(Un)safe routes : maternal mortality and Ethiopia's development agenda

This study juxtaposed women's experiences of birth at home in rural Ethiopia where it is 'safe' with that in a modern health care setting where it is 'unsafe' because the distance from international maternal health policy to its implementation is vast and the 'pathway to maternal survival' can be circuitous.

Unsafe abortion as a birth control method: maternal mortality risks among unmarried Cambodian migrant women on the Thai-Cambodia border

Reproductive health research and policies in Cambodia focus on safe motherhood programs particularly for married women, ignoring comprehensive fertility regulation programs for unmarried migrant women of reproductive age. Maternal mortality risks arising due to unsafe abortion methods practiced by unmarried Cambodian women, across the Thai-Cambodia border, can be considered as a public health emergency. Since Thailand has restrictive abortion laws, Cambodian migrant women who have irregular migration status in Thailand experimented with unsafe abortion methods that allowed them to terminate their pregnancies surreptitiously. Unmarried migrant women choose abortion as a preferred birth control method seeking repeat “unsafe” abortions instead of preventing conception. Drawing on the data collected through surveys, in-depth interviews, and document analysis in Chup Commune (pseudonym), Phnom Penh, and Bangkok, the authors describe the public health dimensions of maternal mortality risks faced by unmarried Cambodian migrant women due to various unsafe abortion methods employed as birth control methods.

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND: The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery. METHODS: We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values. FINDINGS: 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland. INTERPRETATION: Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa. FUNDING: Bill & Melinda Gates Foundation.

Maternal health in Lao PDR : repositioning the goal posts

This paper reviews attempts made in the Lao People's Democratic Republic (PDR) to achieve Millennium Development Goal (MDG) 5: Improve Maternal Health and its two targets: (1) to reduce by three quarters the maternal mortality ratio and (2) to achieve universal access to reproductive health. It will be shown that significant strides have been made in relation to both the targets, especially in the province of Xayaboury where the contraceptive prevalence rate is the highest and maternal mortality is the lowest in the country. That said, it is unlikely that either target will be realised by 2015 for the nation as a whole. Some of the reasons for this are canvassed such as problems with the existing health infrastructure and its personnel, the cost of health care, the demographic profile and cultural expectations of women of childbearing age, geographic barriers, the absence of communication and transport infrastructure and the influence of international donors on how monies are expended. As discussions now begin to set the framework for the post-MDG compact of the international community to address poverty and well-being, it would be valuable to consider the multiplicity of factors which directly impact maternal and infant mortality rates (such as family planning, age at first birth, access to antenatal care and government expenditure on maternal health care) and explain what causes change, over non-contextualised statistics that simply report changes.

Researching maternal, neonatal and child health service use in rural and pastoralist Ethiopia: A key informant research approach

Like many nations in sub-Saharan Africa, Ethiopia has both a high neonatal mortality rate and maternal mortality ratio and is unlikely to meet Millennium Development Goals 4 and 5 by 2015. This working paper examines how Key Informant Research (KIR) in rural and pastoralist Ethiopia will identify facilitators and barriers to the use of maternal, neonatal and child health services. The methodology is informed by Participative Ethnographic Evaluation Research (PEER) and Key Informant Monitoring (KIM). Key Informant Research (KIR) training will provide research skills to Health Extension Workers (HEWs) and Non-government organisation (NGO) staff to enable them to develop research questions, collect data and participate in preliminary data analysis. This will enable the identification of strategies that improve the identification of risk, enhance early referral, increase access, affordability and acceptability of skilled birthing services in rural and pastoralist Ethiopia.

Health extension workers' and mothers' attitudes to maternal health service utilization and acceptance in Adwa Woreda, Tigray Region, Ethiopia.

BACKGROUND: The maternal health system in Ethiopia links health posts in rural communities (kebeles) with district (woreda) health centres, and health centres with primary hospitals. At each health post two Health Extension Workers (HEWs) assist women with birth preparedness, complication readiness, and mobilize communities to facilitate timely referral to mid-level service providers. This study explored HEWs' and mother's attitudes to maternal health services in Adwa Woreda, Tigray Region. METHODS: In this qualitative study, we trained 16 HEWs to interview 45 women to gain a better understanding of the social context of maternal health related behaviours. Themes included barriers to health services; women's social status and mobility; and women's perceptions of skilled birth attendant's care. All data were analyzed thematically. FINDINGS: There have been substantial efforts to improve maternal health and reduce maternal mortality in Adwa Woreda. Women identified barriers to healthcare including distance and lack of transportation due to geographical factors; the absence of many husbands due to off-woreda farming; traditional factors such as zwar (some pregnant women are afraid of meeting other pregnant women), and discouragement from mothers and mothers-in-law who delivered their children at home. Some women experienced disrespectful care at the hospital. Facilitators to skilled birth attendance included: identification of pregnant women through Women's Development Groups (WDGs), and referral by ambulance to health facilities either before a woman's Expected Due Date (EDD) or if labour started at home. CONCLUSION: With the support of WDGs, HEWs have increased the rate of skilled birth attendance by calling ambulances to transfer women to health centres either before their EDD or when labour starts at home. These findings add to the growing body of evidence that health workers at the community level can work with women's groups to improve maternal health, thus reducing the need for emergency obstetric care in low-income countries.

Finding a 'safe' place on the risk continuum: a case study of pregnancy and birthing in Lao PDR (Lao People's Democratic Republic)

This paper addresses two questions. Firstly: are the risk regimes faced, and perceived, by pregnant women in rural Lao PDR substantially different from those experienced by pregnant women in western societies? Secondly, if the Lao experiences and perceptions are different, can improvements in maternal health in Lao PDR be achieved without Laotians inheriting the risk regimes of late modernity experienced by many women in western societies? Secondary analysis is undertaken of data collected in 2005 for the evaluation of a pilot maternity waiting home in Bolikhan, Lao PDR. The results suggest significantly different risk perceptions and experiences between Lao and western communities, based on contrasting views of embodiment, identity construction and cosmologies. In the Lao rural communities studied, there is little evidence yet of 'risk society' despite the introduction of western technologies and practices to improve maternal mortality and morbidity. It is argued that 'risk society' can be avoided.

The three delays as a framework for examining safe motherhood in Kafa zone, SNNPR, Ethiopia

The study examines delay as a crucial factor contributing to maternal mortality, using the conceptual framework of the Three Phases of Delay to explore factors that hinder the provision and utilisation of high quality, timely obstetric care in Kafa Zone, SNNPR, in Ethiopia. The Three Delays constitute the delay in deciding to seek medical care during an obstetric emergency, in reaching a medical facility, and in receiving suitable treatment in a health facility. Various aspects of the Three Delays are evaluated to examine problems of delay, transportation, and the referral system that is considered a vital element of the Ethiopian 'National Reproductive Health Strategy'.

‘Waiting-to-see’ if the baby will come : findings from a qualitative study in Kafa Zone, Ethiopia

Background: Much of the quantitative research on maternal mortality in developing countries focuses on the need for health service interventions such as skilled attendants at birth and emergency obstetric and newborn care. A growing number of studies document the need for a more comprehensive perspective and include the macrostructural, that is, the social, cultural, economic and political determinants of health.
Objectives: To examine the salient aspects of birth at home and variables that influence decision making around transfer to a health facility during prolonged/obstructed labor.
Methods: Ethnography using participant observation and semi-structured interviews was conducted in 2007. A total of 56 mothers in Kafa Zone were selected: 20 in-depth interviews with women who gave birth at home; four who gave birth in a health facility; and 32 during antenatal care. Interviews were also conducted with health staff from Bonga Hospital and 15 health centers or health posts. Analysis followed a process of data reduction, data display and conclusion drawing/verification with the data organized around key themes.
Results: Most women gave birth at home assisted by their neighbor, mother, mother-in-law, or husband. It is likely women who gave birth at home feel ‘safe’ because that is where birth normally takes place and where they feel supported by close relatives and neighbors. Prolonged labor or ‘waiting-to-see’ if the baby would come was somewhat normalized and resulted in considerable delays to seeking assistance. Women felt it was ‘unsafe’ to go to a health facility because of the very real possibility that they would die on the way.
Conclusion: The findings highlight the importance of educating the local communities to recognize pregnancy related risks and to develop and implement appropriate responses, especially early referral, as communities play an important mobilizing role to health services.

The place of birth in Kafa Zone, Ethiopia

In this qualitative study, I used an ethnographic approach to provide an understanding about the place of birth in rural and semiurban Kafa Zone, Ethiopia. I interviewed women about birth at home and asked what would happen if there were serious problems and a woman was taken to a health facility. The development of health services aimed at reducing maternal mortality implies that the place of birth must change from home to health facility, but the distance from international policy to its implementation is vast and the pathway is not a direct, linear route.

Home delivery in Southern Lao PDR: challenges to achieving MDG 4 & 5 targets

This study investigated rural Lao PDR village women's views and experiences of recent, or impeding, childbirth to better understand barriers to maternity service usage. Lao PDR has the highest maternal mortality rate (MMR) in the South-East Asian region with very low utilization rates for skilled birth assistance and health sector delivery services. The study site, Sekong, a southern Lao province, was lowest in the country on virtually all indicators of reproductive and maternal health, despite several recent maternal health service interventions. The study's aim was to gain a fuller understanding of barriers to maternity services usage to contribute towards maternity services enhancement, and district and national policy-making for progressing towards 2015 MDG 4 & 5 targets. 

Pluralist risk cultures: the sociology of childbirth

Western medical approaches to childbirth typically locate risk in women’s bodies,making it axiomatic that ‘good’ maternity care is associated with medically trainedattendants. This logic has been extrapolated to developing societies, like Vanuatu, anIsland state in the Pacific, struggling to provide good maternity care in line with theWorld Health Organization’s Millennium Development Goals. These goals include thereduction of maternal mortality by two-thirds by 2015, but Vanuatu must overcomechallenging hurdles – medical, social and environmental – to achieve this goal.Vanuatu is a hybridised society: one where the pre-modern and modern coincide inparallel institutions, processes and practices. In 2010, I undertook an inductive study of30 respondents from four main subcultures – women living in outer rural communitieswith limited access to Western-trained health workers; women from inner urbancommunities with ease of access to medical clinics; traditional birth attendants whoare formally untrained but highly specialised and practised mainly in remote communities;and Western-trained medical clinicians (obstetricians and midwives). I invitedall the participants to comment on what constituted a ‘good birth’. In this article, Ishow that participants interpreted this variously according to how they believed theuncertainties of childbirth could be managed. Objectivist approaches that define risk asan objective reality amenable to quantifiable measurement are thus rendered inadequate.Interpretivist approaches better explain the reality that social actors not only findrisk in different sites but gravitate towards different practices, discourses and individualsthey can trust especially those with whom they feel a strong sense of community.Strategies are, therefore, formed less through scientific rationality but according tofeelings and emotions and the lived experience. The concept of risk cultures conveysthis complexity; they are formed around values rather than calculable rationalities. Riskcultures form self-reflexively to manage contingent circumstances.

Sex and death: CHD1Z associated with high mortality in moorhens

Sex ratios in clutches of moorhens (Gallinula chloropus) in Britain were measured on 83 chicks using the sex-linked CHD1 gene (Chromo-helicase/ATPase-DNA binding protein 1). Among birds, the female is the hetero-gametic sex (Z and W chromosomes), and the male is homogametic (two copies of the Z chromosome). We report variation among the PCR-amplified fragments of the CHD1Z, and the death of nearly all heterozygous male chicks (92%). In contrast, survivorship among females and homozygote males was 54–60%. Mortality in male heterozygotes was significantly higher than that of male homozygotes (P < 0.001). Chick and egg biometrics were not significantly different between these males. The CHD1Z was unlikely to be directly responsible but may have been hitchhiked by the causal gene(s). The observations appear to follow a classic underdominance (heterozygote inferiority) pattern, but raise the paradoxical question of why one form of the Z chromosome has not been fixed, as is expected from evolutionary theory. We discuss possible explanations and include a survey of British populations based on skin specimens.

Association between maternal education and objectively measured physical activity and sedentary time in adolescents

BACKGROUND: Investigating socioeconomic variation in physical activity (PA) and sedentary time is important as it may represent a pathway by which socioeconomic position (SEP) leads to ill health. Findings on the association between children's SEP and objectively assessed PA and/or sedentary time are mixed, and few studies have included international samples.

OBJECTIVE: Examine the associations between maternal education and adolescent's objectively assessed PA and sedentary time.

METHODS: This is an observational study of 12 770 adolescents (10-18 years) pooled from 10 studies from Europe, Australia, Brazil and the USA. Original PA data were collected between 1997 and 2009. The associations between maternal education and accelerometer variables were examined using robust multivariable regression, adjusted for a priori confounders (ie, body mass index, monitor wear time, season, age and sex) and regression coefficients combined across studies using random effects meta-analyses. Analyses were conducted in March 2014.

RESULTS: Adolescents of university educated mothers spent more time sedentary (9.5 min/day, p=0.005) and less time in light activity (10 min/day, p<0.001) compared with adolescents of high school educated mothers. Pooled analysis across two studies from Brazil and Portugal (analysed separately because of the different coding of maternal education) showed that children of higher educated mothers (tertiary vs primary/secondary) spent less time in moderate to vigorous PA (MVPA) (6.6 min/day, p=0.001) and in light PA (39.2 min/day: p<0.001), and more time sedentary (45.9 min/day, p<0.001).

CONCLUSIONS: Across a number of international samples, adolescents of mothers with lower education may not be at a disadvantage in terms of overall objectively measured PA.