eclampsia (14.9%), obstructed labor (6.4%), hemorrhage antepartum (4.25%), abortions and MTP (10.6%), and indirect causes (12.8%). Improvement is needed in literacy, contraception, women's empowerment, and prenatal care in order to reach the goal of reduced maternal mortality by the year 2000.     

Maternal mortality in a rural district of southeastern Tanzania: an application of the sisterhood method

BACKGROUND: Deaths from maternal causes represent the leading cause of death among women of reproductive age in most developing countries. It is estimated that the highest risk occurs in Africa, with 20% of world births but 40% of the world maternal deaths. The level of maternal mortality is difficult to assess especially in countries without an adequate vital registration system. Indirect techniques are an attractive cost-effective tool to provide estimates of orders of magnitude for maternal mortality. METHOD: The level of maternal mortality estimated by the sisterhood method is presented for a rural district in the Morogoro Region of Southeastern Tanzania and the main causes of maternal death are studied. Information from region-specific data using the sisterhood method is compared to data from other sources. RESULTS: The maternal mortality ratio (MMR) was 448 maternal deaths per 100,000 live births (95%CI : 363-534 deaths per 100,000 live births). Maternal causes accounted for 19% of total mortality in this age group. One in 39 women who survive until reproductive age will die before age 50 due to maternal causes. The main cause of death provided by hospital data was puerperal sepsis (35%) and postpartum haemorrhage (17%); this is compatible with the main causes reported for maternal death in settings with high levels of maternal mortality, and similar to data for other regions in Tanzania. The sisterhood method provides data comparable with others, together with a cost-effective and reliable estimate for the determination of the magnitude of maternal mortality in the rural Kilombero District.     

Maternal mortality in Vietnam in 1994-95

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.     

Socioeconomic and Geographical Disparities in Under-Five and Neonatal Mortality in Uttar Pradesh,India

As a part of the Millennium Development Goals, India seeks to substantially reduce its burden of childhood mortality. The success or failure of this goal may depend on outcomes within India’s most populous state, Uttar Pradesh. This study examines the level of disparities in under-five and neonatal mortality across a range of equity markers within the state. Estimates of under-five and neonatal mortality rates were computed using five datasets, from three available sources: sample registration system, summary birth histories in surveys, and complete birth histories. Disparities were evaluated via comparisons of mortality rates by rural–urban location, ethnicity, wealth, and districts. While Uttar Pradesh has experienced declines in both rates of under-five (162–108 per 1,000 live births) and neonatal (76–49 per 1,000 live births) mortality, the rate of decline has been slow (averaging 2 % per annum). Mortality trends in rural and urban areas are showing signs of convergence, largely due to the much slower rate of change in urban areas. While the gap between rich and poor households has decreased in both urban and rural areas, trends suggest that differences in mortality will remain. Caste-related disparities remain high and show no signs of diminishing. Of concern are also the signs of stagnation in mortality amongst groups with greater ability to access services, such as the urban middle class. Notwithstanding the slow but steady reduction of absolute levels of childhood mortality within Uttar Pradesh, the distribution of the mortality by sub-state populations remains unequal. Future progress may require significant investment in quality of care provided to all sections of the community.     

Adoption of Medicaid Expansion Is Associated with Lower Maternal Mortality

ObjectivesThis study explores the effect of Medicaid expansion under the Affordable Care Act on the maternal mortality ratio in the United States.MethodsA difference-in-differences research design was used to analyze the effect of Medicaid expansion on maternal mortality. Maternal mortality was defined with and without late maternal deaths, to substantiate the contribution of increased preconception and postpartum insurance coverage. To examine whether there was a racial difference in the effects of Medicaid expansion, models were stratified by the woman's race/ethnicity for non-Hispanic Black women, non-Hispanic White women, and Hispanic women.ResultsMedicaid expansion was significantly associated with lower maternal mortality by 7.01 maternal deaths per 100,000 live births (p = .002) relative to nonexpansion states. When maternal mortality definitions excluded late maternal deaths, Medicaid expansion was significantly associated with a decrease in maternal mortality per 100,000 live births by 6.65 (p = .004) relative to nonexpansion states. Medicaid expansion effects were concentrated among non-Hispanic Black mothers, suggesting that expansion could be contributing to decreasing racial disparities in maternal mortality.ConclusionsAlthough maternal mortality overall continues to increase in the United States, the maternal mortality ratio among Medicaid expansion states has increased much less compared with nonexpansion states. These results suggest that Medicaid expansion could be contributing to a relative decrease in the maternal mortality ratio in the United States. The decrease in the maternal mortality ratio is greater when maternal mortality estimates include late maternal deaths, suggesting that sustained insurance coverage after childbirth as well as improved preconception coverage could be contributing to decreasing maternal mortality.     

Maternal mortality in rural Gambia: levels, causes and contributing factors

A demographic study carried out in a rural area of the Gambia between January 1993 and December 1998 recorded 74 deaths among women aged 15-49 years. Reported here is an estimation of maternal mortality among these 74 deaths based on a survey of reproductive age mortality, which identified 18 maternal deaths by verbal autopsy. Over the same period there were 4245 live births in the study area, giving a maternal mortality ratio of 424 per 100,000 live births. This maternal mortality estimate is substantially lower than estimates made in the 1980s, which ranged from 1005 to 2362 per 100,000 live births, in the same area. A total of 9 of the 18 deaths had a direct obstetric cause--haemorrhage (6 deaths), early pregnancy (2), and obstructed labour (1). Indirect causes of obstetric deaths were anaemia (4 deaths), hepatitis (1), and undetermined (4). Low standards of health care for obstetric referrals, failure to recognize the severity of the problem at the community level, delays in starting the decision-making process to seek health care, lack of transport, and substandard primary health care were identified more than once as probable or possible contributing factors to these maternal deaths.     

Maternal Mortality Decline in the Kassena-Nankana District of Northern Ghana

Objective In the absence of an adequate vital registration system in Ghana, the Navrongo demographic surveillance system (NDSS) established in 1993 presents a viable alternative to monitor, in a poor rural district, the UN Millennium Development Goal on maternal health (MDG) of reducing maternal mortality by 75% between 1990 and 2015. Methods Of the 518 women aged 12–49 years identified in the NDSS database to have died in the Kassena-Nankana district in the period January 2002–December 2004, spouses or family members completed verbal autopsy interviews for 516 female deaths. Results Of the 516 female deaths, 45 were identified as maternal deaths. 71% of the maternal deaths were attributed to direct maternal causes while 29% were due to indirect maternal causes. Abortion-related deaths were the most frequent cause of maternal deaths. The maternal mortality ratio for the period 2002–2004 was 373 maternal deaths per 100,000 live births indicating a 40% reduction of maternal mortality from the 1995–1996 level of 637 maternal deaths per 100,000 live births. However, the health-facility based maternal mortality ratio in the district (which excludes maternal deaths outside health facilities) was 141 maternal deaths per 100,000 live births for the period 2002–2004. Conclusion This district may be on track to achieve the MDG on maternal health. Ultimately, strengthening vital registration systems to provide timely information to policymakers should supersede the other methods of measuring maternal mortality.     

Maternal mortality in St. Petersburg, Russian Federation

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.     

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.     

Reproductive health in Romania: reversing the Ceausescu legacy

As a result of the restrictive reproductive health policies enforced under the 25-year Ceausescu dictatorship, Romania ended the 1980s with the highest recorded maternal mortality of any country in Europe--159 deaths per 100,000 live births in 1989. An estimated 87 percent of these maternal deaths were caused by illegal and unsafe abortion. Under the Ceausescu regime, all contraceptive methods were forbidden and induced abortion was available only for women who met extremely narrow criteria. Immediately after the December 1989 revolution that overthrew Ceausescu, the new government removed restrictions on contraceptive use and legalized abortion. This legislative change has had beneficial effects on women's health, seen in the drop in maternal mortality in 1990 to 83 deaths per 100,000 live births--almost half the ratio in 1989. In addition, changes instituted since the revolution have led to the improved availability of reproductive health services and to the creation of new educational and training opportunities related to reproductive health services and to the creation of new educational and training opportunities related to reproductive health. The newly created contraceptive and abortion services have presented health system managers and policymakers with many challenges as they work to expand the availability of high-quality, comprehensive reproductive health care in a setting of economic hardship, political unrest, insufficient infrastructure, and outdated medical knowledge and practice.     

Completeness of a Maternal and Perinatal Mortality Enhanced Surveillance System in Pakistan: Evidence from Capture–Recapture Methods

Objectives An enhanced surveillance system that integrated health information systems and extended surveillance to previously uncovered areas to capture all births, perinatal and maternal deaths in a rural district of Pakistan was established in 2015, and this study uses capture–recapture methodology to assess completeness. Methods Births and deaths collected by the survey were matched with the data captured by the enhanced surveillance system. Capture–recapture methodology was used to estimate the total number of births and deaths, measure the degree of underestimation, and adjust mortality rates. Results Of all births, 99% were captured by the enhanced surveillance system. Ninety percent of neonatal deaths and 86% of early neonatal deaths were recorded. The recorded neonatal mortality rate was 40 per 1000 live births (95% CI 35–44), and after adjustment for under-enumeration was 42 per 1000 live births (95% CI 37–46). Recorded rates underestimated neonatal mortality by 5% and perinatal mortality by 7%. Five stillbirths were recorded by the survey and all were matched to recorded stillbirths. The one maternal death recorded by the survey was matched with the maternal death captured by the enhanced surveillance system. The maternal mortality ratio prior to adjustment for under-enumeration was 247 per 100,000 live births (95% CI 147–391), whereas after adjustment it was 246 per 100,000 live births (95% CI 146–389). Conclusion Application of capture–recapture methods to the enhanced surveillance system indicated a high completeness of birth and death recording by the surveillance system.     

Survey to validate neonatal tetanus elimination in Andhra Pradesh, India

Neonatal Tetanus (NNT) elimination has been defined as an annual incidence of <1 case of NNT per 1,000 live births in each district of a province, state, or country. Reported incidence of NNT does not always reflect the true dimension of the problem. Thus, NNT mortality survey was planned during November 2003 to validate NNT elimination in the state of Andhra Pradesh. Firstly, based on review of records and recommended standard algorithm, two highest risk districts, namely Kurnool and Mahbubnagar were identified. In the second stage, NNT mortality survey was conducted in these two districts using lot quality assurance-cluster sampling (LQA-CS) methodology. In each of the two districts, 62 neonatal deaths were detected with no deaths due to NN, indicating incidence of NNT below 1/1000 LB. Thus, validation of NNT elimination may be concluded.     

Healthier mothers and babies

At the beginning of the 20th century, for every 1000 live births, six to nine women in the United States died of pregnancy-related complications, and approximately 100 infants died before age 1 year. From 1915 through 1997, the infant mortality rate declined >90% to 7.2 per 1000 live births, and from 1900 through 1997, the maternal mortality rate declined almost 99% to <0.1 reported death per 1000 live births (7.7 deaths per 100,000 live births in 1997). Environmental interventions, improvements in nutrition, advances in clinical medicine, improvements in access to health care, improvements in surveillance and monitoring of disease, increases in education levels, and improvements in standards of living contributed to this remarkable decline. Despite these improvements in maternal and infant mortality rates, significant disparities by race and ethnicity persist. This report summarizes trends in reducing infant and maternal mortality in the United States, factors contributing to these trends, challenges in reducing infant and maternal mortality, and provides suggestions for public health action for the 21st century.     

广州市花都区2000~2019年孕产妇死亡影响因素变化趋势分析

目的分析广州市花都区2000~2019年孕产妇死亡的社会人口学特征和医疗保健服务情况,总结孕产妇死亡影响因素的变化趋势,为降低孕产妇死亡率提出干预措施。方法回顾性分析广州市花都区2000~2019年度孕产妇死亡报告表、核实调查报告、病历摘要及死亡评审资料。结果 (1)在研究的20年共发生孕产妇死亡83例,前10年广州市户籍和全人口的平均孕产妇死亡率分别为23.41/10万活产、54.42/10万活产;后10年分别为10.56/10万活产、15.00/10万活产。孕产妇死亡率呈"先快速后平稳"的下降趋势,流动人口年均降幅大于户籍人口。(2)前后10年社会人口学特征、孕产期保健状况、死因分类有明显变化。前10年主要死因为羊水栓塞、产后出血和心血管疾病,影响孕产妇死亡的第一位环节是个人家庭居民团体;后10年主要死因为心血管疾病、产后出血和恶性肿瘤,影响孕产妇死亡的第一位环节为医疗保健系统。前后20年的第一位影响方面均是知识技能。结论孕产妇死亡受医学和社会诸多因素影响。要进一步降低孕产妇死亡率,对医疗保健系统提出更高的要求,需要提高对妊娠合并基础疾病的识别、监测和多学科救治能力。     

Maternal mortality surveillance, United States, 1980-1985

To better define the incidence, causes, and risk factors associated with maternal deaths, the Division of Reproductive Health, Center for Chronic Disease Prevention and Health Promotion, CDC, coordinated a study by the Maternal Mortality Collaborative, a Special Interest Group of the American College of Obstetricians and Gynecologists (ACOG). In 1983, this group established voluntary surveillance of maternal deaths for the years 1980-1985. The Maternal Mortality Collaborative reported 601 maternal deaths from 19 reporting areas for 1980-1985, representing a maternal mortality ratio of 14.1 per 100,000 live births. Overall, 39% more maternal deaths were reported by the Maternal Mortality Collaborative than by the National Center for Health Statistics for these reporting areas. Overall, women over 30 years of age had a higher risk of dying than did younger women. For each age group, women of black and other races who were 30 years and older having the highest risk. The leading causes of maternal deaths were embolism, hypertension in pregnancy, sequelae from ectopic pregnancy, hemorrhage, cerebrovascular accidents, and anesthesia complications. Of the 111 nonmaternal deaths, 90 (82%) were attributed to unintentional or intentional injuries. As a result of the success of this voluntary reporting system, the Division of Reproductive Health initiated National Pregnancy Mortality Surveillance in January 1988.     

Estimates of the maternal mortality ratio in two districts of the Brong-Ahafo region, Ghana.

OBJECTIVE: To estimate the maternal mortality ratio (MMR) by the sisterhood method in two districts of the Brong-Ahafo region of Ghana, and to determine the impact of different assumptions and analytical decisions on these estimates. METHODS: Indirect estimates of the MMR were calculated from data collected in 1995 by Family Health International (FHI) on 5202 women aged 15-49 years, using a household screen of randomly selected areas in the two districts. Other data from the nationally representative 1994 Ghana Infant, Child and Maternal Mortality Survey (ICMMS) and from the 1997 Kassena-Nankana District study were also used for comparison. FINDINGS: Based on the FHI data, the MMR was estimated to be 269 maternal deaths per 100,000 live births for both districts combined, a figure higher than ICMMS estimates. Biases during data collection may account for this difference, including the fact that biases underestimating mortality are more common than those overestimating it. Biases introduced during data analysis were also considered, but only the total fertility rate used to calculate the MMR seemed to affect the estimates significantly. CONCLUSIONS: The results indicate that the sisterhood method is still being refined and the extent and impact of biases have only recently received attention. Users of this method should be aware of limitations when interpreting results. We recommend using confidence limits around estimates, both to dispel false impressions of precision and to reduce overinterpretation of data.     

Mortality of women in reproductive age in the municipality of S?o Paulo (Brazil), 1986. I. Methodology and general results

The purpose of this study was to evaluate the accuracy of the death certificates of a sample of a quarter of all deaths in women of reproductive age (10-49 years) resident in the Municipality of S. Paulo, SP, Brazil, in 1986. For each death, further data were gathered by means of household interviews and from medical records and autopsy information where available. Nine hundred and fifty-three deaths were analysed, for whom there were good quality death certificates except with regard to maternal deaths an terminal respiratory diseases, the former being greatly under-reported. The official maternal mortality rate was 44.5 per 100,000 live births but the true rate was 99.6 per 100,000 live births. The three main causes of death were cardiovascular diseases, neoplasms and external causes. A great proportion of smokers was found among the deceased women (40.4%). Eleven percent of the deceased consumed large amounts of alcoholic beverages regularly.     

Maternal mortality in developing countries

The authors of this letter respond to earlier letters prepared in response to their article on maternal mortality in developing countries. It is conceded that maternal mortality is high in India and Bangladesh; however, statistics from Gambia are based on small populations and are therefore inconclusive. It is noted that a 7-year survey of 4000 households in Machakos, Kenya, where 73% of deliveries occurred at home, yielded a maternal mortality rate of only 0.8/1000 deliveries. Finally, it is asserted that the measurement traditionally used in estimating maternal mortality for many African countries (ratio of recorded maternal deaths to recorded deliveries) is misleading. Maternal deaths are more likely than deliveries to be recorded. In Niger, the number of maternal deaths increased from 1980 (374) to 1982 (484). The ratio of maternal deaths to expected live births also increased from 135 to 166/100,000, whereas the traditionally calculated maternal mortality rate decreased from 519 to 420/100,000 due to changes in the denominators. It is recommended that health authorities of African countries such as Niger consider setting an absolute number of maternal deaths below which they would try to bring the current toll.