PUB 540 The Impact of Place on Maternal and Infant Health

May 12, 2022
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PUB 540 The Impact of Place on Maternal and Infant Health

PUB 540 The Impact of Place on Maternal and Infant Health

Read "The Environment That Racism Built: The Impact of Place on Maternal and Infant Health,"
by Frederick (2018), located on the Center for American Progress website.

Stanford Scholars Examine Racism, Social Change and How to Build a More Just Future
Read "Stanford Scholars Examine Racism, Social Change and How to Build a More Just
Future," by De Witte, from Stanford News (2020), located on the Stanford University website.

CITI Training Instructions

Page 7 Grand Canyon University

2022 ©

Prepared on: May 9,
Refer to the "CITI Training Instructions" to register for and complete the CITI Training
assignment assigned in this topic.

Reducing Racial Inequities in Health: Using What We Already Know to Take Action
Read "Reducing Racial Inequities in Health: Using What We Already Know to Take Action," by
Williams and Cooper, from International Journal of Environmental Research and Public Health (2019).

Public Health Code of Ethics
Read "Public Health Code of Ethics," by the American Public Health Association (APHA), located
on the APHA website.

Scraping the Web for Public Health Gains: Ethical Considerations From a Big Data Research
Project on HIV and Incarceration
Read "Scraping the Web for Public Health Gains: Ethical Considerations From a 'Big Data'
Research Project on HIV and Incarceration," by Rennie, Buchbinder, Juengst, Brinkley-
Rubinstein, Blue, and Rosen, from Public Health Ethics (2020).

Naming Institutionalized Racism in the Public Health Literature: A Systematic Literature
Read "Naming Institutionalized Racism in the Public Health Literature: A Systematic
Literature Review," by Hardeman, Murphy, Karbeah, and Kozhimannil, from Public Health Reports

Over the past decade, in order to accelerate progress towards achieving MDGs 4 and 5, a number of countries in the SSA region have searched for innovative strategies to encourage women to seek care at health facilities and to increase facility-based deliveries [2021]. Abolition of user fees and financial incentives are some of the promising strategies. Evaluation research suggests that under certain conditions, these strategies can increase facility-based deliveries in SSA [2223]. However, the extent of reduction in maternal and perinatal mortality as a result of the increase in facility-based deliveries is not known.

Few studies report on the impact of place of delivery on maternal and perinatal mortality in SSA, probably reflecting the pragmatic and ethical difficulties of conducting such studies [24]. To date we are unaware of any randomized control trial (RCT), which would allow causal inference. An observational study in Nigeria has found no association between perinatal mortality and place of delivery [25]. Another study on neonatal mortality that pooled studies in low and middle income countries (LMIC) found that neonatal mortality was significantly lower for facility-based deliveries compared to home deliveries (RR 0.71, 95% CI: 0.54-0.87), but this did not include stillbirths or maternal outcomes [26]. Robust evidence on the relative effectiveness of place of delivery, using health outcome measures, is needed to inform policy formulation in SSA. This information may also make it possible to assess the comparative effectiveness of alternative interventions for reducing maternal and perinatal mortality.

The aim of this paper is to estimate from secondary data how maternal and perinatal mortality in SSA is affected by place of delivery. Mortality is chosen as a health outcome because it is relatively easy to measure and therefore likely to achieve valid results [27]. Additionally, unlike neonatal mortality that only takes live births into account, perinatal mortality also includes stillbirths making it a comprehensive and suitable indicator for assessing outcomes of both intrapartum and immediate post partum care services [28].


Literature search

Using a predefined protocol, we carried out a systematic search of the literature following guidelines for meta-analysis of observational studies in Epidemiology (MOOSE) [29] and preferred reporting items for systematic reviews and meta-analysis (PRISMA) (see Additional file 1). The search was conducted between January and August 2013. A physician with support of a librarian conducted the search. Medical and social science databases and journal libraries included, but were not limited to, PubMed, EBSCO Host, Web of Science, ScienceDirect, Wiley, Cochran library and Google Scholar. We searched for studies conducted in SSA, involving pregnant women and reporting on risk of maternal and perinatal mortality/death by place of birth or delivery. Reference lists of selected publications were assessed in order to identify other potential papers of interest.

The key words used were “Maternal mortality”, “Maternal deaths”, “Perinatal mortality”, “Perinatal deaths”, risk, “Place of birth/delivery”, study, Africa and “sub-Saharan Africa”. In the selected publications, the following definitions were used. Maternal deaths were defined as all direct and indirect obstetric deaths during pregnancy, delivery, and the first 42 days after birth. Perinatal deaths were defined as pregnancy losses occurring after seven completed months of gestation (stillbirths), or deaths within the first seven days of delivery of a live born child (early neonatal deaths) weighing 1000 grams or more. Place of delivery was either facility-based (defined as birth or delivery in a formal health facility whether or not attended by a skilled medical attendant) or home (defined as birth or delivery outside of a formal health facility whether or not attended by a skilled traditional birth attendant). Studies reporting on perinatal mortality were considered eligible if they reported on pregnancy outcomes from 7 complete months until 7 days after birth. Studies reporting on maternal mortality were eligible if they reported on maternal deaths as soon as pregnancy was identified until 42 days after birth. In addition the studies had to be written in English and published between 1990 and 2013.

Data quality and extraction

Each study was subjected to a quality review using a modified Newcastle-Ottawa scale for cohort studies [30]. Key quality items assessed included representativeness of the population, population characteristics such as gestation age at enrollment and duration of pregnancy follow up, information about study design (population based cohort vs. demographic and health surveillance), ascertainment of exposure and proportion of home deliveries, and use of standard definitions for main outcome measures and denominators used (e.g. births, live births). We also extracted information that may have affected the outcomes such as frequency of data collection, proportion of refusals, loss to follow up and sample sizes.

We noted general study information (e.g. year of study publication and authors) and the primary health outcomes for the study: maternal and perinatal mortality ratio by place of delivery. As the outcomes of interest are ratios, we extracted information on relevant numerators and denominators that would enable independent calculations of these ratios. In cases where an appropriate denominator was not provided (e.g. number of live births at home), but the numerator and corresponding appropriate ratio was given, we estimated the denominator by simple proportion. We precluded studies that aimed to ascertain risk of a particular exposure (e.g. HIV infection or severe anaemia in pregnancy) or an intervention (e.g. Prevention of mother to child transmission of HIV) on perinatal/maternal mortality, with insufficient (<25%) assignment of outcomes of interest to place of delivery and where reported data could not completely fill a 2 × 2 table. Where possible, we contacted some authors either to confirm information or provide extra details. Two individuals independently extracted the information and resolved disparities by consensus.

Statistical analysis

Study quality was scored in two categories: high if more than 60% of the quality items were reported and low otherwise. For both primary health outcomes of interest, we estimated the crude odds ratio (OR) by place of delivery in each study and then calculated the weighted average of the OR across the studies using meta analytic procedures [31]. The OR from each study can be combined using a variety of analytical methods, which are classified as: a) fixed effect models which weight studies according to the amount of information they contain; or b) random-effects models, which incorporate an estimate of between-study variation in the weighting [3233]. We assessed study heterogeneity using I2 statistic, which measures the percentage of variation in OR attributable to heterogeneity between studies. The fixed effects model was used when I2 was low < 50% [34] otherwise we used random-effects model to calculate individual study OR and corresponding 95% confidence intervals (95% CI) and to pool the results across the studies.

The potential effect of place of delivery on maternal and perinatal mortality was estimated by attributable risk percentage reduction, defined as the portion of the incidence of an outcome in the exposed that is due to the exposure: [(Ie-Iu)/Ie]*100 where Ie and Iu are incidences in the exposed and unexposed groups, respectively [35]. In our analysis, this represents the incidence of mortality in the exposed (home delivery group) that would be prevented if the exposure (home deliveries) were eliminated. We used a Poisson method to calculate mortality ratios and their 95% CIs as Poisson method approximates distribution of these ratios better [36]. STATA version 12.0 (Stata Corp, College Station, Texas) was used for analysis. No ethical review was required for the study.


As shown in Figure 1, a total of 1247 studies were identified through the literature search. We discarded 615 studies after appraising the titles as they contained irrelevant information or were redundant. We then screened abstracts for the remaining 632 studies before excluding 617 more studies. The reasons for exclusions were a) the studies were not population based or did not report outcomes by place of delivery (n = 594); b) the studies were evaluating impact of an interventions or risk of an exposure (n = 19); and c) the studies were duplicate publications (n = 4). We retrieved 15 studies in full, of which 6 studies were further excluded (5 prospective cohorts and 1 retrospective cohort) because the reported data for 5 studies were not sufficient to completely fill a 2 × 2 table [3741] and 1 study [42] did not have enough information on place of delivery.

Figure 1
figure 1

Flow chart showing identification, screening and inclusion of studies for meta-analysis of maternal and perinatal mortality by place of delivery in sub-Saharan Africa, 1990–2013.

Of the 9 studies that met the inclusion criteria for the analysis: 6 studies [4348] reported on perinatal mortality and the other 3 studies [364950] reported on maternal mortality. All were population based prospective cohort studies and had high quality scores. The mean study quality score for the selected studies was 10 out of 15 possible points (see Additional file 2). The most common limitations identified were lack of randomization in group allocation and lack of independent blind assessment of study outcomes. The 9 retained studies contained information on 36,772 pregnancy episodes in total. Of these 9,362 (25.5%) had information on the perinatal outcome alone. Table 1 provides further details on the characteristics of the studies included in the meta-analysis.

Table 1 Characteristics of studies included in meta-analysis of perinatal and maternal mortality by place of delivery in sub-Saharan Africa

Perinatal mortality

To estimate the protective effect of place of delivery, we first calculated the odds of perinatal mortality by place of delivery. Using a fixed effects model, Figure 2 shows that the pooled crude odds of perinatal mortality is significantly higher for home compared to facility delivery (OR 1.21, 95% CI: 1.02-1.46). As there is a high between-study heterogeneity I2 = 73.7, we also estimated the pooled effect with a random effects model [51]. The estimate from the more conservative random effects model is exactly the same, but is no longer significant, (OR 1.21, 95% CI: 0.79-1.84). The results of the individual studies are also mixed. Two studies are in favor of home delivery [4752], one is neutral [PLACE THIS ORDER OR A SIMILAR ORDER WITH ALL NURSING ESSAYS TODAY AND GET AN AMAZING DISCOUNT  ordernowcc-blue

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