451. Indirect causes of maternal mortality

Abstract

Traditionally, the International Statistical Classification of Diseases has distinguished ‘direct’ from ‘indirect’ maternal deaths. Within this paradigm, direct deaths are those resulting from obstetric complications, whilst indirect deaths are those resulting from pre-existing disease or non-obstetric disease developing during pregnancy, but aggravated by physiologic effects of pregnancy. Such indirect deaths, for instance, include cancer-related deaths or cardiac deaths in women with pre-existing heart disease. Compared to direct obstetric deaths, indirect deaths have historically received less attention from health policy makers. Indirect deaths, however, outnumber directs deaths in many high-income countries and are on the rise in many low- and middle-income countries, irrespective of reductions in maternal mortality taking place in many settings. Studies into the incidence of indirect deaths suffer from under-reporting and misclassification, and care for women with non-obstetric disease is often hampered by lack of clarity as to which professional should take responsibility for care and oversight. There are several reasons as to why the distinction between direct and indirect deaths has become arbitrary and in some ways even counterproductive, leading to continued neglect of indirect causes of death. Examples of such reasons will be given during the presentation. If we change our perspective on maternal mortality and stop making a distinction between direct and indirect mortality, we might actually be able to achieve faster progress in overall maternal mortality reductions. A theme-based approach classifying deaths according to organ system, which is coordinated by obstetricians or obstetric physicians and which involves medical specialists from other relevant disciplines in efforts to improve quality of care, might be a more sensible way forward.