Access to care and maternal mortality in Jamaican hospitals: 1993-1995

Maternal mortality due to cardiac disease in low- and middle-income countries

Objectives

To assess the frequency of maternal death (MD) due to cardiac disease in low‐ and middle‐income countries (LMIC).

Methods

Systematic review searching Medline, EMBASE, Web of Science, Cochrane Library, Emcare, LILACS, African Index Medicus, IMEMR, IndMED, WPRIM, IMSEAR up to 01/Nov/2017. Maternal mortality reports from LMIC reviewing all MD in a given geographical area were included. Hospital‐based reports or those solely based on verbal autopsies were excluded. Numbers of MD and cardiac‐related deaths were extracted. We calculated cardiac disease MMR (cMMR, cardiac‐related MD/100 000 live births) and proportion of cardiac‐related MDs among all MDs. Frequency of cardiac MD was compared with the MMR of the country.

Results

Forty‐seven reports were included, which reported on 38,486 maternal deaths in LMIC. Reported cMMR ranged from 0/100 000 live births (Moldova, Ghana) to 31.9/100 000 (Zimbabwe). The proportion of cardiac‐related MD ranged from 0% (Moldova, Ghana) to 24.8% (Sri Lanka). In countries with a higher MMR, cMMR was also higher. However, the proportion of cardiac‐related MD was higher in countries with a lower MMR.

Conclusions

The burden of cardiac‐related mortality is difficult to assess due limited availability of mortality reports. The proportion of cardiac deaths among all MD appeared to be higher in countries with a lower MMR. This is in line with what has been called ‘obstetric transition’: pre‐existing medical diseases including cardiac disease are becoming relatively more important where the MMR falls.

Maternal Origin and Risk of Neonatal and Maternal ICU Admission

OBJECTIVES

To evaluate maternal world region of birth, as well as maternal country of origin, and the associated risk of admission of 1) a mother to a maternal ICU, 2) her infant to a neonatal ICU, or 3) both concurrently to an ICU.

DESIGN

Retrospective population-based cohort study.

SETTING

Entire province of Ontario, Canada, from 2003 to 2012.

PATIENTS

All singleton maternal-child pairs who delivered in any Ontario hospital.

MEASUREMENTS AND MAIN RESULTS

We explored how maternal world region of birth, and specifically, maternal country of birth for the top 25 countries, was associated with the outcome of 1) neonatal ICU, 2) maternal ICU, and 3) both mother and newborn concurrently admitted to ICU. Relative risks were adjusted for maternal age, parity, income quintile, chronic hypertension, diabetes mellitus, obesity, dyslipidemia, drug dependence or tobacco use, and renal disease. Compared with infants of Canadian-born mothers (110.7/1,000), the rate of neonatal ICU admission was higher in immigrants from South Asia (155.2/1,000), Africa (140.4/1,000), and the Caribbean (167.3/1,000; adjusted relative risk, 1.41; 95% CI, 1.36-1.46). For maternal ICU, the adjusted relative risk was 1.79 (95% CI, 1.43-2.24) for women from Africa and 2.21 (95% CI, 1.78-2.75) for women from the Caribbean. Specifically, mothers from Ghana (adjusted relative risk, 2.71; 95% CI, 1.75-4.21) and Jamaica (adjusted relative risk, 2.74; 95% CI, 2.12-3.53) were at highest risk of maternal ICU admission. The risk of both mother and newborn concurrently admitted to ICU was even more pronounced for Ghana and Jamaica.

CONCLUSIONS

Women from Africa and the Caribbean and, in particular, Ghana and Jamaica, are at higher risk of admission to ICU around the time of delivery, as are their newborns.

Geographic accessibility to obstetric care and maternal mortality in a large metropolitan area of Brazil

OBJECTIVE

To assess maternal mortality and its association with accessibility to obstetric care in the metropolitan region of Rio de Janeiro, Brazil.

METHODS

Maternal mortality was assessed from 2 national databases, one administrative and the other designed for epidemiologic purposes. Distances traveled from residence to hospital via the transit network were calculated using a specialized information system. Deaths were grouped by area of residence, and maternal mortality ratios (number of deaths per 100,000 live births) as well as death incidence ratios (deaths/live births in 2 regions or hospital types) were calculated for these areas.

RESULTS

We identified 236 deaths and estimated under-reporting at 30%. The most common causes of death were hypertension-related disorders, "other obstetric conditions," and complications from abortion; the longest traveled distance was 66.43 km (mean, 13.65 km); and maternal mortality ratios varied between 25.54% and 56.45%, the highest values being for areas with the lowest municipal human development index. The highest death incidence ratios were found at general hospitals without specialized obstetric care.

CONCLUSION

Maternal mortality is still a serious problem in the studied region. The wide variations among areas of different socioeconomic conditions suggest the need for a better allocation of health care resources.

‘MAYBE IT WAS HER FATE AND MAYBE SHE RAN OUT OF BLOOD’: FINAL CAREGIVERS' PERSPECTIVES ON ACCESS TO CARE IN OBSTETRIC EMERGENCIES IN RURAL INDONESIA

Maternal mortality persists in low-income settings despite preventability with skilled birth attendance and emergency obstetric care. Poor access limits the effectiveness of life-saving interventions and is typical of maternal health care in low-income settings. This paper examines access to care in obstetric emergencies from the perspectives of service users, using established and contemporary theoretical frameworks of access and a routine health surveillance method. The implications for health planning are also considered. The final caregivers of 104 women who died during pregnancy or childbirth were interviewed in two rural districts in Indonesia using an adapted verbal autopsy. Qualitative analysis revealed social and economic barriers to access and barriers that arose from the health system itself. Health insurance for the poor was highly problematic. For providers, incomplete reimbursements, and low public pay, acted as disincentives to treat the poor. For users, the schemes were poorly socialized and understood, complicated to use and led to lower quality care. Services, staff, transport, equipment and supplies were also generally unavailable or unaffordable. The multiple barriers to access conferred a cumulative disadvantage that culminated in exclusion. This was reflected in expressions of powerlessness and fatalism regarding the deaths. The analysis suggests that conceiving of access as a structurally determined, complex and dynamic process, and as a reciprocally maintained phenomenon of disadvantaged groups, may provide useful explanatory concepts for health planning. Health planning from this perspective may help to avoid perpetuating exclusion on social and economic grounds, by health systems and services, and help foster a sense of control at the micro-level, among peoples' feelings and behaviours regarding their health. Verbal autopsy surveys provide an opportunity to routinely collect information on the exclusory mechanisms of health systems, important information for equitable health planning.

Maternal mortality surveillance in Jamaica

OBJECTIVES

To assess factors associated with under-reporting of maternal deaths from 1998, when maternal deaths became a Class I notifiable event in Jamaica and continuous maternal mortality surveillance was introduced, through 2003.

METHODS

The number of deaths notified was compared with the number of independently identified deaths for each period and region studied, and key informants reported on their experience of the surveillance process.

RESULTS

By 2000, approximately 80% of maternal deaths were reported, and was more consistent in 2 of the 4 regions. In these 2 regions someone was responsible for active surveillance and there was an established maternal mortality committee to review cases. Factors associated with nonreporting were no postmortem examination, death in the first trimester of pregnancy, and time interval between pregnancy termination and death. The surveillance staff requested guidelines on monitoring interregional transfers and technical assistance in developing action plans.

CONCLUSION

Active hospital surveillance must include all wards, including the emergency department. Community surveillance should include forensic pathologists. National leadership is needed to summarize trends, address policy, and provide technical assistance to the surveillance staff.

Risk factors of maternal death in Mexico

BACKGROUND

One of the United Nations' Millennium Development Goals for 2015 is to reduce the maternal mortality ratio by three fourths. Ninety-nine percent of maternal deaths occur in developing countries, and the World Health Organization encourages investigations in these settings to determine the risk factors of maternal deaths. Our aim was to identify these risk factors in a hospital-based study in Mexico.

METHODS

The study was conducted at the Hospital of Obstetrics and Gynecology at the Mexican Institute of Social Security in Leon, Guanajuato, Mexico, from January 1, 1992, to March 31, 2004. Women were divided into groups of 110 individuals who had died during pregnancy, delivery, or postpartum, and 440 women who survived the postpartum period. We used a logistic regression analysis to find the significant risk factors for maternal deaths. Odds ratios with 95% t confidence intervals were estimated.

RESULTS

The maternal mortality ratio was 47.3 per 100,000 live births. The main causes of death were hemorrhage (30.9%), preeclampsia/eclampsia (28.2%), and septic shock (10.9%). Six factors were significantly associated with maternal death: age (OR = 1.09, 95% CI = 1.00-1.18), marital status (OR = 16.2, 95% CI = 1.3-196.1), number of antenatal visits (OR = 1.3, 95% CI = 1.0-1.6), preexisting medical conditions (OR = 23.3, 95% CI = 6.6-81.6), obstetric complications in previous pregnancies (OR = 28.3, 95% CI = 4.9-163.0), and mode of delivery (OR = 1.6, 95% CI = 1.0-2.4).

CONCLUSIONS

Socioeconomic, medical, and obstetric risk factors are associated with maternal deaths in Mexico.

Epidemiologic transition in maternal mortality and morbidity: new challenges for Jamaica

OBJECTIVE

Given interventions implemented in recent years to reduce maternal deaths, we sought to determine the incidence and causes of maternal deaths for 1998-2003.

METHOD

Records of public hospitals and state pathologists were reviewed to identify pregnancy-related deaths within 12 months of delivery and determine their underlying causes.

RESULTS

Maternal mortality declined (p=0.023) since surveillance began in 1981-83. The fall in direct mortality (p=0.0003) included 24% fewer hypertension deaths (introduction of clinical guidelines, reorganization of antenatal services) and 36% fewer hemorrhage deaths (introduction of plasma expanders). These improvements were tempered by growing indirect mortality (p=0.057), moving to 31% of maternal deaths from 17% in 1993-95.

INTERPRETATION

Declines in direct mortality may be associated with surveillance and related improvements in obstetric care. Increased indirect deaths from HIV/AIDS, cardiac disease, sickle cell disease and asthma suggests the need to improve collaboration with medical teams to implement guidelines to care for pregnant women with chronic diseases.

Characteristics of preeclampsia- and eclampsia-related maternal death in rural Haiti

OBJECTIVE

The maternal mortality ratio in Haiti remains one of the highest in the world at 600/100 000 live births. Preeclampsia- and eclampsia-related complications are one of the leading causes of maternal death. In this resource-limited setting, effective, efficient hospital-based interventions are necessary to reduce this risk. Our objective was to assess the utility of common laboratory and clinical admission data for the determination of preeclampsia- and eclampsia-related maternal death.

STUDY DESIGN

We performed an analysis of women presenting to the Hôpital Albert Schweitzer with preeclampsia and eclampsia during a 3-year period. Factors analyzed were: maternal age, parity, gestational age, hematocrit, serum creatinine, urine protein, systolic and diastolic blood pressure, intrauterine fetal death (IUFD), coma on arrival, and address (residence within or outside hospital catchment area). Stepwise logistic regression identified factors predictive of maternal mortality.

RESULTS

Preeclampsia/eclampsia affected 423 of 2295 deliveries (18%) and resulted in 19 deaths. Multivariate analysis identified the following predictors of maternal mortality: IUFD (RR 7.57; 95% CI 2.76-12.69), eclampsia (RR 6.91; 95% CI 2.08-12.64), and oliguria (RR 5.39; 95% CI 1.80-10.69).

CONCLUSION

In this setting, traditional admission laboratory and clinical tests were not useful in maternal mortality prediction. The analysis highlights clinical characteristics of women at highest risk for maternal death.

Safe motherhood in Jamaica: from slavery to self-determination

The development of maternal health care in Jamaica is reviewed by examining government documents and publications to identify social and political factors associated with maternal mortality decline. Modern maternity services began with the 1887 establishment of the Victoria Jubilee Hospital and Midwifery School. Community midwives were deployed widely by the 1930s and community antenatal care expanded in the 1950s. Social policies in the 1970s increased women's access to primary health care, education and social support; improved transportation in the 1990s facilitated hospital delivery. Maternal mortality declined rapidly from approximately 600/100 000 in the 1930s to 200/100 000 in 1960, led by a 69% decline in sepsis by 1950, and a 72% decline from all causes thereafter, settling at approximately 100/100 000 in the 1980s. Skilled birth attendant deliveries moved from 39% in 1950 to 95% in 2001 and hospital births from 31% in 1960 to 91% in 2001. Maternal mortality plateaued at 70-80% prevalence of skilled delivery care. Deployment of midwives into rural communities and social development focused on women and children were associated with the observed improvements. Further reductions will require greater attention to the quality of emergency obstetric care.

The influence of hospital closures in Nova Scotia on perinatal outcomes

OBJECTIVE

To evaluate the effect of hospital closures on critical obstetrical interventions and perinatal outcomes in rural communities in Nova Scotia, Canada.

METHODS

A population-based cohort study was carried out for the years 1988 to 2002, using data extracted from the Nova Scotia Atlee Perinatal Database. Regions of maternal residence were defined geographically and administratively as Eastern, Northern,Western, and Central. The time periods of 1988 to 1993 and 1996 to 2002 were chosen based on the timing of hospital closures. Changes in rates of several perinatal outcomes were examined by region in relation to the extent of hospital closures experienced by that region.

RESULTS

The majority of hospital closures occurred in 1994 to 1995 with the establishment of new health regions, and affected the Western region most profoundly. In comparison with the Central region (relative risk [RR], 0.56; 95% confidence interval [CI], 0.53-0.59), the temporal reduction in the rate of forceps-assisted vaginal delivery was smaller in the Western region (RR, 0.83; 95% CI, 0.76-0.91; P < .001), but greater in the Northern (RR, 0.36; 95% CI, 0.32-0.41; P < .001) and Eastern (RR, 0.26; 95% CI, 0.23-0.30; P < .001) regions. The temporal increase in the rate of breastfeeding at discharge from hospital was smaller in the Northern region (RR, 1.36; 95% CI, 1.29-1.45; P < .001) compared to that in the Central region (RR, 1.55; 95% CI, 1.49-1.61). The decrease in the rate of fetal growth restriction was smaller in the Western (RR, 0.95; 95% CI, 0.87-1.02; P = .002) and Eastern (RR, 0.90; 95% CI, 0.82-0.98; P = .002) regions of residence compared to the Central region (RR, 0.75; 95% CI, 0.71-0.79). There were no significant regional differences in temporal patterns of preterm induction and/or preterm Caesarean delivery, or perinatal mortality.

CONCLUSION

Although trends over time demonstrated some regional differences in obstetrical interventions and perinatal outcomes, our retrospective evaluation did not reveal a consistent relationship between reductions in maternity services associated with hospital closures and systematic, population-level adverse perinatal consequences in Nova Scotia.

Are oral contraceptive use and pregnancy complications risk factors for atopic disorders among offspring?

In utero programming of atopic manifestations has been suggested. We investigated the association between oral contraceptive (OC) use before, and complications during pregnancy (CDP) and asthma, along with other atopic manifestations. The study is based on neonates from Kingston and St Andrew, a geographic subcohort from the Jamaican Perinatal Morbidity, Mortality Survey conducted in 1986-1987. Information on OC use and CDP was extracted from maternal interviews and medical records. In a follow up in 1997-1998, via interviews with mothers, trained nurses collected information on asthma/wheezing, coughing, eczema, and hay fever. Data, specific to this paper, from birth and 11-12 yr of age was available for a total of 1040 of the 1720 members of the geographic subcohort. Using logistic regression, controlling for confounders, we estimated adjusted odds ratio (aOR) and corresponding 95% confidence intervals (CI). For asthma or wheezing, and coughing, aOR for OC use were 1.81 (95% CI: 1.25-2.61), and 2.72 (95% CI: 1.41-5.24), respectively. CDP was only shown to be a significant risk factor for hay fever. Additionally, a higher number of older siblings were protective for hay fever. The results suggest that asthma in childhood may be programmed in utero.

Efectos de un programa de mejoramiento de la calidad en servicios materno perinatales en el Peru: la experiencia del proyecto 2000

OBJETIVOS: comparar la calidad de los servicios de salud materno perinatales (SMP) de los establecimientos participantes en un programa de mejora de calidad (PMC) y compararlos con un grupo control; evaluar comparativamente los conocimientos y actitudes de usuarias de servicios de salud materna; y determinar la contribución del PMC en los niveles de calidad. MÉTODOS: fue implementado un PMC en 74 establecimientos de salud seleccionados para mejorar la calidad. Se desarrolló un cuasiexperimento controlado en 74 hospitales, centros de salud y establecimientos periféricos. El análisis de la calidad de los SMP se realizó mediante comparación de promedios de escalas centesimales; los conocimientos y actitudes de las usuarias mediante análisis bivariado; y la predicción del nivel de calidad a través de análisis multivariado. RESULTADOS: al final de la intervención, la puntuación de los establecimientos con PMC tuvo un promedio de 61,8 puntos y de 37,5 en el grupo de comparación, (p <0,001). El promedio de conocimientos de signos de alarma obstétricos fue mayor en las usuarias PMC (3,6 signos/entrevistada) versus 2,5 en usuarias sin PMC, (p <0,05). La intención de parto institucional fue dos veces mayor en las usuarias de los servicios con PMC, (p = 0,038). Los predictores significativos de calidad fueron la mejora continua de la calidad y la disponibilidad de profesionales de salud. CONCLUSIONES: el nivel de calidad es mayor en los servicios que desarrollaron PMC. Las usuarias de tales servicios tienen más conocimientos de los signos de alarma obstétricos y mejor actitud hacia el parto institucional. El PMC ha contribuido para tales logros.