ResearchGate See discussions stats, and author profiles for this publication ato /eseaychyate.net/publication 21597520 A framework for analyzing the determinants of maternal mortality. ARTICLE | STUDIES IN FAMILY PLANNING - JANUARY 1992, catarions DOWNLOADS views 100 1,397 597 ‘2 AUTHORS, INCLUDING: Deborah Maine Columbia University 59 PUBLICATIONS 2,381 CITATIONS SEE PROFILEA Framework for Analyzing the Determinants of Maternal Mortality James McCarthy; Deborah Maine Studies in Family Planning, Vol. 23, No. 1. (Jan, - Feb., 1992), pp. 23-33. Stable URL: http:flinks,jstor-org/sici?sici=009-3665% 281992101 G2F2%2029%2A 1%4C22%3 A AFFATD%3E2.0. COIB2-H Studies in Family Planning is currently published by Population Council ‘Your use of the ISTOR archive indicates your acceptance of ISTOR’s Terms and Conditions of Use, available at nip ftw, jstor-orglaboutterms.tml. 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For more information regarding ISTOR, please contact suppom@jstor org. tp ews. jtor rah Fi Mar 24 16:17:51 2006A Framework for Analyzing the Determinants of Maternal Mortality James McCarthy and Deborah Maine Hundreds of thousands of women in deoeloping countries die eack year from complications of pregnancy, attempted abortion, and childbirth. This article presents. a comprehensive and integrated framework for analyzing the cultural, social, economic, behavioral, an biological factors that insluence maternal mortality. The developrent of a conpre- ertsive framework toas carried out by rebiewineg the widely accepted framezaorks that have been developed for fertility and child survival, and by reviewing the existing lerature on maternal mortality, iscuding the results of research studies aed accounts of intervention programs, The priteipal result ofthis exercise ts tne framemark itself. One of the mir corelusions is Hat all determinants of maternal nscrtality an, ence, all efforts to reduce maternat mortality) rest operate through 2 sequence of oly thee intermediate aulcomes. These eforts must ether (7) reduce the likelihood that tooman will become pregnant; (2) reduce the likelthoad that a pregnaré womar will experience a serious complication of pregnancy or childbirth; or (3) inqprave the outcomes for women with complications, Several types of rateraentions are mast tikely to have substantial and immediate effects on maternal mortality, including {family planscing programs to prevent pregnancies, safe abortion services to reduce the incidence of complications, and improvements in labor and delivery services to increase the survieal of memen who do experience complications. (Grunts IN Fataby Panic 1992; 25, 1: 23-33) As recently as 1985, maternal mortality in developing countries was referred to as “a neglected tragedy” (Rosenfield and Maine, 1985), Although accurate data on ‘maternal mortality are not available, estimates are that 500,000 women in developing countzies die each year from complications of prognancy, abortion attempts, and childbirth (WHO, 1985). In many countries, maternal mortality is the leading cause of death among women in the reproductive ages. Further, the discrepancy between maternal mortality rates in developing countries and those in the developed world is greater than that of any other demographic indicator. The number of maternal deaths among women of reproductive age in Bangladesh and India is about 100 times the number in the United States, Infant mortality, by contrast, is about 10 to 15 Jamies McCarty, Ph.D. is Director, Cester for Population ‘nd Favntily Heaith and Professor of Public Healt, Columbia University, 60 Hazen Avenue, Naw York, NY 10032; and Deborah Maine, M.P.H. is Director, Prevention of Maternal Mortality Program, Center for Population and Fansily Health, Colson University times greater in the former countries (WHO, 1985; United Nations Population Division, 1988). Asdramaticas these statistics are, they tel} only part of the story, since many other women experience substantial suffering and per- manent injury as a result of pregnancy and childbirth, In the last five years, a number of organizations have participated in the launch of the Safe Motherhood Ini- tiative by supporting both research on the determinants of maternal mortality and interventions to reduce levels of maternal mortality, These research and programmatic efforts have considered a diverse set of factors thought to be associated with maternal mortality. For example, some recent papers have included lists of the causes and risks of maternal moxtality, which are usually organized into such categories as obstetric, health service, repro- ductive, sociaecanomic, and transportation factors (Maine et at., 1987; Royston and Armstrong, 1989) Among the interventions being promoted by various safe motherhood /maternal mortality projects are those that encourage change in the status of women; programs that offer family planning, prenatal care, nutritional supple- mentation, and tetanus immunization; programs that provide more effective linkages between traditional birth attendants and the modern health system; and programs Volume 23 Number January/Pebcuary 1992 23that undertake overall improvements in access to and the quality of emergency obstetric care (WHO, 1989; Boerma, 1987). Obviously, these causal factors and potential in- terventions operate at quite different levels of proximity to the event of a maternal death; some are directly bio- logical, whereas others are related to aspects of social or- genization and health services, Relatively few reports or programs, however, have explicitly or systematically can- sidered the mechanisms or pathways through which these diverse factors in‘luence maternal mortality. There are a few exceptions; several auithors have begun to ad- dress more systematically the entire process that culmi- nates in maternal death or serious maternal. morbidity. In some moving passages, Pathalla (1987) described the “road to death" that women follow, a road that starts ‘with the underlying socioeconomic conditions of lifeand continues to include the demographicand health service factors that contribute to death, Others have focused their efforts on that segment of the process that starts with the event of a pregnancy complication, and have examined various factors that influence delays in deciding to seek medical care, in reaching. a place where care is available, and in receiving appropriate care (Thaddeus and Maine, 1990), ‘Although these papers have taken a more system- atic approach to understanding the determinants of ma- temal mortality, they have not presented fully developed, comprehensive frameworks or models for the determi- nants of maternal mortality. The understanding of other demographic events, notably fertility and child survival, has been advanced by the development of frameworks that specify the biological and behavioral mechanisms through which social, economic, and cultural factors op erate to produce a birth or the survival af a child to age five (Davis and Blake, 1956; Bongaatts, 1978; Mosley and ‘Chen, 1984), Using the same epprozch as these earlier efforts, we present a framework for the analysis of ma- ternal mortality—a framework that we hope will be es- pecially useful for research in developing countries. The Gevefopment of an analytical model of maternal mortal- ity is an indication that the Safe Motherhood Initiative is coming of age Many of the issues discussed in this article are fa- miliar to people working on the Safe Motherhood Initia- tive; sufficient research data and program experience al- ready exist to guide efforts {o understand and change patterns of maternal mortality. However, there is now enough evidence from both research studies and pro- grams to support the developmentof a “first generation” framework. Our overall goals in developing a framework for analyzing the determinants of maternal mortality are to stimulate further discussion, further research, and new programs. Our assumption is that consideration of such 2A Skadion in Family Planning, a framework will result in programs and research projects that are more focused and ultimately more ef- fective in saving women’s tives, Furthermore, experience from these future research efforts and program interven- tions will undoubtedly contribute to refinements of the framework presented here ‘The primary focus of this article is on the determi- nants of maternal mortality, but the framework we pro- ppose can also be applied to chronic morbidity that re- sults from pregnancy or childbirth. Although the term “maternal morbidity” encompasses wide variety of con- ditions, some of which are relatively minor and of very short duration and others of which are severe and lang- standing, our framework is designed to capture the de- terminants of long-term, serious morbidity only, We use the term “disability” to refer to chronic, severe morbid- ity that results from either pregnancy or childbirth; and we refer to matemal death or disability as the ultimate ‘outcome of the framework presented below. ‘The Concepts behind the Framework Figure 1 presents a relatively simple framework for ana- lyzing the determinants of maternal mortality and mor- bidity. Itincludes the basic stages in the process that re- sult in maternal disability or death and a brief description of cach of those stages. The framework is organized around three general stages or components of the pro cess af maternal mortality. Clasest ta the event of a ma- ternal death area sequence of situations or outcomes that ‘culminates in either disability or death; these outcomes are pregnancy and pregnancy-related complications. A woman must be pregnant and experience some compli cation of pregnancy or childbirth, or have a preexisting health problem that is aggravated by pregnancy, before her death can be defined as a maternal death, This se- quence of outcomes is most directly influenced by five sets of intermediate determinants; the health status of the woman; her reproductive status; her access to health ser- vices; her health care behavior (including her use of health services); and a set of unknown factors. Finally, a set of socioeconomic and cultural background factors is at the greatest distance from a maternal death. Considering pregnancy and pregnancy complica- tions as pazt of the sequence of events or outcomes that culminates in maternal disability or death leads to an ob- vious but important set af propositions. Any factor that is thought to influence maternal mortality, and therefore any efforts to reduce maternal mortality, must operate through these events. These efforts must 1 reduce the likelihood that a woman will become pregnant;Figure 1 A framework for analyzing the determinants of maternal mortality and morsidty ‘Access to health serviow Tal care buhavioz/se of Pesib sarees (Death asatiy om vs _ -----==2_____ | | | | I | | (eee | Sedescnsrie | | caluclfatees | 1 Comaton Unknown or unpredicted fctors 2 reduce the likelihood that « pregnant woman will experience a serious complication of preg- nancy or childbirth; or 3. improve the outcomes for women with compli- ations. ‘Therefore, in all research studies and for all proposed interventions, the manner in which a given variable or program activity is expected ultimately to affect one of the outcomes in the sequence should be made clear. A review of existing research on this topic and programs in place or proposed suggests that these connections are rarely explicit ‘The framework in Figure 1 is complete in that it cov- xs all ofthe possible factors that influence maternal mor- tality, and it specifies the general mechanisms through which the more distant factors must operate. The frame- work is not, however, very precise; the boxes can be thought of as general concepts that can encompass a much larger set of variables. Figure 2 elaborates on the basic framework by incorporating many of the specific variables that could be used to measure the concepts in the basic framework. There are many such variables, and the framework presented in Figure 2 is clearly quite com- plicated. However, in spite of this complexity, a discus- sion of these specific variables can illustrate how the framework might be used in either a program orresearch setting, Our discussion of variables is ordered from those closest to the event af death and disability to those most distant from that event. Sequence of Outcomes Pregnancy By definition, pregnancy isa necessary precondition for maternal death, It is the biological state through which all other factors must influence maternal death. Although there an be no maternal death until there is a pregnancy, itis important to include pregnancy as the starting point of the sequence of outcomes leading to maternal mortal- ity, because the risk of pregnancy varies considerably from woman to woman, and because pregnancy rates vary so greatly among different groups af women! Complications Maternal (or obstetric) deaths can be classified as either direct or indirect. A direct obstetric death is one due to complications of pregnancy, delivery, or the postpartum period, including abortion complications. Indirect abstet ric deaths are those due to existing medical conditions that are made worse by the pregnancy ot delivery. On average, approximately three-quarters of maternal deaths in developing countries are due ta direct obstetric causes, and one-quarter are due to indirect causes (WHO, 1985), Furthermore,a very limited number of complications are responsible for the vast majority of deaths. For direct ob- Volume 23 Number} January/Pebeuary 1992 25Figure 2 A dotailod framework for analyzing the determinants of maternal mortality and morbidity Distant Intermedioe Oxtcomes dsterminaets eterminants Worters tal National statis in family and community Esucstion Occupation Ineerse Social and Lapa autonomy Pilar hatory oF Age Day Marital satus Range of services Quali of cace Heal sas anemia, heh, weigh nfections atl paraicaseaes (eeafaca, hepatite, tubereslo) ‘Other chrene conditions (diabetes, hypertension! Reproductive ante Fowl sats Complication ineommamity Remar ‘Acces to health services fection Lecaion of services for Praga induced Scion ofthe: ier Stns ote Scaxpaton of thes family plan ee Cather primary cace Cfimeraener abeterie care ‘Acces to information shovt services regnany covvlications svaiable Community stats Agaregste wets Catrmaniy resources (eg doctors, cise, setbutences| Ua of fri pl stetric deaths, hemorchage, infection, sequelae of illicit induced abortion, pregnancy-induced hypertension, and obstructed labor ruptured uterus are the major causes (Maine et al,, 1987). There can be considerable overlap among these causes; for example, a hemorrhage may re- sult from 2 suplured uterus, or a serious infection could ‘bea sequela of prolonged and obstructed labor. The category “complications” in the framework refers to these and possibly other complications that di- rectly contribute to maternal deaths. Conditions that con- tribute indirectly 4 maternal death are more appropri- ately included as a component of a woman’s health status, one of the intermediate determinants discussed below. Disability or Death ‘The final outcomes in the framework are either disabil- 26 Studiesin Family Passing “Health care bshavior/ase of health services Use of prenatal exe Use of rovern care for labor and delivers Ue of ile indsced abortion Unkown of unpredicted factors Death aby se of Farol tadiueral practices ity or death. Although there has not been extensive re- search on pregnancy and childbirth-related disability in developing countries, its likely that there ate anly a few nonfatal conditions that are responsible for most serious disability. These include chronic urinary tract infection, uterine prolapse, and vaginal fistulae, each of which isa serious, chronic condition that can have a considerable impact on the physical and social well-being of wornen, Intermediate Determinants Health Status ‘A. woman's personal health status prior to and during a pregnancy can have an important influence on het chances of developing and surviving a complication. The leading preexisting health conditions that are exacerbatedbby pregnancy and delivery and account for approxi- mately one-quarter of maternal deaths ia developing countries are malaria, hepatitis, anemia, and malnutri- tion Maine et al., 1987; Royston and Armstrong, 1987). Furthermore, the presence of some of these conditions may put women at higher risk of dying from one of the direct complications of pregnancy. Malaria, for example, may not only be more severe in pregnant women, but it may also contribute to anernia, which in turn may de crease a woman’s chance of surviving 2 hemorrhage Reproductive Status ‘The relationships between maternal mortality and cer- tain reproductive characteristics ate among the best docu- ‘mented in the literature (Maine, 1981). These character- istics include age and pregnancy order, which are known to have a dassic “J-shaped” relation with the maternal mortality ratio, with risks that are high for very young women, older women, women with no children, and those with many children, but ate lower for women in ‘between. Age, especially very young age, is also associ- ated with disability that results from pregnancy and childbirth. For example, vesice-vaginal fistulae are much more common among very young mothers, who are more likely than others to experience prolonged labor as a result of immature pelvises (Tahaib, 1989). Parity ‘can influence one of the ather major disabilities that re- sults from pregnancy, uterine prolapse, which is much more common among high-parity women (Omran and Standley, 1976) ‘The wantedness of a pregnancy is also an impor~ tant variable, especially since wamen who have an un- wanted pregnancy are mote likely than others to seek an abortion, even if the only procedures available ate un- safe, iliit abortions that greatly increase the risk of death. and disability (Kwast and Liff, 1988). Daring the last decade, evidence accumulated show- ing a strong relationship between the spacing of @ ‘woman's births and the survival of her children (Maine and McNamara, 1987). Birth spacing, which is not in- cluded on the list, can be influenced by contraceptive use, breastfeeding, ot postpartum abstinence, Since many of the reproductive variabies that affect infant survival also affect maternal survival (for example, age and pregnancy order), one might hypothesize that birth spacing influ- ‘ences the outcome for the mother as well. To date, how- ever, there aze no studies that support this hypothesis, Access to Health Services ‘The medical technology to prevent almost all deaths from common obstetric complications has been available for decades. This technology falls into two major categories: treatments for women who want to havea safe and suc- cessful birth, and aptions for wamen who want to avoid pregnancy and childbirth. The former category includes blood transfusions, antibiotics and other drugs, and ce- sarean sections; the latter includes use of contraceptives and safe abortion procedures. But access to preventive and curative health services that can provide this tech- nology is limited in developing countries. In many set- tings, the physical distances between services and women in need of reproductive health care are consid~ erable. Physical distance from facilities has been shown to be associated with maternal mortality in several stud- ies (Fortney et al, 1985; Walker etal, 1985). ‘Access, however, is a much broader concept than physical distance, It includes financial access and access to adequate care, (Each of these variables could, in turn, bbe subdivided into much more precise operational defi- nitions. For example, the World Health Organization [1986] has identified a number of specific services that are essential to the care of pregnant women.) There is ample evidence thet financial barriers, shortages of trained personnel, especially in rural areas, and poor per formance on the part of trained personel all contribute to high levels of maternal mortality in developing coun- tries (Ekwempu et a., 990; Omu, 1981; WHO, 1985). Health Cave Betavior Use of Health Services For services to be effective, women have to use them. The use of prenatal care (to diagnose either preexisting health ‘problems or to detect certain complications) and the use ‘of care during and after labor and delivery (to treat com- plications that may arise then) are particularly inyportant in the case of maternal mortality. Other health care be- haviors are also likely to have important influences on the outcome of pregnancy for women. Obvious examples include the use of illicit abortionists and harmful but tea- ditional practices during pregnancy and childbirth. In some areas, traditional practices include the improper use of drugs, pushing on the abdomen to hasten delivery, and even the use of certain surgical procedures. For ex- ample, in northern Nigeria, traditional healers make “Gishiri cuts” (incisions in the vagina) on women who are not making progress in labor, More removed in time from labor and delivery, but still quite harmful, are the ‘more radical forms of female circumcision practiced in many societies. Unknown oy Unpredicted Factors Another essential fact to consider is that pregnancy com plications can arise from factors other than a lack of ac- cess to oF use of health services, or poor health condi- tions prior to or during a pregnancy, or a woman's reproductive status. Women who are from advantaged backgrounds, who have ample access to high-quality health services (including prenatal care), and who are in good health priot to pregnancy do experience serious obstetric complications for reasons that cannot be ex- Volume 23 Number] January/February 1992 27plained or predicted. A recent study of nonhospital birth «enters in the United States is particularly illuminating Of almost 12,000 women who went to the birth centers for prenatal care, 15 percent were referred to hospitals hecause they were considered to have an unacceptably high risk of unfavorable outcomes. Thase who contin- uued at the birth centers were deemed to be “low risk” and had an average of 11 prenatal visits. Despite this in- tensive screening and prenatal care, almost 8 percent of these women had a serious maternal or fetal complica: tion (Rooks et al., 1980). In developing country settings, predicting obstetric complications is equally difficult. For example, although a bad obstetric history is known pre- dictor of obstructed labor, a study in Zaire found that only 29 percent of the cases of obstructed lahor could have been predicted based on obstetric history. The other 7} percent of cases occured in women with no known risk factors (Kasongo Project Team, 19873. Distant Determinants Socicecortomtic Status It is well known that the risk of dying is strongly influ- enced by one’s position in society. In most circumstances and for most diseases, including maternal mortality, the poor and disadvantaged are more likely to die than are more affluent people. Differentials in maternal mortal- ity by socioeconomic status exist among countries and within countries. However, socioeconomic status is a complex concept, one that operates at the individual, family, and community level Figure 2 illustrates some of the variables that can serve as indicators of socioeconomic status, For women, their status in the family and in the community ean be related to their level of education, their occupation, their level of personal income or wealth, and their autonomy (lor example, their ability to travel on their own or to make independent decisions to tse health facilities). At the family level, status can be associated with aggregate family income as well as with the occupation and edux cation of family members. Finally, the collective resources and wealth of a local community are also important di- mensions of socioeconomic status that are likely to have aninfluence on the health of contanemity members ‘As consistent as fineings in the literature are about the association hetween socioeconomic status and ma- ternal mortality, itis important to recognize that there is nothing automatic of direct about the association. The influence of sociaeconomic status must operate through some set of intermediate determinants that affects one ‘ofthe outcomes in the framework (pregnancy, pregnancy complications, and death or disability). The best iltustra~ tion of this idea comes from examples of the association 28 Studiesin Famity Plancing ‘between elements of status and mortality that are the op- posite of what one would expect. In one group of well- nourished, well-educated, and relatively affluent people in the United States, the maternal mortality ratio ¢num- ber of maternal deaths per 100,000 live births) in 1983 ‘wes 872, at a time when the ratio for the entire country was eight. This level of maternal mortality was 100 times the national average, higher than that of urban India and comparable ta fevels in rural India (Kaunitz.et al, 1984; Bhatia, 1985; U.S. Department of Health and Human Ser- vices, 1987). This economically advantaged group, a furt- damentalist religious sect called the Faith Assembly of God, has such high levels of maternal mortality because its members do not believe in using any modern medi- cal care, including obstetric care. Conversely, in Bahrain and Kuwait, levels of maternal mortality are quite low, despite the fact that women in these societies have low status. They do, however, have ready access to relatively high-quality obstetric care (Royston and Acmstrong, 3089), Further, although women’s education and socio- economic status are inversely associated with maternal ‘mortality in developed countries today, in the late 19¢h and early 20th centuries in Britain, women in the middle and upper classes actually experienced higher mortality than did poorer women (Loudon, 1986), This situation was a result ofthe use of “interventionist obstetrics,” in- cluding excessive use of chloroform and forceps by phy- sicians, with the result that midwives using less invasive approaches provided safer deliveries to their clients, who were usually poorer than the clients of physicians, The number of possible combinations of all the vari- ables listed in Figure ?2 is obviously vast, and clearly not all variables could be included in all studies or addressed by all programs, The list of variables in the figure is also not exhaustive; other factors could he included under the categories of distant and intermediate determinants. Jn making choices for variables to be included in studies or addressed by programs, consideration should be given to thoce variables that clearly measure the precise mecha- nisms through which the more general concepts oper- ate. More detailed frameworks could be developed to re- flect how different variables operate within each of the concepts in our basic model; and frameworks could be developed to convey, in much more detail, (he process ‘of movement from one stage to another in the basic model. For example, among the intermediate determi- rants, 2 woman’s health status is certainly influenced by ‘both her access to health services and her health care be- havior; access to health services also influences health care behavior, especially the use of health services. The framework could also be further elaborated by describing, in more detail the sequence of events from pregnancy to death or disability and by considering haweach of the intermediate variables operates at each of the ‘mare specific stages in the sequence. Far example, Mosley has suggested that three stages of pregnancy and deliv- ery be considered: the early stages of pregnancy; the pe- riod immediately surrounding labor and delivery; and the postpartum period. Complications can arise at each of these stages—complications that in many cases are likely (0 be confined to that specific stage. Abortion is ‘most likely to be associated with complications early in pregnancy, whereas access to emergency obstetrical care will be associated with complications around the time of labor and delivery and in the postpartum period (Mosley, 1990). Depending on the relative importance of different complications in. a given setting, program in- terventions and research efforts might be focused on one of these more specific stages between pregnancy and death or disability. However, even in its general form, the framework does provide suggestions for research on the determi- nants of maternal mortality and for programs designed to prevent maternal deaths Implications for Research A framework for analyzing the determinants of a demo- graphic event improves research if that framework elari- fies the mechanisms through which social, behavioral, and biological factors interact to produce an outcome? Suggestions of this kind of clarification can easily be drawn from the maternal mortality framework just de- scribed. For example, a common assertion in the Jitera- ‘ure is that the status of women or women’s education {s related to maternal mortality (Royston and Armstrong, 1989), Less common is @ precise statement of the inter- ‘mediate mechanisms underlying this observed associa- tion, Several themes for research that might producesuch statements are implied by the framework. To answer the question of how women’s education, for example, may influence maternal mortality, we first need to determine the precise mechanisms and sequences of events through which education affects maternal death or disability. ‘Three mechanisms are possible. First, education (through its association with later age at martiage or increased use of contraceptives within marriage) is likely to be assoct- ated with lower fertility and hence with fewer pregnan- ies. Fiducation could also be associated with the devel- ‘opment of fewer complications among pregnant women if better-educated women are in general in better health than others before and during pregnancy. Finally, edu- cation could be associated with a greater likelihood of zecelving appropriate care for complications that do arise. ‘This last association, in turn, could result from sev- ezal different patterns, singly or in combination with one another. More educated women might be better informed about the symptoms of complications and could there- fore be more likely to make a timely decision to seek care ‘when a complication arises. Such women might also be concentrated in urban areas and thus would live closer tohealth care facilities, or they might have better access to tho transportation needed to reach those facilities. Fi- nally, educated women might be more likely to receive appropriate and timely care when they do reach a health facility, either because they are better able ta pay for that ‘are or because, by virtue of their status, Ghey are more likely to be well-treated. Rach of these mechanisms could well operatein some or all societies. An important question, however, is the magnitude of the effect operating through each of the possible mechanisms and the relative importance af each. ‘These magnitudes are very likely to differ considerably both within and among societies. Moreover, some of these associations are causal jn nature and athers are not Knowledge of the relative magnitude of the effecis and ofthe causal or noncausal nature of associations should be of interest both to researchers studying maternal mor- {ality and to officials implementing programs to reduce maternal deaths, Similar sets of research questions could be developed to examine the role of ather background variables in. ma- temal mortality. However, research based on the fratne- work need not start with a focuson a background variable. For example, research questions could be developed to ex- amine the influence of poor maternal nutrition. on mortal- ity by studying the association between mutrtional stats and the development of complications of pregnancy or the treatment of complications (if certain complications are imate serious in the presence of poor nutrition), In addition to the need for studies of maternal mor- tality to specity the intermediate mechanisms through which more distant factors affect the outcomes that cule minate in death or disability, research must also address the relative importance af different factors. The frame- work itself can be used to help suggest the pathways from distant determinants through intermediate deter- snintants and through the sequences of outcomes that lead tomaiernal death and disability. Results of research stud- ies are requited to evaluate the strength of different path- ways, and hence to evaluate the relative power of differ- eat interventions to reduce maternal mortality, an issue that will be discussed at greater length in the following section. Asingle research study that specified all the various pathways that culminate in maternal death and that evaluated the relative importance of those pathways, al- though potentially of great interest, would be an enor- Volume 23 Number January/February 1982 29mous and probably impossible undertaking. Answers to all the questions raised about the association between ‘women’s education and maternal mortality, for example, would require a large, complicated, and very expensive research project. Inthe absence of sucha comprehensive study, the framework can still be used to guide more fo- cused research efforts, providing those studies with clear ‘boundaries and a sense of their contributions and limi- tations Implications for Programs ‘The major implications of the framework for programs aimed at reducing maternal deaths are related to the identification of three outcames that culminate in death a conception, a complication, and the treatment of com- plications. Societies that have achieved the lowest levels * of maternal mortality have done so by preventing preg- nancies, by reducing the incidence of certain complica- tions, and by having adequate facilities and well-trained staff to treat complications. Im countries that are still experiencing high rates of matemal mortality, programs must be developed to im- prove both prevention and teeaiment. The most effective preventive measure will he the widespread acceptance of family planaing practices. By reducing the number of pregnancies, family planning will reduce the risk that a ‘woman will die from pregnancy-related causes, In soci- ties characterized by both high fertility and high ma- ternal mortality, the contribution of family planning to increased maternal survival could be considerable, In- creases in the age at marriage, especially in those popu- lations in which marriage age is very Tow, could also in- fluence maternal mortality, nat only by reducing fertility but also by reducing the chance that a woman's pelvis ‘will be immature at the time of her firat birth, a condi- tion that i associated with obstructed labor. In addition to preventing pregnancies, programs also need to focus on preventing complications among preg- nant women, The most effective strategies for preven- ion of complications involve efforts to ameliorate the prepregnancy heal status of women and to improve certain health behaviors. Nutrition programs for young girls, for example, might increase the chances that @ woman will be physical'y mature before her first preg nancy and thus [ess likely to experience obstructed la- bor. Therefore, programs that improve the nutritional sta- {us of young girls could, eventually, have ais impact on maternal mortality by reducing the incidence of ob- structed labor, The effect of improvements in treating other health indicators, such as malavia, anemia, and hepatitis, could be more immediate. Also, eliminating harmful practices uch as Gisiri cuts and fernale circum 30 Staion in Farlly Planning, cision might prevent some direct obstetric deaths. However, an important implication for programs that is clear from the framework is that prevention is not enough. Camplete prevention of all high-risk cases and substantial improvements in women’s health status will not eliminate complications. In a comprehensive pro- ‘gram to prevent maternal deaths, there will be a need to detect and treat complications of pregnancy. Programs must be able to provide adequate services to treat com- plications that can be detected early in pregnancy as 2 result of prenatal care, as well as to provide emergency ‘care for complications that are not predicted early in pregnancy. Not only are some complications difficult to predict, but many do not develop until labor begins. The level of treatment required does not necessarily imply a focus on high-technology tertiary care in large hospitals, Referral systems that take maximum advantage of exist- ing facilities and improvements in the ability of first re- ferral centers to provide essential obstetric services would have substantial impacts on maternal mortality (WHO, 1986). Obviously, not all programs can address each of these outcomes and intermediate determinants at once However, even if programs need to limit their interven tions because of a lack of resources, officials designing, the programs should be aware of the total picture, rec- ‘ognizing the contribution that specific Initiatives can make as well as the situations that those initiatives will leave unchanged. Whereas the above discussion on the implications for programs is very genera, itis possible to be much mare specific by taking each proposed inter- vention, tracing its potential impact through the entire framework, and using the results of research to identity the relative contribution of different interventions to the reduction of maternal deaths, We can demonstrate the usefulness of the framework by examining seven interventions that are often consid- exed as part of the Safe Motherhood Initiative.‘ These in- terventions are: (8) provision of family planning services; 2) improvements in the sacioeconamic status of women; (3) provision of safe, legal abortion services; (4) provie sion of prenatal care; (5) improvements in emergency obstetric care; (6) training of traditional birth attendants, and (7) education and mobilization of the community. ‘The first conclusion of such an exercise is the recog- nition that only three of these interventions will have a direct effect on maternal mortality. Family planning wil reduce maternal mortality by reducing the number of pregnancies; safe, legal ahortion will reduce maternal mortality by greatly reducing the complications that re- sult from botched abortions; and improvements in emer- gency obstetric care will reduce matemal mortality by improving the survival rate among women wha develop complications. Each of the other interventions can onlywork through some other intermediate determinants or ‘outcomes, Improvements in the socioeconomic status af womten, for example, would have to have an effect on their health status, their reproductive status, or their ac- cess to or use of health services. Prenatal care, the tra ing of traditional birth attendants, and community edu- cation would each have to be linked in some way to a referral network that included a range of services, prob- ably including emergency obstetrical care, Therefore, ‘programs that propose interventions such as these, which are not directly linked ta the sequence of outcomes that culminate in death or disability, need to specify in some detail the mechanisms through which the inéervention is expected to operate and to consider whether facilities or programs are in place to make sure that those mecha- nisms will function. Conducting 2 similar exercise before making a final Gecision on any particular intervention would provide program officials with a useful perspective on the po- tential implications of their decisions, The exercise need not be difficult or particularly time-consuming. It re- quires a basic understanding of the full range of factors known to influence maternal mortality combined with a thorough knowledge of the setting into which a program will be introduced. Familiarity with the setting should include knowledge of the services currently available andl of the current beliefs and practices af women in the com. munity as they relate to pregnancy, labor, and delivery. Previous research has shown that this information does not require extensive and expensive sample surveys. Se- lected focusegtoup discussions and institutional inven- tories can provide the needed information relatively quickly and at low cost (Prevention of Maternal Mortal- ity Network, 1990). Program officials can also, without {60 much difficutty, consult the results of research that have recently been. summarized in several publications (Thaddeus and Maine, 1990; Royston and Armstrong, 1989; Maine, 1991). Information on local conditions and awareness of the results of prior research on the deter- ‘minants of maternal mortality, combined with the com- prehensive perspective ofthe framework, should provide program officials with the material they need to design realistic and effective programs. Conclusions ‘The framework presented above provides a context within which discussions of both research and programs ‘on maternal mortality can take place. Assuming that the framework is complete (that is, that all possible mecha- nisms and pathways can be accommadated), the major task facing both researchers and progeam officials is the estimation of the relative importance of the various paths to reducing maternal mortality. To develop estimates of the relative costs and benefits of different interventions, program officials need to consider research findings on the magnitude of given effects as well as information on the cosis of different programs. Further research is re- quired before such cost-benefit exercises, based on ac- tual data, can be carried out. Exercises of this type con- ducted to date have been based largely on assumptions, albeit very reasonable assumptions (Maine ot al, 1987: Herz and Meascham, 1987), In addition to cost-benefit considerations, program officials must also consider the time period over which ‘a given intervention can be expected to influence mater- nal mortality. When one thinks in terms of a complete framework, iti clear that changes in certain factors (usu- allly those closest in the framework to the outcome} will have a more immediate impact on maternal mortality. Improvements in the treatment of complications, for ex- ample, will effect the morality of the cuerent cohort of pregnant women. Improvements in the nutritional sta- tas of women might have some immediate impact, but the full impact will not be felt until an entire generation. of women has experienced better nutrition since birth. ‘The timing of the effect of eliminating female circumci- sion will depend on the age at which the procedure is traditionally performed: The farther that age is removed from the childbearing years, the langer it will take for its elimination to have an effect on maternal mortality, The implication of these differences in the timing of the ef- fects of interventions is not that programs should con- centrate exclusively on interventions that have only im- ‘mediate effects; the implications are that, when they design programs, officials should be aware of the full set of factors that affect maternal mortality, the mechanisms through which they work, the potential power af differ- ent interventions to reduce maternal deaths, and the time frame over which improvements in mortality can be ex pected to accur. Hy stating the need for further research, however, we do not mean to underestimate what we already know about both the determinants of maternal mortality and the relative power of different interventions to reduce maternal deaths. 4 recent analysis of existing informa- tion concluded that family planning programs, programs to provide safe and legal abortion services, and programs to improve the treatment of obstetric complications ‘would have substantial and immediate effects on mater- nal mortality. Programs to increase women’s status, (0 extend access to prenatal care, to train teaditional birth attendants, and io educate and mobilize communities ‘would be less likely to have an effect on maternal mor- tality unless they were complemented by improved fam- ily planning, abortion, or labor and delivery services (Maine, 1991), Further research on these issues, especially Volume 23 Nusiber! January /Febeuary 1962 31‘operations research linked to program interventions, ‘would provide a valuable contribution to the Safe Moth- ‘ethood Initiative, either by confirming or by question- ing these conclusions. Acknowledgments ‘The authare wish to thank several colleagues who read earlier drafts of this article and provided helpful comments, includ- ing Magda Ghanma, Stephen [saacs, Henry Mosley, Allan Rosenfield, and Joe Wray. jack Kileulen, Rafael dei Rosario, and Yolanda Roman helped in the production af the artide, and Mary O'Connor edited the manuscript Nates 1A smite situation exits in models af the determinants cf fertility that include ental frequency asa proximate dererminant Invitro Jerilization and otver techniques of sssted reproduction notwith- standing, for the vast majonty of women, intercourse isa neces “sary condition for ‘erty Bat since paterns of intercourse vary among ined and ccieris, (sTogicel conclude intercourse as avatiableina model the proximate determinants of fertity. 2. Although wseofilicitindueed abortion soften described 263 “com> postion,” itis included in ove framework under the category of "Health case behavior/sse of health services” The result of this porticuler behavior can be hestarchage or infeton two ofthe mare prevalent complications 13 Although we present separate sections on implications for research ‘ane ienplntons for peageams, in fect the twa Issues are closely ‘eloted, For example results frm researc that illuminate the pro est clsinating in matersal mortality wil in many cases have ob ‘ious implcetons for programs, Hence, the division of these sec ‘Hons shouldbe viewed as a convenience. 4 A mere exbaustive account of these Interventions can be Cound in Maine 0991) References hatin, }C. 1985. “Maternal mortality in Ananthapar District, India Preliminary findings of a study.” Paper presented a the World Health Organization (WHO) Interregional Meeting onthe Prevere ton af Materns! Morality, Cerava, 11-15 November: Boera J Ties. 987, “Levels of ataal mortality in developing onus tes” Stains» Fay Planing 18,42 213-221 Bongasts, hx. 1978 “A famewark for analyting the proximate de- tesminan offre” Popelatan nd Developme Revue 4 1: 105~ 1 Davis, Kingsley an Judith Blake 1956 “Social structare and fertility [An analytical framework.” Ezonsmic Development end Cultural (Change 4201-238, kryempe, C. et al, 1980. Structural adjustment and health in AK ica” Lancet 6656-57 32. Studlesin Family Plancing Fathalla, Mahmoud, 1987. “The long eoad to maternal death" People 14585, Fortney, fudith A. eta. 185, “Matecnal mortality in frdonesia and Egypt” Paper presented 2 the WHO Interregional Mecting om the Prevention of Matertal Mortality, Geneva, 11-15 November. Hera, Barbara nd Anthony R Meascham, 1987, "The Safe Motheriond Ttative-Prapasal lor action ” Washington, OC The World Bank, Kasongo Project Team. 1987, “Antenatal screening for fetopelvie istoias: A cost tfectiveness approach tothe choice of simple in- dicstors or une by aoeliary personnel” jaurl of Tropica Medicina end Hygiene 7,4 17-183, Kautz, Andrew Metal. 1954. “Perinatal and maternal mertalty ina relighoas group avoiding obstetrical care” Americ four of Ob- sais aed Oyrcslgy 15,7: 25-91. ast, Barbora E and JE Lilt. 1988, “Factors associated with mates~ al mortality in Addis Ababa, Bihiop.”Duternainal furl of Epi Aenelogy V7, 105-12, Louden, Irvine, 1955 “Obsteic care, socal class, andl maternal mot- rai.” British Mal laura] 29% 606-08. Maine, Debora. 191, Fumly Planing: slmuct or the Hei of Women and Children, Newr Yor Columbis University, Center for Popul tion and Farily Health. 1991, fe Motherhand Programs: Options and lanes. News York (Columbia University, Center fr Population and Farily Health Maine, Deboral etal, 1987, “Prevention of maternal deaths in devel- ‘oping countries: Program options and practical considerations” Daper prepared forthe Internationa Safe Motherhood Canferenc, Nair, 10-13 Feeruary. Maine, Desorah and Regina McNamara, 1987. Birth Spacing an Chit ‘Sura, New York: Columbia University, Center for Population ‘and Ferily Health, Mosley. W. Henry, 1950 Personal communieation, December. Mosley, W, Fenty and Lincoln C. Chen 1984. “An analytical fame work forthe sty of il survival in developing counties” Pop ation ad Delp Revi 08-25-48, Notional Center for Health Statistics 1987. Val Static ofthe Mitt States 1983 Val fI—Mortality, Par A Hyattsville, MD: US Depart- ment of Health and Human Services, ‘Omran, AIR and CC, Standley (eds) 1976, Fart Formation Pits (ted Healthc am Dterratinal Collaborative Stayin nin, lean, Lab om, Phipps, avd Purley, Ganev WHO. dives ka Nigeria” Leet 1: 620-624. Prevention of Maternal Mortality Network 1988, “Bareiaes wo treatment ‘of obstetrical emergencies i West Attica: A report on focus group reeearch in Nigeria, Ghana and Slerea Lacne” Background paper tor the Sate Metherhoce Conference, Abuja, Nigeria, 11-15 Sep tember Reaks, J.P etal, 1989, “Outcomes of cae in birth centers The Nations Tirth Center Study,” New England urna of Madina 321,26: 1,804- 1am Rosenfield, Allan and Deborah Maine, 1955, "Maternal moralty—a neglected tngesy: Where s the M tn MCH™ Lancet 2, 8, 446: 83- 85 Royston, Brica and Sue Atmistong (@ds) 1989, Preventing Metta! Deaths, Geneva: WHO, “Tehri, Farhang. 1992. "An iniativecn vestcovaginal fistula.” Lance, 1 8,680: 1316-1317. Oma, A 1881, “Fractional‘Thaddeus, Sereen and Deborah Maine. 1950. Too Fer to Wolk: Maternal Mortality = Contest Neve York Columbia University, Center for Population and Family Health Usited Nations Popatation Division. 1988. ited Nations Worke Pape tation Chart 1988 New York United Nations, Walker, GIA. etal. 1985, "Matcenal morality ix famaica: A conden ‘al ingury nto all msatreal deaths is [emai 1981-1985 "Paper presented at WHO Ievarregional Mesting ax. the Prevention of Ma ternal Marly, Geneva, 11-15 November ‘World Health Organization (WHO), 1985. Prevention of Matera Mor- tale Reprt of @ WHO Interregional Mestog, Genese, 11-15 Noaen- bar 1585. Geneva. WHO. 1965, Essmtid Obsteiric Functions a Piet Referral Level 1a Re: ee Maernal Marty. Report ofa Technics! Workig Group, fe 2 27,1986. Geneva: WHO. 1989, Safe Motharond nitive: Repor ofthe Send Meeting of Interest Portes. Genevs: WHO. Volume 23. Number? January Fetrusey 1992 33