Education and severe maternal outcomes in developing countries: a multicountry cross-sectional survey

Authors

  • Ö Tunçalp,

    Corresponding author
    1. UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
    • Correspondence: Dr Ö Tunçalp, Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva CH–1211, Switzerland. Email tuncalpo@who.int

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  • JP Souza,

    1. UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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  • MJ Hindin,

    1. Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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  • CA Santos,

    1. Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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  • TH Oliveira,

    1. Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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  • JP Vogel,

    1. UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
    2. School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, WA, Australia
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  • G Togoobaatar,

    1. Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
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  • DQ Ha,

    1. National Hospital of Obstetrics and Gynecology of Vietnam, Hanoi, Vietnam
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  • L Say,

    1. UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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  • AM Gülmezoglu,

    1. UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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  • on behalf of the WHO Multicountry Survey on Maternal and Newborn Health Research Network


Abstract

Objective

To assess the relationship between education and severe maternal outcomes among women delivering in healthcare facilities.

Design

Cross-sectional study.

Setting

Twenty-nine countries in Africa, Asia, Latin America, and the Middle East.

Population

Pregnant women admitted to 359 facilities during a period of 2–4 months of data collection between 2010 and 2011.

Methods

Data were obtained from hospital records. Stratification was based on the Human Development Index (HDI) values of the participating countries. Multivariable logistic regression analyses were conducted to assess the association between maternal morbidity and education, categorised in quartiles based on the years of formal education by country. Coverage of key interventions was assessed.

Main outcome measures

Severe maternal outcomes (near misses and death).

Results

A significant association between low education and severe maternal outcomes (adjusted odds ratio, aOR, 2.07; 95% confidence interval, 95% CI, 1.46–2.95), maternal near miss (aOR 1.80; 95% CI 1.25–2.57), and maternal death (aOR 5.62; 95% CI 3.45–9.16) was observed. This relationship persisted in countries with medium HDIs (aOR 2.36; 95% CI 1.33–4.17) and low HDIs (aOR 2.65; 95% CI 1.54–2.57). Less educated women also had increased odds of presenting to the hospital in a severe condition (i.e. with organ dysfunction on arrival or within 24 hours: aOR 2.06; 95% CI 1.36–3.10). The probability that a woman received magnesium sulphate for eclampsia or had a caesarean section significantly increased as education level increased (< 0.05).

Conclusions

Women with lower levels of education are at greater risk for severe maternal outcomes, even after adjustment for key confounding factors. This is particularly true for women in countries that have poorer markers of social and economic development.

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