title: Maternal mortality: a cross-sectional study in global health.
abstract: BACKGROUND
  Although most of maternal deaths are preventable, maternal mortality reduction programs have not been completely successful. As targeting individuals alone does not seem to be an effective strategy to reduce maternal mortality (Millennium Development Goal 5), the present study sought to reveal the role of many distant macrostructural factors affecting maternal mortality at the global level.
  
  
  METHODS
  After preparing a global dataset, 439 indicators were selected from nearly 1800 indicators based on their relevance and the application of proper inclusion and exclusion criteria. Then Pearson correlation coefficients were computed to assess the relationship between these indicators and maternal mortality. Only indicators with statistically significant correlation more than 0.2, and missing values less than 20% were maintained. Due to the high multicollinearity among the remaining indicators, after missing values analysis and imputation, factor analysis was performed with principal component analysis as the method of extraction. Ten factors were finally extracted and entered into a multiple regression analysis.
  
  
  RESULTS
  The findings of this study not only consolidated the results of earlier studies about maternal mortality, but also added new evidence. Education (std. B = -0.442), private sector and trade (std. B = -0.316), and governance (std. B = -0.280) were found to be the most important macrostructural factors associated with maternal mortality. Employment and labor structure, economic policy and debt, agriculture and food production, private sector infrastructure investment, and health finance were also some other critical factors. These distal factors explained about 65% of the variability in maternal mortality between different countries.
  
  
  CONCLUSIONS
  Decreasing maternal mortality requires dealing with various factors other than individual determinants including political will, reallocation of national resources (especially health resources) in the governmental sector, education, attention to the expansion of the private sector trade and improving spectrums of governance. In other words, sustainable reduction in maternal mortality (as a development indicator) will depend on long-term planning for multi-faceted development. Moreover, trade, debt, political stability, and strength of legal rights can be affected by elements outside the borders of countries and global determinants. These findings are believed to be beneficial for sustainable development in Post-2015 Development Agenda.
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences (TUMS), Tehran, Iran. sima.amis@gmail.com.
authors.forename: Sima
authors.initials: S
authors.lastname: Sajedinejad
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences (TUMS), Tehran, Iran. rezamajd@tums.ac.ir.|Knowledge Utilization Research Center (KURC), Tehran University of Medical Sciences (TUMS), Tehran, Iran. rezamajd@tums.ac.ir.
authors.forename: Reza
authors.initials: R
authors.lastname: Majdzadeh
authors.affiliation: Department of Anthropology, Faculty of Social Sciences, University of Tehran (UT), Tehran, Iran. vedadha@ut.ac.ir.
authors.forename: AbouAli
authors.initials: A
authors.lastname: Vedadhir
authors.affiliation: Department of Demography and Population Studies, Faculty of Social Sciences, University of Tehran, Tehran, Iran. smghazi@ut.ac.ir.
authors.forename: Mahmoud Ghazi
authors.initials: MG
authors.lastname: Tabatabaei
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences (TUMS), Tehran, Iran. mohamadk@tums.ac.ir.
authors.forename: Kazem
authors.initials: K
authors.lastname: Mohammad
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D014943:Global Health; D006305:Health Status Indicators; D006801:Humans; D008428:Maternal Mortality / Q000639:trends*; D008875:Middle Aged; D055815:Young Adult