Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study

Obstetric risk profiles and causes of death: Estimating their association with cesarean sections among maternal deaths in Mexico

BACKGROUND

Maternal mortality is a critical indicator of healthcare quality, and in Mexico, this has become increasingly concerning due to the stagnation in its decline, alongside a concurrent increase in cesarean section (C-section) rates. This study characterizes maternal deaths in Mexico, focusing on estimating the association between obstetric risk profiles, cause of death, and mode of delivery.

METHODS

Utilizing a retrospective observational design, 4,561 maternal deaths in Mexico from 2010-2014 were analyzed. Data were sourced from the Deliberate Search and Reclassification of Maternal Deaths database, alongside other national databases. An algorithm was developed to extract the Robson Ten Group Classification System from clinical summaries text, facilitating a nuanced analysis of C-section rates. Information on the reasons for the performance of a C-section was also obtained. Logistic regression and multinomial logistic regression models were used to estimate the relation between obstetric risk factors, mode of delivery and causes of maternal death, adjusting for covariates.

RESULTS

Among maternal deaths in Mexico from 2010-2014, 47.1% underwent a C-section, with a significant history of previous C-sections observed in 31.4% of these cases, compared to 17.4% for vaginal deliveries (p<0.001). Early prenatal care in the first trimester was more common in C-section cases (46.8%) than in vaginal deliveries (38.3%, p<0.001). A stark contrast was noted in the place of death, with 82.4% of post-C-section deaths occurring in public institutions versus 69.1% following vaginal births. According to Robson's classification, the highest C-section rates were in Group 4 (67.2%, p<0.001) and Group 8 (66.9%, p<0.001). Logistic regression analysis revealed no significant difference in the odds of receiving a C-section in private versus other settings after adjusting for Robson criteria (OR: 1.21; 95% CI: 0.92, 1.60). A prior C-section significantly increased the likelihood of another (OR: 2.38; CI 95%: 2.01, 2.81). The analysis also indicated C-sections were significantly tied to deaths from hypertensive disorders (RRR = 1.25, 95% CI [1.12, 1.40]). In terms of indications, 6.3% of C-sections were performed under inadequate indications, while the indication was not identifiable in 33.1% of all C-sections.

CONCLUSIONS

This study highlights a significant overuse of C-sections among maternal deaths in Mexico (2010-2014), revealed through the Robson classification and ana analysis of the reported indications for the procedure. It underscores the need for revising clinical decision-making to promote evidence-based guidelines and favor vaginal deliveries when possible. High C-section rates, especially noted disparities between private and public sectors, suggest economic and non-clinical factors may be at play. The importance of accurate data systems and further research with control groups to understand C-section practices' impact on maternal health is emphasized.

Scenarios of maternal mortality reduction by 2030 in the Americas: insights from its tempo

BACKGROUND

The enduring threat of maternal mortality to health worldwide and in the Americas has been recognized in the global and regional agendas and their targets to 2030. To inform the direction and amount of effort needed to meet those targets, a set of equity-sensitive regional scenarios of maternal mortality ratio (MMR) reduction based on its tempo or speed of change from baseline year 2015 was developed.

METHODS

Regional scenarios by 2030 were defined according to: i) the MMR average annual rate of reduction (AARR) needed to meet the global (70 per 100,000) or regional (30 per 100,000) targets and, ii) the horizontal (proportional) or vertical (progressive) equity criterion applied to the cross-country AARR distribution (i.e., same speed to all countries or faster for those with higher baseline MMR). MMR average and inequality gaps -absolute (AIG), and relative (RIG)- were scenario outcomes.

RESULTS

At baseline, MMR was 59.2 per 100,000; AIG was 313.4 per 100,000 and RIG was 19.0 between countries with baseline MMR over twice the global target and those below the regional target. The AARR needed to meet the global and regional targets were -7.60% and -4.54%, respectively; baseline AARR was -1.55%. In the regional MMR target attainment scenario, applying horizontal equity would decrease AIG to 158.7 per 100,000 and RIG will remain invariant; applying vertical equity would decrease AIG to 130.9 per 100,000 and RIG would decrease to 13.5 by 2030.

CONCLUSION

The dual challenge of reducing maternal mortality and abating its inequalities will demand hefty efforts from countries of the Americas. This remains true to their collective 2030 MMR target while leaving no one behind. These efforts should be mainly directed towards significantly speeding up the tempo of the MMR reduction and applying sensible progressivity, targeting on groups and territories with higher MMR and greater social vulnerabilities, especially in a post-pandemic regional context.

Tackling maternal mortality by improving technical efficiency in the production of primary health services: longitudinal evidence from the Mexican case

Ensuring regular and timely access to efficient and quality health services reduces the risk of maternal mortality. Specifically, improving technical efficiency (TE) can result in improved health outcomes. To date, no studies in Mexico have explored the connection of TE with either the production of maternal health services at the primary-care level or the maternal-mortality ratio (MMR) in populations without social security coverage. The present study combined data envelopment analysis (DEA), longitudinal data and selection bias correction methods with the purpose of obtaining original evidence on the impact of TE on the MMR during the period 2008-2015. The results revealed that MMR fell 0.36% (P < 0.01) for every percentage point increase in TE at the jurisdictional level or elasticity TE-MMR. This effect proved lower in highly marginalized jurisdictions and disappeared entirely in those with low- or medium-marginalization levels. Our findings also highlighted the relevance of certain social and economic aspects in the attainment of TE by jurisdictions. This clearly demonstrates the need for comprehensive, cross-cutting policies capable of modifying the structural conditions that generate vulnerability in specific population groups. In other words, achieving an effective and sustainable reduction in the MMR requires, inter alia, that the Mexican government review and update two essential elements: the criteria behind resource allocation and distribution, and the control mechanisms currently in place for executing and ensuring accountability in these two functions.

Medical complications in pregnancy at Mulago Hospital, Uganda's national referral hospital

INTRODUCTION

Medical complications in pregnancy contribute significantly to maternal morbidity in sub-Saharan Africa. Anecdotally, obstetricians in Uganda do not feel equipped to treat complex medical cases, and receive little support from physicians.

METHODS

The aim of the study was to quantify the burden of complex medical conditions on the obstetric high dependency unit at Mulago National Referral Hospital, and potential deficiencies in the referral of cases and training in obstetric medicine. A prospective audit was taken on the obstetric high dependency unit from April to May 2014. In addition, 50 trainees in obstetrics and gynaecology filled a nine-point questionnaire regarding their experiences.

RESULTS

Complex medical disorders of pregnancy accounted for 22/106 (21%) admissions to the high dependency unit, and these cases were responsible for 51% of total bed occupancy, and had a case fatality rate of 6/22 (27.2%). Only 6/14 (43%) of referrals to medical specialties were fulfilled within 48 h. Of the six women who died due to medical conditions, three specialty referrals were made, none of which were fulfilled. Trainees reported deficiencies in obstetric medicine training and in referral of complex conditions. They were least confident addressing non-communicable conditions in pregnancy.

DISCUSSION

Deficiencies exist in the care of women with complex medical conditions in pregnancy in Uganda. Frameworks of obstetric medicine training and referral of complex cases should be explored and adapted to the sub-Saharan African setting.

Government expenditure on health and maternal mortality in México: A spatial-econometric analysis

OBJECTIVE

To assess the relationship between government expenditure on maternal health (GE) and maternal mortality (MM) in Mexican poor population between 2000 and 2015 in the 2457 Mexican municipalities.

METHODS

Using administrative data, we performed the analysis in three stages: First, we tested the presence of selection bias in MM. Next, we assessed the presence of spatial dependence in the incidence and severity of MM. Finally, we estimated a spatial error model considering the correction of estimates for the spatial dependence and selection bias assessed before.

RESULTS

MM and GE were not randomly distributed throughout the Mexican territory; the most socially vulnerable municipalities exhibited the highest levels of MM severity but the lowest levels of GE and available human and physical resources for maternal health; the incidence of MM was independent of GE; elasticity of GE-severity in MM was -4% (P < 0.01).

CONCLUSIONS

Resource allocation for maternal health must move towards a more comprehensive vision, and efforts to achieve an effective delivery of universal health services must improve, particularly regarding the most vulnerable municipalities.

Hospitals by day, dispensaries by night: Hourly fluctuations of maternal mortality within Mexican health institutions, 2010-2014

BACKGROUND

Quality of obstetric care may not be constant within clinics and hospitals. Night shifts and weekends experience understaffing and other organizational hurdles in comparison with the weekday morning shifts, and this may influence the risk of maternal deaths.

OBJECTIVE

To analyze the hourly variation of maternal mortality within Mexican health institutions.

METHODS

We performed a cross-sectional multivariate analysis of 3,908 maternal deaths and 10,589,444 births that occurred within health facilities in Mexico during the 2010-2014 period, using data from the Health Information Systems of the Mexican Ministry of Health. We fitted negative binomial regression models with covariate adjustment to all data, as well as similar models by basic cause of death and by weekdays/weekends. The outcome was the Maternal Mortality Ratio (MMR), defined as the number of deaths occurred per 100,000 live births. Hour of day was the main predictor; covariates were day of the week, c-section, marginalization, age, education, and number of pregnancies.

RESULTS

Risk rises during early morning, reaching 52.5 deaths per 100,000 live births at 6:00 (95% UI: 46.3, 62.2). This is almost twice the lowest risk, which occurred at noon (27.1 deaths per 100,000 live births [95% U.I.: 23.0, 32.0]). Risk shows peaks coinciding with shift changes, at 07:00, and 14:00 and was significantly higher on weekends and holidays.

CONCLUSIONS

Evidence suggests strong hourly fluctuations in the risk of maternal death with during early morning hours and around the afternoon shift change. These results may reflect institutional management problems that cause an uneven quality of obstetric care.

Maternal mortality audit in Suriname between 2010 and 2014, a reproductive age mortality survey

BACKGROUND

The fifth Millennium Development Goal (MDG-5) aimed to improve maternal health, targeting a maternal mortality ratio (MMR) reduction of 75% between 1990 and 2015. The objective of this study was to identify all maternal deaths in Suriname, determine the extent of underreporting, estimate the reduction, audit the maternal deaths and assess underlying causes and substandard care factors.

METHODS

A reproductive age mortality survey was conducted in Suriname (South-American upper-middle income country) between 2010 and 2014 to identify all maternal deaths in the country. MMR was compared to vital statistics and a previous confidential enquiry from 1991 to 1993 with a MMR 226. A maternal mortality committee audited the maternal deaths and identified underlying causes and substandard care factors.

RESULTS

In the study period 65 maternal deaths were identified in 50,051 live births, indicating a MMR of 130 per 100.000 live births and implicating a 42% reduction of maternal deaths in the past 25 years. Vital registration indicated a MMR of 96, which marks underreporting of 26%. Maternal deaths mostly occurred in the urban hospitals (84%) and the causes were classified as direct (63%), indirect (32%) or unspecified (5%). Major underlying causes were obstetric and non-obstetric sepsis (27%) and haemorrhage (20%). Substandard care factors (95%) were mostly health professional related (80%) due to delay in diagnosis (59%), delay or wrong treatment (78%) or inadequate monitoring (59%). Substandard care factors most likely led to death in 47% of the cases.

CONCLUSION

Despite the reduction in maternal mortality, Suriname did not reach MDG-5 in 2015. Steps to reach the Sustainable Development Goal in 2030 (MMR ≤ 70 per 100.000 live births) and eliminate preventable deaths include improving data surveillance, installing a maternal death review committee, and implementing national guidelines for prevention and management of major complications of pregnancy, childbirth and puerperium.

Contraceptive knowledge and use among women living in the poorest areas of five Mesoamerican countries

OBJECTIVE

To identify factors associated with contraceptive use among women in need living in the poorest areas in five Mesoamerican countries: Guatemala, Honduras, Nicaragua, Panama and State of Chiapas (Mexico).

STUDY DESIGN

We analyzed baseline data of 7049 women of childbearing age (15-49 years old) collected for the Salud Mesoamérica Initiative. Data collection took place in the 20% poorest municipalities of each country (July, 2012-August, 2013).

RESULTS

Women in the poorest areas were very poorly informed about family planning methods. Concern about side effects was the main reason for nonuse. Contraceptive use was lower among the extremely poor (<$1.25 USD PPP per day) [odds ratio (OR): 0.75; confidence interval (CI): 0.59-0.96], those living more than 30 min away from a health facility (OR 0.71, CI: 0.58-0.86), and those of indigenous ethnicity (OR 0.50, CI: 0.39-0.64). Women who were insured and visited a health facility also had higher odds of using contraceptives than insured women who did not visit a health facility (OR 1.64, CI: 1.13-2.36).

CONCLUSIONS

Our study showed low use of contraceptives in poor areas in Mesoamerica. We found the urgent need to improve services for people of indigenous ethnicity, low education, extreme poverty, the uninsured, and adolescents. It is necessary to address missed opportunities and offer contraceptives to all women who visit health facilities. Governments should aim to increase the public's knowledge of long-acting reversible contraception and offer a wider range of methods to increase contraceptive use.

IMPLICATIONS

We show that unmet need for contraception is higher among the poorest and describe factors associated with low use. Our results call for increased investments in programs and policies targeting the poor to decrease their unmet need.

Indirect maternal deaths: UK and global perspectives

Indirect maternal deaths outnumber direct deaths due to obstetric causes in many high-income countries, and there has been a significant increase in the proportion of maternal deaths due to indirect medical causes in low- to middle-income countries. This review presents a detailed analysis of indirect maternal deaths in the UK and a perspective on the causes and trends in indirect maternal deaths and issues related to care in low- to middle-income countries. There has been no significant decrease in the rate of indirect maternal deaths in the UK since 2003. In 2011-2013, 68% of all maternal deaths were due to indirect causes, and cardiac disease was the single largest cause. The major issues identified in care of women who died from an indirect cause was a lack of clarity about which medical professional should take responsibility for care and overall management. Under-reporting and misclassification result in underestimation of the rate of indirect maternal deaths in low- to middle-income countries. Causes of indirect death include a range of communicable diseases, non-communicable diseases and nutritional disorders. There has been evidence of a shift in incidence from direct to indirect maternal deaths in many low- to middle-income countries due to an increase in non-communicable diseases among women in the reproductive age. The gaps in care identified include poor access to health services, lack of healthcare providers, delay in diagnosis or misdiagnosis and inadequate follow-up during the postnatal period. Irrespective of the significant gains made in reducing maternal mortality in many countries worldwide, there is evidence of a steady increase in the rate of indirect deaths due to pre-existing medical conditions. This heightens the need for research to generate evidence about the risk factors, management and outcomes of specific medical comorbidities during pregnancy in order to provide appropriate evidence-based multidisciplinary care across the entire pathway: pre-pregnancy, during pregnancy and delivery, and postpartum.

Dissonant health transition in the states of Mexico, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

Child and maternal health outcomes have notably improved in Mexico since 1990, whereas rising adult mortality rates defy traditional epidemiological transition models in which decreased death rates occur across all ages. These trends suggest Mexico is experiencing a more complex, dissonant health transition than historically observed. Enduring inequalities between states further emphasise the need for more detailed health assessments over time. The Global Burden of Diseases, Injuries, and Risk Factors Study 2013 (GBD 2013) provides the comprehensive, comparable framework through which such national and subnational analyses can occur. This study offers a state-level quantification of disease burden and risk factor attribution in Mexico for the first time.

METHODS

We extracted data from GBD 2013 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) in Mexico and its 32 states, along with eight comparator countries in the Americas. States were grouped by Marginalisation Index scores to compare subnational burden along a socioeconomic dimension. We split extracted data by state and applied GBD methods to generate estimates of burden, and attributable burden due to behavioural, metabolic, and environmental or occupational risks. We present results for 306 causes, 2337 sequelae, and 79 risk factors.

FINDINGS

From 1990 to 2013, life expectancy from birth in Mexico increased by 3·4 years (95% uncertainty interval 3·1-3·8), from 72·1 years (71·8-72·3) to 75·5 years (75·3-75·7), and these gains were more pronounced in states with high marginalisation. Nationally, age-standardised death rates fell 13·3% (11·9-14·6%) since 1990, but state-level reductions for all-cause mortality varied and gaps between life expectancy and years lived in full health, as measured by HALE, widened in several states. Progress in women's life expectancy exceeded that of men, in whom negligible improvements were observed since 2000. For many states, this trend corresponded with rising YLL rates from interpersonal violence and chronic kidney disease. Nationally, age-standardised YLL rates for diarrhoeal diseases and protein-energy malnutrition markedly decreased, ranking Mexico well above comparator countries. However, amid Mexico's progress against communicable diseases, chronic kidney disease burden rapidly climbed, with age-standardised YLL and DALY rates increasing more than 130% by 2013. For women, DALY rates from breast cancer also increased since 1990, rising 12·1% (4·6-23·1%). In 2013, the leading five causes of DALYs were diabetes, ischaemic heart disease, chronic kidney disease, low back and neck pain, and depressive disorders; the latter three were not among the leading five causes in 1990, further underscoring Mexico's rapid epidemiological transition. Leading risk factors for disease burden in 1990, such as undernutrition, were replaced by high fasting plasma glucose and high body-mass index by 2013. Attributable burden due to dietary risks also increased, accounting for more than 10% of DALYs in 2013.

INTERPRETATION

Mexico achieved sizeable reductions in burden due to several causes, such as diarrhoeal diseases, and risks factors, such as undernutrition and poor sanitation, which were mainly associated with maternal and child health interventions. Yet rising adult mortality rates from chronic kidney disease, diabetes, cirrhosis, and, since 2000, interpersonal violence drove deteriorating health outcomes, particularly in men. Although state inequalities from communicable diseases narrowed over time, non-communicable diseases and injury burdens varied markedly at local levels. The dissonance with which Mexico and its 32 states are experiencing epidemiological transitions might strain health-system responsiveness and performance, which stresses the importance of timely, evidence-informed health policies and programmes linked to the health needs of each state.

FUNDING

Bill & Melinda Gates Foundation, Instituto Nacional de Salud Pública.

Towards an Inclusive and Evidence-Based Definition of the Maternal Mortality Ratio: An Analysis of the Distribution of Time after Delivery of Maternal Deaths in Mexico, 2010-2013

Progress towards the Millennium Development Goal No. 5 was measured by an indicator that excluded women who died due to pregnancy and childbirth after 42 days from the date of delivery. These women suffered from what are defined as late deaths and sequelae-related deaths (O96 and O97 respectively, according to the International Classification of Diseases, 10th revision). Such deaths end up not being part of the numerator in the calculation of the Maternal Mortality Ratio (MMR), the indicator that governments and international agencies use for reporting. The issue is not trivial since these deaths account for a sizeable fraction of all maternal deaths in the world and show an upward trend over time in many countries. The aim of this study was to analyze empirical data on maternal deaths that occurred between 2010 and 2013 in Mexico, linking databases of the Deliberate Search and Reclassification of Maternal Deaths (BIRMM) and the Birth Information Subsystem (SINAC) of the Ministry of Health. Data were analyzed by negative binomial regression, survival analysis and multiple cause analysis. While the reported MMR decreased by 5% per year between 2010 and 2013, the MMR due to late and sequelae-related deaths doubled from 3.5 to 7 per 100,000 live-births in 2013 (p <0.01). A survival analysis of all maternal deaths revealed nothing particular around the 42 day threshold, other than the exclusion of 18% of women who died due to childbirth in 2013. The multiple cause analysis showed a strong association between the excluded deaths and obstetric causes. It is suggested to review the construction of the MMR to make it a more inclusive and dignified measurement of maternal mortality by including all deaths due to pregnancy and childbirth into the Maternal Death definition.