Women's Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: A Natural Experiment in Chile from 1957 to 2007

Abstract

BackgroundThe aim of this study was to assess the main factors related to maternal mortality reduction in large time series available in Chile in context of the United Nations' Millennium Development Goals (MDGs).MethodsTime series of maternal mortality ratio (MMR) from official data (National Institute of Statistics, 1957–2007) along with parallel time series of education years, income per capita, fertility rate (TFR), birth order, clean water, sanitary sewer, and delivery by skilled attendants were analysed using autoregressive models (ARIMA). Historical changes on the mortality trend including the effect of different educational and maternal health policies implemented in 1965, and legislation that prohibited abortion in 1989 were assessed utilizing segmented regression techniques.ResultsDuring the 50-year study period, the MMR decreased from 293.7 to 18.2/100,000 live births, a decrease of 93.8%. Women's education level modulated the effects of TFR, birth order, delivery by skilled attendants, clean water, and sanitary sewer access. In the fully adjusted model, for every additional year of maternal education there was a corresponding decrease in the MMR of 29.3/100,000 live births. A rapid phase of decline between 1965 and 1981 (−13.29/100,000 live births each year) and a slow phase between 1981 and 2007 (−1.59/100,000 live births each year) were identified. After abortion was prohibited, the MMR decreased from 41.3 to 12.7 per 100,000 live births (−69.2%). The slope of the MMR did not appear to be altered by the change in abortion law.ConclusionIncreasing education level appears to favourably impact the downward trend in the MMR, modulating other key factors such as access and utilization of maternal health facilities, changes in women's reproductive behaviour and improvements of the sanitary system. Consequently, different MDGs can act synergistically to improve maternal health. The reduction in the MMR is not related to the legal status of abortion.

Frequency and Risk Factors Associated with Mortality in Pregnant Women in Tehran-Iran

“…In the present study, there was a significant relationship between the number of abortions and maternal mortality (P-value = 0.026) and 27.3% in case group and 13.5% in the control group had a history of one or more abortions, but in the study by Koch et al (2012), reducing the maternal mortality ratio was not associated with legal abortion (Koch et al, 2012).…”

Consenso salud materna para Chile en el nuevo milenio

“…En nuestra región (Latinoamérica y el Caribe), se observa una tendencia sostenida a la mejoría de estos indicadores materno-infantiles, pero aún insuficiente para alcanzar las Metas del Milenio el 2015, particularmente cuando se analiza la tendencia desagregada a nivel de países (8)(9)(10). Nuestra región presenta una situación de inequidad inaceptablemente alta, la que se expresa por la persistencia de indicadores significativamente mayores en poblaciones con menores niveles de ingreso y educación, en poblaciones rurales y en pueblos indígenas.…”

“…Actualmente se encuentra entre los tres países con menor mortalidad materna del continente americano y el de menor mortalidad en toda Latinoamérica (9).…”

“…A nivel nacional al alcanzar indicadores de menos de 20 muertes maternas por cien mil nacidos vivos, el perfil etiológico ha cambiado de ser predominantemente de causas directas u obstétricas a causas indirectas asociadas al embarazo (8)(9)(10). …”

“…El perfil actual es complejo y el estancamiento de la mortalidad materna sugiere que se requiere una forma de abordaje nueva y complementaria a las grandes políticas públicas que le permitieron a Chile en los últimos 50 o más años, posicionarse como uno de los países del continente más seguros para ser madre (9).…”