lancet-header

Preprints with The Lancet is part of SSRN´s First Look, a place where journals identify content of interest prior to publication. Authors have opted in at submission to The Lancet family of journals to post their preprints on Preprints with The Lancet. The usual SSRN checks and a Lancet-specific check for appropriateness and transparency have been applied. Preprints available here are not Lancet publications or necessarily under review with a Lancet journal. These preprints are early stage research papers that have not been peer-reviewed. The findings should not be used for clinical or public health decision making and should not be presented to a lay audience without highlighting that they are preliminary and have not been peer-reviewed. For more information on this collaboration, see the comments published in The Lancet about the trial period, and our decision to make this a permanent offering, or visit The Lancet´s FAQ page, and for any feedback please contact preprints@lancet.com.

Maternal Mortality, Stillbirths, and Neonatal Mortality: A Transition Model Based on Analyses of 149 Countries

17 Pages Posted: 20 Sep 2022

See all articles by Ties Boerma

Ties Boerma

University of Manitoba - Department of Community Health Sciences (CHS)

O. Campbell

London School of Hygiene & Tropical Medicine - Faculty of Public Health & Policy

Agbessi Amouzou

Johns Hopkins University - Department of International Health

Cauane Blumenberg

Federal University of Pelotas (UFPel)

Hannah Blencowe

London School of Hygiene & Tropical Medicine

Allisyn C. Moran

World Health Organization (WHO) - Department of Maternal, Newborn, Child and Adolescent Health

Joy E. Lawn

London School of Hygiene & Tropical Medicine - MARCH Centre

Gloria Ikilezi

Bill and Melinda Gates Foundation

More...

Abstract

Background: Maternal mortality, stillbirths and neonatal mortality account for almost 5 million deaths a year, and are often analysed separately in global health, despite having overlapping causes and interventions. We propose a comprehensive five-phase mortality transition model to improve analyses of country progress, current situation, and future trends and drivers of progress.

Methods: We used estimates for 149 countries to assess changes in maternal mortality and a single metric of stillbirths and neonatal deaths. Based on ratios of maternal to stillbirth and neonatal mortality, we identified five phases of transition, in which phase I has the highest mortality. We examined phase-specific changes during 2000-2017 for cause-of-death patterns, fertility and socioeconomic indicators, health workforce and financing, service coverage, inequalities with global estimates and data from 320 national surveys.

Findings: Among 113 countries in phases I to IV, 59% progressed at least one phase between 2000 and 2017, and four advanced two phases. The ratio of stillbirth and neonatal deaths to maternal deaths increased from less than 10 in phase I to well over 50 in phases IV and V. Progression was associated with a declining proportion of deaths due to infectious diseases and peri-partum complications, declining total and adolescent fertility rates, changes in health workforce densities, and skills mix from phase III onwards, increasing per capita health spending and reduced shares of out-of-pocket health expenditures. From phase I to V, the median coverage of first antenatal care visits increased from 78% to 98%, four or more ANC visits from 48% to 90%, institutional births from 42% to 98%, and caesarean-section rates from 3% to 27%. The transition in high mortality phases involved a major increase of births in lower-level health facilities, while subsequent progress was characterized by rapid increases in hospital births. Wealth-related inequalities decreased moderately for neonatal mortality during phase I to IV but reduced strongly for institutional birth coverage, including a shift from top to bottom inequality.

Interpretation: The five-phase maternal mortality, stillbirth and neonatal mortality transition model can be used to benchmark current situation at national or sub-national level, identify outliers to better assess drivers of progress, and inform strategic planning and investments towards SDG targets. It can also facilitate programming for integrated strategies to end preventable maternal mortality and neonatal mortality and stillbirths.

Funding: This work was conducted as part of the Maternal and Newborn Health Exemplars study, which is supported by Global Health Exemplars initiative of Gates Ventures, and the work of the Countdown to 2030 for Women’s, Children’s and Adolescents’ Health, supported by the Bill & Melinda Gates Foundation.

Declaration of Interest: The authors report no conflict of interest.

Keywords: Mortality transition, maternal mortality, stillbirths, neonatal mortality, causes of death, fertility, coverage, health systems, socioeconomic development

Suggested Citation

Boerma, Ties and Campbell, O. and Amouzou, Agbessi and Blumenberg, Cauane and Blencowe, Hannah and Moran, Allisyn C. and Lawn, Joy E. and Ikilezi, Gloria, Maternal Mortality, Stillbirths, and Neonatal Mortality: A Transition Model Based on Analyses of 149 Countries. Available at SSRN: https://ssrn.com/abstract=4224492 or http://dx.doi.org/10.2139/ssrn.4224492

Ties Boerma (Contact Author)

University of Manitoba - Department of Community Health Sciences (CHS) ( email )

750 Bannatyne Ave
Winnipeg, R3E 0W3
Canada

O. Campbell

London School of Hygiene & Tropical Medicine - Faculty of Public Health & Policy ( email )

Agbessi Amouzou

Johns Hopkins University - Department of International Health ( email )

Cauane Blumenberg

Federal University of Pelotas (UFPel) ( email )

Hannah Blencowe

London School of Hygiene & Tropical Medicine ( email )

Keppel Street
London, WC1E 7HT
United Kingdom

Allisyn C. Moran

World Health Organization (WHO) - Department of Maternal, Newborn, Child and Adolescent Health ( email )

Avenue Appia 20
Geneva, 1211
Switzerland

Joy E. Lawn

London School of Hygiene & Tropical Medicine - MARCH Centre ( email )

Gloria Ikilezi

Bill and Melinda Gates Foundation ( email )