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Haider MM, Siddique AB, Jabeen S, Hossain AT, Khan S, Rahman MM, Zohora FT, Chakraborty N, Nahar Q, Rahman AE, Jamil K, El Arifeen S. Levels, trends, causes, place and time of, care-seeking for, and barriers in preventing indirect maternal deaths in Bangladesh: An analysis of national-level household surveys. J Glob Health 2023; 13:04019. [PMID: 37114719 PMCID: PMC10363693 DOI: 10.7189/jogh.13.04019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
Background Eclampsia, haemorrhage, and other direct causes are the primary burden of maternal mortality in Bangladesh, often reducing attention given to indirect maternal deaths (IMDs). However, Sustainable Development Goals may not be achieved without actions to prevent IMDs. We examined the levels, trends, specific causes, timing, place, and care-seeking, and explored the barriers to IMD prevention. Methods We used three nationally representative surveys conducted in 2001, 2010, and 2016 to examine levels and trends in IMDs. The analysis of specific causes, timing, and place of IMDs, and care-seeking before the deaths was based on 37 IMDs captured in the 2016 survey. Finally, we used thematic content analysis of the open history from the 2016 survey verbal autopsy (VA) questionnaire to explore barriers to IMD prevention. Results After increasing from 51 deaths per 100 000 live births in 2001 to 71 in 2010, the indirect maternal mortality ratio (IMMR) dropped to 38 deaths per 100 000 live births in 2016. In 2016, the indirect causes shared one-fifth of the maternal deaths in Bangladesh. Stroke, cancer, heart disease, and asthma accounted for 80% of the IMDs. IMDs were concentrated in the first trimester of pregnancy (27%) and day 8-42 after delivery (32%). Public health facilities were the main places for care-seeking (48%) and death (49%). Thirty-four (92%) women who died from IMDs sought care from a health facility at least once during their terminal illness. However, most women experienced at least one of the "three delays" of health care. Other barriers were financial insolvency, care-seeking from unqualified providers, lack of health counselling, and the tendency of health facilities to avoid responsibilities. Conclusions IMMR remained unchanged at a high level during the last two decades. The high concentration of IMDs in pregnancy and the large share due to chronic health conditions indicate the need for preconception health check-ups. Awareness of maternal complications, proper care-seeking, and healthy reproductive practices may benefit. Improving regular and emergency maternal service readiness is essential.
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Affiliation(s)
- M Moinuddin Haider
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abu Bakkar Siddique
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sabrina Jabeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Aniqa Tasnim Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shusmita Khan
- Data for Impact, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Md Mahabubur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Fatema Tuz Zohora
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Nitai Chakraborty
- Data for Impact, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Quamrun Nahar
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Ahmed Ehsanur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Reardon DC, Thorp JM. Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis. SAGE Open Med 2017; 5:2050312117740490. [PMID: 29163945 PMCID: PMC5692130 DOI: 10.1177/2050312117740490] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 10/09/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Measures of pregnancy associated deaths provide important guidance for public health initiatives. Record linkage studies have significantly improved identification of deaths associated with childbirth but relatively few have also examined deaths associated with pregnancy loss even though higher rates of maternal death have been associated with the latter. Following PRISMA guidelines we undertook a systematic review of record linkage studies examining the relative mortality risks associated with pregnancy loss to develop a narrative synthesis, a meta-analysis, and to identify research opportunities. METHODS MEDLINE and SCOPUS were searched in July 2015 using combinations of: mortality, maternal death, record linkage, linked records, pregnancy associated mortality, and pregnancy associated death to identify papers using linkage of death certificates to independent records identifying pregnancy outcomes. Additional studies were identified by examining all citations for relevant studies. RESULTS Of 989 studies, 11 studies from three countries reported mortality rates associated with termination of pregnancy, miscarriage or failed pregnancy. Within a year of their pregnancy outcomes, women experiencing a pregnancy loss are over twice as likely to die compared to women giving birth. The heightened risk is apparent within 180 days and remains elevated for many years. There is a dose effect, with exposure to each pregnancy loss associated with increasing risk of death. Higher rates of death from suicide, accidents, homicide and some natural causes, such as circulatory diseases, may be from elevated stress and risk taking behaviors. CONCLUSIONS Both miscarriage and termination of pregnancy are markers for reduced life expectancy. This association should inform research and new public health initiatives including screening and interventions for patients exhibiting known risk factors.
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Affiliation(s)
| | - John M Thorp
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Calvert C, Ronsmans C. Pregnancy and HIV disease progression: a systematic review and meta-analysis. Trop Med Int Health 2015; 20:122-45. [PMID: 25358498 DOI: 10.1111/tmi.12412] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess whether pregnancy accelerates HIV disease progression. METHODS Studies comparing progression to HIV-related illness, low CD4 count, AIDS-defining illness, HIV-related death, or any death in HIV-infected pregnant and non-pregnant women were included. Relative risks (RR) for each outcome were combined using random effects meta-analysis and were stratified by antiretroviral therapy (ART) availability. RESULTS 15 studies met the inclusion criteria. Pregnancy was not associated with progression to HIV-related illness [summary RR: 1.32, 95% confidence interval (CI): 0.66-2.61], AIDS-defining illness (summary RR: 0.97, 95% CI: 0.74-1.25) or mortality (summary RR: 0.97, 95% CI: 0.62-1.53), but there was an association with low CD4 counts (summary RR: 1.41, 95% CI: 0.99-2.02) and HIV-related death (summary RR: 1.65, 95% CI: 1.06-2.57). In settings where ART was available, there was no evidence that pregnancy accelerated progress to HIV/AIDS-defining illnesses, death and drop in CD4 count. In settings without ART availability, effect estimates were consistent with pregnancy increasing the risk of progression to HIV/AIDS-defining illnesses and HIV-related or all-cause mortality, but there were too few studies to draw meaningful conclusions. CONCLUSIONS In the absence of ART, pregnancy is associated with small but appreciable increases in the risk of several negative HIV outcomes, but the evidence is too weak to draw firm conclusions. When ART is available, the effects of pregnancy on HIV disease progression are attenuated and there is little reason to discourage healthy HIV-infected women who desire to become pregnant from doing so.
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Affiliation(s)
- Clara Calvert
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Poorolajal J, Alafchi B, Najafi Vosoogh R, Hamzeh S, Ghahramani M. Risk factors for maternal mortality in the west of Iran: a nested case-control study. Epidemiol Health 2014; 36:e2014028. [PMID: 25381997 PMCID: PMC4271708 DOI: 10.4178/epih/e2014028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 11/08/2014] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES: With a gradual decline in maternal mortality in recent years in Iran, this study was conducted to identify the remaining risk factors for maternal death. METHODS: This 8-year nested case-control study was conducted in Hamadan Province, in the west of Iran, from April 2006 to March 2014. It included 185 women (37 cases and 148 controls). All maternal deaths that occurred during the study period were considered cases. For every case, four women with a live birth were selected as controls from the same area and date. Conditional logistic regression analysis was performed and the odds ratio (OR) and its 95% confidence interval (CI) were obtained for each risk factor. RESULTS: The majority of cases were aged 20-34 years, died in hospital, and lived in urban areas. The most common causes of death were bleeding, systemic disease, infection, and pre-eclampsia. The OR estimate of maternal death was 8.48 (95% CI=1.26-56.99) for advanced maternal age (≥35 years); 2.10 (95% CI=0.07-65.43) for underweight and 10.99 (95% CI=1.65-73.22) for overweight or obese women compared to those with normal weight; 1.56 (95% CI=1.08-2.25) for every unit increase in gravidity compared to those with one gravidity; 1.73 (95% CI=0.34-8.88) for preterm labors compared to term labors; and 17.54 (95% CI= 2.71-113.42) for women with systemic diseases. CONCLUSIONS: According to our results, advanced maternal age, abnormal body mass index, multiple gravidity, preterm labor, and systemic disease were the main risk factors for maternal death. However, more evidence based on large cohort studies in different settings is required to confirm our results.
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Affiliation(s)
- Jalal Poorolajal
- Modeling of Noncommunicable Disease Research Center, Department of Epidemiology and Biostatistics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Behnaz Alafchi
- Department of Epidemiology and Biostatistics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Roya Najafi Vosoogh
- Department of Epidemiology and Biostatistics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Sahar Hamzeh
- Department of Epidemiology and Biostatistics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Masoomeh Ghahramani
- Department of Family Planning, Vice-Chancellor of Health Services, Hamadan University of Medical Sciences, Hamadan, Iran
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Saleem S, McClure EM, Goudar SS, Patel A, Esamai F, Garces A, Chomba E, Althabe F, Moore J, Kodkany B, Pasha O, Belizan J, Mayansyan A, Derman RJ, Hibberd PL, Liechty EA, Krebs NF, Hambidge KM, Buekens P, Carlo WA, Wright LL, Koso-Thomas M, Jobe AH, Goldenberg RL. A prospective study of maternal, fetal and neonatal deaths in low- and middle-income countries. Bull World Health Organ 2014; 92:605-12. [PMID: 25177075 DOI: 10.2471/blt.13.127464] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 02/13/2014] [Accepted: 03/10/2014] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To quantify maternal, fetal and neonatal mortality in low- and middle-income countries, to identify when deaths occur and to identify relationships between maternal deaths and stillbirths and neonatal deaths. METHODS A prospective study of pregnancy outcomes was performed in 106 communities at seven sites in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. Pregnant women were enrolled and followed until six weeks postpartum. FINDINGS Between 2010 and 2012, 214,070 of 220,235 enrolled women (97.2%) completed follow-up. The maternal mortality ratio was 168 per 100,000 live births, ranging from 69 per 100,000 in Argentina to 316 per 100,000 in Pakistan. Overall, 29% (98/336) of maternal deaths occurred around the time of delivery: most were attributed to haemorrhage (86/336), pre-eclampsia or eclampsia (55/336) or sepsis (39/336). Around 70% (4349/6213) of stillbirths were probably intrapartum; 34% (1804/5230) of neonates died on the day of delivery and 14% (755/5230) died the day after. Stillbirths were more common in women who died than in those alive six weeks postpartum (risk ratio, RR: 9.48; 95% confidence interval, CI: 7.97-11.27), as were perinatal deaths (RR: 4.30; 95% CI: 3.26-5.67) and 7-day (RR: 3.94; 95% CI: 2.74-5.65) and 28-day neonatal deaths (RR: 7.36; 95% CI: 5.54-9.77). CONCLUSION Most maternal, fetal and neonatal deaths occurred at or around delivery and were attributed to preventable causes. Maternal death increased the risk of perinatal and neonatal death. Improving obstetric and neonatal care around the time of birth offers the greatest chance of reducing mortality.
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Affiliation(s)
- Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Elizabeth M McClure
- Social, Statistical and Environmental Sciences, RTI International, PO Box 12194, 3040 East Cornwallis Road, Durham, NC 27709-2194, United States of America (USA)
| | | | | | - Fabian Esamai
- Department of Pediatrics, Moi University, Eldoret, Kenya
| | - Ana Garces
- Universidad Francisco Marroquin, Guatemala City, Guatemala
| | - Elwyn Chomba
- Department of Pediatrics, University of Zambia, Lusaka, Zambia
| | | | - Janet Moore
- Social, Statistical and Environmental Sciences, RTI International, PO Box 12194, 3040 East Cornwallis Road, Durham, NC 27709-2194, United States of America (USA)
| | | | - Omrana Pasha
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Jose Belizan
- Institute of Clinical Effectiveness, Buenos Aires, Argentina
| | | | - Richard J Derman
- Department of Obstetrics and Gynecology, Christiana Health Care, Newark, USA
| | - Patricia L Hibberd
- Department of Pediatrics, Massachusetts General Hospital for Children, Boston, USA
| | - Edward A Liechty
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, USA
| | - Nancy F Krebs
- Department of Pediatrics, University of Colorado Health Sciences Center, Denver, USA
| | - K Michael Hambidge
- Department of Pediatrics, University of Colorado Health Sciences Center, Denver, USA
| | - Pierre Buekens
- Tulane University School of Public Health and Tropical Medicine, New Orleans, USA
| | | | - Linda L Wright
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, USA
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, USA
| | - Alan H Jobe
- Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, USA
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Yoshimatsu J, Ikeda T, Katsuragi S, Minematsu K, Toyoda K, Nagatsuka K, Naritomi H, Miyamoto S, Iihara K, Yamamoto H, Ohno Y. Factors contributing to mortality and morbidity in pregnancy-associated intracerebral hemorrhage in Japan. J Obstet Gynaecol Res 2014; 40:1267-73. [DOI: 10.1111/jog.12336] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 10/25/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Jun Yoshimatsu
- Department of Perinatology and Gynecology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology; Mie University; Osaka Japan
| | - Shinji Katsuragi
- Department of Obstetrics and Gynecology; Sakakibara Heart Institute; Tokyo Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Suita Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Suita Japan
| | - Kazuyuki Nagatsuka
- Department of Neurology; National Cerebral and Cardiovascular Center; Suita Japan
| | - Hiroaki Naritomi
- Department of Neurology; National Cerebral and Cardiovascular Center; Suita Japan
| | - Susumu Miyamoto
- Department of Neurosurgery; National Cerebral and Cardiovascular Center; Suita Japan
| | - Koji Iihara
- Department of Neurosurgery; National Cerebral and Cardiovascular Center; Suita Japan
| | - Haruko Yamamoto
- Advanced Medical Technology Development; National Cerebral and Cardiovascular Center; Suita Japan
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Garenne M, Kahn K, Collinson M, Gómez-Olivé X, Tollman S. Protective effect of pregnancy in rural South Africa: questioning the concept of "indirect cause" of maternal death. PLoS One 2013; 8:e64414. [PMID: 23675536 PMCID: PMC3652829 DOI: 10.1371/journal.pone.0064414] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 04/12/2013] [Indexed: 11/18/2022] Open
Abstract
Background Measurement of the level and composition of maternal mortality depends on the definition used, with inconsistencies leading to inflated rates and invalid comparisons across settings. This study investigates the differences in risk of death for women in their reproductive years during and outside the maternal risk period (pregnancy, delivery, puerperium), focusing on specific causes of infectious, non-communicable and external causes of death after separating out direct obstetrical causes. Methods Data on all deaths of women aged 15–49 years that occurred in the Agincourt sub-district between 1992 and 2010 were obtained from the Agincourt health and socio-demographic surveillance system (HDSS) located in rural South Africa. Causes of death were assessed using a validated verbal autopsy instrument. Analysis included 2170 deaths, of which 137 occurred during the maternal risk period. Findings Overall, women had significantly lower mortality during the maternal risk period than outside it (age-standardized RR = 0.75; 95% CI = 0.63–0.89). This was true in most age groups with the exception of adolescents aged 15–19 years where the risk of death was higher. Mortality from most causes, other than obstetric causes, was lower during the maternal risk period except for malaria, cardiovascular diseases and violence where there were no differences. Lower mortality was significant for HIV/AIDS (RR = 0.29, P<0.0001), cancers (RR = 0.10, P<0.023), and accidents (RR = 0, P<0.0001). Interpretation In this rural setting typical of much of Southern Africa, pregnancy was largely protective against the risk of death, most likely because of a strong selection effect amongst those women who conceived successfully. The concept of indirect cause of maternal death needs to be re-examined.
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Affiliation(s)
- Michel Garenne
- MRC/Wits Rural Public Health and Health Transitions Research Unit-Agincourt, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Garenne M. Estimating obstetric mortality from pregnancy-related deaths recorded in demographic censuses and surveys. Stud Fam Plann 2012; 42:237-46. [PMID: 22292243 DOI: 10.1111/j.1728-4465.2011.00287.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Demographic surveys and censuses often record pregnancy-related deaths, defined as those occurring during the maternal risk period (pregnancy, delivery, and six weeks postpartum), but do not include cause of death. This study presents a method for estimating obstetric mortality from pregnancy-related deaths data. Calculations are based on multiple-decrement life tables, and data needed are simply age-specific fertility and mortality rates that are commonly available in Demographic and Health Survey (DHS) or census data, and an estimate of the relative risk of death from nonobstetric causes during the maternal risk period. The method is tested on 59 DHS surveys from Africa. Results show that, on average, less than half of the pregnancy-related deaths are attributable to obstetric causes. This proportion varies with the level of mortality and fertility, and in particular with the prevalence of HIV in the population.
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Maternal mortality in South Africa: An update from the 2007 Community Survey. JOURNAL OF POPULATION RESEARCH 2010; 8:89-101. [PMID: 22984345 DOI: 10.1007/s12546-010-9037-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The 2007 Community Survey conducted in South Africa included questions on maternal deaths in the previous 12 months (pregnancy-related deaths). The Maternal Mortality Ratio (MMR) was estimated at 700 per 100,000 live births, some 30% more than at the 2001 census. This high level occurred despite a low proportion of maternal deaths (4.3%) among deaths of women aged 15-49 years, which was even lower than the proportion of time spent in the maternal risk period (7.6%). The high level of MMR was due to the astonishingly high level of adult mortality, which increased by 46% since 2001. The main reasons for these excessive levels were HIV/AIDS and external causes of death (accidents and violence). Differentials in MMR were very marked, and similar to those found in 2001 with respect to urban residence, race, province, education, income, and wealth. Provincial levels of MMR correlated primarily with HIV/AIDS prevalence. Maternal mortality defined as `pregnancy-related death' appears no longer as a proper indicator of `safe motherhood' in this situation.
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Garenne M, McCaa R, Nacro K. Maternal mortality in South Africa in 2001: From demographic census to epidemiological investigation. Popul Health Metr 2008; 6:4. [PMID: 18718008 PMCID: PMC2533290 DOI: 10.1186/1478-7954-6-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Accepted: 08/21/2008] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Maternal mortality remains poorly researched in Africa, and is likely to worsen dramatically as a consequence of HIV/AIDS. METHODS The 2001 census of South Africa included a question on deaths in the previous 12 months, and two questions on external causes and maternal mortality, defined as "pregnancy-related deaths". A microdata sample from the census permits researchers to assess levels and differentials in maternal mortality, in a country severely affected by high death rates from HIV/AIDS and from external causes. RESULTS After correcting for several minor biases, our estimate of the Maternal Mortality Ratio (MMR) in 2001 was 542 per 100,000 live births. This level is much higher than previous estimates dating from pre-HIV/AIDS times. This high level occurred despite a relatively low proportion of maternal deaths (6.4%) among deaths of women aged 15-49 years, and was due to the astonishingly high level of adult mortality, some 4.7 times higher than expected from mortality below age 15 or above age 50. The main reasons for these excessive levels were HIV/AIDS and external causes of deaths. Our regional estimates of MMR were found to be consistent with other findings in the Cape Town area, and with the Agincourt DSS. The differentials in MMR were considerable: 1 to 9.2 for population groups (race), 1 to 3.2 for provinces, and 1 to 2.4 for levels of education. Relationship with income and wealth were complex, with highest values for middle income and middle wealth index. The effect of urbanization was small, and reversed in a multivariate analysis. Higher risks in provinces were not necessarily associated with lower income, lower education or higher proportions of home delivery, but correlated primarily with the prevalence of HIV/AIDS. CONCLUSION Demographic census microdata offer the opportunity to conduct an epidemiologic analysis of maternal mortality. In the case of South Africa, the level of MMR increased dramatically over the past 10 years, most likely because of HIV/AIDS. Indirect causes of maternal deaths appear much more important than direct obstetric causes. The MMR appears no longer to be a reliable measure of the quality of obstetric care or a measure of safe motherhood.
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Affiliation(s)
- Michel Garenne
- French Institute for Research and Development (IRD) and Institut Pasteur, Paris, France
| | - Robert McCaa
- Minnesota Population Center, University of Minnesota, USA, and Coordinator of the IPUMS-International project, USA
| | - Kourtoum Nacro
- United Fund for Population Activities (UNFPA), New York, USA
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Hurt LS, Alam N, Dieltiens G, Aktar N, Ronsmans C. Duration and magnitude of mortality after pregnancy in rural Bangladesh. Int J Epidemiol 2008; 37:397-404. [PMID: 18276635 DOI: 10.1093/ije/dym274] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Women remain at increased risk of mortality for some time after pregnancy although the length of this period is unclear. The aim of this study is to examine mortality after pregnancy in rural Bangladesh using data from a unique demographic surveillance system. METHODS We included all person-time in women aged 15-50 between 1983 and 2001 and compared mortality rates by time since pregnancy outcome (live birth, stillbirth, induced and spontaneous abortion) using Poisson regression, adjusting for socio-demographic factors. RESULTS Mortality was highest on the first day after pregnancy (adjusted RR compared with third to fourth year post-partum 105.74, 95% CI: 76.08, 146.95) and remained elevated until 180 days (adjusted RR 1.55, 95% CI: 1.13, 2.11). Pregnancies ending in abortions and stillbirths accounted for 50% of deaths in women within 6 weeks of the end of pregnancy, and mortality after these outcomes was between two and four times as high as mortality after a livebirth. CONCLUSION The high mortality rates immediately after birth provide strong support for a skilled attendance strategy. After abortions or stillbirths, women should be under surveillance for up to 1 week. Further work on the cause of deaths in the late post-partum period is required to understand the mechanisms behind increased mortality risks at these times.
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Affiliation(s)
- Lisa Sioned Hurt
- Nutrition and Public Health Intervention Research Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
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Lieve VDP, Shafer LA, Mayanja BN, Whitworth JAG, Grosskurth H. Effect of pregnancy on HIV disease progression and survival among women in rural Uganda. Trop Med Int Health 2007; 12:920-8. [PMID: 17697086 DOI: 10.1111/j.1365-3156.2007.001873.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the effect of pregnancy on HIV disease progression and survival among HIV-infected women in rural Uganda, prior to the introduction of anti-retroviral therapy (ART). METHODS From a clinical cohort established in 1990, we selected records from HIV-infected women of reproductive age. We conducted two analyses: (1) all HIV-infected cases contributing to analysis of CD4 decline, using a linear regression model with random intercepts and slopes; (b) incident cases with known date of seroconversion contributed to analyses of median time to CD4 <200 cells/microl, AIDS and death. RESULTS A total of 139 women were included in the analysis of CD4 decline. Women who subsequently became pregnant had higher CD4 counts at enrolment and had a slower CD4 decline than those who did not become pregnant. In women who became pregnant, CD4 decline was faster after pregnancy than before (P < 0.0001). The survival analyses showed no significant differences between women who became pregnant and those who did not with respect to median time to CD4 count <200, AIDS or death. CONCLUSIONS The initial comparative immunological advantage possessed by fertile women before they become pregnant is subsequently lost as a result of their pregnancy. Women should be informed about the potential negative effect of pregnancy on their immunological status and should be offered contraception. In resource-limited settings, women determined to become pregnant should be given priority for ART if eligible.
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Bollen KA, Glanville JL, Stecklov G. Socio-economic status, permanent income, and fertility: a latent-variable approach. Population Studies 2007; 61:15-34. [PMID: 17365871 DOI: 10.1080/00324720601103866] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This paper examines how permanent income and other components of socio-economic status (SES) are related to fertility in less developed countries. Because permanent income cannot be measured directly, we employ a latent-variable method. We compare our results with those of the more common proxy-variable method and investigate the consequences of not accounting for measurement error. Using data from Ghana and Peru, we find that permanent income has a large, negative influence on fertility and that research must take the latent nature of permanent income into account to uncover its influence. Controlling for measurement error in the proxies for permanent income can also lead to substantial changes in the estimated effects of control variables. Finally, we examine which of the common proxies for permanent income most closely capture the concept. The results have implications beyond this specific dependent variable, providing evidence on the sensitivity of microanalyses to the treatment of long-term economic status.
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Khlat M, Guillaume A. [Pregnancy-related deaths. Genesis of the concept and methodological aspects]. Rev Epidemiol Sante Publique 2006; 54:543-9. [PMID: 17194985 DOI: 10.1016/s0398-7620(06)76753-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Within the past 10 years, the outlook on the causes underlying maternal deaths has evolved, with the advent in the last "International classification of diseases" of the concepts of late maternal mortality and pregnancy-related mortality. Those concepts have led to an enlargement of the field, in terms of the range of causes as well as of the length of the time period at risk. Causes of death traditionally considered as "fortuitous" are now included in the count, given that the notion of pregnancy-related mortality covers all deaths occurring during pregnancy or at the latest one year after pregnancy termination, whatever the cause. Given this background, we critically review the definitions and classification systems of deaths of pregnant or post-partum women, and discuss the philosophy underlying these conceptual changes, and their consequences in terms of data collection and measurement issues.
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Affiliation(s)
- M Khlat
- Institut National d'Etudes Démographiques, 133, boulevard Davout, 75980 Paris Cedex 20.
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Hurt LS, Ronsmans C, Thomas SL. The effect of number of births on women's mortality: systematic review of the evidence for women who have completed their childbearing. Population Studies 2006; 60:55-71. [PMID: 16464775 DOI: 10.1080/00324720500436011] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Mortality in women who have completed their childbearing may increase with the number of births experienced because of maternal depletion or a trade-off between reproduction and mortality. We report a systematic review of the evidence on this association. We searched Medline, Embase, Popline, and the Science Citation Index for published and unpublished studies up to September 2003, and the book catalogues of relevant London libraries. Where necessary we also contacted authors for additional information. Mortality declined with increasing numbers of births in twelve historical cohorts, but in eight contemporary cohorts the highest mortality was seen in the nulliparous and in women with more than four births. All effects seen were small and there were few statistically significant results. Studies examining the relationship in other ways (such as by linear trends or by mean number of births by age at death) found inconsistent associations. We discuss methodological, social, and biological factors that may have affected these associations.
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Affiliation(s)
- L S Hurt
- Nutrition and Public Health Intervention Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Kintampo Health Research Centre, Brong Ahafo, Ghana.
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Burke SDA, Sawchuk LA. Tuberculosis mortality and recent childbirth: a retrospective case-control study of Gibraltarian women, 1874-1884. Soc Sci Med 2003; 56:477-90. [PMID: 12570968 DOI: 10.1016/s0277-9536(02)00048-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Prior to the introduction of effective treatment for pulmonary tuberculosis, there was little consensus on the potential health risk of pregnancy among infected women. While, intuitively, pregnancy was viewed as a risk for tuberculosis disease and mortality, early studies could not establish such a link with any great certainty. Our case study combines the methods of family reconstitution and a case-control approach to explore the possibility that the physiological and social strains of recent childbirth and the early mothering of infants may have been risk factors in adult female tuberculosis mortality in late 19th-century Gibraltar. The study is based on 244 reproductive age women who died between 1874 and 1884; some 55% of these deaths were attributed to tuberculosis. The record linkage indicates that almost 12% of the women who died had given birth within the year preceding their death. Factoring in the effects of age at death, marital status, and religion, the logistic regression results indicate that recent childbirth did not increase the risk of tuberculosis mortality among these women.
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Affiliation(s)
- Stacie D A Burke
- Department of Anthropology, McMaster University, 1280 Main Street West, Ont., L8S 4L9, Hamilton, Canada.
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Goodburn E. Commentary: Evidence for a ‘healthy pregnant woman effect’ in Niakhar, Senegal? Int J Epidemiol 2001. [DOI: 10.1093/ije/30.3.474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ronsmans C, Khlat M, Kodio B, Ba M, De Bernis L, Etard J. Evidence for a 'healthy pregnant woman effect' in Niakhar, Senegal? Int J Epidemiol 2001; 30:467-73; discussion 474-5. [PMID: 11416066 DOI: 10.1093/ije/30.3.467] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although it is generally believed that pregnancy exposes women to a wide variety of excess health risks that go beyond the direct obstetric complications of pregnancy, the epidemiological evidence in support of such excess indirect risks is inconclusive. In this article we attempt to document the contribution of indirect causes of death to maternal mortality in rural Senegal by using an epidemiological approach whereby the time spent during pregnancy and postpartum is considered a transient period of exposure to the health hazards of childbearing. METHODS We use data from an ongoing demographic surveillance system in Niakhar, Senegal and calculate rate ratios comparing death rates in pregnant or recently pregnant women (exposed) with death rates in other women (unexposed), including and excluding direct obstetric deaths. RESULTS Between ages 20 and 44, pregnancy does not confer additional risks to women. After excluding direct obstetric deaths, exposed women aged 20--39 have surprisingly lower risks of death than unexposed women of the same age. For the very young (15-19) and the very old (45-49), on the other hand, the excess risks associated with pregnancy are considerable and, among women age 45 or older, persist even after excluding direct obstetric deaths. CONCLUSION The apparent protective effect of pregnancy on women's health that is observed in this study illustrates the paradoxical nature of the concept of indirect causes of maternal mortality, and the difficulties in measuring the risks of death attributable to the pregnancy. Further studies aimed at separating risks attributable to the pregnancy from those that are incidental to the pregnancy are required.
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Affiliation(s)
- C Ronsmans
- Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, UK.
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Abstract
The contribution of violence to mortality during pregnancy remains controversial. In this study in Bangladesh, pregnant adolescents had a three-fold increase in mortality from intentional and unintentional injuries compared with girls who were not pregnant.
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