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. - World Health Organization.

In 2000, the UN estimated global maternal mortality at 529,000, of which less than 1% occurred in the developed world. Most of these deaths have been preventable for decades, because treatments to avoid such deaths have been well known since the 1950s.

According to the CDC, maternal mortality in the USA fell as in the following graph:

UK Figures

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 pre-existing or newly developed health problem. Other fatalities during but unrelated to a pregnancy are termed accidental, incidental, or non-obstetrical maternal deaths.

The major causes of maternal death are:-

  • bacterial infection,
  • variants of gestational hypertension including pre-eclampsia and HELLP syndrome,
  • obstetrical hemorrhage,
  • ectopic pregnancy,
  • puerperal sepsis,
  • amniotic fluid embolism,
  • and complications of unsafe or unsanitary abortions.

Lesser known causes of maternal death include:-

  • renal failure,
  • cardiac failure, and
  • hyperemesis gravidarum.


Over 90% of maternal deaths occur in developing countries.

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.[7]

Lowest rates included Iceland 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.[8]

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.

United Kingdom

In the UK, maternal mortality rates can be calculated in two ways:

1. Through official death certification to the Registrars General (the Office for National Statistics and its equivalents).
2. Through deaths reported to the Confidential Enquiry into Maternal and Child Health (CEMACH).2 A report is produced every 3 years.

The overall maternal death rate for the Enquiry is calculated from the number of deaths assessed as being due to Direct and Indirect deaths.

  • Direct deaths are defined as those related to obstetric complications during pregnancy, labour or puerperium (6 weeks) or resulting from any treatment received.
  • Indirect deaths are those associated with a disorder the effect of which is exacerbated by pregnancy.
  • Late deaths occur ≥ 42 days after end of pregnancy.

Most maternal mortality occurs in developing world with >500,000/year.4,5 Risk factors for maternal deaths in the UK include:

  • Social disadvantage:
    Women living in families where both partners were unemployed, where social exclusion was an associated problem, were up to 20 times more likely to die than women from the more advantaged groups. In addition, single mothers were three times more likely to die than those in stable relationships.
  • Poor communities:
    Women living in the most deprived areas had a 45% higher death rate than women living in the most affluent areas.
  • Minority ethnic groups:
    Women from ethnic groups were, on average, three times more likely to die than caucasian women. Black African women, including asylum seekers and newly arrived refugees had a mortality rate seven times higher than caucasian women. These groups were shown to have had major problems in obtaining obstetric care. This disparity in mortality rates between ethnic groups has been noted in other affluent societies.6
  • Late booking or poor attendance:
    20% of the women who died from Direct or Indirect causes booked for maternity care after 22 weeks of gestation, or had missed over four routine antenatal visits.
  • Delayed pregnancy:
    In 2003-05 the increase in the numbers and proportion of maternities which were to women aged 35 and over continued.
  • Obesity:
    There is an increasing trend for greater BMI.
  • Domestic violence:
    14% of all the women who died declared that they were subject to violence in the home.
  • Substance abuse:
    8% of all the women who died were substance misusers.
  • Suboptimal clinical care:
    67% of the women who died were considered to have some form of suboptimal clinical care.

Lack of inter-professional and/or inter-agency communications:
There were many cases where the care provided to the women who died was hampered by a lack of cross-disciplinary working. In several cases crucial clinical information, which may have affected the outcome, was not passed from the GP to the midwifery or obstetric services, or shared between consultants in other specialities.

Management

It is the responsibility of the GP or community midwife to notify the local Director of Public Heath.

If death occurs in hospital a co-ordinator, usually a midwife, should be appointed.
They should perform the following and keep a complete record of all actions:

  • Ensure relatives have a suitable member of staff as a single contact point.
  • Consultant on-call should see relatives as soon as possible and woman's own consultant told of death as soon as next in hospital.
  • Supervisor of midwives is informed.
  • Mortuary and pathologist on duty informed.
  • Try to obtain permission from next-of-kin for post-mortem examination to confirm cause of death (coroner may direct one performed if any doubt). N.B. If there a dead fetus in utero, there is no legal requirement for a death certificate but one can often be supplied if wished.
  • Ask relatives if they would like to see a culturally appropriate religious adviser.
  • All relevant documents are sent to the coroner.

Consider offering support to staff involved.

 

Maternal death rates in the 20th century

The death rate for women giving birth has fallen dramatically in the 20th century.

The historical level of maternal deaths is probably around 1 in 100 births.

Mortality rates reached horrible proportions 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.

The number today in the United States is 11 in 100,000.


The decline in maternal deaths has been due largely to improved

  • asepsis,
  • use of caesarean section,
  • fluid management and blood transfusion,
  • better prenatal care.

Maternal mortality: an enduring epidemic. (2009)

Women's Health


This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.


women's health