Variations In Maternal Mortality Research Articles

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.

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.

Bayesian multilevel model on maternal mortality in Ethiopia

Maternal mortality is one of the socio-economic problems and widely considered a serious indicator of the quality of a health. Ethiopia is considered to be one of the top six sub-Saharan countries with severe maternal mortality. The objective of this study was to investigate the effects of the Demographic and Socio-economic determinant factors of maternal mortality in Ethiopia. Data from the 2016 Ethiopia Demographic and Health Survey indicated that the sample of women (15–49) was (n = 10,103). The Bayesian multilevel we were used to explore the major risk factors and regional variations in maternal mortality in Ethiopia. Markov chain Monte Carlo methods with non-informative priors have been applied. The Deviance Information Criterion model selection criteria were used to select the appropriate model. The analysis result, 145 (1.43%) mothers were died due to pregnancy. Using model selection criteria Bayesian multilevel random coefficient was found to be appropriate. With this model, Age of mother, marital status, number of living children, wealth index and Education are found to be the significant determinants of maternal mortality in Ethiopia. The study indicated that there was within and between regional variations in maternal mortality. Inference is the fully Bayesian multilevel model based on recent Markov chain Monte Carlo techniques. The socioeconomic, demographic and environmental determinants included in the study were found to be statistically significant. The result of the Bayesian multilevel model in this study has shown that educational attainment, wealth index, an age of mother, status and number of living children was a significant factor of maternal mortality.

Disparities in pregnancy-related deaths: spatial and Bayesian network analyses of maternal mortality ratio in 54 African countries

BackgroundMaternal mortality remains a public health problem despite several global efforts. Globally, about 830 women die of pregnancy-related death per day, with more than two-third of these cases occurring in...

Risk Factors of Maternal Mortality in Calabar

Maternal mortality remains unacceptably high despite both local and international programs carried at reducing the incidence. Nigeria suffers from 800 maternal death per 100,000 births. This study examines the extent to which cultural practices and quality of medical care determines maternal mortality in Calabar, Cross River State. Using the survey research design, data were collected from 400 women aged between 15 and 49 from Calabar using a self-developed structured questionnaire. The participants were selected using cluster and purposive sampling technique. Data collected from the field was analyzed using descriptive statistics and regression analyses at 0.05 confidence level. Result from the analysis revealed that uncivilized cultural practices lead to high maternal mortality. 75.64 per cent of the participant reported cases of complications during birth in the hands of traditional birth attendants. cultural practices account for 49 per cent of the variation in maternal mortality. Also, result revealed that poor care delivery or quality of medical care leads to high maternal mortality. 54.14 per cent of the participants reported that the cost of medical care for a pregnant woman in the hospital is too expensive. 69.43 per cent reported there have been deaths as a result of lack of care in hospitals. Based on these findings There is need for the government and its health ministry to increase the number of primary health centres in the nation as well as strengthen this health centres to collect high-quality data to respond to the needs and priority of women and girls amongst others.

Regional Variations in Maternal Mortality and Health Workforce Availability in the United States.

Skilled, high-quality health providers and birth attendants are important for reducing maternal mortality. To assess whether U.S. regional variations in maternal mortality rates relate to health workforce availability. Comparison of regional variations in maternal mortality rates and women's health provider rates per population and identification of a relationship between these measures. U.S. health system. Women of child-bearing age and women's health providers, as captured in federal data sources from the Centers for Disease Control and Prevention, Census Bureau, and Health Resources and Services Administration. Regional-to-national rate ratios for maternal mortality and women's health provider availability, calculated per population for women of reproductive age. Provider availability was examined across occupations (obstetrician-gynecologists, internal medicine physicians, family medicine physicians, certified nurse-midwives), in service-based categories (birth-attending and primary care providers), and across the entire women's health workforce (all studied occupations). Maternal deaths per population increased nationally from 2009 to 2017 and, in 2017, were significantly higher in the South and lower in the Northeast (P < 0.001) than nationally. The occupational composition and per-population availability patterns of the women's health workforce varied regionally in 2017. The South had the lowest availability in the nation for nearly every health occupation and category studied, and the Northeast had the highest. This exploratory analysis suggests that subnational levels of provider availability across a region may be associated with higher maternal mortality rates. No causal relationship was established. Nationally representative maternal mortality and health workforce data sources have well-known limitations. Low numbers of observations limit statistical analyses. Regional variations in maternal mortality rates may relate to the availability of birth-attending and primary care providers. None.

Distribution of midwives in Mongolia: A secondary data analysis

IntroductionMidwives are at the core of strengthening the health system, especially in the crucial period around pregnancy, childbirth, and the early weeks of life. In 2016, the national-level maternal mortality ratio in Mongolia was 48.6 deaths per 100,000 live births, but this was much higher (up to 212.9 deaths/100,000) in some rural provinces of the country. The wide variation in maternal mortality between urban and rural areas of Mongolia might be related to the distribution of midwives and equity of access to maternity care. ObjectivesIn the present study, we aimed to determine the distribution of midwives in each province of Mongolia and to examine inequality in the distribution of midwives nationwide. DesignA secondary data analysis. MethodsData from the Centre of Health Development and the National Statistical Office of Mongolia were obtained and analysed. First, we assessed the distribution of midwives at provincial and regional levels, along with the association between these distributions and the maternal mortality ratio in 2016. We then calculated the inequality of these distributions using the Gini coefficient and examined trends for the years 2010–2016. We compared results for urban, suburban, and rural provinces. Rural areas are sparsely populated and enormous in size, so it may be difficult access to basic healthcare services. It was considered important, therefore, to assess the number of midwives per 1000 km2 as well as the commonly used indicator of per 10,000 population. ResultsWhen the land area in each province was taken into consideration rather than only the population, wider variations between urban, suburban, and rural provinces became apparent. Provinces varied according to the number of midwives per 10,000 population by a factor of three (range 2.0–6.2/midwives); while provinces varied according to the number of midwives per 1000 km2 by a factor of approximately 300 (range 0.2–61.2/midwives). The Gini coefficient for the number of midwives per 10,000 population in 2016, R = 0.201, revealed "relative" equality. This was slightly reduced from R = 0.305 in 2010 and indicated a shift toward equality. However, the Gini coefficient for the number of midwives per 1000 km2 area indicated "severe" inequality of R = 0.524 in 2016. This was increased from R = 0.466 in 2010, indicating that no improvement has been seen over these years. ConclusionsOur study suggests that two different measures of midwifery distribution should be used as indicators: number of midwives "per 10,000 population" and "per 1000 km2 area". In rural areas such as parts of Mongolia, geographical features and population density are important features of the local context. To deliver healthcare services in a timely manner and within a reasonable distance for pregnant women who need care, the indicator of per 1000 km2 area would be more suitable for rural and sparsely populated areas than the indicator of per 10,000 population, which is commonly used for urban and settled areas. Based on our findings, to reduce the wide gap in MMR between rural and urban areas, we recommend at least one midwife per 1000 km2 area in rural regions of Mongolia.

Geographical Variations in Maternal Mortality Due to Obstetric Haemorrhage and Its Association with Potential Risk Factors in Central and Western China: A Bayesian Spatiotemporal Analysis

Background: China planned to achieve its fifth Millennium Development Goals by 2015, including reducing maternal mortality. The leading cause of maternal mortality in the country is obstetric haemorrhage. However, there is limited evidence on the burden of maternal mortality due to obstetric haemorrhage. It is also unclear which ecological-level risk factor is associated with maternal mortality due to obstetric haemorrhage. Methods: The data on maternal mortality due to obstetric haemorrhage were collected from the China Maternal Mortality Surveys conducted in 1832 counties of mainland China over the 2010-2013 period. The Bayesian spatiotemporal regression and the Geodetector model were used to examine the spatiotemporal distribution of the maternal mortality ratio (MMR) due to obstetric haemorrhage, as well as its association with per capita income, the proportion of pregnant women who received antenatal care at least five times, the hospital delivery rate, and the distance from the nearest blood station (DBS). Findings: The overall MMR due to obstetric haemorrhage decreased in China, but the trends largely varied by region. There were 568 hotspot counties, located mostly in China's western regions. Western China had the highest MMR due to obstetric haemorrhage. The proportion of pregnant women who had five or more maternal checkups and the DBS were the major risk factors for maternal mortality due to obstetric haemorrhage. The MMR increased from 1.92 to 2.51 to 7.06, with an increase in the DBS from 100 km, respectively. Interpretation: The findings provide information for accurate spatial targets and public health policies to reduce maternal deaths at both country and regional levels. Funding Statement: The case study was supported by the MOST (2012CB955503), the NSFC (41271404 and 41421001), the China Medical Board (grant number 11-065), and the United Nations International Children's Emergency Fund (2016EJH011). The data were collected by Sichuan University and processed by the Institute of Geographic Sciences and Natural Resources Research. Declaration of Interests: The authors declare they have no actual or potential competing financial interests.

A retrospective analysis of trends in maternal mortality in a Gambian tertiary health centre

BackgroundMaternal mortality ratio (MMR) has been on the decline in the Gambia since 1990. However, there has been no steady decline in maternal mortality ratio in the Edward Francis Small Teaching Hospital, the only tertiary health facility in the Gambia. The aim of the study is to determine the trend in maternal mortality over the last 8 years.A retrospective review of all maternal deaths occurring at the Edward Francis Small Teaching Hospital from 1st January 2007 to 31st December 2014 was done. Case abstraction was done with a pre-structured questionnaire using the WHO definition of maternal mortality.ResultsThere were 663 maternal deaths recorded during the study period. During the same period the total number of live births were 38,896. The annual MMR in each year varied with a range between 1461 and 2105 per 100,000 live births. The MMR in the hospital in on the rise compared to earlier studies. The causes of maternal mortality have not changed much in the hospital. However, the seasonal variation in maternal mortality in earlier studies attributed to the influence of malaria and anaemia was not seen in this study. We attribute this change to the widespread use of intermittent prophylactic treatment for malaria in the antenatal period.ConclusionWhile MMR was decreasing in the country, it was increasing in the only tertiary health facility in the country. This was attributed to increasing referrals from other health facilities. The influence of malaria and anemia as a cause of maternal mortality seems to be declining.

Safer Muslim motherhood: Social conditions and maternal mortality in the Muslim world

ABSTRACTThe greatest variation in maternal mortality is among poor countries and wealthy countries that rely on emergency obstetric technology to save a woman’s life during childbirth. However, substantial variation in maternal mortality ratios (MMRs) exists within and among poor countries with uneven access to advanced obstetric services. This article examines MMRs across the Muslim world and compares the impact of national wealth, female education, and skilled birth attendants on maternal mortality. Understanding how poor countries have lowered MMRs without access to expensive obstetric technologies suggests that certain social variables may act protectively to reduce the maternal risk for life-threatening obstetric complications that would require emergency obstetric care.

Abstract P318: Wide State-By-State Variation in Maternal Mortality and Chronic Diseases That Contribute to Pregnancy Complications

Background: Among developed countries, the United States has the highest maternal mortality rate. Between 1987 and 2011, the US maternal mortality rate more than doubled from 7.2 to 17.8 deaths per 100,000 live births. More than 1,300 pregnancy-related deaths occurred in the United States in 2011-2012. Additionally, an increasing number of women have chronic health conditions, such as hypertension, diabetes, and chronic heart disease, that increase their risk of pregnancy complications, including maternal mortality. Reducing the prevalence of these diseases may be an important step toward reducing maternal mortality. To examine the current state of maternal mortality and chronic diseases in the United States, the geographical variation of these factors was examined. Methodology: State-level prevalence estimates were calculated for diabetes, heart disease, and hypertension awareness among women of reproductive age (18 to 44 years) using data from the 2013-2014 Behavioral Risk Factor Surveillance System. State-level maternal mortality rates were calculated using CDC’s 2010-2014 National Vital Statistics System. Maternal mortality was defined as the number of deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births. Results: The maternal mortality rate is 6.8 times higher in Georgia (39.3 deaths per 100,000 live births) than in Massachusetts (5.8 deaths per 100,000 live births). Nationally, there are an estimated 19.9 maternal deaths per 100,000 live births. The prevalence of chronic diseases that increase risk of pregnancy complications also vary by state. For example, diabetes (excluding gestational diabetes) ranges from a low of 1.9% of women aged 18 to 44 in Alaska, Minnesota, and Wisconsin to a high of 4.8% in Alabama. Nationally, an estimated 3.1% of women aged 18 to 44 have been told by a doctor that they have diabetes. Conclusion: The prevalence of chronic diseases in women of reproductive age vary based on state of residence, as does the maternal mortality rate. Raising awareness about the variation in these measures is an important step toward identifying what strategies are being utilized in states with a low prevalence of diabetes, heart disease, and hypertension, and determining how their public health efforts may help those states facing challenges in these areas.

Health-system determinants of declines in maternal mortality in China between 1996 and 2013: a provincial econometric analysis

BackgroundMaternal mortality in China has decreased strikingly over the past 20 years, and China is one of the few countries achieving Millennium Development Goal 5. Between 1996 and 2013, China substantially strengthened the maternal-health sector: a large number of funds were invested in maternal health, maternal health facilities were substantially improved, and maternal-health professionals received increased training. China also made substantial investments in the overall health-systems reform, including increases in overall health expenditure, universal health insurance coverage, and the number of health professionals per person. All of these health-systems improvements are thought to have contributed to reductions in maternal mortality in China, but which improvements carried the greatest weight were not known. The aim of this study was to examine health-systems determinates of declines in maternal mortality in China. MethodsWe used a panel dataset of 31 provinces from China between 1996 and 2013 to examine the effects of health-systems factors on maternal mortality. Our data on health systems were obtained from China Statistical Yearbooks, China Health Statistical Yearbooks, and other national and provincial publications. Data on maternal mortality were obtained from the Annual Report of Maternal and Child Health information. We ran fixed-effects regressions using the logarithm of maternal mortality as the dependent variable. The health-system determinants studied were health expenditure, number of hospital beds, human resources, and length of highways. We controlled for income, female literacy, birth rate, and local tax revenue capacity. All data used were publicly available, aggregate secondary data; therefore, this study was exempt from ethics approval. No individual patient data were used, so no informed consent from patients was necessary. FindingsMaternal mortality fell from 66 to 14 deaths per 100 000 livebirths between 1996 and 2013 (32 to 8 deaths per 100 000 livebirths in eastern region, 52 to 13 deaths per 100 000 livebirths in central region, and 109 to 23 deaths per 100 000 in western region). Hospital beds per 1000 population (elasticity –0·78 [p=0·023]) and length of highways (–0·31 [p=0·010]) were significantly associated with maternal mortality. Health expenditure and the density of health workers had no effect on maternal mortality.” InterpretationAccess to health care is important in accounting for variation in maternal mortality between provinces and over time in China. Hospital infrastructure, in particular, might have been a key driver of the reduction in maternal mortality in the past two decades. FundingUS Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn and Child Survival grant from the Bill & Melinda Gates Foundation, Government of Canada, Foreign Affairs, Trade and Development, and Sichuan University, Chengdu, China.

Oxytocin and arterial embolisation: use or overuse?

Inter-country variations in maternal mortality, even in countries where maternal death is rare, can be an important indication that care can be improved. Maternal mortality from postpartum haemorrhage (PPH) is four times higher in France than the UK. Further investigation is clearly needed to identify reasons for this observed difference and to begin to develop preventive actions. This population-based study of all women with PPH at more than 100 hospitals in France includes women who may be regarded as having a ‘near-miss’ maternal morbidity: PPH managed with second and third-line interventions such as arterial embolisation, pelvic vessel ligation, uterine compression sutures and hysterectomy. This approach, studying women with severe morbidity, is recognised as the way forward in countries where maternal death rates are low in order to glean important information to aid prevention. As the authors note, these are observational data, although collected in the context of a trial, and hence any comparison of effectiveness of different therapies has to be interpreted with caution. Nevertheless, some messages for clinical practice are very clear. Six percent of women managed with an invasive treatment for PPH had no prior treatment with uterotonics; a similar observation was made in a national study in the UK (Knight et al, BJOG 2007; 114:1380-7). Fifty-eight percent of the women who had an invasive therapy for PPH had uterine atony as the primary cause of the haemorrhage, and yet overall only 83% of women had a prophylactic uterotonic for the third stage of labour; 73% in women with a vaginal delivery. This contrasts directly to the estimated 60% of women in France who receive oxytocin for augmentation of labour. Oxytocin exposure in labour is known to be associated with risk of PPH and is likely to render third stage prophylaxis less effective. Misuse of uterotonics was a factor identified to be associated with maternal death from PPH in the UK (Paterson-Brown et al, Saving Lives, Improving Mothers’ Care 2014, NPEU. p45-55). Oxytocin, but at the right time, seems then to be the clear message from these data – more cautious use in labour and more liberal use for third stage prophylaxis and PPH treatment. A four times higher mortality rate in one high resource country over another is unacceptable, and universal oxytocin prophylaxis for the third stage of labour should surely become the expected norm in France and elsewhere. The use of uterine artery embolisation for management of PPH is much higher in France than other countries, and the authors speculate that clinicians in France have a lower threshold for its use. Although defining PPH robustly can be difficult given the known inaccuracy of estimation of blood loss (Bose et al, BJOG 2006; 113:919-24), given the high costs of this as an intervention, guidelines must incorporate robust recommendations on when its use is appropriate. The authors speculate that the situation will be improved with prior use of intrauterine balloon tamponade, but its evidence-base is limited, and there are undoubtedly situations when its use exacerbates rather than improves the situation when women are in extremis (Paterson Brown et al, see above). The main message has to be, whatever the circumstances, preventing and controlling the haemorrhage, and controlling it early, is imperative to improve outcomes for women. None declared. Completed disclosure of interests form available to view online as supporting information.

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P2-513 Social and geographical variations of maternal mortality in Mexico

IntroductionThis paper analyses the trend of maternal mortality rate in Mexico according to the level of social marginalisation between 1990 and 2008 and identifies socioeconomic factors that better explain the...

An Appraisal of the Maternal Mortality Decline in Nepal

BackgroundA decline in the national maternal mortality ratio in Nepal has been observed from surveys conducted between 1996 and 2008. This paper aims to assess the plausibility of the decline and to identify drivers of change.MethodsNational and sub-national trends in mortality data were investigated using existing demographic and health surveys and maternal mortality and morbidity surveys. Potential drivers of the variation in maternal mortality between districts were identified by regressing district-level indicators from the Nepal demographic health surveys against maternal mortality estimates.ResultsA statistically significant decline of the maternal mortality ratio from 539 maternal deaths to 281 per 100,000 (95% CI 91,507) live births between 1993 and 2003 was demonstrated. The sub-national changes are of similar magnitude and direction to those observed nationally, and in the terai region (plains) the differences are statistically significant with a reduction of 361 per 100,000 live births (95% CI 36,686) during the same time period.The reduction in fertility, changes in education and wealth, improvements in components of the human development index, gender empowerment and anaemia each explained more than 10% of the district variation in maternal mortality. A number of limitations in each of the data sources used were identified. Of these, the most important relate to the underestimation of numbers of deaths.ConclusionIt is likely that there has been a decline in Nepal's maternal mortality since 1993. This is good news for the country's sustained commitments in this area. Conclusions on the magnitude, pattern of the change and drivers of the decline are constrained by lack of data. We recommend close tracking of maternal mortality and its determinants in Nepal, attention to the communication of future estimates, and various options for bridging data gaps.

Time trends and regional differences in maternal mortality in China from 2000 to 2005.

To examine trends and variations in maternal mortality in China between 2000 and 2005. We used Poisson regression analysis of data from the Chinese National Maternal and Child Health Routine Reporting System between 2000 and 2005 to identify time trends in the maternal mortality ratio (MMR) by province and region. The MMR declined by an average of 5% per year (crude relative risk, RR: 0.95; 95% confidence interval, CI: 0.94-0.97). There was no interaction between region and year (P = 0.2311). Mortality declined by 5% per year in the eastern region (crude RR: 0.95; 95% CI: 0.92-0.97), by 5% per year in the central region (crude RR; 0.95; 95% CI: 0.94-0.96), and by 4% per year in the western region (crude RR: 0.96; 95% CI: 0.94-0.98). The absolute difference in MMR between the western and eastern regions declined from 65.4 deaths per 100,000 live births in 2000 to 49.4 per 100,000 live births in 2005. China is making good progress towards achieving the fifth Millennium Development Goal, and there is no evidence of a widening gap between better-off and economically more deprived provinces.

Seasonal variations in maternal mortality in Maputo, Mozambique: the role of malaria

To evaluate the impact of malaria on maternal death through the analysis of the seasonal variations of crude and malaria-specific maternal mortality rates. All maternal deaths and live births occurring at Maputo Central Hospital, located in an urban area, between January 2001 and December 2003, were retrospectively recorded. Clinical diagnoses of the causes of death and period of the year were analysed. Two hundred and seventy-eight deaths were recorded. The overall crude maternal mortality rate was 995/100 000 live births. Malaria was the most frequent cause of maternal death, accounting for 23%. Crude and malaria-specific maternal mortality rates showed a similar pattern of seasonal variation, with peaks at the beginning and the end of the malaria transmission season. The malaria-specific maternal mortality rate was significantly higher during the rainy seasons (rate ratio 1.919; 95% CI 1.061, 3.470; P = 0.031). Malaria may contribute to maternal mortality in highly endemic countries in sub-Saharan Africa, at least in urban areas. Efforts to improve malaria control in pregnancy may have an impact on maternal mortality in sub-Saharan Africa.

Obstetric deaths in Bangladesh, 1996–1997

Objectives: The purpose of this study was to measure and to describe obstetric deaths in Bangladesh. Methods: We reviewed hospital records and interviewed health workers in clinic sites and field workers who cared for pregnant women. Results: We obtained case reports of 28 998 deaths of women aged 10–50, of which 8562 (29.5%) were maternal deaths. Most (7086, 82.8%) of these deaths were due to obstetric causes. The most common causes of direct obstetric death were eclampsia (34.3%), hemorrhage (27.9%), and obstructed and/or prolonged labor (11.3%). National direct obstetric death rate was estimated to be 16.9 per 100 000 women. Conclusions: Efforts to reduce fertility in Bangladesh have led to an estimated 49% reduction in the maternal mortality rate per 1000 women during the past 18 years. Variations in maternal mortality suggest the need to develop local strategies to improve obstetric care.

Operational factors of maternal mortality in Zimbabwe

Most studies on maternal mortality have looked at the direct clinical causes and the distribution of actual rates. Much less attention has been given to prevailing health care systems or community factors associated with such deaths. A case-control study design using incident cases was used to identify the magnitude of maternal deaths and community and health care operational factors in both an urban and a rural setting in Zimbabwe. The maternal mortality ratio for the rural setting was 168/100000 live births. For the rural setting the major direct causes of death were hemorrhage (24.8%) abortion complications (15.2%) puerperal sepsis (13.3%) and eclampsia (4.8%). For the urban setting they were eclampsia (26.2%) abortion complications (23.0%) puerperal sepsis (14.8%) and hemorrhage (9.8%). Whereas rural-urban variations in maternal mortality were observed inter-rural district variations were also apparent especially with poor medical resources poor communication and delayed interventions. Risk factors for maternal mortality were present at each of the various levels of care. Lack of antenatal care (ANC) had a significant odds ratio (OR 10.7 rural and 4.6 urban) contribution to maternal mortality. When abortions and ectopics were excluded the OR for absent ANC was 4.1 (rural) and 2.6 (urban). Lack of timely transport to nearest clinic or hospital adversely affected pregnancy outcome in both rural and urban settings. Despite delivery place planning predisposing health conditions and some danger signals few of the women utilized the venue originally planned for delivery. Health education community sensitization and teaching on risk signal awareness as well as health care delivery system strengthening are recommended for reducing the high maternal mortality rates. (authors)