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BackgroundWith recent results showing a global decline in overall maternal mortality during the last two decades and with the target date for achieving the Millennium Development Goals only four years away, the question of how to continue or even accelerate the decline has become more pressing. By knowing where the risk is highest as well as where the numbers of deaths are greatest, it may be possible to re-direct resources and fine-tune strategies for greater effectiveness in efforts to reduce maternal mortality.MethodsWe aggregate data from 38 Demographic and Health Surveys that included a maternal mortality module and were conducted in 2000 or later to produce maternal mortality ratios, rates, and numbers of deaths by five year age groups, separately by residence, region, and overall mortality level.FindingsThe age pattern of maternal mortality is broadly similar across regions, type of place of residence, and overall level of maternal mortality. A “J” shaped curve, with markedly higher risk after age 30, is evident in all groups. We find that the excess risk among adolescents is of a much lower magnitude than is generally assumed. The oldest age groups appear to be especially resistant to change. We also find evidence of extremely elevated risk among older mothers in countries with high levels of HIV prevalence.ConclusionsThe largest number of deaths occurs in the age groups from 20-34, largely because those are the ages at which women are most likely to give birth so efforts directed at this group would most effectively reduce the number of deaths. Yet equity considerations suggest that efforts also be directed toward those most at risk, i.e., older women and adolescents. Because women are at risk each time they become pregnant, fulfilling the substantial unmet need for contraception is a cross-cutting strategy that can address both effectiveness and equity concerns.

Despite renewed interest in postpartum family planning programs, the question of the time at which women should be expected to start contraception after a birth remains unanswered. Three indicators of postpartum unmet need consider women to be fully exposed to the risk of pregnancy at different times: right after delivery (prospective indicator), after six months of amenorrhea (intermediate indicator), and at the end of amenorrhea (classic indicator). DHS data from 57 countries in 2005-13 indicate that 62 percent (prospective), 43 percent (intermediate), and 32 percent (classic) of women in the first year after a birth have an unmet need for contraception (40 percent when including abstinence). While the protection afforded by postpartum abstinence and lactational amenorrhea lowers unmet need, further analysis shows that women also often rely on these methods without being actually protected. Programs should acknowledge these methods' widespread use and inform women about their limits. Also, the respective advantages of targeting the postnatal period, the end of six months of amenorrhea/exclusive breastfeeding, or the resumption of sexual intercourse to offer contraceptive services should be tested.

High contraceptive discontinuation results in millions of

BackgroundThe first 12 months following childbirth are a period when a subsequent pregnancy holds the greatest risk for mother and baby, but also when there are numerous contacts with the healthcare system for postnatal care for mother and baby (immunisation, nutrition, etc.). The benefits and importance of postpartum family planning are well documented. They include a reduction in risk of miscarriage, as well as mitigation of (or protection against) low birth weight, neonatal and maternal death, preterm birth, and anaemia.ObjectivesThe objectives of this paper are to assess patterns and trends in the use of postpartum family planning at the country level, to determine whether postpartum family planning is associated with birth interval and parity, and to identify the health services most closely associated with postpartum family planning after adjusting for socio-economic characteristics.DesignData were used from Demographic and Health Surveys that contain a reproductive calendar, carried out within the last 10 years, from Ethiopia, Malawi, and Nigeria. All women for whom the calendar was completed and who gave birth between 57 and 60 months prior to data collection were included in the analysis. For each of the births, we merged the reproductive calendar with the birth record into a survey for each country reflecting the previous 60 months. The definition of the postpartum period in this paper is based on a period of 3 months postpartum. We used this definition to assess early adoption of postpartum family planning. We assessed variations in postpartum family planning according to demographic and socio-economic variables, as well as its association with various contact opportunities with the health system [antenatal care (ANC), childbirth in facilities, immunisation, etc.]. We did simple descriptive analysis with tabular, graphic, and ‘equiplot’ displays and a logistic regression controlling for important background characteristics.ResultsOverall, variation in postpartum use of modern contraception was not affected over the years by age or marital status. One contrast to this is in Ethiopia, where the data show a significant increase in uptake of postpartum contraception among adolescents from 2005 to 2011. There are systematic and pervasive equity issues in the use of modern postpartum family planning by education level, place of residence, and wealth quintile, especially in Ethiopia where the gaps are very large. Disaggregation of data also point to significant sub-national variations. After adjusting for socio-economic variables, the most consistent health sector services associated with modern postpartum contraception are institutional childbirth and child immunisation. ANC is less likely to be associated with the use of modern postpartum family planning.ConclusionPostpartum use of modern family planning has remained very low over the years, including for childbearing adolescents. Our results indicate that improving postpartum family planning requires policies and strategies to address the inequalities caus...

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BackgroundChoosing an optimum set of child health interventions for maximum mortality impact is important within resource poor policy environments. The Lives Saved Tool (LiST) is a computer model that estimates the mortality and stillbirth impact of scaling up proven maternal and child health interventions. This paper will describe the methods used to estimate the impact of scaling up interventions on neonatal and child mortality.Model structure and assumptionsLiST estimates mortality impact via five age bands 0 months, 1-5 months, 6-11 months, 12-23 months and 24 to 59 months. For each of these age bands reductions in cause specific mortality are estimated. Nutrition interventions can impact either nutritional statuses or directly impact mortality. In the former case, LiST acts as a cohort model where current nutritional statuses such as stunting impact the probability of stunting as the cohort ages. LiST links with a demographic projections model (DemProj) to estimate the deaths and deaths averted due to the reductions in mortality rates.Using LiSTLiST can be downloaded at http://www.jhsph.edu/dept/ih/IIP/list/ where simple instructions are available for installation. LiST includes default values for coverage and effectiveness for many less developed countries obtained from credible sources.ConclusionsThe development of LiST is a continuing process. Via technical inputs from the Child Health Epidemiological Group, effectiveness values are updated, interventions are adopted and new features added.

Abstract. By utilizing self‐reported race and ancestry in the 1980 and 1990 USA censuses and the Blinder‐Oaxaca decomposition technique, the extent of wage discrimination experienced by women and by men is examined across 50 ethnic/racial groups. Systematic evidence of negative discrimination is revealed in both census years for Asian, Indian, black (African‐American), Vietnamese, Cuban, Mexican, Puerto Rican, and Native American males. To assess the charge that the Blinder‐Oaxaca decomposition indicates cultural rather than discriminatory differentials, two additional data experiments are performed—one that controls for color and varies culture, and one that controls for culture and varies color. Race appears to matter.