After decades of decrease, maternal mortality rates have shown a slight increase in Europe. Immigrants, especially Africans, have shown to be at higher risk than native women. This could not be explained solely by well-known obstetric and socio-economic risk factors. The aim of this thesis was to study incidence, classification and quality of care of maternal deaths in Sweden, with focus on the foreign-born population. The study population was identified through linkage of the Cause of Death Register, Medical Birth Register, and National Patient Register, and medical records obtained from hospitals. Data from registers, death certificates, and medical records were reviewed. Suboptimal care was studied by structured implicit review of medical records. Differences between foreign- and Swedish-born women were analysed by relative risks, Chi2- and Fisher’s exact test. Underreporting of maternal mortality was shown to be substantial: as compared to the official statistics, 64% more maternal deaths were identified. Women born in low-income countries were identified as being at highest risk of dying during reproductive age in Sweden. The relative risk of dying from diseases related to pregnancy was 6.6 (95% confidence interval 2.6–16.5) for women born in low-income countries, as compared to Swedish-born women. Major and minor suboptimal factors related to care-seeking, accessibility, and quality of care were found to be associated with a majority of maternal deaths and significantly more often to foreign-born women. Suboptimal factors identified included non-compliance, communication barriers, and inadequate care. The rate of suicides during pregnancy or within one year after delivery did not change during the last three decades, and was higher for foreign-born women. A majority of women who committed suicide had been under psychiatric care, but such documentation at antenatal care was inconsistent, and planning for follow-up postpartum was generally lacking. The conclusion of this thesis is that foreign-born women are a high-risk group for maternal death and morbidity that calls for clinical awareness with respect to their somatic and psychiatric history, care-seeking behaviour, and communication barriers. Cross-disciplinary care is necessary, both in obstetric emergencies and in cases of maternal psychiatric illness, to avert maternal death and suicide.

This thesis consists of three essays that address various aspects of the economics of maternal health care. The first two essays examine the determinants of utilization of maternal health care services in low-income countries, while the third essay examines the determinants of utilization of prenatal ultrasonography in Canada. The first essay examines the influence of prenatal attendance (as well as a wide array of observed individual-, household- and community-level characteristics) on a woman’s decision to give birth at a health facility or at home for thirty-two low-income countries (across Asia, Sub-Saharan Africa and Latin America). This empirical investigation employs the Demographic and Health Surveys (DHS) data and a two-level random intercept model. The results show that prenatal attendance has a substantial influence on the use of facility delivery in all three geographical regions. Women having four prenatal visits were 7.3 times more likely to deliver at a health facility than those with no prenatal care. The second essay addresses two related questions: what factors determine a woman’s decision to seek prenatal care; and are those the same factors that determine the frequency of care? This investigation also utilizes Demographic and Health Surveys (DHS) data for thirty-two low-income countries (across Asia, Sub-Saharan Africa and Latin America) and applies a two-part and multi-level model to that data. The results suggest that, though a wide range of factors influence both decisions, that influence varies in magnitude across the two decisions, as well as across the three geographical regions. The third essay examines the influence of various socioeconomic and demographic factors on the frequency of prenatal ultrasounds in Canada, while controlling for maternal risk profiles. This investigation utilizes data from the Maternity Experience Survey (MES) of the Canadian Perinatal Surveillance System and employs a count data regression model (the Poisson distribution) to estimate the effect of various factors on the number of prenatal ultrasounds. The results of this investigation suggest that, even after controlling for maternal risk factors, the type of health-care provider, province of prenatal care, and timings of first ultrasound are the strongest predictors of number of ultrasounds.

The global burden of injury is severely underappreciated and disproportionately affects low-income countries. With timely, appropriate orthopaedic treatment disability and mortality can be prevented, yet appropriate health resources are seldom available. Without orthopaedic medical devices (OMDs), quality of orthopaedic care suffers and the burden of preventable injury is exacerbated. A qualitative case study of 45 key informant interviews was conducted in Uganda to explore accessibility of OMDs, such as plaster, external fixators and implants. Data analysis elicited four major themes as barriers preventing access to OMDs in Uganda: 1) Poor leadership in government and corruption; 2) inadequate human resources; 3) inefficient and insufficient health care infrastructure; and 4) high costs of OMDs and poverty. Potential solutions for improving access to orthopaedic care were categorized as policies prioritizing orthopaedic services, training more orthopaedic specialists and creating incentives for them to work in underserviced areas, and innovative strategies funding for orthopaedic services.

The global burden of injury is severely underappreciated and disproportionately affects low-income countries. With timely, appropriate orthopaedic treatment disability and mortality can be prevented, yet appropriate health resources are seldom available. Without orthopaedic medical devices (OMDs), quality of orthopaedic care suffers and the burden of preventable injury is exacerbated. A qualitative case study of 45 key informant interviews was conducted in Uganda to explore accessibility of OMDs, such as plaster, external fixators and implants. Data analysis elicited four major themes as barriers preventing access to OMDs in Uganda: 1) Poor leadership in government and corruption; 2) inadequate human resources; 3) inefficient and insufficient health care infrastructure; and 4) high costs of OMDs and poverty. Potential solutions for improving access to orthopaedic care were categorized as policies prioritizing orthopaedic services, training more orthopaedic specialists and creating incentives for them to work in underserviced areas, and innovative strategies funding for orthopaedic services.

Thesis (Ph. D.)--University of Alabama at Birmingham, 2007. / Additional advisors: Lois M. Christensen, Lynn D. Kirkland, Maryann Manning, Dorothy Riley. Description based on contents viewed June 12, 2008; title from title screen. Includes bibliographical references (p. 121-126).

Thesis (Ph. D.)--University of Alabama at Birmingham, 2007. / Additional advisors: Lois M. Christensen, Lynn D. Kirkland, Maryann Manning, Dorothy Riley. Includes bibliographical references (p. 121-126).

Thesis (M. Sc.)--University of Hong Kong, 1997. / Year of submission on cover: 1997. Includes bibliographical references (leaf 87-90).

Thesis (M.S.W.)--Smith College School for Social Work, Northampton, Mass., 2009. / Includes bibliographical references (p. 79-82).

Thesis (Ph. D.)--University of Texas at Austin, 2004. / Supervisor: John E. Roueche. Vita. Includes bibliographical references.

Thesis (Ph. D.)--Ohio State University, 2007. / Title from first page of PDF file. Includes bibliographical references (p. 210-223).