Dissertations / Theses on the topic 'Maternal mortality'

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Fundação de Ensino e Pesquisa em Ciências da Saúde (FEPECS)
Realizar uma revisão da literatura mundial e nacional sobre mortalidade materna, descrevendo a população vulnerável, os fatores de risco, as causas, as difi culdades para obtenção dos dados e as medidas de prevenção, de forma a subsidiar as ações de saúde. A coleta dos dados foi realizada por meio de pesquisa de artigos nas bases eletrônicas, SCIELLO, PUBMED, LILACS e MEDLINE, além de materiais publicados por organizações mundiais e nacionais. Foram selecionados estudos publicados no periodo de janeiro de 2000 a maio de 2011, utilizando-se os seguintes descritores: “maternal mortality”[MeSH Terms] OR (“maternal”[All Fields] AND “mortality”[All Fields]) OR “maternal mortality”[All Fields], nos idiomas português, inglês e espanhol. Foram selecionados 36 artigos que atendiam aos critérios de inclusão. O óbito materno está diretamente relacionado com as condições de vida da população e apresenta elevada disparidade entre as diversas regiões sócio-econômicas. Embora a mortalidade materna seja o melhor indicador de saúde da população feminina, seus números muitas vezes são apresentados de forma irreal, pela difi culdade da identifi cação dos casos nos registros de óbito. Medidas de prevenção associadas a diagnóstico e tratamento precoces e adequados são fatores benéfi cos na redução desses óbitos maternos. Apesar da tecnologia avançada e do reconhecimento de algumas medidas de prevenção, um grande número de mulheres morre diariamente por complicações no ciclo gravídico-puerperal. É evidente que para a redução desta tragédia é necessário o comprometimento político, social e econômico com a saúde, para promover as reformas necessárias na assistência ao ciclo gravídico-puerperal
Accomplishing a review of worldwide and Brazilian literature on maternal mortality, describing the vulnerable population, risk factors, causes, and difficulties in obtaining the data and preventive measures, in order to subsidize health actions. The data collection was accomplished through a search for articles in the electronic data basis SCIELLO, PUBMED, LILACS and MEDLINE, in addition to published materials from worldwide and Brazilian organizations. Studies published between January 2000 and May 2011 have been selected using the following reference: “maternal mortality” [MeSH Terms] OR (“maternal”[All Fields] AND “mortality” [All Fields]) OR “maternal mortality” [All Fields], in Portuguese, English and Spanish languages. 36 articles that fi tted the criteria for inclusion have been selected.. Maternal death is directly related to the quality of life of the population and presents high disparity among the diverse social-economic regions. Even though maternal mortality is the most accurate health indicator for the female population, its numbers many a time are presented in unreal manners, due to the diffi culties in identifying the cases based on obit registries. Preventing measures associated to early diagnosis and proper treatment are benefi cial factors to the decrease of such maternal deaths. In spite of advanced technology and the recognition of some preventive measures, a large number of women decease daily out of complications through the pregnant and puerperal cycle. It is evident that in order to reduce such tragedy, political, social and economical commitment to Health is necessary to promote the needed reforms in the pregnant and puerperal cycle assistance

The objective of this study was to determine the clinical and epidemiological profile of women who died at the Caucaia Health Region from 2009 to 2014, through the epidemiological investigation of the pathway performed by these women to access, Death, and if there was an opinion of the Maternal Mortality Prevention Committee. This is a documental, descriptive and quantitative approach, with a population and a sample of 56 maternal deaths. Data were collected in the first half of 2016, using death certificates and M5 investigation forms found in the Information System on Mortality. The chosen variables were analyzed using SPSS 17.0 program and presented in absolute frequency and simple proportion. The research protocol was approved by the Ethics Committee of the Federal University of CearÃ, with opinion No. 1,403,777. It was found that the deaths occurred in women with a mean age 28.2 years (62.4%), mulattos (62.5%), single (57.1%), incomplete primary education (33.9%), housewives (48.2%). Obstetric data revealed bond to the Family Health Team (82.1%), prenatal consultations with more than 5 (51.8%), and only 25% directed to high-risk prenatal care. 80% delivery occurred in maternity, 48.2% caesarean section. The deaths occurred in hospital (76.8%), postpartum period (69.7%), the main causes of hypertension (16.1%) and infections (16.1%) and emboli (14.3 %), characterizing deaths from direct obstetric causes (58.3%) and preventable by appropriate action to prevent, control and attention to the causes of maternal death (73.2%). The Mortality Committee analyzed 87.5% of deaths. Despite the ease of access, there is poor quality of care. There is no guaranteed linking. The deaths could have been prevented through actions for the organization of the Maternal and Child Network with the expansion of resolutive and quality health services, the training of professionals for prenatal, childbirth and puerperium care, improvement of the recording of information, and strengthening the work of the municipal and regional Maternal, Child and Fetal Mortality Committees for the promotion of maternal and child health.
Este estudo teve por objetivo conhecer o perfil clÃnico-epidemiolÃgico das mulheres que foram a Ãbito materno na RegiÃo de SaÃde de Caucaia no perÃodo de 2009 a 2014, identificando por meio da investigaÃÃo epidemiolÃgica o trajeto realizado por essas mulheres, para acesso, atendimento, classificaÃÃo do Ãbito, e se houve parecer do Comità de PrevenÃÃo de Mortalidade Materna. Trata-se de um estudo do tipo epidemiolÃgico documental, descritivo e com abordagem quantitativa, com uma populaÃÃo e amostra de 56 Ãbitos maternos. Os dados foram coletados no primeiro semestre de 2016, utilizando as declaraÃÃes de Ãbito e fichas de investigaÃÃo M5 encontradas no Sistema de InformaÃÃo em Mortalidade. As variÃveis escolhidas foram analisadas pelo programa SPSS 17.0 e apresentadas em frequÃncia absoluta e proporÃÃo simples. A pesquisa foi submetida e aprovada no Comità de Ãtica em Pesquisa da Universidade Federal do CearÃ, com o parecer n 1.403.777. Identificou-se que os Ãbitos ocorreram em mulheres com idade mÃdia de 28,2 anos (62,4%), raÃa parda (62,5%), solteiras (57,1%), escolaridade baixa (33,9%) e donas de casa (48,2%). Os dados obstÃtricos revelaram vinculo à Equipe de SaÃde da FamÃlia (82,1%), prÃ-natal com mais de 5 consultas (51,8%), e apenas 25% encaminhadas ao prÃ-natal de alto risco. Em 80%; o parto ocorreu em maternidade, sendo 48,2% cesariana. As mortes ocorreram em hospital (76,8%), no perÃodo do puerpÃrio (69,7%), tendo como principais causas a hipertensÃo (16,1%), infecÃÃes (16,1%) e embolias (14,3%), caracterizando Ãbitos por causas obstÃtricas diretas (58,3%) e evitÃveis por adequada aÃÃo de prevenÃÃo, controle e atenÃÃo Ãs causas de morte materna (73,2%). O Comità de Mortalidade analisou 87,5% dos Ãbitos, apesar da facilidade no acesso, a qualidade da assistÃncia ruim. NÃo hà vinculaÃÃo garantida. As mortes poderiam ter sido evitadas mediante aÃÃes para a organizaÃÃo da Rede Materno-Infantil com ampliaÃÃo de serviÃos de saÃde resolutivos e de qualidade, capacitaÃÃo dos profissionais para os cuidados no prÃ-natal, parto e puerpÃrio, melhoria do registro das informaÃÃes, e fortalecimento do trabalho dos ComitÃs de Mortalidade Materna, Infantil e Fetal municipais e regional para a promoÃÃo da saÃde materna e infantil.

Mares i llevadores: pràctiques i polítiques reproductives al districte Sikka de l'illa de Flores, Indonèsia analitza com les polítiques reproductives globals permean la comunitat Sikka generant canvis en les creences, rituals i pràctiques reproductives. Per a això, aquesta investigació, se centra principalment en les interaccions de bidan (llevadores biomèdiques), du'a rawin (llevadores amb coneixement local) i mares rurals, per analitzar si i de quina manera s'han modificat els processos reproductius en el districte Sikka. Observar les pràctiques reproductives com a clau per accedir a la vida social de la comunitat, i, en concret, d'aquests col·lectius femenins, permet mostrar no només els canvis produïts o en procés, sinó també els aspectes més valorats de les seves pràctiques reproductives culturals (Davis -Floyd & Sargent 1997b, Ginsburg & Rapp 1995b); entre ells, el deure de transmetre el Adat (coneixement local) com a forma de reciprocitat i agraïment a la comunitat ancestral pel regal de la vida (Butterworth 2008). Per entendre aquest context, cal conèixer la història de país. Des de la independència d'Indonèsia el 1945, els diferents governs han tractat de construir una identitat nacional a partir de la gran diversitat cultural de país a través de mecanismes com el Pancasila, base filosòfica de l'Estat, basat en el lema "Unitat en la diversitat" i el terme Gotong Royong o "cooperació mútua", animant a que les comunitats prioritzin una nació comuna a les seves diferències (Bowen 1986). Als anys 80, el país es va sumar a la comunitat internacional en el treball de reduir la seva alta mortalitat materna, intentant assolir els objectius internacionals mitjançant l'estratègia global d'augmentar el nombre de bidan i reemplaçar a les dukun bayi (Niehof 2014). No obstant això, el 1999, es va produir un canvi substancial amb la descentralització democràtica de les seves polítiques que donaven flexibilitat a l'aplicabilitat de les mateixes d'acord a les necessitats locals (Hull & Adioetomo 2002, Magrath 2016). Paral·lelament, des dels anys 2000, es reconeix la importància de les TBAs en les diferents cultures i es dóna suport globalment el seu treball conjunt amb les SBAS (Sibley et al. 2004). No obstant això, tot i que el Ministeri de Salut indonesi donés llibertat a cada govern local, la pressió per assolir els objectius internacionals continua influint en el manteniment o adopció de mecanismes de recentralització per tenir un major control de l'procés (Magrath 2016). Per tant, la imposició d'idees, polítiques i pràctiques reproductives, impacta de manera multidireccional no només a la relacions reproductives o familiars sinó també en les relacions socials i la lògica sociocultural de cada context (Ginsburg & Rapp 1995b), ja que, encara que la taxa de mortalitat materna de el país sigui de les més altes i els resultats revelen que la salut reproductiva de les dones es veu beneficiada amb aquesta complementarietat, no tots els districtes ho entenen així. Per què passa això? Quin és el cas de districte Sikka i quines són les seves conseqüències en la concepció, embaràs, part i postpart?
Madres y matronas: prácticas y políticas reproductivas en el distrito Sikka de la Isla de Flores, Indonesia analiza cómo las políticas reproductivas globales permean la comunidad sikka generando cambios en las creencias, rituales y prácticas reproductivas. Para ello, esta investigación, se centra principalmente en las interacciones de bidan (matronas biomédicas), du'a rawin (matronas con conocimiento local) y madres rurales, para analizar si y de qué manera se han modificado los procesos reproductivos en el distrito Sikka. Observar las prácticas reproductivas como llave para acceder a la vida social de la comunidad, y, en concreto, de dichos colectivos femeninos, permite mostrar no solo los cambios producidos o en proceso, sino también los aspectos más valorados de sus prácticas reproductivas culturales (Davis-Floyd & Sargent 1997b, Ginsburg & Rapp 1995b); entre ellos, el deber de transmitir el Adat (conocimiento local) como forma de reciprocidad y agradecimiento a la comunidad ancestral por el regalo de la vida (Butterworth 2008). Para entender este contexto, es necesario conocer la historia del país. Desde la independencia de Indonesia en 1945, los diferentes gobiernos han tratado de construir una identidad nacional a partir de la gran diversidad cultural del país a través de mecanismos como el Pancasila, base filosófica del Estado, basado en el lema "Unidad en la diversidad" y el término Gotong Royong o "ooperación mutua", animando a que las comunidades prioricen una nación común a sus diferencias (Bowen 1986). En los años 80, el país se sumó a la comunidad internacional en el trabajo de reducir su alta mortalidad materna, intentando alcanzar los objetivos internacionales mediante la estrategia global de aumentar el número de bidan y remplazar a las dukun bayi (Niehof 2014). Sin embargo, en 1999, se produjo un cambio sustancial con la descentralización democrática de sus políticas que daban flexibilidad a la aplicabilidad de las mismas de acuerdo a las necesidades locales (Hull & Adioetomo 2002, Magrath 2016). Paralelamente, desde los años 2000, se reconoce la importancia de las TBAs en las distintas culturas y se apoya globalmente su trabajo conjunto con las SBAs (Sibley et al. 2004). No obstante, a pesar de que el Ministerio de Salud indonesio diese libertad a cada gobierno local, la presión por alcanzar los objetivos internacionales continúa influyendo en el mantenimiento o adopción de mecanismos de recentralización para tener un mayor control del proceso (Magrath 2016). Por tanto, la imposición de ideas, políticas y prácticas reproductivas, impacta de forma multidireccional no solo en la relaciones reproductivas o familiares sino también en las relaciones sociales y la lógica sociocultural de cada contexto (Ginsburg & Rapp 1995b), ya que, aunque la tasa de mortalidad materna del país sea de las más altas y los resultados revelen que la salud reproductiva de las mujeres se ve beneficiada con esta complementariedad, no todos los distritos lo entienden así. ¿Por qué ocurre esto? ¿Cuál es el caso del distrito Sikka y cuáles son sus consecuencias en la concepción, embarazo, parto y posparto?
Mothers and Midwives: Reproductive Practices and Policies in the Sikka District of Flores Island, Indonesia analyzes how global reproductive politics permeate the Sikka community, generating changes in the local beliefs, rituals, and reproductive practices. This investigation centers principally on interactions among bidan (biomedical midwives), du’a rawin (midwives with local knowledge), and rural mothers, to ascertain if and how reproductive practices in the regency of Sikka may have changed in recent years. Observing reproductive practices allows access both to a community’s overall social life as well as to the aforementioned female collectives, facilitating the apprehension not only of changes that have already taken place or are in progress, but also of the most valued of a culture’s reproductive practices (Davis-Floyd & Sargent 1997b, Ginsburg & Rapp 1995b). Among such aspects in the Sikka context are the obligation to transmit Adat (local knowledge) in order to express reciprocity and gratitude to the ancestral community for the gift of life (Butterworth 2008). In order to fully understand the context in which this investigation took place, it is necessary to know the history of Indonesia. Since independence in 1945, various governments have attempted to forge a national identity out of the country’s significant cultural diversity through mechanisms such as Pancasila, the philosophical foundation of the state. This philosophy is based on the theme of “Unity in diversity” and the term Gotong Royong, or, “mutual cooperation”, thereby encouraging distinct communities to prioritize the national commonalities over their individual differences (Bowen 1986). In the 1980s, Indonesia joined with the international community in an effort to reduce their high rate of maternal mortality, attempting to achieve international objectives via a global strategy of increasing the number of bidan and thereby replacing the dukan bayi (Niehof 2014). However, a significant change took place in 1999 with the democratic decentralization of governmental policies, which allowed for a more flexible application of certain policies in accordance with local needs (Hull & Adioetomo 2002, Magrath 2016). At the same time, since the early 2000s, the importance of the TBAs to various cultures has been recognized and their work alongside SBAs is now universally supported (Sibley et al. 2004). Nevertheless, despite the fact that the Indonesian Health Ministry gives autonomy to each local government, the pressure to achieve international objectives continues to exert heavy influence via the adoption and maintenance of mechanisms of recentralization, in order to exercise greater control over the process (Magrath 2016). As a result, the imposition of reproductive ideas, policies and practices has had a multidirectional impact not only on reproductive and family relations but also on social relationships and the sociocultural logic of each individual context (Ginsburg & Rapp 1995), such that, although the country’s maternal mortality rate is one of the highest in the world and research shows that women’s reproductive health improves with complementary interventions, not all of the country’s districts understand the situation this way. Why should this be? More specifically, what is the situation in the Sikka District, including the consequences for conception, pregnancy, childbirth and the postpartum period?

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.

A community health survey was conducted in Karachi, Pakistan, with three objectives: first, to estimate maternal mortality using the sisterhood method; second, to describe current fertility and family planning trends; and third, to determine which factors are associated with the utilization of prenatal care.
The study population of 2,897 households was chosen randomly from the catchment area of the three maternity hospitals of the Aga Khan Health Services of Pakistan. Data were collected using household interviews of all married women less than 55 years of age.
Results show a maternal mortality estimate of 153 deaths per 100,000 live births and perinatal mortality of 30/1000. Strong declining trends in fertility and increased utilization of prenatal care were documented in this urban population, in contrast to recent national survey data. After adjustment for socioeconomic factors and confounding variables, maternal education and perceived importance of prenatal care were found to be important predictors of the utilization of maternal health care. The majority of families in this population utilize the private sector for family planning and pregnancy care.
The study demonstrates the importance of maternal education and attitudes in promoting utilization of adequate maternal health care, and documents the emerging role of the private sector in the provision of maternal health services in Karachi.

Introduction A future healthy world is highly associated with the children and their mothers, the Millennium Development Goals (MDGs) prioritize the child and maternal health with the targets “the under-five mortality rate should be reduced by two thirds from 1990 to 2015”. A transform program in the Philippines, launched by a NGO, aims to change the life of ultra-poor, and the interventions’ impact was measured in this study. Method The study selected participants who had completed the surveys in the short term (n=2183) and long term (n=196). The Chi-square test, Cochran-Armitage trend test, and Generalized Estimating Equation (GEE) model were applied to examine the hypotheses: (1) the program would have positive impacts on child health, (2) the child mortality is related to the maternal social-demographic factors and health behaviors. In the GEE model, the univariate and multivariate binary logistic regression was used to estimate the crude and adjusted odds ratio (OR). Result The univariate and multivariate analysis both show the maternal age is closely associated with the child mortality, and the child mortality of older women is higher than the younger in the short term survey (univariate: OR:8.36, 95%CI:4.17-16.77, multivariate: OR: 8.89, 95%CI: 4.27-18.54). In the long term, the results demonstrate that the child mortality of delivering in hospital (OR:0.29, 95%CI:0.11-0.76) and birthing home (OR: 0.46, 95%CI: 0.21-0.98) both lower than home (reference group). Compared to Bacolod, the child mortality rate of Gensan and Koronadal is lower in the short term. We found no difference in other maternal social-demographic factors and health behaviors. During the survey period, the literacy, PhilHealth, institutional delivery, delivery care provider, postnatal home visits, breastfeeding, and child mortality all improved, and the improvements of PhilHealth, postnatal home visits, breastfeeding were statistically significant. Conclusion The findings suggest that the program needs to constantly deliver more community-based interventions, such as: institutional delivery, skilled birth attendance, postnatal care, which would transform the children health of ultra poverty in the long run.
published_or_final_version
Public Health
Master
Master of Public Health

This thesis investigates the role of the British colonial state in India in moves to combat maternal mortality and to spread western methods of midwifery among the Indian population. The first part of the thesis concentrates on the Madras Presidency, where the provincial government took a pioneering role in the field; later chapters consider developments in Bombay. The role of the Crown is considered in detail as is the important part played by the Countess of Dufferin's Fund, a voluntary organisation which was closely identified with state maternity and female medical provision. Research was mainly archival, although some use was made of accounts of work by anthropologists and midwives working with Indian traditional birth attendants, or dais. Central to the research were the written records of the Government of India and of the provincial governments of Madras and Bombay held in the British Library, and the records of the General Department of the Government of Bombay held in the Maharashtra State Archives in Mumbai. I was granted privileged access to the Royal Archives at Windsor and to the records of Interserve, the Church of England Missionary Society; I was also the first researcher in this field to consult the Dufferin Fund papers in the Public Records Office of Northern Ireland in Belfast. This thesis offers an important corrective to the standard historiography of women's health in British India, which has generally dismissed the role and even the interest of the state in the issue. This thesis argues that the government lying-in hospital in Madras formed a significant forum for social encounter between Indians and British and that it served as the epicentre of a major initiative by the Madras government to spread western medical practice and ideas throughout the presidency. It also highlights how rivalry between the different presidencies of British India lent maternity provision considerable significance as a field of political manoeuvre. It further argues that in the latter years of the nineteenth century the British authorities sought to use concern about Indian maternity conditions and women's health to neutralise and undermine both the Indian nationalist movement and the burgeoning movement for female emancipation.

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.

Worldwide, more than 1 million infants die as a result of premature birth. In the United States, where 1 in 10 births occurs preterm, premature birth is the leading cause of infant mortality. Premature infants have high rates of mortality and morbidity, with the highest rates seen in those infants born extremely preterm -- prior to 30 weeks gestation. Severe morbidity in these infants often contributes to life-long health problems. Maternal hypertension (HTN) is one contributor to preterm birth and also contributes to fetal growth restriction, resulting in birth weights which are small for gestational age (SGA, and generally within the lowest 10th percentile). Within this high risk population, SGA infants have increased risk of mortality compared to appropriate for gestational age infants. Therefore the impact of maternal HTN on neonatal outcome might be presumed to be negative. Previous studies however, have been contradictory, with both higher and lower rates of infant mortality reported in infants born to mothers with HTN, as well as differing reports analyzing the relationship between serious morbidity and maternal HTN. Utilizing the Vermont Oxford Network Very Low Birth Weight database, a collaborative database of Level III Neonatal Intensive Care Units across the world, 88,275 North American infants born between 22+0 and 29+6 weeks gestational age between 2008 and 2011 were identified. This dissertation explores the relationship between maternal HTN and gestational age at time of birth within this population, and the reported rates of morbidity and mortality in infants born prior to 30 weeks gestation. The independent contributions of maternal HTN with neonatal morbidity and mortality in our population were estimated using logistic regression and adjusting for factors previously known to be associated with risk, including birth weight, antenatal steroid exposure, infant sex, maternal race/ethnicity, prenatal care, inborn/outborn status, and birth year. We hypothesized that mortality rates would be lower for infants born to mothers with HTN compared to those born due to other factors, when corrected for the noted confounding variables and surviving infants would have better prognoses, as evidenced by lower rates of severe morbidity, including bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, and infection. Within the higher-risk SGA population, we hypothesized that mortality rates would be higher than observed in appropriately grown infants, but decreased in those born to mothers with HTN, despite the association between maternal HTN and SGA. This dissertation begins with an explanation of current knowledge about preterm birth, maternal HTN, and their associations. Chapter 2 focuses on the relationship between maternal HTN and infant mortality in extremely preterm infants. Chapter 3 examines the risk associated with severe morbidities in surviving infants. In addition, we also use a combined morbidity risk assessment score which has previously been used to determine future risk of long term disability. In Chapter 4, SGA infants are separately evaluated for their risk of mortality and the association with maternal HTN. These analyses support the high mortality and morbidity rates seen in extremely preterm infants. Maternal HTN, after adjustment, results in reduced risk of both mortality and severe morbidities in infants compared to infants born to mothers with other underlying contributors to preterm birth. This suggests that clinical practices and parental counseling should reflect differing risk profiles in sub-populations of extremely preterm infants.

The World Health Organization (WHO) found that 6.6 million children under five died in 2012 (WHO 2013). Almost half of all of these child deaths take place in the first month of life, and 75% of all under five deaths occur within the child's first year of life (WHO 2013). The aim of this study is to compare the most influential factors that decrease infant and neonatal mortality in order to find where policy makers, governments, and international organizations need to focus their efforts in order to get all countries on track for Millennium Development Goal 4 to reduce child mortality. Mosley and Chen (1984) suggest that infant mortality should be studied more as a process with multifactorial origins opposed to an acute, single phenomenon. To study the multifaceted nature of infant mortality they suggest grouping select variables into broad categories. This paper uses this model to test the contribution of the following four types of factors: 1) healthcare system 2) social determinants 3) reproductive behavior and 4) national context in order to understand which category impacts infant mortality most significantly. This study utilizes the Demographic and Health Surveys and was estimated using a discrete time hazard model. Results suggest that social determinants reduce infant mortality most significantly over the other three factors and that maternal education is the key to reaching Millennium Development Goal 4. This research suggests that healthcare interventions, although important, are not a substitute for mother's education. The combination of prenatal care and maternal education will ensure the safest first year for a child.

Background Each neonatal death counts, as recognised by the Every Newborn Action Plan (ENAP). This is an important aspect in attaining the third Sustainable Development Goal by 2030. Accurate neonatal mortality data as well as an understanding of the causality and context is essential to plan interventions to reduce neonatal deaths and attain the third Sustainable Development Goals (SDG) of a neonatal mortality rate of less than 12 per 1000 livebirths by 2035. Objectives The objectives of this study were: (i) to determine neonatal mortality occurring in and out of health facilities in the Metro West GSA using the three audit programmes; Perinatal Problem Identification Programme (PPIP), Child Healthcare Problem Identification Programme (Child PIP) and Forensic Pathology Services (ii) to ascertain the cause of death specific neonatal mortality (iii) to describe the avoidable factors in each death as coded by the three audit programmes (iv) to make recommendations for the alignment of existing audit databases to obtain accurate neonatal statistics for the Metro West GSA. Methods This was a retrospective descriptive study of neonatal deaths undertaken in the public healthcare setting in the Cape Town Metro West GSA from January 2014 till December 2017. Existing data from PPIP, Child PIP and the CDR/FPS was used. Neonatal deaths were defined as in the first 28 days of life where there had been signs of life at delivery and a birthweight greater than 500g. Neonatal deaths were excluded where birth had occurred outside of the GSA or in the private health care setting. The audit data with regards to cause of death and avoidable or modifiable factors was obtained for each death. Results From a total of 134843 live deliveries, 1243 neonatal deaths were identified: 976(78%) from PPIP, 58(5%) from Child PIP and 209 (17%) from CDR/FPS. Sixteen per cent of the deaths occurred outside of healthcare facilities. The neonatal mortality rate (NMR) for PPIP was 7.2, Child PIP 0.43 and CDR 1,6 per 1000 livebirths. When the audit systems were combined, the annual NMR over the study period varied from 8.05 to 10.1 with a mean of 9.2 per 1000 livebirths over the entire period. Seventy-eight per cent of the deaths occurred in the early neonatal period with a mean early neonatal mortality rate of 7.2 per 1000 livebirths. The mean late NMR was 2 per 1000 livebirths. Where all neonatal deaths were considered for those more than 500g, the main cause of death was immaturity related, then infection related followed by congenital disorders and then hypoxia related. Seventy-four per cent of deaths occurred in those less than 2500g at birth and 41% were less than 1000g and defined as extremely low birthweight. In the group of neonates greater than 1000g, the main cause of death was infection related deaths, closely followed by congenital disorders and then hypoxia, followed by immaturity. Most of infection related deaths were collected by the CDR and Child PIP. A third of Child PIP and PPIP deaths and half of the CDR deaths were coded as avoidable. The prevalence of deaths due to abandonment either by passive or active neonaticide contributed towards the higher proportion of preventable deaths in the CDR group. Conclusions The burden of deaths due to immaturity is high and may be attributed to the finding that 41% of neonatal deaths were in the ELBW group. Current viability criteria that aim at optimum use of resources may improve survival amongst this group. Infection related deaths were shown by this study to have a greater burden than recorded from PPIP data; most of these deaths were derived from Child PIP and CDR data. Also, where 10% of neonatal deaths were sudden unexpected deaths (SUDIs), a better understanding and definition of this group is urgently required as many of these deaths were subsequently found to be secondary to lower respiratory infections. It is further relevant that where 20% of CDR deaths or 3% of all the study deaths were due to active and passive neonaticide, this entity should be monitored and investigated. The study showed that the GSA has achieved the SDG for NMR of less than 12 per 1000 livebirth. However, a mean NMR of 9.2 per 1000 livebirths is not comparable to other upper middle-income countries. As 38% of the deaths were coded as avoidable, appropriate programmes to address these factors could reduce the NMR to 5.7 per 1000 livebirths. A strong recommendation from this study would be to use all three audit systems to calculate the NMR, understand the causes of neonatal deaths and plan programmes to improve neonatal survival in this GSA.

Orientador: Mary Angela Parpinelli
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: Introdução: A mortalidade materna (MM) é um forte indicador de disparidades nos direitos das mulheres. O estudo dos casos de Near Miss (NM) é estratégico para identificar falhas no atendimento obstétrico. Em números absolutos, tanto MM quanto a ocorrência de eclâmpsia são eventos raros. Objetivo: avaliar os principais preditores de desfecho maternal grave (DMG: NM materno e MM) para eclâmpsia. Métodos: análise secundária de um estudo transversal, multicêntrico, incluindo 27 unidades obstétricas de referência de todas as cinco regiões do Brasil, entre 2009/2010. Foram identificados 426 casos de eclâmpsia e classificados de acordo com os resultados: DMG e não-DMG. As regiões brasileiras foram divididas em regiões de menor e maior renda e calculados os indicadores de cuidados obstétricos pela OMS. SPSS® e Stata® softwares foram utilizados para avaliar as características maternas, história clínica e obstétrica e o acesso aos serviços de saúde como preditores para a DMG, e correspondentes resultados perinatais, através do cálculo das razões prevalência (RP), respectivos intervalos de confiança de 95% (IC) e ainda aplicada à análise de regressão múltipla de Poisson (ajustada para o efeito cluster). Resultados: a prevalência e o índice de mortalidade por eclâmpsia em regiões de menor e maior renda foram de 0,8% / 0,2% e 8,1% / 22%, respectivamente. Dificuldades no acesso aos serviços de saúde: internação em UTI (RP ajustada 3,61, IC 95% 1,77-7,35) e monitorização inadequada (RP ajustada 2,31, IC 95% 1,48-3,59) foram associadas com DMG, também a morte perinatal foi maior neste grupo (RP ajustada 2,30; IC de 95% 1,45-3,65). Conclusão: a morbidade / mortalidade associada com eclâmpsia foi elevada no Brasil, especialmente nas regiões de baixa renda. A qualificação do atendimento à saúde materna e melhorias nos atendimentos das emergências são essenciais para aliviar a carga de eclâmpsia
Abstract: Background: Maternal mortality (MM) is a core indicator of disparities in women rights. Studying Near Miss cases is strategic to identify breakdowns in obstetrical care. In absolute numbers, both MM and the occurrence of eclampsia are rare events. We aim to assess the obstetric care indicators and main predictors for severe maternal outcome from eclampsia (SMO: maternal death plus maternal near miss). Methods: secondary analysis of a multicentre cross-sectional study, including 27 referral obstetric units from all five regions of Brazil, from 2009/2010. 426 cases of eclampsia were identified and classified according to outcomes: SMO and non-SMO. We divided Brazilian regions in lower and higher income regions and calculated the obstetric care indicators by WHO. SPSS® and Stata® softwares were used to assess the maternal characteristics, clinical and obstetrical history, access to health services as predictors for SMO, and correspondent perinatal outcomes, by calculating the prevalence ratios (PR), respective 95% confidence interval (CI) and also applying Poisson multiple regression analysis (adjusted for cluster effect). Results: prevalence and mortality index for eclampsia in lower and higher income regions were0.8%/ 0.2% and 8,1%/ 22%, respectively. Difficulties on access health care: ICU admission (adjPR 3.61; 95%CI 1.77-7.35) and inadequate monitoring (adjPR 2.31; 95%CI 1.48-3.59) were associated with SMO, also perinatal death was higher in this group (adjPR 2.30; 95%CI 1.45-3.65). Conclusions: morbidity/mortality associated with eclampsia were high in Brazil, especially in lower income regions. Qualifying maternal health and improvements in emergency care are essential to relieve the burden of eclampsia
Mestrado
Saúde Materna e Perinatal
Mestra em Ciências da Saúde

Magister Public Health - MPH
Background: Antenatal care serves as a key entry point for a pregnant woman to receive a broad range of services and should be initiated at the onset of pregnancy (WHO, 2016). Cameroon has one of the highest maternal mortality ratios in the world (UNICEF, 2016). The majority of pregnant women in Cameroon initiate antenatal care after the first trimester (Njim, 2016). Most studies on initiation of antenatal care in Cameroon have not explored in greater depth the reasons why most of the pregnant women initiate antenatal care late. Methodology: The aim of the study is to understand the reasons why pregnant women initiate antenatal care late in Nkwen Baptist Health Center, North West Region, Cameroon. It is an exploratory study and applied purposive sampling to recruit eighteen pregnant women and three key informants for data collection through individual interviews. Pregnant women who initiated antenatal care after the first trimester were recruited during antenatal care clinics and interviewed in a room at the antenatal care unit. Key informants were midwives working at the antennal care unit. Participation in the study was voluntary. Participants were explained the purpose of the study and signed a consent form if they were willing to participate in the research. Participation in the research did not inhibit the respondent’s access to care. Data was collected using an audio tape and analyzed using Thematic Coding Analysis (TCA) to identify recurring themes that emerged from the data to adequately describe the perceptions of respondents on the reasons for late initiation of antenatal care.