High Maternal Mortality Ratio Research Articles

Knowledge and practice of health workers towards maternal and child health in the Democratic Republic of the Congo: a cross-sectional study

BackgroundThe burden of maternal and child mortality is high in the Democratic Republic of the Congo (DRC). While health workers (HWs) with adequate knowledge and practice of maternal and child health (MCH) are crucial to reduce this burden, the skill level of HWs in charge of MCH in the DRC is currently insufficient. This study aimed to assess the knowledge and practice of HWs towards MCH in Kasai and Maniema, two DRC provinces with very high maternal mortality ratios and under-5 mortality rates.MethodsThis cross-sectional study was conducted in 96 health facilities of Kasai and Maniema provinces in 2019. All HWs in charge of MCH were eligible for the study. Data were collected using a structured questionnaire containing 76 questions on knowledge and practice of MCH. Analyses were performed using the Wilcoxon-Mann-Whitney test, Kendall’s correlation test, and a multivariate linear mixed regression model.ResultsAmong participating HWs, 42.6% were A2 nurses (lowest qualification), 81.9% had no up-to-date training in MCH, and 48.4% had only 1-5 years of experience in MCH. In the two provinces combined, about half of HWs had poor knowledge (50.6%) and poor practice (53.3%) of MCH. Knowledge and practice scores were higher in Maniema than in Kasai (P < 0.001). Good knowledge and practice scores were significantly associated with high qualification (P = 0.001), continuing up-to-date training in MCH (P = 0.009), and 6 years of experience or more in MCH (P = 0.01).ConclusionIn Maniema and Kasai provinces, about half of HWs had poor knowledge and poor practice of MCH. The conversion of A1 nurses into midwives as well as the provision of up-to-date training in MCH, supervision, and mentorship could improve the skill level of HWs and could thus reduce the burden of MCH in the DRC.

Factors influencing delivery-related complications and their consequences in hard-to-reach areas of Bangladesh

Background and objectivesBangladesh's high maternal mortality ratio is exacerbated by delivery-related complications, particularly in hard-to-reach (HtR) areas with limited healthcare access. Despite this, few studies have explored delivery-related complications and factors contributing to these complications among the disadvantaged population. This study aimed to investigate the factors contributing to delivery-related complications and their consequences among the mothers residing in the HtR areas of Bangladesh. MethodsData were collected using a cross-sectional study design from 13 HtR sub-districts of Bangladesh between September 2019 and October 2019. Data from 1,290 recently delivered mothers were analysed. ResultsAround 32% (95% CI: 29.7–34.8) of the mothers reported at least one delivery-related complication. Prolonged labour pain (21%) was the highest reported complication during the delivery, followed by obstructive labour (20%), fever (14%), severe headache (14%). Mothers with higher education, a higher number of antenatal care (ANC) visits, complications during ANC, employed, and first-time mothers had higher odds of reporting delivery-related complications. More than one-half (51%) of these mothers had normal vaginal delivery. Nearly one-fifth (20%) of mothers who reported delivery-related complications were delivered by unskilled health workers at homes. On the other hand, about one-fifth (19%) of the mothers without any complications during delivery had a caesarean delivery. Nine out of ten of these caesarean deliveries were done at the private facilities. ConclusionDelivery-related complications are significantly related to a woman's reproductive history and other background characteristics. Unnecessary caesarean delivery is prominent at private facilities.

Thirty Years of United Nations Inter-Agency Working Group's Global, Regional, and National Maternal Mortality Estimates Revisited.

Over the last three decades, the United Nations interagency working group series of model-based maternal mortality estimation showed a significant reduction in maternal mortality ratio (MMR) at global, regional, and national levels. However, the contribution of sub-Saharan Africa for the global maternal deaths in 2020 was nearly two-fold higher than before, and the top five countries with high burden of maternal deaths remained unchanged after four decades. In this commentary, we argue that not all countries with high maternal deaths had high MMR; the lower MMR was noted as shadowing the large number of maternal deaths in countries with high rates of total births. We critically appraised the changes and challenges in maternal mortality measurements. We recommend the use of multiple indicators and categorizing the absolute number of maternal deaths to assess individual countries' maternal health status. As the majority of maternal deaths are preventable and all maternal deaths are catastrophic to the family, estimating the absolute number of maternal deaths should be given equal weight in future research undertakings.

A systematic review of behaviour change interventions to improve maternal health outcomes in sub-Saharan Africa.

The rate of decline in the global burden of avoidable maternal deaths has stagnated and remains an issue of concern in many sub-Saharan Africa countries. As per the most recent evidence, an average maternal mortality ratio (MMR) of 223 deaths per 100,000 live births has been estimated globally, with sub-Saharan Africa's average MMR at 536 per 100,000 live births-more than twice the global average. Despite the high MMR, there is variation in MMR between and within sub-Saharan Africa countries. Differences in the behaviour of those accessing and/or delivering maternal healthcare may explain variations in outcomes and provide a basis for quality improvement in health systems. There is a gap in describing the landscape of interventions aimed at modifying the behaviours of those accessing and delivering maternal healthcare for improving maternal health outcomes in sub-Saharan Africa. Our objective was to extract and synthesise the target behaviours, component behaviour change strategies and outcomes of behaviour change interventions for improving maternal health outcomes in sub-Saharan Africa. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our protocol was published a priori on PROSPERO (registration number CRD42022315130). We searched ten electronic databases (PsycINFO, Cochrane Database of Systematic Reviews, International Bibliography of Social Sciences, EMBASE, MEDLINE, Scopus, CINAHL PLUS, African Index Medicus, African Journals Online, and Web of Science) and included randomised trials and quasi-experimental studies. We extracted target behaviours and specified the behavioural interventions using the Action, Actor, Context, Time, and Target (AACTT) framework. We categorised the behaviour change strategies using the intervention functions described in the Behaviour Change Wheel (BCW). We reviewed 52 articles (26 randomized trials and 26 quasi-experimental studies). They had a mixed risk of bias. Out of these, 41 studies (78.8%) targeted behaviour change of those accessing maternal healthcare services, while seven studies (13.5%) focused on those delivering maternal healthcare. Four studies (7.7%) targeted mixed stakeholder groups. The studies employed a range of behaviour change strategies, including education 37 (33.3%), persuasion 20 (18%), training 19 (17.1%), enablement 16 (14.4%), environmental restructuring 8 (7.2%), modelling 6 (5.4%) and incentivisation 5 (4.5%). No studies used restriction or coercion strategies. Education was the most common strategy for changing the behaviour of those accessing maternal healthcare, while training was the most common strategy in studies targeting the behaviour of those delivering maternal healthcare. Of the 52 studies, 40 reported effective interventions, 7 were ineffective, and 5 were equivocal. A meta-analysis was not feasible due to methodological and clinical heterogeneity across the studies. In conclusion, there is evidence of effective behaviour change interventions targeted at those accessing and/or delivering maternal healthcare in sub-Saharan Africa. However, more focus should be placed on behaviour change by those delivering maternal healthcare within the health facilities to fast-track the reduction of the huge burden of avoidable maternal deaths in sub-Saharan Africa.

Projections of maternal mortality ratios in Bangladesh.

The objective of this study was to predict when Bangladesh would achieve Sustainable Development Goal Target 3.1, which is to reduce the maternal mortality ratio (MMR) to less than 70 per 100 000 live births. We used secondary data from the 1993 to 2017 Bangladesh Demographic and Health Surveys and other sources to project the MMR until 2060 under several scenario assumptions using an autoregressive moving average model with exogenous variables (ARMAX). Explanatory variables were selected based on the three delays model, and a reference forecast and four practical scenarios were simulated: Scenario 1 assumed a 4% annual increase in institutional deliveries, Scenario 2 followed the national goals, the reference forecast and Scenario 3 varied in terms of district-wise increase rates (Scenario 3 had a lower rate of increase), and Scenario 4 assumed minimal changes in institutional deliveries. Scenario 1 was the earliest, with an MMR of <70 per 100 000 live births in 2026. Scenario 2 would meet the target of <70 per 100 000 live births in 2029. The reference forecast had the third lowest MMR, with 69.78 per 100 000 live births (95% prediction intervals (PI) = 32.44 to 107.11) in 2049. Although the MMR for Scenario 3 decreased slowly, it would not reduce below 70 per 100 000 live births by 2060. Scenario 4, which had the highest MMR, also resulted in the MMR not reducing below 70 per 100 000 live births by 2060. To increase the institutional delivery rate and reduce the MMR, as in Scenarios 1 and 2, it is necessary to improve the institutional delivery rate in regions with low institutional delivery rates. Additionally, health facilities need to provide appropriate quality medical care to increase the institutional delivery rate and contribute to a decrease in the MMR, as shown by the results of this study.

Maternal age extremes and adverse pregnancy outcomes in low-resourced settings.

Adolescent (<20 years) and advanced maternal age (>35 years) pregnancies carry adverse risks and warrant a critical review in low- and middle-income countries where the burden of adverse pregnancy outcomes is highest. To describe the prevalence and adverse pregnancy (maternal, perinatal, and neonatal) outcomes associated with extremes of maternal age across six countries. We performed a historical cohort analysis on prospectively collected data from a population-based cohort study conducted in the Democratic Republic of Congo, Guatemala, India, Kenya, Pakistan, and Zambia between 2010 and 2020. We included pregnant women and their neonates. We describe the prevalence and adverse pregnancy outcomes associated with pregnancies in these maternal age groups (<20, 20-24, 25-29, 30-35, and >35 years). Relative risks and 95% confidence intervals of each adverse pregnancy outcome comparing each maternal age group to the reference group of 20-24 years were obtained by fitting a Poisson model adjusting for site, maternal age, parity, multiple gestations, maternal education, antenatal care, and delivery location. Analysis by region was also performed. We analyzed 602,884 deliveries; 13% (78,584) were adolescents, and 5% (28,677) were advanced maternal age (AMA). The overall maternal mortality ratio (MMR) was 147 deaths per 100,000 live births and increased with advancing maternal age: 83 in the adolescent and 298 in the AMA group. The AMA groups had the highest MMR in all regions. Adolescent pregnancy was associated with an adjusted relative risk (aRR) of 1.07 (1.02-1.11) for perinatal mortality and 1.13 (1.06-1.19) for neonatal mortality. In contrast, AMA was associated with an aRR of 2.55 (1.81 to 3.59) for maternal mortality, 1.58 (1.49-1.67) for perinatal mortality, and 1.30 (1.20-1.41) for neonatal mortality, compared to pregnancy in women 20-24 years. This pattern was overall similar in all regions, even in the <18 and 18-19 age groups. The maternal mortality ratio in the LMICs assessed is high and increased with advancing maternal age groups. While less prevalent, AMA was associated with a higher risk of adverse maternal mortality and, like adolescence, was associated with adverse perinatal mortality with little regional variation.

Self-care practices of pregnant women: A qualitative study in a Nigerian rural community

Context: Inadequate self-care during pregnancy is a contributor to the poor maternal health indices in Cross River State; including the high maternal mortality ratio of 2,000/100,000 live births.&#x0D; Objectives: The objectives of the study were to identify self-care practices adopted by women during pregnancy and delivery and to identify barriers to quality self care.&#x0D; Methods: Focus Group Discussions, Key informant interviews and in-depth interviews were conducted among pregnant women, women of reproductive age and other stakeholders in Biase Local Government Area of Cross River State.&#x0D; Results: The study revealed inadequate knowledge and practice of self-care during pregnancy. Some pregnant women were unable to recognize early signs of pregnancy while others, especially young unmarried girls, tried to hide the pregnancy. Barriers to effective self-care identified included myths and misconceptions, especially the belief that health-related events during pregnancy are caused by witches and wizards, lack of preparation for pregnancy and abandonment of pregnant women by partners, usually due to unwillingness and/or inability to father the child.&#x0D; Conclusion: There is need for pre-marital and pre-natal counselling and health education so as to address identified gaps in knowledge and practice and lack of male involvement in maternal healthcare.

Reduction in maternal mortality ratio varies by district in Sidama National Regional State, southern Ethiopia: Estimates by cross-sectional studies using the sisterhood method and a household survey of pregnancy and birth outcomes.

Few studies assess the magnitude, variations, and reduction of maternal mortality at a lower administrative level. This study was conducted to estimate the life time risk (LTR) of maternal death and the maternal mortality ratio (MMR) and assess the reduction in MMR. This is a population-based cross-sectional study conducted in six districts of Sidama National Regional State, southern Ethiopia, from July 2019 to May 2020. The study was conducted with men and women aged 15-49 years. By creating a retrospective cohort of women of reproductive age, we calculated the LTR of maternal mortality and approximated the MMR using the total fertility of the rural Ethiopian population. Variations in maternal mortality was assessed based on characteristics of the respondents, like age, sex, and the districts where they lived. Reduction in MMR was examined using the estimates of the sisterhood method and the 5-year recall of pregnancy and birth outcome household survey. We analysed 17374 (99.6%) respondents: 8884 (51.1%) men and 8490 (48.9%) women. The 17,374 respondents reported 64,387 maternal sisters. 2,402 (3.7%) sisters had died; 776 (32.3%) were pregnancy-related deaths. The LTR of maternal death was 3.2%, and the MMR was 623 (95% CI: 573-658) per 100,000 live births (LB). The remote district (Aroresa) had a MMR of 1210 (95% CI: 1027-1318) per 100,000 LB. The estimates from male and female respondents were not different. A significant reduction in MMR was observed in districts located near the regional centre. However, no reduction was observed in districts located far from the regional centre. The high MMR with district-level variations and the lack of mortality reduction in districts located far from the centre highlight the need for instituting interventions tailored to the local context to save mothers and accelerate reductions in MMR.

Global patterns of cancer transitions: A modelling study.

Cancer is a major contributor to global disease burden. Many countries experienced or are experiencing the transition that non-infection-related cancers replace infection-related cancers. We aimed to characterise burden changes for major types of cancers and identify global transition patterns. We focused on 10 most common cancers worldwide and extracted age-standardised incidence and mortality in 204 countries and territories from 1990 to 2019 through the Global Burden of Disease Study. Two-stage modelling design was used. First, we applied growth mixture models (GMMs) to identify distinct trajectories for incidence and mortality of each cancer type. Next, we performed latent class analysis to detect cancer transition patterns based on the categorisation results from GMMs. Kruskal-Wallis H tests were conducted to evaluate associations between transition patterns and socioeconomic indicators. Three distinct patterns were identified as unfavourable, intermediate and favourable stages. Trajectories of lung and breast cancers had the strongest association with transition patterns among men and women. The unfavourable stage was characterised by rapid increases in lung, breast and colorectal cancers alongside stable or decreasing burden of gastric, cervical, oesophageal and liver cancers. In contrast, the favourable stage exhibited rapid declines in most cancers. The unfavourable stage was associated with lower sociodemographic index, health expenditure, gross domestic product per capita and higher maternal mortality ratio (P < .001 for all associations). Our findings suggest that unfavourable, intermediate and favourable transition patterns exist. Countries and territories in the unfavourable stage tend to be socioeconomically disadvantaged, and tailored intervention strategies are needed in these resource-limited settings.

Trends and Patterns of Maternal Deaths in Sierra Leone, January 2017-December 2020

Sierra Leone is a country with an extremely high maternal mortality ratio (MMR) with over 1000 maternal deaths per 100,000 live births. We analyzed data from the national maternal death surveillance and response system to describe the trend and determine the burden of maternal deaths in Sierra Leone.

Scenarios of maternal mortality reduction by 2030 in the Americas: insights from its tempo

BackgroundThe enduring threat of maternal mortality to health worldwide and in the Americas has been recognized in the global and regional agendas and their targets to 2030. To inform the direction and amount of effort needed to meet those targets, a set of equity-sensitive regional scenarios of maternal mortality ratio (MMR) reduction based on its tempo or speed of change from baseline year 2015 was developed.MethodsRegional scenarios by 2030 were defined according to: i) the MMR average annual rate of reduction (AARR) needed to meet the global (70 per 100,000) or regional (30 per 100,000) targets and, ii) the horizontal (proportional) or vertical (progressive) equity criterion applied to the cross-country AARR distribution (i.e., same speed to all countries or faster for those with higher baseline MMR). MMR average and inequality gaps –absolute (AIG), and relative (RIG)– were scenario outcomes.ResultsAt baseline, MMR was 59.2 per 100,000; AIG was 313.4 per 100,000 and RIG was 19.0 between countries with baseline MMR over twice the global target and those below the regional target. The AARR needed to meet the global and regional targets were -7.60% and -4.54%, respectively; baseline AARR was -1.55%. In the regional MMR target attainment scenario, applying horizontal equity would decrease AIG to 158.7 per 100,000 and RIG will remain invariant; applying vertical equity would decrease AIG to 130.9 per 100,000 and RIG would decrease to 13.5 by 2030.ConclusionThe dual challenge of reducing maternal mortality and abating its inequalities will demand hefty efforts from countries of the Americas. This remains true to their collective 2030 MMR target while leaving no one behind. These efforts should be mainly directed towards significantly speeding up the tempo of the MMR reduction and applying sensible progressivity, targeting on groups and territories with higher MMR and greater social vulnerabilities, especially in a post-pandemic regional context.

Development and pilot test of a smartphone app for midwifery care in Tanzania: A comparative cross-sectional study.

To address Tanzania's high maternal mortality ratio, it is crucial to increase women's access to healthcare. To improve access, the quality of antenatal care needs to be improved. Therefore, we conducted a pilot study of a smartphone app for midwives and examined its potential effects on the learning outcomes of midwives and birth preparedness of pregnant women in Tanzania. This mixed-methods, pilot study provided an educational app for midwives in the intervention group, obtained data about the continuous use of the app, measured midwives' learning outcomes, directed focus group discussions on the usability of the app, and conducted surveys among pregnant women about birth preparedness in the intervention and control groups to evaluate if midwives provided proper information to them. The control group received regular antenatal care and answered the same survey. Participants were 23 midwives who participated in the testing and provided learning outcome data. Twenty-one participated in focus group discussions. Results showed that 87.5% of midwives continued to study with the app two months post-intervention. A mini-quiz conducted after using the app showed a significant increase in mean scores (6.9 and 8.4 points, respectively) and a non-significant increase on the questionnaire on women-centered care (98.6 and 102.2 points, respectively). In the focus group discussions, all midwives expressed satisfaction with the app for several reasons, including comprehensive content, feelings of confidence, and reciprocal communication. There were 207 pregnant women included in the analysis. The intervention group had significantly higher knowledge scores and home-based value scores than did controls. The total scores and other subscales did not show statistical significance for group differences. The results indicate the potential impact of the midwifery education app when it is implemented on a larger scale, especially considering that the results show a potential effect on midwives' learning outcomes.

Variation in maternal mortality in Sidama National Regional State, southern Ethiopia: A population based cross sectional household survey.

Maternal mortality studies conducted at national level do not provide information needed for planning and monitoring health programs at lower administrative levels. The aim of this study was to measure maternal mortality, identify risk factors and district level variations in Sidama National Regional State, southern Ethiopia. A cross sectional population-based survey was carried in households where women reported pregnancy and birth outcomes in the past five years. The study was conducted in the Sidama National Regional State, southern Ethiopia, from July 2019 to May 2020. Multi-stage cluster sampling technique was employed. The outcome variable of the study was maternal mortality. Complex sample logistic regression analysis was applied to assess variables independently associated with maternal mortality. We registered 10602 live births (LB) and 48 maternal deaths yielding the overall maternal mortality ratio (MMR) of 419; 95% CI: 260-577 per 100,000 LB. Aroresa district had the highest MMR with 1142 (95% CI: 693-1591) per 100,000 LB. Leading causes of death were haemorrhage 21 (41%) and eclampsia 10 (27%). Thirty (59%) mothers died during labour or within 24 hours after delivery, 25 (47%) died at home and 17 (38%) at health facility. Mothers who did not have formal education had higher risk of maternal death (AOR: 4.4; 95% CI: 1.7-11.0). The risk of maternal death was higher in districts with low midwife to population ratio (AOR: 2.9; 95% CI: 1.0-8.9). The high maternal mortality with district level variations in Sidama Region highlights the importance of improving obstetric care and employing targeted interventions in areas with high mortality rates. Due attention should be given to improving access to female education. Additional midwives have to be trained and deployed to improve maternal health services and consequently save the life of mothers.

Discharge Readiness and Associated Factors Among Postpartum Women in Tamale, Ghana.

Ghana experiences a relatively high maternal mortality ratio, with the majority of maternal deaths occurring in the postpartum period. Discharge readiness is a reliable indicator of maternal health outcomes and involves a postpartum woman's perception of preparedness to leave the hospital following delivery. We measured the discharge readiness of postpartum women in Ghana through an institutional-based cross-sectional study involving 151 participants. Participants completed an interviewer-administered survey, and data analyses included linear regression models. The study sample demonstrated relatively high discharge readiness, with a mean score of 177.57 on a scale from 0.00 to 220.00. Higher gravidity was positively associated with discharge readiness score, while longer length of hospital stay and receiving educational handouts were negatively associated with discharge readiness score. Clinical interventions addressing the factors found to be associated with discharge readiness have significant potential to improve postpartum care and maternal outcomes in Ghana.

Determinants of Antenatal Healthcare Services Utilisation: A Case of Dodoma, Tanzania.

Antenatal Care (ANC) coverage is a key determinant of maternal and perinatal morbidity and mortality. Low utilization of ANC services and high Maternal Mortality Ratio (MMR) have been reported in the East African Region. Due to the paucity of information on the determinants of ANC utilization in this region, we conducted the study aiming at exploring factors influencing the utilization of ANC services. We further sought opinions that will aid the improvement of utilization of ANC services. A triangulation mixed-method study was conducted in August 2021 among forty-five women and ten healthcare providers in a selected health center located in Dodoma Urban District, Tanzania. Information was gathered using semi-structured questionnaires and in-depth interviews. Quantitative data were analysed using IBM SPSS Statistics. The relationship between the outcome variable and the predictor variables was assessed by either the Chi-square test or Fisher's exact test and a p value<.05 was considered statistically significant. Manual thematic analysis was used for qualitative data after thorough transcript and documentary reviews. Almost half (48.9%) of the interviewed women attended ANC services at least once during their last pregnancy. Women who reported having a low income and those who spent more than an hour reaching the health facility had poor ANC attendance (p value<.05). The main themed factors that negatively impacted ANC utilization included cultural practices and gender norms, poor communication between partners, and long waiting time at the ANC clinics. Utilization of ANC services was found to be low among women living in Dodoma Urban District. ANC attendance varied with the level of income and the time women spent reachingt the health facility. Cultural practices and gender norms, communication between spouses, and service waiting time were mentioned to influence ANC attendance. Public and private sectors should invest in maternal health, provide affordable services and formulate strategies to improve the accessibility of ANC services. Interventions should target women of low socio-economic class and those living in remote areas. Moreover, schemes to address the sociocultural barriers to ANC utilization need to be formulated.

The impact of community midwives on maternal healthcare utilization.

Globally 800 women die every day from preventable causes related to pregnancy and childbirth. One of the major reasons for high maternal mortality ratios in many developing countries is the low proportion of births attended by Skilled Birth Attendants (SBA). To address the high number of maternal deaths, in 2008 the Government of Pakistan introduced the Community Midwives Program. Under the program, women from across the country were trained and deployed as Community Midwives. In this study, I use six rounds of Pakistan Social and Living Measurement Survey to estimate the impact of this program on maternal healthcare utilization. I find that women residing in districts with higher Community Midwives per capita were 9 percentage points more likely to be attended by a SBA at the time of delivery and were 8 percentage points more likely to give birth at a medical facility as opposed to birthing at home. I find no evidence of impact on take up of prenatal and post-natal check-ups. The use of Community Midwives may be a cost effective tool to reduce maternal deaths, especially for developing countries with low health budgets.

Maternal mortality in South region of Brazil: an analysis from 2000 to 2018

This study characterises maternal mortality in southern Brazil and verifies its trends between 2000 and 2018. It is an ecological time-series study, analysing secondary data from the Department of Informatics of the Unified Health System. The trend of the maternal mortality ratio (MMR) was calculated using generalised linear regression, and the ratios of the rates according to women's characteristics, with a confidence interval (CI) of 95%. The MMR in the South region went from 53.4 to 36.8 deaths per 100,000 live births from 2000 to 2018, a reduction trend of 1.2 percentage points per year. Mortality was directly related to increasing age (p < .001) and inversely related to schooling (p < .001) and predominated in non-white women (p < .001). The main cause of death was direct causes, including hypertensive disorders. Despite the reduction trend in maternal mortality in southern Brazil, the MMR observed is constantly above the recommended by the World Health Organisation. Impact Statement What is already known on this subject? The Maternal Mortality Ratio (MMR) is an indicator that allows an analysis of women's health in relation to the socio-economic and care characteristics of the region where they live. Between 2000 and 2015, Brazil had presented a high MMR, with around 50 deaths per 100,000 live births, while WHO considers a reasonably adequate MMR of fewer than 20 deaths per 100,000 live births. What do the results of this study add? This study updates data about MMR in the Southern Region of Brazil, the one which has the lowest rates in the country, but with variable values between the states. There was a reduction in MMR in southern Brazil between 2000 and 2018 but higher rates for women over 30 years old and in a situation of social vulnerability, as low-income and non-white women. Santa Catarina State presented stable values in the period and remained below the RMM averages of the other states during all years. What are the implications of these findings for clinical practice and/or further research? Comparing previous and current Maternal Mortality Rates in the regional context is important to adapt public health policies for the most affected population. Maternal death is still a reality for single and low-income women, who have greater difficulty in access to health care. Strategies in the Unified Health System are needed to tackle this problem.

Estimates and correlates of district-level maternal mortality ratio in India.

Despite the progress achieved, approximately one-quarter of all maternal deaths worldwide occur in India. Till now, India monitors maternal mortality in 18 out of its 36 provinces using information from the periodic sample registration system (SRS). The country does not have reliable routine information on maternal deaths for smaller states and districts. And, this has been a major hurdle in local-level health policy and planning to prevent avoidable maternal deaths. For the first time, using triangulation of routine records of maternal deaths under the Health Management Information System (HMIS), Census of India, and SRS, we provide Maternal Mortality Ratio (MMR) for all states and districts of India. Also, we examined socio-demographic and health care correlates of MMR using large-sample and robust statistical tools. The findings suggest that 70% of districts (448 out of 640 districts) in India have reported MMR above 70 deaths-a target set under Sustainable Development Goal-3. According to SRS, only Assam shows MMR of more than 200, while our assessment based on HMIS suggests that about 6-states (and two union territories) and 128-districts have MMR above 200. Thus, the findings highlight the presence of spatial heterogeneity in MMR across districts in the country, with spatial clustering of high MMR in North-eastern, Eastern, and Central regions and low MMR in the Southern and Western regions. Even the better-off states such as Kerala, Tamil Nadu, Andhra Pradesh, Karnataka, and Gujarat have districts of medium-to-high MMR. In order of their importance, fertility levels, the sex ratio at birth, health infrastructure, years of schooling, postnatal care, maternal age and nutrition, and poor economic status have emerged as the significant correlates of MMR. In conclusion, we show that HMIS is a reliable, cost-effective, and routine source of information for monitoring maternal mortality ratio in India and its states and districts.

SOCIODEMOGRAPHIC FACTORS AFFECTING BIRTH PREPAREDNESS AND COMPLICATION READINESS AMONG PREGNANT WOMEN ATTENDING ANTENATAL CLINIC IN YENAGOA, SOUTH-SOUTH, NIGERIA

&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Maternal mortality still remains a substantial burden and hence progress towards the fifth Millennium Development Goal (MDG 5) was particularly slow. The maternal mortality ratio (MMR) in developing regions is 15 times (240/100,000 live births) higher than in developed regions (16/100,000live births). Sub-Saharan Africa had the highest MMR at 500 maternal deaths per 100,000 live births. &lt;strong&gt;Objectives: &lt;/strong&gt;To assess the sociodemographic factors affecting birth preparedness and complication readiness&lt;strong&gt; &lt;/strong&gt;amongst those attending antenatal clinics in Yenagoa metropolis. &lt;strong&gt;Methods: &lt;/strong&gt;This was a cross-sectional descriptive study done amongst pregnant women of childbearing ages attending ANC clinics using an interviewer-administered semi-structured questionnaire. Participants were selected using a systematic random sampling technique. The data collected were analyzed using SPSS version 20. &lt;strong&gt;Results: &lt;/strong&gt;Most of the respondents 258 (99.2%) were Christians. The majority 239 (91.9%) of the respondents were married. One hundred and thirteen (43.5%) respondents were Ijaw in their ethnic group, followed Igbo; 71 (27.3%). The majority 141 (54.2%) of respondents had a secondary level of education Socioeconomic status II had the highest frequency 97 (37.3%), then status I, 94 (36.2%) Birth preparedness and complication readiness of mothers was significantly (&lt;em&gt;p&lt;/em&gt; &amp;lt;0.05) associated with mother’s education, socioeconomic status and knowledge of obstetric danger signs. Birth preparedness and complication readiness of mothers were not significantly (&lt;em&gt;p&lt;/em&gt; &amp;gt; 0.05) associated with the age of the expectant mother, marital status, family size, gestational age, antenatal care follow-up, number of antenatal care visits and time to the nearest health facility. &lt;strong&gt;Conclusion: &lt;/strong&gt;Educational status, socioeconomic status and knowledge of key danger signs during pregnancy were independent predictors of birth preparedness and complication readiness. There is a need for improvement of the above factors in other to enhance birth preparedness and complication readiness.&lt;/p&gt;&lt;p&gt; &lt;/p&gt;&lt;p&gt;&lt;strong&gt; Article visualizations:&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;img src="/-counters-/edu_01/0949/a.php" alt="Hit counter" /&gt;&lt;/p&gt;

Bangladesh at Fifty: Changes and Challenges in Population and Development

Bangladesh turned 50 in 2021 having made remarkable progress in population and development, such as reducing total fertility and maternal mortality, boosting contraceptive prevalence, reducing infant and child mortality, increasing life expectancy at birth, and enhancing gender parity in schooling, women's empowerment, and overall development. This paper explores the past and determines the drivers of population change and development challenges, the current situation, and future trends and issues up to 2041—the year benchmarked for the country to attain 'developed' status. The study uses censuses, national-level surveys, population projections, and UN and World Bank data. Reducing total fertility, curbing child marriage, addressing adolescent motherhood and their unmet need for family planning, reducing high maternal mortality ratios, the double burden of diseases and malnutrition, addressing population ageing, high youth unemployment, low female labor force participation, and increased climate change vulnerabilities are critical challenges. The demographic dividend needs urgent action. To reach the SDGs by 2030, the country must eliminate unmet contraception needs, preventable maternal deaths, and gender-based violence, and harmful practices, including child marriages.