Rural-urban differentials in pregnancy-related mortality in Zambia: estimates using data collected in a census

Global maternal mortality projections by urban/rural location and education level: a simulation-based analysis

Background

Maternal mortality remains a challenge in global health, with well-known disparities across countries. However, less is known about disparities in maternal health by subgroups within countries. The aim of this study is to estimate maternal health indicators for subgroups of women within each country.

Methods

In this simulation-based analysis, we used the empirically calibrated Global Maternal Health (GMatH) microsimulation model to estimate a range of maternal health indicators by subgroup (urban/rural location and level of education) for 200 countries/territories from 1990 to 2050. Education levels were defined as low (less than primary), middle (less than secondary), and high (completed secondary or higher). The model simulates the reproductive lifecycle of each woman, accounting for individual-level factors such as family planning preferences, biological factors (e.g., anemia), and history of maternal complications, and how these factors vary by subgroup. We also estimated the impact of scaling up women's education on projected maternal health outcomes compared to clinical and health system-focused interventions.

Findings

We find large subgroup differences in maternal health outcomes, with an estimated global maternal mortality ratio (MMR) in 2022 of 292 (95% UI 250-341) for rural women and 100 (95% UI 84-116) for urban women, and 536 (95% UI 450-594), 143 (95% UI 117-174), and 85 (95% UI 67-108) for low, middle, and high education levels, respectively. Ensuring all women complete secondary school is associated with a large impact on the projected global MMR in 2030 (97 [95% UI 76-120]) compared to current trends (167 [95% UI 142-188]), with especially large improvements in countries such as Afghanistan, Chad, Madagascar, Niger, and Yemen.

Interpretation

Substantial subgroup disparities present a challenge for global maternal health and health equity. Outcomes are especially poor for rural women with low education, highlighting the need to ensure that policy interventions adequately address barriers to care in rural areas, and the importance of investing in social determinants of health, such as women's education, in addition to health system interventions to improve maternal health for all women.

Funding

John D. and Catherine T. MacArthur Foundation, 10-97002-000-INP.

Effects of economic support, comprehensive sexuality education and community dialogue on sexual behaviour: Findings from a cluster-RCT among adolescent girls in rural Zambia

Adolescent girls in Sub-Saharan Africa are at high risk of poor sexual and reproductive health outcomes. We present findings from a cluster-randomised trial in rural Zambia on the effects of economic support, comprehensive sexuality education (CSE) and community dialogue on sexual activity, contraceptive use and beliefs among adolescent girls. We recruited 157 schools in 2016, and all girls in grade 7 were invited to participate. Schools were randomised to either economic support, combined economic support, CSE and community dialogue, or control. Economic support consisted of unconditional cash transfers to girls and their guardians, and payment of school fees for girls continuing to grades eight and nine. CSE and community dialogue meetings focused on practices around girls' fertility, marriage and education. The interventions lasted two years from 2016 to 2018, with follow-up for another two years. The effects on outcomes were measured in 2018 and 2019 and compared using generalised estimating equations. We found that economic support lowered sexual activity (risk ratio (RR) 0.70; 95% C.I. 0.54 to 0.91), with a small added benefit of CSE and community dialogue. Economic support and the additional CSE and community dialogue were effective in lowering unprotected sexual activity (RR 0.53 for combined support vs. control; 95% C.I. 0.37 to 0.75). There was no evidence of intervention effects on contraceptive use among those ever sexually active, but the addition of CSE and community dialogue improved contraceptive use among those recently sexually active (RR 1.26; 95% C.I. 1.06 to 1.50) and knowledge regarding contraceptives (RR 1.18; 95% C.I. 1.01 to 1.38) compared to economic support alone. Perceived community support regarding contraceptives was lower in both intervention arms compared to the control. These findings indicate that economic support in combination with CSE and community dialogue can improve the sexual and reproductive health of adolescent girls.

The development of adolescent agency and implications for reproductive choice among girls in Zambia

Background

A substantial proportion of adolescent girls in Zambia lack the ability to decide their reproductive future. We examined the role of agency in early and unwanted adolescent childbearing.

Methods

Using latent transition analysis, we characterized a multi-dimensional profile of adolescent agency annually over a four-year period. We investigated the influence of early life access to resources and time-varying predictors (school retention, violence, early marriage and unwanted/mistimed pregnancy and childbearing) on agency profile membership as well as transitions in agency status over time.

Results

Four agency profiles were identified, with differences by age cohort (10–14 years vs. 15–19 years). Three profiles identified in both age cohorts were: Low-moderate agency, Self-assured gender conformers, and High agency. Unique to younger girls was the Gender conscious, low belief in abilities status, while among older girls was the Self-assured selective gender conscious status. While younger girls were likely to transition to the highest agency status over time, high agency membership declined among older girls. Early life resources were associated with augmented agency while exposure to negative events, particularly early marriage, were associated with detraction from high agency status. Girls who expressed high self-efficacy but gender-conforming values were most at risk of early marriage and unwanted/mistimed pregnancy while High agency girls were at comparatively low risk.

Conclusions

Results show agency is dynamic but less mutable with increasing age. Early adolescent strategies which address inequitable gender norms and limit early marriage, may guard against losses to agency which contribute to unwanted fertility outcomes.

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Findings support agency as a dynamic, multidimensional construct in adolescence.

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In general, access to resources promoted agency across dimensions.

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Time-varying events, particularly early marriage, detracted from agency status.

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Agency dimensions combined in unique ways with distinct implications for early/unwanted fertility.

Vanilla bisquits and lobola bridewealth: parallel discourses on early pregnancy and schooling in rural Zambia

Background

Adolescent pregnancy is a complex socio-economic phenomenon ranking high on the global health policy agenda. Early childbearing is associated with early marriage and school drop-out, and is defined as a problem to the health and development of girls. This paper reports from formative research. The formative research aimed to explore socio-cultural and structural dynamics at work behind early pregnancy and school drop out in rural Zambia. The study findings have been used to inform a school based intervention to reduce early pregnancy (RISE: ‘Research Initiative to Support the Empowerment of Girls’). Theoretically the study is informed by social constructionism.

Methods

A qualitative approach was employed. Semi-structured qualitative interviews (61) and focus group discussions (7) were carried out with girls (in and out of school), boys, parents, teachers, health workers and community- and district leaders in 2014–15. Systematic text condensation was drawn upon in the analysis of the material.

Results

The study findings indicate that the official Zambian discourse that presents early pregnancy as a serious challenge and schooling as the prime way to confront the problem enjoy substantial support at community levels. However, a parallel discourse on fertility, early marriage and childbearing as social and economic security surfaced and was articulated by the same study participants. The latter contrasting discourse questioned schooling as the only solution to secure a girl’s future arguing that there are many reasons why early pregnancy may emerge as rational.

Conclusions

Grasping the complexity of local discourse is vital in planning health interventions. The present study revealed that although delayed child bearing and schooling among girls enjoyed high status and legitimacy in the study area, the social and economic context worked to reward early marriage. Interventions to reduce early pregnancies in rural Zambian communities need to fundamentally address the material constraints that condition and reinforce a culture of early childbearing.

Parent-child communication about sexual issues in Zambia: a cross sectional study of adolescent girls and their parents

Background

Parent-child communication about sexual issues can reduce risky sexual behaviour amongst adolescents. Risky sexual behaviour is of concern in sub-Saharan Africa where the prevalence of early pregnancy, unsafe abortion and HIV are high. Parent-child communication about sexual issues presents a feasible approach for reducing sexual risk amongst adolescents in sub-Saharan Africa but limited research exists from the region. This study from Zambia examines the sociodemographic and psychosocial factors that are associated with whether parents communicate with their daughters about sexual issues.

Methods

Data from a cluster randomized controlled trial examining the effect of interventions aiming to reduce teenage pregnancy and school drop out in Zambia was used. The data was collected between January–July in 2018 and consists of structured, face to face interviews with 4343 adolescent girls and 3878 parents. Cross sectional analyses examined the associations between parent-child communication about sexual issues and sociodemographic and psychosocial characteristics using univariate and multivariable logistic regression models.

Results

Adolescent girls who felt connected to their parents and those who perceived their parents to be comfortable in communicating about sex, were more likely to speak to their parents about sexual issues than those who did not (AOR 1.23, 95% CI 1.01–1.52; and AOR 2.94, 95% CI 2.45–3.54, respectively). Girls whose parents used fear-based communication about sexual issues, and those who perceived their parents as being opposed to education about contraception, were less likely to communicate with their parents about sex than those who did not (AOR 0.76, 95% CI 0.65–0.89; and AOR 0.76, 95% CI 0.63–0.91, respectively). Girls enrolled in school were less likely to communicate with their parents about sex than those out of school (AOR 0.56, 95% CI 0.44–0.71).

Conclusion

Parenting style, children’s perception of parental attitudes and parental communication styles are associated with whether parents and children communicate about sexual issues. This may imply that parents can improve the chances of communicating with their children about sex by conveying non-judgemental attitudes, using open communication styles with neutral messages and appearing comfortable whilst displaying positive attitudes towards communication around sex and contraceptive use.

Trial registration

ISRCTN registry: ISRCTN12727868, (4 March 2016).

Variations in sex ratios estimated from census and survey data in Zambia, 1969-2014

The sex ratio question has been an area of growing interest in population dynamics, especially in developing countries with respect to the issue of missing women, but few studies have examined this in sub-Saharan Africa. Both at birth and in the general population, sex ratios follow an expected demographic pattern in the absence of the interference of historical events affecting either males or females in a population. In Zambia, an unexpected demographic pattern of sex ratios is exhibited in census and survey data. This study used data from censuses and surveys conducted from 1969 to 2014 to examine variations in sex ratios in the Zambian population. It was found that sex ratio imbalances were largely due to data deficiencies due to age misreporting and under-enumeration. A consistent under-enumeration of young adult males in the 20-34 years age group was found. A systematic pattern of high sex ratios, above 100, for ages 40+ was found, represented by synthetic cohorts traceable from the 1969 census, progressing to the 2000 census and phased out in the 2010 census. Extremely high adult male mortality was found in 2010 in the 35-59 years age group, primarily attributable to HIV/AIDS. Understanding the demographic pattern of sex ratios in a population is relevant for policies to improve the quality of data collection systems, and socioeconomic development planning, for the young age group population, which is prone under-enumeration.

Levels and determinants of maternal mortality in northern and southern Nigeria

Background

Maternal mortality is still a major risk for women of childbearing age in Nigeria. In 2008, Nigeria bore 14% of the global burden of maternal mortality. The national maternal mortality ratio has remained elevated despite efforts to reduce maternal deaths. Though health disparities exist between the North and South of Nigeria, there is a dearth of evidence on the estimates and determinants of maternal mortality for these regions.

Methods

This study aimed to assess differences in the levels and determinants of maternal mortality in women of childbearing age (15–49 years) in the North and South of Nigeria. The Nigeria Demographic and Health Surveys (2008 and 2013) were used. The association between maternal mortality (outcome) and relevant sociocultural, economic and health factors was tested using multivariable logistic regression in a sample of 51,492 living or deceased women who had given birth.

Results

There were variations in the levels of maternal mortality between the two regions. Maternal mortality was more pronounced in the North and increased in 2013 compared to 2008. For the South, the levels slightly decreased. Media exposure and education were associated with maternal mortality in the North while contraceptive method, residence type and wealth index were associated with maternal death in the South. In both regions, age and community wealth were significantly associated with maternal mortality.

Conclusions

Differences in the levels and determinants of maternal mortality between the North and South of Nigeria stress the need for efforts to cut maternal deaths through new strategies that are relevant for each region. These should improve education of girls in the North and access to health information and services in the South. Overall, new policies to improve women’s socioeconomic status should be adopted.

Using census data to measure maternal mortality: A review of recent experience

BACKGROUND

The Sustainable Development Goals adopted by the United Nations General Assembly in 2015 (United Nations 2015) set national targets for reducing maternal mortality, putting pressure on governments of countries lacking comprehensive statistical systems to find other ways to measure it. One approach tested since the 1990s has been to collect necessary data through national population censuses.

OBJECTIVE

This paper reviews maternal mortality data from the 2010 round of censuses for several countries to determine whether the census is useful for monitoring maternal mortality.

METHODS

Data on births, deaths, and pregnancy-related deaths from two censuses for 10 countries was evaluated using standard methods; adjustments were applied to the reported numbers if so indicated.

RESULTS

In general, the censuses underreported births moderately and underreported deaths by larger amounts; except in one case, proportions of pregnancy-related deaths appeared plausible. Adjusted estimates of the pregnancy-related mortality ratio (PRMR) were generally higher than estimates from Demographic and Health Survey sibling data or estimates of maternal mortality developed by cross-national studies.

CONCLUSIONS

Analysis of recent data confirms results of earlier assessments: Census data provides imperfect but still valuable information on maternal mortality. Data requires careful assessment and often adjustment, resulting in estimates with large uncertainty.

CONTRIBUTION

This paper provides additional evidence as to whether maternal mortality can usefully be measured by population censuses in countries lacking civil registration data.

Emergency transportation interventions for reducing adverse pregnancy outcomes in low- and middle-income countries: a systematic review protocol

BACKGROUND

Transportation interventions seek to decrease delay in reaching a health facility for emergency obstetric care and are, thus, believed to contribute to reductions in such adverse pregnancy and childbirth outcomes as maternal deaths, stillbirths, and neonatal mortality in low- and middle-income countries (LMICs). However, there is limited empirical evidence to support this hypothesis. The objective of the proposed review is to summarize and critically appraise evidence regarding the effect of emergency transportation interventions on outcomes of labor and delivery in LMICs.

METHODS

The following databases will be searched from inception to March 31, 2018: MEDLINE/PubMed, EMBASE, Web of Science, EBSCO (PsycINFO and CINAHL), the Cochrane Pregnancy and Child Birth Group's Specialized Register, and the Cochrane Central Register of Controlled Trials. We will search for studies in the grey literature through Google and Google Scholar. We will solicit unpublished reports from such relevant agencies as United Nations Fund for Population Activities (UNFPA), the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), the United States Agency for International Development (USAID), and the United Kingdom Department for International Development (DfID) among others. Data generated from the search will be managed using Endnote Version 7. We will perform quantitative data synthesis if studies are homogenous in characteristics and provide adequate outcome data for meta-analysis. Otherwise, data will be synthesized, using the narrative synthesis approach.

DISCUSSION

Among the many barriers that women in LMICs face in accessing life-saving interventions during labor and delivery, lack of access to emergency transportation is particularly important. This review will provide a critical summary of evidence regarding the impact of transportation interventions on outcomes of pregnancy and childbirth in LMICs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017080092.

Effectiveness of a girls' empowerment programme on early childbearing, marriage and school dropout among adolescent girls in rural Zambia: study protocol for a cluster randomized trial

Background

Adolescent pregnancies pose a risk to the young mothers and their babies. In Zambia, 35% of young girls in rural areas have given birth by the age of 18 years. Pregnancy rates are particularly high among out-of-school girls. Poverty, low enrolment in secondary school, myths and community norms all contribute to early childbearing. This protocol describes a trial aiming to measure the effect on early childbearing rates in a rural Zambian context of (1) economic support to girls and their families, and (2) combining economic support with a community intervention to enhance knowledge about sexual and reproductive health and supportive community norms.

Methods/design

This cluster randomized controlled trial (CRCT) will have three arms. The clusters are rural schools with surrounding communities. Approximately 4900 girls in grade 7 in 2016 will be recruited from 157 schools in 12 districts. In one intervention arm, participating girls and their guardians will be offered cash transfers and payment of school fees. In the second intervention arm, there will be both economic support and a community intervention. The interventions will be implemented for approximately 2 years. The final survey will be 4.5 years after recruitment. The primary outcomes will be “incidence of births within 8 months of the end of the intervention period”, “incidence of births before girls’ 18th birthday” and “proportion of girls who sit for the grade 9 exam”. Final survey interviewers will be unaware of the intervention status of respondents. Analysis will be by intention-to-treat and adjusted for cluster design and confounders. Qualitative process evaluation will be conducted.

Discussion

This is the first CRCT to measure the effect of combining economic support with a community intervention to prevent adolescent childbearing in a low- or middle-income country. We have designed a programme that will be sustainable and feasible to scale up. The findings will be relevant for programmes for adolescent reproductive health in Zambia and similar contexts.

Trial registration

ISRCTN registry: ISRCTN12727868, (4 March 2016).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1682-9) contains supplementary material, which is available to authorized users.

Role of birth spacing, family planning services, safe abortion services and post-abortion care in reducing maternal mortality

Access to contraception reduces maternal deaths by preventing or delaying pregnancy in women who do not intend to be pregnant or those at higher risk of complications. However, not all unintended pregnancies can be prevented through increase in contraceptive use, and access to safe abortion is needed to prevent unsafe abortions. Despite not preventing the problem, provision of emergency care for complications can help prevent deaths from such unsafe abortions. Safe abortion in early pregnancy can be provided at primary care level and by non-physician providers, and the risks of mortality associated with such safe, legal abortions are minimal. Although entirely preventable, unsafe abortions continue to occur because of numerous barriers such as legal and policy restrictions, service delivery issues and provider attitudes to abortion stigma. Overall, the provision of contraception and safe abortion is important not just to prevent maternal deaths but as a measure of our ability to respect women's decisions and ensure that they have access to timely, evidence-based care that protects their health and human rights.