Birth and Delivery Birth Outcomes
RRM Academy Synopsis
Chile's maternal deaths fell as women's education rose
Chile's maternal death ratio fell as women's schooling rose from 1957 to 2007, a natural experiment with national yearly data found. The downward slope showed no significant change after the 1989 abortion prohibition. The models also included fertility rate, skilled birth attendants, clean water and sewers.
Key Findings
- The maternal mortality ratio peaked at 293.7 per 100,000 live births in 1961 and stood at 18.2 in 2007. The data covered 14,413 maternal deaths and 13,799,330 live births.
- In the fully adjusted model, each additional year of women's education was associated with a decrease in the maternal mortality ratio of 29.31 per 100,000 live births.
- The ratio fell by 13.29 per 100,000 live births each year between 1965 and 1981 and by 1.59 each year in the slower phase that followed.
- After the 1989 law prohibiting therapeutic abortion, the ratio fell from 41.3 to 12.7 per 100,000 live births by 2003, a 69.2% decrease. The slope from 1981 showed no significant change.
- After 1965, each 1% increase in the share of births to first-time mothers older than 29 was associated with an estimated 30 more maternal deaths per 100,000 live births.
Interpretation
The study is a natural experiment. It applies time-series models and segmented regression to Chile's national yearly data. Each data point is a national figure, so the results describe population trends. The authors note that this design does not allow causal relationships to be established. The predictors moved in parallel over 50 years, which the authors addressed through the autoregressive part of their models. Four versions of the international disease classification were used. Spontaneous and induced abortion deaths could not be separated for all periods. All findings come from one country.
RRM Context
The authors list natural family planning among the ways schooling may help women use health services. They also report that later maternal deaths came more often from long-term illness that began before pregnancy. Restorative reproductive medicine builds body literacy and checks whole-body health before conception.
Abstract
Background
The aim of this study was to assess the main factors related to maternal mortality reduction in large time series available in Chile in context of the United Nations' Millennium Development Goals (MDGs).
Methods
Time series of maternal mortality ratio (MMR) from official data (National Institute of Statistics, 1957-2007) along with parallel time series of education years, income per capita, fertility rate (TFR), birth order, clean water, sanitary sewer, and delivery by skilled attendants were analysed using autoregressive models (ARIMA). Historical changes on the mortality trend including the effect of different educational and maternal health policies implemented in 1965, and legislation that prohibited abortion in 1989 were assessed utilizing segmented regression techniques.
Results
During the 50-year study period, the MMR decreased from 293.7 to 18.2/100,000 live births, a decrease of 93.8%. Women's education level modulated the effects of TFR, birth order, delivery by skilled attendants, clean water, and sanitary sewer access. In the fully adjusted model, for every additional year of maternal education there was a corresponding decrease in the MMR of 29.3/100,000 live births. A rapid phase of decline between 1965 and 1981 (-13.29/100,000 live births each year) and a slow phase between 1981 and 2007 (-1.59/100,000 live births each year) were identified. After abortion was prohibited, the MMR decreased from 41.3 to 12.7 per 100,000 live births (-69.2%). The slope of the MMR did not appear to be altered by the change in abortion law.
Conclusion
Increasing education level appears to favourably impact the downward trend in the MMR, modulating other key factors such as access and utilization of maternal health facilities, changes in women's reproductive behaviour and improvements of the sanitary system. Consequently, different MDGs can act synergistically to improve maternal health. The reduction in the MMR is not related to the legal status of abortion.
