Review of maternal mortality and maternal health outcomes in bolivia and chile

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Melanie Nicole Grafals

BS Political Science, University of Central Florida, 2010

Submitted to the Graduate Faculty of

Behavioral and Community Health Sciences

Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Public Health

University of Pittsburgh




This essay is submitted


Melanie Nicole Grafals

April 25, 2014

and approved by

Essay Advisor:

Martha Ann Terry, PhD _________________________________

Assistant Professor and Director, MPH Program

Department of Behavioral and Community Health Sciences

Graduate School of Public Health

University of Pittsburgh

Essay Reader:

Tammy M. Haley PhD, CRNP _________________________________

Assistant Professor of Nursing, RN-BSN Program Coordinator

Division of Biological and Health Sciences

University of Pittsburgh at Bradford

Copyright © by Melanie Nicole Grafals



Martha Ann Terry, PhD

Melanie Nicole Grafals, MPH

University of Pittsburgh, 2014

Globally, 287,000 women die every year from pregnancy-related complications. In Latin America, despite improvements in maternal health, not all countries have been successful in reducing the rate of maternal mortality. This essay reviews existing literature regarding the maternal health situations in Bolivia and in Chile. In Bolivia, the high rate of maternal mortality is an issue of great public health significance. Chile, on the other hand, has been much more effective in reducing maternal related deaths. By providing a context of the historical, social, political, economic, and health care-related factors in these and other Latin American countries, this essay discusses interventions that have been effective in morbidity and mortality reduction, and interventions that have stalled or failed. Finally, the essay provides recommendations for future maternal health interventions in both Bolivia and Chile. If culturally appropriate maternal health and educational programs are implemented, the lives of countless women can be saved.


1.0 Introduction 1






3.0 METHODS 33

4.0 RESULTS 35





bibliography 56

Figure 1. Maternal Mortality Rate in Latin America 9

Figure 2. GDP in Latin America 10

Figure 3. Healthcare Expenditure (% of GDP) 11

Figure 4. GDP Per Capita 11

Figure 5. Map of Bolivia 17

Figure 6. Map of Chile 25

I would like to thank my mother, father, and sister for loving and supporting me and for dealing with cranky phone calls whenever I experienced writer’s block. I also thank my boyfriend Bradley, for the encouragement, the countless pep talks and for keeping me company as I wrote. I am thankful for my friends for their never-ending belief in me. I am grateful for the direction and input from Dr. Tammy Haley, regardless of the distance between us from Bradford to Pittsburgh. Lastly, I thank my advisor, Dr. Martha Terry, who from day one has been my fiercest advocate. I am so grateful for her support, guidance, compassion, humor, and love.

  1. Introduction

Maternal mortality is an indicator for the overall health of a population [1]. Maternal mortality rates vary around the world and are impacted by a many factors. Estonia has the lowest maternal mortality rate globally, at two deaths per 100,000 live births. South Sudan has the highest at 2,054 deaths per 100,000 live births [2]. In fact, Sub Saharan Africa has the highest rates of maternal death in the world [1]. While Latin America is not experiencing levels comparable to South Sudan, there is still great suffering occurring in the region as a result of pregnancy and childbirth [3]. Bolivia is the Latin American country with the highest maternal mortality, at number 58 of 184 countries ranked by the Central Intelligence Agency (CIA). Chile, on the other hand, has some of the best maternal health outcomes in Latin America and ranks 131 out of 184 on the same scale of global maternal mortality rates [2].

This essay explores why such disparity exists between Bolivia and Chile. The background puts these two countries in perspective by providing contextual material on other Latin American countries that also share Spanish colonial histories and Christian traditions. Economy, culture, government, history, health care, and the role of women will be explored in depth in this section to better understand the current environment in Bolivia and Chile. This essay also identifies which segments of the populations are experiencing the worst maternal-health related problems.

The results section highlights maternal health interventions that have been implemented in Bolivia and Chile and what the outcomes of each program are. The discussion section analyzes what the results indicate for the future of maternal health in each country. Lastly, the conclusion of the essay provides recommendations for future interventions to improve maternal health.



Maternal mortality is defined as “the death of women during pregnancy, childbirth, or in the 42 days after delivery” [4, pg. 1609]. The maternal mortality ratio is the measure most frequently used to define maternal mortality; it is the number of maternal deaths per live birth that occur in the same time period [5]. Another commonly used measure is the maternal mortality rate. It is the number of maternal deaths in a population divided by the number of women of reproductive age (15-49 years old) that are alive during the specific period of interest [6]. The main causes of maternal mortality worldwide are complications that arise during and after pregnancy and delivery [7]. These complications include hemorrhaging (particularly after childbirth), infection, pre-eclampsia, eclampsia, and abortion. Additionally, diseases such as HIV or malaria cause maternal mortality [7].

Globally, 287,000 women die every year from pregnancy-related complications [8]. In developing parts of the world, approximately 222 million women are not using modern contraception, despite wanting to avoid pregnancy. If these women were able to access contraceptives, an estimated 79,000 maternal deaths would be avoided [8]. Maternal mortality impacts the global economy; annually, about $15 million in productivity is lost as a result of slowed or stalled economic growth because of the death of women during pregnancy or shortly after pregnancy. Health of a newborn is closely linked to that of the mother [8]. The death of a mother can disrupt the functioning of the family unit. Oftentimes, if she leaves behind a newborn or any other young children, they will be in a defenseless position without her [9].

The majority of maternal deaths are preventable. Increased access to antenatal care, skilled birth attendants, and support following delivery are necessary to improve maternal health [7]. Proper nutrition, adequate health care and family planning services can also prevent maternal deaths [10].

The barriers that prohibit women from accessing the care that they need during pregnancy and delivery can be the result of poverty, inadequate information, cultural practices, and distance to health care facilities [7]. Even though achievements have been made worldwide to reduce poverty, there are still 1.2 billion people living in extreme poverty [11]. According to a Demographic and Health Survey (DHS) conducted in the 1990s, an analysis of 55 countries showed that women in the poorest quintile were 5.2 times less likely to deliver with a doctor, nurse, or skilled attendant present than women in the riches quintile. Women living in the poorest regions of the world have the lowest maternal health care access and utilization [12].

Poverty is one of the main reasons why girls do not receive education [13]. Women who are uneducated are 2.7 times at a greater risk of maternal mortality than those who receive education. Even among women who are educated, those with one to six years of education have twice the risk of maternal mortality than women with more than 12 years of education [10]. A woman’s level of education is likely to be associated with marriage at an older age and contraception use, which correlates to lower fertility [14]. More educated women are also less likely to develop complications during pregnancy because they tend to be in better health prior to becoming pregnant than less educated women. Education may also impact a woman’s decision to seek care in the event of an obstetric complication [14].

Violence towards women and girls and practices like child marriage prevent girls from receiving education and contribute to poor health outcomes [13]. Gender inequality affects women through discrimination, infringement of autonomy, lack of income control, prohibiting involvement in social networks, and perpetuating violence [12]. Together these factors impact a woman’s ability and choice to seek and effectively utilize maternal health services. Cultural practices and social norms may place young women at a great disadvantage because of traditional marriage age. It is estimated that 17 million women globally are married before the age of 20, primarily in low-income countries [12]. Marriage at a young age is often indicative of young age at first child birth and high fertility, both of which are linked to maternal mortality and maternal morbidity [12].

An important framework in maternal mortality is the three delays model [15, 16]. The model defines three phases that explain the major delays in receiving emergency care from the onset of pregnancy complications to the availability of treatment. The first phase is the delay in the decision of the woman or her family to get care [15]. The second delay is in reaching the health care facility. This could be a problem because of isolation or lack of transportation [16]. The third delay takes place at the health facility, where oftentimes women do not receive adequate and/or necessary care [15, 16]. One or any combination of these delays can contribute to a woman’s death [15].

In 2000, the international community and development institutions established the United Nations Millennium Development Goals (MDGs). The MDGs were created as a roadmap to end poverty and improve global health. There are eight MDGs; eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality and empower women, reduce child mortality, improve maternal health, combat HIV/AIDS, malaria and other diseases, ensure environmental sustainability, and global partnership for development. All of these goals have measurable, time-specific targets to be accomplished by 2015 [17].

The fifth MDG is to improve maternal health. Its aim is to reduce the maternal mortality ratio “by three quarters, between 1990 and 2015” and by 2015 to gain “universal access to reproductive health” [10]. Despite having reduced maternal mortality by 47% worldwide in the last 20 years, achieving the fifth MDG by 2015 is unlikely without more political will [10].

In developing areas, only half of pregnant women “receive the recommended minimum of four antenatal care visits” [10]. In 2011, of the approximately 120 million babies born [18], 47 million were delivered without a skilled birth attendant present [10]. To combat global maternal mortality, contraceptive use must increase, education for girls and women must become a top priority, having a skilled birth attendant present at birth needs to expand to rural areas, and “emergency obstetric care” must be made available to all pregnant women [10]. Increasing the coverage of contraceptives and family planning services prevents unwanted pregnancies and subsequent pregnancy complications. Providing universal access to maternal health services is crucial throughout preconception, antenatal and post-partum periods. In addition to increasing the presence of a skilled birth attendant during childbirth, it is critical that the availability of 24-hour medical staff be increased to provide assistance during obstetric complications [19].

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