Causes of High Maternal Mortality

Maternal death
"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." WHO 2000. One definition of many; others include accidental and incidental causes. Cases with "incidental causes" include deaths secondary to violence that may be related to the pregnancy and be affected by the socioeconomic and cultural environment. 10% of maternal deaths occur late - 42 days after a termination or delivery hence 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 (2).e
There are however distinctions made between a irect 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 pre-existing or newly developed health problem. Other deaths during but unrelated to a pregnancy are often termed accidental, incidental, or nonobstetrical maternal deaths.
Major causes
The major causes of maternal death are bacterial infection, toxemia, obstetrical hemorrhage, ectopic pregnancy, puerperal sepsis, amniotic fluid embolus, and complications of abortions.
As stated by the 2005 WHO report "Make Every mother and Child Count" they are: severe bleeding/hemorrhage (25%), infections (13%), eclampsia (12%), obstructed labour (8%), complications of abortion (13%), other direct causes (8%), and indirect causes (20%). Indirect causes such as malaria, anaemia, HIV/AIDS and cardiovascular disease, complicate pregnancy or are aggravated by it.
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. Lowest rates included Iceland at 10 per 100,000 and Austria at 4 per 100,000. In the United States, the maternal death rate was 17 maternal deaths per 100,000 live births in 2000. "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 MMR for each country is listed here: World Health Organisation Reproductive Indicators
The maternal mortality ratio is often referred to as the maternal mortality rate. This is actually a misnomer as it is in fact a ratio, and not a rate at all.
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 increases the risk of maternal death from cardiovascular disease. Subtracting one pound of infant birth weight doubles the risk of maternal death. Therefore, the heavier the birth weight of child, the lower the risk of maternal death.
Maternal death rates in the 20th century
The death rate for women giving birth plummeted in the 20th century.
At the beginning of the century, maternal death rates were around their historical level of nearly 1 in 100 for live births. The number today in the United States is 1 in 10,000, a 99% decline.
The decline in maternal deaths has been due largely to improved asepsis, use of caesarean section, fluid management and blood transfusion, and better prenatal care.

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It is well known that regional maternal mortality and morbidity is very high. Although Member Countries have made concerted efforts, the problem seems intractable. It also appears that in reality, the problem may be far worse than is indicated by official statistics.
The impression of the first sight of our children at birth is something that will be enduring, indelible in our memories to be cherished as long as we live. The miracle of birth is an experience that health workers never tire of. The birth of a child brings indescribable joy especially to the mother, the father, the family, the community and also the health workers attending the mother antenatally, and during birth. On the contrary, a maternal death is a devastating event for the husband, the family, the community and also the health workers who attended on the mother. The tragedy of a maternal death has been put into verse and song. The well-known singer Nana Mascouri expresses her feelings in one of her songs, where she says, "some times I feel like a motherless child".
The Context
Preventing maternal mortality is one of the cardinal goals of maternal and child health services and obstetrics. The godfather of the quest to reduce maternal mortality in Sri Lanka is Dr Nalin Rodrigo, the well-respected doyen of obstetricians. In his introduction to the preface to the publication, "maternal deaths in Sri Lanka" he opines, "to obstetricians, maternal mortality is not about numbers. It is about making safe for women, the life enhancing process of giving birth. Safety depends on women's own ability to seek care and the service providers’ ability to provide timely and quality care. Almost every maternal death is an event that could have been avoided. Such deaths should never have been allowed to happen in the first instance. There was a dramatic drop in the MMR in Sri Lanka, from 1 652 / 100 000 live births in 1945, to 23 in 1996 (1). Although we are proud of the remarkable achievements Sri Lanka has made in reducing maternal mortality and morbidity over the past decades, much more remains to be done.
Complex emergencies
During the last two decades, Sri Lanka experienced a complex emergency. Maternal and child health care services were disrupted to a large extent. Antenatal and natal care suffered and maternal mortality in the affected areas was regrettably, estimated at more than thrice in the rest of the country. (2)
Review of maternal deaths
Every maternal death in this country is reviewed at least at two levels if not more. The Medical Officer of Health, who is in charge of the MCH services at the field level, carries out a confidential inquiry into every single maternal death. A committee chaired by the Director-General of Health Services and consisting of high-level officials of the Ministry of Health, representatives of the College of Obstetricians and Gynaecologists (SLCOG), the provincial administration and family health workers concerned, review every maternal death. In addition, some of the districts and provinces have their own maternal mortality reviews. In most teaching hospitals, it is an annual event. These reviews have given us regular and deep insights into the secular changes in rates as well as the contributory causes of maternal deaths. The findings have been ploughed back into the system to address operational deficiencies. We have found these exhaustive reviews to be extremely useful. Of course, the findings have never, ever, been used for disciplinary purposes.
Review of estimates and causes
There is considerable difficulty, even in developed countries, in recognizing maternal deaths, with consequent under-estimation. The SLCOG assisted by UNICEF carried out a study to obtain an accurate estimate of maternal deaths in 1996.(3) The study also reviewed the factors contributing to maternal deaths focusing on the patient’s responsibility to seek care and the institutional responsibility to provide care.
By a process of pooling of information from all maternal death reviews, 312 maternal deaths were estimated to have occurred in 1996. This is 3.9 times the number reported by the civil registration system. Some of the reasons for the under-estimation were found to be:
Non-receipt of registration docu-ment by Registrar-General’s Depart-ment (81 out of 312 deaths).
Inaccurate reporting of cause of deaths. (More than 75% of non-identified deaths).
Errors in coding of causes of deaths (25%).

Categories of causes
A significant 23.7% were indirect causes (commonest heart disease). Anaemia was an important cause in the plantation sector. Postpartum haemorrhage was by far the leading direct cause of death followed by hypertensive disorders of pregnancy. A significant finding was that abortion was the third leading direct cause (the great majority are criminal abortions).
Contributory factors
Deaths were, as expected, predominantly from the disadvantaged and socially marginalized groups. Failure to seek timely care and disregarding of medical advice on contraception, even when affected by life threatening conditions, was a disconcerting finding. Evidently, they disregarded medical advice because of overwhelming domestic problems and paid the supreme penalty. Institutional failures accounted for an unacceptable proportion of deaths.
The combined maternal mortality ratio estimated for the three areas was 433 deaths per 100,000 live births. The ratio ranged from a low of 281 deaths per 100,000 live births in Karachi (where access to health care is excellent) to a high of 673 deaths per 100,000 live births in the Khuzdar province of Balochistan (where access is poor).
The majority of maternal deaths (78%) were directly attributable to pregnancy; the most common causes were hemorrhage (53%), sepsis (16%) and eclampsia (14%). The distribution of causes of maternal death was similar across regions, although eclampsia had caused maternal deaths almost twice as often in Karachi as in Balochistan or the North West Frontier Province (23% vs. 13% and 11%). Hemorrhage-related maternal deaths were most common in the North West Frontier Province (55%); deaths from sepsis occurred most frequently in Balochistan and eclampsia-related deaths were most common in Karachi (23%).
According to a multiple logistic regression analysis, women who lived in houses made of wood or mud were twice as likely as other women to die of maternal causes and those who did not have access to drinkable water were 50% more likely to die (odds ratio 1.5). Living 40 miles or more from the nearest hospital was only marginally significant as a predictor of maternal death (1.3).
Compared with women aged 25-39, those younger than 20 were three times as likely to die and those aged 20-24 years were almost twice as likely to die of maternal causes. Women who had had eight or more live births were 1.6 times as likely to die as women who had had 2-7 births. In addition, women who had had a previous stillbirth or abortion were more than five times as likely to die from pregnancy-related causes (odds ratio, 5.3).
Using odds ratios, the researchers calculated the proportion by which the incidence of maternal deaths would be reduced if exposure to each social, environmental and demographic risk factor was eliminated. According to this measure, maternal deaths resulting from a poor previous pregnancy outcome would be reduced by 44% and those from poor housing construction material by 42%. When young age, associated in the logistic regression analysis with increased odds of dying, was eliminated, the calculated population-attributable risk indicated an 11% reduction in deaths to women aged 20-24 and a 5% reduction in deaths to women younger than 20. Having had a large number of births was highly significant in the logistic regression analysis, but was only moderately important according to the population-attributable risk. Deaths to women who had had a large number of births were reduced by 12%.
The investigators point out that 80% of the maternal deaths were the result of direct causes and were therefore preventable, especially the 42% caused by hemorrhage. They note that poor housing construction material and lack of access to drinkable water "are proxy indicators for poor socioeconomic status." They concluded that focusing on high-risk groups of pregnant women and training, monitoring and supervising birth attendants in the provision of medications that hasten labor would "go a long way in decreasing the proportion of maternal deaths attributed to direct, avoidable causes.