https://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X%2814%2970227-X.pdf

Global causes of maternal death: a WHO systematic analysis

Objectives To identify the barriers and facilitators to accessing first-trimester abortion services for women in the developed world. Methods Systematic review of published literature. CINAHL, PubMed, Proquest, MEDLINE, InformIT, Scopus, PsycINFO and Academic Search Premier were searched for papers written in the English language, from the developed world, including quantitative and qualitative articles published between 1993 and 2014. Results The search initially yielded 2511 articles. After screening of title, abstract and removing duplicates, 38 articles were reviewed. From the provider perspective, barriers included moral opposition to abortion, lack of training, too few physicians, staff harassment, and insufficient hospital resources, particularly in rural areas. From the women9s perspective, barriers included lack of access to services (including distance and lack of service availability), negative attitudes of staff, and the associated costs of the abortion procedure. Service access could be enhanced by increasing training, particularly for mid-level practitioners; by increasing the range of service options, including the use of telehealth; and by creating clear guidelines and referral procedures to alternative providers when staff have a moral opposition to abortion. Conclusion Despite fewer legal barriers to accessing abortion services, the evidence from this review suggests that women in developed countries still face significant inequities in terms of the level of quality and access to services as recommended by the World Health Organization.

https://srh.bmj.com/content/familyplanning/41/3/170.full.pdf

Barriers and facilitators of access to first-trimester abortion services for women in the developed world: a systematic review.

Unsafe abortion is one of the commonest causes of maternal mortality. Abortion-related maternal deaths are higher in countries with the most restrictive abortion laws. We assess whether maternal mortality varies within and between countries over time according to the flexibility of abortion laws (the number of reasons a woman can have an abortion). We conducted an ecological study to assess the association between abortion laws and maternal mortality in 162 countries between 1985 and 2013. Aggregate-level data on abortion laws and maternal mortality were extracted from United Nations (UN), and World Health Organization’s (WHO) database respectively. A flexibility score of abortion laws (Score 0–7) was calculated by summing the number of reasons for which abortion was legally allowed in each country. The outcome was maternal mortality ratio (MMR), which represented maternal deaths per 100,000 live births. MMR was modelled as a continuous variable and flexibility score as an ordinal ranked variable (categories 0–7 with 0 as the reference, and   = 3). We used fixed effects linear regression models to estimate the association between flexibility score and MMR, adjusting for gross domestic product per capita (GDP per capita), and time in five-year intervals. Compared to when a country’s flexibility score was < 3, maternal deaths were reduced by 45 per 100,000 live births (95% CI: -64, − 26) when the flexibility score increased ≥3, after adjusting for the GDP per capita and five-year time intervals. With the exception of a flexibility score 6, MMR was lower when higher than zero. This may indicate the role of other country- specific effects. This study provides evidence that abortion law reform in countries with restricted abortion laws may reduce maternal mortality.

/pdf/abortion-laws-reform-may-reduce-maternal-mortality-an-3qqchx33t9.pdf

Abortion laws reform may reduce maternal mortality: an ecological study in 162 countries.

While the main causes of maternal mortality in low and middle income countries are well understood, less is known about whether patterns for causes of maternal deaths among adolescents are the same as for older women. This study systematically reviews the literature on cause of maternal death in adolescence. Where possible we compare the main causes for adolescents with those for older women to ascertain differences and similarity in mortality patterns. An initial search for papers and grey literature in English, Spanish and Portuguese was carried out using a number of electronic databases based on a pre-determined search strategy. The outcome of interest was the proportion of maternal deaths amongst adolescents by cause of death. A total of 15 papers met the inclusion criteria established in the study protocol. The main causes of maternal mortality in adolescents are similar to those of older women: hypertensive disorders, haemorrhage, abortion and sepsis. However some studies indicated country or regional differences in the relative magnitudes of specific causes of adolescent maternal mortality. When compared with causes of death for older women, hypertensive disorders were found to be a more important cause of mortality for adolescents in a number of studies in a range of settings. In terms of indirect causes of death, there are indications that malaria is a particularly important cause of adolescent maternal mortality in some countries. The main causes of maternal mortality in adolescents are broadly similar to those for older women, although the findings suggest some heterogeneity between countries and regions. However there is evidence that the relative importance of specific causes may differ for this younger age group compared to women over the age of 20 years. In particular hypertensive conditions make up a larger share of maternal deaths in adolescents than older women. Further, large scale studies are needed to investigate this question further.

https://link.springer.com/content/pdf/10.1186%2Fs12884-016-1120-8.pdf

The causes of maternal mortality in adolescents in low and middle income countries: a systematic review of the literature

Millennium Development Goal 5 has not been universally achieved, particularly in sub-Saharan Africa. Understanding whether maternal deaths occur during pregnancy, childbirth, or puerperium is important to effectively plan maternal health programs and allocate resources. Our main research objectives are to (1) describe the proportions and rates of mortality for the antepartum, intrapartum, and postpartum periods; (2) document how these trends vary by sub-region; and (3) investigate ecological correlations between these rates and maternal care interventions. We used data from the Demographic and Health Survey program, which comprises 84 surveys from 34 sub-Saharan African countries conducted between 1990 and 2014. We calculated age-standardized maternal mortality rates and time-specific maternal mortality rates and proportions, and we assessed correlations with maternal care coverage. We found high levels of maternal mortality in all three periods. Time-specific maternal mortality rates varied by country and region, with some showing an orderly decline in all three periods and others exhibiting alarming increases in antepartum and postpartum mortality. Ecological analysis showed that antenatal care coverage was significantly associated with low antepartum mortality, whereas the presence of a skilled attendant at childbirth was significantly associated with low postpartum mortality. In sub-Saharan Africa, maternal deaths occur at high rates in all three risk periods, and vary substantially by country and region. The provision of maternal care is a predictor of time-specific maternal mortality. These results confirm the need for country-specific interventions during the continuum of care to achieve the global commitment to eliminating preventable maternal mortality.

/pdf/timing-of-maternal-death-levels-trends-and-ecological-1ugpin6j00.pdf

Timing of maternal death: Levels, trends, and ecological correlates using sibling data from 34 sub-Saharan African countries.

Background 
The WHO estimates that 13% of maternal mortality is due to unsafe abortion, but challenges with measurement and data quality persist. To our knowledge, no systematic assessment of the validity of studies reporting estimates of abortion-related mortality exists.


Study Design 
To be included in this study, articles had to meet the following criteria: (1) published between September 1st, 2000-December 1st, 2011; (2) utilized data from a country where abortion is “considered unsafe”; (3) specified and enumerated causes of maternal death including “abortion”; (4) enumerated ≥100 maternal deaths; (5) a quantitative research study; (6) published in a peer-reviewed journal.


Results 
7,438 articles were initially identified. Thirty-six studies were ultimately included. Overall, studies rated “Very Good” found the highest estimates of abortion related mortality (median 16%, range 1–27.4%). Studies rated “Very Poor” found the lowest overall proportion of abortion related deaths (median: 2%, range 1.3–9.4%).


Conclusions 
Improvements in the quality of data collection would facilitate better understanding global abortion-related mortality. Until improved data exist, better reporting of study procedures and standardization of the definition of abortion and abortion-related mortality should be encouraged.

/pdf/measuring-unsafe-abortion-related-mortality-a-systematic-1q9xt6fmwa.pdf

Measuring unsafe abortion-related mortality: a systematic review of the existing methods.

Objectives. To evaluate whether the Operation Peacemaker Fellowship, an innovative firearm violence-prevention program implemented in Richmond, California, was associated with reductions in firearm and nonfirearm violence.Methods. We compiled city- and jurisdiction-level quarterly counts of violent firearm and nonfirearm incidents from statewide records of deaths from and hospital visits for homicide and assault (2005-2016) and from nationwide crime records of homicides and aggravated assaults (1996-2015). We applied a generalization of the synthetic control method to compare observed patterns in firearm and nonfirearm violence after implementation of the program (June 2010) to those predicted in the absence of the program, using a weighted combination of comparison cities or jurisdictions.Results. The program was associated with reductions in firearm violence (annually, 55% fewer deaths and hospital visits, 43% fewer crimes) but also unexpected increases in nonfirearm violence (annually, 16% more deaths and hospital visits, 3% more crimes). These associations were unlikely to be attributable to chance for all outcomes except nonfirearm homicides and assaults in crime data.Conclusions. The Operation Peacemaker Fellowship may have been effective in reducing firearm violence in Richmond but may have increased nonfirearm violence.

Firearm and Nonfirearm Violence After Operation Peacemaker Fellowship in Richmond, California, 1996–2016

/pdf/multiple-bias-analysis-an-application-to-quantify-systematic-38r5d42ta9.pdf

Multiple bias analysis: an application to quantify systematic error in measures of abortion related maternal mortality

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Measuring unsafe abortion-related mortality: a systematic review of the existing methods.

Firearm and Nonfirearm Violence After Operation Peacemaker Fellowship in Richmond, California, 1996–2016

Multiple bias analysis: an application to quantify systematic error in measures of abortion related maternal mortality