Maternal death or maternal mortality is defined in slightly different ways by several different health organizations. The World Health Organization (WHO) defines maternal death as the death of a pregnant mother due to complications related to pregnancy, underlying conditions worsened by the pregnancy or management of these conditions. This can occur either while she is pregnant or within six weeks of resolution of the pregnancy. The CDC definition of pregnancy-related deaths extends the period of consideration to include one year from the resolution of the pregnancy. Pregnancy associated death, as defined by the American College of Obstetricians and Gynecologists (ACOG), are all deaths occurring within one year of a pregnancy resolution. Identification of pregnancy associated deaths is important for deciding whether or not the pregnancy was a direct or indirect contributing cause of the death.
There are two main measures used when talking about the rates of maternal mortality in a community or country. These are the maternal mortality ratio and maternal mortality rate, both abbreviated as "MMR". By 2017, the world maternal mortality rate had declined 44% since 1990; however, every day 808 women die from pregnancy or childbirth related causes. According to the United Nations Population Fund (UNFPA) 2017 report, about every 2 minutes a woman dies because of complications due to childbirth or pregnancy. For every woman who dies, there are about 20 to 30 women who experience injury, infection, or other birth or pregnancy-related complications.
UNFPA estimated that 303,000 women died of pregnancy or childbirth-related causes in 2015. The WHO divides causes of maternal deaths into two categories: direct obstetric deaths and indirect obstetric deaths. Direct obstetric deaths are causes of death due to complications of pregnancy, birth or termination. For example, these could range from severe bleeding to obstructed labor, for which there are highly effective interventions. Indirect obstetric deaths are caused by pregnancy interfering or worsening an existing condition, like a heart problem.
As women have gained access to family planning and skilled birth attendant with backup emergency obstetric care, the global maternal mortality ratio has fallen from 385 maternal deaths per 100,000 live births in 1990 to 216 deaths per 100,000 live births in 2015. Many countries halved their maternal death rates in the last 10 years. Although attempts have been made to reduce maternal mortality, there is much room for improvement, particularly in low-resource regions. Over 85% of maternal deaths are in low-resource communities in Africa and Asia. In higher resource regions, there are still significant areas with room for growth, particularly as they relate to racial and ethnic disparities and inequities in maternal mortality and morbidity rates.
Overall, maternal mortality is an important marker of the health of the country and reflects on its health infrastructure. Lowering the amount of maternal death is an important goal of many health organizations worldwide.
Causes
Direct obstetric deaths
Overview Direct obstetric deaths are due to complications of pregnancy, birth, termination, or complications arising from their management.
The causes of maternal death vary by region and level of access. According to a study published in the Lancet which covered the period from 1990 to 2013, the most common causes of maternal death world-wide are postpartum bleeding (15%), complications from unsafe abortion (15%), hypertensive disorders of pregnancy (10%), postpartum infections (8%), and obstructed labor (6%). Other causes include blood clots (3%) and pre-existing conditions (28%).
Descriptions by condition Postpartum bleeding happens when there is uncontrollable bleeding from the uterus, cervix, or vaginal wall after birth. This can happen when the uterus does not contract correctly after birth, there is leftover placenta in the uterus, or there are cuts in the cervix or vagina from birth.
Hypertensive disorders of pregnancy happen when the body does not regulate blood pressure correctly. In pregnancy, this is due to changes at the level of the blood vessels, likely because of the placenta. This includes medical conditions like gestational hypertension and pre-eclampsia.
Postpartum infections are infections of the uterus or other parts of the reproductive tract after the resolution of a pregnancy. They are usually bacterial and cause fever, increased pain, and foul-smelling discharge.
Obstructed labor happens when the baby does not properly move into the pelvis and out of the body during labor. The most common cause of obstructed labor is when the baby's head is too big or angled in a way that does not allow it to pass through the pelvis and birth canal.
Blood clots can occur in different vessels in the body, including vessels in the arms, legs, and lungs. They can cause problems in the lungs and travel to the heart or brain, thereby leading to complications.
Unsafe abortion
When abortion is legal and accessible, it is widely regarded as safer for the mother than carrying a pregnancy to term and delivery. In fact, a study published in the journal Obstetrics & Gynecology reported that in the United States, carrying a pregnancy to term and delivering a baby comes with a 14 times increased risk of death for the mother as compared to a legal abortion. However, in many regions of the world, abortion is not legal and can be unsafe for the mother. Maternal deaths caused by improperly performed procedures are preventable and contribute 13% to the maternal mortality rate worldwide. This number is increased to 25% in countries where other causes of maternal mortality are low, such as in Eastern European and South American countries. This makes unsafe abortion practices the leading cause of maternal death worldwide.
Unsafe abortion is another major cause of maternal death worldwide. In regions where abortion is legal and accessible, abortion is safe and does not contribute greatly to overall rates of maternal death. However, in regions where abortions are not legal, available, or regulated, unsafe abortion practices can cause significant rates of maternal death. According to the World Health Organization in 2009, every eight minutes a woman died from complications arising from unsafe abortions.
The WHO defined unsafe abortion practices as procedures performed by someone without the appropriate training and/or ones that are performed in an environment that is not considered safe or clean.World Health Organization, Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2000, 4th ed. Using this definition, the WHO estimates that out of the 45 million abortions that are performed each year globally, 19 million of these are considered unsafe, and 97% of these unsafe abortions occur in developing countries. Complications include hemorrhage, infection, sepsis and genital trauma.
Rates
Four primary types of data sources are used to collect abortion-related maternal mortality rates: confidential enquiries, registration data, verbal autopsy, and facility-based data sources. A verbal autopsy is a systematic tool that is used to collect information on the cause of death from laypeople and not medical professionals.
Confidential enquiries for maternal deaths do not occur very often on a national level in most countries. Registration systems are usually considered the "gold standard" method for mortality measurements. However, they have been shown to miss anywhere between 30 and 50% of all maternal deaths. Another concern for registration systems is that 75% of all global births occur in countries where vital registration systems do not exist, meaning that many maternal deaths occurring during these pregnancies and deliveries may not be properly recorded through these methods. There are also issues with using verbal autopsies and other forms of surveys in recording maternal death rates. For example, the family's willingness to participate after the loss of a loved one, misclassification of the cause of death, and under-reporting all present obstacles to the proper reporting of maternal mortality causes. Finally, a potential issue with facility-based data collection on maternal mortality is the likelihood that women who experience abortion-related complications will seek care in medical facilities. This is due to fear of social repercussions or legal activity in countries where unsafe abortion is common since it is more likely to be legally restrictive and/or more highly stigmatizing. Another concern for issues related to errors in proper reporting for accurate understanding of maternal mortality is the fact that global estimates of maternal deaths related to a specific cause present those related to abortion as a proportion of the total mortality rate. Therefore, any change, whether positive or negative, in the abortion-related mortality rate is only compared relative to other causes, and this does not allow for proper implications of whether abortions are becoming safer or less safe with respect to the overall mortality of women.
Prevention The prevention and reduction of maternity death is one of the United Nations' Sustainable Development Goals, specifically Goal 3, "Good health and well being". Promoting effective contraceptive use and information distributed to a wider population, with access to high-quality care, can make steps towards reducing the number of unsafe abortions. For nations that allow contraceptives, programs should be instituted to allow easier accessibility to these medications. However, this alone will not eliminate the demand for safe services, awareness on safe abortion services, health education on prenatal check-ups, and proper implementation of diets during pregnancy and lactation also contribute to its prevention.
Indirect obstetric deaths Indirect obstetric deaths are caused by preexisting health problem worsened by pregnancy or newly developed health problem unrelated to pregnancy . Fatalities during but unrelated to a pregnancy are termed accidental, incidental, or non-obstetrical maternal deaths.
Indirect causes include malaria and anaemia. The most common causes of anaemia are poor nutrition, iron, and other micronutrient deficiencies, which are in addition to malaria, hookworm, and schistosomiasis (2005 WHO report p45). HIV/AIDS, and cardiovascular disease, all of which may complicate pregnancy or be aggravated by it. Risk factors associated with increased maternal death include the age of the mother, obesity before becoming pregnant, other pre-existing chronic medical conditions, and cesarean delivery. Cited in CDC 2017 report.
Risk factors According to a 2004 WHO publication, sociodemographic factors such as age, access to resources, and income level are significant indicators of maternal outcomes. Young mothers face higher risks of complications and death during pregnancy than older mothers, especially adolescents aged 15 years or younger. Adolescents have higher risks for postpartum hemorrhage, endometritis, operative vaginal delivery, episiotomy, low birth weight, preterm delivery, and small-for-gestational-age infants, all of which can lead to maternal death. The leading cause of death for girls at the age of 15 in developing countries is complications during pregnancy and childbirth. They have more pregnancies, on average, than women in developed countries, and it has been shown that 1 in 180 15-year-old girls in developing countries who become pregnant will die due to complications during pregnancy or childbirth. This is compared to women in developed countries, where the likelihood is 1 in 4900 live births. However, in the United States, as many women of older age continue to have children, the maternal mortality rate has risen in some states, especially among women over 40 years old.