Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study.

Margaret C Hogan,Ana L Rhenals-Osorio,Blair G Darney,Bertha L Vázquez Sierra,Patricia N Soliz-Sánchez,Luis M Torres-Palacios,Emmanuela Gakidou,Rafael Lozano,Biani Saavedra-Avendano

doi:10.2471/blt.15.163360

Abstract

ObjectiveTo describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities.MethodsWe conducted a repeated cross-sectional study using the 2006–2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe new cases, cause distributions and the reclassification of maternal mortality cases by the BIRMM process. We used statistical tests to analyse differences in sociodemographic characteristics between direct and indirect deaths and differences in the proportion of overall direct and indirect deaths, by year and by municipality poverty level.FindingsA total of 9043 maternal deaths were subjected to the review process. There was a 13% increase (from 7829 to 9043) in overall identified maternal deaths and a threefold increase in the proportion of maternal deaths classified as late maternal deaths (from 2.1% to 6.9%). Over the study period direct obstetric deaths declined, while there was no change in deaths from indirect obstetric causes. Direct deaths were concentrated in women who lived in the poorest municipalities. When compared to those dying of direct causes, women dying of indirect causes had fewer pregnancies and were slightly younger, better educated and more likely to live in wealthier municipalities.ConclusionThe BIRMM is one approach to correct maternal death statistics in settings with poor resources. The approach could help the health system to rethink its strategy to reduce maternal deaths from indirect obstetric causes, including prevention of unwanted pregnancies and improvement of antenatal and post-obstetric care.

Highlights

Maternal mortality – defined as the death of a woman during pregnancy, childbirth or in the 42 days after delivery – is used as an outcome measure for any health system
The indicator of maternal mortality is the maternal mortality ratio (MMR), which is defined as the number of maternal deaths per 100 000 live births
The International statistical classification of diseases and related health problems, 10th revision (ICD-10)[8] manual divides the causes of maternal mortality into three broad categories: direct obstetric deaths; indirect obstetric deaths; and late maternal death.[8,9]

Summary

Introduction

Maternal mortality – defined as the death of a woman during pregnancy, childbirth or in the 42 days after delivery – is used as an outcome measure for any health system. The indicator of maternal mortality is the maternal mortality ratio (MMR), which is defined as the number of maternal deaths per 100 000 live births. MMR is a problematic indicator to measure, due to the relative few maternal deaths.[1,2,3,4,5] It is even more challenging to measure cause-specific maternal mortality, since available methods have either low sensitivity or specificity.[6] accurate estimates of cause-specific maternal mortality are often not available in many countries.[7]. Indirect and late maternal causes are likely to be misclassified as non-maternal deaths.[6,13,14] Even within countries with a very high quality vital registration system, there is a wide variation in the fraction of maternal deaths attributable to indirect causes; estimates range from zero to more than half of all reported maternal deaths.[13,14,15,16,17,18,19,20,21,22]

Methods

Results

Discussion

Conclusion