Classification differences and maternal mortality: a European study. MOMS Group. MOthers' Mortality and Severe morbidity

OBJECTIVES: To compare the ways maternal deaths are classified in national statistical offices in Europe and to evaluate the ways classification affects published rates. METHODS: Data on pregnancy-associated deaths were collected in 13 European countries. Cases were classified by a European panel of experts into obstetric or non-obstetric causes. An ICD-9 code (International Classification of Diseases) was attributed to each case. These were compared to the codes given in each country. Correction indices were calculated, giving new estimates of maternal mortality rates. SUBJECTS: There were sufficient data to complete reclassification of 359 or 82% of the 437 cases for which data were collected. RESULTS: Compared with the statistical offices, the European panel attributed more deaths to obstetric causes. The overall number of deaths attributed to obstetric causes increased from 229 to 260. This change was substantial in three countries (P < 0.05) where statistical offices appeared to attribute fewer deaths to obstetric causes. In the other countries, no differences were detected. According to official published data, the aggregated maternal mortality rate for participating countries was 7.7 per 100,000 live births, but it increased to 8.7 after classification by the European panel (P < 0.001). CONCLUSION: The classification of pregnancy-associated deaths differs between European countries. These differences in coding contribute to variations in the reported numbers of maternal deaths and consequently affect maternal mortality rates. Differences in classification of death must be taken into account when comparing maternal mortality rates, as well as differences in obstetric care, underreporting of maternal deaths and other factors such as the age distribution of mothers.     

Every death counts: measurement of maternal mortality via a census

Methods for measuring maternal mortality at national and subnational levels in the developing world lag far behind the demand for estimates. We evaluated use of the national population census as a means of measuring maternal mortality by assessing data from five countries (Benin, Islamic Republic of Iran, Lao People's Democratic Republic, Madagascar, and Zimbabwe) which identified maternal deaths in their censuses. Standard demographic methods were used to evaluate the completeness of reporting of adult female deaths and births in the year prior to the census. The results from these exercises were used to adjust the data. In four countries, the numbers of adult female deaths needed to be increased and three countries required upward adjustment of the numbers of recent births. The number of maternal deaths was increased by the same factor as that used for adult female deaths on the assumption that the proportion of adult female deaths due to maternal causes was correct. Age patterns of the various maternal mortality indicators were plausible and consistent with external sources of data for other populations. Our data suggest that under favourable conditions a national census is a feasible and promising approach for the measurement of maternal mortality. Moreover, use of the census circumvents several of the weaknesses of methods currently in use. However, it should also be noted that careful evaluation of the data and adjustment, if necessary, are essential. The public health community is urged to encourage governments to learn from the experience of these five countries and to place maternal mortality estimation in the hands of statistical agencies.     

Maternal death: unequal risks

Nearly 99% of maternal deaths in the world each year occur in developing countries. New efforts have recently been undertaken to combat maternal mortality through research and action. The medical causes of such deaths are coming to be better understood, but the social mechanisms remain poorly grasped. Maternal mortality rates in developing countries are difficult to interpret because they tend to exclude all deaths not occurring in health care facilities. The countries of Europe and North America have an average maternal mortality rate of 30/100,000 live births, representing about 6000 deaths each year. The developing countries of Asia, Africa, and Latin America have rates of 270-640/100,000, representing some 492,000 deaths annually. For a true comparison of the risks of maternal mortality in different countries, the risk itself and the average number of children per woman must both be considered. A Nigerian woman has 375 times greater risk of maternal death than a Swedish woman, but since she has about 4 times more children, her lifetime risk of maternal death is over 1500 times greater than that of the Swedish woman. The principal medical causes of maternal death are known: hemorrhages due to placenta previa or retroplacental hematoma, mechanical dystocias responsible for uterine rupture, toxemia with eclampsia, septicemia, and malaria. The exact weight of abortion in maternal mortality is not known but is probably large. The possible measures for improving such rates are of 3 types: control of fertility to avoid early, late, or closely spaced pregnancies; effective medical surveillance of the pregnancy to reduce the risk of malaria, toxemia, and hemorrhage, and delivery in an obstetrical facility, especially for high-risk pregnancies. Differential access to high quality health care explains much of the difference between mortality rates in urban and rural, wealthy and impoverished areas of the same country. The social determinants of high maternal mortality rates include political, geographic, and economic mechanisms of exclusion which affect the vast majority of the population in developing countries. Political power is concentrated in the hands of relatively small groups whose decisions about such expenditures as health care are usually more favorable to the privileged. A consequence of the very unequal regional development in most Third World countries is that health, educational, and most other resources are concentrated in large cities and perhaps 1 or 2 strategic regions, leaving most of the population underserved. The low social position of women leaves them doubly vulnerable. The social factors adding to risks of maternal mortality should be considered in programs of prevention if the causes and not just the consequences are to be addressed.     

Abortion policy and women's health in developing countries

The World Health Organization estimates that almost half a million women in developing countries die in pregnancy and childbirth every year. Unsafe induced abortion is responsible for perhaps one-quarter of these deaths. In this article, the author reviews the legal, medical, and social contexts in which women in developing countries resort to clandestine abortion. Despite intensified international concern with reducing high rates of maternal mortality and morbidity, national policy makers and participants at international conferences on maternal health--with a few important exceptions--have not recommended that safe, legal services for terminating unwanted pregnancies be offered as an essential element of basic reproductive health care. United States international policy on funding abortion-related activities in maternal health and family planning programs is especially restrictive. A new policy approach is clearly needed if unacceptably high rates of maternal morbidity and mortality in many countries are to be reduced.     

Health for all: the dream and the reality

What has become clear in the 10 years since Alma-Ata is the global split between the health of the "haves" and the "have nots". This split is not a clean one and there are a number of countries spread out along the line from poorest to richest. Many of these countries are progressing along this line at a speed measurable with familiar indicators: increases in per capita income and literacy, decreases in maternal and under-5s mortality rates. Progress is uneven: 64 countries (40% of the world's population) experience more than 80% of the world's under-5s deaths and more than 90% of the maternal mortality. Although under-5s mortality is projected to be much lower by the year 2000, Africa and southern Asia are predicted to have unacceptably high rates of 100 deaths/1000 live births. Even though solutions are available to fundamental health problems, the progress has been slow. In the industrial countries an important step has been the creation of a European region-wide strategy for health for all. In 1980 the 33 European Member States of WHO set 38 targets and designated 65 indicators for systematic and routine monitoring by countries. An evaluation in 1985 revealed that European members had made strong efforts to monitor progress and a number of countries had formulated national strategies in line with the regional one. Canada and the US have also taken steps in adopting national strategies: Canada has made strides in organization of health services, the US in recognizing the inequities in the availability of health services to low income populations. In developing countries a few countries have made significant progress beyond what had been expected, especially Costa Rica, Sri Lanka, and Kerala State in India as measured in reduced infant mortality rates. An analysis by Caldwell showed that these countries had a number of conditions in common: reasonable level of female education and female autonomy, a politically active community, and easy access to health services promoting maternal and child care, immunization, family planning, home visits and food availability. The poorest countries have lacked these conditions and their progress has been slow and painful.     

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.     

The magnitude of the maternal mortality problem in sub-Saharan Africa

Estimates of national levels of maternal mortality in sub-Saharan Africa are based on limited and defective data and subject to considerable discussion. In this paper, existing data from several sources are reviewed. The attempt has been made to assess the level of maternal mortality by studying the relative importance of maternal death, health services coverage data, perinatal mortality, causes of maternal death and traditional birth practices. It is concluded that national levels of maternal mortality in sub-Saharan Africa most likely vary from 250 to 700 per 100,000 live births, in proportion to the variation in overall levels of mortality in the countries. There is a need for more studies either based on data from peripheral hospitals or on community surveys. Such studies should analyse coverage of deliveries, coverage of maternal deaths, causes of maternal deaths, socioeconomic differentials, perinatal mortality and should pay special attention to the increasing problem of abortion-related mortality.     

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.     

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.     

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.     

The likely increase in maternal mortality rates in the United Kingdom and in France until 2005

Summary. In the UK, the decline in maternal mortality rates has stopped. In France, where they are higher than in most European countries, maternal mortality rates have been increasing since 1990. Based on the population projections published by Eurostat, maternal mortality predictions have been made for 1995, 2000, 2005 and 2010. A rise in the level of maternal mortality rates of more than 0.5 per 100000 livebirths is expected between now and 2005, in both countries. In the present context of near stability, this rise could be viewed as an important increase. Maternal mortality rises with maternal age and the proportion of births to women over thirty is growing and will continue to rise until 2000–2005. This structural and demographic evolution explains the expected rise of maternal mortality rates and shows how the change in the maternal age distribution of births will affect these rates.     

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。     

How should we measure maternal mortality in the developing world? A comparison of household deaths and sibling history approaches.

OBJECTIVE: A reduction in the maternal mortality ratio (MMR) is one of six health-related Millennium Development Goals (MDGs). However, there is no consensus about how to measure MMR in the many countries that do not have complete registration of deaths and accurate ascertainment of cause of death. In this study, we compared estimates of pregnancy-related deaths and maternal mortality in a developing country from three different household survey measurement approaches: a module collecting information on deaths of respondents' sisters; collection of information about recent household deaths with a time-of-death definition of maternal deaths; and a verbal autopsy instrument to identify maternal deaths. METHODS: We used data from a very large nationally-representative household sample survey conducted in Bangladesh in 2001. A total of 104 323 households were selected for participation, and 99 202 households (95.1% of selected households, 98.8% of contacted households) were successfully interviewed. FINDINGS: The sisterhood and household death approaches gave very similar estimates of all-cause and pregnancy-related mortality; verbal autopsy gave an estimate of maternal deaths that was about 15% lower than the pregnancy-related deaths. Even with a very large sample size, however, confidence intervals around mortality estimates were similar for all approaches and exceeded +/- 15%. CONCLUSION: Our findings suggest that with improved training for survey data collectors, both the sisterhood and household deaths methods are viable approaches for measuring pregnancy-related mortality. However, wide confidence intervals around the estimates indicate that routine sample surveys cannot provide the information needed to monitor progress towards the MDG target. Other approaches, such as inclusion of questions about household deaths in population censuses, should be considered.     

Pregnancy-related mortality in Guatemala, 1993-1996.

To select the proper interventions that could prevent maternal mortality, adequate and appropriate maternal mortality data are needed. Nevertheless, the quality and quantity of information and the scope of maternal health- and death-related data are inadequate in many countries, particularly in the developing world. From January 1993 to December 1996 a surveillance program in maternal mortality was developed to conduct surveillance studies in the department of Guatemala, Guatemala. With an active surveillance system, our approach gave a more complete picture of maternal death and produced information on the specific causes of maternal mortality. Using multiple sources of information, we reviewed and analyzed all deaths of women of childbearing age (10 to 49 years). Each death was investigated to determine whether it was pregnancy-related or not. The maternal mortality ratio for the four-year study period was 156.2 deaths per 100,000 live births. Women 35 and older had a higher risk of maternal death than women under that age. Women who were 35-39 years old had a maternal death risk almost three times as high as women aged 20-24. For women who were 40 or older the risk was more than double that of women 20-24 years old. Overall, the two leading causes of maternal mortality were infection and hemorrhage. Vaginal deliveries where there was medical assistance had the highest rate of delivery-related maternal death from general infection. In deliveries attended by nonmedical personnel, delivery-related maternal deaths from hemorrhage were most frequently associated with retained placenta. Developing countries are called on to implement systems that can provide continuous and systematic data collection so that policymakers and health managers have adequate information to design proper interventions to save women's lives.     

The Safe Motherhood Initiative: a call for action

An official call for action was issued at the end of the conference on Safe Motherhood held in Nairobi, Kenya, in February 1987. The conference was organized to draw attention to the half million maternal deaths that occur each year. Women in developing countries run 50-100 times the risk of dying in pregnancy or childbirth than their counterparts in developed countries. There are only 2.9 maternal deaths/100,000 live births in developing countries compared to 300-1000 maternal deaths/100,000 live births in developing countries. Illegal abortion from unwanted pregnancies accounts for 25-50% of these deaths. The causes of maternal mortality are rooted in the adverse social, cultural, economic, and political environment women face in the Third World. These causes must be addressed if women's health and status are to be improved in the long term. On the other hand, there is an immediate need for low-cost, effective interventions that can have a major impact on reducing mortality and morbidity from obstructed labor, hemorrhage, toxemia, infection, and complications of abortion. A political commitment must be generated to reallocate resources so that maternal mortality can be reduced by 50% in 1 decade. Needed is an integrated approach to maternal health care that makes it a priority within the context of primary health care services and overall development policy. Women need to be involved in planning and implementing programs and policies to ensure that their needs and preferences are taken in account. In addition, family planning and family life education programs need to be expanded and made socially, culturally, financially, and geographically accessible. These activities need to involve both governments and take advantage of the flexibility, responsiveness, and creativity of nongovernmental organizations.     

Traffic-related mortality in industrialized and less developed countries.

Road traffic-related mortality has traditionally been regarded as a problem primarily of industrialized countries. There is, however, growing evidence of a strong negative relationship between economic development and exposure-adjusted traffic-related death rates. Cross-sectional data on road traffic-related deaths in 1990 were obtained from 83 countries. The relationship between such mortality and a number of independent variables was examined at the individual country level by means of multiple regression techniques. These were also used to elucidate factors associated with variations in age, sex, and case-fatality patterns of road traffic mortality. Countries were grouped according to region and socioeconomic features, and the mortality data were summarized by these groups. The gross national product per capita was positively correlated with traffic-related mortality/100,000 population/year (P = 0.01), but negatively correlated with traffic deaths/1000 registered vehicles (P < 0.0001). Increasing population density was associated with a proportionately greater number of traffic-related deaths in the young and the elderly (P = 0.036). Increasing GNP per capita and increased proportional spending on health care were associated with decreasing case-fatality rates among traffic-accident victims (P = 0.02 and 0.017, respectively). Middle-income countries appear to have, on average, the largest road-traffic mortality burden. After adjusting for motor vehicle numbers, however, the poorest countries show the highest road traffic-related mortality rates. Many industrialized countries would appear to have introduced interventions that reduce the incidence of road traffic injury, and improve the survival of those injured. A major public health challenge is to utilize this experience to avoid the predicted increase in traffic-related mortality in less developed countries.     

First do no harm: the impact of recent armed conflict on maternal and child health in Sub-Saharan Africa

OBJECTIVES: To compare the rates of under-5 mortality, malnutrition, maternal mortality and other factors which influence health in countries with and without recent conflict. To compare central government expenditure on defence, education and health in countries with and without recent conflict. To summarize the amount spent on SALW and the main legal suppliers to countries in Sub-Saharan African countries (SSA), and to summarize licensed production of Small Arms and Light Weapons (SALW) in these countries. DESIGN: We compared the under-5 mortality rate in 2004 and the adjusted maternal mortality ratio in SSA which have and have not experienced recent armed conflict (post-1990). We also compared the percentage of children who are underweight in both sets of countries, and expenditure on defence, health and education. SETTING: Demographic data and central government expenditure details (1994-2004) were taken from UNICEF's The State of the World's Children 2006 report. MAIN OUTCOME MEASURES: Under-5 mortality, adjusted maternal mortality, and government expenditure. RESULTS: 21 countries have and 21 countries have not experienced recent conflict in this dataset of 42 countries in SSA. Median under-5 mortality in countries with recent conflict is 197/1000 live births, versus 137/1000 live births in countries without recent conflict. In countries which have experienced recent conflict, a median of 27% of under-5s were moderately underweight, versus 22% in countries without recent conflict. The median adjusted maternal mortality in countries with recent conflict was 1000/100,000 births versus 690/100,000 births in countries without recent conflict. Median reported maternal mortality ratio is also significantly higher in countries with recent conflict. Expenditure on health and education is significantly lower and expenditure on defence significantly higher if there has been recent conflict. CONCLUSIONS: There appears to be an association between recent conflict and higher rates of under-5 mortality, malnutrition and maternal mortality. Governments spend more on defence and less on health and education if there has been a recent conflict. SALW are the main weapon used and France and the UK appear to be the two main suppliers of SALW to SSA.     

Mediational pathways connecting secondary education and age at marriage to maternal mortality: A comparison between developing and developed countries

While studies have shown that maternal mortality rates have been improving worldwide, rates are still high across developing nations. In general, poor health of women is associated with higher maternal mortality rates in developing countries. Understanding country-level risk factors can inform intervention and prevention efforts that could bring high maternal mortality rates down. Specifically, the authors were interested in investigating whether: (1) secondary education participation (SEP) or age at marriage (AM) of women were related to maternal mortality rates, and (2) adolescent birth rate and contraceptive use (CU) acted as mediators of this association. The authors add to the literature with this current article by showing the relation of SEP and AM to maternal mortality rates globally (both directly and indirectly through mediators) and then by comparing differences between developed and developing/least developed countries. Path analysis was used to test the hypothesized model using country level longitudinal data from 2000 to 2010 obtained from United Nations publications, World Health Organization materials, and World Bank development reports. Findings include a significant correlation between SEP and AM for developing countries; for developed countries the relation was not significant. As well, SEP in developing countries was associated with increased CU. Women in developing countries who finish school before marriage may have important social capital gains.     

Maternal mortality among the Kassena-Nankana of northern Ghana

This report presents key findings from a maternal mortality study conducted in the Kassena-Nankana District of northern Ghana in 1997-98. Sibling history data collected in the course of this survey are analyzed together with longitudinal data from the Navrongo Demographic Surveillance System (NDSS). A comparison between mortality data from these two sources indicates that obtaining reasonably accurate estimates of age-specific death rates is possible by using the sisterhood method. Direct and indirect estimates from the maternal mortality study and the NDSS suggest a decline in the maternal mortality ratio for the Kassena-Nankana District from 800 to 600 maternal deaths per 100,000 live births over the past 14 years.