Andrea Nove

Maternal mortality in adolescents compared with women of other ages: evidence from 144 countries

BACKGROUND Adolescents are often noted to have an increased risk of death during pregnancy or childbirth compared with older women, but the existing evidence is inconsistent and in many cases contradictory. We aimed to quantify the risk of maternal death in adolescents by estimating maternal mortality ratios for women aged 15-19 years by country, region, and worldwide, and to compare these ratios with those for women in other 5-year age groups. METHODS We used data from 144 countries and territories (65 with vital registration data and 79 with nationally representative survey data) to calculate the proportion of maternal deaths among deaths of females of reproductive age (PMDF) for each 5-year age group from 15-19 to 45-49 years. We adjusted these estimates to take into account under-reporting of maternal deaths, and deaths during pregnancy from non-maternal causes. We then applied the adjusted PMDFs to the most reliable age-specific estimates of deaths and livebirths to derive age-specific maternal mortality ratios. FINDINGS The aggregated data show a J-shaped curve for the age distribution of maternal mortality, with a slightly increased risk of mortality in adolescents compared with women aged 20-24 years (maternal mortality ratio 260 [uncertainty 100-410] vs 190 [120-260] maternal deaths per 100 000 livebirths for all 144 countries combined), and the highest risk in women older than 30 years. Analysis for individual countries showed substantial heterogeneity; some showed a clear J-shaped curve, whereas in others adolescents had a slightly lower maternal mortality ratio than women in their early 20s. No obvious groupings were apparent in terms of economic development, demographic characteristics, or geographical region for countries with these different age patterns. INTERPRETATION Our findings suggest that the excess mortality risk to adolescent mothers might be less than previously believed, and in most countries the adolescent maternal mortality ratio is low compared with women older than 30 years. However, these findings should not divert focus away from efforts to reduce adolescent pregnancy, which are central to the promotion of womens educational, social, and economic development. FUNDING WHO, UN Population Fund.

Comparing the odds of postpartum haemorrhage in planned home birth against planned hospital birth: results of an observational study of over 500,000 maternities in the UK

BackgroundThe aim of this study is to compare the odds of postpartum haemorrhage among women who opt for home birth against the odds of postpartum haemorrhage for those who plan a hospital birth. It is an observational study involving secondary analysis of maternity records, using binary logistic regression modelling. The data relate to pregnancies that received maternity care from one of fifteen hospitals in the former North West Thames Regional Health Authority Area in England, and which resulted in a live or stillbirth in the years 1988–2000 inclusive, excluding ‘high-risk’ pregnancies, unplanned home births, pre-term births, elective Caesareans and medical inductions.ResultsEven after adjustment for known confounders such as parity, the odds of postpartum haemorrhage (≥1000ml of blood lost) are significantly higher if a hospital birth is intended than if a home birth is intended (odds ratio 2.5, 95% confidence interval 1.7 to 3.8). The ‘home birth’ group included women who were transferred to hospital during labour or shortly after birth.ConclusionsWomen and their partners should be advised that the risk of PPH is higher among births planned to take place in hospital compared to births planned to take place at home, but that further research is needed to understand (a) whether the same pattern applies to the more life-threatening categories of PPH, and (b) why hospital birth is associated with increased odds of PPH. If it is due to the way in which labour is managed in hospital, changes should be made to practices which compromise the safety of labouring women.

Improving the resilience and workforce of health systems for women’s, children’s, and adolescents’ health

To achieve the sustainable development goals related to maternal, child, and adolescent health, countries need to integrate targeted interventions within their national health strategies and leverage them into financing, workforce, and monitoring capacity across the system, say James Campbell and colleagues.

The methodological challenges of attempting to compare the safety of home and hospital birth in terms of the risk of perinatal death

This paper identifies a number of methodological difficulties associated with the comparison of home and hospital birth in terms of the risk of perinatal death, and suggests ways in which these problems can be overcome. A review of recent studies suggests that most available data sources are unable to overcome all of these challenges, which is one of the reasons why the debate about whether perinatal death is more likely if a home birth is planned or if a hospital birth is planned has not been satisfactorily resolved. We argue that the debate will be settled only if perinatal mortality data from a sufficiently large number of maternity care providers over a sufficiently long period of time can be pooled and made available for analysis. The pooling of data will bring about its own difficulties due to variations over time and between providers and geographical areas, which would need to be taken into account when analysing pooled data. However, given the impracticality of a randomised controlled trial and the rarity of home birth in most of the Western world, we argue that more effort should be made to pool data for perinatal mortality and other rare pregnancy outcomes, and share them between health providers and researchers. Thus, high-quality analyses could be conducted, allowing all women to make an informed choice about place of birth. However, pooling data from countries or states with very different maternity care systems should be avoided.

Midwifery 2030: a woman’s pathway to health. What does this mean?

The 2014 State of the Worlds Midwifery report included a new framework for the provision of woman-centred sexual, reproductive, maternal, newborn and adolescent health care, known as the Midwifery2030 Pathway. The Pathway was designed to apply in all settings (high-, middle- and low-income countries, and in any type of health system). In this paper, we describe the process of developing the Midwifery2030 Pathway and explain the meaning of its different components, with a view to assisting countries with its implementation. The Pathway was developed by a process of consultation with an international group of midwifery experts. It considers four stages of a womans reproductive life: (1) pre-pregnancy, (2) pregnancy, (3) labour and birth, and (4) postnatal, and describes the care that women and adolescents need at each stage. Underpinning these four stages are ten foundations, which describe the systems, services, workforce and information that need to be in place in order to turn the Pathway from a vision into a reality. These foundations include: the policy and working environment in which the midwifery workforce operates, the effective coverage of sexual, reproductive, maternal, newborn and adolescent services (i.e. going beyond availability and ensuring accessibility, acceptability and high quality), financing mechanisms, collaboration between different sectors and different levels of the health system, a focus on primary care nested within a functional referral system when needed, pre- and in-service education for the workforce, effective regulation of midwifery and strengthened leadership from professional associations. Strengthening of all of these foundations will enable countries to turn the Pathway from a vision into reality.

Equality in Maternal and Newborn Health: Modelling Geographic Disparities in Utilisation of Care in Five East African Countries.

Background Geographic accessibility to health facilities represents a fundamental barrier to utilisation of maternal and newborn health (MNH) services, driving historically hidden spatial pockets of localized inequalities. Here, we examine utilisation of MNH care as an emergent property of accessibility, highlighting high-resolution spatial heterogeneity and sub-national inequalities in receiving care before, during, and after delivery throughout five East African countries. Methods We calculated a geographic inaccessibility score to the nearest health facility at 300 x 300 m using a dataset of 9,314 facilities throughout Burundi, Kenya, Rwanda, Tanzania and Uganda. Using Demographic and Health Surveys data, we utilised hierarchical mixed effects logistic regression to examine the odds of: 1) skilled birth attendance, 2) receiving 4+ antenatal care visits at time of delivery, and 3) receiving a postnatal health check-up within 48 hours of delivery. We applied model results onto the accessibility surface to visualise the probabilities of obtaining MNH care at both high-resolution and sub-national levels after adjusting for live births in 2015. Results Across all outcomes, decreasing wealth and education levels were associated with lower odds of obtaining MNH care. Increasing geographic inaccessibility scores were associated with the strongest effect in lowering odds of obtaining care observed across outcomes, with the widest disparities observed among skilled birth attendance. Specifically, for each increase in the inaccessibility score to the nearest health facility, the odds of having skilled birth attendance at delivery was reduced by over 75% (0.24; CI: 0.19–0.3), while the odds of receiving antenatal care decreased by nearly 25% (0.74; CI: 0.61–0.89) and 40% for obtaining postnatal care (0.58; CI: 0.45–0.75). Conclusions Overall, these results suggest decreasing accessibility to the nearest health facility significantly deterred utilisation of all maternal health care services. These results demonstrate how spatial approaches can inform policy efforts and promote evidence-based decision-making, and are particularly pertinent as the world shifts into the Sustainable Goals Development era, where sub-national applications will become increasingly useful in identifying and reducing persistent inequalities.

Establishing a baseline to measure change in political will and the use of data for decision-making in maternal and newborn health in six African countries

The Evidence for Action (E4A) program assumes that both resource allocation and quality of care can improve via a strategy that combines evidence and advocacy to stimulate accountability. The present paper explains the methods used to collect baseline monitoring data using two tools developed to inform program design in six focus countries. The first tool is designed to understand the extent to which decision‐makers have access to the data they need, when they need it, and in meaningful formats, and then to use the data to prioritize, plan, and allocate resources. The second tool seeks the views of people working in the area of maternal and newborn health (MNH) about political will, including: quality of care, the political and financial priority accorded to MNH, and the extent to which MNH decision‐makers are accountable to service users. Findings indicate significant potential to improve access to and use of data for decision‐making, particularly at subnational levels. Respondents across all six program countries reported lack of access by ordinary citizens to information on the health and MNH budget, and data on MNH outcomes. In all six countries there was a perceived inequity in the distribution of resources and a perception that politicians do not fully understand the priorities of their constituents.

Using advocacy and data to strengthen political accountability in maternal and newborn health in Africa.

Accountability mechanisms help governments and development partners fulfill the promises and commitments they make to global initiatives such as the Millennium Development Goals and the Global Strategy on Womens and Childrens health, and regional or national strategies such as the Campaign for the Accelerated Reduction in Maternal Mortality in Africa (CARMMA). But without directed pressure, comparative data and tools to provide insight into successes, failures, and overall results, accountability fails. The analysis of accountability mechanisms in five countries supported by the Evidence for Action program shows that accountability is most effective when it is connected across global and national levels; civil society has a central and independent role; proactive, immediate and targeted implementation mechanisms are funded from the start; advocacy for accountability is combined with local outreach activities such as blood drives; local and national champions (Presidents, First Ladies, Ministers) help draw public attention to government performance; scorecards are developed to provide insight into performance and highlight necessary improvements; and politicians at subnational level are supported by national leaders to effect change. Under the Sustainable Development Goals, accountability and advocacy supported by global and regional intergovernmental organizations, constantly monitored and with commensurate retribution for nonperformance will remain essential.

Characteristics associated with intending and achieving a planned home birth in the United Kingdom: An observational study of 515,777 maternities in the North West Thames region, 1988-2000

BACKGROUND AND OBJECTIVES: This study aims to identify factors that have an independent association with planned home birth. It investigates the social, demographic, and obstetric profile of those who choose home birth as compared with those choosing hospital birth. This crucial evidence is lacking in the U.K. context and is needed when comparing pregnancy outcomes of different birth settings. Otherwise, the comparison is problematic because observed differences in incidence of pregnancy outcomes may be due to the fact that different types of women choose different birth settings. It is important to understand these differences in order to control for them. METHOD: This is an observational study involving secondary analysis of computerized maternity records from 15 hospitals in the former North West Thames Regional Health Authority (RHA) area. All pregnancies that resulted in a live or stillbirth in the years 1988–2000 are included (N = 515,777). Two binary logistic regression models are used: one with intended place of birth at booking as the outcome and the other with actual place of birth as the outcome. RESULTS: Women who are parous, White European, aged 30 and older, living in a relatively affluent area, and partnered are most likely to intend a home birth. Among those who intend a home birth at the end of pregnancy, predictors of achieving a home birth include an uncomplicated and relatively short labor, being parous, a low-risk pregnancy, and being White European. The hospital providing maternity care predicts the outcome for both models. CONCLUSIONS: Key variables robustly predict an intention to deliver at home and the achievement of a planned home birth. Studies comparing the outcomes of different birth settings in the United Kingdom should control for these variables.

The need for innovation and implementation research for maternal and newborn health

1 WHO, UNICEF, UNFPA, World Bank Group, UN Population Division. Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: WHO, 2015. 2 UN Population Fund. Family planning; overview. http://www.unfpa.org/familyplanning (accessed Aug 12, 2016). 3 WHO. Neonatal mortality; situation and trends. http://www.who.int/gho/child_health/ mortality/neonatal_text/en/ (accessed Aug 12, 2016). 4 Temmerman M, Khosla R, Bhutta ZA, Bustreo F. Towards a new Global Strategy for Women’s, Children’s and Adolescents’ Health. BMJ 2015; 351: h4414. 5 Research & Innovation Horizon Prizes. Birth Day Prize. http://ec.europa.eu/research/ horizonprize/index.cfm?prize=birthday (accessed Aug 12, 2016). Inequity is a key factor to consider in MNH research, particularly regarding adolescents and migrants. Innovative approaches are needed to ensure quality of care for adolescents for whom few specialised services are available, and for the large numbers of migrants with a documented lack of access to health services. The development of effective, innovative solutions requires collaboration between academic researchers from diff erent disciplines, scientists, clinicians, and—perhaps m o s t i m p o r t a n t l y — w o m e n , their families, and communities. The involvement of end users in identifying problems and solutions provides vital insights and increases the likelihood that solutions will be taken up at scale; their involvement should be part of the assessment criteria of any research proposal. The new global architecture, with the Sustainable Development Goals and the Global Strategy for Women’s, Children’s and Adolescents’ Health, ensures that MNH remains high on the political agenda. However, we must move from political commitment to action, via the creation and dissemination of evidence. The commitment of the research community should go beyond conducting and publishing research findings: from conception until the use of results, any research should be carried out in continuous partnership— with policy makers, politicians, development partners, and the media— to ensure that evidence is properly translated into policy and practice. We are far from reaching the goal of safe pregnancy and childbirth for all women and girls, in all countries. Research and innovation are essential ingredients for progress. The European Union has invested over €690 million in research directly related to MNH in 2007–13, and will continue its commitment under Horizon 2020, with new funding modalities like the Birth Day Prize, which aim to mobilise new and innovative actors.