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[New York, New York], Guttmacher Institute, 2018 Apr. 2 p.The United States -- through its Agency for International Development (USAID) -- has long been a global leader in enabling women’s access to contraceptive services in the world’s poorest countries. Empowering women with control over their own fertility yields benefits for them, their children and their families. It means fewer unintended -- and often high-risk -- pregnancies and fewer abortions, which in poor countries are often performed under unsafe conditions. Better birth spacing also makes for healthier mothers, babies and families, and pays far-reaching dividends at the family, society and country levels.
BMC Pregnancy and Childbirth. 2017 Jun 19; 17(1):194.BACKGROUND: WHO proposed the WHO Maternal Near Miss (MNM) tool, classifying women according to several (potentially) life-threatening conditions, to monitor and improve quality of obstetric care. The objective of this study is to analyse merged data of one high- and two low-resource settings where this tool was applied and test whether the tool may be suitable for comparing severe maternal outcome (SMO) between these settings. METHODS: Using three cohort studies that included SMO cases, during two-year time frames in the Netherlands, Tanzania and Malawi we reassessed all SMO cases (as defined by the original studies) with the WHO MNM tool (five disease-, four intervention- and seven organ dysfunction-based criteria). Main outcome measures were prevalence of MNM criteria and case fatality rates (CFR). RESULTS: A total of 3172 women were studied; 2538 (80.0%) from the Netherlands, 248 (7.8%) from Tanzania and 386 (12.2%) from Malawi. Total SMO detection was 2767 (87.2%) for disease-based criteria, 2504 (78.9%) for intervention-based criteria and 1211 (38.2%) for organ dysfunction-based criteria. Including every woman who received >/=1 unit of blood in low-resource settings as life-threatening, as defined by organ dysfunction criteria, led to more equally distributed populations. In one third of all Dutch and Malawian maternal death cases, organ dysfunction criteria could not be identified from medical records. CONCLUSIONS: Applying solely organ dysfunction-based criteria may lead to underreporting of SMO. Therefore, a tool based on defining MNM only upon establishing organ failure is of limited use for comparing settings with varying resources. In low-resource settings, lowering the threshold of transfused units of blood leads to a higher detection rate of MNM. We recommend refined disease-based criteria, accompanied by a limited set of intervention- and organ dysfunction-based criteria to set a measure of severity.
Maternal Death Surveillance and Response: A Tall Order for Effectiveness in Resource-Poor Settings [editorial]
Global Health: Science and Practice. 2017 Sep 27; 5(3):333-337.Most countries with high maternal (and newborn) mortality have very limited resources, overstretched health workers, and relatively weak systems and governance. To make important progress in reducing mortality, therefore, they need to carefully prioritize where to invest effort and funds. Given the demanding requirements to effectively implement the maternal death surveillance and response (MDSR) approach, in many settings it makes more sense to focus effort on the known drivers of high mortality, e.g., reducing geographic, financial, and systems barriers to lifesaving maternal and newborn care.
Geneva, Switzerland, WHO, 2017. 4 p. (WHO/RHR/17.02)Strategic approaches to reduce maternal mortality in the past 15 years have mainly focused on clinical interventions and health system strengthening. The greatest attention has been on postpartum haemorrhage and hypertensive disorders, the two leading direct causes of maternal mortality. Further reducing maternal deaths is a priority for achieving the Sustainable Development Goals, implementing the UN Global Strategy for Women’s, Children’s and Adolescents’ Health and critical for the Strategies toward Ending Preventable Maternal Mortality (EPMM). However, the third most common direct cause of maternal mortality, maternal sepsis, received less attention, research and programming. Undetected or poorly managed maternal infections can lead to sepsis, death or disability for the mother and increased likelihood of early neonatal infection and other adverse outcomes. Recognizing the need to foster new thinking and to catalyse greater action to address this important cause of maternal and newborn mortality and morbidity, the World Health Organization (WHO) and Jhpiego have launched the Global Maternal and Neonatal Sepsis Initiative, dedicated to focusing additional effort, energizing stakeholders and accelerating progress in the area of maternal and neonatal infection and sepsis. This statement defines maternal sepsis and operationalizes the definition.
Addressing the Child and Maternal Mortality Crisis in Haiti through a Central Referral Hospital Providing Countrywide Care.
Permanente Journal. 2016 spring; 20(2):59-70.The neonatal, infant, child, and maternal mortality rates in Haiti are the highest in the Western Hemisphere, with rates similar to those found in Afghanistan and several African countries. We identify several factors that have perpetuated this health care crisis and summarize the literature highlighting the most cost-effective, evidence-based interventions proved to decrease these mortality rates in low- and middle-income countries.To create a major change in Haiti's health care infrastructure, we are implementing two strategies that are unique for low-income countries: development of a countrywide network of geographic "community care grids" to facilitate implementation of frontline interventions, and the construction of a centrally located referral and teaching hospital to provide specialty care for communities throughout the country. This hospital strategy will leverage the proximity of Haiti to North America by mobilizing large numbers of North American medical volunteers to provide one-on-one mentoring for the Haitian medical staff. The first phase of this strategy will address the child and maternal health crisis.We have begun implementation of these evidence-based strategies that we believe will fast-track improvement in the child and maternal mortality rates throughout the country. We anticipate that, as we partner with private and public groups already working in Haiti, one day Haiti's health care system will be among the leaders in that region.
Midwifery. 2016 Feb; 33:7.Add to my documents.
Medical Anthropology. 2016 Jul-Aug; 35(4):322-37.This essay discusses the Indian government's implementation of maternal death reviews (MDR) across the country in response to a global WHO strategy called 'Beyond the Numbers.' India's MDR process attempts to better count and assess maternal deaths across the country, yet considerable challenges remain. Existing studies of the MDR process in India still reveal systemic failures including poor quality of obstetric care, as well as omissions or delays of care that are covered up or denied. An ethnographic case study suggests ways that ethnographic sensibilities or techniques could be used to harness community stakeholders or lay perspectives by privileging ambiguity, multiplicity, and conflicting views in order to reveal these systemic omissions or failures of accountability. It concludes by suggesting how ethnographic ways of knowing might elicit lay concerns or critiques that threaten the very medical privileges that the MDR process inadvertently shores up.
[Washington, D.C.], World Bank, 2012 Jun. 4 p. (en breve No. 177)The Latin America and Caribbean (LAC) region fares well on achievement of the MDG targets when compared with other regions, but the region has great disparities between and within countries on these goals. The region is also performing better than the rest of the developing world in relation to child mortality, having achieved more than 70% of the progress needed to reduce under-five mortality by two-thirds. However, LAC still faces serious challenges regarding maternal mortality, achieving good public and individual health and alleviating poverty. For LAC, the MDGs are a historic opportunity to address all forms of inequality and attain the political will needed to achieve these goals. (excerpt)
BMJ Open. 2015; 5(10):e007004.OBJECTIVES: To explore whether the rule of law is a foundational determinant of health that underlies other socioeconomic, political and cultural factors that have been associated with health outcomes. SETTING: Global project. PARTICIPANTS: Data set of 96 countries, comprising 91% of the global population. PRIMARY AND SECONDARY OUTCOME MEASURES: The following health indicators, infant mortality rate, maternal mortality rate, life expectancy, and cardiovascular disease and diabetes mortality rate, were included to explore their association with the rule of law. We used a novel Rule of Law Index, gathered from survey sources, in a cross-sectional and ecological design. The Index is based on eight subindices: (1) Constraints on Government Powers; (2) Absence of Corruption; (3) Order and Security; (4) Fundamental Rights; (5) Open Government; (6) Regulatory Enforcement, (7) Civil Justice; and (8) Criminal Justice. RESULTS: The rule of law showed an independent association with infant mortality rate, maternal mortality rate, life expectancy, and cardiovascular disease and diabetes mortality rate, after adjusting for the countries' level of per capita income, their expenditures in health, their level of political and civil freedom, their Gini measure of inequality and women's status (p<0.05). Rule of law remained significant in all the multivariate models, and the following adjustment for potential confounders remained robust for at least one or more of the health outcomes across all eight subindices of the rule of law. Findings show that the higher the country's level of adherence to the rule of law, the better the health of the population. CONCLUSIONS: It is necessary to start considering the country's adherence to the rule of law as a foundational determinant of health. Health advocates should consider the improvement of rule of law as a tool to improve population health. Conversely, lack of progress in rule of law may constitute a structural barrier to health improvement. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Globalization and women's and girls' health in 192 UN-member countries convention on the elimination of all forms of discrimination against women.
International Journal of Social Economics. 2016 Jul 11; 43(7):692-721.Purpose - The purpose of this paper is to explore the relationship between the ratification of the United Nations' (UN's) Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and women's and girls' health outcomes using a unique longitudinal data set of 192 UN-member countries that encompasses the years from 1980 to 2011. Design/methodology/approach - The authors focus on the impact of CEDAW ratification, number of reports submitted after ratification, years passed since ratification, and the dynamic impact of CEDAW ratification by utilizing ordinary least squares (OLS) and panel fixed effects methods. The study investigates the following women's and girls' health outcomes: Total fertility rate, adolescent fertility rate, infant mortality rate, maternal mortality ratio, neonatal mortality rate, female life expectancy at birth (FLEB), and female to male life expectancy at birth. Findings - The OLS and panel country and year fixed effects models provide evidence that the impact of CEDAW ratification on women's and girls' health outcomes varies by global regions. While the authors find no significant gains in health outcomes in European and North-American countries, the countries in the Northern Africa, sub-Saharan Africa, Southern Africa, Caribbean and Central America, South America, Middle-East, Eastern Asia, and Oceania regions experienced the biggest gains from CEDAW ratification, exhibiting reductions in total fertility, adolescent fertility, infant mortality, maternal mortality, and neonatal mortality while also showing improvements in FLEB. The results provide evidence that both early commitment to CEDAW as measured by the total number of years of engagement after the UN's 1980 ratification and the timely submission of mandatory CEDAW reports have positive impacts on women' and girls' health outcomes. Several sensitivity tests confirm the robustness of main findings. Originality/value - This study is the first comprehensive attempt to explore the multifaceted relationships between CEDAW ratification and female health outcomes. The study significantly expands on the methods of earlier research and presents novel methods and findings on the relationship between CEDAW ratification and women's health outcomes. The findings suggest that the impact of CEDAW ratification significantly depends on the country's region. Furthermore, stronger engagement with CEDAW (as indicated by the total number of years following country ratification) and the submission of the required CEDAW reports (as outlined in the Convention's guidelines) have positive impacts on women's and girls' health outcomes.
Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division.
Geneva, Switzerland, World Health Organization, 2015. 100 p.In 2000, the United Nations (UN) Member States pledged to work towards a series of Millennium Development Goals (MDGs), including the target of a three-quarters reduction in the 1990 maternal mortality ratio (MMR; maternal deaths per 100 000 live births), to be achieved by 2015. This target (MDG 5A) and that of achieving universal access to reproductive health (MDG 5B) together formed the two targets for MDG 5: Improve maternal health. In the five years counting down to the conclusion of the MDGs, a number of initiatives were established to galvanize efforts towards reducing maternal mortality. These included the UN Secretary-General’s Global Strategy for Women’s and Children’s Health, which mobilized efforts towards achieving MDG 4 (Improve child health) as well as MDG 5, and the high-level Commission on Information and Accountability (COIA), which promoted “global reporting, oversight, and accountability on women’s and children’s health”. Now, building on the momentum generated by MDG 5, the Sustainable Development Goals (SDGs) establish a transformative new agenda for maternal health towards ending preventable maternal mortality; target 3.1 of SDG 3 is to reduce the global MMR to less than 70 per 100 000 live births by 2030.
Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group.
Lancet. 2016 Jan 30; 387(10017):462-74.BACKGROUND: Millennium Development Goal 5 calls for a 75% reduction in the maternal mortality ratio (MMR) between 1990 and 2015. We estimated levels and trends in maternal mortality for 183 countries to assess progress made. Based on MMR estimates for 2015, we constructed projections to show the requirements for the Sustainable Development Goal (SDG) of less than 70 maternal deaths per 100,000 livebirths globally by 2030. METHODS: We updated the UN Maternal Mortality Estimation Inter-Agency Group (MMEIG) database with more than 200 additional records (vital statistics from civil registration systems, surveys, studies, or reports). We generated estimates of maternal mortality and related indicators with 80% uncertainty intervals (UIs) using a Bayesian model. The model combines the rate of change implied by a multilevel regression model with a time-series model to capture data-driven changes in country-specific MMRs, and includes a data model to adjust for systematic and random errors associated with different data sources. RESULTS: We had data for 171 of 183 countries. The global MMR fell from 385 deaths per 100,000 livebirths (80% UI 359-427) in 1990, to 216 (207-249) in 2015, corresponding to a relative decline of 43.9% (34.0-48.7), with 303,000 (291,000-349,000) maternal deaths worldwide in 2015. Regional progress in reducing the MMR since 1990 ranged from an annual rate of reduction of 1.8% (0.0-3.1) in the Caribbean to 5.0% (4.0-6.0) in eastern Asia. Regional MMRs for 2015 ranged from 12 deaths per 100,000 livebirths (11-14) for high-income regions to 546 (511-652) for sub-Saharan Africa. Accelerated progress will be needed to achieve the SDG goal; countries will need to reduce their MMRs at an annual rate of reduction of at least 7.5%. INTERPRETATION: Despite global progress in reducing maternal mortality, immediate action is needed to meet the ambitious SDG 2030 target, and ultimately eliminate preventable maternal mortality. Although the rates of reduction that are needed to achieve country-specific SDG targets are ambitious for most high mortality countries, countries that made a concerted effort to reduce maternal mortality between 2000 and 2010 provide inspiration and guidance on how to accomplish the acceleration necessary to substantially reduce preventable maternal deaths. FUNDING: National University of Singapore, National Institute of Child Health and Human Development, USAID, and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction. Copyright (c) 2016 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. Published by Elsevier Ltd.. All rights reserved.
Severe maternal morbidity and near misses in tertiary hospitals, Kelantan, Malaysia: a cross-sectional study.
BMC Public Health. 2016 Mar 5; 16(229):1-13.Background Severe maternal conditions have increasingly been used as alternative measurements of the quality of maternal care and as alternative strategies to reduce maternal mortality. We aimed to study severe maternal morbidity and maternal near miss among women in two tertiary hospitals in Kota Bharu, Kelantan, Malaysia. Methods A cross-sectional study with record review was conducted in 2014. Severe maternal morbidity and maternal near miss were classified using the new World Health Organization criteria. Health indicators for obstetric care were calculated and descriptive analyses were performed using SPSS version 22.0. Results In total, 21,579 live births, 395 women with severe maternal morbidity, 47 women with maternal near miss and two maternal deaths were analyzed. The severe maternal morbidity incidence ratio was 18.3 per 1000 live births and the maternal near miss incidence ratio was 2.2 per 1000 live births. The maternal near miss mortality ratio was 23.5 and the mortality index was 4.1%. The process indicators for essential interventions were almost 100.0%. Haemorrhagic disorders were the most common event for severe maternal morbidity (68.6%) and maternal near miss (80.9%) and management-based criteria accounted for 85.1%. Conclusions Comprehensive emergency care and intensive care as well as overall improvements in the quality of maternal health care need to be achieved to substantial reduce maternal death.
Searching for the definition of macrosomia through an outcome-based approach in low- and middle-income countries: a secondary analysis of the WHO Global Survey in Africa, Asia and Latin America.
BMC Pregnancy and Childbirth. 2015; 15(1):324.BACKGROUND: No consensus definition of macrosomia currently exists among researchers and obstetricians. We aimed to identify a definition of macrosomia that is more predictive of maternal and perinatal mortality and morbidity in low- and middle-income countries. METHODS: We conducted a secondary data analysis using WHO Global Survey on Maternal and Perinatal Health data on Africa and Latin America from 2004 to 2005 and Asia from 2007 to 2008. We compared adverse outcomes, which were assessed by the composite maternal mortality and morbidity index (MMMI) and perinatal mortality and morbidity index (PMMI) in subgroups with birthweight (3000-3499 g [reference group], 3500-3999 g, 4000-4099 g, 4100-4199 g, 4200-4299 g, 4300-4399 g, 4400-4499 g, 4500-4999 g) or country-specific birthweight percentile for gestational age (50(th)-74(th) percentile [reference group], 75(th)-89(th), 90(th)-94(th), 95(th)-96(th), and >/=97(th) percentile). Two-level logistic regression models were used to estimate odds ratios of MMMI and PMMI. RESULTS: A total of 246,659 singleton term births from 363 facilities in 23 low- and middle-income countries were included. Adjusted odds ratios (aORs) for intrapartum caesarean sections exceeded 2.0 when birthweight was greater than 4000 g (2 . 00 [95 % CI: 1 . 68, 2 . 39], 2 . 42 [95 % CI: 2 . 02, 2 . 89], 2 . 01 [95 % CI: 1 . 74, 2 . 33] in Africa, Asia and Latin America, respectively). aORs of MMMI reached 2.0 when birthweight was greater than 4000 g, 4500 g in Asia and Africa, respectively. aORs of PMMI approached to 2.0 (1 . 78 [95 % CI: 1 . 16, 2 . 74]) when birthweight was greater than 4500 g in Latin America. When birthweight was at the 90(th) percentile or higher, aORs of MMMI and PMMI increased, but none exceeded 2.0. CONCLUSIONS: The population-specific definition of macrosomia using birthweight cut-off points irrespective of gestational age (4500 g in Africa and Latin America, 4000 g in Asia) is more predictive of maternal and perinatal adverse outcomes, and simpler to apply compared to the definition based on birthweight percentile for a given gestational age.
Delivering the Millennium Development Goals to reduce maternal and child mortality: a systematic review of impact evaluation evidence.
[Washington, D.C.], World Bank, Independent Evaluation Group, .  p.Interventions that may improve maternal and child health are numerous and spread across many development sectors. Even when such interventions are known to be effective in controlled conditions, however, questions remain about implementation, delivery, and uptake. This review gathers impact evaluation evidence of fielded interventions that aim to improve skilled birth attendance and reduce maternal and child mortality rates. To aid policy makers, it reviews effectiveness evidence from multiple sectors on the distal causes of maternal and child mortality, complementing the body of effectiveness evidence from reviews specific to the health sector (such as the Lancet series on maternal and child health) that focus on proximate interventions for intermediate outcomes. This systematic review by the Independent Evaluation Group (IEG) is a learning exercise that looks beyond World Bank experience. In doing so, it draws on impact evaluations other than those conducted by the Bank or on Bank projects. It is intended to be used as a reference for practitioners in the Bank and elsewhere with an interest in interventions that have demonstrated attributable improvements in skilled birth attendance and reductions in maternal and child mortality. This review also identifies important gaps in the impact evaluation evidence for interventions that may be effective in reducing maternal and child mortality but whose impacts have not yet been tested using robust impact evaluation methods. (Excerpt)
Report on Ending Preventable Maternal Mortality (EPMM) Metrics Technical Meeting. Phase I: Developing a core set of maternal health indicators for GLOBAL monitoring and reporting.
[Unpublished] 2015 Sep 22.  p.In total, forty-five people participated in one or more stages of the process undertaken to reach consensus on a core set of priority, methodologically robust maternal health (MH) indicators with direct relevance for reducing preventable mortality (proximal to causes of death) for global monitoring and reporting by all countries. Consensus was reached on twelve maternal health indicators, with advancement on definitions that include the numerator, denominator, disaggregators, and data sources, which can contribute to a global monitoring framework for Ending Preventable Maternal Mortality (included as an Appendix to this meeting report). The definitions and data sources to accompany the Core Maternal Health Indicators for Global Monitoring and Reporting require further refinement, as per the outcomes of the meeting, and will be subject to ongoing review before finalization. There was consensus that it would be appropriate for WHO to put forward this core set of maternal health indicators in further member state consultation and deliberation through global processes, including integration and harmonization with core metrics from the Every Newborn Action Plan (ENAP) as part of a combined monitoring framework for maternal and newborn health. All participants pledged their support for these processes. Furthermore, agreement was reached on four priority areas in which immediate work is required to develop much needed indicators for global monitoring and reporting by all countries, through further refinement of definitions, further development of data sources, and further measure testing and validation. Such efforts should be undertaken in collaboration and coordination with other ongoing indicator development initiatives. Finally, a “parking lot” list of additional indicators of interest was generated. These represent indicators that are either desirable for use at different levels of the health system but not appropriate for global monitoring, or desirable for further research and development to enhance their validity or feasibility for future use in a global monitoring framework. (Excerpt)
BJOG: An International Journal of Obstetrics and Gynaecology. 2014 Sep; 121 Suppl 4:11-4.In the World Health Organization (WHO) European region despite official high coverage of essential interventions for maternal and neonatal care, there are still significant gaps in the delivery of effective interventions. Since 2001, WHO designed and implemented the Making Pregnancy Safer programme, which includes hands-on training courses in effective perinatal care for maternity teams, development of clinical guidelines, maternal mortality and morbidity case reviews, and assessments of quality of care. This has contributed to enhancing capacity at country level to improve organisation and provision of care. This paper describes the programme's components, challenges, achievements and results. (c) 2014 Royal College of Obstetricians and Gynaecologists.
Indirect causes of severe adverse maternal outcomes: a secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health.
BJOG: An International Journal of Obstetrics and Gynaecology. 2014 Mar; 121 Suppl 1:32-9.OBJECTIVE: To assess the proportion of severe maternal outcomes resulting from indirect causes, and to determine pregnancy outcomes of women with indirect causes. DESIGN: Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health. SETTING: A total of 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East. SAMPLE: A total of 314 623 pregnant women admitted to the participating facilities. METHODS: We identified the percentage of women with severe maternal outcomes arising from indirect causes. We evaluated the risk of severe maternal and perinatal outcomes in women with, versus without, underlying indirect causes, using adjusted odds ratios and 95% confidence intervals, by a multilevel, multivariate logistic regression model, accounting for clustering effects within countries and health facilities. MAIN OUTCOME MEASURES: Severe maternal outcomes and preterm birth, fetal mortality, early neonatal mortality, perinatal mortality, low birthweight, and neonatal intensive care unit admission. RESULTS: Amongst 314 623 included women, 2822 were reported to suffer from severe maternal outcomes, out of which 20.9% (589/2822; 95% CI 20.1-21.6%) were associated with indirect causes. The most common indirect cause was anaemia (50%). Women with underlying indirect causes showed significantly higher risk of obstetric complications (adjusted odds ratio, aOR, 7.0; 95% CI 6.6-7.4), severe maternal outcomes (aOR 27.9; 95% CI 24.7-31.6), and perinatal mortality (aOR 3.8; 95% CI 3.5-4.1). CONCLUSIONS: Indirect causes were responsible for about one-fifth of severe maternal outcomes. Women with underlying indirect causes had significantly increased risks of severe maternal and perinatal outcomes. (c) 2014 RCOG The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.
Geneva, Switzerland, WHO, 2014.  p.The action plan sets out a vision of a world in which there are no preventable deaths of newborns or stillbirths, where every pregnancy is wanted, every birth celebrated, and women, babies and children survive, thrive and reach their full potential. Nearly 3 million lives could be saved each year if the actions in the plan are implemented and its goals and targets achieved. Based on evidence of what works, and developed within the framework for Every Woman Every Child, the plan enhances and supports coordinated, comprehensive planning and implementation of newborn-specific actions within the context of national reproductive, maternal, newborn, child and adolescent health strategies and action plans, and in collaboration with stakeholders from the private sector, civil society, professional associations and others. The goal is to achieve equitable and high-quality coverage of care for all women and newborns through links with other global and national plans, measurement and accountability. Strategic objectives and targets to achieve the goal of ending preventable maternal deaths have also been prepared. The objectives are complementary to those of the Every Newborn action plan and intended for coordinated implementation.
The World Health Organization Multicountry Survey on Maternal and Newborn Health project at a glance: the power of collaboration.
BJOG: An International Journal of Obstetrics and Gynaecology. 2014 Mar; 121 Suppl 1:v-viii.Add to my documents.
Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division.
Geneva, Switzerland, WHO, 2014.  p.Millennium Development Goal (MDG) 5 Target 5A calls for the reduction of maternal mortality ratio by three quarters between 1990 and 2015. It has been a challenge to assess the extent of progress due to the lack of reliable and accurate maternal mortality data -- particularly in developing-country settings where maternal mortality is high. As part on going efforts, the WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division updated estimates of maternal mortality for the years 1990, 1995, 2000, 2005 and 2013.
International Perspectives On Sexual and Reproductive Health. 2013 Mar; 39(1):32-41.CONTEXT: Despite the fact that most maternal deaths are preventable, maternal mortality remains high in many developing countries. Target A of Millennium Development Goal (MDG) 5 calls for a three-quarters reduction in the maternal mortality ratio (MMR) between 1990 and 2015. METHODS: We derived estimates of maternal mortality for 172 countries over the period 1990-2008. Trends in maternal mortality were estimated either directly from vital registration data or from a hierarchical or multilevel model, depending on the data available for a particular country. RESULTS: The annual number of maternal deaths worldwide declined by 34% between 1990 and 2008, from approximately 546,000 to 358,000 deaths. The estimated MMR for the world as a whole also declined by 34% over this period, falling from 400 to 260 maternal deaths per 100,000 live births. Between 1990 and 2008, the majority of the global burden of maternal deaths shifted from Asia to Sub-Saharan Africa. Differential trends in fertility, the HIV/AIDS epidemic and access to reproductive health are associated with the shift in the burden of maternal deaths from Asia to Sub-Saharan Africa. CONCLUSIONS: Although the estimated annual rate of decline in the global MMR in 1990-2008 (2.3%) fell short of the level needed to meet the MDG 5 target, it was much faster than had been thought previously. Targeted efforts to improve access to quality maternal health care, as well as efforts to decrease unintended pregnancies through family planning, are necessary to further reduce the global burden of maternal mortality.
Maternal near miss and mortality in a rural referral hospital in northern Tanzania: a cross-sectional study.
BMC Pregnancy and Childbirth. 2013; 13:141.BACKGROUND: Maternal morbidity and mortality in sub-Saharan Africa remains high despite global efforts to reduce it. In order to lower maternal morbidity and mortality in the immediate term, reduction of delay in the provision of quality obstetric care is of prime importance. The aim of this study is to assess the occurrence of severe maternal morbidity and mortality in a rural referral hospital in Tanzania as proposed by the WHO near miss approach and to assess implementation levels of key evidence-based interventions in women experiencing severe maternal morbidity and mortality. METHODS: A prospective cross-sectional study was performed from November 2009 until November 2011 in a rural referral hospital in Tanzania. All maternal near misses and maternal deaths were included. As not all WHO near miss criteria were applicable, a modification was used to identify cases. Data were collected from medical records using a structured data abstraction form. Descriptive frequencies were calculated for demographic and clinical variables, outcome indicators, underlying causes, and process indicators. RESULTS: In the two-year period there were 216 maternal near misses and 32 maternal deaths. The hospital-based maternal mortality ratio was 350 maternal deaths per 100,000 live births (95% CI 243-488). The maternal near miss incidence ratio was 23.6 per 1,000 live births, with an overall case fatality rate of 12.9%. Oxytocin for prevention of postpartum haemorrhage was used in 96 of 201 women and oxytocin for treatment of postpartum haemorrhage was used in 38 of 66 women. Furthermore, eclampsia was treated with magnesium sulphate in 87% of all cases. Seventy-four women underwent caesarean section, of which 25 women did not receive prophylactic antibiotics. Twenty-eight of 30 women who were admitted with sepsis received parenteral antibiotics. The majority of the cases with uterine rupture (62%) occurred in the hospital. CONCLUSION: Maternal morbidity and mortality remain challenging problems in a rural referral hospital in Tanzania. Key evidence-based interventions are not implemented in women with severe maternal morbidity and mortality. Progress can be made through up scaling the use of evidence-based interventions, such as the use of oxytocin for prevention and treatment of postpartum haemorrhage.
Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study.
Lancet. 2013 May 18; 381(9879):1747-1755.Background: We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. Methods: In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; i.e., maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (e.g., the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (i.e., the ability to produce a positive effect on health outcomes) through standardised mortality ratios. Results: From May 1, 2010, to Dec 31, 2011, we included 314 623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]). Interpretation: High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy.
Lancet. 2013 May 18; 381(9879):1689.Although not to the same degree as in developing countries, maternal mortality remains a problem in the USA, especially among underserved populations. Pregnant women in the USA are affected by the same life-threatening health disorders as women worldwide: hypertension, hemorrhage, and sepsis, among others. The author discusses in a woman’s ability to obtain health insurance in the USA. The Affordable Care Act, the Department of Health and Human Services, and the Center for Medicare and Medicaid Innovation have changed the way women access health services during pregnancy and enhanced prenatal care models. The author encourages that all parties assess the state of women’s health in their home countries, which includes both developing and developed countries.