Academic journal article International Perspectives on Sexual and Reproductive Health

A Woman Cannot Die from a Pregnancy She Does Not Have

Academic journal article International Perspectives on Sexual and Reproductive Health

A Woman Cannot Die from a Pregnancy She Does Not Have

Article excerpt

More than 99% of maternal deaths* occur in low-resource settings; in parts of the developing world, as many as one in six women die of maternal causes. (1) Currently, seven developing countries--Afghanistan, Angola, Malawi, Niger, Rwanda, Sierra Leone and Tanzania--have maternal mortality ratios of at least 1,400 maternal deaths per 100,000 live births. (2)

Levels of maternal mortality were similarly high in Europe and North America only a century ago; today, however, a woman's lifetime risk of dying from maternal causes is as low as one in 30,000 in these areas (e.g., the MMR in Sweden in 2005 was 12/100,000). (1) (3-4) Much of this decline in maternal mortality has resulted from improvements in obstetric care (including early recognition of risk factors for pregnancy complications), access to safe abortion and other advances in health care. (1)

Such improvements in obstetric care are urgently needed in the developing world--lor example, all women should have a skilled birth attendant and access to medical facilities--and would do much to reduce the high rates of maternal death. However, a commitment to complex, high-cost, long-term solutions to the problem of maternal mortality should not divert us from immediate, low-cost, low-tech approaches.5 One such solution is simply reducing fertility.

Fertility has declined during the last century, particularly in industrialized countries, (5), (6), (7) and this decline has accompanied changes in family structure and desired family size, urbanization, and increased access to and use of modern contraceptives. However, in many developing regions where maternal mortality is high, fertility remains high as well. The total fertility rate (TFR)--the average number of live births a woman has during her lifetime--is still at least five children per woman in 34 countries and territories, most of them in Sub-Saharan Africa. (2)

In Prata and colleagues' 2010 cost-benefit analysis of different aspects of maternal care, the combination of two reproductive health interventions that affect fertility rates-providing family planning and providing access to safe abortion--was the most economical way to reduce maternal deaths in low-resource settings. (8) However, two questions remain: Exactly what role do fertility decline and im provements in obstetric care play in reducing maternal mortality? And, which intervention decreases maternal mortality most effectively?

A Hypothetical Exercise

To highlight the role of fertility decline in reducing maternal deaths, we conducted an exercise using historical data on fertility and maternal mortality to create two hypothetical scenarios. In the first scenario, fertility levels in a population stayed the same between the early 1900s and the early 2000s, while maternal mortality ratios fell to 2005 levels. This scenario estimated the impact of improved obstetric care on maternal mortality. In the second scenario, we reversed the situation, using century-old maternal mortality rates in combination with current TFRs; this allowed . us to estimate how reducing fertility affects the number of maternal deaths.

Our analysis focused on Sweden, one of the few countries for which long-term, high-quality, age-specific data on fertility and maternal mortality ratios are available. We used data from 1911 and 2005 (or as close to these years as possible) for women aged 15-49. Because maternal mortality is rare in Sweden (in 2005, only six women died of causes related to pregnancy or childbirth9), we could not calculate age-specific maternal mortality ratios ior 2005. Therefore, we used Wildman and colleagues' 20044 estimates of age-specilic maternal mortality ratios for European countries with low maternal mortality. The larger population size of the pooled multicountry data set allowed for more precise and accurate ratios for each age-group, and we feel confident that these are reasonable estimates for Sweden. …

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