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Source publication
Objective
To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities.
Methods
We conducted a repeated cross-sectional study using the 2006–2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe...
Contexts in source publication
Context 1
... investigated the underlying cause of death for those who had been assigned to a subset of 46 ICD-10 codes that we suspected of being maternal deaths but did not have maternal codes from the ICD-10 O chapter. 25 (The list of the 46 ICD codes are available from the corresponding author). In addition to these 46 codes, we also investigated: deaths that were assigned maternal codes found in the ICD-10 O chapter (Table 1); deaths with suspicious or incomplete codes; deaths with complications but without a valid underlying cause of death; and all death certificates where the pregnancy checkbox had been ticked. ...
Context 2
... This study was approved by the ethics committee of the National Insti- tute of Public Health, Mexico. Table 1 presents the ICD-10 categories and associated sub-categories and titles for codes used for deaths identified as indirect obstetric deaths, as listed in the manual. The list includes all codes that constitute the internationally agreed definition of indirect maternal death. ...
Context 3
... enfoque podría ayudar al sistema sanitario a reconsiderar su estrategia para reducir las muertes maternas por causas obstétricas indirectas, incluyendo la prevención de embarazos no deseados y la mejora del cuidado prenatal y postobstétrico. Table 3. Cause of death reclassified as indirect maternal deaths, Mexico, 2006-2013 ICD-10 block 8 Title No. ...
Citations
... To this end, improving the scope and quality of national and local civil registration and vital statistics, health information, and maternal death surveillance systems; and establishing protocols to search for and analyze each maternal death, and deaths of women of childbearing age suspected of concealing a maternal death, in order to progressively reduce underreporting and misclassification, should be strengthened [19]. Likewise, building institutional capacities for health inequality monitoring should be promoted [20], not just to keep track on the health equity impact of maternal mortality reduction interventions, but to create accountability on the promise to leave no one behind [21]. ...
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.
... In Mexico, between 1990 and 2013, there was an important reduction from 88.7 to 38.2, equivalent to 50.5 maternal deaths per 100 000 live births: still a high figure according to the millennium goals. 4 Additionally, throughout the country this problem shows significant discrepancies by geographical areas. In the areas with greater poverty, illiteracy, speakers of indigenous language, lower human development index and greater degree of social lag, the risk of death for women during pregnancy, birth, or puerperium is four to seven times greater. ...
Objective:
To explore the use of birth care in a Sentinel Unit.
Materials and methods:
We interviewed eight health providers and 12 female users of health services to explore the main reasons to use birth care in a Sentinel Unit.
Results:
Findings indicate that the reasons for which health providers do not attend births were fear of legal claims by users, lack of institutional support if complications arise, lack of training, not feeling confident in obstetric care, and the lack of necessary supplies. Female users mentioned the perception of a lack of trained physicians and a lack of necessary materials and medicines.
Conclusions:
Despite the strengthening of the infrastructure and human resources, as well as a 24/365 model attention and the increase of health personnel in the sentinel units, there are still significant barriers in certain units to achieve compliance with coverage of quality obstetric care focused on the needs of women.
... To this end, improving the scope and quality of national and local civil registration and vital statistics, health information, and maternal death surveillance systems; and establishing protocols to search for and analyze each maternal death, and deaths of women of childbearing age suspected of concealing a maternal death, in order to progressively reduce underreporting and misclassification, should be strengthened [19]. Likewise, building institutional capacities for health inequality monitoring should be promoted [20], not just to keep track on the health equity impact of maternal mortality reduction interventions, but to create accountability on the promise to leave no one behind [21]. ...
... The MMR has been widely acknowledged as a general indicator of overall health in populations, the status of women in society, and the functioning of health-care systems [34]. The MMR denotes the number of maternal deaths per 100,000 live births [35]. Maternal death is defined as the death of a woman while pregnant or within 42 days of pregnancy terminationirrespective of the duration and the site of the pregnancyfrom any cause related to or aggravated by the pregnancy or its management, but not from an accidental or incidental cause [35,36]. ...
... The MMR denotes the number of maternal deaths per 100,000 live births [35]. Maternal death is defined as the death of a woman while pregnant or within 42 days of pregnancy terminationirrespective of the duration and the site of the pregnancyfrom any cause related to or aggravated by the pregnancy or its management, but not from an accidental or incidental cause [35,36]. Our study analyzed maternal deaths and live births that occurred among women without social security coverage and were registered in their place of residence. ...
... Consistent with previous studies and in order to achieve an inclusive analysis, our estimate focused on women between the ages of 10-54y and included post-discharge maternal deaths as well as deaths from sequelae of obstetric or other indirect causes previously documented as relevant [35,36]. Maternal death information was drawn from the mortality databases of the National Health Information System (SINAIS by its Spanish initials) [10]; birth information was drawn from the population projections 2005-2030 of the National Population Council (CONAPO by its Spanish initials) [10]. ...
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.
... 22 Furthermore, MM is a phenomenon concentrated in specific parts of the country and is closely associated with poverty. 23,24 The relationship between government expenditure and MM has scarcely been studied owing mainly to the difficulty of identifying government expenditure on maternal health (GE) in a timely manner. While relevant literature indicates that such a relationship exists, 25 its magnitude is as yet uncertain. ...
... Following previous studies, 23,33 we calculated the annual municipal MM ratio and according to place of residence. ...
... This focus on mortality is being addressed, as data collection is increasingly utilising indices such as 'severe maternal morbidity' or 'near-miss events' 26 to gain a more comprehensive picture of various medical contributions, rather than just the simplistic final event of mortality. 27,28 The classification system of 'direct' and 'indirect' deaths is likely to remain for now. Perhaps, we should consider generating terms that describe obstetric conditions that are predictable by the recognition of co-morbidities earlier in pregnancy, or those which require knowledge of multi-organ physiology; whether or not the condition is specific to pregnancy seems satisfying but inconsequential. ...
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.
... After the implementation of the Intentional Search and Reclassification of Maternal Deaths System (BIRMM, acronym in Spanish) in 2002, approximately 20% maternal deaths originally classified as non-maternal deaths were recovered [4][5][6]. Due to improving registries, indirect maternal deaths have been analyzed with a greater degree of certainty [7], as well as the contribution of late maternal deaths and obstetric sequelae deaths to maternal mortality in Mexico [8]. Nevertheless, despite the gains in the measurement of maternal mortality, the MMR has not declined as expected, which points to insufficient knowledge of its determinants. ...
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.
... Mungra et al. reported a MMR of 226 between 1991 and 1993, which indicates a 42% reduction in maternal deaths and an improvement in underreporting from 64% to 26% [4,5]. A comparison of the MMR and underreporting is difficult, as to our best knowledge there are few countries that have performed a RAMoS of confidential enquiry [16][17][18][19]. ...
... Though our study suggests that, over the years, there is a growing reliability on identification of maternal deaths, the underreporting rate in Suriname (26%) is still higher than reported in Jamaica (20%), Argentina (9.5%) and Mexico (13%) [16][17][18][19]. ...
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.
... The new system reclassified a further 10% of direct deaths as indirect, leading to an overall 6.8% increase in maternal deaths categorised as indirect. 18 Despite these problems in measurement, a comparison of the WHO analysis of the causes of maternal deaths between two time periods, 1990-2002 and 2003-2009 showed that the proportion of deaths due to indirect causes has increased substantially in LMICs, the most notable increase being in Latin America and the Caribbean (Table 1). A recent systematic review suggested that 28% of maternal deaths in LMICs in 2003-2009 were due to indirect causes compared with 27% due to haemorrhage and 14% due to hypertensive disorders. ...
... Effects of this epidemiological transition are already evident in Mexico where the rate of indirect maternal death has remained unchanged during a period of eight years (13.3 per 100,000 live births in 2013 compared with 12.2 per 100,000 live births in 2006) in contrast to a significant decline in direct maternal deaths. 18 While China has made rapid progress in reducing maternal deaths, a study reported a doubling of indirect maternal deaths in the large metropolitan Wuhan city within a decade from 15 per 100,000 live births in 2001 to 37 per 100,000 live births in 2012; cardiac disease was the leading cause. 31 Similarly, maternal mortality has decreased in Sri Lanka, but the proportion of deaths due to indirect causes has increased steadily from 1930 to 2000. ...
... Yet, these strategies have been shown to have no significant effect on reducing the substantial burden of indirect maternal deaths. 17 Lessons from the confidential enquiries into maternal deaths from the UK, 4,10 Kerala in India, 37 South Africa 21 and studies from other countries 7,18,31,32 suggest the need for policy actions to ensure that health services for pregnant women with medical and mental health conditions are designed to provide appropriate evidence-based multidisciplinary care across the entire pathway; pre-pregnancy, during pregnancy and delivery, and postpartum. In recognition of the potential risks of pregnancy associated with pre-existing conditions, women should be informed about the risks and receive pre-pregnancy counselling from those with expertise in their medical condition and pregnancy. ...
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.
... Not everyone has regular access to services. Ministries of health need to increase access to and use of effective contraception among the poor, which continues to be a central strategy to reduce maternal mortality [13]. ...
... Additionally, in Nicaragua, the healthcare delivery model stresses community participation and reinforces the community distribution of contraceptives in hard-to-reach areas [4,23]. Although development aid for family planning programs has fallen significantly in the region [7,13], strategic international investments could incentivize governments to address unmet needs in the poorest areas. ...
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 (15-49years 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 30min 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.
