Maternal mortality in six low and lower-middle income countries from 2010 to 2018: risk factors and trends

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Abstract

Background

Maternal mortality is a public health problem that disproportionately affects low and lower-middle income countries (LMICs). Appropriate data sources are lacking to effectively track maternal mortality and monitor changes in this health indicator over time.

Methods

We analyzed data from women enrolled in the NICHD Global Network for Women’s and Children’s Health Research Maternal Newborn Health Registry (MNHR) from 2010 through 2018. Women delivering within research sites in the Democratic Republic of Congo, Guatemala, India (Nagpur and Belagavi), Kenya, Pakistan, and Zambia are included. We evaluated maternal and delivery characteristics using log-binomial models and multivariable models to obtain relative risk estimates for mortality. We used running averages to track maternal mortality ratio (MMR, maternal deaths per 100,000 live births) over time.

Results

We evaluated 571,321 pregnancies and 842 maternal deaths. We observed an MMR of 157 / 100,000 live births (95% CI 147, 167) across all sites, with a range of MMRs from 97 (76, 118) in the Guatemala site to 327 (293, 361) in the Pakistan site. When adjusted for maternal risk factors, risks of maternal mortality were higher with maternal age > 35 (RR 1.43 (1.06, 1.92)), no maternal education (RR 3.40 (2.08, 5.55)), lower education (RR 2.46 (1.54, 3.94)), nulliparity (RR 1.24 (1.01, 1.52)) and parity > 2 (RR 1.48 (1.15, 1.89)). Increased risk of maternal mortality was also associated with occurrence of obstructed labor (RR 1.58 (1.14, 2.19)), severe antepartum hemorrhage (RR 2.59 (1.83, 3.66)) and hypertensive disorders (RR 6.87 (5.05, 9.34)). Before and after adjusting for other characteristics, physician attendance at delivery, delivery in hospital and Caesarean delivery were associated with increased risk. We observed variable changes over time in the MMR within sites.

Conclusions

The MNHR is a useful tool for tracking MMRs in these LMICs. We identified maternal and delivery characteristics associated with increased risk of death, some might be confounded by indication. Despite declines in MMR in some sites, all sites had an MMR higher than the Sustainable Development Goals target of below 70 per 100,000 live births by 2030.

Trial registration

The MNHR is registered at NCT01073475.

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Most cited references 17

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National, regional, and global levels and trends in maternal mortality between 1990 and 2015 with scenario-based projections to 2030: a systematic analysis by the United Nations Maternal Mortality Estimation Inter-Agency Group

Leontine Alkema, Doris Chou, Daniel W Hogan … (2015)

Summary Background Millennium Development Goal (MDG) 5 calls for a reduction of 75% in the maternal mortality ratio (MMR) between 1990 and 2015. We estimated levels and trends in maternal mortality for 183 countries to assess progress made. Based on MMR estimates for 2015, we constructed scenario-based projections to highlight the accelerations needed to accomplish the Sustainable Development Goal (SDG) global target of less than 70 maternal deaths per 100,000 live births globally by 2030. Methods We updated the open access UN Maternal Mortality Estimation Inter-agency Group (MMEIG) database. Based upon nationally-representative data for 171 countries, we generated estimates of maternal mortality and related indicators with uncertainty intervals using a Bayesian model, which extends and refines the previous UN MMEIG estimation approach. The model combines the rate of change implied by a multilevel regression model with a time series model to capture data-driven changes in country-specific MMRs, and includes a data model to adjust for systematic and random errors associated with different data sources. Results The global MMR declined from 385 deaths per 100,000 live births (80% uncertainty interval ranges from 359 to 427) in 1990 to 216 (207 to 249) in 2015, corresponding to a relative decline of 43.9% (34.0 to 48.7) during the 25-year period, with 303,000 (291,000 to 349,000) maternal deaths globally in 2015. Regional progress in reducing the MMR since 1990 ranged from an annual rate of reduction of 1.8% (0 to 3.1) in the Caribbean to 5.0% (4.0 to 6.0) for Eastern Asia. Regional MMRs for 2015 range from 12 (11 to 14) for developed regions to 546 (511 to 652) for sub-Saharan Africa. Accelerated progress will be needed to achieve the SDG goal; countries will need to reduce their MMRs at an annual rate of reduction of at least 7.5%. Interpretation Despite global progress in reducing maternal mortality, immediate action is required to begin making progress towards the ambitious SDG 2030 target, and ultimately eliminating preventable maternal mortality. While the rates of reduction that are required to achieve country-specific SDG targets are ambitious for the great majority of high mortality countries, the experience and rates of change between 2000 and 2010 in selected countries–those with concerted efforts to reduce the MMR- provide inspiration as well as guidance on how to accomplish the acceleration necessary to substantially reduce preventable maternal deaths. Funding Funding from grant R-155-000-146-112 from the National University of Singapore supported the research by LA and SZ. AG is the recipient of a National Institute of Child Health and Human Development, grant # T32-HD007275. Funding also provided by USAID and HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction).

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Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

Nicholas J. Kassebaum, Ryan M Barber, Zulfiqar Bhutta … (2016)

In transitioning from the Millennium Development Goal to the Sustainable Development Goal era, it is imperative to comprehensively assess progress toward reducing maternal mortality to identify areas of success, remaining challenges, and frame policy discussions. We aimed to quantify maternal mortality throughout the world by underlying cause and age from 1990 to 2015.

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Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015

Haidong Wang, Zulfiqar Bhutta, Matthew M Coates … (2016)

Established in 2000, Millennium Development Goal 4 (MDG4) catalysed extraordinary political, financial, and social commitments to reduce under-5 mortality by two-thirds between 1990 and 2015. At the country level, the pace of progress in improving child survival has varied markedly, highlighting a crucial need to further examine potential drivers of accelerated or slowed decreases in child mortality. The Global Burden of Disease 2015 Study (GBD 2015) provides an analytical framework to comprehensively assess these trends for under-5 mortality, age-specific and cause-specific mortality among children under 5 years, and stillbirths by geography over time.

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Author and article information

Contributors

Melissa Bauserman:

ORCID: http://orcid.org/0000-0002-4992-9895

melissa_bauserman@med.unc.edu

Journal

Journal ID (nlm-ta): Reprod Health

Journal ID (iso-abbrev): Reprod Health

Title: Reproductive Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1742-4755

Publication date (Electronic): 17 December 2020

Publication date PMC-release: 17 December 2020

Publication date Collection: 2020

Volume: 17

Issue : Suppl 3 Issue sponsor : Publication of this supplement was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development to RTI International. The articles have undergone the journal's standard peer review process for supplements. The supplement editors declare no competing interests.

Electronic Location Identifier: 173

Affiliations

[1 ]GRID grid.10698.36, ISNI 0000000122483208, Department of Pediatrics, , University of North Carolina School of Medicine, ; 101 Manning Drive, CB 7596, Chapel Hill, NC 27599-7596 USA

[2 ]GRID grid.62562.35, ISNI 0000000100301493, RTI International, ; Durham, NC USA

[3 ]GRID grid.9783.5, ISNI 0000 0000 9927 0991, Kinshasa School of Public Health, ; Kinshasa, Democratic Republic of Congo

[4 ]GRID grid.415827.d, Lata Medical Research Foundation, ; Nagpur, India

[5 ]GRID grid.413489.3, ISNI 0000 0004 1793 8759, Adjunct Faculty Medical Research, Datta Meghe Institute of Medical Sciences, ; Sawangi, India

[6 ]GRID grid.189504.1, ISNI 0000 0004 1936 7558, Boston University School of Public Health, ; Boston, MA USA

[7 ]Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala

[8 ]GRID grid.241116.1, ISNI 0000000107903411, University of Colorado School of Medicine, ; Denver, CO USA

[9 ]GRID grid.79730.3a, ISNI 0000 0001 0495 4256, Moi University School of Medicine, ; Eldoret, Kenya

[10 ]GRID grid.257413.6, ISNI 0000 0001 2287 3919, Indiana School of Medicine, , University of Indiana, ; Indianapolis, IN USA

[11 ]GRID grid.265892.2, ISNI 0000000106344187, University of Alabama at Birmingham, ; Birmingham, AL USA

[12 ]GRID grid.79746.3b, ISNI 0000 0004 0588 4220, University Teaching Hospital, ; Lusaka, Zambia

[13 ]GRID grid.414956.b, ISNI 0000 0004 1765 8386, KLE Academy Higher Education and Research, , J N Medical College Belagavi, ; Belgaum, Karnataka India

[14 ]GRID grid.265008.9, ISNI 0000 0001 2166 5843, Thomas Jefferson University, ; Philadelphia, USA

[15 ]GRID grid.7147.5, ISNI 0000 0001 0633 6224, Aga Khan University, ; Karachi, Pakistan

[16 ]GRID grid.414142.6, ISNI 0000 0004 0600 7174, Maternal and Child Health Division (icddr, b), ; Dhaka, Bangladesh

[17 ]GRID grid.1013.3, ISNI 0000 0004 1936 834X, Sydney School of Public Health, , The University of Sydney, ; Sydney, NSW 2006 Australia

[18 ]GRID grid.420089.7, ISNI 0000 0000 9635 8082, Eunice Kennedy Shriver National Institute of Child Health and Human Development, ; Bethesda, MD USA

[19 ]GRID grid.21729.3f, ISNI 0000000419368729, Department of Obstetrics and Gynecology, , Columbia University School of Medicine, ; New York, NY USA

Author information

Melissa Bauserman http://orcid.org/0000-0002-4992-9895

Article

Publisher ID: 990

DOI: 10.1186/s12978-020-00990-z

PMC ID: 7745363

PubMed ID: 33334343

SO-VID: bc0546a1-7bcb-41f5-917c-e46be95a5c1e

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 28 August 2020

Date accepted : 2 September 2020

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100000071, National Institute of Child Health and Human Development;

Award ID: U10HD076465

Award Recipient : Carl Bose

Custom metadata

ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: low-resource countries,maternal mortality,sustainable development goals,global network

Data availability:

ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: low-resource countries, maternal mortality, sustainable development goals, global network

Maternal mortality in six low and lower-middle income countries from 2010 to 2018: risk factors and trends

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Abstract

Background

Methods

Results

Conclusions

Trial registration

Related collections

UN Sustainable Development Goals

Most cited references 17

National, regional, and global levels and trends in maternal mortality between 1990 and 2015 with scenario-based projections to 2030: a systematic analysis by the United Nations Maternal Mortality Estimation Inter-Agency Group

Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015

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