What Is the Relationship Between Births to Single Women and Their Level of Education?

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The relationship between maternal education and mortality amongst women giving nascency in health intendance institutions: Analysis of the cross sectional WHO Global Survey on Maternal and Perinatal Wellness

• Lale Sayⁱⁱ,
• João-Paulo Souza²,
• Carol J Hogue³,
• Dinorah L Callesⁱⁱⁱ,
• A Metin Gülmezogluⁱⁱ &
• Rosalind Raine¹

BMC Public Health book 11, Article number:606 (2011) Cite this commodity

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Abstruse

Background

Approximately one-third of a million women dice each yr from pregnancy-related weather condition. Iii-quarters of these deaths are considered avoidable. Millennium Development Goal five calls for a reduction in maternal mortality and the establishment of universal admission to high quality reproductive health care. In that location is prove of a human relationship between lower levels of maternal pedagogy and higher maternal mortality. This study examines the relationship betwixt maternal education and maternal bloodshed among women giving birth in health care institutions and investigates the clan of maternal historic period, marital condition, parity, institutional capacity and land-level investment in health care with these relationships.

Methods

Cantankerous-sectional information was nerveless on 287,035 inpatients giving birth in 373 health care institutions in 24 countries in Africa, Asia and Latin America, between 2004-2005 (in Africa and Latin America) and 2007-2008 (in Asia) as part of the WHO Global Survey on Maternal and Perinatal Health. Analyses investigated associations between indicators measured at the individual, institutional and country level and maternal mortality during the intrapartum period: from access to, until belch from, the institution where women gave nativity. There were 363 maternal deaths.

Results

In the adjusted models, women with no pedagogy had ii.seven times and those with between one and six years of instruction had twice the risk of maternal bloodshed of women with more than 12 years of education. Institutional capacity was not associated with maternal mortality in the adapted model. Those not married or cohabiting had almost twice the risk of death of those who were. At that place was a significantly higher risk of death amidst those anile over 35 (compared with those aged betwixt 20 and 25 years), those with higher numbers of previous births and lower levels of state investment in health intendance. There were also additional effects relating to country of residence which were not explained in the model.

Conclusions

Lower levels of maternal teaching were associated with higher maternal mortality even amongst women able to access facilities providing intrapartum intendance. More than attention should be given to the wider social determinants of health when devising strategies to reduce maternal mortality and to accomplish the increasingly elusive MDG for maternal mortality.

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Background

It is estimated that each twelvemonth approximately i third of a million women worldwide die due to pregnancy-related conditions [1]. 99% of these deaths occur in developing countries and approximately three-quarters of them are considered avoidable [2]. Millennium Development Goal five (MDG5) calls for a reduction in the maternal mortality ratio (i.e. the number of maternal deaths per 100,000 alive births) by three quarters by 2015 and the establishment of universal access to high quality reproductive health care [3–5]. Achievement of MDG5 in role requires improved provision of family unit planning services to enable women to have fewer, better spaced pregnancies [6]. Yet major causes of maternal death include intra-partum emergencies such equally bleeding, obstructed labour and infections [seven], and these also need to be addressed. Only a tertiary of women who require lifesaving care following a complexity in delivery receive information technology [8]. Information technology is therefore argued that a vital prerequisite to reducing maternal deaths is universal access to high quality pregnancy and delivery intendance [9]. This includes an advisable and effective referral system and emergency obstetric care, including blood, medications and obstetric surgeries close to the people [3].

The consensus view is that a series of well tested interventions and a continuum of intendance should be the primary focus for efforts to reduce maternal mortality [6, 9]. However, findings from the recent WHO Commission on Social Determinants of Health draw renewed attending to the demand for the link between women's socio-economic characteristics and health to also be considered [10]. The more socially and economically advantaged people are, the better their health. Years of formal education are a well-recognised indicator of social position and have been ofttimes used in international surveys to explore social inequalities [11]. These studies bear witness that people with progressively more advanced levels of education take better health and longer lives than those without [11]. But information technology has been argued that women's education should non be treated merely every bit a proxy for the social determinants of health but as an important force in its ain correct [12]. Women's educational levels (relative to those of men) accept been plant to exist associated with maternal death [13]. At that place is a positive relationship betwixt levels of maternal education and health service apply,[14] fifty-fifty in agin family or socioeconomic situations [fifteen]. Furthermore, lack of instruction is highlighted as ane of a number of stressors (along with limited money and determination-making power) affecting women during pregnancy and childbirth, creating vulnerability and increasing the likelihood of negative outcomes [16]. It is possible that much of the health disadvantage associated with depression levels of maternal education can be addressed through universal access to quality health services; however, this hypothesis has not been tested empirically.

It is now recognised that MDG5 is highly unlikely to be accomplished past 2015 [17]. It is maintained that a key stumbling block is the inability to establish and maintain robust health systems with appropriate obstetric facilities where they are nearly needed [three]. In view of the recognition of the role of education as a factor in mortality decline, we examined the contribution of maternal instruction to maternal bloodshed amongst women who were able to deliver in health care facilities and whether this contribution is attenuated by the services available in those institutions. We take reward of the unique opportunities in the international data from the World Wellness Organisation (WHO) Global Survey on Maternal and Perinatal Health to investigate the relationship between the level of wellness care services bachelor in institutions where women gave nascence, women's educational level and maternal mortality. Our hypothesis was that the statistical relationship between maternal instruction and mortality would not be attenuated by adjusting for the effects of the services available in the institutions where women give birth.

Methods

The WHO Global Survey on Maternal and Perinatal Health is a multi-country, health intendance facility-based, cantankerous-sectional survey that collected data for all women giving birth in 373 randomly selected facilities from 24 randomly selected countries in Africa, Latin America and Asia. The methodological details of the survey have been published elsewhere [18, 19]. In brief, the main research was conducted using a stratified multistage cluster sampling design in order to obtain a sample of countries and health institutions worldwide. Countries in the WHO regions were further grouped according to their mortality levels for adults and those nether five years of age. From each of these sub-regions, countries were selected, with probability proportional to population size. In each selected country, two regions or provinces, in add-on to the upper-case letter urban center, were randomly selected with probability of pick proportional to their population size. In each selected province, a census of all wellness intendance facilities with more than 1000 births per year and those able to perform caesarean sections was obtained and seven facilities were randomly selected by computer, with probability of choice proportional to the number of births per year. Written permission from all Ministries of Health of the participating countries and the Directors of the selected facilities was obtained. The WHO Ethics Review Committee and that of each country independently approved the protocol.

Data collection took identify between 2004-2005 in countries in Africa and Latin America and betwixt 2007-2008 in Asia, over a period of two or three months depending on institutional delivery numbers. All women having a delivery after more than 20 weeks gestation during the data collection period in the selected facilities were included in the study. Women who died earlier commitment or who died having been referred postpartum to the health facility were excluded. All maternal deaths taking place after hospital belch or later the 7th postpartum 24-hour interval were not captured.

Information on the demographic and health characteristics, pregnancy, delivery and maternal and perinatal outcomes (up to discharge) of individual women was obtained from medical records. Trained data clerks reviewed the medical records of all women giving birth at the establishment and of their babies during the study period. Information describing each facility were collected on a standard proforma by the hospital coordinator in consultation with the Managing director or Head of Obstetrics. Random checks comparing collected information and infirmary records and internal consistency checks were performed. Institutional data collected included the availability of bones services (east.g. reliable water supply, sterilization equipment, a blood bank), full general medical services (including adult and neonatal intensive care), laboratory facilities for analysing antenatal screening tests; anaesthesiology resources; emergency obstetric services, intrapartum facilities (including the availability of staff skilled in caesarean department and ultrasound), the level of clinically trained staff and the presence of clinical protocols.

Measures

Our main outcome was maternal bloodshed during the intrapartum period. Mortality information was available for 286,620 individuals.

Our main independent variable was the number of years of formal educational activity received by the mother, categorised according to the UNESCO international standard classification of education [xx]. This nomenclature allocates individuals to one of five groups which correspond to the level of instruction expected after a given number of years of educational activity: no education (cypher years of instruction); chief (between one and half-dozen years of education); lower secondary (between seven and nine years of education); upper secondary (between x and 12 years of education); post-secondary/tertiary (more than 12 years of pedagogy). Data on education was available for 272,138 individuals.

We included a summary index of Institutional Capacity, which was used in the original written report to determine the level of services available in each of the facilities to summarise an establishment'southward chapters to provide obstetric care [21]. This Index comprised eight categories reflecting the: standard of building/basic services, maternal intrapartum care and homo resources; availability of general medical care, anaesthesiology, emergency obstetric services; and provision of screening tests and academic resources and clinical protocols. The Alphabetize is determined by allocating 2 points to an institution for each of 20 eight 'Essential' services and one for each of nine 'Additional' services bachelor (Tabular array 1). Nosotros then calculated an overall unweighted score for each institution. Merely those with no missing data on any item were included in the alphabetize. At that place was a potential maximum score of 56 points for institutions where every 'Essential' service was available and 66 points for those institutions where every 'Essential' and every 'Additional' service was available. Scores for the sampled institutions ranged from eight to 63 points. The scores were included equally a continuous variable. Index scores were available for 269,260 women.

Table 1 Indicators included in the Institutional Capacity Index

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Other independent variables included in the analysis were maternal historic period (N = 286,360), marital status (coded married or not (N = 286,023), number of previous births (Due north = 286,087) and indicators of national wellness arrangement. The furnishings of maternal age were investigated using continuous (quadratic) and categorical approaches (coded equally historic period 10-nineteen, 20-25, 26-xxx, 31-35 and 36 years and over). Maternal age, marital status, number of previous births and national wellness arrangement have all been previously shown to be associated with maternal bloodshed [9, 22, 23]. Preliminary analyses suggested that the relationships between maternal bloodshed and maternal age were not linear. A grouped age variable was employed in the fully-adapted models to let greater insight into the nature of these relationships, and for clarity of interpretation.

We took account of the national wellness arrangement in each state, using a typology based on the national economic level and the extent of state responsibility for the provision and organisation of health services [24]. Following this typology, nosotros identified two indicators at the country level: 'level of wellness resources' (defined every bit the per capita health expenditure in international dollars in 2006) and 'level of country responsibleness for health' (defined as public expenditure as percentage of total wellness expenditure in 2006). Both indicators were included equally continuous variables. This information was available for all countries included in the sample.

Preliminary regression analyses showed collinearity betwixt the indicators exploring national public expenditure on health care and national per capita health expenditure, suggesting considerable overlap between the two measures in terms of their relationship with maternal mortality. Findings showed that the indicator of state responsibility for wellness had a greater influence on maternal mortality than that for level of health resources. Only the indicator for level of country responsibleness was included in the model.

Continuous indicators of maternal historic period (used only in bivariate models), number of previous births, institutional capacity and level of state responsibility for health were each centred around their mean. This statistical adjustment enhances the interpretation of the analyses because it focuses the findings on variations from the sample means. Individuals with item-specific missing were included in the analyses.

Assay

We employed a series of logistic regression analyses to investigate univariate relationships between maternal mortality and each of the independent variables. Those with more than 12 years of pedagogy and those aged betwixt 20 and 25 years onetime were reference categories for their respective analyses.

Nosotros then applied a multilevel model to explore the combined impact of each of the independent variables on maternal mortality. This model comprised iii levels - individual female parent, health care facility and country - to permit for the clustered nature of the sample. This random effects model generalises the ordinary fixed-furnishings logistic (regression) model by assuming that the individual probabilities of maternal mortality are equal to the stock-still-effects model plus random variation due to unobserved, or unmeasured, effects relating to the institution and country.

We practical a iii-level random effects logistic regression model to investigate the factors influencing maternal bloodshed. We estimate p _ijk , the probability of maternal mortality for the ith respondent in the jth facility in the kth country, using a vector of covariates corresponding to the ith respondent in the jth facility in the kth land. The fixed furnishings included at the individual level of the multilevel model are maternal education, marital status, parity, maternal historic period. Public expenditure on wellness care was included as a fixed event at the land level. The Institutional Chapters Index was included at the health-care-facility level of the multilevel model, with a random gradient varying with country. The models employed hither allowed for national variations in basic levels of maternal mortality (using a random country-specific intercept) and in the relationship between the Institutional Capacity Index and maternal bloodshed (using a random country-specific slope for the Index). The random effects were given a multivariate normal distribution, with mean nada and covariance matrix which accounts for correlation between slope and intercept. When σ_u = 0, the model reduces to the ordinary logistic model, indicating that there was no meaning correlation in the risk of maternal mortality between country. The significance of the random effects terms was tested with a modified likelihood ratio test past comparing the null hypothesis σ_u = 0 against the alternative hypothesis σ_u > 0 ([25, 26]). Logistic regression analyses were conducted using Stata version 9. Multilevel modelling was conducted using MLwin version 2.12.

Results

We analysed information on 287,035 women, of whom 363 had died before being discharged from the institution where they delivered (Tabular array 2). 1 country (Japan) had no maternal deaths during the period. Of those countries with maternal deaths, xiv had fewer than ten, 2 had between ten and twenty, four had between twenty and 40, and iii had betwixt forty and 75. The deaths were distributed across the three regions, though non evenly: 25 occurred in Latin America, 100 in Asia and 238 in Africa. Intrapartum maternal mortality rates varied between the regions. Rates in Africa (290 per 100,000 women) were more than than 3 times as loftier as in Asia (at 90 per 100,000 women) and almost ten times as high as in Latin America (at 30 per 100,000 women) (Table 1; Boosted File 1, Tabular array S1).

Table 2 Characteristics of the women, institutions and countries sampled, classified past region

Full size table

There were differences in the number of years of formal education received by women in the three regions (Table ii). Almost 15% of the women attending wellness intendance facilities in Africa received no formal education compared with eight.4% of those in Asia and 1.6% of those in Latin America. However, the inter-quartile range of total years of education was like beyond the three regions. Women attending wellness care facilities in Latin America had a slightly lower mean age than those in Africa and Asia. Women attending health care facilities in Asia were most likely to exist married or cohabiting, and those in Latin America were most likely to exist single. In Latin America, 22% of women attending health care facilities were single, compared with 12% of women in Africa and 6% in Asia. Women attending wellness care facilities in Asia had the everyman number of previous births and women attending health intendance facilities in Africa had the highest number.

The health intendance facilities sampled in Africa had a lower hateful Capacity Index score than those in Asia and Latin America (Table 2). Almost 75% of institutions in the African countries sampled and more than 25% of those in Latin America and Asia lacked the total range of 'Essential' services for intrapartum care (and did non attain the maximum score of 56 points available for institutions with every 'Essential' service).

The hateful national per capita health expenditure in the Latin American countries examined was five and a one-half times that in the African countries examined (Table ii). The expenditure in the Asian countries examined was twice that in the African countries examined. The mean national public expenditure on wellness intendance, as a proportion of total health expenditure, was everyman in the Asian countries and highest in the Latin American countries examined.

Figure 1 shows the distribution of maternal deaths past educational category. Findings from the univariate regression analyses in which we modelled associations betwixt maternal mortality and each of the independent variables separately, indicated that the run a risk of maternal mortality increased with each reduction in educational level (Table 3). There was a statistically significant variation in the gamble of maternal mortality among those with fewer than seven compared with those with more than 12 years of teaching. Women with no education had almost four times the risk (odds ratio 3.92: 95% confidence interval two.threescore,5.92) and those with between 1 and half-dozen years of education had almost twice the gamble (odds ratio 1.88: 95% confidence interval 1.26,2.79) of maternal bloodshed compared with women with more than 12 years of education. There was a college take a chance of maternal mortality among women giving birth in institutions with less capacity (1.02:1.01,1.03). Institutions with 'less chapters' than others are those with at least one unit less in the institutional chapters index. Higher take a chance of maternal mortality was likewise associated with maternal age at birth over 35 (1.79:i.29,2.47), not being married or cohabiting (1.60:1.24,ii.07), at least i more previous nativity (i.26:1.21,one.31) and at least ane unit of measurement lower national public expenditure on health intendance (1.03:1.02,1.04).

Figure 1

Distribution of maternal deaths past years of maternal education.

Total size image

Table iii Risk of maternal mortality by individual, institutional and national characteristics

Full size tabular array

The relationship between lower levels of education and a higher gamble of mortality persisted after adjusting for the other potential explanatory factors in the multi-level model, although the divergence in mortality chance between no and high levels of didactics was attenuated in the adjusted model (Table four). Women with no education had over ii and a half times the risk (ii.69:1.61,4.50) and those with between one and six years of education had twice the risk (odds ratio 1.98: 95% confidence interval 1.26,3.12) of maternal mortality compared with women with more than than 12 years of education, after adjusting for the furnishings of marital status, maternal historic period, parity, institutional chapters and levels of country investment in wellness care. A number of approaches were taken to adjust for the furnishings of maternal age. There was little variation between the impact of adjusting for quadratic/continuous or categorical indicators of age on the associations betwixt maternal education and mortality. Even so, a clear indication of the nature of the human relationship between maternal mortality and age was all-time accomplished using the categorical measure. Analyses (not shown) suggested that it was the inclusion of parity and, to a lesser extent, national public expenditure on health care which nearly attenuated the variations in the risk of maternal mortality betwixt those with no and college levels of maternal education. The Institutional Chapters Index was not associated with maternal bloodshed in the adjusted model.

Tabular array four Risk of maternal mortality by individual, institutional and national characteristics: results from the fully adjusted multi-level regression model

Full size tabular array

Being single, separated, divorced or widowed was associated with about twice the risk of maternal death in the multilevel model compared with those who were married or cohabiting (one.81:i.29,2.53). At that place was a significantly college risk of expiry among those anile over 35 compared with those anile between 20 and 25 years (1.62:one.06,ii.47). College numbers of previous births (1.08:1.00,i.16) and lower levels of land investment in health care (1.04:ane.01,1.07) were also associated with higher hazard of maternal death. Additional analyses of the relationships betwixt maternal mortality and number of previous births in the single-level models, using categorical and continuous approaches to its classification (not shown) indicated that there was a significantly higher hazard of maternal mortality among those who had previously had four or more births compared with those who had had none. Nonetheless, this human relationship was attenuated in the adjusted model, where there was a significantly higher run a risk of maternal bloodshed only among those who had previously had nine or more than births, compared with those who had had none.

The odds of maternal mortality were correlated at the country level. The significant random effects co-efficient indicated that there were additional effects on maternal mortality related to country of residence which were not explained by the measures included in the model (1.01:1.00,1.02). The relationships between the random intercept (α) and the random slope (β) were not significant (1.01:0.95,one.08) and there was no heterogeneity across institutions within countries. These findings indicated that variations in maternal mortality between institutions were explained by differences in their Chapters Indices (rather than other differences between them), and that the implications of this capacity for maternal mortality were consistent beyond countries.

Discussion

In this international survey of 287,035 women giving birth in health intendance institutions in 24 countries, women with lower educational levels are more likely to die than women with higher educational levels. Other studies have also reported an association between female education and maternal mortality [27]. All the same we have demonstrated that, for women who were able to deliver in infirmary facilities, the higher mortality of women with lower levels of didactics cannot be explained by the level of services available at the institution where they gave birth. Maternal historic period, marital status, parity and level of state investment in health services likewise had pregnant independent impacts on maternal bloodshed. Adjusting for maternal age, marital status, parity and level of state investment in health services does not explain the influence of maternal pedagogy on mortality. Past delivering in a health care facility, many of these women, particularly those in Africa and Asia, were able to access a level of health resources higher up that available to many women living in those regions [28]. Yet even for women able to access facilities providing intrapartum care, the impacts of wider social determinants on health (specifically educational level) and mortality persisted.

Study strengths and limitations

Our study has a number of strengths. These information are in many ways unique. The database includes virtually 300,000 deliveries with information collected in a standardized style from a big, worldwide network of wellness intendance facilities. These data address concerns regarding the limited availability of data on measures of infrastructure and quality in facilities in developing countries [three]. Although the information source is only facility-based and is non representative of the population, the random selection of provinces and facilities within those provinces ensured that at that place was no selection bias by chapters, proximity or population served. We examined many facilities and regions that had non taken part in a research project of this nature earlier. Although we were not able to mensurate the quality of care each woman received during commitment, using a standard measure of capacity across a multifariousness of institutions allowed us to appraise whether the services available were able to modify the negative effect of social disadvantage (as measured by teaching level) on maternal mortality.

A major limitation of this study was the small number of maternal deaths, which may have influenced the reliability of our results. There were three other limitations. Starting time: data availability ways that we examined maternal deaths which occurred during the intrapartum menstruum only, and could not include antepartum deaths due to ballgame complications or ectopic pregnancy. The potential implications of this restriction is potentially limited equally the large majority of maternal deaths take identify in this period [22]. This also meant that we are unable to adjust for cause of decease, admission to antenatal care or medical co-morbidities. Women who died undelivered or who died following belch from the institution were not included equally maternal deaths in the survey. Additional bias may take been introduced if the motivation for women's attendance at health facilities varied by educational level, for example if those with lower education levels attended only following complications while the attendance of other women was more general. Although we adjusted for a number of adventure factors for complicated deliveries, we were not able to adjust for morbidities. Finally, our adjustment for national contextual variables is crude and nosotros are unable to take account of potentially important regional and national level influences on maternal bloodshed, such as the impact of variations in crusade of death [22, 29–31] or cultural norms, for example those related to childbearing outside marriage [23]. Our results indicated that there were additional influences on maternal bloodshed, particularly related to country of residence which remain unmeasured and require further investigation.

Possible explanations for findings

Education may take both a direct and indirect relationship with maternal mortality. Increasing levels of educational attainment are probable to heighten the capacity of women to obtain, process and sympathize bones wellness information virtually the benefits of expert prenatal intendance and the reproductive health services needed to make appropriate health decisions. For instance, more educated women may exist less likely to accept traditional explanations for life and death and instead take on wide data virtually nascence spacing, the signs of pregnancy complications and the need to improve their nutritional status to reduce the take chances of iron deficiency anaemia, all of which are of key importance in the bulldoze to reduce maternal deaths. Furthermore, more educated women are probable to be more confident virtually asking questions about their health care needs and are more probable to be listened to by health care professionals [12]. The indirect human relationship betwixt educational levels and maternal bloodshed may be through increasing women's self-esteem and thus their empowerment to make health related decisions. Women's improved admission to teaching is too indicative of their more equal position in society [xiii]. The importance of progress on MDG3 (to promote gender equality and female empowerment, including with regard to teaching) for the achievement of MDG5 should not be underestimated [32–35]. The relationships between education and status provide more highly educated women with more than autonomy to make decisions most the number of children they have, their diet during pregnancy and their access to wellness intendance [13]. The education of women changes the residual of familial relationships which has profound potential for benign effects on maternal mortality. The increased hazard of maternal mortality among non-married/cohabiting women is indicative of the ways in which women's social and economical disadvantage combine with attitudes towards childbearing exterior marriage to affect women's lives [23].

The increased chance of maternal bloodshed among women aged over 35 is not specific to countries in Asia, Africa and Latin America [36], and appears to be related to the increased risk of ill wellness among older women which produce complications during pregnancy and childbirth [37] and the increased likelihood of caesarean delivery at older ages [38]. There is also evidence that the main causes of decease vary between women giving birth above and below the age of 35 [39].

Conclusions

It is accepted that attaining MDG5 depends on widespread improvements in the level and quality of antenatal and obstetric facilities in developing countries. Notwithstanding an exclusive focus on medical and technological approaches to the achievement of this MDG risks overlooking the critical contribution of societal conditions to wellness [32]. More attention should exist given to the wider social determinants of health, including didactics, and to the factors associated with their interaction with universal wellness provision, when devising strategies to reduce maternal mortality and to attain the increasingly elusive MDG for maternal mortality.

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Acknowledgements

The authors wish to thank Gianluca Baio, Tarani Chandola and Paola Zaninotto for their statistical advice during the drafting of this newspaper. Nosotros too wish to thank Imelda Balchin and Wendy Pollock for their comments on an earlier draft of this paper.

SK was funded by the WHO to undertake this research. RR is partly funded past the NIHR UCLH/UCL Comprehensive Biomedical Research Centre. LS, JPS and AMG are WHO staff.

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Affiliations

1. Department of Epidemiology & Public Health, UCL, 1-19 Torrington Place, London, WC1E 6BT, United kingdom

   Saffron Karlsen & Rosalind Raine

2. Department of Reproductive Health and Research, Earth Health Organisation, Avenue Appia xx, Geneva, CH-1211, Switzerland

   Lale Say, João-Paulo Souza & A Metin Gülmezoglu

3. Rollins Schoolhouse of Public Health, Emory Academy, 1518 Clifton Rd NE, Atlanta, GA, 30322, United states of america

   Ballad J Hogue & Dinorah 50 Calles

Corresponding author

Correspondence to Saffron Karlsen.

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Competing interests

All authors desire to declare (ane) Fiscal support for SK for the submitted work from the WHO. Other authors received no financial support for the submitted work from anyone other than their employer. All authors also declare (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might take an interest in the submitted work; (4) No non-fiscal interests that may exist relevant to the submitted work.

The authors state their independence from the funders of this work. The funding sources had no role in the report design, analysis or interpretation, the writing of the report or decision to submit the newspaper for publication. The opinions stated in this paper are those of the authors every bit individuals, independent from the funding sources. They non necessarily represent the views of the World Wellness Organisation or its member countries.

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12889_2011_3384_MOESM1_ESM.DOC

Additional file one: National maternal mortality and institutional delivery rates. Information on the maternal mortality and institutional commitment rates for each country included in the analysis, by WHO region. (DOC 44 KB)

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Karlsen, S., Say, L., Souza, JP. et al. The relationship betwixt maternal pedagogy and mortality amidst women giving birth in wellness care institutions: Analysis of the cross exclusive WHO Global Survey on Maternal and Perinatal Health. BMC Public Health 11, 606 (2011). https://doi.org/10.1186/1471-2458-11-606

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• Received: 04 February 2011

• Accepted: 29 July 2011

• Published: 29 July 2011

• DOI : https://doi.org/x.1186/1471-2458-11-606

Keywords

• Maternal Mortality
• Maternal Death
• Maternal Education
• Health Care Institution
• Perinatal Health

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