title: Obstetric transition in the World Health Organization Multicountry Survey on Maternal and Newborn Health: exploring pathways for maternal mortality reduction.
abstract: OBJECTIVE
  To test whether the proposed features of the Obstetric Transition Model-a theoretical framework that may explain gradual changes that countries experience as they eliminate avoidable maternal mortality-are observed in a large, multicountry, maternal and perinatal health database; and to discuss the dynamic process of maternal mortality reduction using this model as a theoretical framework.
  
  
  METHODS
  This was a secondary analysis of a cross-sectional study by the World Health Organization that collected information on more than 300 000 women who delivered in 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East, during a 2-4-month period in 2010-2011. The ratios of Potentially Life-Threatening Conditions, Severe Maternal Outcomes, Maternal Near Miss, and Maternal Death were estimated and stratified by stages of obstetric transition. The characteristics of each stage are defined.
  
  
  RESULTS
  Data from 314 623 women showed that female fertility, indirectly estimated by parity, was higher in countries at a lower obstetric transition stage, ranging from a mean of 3 children in Stage II to 1.8 children in Stage IV. Medicalization increased with obstetric transition stage. In Stage IV, women had 2.4 times the cesarean deliveries (15.3% in Stage II and 36.7% in Stage IV) and 2.6 times the labor inductions (7.1% in Stage II and 18.8% in Stage IV) as women in Stage II. The mean age of primiparous women also increased with stage. The occurrence of uterine rupture had a decreasing trend, dropping by 5.2 times, from 178 to 34 cases per 100 000 live births, as a country transitioned from Stage II to IV.
  
  
  CONCLUSIONS
  This analysis supports the concept of obstetric transition using multicountry data. The Obstetric Transition Model could provide justification for customizing strategies for reducing maternal mortality according to a country's stage in the obstetric transition.
authors.affiliation: Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil.
authors.forename: Solange da Cruz
authors.initials: Sda C
authors.lastname: Chaves
authors.affiliation: Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil.
authors.forename: José Guilherme
authors.initials: JG
authors.lastname: Cecatti
authors.affiliation: Centro Rosarino de Estudios Perinatales, Rosario, Argentina.
authors.forename: Guillermo
authors.initials: G
authors.lastname: Carroli
authors.affiliation: Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
authors.forename: Pisake
authors.initials: P
authors.lastname: Lumbiganon
authors.affiliation: Emory University, Atlanta, Georgia, United States of America.
authors.forename: Carol J
authors.initials: CJ
authors.lastname: Hogue
authors.affiliation: Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
authors.forename: Rintaro
authors.initials: R
authors.lastname: Mori
authors.affiliation: Ministry of Education.
authors.forename: Jun
authors.initials: J
authors.lastname: Zhang
authors.affiliation: Family Health Bureau, Ministry of Health, Colombo, Sri Lanka.
authors.forename: Kapila
authors.initials: K
authors.lastname: Jayaratne
authors.affiliation: Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
authors.forename: Ganchimeg
authors.initials: G
authors.lastname: Togoobaatar
authors.affiliation: Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil, jpsouza@fmrp.usp.br.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Pileggi-Castro
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Meghan
authors.initials: M
authors.lastname: Bohren
authors.affiliation: United Nations Development Program.
authors.forename: Joshua Peter
authors.initials: JP
authors.lastname: Vogel
authors.affiliation: United Nations Development Program.
authors.forename: Özge
authors.initials: Ö
authors.lastname: Tunçalp
authors.affiliation: United Nations Development Program.
authors.forename: Olufemi Taiwo
authors.initials: OT
authors.lastname: Oladapo
authors.affiliation: United Nations Development Program.
authors.forename: Ahmet Metin
authors.initials: AM
authors.lastname: Gülmezoglu
authors.affiliation: United Nations Development Program.
authors.forename: Marleen
authors.initials: M
authors.lastname: Temmerman
authors.affiliation: Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil, jpsouza@fmrp.usp.br.
authors.forename: João Paulo
authors.initials: JP
authors.lastname: Souza
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000706:statistics & numerical data* / Q000639:trends; D003906:Developing Countries; D005260:Female; D005298:Fertility; D014943:Global Health; D019538:Health Care Surveys; D006801:Humans; D007223:Infant; D000068104:Infant Health / Q000639:trends*; D007226:Infant Mortality / Q000639:trends; D007231:Infant, Newborn; D007751:Labor, Induced / Q000706:statistics & numerical data; D008423:Maternal Age; D008428:Maternal Mortality / Q000639:trends*; D008430:Maternal-Child Health Centers / Q000706:statistics & numerical data; D062528:Medicalization / Q000639:trends; D011247:Pregnancy; D011256:Pregnancy Outcome; D011322:Primary Prevention; D012959:Socioeconomic Factors; D050497:Stillbirth / Q000453:epidemiology; D014944:World Health Organization; D055815:Young Adult