Abortion and Maternal Mortality Ratio

New modelled estimates of maternal mortality

Nigeria has the 47th highest gross domestic product (GDP) worldwide and is the world’s 8th largest exporter of petroleum. It has a maternal mortality ratio (MMR) of 800/100 000 live births. In contrast, Sri Lanka is 78th on the GDP list but has an MMR of only 92. Among the wealthy countries, Sweden has the 20th highest GDP and a MMR of 2, while USA, despite being the richest country in the world, has a MMR of 17.1,2 If we are to reduce maternal mortality worldwide, it is crucial that we understand the reasons for the wide variation in MMRs. One would expect that the MMR would correlate with the prevalence of major complications of pregnancy, but such complications occur in a remarkably constant 15% or so of pregnancies throughout the world. Nor does the MMR correlate well with a country’s wealth as the examples above show. What is, however, highly predictive of a country’s MMR is the quality of its health services. Comparing each country’s MMR and healthcare quality (as defined in the World Health Organization World Health Report of 2000) shows the two to be closely correlated (Figure 1).2,3 ‘Quality of health care’ is used here in its holistic sense—not just as a measure of the best the country can provide in its large teaching hospitals and private clinics but how effectively good quality health care reaches the country’s poorest in rural areas well away from the capital. It also takes into account the health services’ effect on the nation’s health, the way the health workers treat individuals on a personal level (as regards dignity, confidentiality and client orientation) and the fairness of financial contributions. The UK provides a classic example of the importance of the effect of a good quality health service on maternal mortality rates. It is no coincidence that the major fall in its MMR coincided with the launch of the NHS in the 1940s which provided free care for all at the point of delivery.4 The quality of maternity care also improved greatly at this time as blood transfusions and antibiotics became available. The NHS made these advances available to the many and not just the privileged few. Conversely, the recent crisis at Northwick Park Hospital in London shows how quickly maternal mortality rates can rise if the quality of maternal care deteriorates.5 The impressive second report on the South African Confidential Enquiries into Maternal Deaths emphasises the pivotal role of health services in reducing MMRs.6 Of their ten key recommendations, all but one relates to improvements in the health services rather than introducing new procedures or therapies. They recommend speeding up access to services (better ambulance services and referral systems), service development (better contraceptive/abortion services and improved antenatal screening) and improved quality of care (written protocols, optimising levels of staff and equipment, blood transfusion, partogram use and effective anaesthetic services). The one recommendation that is not directly health service related is the final one that calls for the empowerment of women. If tuberculosis is the disease of poor housing, and gonorrhoea a ‘social disease’, then surely maternal mortality is the classic example of a disease of poor health services. For those of us trying to reduce maternal mortality from a medical perspective, we will be unable to achieve fundamental change without a massive improvement in health services in those areas of the world that are currently poorly served. Indeed, as exemplified in the title of the BJOG 2005 supplement on the developing world, much of the research on DOI: 10.1111/j.1471-0528.2006.01185.x www.blackwellpublishing.com/bjog Editorial

Aims: To determine prevalence, causes and factors leading to severe acute maternal morbidity and mortality during COVID 19 pandemic.
 Methods: The was a cross sectional observational study conducted in the department of Obstetrics and Gynaecology of Manipal teaching hospital from March 2020 to February 2022 amid COVID 19 pandemic. Women who sustained severe acute maternal morbidity (according to World health organization organ system criteria) and maternal deaths during pregnancy, labour and six weeks postpartum were included. Maternal characteristics, total live births, pregnancy outcome, causes and factors leading to morbidity and mortality were noted. The acquisitioned data was analyzed using Statistical Package for Social Sciences version 21.
 Results: There were 37 cases of severe acute maternal morbidity and 2 cases of maternal deaths. The severe acute maternal morbidity ratio was 9.4 per 1000 live births and maternal mortality ratio was 51 per 100,000 live births. Therefore, severe acute maternal morbidity mortality ratio was 18.5:1 and mortality index 5.1%. Haematological and coagulation system (45.9%) and neurological system (29.7%) were the common organ systems involved. Hypertensive disorders (40.5%) and haemorrhage (32.4%) were the main causes of severe acute morbidity. Both maternal deaths occurred due to eclampsia. There was no severe acute maternal morbidity or mortality due to COVID infection in pregnancy. Delay in seeking and reaching to the health centre (65%) was major delay leading to severe morbidity and mortality.
 Conclusions: Indices and causes of severe acute maternal morbidity and mortality during COVID 19 pandemic was not worse compared to those prior to COVID 19 pandemic. Primary delay in seeking and reaching health care was the main factor leading to severe morbidity and mortality.

BackgroundMaternal mortality ratio is an important indicator to evaluate the health status in developing countries. Previous studies on maternal mortality ratio in China were limited to certain areas or short periods of time, and there was a lack of research on correlations with public health funding. This study aimed to assess the trends in the maternal mortality ratio, the causes of maternal death, and the correlations between maternal mortality ratio and total health financing composition in China from 1990 to 2019.MethodsData in this longitudinal study were collected from the China Health Statistics Yearbooks (1991–2020) and China Statistical Yearbook 2020. Linear regression analysis was used to assess the trends in the maternal mortality ratio in China. Pearson correlation analysis was used to assess the correlations between national maternal mortality ratio and total health financing composition.ResultsThe yearly trends of the national, rural and urban maternal mortality ratio were − 2.290 (p < 0.01), − 3.167 (p < 0.01), and − 0.901 (p < 0.01), respectively. The gap in maternal mortality ratio between urban and rural areas has narrowed. Obstetric hemorrhage was the leading cause of maternal death. The mortalities ratios for the main causes of maternal death all decreased in China from 1990 to 2019. The hospital delivery rate in China increased, with almost all pregnant women giving birth in hospitals in 2019. Government health expenditure as a proportion of total health expenditure was negatively correlated with the maternal mortality ratio (r = − 0.667, p < 0.01), and out-of-pocket health expenditure as a proportion of total health expenditure was positively correlated with the maternal mortality ratio (r = 0.516, p < 0.01).ConclusionChina has made remarkable progress in improving maternal survival, especially in rural areas. The maternal mortality ratio in China showed a downward trend over time. To further reduce the maternal mortality ratio, China should take effective measures to prevent obstetric hemorrhage, increase the quality of obstetric care, improve the efficiency and fairness of the government health funding, reduce income inequality, and strengthen the medical security system.

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Analysis of maternal mortality in the Slovak Republic in the years 2007-2018. The analysis of selected maternal mortality data in the years 2007-2018. In the years 2007-2018, 84 women died during pregnancy or within 42 days of the end of pregnancy - maternal mortality ratio was 12.57 per 100,000 live births. Direct maternal mortality ratio in this period was 4.64 (31 maternal deaths), indirect maternal mortality 6.74 (45 maternal deaths) and direct obstetrics death ratio was 11.38 per 100,000 live births. Pregnancy-associated but unrelated maternal death ratio was 1.19 (eight maternal deaths). The Slovak Gynecological and Obstetric Society revealed a 64% underestimation of maternal mortality data in comparison with routine statistical data. Maternal mortality ratio in the Slovak Republic was one of the highest in the European Union and was discordant with a good level of perinatal mortality. In the Slovak Republic, it is necessary to look for ways to reduce maternal mortality and improve data collection.

BackgroundMaternal and infant mortality are highly devastating, yet, in many cases, preventable events for a community. The human development of a country is a strong predictor of maternal and infant mortality, reflecting the importance of socioeconomic factors in determinants of health. Previous research has shown that the Human Development Index (HDI) predicts infant mortality rate (IMR) and the maternal mortality ratio (MMR). Inequality has also been shown to be associated with worse health in certain populations. The main purpose of the present study was to determine the correlation and predictive power of the Inequality Adjusted Human Development Index (IHDI) as a measure of inequality with the Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR), Early Neonatal Mortality Rate (ENMR), Late Neonatal Mortality Rate (LNMR), and the Post Neonatal Mortality Rate (PNMR).Methods and FindingsData for the present study were downloaded from two sources: infant and maternal mortality data were downloaded from the Global Burden of Disease 2013 Cause of Death Database and the Human Development Index (HDI) and Inequality-Adjusted Human Development Index (IHDI) data were downloaded from the United Nations Development Program (UNDP). Pearson correlation coefficients were estimated, following logarithmic transformations to the data, to examine the relationship between HDI and IHDI with MMR, IMR, ENMR, LNMR, and PNMR. Steiger’s Z test for the equality of two dependent correlations was utilized in order to determine whether the HDI or IHDI was more strongly associated with the outcome variables. Lastly, we constructed OLS regression models in order to determine the predictive power of the HDI and IHDI in terms of the MMR, IMR, ENMR, LNMR, and PNMR.Maternal and infant mortality were both strongly and negatively correlated with both HDI and IHDI; however, Steiger’s Z test for the equality of two dependent correlations revealed that IHDI was more strongly correlated than HDI with MMR (Z = 4.897, p < 0.001), IMR (Z = 2.524, p = 0.012), ENMR (Z = 2.936, p = 0.003), LNMR (Z = 2.272, p = 0.023), and PNMR (Z = 2.277, p = 0.023). Furthermore, side-by-side OLS regression models revealed that, when IHDI was used as the predictor variable instead of HDI, the R2 value was 0.053 higher for MMR, 0.025 higher for IMR, 0.038 higher for ENMR, 0.029 higher for LNMR, and 0.026 higher for PNMR.ConclusionsEven when both the HDI and the IHDI correlate with the infant and maternal mortality rates, the IHDI is a better predictor for these two health indicators. Therefore, these results add more evidence that inequality is playing an important role in determining the health status of various populations in the world and more efforts should be put into programs to fight inequality.

Trends in maternal mortality in Suriname: 3 confidential enquiries in 3 decades

To analyze time trend and regional disparities in maternal mortality ratio (MMR) and major causes of maternal death in China from 1996 to 2010. Data used in this study were based on national maternal mortality surveillance system. From 1996 to 2005, it included 176 monitoring districts (countries) in 31 provinces, autonomous regions and municipalities in the inner land. From 2006 to the present, it covered 336 districts (countries). MMR, major causes of maternal death and their reduction margin, average annual reduction rate in different times and regions from 1996 to 2010 were analyzed. The trend and regional differences in MMRs and major causes of mortality were analyzed using Cochran-Armitage trend and Poisson Test. From 1996 to 2010, Chinese MMR has decreased by 53.2% from 64.7 in 1996 to 30.0 per 100 000 live births in 2010. MMR was higher in rural areas (30.1/100 000) than in urban areas (29.7/100 000), and highest in the west region (46.1/100 000) followed by the middle region (29.1/100 000) and the east region (17.8/100 000) in 2010. MMR in east, middle and west regions have decreased by 37.76%, 57.02% and 66.27% respectively from 1996 to 2010. The disparities between different regions were decreasing. From 2006 to 2010, MMR in rural areas has dropped to 1.82 times of the city, and that in the west was 3 times of the east. Obstetric hemorrhage was still the leading cause of maternal death, responsible for 47.9% maternal deaths in 1996 and 27.8% in 2010. The risk of death due to obstetric hemorrhage was decreasing. The MMR in China showed the decreasing trends. Although the regional disparities were still remarkable, they demonstrated narrowing trends. Interventions on maternal death should be focused in rural areas and west regions.

This study characterises maternal mortality in southern Brazil and verifies its trends between 2000 and 2018. It is an ecological time-series study, analysing secondary data from the Department of Informatics of the Unified Health System. The trend of the maternal mortality ratio (MMR) was calculated using generalised linear regression, and the ratios of the rates according to women's characteristics, with a confidence interval (CI) of 95%. The MMR in the South region went from 53.4 to 36.8 deaths per 100,000 live births from 2000 to 2018, a reduction trend of 1.2 percentage points per year. Mortality was directly related to increasing age (p < .001) and inversely related to schooling (p < .001) and predominated in non-white women (p < .001). The main cause of death was direct causes, including hypertensive disorders. Despite the reduction trend in maternal mortality in southern Brazil, the MMR observed is constantly above the recommended by the World Health Organisation. Impact Statement What is already known on this subject? The Maternal Mortality Ratio (MMR) is an indicator that allows an analysis of women's health in relation to the socio-economic and care characteristics of the region where they live. Between 2000 and 2015, Brazil had presented a high MMR, with around 50 deaths per 100,000 live births, while WHO considers a reasonably adequate MMR of fewer than 20 deaths per 100,000 live births. What do the results of this study add? This study updates data about MMR in the Southern Region of Brazil, the one which has the lowest rates in the country, but with variable values between the states. There was a reduction in MMR in southern Brazil between 2000 and 2018 but higher rates for women over 30 years old and in a situation of social vulnerability, as low-income and non-white women. Santa Catarina State presented stable values in the period and remained below the RMM averages of the other states during all years. What are the implications of these findings for clinical practice and/or further research? Comparing previous and current Maternal Mortality Rates in the regional context is important to adapt public health policies for the most affected population. Maternal death is still a reality for single and low-income women, who have greater difficulty in access to health care. Strategies in the Unified Health System are needed to tackle this problem.

Unsafe Abortion: Global and Regional Incidence, Trends, Consequences, and Challenges

BackgroundAlthough the Philippines launched its Maternal, Neonatal, and Child Health and Nutrition strategy in 2008 to reduce maternal mortality, its impact on maternal health services (MHS) utilization and maternal mortality ratio (MMR) remains unclear. This study examines MHS utilization trends and their association with MMR across the Philippines from 2010 to 2019.MethodsWe conducted an ecological study using panel data in the Philippines during 2010–2019. Secondary analyses took place on datasets from the Department of Health and the Philippine Statistics Authority. Multivariate analyses were performed to investigate the association between MHS utilization and MMR.ResultsFrom 2010 to 2019, national mean MMR declined from 74.85 to 57.19 deaths per 100 000 live births. Facility-based deliveries increased by 39.57% and births attended by medical doctors by 19.01%. Results from fixed-effects models revealed no significant association between MHS utilization and change in MMR over the 10-y period. However, utilization of antenatal care in Luzon (β=−1.528, p=0.005) and postpartum care in Mindanao (β=−1.604, p=0.020) was attributable to MMR reduction in 2019.ConclusionsWhile a national decline in MMR was observed from 2010 to 2019, significant regional disparities in MMR existed. The impact of MHS utilization varied over time and location.

BackgroundSeveral studies concluded that there is a reduction of maternal deaths with improved access to caesarean section, while other studies showed the existence of a direct association between the two variables. In Ethiopia, literature about the association between maternal mortality and caesarean section is scarce. This study was aimed to assess the association between maternal mortality ratios and caesarean section rates in hospitals in Ethiopia.MethodsAnalysis was done of a national maternal health dataset of 293 hospitals that accessed from the Ethiopian Public Health Institute. Hospital specific characteristics, maternal mortality ratios and caesarean section rates were described. Pearson’s correlation coefficient was used to determine the direction of association between maternal mortality ratios and caesarean section rate, taking regions into consideration. Presence of a linear association between these variables was declared statistically significant at p-value < 0.05.ResultsThe overall maternal mortality ratio in Ethiopian hospitals was 149 (95% CI: 136–162) per 100,000 livebirths. There was significant regional variation in maternal mortality ratios, ranging from 74 (95% CI: 51–104) per 100,000 livebirths in Tigray region to 548 (95% CI: 251-1,037) in Afar region. The average annual caesarean section rate in hospitals was 20.3% (95% CI: 20.2–20.5). The highest caesarean section rate of 38.5% (95% CI: 38.1–38.9) was observed in Addis Ababa, while the lowest rate of 5.7% (95% CI: 5.2–6.2) occurred in Somali region. At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates. Similarly, unlike in other regions, there were inverse associations between maternal mortality ratios and caesarean section rates in Addis Ababa, Afar Oromia and Somali, although associations were not statistically significant.ConclusionsAt national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates in hospitals, although there were regional variations. Additional studies with a stronger design should be conducted to assess the association between population-based maternal mortality ratios and caesarean section rates.

Maternal mortality ratio (MMR) is one of the important indicators for assessing the health status of pregnant women and socioeconomic development. With the development of economy and health status of pregnant women, MMR has continuously decreased especially in developed countries where maternal death is rare. Only using the available information from maternal death or MMR can no longer comprehensively evaluate the quality of maternal health care and the development of women′s health care. Additionally, it is difficult to provide adequate and effective information to improve maternal health policies because of a small number of maternal deaths. Maternal near miss management as an early indicator to describe the dynamic process of maternal death, has great significance for strengthening the dynamic management of maternal deaths and reducing MMR. In order to strengthen the emergency management system of maternal near miss, we review the global management and rescue status of maternal near miss and sum up the experience, to effectively improve the efficiency and quality of maternal rescue, and to reduce the MMR. Key words: Maternal mortality; Maternal near miss morbidity; Management; Prevention; Maternal near miss

BackgroundThe maternal mortality ratio (MMR) is an important indicator of maternal health and socioeconomic development. Although China has experienced a large decline in MMR, substantial disparities across regions are still apparent. This study aims to explore causes of socioeconomic related inequality in MMR at the province-level in China from 2004 to 2016.MethodsWe collected data from various issues of the China Health Statistics Yearbook, China Statistics Yearbook, and China Population and Employment Statistics Yearbook to construct a longitudinal sample of all provinces in China. We first examined determinants of the MMR using province fixed-effect models, accounted for socioeconomic condition, health resource allocation, and access to health care. We then used the concentration index (CI) to measure MMR inequality and employed the direct decomposition method to estimate the marginal impact of the determinants on the inequality index. Importance of the determinants were compared based on logworth values.ResultsDuring our study period, economically more deprived provinces experienced higher MMR than better-off ones. There was no evidence of improved socioeconomic related inequality in MMR. Illiteracy proportion was positively associated with the MMR (p < 0.01). In contrast, prenatal check-up rate (p = 0.05), hospital delivery rate (p < 0.01) and rate of delivery attended by professionals (p = 0.02) were negatively associated with the MMR. We also find that higher maternal health profile creation rate (p < 0.01) was associated with a pro-poor change of MMR inequality.ConclusionAccess to healthcare was the most important factor in explaining the persistent MMR inequality in China, followed by socioeconomic condition. We do not find evidence that health resource allocation was a contributing factor.