The Consequences of Maternal Morbidity and Maternal Mortality

REPORT OF A WORKSHOP

Committee on Population

Holly E. Reed, Marjorie A. Koblinsky, and W. Henry Mosley, editors

Commission on Behavioral and Social Sciences and Education

National Research Council

NATIONAL ACADEMY PRESS
Washington, DC



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The Consequences of Maternal Morbidity and Maternal Mortality: REPORT OF A WORKSHOP The Consequences of Maternal Morbidity and Maternal Mortality REPORT OF A WORKSHOP Committee on Population Holly E. Reed, Marjorie A. Koblinsky, and W. Henry Mosley, editors Commission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, DC

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The Consequences of Maternal Morbidity and Maternal Mortality: REPORT OF A WORKSHOP NATIONAL ACADEMY PRESS 2101 Constitution Ave., NW Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This project was funded by the William and Flora Hewlett Foundation, the Andrew W. Mellon Foundation, and the United States Agency for International Development. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations that provided support for the project. International Standard Book Number 0-309-06943-2 Suggested citation: National Research Council (2000) The Consequences of Maternal Morbidity and Maternal Mortality: Report of a Workshop. Committee on Population. Holly E. Reed, Marjorie A. Koblinsky, and W. Henry Mosley, editors. Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press. Additional copies of this report are available from National Academy Press 2101 Constitution Avenue, NW Washington, DC 20418 Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). This report is also available on line at http://www.nap.edu Printed in the United States of America Copyright 2000 by the National Academy of Sciences. All rights reserved.

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The Consequences of Maternal Morbidity and Maternal Mortality: REPORT OF A WORKSHOP THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

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The Consequences of Maternal Morbidity and Maternal Mortality: REPORT OF A WORKSHOP COMMITTEE ON POPULATION 1998 JANE MENKEN (Chair), Institute of Behavioral Sciences, University of Colorado, Boulder CAROLINE H. BLEDSOE, Department of Anthropology, Northwestern University JOHN BONGAARTS, Population Council, New York City DAVID A. LAM, Population Studies Center, University of Michigan, Ann Arbor LINDA G. MARTIN, RAND, Santa Monica, California MARK R. MONTGOMERY, Population Council, New York City, and Department of Economics, State University of New York, Stony Brook W. HENRY MOSLEY, Department of Population and Family Health Sciences, Johns Hopkins University ALBERTO PALLONI, Center for Demography and Ecology, University of Wisconsin, Madison JAMES P. SMITH, RAND, Santa Monica, California BETH J. SOLDO, Department of Demography, Georgetown University LINDA J. WAITE, Population Research Center, University of Chicago BARNEY COHEN, Director HOLLY REED, Research Associate ELIZABETH WALLACE, Project Assistant

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The Consequences of Maternal Morbidity and Maternal Mortality: REPORT OF A WORKSHOP WORKSHOP ON THE CONSEQUENCES OF PREGNANCY, MATERNAL MORBIDITY, AND MORTALITY FOR WOMEN, THEIR FAMILIES, AND SOCIETY Presenters MARTHA AINSWORTH, World Bank, Washington, DC ALAKA M. BASU, Division of Nutritional Sciences, Cornell University JACQUELYN C. CAMPBELL, School of Nursing, Johns Hopkins University WILLARD CATES, JR., Family Health International, Research Triangle Park, North Carolina JULIA DAYTON, Department of Epidemiology and Public Health, Yale University SONALDE DESAI, Department of Sociology, University of Maryland, College Park STAN D'SOUZA, International Population Concerns, Brussels, Belgium RONALD H. GRAY, School of Hygiene and Public Health, Johns Hopkins University MARJORIE A. KOBLINSKY, MotherCare/John Snow, Inc., Arlington, Virginia LISA M. LEE, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia REYNALDO MARTORELL, Department of International Health, Emory University JANE MENKEN, Institute of Behavioral Sciences, University of Colorado, Boulder KATHLEEN MERCHANT, Community Well-Being International, Henderson, Nevada W. HENRY MOSLEY, Department of Population and Family Health Sciences, Johns Hopkins University MEAD OVER, World Bank, Washington, DC JOY RIGGS-PERLA, Center for Population, Health, and Nutrition, U.S. Agency for International Development CARINE RONSMANS, Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, London SHEA RUTSTEIN, Macro International, Calverton, Maryland JASON B. SMITH, Family Health International, Research Triangle Park, North Carolina MICHAEL A. STRONG, U.S. Agency for International Development, Nairobi, Kenya ANNE TINKER, World Bank, Washington, DC L. LEWIS WALL, Louisiana State University Medical Center, New Orleans, and School of Public Health, Tulane University KEITH P. WEST, JR., School of Hygiene and Public Health, Johns Hopkins University

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The Consequences of Maternal Morbidity and Maternal Mortality: REPORT OF A WORKSHOP Other Participants CARLA ABOUZAHR, World Health Organization, Geneva, Switzerland JENNIFER ADAMS, Center for Population, Health, and Nutrition, U.S. Agency for International Development FRANK ANDERSON, Bureau for Humanitarian Response, U.S. Agency for International Development PATRICIA BAILEY, Family Health International, Research Triangle Park, North Carolina ALFRED BARTLETT, Center for Population, Health, and Nutrition, U.S. Agency for International Development INGVILD BELLE, Inter-American Development Bank, Washington, DC CYNTHIA BERG, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, Georgia CAROLINE H. BLEDSOE, Department of Anthropology, Northwestern University ANNETTE BONGIOVANNI, Bureau for Latin America and the Caribbean, U.S. Agency for International Development SANDRA DECASTRO BUFFINGTON, Center for Population, Health, and Nutrition, U.S. Agency for International Development LATASHA COLE, Global Health Council, Washington, DC COLLEEN CONROY, MotherCare/John Snow, Inc., Arlington, Virginia COLLETTE CURRAN, Population Reference Bureau, Washington, DC NILS DAULAIRE, Global Health Council, Washington, DC PATRICIA DAVID, Population Reference Bureau, Washington, DC FRANCE DONNAY, UNICEF, New York, New York LESLIE ELDER, MotherCare/John Snow, Inc., Arlington, Virginia PHYLLIS GESTRIN, Bureau for Africa, U.S. Agency for International Development MOLLY GINGERICH, Center for Population, Health, and Nutrition, U.S. Agency for International Development JOHN HAAGA, Population Reference Bureau, Washington, DC SANDRA HUFFMAN, Academy for Educational Development, Washington, DC ZAHID HUQUE, MotherCare/John Snow, Inc., Arlington, Virginia EDNA JONAS, Consultant, Silver Spring, Maryland KATHERINE JONES, Bureau for Humanitarian Response, U.S. Agency for International Development MICHAEL KOENIG, School of Hygiene and Public Health, Johns Hopkins University KATHERINE KRASOVEC, Abt Associates, Inc., Bethesda, Maryland MIRIAM LABBOK, Center for Population, Health, and Nutrition, U.S. Agency for International Development

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The Consequences of Maternal Morbidity and Maternal Mortality: REPORT OF A WORKSHOP JEANNE McDERMOTT, MotherCare/John Snow, Inc., Arlington, Virginia THOMAS MERRICK, World Bank, Washington, DC MAUREEN NORTON, Center for Population, Health, and Nutrition, U.S. Agency for International Development SHIRLIE PINKHAM, Bureau for Population, Refugees, and Migration, U.S. Department of State MIRIAM SCHNEIDMAN, World Bank, Washington, DC ELISABETH SOMMERFELT, JHPIEGO Corporation, Baltimore, Maryland MARY ELLEN STANTON, Center for Population, Health, and Nutrition, U.S. Agency for International Development ANN STARRS, Family Care International, New York, New York PATRICIA STEPHENSON, Center for Population, Health, and Nutrition, U.S. Agency for International Development KRISTA STEWART, Center for Population, Health, and Nutrition, U.S. Agency for International Development REMA VENU, UNICEF, New York, New York VIRGINIA VITZTHUM, Center for Population, Health, and Nutrition, U.S. Agency for International Development BEVERLY WINIKOFF, Population Council, New York FAITH MITCHELL, Director, Division on Social and Economic Studies BARNEY COHEN, Director, Committee on Population HOLLY E. REED, Research Associate, Committee on Population ELIZABETH WALLACE, Project Assistant, Committee on Population

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The Consequences of Maternal Morbidity and Maternal Mortality: REPORT OF A WORKSHOP Contents     Preface   xi     Introduction   1     Framing the Subject: What Is Known About Maternal Morbidity and Mortality   3     Evidence on the Consequences of Maternal Mortality   5     Evidence on the Consequences of Maternal Morbidity   11     Opportunities for Further Research   17     References   19  Appendix A:   Definitions   23  Appendix B:   Workshop Agenda   26

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The Consequences of Maternal Morbidity and Maternal Mortality: REPORT OF A WORKSHOP Preface The National Research Council (NRC) established the Committee on Population in 1983 to bring the knowledge and methods of the population sciences to bear on major issues of science and public policy. The committee's work includes both basic studies of fertility, health and mortality, and migration, and applied studies aimed at improving programs for the public health and welfare in the United States and developing countries. The committee also fosters communication among researchers in different disciplines and countries and policy makers in government and international agencies. In 1997 the committee published Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions, a report that recommended actions to improve reproductive health for women around the world. As a follow-on activity, the committee proposed an investigation into the social and economic consequences of maternal morbidity and mortality. With funding from the William and Flora Hewlett Foundation, the Andrew W. Mellon Foundation, and the U.S. Agency for International Development, the committee organized a workshop on this topic in Washington, DC, on October 19-20, 1998. A Committee on Population workshop is intended to be a stimulating forum for leading scientists and policy makers from a variety of different disciplines to discuss what is known about a particular scientific topic. The Workshop on the Consequences of Pregnancy, Maternal Morbidity, and Mortality for Women, Their Families, and Society brought together researchers from the fields of anthropology, demography, economics, medicine, public health, and sociology and policy makers from government agencies, nongovernmental, and international organizations. The goal of the workshop was to assess the existing scientific

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The Consequences of Maternal Morbidity and Maternal Mortality: REPORT OF A WORKSHOP knowledge about the consequences of maternal morbidity and mortality and to discuss key findings from recent research. Although the existing research on this topic is scarce, presenters drew on similar literature on the consequences of adult disease and death, especially the growing literature on the socioeconomic consequences of AIDS, to look at potential consequences from maternal disability and death. Given the limitations of both time and scope that are inherent to a workshop, some other important topics could not be addressed. These included: the consequences of several types of morbidities, such as prolapse, eclampsia, ectopic pregnancy, and complications from unsafe abortion; the psychosocial affects of maternal morbidity and mortality; the fiscal costs of reproductive disability and death; and the changes in social structure that may result from maternal morbidity and mortality. The fact that they were not discussed does not indicate that they are not important topics deserving of future consideration. This report summarizes the presentations and discussion at the workshop. Although some references are provided, it is by no means a comprehensive review of the subject. It is hoped that this report will encourage further investigation into the consequences of maternal morbidity and mortality. I am grateful to my fellow committee members, Caroline Bledsoe, John Bongaarts, and Henry Mosley, who served with me on the subcommittee that organized the workshop. In addition, the committee was extremely fortunate in being able to enlist the services of Marge Koblinsky, one of the leading experts in this field. She collaborated with the committee members, provided valuable advice and direction during the planning stages of the meeting, and cochaired the meeting with Henry Mosley. Keith West, from the Johns Hopkins University and Leslie Elder, from John Snow, Inc. both helped to review the section on nutrition in this report. The staff at the National Research Council managed the workshop from start to finish and made it all possible. Holly Reed, research associate, helped develop the framework for the workshop, coordinated the contributions of the participants, and worked with Marge Koblinsky and Henry Mosley to produce this report. Elizabeth Wallace, project assistant, assisted with logistical and travel arrangements for the workshop. Eugenia Grohman, associate director for reports for the Commission on Behavioral and Social Sciences and Education, skillfully edited the manuscript and guided it through the review process. The work was carried out under the general direction of Barney Cohen. This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness

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The Consequences of Maternal Morbidity and Maternal Mortality: REPORT OF A WORKSHOP to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report: Oona Campbell, Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine; David A. Lam, Population Studies Center, University of Michigan, Ann Arbor; Deborah Maine, School of Public Health, Columbia University; T. Paul Schultz, Department of Economics, Yale University; and John Strauss, Department of Economics, Michigan State University. Although the individuals listed above have provided constructive comments and suggestions, it must be emphasized that responsibility for the final content of this report rests entirely with the authoring committee and the institution. The work of the committee and the NRC, however, could not be done without the valuable contributions of experts who present their research and viewpoints in workshops like the one on which this report is based. (See Appendix B for the workshop agenda.) We are most grateful to these dedicated workshop participants, whose ideas and discussions are summarized here. We hope that this publication helps ensure that their work will continue to contribute to research and policy on reproductive and maternal morbidity and maternal mortality and their consequences. Jane Menken, Chair Committee on Population

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