Maternal mortality is a sensitive indicator of social inequalities and is closely linked to socioeconomic and marital status. In the former West Germany the risk of maternal death is 1.8 times higher in unmarried women than in married women,1 and being unmarried is closely associated with lower socioeconomic status.2
German reunification, which took place in 1990, was accompanied by major social and societal changes in the former East Germany. Overall fertility declined by 60% between 1989 and 1994, but the proportion of births to unmarried women rose progressively from 23% in 1980 to 42% in 1996. We examined the impact of marital status on maternal mortality in the period before and the period after German reunification in the area covered by the former East Germany (referred to in this article as eastern Germany).
Methods and results
We calculated the maternal mortality ratio by relating the number of maternal deaths (codes 630-676 according to the international classification of diseases, ninth revision) among women resident in eastern Germany in 1980-96 to the respective number of live births, using national register data. We investigated the effect of marital status, controlling for maternal age and year of death, in a Poisson regression model.
Altogether, 413 maternal deaths and 2.99 million live births were reported (table). The overall maternal mortality ratio was stable before, and declined after, reunification. Before reunification, unmarried women had a risk of maternal death equal to that of married women (table); after reunification, they had 2.6 times the age adjusted risk of married women. Unmarried status thus became a significant risk factor for maternal mortality in eastern Germany after reunification.
Comment
Maternal death registration in the former East Germany required panel review and compulsory postmortem examination and was regarded as nearly complete.3 At reunification, the more relaxed reporting system of the former West Germany was adopted. As no evidence exists of major differences in accessibility or quality of obstetric care in the former East Germany compared with eastern Germany after reunification, the decrease in overall maternal mortality after reunification probably reflects more incomplete reporting. The observed emergence of a higher relative risk among unmarried women is less likely to be an artefact: the definition of marital status in data for eastern Germany has remained unchanged over the study period, and a change in the completeness of reporting of maternal deaths is unlikely to be associated with marital status.
Two phenomena, however, show a distinct temporal association with, and could thus help to explain, the emergence of unmarried status as a marker of increased maternal risk in eastern Germany: changes in support programmes for pregnant women and mothers, and socioeconomic changes. Support measures in the former East Germany included cash incentives to women who regularly attended prenatal care; a follow up of women who did not attend4; and a guaranteed job for women with children. Single mothers were guaranteed social protection and support by the constitution.5 After reunification these measures were eliminated. In eastern Germany in particular, job security is now very low and the number of crèches is declining sharply. Concurrently, being unmarried became associated with lower socioeconomic status, as was already the case in the former West Germany.2,5 For example, in unified Germany, 22% of unmarried mothers but only 2% of married mothers with children aged under 18 years received social welfare payments in 1996.1
After reunification, unmarried mothers in the study area emerged as a group with higher maternal risk and lower socioeconomic status, similar to unmarried women in the former West Germany.1 As an increasing proportion of all births occur outside marriage both in Germany and in many other countries, further research is needed to establish to what degree the special support services in the former East Germany contributed towards a measure of health equity among pregnant women, regardless of marital status.
Table.
Demographic data and relative risk of maternal death by marital status, eastern Germany
| Variable | Before reunification, 1980-90 | After reunification, 1991-6 |
|---|---|---|
| Demography: | ||
| Total No of live births (No and proportion of unmarried women) | 2 453 627 (767 619; 31.3%) | 532 394 (222 126; 41.7%) |
| Total No of maternal deaths (No and proportion of cases of unmarried women) | 368 (102; 27.7%) | 45 (26; 57.8%) |
| Overall crude maternal mortality ratio per 100 000 live births (95% CI) | 15 (13.5 to 16.6) | 8.5 (6.3 to 11.3) |
| Modelling: | ||
| Crude relative risk of unmarried v married women (95% CI) | 0.84 (0.67 to 1.06) | 1.91 (1.06 to 3.45)† |
| Age adjusted relative risk of unmarried v married women (95% CI) | 1.08 (0.85 to 1.36) | 2.56 (1.41 to 4.63)‡ |
CI=confidence interval.
P=0.01 in the χ2 test for unequal rate ratios.
P=0.01 in the likelihood ratio test for interaction between marital status and time period of death.
Acknowledgments
We thank Ms Köhn of the Statistical Office in Berlin and Mr Hammer of the Federal Statistical Office in Wiesbaden for providing the data on live births and mortality. Matthias Borchert gave helpful comments on an earlier version of this paper.
Footnotes
Funding: None.
Competing interests: None declared.
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