Perinatal and maternal mortality in a religious group avoiding obstetric care

Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countries

BACKGROUND

Maternal mortality, stillbirths, and neonatal mortality account for almost 5 million deaths a year and are often analysed separately, despite having overlapping causes and interventions. We propose a comprehensive five-phase mortality transition model to improve analyses of progress and inform strategic planning.

METHODS

In this empirical data-driven study to develop a model transition, we used UN estimates for 151 countries to assess changes in maternal mortality, stillbirths, and neonatal deaths. On the basis of ratios of maternal to stillbirth and neonatal mortality, we identified five phases of transition, in which phase 1 has the highest mortality and phase 5 has the lowest. We used global databases to examine phase-specific characteristics during 2000-20 for causes of death, fertility rates, abortion policies, health workforce and financing, and socioeconomic indicators. We analysed 326 national surveys to assess service coverage and inequalities by transition phase.

FINDINGS

Among 116 countries in phases 1 to 4 in 2000, 73 (63%) progressed at least one phase by 2020, six advanced two phases, and three regressed. The ratio of stillbirth and neonatal deaths to maternal deaths increased from less than 10 in phase 1 to well over 50 in phase 4 and phase 5. Progression was associated with a declining proportion of deaths caused by infectious diseases and peripartum complications, declining total and adolescent fertility rates, changes in health-workforce densities and skills mix (ie, ratio of nurses or midwives to physicians) from phase 3 onwards, increasing per-capita health spending, and reducing shares of out-of-pocket health expenditures. From phase 1 to 5, the median coverage of first antenatal care visits increased from 66% to 98%, four or more antenatal care visits from 44% to 94%, institutional births from 36% to 99%, and caesarean section rates from 2% to 25%. The transition out of high-mortality phases involved a major increase in institutional births, primarily in lower-level health facilities, whereas subsequent progress was characterised by rapid increases in hospital births. Wealth-related inequalities reduced strongly for institutional birth coverage from phase 3 onwards.

INTERPRETATION

The five-phase maternal mortality, stillbirth, and neonatal mortality transition model can be used to benchmark the current indicators in comparison to typical patterns in the transition at national or sub-national level, identify outliers to better assess drivers of progress, and inform strategic planning and investments towards Sustainable Development Goal targets. It can also facilitate programming for integrated strategies to end preventable maternal mortality and neonatal mortality and stillbirths.

FUNDING

Bill & Melinda Gates Foundation.

Religion, women's health, and obstetrician-gynecologists

Religions continue to be a strong moral, even political, force in the world. They are often seen to be in conflict with women's health; we argue that this should not continue to be the case. The conflict can be traced back to when religions had their birth and early development in patriarchal communities in which women were marginalized to the edges of society. In addition, religious leadership has traditionally been dominated by men and exclusive of women. The recent introduction of new scientific technologies, which has empowered women to regulate and control their fertility, challenged traditional norms and raised a religious-inspired moral panic. However, a recent initiative has been gaining momentum. An enlightened religious leadership and a new generation of feminist religious activists are calling for a review of the original texts and a reinterpretation in a sociocultural context that is different from when they were first revealed. Obstetrician-gynecologists, while having to practice in a socioreligious context and continuing to face challenges in providing health care in religiously diverse societies, have a social responsibility to stand by women and to uphold that religions do not and should not stand in the way of advancing their health and rights.

A systematic review of individual and ecological determinants of maternal mortality in the world based on the income level of countries

BACKGROUND

This systematic review was conducted to map the literature on all the existing evidence regarding individual and ecological determinants of maternal mortality in the world and to classify them based on the income level of countries. Such a systematic review had not been conducted before.

METHODS

We conducted an electronic search for primary and review articles using "Maternal Mortality" and "Determinant" as keywords or MeSH terms in their Title or Abstract, indexed in Scopus, PubMed, and Google with no time or geographical limitation and also hand searching was performed for most relevant journals. STROBE and Glasgow university critical appraisal checklists were used for quality assessment of the included studies. Data of the determinants were extracted and classified into individual or ecological categories based on income level of the countries according to World Bank classification.

RESULTS

In this review, 109 original studies and 12 review articles from 33 countries or at global level met the inclusion criteria. Most studies were published after 2013. Most literature studied determinants of low and lower-middle-income countries. The most important individual determinants in low and lower-middle-income countries were location of birth, maternal education, any delays in health services seeking, prenatal care and skilled birth attendance. Household-related determinants in low-income countries included improved water source and sanitation system, region of residence, house condition, wealth of household, and husband education. Additionally, ecological determinants including human resources, access to medical equipment and facilities, total fertility rate, health financing system, country income, poverty rate, governance, education, employment, social protection, gender inequality, and human development index were found to be important contributors in maternal mortality. A few factors were more important in higher-income countries than lower-income countries including parity, IVF births, older mothers, and type of delivery.

CONCLUSION

A comprehensive list of factors associated with maternal death was gathered through this systematic review, most of which were related to lower-income countries. It seems that the income level of the countries makes a significant difference in determinants of maternal mortality in the world.

Mortalidade perinatal no Brasil em 2018: análise epidemiológica segundo a classificação de Wiggleworth modificada

Resumo: A mortalidade perinatal engloba a mortalidade fetal e a neonatal precoce (0 a 6 dias). Este estudo descreveu os óbitos perinatais ocorridos no Brasil em 2018, segundo a classificação de Wigglesworth modificada. As fontes de dados foram os Sistemas de Informações sobre Mortalidade e sobre Nascidos Vivos. Foram calculadas as taxas de mortalidade fetal e perinatal por mil nascimentos totais (nascidos vivos mais natimortos) e a taxa de mortalidade neonatal precoce por mil nascidos vivos, e comparadas usando seus respectivos intervalos de 95% de confiança (IC95%). Os óbitos perinatais foram classificados nos grupos de causas anteparto, anomalias congênitas, prematuridade, asfixia e causas específicas. Foi calculado, para cada grupo de causas, o número de óbitos por faixa de peso, além das taxas de mortalidade e os respectivos IC95%, e feita a distribuição espacial das taxas de mortalidade por Unidade da Federação (UF). Foram registrados 35.857 óbitos infantis, sendo 18.866 (52,6%) neonatais precoces; os natimortos somaram 27.009. Os óbitos perinatais totalizaram 45.875, perfazendo uma taxa de mortalidade de 15,5‰ nascimentos. A maior taxa de mortalidade (7,6‰; 7,5‰-7,7‰) foi observada no grupo anteparto, seguido da prematuridade (3,6‰; 3,6‰-3,7‰). No grupo anteparto, 14 das 27 UFs (sendo oito na Região Nordeste e quatro na Região Norte) apresentaram as taxas de mortalidade perinatal acima da nacional. A taxa de mortalidade perinatal no Brasil mostrou-se elevada, e a maioria dos óbitos poderia ser prevenida com investimento em cuidados pré-natais e ao nascimento.

Exploring the conceptualisation and study of freebirthing as a historical and social phenomenon: a meta-narrative review of diverse research traditions

Freebirthing is a clandestine practice whereby women intentionally give birth without healthcare professionals (HCPs) present in countries where there are medical facilities available to assist them. Women who make this decision are frequently subjected to stigma and condemnation, yet research on the phenomenon suggests that women's motivations are often complex. The aim of this review was to explore how freebirth has been conceptualised over time in the English-language academic and grey literature. The meta-narrative methodology employed enables a phenomenon to be understood within and between differing research traditions, as well as against its social and historical context. Our research uncovered nine research traditions (nursing, autobiographical text with birthing philosophy, midwifery, activism, medicine, sociology, law and ethics, pregnancy and birth advice, and anthropology) originating from eight countries and spanning the years 1957-2018. Most of the texts were written by women, with the majority being non-empirical. Empirical studies on freebirth were usually qualitative, although there were a small number of quantitative medical and midwifery studies; these texts often focused on women's motivations and highlighted a range of reasons as to why a woman would decide to give birth without HCPs present. Motivations frequently related to women's previous negative maternity experiences and the type of maternity care available, for example medicalised and hospital-based. The use of the meta-narrative methodology allowed the origins of freebirth in 1950s America to be traced to present-day empirical studies of the phenomenon. This highlighted how the subject and the publication of literature relating to freebirth are embedded within their social and historical contexts. From its very inception, freebirth aligns with the medicalisation of childbirth, the position of women in society, the provision of maternity care and the way in which women experience maternity services.

Praying until Death: Apostolicism, Delays and Maternal Mortality in Zimbabwe

Religion affects people's daily lives by solving social problems, although it creates others. Female sexual and reproductive health are among the issues most affected by religion. Apostolic sect members in Zimbabwe have been associated with higher maternal mortality. We explored apostolic beliefs and practices on maternal health using 15 key informant interviews in 5 purposively selected districts of Zimbabwe. Results show that apostolicism promotes high fertility, early marriage, non-use of contraceptives and low or non-use of hospital care. It causes delays in recognizing danger signs, deciding to seek care, reaching and receiving appropriate health care. The existence of a customized spiritual maternal health system demonstrates a huge desire for positive maternal health outcomes among apostolics. We conclude that apostolic beliefs and practices exacerbate delays between onset of maternal complications and receiving help, thus increasing maternal risk. We recommend complementary and adaptive approaches that address the maternal health needs of apostolics in a religiously sensitive manner.

Alternative versus standard packages of antenatal care for low-risk pregnancy

BACKGROUND

The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation.

OBJECTIVES

To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 March 2015), reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, versus standard care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. We assessed studies for risk of bias and graded the quality of the evidence.

MAIN RESULTS

We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). Most of the data included in the review came from the three large, well-designed cluster-randomised trials that took place in Argentina, Cuba, Saudi Arabia, Thailand and Zimbabwe. All results have been adjusted for the cluster design effect. All of the trials were at some risk of bias as blinding of women and staff was not feasible with this type of intervention. For primary outcomes, evidence was graded as being of moderate or low quality, with downgrading decisions due to risks of bias and imprecision of effects.The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal-oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31; five trials, 56,431 babies; moderate-quality evidence). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (RR 0.90; 95% CI 0.45 to 1.80, two trials); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (RR 1.15; 95% CI 1.01 to 1.32, three trials).There was no clear difference between groups for our other primary outcomes: maternal death (RR 1.13, 95%CI 0.50 to 2.57, three cluster-randomised trials, 51,504 women, low-quality evidence); hypertensive disorders of pregnancy (various definitions including pre-eclampsia) (RR 0.95, 95% CI 0.80 to 1.12, six studies, 54,108 women, low-quality evidence); preterm birth (RR 1.02, 95% CI 0.94 to 1.11; seven studies, 53,661 women, moderate-quality evidence); and small-for-gestational age (RR 0.99, 95% CI 0.91 to 1.09, four studies 43,045 babies, moderate-quality evidence).Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02, five studies, 43,048 babies, moderate quality evidence). There were no clear differences between the groups for the other secondary clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs.

AUTHORS' CONCLUSIONS

In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.

Unassisted childbirth: why mothers are leaving the system

Unassisted childbirth is a topical subject that has sparked ethical and legal debate. Although there are little data surrounding unassisted birthing practice, concerns over consent, procedural intervention and loss of the birthing experience may be driving women away from formal healthcare. The healthcare system needs to work toward understanding this practice and, perhaps with the support of legislation, address the concerns of mothers in order to ensure optimal childbirth outcomes.

The outcome of midwife-led labor in low-risk women within an obstetric referral unit

OBJECTIVE

To analyze maternal and neonatal outcomes of midwife-led labor in low-risk women at term.

METHODS

Prospective observational cohort of 1788 singleton low-risk pregnancies in spontaneous term labor, managed according to a specific midwife-led labor protocol. Primary outcomes were mode of delivery, episiotomy, 3rd-4th degree lacerations, post-partum hemorrhage (PPH), need for blood transfusions, pH and Apgar score and NICU admissions.

RESULTS

A total 1754 low-risk women (50.3% of all deliveries) were included in the analysis. Epidural analgesia was performed in 29.8% of cases. The rate of cesarean section was 3.7%. Episiotomy was performed in 17.6% of women. PPH > 1000 ml occurred in 1.7% of cases. 3.2% and 0.3% of the cases had an Apgar score <7 and pH < 7.10, respectively, while 0.3% of the newborns were admitted to NICU. Consultant-led labor was required for emerging risk factors during 1st and 2nd stage of labor in 16.1 and 8.6% of cases, respectively. Although maternal outcome were worse in women with emerging risk factors in labor, while neonatal outcomes were not affected by the presence these complications.

CONCLUSIONS

In hospital settings, midwife-led labor in low-risk women might unfold its major advantages without additional risks of medicalization for the mother and the neonate.

Spatial analysis of choice of place of delivery in Nigeria

OBJECTIVE

Access to quality healthcare during childbirth is a crucial factor for taming maternal and child mortality and morbidity. Increasing this access in developing countries depends on understanding the factors influencing maternal healthcare decision at a geographical location. This study analyzes spatial pattern in choice of place of delivery in Nigeria.

METHOD

Data analyzed came from Nigerian Demographic and Health Survey data set. The choice of place delivery was considered a multi-categorical response and a multinomial logistic regression model used to evaluate spatial variations in choosing a particular place to deliver against home delivery.

RESULTS

Results show a north-south divide in choosing health facilities against homes for delivery. The likelihood of institutional delivery was significantly lower for women residing in Bayelsa and the majority of the states in northern Nigeria. As women advance in age, they have more likelihood of having institutional deliveries. Other contributing factors that favor institutional deliveries include use of antenatal care services, urban dwelling, mass media and parity.

CONCLUSION

Usage of mass media to campaign for institutional deliveries particularly in northern Nigeria, among younger women and those of higher parity; encouraging the use of antenatal services and even distribution of health facilities making them easily accessible to rural women are important for enhancing chances of institutional deliveries. Also, state-specific policies in this regard are indispensable.

[Do the quality of prenatal care have an impact on obstetrical outcomes?]

OBJECTIVES

To assess the rate of pregnant women not having accurate prenatal care utilization. The others goals were to assess the impact of an inadequate quantitative or qualitative prenatal care on obstetrical outcomes.

PATIENTS AND METHODS

Historical cohort study with a prospective data registration. Hospitalised patients at the maternity ward of the University Hospital of Pointe-à-Pitre were eligible if they gave birth after 22 weeks (or≥500g) at home, outside a maternity ward or in another maternity ward. Early postpartum maternal transfers were included but not medical abortions. The principal outcome was preterm birth (before 37 weeks' gestation).

RESULTS

Patients without an appointment before 15weeks or without an appointment each month before their delivery represented 27.4% of women (n=2344). We stressed more preterm deliveries outside the maternity ward among the group with an inadequate prenatal care utilization vs. the other group (3,89% vs. 0,88%) (p<0,0001). We did not find any difference concerning the perinatal outcomes among the women with an inadequate quality prenatal care.

DISCUSSION AND CONCLUSION

Our study did not stress a difference concerning perinatal outcomes among women with an inadequate quantitative or qualitative prenatal care utilization.

Maternal and child health epidemic-assistance investigations, 1946-2005

In this article, the authors focus on epidemic-assistance investigations that dealt with maternal and child health problems, including unintended and adolescent pregnancy and family planning; international reproductive health surveys among refugees; pregnancy outcomes, including abortion, maternal mortality, infant mortality, and birth defects; leukemia; and Reye syndrome. During 1946-2005, a total of 1,969 investigations had sufficient data to classify them as possibly related to maternal and child health and were characterized by distinctive periods. Those related to family planning, pregnancy intention, and reproductive health among refugees began in the early 1970s and continued through 2005. Abortion-related investigations occurred during 1971-1982. Investigations of non-abortion-related maternal morbidity and mortality began in 1979 and included 2 international epidemic-assistance investigations. Investigations of clusters of disease among infants began in the 1960s, with a special focus on Reye syndrome during 1964-1984. Investigations of childhood cancer and birth defects began in the late 1950s. The Centers for Disease Control and Prevention has used the epidemic-assistance investigations mechanism to respond to a wide range of health concerns of women and children. The investigations of abortion-related health problems might have had the best-documented impact on public policy and public health.

Alternative versus standard packages of antenatal care for low-risk pregnancy

BACKGROUND

The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation.

OBJECTIVES

To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2010), reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, with standard care.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data independently.

MAIN RESULTS

We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (five trials; risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (2 trials; RR 0.90; 95% CI 0.45 to 1.80); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (3 trials RR 1.15; 95% CI 1.01 to 1.32). Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02). There were no clear differences between the groups for the other reported clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs.

AUTHORS' CONCLUSIONS

In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.

The relationship between birth with a health professional and maternal mortality in observational studies: a review of the literature

OBJECTIVE

To examine the nature of the association between maternal mortality and birth with a health professional in observational studies.

METHODS

Review of ecological studies relating the overall proportion of births with a health professional with the maternal mortality ratio at national level, and studies exploring the relationship between the presence of a health professional at birth and the risk of dying at the individual level. We report methodological challenges, including data quality and sources and the analytical approaches used. For the individual studies, crude odds ratios and 95% confidence intervals were calculated.

RESULTS

The 10 ecological studies are largely descriptive, a causal inference is tentative and there is poor controlling of confounders. The 10 individual studies examining the risk of death with and without a health professional showed little evidence that giving birth with a health professional reduces a woman's risk of dying, and in some settings it appears to be associated with an increased risk of death.

CONCLUSIONS

None of these study designs are optimal in evaluating the impact of births with a health professional on reducing maternal mortality. Analytically, greater insights can be gained by examining ecological relationships within countries, and by complementing the individual analyses with information on the health status of women when they first reach the health professional and whether or not the women planned to have a health professional present during birth.

Religion and medical neglect

This is a literature review of religion-associated medical neglect of children. It attempts to document the most common denominations involved in religion-associated medical neglect. There is a discussion of the history of religious exemptions to medical care and health risks to children as a result of religious exemption. Suggestions are made for the clinician regarding recognition and management of religion-associated medical neglect in children.

Under-attending free antenatal care is associated with adverse pregnancy outcomes

BACKGROUND

Most pertinent studies of inadequate antenatal care concentrate on the risk profile of women booking late or not booking at all to antenatal care. The objective of this study was to assess the outcome of pregnancies when free and easily accessible antenatal care has been either totally lacking or low in number of visits.

METHODS

This is a hospital register based cohort study of pregnancies treated in Kuopio University Hospital, Finland, in 1989 - 2001. Pregnancy outcomes of women having low numbers (1-5) of antenatal care visits (n = 207) and no antenatal care visits (n = 270) were compared with women having 6-18 antenatal visits (n = 23137). Main outcome measures were: Low birth weight, fetal death, neonatal death. Adverse pregnancy outcomes were controlled for confounding factors (adjusted odds ratios, OR: s) in multiple logistic regression models.

RESULTS

Of the analyzed pregnant population, 1.0% had no antenatal care visits and 0.77% had 1-5 visits. Under- or non-attendance associated with social and health behavioral risk factors: unmarried status, lower educational level, young maternal age, smoking and alcohol use. Chorio-amnionitis or placental abruptions were more common complications of pregnancies of women avoiding antenatal care, and pregnancy outcome was impaired. After logistic regression analyses, controlling for confounding, there were significantly more low birth weight infants in under- and non-attenders (OR:s with 95% CI:s: 9.18 (6.65-12.68) and 5.46 (3.90-7.65), respectively) more fetal deaths (OR:s 12.05 (5.95-24.40) and 5.19 (2.04-13.22), respectively) and more neonatal deaths (OR:s 10.03 (3.85-26.13) and 8.66 (3.59-20.86), respectively).

CONCLUSION

Even when birth takes place in hospital, non- or under-attendance at antenatal care carries a substantially elevated risk of severe adverse pregnancy outcome. Underlying adverse health behavior and possible abuse indicate close surveillance of the newborn.

Outcomes of planned home birth: an integrative review

Current evidence indicates the critical importance of several factors that contribute to improved perinatal outcomes: a facilitating environment at the place of birth, skilled birth attendance, and the continuum of perinatal care for women and newborns. This level of care is often referred to as "first-level" care, and is most readily provided in birthing centers and primary level health facilities. However, there is a body of evidence that has been compiled over the past several decades that addresses the safety of planned home birth, under circumstances that emulate these elements of "first-level" care. These studies demonstrate a remarkable consistency in the generally favorable results of maternal and neonatal outcomes, both over time and among diverse population groups. These outcomes are also favorable when viewed in comparison to various reference groups (birth center births, planned hospital births, and vital statistics). These data should influence policy in support of planned home birth, including policy that endorses building or sustaining a home birth infrastructure in parallel to the efforts to build capacity for facility-based birth. Such public policy would also be in keeping with the fundamental right of women to have choice in childbirth, particularly when options are equally good.

Maternal mortality rates in the last eight years: A university hospital-based study from Turkey

OBJECTIVE

To analyze the cause of changing maternal mortality ratios (MMRs) in a tertiary women's health center in Turkey in the last eight years.

MATERIALS AND METHODS

Charts of patients seen between 1998 and 2005 were retrospectively reviewed. Statistical analysis was performed using the Chi-square test. The results were accepted to be significant when the p value was <0.05.

RESULTS

During this period, 27 pregnancy-related deaths were identified via hospital death records. The MMR was found to have decreased in rate by approximately 50% from 822.2/100,000 live births in the previous report including the years 1978-1997 to 412.0/100,000 during the last eight years (p < 0.01). Pregnancy-induced hypertension was still the most frequent cause of maternal death. The decrease in MMR was due to the decrease in the ratio of maternal infection (26.4% in 1978-1997 to 7.4% in 1998-2005, p < 0.01).

CONCLUSION

Although treatment in the antenatal care and health service has decreased maternal deaths, it was discovered that the MMR has not reached the optimum levels found in developed countries in the last eight years. Also the percentage of direct obstetric deaths (with the exception of those caused by infection) showed no change and was similar to that found in the previous report (1978-1997).

Religion, spirituality, and medicine: research findings and implications for clinical practice

A growing body of scientific research suggests connections between religion, spirituality, and both mental and physical health. The findings are particularly strong in patients with severe or chronic illnesses who are having stressful psychologic and social changes, as well as existential struggles related to meaning and purpose. Recent studies indicate that religious beliefs influence medical decisions, such as the use of chemotherapy and other life-saving treatments, and at times may conflict with medical care. This article addresses the ways physicians can use such information. Spirituality is an area that makes many physicians uncomfortable, since training in medical schools and continuing medical education programs are limited. Not only do most physicians lack the necessary training, they worry about spending additional time with patients and overstepping ethical boundaries. While these concerns are valid, each can be addressed in a sensible way. Taking a spiritual history, supporting the patient's beliefs, and orchestrating the fulfillment of spiritual needs are among the topics this article will address. The goal is to help physicians provide medical care that is sensitive to the way many patients understand and cope with medical illness.

The evidence for emergency obstetric care

PURPOSE

We searched for evidence for the effectiveness of emergency obstetric care (EmOC) interventions in reducing maternal mortality primarily in developing countries.

METHODS

We reviewed population-based studies with maternal mortality as the outcome variable and ranked them according to the system for ranking the quality of evidence and strength of recommendations developed by the US Preventive Services Task Force. A systematic search of published literature was conducted for this review, including searches of Medline, PubMed, Cochrane Database of Systematic Reviews, the Cochrane Pregnancy and Childbirth Database and the Cochrane Controlled Trials Register.

RESULTS

The strength of the evidence is high in several studies with a design that places them in the second and third tier in the quality of evidence ranking system. No studies were found that are experimental in design that would give them a top ranking, due to the measurement challenges associated with maternal mortality, although many of the specific individual clinical interventions that comprise EmOC have been evaluated through experimental design. There is strong evidence based on studies, using quasi-experimental, observational and ecological designs, to support the contention that EmOC must be a critical component of any program to reduce maternal mortality.

Socioeconomic and physical distance to the maternity hospital as predictors for place of delivery: an observation study from Nepal

Background

Although the debate on the safety and women's right of choice to a home delivery vs. hospital delivery continues in the developed countries, an undesirable outcome of home delivery, such as high maternal and perinatal mortality, is documented in developing countries. The objective was to study whether socio-economic factors, distance to maternity hospital, ethnicity, type and size of family, obstetric history and antenatal care received in present pregnancy affected the choice between home and hospital delivery in a developing country.

Methods

This cross-sectional study was done during June, 2001 to January 2002 in an administratively and geographically well-defined territory with a population of 88,547, stretching from urban to adjacent rural part of Kathmandu and Dhading Districts of Nepal with maximum of 5 hrs of distance from Maternity hospital. There were no intermediate level of private or government hospital or maternity homes in the study area. Interviews were carried out on 308 women who delivered within 45 days of the date of the interview with a pre-tested structured questionnaire.

Results

A distance of more than one hour to the maternity hospital (OR = 7.9), low amenity score status (OR = 4.4), low education (OR = 2.9), multi-parity (OR = 2.4), and not seeking antenatal care in the present pregnancy (OR = 4.6) were statistically significantly associated with an increased risk of home delivery. Ethnicity, obstetric history, age of mother, ritual observance of menarche, type and size of family and who is head of household were not statistically significantly associated with the place of delivery.

Conclusions

The socio-economic standing of the household was a stronger predictor of place of delivery compared to ethnicity, the internal family structure such as type and size of family, head of household, or observation of ritual days by the mother of an important event like menarche. The results suggested that mothers, who were in the low-socio-economic scale, delivered at home more frequently in a developing country like Nepal.

Epidemiological transitions, reproductive health, and the Flexible Response Model

In concert with improving standards of living since the mid-19th century, chronic and non-infectious diseases replaced infectious diseases as the major causes of mortality in more developed countries. Thus, economic development has been seen as one strategy to improve women's reproductive health. However, rates of two of the major contributors to women's illness, maternal mortality and breast cancer, do not correspond well with the level of economic development. Drawing upon our longitudinal study of reproductive functioning among rural Bolivians (Project Reproduction and Ecology in Provincia Aroma (REPA)), we propose an evolutionary model to explain variation in certain aspects of women's reproductive health. Our findings suggest new avenues of inquiry into the determinants of reproductive health and have implications for improving the well-being of women worldwide.

Where is the "E" in MCH? The need for an evidence-based approach in safe motherhood

Measuring the impact of obstetric interventions on maternal mortality and/or morbidity is especially difficult in developing countries, where most maternal deaths occur. Therefore, program planning has been based on theory rather than proved effectiveness. After reviewing both the strategies that have been promoted to reduce maternal mortality and the adequacy of existing evidence used to justify their selection, the investigators highlight reasons why rigorous criteria for the selection and evaluation of interventions should be adopted. Adequate evaluation of intervention effectiveness under real-life conditions in developing countries is an efficient way to identify interventions for large-scale program replication and could speed progress in reducing maternal deaths.

Religion and medicine I: historical background and reasons for separation

Religion and medicine have a long, intertwined, tumultuous history, going back thousands of years. Only within the past 200-300 years (less than 5 percent of recorded history) have these twin healing traditions been clearly separate. This series on religion and medicine begins with a historical review, proceeding from prehistoric times through ancient Egypt, Greece, and early Christianity through the Middle Ages, the Renaissance, and the Age of Enlightenment, when the split between religion and medicine became final and complete. Among the many reasons for the continued separation is that religion may either be simply irrelevant to health or, worse, that it may have a number of negative health effects. I review here both opinion and research supporting this claim.

Nutrition and maternal mortality in the developing world

This review relates nutritional status to pregnancy-related death in the developing world, where maternal mortality rates are typically >/=100-fold higher than rates in the industrialized countries. For 3 of the central causes of maternal mortality (ie, induced abortion, puerperal infection, and pregnancy-induced hypertension), knowledge of the contribution of nutrition is too scanty for programmatic application. Hemorrhage (including, for this discussion, anemia) and obstructed labor are different. The risk of death is greatly increased with severe anemia (Hb <70 or 80 g/L); there is little evidence of increased risk associated with mild or moderate anemia. Current programs of universal iron supplementation are unlikely to have much effect on severe anemia. There is an urgent need to reassess how to approach anemia control in pregnant women. Obstructed labor is far more common in short women. Unfortunately, nutritional strategies for increasing adult stature are nearly nonexistent: supplemental feeding appears to have little benefit after 3 y of age and could possibly be harmful at later ages, inducing accelerated growth before puberty, earlier menarche (and possible earlier marriage), and unchanged adult stature. Deprived girls without intervention typically have late menarche, extended periods of growth, and can achieve nearly complete catch-up growth. The need for operative delivery also increases with increased fetal size. Supplementary feeding could therefore increase the risk of obstructed labor. In the absence of accessible obstetric services, primiparous women <1.5 m in height should be excluded from supplementary feeding programs aimed at accelerating fetal growth. The knowledge base to model the risks and benefits of increased fetal size does not exist.

Maternal mortality in the past and its relevance to developing countries today

High maternal mortality was a feature of the Western world from the mid-19th century, when reliable record keeping commenced, to the mid-1930s. During this time, maternal mortality rates tended to remain on a high plateau, although there was wide disparity between countries in the height of the plateau. From approximately 1937, maternal mortality rates began to decline everywhere, and within 20 y, the intercountry differences had almost disappeared. The decline in maternal mortality rates was so dramatic that current rates for developed countries are between one-fortieth and one-fiftieth of the rates that prevailed 60 y ago. In this paper, the reasons for the high mortality before 1937 and its decline since that date are discussed. It is suggested that the main determinant of maternal mortality was the overall standard of maternal care provided by birth attendants. Poverty and associated malnutrition played little part in determining the rate of maternal mortality. This view is supported by much evidence, including the fact that, unlike for infant mortality rates, maternal mortality rates tended to be higher in the upper than in the lower social classes. The potential relevance of these findings to developing countries is discussed.

The Safe Motherhood Initiative: why has it stalled?

Complications of pregnancy and childbirth are still the leading cause of death and disability among women of reproductive age in developing countries. After decades of neglect, the founding of the Safe Motherhood Initiative in 1987 promised action on this problem. A dozen years later, there is no evidence that maternal mortality has declined and there are still few sizeable programs. A major reason for this disappointing record is that the initiative lacks a clear, concise, feasible strategy. This article reviews the available options and proposes a strategy based on improving the availability and quality of medical treatment of obstetric complications. Once district hospitals and health centers provide such needed care, community mobilization to improve prove utilization may be beneficial. Substantial reductions in maternal deaths would be possible in a relatively short period of time if this strategy were embraced.

Poor antenatal care in 20 French districts: risk factors and pregnancy outcome

STUDY OBJECTIVE

Poor attendance to antenatal visits was studied to identify risk factors and to analyse the association with adverse pregnancy outcome.

DESIGN

All poor attenders and a sample of good attenders were compared within three groups of women: women < 20 years, French women > or = 20 years, and foreigners > or = 20 years.

SETTING

20 French districts including 85,000 births from January to June 1993.

SUBJECTS

848 poor attenders and 759 good attenders. Poor attenders made fewer than four antenatal visits or began care during or after the sixth month. Good attenders made at least four visits and began care before the sixth month.

MAIN RESULTS

1.1% of the women were poor attenders. Risk factors for poor attendance were single status and lack of health insurance in the group under 20; young age, high parity, and single status in the French group aged over 20; and single status and lack of health insurance in the foreign group aged over 20. For poor attenders, the odds ratios for preterm delivery were 5.8 (95% CI: 3.2, 10.5) among French women and 3.3 (95% CI: 1.5, 7.4) among foreign women with health insurance. Poor attendance was not associated with poor pregnancy outcome in the group under 20, and among foreign women over 20 without health insurance, but both groups had high rates of preterm delivery and low birth weight.

CONCLUSION

Lack of health insurance is an important barrier to health care during pregnancy. Poor antenatal care is an important risk factor for adverse pregnancy outcome among women who have easy access to health care services.

The perinatal mortality rate as an indicator of quality of care in international comparisons

The perinatal mortality rate is used as an indicator of the quality of antenatal and perinatal care, yet uncritical application of this indicator in international comparisons can be misleading. The perinatal mortality rate depends on a number of factors and important determinants that need to be assessed separately before reaching conclusions about quality-of-care issues. This article provides a conceptual model of the construction of the perinatal mortality rate. It illustrates the relationship between quality of antenatal and perinatal care and risk factors for perinatal mortality and how these lead to the perinatal mortality rate. It also indicates how differences in registration procedures and practices influence the final mortality figures published by individual countries. For international comparison, the first step is to apply common definitions. The rate can vary by 50% depending on the definition used. Also, sources of registration bias need to be examined, because they differ considerably by country. Underregistration is known to be as high as 20% of perinatal deaths. The next step is to correct perinatal mortality figures according to differences in known risk factors. The perinatal mortality rate then can serve as a reasonable indicator for the quality of antenatal and perinatal care. In western countries, perinatal mortality could be reduced by as much as 25% with improved standards of care. Policies and practices in individual countries concerning ethical issues related to termination of pregnancy and care of newborn infants with (very) poor prognosis need to be taken into account as well. They are not related to quality of care, but do have a relatively large impact on the perinatal mortality rate.

An European concerted action investigating the validity of perinatal mortality as an outcome indicator for the quality of antenatal and perinatal care

In this paper the concepts, objectives, design, and data analysis procedures of the EuroNatal study are described. This study started in 1996 and is a concerted action including 14 countries in Europe. The EuroNatal study aims at determining the validity of national perinatal mortality rates as an outcome indicator for the quality of antenatal and perinatal care. It is based on a conceptual model describing the relationships between differences in quality of antenatal and perinatal care, maternal and infant risk factors, variation in applied definitions, reliability of registration procedures and practices, and the outcome in terms of "true" and "observed" differences in perinatal mortality. In the first part of the study data is collected at national and aggregate level; in the second part data is collected retrospectively on individual cases of perinatal mortality in a regional sample area. Analysis of the individual cases of perinatal mortality will be by means of a perinatal audit conducted by an international expert panel. The project builds upon the work done by the participants in their respective countries. By applying common research protocols, international comparability of data collection will be enhanced and will help to create a common body of knowledge in the area of perinatal epidemiology and perinatal care. Comparison between countries is likely to lead to new insights into the strengths and weaknesses of antenatal and perinatal care systems of individual countries.

The conceptual framework of the PMM Network

Understanding the determinants of maternal mortality is a complex task, in part because maternal deaths are influenced by many different categories of events or conditions. Biology, economics, culture, demography and the distribution and effectiveness of health services all contribute. Conceptual frameworks have made important contributions to our understanding of the determinants of other, equally complex events, such as fertility and child survival. Also referred to as 'proximate determinants frameworks', such models are useful because they identify the specific mechanisms through which social, economic and cultural factors lead to the event of interest. Our model identifies the precise sequence of events that lead to maternal death (pregnancy, complication and death) and specifies categories of intermediate factors and distant factors that directly affect one or more of these events. When the world literature on maternal mortality was analyzed in light of the causal pathways laid out in the conceptual framework, it became clear that some pathways are more amenable to intervention and change than others. Implications for strategies, programs and monitoring and evaluation are discussed.

Meta-analysis of the safety of home birth

BACKGROUND

The safety of planned home birth is controversial. This study examined the safety of planned home birth backed up by a modern hospital system compared with planned hospital birth in the Western world.

METHODS

A meta-analysis of six controlled observational studies was conducted, and the perinatal outcomes of 24,092 selected and primarily low-risk pregnant women were analyzed to measure mortality and morbidity, including Apgar scores, maternal lacerations, and intervention rates. Confounding was controlled through restriction, matching, or in the statistical analysis.

RESULTS

Perinatal mortality was not significantly different in the two groups (OR = 0.87, 95% Ci 0.54-1.41). The principal difference in the outcome was a lower frequency of low Apgar scores (OR = 0.55; 0.41-0.74) and severe lacerations (OR = 0.67; 0.54-0.83) in the home birth group. Fewer medical interventions occurred in the home birth group: induction (statistically significant ORs in the range 0.06-0.39), augmentation (0.26-0.69), episiotomy (0.02-0.39), operative vaginal birth (0.03-0.42), and cesarean section (0.05-0.31). No maternal deaths occurred in the studies. Some differences may be partly due to bias. The findings regarding morbidity are supported by randomized clinical trials of elements of birth care relevant for home birth, however, and the finding relating to mortality is supported by large register studies comparing hospital settings of different levels of care.

CONCLUSION

Home birth is an acceptable alternative to hospital confinement for selected pregnant women, and leads to reduced medical interventions.

Observed versus expected obstetric complications: an assessment of coverage of obstetric care in developing countries

The objective of this study was to evaluate access to obstetric care in a rural district in East Africa using easily collected and evaluated data and avoiding expensive field surveys, complicated study design or statistical methods. The number of observed obstetric complications occurring during 12 months in a rural East African district hospital (the only institution with surgical facilities and access to blood transfusion in the district) were compared to the number of expected complications the district should 'generate'. Of the expected > 10000 deliveries < 25% took place in the district hospital. The place of confinement for the other deliveries was not determined. As compared to the total number of expected conditions within the study district < 25% of the breech and < 45% twin deliveries took part in the district hospital and < 10% of pregnancies complicated by placental abruptions and < 5% of the pregnancies complicated by placenta praevia were managed in the district hospital. Comparing the number of serious pregnancy complications which were managed in the hospital to the total expected number for a particular region allows a simple assessment of the accessibility of obstetric care. This ratio might be more useful when evaluating obstetric care than traditional parameters as it stresses the importance of accessibility of care for the whole community.