Advancing maternal and perinatal health in low- and middle-income countries: A multi-country review of policies and programmes.

The Sustainable Development Goals prioritize maternal mortality reduction, with a global average target of < 70 per 100,000 live births by 2030. Current pace of reduction is far short of what is needed to achieve the global target. It is estimated that globally there are 300,000 maternal deaths, 2.4 million newborn deaths and 2 million stillbirths annually. Majority of these deaths occur in low-and-middle-income countries. Global initiatives like, Ending Preventable Maternal Mortality (EPMM) and Every Newborn Action Plan (ENAP), have outlined the broad strategies for maternal and newborn health programmes. A set of coverage targets and ten milestones were launched to support low-and-middle-income countries in accelerating progress in improving maternal, perinatal and newborn health and wellbeing. WHO, UNICEF and UNFPA, undertook a scoping review to understand how country strategies evolved in different contexts over the past two decades to improve maternal survival and wellbeing, and how countries in similar settings could accelerate progress considering the changing epidemiology and demography. Case studies were conducted to inform countries in similar settings and various global initiatives. Six countries were selected based on standard criteria-Cambodia, Democratic Republic of the Congo, Georgia, Guatemala, Pakistan and Sierra Leone representing different stages of the obstetric transition. A conceptual framework, encapsulating the interrelated factors impacting maternal health outcomes, was used to organize data collection and analysis. While all six countries made remarkable progress in improving maternal and perinatal health, the pace of progress and the factors influencing the successes and challenges varied across the countries. The context, opportunities and challenges varied from country to country. Two strategic directions were identified for next steps including the need to implement and evaluate innovative service delivery models using an updated obstetric transition as an organizing framework and expanding our vision to address equity and well-being.

Audit of Early and Late Maternal Deaths in Georgia: Potential for Improving Substandard Obstetric Care.

INTRODUCTION: Quality of care is an important factor in reducing preventable maternal deaths, yet it is a significant challenge in many countries. Substandard and poor quality of care is the leading factor in two-thirds of maternal deaths in European countries. Our study investigated the deaths of all women of reproductive age in 2012 in Georgia. The aim was to define the underlying causes of maternal deaths and to identify the factors in women's care which contributed to the fatal outcomes. METHODS: A national Reproductive Age Mortality Survey was conducted in Georgia in 2014-15. Data from multiple sources was triangulated to identify all deaths of women of reproductive age. This was followed by verbal autopsy diagnoses. Each case of early and late maternal death was investigated through interviews and medical record reviews at the last medical facility providing care for the deceased woman. A specialist panel reviewed and assigned underlying causes of death, assessed the management of each woman's condition, and identified elements of suboptimal care. RESULTS: We identified a total of 23 maternal deaths, including 15 (65%) early and eight (35%) late deaths. The maternal mortality ratio was 26.3 per 100 000 live births. The four leading causes of early maternal deaths were: sepsis, hemorrhage, embolism, and pregnancy-induced hypertension. Embolism and sepsis were the direct causes of the eight late maternal deaths. Cancer, tuberculosis, and postpartum suicide constituted the indirect causes of death. Improvements in care which would have made a difference to the outcomes were identified in 87% of early maternal deaths and 67% of late maternal deaths due to direct obstetric causes. DISCUSSION: Delayed recognition and inappropriate management of maternal complications were common across almost all cases studied. The findings from Georgia highlight the conclusion that most maternal deaths were preventable and that improvement in obstetric care is urgently required.

Socio-Demographic Determinants of Road Traffic Fatalities in Women of Reproductive Age in the Republic of Georgia: Evidence from the National Reproductive Age Mortality Study (2014).

PURPOSE: Globally and in the European region, the road traffic injuries (RTI) have emerged as a major public health and development problem, killing the most productive adult members of a population, including women. This study aimed to identify the key socio-demographic determinants of premature and avoidable RTI mortality in reproductive-aged women (15-49 years) in Georgia. MATERIALS AND METHODS: The study employed verbal autopsy data from the second national reproductive age mortality survey (RAMOS 2014). Univariate and multivariate logistic regression models were fitted using the Firth method to assess the crude and adjusted effects of each individual level socio-demographic factor on the odds of RTI-attributed death, with corresponding 95% confidence intervals (COR and AOR, 95% CI). RESULTS: Of 843 women aged 15-49 years, 78 (9.3%) were the victims of fatal traffic crashes. After multivariate adjustment, the odds of dying from RTI were significantly higher in women aged 15-29 years (AOR=7.73, 95% CI= 4.20 to 14.20), those being employed (AOR=2.11, 95% CI= 1.22 to 3.64) and the wealthiest (AOR=2.88, 95% CI= 1.44 to 5.77) compared, respectively, to their oldest (40-49 years), unemployed and poorest counterparts. Conversely, there were no statistically significant ethnic, marital, rural/urban, and educational disparities in women's RTI fatalities. Overall, motorized four-wheeler occupants (78.2%), particularly passengers (71.8%), appeared to be the most common victims of fatal road injuries than pedestrians (20.5%). Alarmingly, the vast majority (85.9%) of any type of road users died instantly at the scene of collision, as compared to deaths en route to hospital (1.3%) or in hospital (11.5%). CONCLUSION: Age, employment, and wealth status appeared to be the strong independent predictors of young women's RTI mortality in Georgia. Future comprehensive research would be advantageous for further deciphering the differential impact of social determinants on traffic-induced fatalities, as a vital platform for evidence-based remedial actions on this predictable and preventable safety hazard.

Socio-Demographic Determinants of Mortality from Chronic Noncommunicable Diseases in Women of Reproductive Age in the Republic of Georgia: Evidence from the National Reproductive Age Mortality Study (2014).

PURPOSE: Worldwide, noncommunicable diseases (NCDs) are the leading cause of premature death of women, taking the highest toll in developing countries. This study aimed to identify key socio-demographic determinants of NCD mortality in reproductive-aged women (15-49 years) in Georgia. MATERIALS AND METHODS: The study employed the verbal autopsy data from the second National Reproductive Age Mortality Survey 2014. Univariate and multivariate logistic regression models were fitted to explore the association between each risk factor and NCD mortality, measured by crude and adjusted odds ratio (AOR) with respective 95% confidence intervals (95% CI). RESULTS: In the final sample of 843 women, 586 (69.5%) deaths were attributed to NCDs, the majority of which occurred outside a hospital (72.7%) and among women aged 45-49 years (46.8%), ethnic Georgians (85.2%), urban residents (60.1%), those being married (60.6%), unemployed (75.1%) or having secondary and higher education (69.5%), but with nearly equal distribution across the wealth quintiles. After multivariate adjustment, the odds of dying from NCDs were significantly higher in women aged 45-49 years (AOR=17.69, 95% CI= 9.35 to 33.50), those being least educated (AOR=1.55, 95% CI= 1.01 to 2.37) and unemployed (AOR=1.47, 95% CI= 1.01 to 2.14) compared, respectively, to their youngest (15-24 years), more educated and employed counterparts. Strikingly, the adjusted odds were significantly lower in "other" ethnic minorities (AOR=0.29, 95% CI= 0.14 to 0.61) relative to ethnic Georgians. Contrariwise, there were no significant associations between NCD mortality and women's marital or wealth status, place of residence (rural/urban) or place of death. CONCLUSION: Age, ethnicity, education, and employment were found to be strong independent predictors of young women's NCD mortality in Georgia. Further research on root causes of inequalities in mortality across the socioeconomic spectrum is warranted to inform equity- and life course-based multisectoral, integrated policy responses that would be conducive to enhancing women's survival during and beyond reproduction.

Who obtains abortion in Georgia and why?

PURPOSE: While induced abortion practices are common in Georgia, the sociodemographic subgroups of women predominantly affected by abortion and their leading motives have not yet been explored. The study aims to understand differentials in women undergoing abortion according to background characteristics and get insight into their reasons for availing of abortion services. MATERIALS AND METHODS: We analyzed the data on 2,054 abortions from the Georgian Reproductive Health Survey 2010. We computed an abortion index (AI) to identify the subgroups of women with the highest relative abortion rates. We performed descriptive analysis of the reasons for pregnancy termination and assessed the statistical significance of differences in proportions using the chi-squared test. We applied multivariate binary logistic regression analyses to study the sociodemographic predictors of the four leading reasons for abortion. RESULTS: In Georgia, women seeking abortion were predominantly those with two or more children (AI 1.9-2.2), from an Azeri ethnic group (AI 2.0), in the age category 25-34 years (AI 1.5), married (AI 1.5), or practicing Islam (AI 1.5). Unwillingness to have more children was the most commonly cited reason for the abortion decision (49.4%), followed by socioeconomic concerns (22.0%) and desire to space out pregnancies (18.1%). Health-related reasons were cited by only 7.5% as a leading motive for abortion. CONCLUSION: Women with specific background characteristics are disproportionally affected by abortion and, thus, are in utmost need of support in successful birth planning. Desire to stop or space childbearing and socioeconomic challenges are the overriding motives for terminating unintended pregnancies. Planning and execution of effective family planning programs targeting those at greatest risk for abortion have the potential to reduce the burden of induced abortion in Georgia.

Leading causes of death of women of reproductive age in the Republic of Georgia: findings from the National Reproductive Age Mortality Survey (2014).

PURPOSE: An understanding of women's health problems during the reproductive years, based on reliable cause-of-death data, is of critical importance to avoid premature female mortality. This study aimed to investigate mortality levels, cause-specific patterns, and trends in women of reproductive age in Georgia. MATERIALS AND METHODS: The National Reproductive Age Mortality Survey (2014) was conducted to identify all causes of death for women aged 15-49 years in 2012. The leading causes were compared with those in 2006, using directly age-standardized death rates (ASDRs). The accuracy of official cause-of-death data was assessed against verbal autopsy (VA) diagnoses, using kappa statistics, sensitivity, positive predictive value, and misclassification analyses. RESULTS: Of 913 eligible deaths, VAs were completed for 878 deaths. Noncommunicable diseases (NCDs) were the dominant causes of death (69.6% or 53.1/100,000), with cancer taking a major toll (45.2% or 34.5/100,000), followed by injuries (18.6% or 14.2/100,000). Breast cancer (12.5%), road injuries (9.1%), cervical cancer (6.5%), cerebrovascular diseases (5.2%), uterine cancer (4.1%), brain cancer (3.4%), suicide (3.1%), stomach cancer (3.0%), maternal disorders (2.6%), and liver cirrhosis (2.2%) contributed to the 10 leading specific causes of death, with the majority being substantially underreported in official statistics. This was primarily due to a significantly higher proportion (84%, p<0.05) of deaths routinely assigned ill-defined codes. Since 2006, statistically significant changes in ASDRs, with declines, were observed only for undetermined causes (40%, p<0.05) and ovarian cancer (54%, p<0.05); ovarian cancer and tuberculosis were replaced by stomach cancer and liver cirrhosis in the top 10 cause-of-death list. CONCLUSION: NCDs continue to be the major health threats for Georgian women of reproductive age. The VA method proved a feasible tool to yield essential cause-of-death information for this population. Further research is needed to inform national health promotion and disease prevention interventions to be focused on NCDs and reproductive health needs with an integrated approach.

Effects of gestational age and the mode of surgical abortion on postabortion hemorrhage and fever: evidence from population-based reproductive health survey in Georgia.

BACKGROUND: Every year around 50 million unintended pregnancies worldwide are terminated by induced abortion. Even in countries, where it is legalized and performed in a safe environment, abortion carries some risk of complications for women. Findings of researchers on the factors that influence the sequelae of abortion are controversial and inconsistent. This study evaluates the effects of gestational age and the method of surgical abortion (i.e., dilatation and curettage and vacuum aspiration) on the most common abortion complications: postabortion hemorrhage and fever. METHODS: We performed a secondary analysis of the data from the population-based Georgian Reproductive Health Survey 2010. Information on 1974 surgical abortions performed >30 days prior to the survey interview were analyzed during the study. Logistic regression statistical analysis was applied to compare the abortion sequelae that followed vacuum aspiration and dilatation and curettage at different gestational ages (<10 weeks and ≥10 weeks). We examined two major early abortion-related complications: postabortion hemorrhage and febrile morbidity (fever ≥38 °C). RESULTS: Postabortion hemorrhage was reported in 43 cases (1.9%), and febrile morbidity occurred in 44 cases (2%) among all of the surgical abortions. The abortions performed by dilatation and curettage were associated with an estimated fourfold increased risk of developing hemorrhage (OR 4.4, 95% CI 2.2-8.6) and a twofold increased risk of developing fever (OR 2.37, 95% CI 1.17-4.79) compared with the abortions that were performed via vacuum aspiration. The risk of postabortion hemorrhage (OR 1.9, 95% CI 0.8-4.4) or fever (OR 0.9, 95% CI 0.4-2.1) did not significantly differ at gestational age < 10 weeks and ≥10 weeks. CONCLUSION: Vacuum aspiration was associated with reduced risks of postabortion hemorrhage and fever compared to dilatation and curettage. Gestational age ≥ 10 weeks was not found to be a predictive factor of immediate postabortion complications: hemorrhage and fever.

A maternal death from self-induced medical abortion: a call for action.

OBJECTIVES: In Georgia, which has a longstanding, liberalised abortion law, the abortion procedure is generally safe if it is performed in a medical facility. However, when socioeconomic barriers prevent women from seeking safe abortion services, some risk their life by self-terminating an unintended pregnancy. We present a case of maternal mortality after a self-induced medical abortion, with the aim to investigate the underlying non-clinical causes of maternal death and the relevant policy implications. CASE: A 34-year-old socially vulnerable woman self-administered 10 tablets of oral misoprostol to terminate an 18-week pregnancy. She expelled the fetus the following day. A week later, she developed excessive vaginal bleeding, difficulty in breathing and tachycardia. She was hospitalised and diagnosed with sepsis due to a retained placenta. Uterine curettage and aggressive conservative management, followed by total abdominal hysterectomy, failed to stop the fulminant septic process. The patient's condition deteriorated rapidly and she died 15 h after admission to hospital. CONCLUSION: Socially disadvantaged women in Georgia have limited access to safe abortion services, and some are impelled to self-induce abortion in order to terminate an unintended pregnancy. Inclusion of family planning and abortion services in the Universal Health Care benefits package for socially vulnerable families may reduce the morbidity and mortality associated with unsafe abortion practices.

Repeat induced abortions in Georgia, characteristics of women with multiple pregnancy terminations: secondary analysis of the Reproductive Health Survey 2010.

OBJECTIVE: To examine the multi-faceted characteristics of women with repeat induced abortions and assess post-abortion family planning service provision in Georgia. STUDY DESIGN: We performed secondary analysis of the data from the Georgian Reproductive Health Survey 2010. A logistic regression model was used to assess the socio-demographic and behavioral factors, contraceptive practices in relation to repeat induced abortions for 2203 women of reproductive age with at least one induced abortion. The Chi-Square test was used to evaluate provision of post-abortion family planning services. RESULTS: Among the targeted women, 70% (n=1539) had repeat induced abortions. The odds of terminating pregnancy raised exponentially with age (OR 3.12, 95% CI: 2.11-4.61), number of complete pregnancies (3 vs. 0-1 complete pregnancies: OR 3.25, 95% CI: 2.36-4.48) and lower education (OR 1.38, 95% CI: 1.10-1.73). The current use of contraception had a protective effect on the occurrence of repeat induced abortions (OR 0.69, 95% CI: 0.53-0.89 for modern and OR 0.68, 95% CI: 0.50-0.92 for traditional methods). The contraceptive counseling and family planning method was provided only to 32% and 6% of post-abortion women, respectively before discharge from the clinic. Repeat induced abortions were found to be significantly more common (P<0.05) among women who did not receive any post-abortion contraceptive at the site of care (n=1627/1929) compared to those who left the abortion facility with family planning method (n=94/125). CONCLUSION: Low education, higher age, high parity and non-usage of contraceptives carry an increased risk of repeat induced abortions. Post-abortion family planning service delivery is limited in Georgia. Mandating provision of universal post-abortion contraception at the sites of care has a potential to reduce repeat induced abortions and should become a standard of practice for all clinics providing abortion services in Georgia.