A research report submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Public Health in the field of Health Systems and Policy / Introduction: The maternal mortality ratio in Sedibeng District, Gauteng Province, from 2002 – 2004 was 220/100000. For the past decade HIV has been identified as a factor that has slowed the decline in maternal deaths in South Africa. The purpose of this study was to describe personal and service level factors contributing to maternal mortality of HIV positive women. It is hoped that the results of this study will be useful in developing interventions that will assist to curb the maternal mortality ratio. Methodology: Maternal death records were reviewed for the period 2004-2009. Data was collected on antenatal care, hospital care after admission and access to HIV services. The data were analysed using Stata 10. The results were compared with the national guidelines for the care of HIV positive pregnant women so as to identify discrepancies between the two. Results: One hundred and twenty five maternal death records were reviewed. Of these, 90% booked late for antenatal care i.e. beyond 20 weeks gestation. The majority (60.8%) of the women were HIV positive. Of the HIV positive women, 37.5% had CD 4 counts less than 200, which made them eligible for antiretroviral therapy. Of those that were eligible for antiretroviral therapy, 50.0% did not access the antiretrovirals due to late booking and loss to follow-up. Another main finding was that 36% died during the postnatal period. Conclusion: The antenatal bookings occurred after 12 weeks gestation which limited the time for starting patients on antiretroviral therapy. The high number of deaths during the postnatal period may indicate poor postnatal care and follow-up; as antiretroviral therapy could have been started during the postnatal period. Recommendations: Early antenatal booking and early HIV testing should be encouraged in communities. Antenatal services should be integrated so that HIV positive pregnant women are treated comprehensively and that the focus is not only on HIV, but also on other conditions such as TB, pneumonia, anaemia and hypertension. All pregnant HIV positive women must be done CD 4 counts; and all those found to be eligible for antiretroviral therapy should be given antiretrovirals timeously. Such women should be followed up and monitored closely. Postnatal check-up at 3 days should be strengthened for the mother-and-baby pair.

Introduction: The distribution of the causes of maternal deaths, and the impact of facility-based obstetric care access (obstetric access) at the individual and population level in India have not yet been quantified. Objectives: (i) estimate the physician agreement for coding of maternal deaths; (ii) explain the distribution of maternal mortality in India; and (iii) quantify the effect of obstetric access on the probability of maternal death, accounting for effect modification of state level skilled attendant coverage. Methods: I used the nationally representative Million Death Survey (MDS) of the causes of death from 2001-3. I identified context-specific risk factors from the field reports to provide information on care patterns before deaths. The 1096 MDS maternal deaths were matched to 147 001 controls of non-fatal deliveries from a representative fertility survey. Findings: 1.Inter-rater reliability was substantial for two physicians assigning a cause of death. 2. Three-quarters of India's maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated births in India. The distribution of major causes of maternal deaths (most notably hemorrhage, obstruction, sepsis, abortion) did not differ between poorer and richer states. Two-thirds of maternal deaths died seeking healthcare, most in a critical medical condition. 3. The probability of maternal death decreased with increasing skilled attendant coverage, among both women who had and had not accessed obstetric care. The risk of death among women who had obstetric access was higher (at 50% coverage, OR=2.32) than among those women who did not. However at higher population levels of coverage of safe birth, obstetric access had no effect. This effect appears to be driven partially by reverse causality, in which critical illness is shown to confound the association between care seeking and death. Conclusions: Simple MDS methods enable measurement of the levels, determinants of maternal deaths. Currently, obstetric access in India appears to be an indicator for inequitable access and poor quality even though it is a life-saving intervention. Reduction in maternal mortality in India will require expanded population-based coverage of skilled birth attendance and improved and early access to high quality obstetric care.

Introduction: The distribution of the causes of maternal deaths, and the impact of facility-based obstetric care access (obstetric access) at the individual and population level in India have not yet been quantified. Objectives: (i) estimate the physician agreement for coding of maternal deaths; (ii) explain the distribution of maternal mortality in India; and (iii) quantify the effect of obstetric access on the probability of maternal death, accounting for effect modification of state level skilled attendant coverage. Methods: I used the nationally representative Million Death Survey (MDS) of the causes of death from 2001-3. I identified context-specific risk factors from the field reports to provide information on care patterns before deaths. The 1096 MDS maternal deaths were matched to 147 001 controls of non-fatal deliveries from a representative fertility survey. Findings: 1.Inter-rater reliability was substantial for two physicians assigning a cause of death. 2. Three-quarters of India's maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated births in India. The distribution of major causes of maternal deaths (most notably hemorrhage, obstruction, sepsis, abortion) did not differ between poorer and richer states. Two-thirds of maternal deaths died seeking healthcare, most in a critical medical condition. 3. The probability of maternal death decreased with increasing skilled attendant coverage, among both women who had and had not accessed obstetric care. The risk of death among women who had obstetric access was higher (at 50% coverage, OR=2.32) than among those women who did not. However at higher population levels of coverage of safe birth, obstetric access had no effect. This effect appears to be driven partially by reverse causality, in which critical illness is shown to confound the association between care seeking and death. Conclusions: Simple MDS methods enable measurement of the levels, determinants of maternal deaths. Currently, obstetric access in India appears to be an indicator for inequitable access and poor quality even though it is a life-saving intervention. Reduction in maternal mortality in India will require expanded population-based coverage of skilled birth attendance and improved and early access to high quality obstetric care.

Magister Curationis - MCur / Background and Problem Statement: Maternal mortality is a global health issue, which mostly affects the developing countries. The United Nations (UN) member states have made a commitment to reduce maternal mortality by 75% by 2015. However, one of the biggest challenges in monitoring maternal deaths in Sub-Sahara Africa including Ghana, is the lack of adequate information for the accurate estimation of the maternal mortality rate (MMRate), and to identify causes of death. The World Health Organization (WHO) developed strategies and guidelines to assist countries to generate accurate information regarding maternal deaths. Maternal death review is one such strategy that was implemented in Ghana. Midwives are among the health workers who participate in the implementation of this strategy in different health facilities.However, what is not well understood is the role that midwives play in the implementation of Maternal Death Review (MDR).The purpose of the study: To explore and describe the roles that midwives play in the implementation of MDR in selected health facilities in Ghana‟s Ashanti Region.Methodology: A qualitative descriptive design was used to guide the research.Purposive sampling was conducted to select midwives who have been involved in maternal death review from the teaching, regional and district referral hospitals. Data was collected by conducting semi-structured individual interviews. Data saturation was reached after twenty interviews. Thematic Content Analysis was used to manage and analyse data. The Facility-based maternal death review model was used to assist the researcher to identify and organize the emerged themes. Ethical clearance was obtained from the University, as well as approval from the management of the health facilities prior to approaching the informants.Main findings: The results of this study indicate that midwives in Ghana‟s Ashanti Region are undertaking various activities and duties in all the stages of the Facilitybased maternal review model. The type of activities and duties undertaken by midwives varied according to their seniority and the level of the health facilities.Conclusion and recommendation: The findings of this study bring insight into the roles played by midwives in the implementation of the Facility-based maternal death review process in the health facilities in Ghana‟s Ashanti Region. These findings have a direct implication for the training and education of midwives. It is recommended that issues related to maternal death review methods and processes be included in the formal and continuing training and education of midwives. However, further research considering the training and practice development needs of midwives in respect of implementation of maternal death review is required.

Magister Public Health - MPH / Background: Maternal mortality is a significant public health problem world-wide,as it is an important indicator for the functioning of the health system. The maternal mortality ratio for Botswana is higher than other countries with comparable economic growth, despite impressive access to health services. In order to develop relevant programs and policies to reduce maternal mortality, the factors associated with maternal mortality were studied. The study aimed to describe the maternal and health services factors associated with maternal mortality in South East Botswana. Methodology: A quantitative case-control study was used to retrospectively review medical records for 71 cases of maternal deaths and 284 controls randomly selected from mothers who delivered in the same year and at the same health facility, in South East Botswana from 2007 to 2009. Information was collected on the maternal and health services characteristics of the cases and controls including age, level of education, marital status, parity, utilization of health facilities that consist of antenatal care (ANC), type of delivery, complications during pregnancy, type of health facility and ANC provider. Data was analyzed using Predictive Analysis Software (PASW) Version 18.Two-sample t- test, Pearson’s Chi-square test and the Fisher’s exact test were used to test the difference between the proportions of the various categories of variables in cases and controls. Univariate logistic regression analysis was applied to identify the risk factors associated with maternal deaths. A multivariate logistic regression model was estimated to see the joint effects of the identified risk factors for maternal mortality. Hosmer and Lemeshow test was used to test the goodness of fit of the model. Results: The mean age of the maternal deaths was 28.0 ± 5.3 years and they had taken place at a hospital (100%). A large number of deaths occurred before delivery(59.0%). The causes of maternal death included both direct (73%) and indirect causes (27%). Direct causes were the leading causes of death and they were abortion(22.5%) and haemorrhage (18.3%). The maternal characteristics associated with maternal mortality were having complications at delivery (OR=20.91), not receiving ANC (OR=6.31) and delivering by caesarean section (OR= 2.66). The health facility characteristics associated with maternal mortality were delivering outside the health facility (OR=14.78), having been referred from another facility (OR=8.62) and delivering at a general hospital (OR=5.91). The data produced a model with good fit that included one maternal risk factor and three health facility risk factors. These were being admitted with preterm labour, delivering at a general hospital or before arrival at the health facility and having been referred from another health facility. Conclusion: Maternal mortality was associated with both maternal and health facility risk factors. The model developed may be used to identify and manage highrisk women to reduce the number of maternal deaths. It was recommended that, the current system should continue to be monitored and evaluated through the Maternal Mortality Monitoring System (MMMS). Furthermore, the referral and management of complications needs to be strengthened through a multi-sectoral approach.

Se presenta el caso de una mujer de 19 años con 29 semanas de gestación, procedente de Llumpe (Ancash) con antecedentes de viajes a las localidades de Chanchamayo (Junín) y Rinconada (Ancash). Ingresó al Hospital de Chacas (Ancash) por presentar mal estado general, deshidratación, dificultad respiratoria, ictericia, sensación de alza térmica y dolor abdominal, tuvo reporte de: hemoparásitos 60% en frotis sanguíneo. Fue transferida al Hospital Ramos Guardia (Huaraz) donde presentó mayor dificultad respiratoria, coluria, hematuria, disminución del débito urinario y reporte de Plasmodium (+), luego fue transferida al Hospital Cayetano Heredia (Lima) donde ingresó a la Unidad de Cuidados Intensivos (UCI), con evolución a falla multiorgánica, óbito fetal y muerte. Recibió indicación de ventilación mecánica, tratamiento con clindamicina y quinina, que no recibió por falta de disponibilidad. La evolución de la enfermedad fue tórpida, cursando con falla orgánica múltiple y muerte. Se confirmó infección por Plasmodium vivax. Destacamos la importancia de mejorar nuestras capacidades de diagnóstico y manejo para brindar un tratamiento adecuado y oportuno. / This is the case of a 19-year-old woman, with 29 weeks of pregnancy, from Llumpe (Ancash, Peru) with a history of traveling to the towns of Chanchamayo (Junín, Peru) and Rinconada (Ancash, Peru). She was admitted to the Chacas Hospital (Chacas, Ancash, Peru) with a general poor condition, dehydration, respiratory distress, jaundice, apparent elevation of body temperature, and abdominal pain. A microscopic examination of blood films revealed a 60% of hemoparasites. She was transferred to the Ramos Guardia Hospital (Huaraz, Peru) where presented more difficulty to breath, choluria, haematuria and decreased urine output, also a positive test for Malaria parasites (Plasmodium). Then, she was transferred to the Cayetano Heredia Hospital (Lima, Peru), admitted to the intensive care unit (ICU) where she suffered multiple organ failure and death. The product was stillborn. She had indication of mechanical ventilation, and antibiotic treatment with clindamycin and quinine which did not received by unavailability. The disease evolution was torpid. Plasmodium vivax infection was confirmed. We emphasize the importance of improving our diagnostic capabilities and management to provide adequate and timely treatment.

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.

[pt] Partindo da lente dos direitos humanos para compreender a temática dos direitos sexuais e reprodutivos, o presente trabalho se debruça sobre os limites e o alcance das diretrizes humanísticas diante das mulheres vítimas de violência e morte no âmbito do sistema de saúde. O ensaio tem como foco principal o tema da mortalidade materna, identificada como importante indicador das condições de vida e saúde das mulheres e suscitada enquanto grave violação de direitos humanos e busca, por meio de uma abordagem interseccional, conceder luz aos diversos eixos de opressão presentes na abordagem a partir das contribuições de autoras como Kimberlé Crenshaw, Patricia Hill Collins e Jurema Werneck. Com a constatação de que mais de noventa por cento das mortes maternas são evitáveis, bem como com a convivência de altos índices de mortalidade materna anuais no país, o trabalho aborda o tema enquanto parte de um projeto político firmado a partir da imposição de sofrimento, da precarização de vidas e da estigmatização de corpos, considerando os direcionamentos políticos que parecem convergir para um cenário de intensificação de violação de direitos. Articulando conceitos de Judith Butler, o ensaio atenta à mortalidade materna a partir da perspectiva da morte digna ou não de lamento, buscando formas de reafirmação dos direitos humanos a partir de seu comprometimento concreto com as mulheres que vivenciam formas de violência no sistema de saúde nacional. / [en] Based on the lens of human rights to understand the theme of sexual and reproductive rights, the present paper focuses on the limits and the scope of the humanistic guidelines before women victims of violence and death within the health system. The main focus of the essay is the issue of maternal mortality, identified as an important indicator of women s living conditions and health, and raised as a serious violation of human rights, and seeks, through an intersectional approach, to give light to the various categories of social inequality present in the analysis from the contributions of authors such as Kimberlé Crenshaw, Patricia Hill Collins and Jurema Werneck. With the observation that more than ninety percent of maternal deaths are preventable, as well as with the coexistence of high annual maternal mortality rates in the country, the study addresses this issue as part of a political project based on the imposition of suffering, the precariousness of lives and the stigmatization of bodies, taking into account the political orientations that seem to converge to a scenario of intensification of violation of rights. Articulating concepts by Judith Butler, the essay focuses on maternal mortality from the perspective of death qualifying or not as grievable, seeking ways to reaffirm human rights based on its concrete commitment to women experiencing forms of violence in the national health system.

Unsafe abortion is a worldwide reproductive health issue and a contributing factor of high numbers of maternal death in the developing world. Many international conferences and assemblies acknowledge the issue and urge governments to take action. Abortion is a phenomenon surrounded by strong opinions, many times regulated by restrictive laws as well as socio-ethical, religious and cultural norms. Factors often active in making abortion a clandestine procedure which take place under unsafe conditions.The Philippines have one of the most restrictive laws on abortion in the world, but it does not diminish the occurrence of abortion in the country. There is unmet need for family planning that in turn makes way for unwanted pregnancies ending in unsafe abortion. Attempts in congress aiming at providing universal reproductive health service are being opposed and the issue of abortion is surrounded by its criminal ban and a great social stigma. The Roman Catholic Church is very present in the Philippine society and also offers a powerful voice against abortion and equally rejects modern contraception.This study look into how the issue of abortion – under its criminal ban – is being dealt with and if there are any actors/groups/organisations of social work, within the reproductive health sector or women’s organisations acting upon this, making abortion an issue and a part of their work. It asks if there is any advocacy for abortion in the Philippines and any interventions for the women concerned. If so, how is abortion spoken about and understood and how is that notion put into action? Groups are identified as either anti-abortion or pro-abortion, two discourses addressing abortion as a public health issue in fundamentally different ways.There are groups that might not be public about their opinion being pro-abortion, as they do not wish to get on the wrong side of the general opinion or negatively affect their reputation. Some pro-abortion groups are found acting against the law by providing safe abortions for these women. Trough social constructivist glasses this study look at the structure surrounding abortion in the Philippines, analysing how these discourses are being reconstructed and transferred under different postulations as anti-abortion or pro-abortion.

L’accouchement et ses conséquences demeurent une des principales causes d’incapacité et de décès pour les femmes dans les pays en développement et comprendre l’utilisation tardive des soins obstétricaux d’urgence au moment d’une complication obstétricale constitue un véritable défi en santé publique. La présente étude qualitative relate l’expérience d’accouchement difficile au Mali, en milieu rural. Dans un contexte de pluralité de systèmes de soins, l’objet de cette étude consiste à déterminer les raisons de l’arrivée tardive des femmes au centre de santé de 1ier ligne, à saisir la compréhension qu’elles ont de l’utilisation des services sanitaires, enfin à reconstruire les processus de prise de décisions de recourir aux soins modernes. Cette étude s’inscrit dans une démarche de type ethnographique. Des entretiens semi dirigés et l’observation des interactions entre les femmes et les professionnels de santé ont constitué le corpus de données. Nous retenons qu’une série de facteurs entrent en jeu pour comprendre le problème de l’utilisation tardive des soins obstétricaux d’urgence. Des contraintes exogènes liées à la distance et l’immédiateté de l’urgence obstétricale c'est-à-dire la mobilisation des ressources et des moyens de transport, accompagnées de contraintes endogènes telles que la subordination des femmes au consentement familial, la perception de la qualité des soins et de la compétence des soignants, influencent systématiquement le choix de recourir aux soins modernes. Le phénomène de gestion collective de la complication obstétricale s’inscrit dans un contexte d’intéractions complexes où l’opinion des femmes est totalement minimisée. / Childbirth and its consequences remain a leading cause of disability and death for women in developing countries and the late use of emergency obstetric care during obstetric complications is a challenge in public health. This qualitative study describes the experience of difficult childbirth in Mali, in rural areas. In a context of multiple systems of care, the purpose of this study is first to determine the reasons for the late arrival of women in the health center, to grasp their understanding of the use of health care services, and finally to reconstruct the decision making process to use modern health care. This study is part of an ethnographic approach. Semi-structured interviews and observation of interactions between women and health professionals were conducted. Numerous factors come into play to understand the problem of late use of emergency obstetric care. Exogenous constraints related to the distance and immediacy of the obstetric emergency that is to say the mobilization of resources and means of transport, influence the choice of women to use modern obstetric cares. In the same way, endogenous constraints such as the subordination of women in the family consent, perception of quality of care and skill of caregivers, systematically influence the choice to use modern health care. Collective management of obstetric complications we have observed, occur in a context where the opinion of women is completely minimized.