Epidemiologic transition in maternal mortality and morbidity: new challenges for Jamaica

Burden, Incidence, Mortality and Lethality of Maternal Disorders in Mexico 1990-2019: An Analysis for the Global Burden of Disease Study 2019

BACKGROUND

Estimates of the sub-national distribution of maternal disorders in Mexico beyond Maternal Mortality Ratios are scarce. Characterizing the sub-national variation of maternal disorders may make it possible to focus more on interventions and thereby reduce their occurrence in a more meaningful and sustained manner.

AIM

To analyze and describe the sub-national distribution, magnitude, trends and changes in the contribution of maternal causes to women's loss of health in Mexico from 1990-2019.

METHODS

Using estimates from the Global Burden of Disease (GBD) 2019 study, we describe the distribution and trends of maternal mortality ratio (MMR), mortality rate, case-fatality rate and disability-adjusted life years (DALYs) due to maternal causes, at both national and state levels.

RESULTS

Between 1990 and 2019, DALYs attributable to maternal causes had decreased 59.5%, mortality 63.8%, and incidence 46.5%. However, Maternal Mortality Ratio only decreased by 33%. The case-fatality rate of maternal disorders decreased by 50% overall; although for obstructed labor and uterine rupture, it remained unchanged. Lethality showed great variation between states, with a 3 fold difference between the maximum and minimum values.

CONCLUSIONS

Although mortality and incidence of maternal causes in Mexico have greatly decreased in the last 30 years, these changes mostly reflect declines in fertility. The decrease seen in case-fatality rates is driven by decreases in causes such as hypertension and hemorrhage, though for others it remained constant. Efforts should be directed at improving access to, and management of, locally frequent maternal emergencies, formulating tailor-made regional interventions for maternal health.

Maternal mortality among women with sickle cell disease in Jamaica over two decades (1998-2017)

BACKGROUND

Sickle cell disease (SCD) affects 2.8% of Jamaican antenatal women. Between 1998-2007 their maternal mortality ratio was 7-11 times higher than women without these disorders. We aim to determine if outcomes improved between 2008 and 17 amid declining fertility and changes in referral obstetric care.

METHODS

Maternal deaths in Jamaica's maternal mortality surveillance database (assembled since 1998) with SCD reported as underlying or associated cause of death were compared to those without known SCD, over two decades from 1998 to 2017. Social, demographic and health service variables were analysed using SPSS and EpiInfo Open.

FINDINGS

Over the two decades from 1998 to 2017, 806 (74%) of the 1082 pregnancy-associated deaths documented by the Jamaican Ministry of Health and Wellness were maternal deaths. The maternal mortality ratio (MMR) did not statistically change over the two periods for women with (p = 0.502) and without SCD (p = 0.629). The MMR among women with and without SCD in 2008-17 was 378.1 (n = 41) and 89.2/100,000 live births (n = 336) respectively, an odds ratio of 4.24 (95% CI: 3.07-5.87). When deaths due to their blood disorders were excluded, risk remained elevated at 2.17 (95% CI: 1.36-3.32). There was an upward trend in direct deaths over the two decades (p [trend]=0.051).

INTERPRETATION

MMRs were unchanged over two decades for Jamaicans with SCD. The high contribution to maternal mortality by women with SCD may explain some of the persistently higher mortality experience of women in the African diaspora. Multi-disciplinary evidence-based strategies need to be developed and tested which improve survival for women with SCD who want to have children.

FUNDING

No external funding was provided.

The evolving contribution of non-communicable diseases to maternal mortality in Jamaica, 1998-2015: a population-based study

OBJECTIVE

To describe trends in indirect cause-specific pregnancy-related mortality from 1998 to 2015.

DESIGN

Secondary analysis of annual, national cross-sectional database of maternal and late maternal deaths, identified through active surveillance of deaths among women aged 10-50 years.

SETTING

Jamaica, a middle-income Caribbean country.

POPULATION

Maternal and late maternal deaths.

METHODS

Descriptive trend analyses of demographic and cause-specific maternal and pregnancy-related mortality ratios undertaken comparing the periods 1998-2003, 2004-2009 and 2010-2015. Multivariate logistic regression was used to confirm changes in risk of indirect death.

MAIN OUTCOME MEASURES

Maternal, pregnancy-related, direct, indirect and cause-specific mortality ratios (deaths/100 000 live births).

RESULTS

Maternal deaths from indirect conditions increased between the first two periods (P = 0.004) and stabilised in the third (P = 0.085). Associated with upward movement in cardiovascular deaths (P_[trend] = 0.003), women under 25 years were at elevated risk (odds ratio 1.44, 95% CI 1.00-2.08; P = 0.052). Haematological/immunological conditions (69% sickle cell disease) ranked second but did not vary with time. Health service utilisation was similar across age, parity, health region and major cause categories (non-communicable diseases, non-obstetric infections, direct), however women with indirect conditions spent more time in hospital (median 5 days versus 3 days) and more often died after the puerperium.

CONCLUSIONS

Medical conditions, especially cardiovascular disease, are increasingly associated with maternal and late maternal mortality. Middle-income countries need to simultaneously improve management of indirect conditions, while redoubling efforts to reduce direct deaths. Postpuerperal medical services should be integrated into routine infant health services to improve continuity of care during this high-risk period.

TWEETABLE ABSTRACT

Maternal survival (SDG 3.1) in LMICs requires better care for women with both non-communicable diseases and obstetric conditions.

Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study

Objective

To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities.

Methods

We conducted a repeated cross-sectional study using the 2006–2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe new cases, cause distributions and the reclassification of maternal mortality cases by the BIRMM process. We used statistical tests to analyse differences in sociodemographic characteristics between direct and indirect deaths and differences in the proportion of overall direct and indirect deaths, by year and by municipality poverty level.

Findings

A total of 9043 maternal deaths were subjected to the review process. There was a 13% increase (from 7829 to 9043) in overall identified maternal deaths and a threefold increase in the proportion of maternal deaths classified as late maternal deaths (from 2.1% to 6.9%). Over the study period direct obstetric deaths declined, while there was no change in deaths from indirect obstetric causes. Direct deaths were concentrated in women who lived in the poorest municipalities. When compared to those dying of direct causes, women dying of indirect causes had fewer pregnancies and were slightly younger, better educated and more likely to live in wealthier municipalities.

Conclusion

The BIRMM is one approach to correct maternal death statistics in settings with poor resources. The approach could help the health system to rethink its strategy to reduce maternal deaths from indirect obstetric causes, including prevention of unwanted pregnancies and improvement of antenatal and post-obstetric care.

The development and experience of epidemiological transition theory over four decades: a systematic review

BACKGROUND

Epidemiological transition (ET) theory, first postulated in 1971, has developed alongside changes in population structures over time. However, understandings of mortality transitions and associated epidemiological changes remain poorly defined for public health practitioners. Here, we review the concept and development of ET theory, contextualising this in empirical evidence, which variously supports and contradicts the original theoretical propositions.

DESIGN

A Medline literature search covering publications over four decades, from 1971 to 2013, was conducted. Studies were included if they assessed human populations, were original articles, focused on mortality and health or demographic or ET and were in English. The reference lists of the selected articles were checked for additional sources.

RESULTS

We found that there were changes in emphasis in the research field over the four decades. There was an increasing tendency to study wide-ranging aspects of the determinants of mortality, including risk factors, lifestyle changes, socio-economics, and macro factors such as climate change. Research on ET has focused increasingly on low- and middle-income countries rather than industrialised countries, despite its origins in industrialised countries. Countries have experienced different levels of progress in ET in terms of time, pace, and underlying mechanisms. Elements of ET are described for many countries, but observed transitions have not always followed pathways described in the original theory.

CONCLUSIONS

The classic ET theory largely neglected the critical role of social determinants, being largely a theoretical generalisation of mortality experience in some countries. This review shows increasing interest in ET all over the world but only partial concordance between established theory and empirical evidence. Empirical evidence suggests that some unconsidered aspects of social determinants contributed to deviations from classic theoretical pathways. A better-constructed, revised ET theory, with a stronger basis in evidence, is needed.

Measuring unsafe abortion-related mortality: a systematic review of the existing methods

BACKGROUND

The WHO estimates that 13% of maternal mortality is due to unsafe abortion, but challenges with measurement and data quality persist. To our knowledge, no systematic assessment of the validity of studies reporting estimates of abortion-related mortality exists.

STUDY DESIGN

To be included in this study, articles had to meet the following criteria: (1) published between September 1(st), 2000-December 1(st), 2011; (2) utilized data from a country where abortion is "considered unsafe"; (3) specified and enumerated causes of maternal death including "abortion"; (4) enumerated ≥100 maternal deaths; (5) a quantitative research study; (6) published in a peer-reviewed journal.

RESULTS

7,438 articles were initially identified. Thirty-six studies were ultimately included. Overall, studies rated "Very Good" found the highest estimates of abortion related mortality (median 16%, range 1-27.4%). Studies rated "Very Poor" found the lowest overall proportion of abortion related deaths (median: 2%, range 1.3-9.4%).

CONCLUSIONS

Improvements in the quality of data collection would facilitate better understanding global abortion-related mortality. Until improved data exist, better reporting of study procedures and standardization of the definition of abortion and abortion-related mortality should be encouraged.

Excess risk of maternal death from sickle cell disease in Jamaica: 1998-2007

Background

Decreases in direct maternal deaths in Jamaica have been negated by growing indirect deaths. With sickle cell disease (SCD) a consistent underlying cause, we describe the epidemiology of maternal deaths in this population.

Methods

Demographic, service delivery and cause specific mortality rates were compared among women with (n = 42) and without SCD (n = 376), and between SCD women who died in 1998–2002 and 2003–7.

Results

Women with SCD had fewer viable pregnancies (p: 0.02) despite greater access to high risk antenatal care (p: 0.001), and more often died in an intensive care unit (p: 0.002). In the most recent period (2003–7) SCD women achieved more pregnancies (median 2 vs. 3; p: 0.009), made more antenatal visits (mean 3.3 vs. 7.3; p: 0.01) and were more often admitted antenatally (p:<0.0001). The maternal mortality ratio for SCD decedents was 7–11 times higher than the general population, with 41% of deaths attributable to their disorder. Cause specific mortality was higher for cardiovascular complications, gestational hypertension and haemorrhage. Respiratory failure was the leading immediate cause of death.

Conclusions

Women with SCD experience a significant excess risk of dying in pregnancy and childbirth [MMR: (SCD) 719/100,000, (non SCD) 78/100,000]. MDG5 cannot be realised without improving care for women with SCD. Tertiary services (e.g. ventilator support) are needed at regional centres to improve outcomes in this and other high risk populations. Universal SCD screening in pregnancy in populations of African and Mediterranean descent is needed as are guidelines for managing SCD pregnancies and educating families with SCD.

Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis

BACKGROUND

With 4 years until 2015, it is essential to monitor progress towards Millennium Development Goals (MDGs) 4 and 5. Although estimates of maternal and child mortality were published in 2010, an update of estimates is timely in view of additional data sources that have become available and new methods developed. Our aim was to update previous estimates of maternal and child mortality using better data and more robust methods to provide the best available evidence for tracking progress on MDGs 4 and 5.

METHODS

We update the analyses of the progress towards MDGs 4 and 5 from 2010 with additional surveys, censuses, vital registration, and verbal autopsy data. For children, we estimate early neonatal (0-6 days), late neonatal (7-28 days), postneonatal (29-364 days), childhood (ages 1-4 years), and under-5 mortality. We use an improved model for estimating mortality by age under 5 years. For maternal mortality, our updated analysis includes greater than 1000 additional site-years of data. We tested a large set of alternative models for maternal mortality; we used an ensemble model based on the models with the best out-of-sample predictive validity to generate new estimates from 1990 to 2011.

FINDINGS

Under-5 deaths have continued to decline, reaching 7·2 million in 2011 of which 2·2 million were early neonatal, 0·7 million late neonatal, 2·1 million postneonatal, and 2·2 million during childhood (ages 1-4 years). Comparing rates of decline from 1990 to 2000 with 2000 to 2011 shows that 106 countries have accelerated declines in the child mortality rate in the past decade. Maternal mortality has also continued to decline from 409,100 (uncertainty interval 382,900-437,900) in 1990 to 273,500 (256,300-291,700) deaths in 2011. We estimate that 56,100 maternal deaths in 2011 were HIV-related deaths during pregnancy. Based on recent trends in developing countries, 31 countries will achieve MDG 4, 13 countries MDG 5, and nine countries will achieve both.

INTERPRETATION

Even though progress on reducing maternal and child mortality in most countries is accelerating, most developing countries will take many years past 2015 to achieve the targets of the MDGs 4 and 5. Similarly, although there continues to be progress on maternal mortality the pace is slow, without any overall evidence of acceleration. Immediate concerted action is needed for a large number of countries to achieve MDG 4 and MDG 5.

FUNDING

Bill & Melinda Gates Foundation.

A survey of providers' knowledge, opinions, and practices regarding induced abortion in Jamaica

OBJECTIVE

To determine the stance of providers in Jamaica regarding the suggested change in abortion law and proposal to train providers.

METHODS

A face-to-face anonymous survey of 35 obstetrician-gynecologists (Obs) and 228 general practitioners (GPs) in Kingston was used to assess knowledge, opinions and practice.

RESULTS

Demand for abortion was high: 94.7% of GPs and 100% of Obs had been asked to perform an abortion. Although 50.7% of GPs and 70.6% of Obs had performed abortions, 81.2% and 88.6%, respectively, had referred women to another provider. Training was more likely for Obs (65.7% versus 52.2%; P<0.001). Patient assessment was appropriate, but written guidelines, counseling, and social services referral were uncommon. More Obs knew the laws (62.9% versus 42.5%; P=0.052). Most participants did not agree to abortion under any circumstance, but only 25.3% had moral or religious objections, and only 9.4% refused to perform abortions because they were illegal. Most providers felt that abortions should be made more accessible, and almost all felt that abortions should be performed only by Obs.

CONCLUSION

Demand for abortions is high in Jamaica, but many doctors refer clients to another provider. Patient assessment is good, but support services need improvement.

What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries

The first target of the fifth United Nations Millennium Development Goal is to reduce maternal mortality by 75% between 1990 and 2015. This target is critically off track. Despite difficulties inherent in measuring maternal mortality, interventions aimed at reducing it must be monitored and evaluated to determine the most effective strategies in different contexts. In some contexts, the direct causes of maternal death, such as haemorrhage and sepsis, predominate and can be tackled effectively through providing access to skilled birth attendance and emergency obstetric care. In others, indirect causes of maternal death, such as HIV/AIDS and malaria, make a significant contribution and require alternative interventions. Methods of planning and evaluating maternal health interventions that do not differentiate between direct and indirect maternal deaths may lead to unrealistic expectations of effectiveness or mask progress in tackling specific causes. Furthermore, the need for additional or alternative interventions to tackle the causes of indirect maternal death may not be recognized if all-cause maternal death is used as the sole outcome indicator. This article illustrates the importance of differentiating between direct and indirect maternal deaths by analysing historical data from England and Wales and contemporary data from Ghana, Rwanda and South Africa. The principal aim of the paper is to highlight the need to differentiate deaths in this way when evaluating maternal mortality, particularly when judging progress towards the fifth Millennium Development Goal. It is recommended that the potential effect of maternity services failing to take indirect maternal deaths into account should be modelled.

Impact of the Jamaican birth cohort study on maternal, child and adolescent health policy and practice

The Jamaica Perinatal Morbidity and Mortality Survey (JPMMS) was a national study designed to identify modifiable risk factors associated with poor maternal and perinatal outcome. Needing to better understand factors that promote or retard child development, behaviour and academic achievement, we conducted follow-up studies of the birth cohort. The paper describes the policy developments from the JPMMS and two follow-up rounds. The initial study (1986-87) documented 94% of all births and their outcomes on the island over 2 months (n = 10 508), and perinatal (n = 2175) and maternal deaths (n = 62) for a further 10 months. A subset of the birth cohort, identified by their date of birth through school records, was seen at ages 11-12 (n = 1715) and 15-16 years (n = 1563). Findings from the initial survey led to, inter alia, clinic-based screening for syphilis, referral high-risk clinics run by visiting obstetricians, and the redesign and construction of new labour wards at referral hospitals. The follow-up studies documented inadequate academic achievement among boys and children attending public schools, and associations between under- and over-nutrition, excessive television viewing (>20 h/week), inadequate parental supervision and behavioural problems. These contributed to the development of a television programming code for children, a National Parenting Policy, policies aimed at improving inter-sectoral services to children from birth to 5 years (Early Childhood Commission) and behavioural interventions of the Violence Prevention Alliance (an inter-sectoral NGO) and the Healthy Lifestyles project (Ministry of Health). Indigenous maternal and child health research provided a local evidence base that informed public policy. Collaboration, good communication, being vigilant to opportunities to influence policy, and patience has contributed to our success.

Utility of WHOQOL-BREF in measuring quality of life in sickle cell disease

Background

Sickle cell disease is the commonest genetic disorder in Jamaica and most likely exerts numerous effects on quality of life (QOL) of those afflicted with it. The WHOQOL-Bref, which is a commonly utilized generic measure of quality of life, has never previously been utilized in this population. We have sought to study its utility in this disease population.

Methods

491 patients with sickle cell disease were administered the questionnaire including demographics, WHOQOL-Bref, Short Form-36 (SF-36), Flanagan's quality of life scale (QOLS) and measures of disease severity at their routine health maintenance visits to the sickle cell unit. Internal consistency reliabilities, construct validity and "known groups" validity of the WHOQOL-Bref, and its domains, were examined; and then compared to those of the other instruments.

Results

All three instruments had good internal consistency, ranging from 0.70 to 0.93 for the WHOQOL-Bref (except the 'social relationships' domain), 0.86–0.93 for the SF-36 and 0.88 for the QOLS. None of the instruments showed any marked floor or ceiling effects except the SF-36 'physical health' and 'role limitations' domains. The WHOQOL-Bref scale also had moderate concurrent validity and showed strong "known groups" validity.

Conclusion

This study has shown good psychometric properties of the WHOQOL-Bref instrument in determining QOL of those with sickle cell disease. Its utility in this regard is comparable to that of the SF-36 and QOLS.

Maternal mortality surveillance in Jamaica

OBJECTIVES

To assess factors associated with under-reporting of maternal deaths from 1998, when maternal deaths became a Class I notifiable event in Jamaica and continuous maternal mortality surveillance was introduced, through 2003.

METHODS

The number of deaths notified was compared with the number of independently identified deaths for each period and region studied, and key informants reported on their experience of the surveillance process.

RESULTS

By 2000, approximately 80% of maternal deaths were reported, and was more consistent in 2 of the 4 regions. In these 2 regions someone was responsible for active surveillance and there was an established maternal mortality committee to review cases. Factors associated with nonreporting were no postmortem examination, death in the first trimester of pregnancy, and time interval between pregnancy termination and death. The surveillance staff requested guidelines on monitoring interregional transfers and technical assistance in developing action plans.

CONCLUSION

Active hospital surveillance must include all wards, including the emergency department. Community surveillance should include forensic pathologists. National leadership is needed to summarize trends, address policy, and provide technical assistance to the surveillance staff.