In this dissertation, I aim to examine how policy packages focusing on improving reproductive conditions impact adverse maternal outcomes at the local level. I use the National Institute of Reproductive Health’s Local Reproductive Freedom Index (NIRH LRFI) to advance scholarship and policy advocacy on how policies included in that index may lessen the overall maternal mortality rate while also perhaps diminishing the disparity in maternal mortality between women of color and white women in 50 major U.S. cities. I argue that policy may be an effective—though under-studied—avenue for reducing the risk of maternal mortality because policies can be used to target specific social factors that research has demonstrated place individuals at higher risk of a negative outcome. However, these policy avenues usefully can be considered as interconnected policy packages rather than merely as single-policy interventions. Additionally, current research in this area suggests that there is a clear need for more research that combines SDH with policies aimed at improving health outcomes for reproducing individuals, particularly for communities of color (Creanga et al. 2015b; Kozhimannil, Vogelsang, and Hardeman 2015; Osypuk et al. 2015). As such, I situate maternal mortality, and specifically racial disparities in maternal mortality, among social determinants of health. Overall, I argue that to successfully decrease aggregate maternal mortality rates and lessen racial disparities in reproductive health, it is essential to center the experiences and needs of women of color and use a critical lens when evaluating measures assessing reproductive freedom.

Every year roughly 350,000 women die during childbirth, primarily from preventable causes. The developing world accounts for the majority of this number, and in many regions maternal mortality rates are currently increasing despite the advancements our world has seen in the past decades. Maternal mortality has become a global issue, with international initiatives being launched around the globe. However, this problem hits closer to home than many Americans may know. The United States has the highest GDP in the world, yet it has only the 48th lowest maternal mortality rate. In addition, the past decade has seen our national maternal mortality rate increase rather than decrease. Throughout my study I explore why the United States is not a safer nation for women to give birth in considering our status as a wealthy, developed nation. In doing so I expose the problems inherent in the American medical system and the roots of those problems in larger cultural and social issues. Beneath this is an examination of the history of midwifery in the United States and an argument for increased use of midwives by American mothers and increased collaboration between midwives and the American medical system.

Magister Philosophiae - MPhil / Skilled birth attendance at childbirth is vital for decreasing maternal and child mortality in Zimbabwe. Infant mortality and maternal mortality in Zimbabwe are quite high due to low- use of skilled birth attendance. Based on different study sources, home delivery with complications are high, with many socio-economic and demographic associated factors including lack or no use of skilled birth attendance at childbirth in Zimbabwe. Therefore, the study looked at "preventive" which refers to an action taken to reduce or eliminate the probability of specific undesirable events or dangers from happening in the future and the present time in Zimbabwe. The objective of the study was to highlight the significance of the crucial function within the health systems of saving both the lives of a mother and the child. Furthermore to determine the frequent use of maternal health care services (skilled birth attendant) and identify factors affecting them. The data that was used was nationally represented large scale secondary data ZDHS of Zimbabwe with sample population n = 9,171. It was a secondary data that included all the provinces of Zimbabwe, simple random sampling was used that had questionnaires of both man, women and household questionnaires, these questionnaires helped in examining the socio-economic factors and determinants that leads to low-use of skilled birth attendants at childbirth. The prosed statistics analysis that were used were univariate, bivariate and multivariate techniques. The statistical analysis showed that demographic variables such age, place of delivery and socio-economic factors such as level of education of a mother and wealth index (occupation of a parent) and region has a significant effect on the use of skilled birth attendant during birth. Women with higher level of education were found to have high use rate of maternal health care services (Skilled birth attendants), while women with primary and secondary education were found to have high use rate of less ( traditional birth attendant) or no use of skilled birth attendant. Therefore, the female age at birth, place of delivery, level of education and wealth index played a major role in decision making about the importance of having a skilled birth attendant when giving birth. The access to skilled birth attendance was found to be a significant factor in reducing maternal and child mortality in Zimbabwe. Furthermore women need to be educated about the importance of maternal health care services use and postnatal care and the department of health in Zimbabwe can implement mobile clinics for those who are residing far from health facilities.

Objetivo. O valor da mortalidade materna como tema relevante para a Saúde Pública mobilizou esforços de governos e organizações, nacionais e internacionais, para a proposição de programas de prevenção e de redução da mortalidade materna. Os Comitês de Estudos de Morte Materna têm sido considerados como um dos instrumentos importantes no combate à mortalidade materna em todo o mundo. O primeiro Comitê de Estudos de Morte Materna criado no Brasil foi o do estado de São Paulo, em 1988. Este estudo teve como objetivo recuperar e caracterizar a trajetória da criação e implantação desse Comitê e os fatores intervenientes no seu percurso evolutivo. Métodos. Os dados que constituíram a base empírica do estudo foram entrevistas com integrantes, ex-integrantes e fundadores do Comitê do Estado de São Paulo e documentos como: atos oficiais, relatórios técnicos, atas de reuniões, normas operacionais, entre outros. Resultados. A análise dos dados mostrou uma trajetória oscilante, marcada por períodos de atividade e de refluxo tendo sido alteradas, ao longo do tempo, a sua composição e estrutura organizacional, mantendo-se, porém, seus objetivos e funções. Considerações finais. Os dados examinados revelaram que a criação do Comitê representou um avanço para a saúde materna. Mostraram também uma expressiva influência, no percurso do Comitê, das injunções político-institucionais, no âmbito da Administração governamental do estado, no período estudado e o reconhecimento de sua posição como instância situada para além de uma estratégia de vigilância epidemiológica. / As a relevant theme for Public Health, maternal mortality has engendered efforts on the part of Governments as well as of national and international organizations in the proposition of programs for prevention and reduction of maternal mortality. All over the world, the Committees for Stu been considered as important tools on fight against maternal mortality. In Brazil, the first Committee for Studies on Maternal Death was the one created in State of São Paulo, in 1988. The target of the present study was to recover and characterize the trajectory of the creation and implantation of this Committee as well as to make a survey on the intervening factors occurring in its course of evolution. Methods. Data on interviews held with members, former members and founders of São Paulo State Committee for Studies on Maternal Death and documents such as official acts, technical reports, minutes of meetings and, operational norms, among others, constituted the empirical basis for this study. Results. Data analysis disclosed an oscillatory course, marked by periods of activity and reflux. Along the years,both its composition and organizational structure were altered, although maintaining its purposes and functions. Final considerations. According to data, the creation of the Committee represented an improvement for the maternal health. They also indicated that in the course of the Committee there happened, in the studied period, an expensive influence of political-institutional injunctions, in the ambit of the state government administration, and the acknowledgement of this status as an instance located beyond the epidemiological surveillance.

Orientador: José Guilherme Cecatti / Tese ( doutorado ) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-11-09T15:32:48Z (GMT). No. of bitstreams: 1 Pacagnella_RodolfodeCarvalho_D.pdf: 10638117 bytes, checksum: 8f100a09c4f1f7363e14fe20dcfe772e (MD5) Previous issue date: 2011 / Resumo: Introdução: Embora a maioria das causas das mortes maternas seja evitável, não podem ser previstas, mesmo nos melhores contextos, mesmo onde haja pré-natal adequado, educação adequada e bom suporte nutricional. Contudo, embora as complicações no parto e puerpério não sejam previsíveis e nem preveníveis, os indicadores de mortalidade materna são extremamente sensíveis à instituição de cuidados obstétricos adequados e o tempo na obtenção de cuidados adequados é o fator mais importante relacionado às mortes maternas. A partir dessa observação um modelo "three delays" que avalia as demoras na assistência obstétrica tem sido amplamente utilizado como referencial teórico para a pesquisa sobre mortalidade materna. Seu uso tem sido intensificado a partir da utilização do conceito de near-miss materno, uma alternativa à mortalidade materna. Objetivos: Avaliar a associação entre demoras na obtenção de cuidados obstétricos adequados e diferentes desfechos maternos segundo o modelo "three delays". Método: foi realizada ampla revisão bibliográfica e elaboração de um ensaio abordando o marco conceitual sobre o tema e um estudo de corte transversal multicêntrico para vigilância prospectiva e coleta de dados para a identificação dos casos com morbidade materna grave (MMG) e condições potencialmente ameaçadoras da vida (CPAV) segundo critérios previamente definidos pela OMS. Dados sobre as demora foram colhidos dos prontuários médicos e por informações com a equipe assistente. Resultados: Os dados da literatura permitiram inferir que o uso da análise de demoras na assistência obstétrica com o modelo "three delays" pode ser extremamente útil na avaliação dos determinantes da mortalidade materna, especialmente se associada à investigação do near-miss materno. Os dados obtidos no estudo transversal permitiram a comparação entre diferentes desfechos maternos e com isso observou-se uma associação crescente entre a identificação de alguma demora no atendimento obstétrico e desfechos maternos adversos extremos (near-miss materno e óbito). Observou-se 54% de demoras em geral, 52% de demoras nas mulheres apenas com condições potencialmente ameaçadoras da vida, 68,4% no grupo de near-miss materno e 84,1% no grupo de com óbito materno. Conclusão: O modelo "Three delays" é um importante referencial teórico para o estudo dos casos de near-miss materno. A freqüência de demoras na assistência obstétrica está diretamente relacionada ao pior desfecho materno / Abstract: Introduction: Although the majority of causes of maternal deaths are preventable they cannot be predicted, even in the best settings, where there is adequate antenatal care, education and good nutritional support. However, maternal mortality indicators are extremely sensitive to the adequate obstetric care and time in getting appropriate care is the most important factor related to maternal deaths. Considering this, the "three delays model", which evaluates the delays in obstetric care, has been widely used as a theoretical framework for research on maternal mortality. Its use has been intensified since the use of the concept of maternal near-miss, a proxy of maternal mortality. Objectives: To evaluate the association between delays in obtaining adequate obstetric care and different maternal outcomes according to the "three delays model". Methods: We performed an extensive literature review and preparation of an essay addressing the conceptual framework on the issue and a multicenter cross-sectional study for prospective surveillance and data collection of cases with maternal near-miss (MNM) and potentially life threatening conditions (PLTC) according to previously defined criteria by WHO. Data on delay were collected from medical records and interviews with the staff. Results: The literature data allowed inferring that the use of the analysis of delays in obstetric care using the "three delays model" can be extremely useful in assessing the determinants of maternal mortality, especially if associated with the investigation of maternal near-miss. The data provided by the crosssectional study allowed comparison between different maternal outcomes and it was observed that there was a growing association between the identification of some delay in obstetric care and extreme maternal adverse outcomes (nearmiss and maternal death). In general, there was a frequency of 54% delays, 52% of delays in women only with potentially life-threatening conditions, 68.4% in the maternal near-miss group and 84.1% in the group with maternal death. Conclusion: The "Three Delays model" is an important theoretical framework for the study of near-miss cases. The frequency of delays in obstetric care is directly related to worse maternal outcome / Doutorado / Saúde Materna e Perinatal / Doutor em Ciências da Saúde

Objetivo. O valor da mortalidade materna como tema relevante para a Saúde Pública mobilizou esforços de governos e organizações, nacionais e internacionais, para a proposição de programas de prevenção e de redução da mortalidade materna. Os Comitês de Estudos de Morte Materna têm sido considerados como um dos instrumentos importantes no combate à mortalidade materna em todo o mundo. O primeiro Comitê de Estudos de Morte Materna criado no Brasil foi o do estado de São Paulo, em 1988. Este estudo teve como objetivo recuperar e caracterizar a trajetória da criação e implantação desse Comitê e os fatores intervenientes no seu percurso evolutivo. Métodos. Os dados que constituíram a base empírica do estudo foram entrevistas com integrantes, ex-integrantes e fundadores do Comitê do Estado de São Paulo e documentos como: atos oficiais, relatórios técnicos, atas de reuniões, normas operacionais, entre outros. Resultados. A análise dos dados mostrou uma trajetória oscilante, marcada por períodos de atividade e de refluxo tendo sido alteradas, ao longo do tempo, a sua composição e estrutura organizacional, mantendo-se, porém, seus objetivos e funções. Considerações finais. Os dados examinados revelaram que a criação do Comitê representou um avanço para a saúde materna. Mostraram também uma expressiva influência, no percurso do Comitê, das injunções político-institucionais, no âmbito da Administração governamental do estado, no período estudado e o reconhecimento de sua posição como instância situada para além de uma estratégia de vigilância epidemiológica. / As a relevant theme for Public Health, maternal mortality has engendered efforts on the part of Governments as well as of national and international organizations in the proposition of programs for prevention and reduction of maternal mortality. All over the world, the Committees for Stu been considered as important tools on fight against maternal mortality. In Brazil, the first Committee for Studies on Maternal Death was the one created in State of São Paulo, in 1988. The target of the present study was to recover and characterize the trajectory of the creation and implantation of this Committee as well as to make a survey on the intervening factors occurring in its course of evolution. Methods. Data on interviews held with members, former members and founders of São Paulo State Committee for Studies on Maternal Death and documents such as official acts, technical reports, minutes of meetings and, operational norms, among others, constituted the empirical basis for this study. Results. Data analysis disclosed an oscillatory course, marked by periods of activity and reflux. Along the years,both its composition and organizational structure were altered, although maintaining its purposes and functions. Final considerations. According to data, the creation of the Committee represented an improvement for the maternal health. They also indicated that in the course of the Committee there happened, in the studied period, an expensive influence of political-institutional injunctions, in the ambit of the state government administration, and the acknowledgement of this status as an instance located beyond the epidemiological surveillance.

Submitted by Rosivalda Pereira (mrs.pereira@ufma.br) on 2017-05-09T20:02:20Z No. of bitstreams: 1 OlivaniGuarda.pdf: 1436445 bytes, checksum: 999fb8a8ae64b0f9111e85cc447406c0 (MD5) / Made available in DSpace on 2017-05-09T20:02:20Z (GMT). No. of bitstreams: 1 OlivaniGuarda.pdf: 1436445 bytes, checksum: 999fb8a8ae64b0f9111e85cc447406c0 (MD5) Previous issue date: 2017-02-23 / Maternal mortality is a serious public health problem in Brazil, especially in the Northeast region and most significantly in the State of Maranhão. This study aimed to characterize maternal mortality in Maranhão between 2010 and 2014. This is a descriptive, retrospective study of all maternal deaths declared in the SIM between 2010 and 2014 of women residing in the State, by Regional Health. It was based In data collected in SIM, SINASC and in the Deputy Secretary of Health Surveillance of the Government of the State of Maranhão. Sociodemographic variables focused on age, race / color, schooling and marital status. The variables related to the deaths focused on the moment of death, place of occurrence and type of obstetric cause. There were 516 maternal deaths and 472 were submitted to spatial analysis. The following results were observed: MMR in the State presented very high and high values, according to WHO classification, in most of the Health Region in the years studied. The highest spatial density of deaths occurred in the Regional of São Luis. Predominant direct obstetric causes in brown women, between 20 and 29 years, with no partner and with little schooling, which portrays the expression of social inequity and evidences the need to improve prenatal care, delivery and puerperium in the State of Maranhão / A mortalidade materna é um grave problema de saúde pública no Brasil, principalmente na região Nordeste e mais expressivamente no Estado do Maranhão. Este estudo objetivou caracterizar a mortalidade materna no Maranhão no período de 2010 a 2014. Trata-se de um estudo descritivo, retrospectivo de todos os óbitos maternos declarados no SIM entre 2010 a 2014 de mulheres residentes no Estado, por Regional de Saúde. Foi baseado em dados coletados no SIM, SINASC e na Secretaria Adjunta de Vigilância em Saúde do Governo do Estado do Maranhão. As variáveis sociodemográficas enfocaram a faixa etária, raça/cor, escolaridade e situação conjugal. As variáveis relacionadas aos óbitos enfocaram o momento de ocorrência do óbito, local de ocorrência e o tipo de causa obstétrica. Foram encontrados 516 óbitos maternos e destes, 472 foram submetidos à análise espacial. Observaram-se os seguintes resultados: A RMM no Estado apresentou valores muito altos e altos, conforme classificação da OMS, na maioria das Regionais de Saúde nos anos estudados. A maior densidade espacial de óbitos ocorreu na Regional de São Luís. Predominaram as causas obstétricas diretas em mulheres pardas, entre 20 a 29 anos, sem companheiro e com pouca escolaridade, o que retrata a expressão da iniquidade social e evidencia a necessidade de melhorar a assistência ao pré-natal, parto e puerpério no Estado do Maranhão.

Trata-se de um estudo que teve como proposta utilizar os dados do Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS) como medida complementar para a identificação de mortes maternas não informadas. Foram investigados os Estados de São Paulo, Paraná, Pará, Ceará e Mato Grosso, nos anos de 1999 e 2000. Foram utilizados dados secundários dos CD-ROMs Movimento de Autorização de Internação Hospitalar do Sistema Único de Saúde (SUS), em seus arquivos reduzidos, por meio de formulários das AIHs que constituem o banco de dados informatizado e processado nacionalmente pelo SIH-SUS. Os resultados desta investigação possibilitaram identificar 651 mortes, sendo que 596 foram informadas pelo SIH-SUS como mortes maternas e 55 foram mortes maternas mascaradas ou presumíveis, obtidos a partir de procedimentos obstétricos e diagnósticos secundários pertencentes ao Capítulo XV da CID 10 - Gravidez, parto e puerpério, registrados no SIH-SUS. O presente estudo revelou que tal sistema de informação pode ser utilizado como medida complementar para a identificação de mortes maternas não informadas. / This study aimed at using data from the Hospital Information System of the Unified Health System (SIH-SUS) as a complementary measure for the identification of unreported maternal deaths. The states of São Paulo, Paraná, Pará, Ceará and Mato Grosso were investigated for years 1999 and 2000. Secondary data from CD-ROMs for Reports of Hospitalization Authorizations (AIH) of the Unified Health System (SUS) in reduced files were used through AIH forms comprising the database of computerized data which is nationally processed by SIH-SUS. The results of this investigation enabled the identification of 651 deaths, of which 596 were reported by SIH-SUS as maternal deaths and 55 were disguised or presumable maternal deaths obtained from obstetric procedures and secondary diagnoses according to Chapter XV of the International Classification of Diseases 10 - Pregnancy, delivery and puerperium recorded by SIH-SUS. This study showed that this information system can be used as a complementary measure for the identification of unreported maternal deaths.

Introduction: The Center for Disease Control (CDC) reports that the maternal mortality ratio (MMR) in 1987 was 7.2 deaths per 100,000 live births compared to 18.0 deaths in 2015. This increase in MMR has occurred disproportionately. The same report demonstrates that black women are more than 3 times as likely to die of pregnancy-related causes than non-Hispanic white women. The present study explores how structural differences in the economy, education system, and public policy affect the health of black, pregnant women in the U.S. Methods: This research examined epidemiological studies of maternal mortality in the U.S. Data from previous studies was used to investigate the relationship between the racial disparity in MMR and societal, economic, and political factors that contribute to said relationship. Data from the Center for Disease Control (CDC), the U.S. Census Bureau, the United Nations (UN), and the Claremont Colleges Library network was examined. Results: Studies show that between 2008-2012, black women were found to have the greatest prevalence of preexisting conditions prior to pregnancy. Furthermore, white women are more likely to have their labor induced than black, Asian, and Hispanic women. The increased prevalence of preexisting conditions among black women can be greatly attributed to factors stemming from institutional racism. These factors include less access to health care, education, and equal economic opportunities. Conclusion: Implicit bias among practicing health professionals must be addressed via multiethnic education. It is necessary to create an equally safe environment for women of all races. Additionally, health care providers should take on the responsibility of educating pregnant women about any possible preexisting chronic conditions to properly care for themselves. Prenatal health education must be made readily available and accessible to all demographics. Reports demonstrate that the creation of standardized, disease-specific procedures that target chronic conditions may reduce the U.S. MMR. For black women to overcome the current rates of comorbidity, U.S. public policy must change in a way that decreases the disparity in the socioeconomic status of all Americans.

Several factors may affect the choice of place of delivery among expectant mothers in Ghana and few studies have examined the choice of place of delivery with a focus on differences between rural and urban areas. In this study, the factors that influence the choice of place of delivery among expectant mothers in both rural (Tolon District) and urban (Tamale) settings in the northern part of Ghana were identified and compared using the conceptual framework provided by Thaddeus and Maine. A mixed-method study was used to examine expectant mothers and their responses related to factors that affect their choice of place of delivery through a concurrent triangulation using health professional interviews and a detailed participant survey.. The sample consisted of 552 expectant mothers between the ages of 15 and 49 years. Individual interviews were held with 8 health professionals (4 each from rural and urban areas) with a minimum of 5 years of work experience and a focus group discussion with randomly selected pregnant women and lactating mothers. Themes were generated through open coding of the interview data, while multiple regression was performed to identify the factors associated with choice of place of delivery, rural area, preference (60.1%) was for home delivery compared to 20.7% for urban participants. Statistically significant variables affecting the choice of place of delivery among study participants were found to be educational background, the experience of previous deliveries, the attitude of hospital staff toward pregnant women during labor, and frequency of accessing antenatal care. The study's implications may lead to positive change where stakeholders develop and implement policies to promote health facility delivery for expectant mothers in both rural and urban areas of Ghana.