The causes of maternal mortality in adolescents in low and middle income countries: a systematic review of the literature

Background: While the main causes of maternal mortality in low and middle income countries are well understood, less is known about whether patterns for maternal deaths among adolescents are the same as for older women. This study systematically reviews the literature on cause of maternal death in adolescence. Where possible we compare the main causes for adolescents with those for older women to ascertain differences and similarity in patterns of mortality. Methods: An initial search for papers and grey literature in English, Spanish and Portuguese was carried out using a number of electronic databases based on a pre-determined search strategy. The outcome of interest was the proportion of maternal deaths amongst adolescents by cause of death. A total of 15 papers met the inclusion criteria established in the study protocol. Results: The main causes of maternal mortality in adolescents are similar to those of older women: hypertensive disorders, haemorrhage, abortion and sepsis. However there was marked heterogeneity between papers which could indicate country or regional differences in the importance of specific causes of adolescent maternal mortality. When compared with causes of death for older women, hypertensive disorders were found to be a more important cause of mortality for adolescents in a number of studies in a range of settings. In terms of indirect causes of death, there are indications that malaria is a particularly important cause of adolescent maternal mortality in some countries. Conclusion: The main causes of maternal mortality in adolescents are broadly similar to those for older women, although the findings suggest some heterogeneity between countries and regions. However there is evidence that the relative importance of specific causes may differ for this younger age group compared to women over the age of 20 years. In particular hypertensive conditions make up a larger share of maternal deaths in adolescents than older women. Further, large scale studies are needed to investigate this question further

Improving the resilience and workforce of health systems for women’s, children’s, and adolescents’ health

The United Nations’ first Every Woman Every Child strategy, Global Strategy for Women’s and Children’s Health, provided an impetus “to improve the health of hundreds of millions of women and children around the world and, in so doing, to improve the lives of all people.” The updated Global Strategy for Women’s, Children’s, and Adolescents’ Health calls for an even more ambitious agenda of expanding equitable coverage to a broader range of reproductive, maternal, newborn, child, and adolescent health services, as integral to the 2030 targets of the sustainable development goals.These goals cannot be realised by efforts that tackle only specific parts of the global strategy. Instead, an integrated approach is required, to include the complementary functions of stewardship, financing, workforce, supply chain, information systems, and service delivery.3 In this paper we highlight two core aspects that require urgent attention—building the resilience of health systems and ensuring sufficient human resources

Using advocacy and data to strengthen political accountability in maternal and newborn health in Africa

AbstractAccountability mechanisms help governments and development partners fulfill the promises and commitments they make to global initiatives such as the Millennium Development Goals and the Global Strategy on Women’s and Children’s health, and regional or national strategies such as the Campaign for the Accelerated Reduction in Maternal Mortality in Africa (CARMMA). But without directed pressure, comparative data and tools to provide insight into successes, failures, and overall results, accountability fails. The analysis of accountability mechanisms in five countries supported by the Evidence for Action program shows that accountability is most effective when it is connected across global and national levels; civil society has a central and independent role; proactive, immediate and targeted implementation mechanisms are funded from the start; advocacy for accountability is combined with local outreach activities such as blood drives; local and national champions (Presidents, First Ladies, Ministers) help draw public attention to government performance; scorecards are developed to provide insight into performance and highlight necessary improvements; and politicians at subnational level are supported by national leaders to effect change. Under the Sustainable Development Goals, accountability and advocacy supported by global and regional intergovernmental organizations, constantly monitored and with commensurate retribution for nonperformance will remain essential

Home birth in the UK: a safe choice?

The safety of home as a place of birth in developed countries, and the extent to which pregnant women should have the right to choose a home birth, are highly contentious and emotive subjects which have been hotly debated for many years. Since 1993, Government policy in England and Wales has been that pregnant women should have a free and informed choice about whether to give birth at home or in a hospital or birthing centre. However, fewer than 3% of maternities take place at home, indicating either that this option is not routinely available or that most women do not want to have a home birth. Previous research indicates that there is an element of both, and that most women believe that hospital birth is safer than home birth. Although research has demonstrated that, for low-risk pregnancies in most developed countries, perinatal death is no more common for planned home birth than for hospital birth, and that maternal outcomes tend to be better if there is a planned home birth, this research has been done at the population level. At the level of the individual women, there remain lingering doubts over whether home birth can be as safe as hospital birth if there are serious complications in labour. Using data from four UK datasets, this thesis contains detailed analysis of the characteristics of women who plan a home birth in the UK, and how these have varied over time and according to where the woman lives. Recognising that decisions about place of birth are subject to change over the course of a pregnancy, the analysis presented here identifies key factors which robustly predict whether women will express an intention to give birth at home, whether their intentions will change during the pregnancy, and whether those who intend a home birth will actually have a planned home birth. Understanding these predictors helps to understand the factors that may influence women’s choices at different stages of pregnancy. There is evidence from this analysis to suggest that women do not all have equal access to choice about where to give birth. Understanding of the factors that predict women’s choices also enables a fair comparison of the relative safety of planned home birth and planned hospital birth, while controlling for the fact that women who plan a home birth are not a random sub-set of the population of childbearing women. From the perspective of the mother, planning a home birth (whether or not she goes on to give birth at home) is associated with a much lower risk of the potentially life-threatening postpartum haemorrhage (defined as the loss of more than 1,000ml of blood) and several other distressing labour complications such as retained placenta. From the perspective of the baby, the risk of perinatal death is slightly, but not significantly higher, if a home birth is planned than if a hospital birth is planned, even if high-risk pregnancies are included in the analysis. However, there is weak evidence to suggest that, if pregnancy/labour is complicated by malpresentation, umbilical cord prolapse or the need for infant resuscitation via positive pressure/cardiac massage, the risk of perinatal death is higher if a home birth is planned than if a hospital birth is planned. Other pregnancy and labour complications are associated with a higher risk of negative outcomes, but this is true whether a home birth or a hospital birth is planned – hospital birth has not been shown to be safer in these situations. Malpresentation occurs in roughly 1 in 20 pregnancies and is detectable before labour commences, so this research provides some support for the current advice that women with a malpresented foetus should be advised to plan a hospital birth unless and until midwives attending home births can be fully confident in their ability to deliver a malpresented foetus vaginally. Cord prolapse and the need for positive pressure/cardiac massage, on the other hand, are both extremely rare and not predictable before labour. Given their rarity and the lack of strong evidence that home birth is less safe when they occur, rather than being encouraged to plan a hospital birth ‘just in case’, women should be provided with the available information and allowed to come to an informed decision without being put under pressure to choose any particular birth setting. Additionally, midwives attending home births should have a thorough grounding in dealing effectively with these situations when they occur in the home settin

Maternal mortality in adolescents compared with women of other ages: evidence from 144 countries

BackgroundAdolescents are often noted to have an increased risk of death during pregnancy or childbirth compared with older women, but the existing evidence is inconsistent and in many cases contradictory. We aimed to quantify the risk of maternal death in adolescents by estimating maternal mortality ratios for women aged 15–19 years by country, region, and worldwide, and to compare these ratios with those for women in other 5-year age groups.MethodsWe used data from 144 countries and territories (65 with vital registration data and 79 with nationally representative survey data) to calculate the proportion of maternal deaths among deaths of females of reproductive age (PMDF) for each 5-year age group from 15–19 to 45–49 years. We adjusted these estimates to take into account under-reporting of maternal deaths, and deaths during pregnancy from non-maternal causes. We then applied the adjusted PMDFs to the most reliable age-specific estimates of deaths and livebirths to derive age-specific maternal mortality ratios.FindingsThe aggregated data show a J-shaped curve for the age distribution of maternal mortality, with a slightly increased risk of mortality in adolescents compared with women aged 20–24 years (maternal mortality ratio 260 [uncertainty 100–410] vs 190 [120–260] maternal deaths per 100?000 livebirths for all 144 countries combined), and the highest risk in women older than 30 years. Analysis for individual countries showed substantial heterogeneity; some showed a clear J-shaped curve, whereas in others adolescents had a slightly lower maternal mortality ratio than women in their early 20s. No obvious groupings were apparent in terms of economic development, demographic characteristics, or geographical region for countries with these different age patterns.InterpretationOur findings suggest that the excess mortality risk to adolescent mothers might be less than previously believed, and in most countries the adolescent maternal mortality ratio is low compared with women older than 30 years. However, these findings should not divert focus away from efforts to reduce adolescent pregnancy, which are central to the promotion of women's educational, social, and economic development

The methodological challenges of attempting to compare the safety of home and hospital birth in terms of the risk of perinatal death

This paper identifies a number of methodological difficulties associated with the comparison of home and hospital birth in terms of the risk of perinatal death, and suggests ways in which these problems can be overcome. A review of recent studies suggests that most available data sources are unable to overcome all of these challenges, which is one of the reasons why the debate about whether perinatal death is more likely if a home birth is planned or if a hospital birth is planned has not been satisfactorily resolved. We argue that the debate will be settled only if perinatal mortality data from a sufficiently large number of maternity care providers over a sufficiently long period of time can be pooled and made available for analysis. The pooling of data will bring about its own difficulties due to variations over time and between providers and geographical areas, which would need to be taken into account when analysing pooled data. However, given the impracticality of a randomised controlled trial and the rarity of home birth in most of the Western world, we argue that more effort should be made to pool data for perinatal mortality and other rare pregnancy outcomes, and share them between health providers and researchers. Thus, high-quality analyses could be conducted, allowing all women to make an informed choice about place of birth. However, pooling data from countries or states with very different maternity care systems should be avoided

Home births in the UK, 1955-2006

This article presents data on trends in the percentage of maternities taking place at home in the UK. As well as the national trend, the article examines how home maternity levels vary according to mother’s age, number of previous live births within marriage, country of birth, region, local authority and NHS Trust. Examination of trends and variations in home maternity levels provides a context for debates regarding factors that may influence where women give birth