• Ö Tunçalp, J P Souza, M J Hindin, C A Santos, T H Oliveira, J P Vogel, G Togoobaatar, D Q Ha, L Say, A M Gülmezoglu, and WHO Multicountry Survey on Maternal and Newborn Health Research Network.
• UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
• BJOG. 2014 Mar 1; 121 Suppl 1: 57-65.

ObjectiveTo assess the relationship between education and severe maternal outcomes among women delivering in healthcare facilities.DesignCross-sectional study.SettingTwenty-nine countries in Africa, Asia, Latin America, and the Middle East.PopulationPregnant women admitted to 359 facilities during a period of 2-4 months of data collection between 2010 and 2011.MethodsData were obtained from hospital records. Stratification was based on the Human Development Index (HDI) values of the participating countries. Multivariable logistic regression analyses were conducted to assess the association between maternal morbidity and education, categorised in quartiles based on the years of formal education by country. Coverage of key interventions was assessed.Main Outcome MeasuresSevere maternal outcomes (near misses and death).ResultsA significant association between low education and severe maternal outcomes (adjusted odds ratio, aOR, 2.07; 95% confidence interval, 95% CI, 1.46-2.95), maternal near miss (aOR 1.80; 95% CI 1.25-2.57), and maternal death (aOR 5.62; 95% CI 3.45-9.16) was observed. This relationship persisted in countries with medium HDIs (aOR 2.36; 95% CI 1.33-4.17) and low HDIs (aOR 2.65; 95% CI 1.54-2.57). Less educated women also had increased odds of presenting to the hospital in a severe condition (i.e. with organ dysfunction on arrival or within 24 hours: aOR 2.06; 95% CI 1.36-3.10). The probability that a woman received magnesium sulphate for eclampsia or had a caesarean section significantly increased as education level increased (P < 0.05).ConclusionsWomen with lower levels of education are at greater risk for severe maternal outcomes, even after adjustment for key confounding factors. This is particularly true for women in countries that have poorer markers of social and economic development.© 2014 RCOG The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

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