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Since the 1990s developing countries as a whole have made remarkable efforts to reduce under-five mortality rate from 90 to 48 deaths per thousand live births in 2012. As a result the number of annual under-five deaths dropped by nearly 6 million during that period. Unfortunately the pace of reduction was slowest in sub-Saharan Africa making it impossible that the region will reach the target for the Millennium Development Goals (MDGs) 4 but a few countries including some of the poorest such as Ethiopia Liberia Malawi and Niger have already met the MDG 4 target or are making progress that are consistent with the target. At the same time global maternal deaths have been nearly halved since the 1990s from 380 deaths per 100000 live births to 210 in 2013. In sub-Saharan Africa and South Asia the two regions where more than 85% of all maternal deaths occur the maternal mortality ratio (MMR) dropped from 990 to 510 and from 530 to 190 respectively. Skilled birth attendance (SBA) one of the proximate determinants of maternal mortality increased only modestly during the period 1990-2012 from 40% to 53% in sub-Saharan Africa and from 33% to 51% in South Asia. As with most health indicators there are wide variations in the coverage of SBA from 20% or less in Ethiopia and Niger to more than 80% in countries including Benin Namibia and Botswana. Most maternal newborn and child deaths result from causes that can be adequately treated by a package of well-known interventions. One of the main challenges in delivering essential and life-saving interventions to avert these deaths is the shortage of a well-trained supervised and motivated health workforce. With the vast amount of evidence showing that increased availability of skilled health workers is directly linked to improved maternal newborn and child health (MNCH) outcomes health workforce development is increasingly seen as a critical component of MNCH care delivery. (Excerpt)

Indonesia makes maternal health a national priority

Roots of Iraq's maternal and child health crisis run deep

New modelled estimates of maternal mortality

The emergency obstetric care (EmOC) monitoring framework has been used for decades to monitor the availability and use of EmOC services in low- and middle-income countries (LMICs). EmOC monitoring is based around eight signal functions, a shortlist of key clinical interventions capable of averting deaths from the main direct causes of maternal mortality, categorised between two levels of care: basic and comprehensive, with a newborn resuscitation signal function added in 2009. The Re-Visioning Emergency Obstetric and Newborn Care (EmONC) Project (2020–2024) aimed to update the EmOC approach to reflect new knowledge in maternal and newborn health (MNH), and to expand the scope of the original EmOC monitoring framework. The project used technical workstreams and workshops to arrive at new proposals. This paper reports on the approach used to build consensus on a revised set of EmONC signal functions and levels of care. Using a three-round online Delphi approach, consensus (≥85%) was sought from a diverse panel of global MNH experts on EmONC signal functions and their placement at different levels of care, based on existing evidence-based guidelines. The process was iterative, each round building on the previous, and embedded in the wider Re-Visioning EmONC project; the output from each round involved coordination of inputs from multiple tiers of technical experts, including UN agencies, via technical expert groups, workstreams and workshops. The Delphi study recruited 113 experts in MNH from a range of geographic and economic settings, specialities and professions, including clinical, academic and programme expertise. The output from the three rounds included substantial convergence, resulting in set of 25 signal functions (11 obstetric, 13 neonatal and 1 referral) that reflect the spectrum of EmONC required for women and newborns. The revised EmONC signal functions are intended as a simple approach to allow health system managers to visualise their EmONC services, and as a means to hold health systems accountable to provide the main interventions to avert preventable maternal and newborn morbidity and mortality, and stillbirths.

Women’s health—what’s new world wide

BackgroundDespite considerable efforts to reduce the maternal mortality ratio, numerous pregnant women continue to die in many developing countries, including Nigeria. We conducted a study to determine the incidence and causes of maternal mortality over an 8-month period in a rural-based secondary health facility located in Jahun, northern Nigeria.MethodsA retrospective observational study was performed in a 41-bed obstetric ward. From October 2010 to May 2011, demographic data, obstetric characteristics, and outcome were collected from all pregnant women admitted. The total number of live births during the study period was recorded in order to calculate the maternal mortality ratio.ResultsThere were 2,177 deliveries and 39 maternal deaths during the study period, with a maternal mortality ratio of 1,791/100,000 live births. The most common causes of maternal mortality were hemorrhage (26%), puerperal sepsis (19%), and obstructed labor (5%). No significant difference (P = 0.07) in mean time to reach the hospital was noted between fatal cases (1.9 hours, 95% confidence interval [CI] 1.1–2.6) and nonfatal cases (1.4 hours, 95% CI 1.4–1.5). Two hundred and sixty-six women were admitted presenting with stillbirth. Maternal mortality was higher for unbooked patients than for booked patients (odds ratio 5.1, 95% CI 3.5–6.2, P < 0.0001). The neonatal mortality rate was calculated at 46/1,000 live births. The main primary causes of neonatal deaths were prematurity (44%) and birth asphyxia (22%).ConclusionMaternal and neonatal mortality remains unacceptably high in this setting. Reducing unbooked emergencies should be a priority with continuous programs including orthodox practices in order to meet the fifth Millennium Development Goal.

BackgroundMaternal mortality has declined significantly since 1990. While better access to emergency obstetrical care is partially responsible, women’s empowerment might also be a contributing factor. Gender equality composite measures generally include various dimensions of women’s advancement, including educational parity, formal employment, and political participation. In this paper, we compare several composite measures to assess which, if any, are associated with maternal mortality ratios (MMRs) in low-income countries, after controlling for other macro-level and direct determinants.MethodsUsing data from 44 low-income countries (half in Africa), we assessed the correlation of three composite measures – the Gender Gap Index, the Gender Equity Index (GEI), and the Social Institutions and Gender Index (SIGI) – with MMRs. We also examined two recognized contributors to reduce maternal mortality (skilled birth attendance (SBA) and total fertility rate (TFR)) as well as several economic and political variables (such as the Corruption Index) to see which tracked most closely with MMRs. We examined the countries altogether, and disaggregated by region. We then performed multivariate analysis to determine which measures were predictive.ResultsTwo gender measures (GEI and SIGI) and GDP per capita were significantly correlated with MMRs for all countries. For African countries, the SIGI, TFR, and Corruption Index were significant, whereas the GEI, SBA, and TFR were significant in non-African countries. After controlling for all measures, SBA emerged as a predictor of log MMR for non-African countries (β = –0.04, P = 0.01). However, for African countries, only the Corruption Index was a predictor (β = –0.04, P = 0.04). No gender measure was significant.ConclusionsIn African countries, corruption is undermining the quality of maternal care, the availability of critical drugs and equipment, and pregnant women’s motivation to deliver in a hospital setting. Improving gender equality and SBA rates is unlikely to reduce MMR in Africa unless corruption is addressed. In other regions, increasing SBA rates can be expected to lower MMRs.

In Nigeria, maternal, newborn, and child health (MNCH) weeks are campaign-like events designed to accelerate progress toward Millennium Development Goals. The authors examined whether integrating HIV testing into MNCH weeks was feasible and could lead to increased case finding and linkage to prevention of mother-to-child transmission (PMTCT) services. Pregnant women attending MNCH week during the first week of December 2014 in 13 local government areas in Benue State were provided with HIV tests and referrals to PMTCT services. Demographic, past antenatal care (ANC), and HIV testing information were collected using a structured questionnaire. We used routine ANC/PMTCT data from national electronic system (DHIS-2) to compare with the results obtained from MNCH week. A total of 50,271 pregnant women with a median age of 25 years (IQR: 21-29) were offered HIV testing. About 50,253 (99.96%) agreed to get HIV testing, with 1,063 (2.1%) testing positive. Six hundred forty-four (60.6%) of those with positive results were linked to PMTCT. In multivariate analysis, marital status, gestation age, and those with no ANC visit during this pregnancy were associated with a positive HIV test. Approximately 30% (50,253 versus 39,080) more pregnant women received HIV testing in MNCH week compared to those who received HIV testing in routine ANC services in 2013. Of the 50,253 who accepted testing, 15,611 (31.1%) did not attend ANC during this pregnancy, of which 9,615 (61.6%) had not had any previous HIV tests. Four hundred forty-two (4.6%) of these 9,615 tested HIV-positive. Integration of HIV testing into MNCH weeks is feasible and improved uptake of HIV testing and linkage to care. However, the rate of HIV positivity was lower than that reported by previous studies. The findings indicate that MNCH weeks provides opportunity to reach those who do not attend ANC services for HIV care.

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.&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D;

According to the Countdown to 2015 for maternal, newborn, and child survival, only 9 of the 75 Countdown countries will reach the Millennium Development Goal 5 target to reduce the maternal mortality ratio (MMR) by 75% by 2015. Bangladesh is 1 country on track to reach this goal. This study was undertaken to determine how Bangladesh reduced maternal mortality, with a focus on change during 1998 to 2001 and 2007 to 2010. Data from 2 high-quality household surveys, the 2001 and 2010 Bangladesh Maternal Mortality Surveys, were used for the primary analyses. The surveys assessed the country for maternal health, particularly national estimates of MMR, by obtaining information on background characteristics, full birth histories from ever-married women aged 13 to 49 years, and indicators of maternal health. Data were also obtained from 6 demographic and health surveys performed between 1993 and 2011. The analysis focused on comparing the 3-year periods preceding the 2001 and 2010 surveys. Variables in the pooled data set were whether the mother died and, if so, whether the cause was maternal, socioeconomic and demographic characteristics, and maternal care–seeking behaviors. Poisson regression analysis was used to assess relationships between the change in risk of maternal death from 2001 to 2010 and various demographic, socioeconomic, and health care factors. Maternal mortality ratio decreased from 322 (95% confidence interval, 253–391) deaths/100,000 live births in 1998 to 2001 to 194 (95% confidence interval, 149–238) deaths/100,000 live births in 2007 to 2010, for an average annual rate of decrease of 5.6%. Although direct obstetric causes of death decreased between 2001 and 2010 (eclampsia by 50%, hemorrhage by 35%, obstructed labor by 26%, and abortion by 85%), most of these causes remained important in 2010. The 40% reduction in maternal mortality in Bangladesh in less than 10 years was attributed to several major measures. First, a series of 5-year plans focused on comprehensive maternal and child health services and access to family planning services. The main aim was to promote antenatal care, tetanus toxoid immunization, iron supplementation, clean delivery practices, and family planning. Major investments were made to establish and upgrade health facilities to deliver services and train community-based skilled birth attendants to promote safe delivery at home, stimulate demand for maternal health services, and strengthen health education and communication activities toward behavior change in reproductive health. Second, availability and access to facilities providing delivery services improved substantially, especially for private sector facilities. Improvement in access to public sector facilities was likely due to improved transportation. Third, use of maternal health services doubled during 1993 to 2011. A greater than 3-fold increase in deliveries by medically trained providers was noted, primarily after 2001. In addition, the overall cesarean section rate increased greater than 7-fold (2.6%–17.1%). Between 2001 and 2010, fertility dropped from 3.2 to 2.5 children/woman, consistent with the steady increase in use of modern contraceptives. Reductions in fertility were mainly among older, higher-parity women, thus contributing to MMR decrease. Fourth, major improvements in education of women and exposure to mass media contributed to increased awareness about maternal health and improved health-seeking behaviors. Increasing proportions of women live in urban areas with better access to health care. Economic situations in households also substantially improved during this period. The rapid decrease in the Bangladeshi MMR resulted from the changes in the age and parity distribution of births between 2001 and 2010, increases in the use of skilled attendants at delivery, and improved economic status of households along with improved access to facilities, growth of the communication sector, and higher levels of education. The evidence offers a strong rationale for accelerating access to and the quality of facilities providing care for maternal complications and safe delivery services in Bangladesh.

Millennium Development Goal (MDG) number five commits countries to reduce by three quarters the maternal mortality ratio. Other than a reduction in maternal mortality, MDGs commit countries to ensure that women have universal access to reproductive health. Although more women are receiving antenatal care, there are inequalities in care during pregnancy with only one in three rural women in developing regions receiving the recommended care during pregnancy. Culture has been one of the sidelined aspects in the fight against maternal and child mortality. Therefore, World Health Organization in collaboration with Uganda Christian University undertook a women’s empowerment project for improved maternal health in the districts of Gulu, Kotido and Moroto. The premise for the project was the assumption that the realization of improved maternal and newborn health is highly dependent on the maternal health practices of the individual women, their families and communities, influenced by socio-economic variables including culture and traditions. Therefore, managing the socio-economic determinants of maternal health including culture and traditions is an important means to reducing the gap between the community and the skilled health personnel. This paper presents the outcomes of this project and argues that increased maternal health outcomes are likely to occur if negative cultural practices are addressed and the gap between the community and the health facility is bridged through creating processes of an interface between the health facility and community.

BackgroundIn 2000, the eight Millennium Development Goals (MDGs) set targets for reducing child mortality and improving maternal health by 2015.ObjectiveTo evaluate the results of a new education and referral system for antenatal/intrapartum care as a strategy to reduce the rates of Cesarean sections (C-sections) and maternal/perinatal mortality.MethodsDesign: Cross-sectional study. Setting: Department of Gynecology and Obstetrics, Botucatu Medical School, Sao Paulo State University/UNESP, Brazil. Population: 27,387 delivering women and 27,827 offspring. Data collection: maternal and perinatal data between 1995 and 2006 at the major level III and level II hospitals in Botucatu, Brazil following initiation of a safe motherhood education and referral system. Main outcome measures: Yearly rates of C-sections, maternal (/100,000 LB) and perinatal (/1000 births) mortality rates at both hospitals. Data analysis: Simple linear regression models were adjusted to estimate the referral system's annual effects on the total number of deliveries, C-section and perinatal mortality ratios in the two hospitals. The linear regression were assessed by residual analysis (Shapiro-Wilk test) and the influence of possible conflicting observations was evaluated by a diagnostic test (Leverage), with p < 0.05.ResultsOver the time period evaluated, the overall C-section rate was 37.3%, there were 30 maternal deaths (maternal mortality ratio = 109.5/100,000 LB) and 660 perinatal deaths (perinatal mortality rate = 23.7/1000 births). The C-section rate decreased from 46.5% to 23.4% at the level II hospital while remaining unchanged at the level III hospital. The perinatal mortality rate decreased from 9.71 to 1.66/1000 births and from 60.8 to 39.6/1000 births at the level II and level III hospital, respectively. Maternal mortality ratios were 16.3/100,000 LB and 185.1/100,000 LB at the level II and level III hospitals. There was a shift from direct to indirect causes of maternal mortality.ConclusionsThis safe motherhood referral system was a good strategy in reducing perinatal mortality and direct causes of maternal mortality and decreasing the overall rate of C-sections.

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