title: Education and severe maternal outcomes in developing countries: a multicountry cross-sectional survey.
abstract: OBJECTIVE
  To assess the relationship between education and severe maternal outcomes among women delivering in healthcare facilities.
  
  
  METHODS
  Cross-sectional study.
  
  
  METHODS
  Twenty-nine countries in Africa, Asia, Latin America, and the Middle East.
  
  
  METHODS
  Pregnant women admitted to 359 facilities during a period of 2-4 months of data collection between 2010 and 2011.
  
  
  METHODS
  Data were obtained from hospital records. Stratification was based on the Human Development Index (HDI) values of the participating countries. Multivariable logistic regression analyses were conducted to assess the association between maternal morbidity and education, categorised in quartiles based on the years of formal education by country. Coverage of key interventions was assessed.
  
  
  METHODS
  Severe maternal outcomes (near misses and death).
  
  
  RESULTS
  A significant association between low education and severe maternal outcomes (adjusted odds ratio, aOR, 2.07; 95% confidence interval, 95% CI, 1.46-2.95), maternal near miss (aOR 1.80; 95% CI 1.25-2.57), and maternal death (aOR 5.62; 95% CI 3.45-9.16) was observed. This relationship persisted in countries with medium HDIs (aOR 2.36; 95% CI 1.33-4.17) and low HDIs (aOR 2.65; 95% CI 1.54-2.57). Less educated women also had increased odds of presenting to the hospital in a severe condition (i.e. with organ dysfunction on arrival or within 24 hours: aOR 2.06; 95% CI 1.36-3.10). The probability that a woman received magnesium sulphate for eclampsia or had a caesarean section significantly increased as education level increased (P < 0.05).
  
  
  CONCLUSIONS
  Women with lower levels of education are at greater risk for severe maternal outcomes, even after adjustment for key confounding factors. This is particularly true for women in countries that have poorer markers of social and economic development.
authors.affiliation: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Ö
authors.initials: Ö
authors.lastname: Tunçalp
authors.forename: J P
authors.initials: JP
authors.lastname: Souza
authors.forename: M J
authors.initials: MJ
authors.lastname: Hindin
authors.forename: C A
authors.initials: CA
authors.lastname: Santos
authors.forename: T H
authors.initials: TH
authors.lastname: Oliveira
authors.forename: J P
authors.initials: JP
authors.lastname: Vogel
authors.forename: G
authors.initials: G
authors.lastname: Togoobaatar
authors.forename: D Q
authors.initials: DQ
authors.lastname: Ha
authors.forename: L
authors.initials: L
authors.lastname: Say
authors.forename: A M
authors.initials: AM
authors.lastname: Gülmezoglu
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa / Q000453:epidemiology; D001208:Asia / Q000453:epidemiology; D003430:Cross-Sectional Studies; D004522:Educational Status; D005260:Female; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007843:Latin America / Q000453:epidemiology; D008427:Maternal Health Services / Q000458:organization & administration / Q000592:standards; D008428:Maternal Mortality; D008429:Maternal Welfare; D008877:Middle East / Q000453:epidemiology; D011247:Pregnancy; D012923:Social Class; D014944:World Health Organization; D055815:Young Adult
keywords: Education; health systems; human development index; inequity; near miss; severe maternal morbidity