MATERNAL MORTALITY

The Dimensions of the Problem

What is a Maternal Death?

A maternal death is the death of a women while pregnant or within 42 days of termination of pregnancy, regardless of the site or duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management. Maternal deaths are subdivided into direct and indirect obstetric deaths.

Direct obstetric deaths result from obstetric complications of pregnancy, labour, or the postpartum period. They are usually due to one of five major causes - haemorrhave (usually occuring postpartum), sepsis, ecalmpsia, obstructed labour and complications of unsafe abortion - as well as interventions, omissions, incorrect treatment, or events resulting from any of these. Indirect obstetric deaths result from previously existing diseases or from diseases arising during pregnancy (but without direct obstetric causes), which were aggravated by the physiological effects of pregnancy; examples of such diseases include malaria, anaemia, HIV/AIDS and cardiovascular disease.

Measures of Maternal mortality

Maternal mortality ratio/rate represents the risk associated with each pregnancy, i.e. the obstetric risk. It is calculated as the number of maternal deaths during a given year per 100 000 live births during the same period. Although the measure has traditionally been referred to as a rate it is actually a ratio and is now usually called such by researchers.

Where do maternal deaths occur?

The settings where the problem of maternal mortality is most acute are precisely those where it is least likely to be accurately measured.

The first estimates of the extent of maternal mortality around the world were made in the late 1980s. They indicated that globally some 500 000 women die each year from pregnancy related causes. In 1996, WHO and UNICEF revised the estimates for 1990 on the basis of the growing volume of information that has become available in recent years. These new estimates showed that the scale of the problem was significantly greater than had originally been suspected and that closer to 600 000 maternal deaths occur each year, with the overwhelming majority of them in developing countries. In developed countries, the maternal mortality ratio averages around 27 maternal deaths per 100 000 live births; in developing countries the ratio is nearly 20 times higher, at 480 per 100 000, and may be as high as 1000 per 100 000 in some regions.

The maternal mortality ratio is a measure of the obstetric risk faced by a women each time she becomes pregnant. Where women have many pregnancies, the risk of maternal death is magnified. In some developing countries one women in 12 may die from a pregnancy-related problem compared with one in 400 in industrialized settings. The discrepancy between these two figures marks one of the starkest and most telling differentials in development. It also reflects huge differences in national commitment, not only between developed and developing countries, but also between different developing countries, where it is far wider than differentials in infant or child mortality.

Why do women die?

The medical causes of maternal deaths are similar throughout the world.

Globally, around 80% of all maternal deaths are the direct result of complications arising during pregnancy, delivery or the puerperium. The single most common cause - accounting for a quarter of all maternal deaths - is severe bleeding, generally occuring postpartum.

Cause of Maternal Deaths

* Haemorrhage 25%

* Sepsis 15%

* Eclampsia 12%

* Obstructed labour 8%

* Unsafe abortion 13%

* Other direct causes 8%

* Indirect causes 20%

* Haemorrhage, specialy postpartum haemorrhage, is unpredictable, sudden in onst, are more dangerous when a women is anaemic. Globally, some 25% of all maternal deaths are due to haemorrhage. Blood loss can very rapidly lead to death in the absence of prompt and appropriate life-saving care which includes the administration of drugs to control bleeding, massage of the uterus to stimulate contractions and blood transfusion if necessary.

* Sepsis, which is often a consequence of poor hygiene during delivery or of untreated sexually transmitted diseases (STDs), accounts for some 15% of maternal deaths. Such infections can be effectively prevented by careful attention to clean delivery and by detection and management of STDs during pregnancy. Systematic postpartum care will ensure rapid detection of infection and its management by appropriate antibiotics.

* Hypertensive disorders of pregnancy. particularly eclampsia (convulsions), are the cause of approximately 12% of all maternal deaths. Deaths from hypertensive disorders can be prevented by careful monitoring during pregnancy and by treatment with relatively simple anticonvulsant drugs in cases of eclampsia.

* Prolonged or obstructed labour accounts for about 8% of maternal deaths. This is often caused by cephalopelvic disproportion (when the infant's head cannot pass through the maternal pelvis) or by abnormal lie (when the infant is incorrectly positioned for passage through the birth canal). Disproportion is more common where malnutrition is endemic, especially among populations with various traditions and taboos regarding the diets of girls and women. It is worse where girls marry young and are expected to prove their fertility, often before they are fully grown.

* Complications of unsafe abortion are responsible for a sustantial proportion (13%) of maternal deaths. In some parts of the world, one-third or more of all maternal deaths are associated with unsafe abortions. These deaths can be prevented if women have access to family planning information and services, care for abortion-related complications, and where abortion is not prohibited by law, safe abortion care.

Indirect Causes

Approximately 20% of maternal deaths are the result of preexisting conditions that are exacerbated by pregnancy or its management. One of the most significant of these indirect causes of death is anaemia which, as well as causing death through cardiovascular arrest, is thought also to underlie a substantial proportion of direct deaths (particularly those due to haemorrhage and sepsis). Other important indirect causes of death include malaria, hepatitis, heart diseases, and increasingly in some settings, HIV/AIDS. Many of these conditions are relatively or absolute contraindications for pregnancy. Women need to be informed of these problems and enabled to prevent further pregnancies while the conditions are being treated.