OBJECTIVES
When you have completed this unit you should be able to:
- Define and calculate maternal mortality rate.
- List the important causes of maternal mortality.
- Interpret maternal mortality rates.
- Separate direct and indirect causes of maternal death.
- Describe the confidential enquiry into maternal deaths.
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COPYRIGHT
All rights reserved. No part of this Perinatal Education Programme may be altered in any way, nor may copies of the complete Programme be made, without the written permission of the editorial board of the Perinatal Education Trust. To facilitate the improvement of perinatal care in Southern Africa, however, parts of the Programme may be reproduced for teaching purposes provided due acknowledgement is given and the material is not sold for financial profit. While the advice and information in the Programme are believed to be accurate, the editorial board cannot accept responsibility or liability for any errors or omissions that may have been made.
ISBN 0 7992 2141 4
47-1 WHAT IS MATERNAL MORTALITY?
Maternal mortality means the death of a woman during pregnancy (i.e. conception to delivery) and the puerperium (i.e. up to 42 days after delivery). It includes deaths due to miscarriages (abortions) and ectopic pregnancies.
*** A maternal death includes the death of any woman from causes related to, or aggravated by, pregnancy or its management, but not from accidental or incidental causes.
| A MATERNAL DEATH IS DEFINED AS THE DEATH OF A WOMAN AT ANY TIME BETWEEN THE CONCEPTION OF HER INFANT AND 42 DAYS AFTER THE DELIVERY OF THE INFANT |
47-2 WHAT IS THE MATERNAL MORTALITY RATE?
The maternal mortality rate (MMR) is defined as the number of women dying between conception and 6 weeks (42 days) after delivery per 100 000 deliveries. The maternal mortality rate is calculated as follows:
Total number of maternal deaths x 100 000
Total number of deliveries
The maternal mortality rate is usually given for a specific area and a specific period of time. For example, if 10 women die in Cape Town where the annual delivery rate is 50 000, then the maternal mortality rate is:
10 x 100 000 = 20
50 000
Note that the maternal mortality rate is expressed per 100 000 deliveries. Sometimes the maternal mortality rate is also called the maternal mortality ratio.
47-3 WHY DOES MATERNAL MORTALITY INCLUDE THE DEATHS OF WOMEN DURING THE FIRST FEW MONTHS OF PREGNANCY?
Because pregnancy effects the mother's body soon after the start of pregnancy. Problems which occur early in pregnancy, such as ectopic pregnancies and septic abortions, can result in the mother's death.
47-4 WHY DOES THE MATERNAL MORTALITY RATE INCLUDE THE DEATHS OF WOMEN DURING THE 6 WEEKS AFTER DELIVERY?
Because the effects of pregnancy on the mother's body take up to 6 weeks to disappear. Deaths during the puerperium (6 weeks after delivery) are often as a result of complications of pregnancy.
47-5 WHAT IS THE IMPORTANCE OF THE MATERNAL MORTALITY RATE?
It is a very important method of assessing both the standard of health of pregnant women and the standard of care being provided to pregnant women. The maternal mortality rate can also be compared between different areas or between different periods of time in the same area.
A high maternal mortality rate usually indicates either poor maternal health or inadequate care during the pregnancy and puerperium or both. In contrast, a low maternal mortality rate indicates that both maternal health and health care are good.
| THE MATERNAL MORTALITY RATE REFLECTS BOTH THE GENERAL HEALTH OF WOMEN AS WELL AS THE STANDARD OF CARE DURING PREGNANCY AND THE PUERPERIUM |
47-6 WHAT IS THE MATERNAL MORTALITY RATE IN INDUSTRIALISED COUNTRIES?
In industrialised countries, or privileged areas in poor countries, the maternal mortality rate is usually about 10 per 100 000 deliveries. Therefore, it is very uncommon for a woman to die during pregnancy or the puerperium.
*** In 1994-1996 the MMR for the United Kingdom was
12.2/100 000.
47-7 WHAT IS THE MATERNAL MORTALITY RATE IN POOR COUNTRIES?
In poor countries the maternal mortality rate is usually above 50 per 100 000 deliveries. The maternal mortality rate varies widely between poor countries with some very undeveloped communities having a rate as high as 1000 per 100 000.
In many poor areas of industrialised countries the maternal mortality rate is also increased. Worldwide, most maternal deaths occur in poor countries where the death is usually related to poverty and inadequate access to good health care services.
In most poor developing countries the collection of mortality information is very incomplete, making it difficult to calculate the accurate maternal mortality rate.
47-8 WHEN IS THE CAUSES OF A MATERNAL DEATH DETERMINED?
Each maternal death must be discussed in detail to determine the cause and decide whether it could have been prevented. This is usually done at the regular perinatal mortality meeting. It is important to discuss the death as soon as possible while the details of the clinical problems and care are still remembered. The findings of each death must be carefully summarised and included in the maternal mortality report. This is usually prepared annually for each health region.
47-9 WHAT IS THE MATERNAL MORTALITY RATE IN SOUTH AFRICA?
The exact maternal mortality rate in South Africa is not known, as many maternal deaths are still not registered. However, the estimated maternal mortality rate is 150/100 000 deliveries. The maternal mortality rate varies between different districts from as low as 50 to as high as 300.
| THE ESTIMATED MATERNAL MORTALITY RATE FOR SOUTH AFRICA IS 150/ 100 000 |
*** It is important to know the maternal mortality rate in the country where you work.
47-10 ARE MATERNAL DEATHS NOTIFIABLE?
Yes. All maternal deaths are notified by law in South Africa. This includes maternal deaths at home and in private institutions. It is important to include maternal deaths which occur outside the maternity services, e.g. women who have not yet started antenatal care and women who die in medical, surgical or emergency departments.
*** In South Africa in 1977 all maternal deaths were made notifiable.
47-11 WHAT ARE PRIMARY AND FINAL CAUSES OF MATERNAL DEATH?
The primary cause of maternal death is the obstetric factor or condition which lead to the death, i.e. it is the reason why the death occurred. Knowing the primary causes of death helps to identify clinical practices which need to be improved. Deaths can be prevented if the primary causes are well managed.
The final cause of maternal and neonatal death is the event which actually caused the death (a final complication of the disease process), i.e. how the patient died. Knowing the final causes of death helps to identify facilities and resources which need to be improved. It also helps to prevent or improve the management of conditions which can be final causes of death.
For example, if a pregnant woman has a severe antepartum haemorrhage from a placenta praevia and dies of hypovolaemic shock, the primary cause of death is antepartum haemorrhage and the final cause of death is hypovolaemic shock. Similarly, if a woman has eclampsia and dies of a brain haemorrhage, the eclampsia is the primary cause and the brain bleed is the final cause of death.
A list of primary and final causes of maternal death are given in the appendix at the end of this unit.
47-12 HOW CAN THE PRIMARY CAUSES OF MATERNAL DEATHS BE SUBDIVIDED?
The primary causes of maternal deaths are subdivided into 3 groups:
- Direct.
- Indirect.
- Fortuitous.
Usually a forth group called "Unknown" is added. These are maternal deaths where the cause of death cannot be identified.
47-13 WHAT ARE DIRECT CAUSES OF MATERNAL DEATH?
These are deaths which are a direct result of the woman being pregnant. They result from complications of pregnancy or the puerperium, or the management of the pregnancy or pueperium. These deaths would not have happened if the woman had not been pregnant. An example of a direct cause of maternal death is eclampsia.
*** Direct deaths result from obstetric complications of the pregnancy state, from interventions, omissions, incorrect treatment or from a chain of events of any of these.
47-14 WHAT ARE INDIRECT CAUSES OF MATERNAL DEATH?
These are deaths are caused by diseases that existed before the pregnancy or developed during the pregnancy or puerperium. Although not a result of pregnancy or puerperium complications, the pregnant state aggravated the condition. If the woman had not been pregnant, she may not have died from the disease. An example of an indirect cause of maternal death is rheumatic heart disease which became worse during the pregnancy, leading to heart failure.
*** Indirect deaths result from previous existing disease or disease that developed during pregnancy which were not due to direct obstetric causes but which were aggravated by the physiological effects of pregnancy.
47-15 WHAT ARE FORTUITOUS CAUSES OF MATERNAL DEATH?
These are deaths that were unrelated to the pregnancy or puerperium and just happened to occur at this time. The condition causing the death was not aggravated by the pregnancy and would have killed the women even if she had not been pregnant. Examples of fortuitous causes of maternal death include motor vehicle accidents and assault.
Although fortuitous causes of maternal death are recorded in South Africa, they are not included in calculating the maternal mortality rate. Fortuitous deaths are counted to document the extent of violence against women, accidents and suicides.
47-16 IS A CAUSE FOUND FOR ALL DEATHS DURING PREGNANCY AND THE PUERPERIUM?
No. Unfortunately the underlying cause sometimes is unknown. This is often because the history is incomplete and a post mortem examination was not done.
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