روند تعيين‌كننده‌هاي مرگ مادران در ايران در سال‌هاي 1990 تا 2015: يك مطالعه طولي

Determinants of maternal mortality in Iran 1990-2015: a longitudinal study

زمينه و هدف: شناسايي عوامل تعيين‌كننده مرگ مادران به‌منظور سياست‌گذاري علمي و درست براي كاهش مرگ مادران ضروري است. هدف اين مطالعه تعيين روند عوامل موثر بر مرگ مادران در ايران و نقش هر يك از اين عوامل در بين سال‌هاي 1990 تا 2015 ميلادي بود. روش بررسي: مطالعه حاضر يك مطالعه كمي از نوع مطالعات طولي است و از اسفند 1396 تا آذر 1397 در دانشگاه علوم پزشكي تهران انجام شد. ابتدا، با انجام يك مرور نظام‌مند در دنيا، 32 عامل مرتبط با مرگ مادران شناسايي شد. سپس، داده‌هاي مربوط به عوامل شناسايي شده از طريق مراجعه به منابع داخلي مانند وزارت بهداشت و منابع خارجي مانند سايت‌هاي بانك جهاني، سازمان جهاني بهداشت و سازمان ملل متحد جمع‌آوري شدند. در نهايت، پس از طي فرآيند آماده‌سازي و مديريت داده‌ها، 12 شاخص تعيين شد و ارتباط آن‌ها با مرگ مادران با استفاده از مدل‌هاي رگرسيوني بررسي شد. يافته‌ها: ميزان مرگ مادران در ايران در بازه زماني 1990 تا 2015 ميلادي حدود 80% كاهش يافت. افزايش شاخص‌هاي اشتغال، سهم بودجه سلامت و پوشش واكسيناسيون و كاهش ميزان باروري كل و سهم پرداختي از جيب منجر به كاهش معنا‌دار مرگ مادران شد. همچنين، عملكردهاي سياسي، شهرنشيني، درآمد سرانه، دسترسي به محيط بهداشتي و امكانات رفاهي رابطه معنا‌داري با كاهش مرگ مادران نشان دادند. تحصيلات و اميد به زندگي رابطه معناداري با كاهش مرگ مادران نداشتند. نتيجه‌گيري: مرگ مادران در ايران در ربع قرن گذشته كاهش چشمگيري داشت. مرگ مادران افزون‌بر عوامل فردي و بهداشتي، تحت تأثير عوامل كلان اقتصادي، اجتماعي، فرهنگي و سياسي مي‌باشد

Background: Identifying determinants of maternal mortality is essential in developing appropriate health policies for reduction of maternal death. This study aimed to determine the determinants of maternal mortality in Iran during 1990- 2015 and also to identify the trends of these determinants during the same period. Methods: This is a quantitative longitudinal study that has been conducted at the Tehran University of Medical Science, Iran, from March to December 2018. Initially, a long list of determinants (n=32) were identified through a comprehensive systematic reviews. Variables with more than 25% missing data were omitted and the missing values for remaining variables were estimated through statistical methods. The data for the identified variables were gathered through internal sources including Iran’s Ministry of Health and international sources including the websites of World Bank, World Health Organization and United Nations. Finally, 12 indicators as determinants of death were constructed after data processing and data management and their associations with maternal mortality rate in Iran were examined through regression analysis. Results: Maternal mortality rate has been reduced by 80% during 1990- 2015 in Iran. Improvement of indicators including employment status, total health expenditure share (as a percent of GDP), vaccination coverage, urbanization, access to health and welfare facilities, GDP per capita and political performance played a significant role in reduction of maternal deaths according to the multivariate analyses. A reduction in out of pocket payment and total fertility rate also showed a significant association with lower maternal mortality. However neither education level in the country nor life expectancy at birth showed an important role in the maternal mortality rate. Conclusion: Maternal mortality rate was reduced significantly in Iran during the last quarter of the century. Maternal death is not only affected by health and biological factors of mothers, but also, by macro-economic, social and welfare factors. A high political performance of the countries also is a grantor of better health of mothers and the community in general.