Incidence and characteristics of pregnancy-related death across ten low- and middle-income geographical regions: secondary analysis of a cluster randomised controlled trial.

Abstract

The aim of this article is to describe the incidence and characteristics of pregnancy-related death in low- and middle-resource settings, in relation to the availability of key obstetric resources. This is a secondary analysis of a stepped-wedge cluster randomised controlled trial. This trial was undertaken at ten sites across eight low- and middle-income countries in sub-Saharan Africa, India and Haiti. Institutional-level consent was obtained and all women presenting for maternity care were eligible for inclusion. Pregnancy-related deaths were collected prospectively from routine data sources and active case searching. Pregnancy-related death, place, timing and age of maternal death, and neonatal outcomes in women with this outcome. Over 20months, in 536233 deliveries there were 998 maternal deaths (18.6/10000, range 28/10000-630/10000). The leading causes of death were obstetric haemorrhage (36.0%, n=359), hypertensive disorders of pregnancy (20.6%, n=206), sepsis (14.1%, n=141) and other (26.5%, n=264). Approximately a quarter of deaths occurred prior to delivery (28.4%, n=283), 35.7% (n=356) occurred on the day of delivery and 35.9% (n=359) occurred after delivery. Half of maternal deaths (50.6%; n=505) occurred in women aged 20-29years, 10.3% (n=103) occurred in women aged under 20years, 34.5% (n=344) occurred in women aged 30-39years and 4.6% (n=46) occurred in women aged ≥40years. There was no measured association between the availability of key obstetric resources and the rate of pregnancy-related death. The large variation in the rate of pregnancy-related death, irrespective of resource availability, emphasises that inequality and inequity in health care persists. Inequality and inequity in pregnancy-related death persists globally, irrespective of resource availability.