title: The triple threat of pregnancy, HIV infection and malaria: reported causes of maternal mortality in two nationwide health facility assessments in Mozambique, 2007 and 2012.
abstract: BACKGROUND
  The paper's primary purpose is to determine changes in magnitude and causes of institutional maternal mortality in Mozambique. We also describe shifts in the location of institutional deaths and changes in availability of prevention and treatment measures for malaria and HIV infection.
  
  
  METHODS
  Two national cross-sectional assessments of health facilities with childbirth services were conducted in 2007 and 2012. Each collected retrospective data on deliveries and maternal deaths and their causes. In 2007, 2,199 cases of maternal deaths were documented over a 12 month period; in 2012, 459 cases were identified over a three month period. In 2007, data collection also included reviews of maternal deaths when records were available (n = 712).
  
  
  RESULTS
  Institutional maternal mortality declined from 541 to 284/100,000 births from 2007 to 2012. The rate of decline among women dying of direct causes was 66% compared to 26% among women dying of indirect causes. Cause-specific mortality ratios fell for all direct causes. Patterns among indirect causes were less conclusive given differences in cause-of-death recording. In absolute numbers, the combination of antepartum and postpartum hemorrhage was the leading direct cause of death each year and HIV and malaria the main non-obstetric causes. Based on maternal death reviews, evidence of HIV infection, malaria or anemia was found in more than 40% of maternal deaths due to abortion, ectopic pregnancy and sepsis. Almost half (49%) of all institutional maternal deaths took place in the largest hospitals in 2007 while in 2012, only 24% occurred in these hospitals. The availability of antiretrovirals and antimalarials increased in all types of facilities, but increases were most dramatic in health centers.
  
  
  CONCLUSIONS
  The rate at which women died of direct causes in Mozambique's health facilities appears to have declined significantly. Despite a clear improvement in access to antiretrovirals and antimalarials, especially at lower levels of health care, malaria, HIV, and anemia continue to exact a heavy toll on child-bearing women. Going forward, efforts to end preventable maternal and newborn deaths must maximize the use of antenatal care that includes integrated preventive/treatment options for HIV infection, malaria and anemia.
authors.affiliation: RMNCH Unit, Global Health Programs, FHI 360 359 Blackwell Street, Durham, NC, 27701, USA. pbailey@fhi360.org.|Averting Maternal Death & Disability, Mailman School of Public Health, Columbia University, New York, NY, USA. pbailey@fhi360.org.
authors.forename: Patricia E
authors.initials: PE
authors.lastname: Bailey
authors.affiliation: RMNCH Unit, Global Health Programs, FHI 360 359 Blackwell Street, Durham, NC, 27701, USA. ekeyes@fhi360.org.|Averting Maternal Death & Disability, Mailman School of Public Health, Columbia University, New York, NY, USA. ekeyes@fhi360.org.
authors.forename: Emily
authors.initials: E
authors.lastname: Keyes
authors.affiliation: Global Health Fellows Program II, United States Agency for International Development (USAID), Washington, DC, USA. Amoran@usaid.gov.
authors.forename: Allisyn C
authors.initials: AC
authors.lastname: Moran
authors.affiliation: MEASURE Evaluation/Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. singhk@email.unc.edu.|Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. singhk@email.unc.edu.
authors.forename: Kavita
authors.initials: K
authors.lastname: Singh
authors.affiliation: MCSP/Jhpiego, Maputo, Mozambique. leochavane@gmail.com.
authors.forename: Leonardo
authors.initials: L
authors.lastname: Chavane
authors.affiliation: Departamento de Saúde da Comunidade, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique. Baltazar.chilundo@gmail.com.
authors.forename: Baltazar
authors.initials: B
authors.lastname: Chilundo
mesh_terms: D000028:Abortion, Induced / Q000401:mortality; D000293:Adolescent; D000328:Adult; D000740:Anemia / Q000401:mortality; D019380:Anti-HIV Agents / Q000600:supply & distribution / Q000627:therapeutic use; D000962:Antimalarials / Q000600:supply & distribution / Q000627:therapeutic use; D002423:Cause of Death; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality* / Q000517:prevention & control; D006276:Health Facility Size; D017052:Hospital Mortality / Q000639:trends; D006761:Hospitals / Q000706:statistics & numerical data / Q000639:trends; D006801:Humans; D008288:Malaria / Q000188:drug therapy / Q000401:mortality* / Q000517:prevention & control; D008428:Maternal Mortality / Q000639:trends*; D008875:Middle Aged; D009073:Mozambique / Q000453:epidemiology; D006473:Postpartum Hemorrhage / Q000401:mortality*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000401:mortality* / Q000821:virology; D015597:Pregnancy Complications, Parasitic / Q000401:mortality* / Q000469:parasitology; D011271:Pregnancy, Ectopic / Q000401:mortality; D012189:Retrospective Studies; D018805:Sepsis / Q000401:mortality; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents; D000962:Antimalarials