Maternal death

Maternal death
Classification and external resources
ICD-10	O95
ICD-9	646.9

A world map showing countries by maternal mortality, 2010.

Maternal death, or maternal mortality, also "obstetrical death" is the death of a woman during or shortly after a pregnancy. In 2010, researchers from the University of Washington and the University of Queensland in Brisbane, Australia, estimated global maternal mortality in 2008 at 342,900 (down from 526,300 in 1980), of which less than 1% occurred in the developed world.^[1] However, most of these deaths have been medically preventable for decades, as treatments to avoid such deaths have been well-known since the 1950s.

Maternal Mortality definition

According to the World Health Organization (WHO), "A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes."^[2]

Generally there is a distinction between a direct maternal death that is the result of a complication of the pregnancy, delivery, or their management, and an indirect maternal death that is a pregnancy-related death in a patient with a preexisting or newly developed health problem. Other fatalities during but unrelated to a pregnancy are termed accidental, incidental, or nonobstetrical maternal deaths.

Maternal mortality is a sentinel event to assess the quality of a health care system. However, a number of issues need to be recognized. First of all, the WHO definition is one of many; other definitions may also include accidental and incidental causes. Cases with "incidental causes" include deaths secondary to violence against women that may be related to the pregnancy and be affected by the socioeconomic and cultural environment. Also, it has been reported that about 10% of maternal deaths may occur late, that is after 42 days after a termination or delivery,^[3] thus, some definitions extend the time period of observation to one year after the end of the gestation. Further, it is well recognized that maternal mortality numbers are often significantly underreported.^[4]

Reducing the maternal mortality by three quarters between 1990 and 2015 is a specific part of Goal 5 -Improving Maternal Health - of the eight Millennium Development Goals; its progress is monitored at mdgmonitor.org^[5]

Major causes

As stated by the WHO in its 2005 World Health Report "Make Every Mother and Child Count", they are: severe bleeding/hemorrhage (25%), infections (13%), unsafe abortions (13%), eclampsia (12%), obstructed labour (8%), other direct causes (8%), and indirect causes (20%). Indirect causes such as malaria, anaemia,^[6] HIV/AIDS and cardiovascular disease, complicate pregnancy or are aggravated by it.

Forty-five percent of postpartum deaths occur within 24 hours.^[7] Over 90% of maternal deaths occur in developing countries. In comparison, pregnancy-associated homicide accounts for 2 to 10 deaths per 100000 live births, possibly substantially higher due to underreporting.^[8]

In developing countries, the most common cause of maternal death is obstetrical hemorrhage, followed by deep vein thrombosis, in contrast to developed countries, for which the most common cause is thromboembolism.^[9]

Unintended pregnancy is a major cause of maternal deaths. Worldwide, unintended pregnancy resulted in almost 700,000 maternal deaths from 1995 to 2000 (approximately one-fifth of the maternal deaths during that period).^[10] The majority (64%) resulted from complications from unsafe or unsanitary abortion.^[10]

Maternal Mortality Ratio (MMR)

Maternal Mortality Ratio is the ratio of the number of maternal deaths per 100,000 live births. The MMR is used as a measure of the quality of a health care system. Sierra Leone has the highest maternal death rate at 2,000, and Afghanistan has the second highest maternal death rate at 1900 maternal deaths per 100,000 live births, reported by the UN based on 2000 figures. According to the Central Asia Health Review, Afghanistan's maternal mortality rate was 1,600 in 2007.^[11] Lowest rates included Ireland at 0 per 100,000 and Austria at 4 per 100,000. In the United States, the maternal death rate was 11 maternal deaths per 100,000 live births in 2005.^[12] This rose to 13.3 per 100,000 in 2006.^[13] "Lifetime risk of maternal death" accounts for number of pregnancies and risk. In sub-Saharan Africa the lifetime risk of maternal death is 1 in 16, for developed nations only 1 in 2,800.

In 2003, the WHO, UNICEF and UNFPA produced a report with statistics gathered from 2000. The world average per 100,000 was 400, the average for developed regions was 20, and for developing regions 440. Countries with highest maternal mortality were: Sierra Leone (2,000), Afghanistan (1,900), Malawi (1,800), Angola (1,700), Niger (1,600), Tanzania (1,500), Rwanda (1,400), Mali (1,200), Somalia, Zimbabwe, Chad, Central African Republic, Guinea Bissau (1,100 each), Mozambique, Burkina Faso, Burundi, and Mauritania (1,000 each).

Associated risk factors

High rates of maternal deaths occur in the same countries that have high rates of infant mortality, reflecting generally poor nutrition and medical care.

Low birth weight of the child is correlated with maternal death from cardiovascular disease. Subtracting one pound of infant birth weight is correlated with the doubling of the risk of maternal death. Conversely, heavier child birth weight is correlated with lower risk of maternal death.^{[citation needed]}

Another issue that is associated with maternal mortality is the lack of access to skilled medical care during childbirth and the distance of traveling to the nearest clinic to receive proper care. In developing nations, as well as rural areas, this is especially true. Traveling to and back from the clinic is very difficult and costly, especially to poor families when time could have been used for working and providing incomes. Even so, the nearest clinic may not provide decent care because of the lack of qualified staff and equipment such as ones in the Guatemalan highlands.^[14]

Maternal death rates in the 20th century

The death rate for women giving birth plummeted in the 20th century.

The historical level of maternal deaths is probably around 1 in 100 births.^[15] Mortality rates reached very high levels in maternity institutions in the 1800s, sometimes climbing to 40 percent of birthgiving women. At the beginning of the 1900s, maternal death rates were around 1 in 100 for live births.^{[citation needed]} The number in 2005 in the United States was 11 in 100,000, a decline by two orders of magnitude,^[12] although that figure has begun to rise in recent years, having nearly tripled over the decade up to 2010 in California.^[16] The increase may be due to a change in reporting methods by the CDC in 1999. ^[17]

The decline in maternal deaths has been due largely to improved asepsis, fluid management and blood transfusion, and better prenatal care.^{[citation needed]} Recommendations for reducing maternal mortality include access to health care, access to family planning services, and emergency obstetric care, funding and intrapartum care.^[18]

A recent study showed that patients older than 34 yr and non-Hispanic black women were disproportionately represented. Common comorbidities included hypertensive disorders of pregnancy, previous Caesarean delivery, diabetes mellitus, preexisting hypertension, and multiple gestation.^[19] In this study, the authors examined both near-miss morbidity and actual mortality to increase numbers for analysis of morbidity and mortality associated with delivery. This article was also discussed on that journal's blog.^[20]

See also

• Endometritis
• List of women who died in childbirth
• Maternal health
• Maternal near miss
• Obstetrical Dilemma
• Perinatal mortality
• Puerperal fever
• Reproduction
• Reproductive health
• Stillbirth
• Unintended pregnancy
• Maternal mortality in fiction
• Global Library of Women's Medicine

References

1. ^ Hogan MC et al (2010). "Maternal mortality for 181 countries, 1980—2008: a systematic analysis of progress towards Millennium Development Goal 5". The Lancet 375 (9726): 1609–1623. doi:10.1016/S0140-6736(10)60518-1. 
2. ^ Maternal Mortality in Central Asia, Central Asia Health Review (CAHR), 2 June 2008
3. ^ Koonin, Lisa M.; Hani K. Atrash, Roger W. Rochat, Jack C. Smith (1 December 1988). "Maternal Mortality Surveillance, United States, 1980–1985". MMWR 37 (SS-5): 19–29. PMID 3148106. http://www.cdc.gov/mmwR/preview/mmwrhtml/00001754.htm. 
4. ^ Deneux-Tharaux, D; Berg C, Bouvier-Colle MH, Gissler M, Harper M, Nannini A, Alexander S, Wildman K, Breart G, Buekens P. (2005). "Underreporting of Pregnancy-Related Mortality in the United States and Europe". Obstet Gynecol 106 (4): 684–692. doi:10.1097/01.AOG.0000174580.24281.e6. PMID 16199622. 
5. ^ Monitor of Goal 5 of the Millennium Development Goals, accessed on 08-26-2008
6. ^ The commonest causes of anaemia are poor nutrition, iron and other micronutrient deficiencies, malaria, hookworm and schistosomiasis (2005 WHO report p45).
7. ^ Nour NM (2008). "An Introduction to Maternal Mortality". Reviews in Ob Gyn 1: 77–81. 
8. ^ Horon IL, Cheng D (November 2005). "Underreporting of pregnancy-associated deaths". Am J Public Health 95 (11): 1879; author reply 1879–80. doi:10.2105/AJPH.2005.072017. PMC 1449445. PMID 16195505. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1449445. 
9. ^ Venös tromboembolism (VTE) - Guidelines for treatment in C counties. Bengt Wahlström, Emergency department, Uppsala Academic Hospital. January 2008
10. ^ ^{a b} Promises to Keep: The Toll of Unintended Pregnancies on Women's Lives in the Developing World. http://www.globalhealth.org/news/article/2319. Retrieved 2009-01-22. 
11. ^ Maternal Mortality in Central Asia, Central Asia Health Review (CAHR), 2 June 2008.
12. ^ ^{a b} Maternal Mortality in 2005, accessed on 08-30-2008
13. ^ [1], accessed March 15, 2010
14. ^ Thaddeus, S; Maine D (1994). "Too far to walk: Maternal mortality in context". Social Science & Medicine 38 (8): 1091–1110. doi:10.1016/0277-9536(94)90226-7. PMID 8042057. 
15. ^ See for instance mortality rates at the Dublin Maternity Hospital 1784–1849
16. ^ Maternal Mortality Rates Rising in California ABC News Retrieved on March 4, 2010
17. ^ http://www.cdc.gov/nchs/data/series/sr_03/sr03_033.pdf Maternal Mortality and Related Concepts Vital Health Statistics, February 2007
18. ^ Costello, A; Azad K, Barnett S (2006). "An alternative study to reduce maternal mortality". The Lancet 368 (9546): 1477–1479. doi:10.1016/S0140-6736(06)69388-4. 
19. ^ <pmid>21934482</pmid>
20. ^ http://page2anesthesiology.org/2011/maternal-morbidity-and-mortality-also-in-the-united-states/#more-3307

External links

• Maternal Mortality in Central Asia, Central Asia Health Review (CAHR), 2 June 2008.
• Maternal Mortality Estimates 2000 by the WHO & UNICEF
• The World Health Report 2005 – Make Every Mother and Child Count
• Confidential Enquiry into Maternal and Child Health (CEMACH) - UK triennial enquiry into "Why Mothers Die"
• Reducing Maternal Mortality in Developing Countries - Video, presentations, and summary of event held at the Woodrow Wilson International Center for Scholars, March 2008
• Birth of a Surgeon PBS documentary about midwives trained in surgical techniques in Mozambique
• Save A Mother Non-profit focused on MMR reduction.
• The Global Library of Women's Medicine Safer Motherhood Section - non-profit offering freely downloadable material for healthcare professionals