title: The association between government healthcare spending and maternal mortality in the European Union, 1981-2010: a retrospective study.
abstract: OBJECTIVE
  To determine the association between reductions in government healthcare spending (GHS) on maternal mortality in 24 countries in the European Union (EU) over a 30-year period, 1981-2010.
  
  
  METHODS
  Retrospective study.
  
  
  METHODS
  Twenty-four EU countries (a total population of 419 million as of 2010).
  
  
  METHODS
  We used multivariate regression analysis, controlling for country-specific differences in healthcare, infrastructure, population size and demographic structure. GHS was measured as a percentage of gross domestic product. Five-year lag-time analyses were performed to estimate longer standing effects.
  
  
  METHODS
  Maternal mortality rates.
  
  
  RESULTS
  An annual 1% decrease in GHS is associated with significant rises in maternal mortality rates [regression coefficient [R] 0.0177, P = 0.0021, 95% confidence interval [95% CI] 0.0065-0.0289]. For every annual 1% decrease in GHS, we estimate 89 excess maternal deaths in the EU, a 10.6% annual increase in maternal mortality. The impact on maternal mortality was sustained for up to 1 year (R 0.0150, P = 0.0034, 95% CI 0.0050-0.0250). The associations remained significant after accounting for economic, infrastructure and hospital resource controls, in addition to out-of-pocket expenditure, private health spending and total fertility rate. However, accounting for births attended by skilled staff removed the significance of these effects.
  
  
  CONCLUSIONS
  Reductions in GHS were significantly associated with increased maternal mortality rates, which may occur through changes in the provision of skilled health professionals attending births. Examples of reduced GHS such as the implementation of austerity measures and budgetary reductions are likely to worsen maternal mortality in the EU.
authors.affiliation: Imperial College London, London, SW7 2AZ, UK.
authors.forename: M
authors.initials: M
authors.lastname: Maruthappu
authors.affiliation: Imperial College London, London, SW7 2AZ, UK.|Chelsea and Westminster Hospital, London, UK.
authors.forename: K Y B
authors.initials: KY
authors.lastname: Ng
authors.affiliation: The Economist, London, UK.|Faculty of History, University of Oxford, Oxford, UK.
authors.forename: C
authors.initials: C
authors.lastname: Williams
authors.affiliation: Imperial College London, London, SW7 2AZ, UK.|Harvard School of Public Health, Harvard University, Boston, MA, USA.
authors.forename: R
authors.initials: R
authors.lastname: Atun
authors.affiliation: Women and Health Initiative, Harvard School of Public Health, Boston, MA, USA.
authors.forename: P
authors.initials: P
authors.lastname: Agrawal
authors.affiliation: Special Envoy for Financing to the Director General of the World Health Organization (WHO), Geneva, Switzerland.|University of Bern, Bern, Switzerland.
authors.forename: T
authors.initials: T
authors.lastname: Zeltner
mesh_terms: D000328:Adult; D003431:Cross-Cultural Comparison; D016208:Databases, Factual; D003695:Delivery of Health Care / Q000191:economics* / Q000706:statistics & numerical data; D005062:European Union / Q000706:statistics & numerical data*; D005260:Female; D005380:Financing, Government / Q000191:economics*; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand; D006801:Humans; D008428:Maternal Mortality; D011247:Pregnancy; D012189:Retrospective Studies
keywords: Government; healthcare; maternal mortality; obstetrics; spending