Introduction
Research and statistics have indicated that maternal health is among the most critical public health problems in the world today. It has been revealed by recent data that there remains an unacceptable level of maternal mortality globally. The public health challenge is entrenched within global development and health discourse. The current discussions are all based on the possibility for establishing measures to address the quandary effectively. Major progress has been made in the world in the efforts to reduce maternal deaths, but there are still higher levels, especially in Sub-Saharan Africa. In the region, Knight, Self & Kennedy (2013) revealed that only little or completely no progress has been achieved towards this end. Policy makers within the region and internationally are still involved in the efforts to find lasting solutions, but experts agree that there is still a lack of a straightforward intervention to address the issue. Hence, experts point to the effectiveness of a blend of various interventions, including strong health systems, the rights of women for maternal health, and experienced and qualified birth attendants.
Significance of the Study
There is evidence of a serious problem associated with the loss of mothers, particularly during delivery. Statistics reveal alarming rates of maternal deaths, most of which can be prevented with adequate measures and effective interventions. Hence, the need for effective solutions cannot be overemphasized. For success in addressing the problem of maternal mortality, the solution begins with adequate understanding of the problem (Liu et al., 2015). Therefore, research on the factors underlying the problem is critical as it identifies the determinants of the health problem that should be addressed for positive results to be achieved. The trends, regarding the prevalence over a period of time, also points to the areas to be targeted in interventions to reverse the trends. Therefore, towards this end, the objective of the study is to describe and determine the critical factors behind maternal health in the Sub-Saharan Region, with the aim of establishing effective prevention strategies and interventions.
Description of Problem
The problem of maternal mortality is a real problem globally. Therefore, the issue necessitates the aspect of devising adequate global measures to deal with the global problem. While the problem is common globally, it is worse in the developing nations where resources remain inadequate in providing adequate health to mothers. Maternal mortality is considered from the perspective of the death of a mother during pregnancy of days following delivery. In fact, the World Health Organization (WHO) defines the problem as:
“the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” (WHO, 2015, p. 1)
Maternal mortality has two main indicators, including the maternal mortality ration and maternal mortality ratio. The two aspects tend to confuse given the fact that the two are abbreviated the same way, MMR. These two indicators are critical in the process of identifying the prevalence and trends associated with maternal mortality.
Say et al. (2014) indicated that there is a clear connection between the fertility rate, the risk of maternal death, and the broad level of mortality among women during their reproductive age. The relationship as used in estimating the rate of maternal is not widely available, particularly in the developing nations. Maternal mortality is associated with complications that arise during pregnancy, labor, and postpartum. The problem is worse in Sub-Saharan Africa because of the inadequacy of resources and the lack of sufficient medical care during pregnancy and at the birth of the child. All the regions in the world have advanced in the last two and half decades and the rate of maternal mortality has been on the decrease, although the levels remain very high in Sub-Saharan Africa (Liu et al., 2015). In fact, the level of maternal mortality in the region remains unacceptably high. Given the disparity evident between the developed and developing nations, it is clear that maternal mortality can be successfully prevented.
Determinants of the Problem
There are various causes of maternal mortality that have been identified across the world. Interestingly, the causes are mainly preventable with adequate and effective interventions. The figure 1 below is a source of data on the proportion of the factors that relate to maternal mortality globally.
(Figure 1: Global distribution of factors behind maternal mortality. Source: Say et al., 2014).
Knight, Self, and Kennedy (2013) posited that there are many factors associated with the global maternal mortality, which can be direct or indirect. Another reality established in research is that the factors that relate to maternal mortality can differ depending on the region in the world because of the developmental disparity between the regions. In general, there are differences between direct maternal deaths that occur based on the complications in pregnancy, during childbirth, or in managing the two, and those that ensue indirectly. Say et al. (2014) suggested that there are those deaths that can occur during pregnancy, childbirth, or 42 days after birth and are as a result of another health condition that is not related to the pregnancy. The deaths that arise during, but are unrelated to pregnancy, are referred to as an incidental, accidental, or non-obstetrical maternal deaths. There are many factors that have been associated with maternal mortality, and they occur at different rates in different regions in the world.
Postpartum hemorrhage/bleeding (PPH) is the most common cause of maternal death during and in days after birth. The condition is blamed for about 15% of maternal deaths. The bleeding occurs as a result of complications during delivery and can lead to death within hours or days. The hemorrhage has remained the main factor behind maternal mortality. It is estimated to be the cause of 27% of all deaths (not just maternal deaths). It is indicated that all the women who are pregnant at 20 weeks and beyond suffer the risk of PPH and its sequel (Say et al., 2014). While maternal mortality has been on the decline in the developed countries, the factor remains a major cause of maternal mortality in the developing world. In the developed world, PPH normally ranks among the top three factors behind maternal deaths. The other two are embolism and hypertensive disorders. On the other hand, in the developing countries, the maternal mortality rate is more than 1000 mothers per 100,000 live births (Requejo & Bhutta, 2015). The rate in the latter is critical, when compared to the developed world.
Another cause of maternal mortality is unsafe abortion leading to complications that can cause death. The factor is also associated with approximately 15% of all maternal deaths. Globally, unsafe abortion has been revealed as a serious factor behind maternal deaths. The World Health Organization predicates that a woman dies every eight minutes because of the complications that arise from abortion practices that are considered unsafe. Such complications include infection, hemorrhage, genital trauma, and sepsis. Preventable deaths, globally as a result of improper procedures account for 13% of maternal deaths (Say et al., 2014). Additionally, it is predicted that 25% deaths or more occur in nations where there is the problem associated with inadequate access to medical health. In the Sub-Saharan Africa, abortion is commonly unsafe because of the lack of access to the medical facilities and based on the laws in some countries that hinder access to safe facilities. In this case, the use of unconventional means of procuring abortion is the main cause of the maternal deaths.
Hypertensive disorders of pregnancy have been associated with about 10% of maternal deaths. Many deaths are associated with indirect causes that are worsened by the pregnancy. During pregnancy, hypertensive disorders are very common, particularly eclampsia (Say et al., 2014). Problems associated with hypertensive disorders affect the pregnancy by triggering complications during the pregnancy term or labor and delivery. Inadequate resources to manage the complications or the actual complications can cause the death of the mother. Other conditions, including embolism and sepsis that occur because of unsafe delivery practices, are a main cause of maternal deaths. There is another group of women that dies because of postpartum infections at the rate of 8% (WHO, 2015). The infections normally occur when the mother is delivering. The cause of death is most common in areas where there are no adequate quality facilities and in areas where drugs to deal with the infections are not available.
Another common cause of deaths during childbirth is obstructed labor. The deaths that result from this factor are approximated at 6%. The problem becomes worse in the case of neglected obstructed labor (OL). In the developing nations, also because of the inadequacy of resources, the problem is a serious cause of maternal mortality as well as newborn mortality and morbidity. When labor is considered obstructed, it means that the fetus’ presenting part ceases to progress. Hence, the fetus is unable to come out normally through the birth canal. In this case, the only remedy is an operative delivery through instrumental delivery or caesarean section. Some complications are likely to occur, especially the intrauterine infections because of the trauma to the bladder, prolonged rupture of membranes, and trauma of the rectum because of the fetal pressure. It can also result in ruptured uterus with resultant hemorrhage, shock, or death (Requejo & Bhutta, 2015). In essence, the problem becomes a common cause of maternal death in sub-Saharan Africa based on the inadequate resources to perform operative procedures to save the lives of the mother and baby.
Blood clots have also been associated with the deaths of women during pregnancy and childbirth, which is estimated at 3%. When measured against the deaths of all women, pre-existing conditions are suggested to account to 28%. These factors may have nothing to do with pregnancy, but they lead to death during pregnancy, childbirth or postpartum (Knight, Self & Kennedy, 2013). Especially in Sub-Saharan Africa, some of the indirect factors that cause death include anemia, malaria, cardiovascular disease, and HIV/AIDS. These conditions can be worsened or complicated by the pregnancy and childbirth. The management of the conditions before or during the pregnancy is also impaired by the social-economic reality of the region. During pregnancy, conditions such as anemia and HIV/AIDS are managed using drugs and diet, factors that lack where the resources are constrained (Requejo & Bhutta, 2015). Malaria is common in the region, necessitating regular testing and ensuring the use of preventive measures such as anti-malarial and sleeping under insect treated nets. The problem is that these resources are not always available for a large part of the population in the region.
The main factor behind the disparity between the developed and developing nations is the sociodemographic determinant. Some of the factors under this category are level of income, access to resources, and age. All these factors are identified as critical indicators of maternal death and other outcomes. Requejo & Bhutta (2015) revealed that younger mothers are at higher risk of developing complications during pregnancy and childbirth when compared to mothers who are advanced in age. The problem is even worse when the mother is only an adolescent aged 15 years and below. The mothers, at this age, have been revealed to suffer, at higher rates, operative vaginal delivery, puerperal endometritis, postpartum hemorrhage, low birth weight, episiotomy, small-for-gestational-age infants, and preterm delivery (Knight, Self & Kennedy, 2013). Due to the factors such as low income, social isolation, and inadequacy of resources, many girls are married very early and become pregnant during their teenage, increasing their chances of dying during pregnancy and childbirth.
Family and structural support are associated with better maternal outcomes. On the other hand, social isolation and other social disadvantages have effects on maternal health and could easily result in maternal deaths. Resources (or lack thereof) have critical impact on the outcome of mothers during pregnancy, childbirth, and care after delivery. During childbirth, it is critical for the mothers to have access to skilled medical support. However, in Sub-Saharan Africa, access to the services is not readily available, especially for some women who live under social and economic isolation. Some mothers have to travel very long distances to the closest medical facility. The problem is made worse by the reality that there are no adequate infrastructures to ease the travel, which is a serious problem during pregnancy or when one is in labor. The same forces determine the level of access to prenatal medical care (Knight, Self, & Kennedy, 2013). The travel distance and poor infrastructure are all contributing factors to maternal mortality.
Knight, Self & Kennedy (2013) elucidated that the complications underlying maternal mortality can happen devoid of warning signs. They can also take place at any point during the pregnancy or during childbirth. Hence, most of the deaths are preventable as long as the pregnant mothers have access to safe medical care with skilled health workers, nurses, midwives or doctors. Pregnancy and childbirth need to be adequately supervised, with adequate equipment and supplies. In case of an emergency, it needs to be a setting where the mother can be immediately referred for emergency obstetric care. Complications necessitate immediate access to obstetric services, good in quality and well-resourced with life-saving medications, and the capacity to offer blood transfusion required in performing various medical interventions, including Caesarean sections. Lack of the resources is associated with the high rates of maternal mortality in the Sub-Saharan region.
Magnitude of the Problem
Statistics have painted the genuine picture of the magnitude of the problem of maternal mortality, globally, and particularly in Sub-Saharan Africa. In the period between 1990 and 2015, it has been revealed that the rate of maternal mortality declined by 44%, in terms of maternal mortality ratio. According to the UN inter-agency estimations, the noted decline was from 385 to 216 deaths per 100,000 live births. The estimates translated to a reduced rate of 2.3% per annum, on average. Although the results are impressive, it should be noted that the figures are still below the 5.5% annual reduction anticipated by 2015 towards the end of achieving the Millennium Development Goal 5 (WHO, 2015). The reduction has been achieved in all the regions globally, but the reality is that in sub-Saharan Africa, the rate has remained unacceptably high. It is estimated that the lifetime risk in the developed world is 1 in 3,300, while it is 1 in 41 in the developing world. Figure 2 below indicates two important facts; the reduction in maternal mortality since 1990 and the fact the Sub-Saharan Africa has remained high throughout the covered period, in terms of maternal mortality.
(Figure 2: Liu et al., 2015).
In Africa, it is estimated that between 15-30% of the deaths among women of the reproductive age are interconnected to pregnancy-related complications. In Sub-Saharan Africa, estimations based on the association with the general mortality vary with different countries. The estimates were shown to vary from 217/100,000 827 in Kenya and Chad respectively. It was estimated that 80,000 women met their death every year from 1980 to 1985 in the region. The estimated maternal mortality ratio is 460. From studies carried out in Africa, maternal mortality data was revealed to vary greatly in terms of medical causes, levels, and differentials. However, it was shown that interpreting the data was challenging because of different kinds of selection biases. The primary problem in the region is based on the fact that just 34% of births have been revealed to occur in health centers throughout the continent (Knight, Self & Kennedy, 2013). Research on evaluations of the impact of the various interventions is also greatly lacking.
Based on the data provided by the United Nations Population Fund (UNFPA), it suggests that the current data is evidence of:
“About one woman in every two minutes and for every woman who dies, 20 or 30 encounter complications with serious or long-lasting consequences. In fact, worth noting is that these deaths and injuries are entirely preventable” (Alkema et al., 2016, p. 463).
The same data revealed that 289,000, in 2013, died because of complications associated with pregnancy and childbirth. The cause ranged from hemorrhage to obstructed labor. The decline in the number of women dying every year because of pregnancy or childbirth complications has reduced because of the increase in preventive measures, but more efforts are still needed in the developing countries. The reality that more than 800 women are still dying every day is a cause for alarm. The problem is made worse by the reality that for every woman dying, there are 20 more who are suffering major infections, injuries, or disabilities (WHO, 2015). The data indicate the reality that about all the deaths (99%) is concentrated in the developing countries.
Globally, two regions are responsible for 88% of maternal deaths, Sub-Saharan Africa together with South Asia. The statistics indicate that Sub-Saharan Africa is the most affected by the maternal mortality ratio of 546, which is the highest globally. The number translates to 201,000 maternal deaths per annum. The number of deaths in Africans is equivalent of 66% (two-thirds) of the overall maternal mortality rate in the world. While South Asia follows on closely, the rate in the region is not as high as that of Africa. South Asia accounts for only 22% of the global mortality rate, with a ratio of 182, or 66,000 deaths per year (WHO, 2015). The statistics indicate that Sub-Saharan Africa bears the greatest burden of maternal mortality rates and should be the most targeted regions regarding concerted efforts to address the health problem. The problem could be worse than what the data indicate because global and regional averages could be masking the greater disparities between and within countries.
Assessment of the Issue
The statistics discussed paint a critical reality of the lives lost in the process of giving life. The Sub-Saharan region is the most hit by the problem indicating the reality of lost productivity and children who are left without mothers because of the high levels of maternal mortality. Based on the reality of the young lives that are lost in the region, the major impact is in terms of lost productivity and a cycle of poverty because of the economic challenges that face those who are left behind following the death of the mother. The cycle can be experienced from the reality that if a mother dies during pregnancy or when giving birth, there are chances that there are daughters who are left behind and with a risk of becoming pregnant early because of the socio-economic conditions (Alkema et al., 2016). For the families, it is challenging to get out of the cycle of poverty and other social and economic challenges.
In Sub-Saharan Africa, the most affected are the young women, some as young as 15 years and even below. The maternal death lifetime risk is the possibility that a 15-year-old teenager will face death because of the pregnancy-related complications over her lifetime. The probability is obtained by considering the overall fertility rate and the maternal mortality rate. Hence, in regions that are in high-fertility contexts, the risk of death tends to be higher. It is revealed that the maternal mortality ratio in some countries is higher than in others, with countries in Africa being the most affected. The reality indicates the potential for the elevated loss of lives from pregnancy-related complications (Alkema et al., 2016). Hence, in the region, countries are losing young women at a very alarming rate, an instance that indicates the importance of coming up with effective preventive measures to save the lives and the productivity level of the countries and the region.
There is no doubt that the situation has been improving globally, with the maternal mortality deaths continuing to decrease. The reality has been the same even in Africa. However, there is still nothing to celebrate in the region because the rates of maternal mortality and morbidity have remained alarmingly high. The high rates have affected the objectives of providing safe motherhood in the countries within the region. In 1994, the Program of Action of the International Conference on Population and Development was created towards the end of preventing maternal mortality. The following year, the Fourth World Conference on Women was also established with the same objective. Campaigns associated with reproductive health have come up to draw attention to the seriousness of the problem and lead efforts towards effective measures to prevent the problem. However, things have not changed much, and the situation has even been made worse by the impact of HIV/AIDS in the region (Liu et al., 2015). The disease and other social and health problems have hindered the success of the programs and efforts designed to address the problem.
Evidently, the demographic, economic, and social factors are still playing out in the health problems and the battle cannot be won without targeting these factors and addressing them effectively. However, it is plausible to note that the problem does not affect the entire region equally as there are some countries that are performing exceptionally better than others. Demographic incidents in the wake of the 21st century have been targeted towards reducing adult, child, and infant mortality ratios. Such efforts would work towards elevating health status and life expectancy for women in the region. However, the targets are yet to be achieved, with the rates remaining high in the region (Alkema et al., 2016). The trends and levels of maternal mortality in the region are evident of the need for more concerted efforts to further lower the rates.
Methods of Prevention and Intervention
There has been an increase in the hopes that the problem of maternal mortality will be effectively addressed in the region, resulting in successful prevention of the avoidable deaths. Development community points to the possibility that the international organisations such as WHO might be finally reaching the point where not many women will lose life in the process of giving life. The success in prevention of the problem is founded on the development in the region, allowing for increased access to resources critical in maternal health. With the resources, prevention becomes effective when it is commenced during the pregnancy as well as implementing the necessary steps that would allow healthy pregnancy and safe childbirth. Health campaigns cannot be successful without being backed by access to the important facilities and resources to promote health during pregnancy, at birth and for the first few months postpartum (Kassebaum et al., 2014). With such resources, it is possible to ensure that most of the preventable deaths are avoided and that mothers get to see their children grow in a healthy manner.
The primary determinants of the treatment’s impact are accessibility and quality of the medical support that a mother gets when pregnant and during delivery. It is plausible to note that fertility-related indicators are the most critical forces in relation to the complications’ frequency. The efforts to reduce maternal mortality have been geared towards providing safe and quality care for the pregnant mothers and during delivery. Some of the efforts that have been implemented have been building up more health clinics, especially in the rural parts of the countries in the region. In other countries, there has been implementation of mobile clinics to bring the services closer to the people. The establishments have also initiated campaigns to make the public aware of the available services (Alkema et al., 2016). The efforts are geared towards ensuring that the pregnant women are under observation during their pregnancy and that they get the necessary medical care during delivery.
Programs have been underway in some countries in the region aimed at providing education and training for women on issues relating to the need for proper care during pregnancy and the importance of seeking medical care throughout the pregnancy and during delivery. The importance of nutrition has also been emphasized, including the access to nutritional supplements to ensure healthy pregnancies. Some parts of the region have witnessed provision of free maternity services with adequate resources to prevent women from avoiding care because of related costs. Providing care with no or low cost is critical to ensuring that more women have access to care during pregnancy and birth. Training more care providers, including midwives and nurses has allowed for the increase in access to the necessary care during pregnancy and delivery. Countries in the region have been working towards this end, including provision of better resources. However, the problem that remains is a lack of awareness and inadequate infrastructure in most of the remote parts of the continent.
Conclusion
Maternal mortality remains a serious problem globally, but the rates in the developing nations in Africa are alarming. The global goals of ensuring better maternal health by reducing maternal mortality rates are yet to be achieved. Sub-Saharan African women continue to lose their lives in the process of giving life. The main causes of the deaths are mostly experienced directly or indirectly during pregnancy and at birth. Postpartum hemorrhage is one of the issues associated with the deaths. In addition, other issues allied to maternal mortality include abortion, hypertensive disorders and other pre-existing conditions that become worse as a result of the pregnancy. The rates at which the issue has persisted have been declining since 1990, but in the Sub-Saharan region, the rates have remained high when compared to the global average and the rates in the developed nations. The reality suggests a critical problem that needs to be addressed through effective interventions. There have been measures implemented in the region, but they appear ineffective going with the current statistics. Hence, more research should be done on other measures that will work depending on the social, demographic, and economic reality of the region.
Recommendations
Evidence from the research indicate that while there have been efforts to reduce the maternal mortality rates in Sub-Saharan Africa, the efforts have not achieved adequate results just yet as the high levels of maternal mortality remain. Hence, there is a need for more research and more effective preventive interventions to help save more lives. Among the tested efforts that have worked in the developed nations and could be implemented in the developing nations include reduction of fertility. From research, it is evident that the regions characterised by high fertility tend to have higher rates of maternal mortality. Hence, efforts to reduce the maternal mortality rates could work by reducing fertility rates. Another intervention that could work towards reducing fertility rates is launching campaigns to promote family planning to reduce the chances of unwanted pregnancies and promoting the health of the mother to prevent unnecessary deaths. In addition, the campaigns should target efforts to delay pregnancies; hence, avoiding very early and late pregnancies (Kassebaum et al., 2014). The efforts will work towards reducing the chances of complications relating to the pregnancy which lead to death.
Previous studies have indicated that the measures critical to reduce the problem in the region should be founded on the provision of better health care and services. There are services that are already in place, but they are not tailored towards the reality of the region. More effective preventive interventions should be brought close to the people. National and international efforts should be geared towards bringing affordable health services closer to the people. In fact, this can be achieved through the establishment of more clinics in the rural parts of the countries in the region, resourcing them with both human and other resources critical for the provision of adequate care (Kassebaum et al., 2014). Under this initiative, the women will not have to travel for long distances to access care. Some chose to deliver at home with the help of unqualified attendants, or they deliver along the way as they travel long distances to access care. These issues can be prevented when the services are brought closer to the people.
Countries in the Sub-Saharan Africa are affected by the inadequacy of skilled personnel to provide care to the women during pregnancy and childbirth. In fact, the ratio between care providers and the recipients of care is still wanting. Such is the problem that leaves some women out of the critical care. The problem can be addressed by increasing the numbers of health care providers. Among the effective ways of achieving this is taking advantage of the pool of potential caregivers, including the traditional birth attendants. Developing the necessary skills in these individuals will play out in improving the service provision by increasing the numbers of care providers. Trained personnel will play a role in avoiding harmful practices during pregnancy and delivery. In addition, campaigns at the local level aimed at training the women on nutritional health and family planning will go a long way in reducing the maternal mortality rates. The efforts will work towards helping the mothers to carry the pregnancies safely and deliver in a safe environment.
The Implication of Findings
The findings from the study has major implications for policymakers in the countries and internationally. The efforts to deal with the problem cannot be effective if left to the local and national governments based on the political, social, and economic realities of the countries in the region. Policy makers at the national level have the responsibility of providing health care services to their people. Public health campaigns should be initiated following the data on the grim reality of maternal mortality. The data are provided at the country level which should inform the measures assumed in the country (Knight, Self & Kennedy, 2013). Also, the data indicate the failure in some efforts, pointing to areas that need improvement. Hence, public health efforts at the national level should be based on evidence from research and data analysis. In fact, such approach is the only way the interventions can work.
Globally, the findings of the study are critical as they bring together the reality of the problem and the barriers to effective interventions. International organisations, such as the WHO and the UN have the mandate of supporting effective interventions not only in the developed countries but also in the greatly affected regions such as the Sub-Saharan region. Thus, the results indicate the areas where they should put more efforts to reduce maternal mortality. Concentrating on the highly affected areas will bring the region closer to the developed world in terms of the addressing the problem (Knight, Self & Kennedy, 2013). The findings also indicate the need for more research and effective means of collecting surveillance data on maternal mortality rates. Selectivity affects some of the methods used in the current research, particularly those using hospital-based data. Use of more effective methods will give a better reality of the problem and support effective interventions at the regional and international level.
References
Alkema, L., Chou, D., Hogan, D., Zhang, S., Moller, A. B., Gemmill, A., … & Say, L. (2016). Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. The Lancet, 387(10017), 462-474.
Kassebaum, N. J., Bertozzi-Villa, A., Coggeshall, M. S., Shackelford, K. A., Steiner, C., Heuton, K. R., … & Templin, T. (2014). Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet, 384(9947), 980-1004.
Knight, H. E., Self, A., & Kennedy, S. H. (2013). Why are women dying when they reach hospital on time? A systematic review of the ‘third delay’. PloS one, 8(5), e63846.
Liu, L., Oza, S., Hogan, D., Perin, J., Rudan, I., Lawn, J. E., … & Black, R. E. (2015). Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis. The Lancet, 385(9966), 430-440.
Requejo, J. H., & Bhutta, Z. A. (2015). The post-2015 agenda: staying the course in maternal and child survival. Archives of disease in childhood, 100(Suppl 1), S76-S81.
Say, L., Chou, D., Gemmill, A., Tunçalp, Ö., Moller, A. B., Daniels, J., … & Alkema, L. (2014). Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health, 2(6), e323-e333.
World Health Organization. (2015). Global Health Observatory (GHO) data, 2010. Retrieved, 3, 23.
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