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Tajvar M, Hajizadeh A, Zalvand R. A systematic review of individual and ecological determinants of maternal mortality in the world based on the income level of countries. BMC Public Health 2022; 22:2354. [PMID: 36522731 PMCID: PMC9753301 DOI: 10.1186/s12889-022-14686-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This systematic review was conducted to map the literature on all the existing evidence regarding individual and ecological determinants of maternal mortality in the world and to classify them based on the income level of countries. Such a systematic review had not been conducted before. METHODS We conducted an electronic search for primary and review articles using "Maternal Mortality" and "Determinant" as keywords or MeSH terms in their Title or Abstract, indexed in Scopus, PubMed, and Google with no time or geographical limitation and also hand searching was performed for most relevant journals. STROBE and Glasgow university critical appraisal checklists were used for quality assessment of the included studies. Data of the determinants were extracted and classified into individual or ecological categories based on income level of the countries according to World Bank classification. RESULTS In this review, 109 original studies and 12 review articles from 33 countries or at global level met the inclusion criteria. Most studies were published after 2013. Most literature studied determinants of low and lower-middle-income countries. The most important individual determinants in low and lower-middle-income countries were location of birth, maternal education, any delays in health services seeking, prenatal care and skilled birth attendance. Household-related determinants in low-income countries included improved water source and sanitation system, region of residence, house condition, wealth of household, and husband education. Additionally, ecological determinants including human resources, access to medical equipment and facilities, total fertility rate, health financing system, country income, poverty rate, governance, education, employment, social protection, gender inequality, and human development index were found to be important contributors in maternal mortality. A few factors were more important in higher-income countries than lower-income countries including parity, IVF births, older mothers, and type of delivery. CONCLUSION A comprehensive list of factors associated with maternal death was gathered through this systematic review, most of which were related to lower-income countries. It seems that the income level of the countries makes a significant difference in determinants of maternal mortality in the world.
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Affiliation(s)
- Maryam Tajvar
- grid.411705.60000 0001 0166 0922Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Hajizadeh
- grid.411705.60000 0001 0166 0922Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Rostam Zalvand
- grid.411705.60000 0001 0166 0922Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Li D, Yu C, Song C, Ning W, Xu Y, Ge H, Lin S, Zhou W, Lu Y, Wang X, Hu Z, Lin Y, Wu J. Maternal mortality ratio in Jiangsu Province, China: recent trends and associated factors. BMC Pregnancy Childbirth 2021; 21:447. [PMID: 34172025 PMCID: PMC8235612 DOI: 10.1186/s12884-021-03897-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/17/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In recent years, births to older mothers and multiparous mothers have increased rapidly with the change of birth policy in China. And mothers of advanced age are more likely to have maternal complications and poor birth outcomes. We aimed to estimate the recent trends and underlying risk factors of maternal mortality. METHODS In this systematic assessment, we used data from the National Maternal and Child Health Routine Reporting System (2013-2018), Jiangsu Provincial Maternal Mortality Surveillance System (2017-2018), the Integrated National Mortality Surveillance System (2018), City Statistical Yearbooks (2018), City Health Statistical Yearbooks (2018). The factors associated with maternal mortality ratio (MMR) were explored using the stepwise regression analysis and cluster analysis. RESULTS The MMR maintained at low levels between 2013 and 2016 and there was a slight increase in maternal mortality after 2016 in Jiangsu province. With the implementation of the China's universal two child policies, the percentage of multiparous mothers ascended from 34.2% (95% confidence interval (CI) = 34.1-34.3%) in 2013 to 51.4% (95% CI = 51.3-51.6%) in 2018 (beta = 3.88, P < 0.001). Consistently, the percentage of advanced maternal age (≥ 35) increased from 8.4% (95% CI = 8.4-8.5%) in 2013 to 10.4% (95% CI = 10.3-10.4%) in 2018 (beta = 0.50, P = 0.012). And we found that the percentage of multiparous mothers and advanced maternal age among maternal deaths were higher than all pregnant women (P < 0.001). In the stepwise regression analysis, four risk factors were significantly associated with maternal mortality ratio (primary industry of gross domestic product (GDP), rate of delivery in maternal and child health hospital, rate of cesarean section and rate of low birth weight). As the results derived from cluster analysis, the relatively developed regions had lower preventable maternal mortality ratio (43.5% (95% CI = 31.2-56.7%) vs. 62.6% (95% CI = 52.3-72.0%), P = 0.027). CONCLUSIONS Since the universal two child policy has been associated with changes in health related birth characteristics: women giving birth have been more likely to be multiparous, and more likely to be aged 35 and over. This somewhat magnifies the impact of differences in economic development and obstetric services on MMR. The findings based on prefecture level data suggest that interventions must target economic development, the health system and maternal risk factors in synergy. These approaches will be of great benefit to control or diminish environmental factors associated with preventable deaths and will effectively reduce MMR and narrow the gap among the different regions.
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Affiliation(s)
- Donghua Li
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Chengxiao Yu
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, 211166, China
| | - Ci Song
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, 211166, China
| | - Weiqing Ning
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Yan Xu
- Department of Women and Children, Jiangsu Provincial Commission of Health, Nanjing, 210008, China
| | - Huan Ge
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Song Lin
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Wenjie Zhou
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Yajun Lu
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Xudong Wang
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Zhibin Hu
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, 211166, China
| | - Yuan Lin
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, China.
| | - Jie Wu
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China.
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Huang J, Lu H, Li J, Zhou N, Zang Y, Ren L, Wang J. Comparison of midwives' self-perceived essential competencies between low and high maternal mortality ratio provinces in China. J Clin Nurs 2020; 29:4733-4747. [PMID: 32979861 DOI: 10.1111/jocn.15514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 09/12/2020] [Accepted: 09/16/2020] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To present and compare midwives' self-perceived essential competencies in regions with different maternal mortality ratios, and explore possible competency-related factors. BACKGROUND In China, there is an urgent need for high-quality maternal health care with equal access, as the regional disparity in the maternal mortality ratio remains a big challenge. Midwives' essential competencies refer to the minimum knowledge, skills, and professional behaviours required by midwives, and directly affect the quality of maternal care they provide. However, there is very limited literature evaluating Chinese midwives' essential competencies, especially for midwives working in regions with high maternal mortality ratios. DESIGN A cross-sectional survey design. METHODS The national cross-sectional study using an online questionnaire was conducted with a convenience sample of 2,022 midwives working in regions with different maternal mortality ratios. The STROBE guideline for cross-sectional studies was used in this study. RESULTS Midwives rated themselves higher on their essential competencies in intrapartum care and lower on their essential competencies in assisting or performing the operative vaginal delivery. Specifically, when compared to those from regions of low maternal mortality ratios, midwives from regions with high maternal mortality ratios reported comparatively poor self-perceived essential competencies, especially in the area of detecting and treating pregnancy and childbirth-related complications. The factors influencing midwives' self-perceived essential competencies included majors, education levels, years of experience as a midwife, participation in teaching, and access to in-service training. CONCLUSION In regions with high maternal mortality ratios, improving midwives' essential competencies is a key priority. Furthermore, it is recommended that midwifery education could be conducted in universities, and relevant regulations could be developed to enable midwives to provide a wider scope of care, thereby promoting the development of the midwifery workforce in China. RELEVANCE TO CLINICAL PRACTICE Understanding self-perceived essential competencies of Chinese midwives working in regions with different maternal mortality ratios could guide the midwifery workforce, management, especially midwives' capability building.
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Affiliation(s)
- Jing Huang
- School of Nursing, Peking University, Beijing, China
| | - Hong Lu
- School of Nursing, Peking University, Beijing, China
| | - Jie Li
- School of Nursing, Peking University, Beijing, China
| | - Nan Zhou
- School of Nursing, Peking University, Beijing, China
| | - Yu Zang
- School of Nursing, Peking University, Beijing, China.,School of Nursing, Hebei Medical University, Shijiazhuang, China
| | - Lihua Ren
- School of Nursing, Peking University, Beijing, China
| | - Jianying Wang
- Delivery Room, The Xibei Hospital for Women and Children, Xian, China
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Abstract
BACKGROUND Although prior studies of inpatient maternal mortality in the United States provide data on the overall rate and trend in inpatient maternal mortality, there are no published reports of maternal mortality data stratified by timing of its occurrence across the pregnancy continuum (antepartum, intrapartum, and postpartum). OBJECTIVE The study objective was to determine whether the maternal mortality rate, trends over time, self-reported race/ethnicity, and associated factors vary based on the timing of the occurrence of death during pregnancy. METHODS We conducted a cross-sectional analysis of the Nationwide Inpatient Sample database to identify pregnancy-related inpatient stays stratified by timing. Among women in the sample, we determined in-hospital mortality and used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify comorbidities and behavioral characteristics associated with mortality, including alcohol, drug, and tobacco use. Joinpoint regression was used to calculate rates and trends of in-hospital maternal mortality. RESULTS During the study period, there were 7,411 inpatient maternal mortalities among an estimated 58,742,179 hospitalizations of women 15-49 years of age. In-hospital maternal mortality rate stratified by race showed that African Americans died at significantly higher rates during antepartum, intrapartum, and postpartum periods compared to hospitalizations for Whites or Hispanics during the same time period. Although the postpartum hospitalization represents only 2% of pregnancy-related hospitalizations among women aged 15-49 years, hospitalization during this time period accounted for 27.2% of all maternal deaths during pregnancy-related hospitalization. DISCUSSION Most in-hospital maternal mortalities occur after hospital discharge from child birth (postpartum period). Yet, the postpartum period continues to be the time period with the least maternal healthcare surveillance in the pregnancy continuum. African American women experience three times more in-hospital mortality when compared to their White counterparts.
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Xiao H, Zhang H, Wang D, Shen C, Xu Z, Zhang Y, Jiang G, Yang G, Wan X, Naghavi M. Impact of smoke-free legislation on acute myocardial infarction and stroke mortality: Tianjin, China, 2007-2015. Tob Control 2019; 29:61-67. [PMID: 30692165 PMCID: PMC6952839 DOI: 10.1136/tobaccocontrol-2018-054477] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/26/2018] [Accepted: 10/03/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Smoke-free legislation is an effective way to protect the population from the harms of secondhand smoke and has been implemented in many countries. On 31 May 2012, Tianjin became one of the few cities in China to implement smoke-free legislation. We investigated the impact of smoke-free legislation on mortality due to acute myocardial infarction (AMI) and stroke in Tianjin. METHODS An interrupted time series design adjusting for underlying secular trends, seasonal patterns, population size changes and meteorological factors was conducted to analyse the impact of the smoke-free law on the weekly mortality due to AMI and stroke. The study period was from 1 January 2007 to 31 December 2015, with a 3.5-year postlegislation follow-up. RESULTS Following the implementation of the smoke-free law, there was a decline in the annual trends of AMI and stroke mortality. An incremental 16% (rate ratio (RR): 0.84; 95% CI: 0.83 to 0.85) decrease per year in AMI mortality and a 2% (RR: 0.98; 95% CI: 0.97 to 0.99) annual decrease in stroke mortality among the population aged ≥35 years in Tianjin was observed. Immediate postlegislation reductions in mortality were not statistically significant. An estimated 10 000 (22%) AMI deaths were prevented within 3.5 years of the implementation of the law. CONCLUSION The smoke-free law in Tianjin was associated with reductions in AMI mortality. This study reinforces the need for large-scale, effective and comprehensive smoke-free laws at the national level in China.
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Affiliation(s)
- Hong Xiao
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Hui Zhang
- Tianjin Centers for Disease Control and Prevention, Tianjin, China
| | - Dezheng Wang
- Tianjin Centers for Disease Control and Prevention, Tianjin, China
| | - Chengfeng Shen
- Tianjin Centers for Disease Control and Prevention, Tianjin, China
| | - Zhongliang Xu
- Tianjin Centers for Disease Control and Prevention, Tianjin, China
| | - Ying Zhang
- Tianjin Centers for Disease Control and Prevention, Tianjin, China
| | - Guohong Jiang
- Tianjin Centers for Disease Control and Prevention, Tianjin, China
| | - Gonghuan Yang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences/School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xia Wan
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences/School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
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Liang J, Li X, Kang C, Wang Y, Kulikoff XR, Coates MM, Ng M, Luo S, Mu Y, Wang X, Zhou R, Liu X, Zhang Y, Zhou Y, Zhou M, Li Q, Liu Z, Dai L, Li M, Zhang Y, Deng K, Zeng X, Deng C, Yi L, Zhu J, Murray CJL, Wang H. Maternal mortality ratios in 2852 Chinese counties, 1996-2015, and achievement of Millennium Development Goal 5 in China: a subnational analysis of the Global Burden of Disease Study 2016. Lancet 2019; 393:241-252. [PMID: 30554785 PMCID: PMC6336935 DOI: 10.1016/s0140-6736(18)31712-4] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 07/04/2018] [Accepted: 07/19/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND As one of only a handful of countries that have achieved both Millennium Development Goals (MDGs) 4 and 5, China has substantially lowered maternal mortality in the past two decades. Little is known, however, about the levels and trends of maternal mortality at the county level in China. METHODS Using a national registration system of maternal mortality at the county level, we estimated the maternal mortality ratios for 2852 counties in China between 1996 and 2015. We used a state-of-the-art Bayesian small-area estimation hierarchical model with latent Gaussian layers to account for space and time correlations among neighbouring counties. Estimates at the county level were then scaled to be consistent with country-level estimates of maternal mortality for China, which were separately estimated from multiple data sources. We also assessed maternal mortality ratios among ethnic minorities in China and computed Gini coefficients of inequality of maternal mortality ratios at the country and provincial levels. FINDINGS China as a country has experienced fast decline in maternal mortality ratios, from 108·7 per 100 000 livebirths in 1996 to 21·8 per 100 000 livebirths in 2015, with an annualised rate of decline of 8·5% per year, which is much faster than the target pace in MDG 5. However, we found substantial heterogeneity in levels and trends at the county level. In 1996, the range of maternal mortality ratios by county was 16·8 per 100 000 livebirths in Shantou, Guangdong, to 3510·3 per 100 000 livebirths in Zanda County, Tibet. Almost all counties showed remarkable decline in maternal mortality ratios in the two decades regardless of those in 1996. The annualised rate of decline across counties from 1996 to 2015 ranges from 4·4% to 12·9%, and 2838 (99·5%) of the 2852 counties had achieved the MDG 5 pace of decline. Decline accelerated between 2005 and 2015 compared with between 1996 and 2005. In 2015, the lowest county-level maternal mortality ratio was 3·4 per 100 000 livebirths in Nanhu District, Zhejiang Province. The highest was still in Zanda County, Tibet, but the fall to 830·5 per 100 000 livebirths was only 76·3%. 26 ethnic groups had population majorities in at least one county in China, and all had achieved declines in maternal mortality ratios in line with the pace of MDG 5. Intercounty Gini coefficients for maternal mortality ratio have declined at the national level in China, indicating improved equality, whereas trends in inequality at the provincial level varied. INTERPRETATION In the past two decades, maternal mortality ratios have reduced rapidly and universally across China at the county level. Fast improvement in maternal mortality ratios is possible even in less economically developed places with resource constraints. This finding has important implications for improving maternal mortality ratios in developing countries in the Sustainable Development Goal era. FUNDING National Health and Family Planning Commission of the People's Republic of China, China Medical Board, WHO, University of Washington Center for Demography and Economics of Aging, Bill & Melinda Gates Foundation.
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Affiliation(s)
- Juan Liang
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaohong Li
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China; National Center for Birth Defect Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chuyun Kang
- Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University, Beijing, China; Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Yanping Wang
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xie Rachel Kulikoff
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Matthew M Coates
- Department of Global Health and Social Medicine, Harvard University, Boston, MA, USA
| | - Marie Ng
- IBM Watson Health, San Jose, CA, USA
| | - Shusheng Luo
- Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University, Beijing, China
| | - Yi Mu
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaodong Wang
- Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rong Zhou
- Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xinghui Liu
- Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yali Zhang
- Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University, Beijing, China; Institute of Reproductive and Child Health, Ministry of Health Key Laboratory of Reproductive Health, Peking University, Beijing, China
| | - Yubo Zhou
- Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University, Beijing, China; Institute of Reproductive and Child Health, Ministry of Health Key Laboratory of Reproductive Health, Peking University, Beijing, China
| | - Maigeng Zhou
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Qi Li
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zheng Liu
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Dai
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mingrong Li
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yiyi Zhang
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kui Deng
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xinying Zeng
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Changfei Deng
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ling Yi
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Zhu
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
| | - Haidong Wang
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
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Yakubu Y, Mohamed Nor N, Abidin EZ. A systematic review of micro correlates of maternal mortality. REVIEWS ON ENVIRONMENTAL HEALTH 2018; 33:147-161. [PMID: 29729149 DOI: 10.1515/reveh-2017-0050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 04/12/2018] [Indexed: 06/08/2023]
Abstract
In the year 2000, the World Health Organization launched the Millennium Development Goals (MDGs) which were to be achieved in 2015. Though most of the goals were not achieved, a follow-up post 2015 development agenda, the Sustainable Development Goals (SDGs) was launched in 2015, which are to be achieved by 2030. Maternal mortality reduction is a focal goal in both the MDGs and SDGs. Achieving the maternal mortality target in the SDGs requires multiple approaches, particularly in developing countries with high maternal mortality. Low-income developing countries rely to a great extent on macro determinants such as public health expenditure, which are spent mostly on curative health and health facilities, to improve population health. To complement the macro determinants, this study employs the systematic review technique to reveal significant micro correlates of maternal mortality. The study searched MEDLINE, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Science Direct, and Global Index Medicus of the World Health Organization. Our search was time framed from the 1st January, 2000 to the 30th September, 2016. In the overall search result, 6758 articles were identified, out of which 33 were found to be eligible for the review. The outcome of the systematic search for relevant literature revealed a concentration of literature on the micro factors and maternal mortality in developing countries. This shows that maternal mortality and micro factors are a major issue in developing countries. The studies reviewed support the significant relationship between the micro factors and maternal mortality. This study therefore suggests that more effort should be channelled to improving the micro factors in developing countries to pave the way for the timely achievement of the SDGs' maternal mortality ratio (MMR) target.
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Affiliation(s)
- Yahaya Yakubu
- Department of Economics, Faculty of Economics and Management, University Putra Malaysia, Selangor, Malaysia
- Department of Economics, Faculty of Social and Management Sciences, Bauchi State University Gadau, Bauchi State, Nigeria
| | - Norashidah Mohamed Nor
- Department of Economics, Faculty of Economics and Management, University Putra Malaysia, Selangor, Malaysia
| | - Emilia Zainal Abidin
- Department of Environmental and Occupational Health, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia
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Ren Y, Qian P, Duan Z, Zhao Z, Pan J, Yang M. Disparities in health system input between minority and non-minority counties and their effects on maternal mortality in Sichuan province of western China. BMC Public Health 2017; 17:750. [PMID: 28962594 PMCID: PMC5622414 DOI: 10.1186/s12889-017-4765-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/15/2017] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND The maternal mortality rate (MMR) markedly decreased in China, but there has been a significant imbalance among different geographic regions (east, central and west regions), and the mortality in the western region remains high. This study aims to examine how much disparity in the health system and MMR between ethnic minority and non-minority counties exists in Sichuan province of western China and measures conceivable commitments of the health system determinants of the disparity in MMR. METHODS The MMR and health system data of 67 minority and 116 non-minority counties were taken from Sichuan provincial official sources. The 2-level Poisson regression model was used to identify health system determinants. A series of nested models with different health system factors were fitted to decide contribution of each factor to the disparity in MMR. RESULTS The MMR decreased over the last decade, with the fastest declining rate from 2006 to 2010. The minority counties experienced higher raw MMR in 2002 than non-minority counties (94.4 VS. 58.2), which still remained higher in 2014 (35.7 VS. 14.3), but the disparity of raw MMR between minority and non-minority counties decreased from 36.2 to 21.4. The better socio-economic condition, more health human resources and higher maternal health care services rate were associated with lower MMR. Hospital delivery rate alone explained 74.5% of the difference in MMR between minority and non-minority counties. All health system indicators together explained 97.6% of the ethnic difference in MMR, 59.8% in the change trend, and 66.3% county level variation respectively. CONCLUSIONS Hospital delivery rate mainly determined disparity in MMR between minority and non-minority counties in Sichuan province. Increasing hospital birth rates among ethnic minority counties may narrow the disparity in MMR by more than two-thirds of the current level.
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Affiliation(s)
- Yan Ren
- West China School of Public Health, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Ping Qian
- Sichuan Provincial Maternal and Child Health Hospital, Chengdu, Sichuan, People's Republic of China
| | - Zhanqi Duan
- Health and Family Planning Information Centre of Sichuan Province, Chengdu, Sichuan, People's Republic of China
| | - Ziling Zhao
- Sichuan Provincial Maternal and Child Health Hospital, Chengdu, Sichuan, People's Republic of China
| | - Jay Pan
- West China School of Public Health, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China.,West China Research Center for Rural Health Development, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Min Yang
- West China School of Public Health, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China. .,West China Research Center for Rural Health Development, Sichuan University, Chengdu, Sichuan, People's Republic of China. .,School of Medicine, University of Nottingham, Nottingham, UK.
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9
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Abstract
Indigenous populations worldwide are experiencing social, cultural, demographic, nutritional, and psychoemotional changes that have a profound impact on health. Regardless of their geographical location or sociopolitical situation, health indicators are always poorer for indigenous populations than for nonindigenous ones. The determinants of this gap are multiple and interactive, and their analysis requires a biocultural framework. Indigenous populations suffer from lower life expectancy, high infant and child mortality, high maternal morbidity and mortality, heavy infectious disease loads, malnutrition, stunted growth, increasing levels of cardiovascular and other chronic diseases, substance abuse, and depression. The devastating effects of colonization, the loss of ancestral land, and language and cultural barriers for access to health care are among the most salient themes characterizing the poor health situation of indigenous people. Anthropology is extremely well suited to address the interplay among social, economic, and political forces that shape the local experiences of illness.
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Affiliation(s)
| | - J. Josh Snodgrass
- Department of Anthropology, University of Oregon, Eugene, Oregon 97403
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10
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Du Q, Lian W, Næss Ø, Bjertness E, Kumar BN, Shi SH. The trends in maternal mortality between 1996 and 2009 in Guizhou, China: ethnic differences and associated factors. ACTA ACUST UNITED AC 2015; 35:140-146. [PMID: 25673208 DOI: 10.1007/s11596-015-1403-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 12/10/2014] [Indexed: 11/24/2022]
Abstract
China bears a large burden of global maternal mortality, and the largest burden of maternal deaths in China is in poor western provinces. This study aimed to investigate the trends in maternal mortality and its associated factors in Guizhou province of western China between 1996 and 2009, and examine differences between minority and non-minority counties. A population-based, longitudinal, retrospective study was performed in a poor western province of China with a considerably large ethnic minority population. All 86 counties/districts of Guizhou were included with population at county, township and village level. Maternal mortality data were collected from routine reporting database of Guizhou Provincial Health Bureau. Trend and comparative analyses and multivariate linear regression analyses were performed using SPSS 17.0. Maternal mortality ratio (MMR) and its change over time, differences between ethnic groups were analyzed. A declining trend in maternal mortality and rising trend in hospital delivery in Guizhou was observed; ethnic differences between two ethnic groups persisted. The reduction in maternal mortality between 1996 and 2009 was related with increased gross domestic product, decreased male illiteracy rate, and increased hospital delivery rate. We found the declining trends in maternal mortality in Guizhou with persisting ethnic differences. The declining trends are related with economic development, hospital delivery and male illiteracy. Effective health education on maternal health is urgently needed for the minority groups, and basic education for the new generation should be enhanced to eradicate the illiteracy.
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Affiliation(s)
- Qing Du
- School of Public Health and Management of Binzhou Medical University, Yantai, 264003, China.
| | - Wu Lian
- School of Public Health and Management of Binzhou Medical University, Yantai, 264003, China
| | - Øyvind Næss
- The Norweigian Institute of Public Health, Oslo, 0403, Norway.,The Faculty of Medicine, University of Oslo, Oslo, 0317, Norway
| | - Espen Bjertness
- The Faculty of Medicine, University of Oslo, Oslo, 0317, Norway.,Tibet University Medical College, Lhasa, 850012, China
| | | | - Shu-Hua Shi
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
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11
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Provincial maternal mortality surveillance systems in China. BIOMED RESEARCH INTERNATIONAL 2014; 2014:187896. [PMID: 24995274 PMCID: PMC4065665 DOI: 10.1155/2014/187896] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 05/13/2014] [Indexed: 11/25/2022]
Abstract
Background. Provincial maternal mortality surveillance systems (PMMSS) have been set up in nearly all the provinces in China to monitor local maternal mortality and provide the evidence for maternal health interventions suited to local conditions. However, till now little is known outside of China about the characteristics of PMMSS. Methods. A systematic review of the literature contained in PubMed and China Academic Journal Network Publishing database was carried out. The current situation on PMMSS was described. Provincial disparities on PMMR in six provinces were analyzed by Poisson regression analysis. Results. A total of 35 studies met the inclusion criteria, of which 31 were published in Chinese. PMMSS were set up and adjusted by the provincial government based on their own financial resources and demand. Provinces from remote region had the highest risk of maternal mortality, followed by provinces from inland region and coast region. Conclusions. PMMSS may be the most reliable data source for measuring provincial level MMR in each province. Great provincial disparities on PMMSS and PMMR do exist within the country; more emphasis should be placed on improving PMMSS and reducing PMMR particularly in the provinces with high maternal death burden.
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12
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Liu X, Gao W, Yan H. Measuring and decomposing the inequality of maternal health services utilization in western rural China. BMC Health Serv Res 2014; 14:102. [PMID: 24589223 PMCID: PMC3975923 DOI: 10.1186/1472-6963-14-102] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 02/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To measure socioeconomic inequalities in maternal health services in rural western China and to analyze the determinants' contributions of inequalities. STUDY DESIGN a cross-sectional study. METHODS The data utilized in this study were obtained from a cross-sectional study from 10 provinces in rural Western China in 2005. Wealth index of household socioeconomic status was developed by using principle component analysis. Concentration index, concentration curve and decomposition of the concentration index were employed to measure socioeconomic inequality in maternal health services utilization. RESULTS For more than four times prenatal visits, the concentration index was 0.0605 (95% CI: 0.0603, 0.0607). The concentration index of hospital delivery was 0.0230 (95% CI: 0.0210, 0.0240) and the concentration index of more than 2 times postnatal visits was 0.0842 (95% CI: 0.0836, 0.0847). Han ethnicity woman, particularly in conjunction with high school education and rich wealth status, was the main contributor to inequality in maternal health services utilization. CONCLUSIONS There is a strong pro-rich inequality of maternal health services in rural western China. This study suggests that an effective way to reduce the inequality is not only to narrow the gap of income between the rich and poor, but focus education on ethnic minority woman in rural remote areas.
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Affiliation(s)
| | | | - Hong Yan
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University College of Medicine, P,O Box 46, No,76 West Yanta Road, Xi'an, Shaanxi 710061, China.
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13
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Prevalence of diabetes and hypertension in ethnic minority adults living in rural Yunnan province, China. Int J Diabetes Dev Ctries 2013. [DOI: 10.1007/s13410-013-0137-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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14
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Yuan B, Qian X, Thomsen S. Disadvantaged populations in maternal health in China who and why? Glob Health Action 2013; 6:19542. [PMID: 23561030 PMCID: PMC3617641 DOI: 10.3402/gha.v6i0.19542] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 01/24/2013] [Accepted: 02/12/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND China has made impressive progress towards the Millennium Development Goal (MDG) for maternal and reproductive health, but ensuring that progress reaches all segments of the population remains a challenge for policy makers. The aim of this review is to map disadvantaged populations in terms of maternal health in China, and to explain the causes of these inequities to promote policy action. METHODS We searched PUBMED, Popline, Proquest and WanFang and included primary studies conducted in mainland China. Experts were also contacted to identify additional studies. Disadvantaged populations in terms of MDG 5 and the reasons for this disadvantage explored by authors were identified and coded based on the conceptual framework developed by the WHO Commission on the Social Determinants of Health. RESULTS In China, differences in maternal health service utilization and the maternal mortality ratio among different income groups, and among regions with different socio-economic development still exist, although these differences are narrowing. Groups with low levels of education and ethnic minorities utilize maternal health care less frequently and experience higher maternal mortality, although we could not determine whether these differences have changed in the last decade. Rural-to-urban migrants use maternal health care and contraception to a lower extent than permanent residents of cities, and differential maternal mortality shows a widening trend among these groups. Gender inequity also contributes to the disadvantaged position of women. Intermediary factors that explain these inequities include material circumstances such as long distances to health facilities for women living in remote areas, behavioral factors such as traditional beliefs that result in reduced care seeking among ethnic minorities, and health system determinants such as out-of-pocket payments posing financial barriers for the poor. CONCLUSIONS Inequity in maternal health continues to be an issue worthy of greater programmatic and monitoring efforts in China.
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Affiliation(s)
- Beibei Yuan
- Department of Public Health, Division of Global Health (IHCAR), Karolinska Institutet, Solna, Sweden.
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15
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Maternal mortality in Henan Province, China: changes between 1996 and 2009. PLoS One 2012; 7:e47153. [PMID: 23071740 PMCID: PMC3470574 DOI: 10.1371/journal.pone.0047153] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 09/10/2012] [Indexed: 12/02/2022] Open
Abstract
Background Maternal deaths occur mostly in developing countries and the majority of them are preventable. This study analyzes changes in maternal mortality and related causes in Henan Province, China, between 1996 and 2009, in an attempt to provide a reliable basis for introducing effective interventions to reduce the maternal mortality ratio (MMR), part of the fifth Millennium Development Goal. Methods and Findings This population-based maternal mortality survey in Henan Province was carried out from 1996 to 2009. Basic information was obtained from the health care network for women and children and the vital statistics system, from specially trained monitoring personnel in 25 selected monitoring sites and by household survey in each case of maternal death. This data was subsequently reported to the Henan Provincial Maternal and Child Healthcare Hospital. The total MMR in Henan Province declined by 78.4%, from 80.1 per 100 000 live births in 1996 to 17.3 per 100 000 live births in 2009. The decline was more pronounced in rural than in urban areas. The most common causes of maternal death during this period were obstetric hemorrhage (43.8%), pregnancy-induced hypertension (15.8%), amniotic fluid embolism (13.9%) and heart disease (8.0%). The MMR was higher in rural areas with lower income, less education and poorer health care. Conclusion There was a remarkable decrease in the MMR in Henan Province between 1996 and 2009 mainly in the rural areas and MMR due to direct obstetric causes such as obstetric hemorrhage. This study indicates that improving the health care network for women, training of obstetric staff at basic-level units, promoting maternal education, and increasing household income are important interventional strategies to reduce the MMR further.
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16
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Adegoke A, Utz B, Msuya SE, van den Broek N. Skilled Birth Attendants: who is who? A descriptive study of definitions and roles from nine Sub Saharan African countries. PLoS One 2012; 7:e40220. [PMID: 22808121 PMCID: PMC3393745 DOI: 10.1371/journal.pone.0040220] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 06/02/2012] [Indexed: 12/03/2022] Open
Abstract
Background Availability of a Skilled Birth Attendant (SBA) during childbirth is a key indicator for MDG5 and a strategy for reducing maternal and neonatal mortality in Africa. There is limited information on how SBAs and their functions are defined. The aim of this study was to map the cadres of health providers considered SBAs in Sub Saharan Africa (SSA); to describe which signal functions of Essential Obstetric Care (EmOC) they perform and assess whether they are legislated to perform these functions. Methods and Findings Key personnel in the Ministries of Health, teaching institutions, referral, regional and district hospitals completed structured questionnaires in nine SSA countries in 2009–2011. A total of 21 different cadres of health care providers (HCP) were reported to be SBA. Type and number of EmOC signal functions reported to be provided, varied substantially between cadres and countries. Parenteral antibiotics, uterotonic drugs and anticonvulsants were provided by most SBAs. Removal of retained products of conception and assisted vaginal delivery were the least provided signal functions. Except for the cadres of obstetricians, medical doctors and registered nurse-midwives, there was lack of clarity regarding signal functions reported to be performed and whether they were legislated to perform these. This was particularly for manual removal of placenta, removal of retained products and assisted vaginal delivery. In some countries, cadres not considered SBA performed deliveries and provided EmOC signal functions. In other settings, cadres reported to be SBA were able to but not legislated to perform key EmOC signal functions. Conclusions Comparison of cadres of HCPs reported to be SBA across countries is difficult because of lack of standardization in names, training, and functions performed. There is a need for countries to develop clear guidelines defining who is a SBA and which EmOC signal functions each cadre of HCP is expected to provide.
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Affiliation(s)
- Adetoro Adegoke
- Maternal and Newborn Health Unit, Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Bettina Utz
- Maternal and Newborn Health Unit, Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Sia E. Msuya
- Maternal and Newborn Health Unit, Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Nynke van den Broek
- Maternal and Newborn Health Unit, Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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17
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Liang J, Dai L, Zhu J, Li X, Zeng W, Wang H, Li Q, Li M, Zhou R, Wang Y. Preventable maternal mortality: geographic/rural-urban differences and associated factors from the population-based Maternal Mortality Surveillance System in China. BMC Public Health 2011; 11:243. [PMID: 21501529 PMCID: PMC3108316 DOI: 10.1186/1471-2458-11-243] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 04/19/2011] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Most maternal deaths in developing countries can be prevented. China is among the 13 countries with the most maternal deaths; however, there has been a marked decrease in the maternal mortality ratio (MMR) over the last 3 decades. China's reduction in the MMR has contributed significantly to the global decline of the MMR. This study examined the geographic and rural-urban differences, time trends and related factors in preventable maternal deaths in China during 1996-2005, with the aim of providing reliable evidence for effective interventions. METHODS Data were retrieved from the population-based maternal mortality surveillance system in China. Each death was reviewed by three committees to determine whether it was avoidable. The preventable maternal mortality ratio (PMMR), the ratios of PMMR (risk ratio, RR) and 95% confidence intervals (CI) were used to analyze regional disparities (coastal, inland and remote regions) and rural-urban variations. Time trends in the MMR, along with underlying causes and associated factors of death, were also analysed. RESULTS Overall, 86.1% of maternal mortality was preventable. The RR of preventable maternal mortality adjusted by region was 2.79 (95% CI 2.42-3.21) and 2.38 (95% CI: 2.01-2.81) in rural areas compared to urban areas during the 1996-2000 and 2001-2005 periods, respectively. Meanwhile, the RR was the highest in remote areas, which was 4.80(95%CI: 4.10-5.61) and 4.74(95%CI: 3.86-5.83) times as much as that of coastal areas. Obstetric haemorrhage accounted for over 50% of preventable deaths during the 2001-2005 period. Insufficient information about pregnancy among women in remote areas and out-of-date knowledge and skills of health professionals and substandard obstetric services in coastal regions were the factors frequently associated with MMR. CONCLUSIONS Preventable maternal mortality and the distribution of its associated factors in China revealed obvious regional differences. The PMMR was higher in underdeveloped regions. In future interventions in remote and inland areas, more emphasis should be placed on improving women's ability to utilize healthcare services, enhancing the service capability of health institutions, and increasing the accessibility of obstetric services. These approaches will effectively lower PMMR in those regions and narrow the gap among the different regions.
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Affiliation(s)
- Juan Liang
- National Office for Maternal and Child Health Surveillance, West China Second University Hospital, Sichuan University, No 17, section 3, Ren Min Nan Lu, Chengdu, Sichuan, China
| | - Li Dai
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No 17, section 3, Ren Min Nan Lu, Chengdu, Sichuan, China
| | - Jun Zhu
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No 17, section 3, Ren Min Nan Lu, Chengdu, Sichuan, China
| | - Xiaohong Li
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No 17, section 3, Ren Min Nan Lu, Chengdu, Sichuan, China
| | - Weiyue Zeng
- Obstetric and Gynecologic Department, West China Second University Hospital, Sichuan University, No 17, section 3, Ren Min Nan Lu, Chengdu, Sichuan, China
| | - He Wang
- Obstetric and Gynecologic Department, West China Second University Hospital, Sichuan University, No 17, section 3, Ren Min Nan Lu, Chengdu, Sichuan, China
| | - Qi Li
- National Office for Maternal and Child Health Surveillance, West China Second University Hospital, Sichuan University, No 17, section 3, Ren Min Nan Lu, Chengdu, Sichuan, China
| | - Mingrong Li
- National Office for Maternal and Child Health Surveillance, West China Second University Hospital, Sichuan University, No 17, section 3, Ren Min Nan Lu, Chengdu, Sichuan, China
| | - Rong Zhou
- Obstetric and Gynecologic Department, West China Second University Hospital, Sichuan University, No 17, section 3, Ren Min Nan Lu, Chengdu, Sichuan, China
| | - Yanping Wang
- National Office for Maternal and Child Health Surveillance, West China Second University Hospital, Sichuan University, No 17, section 3, Ren Min Nan Lu, Chengdu, Sichuan, China
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18
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Li X, Zhu J, Dai L, Li Q, Li W, Zeng W, Wang H, Li M, Wang Y, Liang J. Hospitalized delivery and maternal deaths from obstetric hemorrhage in China from 1996 to 2006. Acta Obstet Gynecol Scand 2011; 90:586-92. [PMID: 21355859 DOI: 10.1111/j.1600-0412.2011.01110.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the role of hospitalized delivery in reducing maternal deaths from obstetric hemorrhage in urban and rural areas of China. DESIGN Longitudinal, retrospective study and review of maternal deaths based on data from the Maternal and Child Health Surveillance System (MCHSS). SETTING The surveillance areas of Maternal and Child Health in China from 1996 to 2006. SAMPLE A total of 6 259 336 live births and 1 418 maternal deaths from hemorrhage. METHODS Data on maternal deaths were retrieved from the MCHSS. The leading factors contributing to these deaths were reviewed by three committees. MAIN OUTCOME MEASURES Maternal mortality ratio (MMR), relative risk (RR), leading factors contributing to deaths. RESULTS The MMR due to hemorrhage significantly decreased with increasing hospitalized delivery rates in rural areas, but it did not decrease in urban areas. The RR of maternal deaths from hemorrhage in women with non-hospitalized delivery in comparison to hospitalized delivery were 2.52 (95% confidence interval (CI): 1.71~3.70) in urban areas, and 5.52 (95% CI: 4.79~6.36) in rural areas. The level of knowledge and skills of medical professionals was the leading factor contributing to 79.6% (urban) and 81.0% (rural) of the deaths during hospitalized delivery. CONCLUSION The quality of obstetric care in hospitals has become one of the most important factors influencing the risk of maternal deaths from hemorrhage in China. The knowledge and skills of medical professionals need to be improved, especially in primary hospitals.
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Affiliation(s)
- Xiaohong Li
- National Office for Maternal and Child Health Surveillance, West China Second University Hospital, Sichuan University, No. 17 Section 3 Ren Min Nan Lu, Chengdu, Sichuan, China
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19
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Fisk NM, McKee M, Atun R. Relative and absolute addressability of global disease burden in maternal and perinatal health by investment in R&D. Trop Med Int Health 2011; 16:662-8. [PMID: 21470349 DOI: 10.1111/j.1365-3156.2011.02778.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Maternal and perinatal disease accounts for nearly 10% of the global burden of disease, with only modest progress towards achievement of the Millennium Development Goals. Despite a favourable new global health landscape in research and development (R&D) to produce new drugs for neglected diseases, R&D investment in maternal/perinatal health remains small and non-strategic. Investment in obstetric R&D by industry or the not-for-profit sector has lagged behind other specialties, with the number of registered pipeline drugs only 1-5% that for other major disease areas. Using a Delphi exercise with maternal/perinatal experts in global and translational research, we estimate that equitable pharmaceutical R&D and public sector research funding over the next 10-20 years could avert 1.1% and 1.9% of the global disease burden, respectively. In contrast, optimal uptake of existing research would prevent 3.0%, justifying the current focus on health service provision. Although R&D predominantly occurs in high-income countries, more than 98% of the estimated reduction in disease burden in this field would be in developing countries. We conclude that better pharmaceutical and public sector R&D would prevent around 1/3 and 2/3, respectively, of the disease burden addressable by optimal uptake of existing research. Strengthening R&D may be an important complementary strategy to health service provision to address global maternal and perinatal disease burden.
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Affiliation(s)
- Nicholas M Fisk
- UQ Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia.
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20
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Affiliation(s)
- Rosemary Mander
- School of Health, University of Edinburgh, Doorway 6, Teviot Place, Edinburgh EH8 9AG, UK.
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21
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Lester F, Benfield N, Fathalla MMF. Global women's health in 2010: facing the challenges. J Womens Health (Larchmt) 2010; 19:2081-9. [PMID: 21028939 DOI: 10.1089/jwh.2010.2083] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Women's health is closely linked to a nation's level of development, with the leading causes of death in women in resource-poor nations attributable to preventable causes. Unlike many health problems in rich nations, the cure relies not only on the discovery of new medications or technology but also getting basic services to the people who need them most and addressing underlying injustice. In order to do this, political will and financial resources must be dedicated to developing and evaluating a scaleable approach to strengthen health systems, support community-based programs, and promote widespread campaigns to address gender inequality, including promoting girls' education. The Millennium Development Goals (MDGs) have highlighted the importance of addressing maternal health and promoting gender equality for the overall development strategy of a nation. We must capitalize on the momentum created by this and other international campaigns and continue to advocate for comprehensive strategies to improve global women's health.
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Affiliation(s)
- Felicia Lester
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts 02120, USA.
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22
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Feng XL, Zhu J, Zhang L, Song L, Hipgrave D, Guo S, Ronsmans C, Guo Y, Yang Q. Socio-economic disparities in maternal mortality in China between 1996 and 2006. BJOG 2010; 117:1527-36. [PMID: 20937073 DOI: 10.1111/j.1471-0528.2010.02707.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE China's economic reforms have raised concerns over rising inequalities in maternal mortality, but it is not known whether the gap across socio-economic regions has increased over time. DESIGN A population-based, longitudinal, ecological correlation study. SETTING China. SAMPLE Records from the National Maternal and Child Mortality Surveillance System between 1996 and 2006. METHODS We report levels, causes and timing of maternal deaths, and examine crude and adjusted time trends in the overall and cause-specific maternal mortality ratio in five socio-economic regions (using Poisson regression). We examine whether socio-economic disparities have widened over time using concentration curves. MAIN OUTCOME MEASURES All-causes and cause-specific maternal mortality ratios. RESULTS Maternal mortality (MMR) declined by 6% per year (yearly rate ratio, RR, 0.94; 95% CI 0.93-0.96). The decline was most pronounced in the wealthiest rural type-I counties (RR 0.89; 95% CI 0.85-0.93), and in the poorest rural type-IV counties (RR 0.90; 95% CI 0.82-1.00). There were declines in almost all causes of maternal death. Postpartum haemorrhage (PPH) was by far the leading cause of maternal death (32%, 997/3164). The decline in MMR was largely explained by the increased uptake of institutional births. Concentration curves suggest that wealth-related regional inequalities did not increase over time. CONCLUSIONS China's extraordinary economic growth has not adversely affected disparities in MMR across socio-economic regions over time, but poor rural women remain at disproportionate risk. Other emerging economies can learn from China's focus on the supply and quality of maternity services along with more general health systems strengthening.
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Affiliation(s)
- X L Feng
- Department of Health Policy and Administration, School of Public Health, Peking University, Beijing, China
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23
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Qiu L, Lin J, Ma Y, Wu W, Qiu L, Zhou A, Shi W, Lee A, Binns C. Improving the maternal mortality ratio in Zhejiang Province, China, 1988-2008. Midwifery 2010; 26:544-8. [PMID: 20708312 DOI: 10.1016/j.midw.2010.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 06/02/2010] [Accepted: 06/04/2010] [Indexed: 11/18/2022]
Abstract
OBJECTIVE maternal mortality remains a major public health problem in many countries. The aim of this paper is to describe the progress made in maternal health care in Zhejiang Province, China over 20 years in reducing the maternal mortality ratio (MMR). SETTING Zhejiang Province is located on the mid-east coast of China, approximately 180km south of Shanghai, and has a population of 49 million. Almost all mothers give birth in hospitals or maternal and infant health institutes. METHOD the annual maternal death audit reports from 1988 to 2008 were analysed. These reports were prepared annually by the Zhejiang Prenatal Health Committee after auditing each individual case. MEASUREMENTS AND FINDINGS China has made considerable progress in reducing the MMR. Zhejiang has one of fastest developing economies in China, and since the 86 economic reforms of 1978, health care has improved rapidly and the MMR has declined. During the 1988-2008 period, 2258 maternal deaths were reported from 8,880,457 live births. During these two decades, the MMR decreased dramatically from 48.50 in 1988 to 6.57 per 100,000 in 2008. The MMR in migrant women dropped from 66.87 in 2003 to 21.67 per 100,000 in 2008. The rate of decline was more rapid in rural areas than in the city. There has been a decline in the proportion of deaths with direct obstetric causes and a corresponding increase in the proportion of indirect causes. The proportion of deaths classified as preventable has declined in the past two decades. Social factors are important in maternal safety, and on average 26.8% of maternal deaths were influenced by these factors. CONCLUSION as the economy was developing, maternal safety was made a priority health issue by the Government and health workers. The provincial MMR has dropped rapidly and is now similar to the rates in developed countries and lower than that in the USA. However, more work is still needed to ensure that all mothers, including migrant workers, continue to have these low rates.
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Affiliation(s)
- Liqian Qiu
- Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, China
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24
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Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJL. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375:1609-23. [PMID: 20382417 DOI: 10.1016/s0140-6736(10)60518-1] [Citation(s) in RCA: 1237] [Impact Index Per Article: 88.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Maternal mortality remains a major challenge to health systems worldwide. Reliable information about the rates and trends in maternal mortality is essential for resource mobilisation, and for planning and assessment of progress towards Millennium Development Goal 5 (MDG 5), the target for which is a 75% reduction in the maternal mortality ratio (MMR) from 1990 to 2015. We assessed levels and trends in maternal mortality for 181 countries. METHODS We constructed a database of 2651 observations of maternal mortality for 181 countries for 1980-2008, from vital registration data, censuses, surveys, and verbal autopsy studies. We used robust analytical methods to generate estimates of maternal deaths and the MMR for each year between 1980 and 2008. We explored the sensitivity of our data to model specification and show the out-of-sample predictive validity of our methods. FINDINGS We estimated that there were 342,900 (uncertainty interval 302,100-394,300) maternal deaths worldwide in 2008, down from 526,300 (446,400-629,600) in 1980. The global MMR decreased from 422 (358-505) in 1980 to 320 (272-388) in 1990, and was 251 (221-289) per 100,000 livebirths in 2008. The yearly rate of decline of the global MMR since 1990 was 1.3% (1.0-1.5). During 1990-2008, rates of yearly decline in the MMR varied between countries, from 8.8% (8.7-14.1) in the Maldives to an increase of 5.5% (5.2-5.6) in Zimbabwe. More than 50% of all maternal deaths were in only six countries in 2008 (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo). In the absence of HIV, there would have been 281 500 (243,900-327,900) maternal deaths worldwide in 2008. INTERPRETATION Substantial, albeit varied, progress has been made towards MDG 5. Although only 23 countries are on track to achieve a 75% decrease in MMR by 2015, countries such as Egypt, China, Ecuador, and Bolivia have been achieving accelerated progress. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Margaret C Hogan
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 98121, USA
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Scott S, Ronsmans C. The relationship between birth with a health professional and maternal mortality in observational studies: a review of the literature. Trop Med Int Health 2009; 14:1523-33. [PMID: 19793070 DOI: 10.1111/j.1365-3156.2009.02402.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine the nature of the association between maternal mortality and birth with a health professional in observational studies. METHODS Review of ecological studies relating the overall proportion of births with a health professional with the maternal mortality ratio at national level, and studies exploring the relationship between the presence of a health professional at birth and the risk of dying at the individual level. We report methodological challenges, including data quality and sources and the analytical approaches used. For the individual studies, crude odds ratios and 95% confidence intervals were calculated. RESULTS The 10 ecological studies are largely descriptive, a causal inference is tentative and there is poor controlling of confounders. The 10 individual studies examining the risk of death with and without a health professional showed little evidence that giving birth with a health professional reduces a woman's risk of dying, and in some settings it appears to be associated with an increased risk of death. CONCLUSIONS None of these study designs are optimal in evaluating the impact of births with a health professional on reducing maternal mortality. Analytically, greater insights can be gained by examining ecological relationships within countries, and by complementing the individual analyses with information on the health status of women when they first reach the health professional and whether or not the women planned to have a health professional present during birth.
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Affiliation(s)
- S Scott
- London School of Hygiene and Tropical Medicine, London, UK
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Neonatal nursing and China. Adv Neonatal Care 2007; 7:271-8. [PMID: 18097203 DOI: 10.1097/01.anc.0000304960.14428.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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