Maternal Mortality, Health Determinants, and Covid-19 in the Department of Meta, Colombia: A Cross-sectional Study

1. INTRODUCTION

Maternal mortality (MM) is a significant public health concern. According to the World Health Organization (WHO), it is defined 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” [1]. In 2015, the United Nations (UN) adopted an equity-centered approach to maternal and perinatal mortality as the third sustainable development goal (SDG). Further, to reduce the rates of MM worldwide, WHO adopted SDG 3.1, which aimed to reduce the global MM ratio to < 70 deaths per 100,000 live births by 2030 [1].

Although the trend suggests a decline in MM, the coronavirus disease 2019 (COVID-19) pandemic led to a significant increase in the rate of MM worldwide. In a study by WHO on maternal death trends in terms of MM ratio (MMR), MMR was defined as the number of deaths in women of reproductive age (15–49 years) per 100,000 live births. During 2000–2020, in Colombia, MMR was 90, 71, and 75 in 2000, 2010, and 2020 per 100,000 live births, indicating an increase in the number of cases at the beginning of the pandemic [1, 2].

Remarkably, MM is the end result of various factors affecting women of childbearing age. These factors may be related to the social context, health status, or quality of and access to maternal healthcare services. In addition, inequalities in healthcare may play a role, and these can be explained by different determinants, which can be divided into structural and intermediate categories (corresponding to distal and proximal causative factors in the sociological literature, respectively) according to the Commission on Social Determinants of Health [3, 4]. Altogether, the above factors represent the social determinants of health (SDH). Further, structural determinants are those that particularly create or reinforce social stratification and thus lead to health inequalities [5].

The International Classification of Diseases for MM (ICD-MM) has classified the causes of MM into direct and indirect biomedical categories. Notably, in low-income countries, most deaths occur due to direct obstetric complications during pregnancy, childbirth, or postpartum because of incorrect treatment and omissions [1]. Conversely, indirect deaths occur due to an exacerbated pre-existing disease. Further, non-communicable diseases have become increasingly important, and particularly, hypertension, obesity, and diabetes are more frequently seen among pregnant women [1]. Currently, women tend to conceive later in life, and the association of the above-mentioned noncommunicable diseases with communicable diseases, such as COVID-19, can have severe conse- quences on the outcomes of pregnancy [5]. This is because direct mortality is considered more important in medical practice than indirect mortality; moreover, mortality analysis units focus more on direct mortality [1]. Meanwhile, the classification of coincidental causes based on the WHO guidelines for the application of the International Classification of Diseases ICD-10 to MM has also been considered. This includes deaths occurring during pregnancy, childbirth, or postpartum, and their nosological classification includes external causes of injury due to motor vehicle accidents, attack-assault, rape, other accidents, herbal remedies, etc [1].

However, the biomedical approach based on this classification hinders the identification of the social causes behind the adverse outcomes faced by such women. In general, these causes include socioeconomic and political contexts, structural mechanisms, and socioeconomic strata. Particularly, socioeconomic and political contexts represent any structure, institution, or socioeconomic and political relationship in a society. These factors create and maintain social hierarchies within a society through structural mechanisms related to different socioeconomic strata, classifying populations by class, sex, race/ethnicity, income, education, occupation, or other characteristics. Therefore, structural determinants act via a series of intermediate determinants, creating different conditions that affect health. Intermediate determinants include individual factors that influence health outcomes, such as circumstances related to economic, living, and working conditions; psychological circumstances; behavioral and/or biological factors; and factors associated with the context of the community and healthcare system [6]. In particular, the SDH framework highlights the importance of structural factors in the emergence of different health risks for different health outcomes [6, 7]. In addition, in this framework, power is emphasized as a crucial factor determining social hierarchies and, thereby, health differences between the groups. Finally, this framework can be used to examine the structural aspects and intermediate factors of health inequalities, including maternal health, and to understand the underlying mechanisms or the causal chains that link these factors [8, 9].

The application of the SDH framework may play a significant role in addressing maternal health inequities in Colombia, which requires exploration and a clear understanding of the structural and intermediate factors involved in such inequities as well as the mechanisms by which they are connected to achieve an effective and sustainable application [10-12]. In the present study, we adapted the SDH framework to maternal health by integrating three frameworks widely applied in maternal health factors: the three delays model framework developed by Thaddeus and Maine in 1994 (initially published in 1990), McCarthy and Maine’s framework on the distant and immediate determinants of maternal health developed in 1992 [13], and the United Nations International Children’s Emergency Fund framework [13]. Further, based on our context and the model of Colombian public health surveillance, we adopted the following determinants identified in the unit analysis of MM: women, family, community, and health system.

To improve the prevention of MM in Colombia, each local entity must conduct a unit analysis of MM for each reported case. Notably, in these units, the stages of the process leading to fatal outcomes are followed up, and health services are analyzed in terms of access, quality, compliance with clinical practice guidelines, and barriers to healthcare access. Remarkably, the determinants of health assessed at such units are the vulnerability of women, family, social, and community support networks, and autonomy in decision-making. Finally, the cause of death is determined, and an improvement plan is developed.

Given the above background, the present study aimed to describe the determinants of health identified in maternal deaths registered at the Department of Meta, Colombia, from 2018 to 2021 and to understand their causes or underlying mechanisms by applying the SDH framework.

2. MATERIALS AND METHODS

This retrospective cross-sectional study was conducted via a quantitative approach. In this study, we included the confirmed cases of MM based on the inclusion criteria of the protocol established by Instituto Nacional de Salud (National Institute of Health, INS) using the national epidemiological surveillance system (SIVIGILA) and Web-based maternal mortality epidemiological surveillance system SVEMMBW application from 2018 to 2022 in the Department of Meta, Colombia.

The MM registration records in the Department of Meta were reviewed, especially regarding socio- demographic variables: maternal characteristics (gyne- cological and obstetric records), ethnicity, age, education, vulnerability, marital status, employment status, average monthly income, health system, religion, whether the woman was head of the family, BMI before and after pregnancy, family planning, morbidity during pregnancy, emergency care, prenatal examinations, whether the pregnancy was planned, gynecological and obstetric records, reported cause of death, etc. The SVEMMBW software provides variables on the determinants of health focused on the women’s autonomy, such as making personal and family decisions, the family, social and community support network and access to health services. In Colombia, social health security has three types of insured: those who have the ability to pay are insured under a contributory regime, those who do not have the ability to pay are insured under a subsidized regime, and militaries, congressmen, and professors correspond to the special regime. The socioeconomic strata range from 1 to 5, with 1 corresponding to the lowest income and 5 to the highest income.

• Inclusion criterion: all cases reported and confirmed by SIVIGILA 2018-2022

• Exclusion criteria: unconfirmed cases, patients with missing clinical data or those who did not fulfill the criteria for MM, and patients belonging to other territorial divisions.

Finally, the data of the participants were recorded in an Excel sheet, and data analysis was conducted using the STATA software. In addition, a univariate analysis was performed to estimate absolute and relative frequencies and to describe the behavior and trends of sociodemographic variables. Additionally, variables related to the women’s autonomy, access to healthcare, healthcare received, barriers to access, and sociocultural and mortality aspects were analyzed. Simultaneously, variables associated with early, late, and coincidental deaths, as well as their relationship with pregnancy in terms of direct, indirect, and external causes, were analyzed. The present analysis was conducted in accordance with the surveillance protocol, and multinomial logistic regression was used to determine potential risk associations and understand the extent and association between variables; further, the chi-square test was used to determine the significance of the risk association.

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and Resolution 8430 of 1993 by the Ministerio de la Protección Social (Ministry of Social Protection) of Colombia. According to Article 11 of Resolution 8430/93 of the Ministry of Health and Social Protection, it is a risk-free investigation, given its retrospective temporality and based on a documentary review, which is why informed consent was not required. Furthermore, the study was approved by the Bioethics Committee of Universidad Cooperativa de Colombia.

3. RESULTS

Overall, 59 cases of MM were reported from 2018 to 2022; of these, 27.12% were reported in 2018–2019 (before the pandemic), and 75.88% were reported in 2020–2022 (during the pandemic) Chi2 p=0.000001. There was a significant increase in the incidence of MM during the COVID-19 pandemic, with MMR per 100,000 live births increasing from 68.3 in 2019 to 132.28 in 2021 (Table 1).

The average age of the participants was 29.92 ± 7.7 (range: 15–46) years with a median of 30 years (95% CI: 22.22–37.62). Notably, the incidence of MM was higher in patients aged 25–34 years, accounting for 39% of cases (Table 2).

4. DISCUSSION

The results of our study enable the identification of risk factors for MM among the participants; these factors included the age of 25–34 years, living in a rural settlement, belonging to an indigenous ethnic group, having a low income, and having a low level of education. It is noteworthy that these factors are SDH and have also been identified in other studies conducted in similar contexts. Meanwhile, the association between living in rural settlements and poverty continues to pose a risk to the sexual and reproductive health of women, and this is specifically replicated in low- and middle-income countries [14-16].

Regarding the causes of maternal death, the frequency of indirect maternal deaths during the study period was remarkably high, including deaths due to pre-existing diseases exacerbated by pregnancy or those due to non-obstetric causes. In most cases, these causes lead to early deaths during pregnancy or within 42 days after childbirth. However, the findings of our study are inconsistent with similar studies from low-income countries, although the effects of the pandemic from 2020 to 2022 may have changed the effects of these causes [17, 18].

Notably, the causes of death registered in ICD-10 are still very significant, indicating that, historically, hypertension due to pregnancy, postpartum hemorrhage, and sepsis remain the most common causes. However, the pandemic increased the incidence of indirect mortality.

The present study identified the following two underlying factors of MM at the Department of Meta, Colombia: 1) sociodemographic characteristics of women and 2) care received by them in the healthcare systems. Based on the multinomial analysis, among the sociodemographic factors, extreme age groups (< 20 years old without any schooling and > 35 years old), residing in scattered rural settlements, having low income and educational level, and having limited knowledge of sexual and reproductive rights are the factors compounded by health system determinants, particularly the absence of preconception consultations and inadequate prenatal care [12, 19-21].

The COVID-19 pandemic has undoubtedly increased MM in Meta from 2020 to 2021, particularly in cases of indirect MM related to inequalities and health determinants. This was especially pronounced in the most economically deprived and geographically remote communities, highlighting the challenges associated with accessing and utilizing sexual and reproductive health services. A major shortcoming of the healthcare system is the lack of prioritization of pregnancy, as reflected in the poor quality and rarity of prenatal checkups. These results are consistent with the findings of the UN report [22-24].

The implementation of promotion and prevention measures in rural settlements within the Colombian health system is severely lacking. Although the population is connected to a health system, there are no initiatives to promote access and intervention for risk factors that cause preventable mortality. Moreover, health insurance companies prioritize treatment and rehabilitation over health promotion and disease prevention. Meanwhile, the situations of these individuals, as well as government neglect and illegal economic activities (such as drug trafficking and the presence of violent armed actors) in rural settlements, further complicate equitable access to health systems for communities, particularly affecting the most vulnerable populations [25, 26].

To ensure timely intervention for factors related to indirect MM, in-depth research on how to conduct prenatal checkups is needed, and this is particularly important in Colombia, given the high prevalence of hypertension, diabetes, and obesity. Notably, these diseases are insufficiently controlled due to the low effectiveness of health promotion and disease prevention measures. Further, the pressure to classify MM into direct and indirect types has led healthcare professionals to believe that direct deaths are somehow more important and should receive more attention. However, the prevalence of noncommunicable diseases among young women is increasing. Therefore, this classification can be misleading and lead to biases in clinical care, interventions by epidemiological analysis units on MM, and poor proactivity of insurance companies toward underlying risks. Finally, a noncommunicable disease and an acute event, such as COVID-19 can be a potentially fatal combination for pregnant women [27].

This study has some limitations. First, there was limited access to information, particularly about indigenous communities. Second, there was a dependency on third parties for such information, which did not always provide complete information. Therefore, not all data were collected, and the study did not reach its optimal significance. Further, intervention strategies in primary healthcare should be designed to positively influence the observed determinants and mitigate the incidence of painful deaths in the population.

CONCLUSION

This study indicates the importance of intervening in the determinants of health as a primary care strategy in order to effectively impact the risk factors of pregnant women with a rights-based approach and seeking to strengthen family and community support networks, which requires intersectoral actions. The health system must improve in facilitating access to services for pregnant women and also improve the quality of prenatal care, and pay more attention to comorbidities, complementing the determinant approach in primary health care, in order to effectively mitigate these preventable deaths.

MM is critical to public health as it reflects the progress of a country. Moreover, it has been included in SDGs owing to its impact on orphans and family disintegration. Although the biomedical perspective traditionally focuses on clinical aspects, our study suggests the importance of considering the determinants of health as the primary strategy to effectively address the risk factors affecting pregnant women. This approach prioritizes the rights of women and aims to strengthen family and community support networks. Further, these activities require intersectoral action, and to effectively reduce these preventable deaths, the health system should improve access to health services for pregnant women as well as the quality of prenatal checkups.

REFERENCES