Maternal death

According to the World Health Organization (WHO), 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 management of the two, and an indirect maternal death that is a pregnancy-related death in a patient with a preexisting or newly developed health problem unrelated to pregnancy. Fatalities during but unrelated to a pregnancy are termed accidental, incidental, or nonobstetrical maternal deaths.

The U.S. Joint Commission on Accreditation of Healthcare Organizations calls maternal mortality a "sentinel event", and uses it 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 only one of many; other definitions may 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 period of observation to one year after the end of gestation.

Causes

As stated by the WHO in its 2005 World Health Report "Make Every Mother and Child Count", the major causes of maternal deaths 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 are malaria, anaemia,^[4] HIV/AIDS, and cardiovascular disease, all of which may complicate pregnancy or be aggravated by it.

Forty-five percent of postpartum deaths occur within 24 hours.^[5] Over 90% of maternal deaths occur in developing countries. In comparison, pregnancy-associated homicide accounts for 2 to 10 deaths per 100,000 live births, possibly substantially higher due to underreporting.^[6]

In developing countries, the most common cause of maternal death is obstetrical hemorrhage, followed by hypertensive disorders of pregnancy, in contrast to developed countries, for which the most common cause is thromboembolism.^[7]

Unintended pregnancy is a major cause of maternal death. Globally, preventable deaths from improperly performed procedures constitute 13% of maternal mortality, and 25% or more in some countries where maternal mortality from other causes is relatively low, making unsafe abortion the leading single cause of maternal mortality worldwide.^[8]

Risk factors

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

Prevention

Most maternal deaths are avoidable, as the health-care solutions to prevent or manage complications are well known. All women need is access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth. It is particularly important that all births be attended by skilled health professionals, as timely management and treatment can make the difference between life and death. Poor women are more prone to maternal death due to lack of healthcare and health insurance. Depending on where these women are located, it may be too far for them to get to a hospital and seek the proper care that they need. To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at all levels of the health system.^[9]

A hugely disproportionate number of maternal deaths occur in sub-Saharan Africa. There has been a general improvement in maternal mortality recently, but some countries are performing better than others. Researchers at the Overseas Development Institute studied maternal health systems in four apparently similar countries: Rwanda, Malawi, Niger, and Uganda.^[10] In comparison to the other three countries, Rwanda has an excellent recent record of improving maternal death rates. Based on their investigation of these varying country case studies, the researchers conclude that improving maternal health depends on three key factors: 1. reviewing all maternal health-related policies frequently to ensure that they are internally coherent; 2. enforcing standards on providers of maternal health services; 3. any local solutions to problems discovered should be promoted, not discouraged.

Public health

Reducing the maternal mortality by three quarters between 1990 and 2015 is the first target of Goal 5 — Improving Maternal Health — of the eight Millennium Development Goals; its progress is monitored at mdgmonitor.org^[11]

Proportionally, aid given to improve maternal mortality rates has shrunk as other public health issues, such as HIV/AIDS, have become major international concerns. This can be viewed at . Maternal health aid contributions tend to be lumped together with newborn and child health, so it is difficult to assess how much aid is given directly to maternal health to help lower the rates of maternal mortality. Regardless, there has been progress in reducing maternal mortality rates internationally as can be viewed .

Epidemiology

Maternal Mortality Rate worldwide (2010)^[1]

A maternal death is described by the CIA World Factbook as any death during pregnancy, childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy.^[1] In 2011, there were approximately 273,500 maternal deaths (uncertainty range, 256,300 to 291,700).^[12] Maternal Mortality Ratio (MMR), is the ratio of the number of maternal deaths (excluding accidental or incidental causes) per 100,000 live births for a specified year. Maternal Mortality Rate is the number of maternal deaths (excluding accidental or incidental causes) per 100,000 women of reproductive age for a specified year. The MMR is used as a measure of the quality of a health care system.

In 2010, countries with highest maternal mortality were Chad (1,100), Somalia (1,000), Central African Republic, (890), Sierra Leone (890) and Burundi (800).^[1]

Lowest rates included Estonia at 2 per 100,000 and Singapore at 3 per 100,000. In the United States, the maternal death rate averaged 9.1 maternal deaths per 100,000 live births during the years 1979-1986,^[13] but then rose rapidly to 14 for every 100,000 patients in 2000 to 24 per every 100,000 patients in 2008.^[14] "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.

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 (see Historical mortality rates of puerperal fever). At the beginning of the 1900s, maternal death rates were around 1 in 100 for live births. The number in 2005 in the United States was 11 in 100,000, a decline by two orders of magnitude,^[16] although that figure has begun to rise in recent years, having nearly tripled over the decade up to 2010 in California.^[17] A maternal mortality rate for the U.S. of 24 per 100,000 was reported for 2008.^[1] This change might not actually reflect an increase, due to a change in reporting methods by the CDC in 1999.^[18]

The decline in maternal deaths has been due largely to improved asepsis, fluid management and blood transfusion, and better prenatal care. Recommendations for reducing maternal mortality include access to health care, access to family planning services, and emergency obstetric care, funding and intrapartum care.^[19] Reduction in unnecessary obstetric surgery has also been suggested.

See also

• List of famous women who died in childbirth
• Maternal near miss
• Perinatal mortality
• Obstetric transition
• Maternal mortality in fiction

References

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