A mortalidade materna é um importante indicador de saúde que reflete as condições socioeconômicas e a qualidade de vida de um determinado local. Na maioria das vezes, essas mortes podem ser evitadas por meio de assistência pré-natal de qualidade, assistência hospitalar especializada e recursos humanos aptos às emergências obstétricas. Objetivo: descrever os óbitos maternos declarados ocorridos nos municípios da área de abrangência do Departamento Regional de Saúde de Ribeirão Preto, no período de 2011 a 2016, identificando os principais problemas da assistência prestada. Método: estudo descritivo, retrospectivo com abordagem quantitativa, com análise de dados secundários do Sistema de Informação de Mortalidade, referente aos óbitos maternos declarados. Resultados: a maioria dos óbitos maternos ocorreram em mulheres na faixa etária de 20 a 29 anos (63,9%), com média de idade de 28,1 anos, sendo a maioria solteira (50%), raça branca (66,7%), primíparas (41,7%), com ocupações diversas. O acesso ao pré-natal foi perceptível na captação precoce (72,2%) e no número de consultas durante o pré-natal. A morte materna de causa direta resultou em 77,8% dos óbitos e as principais causas de morte foram hipertensão, infecção e hemorragia. A rede de atenção à saúde da mulher no ciclo gravídico-puerperal possui boa cobertura de atenção básica, equivalente em cobertura de saúde suplementar e possui 20 maternidades em seu território, entre elas, duas com habilitação em gestação de alto risco. Conclusão: a morte materna continua sendo um desafio para a assistência obstétrica, e é fundamental que as boas práticas se tornem rotina. Instituições e profissionais precisam estar adequados e alinhados aos protocolos de atendimento, baseados em evidencias cientificas para um atendimento rápido e preciso. No íntimo de cada morte materna há uma tragédia familiar e um impacto social devastador / Maternal mortality is an important health indicator that reflects the socioeconomic conditions and quality of life of a given location. Most of the time, such deaths can be prevented through quality prenatal care, skilled hospital care, and skilled human resources for obstetric emergencies. Objective: To describe the maternal deaths reported in the municipalities in the coverage area of the Regional Health Department of Ribeirão Preto, from 2011 to 2016, identifying the main problems of care provided. Method: descriptive, retrospective study with quantitative approach, with analysis of secondary data of the Mortality Information System, referring to the reported maternal deaths. Results: the majority of maternal deaths occurred in women between the ages of 20 and 29 years (63.9%), with a mean age of 28.1 years, being the majority single (50%), Caucasian (66.7% %), primiparous (41.7%), with different occupations. Access to prenatal care was noticeable at precocious screening (72.2%) and in the number of prenatal consultations. Direct maternal death resulted in 77.8% of deaths and the main causes of death were hypertension, infection and hemorrhage. The women\'s health care network in the pregnancy-puerperal cycle has good coverage of basic care, equivalent in supplementary health coverage, and has 20 maternity hospitals in its territory, including two with high risk pregnancy. Conclusion: Maternal death continues to be a challenge for obstetric care, and it is essential that good practices become routine. Institutions and professionals need to be adequate and in line with the protocols of care, based on scientific evidence for fast and accurate care. At the heart of every maternal death there is a family tragedy and a devastating social impact

<p><strong>Objective: </strong>The aim of this thesis is to examine and compare the maternal mortality in three different countries; Malawi, India and United Kingdom, as well as highlighting the attributing factors and preventive steps that would reduce the maternal mortality in these countries. <strong>Methods and material: </strong>The studied design that was chosen is an ecological study which means to study the relationship between aggregated health data and exposing factors, for example a geographical area and time period. The reason of choosing this study can be seen in the relationship and the factors that contribute to maternal mortality in Malawi, India and the United Kingdom. In order to attain the objective of the thesis a variety of sources were utilized to find data, statistics and scientific articles concerning maternal mortality in all three countries.<strong>Results and conclusion: </strong>Maternal mortality is the highest in Malawi and India, while it is very low in the United Kingdom when compared with these two countries. The result shows among other things that the maternal mortality is mainly caused by direct causes both in Malawi and India and in the United Kingdom the maternal mortality is mainly from indirect causes. It is also shown that the maternal mortality in these countries have been changed over the years. It is also shown that preventive steps such as family planning, skilled attendance, obstetric emergency care and antenatal care can significantly reduce the maternal mortality rate.</p>

BEYOND THE NUMBERS: CONFIDENTIAL ENQUIRIES INTO MATERNAL DEATHS IN ACCRA-GHANA Researcher: Afisah Yakubu Zakariah Universite Libre de Bruxelles- School of Public Health Reproductive Health and Epidemiology of Perinatal Health Unit Brussels-Belgium Afiyakzak@yahoo.com Promoter: Professor Sophie Alexander-Karlin Universite Libre de Bruxelles- School of Public Health Reproductive Health and Epidemiology of Perinatal Health Unit Brussels-Belgium salexand@ulb.ac.be Co-Promoter: Professor Jos van Roosmalen Leiden University Medical Centre Department of Obstetrics and Gynaecology Leiden-The Netherlands J.J.M.van_Roosmalen@lumc.nl "A thesis submitted for the Degree of Doctor of Philosophy in Public Health Sciences Universite Libre de Bruxelles-School of Public Health Reproductive Health and Epidemiology of Perinatal Health Unit. November, 2008. EXECUTIVE SUMMARY Background Maternal mortality remains a severe problem in many parts of the world, despite efforts to reach MDG 5. Assessing progress towards this goal is difficult because maternal mortality is difficult to measure and the information available at country level does not generally permit the establishment of good baseline data. Countries with high maternal mortality ratios neither have adequate vital registration systems nor adequate resources to carry out surveys. Only few low-income countries have been able to establish a comprehensive reporting system and even where such vital registration systems are in place, maternal deaths are often underreported or misclassified as non-maternal even in large well developed cities. Ghana belongs to the group of low-income countries with high maternal mortality ratios (point estimate 560, lower bound 200 and upper bound 1300) per 100,000 live births and inadequate data on maternal deaths. Previous studies have demonstrated that most of these deaths could be prevented with existing effective practices. In this dissertation, we looked at the registration system of births and deaths in the Greater Accra Region of Ghana. We assessed completeness of registration of maternal deaths and data quality. We also looked at the degree of underreporting of maternal deaths, assessed causes of maternal deaths and substandard care of these cases through a confidential enquiry. This enabled us to identify problems associated with measuring of maternal mortality in Ghana and the standard of care of the cases. Through our findings we were able to make recommendations to achieve MDG 5 in the country by 2015 if implemented. Other maternal and child health (MCH) interventions were also looked as working to improve MCH is a continuum, and no aspect should be neglected. The first relates to seeking evidence based practice in presence of potentially complicated obstetrical conditions like premature rupture of membranes and the second pertains to preventive activities in MCH and concentrates on the results of tetanus immunisation of women in their reproductive age in the Northern Region of Ghana. Objectives 1. To assess the precision (quality) of civil registration of maternal deaths in Ghana 2. To identify the magnitude of maternal deaths using multiple sources and assess the degree of underreporting of these deaths 3. To identify the root causes and related factors of the identified maternal deaths as well as classify the deaths 4. To assess the level of substandard care in maternal deaths in order to identify weakness in the Ghanaian maternity care system and propose locally relevant and affordable solutions to improve maternity care in Ghana 5. To discuss the results of the research with the Decision makers and health care providers leading to an adoption of the method at national level and a reduction of maternal mortality in Ghana as a whole 6. To assess risk factors and management of premature rupture of membranes and make recommendations that will address avoidable complications 7. To assess challenges of other maternal and child health interventions like Tetanus Toxoid immunization in women of reproductive age group and formulate recommendations to increase the coverage in this group. Organization of dissertation This dissertation contains eight chapters. Chapter one is on general introduction, which gives an overview of the problems associated with the reduction of maternal mortality by literature review. Chapter two highlights the profile of Ghana and the Health system Chapter three is on maternal mortality in the Greater Accra region of Ghana for the year 2000. In this chapter, we assessed completeness of registration and data quality as well as the sensitivity and specificity of the civil registration system to capture maternal deaths in Ghana. Chapter four discusses Reproductive Age Mortality Survey (RAMOS) conducted in Accra city (Metropolis) for the year 2002. It showed how effective the method is in identifying maternal deaths using multiple sources approach. In this study, we aimed at identifying the magnitude of maternal deaths in the city and the degree of underreporting during the study period. Chapter five elaborates the main content of this thesis, which is on confidential enquiries into maternal deaths for the year 2002. This chapter deals solely with the seventy three cases of maternal deaths that were identified during the study period (1st January 2002-31st December 2002) with adequate information surrounding the deaths. We identified the root causes and related factors of the identified maternal deaths as well as their classification. We also assessed the level of substandard care in maternal deaths, identified weaknesses in the Ghanaian maternity care system and proposed locally relevant and affordable solutions to improve maternity care in Ghana. Chapter six is on controversy of management of premature rupture of membranes at term. We reviewed systematically the existing evidence on expectant management of PROM and prompt delivery after a premature rupture of membranes at term and gave an answer to this controversy. Chapter seven assessed challenges of other maternal and child health interventions like Tetanus Toxoid immunization in women of reproductive age group and formulated recommendations to increase the coverage in this group. Chapter eight gives the general discussion, conclusion and recommendations. Main results and conclusion The study on the assessment of completeness of registration and data quality of maternal deaths in the Greater Accra Region of Ghana found the process of registration of maternal deaths in the Region to be incomplete even though there is a system of registration of deaths in Ghana. We identified the major causes of under registration of maternal deaths during the study as omission of pregnancy status in the registers. Pregnancy status is not systematically noted in the registers and the death certificate forms. Other contributing factors to the under registration of maternal deaths were erroneous classification of maternal deaths as non-maternal and imprecision in the death certification and registration. The study on Reproductive Age Mortality Survey (RAMOS) in Accra city (Metropolis) for the year 2002 has almost doubled the officially reported figures, which showed that the method is effective in identifying maternal deaths using multiple sources approach. The findings of the confidential enquiries into maternal deaths for the year 2002 showed that the proportion of maternal deaths associated with substandard care factors at various levels is high in the Metropolis even though the city has the best medical services in the country. The study on the controversy of management of premature rupture of membranes at term shows that prompt delivery after the membranes are ruptured averts many complications both for the mother and the baby. It is presented as an illustration of how evidence based guidelines can be instrumental in challenging the maternal mortality problem In the study on challenges of maternal and child health interventions like Tetanus Toxoid immunization in women of reproductive age, we found out that the tetanus toxoid vaccine was perceived as an anti fertility drug by those who refused to be vaccinated. Among other reasons for refusal was complete authority over wives by their husbands and therefore not allowing them to be vaccinated. It also is an illustration of the role of good organisation of care in meeting MDGs 4 and 5. We finally conclude that, even in environments with limited resources, most maternal deaths can be prevented if appropriate measures are put in place to prevent their occurrence. Key words: Maternal mortality, registration, underreporting, RAMOS, confidential enquiries, sub-standard care, PROM.

Objective: The aim of this thesis is to examine and compare the maternal mortality in three different countries; Malawi, India and United Kingdom, as well as highlighting the attributing factors and preventive steps that would reduce the maternal mortality in these countries. Methods and material: The studied design that was chosen is an ecological study which means to study the relationship between aggregated health data and exposing factors, for example a geographical area and time period. The reason of choosing this study can be seen in the relationship and the factors that contribute to maternal mortality in Malawi, India and the United Kingdom. In order to attain the objective of the thesis a variety of sources were utilized to find data, statistics and scientific articles concerning maternal mortality in all three countries.Results and conclusion: Maternal mortality is the highest in Malawi and India, while it is very low in the United Kingdom when compared with these two countries. The result shows among other things that the maternal mortality is mainly caused by direct causes both in Malawi and India and in the United Kingdom the maternal mortality is mainly from indirect causes. It is also shown that the maternal mortality in these countries have been changed over the years. It is also shown that preventive steps such as family planning, skilled attendance, obstetric emergency care and antenatal care can significantly reduce the maternal mortality rate.

INTRODUCTION: Improving maternal and child health care are two of the Millennium Development Goals of the World Health Organization. India is one of the countries worldwide most burdened by maternal and child deaths. The aim of the study was to describe how families participate in nurse-based antenatal and child health care, and the effect of this in relation to referrals to specialist care, institutional deliveries and mortality. METHODS: The intervention took place in a remote rural area in India and was influenced by Swedish nurse-based health care. A baseline survey was performed before the intervention commenced. The intervention included education program for staff members with a model called Training of Trainers and the establishment of clinics as both primary health centers and mobile clinics. Health records and manuals, and informational and educational materials were produced and the clinics were equipped with easily handled instruments. The study period was between 2006 and 2009. Data were collected from antenatal care and child healthcare records. The Chi-square test was used to analyze mortality differences between years. A focus group discussion and a content analysis were performed. RESULTS: Families' participation increased which led to more check-ups of pregnant women and small children. Antenatal visits before 16 weeks among pregnant women increased from 32 to 62% during the period. Women having at least three check-ups during pregnancy increased from 30 to 60%. Maternal mortality decreased from 478 to 121 per 100 000 live births. The total numbers of children examined in the project increased from approximately 6000 to 18 500 children. Infant mortality decreased from 80 to 43 per 1000 live births. Women and children referred to specialist care increased considerably and institutional deliveries increased from 47 to 74%. CONCLUSION: These results suggest that it is possible in a rural and remote area to influence peoples' awareness of the value of preventive health care. The results also indicate that this might decrease maternal and child mortality. The education led to a more patient-friendly encounter between health professionals and patients. / <p>Article No. 2140</p><p>Funding Agencies|Pravara Medical Trust, India||Swedish International Development Cooperation Agency, Sweden||Linkoping University||County Council in Ostergotland, Sweden||</p>

Maternal mortality is a huge concern globally leading to more than a quarter of a million deaths every year. Similarly, an estimated 4 million neonates die every year worldwide, contributing to the majority of deaths of under-5 children. The majority of these deaths take place in under-developed countries, and specifically, in the sub-Saharan Africa region. It is evidenced that maternal ill-health and death contribute to the majority of child deaths. Reducing the death of children under 5 years by two thirds and also improving maternal health/reducing maternal death by three quarters between the years 1990 and 2015 are two of the eight aims of the Millennium Development Goals (MDGs), MDG-4 and MDG-5 respectively. The report on maternal health services in Eritrea, a nation in the sub-Saharan Africa, shows a low utilization of antenatal care, family planning services, and postnatal care. Furthermore, there is insufficient use of skilled assistance at delivery. The purpose of this study was to explore the reproductive health knowledge and practice of women aged 18-49 and the impact of these on infant birth outcomes. Participants were all living in the Central Zone of Eritrea. This study proposed that knowledge of reproductive health is one of the key factors contributing to the health of women in the reproductive age group, and thereby reduction of maternal and child deaths and morbidities. An exploratory cross-sectional study design was implemented in this study using an investigator-designed questionnaire. Data were collected from participants intending to assess awareness on the domains of reproductive health including knowledge of family planning, sexually transmitted diseases (STDs), antenatal and postnatal care, importance of vaccinations, and identification of pregnancy/labor danger signs. Data on the most recent birth outcome that took place in the past five years were collected to investigate any existing associations. Findings showed that a majority of participants recognized danger signs and where to seek help in case of complications related to pregnancy and childbirth. Participants also stated the importance of child vaccination, identified STDs and family planning methods as well. Further, the majority also acknowledged the importance of antenatal care (ANC) and postnatal care by skilled personnel. However, a large percentage did not start ANC visits until after the first trimester. Also, a large number of participants did not know when fetal anomalies were most likely to occur or when conception can happen in relation to the menstrual cycle. Looking at birth outcomes, marital status and educational status showed a significant relationship with birth weight, while educational status was further a significant predictor of maturity of fetus at birth. Overall, these findings indicate the need for increased efforts in providing adequate reproductive health education, especially in certain target areas, so that women are better equipped with the necessary basic reproductive health information. This will hopefully contribute to the betterment of maternal health, further leading to a desired birth outcome.

International organizations (IOs) such as the United Nations Children’s Fund have immense power in influencing state agenda and policies in issues in health such as advocating micronutrient interventions in developing countries. Scholarly literature classifies IOs as “norm entrepreneurs” who can alter state behavior through many forms of rhetoric. The theoretical model, constructivism, notes that IOs are autonomous actors in their decision-making who use states as tools to pursue their own interests. Thus, how do these IOs succeed in sustaining malnutrition-related interventions and programs in Kenya? In this thesis, I argue that IOs can effectively improve malnutrition outcomes by improving the allocation and accessibility of nutritional resources and services, setting an institutional framework for implementing and sustaining programs at hand, and fostering the operation of tools that will assist interventions to scale-up to national nutrition policies. To accomplish this, specific IOs possess external effects such as political will, strong funding, and a multi-sectoral nutrition approach, and multilateral IOs have internal factors such as authority, autonomy, and are able to find opportunities in uncertain situations. I also argue that IOs presented in this paper have made limited strides in reducing aggregate malnutrition rates of stunting, wasting and underweight in Kenya. I ground my analysis on constructivism to understand IO behavior towards malnutrition interventions for children under five in Kenya.

Background: Half a million women died during pregnancy or childbirth in 2005. Bleeding, infections, high blood pressure, obstructed labor, unsafe abortions, malaria and HIV/Aids were the main causes. Tanzania is a highly affected country with 460 maternal deaths per 100 000 live births. Nurses and midwives play an important role in preventing maternal mortality. Purpose: The aim of this study was to explore and analyze nurses’ and midwives’ experiences of maternal mortality prevention on the Tanzanian island of Unguja. Method: Interviews with nine nurses and midwifes from four different hospitals and health care facilities were conducted with the assistance of an interpreter. A structural analysis designed by Ricoeur was undertaken. Results: The findings suggest that family planning, a more accessible health care, referral of severe cases, medical interventions, health education, community resource persons and involving fathers in maternal health care are preventive strategies that can reduce maternal mortality. Conclusion: To further improve the quality of maternal mortality prevention further knowledge aboutindividual differences in learning from health education is needed.  Involvement of all fathers in maternal health care should also be considered. Training of unskilled personnel is believed to improve early identification of life-threatening complications and thereby reduce maternal mortality. / Bakgrund: En halv miljon kvinnor i världen dog under graviditet eller förlossning under 2005. Huvudorsaker var blödningar, infektioner, högt blodtryck, långdragna förlossningar, osäkra aborter, malaria samt HIV/Aids. Tanzania är ett drabbat land med 460 fall av mödradödlighet per 100 000 levande födda barn. Sjuksköterskor och barnmorskor spelar en viktig roll i det preventiva arbetet mot mödradödlighet. Syfte:  Syftet med studien var att utforska och analysera sjuksköterskors och barnmorskors upplevelser och erfarenhet av  arbetet mot mödradödlighet på ön Unguja, Tanzania. Metod: Intervjuer med nio sjuksköterskor och barnmorskor från fyra olika sjukhus/hälsocentraler genomfördes med hjälp av en tolk. En strukturanalys utformad av Ricoeur genomfördes. Resultat: Resultatet visar att familjeplanering, en mer tillgänglig hälso- och sjukvård, remitterande av patienter med allvarliga komplikationer, medicinska interventioner, hälsoutbildning, resurspersoner i samhället och att involvera pappor i mödrahälsovården var preventiva strategier som kan minska mödradödlighet. Slutsats: För att ytterligare förbättra arbetet mot mödradödlighet tycks mer kunskap om individers förmåga att ta till sig hälsoutbildning behövas. Att i ännu större utsträckning även välkomna alla blivande pappor till mödrahälsovården föreslås också kunna fungera preventivt. Utbildning för outbildade kvinnor som hjälper till vid förlossningar (Traditional Birth Attendants) tros kunna förbättra tidig identifikation av livshotande komplikationer och därmed kunna minska mödradödligheten.

Diss. (sammanfattning) Stockholm : Karol. inst., 2004. / Härtill 5 uppsatser.

Thesis (M.P.H.)--University of Texas Health Science Center at Houston, School of Public Health, 2007. / Source: Masters Abstracts International, Volume: 46-01, page: 0341. Adviser: Asha Kapadia. Includes bibliographical references.