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Bande AD, Handiso TB, Hanjelo HW, Jena BH. Early discontinuation of long-acting reversible contraceptives methods and its associated factors in Hosanna town, central Ethiopia: a cross-sectional study. Sci Rep 2024; 14:11841. [PMID: 38782935 PMCID: PMC11116486 DOI: 10.1038/s41598-024-61648-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
Long-acting reversible contraceptive (LARC) method use is an ideal strategy for longer protection against unintended pregnancies, unsafe abortions, maternal morbidities, and mortalities related to pregnancies and childbirth. Despite low utilization of LARC methods in Ethiopia, early discontinuation remains a problem. This study aimed to assess prevalence of early discontinuation of LARC methods and associated factors in Hossana town. A community-based cross-sectional study was conducted among 433 adult women of reproductive age who had a history of LARC use. Logistic regression model was considered for the analysis. Proportion of LARC methods discontinuation within one year was 24.5%, 95% CI (20.6, 26.8%). Women whose age ≥ 30 years (AOR = 3.16, 95% CI: 1.27, 7.89), who had < 3 live children (AOR = 5.17, 95% CI 2.30, 11.61), who had a desire for pregnancy (AOR = 2.35, 95% CI 1.14, 4.85), who did not get pre-insertion counseling on the benefits of LARC methods (AOR = 1.79, 95% CI 1.01, 3.21) and who experienced side effects (AOR = 3.63, 95% CI 2.07, 6.38) were more likely to discontinue LARC methods early than their counterparts. Nearly one-fourth of clients discontinued using the LARC methods within the first year of insertion, highlighting the need to promote longer use for improved protection and success of family planning programs.
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Affiliation(s)
| | - Tilahun Bayene Handiso
- Department of Epidemiology, School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia
| | - Habtamu Wude Hanjelo
- Department of Health Service Management, School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia
| | - Belayneh Hamdela Jena
- Department of Epidemiology, School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia.
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Menashe-Oren A, Stecklov G. Age-specific sex ratios: Examining rural-urban variation within low- and middle-income countries. POPULATION STUDIES 2023; 77:539-558. [PMID: 37594443 DOI: 10.1080/00324728.2023.2233964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 03/20/2023] [Indexed: 08/19/2023]
Abstract
The balance of men and women in society, captured by sex ratios, determines key social and demographic phenomena. Previous research has explored sex ratios mainly at birth and up to age five at national level, whereas we address rural-urban gaps in sex ratios for all ages. Our measures are based on the United Nations data on rural and urban populations by age and sex for 112 low- and middle-income countries in 2015. We show that rural sex ratios are higher than urban sex ratios among children and older people, whereas at working ages, urban areas are dominated by males. Our analysis suggests that the urban transition itself is not driving the gap in rural-urban sex ratios. Rather, internal migration seems to be key in shaping rural-urban sex ratio divergence in sub-Saharan Africa, while both internal migration and mortality differentials appear to be the predominant mechanisms driving sex ratio gaps in Latin America.
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Onambele L, Guillen-Aguinaga S, Guillen-Aguinaga L, Ortega-Leon W, Montejo R, Alas-Brun R, Aguinaga-Ontoso E, Aguinaga-Ontoso I, Guillen-Grima F. Trends, Projections, and Regional Disparities of Maternal Mortality in Africa (1990-2030): An ARIMA Forecasting Approach. EPIDEMIOLOGIA 2023; 4:322-351. [PMID: 37754279 PMCID: PMC10528291 DOI: 10.3390/epidemiologia4030032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/03/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
With the United Nations Sustainable Development Goals (SDG) (2015-2030) focused on the reduction in maternal mortality, monitoring and forecasting maternal mortality rates (MMRs) in regions like Africa is crucial for health strategy planning by policymakers, international organizations, and NGOs. We collected maternal mortality rates per 100,000 births from the World Bank database between 1990 and 2015. Joinpoint regression was applied to assess trends, and the autoregressive integrated moving average (ARIMA) model was used on 1990-2015 data to forecast the MMRs for the next 15 years. We also used the Holt method and the machine-learning Prophet Forecasting Model. The study found a decline in MMRs in Africa with an average annual percentage change (APC) of -2.6% (95% CI -2.7; -2.5). North Africa reported the lowest MMR, while East Africa experienced the sharpest decline. The region-specific ARIMA models predict that the maternal mortality rate (MMR) in 2030 will vary across regions, ranging from 161 deaths per 100,000 births in North Africa to 302 deaths per 100,000 births in Central Africa, averaging 182 per 100,000 births for the continent. Despite the observed decreasing trend in maternal mortality rate (MMR), the MMR in Africa remains relatively high. The results indicate that MMR in Africa will continue to decrease by 2030. However, no region of Africa will likely reach the SDG target.
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Affiliation(s)
- Luc Onambele
- School of Health Sciences, Catholic University of Central Africa, Yaoundé 1110, Cameroon;
| | - Sara Guillen-Aguinaga
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain; (S.G.-A.); (L.G.-A.); (R.A.-B.)
| | - Laura Guillen-Aguinaga
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain; (S.G.-A.); (L.G.-A.); (R.A.-B.)
- Department of Nursing, Suldal Sykehjem, 4230 Sands, Norway
| | - Wilfrido Ortega-Leon
- Department of Surgery, Medical and Social Sciences, University of Alcala de Henares, 28871 Alcalá de Henares, Spain;
| | - Rocio Montejo
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, University of Gothenburg, 413 46 Gothenburg, Sweden;
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, 413 46 Gothenburg, Sweden
| | - Rosa Alas-Brun
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain; (S.G.-A.); (L.G.-A.); (R.A.-B.)
| | | | - Ines Aguinaga-Ontoso
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain; (S.G.-A.); (L.G.-A.); (R.A.-B.)
- Area of Epidemiology and Public Health, Healthcare Research Institute of Navarre (IdiSNA), 31008 Pamplona, Spain
- CIBER in Epidemiology and Public Health (CIBERESP), Institute of Health Carlos III, 46980 Madrid, Spain
| | - Francisco Guillen-Grima
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain; (S.G.-A.); (L.G.-A.); (R.A.-B.)
- Area of Epidemiology and Public Health, Healthcare Research Institute of Navarre (IdiSNA), 31008 Pamplona, Spain
- CIBER in Epidemiology and Public Health (CIBERESP), Institute of Health Carlos III, 46980 Madrid, Spain
- Department of Preventive Medicine, Clínica Universidad de Navarra, 31008 Pamplona, Spain
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Care Bundles: Enhanced Recovery After Delivery. MATERNAL-FETAL MEDICINE 2023. [DOI: 10.1097/fm9.0000000000000178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Li CL, Jiang M, Huang KC, Li J, Xu LG. The trends of maternal mortality ratios and cause pattern in 34 Chinese provinces, 1990-2017. BMC Public Health 2022; 22:1369. [PMID: 35842611 PMCID: PMC9288211 DOI: 10.1186/s12889-022-13770-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 07/08/2022] [Indexed: 11/25/2022] Open
Abstract
Background Understanding the trends and causes to the burden of maternal deaths is a key requirement to further reduce the maternal mortality ratio (MMR), and devise targeted intervention policy. We aimed to evaluate the spatiotemporal trends of MMRs and cause patterns across the 34 provinces of China during 1990–2017. Methods Using data from the Global Burden of Disease Study 2017, we calculated the levels and trends of total maternal deaths and MMR due to ten different causes through Bayesian multivariable regression model for pregnancies aged 10–54 years, and assessed the age and regional distribution over time. Results China has experienced fast decline in MMR, dropped from 95.2 (87.8–102.3) in 1990 to 13.6 (12.5–15.0) in 2017, with an annualised rate of decline of 7.0%. In 1990, the range of MMRs in mainland China was 31.1 in Shanghai, to 323.4 in Tibet. Almost all provinces showed remarkable decline in the last two decades. However, spatial heterogeneity in levels and trends still existed. The annualised rate of decline across provinces from 1990 to 2017 ranged from 0.54% to 10.14%. Decline accelerated between 2005 and 2017 compared with between 1990 and 2005. In 2017, the lowest MMR was 4.2 in Zhejiang; the highest was still in Tibet, but had fallen to 82.7, dropped by 74.4%. MMR was highest in the 40–49 years age group in both 1990 and 2017. In 2017, haemorrhage and hypertensive disorders were the leading two specific causes for maternal deaths. Conclusions MMRs have declined rapidly and universally across the provinces of China. Setting of associated interventions in the future will need careful consideration of provinces that still have MMR significantly higher than the national mean level. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13770-0.
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Affiliation(s)
- Chang-Li Li
- Department of FSTC Clinic, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Meng Jiang
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 310003, Hangzhou, China.
| | - Ke-Cheng Huang
- Department of Gynecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jian Li
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Li-Gang Xu
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
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Temporal Trends of Maternal Mortality Due to Obstetric Hemorrhage in Chinese Mainland: Evidence from the Population-Based Surveillance Data Between 2000 and 2019. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Li D, Yu C, Song C, Ning W, Xu Y, Ge H, Lin S, Zhou W, Lu Y, Wang X, Hu Z, Lin Y, Wu J. Maternal mortality ratio in Jiangsu Province, China: recent trends and associated factors. BMC Pregnancy Childbirth 2021; 21:447. [PMID: 34172025 PMCID: PMC8235612 DOI: 10.1186/s12884-021-03897-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/17/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In recent years, births to older mothers and multiparous mothers have increased rapidly with the change of birth policy in China. And mothers of advanced age are more likely to have maternal complications and poor birth outcomes. We aimed to estimate the recent trends and underlying risk factors of maternal mortality. METHODS In this systematic assessment, we used data from the National Maternal and Child Health Routine Reporting System (2013-2018), Jiangsu Provincial Maternal Mortality Surveillance System (2017-2018), the Integrated National Mortality Surveillance System (2018), City Statistical Yearbooks (2018), City Health Statistical Yearbooks (2018). The factors associated with maternal mortality ratio (MMR) were explored using the stepwise regression analysis and cluster analysis. RESULTS The MMR maintained at low levels between 2013 and 2016 and there was a slight increase in maternal mortality after 2016 in Jiangsu province. With the implementation of the China's universal two child policies, the percentage of multiparous mothers ascended from 34.2% (95% confidence interval (CI) = 34.1-34.3%) in 2013 to 51.4% (95% CI = 51.3-51.6%) in 2018 (beta = 3.88, P < 0.001). Consistently, the percentage of advanced maternal age (≥ 35) increased from 8.4% (95% CI = 8.4-8.5%) in 2013 to 10.4% (95% CI = 10.3-10.4%) in 2018 (beta = 0.50, P = 0.012). And we found that the percentage of multiparous mothers and advanced maternal age among maternal deaths were higher than all pregnant women (P < 0.001). In the stepwise regression analysis, four risk factors were significantly associated with maternal mortality ratio (primary industry of gross domestic product (GDP), rate of delivery in maternal and child health hospital, rate of cesarean section and rate of low birth weight). As the results derived from cluster analysis, the relatively developed regions had lower preventable maternal mortality ratio (43.5% (95% CI = 31.2-56.7%) vs. 62.6% (95% CI = 52.3-72.0%), P = 0.027). CONCLUSIONS Since the universal two child policy has been associated with changes in health related birth characteristics: women giving birth have been more likely to be multiparous, and more likely to be aged 35 and over. This somewhat magnifies the impact of differences in economic development and obstetric services on MMR. The findings based on prefecture level data suggest that interventions must target economic development, the health system and maternal risk factors in synergy. These approaches will be of great benefit to control or diminish environmental factors associated with preventable deaths and will effectively reduce MMR and narrow the gap among the different regions.
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Affiliation(s)
- Donghua Li
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Chengxiao Yu
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, 211166, China
| | - Ci Song
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, 211166, China
| | - Weiqing Ning
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Yan Xu
- Department of Women and Children, Jiangsu Provincial Commission of Health, Nanjing, 210008, China
| | - Huan Ge
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Song Lin
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Wenjie Zhou
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Yajun Lu
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Xudong Wang
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China
| | - Zhibin Hu
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, 211166, China
| | - Yuan Lin
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, China.
| | - Jie Wu
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu Women and Children Health Hospital, Nanjing, 210036, China.
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Shen M, Wu Y, Xiang X. Hukou-based rural-urban disparities in maternal health service utilization and delivery modes in two Chinese cities in Guangdong Province. Int J Equity Health 2021; 20:145. [PMID: 34158068 PMCID: PMC8218440 DOI: 10.1186/s12939-021-01485-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 06/01/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Most existing research on rural-urban health inequalities focuses on disparities in service access and health outcomes based on region. This paper examines rural-urban disparities in maternal healthcare utilization and delivery modes based on household registration (hukou) status to understand the role of state institutions in producing healthcare disparities in China. METHODS Utilizing administrative data from the Public Maternal Health Insurance scheme, we analyzed 54,733 live births in City A (2015-2019) and 25,849 live births in City B (2018-2019) in Guangdong Province in China. We constructed regression models using hukou status (rural versus urban) as the explanatory variable. RESULTS While there is no statistically significant difference in rural and urban mothers' probability of obtaining the minimum recommended number of prenatal care checkups in City A (OR = 0.990 [0.950, 1.032]), mothers with rural hukou status have a lower probability of obtaining the minimum recommended number of visits in City B than their counterparts with urban hukou (OR = 0.781 [0.740, 0.825]). The probability of delivering in tertiary hospital is lower among mothers with rural hukou than among those with urban hukou in both cities (City A: OR = 0.734 [0.701, 0.769]; City B: OR = 0.336 [0.319, 0.354]). Mothers with rural hukou are more likely to have a Cesarean section than those with urban hukou in both cities (City A: OR = 1.065 [1.027, 1.104]; City B: OR = 1.127 [1.069, 1.189]). Compared with mothers with urban hukou, mothers with rural hukou incurred 4 % (95 % CI [-0.046, -0.033]) and 9.4 % (95 % CI [-0.120, -0.068]) less in total medical costs for those who delivered via Cesarean section and 7.8 % (95 % CI [-0.085, -0.071]) and 19.9 % (95 % CI [-0.221, -0.177]) less for those who delivered via natural delivery in City A and City B, respectively. CONCLUSIONS Rural hukou status is associated with younger age, no difference or lower probability of having a minimum number of prenatal checkups, higher likelihood of delivering in nontertiary hospitals, increased Cesarean delivery rates, and lower medical cost for delivery in these two Chinese cities. Evaluating how hukou status influences maternal healthcare in Chinese cities is important for devising targeted public policies to promote more equitable maternal health services.
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Affiliation(s)
- Menghan Shen
- Center for Chinese Public Administration Research, School of Government, Sun Yat-sen University, Guangzhou, China
| | - Yushan Wu
- The Jockey Club School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, N. T. HKSAR, China
| | - Xin Xiang
- Graduate School of Education, Harvard University, 14 Appian Way, MA, 02139, Cambridge, USA.
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Tamang ST, Dorji T, Yoezer S, Phuntsho T, Dorji P. Knowledge and understanding of obstetric danger signs among pregnant women attending the antenatal clinic at the National Referral Hospital in Thimphu, Bhutan: a cross-sectional study. BMC Pregnancy Childbirth 2021; 21:104. [PMID: 33530968 PMCID: PMC7852084 DOI: 10.1186/s12884-021-03580-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The third Sustainable Development Goal for 2030 development agenda aims to reduce maternal and newborn deaths. Pregnant women's understanding of danger signs is an important factor in seeking timely care during emergencies. We assessed knowledge of obstetric danger signs using both recall and understanding of appropriate action required during obstetric emergencies. METHODS This was a cross-sectional study among pregnant women attending antenatal clinic at Bhutan's largest hospital in Thimphu. Recall was assessed against seven obstetric danger signs outlined in the Mother and Child Health Handbook (7 points). Understanding of danger signs was tested using 13 multiple choice questions (13 points). Knowledge was scored out of 20 points and reported as 'good' (≥80%), 'satisfactory' (60-79%) and 'poor' (< 60%). Correlation between participant characteristics and knowledge score as well as number of danger signs recalled was tested using Pearson's correlation coefficient. Association between knowledge score and participant characteristics was tested using t-tests (and Kruskal-Wallis test) for numeric variables. Socio-demographic and clinical characteristics associated with the level of knowledge ('good' versus 'satisfactory' and 'poor' combined) were assessed with odds ratios using a log-binomial regression model. All results with p < 0.05 were considered significant. RESULTS Four hundred and twenty-two women responded to the survey (response rate = 96.0%). Mean (±SD) knowledge score was 12 (±2.5). Twenty women (4.7%) had 'good' knowledge, 245 (58.1%) had 'satisfactory' knowledge and 157 (37.2%) had 'poor' knowledge. The median number of danger signs recalled was 2 (IQR 1, 3) while 68 women (20.3%) could not recall any danger signs. Most women were knowledgeable about pre-labour rupture of membranes (96.0%) while very few women were knowledgeable about spotting during pregnancy (19.9%). Both knowledge score and number of danger signs recalled had significant correlation with the period of gestation. Women with previous surgery on the reproductive tract had higher odds of having 'good' level of knowledge. CONCLUSIONS Most pregnant women had 'satisfactory' knowledge score with poor explicit recall of danger signs. However, women recognized obstetric emergencies and identified the appropriate action warranted.
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Affiliation(s)
- Saran Tenzin Tamang
- Faculty of Postgraduate Medicine, Khesar Gyalpo University of Medical Sciences of Bhutan, Gongphel Lam, Thimphu, 11001, Bhutan.
| | - Thinley Dorji
- Department of Internal Medicine, Armed Forces Medical College, Maharashtra University of Medical Sciences, Pune, India.,Kidu Mobile Medical Unit, His Majesty's People's Project, Thimphu, Bhutan
| | - Sonam Yoezer
- Faculty of Postgraduate Medicine, Khesar Gyalpo University of Medical Sciences of Bhutan, Gongphel Lam, Thimphu, 11001, Bhutan
| | - Thinley Phuntsho
- Kidu Mobile Medical Unit, His Majesty's People's Project, Thimphu, Bhutan
| | - Phurb Dorji
- Kidu Mobile Medical Unit, His Majesty's People's Project, Thimphu, Bhutan.,Department of Obstetrics and Gynaecology, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan
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Tuyisenge G, Crooks VA, Berry NS. "He lets me go although he does not go with me.": Rwandan women's perceptions of men's roles in maternal health. Glob Health Res Policy 2021; 6:2. [PMID: 33431064 PMCID: PMC7802268 DOI: 10.1186/s41256-020-00185-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 12/26/2020] [Indexed: 11/10/2022] Open
Abstract
Background Increasing men’s involvement in their pregnant partners’ wellness has been reported as one of the ways to improve access to and utilization of maternal health services, including birth preparedness and complication readiness. Men can play meaningful roles in the support systems that pregnant women need to achieve better maternal health outcomes. In Rwanda, the roles that men take vary, resulting in diverse expectations and responsibilities to support the health of women during this critical time. In this study, we aimed to examine the views, perspectives, and experiences of women on men’s involvement in maternal health and how this impacts access and utilization of maternal health services. Methods We conducted 21 interviews with pregnant and recently-pregnant women to gain an understanding of their views on men’s involvement in facilitating their partners’ health during pregnancy. Interviews were conducted across five Rwandan districts in both rural and urban settings of the country. Data analysis was guided by a thematic analysis approach. This started with independent transcript review by the investigators, after which a meeting was held to discuss emergent themes and to identify potential codes. A coding scheme was created and transcripts were coded in NVIVO™ software according to conceptual and practical topics that formed an understanding of men’s involvement in maternal care. Results Three key themes emerged during the analytic process that categorize the specific roles that men play in maternal health: 1) facilitating access to maternal health services, which involves assisting women with getting and or attending appointments jointly with men; 2) supporting women’s decisions, wherein men can support the decisions women make with regard to their maternal healthcare in a number of ways; and 3) evaluating information, including gathering information from multiple sources, especially from community health workers, to assist women with making informed decisions. Conclusion Rwandan men take on three types of roles in supporting women’s maternal health, and their responsibilities are experienced differently by women. Interventions involving men are encouraged to increase their understanding of the implications of their involvement in maternal health without compromising women’s autonomy in decision-making and to promote positive maternal health outcomes.
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Affiliation(s)
- Germaine Tuyisenge
- Department of Geography, Simon Fraser University, 8888 University Dr, Burnaby, BC, V5A 1S6, Canada. .,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.
| | - Valorie A Crooks
- Department of Geography, Simon Fraser University, 8888 University Dr, Burnaby, BC, V5A 1S6, Canada
| | - Nicole S Berry
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
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Muhunzi S, Ngocho JS, Mwanamsangu A, Sanga L, Hiza H, Msuya SE, Mahande MJ. Prevalence, predictors and reasons for home delivery amongst women of childbearing age in Dodoma Municipality in central Tanzania. Afr Health Sci 2020; 20:1933-1942. [PMID: 34394260 PMCID: PMC8351834 DOI: 10.4314/ahs.v20i4.52] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction The objective was to determine the prevalence, predictors and reasons for home delivery amongst women of childbearing age in Dodoma, Tanzania. Methods A cross-sectional study was conducted amongst women living in Dodoma Municipality. Data were collected using adapted questionnaires and analysed using SPPS version 23. A multivariable logistic regression model was used to assess the independent predictors of home delivery. Results A total of 425 women of childbearing age were enrolled in this study. The mean (± SD) age of the participants was 28.7 (±7.1) years. The prevalence of home delivery was 35.5% (n=150, 95% CI 30.9 – 40.2). Women with secondary school and above had 93% less odds of home delivery than women who had no education (AOR=0.0795% CI: 0.03–0.18). Women who lived in rural areas (AOR=3.49, 95% CI: 2.12–5.75), and women living more than 5km from health facilities (AOR=2.67, 95% CI: 1.65–4.37) had higher odds of home delivery. The main reasons for home delivery were transportation cost, and long distance to the nearest health facilities. Conclusion In this population, the prevalence of home delivery remained to be high. To address this more collaborative multisectoral effort like strengthening health education and strengthening maternity waiting homes are needed.
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Affiliation(s)
- Situ Muhunzi
- Department of Community Health, Institute of Public Health, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - James Samwel Ngocho
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Amasha Mwanamsangu
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Leah Sanga
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Hellen Hiza
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Sia E Msuya
- Department of Community Health, Institute of Public Health, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Michael J Mahande
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Chen P, Li M, Zhu J, Wang Y, Mu Y, Li Q, Dai L, Liu Z, Liang J, Liu H. Provincial-level outcomes of China's 'Reducing maternal mortality and eliminating neonatal tetanus' program. Sci Rep 2020; 10:13328. [PMID: 32770045 PMCID: PMC7414118 DOI: 10.1038/s41598-020-70257-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 07/08/2020] [Indexed: 12/04/2022] Open
Abstract
To determine whether the nationwide program ‘Reducing maternal mortality and eliminating neonatal tetanus’ contributed to the rapid decline in China’s maternal mortality ratio (MMR) and neonatal tetanus elimination by enhancing hospital delivery, we compared MMR and neonatal tetanus incidence rate (NTR) reductions by province from 2000 to 2013. The difference-in-difference method was used to analyze the program effect. Long-term effects were analyzed relative to MMR and NTR in 2000 and 2002, respectively, while short-term effects in a given year were analyzed relative to MMR and NTR in the preceding year. The national program was associated with a faster decline in MMR in the long term. The rate of decline showed an inverse ‘U’ shape from 2000 to 2013, peaking in 2009. The program had a short-term effect in MMR reduction in 2005, 2007, and 2009. The program was also associated with faster decline in NTR in the short term at some time points, but this association was not consistent and was not found in the long term. In conclusion, the program accelerated decline of MMR from 2000 to 2013 but did not clearly reduce NTR at the province level. Therefore, this targeted program worked efficiently in resource-poor areas.
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Affiliation(s)
- Peiran Chen
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mingrong Li
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Zhu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Ren Min South Road Section 3 No. 17, Chengdu, Sichuan, China
| | - Yanping Wang
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Mu
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qi Li
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Dai
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zheng Liu
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Juan Liang
- Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Hanming Liu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Ren Min South Road Section 3 No. 17, Chengdu, Sichuan, China.
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Spatiotemporal trends and ecological determinants in maternal mortality ratios in 2,205 Chinese counties, 2010-2013: A Bayesian modelling analysis. PLoS Med 2020; 17:e1003114. [PMID: 32413025 PMCID: PMC7228041 DOI: 10.1371/journal.pmed.1003114] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 04/15/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND As one of its Millennium Development Goals (MDGs), China has achieved a dramatic reduction in the maternal mortality ratio (MMR), although a distinct spatial heterogeneity still persists. Evidence of the quantitative effects of determinants on MMR in China is limited. A better understanding of the spatiotemporal heterogeneity and quantifying determinants of the MMR would support evidence-based policymaking to sustainably reduce the MMR in China and other developing areas worldwide. METHODS AND FINDINGS We used data on MMR collected by the National Maternal and Child Health Surveillance System (NMCHSS) at the county level in China from 2010 to 2013. We employed a Bayesian space-time model to investigate the spatiotemporal trends in the MMR from 2010 to 2013. We used Bayesian multivariable regression and GeoDetector models to address 3 main ecological determinants of the MMR, including per capita income (PCI), the proportion of pregnant women who delivered in hospitals (PPWDH), and the proportion of pregnant women who had at least 5 check-ups (PPWFC). Among the 2,205 counties, there were 925 (42.0%) hotspot counties, located mostly in China's western and southwestern regions, with a higher MMR, and 764 (34.6%) coldspot counties with a lower MMR than the national level. China's westernmost regions, including Tibet and western Xinjiang, experienced a weak downward trend over the study period. Nationwide, medical intervention was the major determinant of the change in MMR. The MMR decreased by 1.787 (95% confidence interval [CI]: 1.424-2.142, p < 0.001) per 100,000 live births when PPWDH increased by 1% and decreased by 0.623 (95% CI 0.436-0.798, p < 0.001) per 100,000 live births when PPWFC increased by 1%. The major determinants for the MMR in China's western and southwestern regions were PCI and PPWFC, while that in China's eastern and southern coastlands was PCI. The MMR in western and southwestern regions decreased nonsignificantly by 1.111 (95% CI -1.485-3.655, p = 0.20) per 100,000 live births when PCI in these regions increased by 1,000 Chinese Yuan and decreased by 1.686 (95% CI 1.275-2.090, p < 0.001) when PPWFC increased by 1%. Additionally, the western and southwestern regions showed the strongest interactive effects between different factors, in which the corresponding explanatory power of any 2 interacting factors reached up to greater than 80.0% (p < 0.001) for the MMR. Limitations of this study include a relatively short study period and lack of full coverage of eastern coastlands with especially low MMR. CONCLUSIONS Although China has accomplished a 75% reduction in the MMR, spatial heterogeneity still exists. In this study, we have identified 925 (hotspot) high-risk counties, mostly located in western and southwestern regions, and among which 332 counties are experiencing a slower pace of decrease than the national downward trend. Nationally, medical intervention is the major determinant. The major determinants for the MMR in western and southwestern regions, which are developing areas, are PCI and PPWFC, while that in China's developed areas is PCI. The interactive influence of any two of the three factors, PCI, PPWDH, and PPWFC, in western and southwestern regions was up to and in excess of 80% (p < 0.001).
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Maternal health services utilization and maternal mortality in China: a longitudinal study from 2009 to 2016. BMC Pregnancy Childbirth 2020; 20:220. [PMID: 32295528 PMCID: PMC7161293 DOI: 10.1186/s12884-020-02900-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 03/27/2020] [Indexed: 12/13/2022] Open
Abstract
Background The Chinese government introduced the maternal health services as part of the Basic Public Health Service (BPHS) project in 2009. While China has made progress in reducing maternal mortality, the longitudinal association between the utilization rate of the maternal health services of the BPHS project and such reduction was rarely evaluated with robust methods. Methods We conducted a longitudinal study on the maternal health service utilization rates of the BPHS project and the maternal mortality ratios (MMR) in mainland China and its 31 provincial regions. The data were extracted from the National Health Statistic Yearbooks (2009–2016). Panel data models were used to evaluate the association between the utilization rate and the MMR after adjusting for available covariates on healthcare resources. Stepwise regression models were used to gauge the direction and magnitude of omitted variable bias. Results It was found that the service utilization rate increased from 79.24% in 2009 to 91.67% in 2016, while MMR decreased from 30.90 to 17.88 per 100,000 livebirths at the national level. The results of the fixed effects panel data model revealed that the utilization rate was associated with MMR deduction continuously. With every 1% increase in utilization rate, the maternal death would decrease by 0.35 per 100,000 livebirths after having the health resources variables adjusted. Conclusions The utilization of maternal health services increased continuously after the introduction of BPHS project in 2009 and MMR went downward from then on. The utilization of maternal health services did have significant association with MMR and could reduce MMR effectively. Such improvement could be attributed to the fact that this program was designed to serve the targeted population throughout the continuum of maternal care and the government’s rigorous efforts in stressing equality and standard care in program implementation.
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Mgbekem MA, Nsemo AD, Daufa CF, Ojong IN, Nwakwue N, Andrew-Bassey P. Nurses’ Role in Birth Preparedness and Complication Readiness among Pregnant Women in University of Calabar Teaching Hospital, Calabar. Health (London) 2020. [DOI: 10.4236/health.2020.122006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Tuyisenge G, Crooks VA, Berry NS. Facilitating equitable community-level access to maternal health services: exploring the experiences of Rwanda's community health workers. Int J Equity Health 2019; 18:181. [PMID: 31771605 PMCID: PMC6880498 DOI: 10.1186/s12939-019-1065-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 09/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Rwanda, community health workers (CHWs) are an integral part of the health system. For maternal health, CHWs are involved in linking members of the communities in which they live to the formal health care system to address preventative, routine, and acute maternal care needs. Drawing on the findings from in-depth interviews with maternal health CHWs and observational insights in ten Rwandan districts, we identify specific strategies CHWs employ to provide equitable maternal care while operating in a low resource setting. METHODS Using case study methodology approach, we conducted interviews with 22 maternal health CHWs to understand the nature of their roles in facilitating equitable access to maternal care in Rwanda at the community level. Interviews were conducted in five Rwandan districts. Participants shared their experiences of and perceptions on promoting equitable access to maternal health service in their communities. RESULTS Four key themes emerged during the analytic process that characterize the contexts and strategic ways in which maternal health CHWs facilitate equitable access to maternal care in an environment of resource scarcity. They are: 1) community building; 2) physical landscapes, which serve as barriers or facilitators both to women's care access and CHWs' equitable service provision; 3) the post-crisis socio-political environment in Rwanda, which highlights resilience and the need to promote maternal health subsequent to the genocide of 1994; and, 4) the strategies used by CHWs to circumvent the constraints of a resource-poor setting and provide equitable maternal health services at the community level. CONCLUSION Rwanda's maternal CHWs are heavily responsible for promoting equitable access to maternal health services. Consequently, they may be required to use their own resources for their practice, which could jeopardize their own socio-economic welfare and capacity to meet the demands of their families. Considering the unpaid and untrained nature of this position, we highlight the factors that threaten the sustainability of CHWs' role to facilitate equitable access to maternal care. These threats introduce turbulence into what is a relatively successful community-level health care initiative.
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Affiliation(s)
- Germaine Tuyisenge
- Department of Geography, Simon Fraser University, 8888 University Dr, Burnaby, BC V5A 1S6 Canada
| | - Valorie A. Crooks
- Department of Geography, Simon Fraser University, 8888 University Dr, Burnaby, BC V5A 1S6 Canada
| | - Nicole S. Berry
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
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Rafiq S, Syed W, Ghaffar SF. Trends and causes of maternal mortality in a tertiary care hospital over five years: 2013-2017. Pak J Med Sci 2019; 35:1128-1131. [PMID: 31372155 PMCID: PMC6659062 DOI: 10.12669/pjms.35.4.1091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Objective: Maternal death measurement is essential to a country’s wellbeing and development status. In emerging countries like Pakistan, it remains an intimidating and failed public health challenge. Objectives of our audit were to estimate trends and causes of maternal demise in Lady Reading Hospital, Peshawar, Pakistan. Methods: Between January 2013 to December 2017, a retrospective study was carried out at Medical Teaching Institute, Lady Reading Hospital, Peshawar. A structured proforma was used to collect data from the medical records. To detect trends in mother demise maternal mortality ratio was calculated for each year and for all five years, Spss version 23 was used for data analysis. Results: In the five-year periods 134 deaths were recorded. The maternal mortality during the study period was 431/100,000 live births. An unstable trend in mortality with two crowning periods in 2013 and 2017 was observed. Hemorrhage persisted as the foremost cause of maternal death over the five years period, accounting for 47.76% deaths followed by hypertension, accounting for 25.37% deaths. An increased risk of 35.08% was observed among women aged 25-29 years, followed by 26.11% in 20-24 years and 23.88% in >30 years. Conclusion: There is a decreasing trend of maternal death from 2013 to 2016 but a slight increase was noted in 2017. Hemorrhage was the top cause responsible for the maternal death.
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Affiliation(s)
- Sonia Rafiq
- Dr. Sonia Rafiq, FCPS. Department of Obstetrics & Gynaecology, Lady Reading Hospital, Peshawar, Pakistan
| | - Wajeeha Syed
- Dr. Wajeeha Syed, FCPS. Department of Obstetrics & Gynaecology, Lady Reading Hospital, Peshawar, Pakistan
| | - Simi Fayaz Ghaffar
- Dr. Simi Fayaz Ghaffar, FRCOG, FCPS. Department of Obstetrics & Gynaecology, Lady Reading Hospital, Peshawar, Pakistan
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Zhao P, Diao Y, You L, Wu S, Yang L, Liu Y. The influence of basic public health service project on maternal health services: an interrupted time series study. BMC Public Health 2019; 19:824. [PMID: 31242879 PMCID: PMC6595598 DOI: 10.1186/s12889-019-7207-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 06/20/2019] [Indexed: 11/15/2022] Open
Abstract
Background Reducing maternal mortality remains a global priority. In 2000, the United Nations Member States pledged to work towards a series of Millennium Development Goals (MDGs), in which the fifth target was to reduce maternal mortality ratio by 75% from 1990 to 2015. The Chinese government introduced Basic Public Health Service project in 2009 to the further improvement of maternal health services and reduction in maternal mortality. China had achieved the goal of MDG5 1 year ahead of the schedule in 2014, but the effects of the project on reducing maternal mortality were rarely evaluated with robust methods. Methods We conducted a longitudinal study on maternal mortality ratio by extracting mortality data from the National Maternal Mortality Surveillance System (1991–2016) and maternal health services measures from the China health statistic yearbook (2001–2016). We utilized the segmented linear regression model to assess changes and trends of maternal mortality ratio and maternal health services before and after the introduction of Basic Public Health Service project. Pearson correlation analysis was conducted to measure the strength of association between the maternal mortality ratio and maternal health services. Results The yearly trend change of national maternal mortality ratio was − 1.76 (p < 0.01) after the introduction of Basic Public Health Service project in 2009, while the yearly trend change of maternal health record establish rate, prenatal examination rate, postpartum visit rate was 0.77 (p < 0.01), 0.61 (p < 0.01) and 0.83 (p < 0.01) separately. The negative correlations were also found between national maternal mortality ratio and prenatal examination rate (r = − 0.95, p < 0.01), maternal health record establish rate (r = − 0.93, p < 0.01) and postpartum visit rate (r = − 0.92, p < 0.01). Conclusions The Basic Public Health Service project was found to be associated with the improvements in the maternal health services and reduction in maternal mortality. The design and implementation of the project may serve as a positive example for other developing countries. Continued monitoring and assessment of project effects should be stressed. Electronic supplementary material The online version of this article (10.1186/s12889-019-7207-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pengyu Zhao
- School of Public Health, Chinese Academy of Medical Science & Peking Union Medical College, No.5 Dongdansantiao, 100730, Beijing, People's Republic of China
| | - Yifan Diao
- School of Public Health, Chinese Academy of Medical Science & Peking Union Medical College, No.5 Dongdansantiao, 100730, Beijing, People's Republic of China
| | - Lili You
- School of Public Health, Chinese Academy of Medical Science & Peking Union Medical College, No.5 Dongdansantiao, 100730, Beijing, People's Republic of China
| | - Shichao Wu
- School of Public Health, Chinese Academy of Medical Science & Peking Union Medical College, No.5 Dongdansantiao, 100730, Beijing, People's Republic of China
| | - Li Yang
- School of Public Health, Chinese Academy of Medical Science & Peking Union Medical College, No.5 Dongdansantiao, 100730, Beijing, People's Republic of China
| | - Yuanli Liu
- School of Public Health, Chinese Academy of Medical Science & Peking Union Medical College, No.5 Dongdansantiao, 100730, Beijing, People's Republic of China.
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Primary health care among rural pregnant women in China: achievements and challenges in maternal mortality ratio. Prim Health Care Res Dev 2019; 20:e97. [PMID: 32800000 PMCID: PMC8060817 DOI: 10.1017/s1463423619000306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: The maternal mortality ratio (MMR) is not only an important indicator of maternal and infant safety, but also a sign of the development of economy, education, and medical care in a country. In the last 60 years, the Chinese government has implemented various strategies and policies to reduce the MMR, especially in the rural areas. Aim: This study aimed to discuss the strategies developed by the Chinese government, showing the successful experience of Chinese intervention programs and highlighting the challenges to the government in the context of current economic and social status. Method: This study probed into the Chinese government’s efforts and achievements in the MMR reducing by reviewing the relevant health policies, extracting the data from China Health Statistics Yearbook of 2015, analyzing the reduction of maternal death in rural areas and the major causes from 1991 to 2015, comparing the MMR trend in urban and rural areas, and discussing the changes of the situation in China. Finding: Although it seems that Chinese government’s efforts have brought evangel to the rural pregnant women and significantly reduced rural maternal mortality, the government still needs to develop more equitable and flexible primary health care policies to narrow the imbalance in health resource allocation and pay more attention to the health care for the rural-to-urban migration in China.
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Liu Y, Qin Q, Xiao Y, Li H, Guang S, Tao S, Hu Y. Changes of second-time mothers and their infants under the universal two-child policy in Changsha, China. Midwifery 2019; 77:32-36. [PMID: 31252314 DOI: 10.1016/j.midw.2019.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 06/10/2019] [Accepted: 06/14/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND China announced the implementation of the universal two-child policy in Oct, 2015; every couple was allowed to have two children. However, its influences on maternal well-being and infants' outcomes are still to be discovered. OBJECTIVES To detect influences of the universal two-child policy. To provide information for maternal health care under the new policy. STUDY DESIGN This study enrolled 859 and 1230 women who delivered their second child (hereafter second-time mothers) before and after the policy's implementation, respectively, and the data included maternal demographic characteristics, gestational complications, delivery mode and infants' outcomes. RESULTS After the policy's implementation, the proportion of second-time mothers with advanced age increased significantly. The advanced gestational age is well acknowledged to correlate with higher risk during the pregnancy, both for pregnant women and their babies. However, in our study, the incidence of hypertensive disorders in pregnancy, placenta previa and postpartum haemorrhage decreased significantly after the introduction of the policy and no differences were noted in other gestational complications. Moreover, the hospitalization time was shortened, and caesarean delivery was chosen less frequently. As for the infants, foetal distress exhibited an alleviation and the incidence of premature labour and low birth weight decreased as well. CONCLUSIONS Even though the age of second-time mothers increased after the introduction of the universal two-child policy, their general gestational health condition improved and their infants also exhibited a better outcome, which might be attributed to the improvement of China's maternal medical care system.
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Affiliation(s)
- Yuhao Liu
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, Hunan Province 410011, China.
| | - Qilin Qin
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, Hunan Province 410011, China
| | - Ying Xiao
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, Hunan Province 410011, China
| | - Herui Li
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, Hunan Province 410011, China
| | - Shiqi Guang
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, Hunan Province 410011, China
| | - Sifan Tao
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, Hunan Province 410011, China
| | - Yun Hu
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, Hunan Province 410011, China.
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Liang J, Li X, Kang C, Wang Y, Kulikoff XR, Coates MM, Ng M, Luo S, Mu Y, Wang X, Zhou R, Liu X, Zhang Y, Zhou Y, Zhou M, Li Q, Liu Z, Dai L, Li M, Zhang Y, Deng K, Zeng X, Deng C, Yi L, Zhu J, Murray CJL, Wang H. Maternal mortality ratios in 2852 Chinese counties, 1996-2015, and achievement of Millennium Development Goal 5 in China: a subnational analysis of the Global Burden of Disease Study 2016. Lancet 2019; 393:241-252. [PMID: 30554785 PMCID: PMC6336935 DOI: 10.1016/s0140-6736(18)31712-4] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 07/04/2018] [Accepted: 07/19/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND As one of only a handful of countries that have achieved both Millennium Development Goals (MDGs) 4 and 5, China has substantially lowered maternal mortality in the past two decades. Little is known, however, about the levels and trends of maternal mortality at the county level in China. METHODS Using a national registration system of maternal mortality at the county level, we estimated the maternal mortality ratios for 2852 counties in China between 1996 and 2015. We used a state-of-the-art Bayesian small-area estimation hierarchical model with latent Gaussian layers to account for space and time correlations among neighbouring counties. Estimates at the county level were then scaled to be consistent with country-level estimates of maternal mortality for China, which were separately estimated from multiple data sources. We also assessed maternal mortality ratios among ethnic minorities in China and computed Gini coefficients of inequality of maternal mortality ratios at the country and provincial levels. FINDINGS China as a country has experienced fast decline in maternal mortality ratios, from 108·7 per 100 000 livebirths in 1996 to 21·8 per 100 000 livebirths in 2015, with an annualised rate of decline of 8·5% per year, which is much faster than the target pace in MDG 5. However, we found substantial heterogeneity in levels and trends at the county level. In 1996, the range of maternal mortality ratios by county was 16·8 per 100 000 livebirths in Shantou, Guangdong, to 3510·3 per 100 000 livebirths in Zanda County, Tibet. Almost all counties showed remarkable decline in maternal mortality ratios in the two decades regardless of those in 1996. The annualised rate of decline across counties from 1996 to 2015 ranges from 4·4% to 12·9%, and 2838 (99·5%) of the 2852 counties had achieved the MDG 5 pace of decline. Decline accelerated between 2005 and 2015 compared with between 1996 and 2005. In 2015, the lowest county-level maternal mortality ratio was 3·4 per 100 000 livebirths in Nanhu District, Zhejiang Province. The highest was still in Zanda County, Tibet, but the fall to 830·5 per 100 000 livebirths was only 76·3%. 26 ethnic groups had population majorities in at least one county in China, and all had achieved declines in maternal mortality ratios in line with the pace of MDG 5. Intercounty Gini coefficients for maternal mortality ratio have declined at the national level in China, indicating improved equality, whereas trends in inequality at the provincial level varied. INTERPRETATION In the past two decades, maternal mortality ratios have reduced rapidly and universally across China at the county level. Fast improvement in maternal mortality ratios is possible even in less economically developed places with resource constraints. This finding has important implications for improving maternal mortality ratios in developing countries in the Sustainable Development Goal era. FUNDING National Health and Family Planning Commission of the People's Republic of China, China Medical Board, WHO, University of Washington Center for Demography and Economics of Aging, Bill & Melinda Gates Foundation.
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Affiliation(s)
- Juan Liang
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaohong Li
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China; National Center for Birth Defect Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chuyun Kang
- Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University, Beijing, China; Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Yanping Wang
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xie Rachel Kulikoff
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Matthew M Coates
- Department of Global Health and Social Medicine, Harvard University, Boston, MA, USA
| | - Marie Ng
- IBM Watson Health, San Jose, CA, USA
| | - Shusheng Luo
- Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University, Beijing, China
| | - Yi Mu
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaodong Wang
- Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rong Zhou
- Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xinghui Liu
- Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yali Zhang
- Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University, Beijing, China; Institute of Reproductive and Child Health, Ministry of Health Key Laboratory of Reproductive Health, Peking University, Beijing, China
| | - Yubo Zhou
- Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University, Beijing, China; Institute of Reproductive and Child Health, Ministry of Health Key Laboratory of Reproductive Health, Peking University, Beijing, China
| | - Maigeng Zhou
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Qi Li
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zheng Liu
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Dai
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mingrong Li
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yiyi Zhang
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kui Deng
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xinying Zeng
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Changfei Deng
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ling Yi
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Zhu
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
| | - Haidong Wang
- National Office for Maternal and Child Health Surveillance of China, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
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Lili X, Jian H, Mengjun Z, Yinglan W, Donghua X, Aihua W, Fanjuan K, Hua W, Zhiyu L. Epidemiological analysis of maternal deaths in Hunan province in China between 2009 and 2014. PLoS One 2018; 13:e0207920. [PMID: 30475882 PMCID: PMC6258237 DOI: 10.1371/journal.pone.0207920] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 11/08/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The control of maternal deaths continues to be a significant public health issue and commands an enormous amount of attention, especially under the future family planning policy. Here, we describe the epidemiology and trends of maternal deaths in Hunan province, and give several policy implications. METHODS Maternal deaths in Hunan province between 2009 and 2014 were retrospectively reviewed and analyzed. Cochran-Armitage trend test was used to assess the time trends of maternal mortality rates. Binary logistic regression analyses were undertaken to identify the factors that were associated with unavoidable maternal deaths. RESULTS In total, there were 987 maternal deaths, with the overall MMR declining by 45.24%. The most common causes of maternal death during this period were pregnancy complications (28.37%), obstetric hemorrhage (25.33%), and amniotic fluid embolism (15.70%). Obstetric hemorrhage (28.14%) was higher in rural areas, while pregnancy complications were higher (29.27%) in urban areas. In all, 627 (63.5%) deaths were avoidable. The risk factors associated with unavoidable maternal deaths was above 35 years (aOR = 1.80 95%CI: 1.27-2.55), without prenatal examination (aOR = 8.97 95%CI: 1.11-7.78), low household incomes (aOR = 1.15 95%CI: 1.02-1.29), without adopting the new way to deliver (aOR = 5.15 95%CI: 3.20-8.31), and death location (aOR = 1.09 95%CI: 1.02-1.18). The most frequent and important factors associated with avoidable deaths was improper knowledge and skills of the county medical institutions. CONCLUSIONS Moderate progress was made in reducing the MMR in Hunan province. The government should aim to improve the basic midwifery skills in rural areas and the obstetric emergency rescue service for critically ill pregnant women in urban areas, and strengthen training to improve knowledge and skills in medical institutions in counties.
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Affiliation(s)
- Xiong Lili
- Department of Information Management, Hunan Province Maternal and Children Health Care Hospital, Changsha, Hunan, China
| | - He Jian
- Department of Information Management, Hunan Province Maternal and Children Health Care Hospital, Changsha, Hunan, China
| | - Zeng Mengjun
- Department of Maternal Healthcare Department, Hunan Province Maternal and Children Health Care Hospital, Changsha, Hunan, China
| | - Wu Yinglan
- Department of Maternal Healthcare Department, Hunan Province Maternal and Children Health Care Hospital, Changsha, Hunan, China
| | - Xie Donghua
- Department of Information Management, Hunan Province Maternal and Children Health Care Hospital, Changsha, Hunan, China
| | - Wang Aihua
- Department of Information Management, Hunan Province Maternal and Children Health Care Hospital, Changsha, Hunan, China
| | - Kong Fanjuan
- Department of Information Management, Hunan Province Maternal and Children Health Care Hospital, Changsha, Hunan, China
| | - Wang Hua
- Department of Information Management, Hunan Province Maternal and Children Health Care Hospital, Changsha, Hunan, China
| | - Liu Zhiyu
- Department of Information Management, Hunan Province Maternal and Children Health Care Hospital, Changsha, Hunan, China
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Yang YY, Fang YH, Wang X, Zhang Y, Liu XJ, Yin ZZ. A retrospective cohort study of risk factors and pregnancy outcomes in 14,014 Chinese pregnant women. Medicine (Baltimore) 2018; 97:e11748. [PMID: 30113460 PMCID: PMC6113036 DOI: 10.1097/md.0000000000011748] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This study aims to investigate major complications or symptoms of pregnant women, causes of maternal near-miss, and issues that are relevant to severe maternal disease.A retrospective analysis was performed in the "maternal individual investigation form," which included all critical maternity patients admitted to the First Affiliated Hospital of Anhui Medical University from January 1, 2012 to September 31, 2015.A total of 14,014 pregnant patients who delivered at 28 to 42 weeks of gestation were included. Eight thousand eighty-six patients experienced complications or symptoms, and top 7 of these were postpartum hemorrhage, hypertension during pregnancy, diabetes, anemia, hepatopathy, nephroma, and connective tissue disease, of which the morbidity were 11.92%, 10.15%, 9.34%, 8.57%, 3.13%. 0.56%, and 0.55%, respectively. Delivery times, gestational weeks, and informal pregnancy examinations had significant correlation with maternal near-miss (P < .05); nevertheless, the age at pregnancy, number of pregnancies, and education were not so significant (P > .05). Two hundred sixty-five patients had severe maternal diseases (maternal near miss), and the top 5 causes for severe maternal morbidity were massive blood transfusion, thrombocytopenia, clinical feature of shock, uterus removal induced by uterus infection or bleeding, and coagulation dysfunction, of which the morbidity were 24.15%, 18.87%, 13.58%, 9.43%, and 6.79%, respectively.Delivery times, gestational weeks, and informal pregnancy examinations should be considered in maternal near miss patients. Moreover, hypertensive disorders during pregnancy, postpartum hemorrhage, anemia, thrombocytopenia, hepatopathy, and cardiopathy were the principal causes of maternal near miss. Therefore, the monitoring of these principal causes of severe maternity near miss is important for reducing the maternal morbidity and mortality.
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Affiliation(s)
- Yuan-Yuan Yang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University
- Anhui Provincial Engineering Technology Research Center for Biopreservation and Artificial Organs, Hefei, China
| | - Yi-Hua Fang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University
| | - Xue Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University
| | - Ying Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University
| | - Xiao-Jun Liu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University
| | - Zong-Zhi Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University
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Moyo N, Makasa M, Chola M, Musonda P. Access factors linked to maternal deaths in Lundazi district, Eastern Province of Zambia: a case control study analysing maternal death reviews. BMC Pregnancy Childbirth 2018; 18:101. [PMID: 29661240 PMCID: PMC5902869 DOI: 10.1186/s12884-018-1717-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/26/2018] [Indexed: 12/03/2022] Open
Abstract
Background Access factors associated with maternal death are important to understand because they are considered to be an essential measure of women’s health and indicative of the performance of health care systems in any community globally. This study aimed to analyse the access risk factors linked to maternal deaths in Lundazi district of the Eastern Province of Zambia using secondary data obtained from maternal death reviews and delivery registers. Methods This was a case-control study with cases being recorded maternal deaths for Lundazi district (n = 100) while controls were randomly selected Lundazi District Hospital deliveries (n = 300) for the period 2010 to 2015. STATA™ (Stata Corporation, Texas, TX, USA) version 12.0 was used to analyse data. Odds ratio and 95% confidence intervals with associated p-values were used to analyse disparities between cases and controls while bivariate and multivariate regression analyses were done to show associations. Results The likelihood of experiencing maternal death was 94% less among women who completed their scheduled antenatal care visits than those who did not (OR 0.06, 95% CI = 0.01–0.27, p = < 0.001). Delayed referral associated with maternal deaths and complications were 30% (30) for cases, 12% (37) for controls and 17% (67) for both cases and controls. Long distances, unskilled deliveries were 3%, (15) for both cases and controls with 13% (13) for cases and 1% (2) for controls only. Conclusion Antenatal care is important in screening for pre-existing risk conditions as well as complications in early stages of pregnancy that could impact adversely during pregnancy and childbirth. Delay in seeking health care during pregnancy could be minimised if health services are brought closer to the communities to reduce on distances covered by pregnant women in Lundazi. Maternal education appears to influence antenatal health care utilisation because greater knowledge and understanding of the importance of antenatal care might increase the ability to select most appropriate service. Therefore, there is need for Lundazi District Health Office to scale up interventions that motivate women to make at least four scheduled antenatal care visits during pregnancy as recommended by the World Health Organization. Electronic supplementary material The online version of this article (10.1186/s12884-018-1717-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nkumbula Moyo
- Macha Research Trust, Choma, Zambia. .,Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia.
| | - Mpundu Makasa
- Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Mumbi Chola
- Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Patrick Musonda
- Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia
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25
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Ren Y, Qian P, Duan Z, Zhao Z, Pan J, Yang M. Disparities in health system input between minority and non-minority counties and their effects on maternal mortality in Sichuan province of western China. BMC Public Health 2017; 17:750. [PMID: 28962594 PMCID: PMC5622414 DOI: 10.1186/s12889-017-4765-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/15/2017] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND The maternal mortality rate (MMR) markedly decreased in China, but there has been a significant imbalance among different geographic regions (east, central and west regions), and the mortality in the western region remains high. This study aims to examine how much disparity in the health system and MMR between ethnic minority and non-minority counties exists in Sichuan province of western China and measures conceivable commitments of the health system determinants of the disparity in MMR. METHODS The MMR and health system data of 67 minority and 116 non-minority counties were taken from Sichuan provincial official sources. The 2-level Poisson regression model was used to identify health system determinants. A series of nested models with different health system factors were fitted to decide contribution of each factor to the disparity in MMR. RESULTS The MMR decreased over the last decade, with the fastest declining rate from 2006 to 2010. The minority counties experienced higher raw MMR in 2002 than non-minority counties (94.4 VS. 58.2), which still remained higher in 2014 (35.7 VS. 14.3), but the disparity of raw MMR between minority and non-minority counties decreased from 36.2 to 21.4. The better socio-economic condition, more health human resources and higher maternal health care services rate were associated with lower MMR. Hospital delivery rate alone explained 74.5% of the difference in MMR between minority and non-minority counties. All health system indicators together explained 97.6% of the ethnic difference in MMR, 59.8% in the change trend, and 66.3% county level variation respectively. CONCLUSIONS Hospital delivery rate mainly determined disparity in MMR between minority and non-minority counties in Sichuan province. Increasing hospital birth rates among ethnic minority counties may narrow the disparity in MMR by more than two-thirds of the current level.
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Affiliation(s)
- Yan Ren
- West China School of Public Health, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Ping Qian
- Sichuan Provincial Maternal and Child Health Hospital, Chengdu, Sichuan, People's Republic of China
| | - Zhanqi Duan
- Health and Family Planning Information Centre of Sichuan Province, Chengdu, Sichuan, People's Republic of China
| | - Ziling Zhao
- Sichuan Provincial Maternal and Child Health Hospital, Chengdu, Sichuan, People's Republic of China
| | - Jay Pan
- West China School of Public Health, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China.,West China Research Center for Rural Health Development, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Min Yang
- West China School of Public Health, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China. .,West China Research Center for Rural Health Development, Sichuan University, Chengdu, Sichuan, People's Republic of China. .,School of Medicine, University of Nottingham, Nottingham, UK.
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Mu Y, McDonnell N, Li Z, Liang J, Wang Y, Zhu J, Sullivan E. Amniotic fluid embolism as a cause of maternal mortality in China between 1996 and 2013: a population-based retrospective study. BMC Pregnancy Childbirth 2016; 16:316. [PMID: 27760522 PMCID: PMC5069862 DOI: 10.1186/s12884-016-1106-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 10/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To analyse the maternal mortality ratio, demographic and pregnancy related details in women who suffered a fatal amniotic fluid embolism (AFE) in China. METHODS A retrospective population based study using data collected as part of the National Maternal Mortality Surveillance System between 1996 and 2013. Data were collected onto a standardised form from women whose cause of death was listed as being secondary to AFE. RESULTS Records were available for 640 deaths. Over the 17 year period the maternal mortality ratio for AFE decreased from 4.4 per 100,000 births (95 % confidence interval (CI):2.72-6.12) to 1.9 per 100,000 births (95 % CI:1.35-2.54). Over the same period the proportion of maternal deaths secondary to AFE increased from 6.8 to 12.5 %. The mean age of women who died was 30.1 years and the onset of the AFE occurred prior to delivery in 39 %. The most prominent presenting features included premonitory symptoms (29 %), acute fetal compromise (28 %), maternal haemorrhage (16 %) and shortness of breath (15 %). CONCLUSIONS Maternal mortality secondary to AFE has decreased in China, however at a slower rate than mortality secondary to other conditions. Active surveillance is recommended to assess case fatality rates, risk factors and other lessons specific to this population.
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Affiliation(s)
- Yi Mu
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Ren Min South Road Section 3 No.17, Chengdu, Sichuan, China
| | - Nolan McDonnell
- School of Women's and Infants' Health and School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.,Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, 374 Bagot Road, Subiaco, WA, 6008, Australia
| | - Zhuoyang Li
- Faculty of Health, University of Technology Sydney, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia
| | - Juan Liang
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Ren Min South Road Section 3 No.17, Chengdu, Sichuan, China
| | - Yanping Wang
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Ren Min South Road Section 3 No.17, Chengdu, Sichuan, China
| | - Jun Zhu
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Ren Min South Road Section 3 No.17, Chengdu, Sichuan, China.
| | - Elizabeth Sullivan
- Faculty of Health, University of Technology Sydney, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia.
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Gao H, Wang Q, Hormann E, Stuetz W, Stiller C, Biesalski HK, Scherbaum V. Breastfeeding practices on postnatal wards in urban and rural areas of the Deyang region, Sichuan province of China. Int Breastfeed J 2016; 11:11. [PMID: 27182280 PMCID: PMC4867090 DOI: 10.1186/s13006-016-0070-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 05/02/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite the efforts that have been made to promote breastfeeding in China since the 1990s, there is still a very low prevalence of exclusive breastfeeding. The objective of this study was to assess the current situation of infant feeding practices during the postpartum hospital stay in urban and rural areas of the Deyang region. METHODS Cross-sectional sampling was used in two urban hospitals and five rural clinics in the Deyang region of southwestern China. Interviews with mothers after delivery (urban n = 102, rural n = 99) were conducted before discharge and five focus group discussions were held. RESULTS The prevalence of Caesarean section was high in both urban and rural areas (63.9 % urban vs. 68.4 % rural). After birth, nearly all mothers (98.0 % urban vs. 99.0 % rural) initiated breastfeeding. One week after delivery, the prevalence of exclusive breastfeeding was 8.0 % (9.8 % urban vs. 6.1 % rural), almost exclusive breastfeeding 34.5 % (29.4 % urban vs. 39.8 % rural), mixed feeding 56.0 % (58.8 % urban vs. 53.1 % rural), and exclusive formula feeding 1.5 % (2.0 % urban vs. 1.0 % rural). Breastfeeding initiation (≤ two days after birth) was positively associated (Odds Ratio [OR] 1.97, 95 % Confidence Interval [CI] 1.11, 3.50) with exclusive and almost exclusive breastfeeding, whereas birth length under 50 cm (OR 0.48, 95 % CI 0.26, 0.87), mother's education > 12 years (OR 0.46, 95 % CI 0.24, 0.88) and mother's lack of knowledge about the importance of colostrum (OR 0.35, 95 % CI 0.14, 0.86) were negatively associated with almost exclusive breastfeeding. CONCLUSION Although disparities between urban and rural areas exist, the situation of infant feeding is inadequate in both settings. The high prevalence of Caesarean section, the mothers' poor knowledge of the physiology of breast milk production, the mothers' lack of breastfeeding confidence, the widespread advertising of breast milk substitutes, and the changing perception of the function of breasts, may influence the unfavorable breastfeeding behavior observed in the study area.
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Affiliation(s)
- Haoyue Gao
- />Institute of Social Science in Agriculture (430b), University of Hohenheim, Museumsfluegel, Stuttgart, 70599 Germany
| | - Qi Wang
- />Medical Society of Deyang City, Sichuan, Public Health Bureau of Deyang, Lushan Nan Road No. 299, Jingyang District, Deyang, 618000 China
| | - Elizabeth Hormann
- />Europäisches Institut für Stillen und Laktation, Wittberg 14, Kramsach, 6233 Austria
| | - Wolfgang Stuetz
- />Institute of Biological Chemistry and Nutrition (140a), University of Hohenheim, Garbenstraße 30, Stuttgart, 70599 Germany
| | - Caroline Stiller
- />Institute of Biological Chemistry and Nutrition (140a), University of Hohenheim, Garbenstraße 30, Stuttgart, 70599 Germany
| | - Hans Konrad Biesalski
- />Institute of Biological Chemistry and Nutrition (140a), University of Hohenheim, Garbenstraße 30, Stuttgart, 70599 Germany
- />Food Security Center (793), University of Hohenheim, Wollgrasweg 43, Stuttgart, 70599 Germany
| | - Veronika Scherbaum
- />Institute of Biological Chemistry and Nutrition (140a), University of Hohenheim, Garbenstraße 30, Stuttgart, 70599 Germany
- />Food Security Center (793), University of Hohenheim, Wollgrasweg 43, Stuttgart, 70599 Germany
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Kamal N, Curtis S, Hasan MS, Jamil K. Trends in equity in use of maternal health services in urban and rural Bangladesh. Int J Equity Health 2016; 15:27. [PMID: 26883742 PMCID: PMC4756462 DOI: 10.1186/s12939-016-0311-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 02/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal healthcare utilization is a major determinant of maternal mortality. Bangladesh is experiencing a rapid pace of urbanization with all future growth in population expected to be in urban areas. Health care infrastructure is different in urban and rural areas thus warranting an examination of equity in use rates of maternal healthcare. This paper addresses whether the urban-rural and rich-poor gaps in use of selected maternal healthcare indicators have narrowed or widened over the last decade. The paper also explores changes in the service provider environment in urban and rural domains. METHODS The 2001 and 2010 Bangladesh Maternal Mortality and Health Care Survey data were used to examine trends in use of antenatal care from medically trained providers and in deliveries taking place at health facilities. Separate wealth quintiles were constructed for urban and rural areas. The concentration index was calculated for urban and rural areas to measure equity in distribution of antenatal care (ANC) and facility deliveries across wealth quintiles in urban and rural domains. RESULTS The gap in use of ANC provided by medically trained personnel narrowed in urban and rural areas between 2001 and 2010 while that in facility deliveries widened. The difference in use of ANC by the rich and the poor was not as pronounced as that in utilization of facilities for deliveries. Over the last decade, equity in utilization of health facilities for deliveries has improved at a faster rate in urban areas. Private sector has surpassed the public sector and appears to be the dominant provider of maternal healthcare in both domains with the share of NGOs increasing in urban areas. CONCLUSIONS The faster pace of improvement in equity in maternal healthcare utilization in urban areas is reflective of the changing service environment in urban and rural areas, among other factors.
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Affiliation(s)
- Nahid Kamal
- MEASURE Evaluation, University of North Carolina at Chapel Hill, Chapel Hill, USA. .,Seconded to International Center for Diarrheal Disease Research (icddr,b), Dhaka, Bangladesh.
| | - Sian Curtis
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA.
| | - Mohammad S Hasan
- Department of Population Sciences, University of Dhaka, Dhaka, Bangladesh.
| | - Kanta Jamil
- Office of Population, Health, Nutrition and Education, USAID, Dhaka, Bangladesh.
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Liabsuetrakul T, Prappre T, Pairot P, Oumudee N, Islam M. Development of a web-based epidemiological surveillance system with health system response for improving maternal and newborn health: Field-testing in Thailand. Health Informatics J 2016; 23:109-123. [PMID: 26879329 DOI: 10.1177/1460458216628312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Surveillance systems are yet to be integrated with health information systems for improving the health of pregnant mothers and their newborns, particularly in developing countries. This study aimed to develop a web-based epidemiological surveillance system for maternal and newborn health with integration of action-oriented responses and automatic data analysis with results presentations and to assess the system acceptance by nurses and doctors involved in various hospitals in southern Thailand. Freeware software and scripting languages were used. The system can be run on different platforms, and it is accessible via various electronic devices. Automatic data analysis with results presentations in the forms of graphs, tables and maps was part of the system. A multi-level security system was incorporated into the program. Most doctors and nurses involved in the study felt the system was easy to use and useful. This system can be integrated into country routine reporting system for monitoring maternal and newborn health and survival.
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Affiliation(s)
| | | | | | | | - Monir Islam
- World Health Organization Country Office in Namibia, Namibia
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Bomela NJ. A cross-sectional analysis of the geographic distribution and causes of maternal mortality in South Africa: 2002-2006. BMC Public Health 2015; 15:273. [PMID: 25884380 PMCID: PMC4369832 DOI: 10.1186/s12889-015-1597-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 02/27/2015] [Indexed: 11/25/2022] Open
Abstract
Background Major changes in health policy, health service delivery, specific protocols, guidelines and recommendations for the management of common causes of maternal death have been developed in South Africa since the advent of the current democratic government. However, maternal mortality ratio remains high. The scientific community has conducted numerous studies on maternal mortality in South Africa; save for an analysis of the causes of maternal deaths, stratified by province. This study examines the geographic distribution of maternal causes of death in South Africa. Methods A pooled cross-sectional dataset for the years 2002–2006 retrieved from the vital registration database of Statistics South Africa was used to analyse maternal causes of death. About 8773 maternal deaths between 10–55 years were analysed using frequency tables, cross-tabulations and logistic regression. Maternal mortality ratios (MMR), odds ratios (OR) and 95% confidence intervals (CI) were used to analyse provincial disparities. Results MMR was highest in the Free State (286/100 000) and lowest in the Western Cape (87/100 000). Tuberculosis (10.4%) was the leading single indirect cause of maternal deaths while hypertensive disorders (9.1%) were the leading direct cause of death. KwaZulu-Natal women had a significantly higher risk of dying from sepsis (aOR=3.1,95% CI=1.2-7.9). North West women had the lowest risk of dying from hypertensive disorders (aOR=0.4,95% CI=0.2-0.7). The risk of dying from complications of labour was lowest for Gauteng women (aOR=0.4,95% CI=0.1-0.9). The 30–34 years age group had a significantly high risk (aOR=2.5,95% CI=1.6-4.0) of dying from abortion while the 25–29 years age group had a significantly higher risk of dying from maternal infectious diseases (aOR=2.3,95% CI=1.3-3.9). The 40–44 years age group had a significantly higher risk of dying from haemorrhage (aOR=2.3,95% CI=1.3-3.9 and the 45+ age group from other maternal diseases (aOR=3.3,95% CI=1.2-8.5) and miscellaneous direct causes (aOR=4.1,95% CI=1.7-9.9) respectively. Conclusions The study shows great variations in the distribution and causes of maternal deaths by age and provincial level. Poorer provinces had lower MMR than the better off provinces. The provincial variations in the leading causes of death indicate the importance of targeted interventions at sub-national level. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1597-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nolunkcwe J Bomela
- Department of Research Management, Nelson Mandela Metropolitan University, University Way, Summerstrand, Port Elizabeth, Eastern Cape, 6031, South Africa.
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You X, Tan H, Hu S, Wu J, Jiang H, Peng A, Dai Y, Wang L, Guo S, Qian X. Effects of preconception counseling on maternal health care of migrant women in China: a community-based, cross-sectional survey. BMC Pregnancy Childbirth 2015; 15:55. [PMID: 25880393 PMCID: PMC4353459 DOI: 10.1186/s12884-015-0485-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 02/23/2015] [Indexed: 11/10/2022] Open
Abstract
Background Migrants have long been a disadvantaged group in China’s health care system, especially in terms of maternal health care. Many studies have explored the factors associated with a lack of maternal health care and found many determinants, including social, economic, behavioral, and environmental factors. However, studies focusing on factors associated with maternal health care have rarely examined preconception counseling (PCC). This study explored factors related to PCC uptake among migrant women, and investigated the association between PCC and maternal health care in migrant women. Methods A community-based cross-sectional study was conducted from July to December 2011, in Nanhai, Guangdong Province, and Pinghu, Zhejiang Province, China. A total of 1,012 migrant women who had their most recent pregnancy within 1 year of the survey answered a standardized interviewer-administered questionnaire about maternal health care. Descriptive statistics and multivariable logistic regression were used to analyze the data. Results Only 208 (20.6%, 95% confidence interval [CI]: 18.1–23.1%) of 1,012 migrant women had received PCC. Younger age, having more than one child, lack of knowledge of maternal health care and inter-province migration were predictors of a lack of PCC. PCC was associated with higher consumption of folic acid supplements during the preconception period (adjusted odds ratio [AOR] = 2.65, 95% CI: 1.66–4.23). Among migrants who were resident in Nanhai or Pinghu for less than 5 years, PCC was related to better quality prenatal care (AOR = 3.07, 95% CI: 1.79–5.24). Conclusions The prevalence of PCC among migrant women was low (20.6%, 95% CI: 18.1–23.1%). Positive associations were found between the receipt of PCC and preconception folic acid supplements and quality prenatal care. Future studies focusing on maternal health care should pay attention to PCC and explore the effects of PCC on maternal health care through intervention studies. Continued efforts to increase PCC in migrants should target specific age groups (20–24 years), families with more than one child, and women who have migrated between provinces, as well as provide in-depth knowledge of maternal health care.
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Affiliation(s)
- Xiaofang You
- Department of Maternal and Child Health, School of Public Health, Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Mailbox 138, No. 138 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
| | - Hui Tan
- Department of Maternal and Child Health, School of Public Health, Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Mailbox 138, No. 138 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
| | - Shiyun Hu
- Department of Maternal and Child Health, School of Public Health, Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Mailbox 138, No. 138 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
| | - Jianmei Wu
- Pinghu Institute of Maternal and Child Health, Zhejiang Province, China.
| | - Hong Jiang
- Department of Maternal and Child Health, School of Public Health, Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Mailbox 138, No. 138 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
| | - Aiping Peng
- Department of Maternal and Child Health, School of Public Health, Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Mailbox 138, No. 138 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
| | - Yue Dai
- Department of Maternal and Child Health, School of Public Health, Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Mailbox 138, No. 138 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
| | - Ling Wang
- Department of Maternal and Child Health, School of Public Health, Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Mailbox 138, No. 138 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
| | - Sufang Guo
- United Nations Children's Fund China Country Office, Beijing, China.
| | - Xu Qian
- Department of Maternal and Child Health, School of Public Health, Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Mailbox 138, No. 138 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
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Gipson JD, Gyaltsen K, Gyal L, Kyi T, Hicks AL, Pebley AR. Tibetan women's perspectives and satisfaction with delivery care in a rural birth center. Int J Gynaecol Obstet 2015; 129:244-7. [PMID: 25790795 DOI: 10.1016/j.ijgo.2014.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 12/14/2014] [Accepted: 02/22/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify sociodemographic characteristics and factors involved in Tibetan women's decisions to deliver at the Tibetan Birth and Training Center (TBTC) in rural western China. METHODS In the present mixed-methods study, a random sample of married women who delivered at the TBTC between June 2011 and June 2012 were surveyed. Additionally, four focus group discussions were conducted among married women living in the TBTC catchment area. Descriptive analyses were conducted, and dominant themes were identified. RESULTS In focus group discussions, women (n=33) reported that improved roads and transportation meant that access to health facilities was easier than in the past. Although some of the 114 survey participants voiced negative perceptions of healthcare facilities and providers, 99 (86.8%) indicated that they chose to deliver at the TBTC because they preferred to have a doctor present. Most women (75 [65.8%]) said their mother/mother-in-law made the final decision about delivery location. Women valued logistic and cultural aspects of the TBTC, and 108 (94.7%) said that they would recommend the TBTC to a friend. CONCLUSION Study participants preferred delivery care that combines safety and comfort. The findings highlight avenues for further promotion of facility delivery among populations with lower rates of skilled deliveries.
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Affiliation(s)
- Jessica D Gipson
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA, USA; California Center for Population Research, UCLA, Los Angeles, CA, USA.
| | - Kunchok Gyaltsen
- Tso-ngon (Qinghai) University Tibetan Medical College (TUTMC), Xining City, Qinghai Province, China; Kumbum Tibetan Medical Hospital, Kumbum Monastery, Lusar (CH: Huangzhong), Qinghai Province, China
| | - Lhusham Gyal
- Tso-ngon (Qinghai) University Tibetan Medical College (TUTMC), Xining City, Qinghai Province, China
| | - Tsering Kyi
- Tibetan Birth and Training Center, Tongren County of Huangnan Prefecture, Qinghai Province, China
| | - Andrew L Hicks
- California Center for Population Research, UCLA, Los Angeles, CA, USA; Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Anne R Pebley
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA, USA; California Center for Population Research, UCLA, Los Angeles, CA, USA
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Du Q, Lian W, Næss Ø, Bjertness E, Kumar BN, Shi SH. The trends in maternal mortality between 1996 and 2009 in Guizhou, China: ethnic differences and associated factors. ACTA ACUST UNITED AC 2015; 35:140-146. [PMID: 25673208 DOI: 10.1007/s11596-015-1403-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 12/10/2014] [Indexed: 11/24/2022]
Abstract
China bears a large burden of global maternal mortality, and the largest burden of maternal deaths in China is in poor western provinces. This study aimed to investigate the trends in maternal mortality and its associated factors in Guizhou province of western China between 1996 and 2009, and examine differences between minority and non-minority counties. A population-based, longitudinal, retrospective study was performed in a poor western province of China with a considerably large ethnic minority population. All 86 counties/districts of Guizhou were included with population at county, township and village level. Maternal mortality data were collected from routine reporting database of Guizhou Provincial Health Bureau. Trend and comparative analyses and multivariate linear regression analyses were performed using SPSS 17.0. Maternal mortality ratio (MMR) and its change over time, differences between ethnic groups were analyzed. A declining trend in maternal mortality and rising trend in hospital delivery in Guizhou was observed; ethnic differences between two ethnic groups persisted. The reduction in maternal mortality between 1996 and 2009 was related with increased gross domestic product, decreased male illiteracy rate, and increased hospital delivery rate. We found the declining trends in maternal mortality in Guizhou with persisting ethnic differences. The declining trends are related with economic development, hospital delivery and male illiteracy. Effective health education on maternal health is urgently needed for the minority groups, and basic education for the new generation should be enhanced to eradicate the illiteracy.
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Affiliation(s)
- Qing Du
- School of Public Health and Management of Binzhou Medical University, Yantai, 264003, China.
| | - Wu Lian
- School of Public Health and Management of Binzhou Medical University, Yantai, 264003, China
| | - Øyvind Næss
- The Norweigian Institute of Public Health, Oslo, 0403, Norway.,The Faculty of Medicine, University of Oslo, Oslo, 0317, Norway
| | - Espen Bjertness
- The Faculty of Medicine, University of Oslo, Oslo, 0317, Norway.,Tibet University Medical College, Lhasa, 850012, China
| | | | - Shu-Hua Shi
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
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Echoka E, Dubourg D, Makokha A, Kombe Y, Olsen ØE, Mwangi M, Evjen-Olsen B, Byskov J. Using the unmet obstetric needs indicator to map inequities in life-saving obstetric interventions at the local health care system in Kenya. Int J Equity Health 2014; 13:112. [PMID: 25495052 PMCID: PMC4268791 DOI: 10.1186/s12939-014-0112-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 11/05/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Developing countries with high maternal mortality need to invest in indicators that not only provide information about how many women are dying, but also where, and what can be done to prevent these deaths. The unmet Obstetric Needs (UONs) concept provides this information. This concept was applied at district level in Kenya to assess how many women had UONs and where the women with unmet needs were located. METHODS A facility based retrospective study was conducted in 2010 in Malindi District, Kenya. Data on pregnant women who underwent a major obstetric intervention (MOI) or died in facilities that provide comprehensive Emergency Obstetric Care (EmOC) services in 2008 and 2009 were collected. The difference between the number of women who experienced life threatening obstetric complications and those who received care was quantified. The main outcome measures in the study were the magnitude of UONs and their geographical distribution. RESULTS 566 women in 2008 and 724 in 2009 underwent MOI. Of these, 185 (32.7%) in 2008 and 204 (28.1%) in 2009 were for Absolute Maternal Indications (AMI). The most common MOI was caesarean section (90%), commonly indicated by Cephalopelvic Disproportion (CPD)-narrow pelvis (27.6% in 2008; 26.1% in 2009). Based on a reference rate of 1.4%, the overall MOI for AMI rate was 1.25% in 2008 and 1.3% in 2009. In absolute terms, 22 (11%) women in 2008 and 12 (6%) in 2009, who required a life saving intervention failed to get it. Deficits in terms of unmet needs were identified in rural areas only while urban areas had rates higher than the reference rate (0.8% vs. 2.2% in 2008; 0.8% vs. 2.1% in 2009). CONCLUSIONS The findings, if used as a proxy to maternal mortality, suggest that rural women face higher risks of dying during pregnancy and childbirth. This indicates the need to improve priority setting towards ensuring equity in access to life saving interventions for pregnant women in underserved areas.
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Affiliation(s)
- Elizabeth Echoka
- />Centre for Public Health Research Institute, Kenya Medical Research Institute (KEMRI), P.O. Box 20752-00202, Nairobi, Kenya
| | - Dominique Dubourg
- />Woman and Child Health Research Center, Department of Public Health, Institute of Tropical Medicine Nationalestraat 155, 2000, Antwerpen, Belgium
| | - Anselimo Makokha
- />Department of Food Science, Jomo Kenyatta University of Agriculture and Technology, PO Box 62000-00200, Nairobi, Kenya
| | - Yeri Kombe
- />Centre for Public Health Research Institute, Kenya Medical Research Institute (KEMRI), P.O. Box 20752-00202, Nairobi, Kenya
| | - Øystein Evjen Olsen
- />Centre for International Health, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
- />Stavanger University Hospital, P.O Box 8100, 4068 Stavanger, Norway
| | - Moses Mwangi
- />Centre for Public Health Research Institute, Kenya Medical Research Institute (KEMRI), P.O. Box 20752-00202, Nairobi, Kenya
| | - Bjorg Evjen-Olsen
- />Department of Obstetrics and Gynaecology, Sørlandet Hospital, Flekkefjord, Norway
| | - Jens Byskov
- />Centre for Health Research and Development, Faculty of Health and Medical Sciences, University of Copenhagen, Thorvaldsensvej 57, Frederiksberg, DK 1871 Denmark
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You H, Bogg L, De Costa A, Dong H. Rural maternal mortality ratio in China. LANCET GLOBAL HEALTH 2014; 2:e451-2. [PMID: 25103517 DOI: 10.1016/s2214-109x(14)70232-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hua You
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou, China; Department of Social Medicine and Health Education, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Lennart Bogg
- Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; School of Health, Care and Social Welfare, Malardalen University, Västerås, Sweden
| | - Ayesha De Costa
- Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Hengjin Dong
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou, China; Institute of Public Health, Heidelberg University, Heidelberg, Germany.
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Provincial maternal mortality surveillance systems in China. BIOMED RESEARCH INTERNATIONAL 2014; 2014:187896. [PMID: 24995274 PMCID: PMC4065665 DOI: 10.1155/2014/187896] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 05/13/2014] [Indexed: 11/25/2022]
Abstract
Background. Provincial maternal mortality surveillance systems (PMMSS) have been set up in nearly all the provinces in China to monitor local maternal mortality and provide the evidence for maternal health interventions suited to local conditions. However, till now little is known outside of China about the characteristics of PMMSS. Methods. A systematic review of the literature contained in PubMed and China Academic Journal Network Publishing database was carried out. The current situation on PMMSS was described. Provincial disparities on PMMR in six provinces were analyzed by Poisson regression analysis. Results. A total of 35 studies met the inclusion criteria, of which 31 were published in Chinese. PMMSS were set up and adjusted by the provincial government based on their own financial resources and demand. Provinces from remote region had the highest risk of maternal mortality, followed by provinces from inland region and coast region. Conclusions. PMMSS may be the most reliable data source for measuring provincial level MMR in each province. Great provincial disparities on PMMSS and PMMR do exist within the country; more emphasis should be placed on improving PMMSS and reducing PMMR particularly in the provinces with high maternal death burden.
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Yang S, Zhang B, Zhao J, Wang J, Flick L, Qian Z, Zhang D, Mei H. Progress on the maternal mortality ratio reduction in Wuhan, China in 2001-2012. PLoS One 2014; 9:e89510. [PMID: 24586836 PMCID: PMC3931783 DOI: 10.1371/journal.pone.0089510] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 01/23/2014] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Most maternal deaths occur in developing countries and most maternal deaths are avoidable. China has made a great effort to reduce MMR by three quarters to meet the fifth Millennium Development Goal (MDG5). METHODS This retrospective study reviewed and analyzed maternal death data in Wuhan from 2001 to 2012. Joinpoint regression and multivariate Poisson regression was conducted using the log-linear model to measure the association of the number of maternal deaths with time, cause of death, where the death occurred, and cognitive factors including knowledge, attitude, resource, and management stratified. RESULTS The MMR declined from 33.41 per 100,000 live births in 2001 to 10.63 per 100,000 live births in 2012, with a total decline of 68.18% and an average annual decline of 9.89%. From 2001-2012, the four major causes of maternal death were obstetric hemorrhage (35.16%), pregnancy complications (28.57%), amniotic fluid embolism (16.48%) and gestational hypertension (8.79%). Multivariate Poisson regression showed on average the MMR decreased by.17% each year from 2001-2006 and stayed stagnant since 2007-2012. CONCLUSIONS With the reduction in MMR in obstetric death (e.g. obstetric hemorrhage), there had been a remarkable reduction in MMR in Wuhan in 2001-2012, which may be due to (1) the improvement in the obstetric quality of perinatal care service on prevention and treatment of obstetric hemorrhage and emergency care skills, and (2) the improvement in the maternal health management and quality of prenatal care. Interventions to further reduce the MMR include several efforts such as the following: (1) designing community-based interventions, (2) providing subsidies to rural women and/hospitals for hospital delivery, (3) screening for pregnancy complications, and (4) establishing an emergency rescue system for critically ill pregnant women.
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Affiliation(s)
- Shaoping Yang
- Department of Primary Guidance, Wuhan Women and Children Health Care Center, Wuhan, Hubei Province, China
| | - Bin Zhang
- Department of Primary Guidance, Wuhan Women and Children Health Care Center, Wuhan, Hubei Province, China
| | - Jinzhu Zhao
- Department of Primary Guidance, Wuhan Women and Children Health Care Center, Wuhan, Hubei Province, China
| | - Jing Wang
- College of Public Health and Social Justice, St. Louis University, St. Louis, Missouri, United States of America
| | - Louise Flick
- College of Public Health and Social Justice, St. Louis University, St. Louis, Missouri, United States of America
| | - Zhengmin Qian
- College of Public Health and Social Justice, St. Louis University, St. Louis, Missouri, United States of America
| | - Dan Zhang
- Department of Primary Guidance, Wuhan Women and Children Health Care Center, Wuhan, Hubei Province, China
| | - Hui Mei
- Department of Primary Guidance, Wuhan Women and Children Health Care Center, Wuhan, Hubei Province, China
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Goswami D, Rathore AM, Batra S, Dubey C, Tyagi S, Wadhwa L. Facility-based review of 296 maternal deaths at a tertiary centre in India: could they be prevented? J Obstet Gynaecol Res 2013; 39:1569-79. [PMID: 23875755 DOI: 10.1111/jog.12099] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 01/23/2013] [Indexed: 11/30/2022]
Abstract
AIMS The aim of this study was to identify causes of maternal mortality at the facility and to assess the standard of care, deficiencies in health services and preventability of these deaths using facility-based maternal death reviews. MATERIAL AND METHODS This was a prospective study at a tertiary care hospital that included all women who died during pregnancy or within 42 days of being pregnant during 2005-2010. RESULTS A review of 296 maternal deaths revealed that 59% of these occurred in medical wards. Indirect maternal deaths (54%) outnumbered the direct deaths (46%). Main causes were hepatitis (18%), hemorrhage (10%) and puerperal sepsis (10%). Only 5% of the women had received antenatal care at the facility. One-third (34%) were referred from other centers. The majority (74%) were critically sick at admission. Most of the women (62%) died postpartum. Substandard care and deficient health services were identified in 8% and 20% of the cases, respectively. Sixteen (5%) maternal deaths were deemed preventable and another 36 (12%) possibly preventable. Since most of the preventable deaths (12/16) were due to hemorrhage, measures to control postpartum hemorrhage were promoted at the facility. Findings of the maternal death reviews were regularly conveyed to the State Health Department for prioritization and resource allocation to prevent maternal mortality. CONCLUSION More maternal deaths occurred in the medical than in the obstetrics wards at the facility. The leading causes were hepatitis, hemorrhage and puerperal sepsis. Most of the deaths were non-preventable as the women were critically sick at admission; however, substandard care and health service deficiency were contributory in some of the cases.
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Affiliation(s)
- Deepti Goswami
- Department of Obstetrics and Gynecology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
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Yuan B, Qian X, Thomsen S. Disadvantaged populations in maternal health in China who and why? Glob Health Action 2013; 6:19542. [PMID: 23561030 PMCID: PMC3617641 DOI: 10.3402/gha.v6i0.19542] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 01/24/2013] [Accepted: 02/12/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND China has made impressive progress towards the Millennium Development Goal (MDG) for maternal and reproductive health, but ensuring that progress reaches all segments of the population remains a challenge for policy makers. The aim of this review is to map disadvantaged populations in terms of maternal health in China, and to explain the causes of these inequities to promote policy action. METHODS We searched PUBMED, Popline, Proquest and WanFang and included primary studies conducted in mainland China. Experts were also contacted to identify additional studies. Disadvantaged populations in terms of MDG 5 and the reasons for this disadvantage explored by authors were identified and coded based on the conceptual framework developed by the WHO Commission on the Social Determinants of Health. RESULTS In China, differences in maternal health service utilization and the maternal mortality ratio among different income groups, and among regions with different socio-economic development still exist, although these differences are narrowing. Groups with low levels of education and ethnic minorities utilize maternal health care less frequently and experience higher maternal mortality, although we could not determine whether these differences have changed in the last decade. Rural-to-urban migrants use maternal health care and contraception to a lower extent than permanent residents of cities, and differential maternal mortality shows a widening trend among these groups. Gender inequity also contributes to the disadvantaged position of women. Intermediary factors that explain these inequities include material circumstances such as long distances to health facilities for women living in remote areas, behavioral factors such as traditional beliefs that result in reduced care seeking among ethnic minorities, and health system determinants such as out-of-pocket payments posing financial barriers for the poor. CONCLUSIONS Inequity in maternal health continues to be an issue worthy of greater programmatic and monitoring efforts in China.
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Affiliation(s)
- Beibei Yuan
- Department of Public Health, Division of Global Health (IHCAR), Karolinska Institutet, Solna, Sweden.
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Maternal mortality in Henan Province, China: changes between 1996 and 2009. PLoS One 2012; 7:e47153. [PMID: 23071740 PMCID: PMC3470574 DOI: 10.1371/journal.pone.0047153] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 09/10/2012] [Indexed: 12/02/2022] Open
Abstract
Background Maternal deaths occur mostly in developing countries and the majority of them are preventable. This study analyzes changes in maternal mortality and related causes in Henan Province, China, between 1996 and 2009, in an attempt to provide a reliable basis for introducing effective interventions to reduce the maternal mortality ratio (MMR), part of the fifth Millennium Development Goal. Methods and Findings This population-based maternal mortality survey in Henan Province was carried out from 1996 to 2009. Basic information was obtained from the health care network for women and children and the vital statistics system, from specially trained monitoring personnel in 25 selected monitoring sites and by household survey in each case of maternal death. This data was subsequently reported to the Henan Provincial Maternal and Child Healthcare Hospital. The total MMR in Henan Province declined by 78.4%, from 80.1 per 100 000 live births in 1996 to 17.3 per 100 000 live births in 2009. The decline was more pronounced in rural than in urban areas. The most common causes of maternal death during this period were obstetric hemorrhage (43.8%), pregnancy-induced hypertension (15.8%), amniotic fluid embolism (13.9%) and heart disease (8.0%). The MMR was higher in rural areas with lower income, less education and poorer health care. Conclusion There was a remarkable decrease in the MMR in Henan Province between 1996 and 2009 mainly in the rural areas and MMR due to direct obstetric causes such as obstetric hemorrhage. This study indicates that improving the health care network for women, training of obstetric staff at basic-level units, promoting maternal education, and increasing household income are important interventional strategies to reduce the MMR further.
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Asamoah BO, Agardh A. Alcohol consumption in relation to maternal deaths from induced-abortions in Ghana. Reprod Health 2012; 9:10. [PMID: 22867435 PMCID: PMC3453516 DOI: 10.1186/1742-4755-9-10] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 07/23/2012] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION The fight against maternal deaths has gained attention as the target date for Millennium Development Goal 5 approaches. Induced-abortion is one of the leading causes of maternal deaths in developing countries which hamper this effort. In Ghana, alcohol consumption and unwanted pregnancies are on the ascendancy. We examined the association between alcohol consumption and maternal mortality from induced-abortion. We further analyzed the factors that lie behind the alcohol consumption patterns in the study population. METHOD The data we used was extracted from the Ghana Maternal Health Survey 2007. This was a national survey conducted across the 10 administrative regions of Ghana. The survey identified 4203 female deaths through verbal autopsy, among which 605 were maternal deaths in the 12 to 49 year-old age group. Analysis was done using Statistical software IBM SPSS Statistics 20. A case control study design was used. Cross-tabulations and logistic regression models were used to investigate associations between the different variables. RESULTS Alcohol consumption was significantly associated with abortion-related maternal deaths. Women who had ever consumed alcohol (OR (adjusted) 2.6, 95% CI 1.38-4.87), frequent consumers (OR (adjusted) 2.6, 95% CI 0.89-7.40) and occasional consumers (OR (adjusted) 2.7, 95% CI 1.29-5.46) were about three times as likely to die from abortion-related causes compared to those who abstained from alcohol. Maternal age, marital status and educational level were found to have a confounding effect on the observed association. CONCLUSION Policy actions directed toward reducing abortion-related deaths should consider alcohol consumption, especially among younger women. Policy makers in Ghana should consider increasing the legal age for alcohol consumption. We suggest that information on the health risks posed by alcohol and abortion be disseminated to communities in the informal sector where vulnerable groups can best be reached.
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Affiliation(s)
- Benedict O Asamoah
- Social Medicine and Global Health, Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
| | - Anette Agardh
- Social Medicine and Global Health, Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
- Centre for Adolescent Health, Murdoch Children's Research Institute, Royal Children's Hospital, University of Melbourne, Victoria, Australia
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Liang J, Li X, Dai L, Zeng W, Li Q, Li M, Zhou R, He C, Wang Y, Zhu J. The changes in maternal mortality in 1000 counties in mid-Western China by a government-initiated intervention. PLoS One 2012; 7:e37458. [PMID: 22629398 PMCID: PMC3357422 DOI: 10.1371/journal.pone.0037458] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 04/20/2012] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Since 2000, the Chinese government has implemented an intervention program to reduce maternal mortality and eliminate neonatal tetanus in accordance with the Millennium Development Goals 5. To assess the effectiveness of this intervention program, we analyzed the level, trend and reasons defining the maternal mortality ratio (MMR) in the 1,000 priority counties before and after implementation of the intervention between 1999 and 2007. METHODOLOGY/PRINCIPAL FINDINGS The data was obtained from the National Maternal and Child Health Routine Reporting System. The intervention included providing basic and emergency obstetric equipment and supplies to local medical hospitals, and also included providing professional training to local obstetric doctors, development of obstetric emergency centers and "green channel" express referral networks, reducing or waiving the cost of hospital delivery, and conducting community health education. Based on the initiation time of the intervention and the level of poverty, 1,000 counties, containing a total population of 300 million, were categorized into three groups. MMR significantly decreased by about 50%, with an average reduction rate of 9.24%, 16.06%, and 18.61% per year in the three county groups, respectively. The hospital delivery rate significantly increased. Obstetric hemorrhage was the leading cause of maternal deaths and significantly declined, with an average decrease in the MMR of 11.25%, 18.03%, and 24.90% per year, respectively. The magnitude of the MMR, the average reduction rate of the MMR, and the occurrence of the leading causes of death were closely associated with the percentage of poverty. CONCLUSIONS/SIGNIFICANCE The intervention program implemented by the Chinese government has significantly reduced the MMR in mid-western China, suggesting that well-targeted interventions could be an efficient strategy to reducing MMR in resource-poor areas. Reduction of the MMR not only depends on conducting proven interventions, but also relies on economic development in rural areas with a high burden of maternal death.
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Affiliation(s)
- Juan Liang
- National Office for Maternal and Child Health Surveillance, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaohong Li
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Dai
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Weiyue Zeng
- Obstetric and Gynecologic Department, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qi Li
- National Office for Maternal and Child Health Surveillance, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mingrong Li
- National Office for Maternal and Child Health Surveillance, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rong Zhou
- Obstetric and Gynecologic Department, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chunhua He
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yanping Wang
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- * E-mail: (YW); (JZ)
| | - Jun Zhu
- National Office for Maternal and Child Health Surveillance, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- * E-mail: (YW); (JZ)
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Bibliography. Opbstetric and gynecological anesthesia. Current world literature. Curr Opin Anaesthesiol 2012; 25:389-92. [PMID: 22552532 DOI: 10.1097/aco.0b013e328354632f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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