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Abstract

Background

The aim of this study was to assess the main factors related to maternal mortality reduction in large time series available in Chile in context of the United Nations' Millennium Development Goals (MDGs).

Methods

Time series of maternal mortality ratio (MMR) from official data (National Institute of Statistics, 1957–2007) along with parallel time series of education years, income per capita, fertility rate (TFR), birth order, clean water, sanitary sewer, and delivery by skilled attendants were analysed using autoregressive models (ARIMA). Historical changes on the mortality trend including the effect of different educational and maternal health policies implemented in 1965, and legislation that prohibited abortion in 1989 were assessed utilizing segmented regression techniques.

Results

During the 50-year study period, the MMR decreased from 293.7 to 18.2/100,000 live births, a decrease of 93.8%. Women's education level modulated the effects of TFR, birth order, delivery by skilled attendants, clean water, and sanitary sewer access. In the fully adjusted model, for every additional year of maternal education there was a corresponding decrease in the MMR of 29.3/100,000 live births. A rapid phase of decline between 1965 and 1981 (−13.29/100,000 live births each year) and a slow phase between 1981 and 2007 (−1.59/100,000 live births each year) were identified. After abortion was prohibited, the MMR decreased from 41.3 to 12.7 per 100,000 live births (−69.2%). The slope of the MMR did not appear to be altered by the change in abortion law.

Conclusion

Increasing education level appears to favourably impact the downward trend in the MMR, modulating other key factors such as access and utilization of maternal health facilities, changes in women's reproductive behaviour and improvements of the sanitary system. Consequently, different MDGs can act synergistically to improve maternal health. The reduction in the MMR is not related to the legal status of abortion.

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Most cited references 130

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Unsafe abortion: the preventable pandemic.

David A Grimes, Janie Benson, Susheela Singh … (2006)

Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving women's health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves women's health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.

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Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby.

Allen Wilcox, Clarice R. Weinberg, Donna Baird (1995)

The timing of sexual intercourse in relation to ovulation strongly influences the chance of conception, although the actual number of fertile days in a woman's menstrual cycle is uncertain. The timing of intercourse may also be associated with the sex of the baby. We recruited 221 healthy women who were planning to become pregnant. At the same time the women stopped using birth-control methods, they began collecting daily urine specimens and keeping daily records of whether they had sexual intercourse. We measured estrogen and progesterone metabolites in urine to estimate the day of ovulation. In a total of 625 menstrual cycles for which the dates of ovulation could be estimated, 192 pregnancies were initiated, as indicated by increases in the urinary concentration of human chorionic gonadotropin around the expected time of implantation. Two thirds (n = 129) ended in live births. Conception occurred only when intercourse took place during a six-day period that ended on the estimated day of ovulation. The probability of conception ranged from 0.10 when intercourse occurred five days before ovulation to 0.33 when it occurred on the day of ovulation itself. There was no evident relation between the age of sperm and the viability of the conceptus, although only 6 percent of the pregnancies could be firmly attributed to sperm that were three or more days old. Cycles producing male and female babies had similar patterns of intercourse in relation to ovulation. Among healthy women trying to conceive, nearly all pregnancies can be attributed to intercourse during a six-day period ending on the day of ovulation. For practical purposes, the timing of sexual intercourse in relation to ovulation has no influence on the sex of the baby.

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Advanced maternal age and adverse perinatal outcome.

Bo Jacobsson, Ian Milsom, Lars Ladfors (2004)

The aim of this study was to investigate the influence of maternal age on perinatal and obstetric outcome in women aged 40-44 years and those 45 years or older and to estimate whether adverse outcome was related to intercurrent illness and pregnancy complications. National prospective, population-based, cohort study in women aged 40-44 years and those 45 years or older and in a control group of women aged 20-29 years who delivered during the period 1987-2001. Adjusted odds ratios (OR) were calculated after adjustments for significant malformations, maternal pre-existing diseases, and smoking. Main outcome measures were perinatal mortality, intrauterine fetal death, neonatal death, preterm birth, and preeclampsia. During the 15-year period, there were 1,566,313 deliveries (876,361 women were 20-29 years of age, 31,662 were 40-44 years, and 1,205 were > or = 45 years). Perinatal mortality was 1.4%, 1.0%, and 0.5% in women 45 years or older, 40-44, and 20-29 years, respectively. Adjusted OR for perinatal mortality was 2.4 (95% confidence interval [CI] 1.5-4.0) in women aged 45 years or older, compared with 1.7 (95% CI 1.5-1.9) in women 40-44 years. Adjusted OR for intrauterine fetal death was 3.8 (95% CI 2.2-6.4) in women aged 45 years or older, compared with 2.1 (95% CI 1.8-2.4) in women 40-44 years. Preterm birth, gestational diabetes, and preeclampsia were more common among women 40-44 years of age and those 45 years or older. Perinatal mortality was increased in women with intercurrent illness or pregnancy complications compared with women without these conditions, but there was no evidence that these factors became more important with increasing age. Perinatal mortality, intrauterine fetal death, and neonatal death increased with age. There was also an increase in intercurrent illnesses and pregnancy complications with increasing age, but this did not entirely explain the observed increase in perinatal mortality with age. II-3

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Author and article information

Contributors

: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2012

Publication date (Electronic): 4 May 2012

Volume: 7

Issue: 5

Electronic Location Identifier: e36613

Affiliations

[1 ]Institute of Molecular Epidemiology (MELISA), Center of Embryonic Medicine and Maternal Health, Faculty of Medicine, Universidad Católica de la Santísima Concepción, Concepción, Chile

[2 ]Department of Primary Care and Family Medicine, Faculty of Medicine, University of Chile, Santiago, Chile

[3 ]Doctoral Program, Division of Epidemiology, School of Public Health, Faculty of Medicine, University of Chile, Santiago, Chile

[4 ]Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, United States of America

The University of Adelaide, Australia

Author notes

* E-mail: elardkoch@ 123456gmail.com

Conceived and designed the experiments: EK JT. Performed the experiments: EK JT MB SG CR HA IA. Analyzed the data: EK MB SG. Contributed reagents/materials/analysis tools: EK MB SG JT. Wrote the paper: EK JT MB SG CR. Prepared the methodology of the study: EK. Served as lead author of the manuscript: EK. Conceptualized and supervised the study: EK JT. Assisted with the study design: MB HA IA. Assisted with the data collection: MB. Assisted with homologation of ICD codes: MB. Assisted with figure design: MB. Assisted with editing the article: CR SG JT MB. Assisted with the revision of the final manuscript: HA IA.

Article

Publisher ID: PONE-D-11-20617

DOI: 10.1371/journal.pone.0036613

PMC ID: 3344918

PubMed ID: 22574194

SO-VID: 15d315a7-5d5e-495f-afdf-fc31eff63b0a

Copyright © Koch et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 14 October 2011

Date accepted : 10 April 2012

Page count

Pages: 16

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Women's Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: A Natural Experiment in Chile from 1957 to 2007

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PLOS Climate

Most cited references 130

Unsafe abortion: the preventable pandemic.

Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby.

Advanced maternal age and adverse perinatal outcome.

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