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In reproductive health, obstetric transition is a concept around the secular trend of countries gradually shifting from a pattern of high maternal mortality to low maternal mortality, from direct obstetric causes of maternal mortality to indirect causes, aging of maternal population, and moving from the natural history of pregnancy and childbirth to institutionalization of maternity care, medicalization and over medicalization. [1] This concept was originally proposed in the Latin American Association of Reproductive Health Researchers (ALIRH, 2013) in analogy of the epidemiological, demographic and nutritional transitions.
In the last two decades, the world has seen a substantial reduction of maternal mortality.(1) Considering that maternal mortality is vastly determined by social, societal and contextual factors, this reduction is important not only because of the number of lives that have been spared in this period (an estimated 2,000,000 between 1990 and 2010), but because it denotes that the world is making progress towards development and gender equality.(1,2) However, this progress is still insufficient, unequal and slow: recent estimates suggest that 287,000 women died of causes related to pregnancy and childbirth in 2010. Maternal mortality remains a global tragedy, but the observed progress inspires the international community to believe and strive for the elimination of maternal mortality in the decades to come.(3)
The vast majority of maternal deaths is avoidable and takes place in developing countries. In developed countries, the maternal mortality ratio can be as low as 10 maternal deaths per 100,000 live births while among the least developed countries it can be as a high as 1,000 maternal deaths or more per 100,000 live births.(4) This disparity is also observed within countries and when the population is disaggregated in quintiles of income or education.(5-7) Thus, countries, regions within countries and different population groups within country experience a specific momentum in a dynamic process of reduction of maternal mortality, which may benefit from specific approaches.
In 1929, Thompson described the phenomenon of demographic transition characterized by a gradual shift from a pattern of high mortality and high fertility to a pattern of low mortality and low fertility.(8) Omram (1971) described the epidemiologic transition, with a shift from a pattern of high prevalence of communicable diseases to a pattern of high prevalence of non-communicable diseases.(9) Finally, Poppkin (1993) proposed the nutritional transition model, which helps to understand the transformations in human diets and the global epidemic of obesity.(10) These transitions and other socioeconomic and cultural changes (e.g. globalization, urbanization) led us to develop the concept of “obstetric transition” (11).
As a result of the Millennium Development Goals Project, improved data related to maternal mortality and severe maternal morbidity became available for the period between 1990 and 2010. Altogether, these data reflect a secular trend where countries are gradually shifting from a pattern of high maternal mortality to low maternal mortality, from direct obstetric causes of maternal mortality to indirect causes, moving from the natural history of pregnancy and childbirth to institutionalization of maternity care, medicalization and over medicalization, and aging of maternal population. This is the “obstetric transition” phenomenon, which has implications for the strategies aimed at reducing maternal mortality.
Figure 1 presents trends of maternal mortality by world region for the period 1990 to 2010 derived from recent estimates (2). Considering that countries and world regions are transitioning in the same pathway towards elimination of maternal deaths, five stages can be devised. Countries are experiencing this transition at different paces, and have started this process in different moments of their history (e.g. most developed countries started their transitions more than a century ago, while some developing countries have started their transition much more recently).
In the Stage I (MMR> 1,000 / 100,000) most women are experiencing a situation close to the natural history of pregnancy and childbirth, with very little being done – if anything at all – to reduce the risk of maternal mortality at the population level. Considering 2010 data, Chad and Somalia are countries that could illustrate this stage. Hopefully, as time passes (and progress occurs), no country will remain in this stage. Stage I is characterized by very high maternal mortality, high fertility and the predominance of direct causes of maternal deaths together with a substantial proportion of deaths attributable to communicable diseases such as malaria.
In the Stage II (MMR: 999 – 300) mortality and fertility remain very high, with a similar pattern of causes as compared to the Stage I. However, a greater proportion of women in the population are being able to somewhat detach from the natural history of pregnancy and childbirth. Several countries in the Sub-Saharan Africa could illustrate the Stage II. For Stages I and II, the main issue is access to care. In general, these are countries with a substantial lack of basic infrastructure (such as roads, transportation, health facilities), very low education levels (particularly female literacy), weak health systems, severe shortages of skilled birth attendants and low capacity to deliver essential life-saving interventions. In this context, poor quality of care functions as deterrent for generating demand for health services. In countries in these stages, focus should be directed to creating the basic infra-structure and implement maternal-mortality primary prevention measures (e.g. family planning, iron supplementation, insecticide treated nets, intersectorial measures to remove barriers to access the health system). As the minimal infra-structure is created, health services should strive to deliver quality care in order to become a sensible alternative to pregnant women (demand generation). (21)
In the obstetric transition, the tipping point occurs in the Stage III. In this stage the mortality is still high (MMR 299 – 100 maternal deaths / 100,000 live births), the fertility is variable and direct causes of mortality still predominates. This is a complex stage because access remain an issue for a great deal of the population, but as a large proportion of pregnant women are indeed reaching health facilities, quality of care becomes a major determinant of health outcomes. Not only primary prevention is important, but also secondary and tertiary prevention are critical for improving maternal health outcomes in this stage. In other words, quality of care, with skilled birth attendance and appropriate management of complications and disabilities, is essential to reduce maternal mortality. India, Guatemala and South Africa are countries that could illustrate this stage.
In the Stage IV (MMR <50 maternal deaths / 100,000 live births), the maternal mortality is moderate or low, there is low fertility and the indirect causes of maternal mortality, particularly the non-communicable diseases, acquire greater importance. In order to further advance the reduction of maternal mortality, the main issue becomes quality of care and elimination of delays within health systems. Another aspect that emerges in this stage is the growing role of over medicalization as a threat to quality and improved health outcomes. Various Asian countries and most Latin American countries have joined developed countries in this stage.
In the Stage V, all avoidable maternal deaths are indeed avoided. The maternal mortality rate is very low, the fertility is low or very low, and the non-communicable diseases are the main causes of maternal mortality. As this is an aspirational, largely theoretical stage at the moment, the maternal mortality levels remain uncertain, but could be lower than 5 maternal deaths per 100,000 live births. The main issue in this stage would be the sustainability of excellence in quality of care.
It is worth noting that the main purpose of this framework is to illustrate different phases of a dynamic process and offer a rationale for different focus and solutions for reducing mortality according to the stage in the obstetric transition. The ranges of maternal mortality ratio uses to define the proposed stages of obstetric transition are frequently in country stratification, (2, 16) but the boundaries between these stages are somewhat imprecise and one stage tends to fade into another. Progression is not always linear and, largely due to equity issues, different stages often co-exist in the same country.
Maternal death or maternal mortality is defined in slightly different ways by several different health organizations. The World Health Organization (WHO) defines maternal death as the death of a pregnant mother due to complications related to pregnancy, underlying conditions worsened by the pregnancy or management of these conditions. This can occur either while they are pregnant or within six weeks of resolution of the pregnancy. The CDC definition of pregnancy-related deaths extends the period of consideration to include one year from the resolution of the pregnancy. Pregnancy associated death, as defined by the American College of Obstetricians and Gynecologists (ACOG), are all deaths occurring within one year of a pregnancy resolution. Identification of pregnancy associated deaths is important for deciding whether or not the pregnancy was a direct or indirect contributing cause of the death.
India's population in 2021 as per World Bank is 1.39 billion. Being the world's second-most-populous country and one of its fastest-growing economies, India experiences both challenges and opportunities in context of public health. India is a hub for pharmaceutical and biotechnology industries; world-class scientists, clinical trials and hospitals yet country faces daunting public health challenges like child undernutrition, high rates of neonatal and maternal mortality, growth in noncommunicable diseases, high rates of road traffic accidents and other health related issues.
In demography and medical geography, epidemiological transition is a theory which "describes changing population patterns in terms of fertility, life expectancy, mortality, and leading causes of death." For example, a phase of development marked by a sudden increase in population growth rates brought by improved food security and innovations in public health and medicine, can be followed by a re-leveling of population growth due to subsequent declines in fertility rates. Such a transition can account for the replacement of infectious diseases by chronic diseases over time due to increased life span as a result of improved health care and disease prevention. This theory was originally posited by Abdel Omran in 1971.
Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. In most cases, maternal health encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience. In other cases, maternal health can reduce maternal morbidity and mortality. Maternal health revolves around the health and wellness of pregnant women, particularly when they are pregnant, at the time they give birth, and during child-raising. WHO has indicated that even though motherhood has been considered as a fulfilling natural experience that is emotional to the mother, a high percentage of women develop health problems and sometimes even die. Because of this, there is a need to invest in the health of women. The investment can be achieved in different ways, among the main ones being subsidizing the healthcare cost, education on maternal health, encouraging effective family planning, and ensuring progressive check up on the health of women with children. Maternal morbidity and mortality particularly affects women of color and women living in low and lower-middle income countries.
Malaysia is classified by The World Bank as upper middle income country and is attempting to achieve high-income status by 2020 and to move further up the value-added production chain by attracting investments in high technology, knowledge-based industries and services. Malaysia's HDI value for 2015 was recorded at 0.789 and HDI rank no 59 out of 188 countries and territories on the United Nations Development Programme's Human Development Index. In 2016, the population of Malaysia is 31 million; Total expenditure on health per capita is 1040; Total expenditure on health as % of GDP (2014) was 4.2 Gross national income (GNI) per capita was recorded at 24,620
Tropical diseases, especially malaria and tuberculosis, have long been a public health problem in Kenya. In recent years, infection with the human immunodeficiency virus (HIV), which causes acquired immune deficiency syndrome (AIDS), also has become a severe problem. Estimates of the incidence of infection differ widely.
Morocco became an independent country in 1956. At that time there were only 400 private practitioners and 300 public health physicians in the entire country. By 1992, the government had thoroughly improved their health care service and quality. Health care was made available to over 70% of the population. Programs and courses to teach health and hygiene have been introduced to inform parents and children on how to correctly care for their own and their families' health.
The Tajikistan health system is influenced by the former Soviet legacy. It is ranked as the poorest country within the WHO European region, including the lowest total health expenditure per capita. Tajikistan is ranked 129th as Human Development Index of 188 countries, with an Index of 0.627 in 2016. In 2016, the SDG Index value was 56. In Tajikistan health indicators such as infant and maternal mortality rates are among the highest of the former Soviet republics. In the post-Soviet era, life expectancy has decreased because of poor nutrition, polluted water supplies, and increased incidence of cholera, malaria, tuberculosis, and typhoid. Because the health care system has deteriorated badly and receives insufficient funding and because sanitation and water supply systems are in declining condition, Tajikistan has a high risk of epidemic disease.
A maternal near miss (MNM) is an event in which a pregnant woman comes close to maternal death, but does not die – a "near-miss". Traditionally, the analysis of maternal deaths has been the criterion of choice for evaluating women's health and the quality of obstetric care. Due to the success of modern medicine such deaths have become very rare in developed countries, which has led to an increased interest in analyzing so-called "near miss" events.
Bangladesh is one of the most populous countries in the world, as well as having one of the fastest growing economies in the world.) Consequently, Bangladesh faces challenges and opportunities in regards to public health.
Health in Angola is rated among the worst in the world.
A landlocked sub-Saharan country, Burkina Faso is among the poorest countries in the world—44 percent of its population lives below the international poverty line of US$1.90 per day —and it ranks 185th out of 188 countries on UNDP's 2016 Human Development Index .Rapid population growth, gender inequality, and low levels of educational attainment contribute to food insecurity and poverty in Burkina Faso. The total population is just over 20 million with the estimated population growth rate is 3.1 percent per year and seven out of 10 Burkinabe are younger than 30. Total health care expenditures were an estimated 5% of GDP. Total expenditure on health per capita is 82 in 2014.
The 2010 maternal mortality rate per 100,000 births for Tanzania was 790. This is compared with 449 in 2008 and 610.2 in 1990. The UN Child Mortality Report 2011 reports a decrease in under-five mortality from 155 per 1,000 live births in 1990 to 76 per 1,000 live births in 2010, and in neonatal mortality from 40 per 1,000 live births to 26 per 1,000 live births. The aim of the report The State of the World's Midwifery is to highlight ways in which the Millennium Development Goals can be achieved, particularly Goal 4 – Reduce child
Like many developing countries, Uganda has high maternal mortality ratio at 343 per 100,000 live births. According to the World Health Organization (WHO), a maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. In situations where attribution of the cause of death is inadequate, another definition, pregnancy-related death was coined by the US Centers for Disease Control (CDC), defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.
Health in Guatemala is focused on many different systems of prevention and care. Guatemala's Constitution states that every citizen has the universal right to health care. However, this right has been hard to guarantee due to limited government resources and other problems regarding access. The health care system in place today developed out of the Civil War in Guatemala. The Civil War prevented social reforms from occurring, especially in the sector of health care.
Maternal health in Angola is a very complicated issue. In the Sub-Saharan region of Africa where Angola is located, poor maternal health has been an ongoing problem contributing to the decreased level of health in the population in the early 21st century.
Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant women. It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech.
Sustainable Development Goals is a post Millennium Development Goal agenda by experts in the world which will be implemented within the next 15 years until 2030. It has seventeen goals and 169 targets as a whole where SDG 3 deal with ensuring health lives and promote well-being for all at all ages. Sustainable Development Goal 3 has nine targets and four sub targets related with different areas of health. One of the targets target 3.1 is a target to achieve a reduction of global maternal mortality ratio to less than 70 per 100,000 live births .Maternal death is defined as "The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
Maternal mortality refers to the death of a woman during her pregnancy or up to a year after her pregnancy has terminated; this metric only includes causes related to the pregnancy, and does not include accidental causes. Some sources will define maternal mortality as the death of a woman up to 42 days after the pregnancy has ended, instead of one year. In 1986, the CDC began tracking pregnancy-related deaths to gather information and determine what was causing these deaths by creating the Pregnancy-Related Mortality Surveillance System. Although the United States was spending more on healthcare than any other country in the world, more than two women died during childbirth every day, making maternal mortality in the United States the highest when compared to 49 other countries in the developed world. The CDC reported an increase in the maternal mortality ratio in the United States from 18.8 deaths per 100,000 births to 23.8 deaths per 100,000 births between 2000 and 2014, a 26.6% increase. As of 2018, the US had an estimated 17.4 deaths per 100,000 live births. The mortality rate of pregnant and recently pregnant women in the United States rose almost 30% between 2019 and 2020. According to the CDC, a study that included data from 36 states found that more than 80% of pregnancy-related deaths were preventable between 2017 and 2019.
Maternal mortality in India is the maternal death of a woman in India during pregnancy or after pregnancy, including post-abortion or post-birth periods. Different countries and cultures have different rates and causes for maternal death. Within India, there is a marked variation in healthcare access between regions and in socioeconomic factors, accordingly, there is also variation in maternal deaths for various states, regions, and demographics of women.