Jacqueline S. Bell

The familial technique for linking maternal death with poverty

BACKGROUND Recognition of the synergy between health and poverty is now apparent in the development strategies of many low-income countries, and markers are needed to monitor progress towards poverty-relevant goals. Maternal mortality has been proposed as a possible candidate but evidence is lacking on the link with poverty at the level of individuals. We introduce a new approach to exploring the relation--the familial technique. METHODS We used data from 11 household surveys in ten developing countries to create percentage distributions of women according to their poverty-related characteristics and survival status (alive, non-maternal death, maternal death). These women were identified as the sisters of the adult female respondents in the surveys, and were assigned the same poverty status as their respondent sibling. FINDINGS The analysis showed significant associations, across a diverse set of countries, between womens poverty status (proxied by educational level, source of water, and type of toilet and floor) and survival. These associations indicated a gradient within and across the survival categories. With increasing poverty, the proportion of women dying of non-maternal causes generally increased, and the proportion dying of maternal causes increased consistently. Further analysis reported here for one of the countries--Indonesia, revealed that about 32-34% of the maternal deaths occurred among women from the poorest quintile of the population. The risk of maternal death in this country was around 3-4 times greater in the poorest than the richest group. INTERPRETATION This new method makes efficient use of existing survey data to explore the relation between maternal mortality and poverty, and has wider potential for examining the poor-rich gap.

Women's autonomy in household decision-making: a demographic study in Nepal

BackgroundHow socio-demographic factors influence womens autonomy in decision making on health care including purchasing goods and visiting family and relatives are very poorly studied in Nepal. This study aims to explore the links between womens household position and their autonomy in decision making.MethodsWe used Nepal Demographic Health Survey (NDHS) 2006, which provided data on ever married women aged 15-49 years (n = 8257). The data consists of womens four types of household decision making; own health care, making major household purchases, making purchase for daily household needs and visits to her family or relatives. A number of socio-demographic variables were used in multivariable logistic regression to examine the relationship of these variables to all four types of decision making.ResultsWomens autonomy in decision making is positively associated with their age, employment and number of living children. Women from rural area and Terai region have less autonomy in decision making in all four types of outcome measure. There is a mixed variation in womens autonomy in the development region across all outcome measures. Western women are more likely to make decision in own health care (1.2-1.6), while they are less likely to purchase daily household needs (0.6-0.9). Womens increased education is positively associated with autonomy in own health care decision making (p < 0.01), however their more schooling (SLC and above) shows non-significance with other outcome measures. Interestingly, rich women are less likely to have autonomy to make decision in own healthcare.ConclusionsWomen from rural area and Terai region needs specific empowerment programme to enable them to be more autonomous in the household decision making. Womens autonomy by education, wealth quintile and development region needs a further social science investigation to observe the variations within each stratum. A more comprehensive strategy can enable women to access community resources, to challenge traditional norms and to access economic resources. This will lead the women to be more autonomous in decision making in the due course.

Can obstetric complications explain the high levels of obstetric interventions and maternity service use among older women? A retrospective analysis of routinely collected data.

Objective To determine whether the higher levels of obstetric intervention and maternity service use among older women can be explained by obstetric complications.

Decision making about mode of delivery among pregnant women who have previously had a caesarean section: a qualitative study

Objective  To explore prospectively women’s decision making regarding mode of delivery after a previous caesarean section.

What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries

The first target of the fifth United Nations Millennium Development Goal is to reduce maternal mortality by 75% between 1990 and 2015. This target is critically off track. Despite difficulties inherent in measuring maternal mortality, interventions aimed at reducing it must be monitored and evaluated to determine the most effective strategies in different contexts. In some contexts, the direct causes of maternal death, such as haemorrhage and sepsis, predominate and can be tackled effectively through providing access to skilled birth attendance and emergency obstetric care. In others, indirect causes of maternal death, such as HIV/AIDS and malaria, make a significant contribution and require alternative interventions. Methods of planning and evaluating maternal health interventions that do not differentiate between direct and indirect maternal deaths may lead to unrealistic expectations of effectiveness or mask progress in tackling specific causes. Furthermore, the need for additional or alternative interventions to tackle the causes of indirect maternal death may not be recognized if all-cause maternal death is used as the sole outcome indicator. This article illustrates the importance of differentiating between direct and indirect maternal deaths by analysing historical data from England and Wales and contemporary data from Ghana, Rwanda and South Africa. The principal aim of the paper is to highlight the need to differentiate deaths in this way when evaluating maternal mortality, particularly when judging progress towards the fifth Millennium Development Goal. It is recommended that the potential effect of maternity services failing to take indirect maternal deaths into account should be modelled.

Do obstetric complications explain high caesarean section rates among women over 30? A retrospective analysis

As a growing proportion of women delay childbearing into their later reproductive years, the risks and costs associated with advancing maternal age become increasingly important. Extensive evidence shows that both obstetric interventions and obstetric complications are more common among older women,1 and it is often assumed that the interventions are a consequence of the complications. Delivery by caesarean section is one such intervention that is associated with maternal age and is of importance for public health. The extent to which the association is explained by obstetric complications is, however, not known. Martel et al showed that an association between maternal age and rates for primary caesarean section persisted after adjustment for induction of labour, epidural anaesthesia, meconium stained amniotic fluid, and fetal distress.2 We aimed to build on this finding by considering a greater number of …

The burden of diabetes mellitus during pregnancy in low- and middle-income countries : a systematic review

Background Little is known about the burden of diabetes mellitus (DM) in pregnancy in low- and middle-income countries despite high prevalence and mortality rates being observed in these countries. Objective To investigate the prevalence and geographical patterns of DM in pregnancy up to 1 year post-delivery in low- and middle-income countries. Search strategy Medline, Embase, Cochrane (Central), Cinahl and CAB databases were searched with no date restrictions. Selection criteria Articles assessing the prevalence of gestational diabetes mellitus (GDM), and types 1 and 2 DM were sought. Data collection and analysis Articles were independently screened by at least two reviewers. Forest plots were used to present prevalence rates and linear trends calculated by linear regression where appropriate. Main results A total of 45 articles were included. The prevalence of GDM varied. Diagnosis was made by the American Diabetes Association criteria (1.50-15.5%), the Australian Diabetes in Pregnancy Society criteria (20.8%), the Diabetes in Pregnancy Study Group India criteria (13.4%), the European Association for the Study of Diabetes criteria (1.6%), the International Association of Diabetes and Pregnancy Study Groups criteria (8.9-20.4%), the National Diabetes Data Group criteria (0.56-6.30%) and the World Health Organization criteria (0.4-24.3%). Vietnam, India and Cuba had the highest prevalence rates. Types 1 and 2 DM were less often reported. Reports of maternal mortality due to DM were not found. No geographical patterns of the prevalence of GDM could be confirmed but data from Africa is particularly limited. Conclusion Existing published data are insufficient to build a clear picture of the burden and distribution of DM in pregnancy in low- and middle-income countries. Consensus on a common diagnostic criterion for GDM is needed. Type 1 and 2 DM in pregnancy and postpartum DM are other neglected areas.Background Little is known about the burden of diabetes mellitus (DM) in pregnancy in low- and middle-income countries despite high prevalence and mortality rates being observed in these countries. Objective To investigate the prevalence and geographical patterns of DM in pregnancy up to 1 year post-delivery in low- and middle-income countries. Search strategy Medline, Embase, Cochrane (Central), Cinahl and CAB databases were searched with no date restrictions. Selection criteria Articles assessing the prevalence of gestational diabetes mellitus (GDM), and types 1 and 2 DM were sought. Data collection and analysis Articles were independently screened by at least two reviewers. Forest plots were used to present prevalence rates and linear trends calculated by linear regression where appropriate. Main results A total of 45 articles were included. The prevalence of GDM varied. Diagnosis was made by the American Diabetes Association criteria (1.50–15.5%), the Australian Diabetes in Pregnancy Society criteria (20.8%), the Diabetes in Pregnancy Study Group India criteria (13.4%), the European Association for the Study of Diabetes criteria (1.6%), the International Association of Diabetes and Pregnancy Study Groups criteria (8.9–20.4%), the National Diabetes Data Group criteria (0.56–6.30%) and the World Health Organization criteria (0.4–24.3%). Vietnam, India and Cuba had the highest prevalence rates. Types 1 and 2 DM were less often reported. Reports of maternal mortality due to DM were not found. No geographical patterns of the prevalence of GDM could be confirmed but data from Africa is particularly limited. Conclusion Existing published data are insufficient to build a clear picture of the burden and distribution of DM in pregnancy in low- and middle-income countries. Consensus on a common diagnostic criterion for GDM is needed. Type 1 and 2 DM in pregnancy and postpartum DM are other neglected areas.

An Appraisal of the Maternal Mortality Decline in Nepal

Background A decline in the national maternal mortality ratio in Nepal has been observed from surveys conducted between 1996 and 2008. This paper aims to assess the plausibility of the decline and to identify drivers of change. Methods National and sub-national trends in mortality data were investigated using existing demographic and health surveys and maternal mortality and morbidity surveys. Potential drivers of the variation in maternal mortality between districts were identified by regressing district-level indicators from the Nepal demographic health surveys against maternal mortality estimates. Results A statistically significant decline of the maternal mortality ratio from 539 maternal deaths to 281 per 100,000 (95% CI 91,507) live births between 1993 and 2003 was demonstrated. The sub-national changes are of similar magnitude and direction to those observed nationally, and in the terai region (plains) the differences are statistically significant with a reduction of 361 per 100,000 live births (95% CI 36,686) during the same time period. The reduction in fertility, changes in education and wealth, improvements in components of the human development index, gender empowerment and anaemia each explained more than 10% of the district variation in maternal mortality. A number of limitations in each of the data sources used were identified. Of these, the most important relate to the underestimation of numbers of deaths. Conclusion It is likely that there has been a decline in Nepals maternal mortality since 1993. This is good news for the countrys sustained commitments in this area. Conclusions on the magnitude, pattern of the change and drivers of the decline are constrained by lack of data. We recommend close tracking of maternal mortality and its determinants in Nepal, attention to the communication of future estimates, and various options for bridging data gaps.

The direct health services costs of providing assisted reproduction services in overweight or obese women: a retrospective cross-sectional analysis

BACKGROUND Prevalence of overweight and obesity is rising. Hence, it is likely that a higher proportion of women undergoing assisted reproduction treatment are overweight or obese. METHODS In a retrospective cross-sectional analysis using routinely collected data of an IVF Unit and maternity hospital in a tertiary care setting in the UK, direct costs were assessed for all weight classes. Costs for underweight, overweight and obese were compared with those for women with normal body mass index (BMI). RESULTS Of 1756 women, who underwent their first cycle of IVF between 1997 and 2006, 43 (2.4%) were underweight; 988 (56.3%) had normal BMI; 491 (28.0%) were overweight; 148 (8.4%) were obese (class I) and 86 (4.9%) were obese (class II). The mean (95% CI) cost of each live birth resulting from IVF was pound 18,747 (13 864-27 361) in underweight group; pound 16,497 (15 374-17 817) in women with normal BMI; pound 18,575 (16,648-21,081) in overweight women; pound 18,805 (15 397-23 554) in obese class I; pound 20,282 (15 288-28 424) in obese class II or over. CONCLUSIONS The cost of a live birth resulting from IVF is not different in underweight, overweight and obese class I when compared with women with normal BMI. However, due to increased obstetric complications weight loss should still be recommended prior to commencing IVF even in overweight or obese (class I) women.

Maternal Health Services

This article describes the objectives, scope, and organization of maternity services during the antenatal, intrapartum, and postnatal periods in developing and developed countries. It also discusses the epidemiology and sociodemographic determinants of maternal mortality and morbidity and reviews some relevant issues such as utilization and financing of maternity services. Finally, it discusses some of the challenges of providing comprehensive maternity services and the implications for health policy.