High Maternal Mortality Ratio Research Articles

The struggle to reduce high maternal mortality in Nigeria.

According to UNICEF estimates for Nigeria, maternal mortality ratio is 1100 per 100,000 live births, antenatal care coverage 47 percent, institutional delivery rate 33 percent, and each woman bears six children on the average. Reducing the high maternal mortality ratio, which is the prime concern, has hitherto concentrated on transforming the health system through bringing resources and expertise to bear on the high maternal mortality per se including some of its surrounding elements. It has failed. High maternal mortality must be tackled at a much more fundamental level. In the complexities and uniqueness of Nigeria's current situation, it is suggested that the fundamental remedy is to stamp out the chaos in the country by getting the politics and governance structures right. Accurate population census is paramount. Compulsory registration of births and deaths, fixing the broken-down educational system and bringing back the public service ethos the country once had, are core issues.

A consistent approach to hypertension in pregnancy

This issue opens with an article written by the authors of the latest guidelines for the management of hypertensive disease in pregnancy, published at the end of last year by the Society for Obstetric Medicine of Australia and New Zealand (SOMANZ). There have been several of these ‘consensus statements’ about hypertension in pregnancy and all have strived for the same aim – to achieve consistency in the approach to the management of one of the most common medical disorders in pregnancy. Even with comprehensive antenatal care available for most women there is still significant morbidity and mortality associated with pre-eclampsia and eclampsia. Interestingly, despite the most recent New Zealand figures showing a high maternal mortality ratio (MMR), deaths from hypertension do not feature prominently in the list of causes, suggesting that women who developed this complication were well managed via the various different models of care. This is in contrast with the last Australian figures for the triennium 2003–2005 showing five deaths related to hypertension. The full text of the SOMANZ guidelines is available on the website (http://www.somanz.org). The first two papers in the obstetric section are looking at the outcomes for fetuses with a normal karyotype with either very large nuchal translucency (NT) measurements or extremely low PAPP-A levels. The take-home messages are that some fetuses with very large NT measurements will be normal, and that a low PAPP-A can be an early warning of placental insufficiency. It is still important to answer the question about how low does the PAPP-A need to be to cause concern and how closely should these pregnancies be monitored? Following these is an article from the South Australian group working on non-obstetric causes of cerebral palsy, reporting on genetic susceptibility and viruses. They provide evidence for a role for viral infections in pregnancy as a possible cause of cerebral palsy, as well as arguing that genetic susceptibility plays an important part. On the gynaecological side the paper about knowledge of emergency contraception in students from Far North Queensland is very interesting and demonstrates that changes in availability of treatments doesn't always improve access and usage – education is a key ingredient. The article on the value of laparoscopic skills courses follows on very well from the discussion in the last issue about the future of gynaecological surgery. Despite an Editorial policy to restrict the number, I am sent more and more interesting case reports, and some of these are certainly worthy of publication. There are six included in this issue, including one from East Timor illustrating that there can be significant harm caused to women by illegal abortion, even on our own doorstep. This problem remains a major cause of maternal mortality in developing countries. Finally, since I last wrote there have been two very significant publishing events for our profession. The Report of the Maternity Services Review in Australia has been released, as well as the report from the New Zealand Perinatal and Maternal Mortality Committee. I was very pleased to see that the first recommendation in the Australian review was ‘That the Australian Government, in consultation with states and territories and key stakeholders, agree and implement arrangements for consistent, comprehensive national data collection, monitoring and review, for maternal and perinatal mortality and morbidity’. It would be good to see some action on this front in the near future and ensure that we have timely publication of data (and commentary) on all aspects of maternal and perinatal mortality and morbidity, as well as a clear link to ways to improve outcomes. Perhaps in the future we may see a similar comprehensive approach to looking at women's health outcomes in relation to gynaecological conditions.

Socio-demographic characteristics and the three delays of maternal mortality.

To describe the socio-demographic characteristics and the three delays of maternal mortality in a tertiary teaching hospital. Retrospective, observational study. Department of Obstetrics and Gynaecology, Unit III, Civil Hospital, Karachi, from April 2005 to May 2008. One hundred and four consecutive maternal deaths were reviewed. Data regarding age, parity, sociodemographic characteristics, booking status, referral source, cause of death and the three delays was collected on structured proformas, analyzed by the statistical software, SPSS version 13, and presented in the form of frequencies and percentages. The projected maternal mortality ratio was 1650/100,000 live births. The mean age was 28+/-6.2 years and median parity was two. Seventy-one women (68%) were uneducated, 65 (62.5%) belonged to lower socioeconomic class and 60 (58%) had received no antenatal care. Ninety-eight women (94%) had one or more delays, with 70 (71%) having the first delay, 73 (74%) having the second delay and 47 (48%) the third delay. The most frequent reasons for first, second and third delays were lack of awareness in 88.5% women, long distance in 39.7% women and difficulty in getting blood in 49% women respectively. The very high maternal mortality ratio suggests lack of access of women to quality healthcare facilities. A majority of these women suffered first and second delays in their management, which could be due to their poor sociodemographic factors.

Comparison of maternal mortality between migrating population and permanent residents in Shanghai, China, 1996–2005

Maternal mortality ratio (MMR) in Shanghai residents has been declining in the past two decades and has reached levels comparable to developed countries. The MMR in migrating population in Shanghai remains high, however. The objectives of this study were to compare the trends of MMR between residents and migrating population in Shanghai from 1996 to 2005 and to explore the reasons for the dramatic differences in MMR between the two groups living in the same city. Retrospective cohort study. Shanghai, China. A total of 902,807 pregnancies with live births in Shanghai in the period of 1996-2005. We first compared the overall MMR between migrating population and permanent residents in Shanghai and examined temporal trends of MMR in the two subpopulations. We then compared the causes and maternal characteristics of maternal deaths between the two subpopulations. Maternal mortality and cause of death. A total of 902,807 live births and 243 maternal deaths were recorded in Shanghai in the period of 1996 to 2005, with an average MMR of 26.66 per 100,000 live births. The MMR in Shanghai residents declined dramatically from 22.47 per 100,000 in 1996 to 1.64 per 100,000 live births in 2005 (P < 0.01), while the MMR in migrating population was reduced only moderately from 54.68 per 100,000 live births to 48.46 per 100,000 (P > 0.05). The main causes of maternal deaths in migrating population were postpartum haemorrhage (39.9%), pregnancy-induced hypertension (9.8%), and puerperal infection (9.3%), whereas the main causes of maternal death of Shanghai residents were chronic heart and liver diseases (20.0%), postpartum haemorrhage (12.9%), and amniotic fluid embolism (12.9%). Among the maternal death cases in migrating women, 60% had elementary education or less, 22% were unemployed, 65% had no prenatal visit, 44% gave a birth at home, and 12% of the deaths occurred at home. Lack of access to quality maternity care, especially for the effective management of postpartum haemorrhage, is the main reason for the high MMR in migrating population in Shanghai.

Antenatal care in The Gambia: missed opportunity for information, education and communication.

BackgroundAntenatal care is widely established and provides an opportunity to inform and educate pregnant women about pregnancy, childbirth and care of the newborn. It is expected that this would assist the women in making choices that would contribute to good pregnancy outcome. We examined the provision of information and education in antenatal clinics from the perspective of pregnant women attending these clinics.MethodsA cross sectional survey of 457 pregnant women attending six urban and six rural antenatal clinics in the largest health division in The Gambia was undertaken. The women were interviewed using modified antenatal client exit interview and antenatal record review questionnaires from the WHO Safe Motherhood Needs Assessment kit. Differences between women attending urban and rural clinics were assessed using the Chi-square test. Relative risks with 95% confidence intervals are presented.ResultsNinety percent of those interviewed had attended the antenatal clinic more than once and 52% four or more times. Most pregnant women (70.5%) said they spent 3 minutes or less with the antenatal care provider. About 35% recalled they were informed or educated on diet and nutrition, 30.4% on care of the baby, 23.6% on family planning, 22.8% on place of birth and 19.3% on what to do if there was a complication.About 25% of pregnant women said they were given information about the progress of their pregnancy after consultation and only 12.8% asked their provider any question. Awareness of danger signs was low. The proportions of women that recognised signs of danger were 28.9% for anaemia, 24.6% for hypertension, 14.8% for haemorrhage, 12.9% for fever and 5% for puerperal sepsis. Prolonged labour was not recognised as a danger sign. Women attending rural antenatal clinics were 1.6 times more likely to recognise signs of anaemia and hypertension as indicative of danger compared to women attending urban antenatal clinics.ConclusionInformation, education and communication during antenatal care in the largest health division are poor. Pregnant women are ill-equipped to make appropriate choices especially when they are in danger. This contributes to the persistence of high maternal mortality ratios in the country.

An Autopsy Study of Maternal Mortality in Mozambique: The Contribution of Infectious Diseases

BackgroundMaternal mortality is a major health problem concentrated in resource-poor regions. Accurate data on its causes using rigorous methods is lacking, but is essential to guide policy-makers and health professionals to reduce this intolerable burden. The aim of this study was to accurately describe the causes of maternal death in order to contribute to its reduction, in one of the regions of the world with the highest maternal mortality ratios.Methods and FindingsWe conducted a prospective study between October 2002 and December 2004 on the causes of maternal death in a tertiary-level referral hospital in Maputo, Mozambique, using complete autopsies with histological examination. HIV detection was done by virologic and serologic tests, and malaria was diagnosed by histological and parasitological examination. During 26 mo there were 179 maternal deaths, of which 139 (77.6%) had a complete autopsy and formed the basis of this analysis. Of those with test results, 65 women (52.8%) were HIV-positive. Obstetric complications accounted for 38.2% of deaths; haemorrhage was the most frequent cause (16.6%). Nonobstetric conditions accounted for 56.1% of deaths; HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis were the most common causes (12.9%, 12.2%, 10.1% and 7.2% respectively). Mycobacterial infection was found in 12 (8.6%) maternal deaths.ConclusionsIn this tertiary hospital in Mozambique, infectious diseases accounted for at least half of all maternal deaths, even though effective treatment is available for the four leading causes, HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis. These observations highlight the need to implement effective and available prevention tools, such as intermittent preventive treatment and insecticide-treated bed-nets for malaria, antiretroviral drugs for HIV/AIDS, or vaccines and effective antibiotics for pneumococcal and meningococcal diseases. Deaths due to obstetric causes represent a failure of health-care systems and require urgent improvement.

Reduction of maternal mortality: The need for voluntary blood donors

To explore the relationship between maternal mortality and availability of blood for transfusion at the country level in Latin American and Caribbean countries. The association of blood availability with maternal mortality, expressed either as national maternal mortality ratio or proportion of maternal deaths due to hemorrhage, in selected Latin American and Caribbean countries was analyzed by non-parametric methods. An inverse correlation was found between blood availability and both maternal mortality ratio (p<0.002) and proportion of deaths due to hemorrhage (p<0.05). Limited availability of blood for transfusion in countries with high maternal mortality ratios may hinder comprehensive care of mothers. The results presented here underscore the need for the formation of voluntary blood donors in the pursuit of improved maternal health.

Emergency contraception and fertility awareness among university students in Kampala, Uganda.

Uganda has a high maternal mortality ratio with unsafe abortions being one of the major causes. Young people are particularly vulnerable to unsafe induced abortion with its sequelae. Emergency contraception (EC) may reduce unsafe abortions if easily accessible and acceptable. To determine knowledge about, ever use and attitudes towards EC among resident and non-resident female first year university students in Kampala. This Cross sectional study was carried out at Makerere University from January to March 2005.Out of 5971 females admitted in the academic year 2004/2005,379 answered a self administered questionnaire. The students were approached individually and given the questionnaire if they consented. The mean age of the participants was 21 years. Less than half (45.1%) had ever heard about emergency contraceptive pills (ECPs). The most common sources of information about EC were friends (34%),media (24.8%) and schools (19.4%). The ever pregnancy rate was 3.4 percent and 42 percent were in a steady relationship of three or more months. The contraceptive ever-use rate was 14.5 percent. Among the users the most common methods were condoms (48.9%) and withdrawal (23.4%). Emergency contraceptive pills had been used by seven students. Forty two percent did not know the time interval within which ECPs can work and one third thought it would interrupt an ongoing pregnancy. Thirty five percent did not know when in the menstrual cycle they were likely to conceive. The majority of the students were against over the counter (OTC) availability of EC because of fear of misuse. Knowledge about Emergency contraception and fertility awareness is low among the female first year university students. Friends and the media are an important source of EC information. Awareness and knowledge of EC should be increased.

Fórum: juventude, contracepção e morte materna. Questões pendentes

In 2005, the Brazilian National Commission on Population and Development (CNPD) celebrated its tenth anniversary with the seminar “Gender, Generation, and Race”, including participation by experts, scientists, scholars, and staff from different Ministries. I was in charge of organizing the session on reproductive health, which I hereby present in this Forum section. The three aspects of reproductive health discussed here are related to the systematic violation of women’s reproductive rights by Brazilian society. Childbearing-aged women are at the peak of their lives, and their death is unacceptable, especially since we now have both the means and the technology to avoid it. Another aspect is the denial of women’s right to plan their children. In other words, the Unified National Health System, according to Article 226 of the Brazilian Constitution, Federal Act 9.263, and Ministry of Health Ruling 144, should be providing the means and resources for women to experience their sexuality and reproductive lives with little or no risk to their health. The third point is the fact that this difficulty begins early in women’s lives, when they become sexually active, since they already become exposed to the risk of HIV infection and unwanted pregnancy. All three themes presented here are interrelated and are not emerging issues, but old and pending, in urgent need of solutions, since they place the survival of numerous women in jeopardy. Although legally resolved, the issues dealt with here have not been incorporated definitively into Brazilian health services’ daily practice. In other words, the policy exists on paper, but not in practice. The article by Villela & Doreto speaks of young people, their vulnerabilities, and the changes we need in order to understand public policies for adolescents, taking their reproductive health into account. Data on teenage pregnancy indicate that there is now a huge contingent of young females exposed to HIV/AIDS, the second most common cause of death among Brazilian women. Meanwhile, the article by Martins provides a review of studies on maternal mortality rates and race/color, discussing maternal mortality in black Brazilian women (including pardas and pretas according to the official census classification). Using data from the Committees on Maternal Mortality, the authors identify a higher maternal mortality ratio among black women. According to the United Nations, this is one of the indicators of underdevelopment that has changed the least in the last 20 years. In Brazil, maternal mortality is still a public health problem. Like teenage pregnancy, race and social class permeate this indicator. The Forum concludes with the study by Osis et al., an evaluation of family planning under the National Health System, focusing on operational aspects of family planning activities, including access to contraceptive methods, educational activities, professional training, and the demand for definitive surgical sterilization. Basic health care should be supplying the activities that guarantee women’s reproductive rights, such as prevention of sexually transmitted diseases (including AIDS) and unwanted pregnancy. The right to quality prenatal care and humanized childbirth should also be ensured, as well as access to contraceptive methods, as provided in the report by the 12

Factors Contributing to Maternal Mortality in North-Central Nigeria: A Seventeen-Year Review

Maternal mortality ratio in Nigeria is one of the highest in the world. This paper reports a facility based study in north-central Nigeria to determine the magnitude, trends, causes and characteristics of maternal deaths before and after the launch of the Safe Motherhood Initiative in Nigeria, with a view to suggesting strategic interventions to reduce these deaths. The records of all deliveries and case files of all women who died during pregnancy and childbirth between January 1, 1985 and December 31, 2001, in the maternity unit of Jos University Teaching Hospital, Jos, Nigeria, were reviewed. Data collected were analysed for socio-biological variables including age, booking status, educational level, parity, ethnic group, marital status, mode of delivery, duration of hospital stay before death occurred, cause (s) of maternal deaths. There were 38,768 deliveries and 267 maternal deaths during the period under review, giving a maternal mortality ratio (MMR) of 740/ 100,000 total deliveries. The trend fluctuated between 450 in 1990 and 1,010/100.000 deliveries in 1994. The mean age of maternal death was 26.4 (SD 8.1) years. The greatest risk of MMR was among young teenagers (> 15 years) and older women (< 40 years). Parity-specific maternal mortality ratio was highest in the grand multiparous women. Unbooked as well as illiterate women were associated with very high maternal mortality ratio. The Hausa - Fulani ethnic group contributed the largest number (44%) by tribe to maternal mortality in our study. The major direct causes of deaths were haemorrhage (34.6%), sepsis (28.3%), eclampsia (23.6%) and unsafe abortion (9.6%). The most common indirect causes of death were hepatitis (18.6%), anaesthetic death (14.6%), anaemia in pregnancy (14.6%), meningitis (12.0%), HIV/AIDS (10.6%) and acute renal failure (8.0%). Seventy-nine percent of the maternal deaths occurred within 24 hours of admission. Most of the deaths were preventable. A regional-specific programme should be planned to reduce the deplorably high maternal mortality in north-central Nigeria.

Factors contributing to maternal mortality in north-central Nigeria: a seventeen-year review.

Maternal mortality ratio in Nigeria is one of the highest in the world. This paper reports a facility based study in north-central Nigeria to determine the magnitude, trends, causes and characteristics of maternal deaths before and after the launch of the Safe Motherhood Initiative in Nigeria, with a view to suggesting strategic interventions to reduce these deaths. The records of all deliveries and case files of all women who died during pregnancy and childbirth between January 1, 1985 and December 31, 2001, in the maternity unit of Jos University Teaching Hospital, Jos, Nigeria, were reviewed. Data collected were analysed for socio-biological variables including age, booking status, educational level, parity, ethnic group, marital status, mode of delivery, duration of hospital stay before death occurred, cause (s) of maternal deaths. There were 38,768 deliveries and 267 maternal deaths during the period under review, giving a maternal mortality ratio (MMR) of 740/ 100,000 total deliveries. The trend fluctuated between 450 in 1990 and 1,010/100.000 deliveries in 1994. The mean age of maternal death was 26.4 (SD 8.1) years. The greatest risk of MMR was among young teenagers (> 15 years) and older women (< 40 years). Parity-specific maternal mortality ratio was highest in the grand multiparous women. Unbooked as well as illiterate women were associated with very high maternal mortality ratio. The Hausa - Fulani ethnic group contributed the largest number (44%) by tribe to maternal mortality in our study. The major direct causes of deaths were haemorrhage (34.6%), sepsis (28.3%), eclampsia (23.6%) and unsafe abortion (9.6%). The most common indirect causes of death were hepatitis (18.6%), anaesthetic death (14.6%), anaemia in pregnancy (14.6%), meningitis (12.0%), HIV/AIDS (10.6%) and acute renal failure (8.0%). Seventy-nine percent of the maternal deaths occurred within 24 hours of admission. Most of the deaths were preventable. A regional-specific programme should be planned to reduce the deplorably high maternal mortality in north-central Nigeria.

Editor's choice

Many obstetricians restrict intravenous fluids in women with severe pre-eclampsia for fear of causing pulmonary oedema. However, such women are hypovolaemic, so carefully monitored plasma volume expansion may be more logical, and indeed uncontrolled studies have suggested that it often permits safe temporisation even in severely affected pregnancies. Now Ganzevoort and colleagues from Amsterdam (pp. 1358–1368) report the first randomised controlled trial. It turns out that plasma volume expansion does not reduce adverse fetal outcomes. Rather the trend was slightly the other way with earlier delivery and more neonatal morbidity in the treated group. Those who are interested in the topic should read the paper and accompanying editorial by Eric Steegers in full. Plasma volume expansion is a complex intervention which, in the present study, was generally administered without invasive haemodynamic monitoring and combined with tighter blood pressure control, so enthusiasts may still argue that the results apply only to the precise regime studied. Although there were no maternal deaths and no significant differences in maternal morbidity, Steegers notes that, in the whole of Holland, hypertensive disease is associated with a much higher maternal mortality ratio than in Britain. He speculates that the cause is Dutch doctors' enthusiasm for conservative management rather than for plasma volume expansion. Measuring the accuracy of prenatal diagnosis not only requires large series so that adequate numbers of cases of rare abnormality can be identified, but also linkage with a population-based fetal abnormality register to estimate the rate of false negative diagnoses. This was been achieved by the Northern Congenital Abnormality Survey (pp. 1349–1357). The findings are generally reassuring. Since 1990, researchers in Glasgow have documented a dramatic increase in mean maternal body mass index (BMI) at booking in pregnancy (pp. 1431–1433). Rates of obesity (BMI greater than 30) more than doubled to nearly one in five pregnancies. This is particularly striking since mean parity fell over the same time period, and women generally get fatter as they have more children. The health consequences are likely to be considerable, so much so, that we will be devoting our theme issue next year to the topic of obesity in Obstetrics and Gynaecology. Although children of married parents have better perinatal outcomes than those whose parents are cohabiting or whose father is absent, the cause is unlikely to be the marriage certificate itself. Either healthier couples are more likely to get married, or marriage has some indirect beneficial effect; perhaps it alters other aspects of parental behaviour. Sorting out causation matters because cohabitation is increasing and non-marital childbearing becoming less stigmatising. The authors of the paper on pages 1411–1416 from Finland have done their best by analysing a large dataset in which women who were cohabitating were distinguished from those who were unsupported as well as unmarried. Many other risk factors were also recorded but even after adjustment for these, cohabitation was associated with a significant increase in preterm births. The authors believe that this was unlikely to be explained by different economic circumstances, and speculate that it was related either to differing sexual behaviour or levels of social support. Long-term follow-up studies, whether of children born after innovative health technologies, of mothers treated in unusual ways, or of people surviving previously fatal conditions, are important. On pages 1376–1383 a group from Singapore report normal neurodevelopment among children conceived by intracytoplasmic sperm injection (ICSI). More such studies are needed, and in 2007 the journal will devote our theme issue to the topic of long-term follow-up studies both in and outside pregnancy. Making the correct diagnosis for females with an XY karyotype is vital to prevent irreversible virilising changes at puberty or gonadal malignancy, and to allow accurate genetic counselling. It is therefore worrying that in one specialist clinic the working diagnosis was judged to be correct in less than half of cases (pp. 1407–1410). The reason was, at least in part, due to advances in modern molecular diagnostic techniques which had not been applied to all the patients. The lesson is that such patients must not only be managed in specialist centres but the diagnosis must also be reviewed regularly. This issue sees the publication in the paper version of the journal of the first two summaries (p. 1457 and p. 1458) of trial protocols registered with BJOG. The full protocols are available electronically. We would love to receive more.

Routines in facility-based maternity care: evidence from the Arab World.

To document facility-based practices for normal labour and delivery in Egypt, Lebanon, the West Bank (part of the Occupied Palestinian Territory) and Syria and to categorise common findings according to evidence-based obstetrics. Three studies (Lebanon, West Bank and Syria) interviewed a key informant (providers) in maternity facilities. The study in Egypt directly observed individual labouring women. Maternity wards. Nationally representative sample of hospitals drawn in Lebanon and Syria. In the West Bank, a convenience sample of hospitals was used. In Egypt, the largest teaching hospital's maternity ward was observed. Shared practices were categorised by adapting the World Health Organization's (WHO) 2004 classification of practices for normal birth into the following: practices known to be beneficial, practices likely to be beneficial, practices unlikely to be beneficial and practices likely to be ineffective or harmful. Routine hospital practices for normal labor and delivery. There was infrequent use of beneficial practices that should be encouraged and an unexpectedly high level of harmful practices that should be eliminated. Some beneficial practices were applied inappropriately and practices of unproven benefit were also documented. Some documented childbirth practices are potentially harmful to mothers and their babies. Facility practices for normal labour were largely not in accordance with the WHO evidence-based classification of practices for normal birth. The findings are worrying given the increasing proportion of facility-based births in the region and the improved but relatively high maternal and neonatal mortality ratios in these countries. Obstacles to following evidence-based protocols for normal labour require examination.

Fetomaternal outcome in pregnancy with cardiac disease.

To determine fetal and maternal outcomes in women presenting with heart disease during pregnancy and labor. Descriptive study. Department of Gynae/Obstetrics, MCH, Center, Unit II, PIMS, Islamabad, during a period of 2 years from March 2001 to February 2003. Forty-two pregnant women with heart disease delivered at MCH Center, Unit II, during the study period were included. Maternal outcome measures included obstetric and medical complications and maternal mortality while fetal outcome measures were prematurity, intrauterine growth restriction and perinatal mortality, intrauterine death and indicated terminations of pregnancy. The mean age was 27.50 -/+ 5.17 years (standard deviation). Of the 42 women, 33 (78.6%) were booked for antenatal care and 9 (21.4%) were non-booked. Congenital heart disease was present in 7 (16.7%) while 28 (65.3%) had rheumatic heart disease and mitral valve disease was the commonest. Among the remaining 7 women with acquired heart disease, 3 (7.1%) women had ischemic heart diseases (IHD), 1 (2.4%) had primary pulmonary hypertension, 2 (4.8%) patients had peripartum cardiomyopathy and 1 (2.4%) had aortic dissection. Based on New York Heart Association Functional classification (NYHA) 16 (38.1%) patients were asymptomatic (class I) and 3 (7.1%) in class IV. Thirty-two (76.2%) achieved spontaneous vertex delivery (SVD), LSCS was performed in 4 (9.5%) women, 2 (4.8%) women had spontaneous expulsions of dead fetus and 2 (4.8%) had suction and curettage for therapeutic termination of pregnancy on medical grounds. Obstetric complications occurred in 17 (40.4%) women, 5 (11.9%) had medical complications and 3 (7.1%) maternal mortalities occurred. Regarding fetal outcome, 6 (14.3%) infants had intrauterine growth restriction (IUGR), 2 (4.8%) perinatal deaths occurred due to prematurity while there was 1 (2.4%) intrauterine death. Indicated terminations of pregnancy were done for 4 gestations (7.1%). Low birth weight was noted in 12 (28.6%) infants. Heart disease with pregnancy is a very high risk condition and maternal mortality ratio (MMR) was 7142/100,000 births. The management of these cases should be multidisciplinary to optimize care for these patients and large families be strongly discouraged.

National maternal mortality ratio in Egypt halved between 1992-93 and 2000.

Two surveys of maternal mortality conducted in Egypt, in 1992-93 and in 2000, collected data from a representative sample of health bureaus covering all of Egypt, except for five frontier governorates which were covered only by the later survey, using the vital registration forms. The numbers of maternal deaths were determined and interviews conducted. The medical causes of death and avoidable factors were determined. Results showed that the maternal mortality ratio (MMR) had dropped by 52% within that period (from 174 to 84/100,000 live births). The National Maternal Mortality Survey in 1992-93 (NMMS) revealed that the metropolitan areas and Upper Egypt had a higher MMR than Lower Egypt. In response to these results, the Egyptian Ministry of Health and Population (MOHP) intensified the efforts of its Safe Motherhood programmes in Upper Egypt with the result that the regional situation had reversed in 2000. Consideration of the intermediate and outcome indicators suggests that the greatest effect of maternal health interventions was on the death-related avoidable factors "substandard care by health providers" and "delays in recognizing problems or seeking medical care". The enormous improvements in these areas are certainly due in part to extensive training, revised curricula, the publication of medical protocols and services standards, the upgrading of facilities, and successful community outreach programmes and media campaigns. The impact on the utilization of antenatal care (ANC) has been less successful. Other areas that remain problematic are inadequate supplies of blood, drugs and equipment. Although the number of maternal deaths linked to haemorrhage has been drastically reduced, it remains the primary cause. The drop in maternal mortality in the 1990s in response to Safe Motherhood programmes was impressive and the ability to tailor interventions based on the data from the NMMS of 1992-93 and 2000 was clearly demonstrated. To ensure the continuing availability of information to guide and evaluate programmes for reducing maternal mortality, an Egyptian national maternal mortality surveillance system is being developed.

Editorial: Integrating continuous support of the traditional birth attendant into obstetric care by skilled midwives and doctors: a cost‐effective strategy to reduce perinatal mortality and unnecessary obstetric interventions

In the beginning of 2003 one of the authors (JvR) was privileged to attend a home birth in The Gambia guided by a traditional birth attendant (TBA). The woman was a gravida 2 para 1 and had started labour in the morning. Everybody in the whole compound was anxiously waiting for the child to be born. Nobody (the TBA included) would know whether the baby would be born alive because there was no foetal monitoring whatsoever. The TBA gave continuous emotional support to the woman an evidencebased strategy to improve the outcome of labour. She would have been rather empty-handed had serious complications suddenly occurred. Only in the case of postpartum haemorrhage (PPH) she would be able to administer misoprostol to the woman. In fact the TBA was participating in a randomized trial of misoprostol for the prevention of PPH and although she was illiterate she was able to follow the necessary procedures for the trial. In case of obstructed labour antepartum haemorrhage transverse lie and eclampsia the TBA would have had no tools to deal with these serious complications. Hence TBAs will not have any impact to reduce the appallingly high maternal mortality ratios in the less privileged parts of our global village. TBA practice was therefore considered to be of less value and the international safe motherhood movement started from 1997 onwards to concentrate on skilled attendance during labour and emergency obstetric care when complications would occur. (excerpt)

Conceiving and dying in Afghanistan

Since the first International Safe Motherhood Conference in 1987 there has been increased focus on maternal health and maternal mortality. The design and implementation of effective programmes for maternal health require data of adequate quality despite the challenges of generating such data. Typical approaches have produced data of low quality and limited usefulness. Therefore Linda Bartlett and colleagues’ report in today’s Lancet is of particular merit for its use of rigorous methodology. The methodology of the reproductive-age mortality study (RAMOS) while costly and cumbersome represents the gold standard for measuring maternal mortality. Bartlett and colleagues should be commended for their efforts under difficult circumstances to identify all deaths in women of reproductive age in the study area and further assess whether the deaths were due to maternal causes. With their two-stage methodology Bartlett and colleagues recorded 154 maternal deaths in a population of more than 90000 a national maternal mortality ratio of 1600–2200 maternal deaths per 100000 livebirths in Afghanistan and 6500 maternal deaths per 100000 livebirths (in Badakshan province)—the highest maternal mortality ratio ever reported. Maternal mortality compared with other causes of mortality remains a relatively rare event and for this reason is commonly expressed per 100 000 rather than per 1000. (excerpt)

Maternal mortality in health institutions with emergency obstetric care facilities in Enugu State, Nigeria

SummaryIn order to assess the current level of maternal mortality in health institutions with comprehensive emergency obstetric care in Enugu State, South Eastern Nigeria, a retrospective analysis of maternal deaths for the years 1999–2003 was carried out to establish the maternal mortality ratios in the eligible health institutions. Each maternal death was studied in detail to establish the socio-demographic characteristics of the women who died; their referral sources, type of delay (if any), medical causes of death and their preventability. In-depth interviews of the service providers were carried out to throw more light on the maternal mortality situation in the state. Five out of seven eligible health institutions were studied. Within the 5-year period (1999 – 2003), there were 141 maternal deaths and 18,257 live births giving a maternal mortality ratio of 772 maternal deaths per 100,000. The folders of 89 out of the 141 women who died were retrieved. Of these 89 maternal deaths, 51.7% of them were unemployed, 52.4% were referred from private hospitals; type 3 delay was the commonest type of delay encountered in the care of the women. Referral delay was the main cause of delay accounting for 46.4% of all cases of type 3 delay. The leading causes of maternal deaths among the women were obstetric haemorrhage (19.1%), sepsis (18.0%), prolonged obstructed labour/ruptured uterus (16.9%) and pre-eclampsia/eclampsia (16.9%). The in-depth interviews corroborated the high maternal mortality ratio recorded and the type 3 delays in tackling obstetric emergencies. It also showed some discrepancies between reality and the health providers' perception of the magnitude of maternal mortality situation in the state. It was concluded that in health institutions in Enugu State with comprehensive emergency obstetric care facilities, the maternal mortality ratio remains high due to type 3 delays. Most of the referrals come from private hospitals, hence the need to retrain the private practitioners in emergency obstetric care.

Program note: applying the UN Process indicators for emergency obstetric care to the United States

The United Nations Process Indicators for emergency obstetric care (EmOC) have been used extensively in countries with high maternal mortality ratios (MMR) to assess the availability, utilization and quality of EmOC services. To compare the situation in high MMR countries to that of a low MMR country, data from the United States were used to determine EmOC service availability, utilization and quality. As was expected, the United States was found to have an adequate amount of good-quality EmOC services that are used by the majority of women with life-threatening obstetric complications.

Maternal mortality as an indicator of obstetric care in Europe.

This analysis considers the usefulness of maternal mortality ratio (MMR) as an indicator of obstetric care in the context of low overall maternal mortality. We explore whether variation in the level of MMR among European countries reflects differences in obstetric care. The data presented in this article were collected as part of the European Concerted Action on Mothers' Mortality and Severe morbidity (MOMS). In this study, a panel of experts followed a protocol to determine cause of death and whether it was pregnancy-related. This analysis uses the expert panel's confirmation of cause of death and obstetric attribution. All maternal deaths within 11 European countries. Two hundred and ninety obstetric deaths occuring between 1992 and 1995. We present the results of a multivariable analysis that controls for cause of death, moment of death, place of death, pregnancy outcome, women's age and nationality. We test the hypothesis that countries with higher MMR would have proportionally more cases of direct obstetric death due to thromboembolism, hypertension, haemorrhage or infection compared with other countries in the study. We examine timing of death and maternal age to measure whether there are differences between country groups for older mothers. We find distinct patterns in cause and timing of death and age-specific mortality ratios between countries with different levels of MMR. Despite low rates of maternal mortality in Europe, between-country differences follow patterns with respect to cause and timing of death and maternal age. In addition to representing an important indicator of health status in a country, differences in MMR among European countries provide insight to where obstetric care plays a role maternal deaths.