title: Maternal mortality in Colombia in 2011: a two level ecological study.
abstract: OBJECTIVE
  Maternal mortality reduction is a Millennium Development Goal. In Colombia, there is a large disparity in the maternal mortality ratio (MMR) between and into departments (states) and also between municipalities. We examined socioeconomics variables at the municipal and departmental levels which could be associated to the municipal maternal mortality in Colombia.
  
  
  METHODS
  A multilevel ecology study was carried out using different national data sources in Colombia. The outcome variable was the MMR at municipal level in 2011 with multidimensional poverty at municipal and department level as the principal independent variables and other measures of the social and economic characteristics at municipal and departmental level were also considered explicative variables (overall fertility municipal rate, percentage of local rural population, health insurance coverage, per capita territorial participation allocated to the health sector, transparency index and Gini coefficient). The association between MMR and socioeconomic contextual conditions at municipal and departmental level was assessed using a multilevel Poisson regression model.
  
  
  RESULTS
  The MMR in the Colombian municipalities was associated significantly with the multidimensional poverty (relative ratio of MMR: 3.52; CI 95%: 1.09-11.38). This association was stronger in municipalities from departments with the highest poverty (relative ratio of MMR: 7.14; CI 95%: 2.01-25.35). Additionally, the MMR at municipal level was marginally associated with municipally health insurance coverage (relative ratio of MMR: 0.99; CI 95%: 0.98-1.00), and significantly with transparency index at departmental level (relative ratio of MMR: 0.98; CI 95%: 0.97-0.99).
  
  
  CONCLUSIONS
  Poverty and transparency in a contextual level were associated with the increase of the municipal MMR in Colombia. The results of this study are useful evidence for informing the public policies discussion and formulation processes with a differential approach.
authors.affiliation: Colombian National Health Observatory, Instituto Nacional de Salud, Bogotá, Colombia.
authors.forename: Luz Mery
authors.initials: LM
authors.lastname: Cárdenas-Cárdenas
authors.affiliation: Colombian National Health Observatory, Instituto Nacional de Salud, Bogotá, Colombia.
authors.forename: Karol
authors.initials: K
authors.lastname: Cotes-Cantillo
authors.affiliation: Colombian National Health Observatory, Instituto Nacional de Salud, Bogotá, Colombia.
authors.forename: Pablo Enrique
authors.initials: PE
authors.lastname: Chaparro-Narváez
authors.affiliation: Information Center for Public Health Decisions, National Institute of Public Health, Cuernavaca, México.
authors.forename: Julián Alfredo
authors.initials: JA
authors.lastname: Fernández-Niño
authors.affiliation: Grupo de Economía de la Salud, Universidad de Cartagena, Cartagena de Índias, Colombia.
authors.forename: Angel
authors.initials: A
authors.lastname: Paternina-Caicedo
authors.affiliation: Colombian National Health Observatory, Instituto Nacional de Salud, Bogotá, Colombia.
authors.forename: Carlos
authors.initials: C
authors.lastname: Castañeda-Orjuela
authors.affiliation: Instituto Nacional de Salud, Bogotá, Colombia.
authors.forename: Fernando
authors.initials: F
authors.lastname: De la Hoz-Restrepo
mesh_terms: D000704:Analysis of Variance; D002947:Cities / Q000706:statistics & numerical data; D003105:Colombia / Q000453:epidemiology; D004463:Ecology; D005260:Female; D006801:Humans; D008428:Maternal Mortality; D012959:Socioeconomic Factors