title: Risk factors for maternal death and trends in maternal mortality in low- and middle-income countries: a prospective longitudinal cohort analysis.
abstract: BACKGROUND
  Because large, prospective, population-based data sets describing maternal outcomes are typically not available in low- and middle-income countries, it is difficult to monitor maternal mortality rates over time and to identify factors associated with maternal mortality. Early identification of risk factors is essential to develop comprehensive intervention strategies preventing pregnancy-related complications. Our objective was to describe maternal mortality rates in a large, multi-country dataset and to determine maternal, pregnancy-related, delivery and postpartum characteristics that are associated with maternal mortality.
  
  
  METHODS
  We collected data describing all pregnancies from 2010 to 2013 among women enrolled in the multi-national Global Network for Women's and Children's Health Research Maternal and Neonatal Health Registry (MNHR). We reported the proportion of mothers who died per pregnancy and the maternal mortality ratio (MMR). Generalized linear models were used to evaluate the relationship of potential medical and social factors and maternal mortality and to develop point and interval estimates of relative risk associated with these factors. Generalized estimating equations were used to account for the correlation of outcomes within cluster to develop appropriate confidence intervals.
  
  
  RESULTS
  We recorded 277,736 pregnancies and 402 maternal deaths for an MMR of 153/100,000 live births. We observed an improvement in the total MMR from 166 in 2010 to 126 in 2013. The MMR in Latin American sites (91) was lower than the MMR in Asian (178) and African sites (125). When adjusted for study site and the other variables, no formal education (RR 3.2 [1.5, 6.9]), primary education only (RR 3.4 [1.6, 7.5]), secondary education only (RR 2.5 [1.1, 5.7]), lack of antenatal care (RR 1.8 [1.2, 2.5]), caesarean section delivery (RR 1.9 [1.3, 2.8]), hemorrhage (RR 3.3 [2.2, 5.1]), and hypertensive disorders (RR 7.4 [5.2, 10.4]) were associated with higher risks of death.
  
  
  CONCLUSIONS
  The MNHR identified preventable causes of maternal mortality in diverse settings in low- and middle-income countries. The MNHR can be used to monitor public health strategies and determine their association with reducing maternal mortality.
  
  
  BACKGROUND
  clinicaltrials.gov NCT01073475.
authors.forename: Melissa
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authors.lastname: Bauserman
authors.forename: Adrien
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authors.lastname: Lokangaka
authors.forename: Vanessa
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authors.lastname: Thorsten
authors.forename: Antoinette
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authors.lastname: Tshefu
authors.forename: Shivaprasad S
authors.initials: SS
authors.lastname: Goudar
authors.forename: Fabian
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authors.lastname: Esamai
authors.forename: Ana
authors.initials: A
authors.lastname: Garces
authors.forename: Sarah
authors.initials: S
authors.lastname: Saleem
authors.forename: Omrana
authors.initials: O
authors.lastname: Pasha
authors.forename: Archana
authors.initials: A
authors.lastname: Patel
authors.forename: Albert
authors.initials: A
authors.lastname: Manasyan
authors.forename: Mabel
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authors.lastname: Berrueta
authors.forename: Bhala
authors.initials: B
authors.lastname: Kodkany
authors.forename: Elwyn
authors.initials: E
authors.lastname: Chomba
authors.forename: Edward A
authors.initials: EA
authors.lastname: Liechty
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authors.initials: K
authors.lastname: Hambidge
authors.forename: Nancy F
authors.initials: NF
authors.lastname: Krebs
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Derman
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Hibberd
authors.forename: Fernando
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authors.lastname: Althabe
authors.forename: Waldemar A
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authors.lastname: Carlo
authors.forename: Marion
authors.initials: M
authors.lastname: Koso-Thomas
authors.forename: Robert L
authors.initials: RL
authors.lastname: Goldenberg
authors.forename: Dennis D
authors.initials: DD
authors.lastname: Wallace
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: McClure
authors.forename: Carl L
authors.initials: CL
authors.lastname: Bose
mesh_terms: D000328:Adult; D036861:Delivery, Obstetric / Q000379:methods; D003906:Developing Countries; D004522:Educational Status; D005260:Female; D006801:Humans; D007182:Income; D008137:Longitudinal Studies; D008423:Maternal Age; D063130:Maternal Death / Q000209:etiology*; D008428:Maternal Mortality / Q000639:trends*; D010298:Parity; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology; D011446:Prospective Studies; D011644:Puerperal Disorders / Q000453:epidemiology; D012042:Registries; D012307:Risk Factors; D055815:Young Adult