Levels Of Maternal Mortality Research Articles

Do women’s perspectives of quality of care during childbirth match with those of providers? A qualitative study in Uttar Pradesh, India

ABSTRACTBackground: Persistently high maternal mortality levels are a concern in developing countries. In India, monetary incentive schemes have increased institutional delivery rates appreciably, but have not been equally successful in reducing maternal mortality. Maternal outcomes are affected by quality of obstetric care and socio-cultural norms. In this light there is need to examine the quality of care provided to women delivering in institutions.Objective: This study aimed to examine pregnant women’s expectations of high-quality care in public health facilities in Uttar Pradesh, India, and to contrast this with provider’s perceptions of the same, as well as the barriers that limit their ability to provide high-quality care.Methods: A qualitative descriptive analysis was conducted on data from two studies – focus group discussions with rural women in their last trimester of pregnancy (conducted in 2014) to understand women’s experience and satisfaction with maternal care services, and in-depth interviews with care providers (conducted in 2016–17) to understand provision of person-centred care. Provider perspectives were matched with themes of women’s perspectives on quality of childbirth care in facilities.Results: Major themes of care prioritised by women included availability of doctors at the facility; availability of medicines; food; ambulance services; maintenance of cleanliness and hygiene; privacy; good and safe delivery with no complications; client-provider interaction; financial cost of care. Many women also voiced no expectation of care, indicating disillusionment from the existing system. Providers concurred with women on all themes of care except availability of doctors, as they felt that trained nurses were proficient in conducting deliveries.Conclusions: This study shows that women have clear expectations of quality care from facilities where they go to deliver. Understanding their expectations and matching them with providers’ perspectives of care is critical for efforts to improve the quality of care and thereby impact maternal outcomes.

Provision of medical supply kits to improve quality of antenatal care in Mozambique: a stepped-wedge cluster randomised trial.

SummaryBackgroundHigh levels of maternal and newborn mortality and morbidity remain a daunting reality in many low-income countries. Several interventions delivered during antenatal care have been shown to improve maternal and newborn outcomes, but stockouts of medical supplies at point of care can prevent implementation of these services. We aimed to evaluate whether a supply chain strategy based on the provision of kits could improve quality of care.MethodsWe did a pragmatic, stepped-wedge, cluster-randomised controlled trial at ten antenatal care clinics in Mozambique. Clinics were eligible if they were not already implementing the proposed antenatal care package; they served at least 200 new pregnant women per year; they had Maternal and Child Health (MCH) nurses; and they were willing to participate. All women attending antenatal care visits at the participating clinics were included in the trial. Participating clinics were randomly assigned to shift from control to intervention on prespecified start dates. The intervention involved four components (kits with medical supplies, a cupboard to store these supplies, a tracking sheet to monitor stocks, and a one-day training session). The primary outcomes were the proportion of women screened for anaemia and proteinuria, and the proportion of women who received mebendazole in the first antenatal care visit. The intervention was delivered under routine care conditions, and analyses were done according to the intention-to-treat principle. This trial is registered with the Pan African Clinical Trial Registry, number PACTR201306000550192.FindingsBetween March, 2014, and January, 2016, 218 277 antenatal care visits were registered, with 68 598 first and 149 679 follow-up visits. We found significant improvements in all three primary outcomes. In first visits, 5519 (14·6%) of 37 826 women were screened for anaemia in the control period, compared with 30 057 (97·7%) of 30 772 in the intervention period (adjusted odds ratio 832·40; 99% CI 666·81–1039·11; p<0·0001); 3739 (9·9%) of 37 826 women were screened for proteinuria in the control period, compared with 29 874 (97·1%) of 30 772 in the intervention period (1875·18; 1447·56–2429·11; p<0·0001); and 17 926 (51·4%) of 34 842 received mebendazole in the control period, compared with 24 960 (88·2%) of 28 294 in the intervention period (1·88; 1·70–2·09; p<0·0001). The effect was immediate and sustained over time, with negligible heterogeneity between sites.InterpretationA supply chain strategy that resolves stockouts at point of care can result in a vast improvement in quality during antenatal care visits, when compared with the routine national process for procurement and distribution of supplies.FundingGovernment of Flanders and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Distance from health facility and mothers&amp;rsquo; perception of quality related to skilled delivery service utilization in northern Ethiopia

BackgroundPoor maternal health service utilization is one of the contributing factors to a high level of maternal and newborn mortality in Ethiopia. The factors associated with utilization of services are believed to differ from one context to another. We assessed the factors associated with skilled delivery service utilization in rural northern Ethiopia.Subjects and methodsA community-based survey was conducted among mothers who gave birth in the 12 months preceding the study period, from January to February 2015, in the Tigray region of Ethiopia. Multistage sampling technique was used to select mothers from the identified clusters. Households within a 10 km radius of the health facility were taken as a cluster for a community survey. Data were collected using face-to-face interview at the household level. We compared the mothers who reported giving birth to the index child in a health facility and those who reported delivering at home, in order to identify the predictors of skilled delivery utilization. Multivariable logistic regression model was used to determine the predictors of skilled delivery service utilization. The results are presented with odds ratio (OR) and 95% confidence interval (CI).ResultsA total of 1,796 mothers participated in the study, with a 100% response rate. Distance to health facilities (adjusted odds ratio [AOR] =0.53 [95% CI: 0.39, 0.71]), perception of mothers to the availability of adequate equipment in the delivery service in their catchment area (AOR =1.5 [95% CI: 1.11, 2.13]), experiencing any complication during childbirth, using antenatal care, lower birth order and having an educated partner were the significant predictors of skilled delivery service utilization.ConclusionImplementing community-based intervention programs that will address the physical accessibility of delivery services, such as the ambulance service, road issues and waiting rooms, and improving quality maternity service will likely reduce the current problem.

State Capacity and Health Outcomes: Comparing Argentina’s and Chile’s Reduction of Infant and Maternal Mortality, 1960–2013

Summary There is substantial quantitative evidence linking higher state capacity to better health outcomes, but scant attention has been paid to the specific mechanisms through which this causal influence operates. The problem is compounded by the considerable diversity of ways in which the influence of the state on development outcomes has been conceptualized, making it hard for practitioners to extract policy lessons from this literature. In this study, I seek to help to address both of these problems through a historical-comparative examination of the ways in which state capacity affected infant and maternal mortality reduction in Argentina and Chile over the last half century. I show that Chile’s greater investment in health-specific state capacities was behind the remarkable historical “reversal of fortune” between these two countries in terms of infant and maternal mortality levels from 1960 to the present, as well as behind Chile’s notorious reduction in the territorial inequality of these outcomes. I show the key difference between the two countries was the quality, reach, and homogeneity of their respective public health systems. From a theoretical standpoint, I argue that the notions of bureaucratic quality and infrastructural power are both necessary and complementary perspectives through which to conceptualize state capacity and understand its causal influence over health and other desirable developmental outcomes. In turn, this suggests that a useful way to specify calls for better “governance” and to achieve better long-run health performance may be to invest in the public health system’s technical (bureaucratic) autonomy and in its system-wide planning and coordination capacities.

Risk factors and symptoms associated with maternal and neonatal complications in women with uterine rupture. A 16 years multicentric experience

Objectivehigh maternal and fetal morbidity and mortality levels have been associated with uterine ruptures. The aims of our study were to determine risk factors and signs for maternal and fetal complications in patients with uterine rupture. Study designretrospective, population-based study, in all Val d’Oise public obstetrics departments, France, between 2000 and 2015. All patients with uterine rupture were analyzed using medical records. To identify risk factors and signs for maternal and fetal complications, patients were divided into two groups according to adverse maternal and fetal outcomes or not, and compared. ResultsDuring the study period, 126 patients with complete uterine rupture were identified. In all, 74 (58.7%) had maternal and fetal complications, and these were more frequently observed in patients with unscarred uterus (N=18; p<0.001 and OR 5.52, 95% CI 2.09–14.55), lateral injured uterus (N=21; p<0.001), after labour induction (N=21, p=0.01 and OR 3.69, 95% CI 1.22–13.53), and when a sudden onset of abdominal pain, in patients with previous successful epidural analgesia, occurred (75.9% vs 39.2%, p<0.001 and OR 4.88, 95% CI 1.9–12.13). ConclusionUnscarred and lateral ruptures of uterus were associated with maternal vascular injuries, and higher maternal and fetal complications. Sudden onset of abdominal pain in woman with previous successful epidural analgesia might be predictive of complicated uterine rupture.

Hidden losses and ‘forgotten’ suffering: the bereavement experiences of British Romany Gypsies and Travellers

There are an estimated 300,000 Romany Gypsies and Travellers resident in Britain. Policy enactments and a decline in stopping places have impacted these ethnic minorities’ cultural tradition of nomadism, leading to significant socioeconomic challenges and rapid cultural change in recent decades. Additionally, Gypsies and Travellers face significant health inequalities, including a reduced life expectancy of between 10–12 years compared to ‘mainstream’ populations. Further, considerably higher levels of suicide, maternal and infant mortality, miscarriage and stillbirth are reported. Membership of close-knit and large extended families means that bereavement experiences are common from an early age. Unresolved grief from multiple bereavements can have long-term health implications, including depression, anxiety, and increases in risk-taking behaviours such as alcohol and substance misuse. This paper presents a narrative review of the literature illustrated by quotes from a from a recently completed study that examines the bereavement support needs of Gypsies and Travellers and best practice for organisations seeking to support these ‘hard to reach’ populations.

Maternal mortality in the developed world: a review of surveillance methods, levels and causes of maternal deaths during 2006-2010

This article provides an overview of surveillance methods, levels, and causes of maternal mortality in developed countries, in Europe and the United States, during 2006-2010. Accurate identification of maternal deaths is not always possible, and no two countries in the world use the same surveillance methods for maternal mortality. Despite limitations (e.g. underestimation, misclassification), routine vital registration systems are the backbone of maternal mortality surveillance systems in developed countries. Enhanced surveillance methods involve linkages between deaths of women of reproductive age and births within the preceding year, or the use of additional data sources for maternal deaths. Confidential enquiries into maternal deaths, in place in France, the Netherlands, and the UK are the gold standard in maternal mortality surveillance. Levels of maternal mortality in Europe were the lowest in the world during 2006-2010. While Europe has not seen major changes in maternal mortality in recent years, pregnancy-related mortality increased considerably in the USA, where improvements in the identification of deaths appear to play a part. The triad of infection, hemorrhage, and hypertensive disorders of pregnancy, which in the past accounted for >90% of all maternal deaths, now accounts for 60-70% of such deaths in developed countries. Maternal mortality surveillance provides learning opportunities to prevent future maternal deaths. There is need for integration of linked, multiple data sources into current maternal mortality surveillance systems to improve their utility.

The role of a decision-support smartphone application in enhancing community health volunteers’ effectiveness to improve maternal and newborn outcomes in Nairobi, Kenya: quasi-experimental research protocol

IntroductionImproving maternal and newborn survival remains major aspirations for many countries in the Global South. Slum settlements, a result of rapid urbanisation in many developing countries including Kenya, exhibit high...

A global database of abortion laws, policies, health standards and guidelines.

In June 2017 the United Nations Development Programme/United Nations Population Fund/United Nations Children's Fund/World Health Organization (WHO)/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) in collaboration with the Population Division of the United Nations Department of Economic and Social Affairs (UN DESA) launched a new, open-access Global Abortion Policies Database (available at two different web interfaces: http://www.srhr.org/ abortion-policies; esa.un.org/gapp). The online database contains comprehensive information on the abortion laws, policies, health standards and guidelines for WHO and United Nations (UN) Member States. It is intended for use by policy-makers, human rights bodies, nongovernmental organizations, public health researchers and civil society. The database is designed to further strengthen global and national efforts to eliminate unsafe abortion by facilitating comparative and country-specific analyses of abortion laws and policies, placing them in the context of information and recommendations from WHO technical and policy guidance on safe abortion. (1,2) The main objectives of the database are to promote greater transparency of abortion laws and policies and State accountability for the protection of women and girls' health and human rights. Backdrop to abortion policies The association between restrictive abortion laws and unsafe abortion has been well documented. (3,4) According to an analysis by UN DESA, the average rate of unsafe abortion is estimated to be more than four times higher in countries with more restrictive abortion laws than in countries with less restrictive laws. (5) Restrictive abortion laws are also associated with higher levels of maternal mortality. The average maternal mortality ratio is three times higher in countries with more restrictive abortion laws (223 maternal deaths per 100 000 live births) compared to countries with less restrictive laws (77 maternal deaths per 100 000 live births). (5) Restrictive legal grounds for abortion are only one of many policy barriers that affect women and girls' access to safe abortion. Other barriers include policies that limit provision of abortion care to obstetricians and gynaecologists working at high-level care facilities; conscientious objection by health-care providers; requirements for third-party authorization(s); unnecessary medical tests; mandatory counselling; and mandatory waiting periods. (1) Restrictive abortion laws and policies create risks to women and girls' health by deterring them from seeking care and hindering providers from delivering services within the formal health system. (1) Such laws and policies cause delays for women receiving care by creating complex and burdensome administrative procedures, increasing the costs of safe abortion services and limiting the availability of services and their equitable sociogeographic distribution. (1) Such delays can also result in pregnancy advancing beyond legally allowed gestational limits, thus making women ineligible to receive safe services. (1) Restrictions on access to safe abortion create inequalities both within and between countries, making access to safe abortion a privilege of the rich and leaving poor women little choice but to resort to illegal and usually unsafe practices and providers. (1) Consensus to eliminate unsafe abortion WHO first recognized unsafe abortion as a serious public health problem in 1967. (6) The problem was reaffirmed in the Programme of Action of the International Conference on Population and Development in 1994, which underscored the need for States to address the health consequences of unsafe abortion and to provide safe abortion where it is not against the law. (7) Recognizing the public health challenge posed by unsafe abortion, WHO produced technical and policy guidance on safe abortion for health systems in 2003. …

Spotlight on … global health

Spotlight on … global health

Accountability for maternal healthcare services in Nigeria.

High maternal mortality ratios (MMRs) serve as objective indicators of the poor condition of women's health in any country and point to violations of human rights that are entrenched in national, regional, and global laws. For more than a decade, Nigeria has consistently been one of the top five listed countries with the highest MMRs in the world; in 2015, its MMR was estimated at 814 deaths per 100000 live births, accounting for 19% of maternal deaths worldwide and approximately 58000 deaths each year. Accountability for preventable maternal deaths and injuries is essential to both achieve and sustain a reduction in Nigeria's high levels of maternal mortality. The present article addresses key human rights strategies for securing accountability, and identifies opportunities for healthcare providers to have leadership roles in the fulfilment of legal and ethical obligations to preserve women's lives.

Who benefits from hospital birth? Perceptions of medicalised pregnancy and childbirth among Andean migrants in Santa Cruz de la Sierra, Bolivia

This paper uses ethnographic data on reproductive experiences of indigenous Andean migrant women in the lowland eastern Bolivian city of Santa Cruz de la Sierra as a starting point for discussion of different perspectives on the efforts of the Bolivian state to biomedicalise the processes of pregnancy and childbirth. Pregnant women and babies up to six months of age are covered by the state-funded Universal Mother-Infant Insurance (SUMI) that favours the use of biomedical facilities over the services of traditional midwives that are not covered by the insurance. Unlike in the western Andean highlands of Bolivia, most women in Santa Cruz give birth in hospitals while actively negotiating their options. They are not motivated by strictly medical factors as social or economic circumstances also come into play. Simultaneously, the increased levels of hospital deliveries in Bolivia translate into decreased levels of maternal and perinatal mortality, which in turn help Bolivian statistics to fare better from the point of view of the government and international bodies, such as the WHO. However, the restrictions on qualifying for SUMI are such that women in Santa Cruz are often forced to meet the costs of medical services themselves. I argue that the initial socio-biomedical intention of SUMI has become obscured by its political impact. Keywords: biomedicalization; traditional medicine; migration; childbirth; Santa Cruz de la Sierra; indigenous peoples.

Acceptance and Positive Attitude Increased Utilization of Long Acting and Permanent Family Planning Methods Among Reproductive Age Group Women from Debre Berhan District, Ethiopia: Quantitative and Qualitative Analysis

Background: Wider access and use of long-acting and permanent methods of contraception are the most effective contraceptives available to contribute to reduction of the high levels of maternal mortality and morbidity. Yet, utilization of long acting and permanent contraception methods in Ethiopian is recorded to be low. Objective: The purpose of this study was to describe utilization of long acting reversible and permanent family planning methods and identify associated factors among women of 15-49 years age group in Debre Berhan district, Ethiopia. Methods: A community based cross-sectional study was conducted in four selected kebeles of Debre Berhan. Cluster sampling was used to select study subjects for survey while purposive sampling was used to select study subjects for qualitative study. A pre-tested structured questionnaire was used to collect quantitative data and interviewer topic guide was used for qualitative. The survey data was entered into Epi-Info version 3.5.4 and exported, cleaned and analyzed using SPSS version 21. Open code version 3.6.2 was used to categorize and code qualitative data. Factors associated with utilization of long acting and permanent contraceptive methods were identified using logistic regression model and content analysis of qualitative data. Results: Current utilization of long acting and permanent family planning methods among women of reproductive age was estimated to be 27.3% (95% CI: 23.4-31.2). Women of 24-35 age group were 2.23 (AOR=2.23; 95% CI: 1.18-4.18) times more likely to utilize long acting and permanent contraceptive methods as compared to those women whose age was 35 and above. Women who had positive attitude towards the method were 1.87 times more likely to use long acting and permanent contraceptive methods as compared to those women who had negative attitude (AOR=1.87; 95% CI: 1.13-3.07). Clients who were satisfied with treatment and advice given were 1.81 times more likely to use long acting and permanent contraceptive methods as compared to those clients who were not satisfied (AOR=1.81; 95% CI: 1.1-2.99). Myths and misconceptions about intrauterine device and implants were major barriers for the use of long acting and permanent contraceptive methods. Conclusion: Acceptance, positive attitude, client satisfaction and age were factors affecting utilization, whereas myth and misconception in the community hindered use of long acting and permanent contraceptive methods. Therefore, sustained and appropriate information on long acting and permanent contraceptive methods should be provided to raise awareness and build the attitude of women and the community. District health office should design educational programs that promote long acting family planning and reduce barriers at community level in the town. Moreover, health professionals should improve the quality of long acting and permanent contraceptive methods service, which enhances satisfaction.

Epistemic Injustice and Resistance in the Chiapas Highlands: The Zapatista Case

Though Indigenous women in Mexico have traditionally exhibited some of the highest levels of maternal mortality in the country—a fact that some authors have argued was an important reason to explain the EZLN uprising in 1994—there is some evidence that the rate of maternal mortality has fallen in Zapatista communities in the Chiapas Highlands in the last two decades, and that other health indicators have improved. In this article, we offer an account of the modest success that Zapatista communities have achieved in improving their health levels. In particular, we argue that Zapatista women have implicitly used a form of feminist standpoint theory to diagnose the epistemic (and economic) injustice to which they have been traditionally subjected and to develop an epistemology of resistance that is manifested in actions such as becoming health promoters in their communities. We also argue that this epistemology of resistance is partially responsible for the improvement of health levels in their communities. Finally, on the basis of our discussion of the Zapatista case, we suggest that standpoint theory could play an important role in other healthcare settings involving oppressed minorities.

Cesarean Delivery Rates Revisiting a 3-Decades-Old Dogma

(JAMA 2015;314(21):2238–2240) Cesarean delivery rates have become a major public health concern. Because of some studies showing that higher rates could be associated with negative outcomes, including increased maternal morbidity and mortality and neonatal intensive care unit admission along with unnecessary consumption of health care resources, there have been efforts in some developed countries to decrease national cesarean delivery rates. A cross-sectional, geographical study was conducted by Molina and colleagues estimating annual cesarean delivery rates in World Health Organization (WHO) member countries from data collected during the period 2005 to 2012. The research estimated that, in 2012, there were 22.9 million cesarean deliveries worldwide. The combined data were then analyzed in association with maternal and neonatal mortality rates from those countries where these rates were available. The study concluded that a cesarean delivery rate of 19% resulted in the best outcomes in terms of optimal levels of maternal and neonatal mortality.

Quality in provision of maternity services: the missing link in health-care investments in LMICs?

Overall this important area of quality of care will clearly require more research to be fully understood. Better quality monitoring tools also need to be developed with a focus on labour and labour outcome prediction. Meanwhile to complement Kruk and colleagues’ research efforts smaller facilities need to be better equipped with both the requisite and trained human resources for health care as well as with other inputs that are essential to quality provision of EmONC services. (Excerpt) Copyright © The Author(s). Published by Elsevier Ltd. Open Access.

Maternal health: time for a radical reappraisal

Maternal health: time for a radical reappraisal

When the baby remains there for a long time, it is going to die so you have to hit her small for the baby to come out": justification of disrespectful and abusive care during childbirth among midwifery students in Ghana.

Despite global attention, high levels of maternal mortality continue to plague many low- and middle-income settings. One important way to improve the care of women in labour is to increase the proportion of women who deliver in a health facility. However, due to poor quality of care, including being disrespected and abused, women are reluctant to come to facilities for delivery care. The current study sought to examine disrespectful and abusive treatment towards labouring women from the perspective of midwifery students who were within months of graduation. Key Messages •Midwifery students in Ghana’s public midwifery schools report witnessing and participating in many forms of disrespect and abuse during deliveries as part of their education. While they are clear as to why respectful care is important and necessary, they are able to justify and explain reasons for disrespectful and abusive care. This poor treatment of labouring women was explicitly and tacitly supported by these students’ teachers and preceptors. •All study materials and methods were reviewed and approved by the Ghana Health Service Ethical Review Committee, the Kwame Nkrumah University of Science and Technology Committee on Publication and Human Ethics, and the University of Michigan Institutional Review Board. •This research was made possible through a grant from the African Studies Center, University of Michigan. For this study, we conducted focus groups with final year midwifery students at 15 public midwifery training colleges in all 10 of Ghana’s regions. Focus group discussions were recorded and transcribed. A multi-disciplinary team of researchers from the US and Ghana analysed the qualitative data. While students were able to talk at length as to why respectful care is important, they were also able to recount times when they both witnessed and participated in disrespectful and abusive treatment of labouring women. The themes which emerged from these data are: 1) rationalization of disrespectful and abusive care; 2) the culture of blame and; 3) no alternative to disrespect and abuse. Although midwifery students in Ghana’s public midwifery schools highlight the importance of providing high-quality, patient-centred respectful care, they also report many forms of disrespect and abuse during childbirth. Without better quality care, including making care more humane, the use of facility-based maternity services in Ghana is likely not to improve. This study provides an important starting point for educators, researchers, and policy makers to re-think how the next generation of healthcare providers needs to be prepared to provide high-quality, respectful care to women during labour and delivery in low-resource settings.

Maternal-related deaths and impoverishment among adolescent girls in India and Niger: findings from a modelling study.

BackgroundHigh levels of maternal mortality and large associated inequalities exist in low-income and middle-income countries. Adolescent pregnancies remain common, and pregnant adolescent women face elevated risks of maternal mortality and poverty. We examined the distribution across socioeconomic groups of maternal deaths and impoverishment among adolescent girls (15–19 years old) in Niger, which has the highest total fertility rate globally, and India, which has the largest number of maternal deaths.MethodsIn Niger and India, among adolescent girls, we estimated the distribution per income quintile of: the number of maternal deaths; and the impoverishment, measured by calculating the number of cases of catastrophic health expenditure incurred, caused by complicated pregnancies. We also examined the potential impact on maternal deaths and poverty of increasing adolescent girls' level of education by 1 year. We used epidemiological and cost inputs sourced from surveys and the literature.ResultsThe number of maternal deaths would be larger among the poorer adolescents than among the richer adolescents in Niger and India. Impoverishment would largely incur among the richer adolescents in Niger and among the poorer adolescents in India. Increasing educational attainment of adolescent girls might avert both a large number of maternal deaths and a significant number of cases of catastrophic health expenditure in the 2 countries.ConclusionsAdolescent pregnancies can lead to large equity gaps and substantial impoverishment in low-income and middle-income countries. Increasing female education can reduce such inequalities and provide financial risk protection and poverty alleviation to adolescent girls.

RETRACTED: Maintaining rigor in research: flaws in a recent study and a reanalysis of the relationship between state abortion laws and maternal mortality in Mexico

A recent publication [Koch E, Chireau M, Pliego F, Stanford J, Haddad S, Calhoun B, Aracena P, Bravo M, Gatica S, Thorp J. Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states. BMJ Open 2015;5(2):e006013] claimed that Mexican states with more restrictive abortion laws had lower levels of maternal mortality. Our objectives are to replicate the analysis, reanalyze the data and offer a critique of the key flaws of the Koch study. We used corrected maternal mortality data (2006-2013), live births, and state-level indicators of poverty. We replicate the published analysis. We then reclassified state-level exposure to abortion on demand based on actual availability of abortion (Mexico City versus the other 31 states) and test the association of abortion access and the maternal mortality ratio (MMR) using descriptives over time, pooled chi-square tests and regression models. We included 256 state-year observations. We did not find significant differences in MMR between Mexico City (MMR=49.1) and the 31 states (MMR=44.6; p=.44). Using Koch's classification of states, we replicated published differences of higher MMR where abortion is more available. We found a significant, negative association between MMR and availability of abortion in the same multivariable models as Koch, but using our state classification (beta=-22.49, 95% CI=-38.9; -5.99). State-level poverty remains highly correlated with MMR. Koch makes errors in methodology and interpretation, making false causal claims about abortion law and MMR. MMR is falling most rapidly in Mexico City, but our main study limitation is an inability to draw causal inference about abortion law or access and maternal mortality. We need rigorous evidence about the health impacts of increasing access to safe abortion worldwide. Transparency and integrity in research is crucial, as well as perhaps even more in politically contested topics such as abortion. Rigorous evidence about the health impacts of increasing access to safe abortion worldwide is needed.