Impact Of Health Ⅷ Project On Maternal Death

ObjectiveThe overall objective is to evaluate the impact of Healthâ…§project on matemal death., The specific objectives include:1) to describe the trend of maternal mortality ratio between the year 1998 and 2005 in different types of intervened counties of Healthâ…§project;2) to describe the major causes of maternal deaths in different types of intervened counties of Healthâ…§project;3) to describe the demographic characteristics of the women who died during pregnancy,such as age,pregnant times, the number of prenatal examinations,gestational weeks;4) to describe the trend of maternal mortality ratios of the top three causes of maternal deaths(postpartum hemorrhage,placenta retention,pregnancy-induced hypertension) from 1998 and 2005;5) to apply linear mixed model to systematically evaluate the impact of Healthâ…§Project and to explore the main factors which related to the maternal mortality ratio.Materials and Methods1.Source of materials:Three sources of data including monitoring data of project counties,maternal death certificates and socio-economic and demographic data of project counties were used in this study.The focused in the study was only the counties in Part A of Healthâ…§project.There were 71 counties in Part A of Healthâ…§project.The number of the selected counties in the study was 55 counties because of the too much missing data in some counties, with 38 counties and 1125 dead women in MCH counties and 17 counties and 494 dead women in the general counties / DFID pilot counties.2.Methods:(1) Time trend analysis was used to analyze the trend of maternal mortality ratio, including index method and model method.1) The index method was used to observe the dynamic changes of the matemal mortality,such as the average increased margin.2) Generalized linear mixed model was used to find the factors which influenced the maternal mortality.The GLIMMIX procedure in SAS 9.1.3 was chosen as the tool to fitting the generalized linear mixed model because of the data with correlations or non-constant variability and the response maternal mortality was not normally distributed. Generalized linear mixed model assumes normal(Gaussian) random effects.Conditional on the random effect,data can have any distribution in the exponential family,such as binary,binomial and Poisson.The intervened counties were considered as high level and the repeated measures in the period were considered as low level.In the generalized linear mixed model,the response referred to maternal mortality ratio.The explanatory variables included year, the type of the counties,the rate of prenatal examination,the hospital delivery rate, the proportion of the government fees,the proportion of the farmers and so on. Every explanatory variable except for year and counties was categorized into 5 groups according the percentiles and treated as dummy variables.The main effect was considered with no interaction in the generalized linear mixed model.(2) The general descriptive statistical methods were used to analyze the causes of the pregnant women,such as the order of the causes of the death.Results1.The maternal mortality ratios in Healthâ…§counties dropped from 91.6/100,000 in 1998 to 45.0/100,000 in 2005 with average decreased margin of 0.0966 per year.The maternal mortality ratios in the whole nation dropped from 56.2/100,000 in 1998 to 47.7/100,000 in 2005 with average decreased margin of 0.0232 per year.The results indicated that the maternal mortality ratio in Healthâ…§counties decreased more rapidly than that in the whole nation.2.The decresed margin of maternal mortality ratio was 0.1004 in the MCH counties and 0.0875 in the general counties / DFID pilot counties,which indicates that the maternal mortality ratio in the MCH counties decreased more rapidly than that in the general counties / DFID pilot counties.3.The average frequency of prenatal examination of the women in the Healthâ…§project was less than 3 times,the first prenatal examination was later than the 12 weeks of gestation,which indicated that the level of prenatal care in Healthâ…§counties was lower than the standard level recommended by Ministry of Health of China.4.In Healthâ…§counties,the highest proportion of delivery sites of the dead women was home,accounting for more than 50%,while less than 20%at the county hospital and above.The maternal childbirth in the counties was mainly natural childbirth accounting for more than 70%.As for the Cesarean section,13.1%in the MCH counties,and 6.8%in the general project counties / DFID pilot counties.The hospital delivery rate in MCH counties was 26.0%and 17.6%in the general project counties / DFID pilot counties.5.More than 40 percent of the dead women in Healthâ…§Project died at home.More than 90 percent of the dead women died during or after the delivery.Clinical diagnosis dominated the diagnosis of the causes of death,accounting for more than 50%, followed by the death inferred,accounting for about 40%.6.During the year 1998 and 2005,the top three causes of death(postpartum hemorrhage,placenta retention,pregnancy-induced hypertension) in Healthâ…§counties accounted for 53.7%and the top ten causes of maternal deaths accounted for 86.3%of the causes of maternal deaths.7.The output of generalized linear mixed effect model showed that the factors that affected the maternal mortality ratio mainly focused on year,crude birth rate and hospital delivery rate.The P value of F test in the year was 0.0222 and hospital delivery rate 0.0035 and crude birth rate 0.0604,which showed that the maternal mortality ratios in different years or hospital delivery rate groups were different,but the maternal mortality ratios in different crude birth rate groups were not diffrerent.Conclusions1.Healthâ…§project narrowed the gap of maternal mortality ratio between the intervened counties and the whole national.The Healthâ…§project interventions were indeed improving the maternal health of the intervened counties and decreasing the maternal mortality ratio during the period.2.The maternal mortality ratio showed a downward trend year by year in Healthâ…§project.The maternal mortality ratio in MCH counties decreased more than that in the general counties / DFID pilot counties.This was probabley due to the measures in the MCH counties mainly focused on maternal health,which indicated that strengthening the maternal health interventions could effectively prevent the occurrence of maternal deaths.3.Postpartum hemorrhage was the primary cause of maternal deaths.To take measures to avoid postpartum hemorrhage is conducive to avoiding the occurrence of the incidence of maternal deaths.4.According to the results from generalized linear mixed model,the factors influenced matemal mortality was year and hospital delivery rate.Because of year was decided by macro environment more and difficult to control,to enhance hospital delivery rate and enhance the professionalism of midwives is one of the effective ways to reduce maternal mortality ratio.