Ward Zachary J, Atun Rifat, King Gary, Dmello Brenda Sequeira, Goldie Sue J
Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.
EClinicalMedicine. 2024 May 16;72:102653. doi: 10.1016/j.eclinm.2024.102653. eCollection 2024 Jun.
Maternal mortality remains a challenge in global health, with well-known disparities across countries. However, less is known about disparities in maternal health by subgroups within countries. The aim of this study is to estimate maternal health indicators for subgroups of women within each country.
In this simulation-based analysis, we used the empirically calibrated Global Maternal Health (GMatH) microsimulation model to estimate a range of maternal health indicators by subgroup (urban/rural location and level of education) for 200 countries/territories from 1990 to 2050. Education levels were defined as low (less than primary), middle (less than secondary), and high (completed secondary or higher). The model simulates the reproductive lifecycle of each woman, accounting for individual-level factors such as family planning preferences, biological factors (e.g., anemia), and history of maternal complications, and how these factors vary by subgroup. We also estimated the impact of scaling up women's education on projected maternal health outcomes compared to clinical and health system-focused interventions.
We find large subgroup differences in maternal health outcomes, with an estimated global maternal mortality ratio (MMR) in 2022 of 292 (95% UI 250-341) for rural women and 100 (95% UI 84-116) for urban women, and 536 (95% UI 450-594), 143 (95% UI 117-174), and 85 (95% UI 67-108) for low, middle, and high education levels, respectively. Ensuring all women complete secondary school is associated with a large impact on the projected global MMR in 2030 (97 [95% UI 76-120]) compared to current trends (167 [95% UI 142-188]), with especially large improvements in countries such as Afghanistan, Chad, Madagascar, Niger, and Yemen.
Substantial subgroup disparities present a challenge for global maternal health and health equity. Outcomes are especially poor for rural women with low education, highlighting the need to ensure that policy interventions adequately address barriers to care in rural areas, and the importance of investing in social determinants of health, such as women's education, in addition to health system interventions to improve maternal health for all women.
John D. and Catherine T. MacArthur Foundation, 10-97002-000-INP.
孕产妇死亡率仍是全球卫生领域面临的一项挑战，各国之间存在着众所周知的差异。然而，对于一个国家内不同亚组人群在孕产妇健康方面的差异，我们了解得较少。本研究的目的是估算每个国家内不同亚组女性的孕产妇健康指标。
在这项基于模拟的分析中，我们使用经过实证校准的全球孕产妇健康（GMatH）微观模拟模型，来估算1990年至2050年期间200个国家/地区按亚组（城乡居住地和教育水平）划分的一系列孕产妇健康指标。教育水平被定义为低（小学以下）、中（初中以下）和高（完成初中或更高教育）。该模型模拟了每位女性的生殖生命周期，考虑了个体层面的因素，如计划生育偏好、生物学因素（如贫血）和孕产妇并发症史，以及这些因素在不同亚组中的差异。我们还估计了与以临床和卫生系统为重点的干预措施相比，扩大女性教育规模对预计孕产妇健康结果的影响。
我们发现孕产妇健康结果存在很大的亚组差异，2022年农村女性的估计全球孕产妇死亡率（MMR）为292（95%不确定区间250 - 341），城市女性为100（95%不确定区间84 - 116），低、中、高教育水平女性分别为536（95%不确定区间450 - 594）、143（95%不确定区间117 - 174）和85（95%不确定区间67 - 108）。与当前趋势（167 [95%不确定区间142 - 188]）相比，确保所有女性完成中学教育对2030年预计的全球孕产妇死亡率有很大影响（97 [95%不确定区间76 - 120]），在阿富汗、乍得、马达加斯加、尼日尔和也门等国家改善尤为显著。
巨大的亚组差异给全球孕产妇健康和健康公平带来了挑战。教育程度低的农村女性的健康结果尤其差，这凸显了确保政策干预充分解决农村地区医疗保健障碍的必要性，以及除了卫生系统干预措施外，投资于健康的社会决定因素（如女性教育）以改善所有女性孕产妇健康的重要性。
约翰·D. 和凯瑟琳·T. 麦克阿瑟基金会，10 - 97002 - 000 - INP。
