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other·public health, epidemiology, obstetrics and gynecology, pediatrics, observational study·PMC10299966

Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countries

The Lancet. Global Health · 8 authors, 6 centres

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TL;DR

This study developed a five-phase mortality transition model for maternal, stillbirth, and neonatal deaths using data from 151 countries. It found that 63% of countries in phases 1 to 4 in 2000 progressed at least one phase by 2020, with progression associated with declining infectious disease deaths, lower fertility, and improved health systems.

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The study used UN mortality estimates for 151 countries from 2000 and 2020 to develop a five-phase transition model based on ratios of maternal to stillbirth and neonatal mortality. It analyzed causes of death, fertility, health workforce, financing, and service coverage from global databases and 326 national surveys. Results showed that among 116 countries in phases 1 to 4 in 2000, 73 progressed at least one phase by 2020. The ratio of stillbirth and neonatal deaths to maternal deaths increased from less than 10 in phase 1 to well over 50 in phase 4 and 5. Progression was associated with declining infectious disease and peripartum complication deaths, declining fertility rates, and improving health system indicators. The model provides a benchmark for strategic planning towards Sustainable Development Goal targets. Limitations include reliance on aggregated estimates and potential misclassification due to uncertainty in mortality data.

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other

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public health

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ORIGINAL PAPER

PMC10299966

Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countries

The Lancet. Global Health

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ABSTRACT

Summary Background Maternal mortality, stillbirths, and neonatal mortality account for almost 5 million deaths a year and are often analysed separately, despite having overlapping causes and interventions. We propose a comprehensive five-phase mortality transition model to improve analyses of progress and inform strategic planning. Methods In this empirical data-driven study to develop a model transition, we used UN estimates for 151 countries to assess changes in maternal mortality, stillbirths, and neonatal deaths. On the basis of ratios of maternal to stillbirth and neonatal mortality, we identified five phases of transition, in which phase 1 has the highest mortality and phase 5 has the lowest. We used global databases to examine phase-specific characteristics during 2000–20 for causes of death, fertility rates, abortion policies, health workforce and financing, and socioeconomic indicators. We analysed 326 national surveys to assess service coverage and inequalities by transition phase. Findings Among 116 countries in phases 1 to 4 in 2000, 73 (63%) progressed at least one phase by 2020, six advanced two phases, and three regressed. The ratio of stillbirth and neonatal deaths to maternal deaths increased from less than 10 in phase 1 to well over 50 in phase 4 and phase 5. Progression was associated with a declining proportion of deaths caused by infectious diseases and peripartum complications, declining total and adolescent fertility rates, changes in health-workforce densities and skills mix (ie, ratio of nurses or midwives to physicians) from phase 3 onwards, increasing per-capita health spending, and reducing shares of out-of-pocket health expenditures. From phase 1 to 5, the median coverage of first antenatal care visits increased from 66% to 98%, four or more antenatal care visits from 44% to 94%, institutional births from 36% to 99%, and caesarean section rates from 2% to 25%. The transition out of high-mortality phases involved a major increase in institutional births, primarily in lower-level health facilities, whereas subsequent progress was characterised by rapid increases in hospital births. Wealth-related inequalities reduced strongly for institutional birth coverage from phase 3 onwards. Interpretation The five-phase maternal mortality, stillbirth, and neonatal mortality transition model can be used to benchmark the current indicators in comparison to typical patterns in the transition at national or sub-national level, identify outliers to better assess drivers of progress, and inform strategic planning and investments towards Sustainable Development Goal targets. It can also facilitate programming for integrated strategies to end preventable maternal mortality and neonatal mortality and stillbirths. Funding Bill & Melinda Gates Foundation.

CITATION EXPORT

Ties Boerma, Oona M R Campbell, Agbessi Amouzou et al.. Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countries. The Lancet. Global Health. (2023). https://doi.org/10.1016/S2214-109X(23)00195-X

AUTHORS

8 · 6 CENTRES

Ties Boerma, Oona M R Campbell, Agbessi Amouzou, Cauane Blumenberg, Hannah Blencowe, Allisyn Moran, Joy E Lawn, Gloria Ikilezi

aInstitute for Global Public Health and Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
bDepartment of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
cDepartment of International Health, Johns Hopkins University, Baltimore, MA, USA
dCentre for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
eMaternal Health Unit, WHO, Geneva, Switzerland
fExemplars in Global Health, Gates Ventures, Seattle, WA, USA