{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T03:50:46Z","timestamp":1791431446214,"version":"4.3.3"},"reference-count":47,"publisher":"Public Library of Science (PLoS)","issue":"1","license":[{"start":{"date-parts":[[2025,1,13]],"date-time":"2025-01-13T00:00:00Z","timestamp":1736726400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Maternal mortality ratio (MMR) has decreased worldwide but Pakistan is still striving towards achieving the SDG targets for maternal health. This study highlights the trends in maternal mortality levels and risk factors in Pakistan between 2007 and 2019.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>This study compares the results of secondary data analysis of the Pakistan Maternal Mortality Survey 2019 with the Pakistan Demographic and Health Survey 2007. A nested case-control study was carved to compare maternal deaths with the women who survived a pregnancy, in the same sampling clusters during the same period. Logistic regression was used to estimate odds ratios (OR) for major risk factors of maternal mortality after adjusting for the women\u2019s age, parity, education, and wealth quintile.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>In 2019, Pakistan\u2019s MMR was 186 per 100,000 live births, registering a 33% decline from 2007 (rural 42% vs. urban 11%). The leading causes of maternal mortality were postpartum hemorrhage, hypertensive disease of pregnancy, postpartum infection, and post-abortion complications. Women &gt; 35 years and those expecting their first child were more likely to die from childbirth, while those who had ever used family planning had a lower risk according to the data for both years. In 2007, a distance of &gt; 40 kilometers to a hospital significantly increased the risk of mortality but this association was not significant in 2019. In 2019, women who died were more likely to receive antenatal care than those who survived (adjusted OR 9.3); this association was not significant in 2007.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>The modest reduction in MMR can be attributed to improved access to maternal health services in rural areas with increased antenatal care and institutional deliveries. However, most maternal deaths were caused by poor accessibility to quality emergency obstetric care. Lack of family planning remains a major risk factor for high maternal mortality in Pakistan.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0311730","type":"journal-article","created":{"date-parts":[[2025,1,13]],"date-time":"2025-01-13T18:57:22Z","timestamp":1736794642000},"page":"e0311730","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":12,"title":["Trends in the levels, causes, and risk factors of maternal mortality in Pakistan: A comparative analysis of national surveys of 2007 and 2019"],"prefix":"10.1371","volume":"20","author":[{"given":"Farid","family":"Midhet","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9838-7279","authenticated-orcid":true,"given":"Samina Naeem","family":"Khalid","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shehla","family":"Baqai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shahzad Ali","family":"Khan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,1,13]]},"reference":[{"key":"pone.0311730.ref001","author":"United Nations Statistics Division (UNSD).","year":"2022","journal-title":"The Sustainable Development Goals Report"},{"issue":"2","key":"pone.0311730.ref002","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1080\/13504509.2019.1692316","article-title":"Achieving sustainable development goals: Predicaments and Strategies.","volume":"27","author":"R Bali Swain","year":"2020","journal-title":"International Journal of Sustainable Development & World Ecology."},{"key":"pone.0311730.ref003","author":"World Health Organization","year":"2015","journal-title":"Health in 2015: from MDGs, Millennium Development Goals to SDGs, Sustainable Development Goals."},{"key":"pone.0311730.ref004","author":"World Health Organization","year":"2015","journal-title":"Strategies towards ending preventable maternal mortality (EPMM)."},{"key":"pone.0311730.ref005","unstructured":"United Nations: Sustainable Development Goals 2030 Agenda (Available from: https:\/\/sdgs.un.org\/goals."},{"issue":"3","key":"pone.0311730.ref006","doi-asserted-by":"crossref","first-page":"189","DOI":"10.26719\/emhj.18.029","article-title":"Human development index, maternal mortality rate and under 5 years mortality rate in West and South Asian countries, 1980\u20132010: an ecological study.","volume":"25","author":"Y Alimohamadi","year":"2019","journal-title":"East Mediterr Health J."},{"key":"pone.0311730.ref007","volume-title":"Pakistan Maternal Mortality Survey","author":"National Institute of Population Studies-NIPS","year":"2020"},{"issue":"6","key":"pone.0311730.ref008","doi-asserted-by":"crossref","first-page":"1038","DOI":"10.4236\/ojog.2023.136088","article-title":"Maternal Mortality: A Matter of Public Health Policies.","volume":"13","author":"H dos Prazeres Tavares","year":"2023","journal-title":"Open Journal of Obstetrics and Gynecology"},{"key":"pone.0311730.ref009","author":"World Health Organization","year":"2019","journal-title":"Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division."},{"issue":"2","key":"pone.0311730.ref010","first-page":"263","article-title":"The image world of maternal mortality: visual economies of hope and aspiration in the global campaigns to reduce maternal mortality. Humanity: An International Journal of Human Rights, Humanitarianism, and Development","volume":"10","author":"M. MacDonald","year":"2019"},{"key":"pone.0311730.ref011","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12978-020-00990-z","article-title":"Maternal mortality in six low and lower-middle income countries from 2010 to 2018: risk factors and trends","volume":"17","author":"M. T Bauserman","year":"2020","journal-title":"Reproductive health,"},{"issue":"4","key":"pone.0311730.ref012","first-page":"713","article-title":"Maternal mortality in low and middle-income Countries","volume":"49","author":"E. R. Lawrence","year":"2022","journal-title":"Obstetrics and Gynecology Clinics"},{"issue":"2","key":"pone.0311730.ref013","first-page":"1","article-title":"Risk factors for maternal death and trends in maternal mortality in low-and middle-income countries: a prospective longitudinal cohort analysis.","volume":"12","author":"M Bauserman","year":"2015","journal-title":"Reproductive health."},{"issue":"6","key":"pone.0311730.ref014","doi-asserted-by":"crossref","first-page":"e323","DOI":"10.1016\/S2214-109X(14)70227-X","article-title":"Global causes of maternal death: a WHO systematic analysis","volume":"2","author":"L Say","year":"2014","journal-title":"The Lancet Global Health"},{"issue":"12","key":"pone.0311730.ref015","doi-asserted-by":"crossref","first-page":"1342","DOI":"10.1111\/tmi.13313","article-title":"Monitoring maternal and newborn health outcomes globally: a brief history of key events and initiatives","volume":"24","author":"A. B. Moller","year":"2019","journal-title":"Tropical medicine & international health"},{"key":"pone.0311730.ref016","doi-asserted-by":"crossref","first-page":"662","DOI":"10.1055\/s-0041-1735300","article-title":"Temporal Evolution of Maternal Mortality: 1980\u20132019.","volume":"43","author":"J Vettorazzi","year":"2021","journal-title":"Revista Brasileira de Ginecologia e Obstetr\u00edcia."},{"key":"pone.0311730.ref017","doi-asserted-by":"crossref","first-page":"104380","DOI":"10.1016\/j.amsu.2022.104380","article-title":"Maternal mortality in Pakistan: Challenges, efforts, and recommendations","volume":"81","author":"SK Shaeen","year":"2022","journal-title":"Annals of Medicine and Surgery"},{"key":"pone.0311730.ref018","first-page":"123","article-title":"National Institute of Population Studies (NIPS)(Pakistan), and Macro International Inc.","volume":"7","author":"A Mahmood","year":"2006","journal-title":"Pakistan Demographic and Health Survey."},{"issue":"3","key":"pone.0311730.ref019","doi-asserted-by":"crossref","first-page":"330","DOI":"10.1080\/01443615.2016.1250728","article-title":"Determinants of maternal health care services utilization in Pakistan: evidence from Pakistan demographic and health survey, 2012\u201313","volume":"37","author":"R Zakar","year":"2017","journal-title":"Journal of Obstetrics and Gynaecology"},{"issue":"3","key":"pone.0311730.ref020","first-page":"1","article-title":"Why are the Pakistani maternal, fetal, and newborn outcomes so poor compared to other low and middle-income countries?","volume":"17","author":"A Aziz","year":"2020","journal-title":"Reproductive Health."},{"key":"pone.0311730.ref021","volume-title":"Pakistan Demographic and Health Survey 2006\u201307.","author":"National Institute of Population Studies\u2014NIPS\/Pakistan, Macro International","year":"2008"},{"key":"pone.0311730.ref022","article-title":"An In-depth Analysis of 2006\u201307 Pakistan Demographic and Health Survey Data.","author":"S Ali","year":"2009","journal-title":"National institute of population studies (NIPS) Islamabad."},{"issue":"1","key":"pone.0311730.ref023","doi-asserted-by":"crossref","first-page":"1800","DOI":"10.1186\/s12889-020-09870-4","article-title":"Inequalities in health and health-related indicators: a spatial geographic analysis of Pakistan.","volume":"20","author":"SU Khan","year":"2020","journal-title":"BMC Public Health"},{"issue":"2","key":"pone.0311730.ref024","article-title":"Maternal and Child Health in Underdeveloped Areas and State Borders.","volume":"15","author":"Y. K. Syamruth","year":"2021","journal-title":"Indian Journal of Forensic Medicine & Toxicology"},{"issue":"1","key":"pone.0311730.ref025","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3923\/aje.2012.1.14","article-title":"Maternal, perinatal and neonatal mortality in South-East Asia Region","volume":"5","author":"G. Sharma","year":"2012","journal-title":"Asian Journal of Epidemiology"},{"issue":"2","key":"pone.0311730.ref026","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1089\/jwh.2020.8882","article-title":"Social and structural determinants of health inequities in maternal health","volume":"30","author":"J Crear-Perry","year":"2021","journal-title":"Journal of women\u2019s health"},{"key":"pone.0311730.ref027","article-title":"Life course investments at the Maternal and Child Health Bureau","volume":"149","author":"Supplement 5","year":"2022","journal-title":"Pediatrics"},{"issue":"1","key":"pone.0311730.ref028","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12884-020-02901-3","article-title":"Human Development Index of the maternal country of origin and its relationship with maternal near miss: A systematic review of the literature","volume":"20","author":"S Garc\u00eda-Tiz\u00f3n Larroca","year":"2020","journal-title":"BMC Pregnancy and Childbirth"},{"issue":"1","key":"pone.0311730.ref029","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s40985-018-0081-z","article-title":"How do accountability problems lead to maternal health inequities? A review of qualitative literature from Indian public sector.","volume":"39","author":"M Hamal","year":"2018","journal-title":"Public Health Reviews"},{"issue":"10","key":"pone.0311730.ref030","doi-asserted-by":"crossref","first-page":"e0204810","DOI":"10.1371\/journal.pone.0204810","article-title":"Understanding intersections of social determinants of maternal healthcare utilization in Uttar Pradesh, India.","volume":"13","author":"A Dey","year":"2018","journal-title":"PLoS One"},{"issue":"1","key":"pone.0311730.ref031","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s40985-020-00125-6","article-title":"Social determinants of maternal health: a scoping review of factors influencing maternal mortality and maternal health service use in India.","volume":"41","author":"M Hamal","year":"2020","journal-title":"Public Health Reviews"},{"issue":"1","key":"pone.0311730.ref032","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12884-015-0525-0","article-title":"Determinants of women\u2019s satisfaction with maternal health care: a review of literature from developing countries","volume":"15","author":"A. Srivastava","year":"2015","journal-title":"BMC pregnancy and childbirth"},{"issue":"21","key":"pone.0311730.ref033","doi-asserted-by":"crossref","first-page":"11514","DOI":"10.3390\/ijerph182111514","article-title":"Exploring the role of health expenditure and maternal mortality in South Asian countries: an approach towards shaping better health policy","volume":"18","author":"N Aziz","year":"2021","journal-title":"International Journal of Environmental Research and Public Health"},{"key":"pone.0311730.ref034","author":"Studies NIoP","year":"2019","journal-title":"National Institute of Population Studies, Maternal Mortality Survey 2019."},{"key":"pone.0311730.ref035","article-title":"Chapter 2: An In-depth Analysis of 2006\u201307 Pakistan Demographic and Health Survey Data.","author":"F Midhet","year":"2009","journal-title":"National institute of population studies (NIPS) Islamabad."},{"issue":"6","key":"pone.0311730.ref036","doi-asserted-by":"crossref","first-page":"e0253920","DOI":"10.1371\/journal.pone.0253920","article-title":"Causes contributing to the excess maternal mortality risk for women 35 and over, United States, 2016\u20132017.","volume":"16","author":"MF MacDorman","year":"2021","journal-title":"Plos One."},{"issue":"10285","key":"pone.0311730.ref037","doi-asserted-by":"crossref","first-page":"1658","DOI":"10.1016\/S0140-6736(21)00682-6","article-title":"Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss","volume":"397","author":"S Quenby","year":"2021","journal-title":"The Lancet"},{"issue":"10","key":"pone.0311730.ref038","doi-asserted-by":"crossref","first-page":"e0186287","DOI":"10.1371\/journal.pone.0186287","article-title":"Advanced maternal age and adverse pregnancy outcomes: A systematic review and meta-analysis.","volume":"12","author":"SC Lean","year":"2017","journal-title":"PloS one"},{"key":"pone.0311730.ref039","first-page":"364","article-title":"Role of maternal age and pregnancy history in risk of miscarriage: prospective register-based study","author":"MC Magnus","year":"2019","journal-title":"bmj"},{"issue":"11","key":"pone.0311730.ref040","doi-asserted-by":"crossref","first-page":"e0294225","DOI":"10.1371\/journal.pone.0294225","article-title":"Factors associated with maternal health services utilization in Pakistan: Evidence from Pakistan maternal mortality survey, 2019","volume":"18","author":"F. Midhet","year":"2023","journal-title":"Plos one"},{"issue":"1","key":"pone.0311730.ref041","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12963-020-00245-w","article-title":"The impact of family planning on maternal mortality in Indonesia: what future contribution can be expected?","volume":"19","author":"B Utomo","year":"2021","journal-title":"Population Health Metrics"},{"key":"pone.0311730.ref042","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1016\/j.bpobgyn.2016.07.008","article-title":"Role of birth spacing, family planning services, safe abortion services, and post-abortion care in reducing maternal mortality.","volume":"36","author":"B Ganatra","year":"2016","journal-title":"Best Practice & Research Clinical Obstetrics & Gynaecology."},{"issue":"4","key":"pone.0311730.ref043","first-page":"63","article-title":"Qualitative exploration of factors affecting uptake and demand for contraception and other family planning services in north-West Nigeria","volume":"23","author":"AA Adefalu","year":"2019","journal-title":"African Journal of Reproductive Health"},{"issue":"22","key":"pone.0311730.ref044","doi-asserted-by":"crossref","first-page":"11892","DOI":"10.3390\/ijerph182211892","article-title":"Exploring Readiness for Birth Control in Improving Women Health Status: Factors Influencing the Adoption of Modern Contraceptives Methods for Family Planning Practices.","volume":"18","author":"AM Shah","year":"2021","journal-title":"International Journal of Environmental Research and Public Health"},{"issue":"3","key":"pone.0311730.ref045","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1111\/aeq.12198","article-title":"Does education empower women? The regulated empowerment of Parhi Likhi women in Pakistan.","volume":"48","author":"A. Khurshid","year":"2017","journal-title":"Anthropology & Education Quarterly."},{"issue":"1","key":"pone.0311730.ref046","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/j.annepidem.2012.10.005","article-title":"Association between number of children and mortality of mothers: results of a 37-year follow-up study.","volume":"23","author":"UP Dior","year":"2013","journal-title":"Annals of epidemiology."},{"key":"pone.0311730.ref047","author":"World Health Organization","year":"2023","journal-title":"Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA\/Population Division: executive summary."}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0311730","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,1,13]],"date-time":"2025-01-13T18:57:37Z","timestamp":1736794657000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0311730"}},"subtitle":[],"editor":[{"given":"Fernanda Penido","family":"Matozinhos","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,1,13]]},"references-count":47,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,1,13]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0311730","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,1,13]]}}}