Indirect Causes Of Maternal Death Research Articles

Integration of HIV care into maternal health services: a crucial change required in improving quality of obstetric care in countries with high HIV prevalence

BackgroundThe failure to reduce preventable maternal deaths represents a violation of women’s right to life, health, non-discrimination and equality. Maternal deaths result from weaknesses in health systems: inadequate financing of services, poor information systems, inefficient logistics management and most important, the lack of investment in the most valuable resource, the human resource of health workers. Inadequate senior leadership, poor communication and low staff morale are cited repeatedly in explaining low quality of healthcare. Vertical programmes undermine other service areas by creating competition for scarce skilled staff, separate reporting systems and duplication of training and tasks.DiscussionConfidential enquiries and other quality-improvement activities have identified underlying causes of maternal deaths, but depend on the health system to respond with remedies. Instead of separate vertical programmes for management of HIV, tuberculosis, and reproductive health, integration of care and joint management of pregnancy and HIV would be more effective. Addressing health system failures that lead to each woman’s death would have a wider impact on improving the quality of care provided in the health service as a whole. More could be achieved if existing resources were used more effectively. The challenge for African countries is how to get into practice interventions known from research to be effective in improving quality of care. Advocacy and commitment to saving women’s lives are crucial elements for campaigns to influence governments and policy -makers to act on the findings of these enquiries. Health professional training curricula should be updated to include perspectives on patients’ rights, communication skills, and integrated approaches, while using adult learning methods and problem-solving techniques.SummaryIn countries with high rates of Human Immunodeficiency Virus (HIV), indirect causes of maternal deaths from HIV-associated infections now exceed direct causes of hemorrhage, hypertension and sepsis. Advocacy for all pregnant HIV-positive women to be on anti-retroviral therapy must extend to improvements in the quality of service offered, better organised obstetric services and integration of clinical HIV care into maternity services. Improved communication and specialist support to peripheral facilities can be facilitated through advances in technology such as mobile phones.

Protective Effect of Pregnancy in Rural South Africa: Questioning the Concept of “Indirect Cause” of Maternal Death

BackgroundMeasurement of the level and composition of maternal mortality depends on the definition used, with inconsistencies leading to inflated rates and invalid comparisons across settings. This study investigates the differences in risk of death for women in their reproductive years during and outside the maternal risk period (pregnancy, delivery, puerperium), focusing on specific causes of infectious, non-communicable and external causes of death after separating out direct obstetrical causes.MethodsData on all deaths of women aged 15–49 years that occurred in the Agincourt sub-district between 1992 and 2010 were obtained from the Agincourt health and socio-demographic surveillance system (HDSS) located in rural South Africa. Causes of death were assessed using a validated verbal autopsy instrument. Analysis included 2170 deaths, of which 137 occurred during the maternal risk period.FindingsOverall, women had significantly lower mortality during the maternal risk period than outside it (age-standardized RR = 0.75; 95% CI = 0.63–0.89). This was true in most age groups with the exception of adolescents aged 15–19 years where the risk of death was higher. Mortality from most causes, other than obstetric causes, was lower during the maternal risk period except for malaria, cardiovascular diseases and violence where there were no differences. Lower mortality was significant for HIV/AIDS (RR = 0.29, P<0.0001), cancers (RR = 0.10, P<0.023), and accidents (RR = 0, P<0.0001).InterpretationIn this rural setting typical of much of Southern Africa, pregnancy was largely protective against the risk of death, most likely because of a strong selection effect amongst those women who conceived successfully. The concept of indirect cause of maternal death needs to be re-examined.

Maternal deaths: initial report of an on-going monitoring of maternal deaths at the Federal Medical Centre Katsina, Northwest Nigeria

Objectives: To assess the maternal mortality ratio (MMR) from data collected as maternal deaths occurred over a 4-year period.Methods: A Departmental database established in 2008 was used to keep data on deliveries and maternal deaths as they occurred. The causes of death were decided after a meeting reviewed the case. Analysis was done using Microsoft Excel software and results presented in means and frequencies.Results: Eight thousand two hundred and twenty live deliveries that occurred were complicated by 68 maternal deaths. The MMR was 827/100 000 live births. The MMR for unbooked women was four times higher than for booked women. Obstetric haemorrhage was the main (21.6%) direct cause of death followed by preeclampsia/eclampsia (18.9%). While anaemia was the leading (8.1%) indirect cause of death, tetanus in the puerperium reared its head as an emerging (5.4%) indirect cause of maternal death. None of the women ever used contraceptives. Most deaths occurred in teenage mothers (23.5%), unbooked women (86%) and in the postpartum period (69%).Conclusion: The MMR was high and tetanus in puerperium emerged as an indirect cause of maternal deaths. There is a need to curb the emergence of tetanus in the puerperium as a cause of maternal death.

Pattern of Maternal Mortality in a Rural Referral Hospital: A Six Year Retrospective Study

Objective: To find the frequency and the causes of maternal death in a rural medical college hospital. Method: Retrospective study of 72 maternal deaths over a period of 6 years from January 2007 to December 2012. Results: Over the study period there were 25,174 live births and 72 maternal deaths, maternal mortality rate being 286/lakh live births. Out of which hemorrhage was the leading cause and anemia being the indirect cause of maternal death. Most of the women died within a period of 24 hours of admission and were between the age group of 20-30 years. Most cases were unregistered and referred from outside. Conclusion: Maternal mortality rate in this study is 286. Out of which most of them could have been avoided if they had been registered and received proper antenatal care, with early diagnosis and timely intervention and early referral with well equipped transport facilities. Over all promotion of safe mother hood should be emphasized.

The ROPAC registry: a multicentre collaboration on pregnancy outcomes in women with heart disease

This editorial refers to ‘Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology’, by J.W. Roos-Hesselink et al. , doi:10.1093/eurheartj/ehs270 The haemodynamic changes of pregnancy can have a negative impact on maternal cardiac health, especially in women with pre-existing cardiac disease. In the most recent Confidential Inquiries into Maternal Mortality in the United Kingdom, heart disease was found to be the most common indirect cause of maternal death during pregnancy.1 Pregnancy counselling and management for women with heart disease is being increasingly recognized as an important aspect of their overall cardiac care. With increasing awareness, there has been a growing body of research focused on pregnancy outcomes and risk stratification. There have also been new initiatives to improve clinical care, such as the 2011 European Society of Cardiology (ESC) guidelines on the management of cardiovascular disease during pregnancy.2 While our current understanding of pregnancy risk assessment and management has improved over the past 20 years, many questions can only be answered by collaborative efforts. Roos-Hesselink and colleagues have now presented the first report of their multicentre, multinational Registry On Pregnancy and …

Maternal mortality from cardiac disease in Turkey: a population-based study

Objective: Population-based studies on maternal deaths in Turkey are rare. The aim of the present study was to analyze the cardiac causes of all maternal deaths in Turkey between 2007 and 2009. Materials and methods: In this retrospective study, case files of all pregnancy-associated deaths recorded in Turkey between 2007 and 2009 were reviewed. Records for all pregnancy-associated deaths were reviewed by five authors to identify 129 cases in which a cardiac disease seemed to be the reason. For each of the 129 cases, maternal age, gravidity, parity, antenatal care attendance, district of residence, year of death, mode of delivery, perinatal outcome, and clinical history preceding death were recorded. Results: During the study period, 779 maternal deaths were identified. Our estimate of the maternal mortality ratio (MMR) in 3-year period was 19.7 per 100,000 live births. The report lists 779 deaths, 411 direct and 285 indirect. Indirect obstetric causes of maternal death were primarily cardiac disorders and cerebrovascular diseases. Maternal mortality due to cardiac disease was 15.5% in 2007 and 18.4% in 2008. Valvular heart disease was the leading cause of maternal death from cardiac reasons (25.6%). Maternal mortality due to cardiac disease increased with age. Conclusion: The main cause of indirect maternal death has been cardiac disease in 3-year period.

Maternal Cardiac Disease

Heart disease complicates more than 1% of pregnancies and is now the leading cause of indirect maternal deaths. The spectrum and severity of heart disease observed in reproductive-aged women is changing. Today, congenital heart disease accounts for more than half of cardiac disease in pregnancy, and ischemic heart disease is on the rise as a result of obesity, hypertension, diabetes, and delayed childbearing. Pregnancy is still contraindicated in women with pulmonary hypertension, severe systemic ventricular dysfunction, dilated aortopathy, and severe left-sided obstructive lesions, but advances in medical and surgical management have resulted in an increasing number of patients with congenital heart defects reaching childbearing age who are interested in pregnancy. A multidisciplinary approach can best determine whether acceptable outcomes can be expected and what management strategies may improve the prognosis for pregnant women with heart disease.

PROTOCOL: Nutrition interventions and programs for reducing mortality and morbidity in pregnant and lactating women and women of reproductive age: a systematic review

PROTOCOL: Nutrition interventions and programs for reducing mortality and morbidity in pregnant and lactating women and women of reproductive age: a systematic review

Maternal mortality in Kassala State - Eastern Sudan: community-based study using Reproductive age mortality survey (RAMOS)

BackgroundThe maternal mortality ratio in Sudan was estimated at 750/100,000 live births. Sudan was one of eleven countries that are responsible for 65% of global maternal deaths according to a recent World Health Organization (WHO) estimate. Maternal mortality in Kassala State was high in national demographic surveys. This study was conducted to investigate the causes and contributing factors of maternal deaths and to identify any discrepancies in rates and causes between different areas.MethodsA reproductive age mortality survey (RAMOS) was conducted to study maternal mortality in Kassala State. Deaths of women of reproductive age (WRA) in four purposively selected areas were identified by interviewing key informants in each village followed by verbal autopsy.ResultsOver a three-year period, 168 maternal deaths were identified among 26,066 WRA. Verbal autopsies were conducted in 148 (88.1%) of these cases. Of these, 64 (43.2%) were due to pregnancy and childbirth complications. Maternal mortality rates and ratios were 80.6 per 100,000 WRA and 713.6 per 100,000 live births (LB), respectively. There was a wide discrepancy between urban and rural maternal mortality ratios (369 and 872\\100,000 LB, respectively). Direct obstetric causes were responsible for 58.4% of deaths. Severe anemia (20.3%) and acute febrile illness (9.4%) were the major indirect causes of maternal death whereas obstetric hemorrhage (15.6%), obstructed labor (14.1%) and puerperal sepsis (10.9%) were the major obstetric causes.Of the contributing factors, we found delay of referral in 73.4% of cases in spite of a high problem recognition rate (75%). 67.2% of deaths occurred at home, indicating under utilization of health facilities, and transportation problems were found in 54.7% of deaths.There was a high illiteracy rate among the deceased and their husbands (62.5% and 48.4%, respectively).ConclusionsMaternal mortality rates and ratios were found to be high, with a wide variation between urban and rural populations. Direct causes of maternal death were similar to those in developing countries. To reduce this high maternal mortality rate we recommend improving provision of emergency obstetric care (Emoc) in all health facilities, expanding midwifery training and coverage especially in rural areas.

Enfermedad de Ebstein y gestación: ¿morbilidad imprevisible?

Cardiac disease in pregnancy remains a major cause of indirect maternal death. Specifically, Ebstein's anomaly is an uncommon congenital cardiac abnormality of the tricuspid valve that may be associated with cyanosis and arrhythmias. For female patients with this anomaly who survive to adult life, there is little information on pregnancy, maternal complications and fetal outcomes.We discuss the case of a pregnant woman with this anomaly to address this issue so that these patients can receive appropriate advice and the risks of pregnancy can be successfully managed.

Trends in maternal mortality at University of Maiduguri teaching hospital, Maiduguri, Nigeria - A five year review

Background:Maternal mortality is on the rise in Nigeria with the North- East having the highest ratio, and Borno state records one of the highest maternal mortality ratios in the country. Objective:To determine the trends in maternal mortality in UMTH, identify the background socio- cultural factors, establish the major causes of deaths and determine avoidable factors. Study design:Retrospective study of maternal deaths. Methods: The case records of all recorded cases of maternal deaths between January 2001 and December 2005 inclusive were retrieved and relevant data obtained and analysed. Results: The maternal mortality ratio (MMR) for the period under review was 430 per 100,000 live births. There were annual fluctuations in MMR. However, there was a consistently rising trend in MMR from 2002-2004 with the highest ratio of 545 per 100,000 live births recorded in the year 2004, with a decline in 2005. Thirty (78.9%) of these deaths occurred among the unbooked patients and more than 90% of this were referred as obstetric emergencies. Age range was 14-39 years with a mean of 26.5years. The highest maternal death occurred at the two extremes of reproductive age group (14-19 years and 35 years and above). Grandmultiparas suffered the highest maternal mortality of 36.8%, followed by teenage mothers. P1-4 contributed the least to maternal mortality. The direct causes of maternal death accounted for 92.1% of the deaths. The major causes of death were eclampsia 34.2%, sepsis 26.3% and prolonged obstructed labour/ruptured uterus 13.2%. Amongst the indirect causes of maternal death, HIV/Tuberculosis was the leading cause accounting for 5.3%. Basic but professional antenatal care, skilled attendance at birth, community mobilization and health education messages for a healthy pregnancy and safe birth will help to reduce the unacceptably high maternal mortality ratio in Borno state and the country at large.

Strengthening HIV services for pregnant women: an opportunity to reduce maternal mortality rates in Southern Africa/sub‐Saharan Africa

Reliable data from South Africa emanating from WHO recommendations for the Safe Motherhood programme underscores HIV/AIDS as the most common cause of maternal deaths. The strengthening of HIV services for pregnant women especially in countries with a high burden of HIV infection will reduce HIV-related and un-related maternal mortality rates. High-quality and complete data on maternal deaths is a critical foundation for reliably monitoring temporal trends in maternal deaths, and causes thereof, but needs substantial strengthening in many resource-constrained settings. HIV/AIDS is an increasing contributor to direct and indirect causes of maternal deaths in sub-Saharan Africa. A review of published data on maternal deaths and its association with HIV shows that reliable data come from the Confidential Enquiries into Maternal Deaths from South Africa, population-based surveys in sentinel populations, and facility-based data. Despite an increase in knowledge of the HIV status of pregnant women and the initiation of antiretroviral treatment, reversals in trends towards increased maternal deaths are not being observed. The strengthening of HIV services provides an opportunity to alter HIV epidemic trajectories and reduce maternal deaths.

Maternal Mortality At The State Specialist Hospital Bauchi, Northern Nigeria

To analyse and document our experiences with maternal mortality with the view of finding the trends over the last seven years, common causes and attributing socio-demographic factors. A prospective analysis of maternal mortality. State Specialists Hospital Bauchi, Bauchi Northeastern Nigeria. These include maternal mortality ratio for the period under review and the annual trends, age and parity most affected the direct and indirect causes of maternal mortality in our environment. The Maternal Mortality Ratio (MMR) for the period under review was 1,732 per 100, 000 live births. Six hundred and twenty one of the deaths (81.0%) occurred in 12,067 unbooked deliveries giving a maternal mortality ratio of 5,146 per 100,000 for unbooked mothers. This ratio is approximately eleven times that obtained in booked live deliveries. Age range was 14-44 years and the mean age was 27.8 years. The highest maternal death was in the adolescent mothers. The primigravidas had the highest maternal mortality of 28.9%. The direct obstetric causes of maternal death accounted for 79.4% of the deaths. The major causes of deaths were eclampsia 31.9%, haemorrhage 19.2% and sepsis 10.4%. Amongst the indirect causes of maternal death, anaemia was the leading cause accounting for 12.1%. The annual MMR was highest for the year 2006 (2,586 per 100,000). Maternal mortality is unacceptably high in our environment. The provision of more health facilities where basic and comprehensive antenatal care are provided, skilled attendants at birth, community mobilisation to improve antenatal attendance and the use of TBAs as a link between the pregnant women, families and communities providing important messages for a healthy pregnancy, and safe birth remain the bedrock of containing maternal mortality in our environment.

What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries.

The first target of the fifth United Nations Millennium Development Goal is to reduce maternal mortality by 75% between 1990 and 2015. This target is critically off track. Despite difficulties inherent in measuring maternal mortality, interventions aimed at reducing it must be monitored and evaluated to determine the most effective strategies in different contexts. In some contexts, the direct causes of maternal death, such as haemorrhage and sepsis, predominate and can be tackled effectively through providing access to skilled birth attendance and emergency obstetric care. In others, indirect causes of maternal death, such as HIV/AIDS and malaria, make a significant contribution and require alternative interventions. Methods of planning and evaluating maternal health interventions that do not differentiate between direct and indirect maternal deaths may lead to unrealistic expectations of effectiveness or mask progress in tackling specific causes. Furthermore, the need for additional or alternative interventions to tackle the causes of indirect maternal death may not be recognized if all-cause maternal death is used as the sole outcome indicator. This article illustrates the importance of differentiating between direct and indirect maternal deaths by analysing historical data from England and Wales and contemporary data from Ghana, Rwanda and South Africa. The principal aim of the paper is to highlight the need to differentiate deaths in this way when evaluating maternal mortality, particularly when judging progress towards the fifth Millennium Development Goal. It is recommended that the potential effect of maternity services failing to take indirect maternal deaths into account should be modelled.

Management of cardiac disease in pregnancy

Pregnancy makes a significant demand on the cardiovascular system. Therefore, it follows that women with cardiovascular compromise due to cardiac disease need specialist input and careful management pre-, peri-, and post-partum. In the latest CEMACH report, cardiac disease was the most common cause of indirect maternal deaths and the most common cause of death overall. In particular, during 2003–5, there was an increase in deaths due to myocardial infarction, thoracic aortic dissection, and rheumatic mitral stenosis. The causes of maternal cardiac deaths in 2003–5 are summarized in Table 1. Of particular relevance to anaesthesia and intensive care is that the majority of pregnant women who die of heart disease have not been identified as being ‘at risk’ before labour. Maternal cardiac disease has the potential to remain undiagnosed during pregnancy, but presentation often occurs after 20 weeks gestation and frequently at the time of delivery or immediately post-partum. This is most likely to happen in women who have avoided, or not presented for, antenatal care. An appreciation of the issues involved in the care of the parturient with cardiac disease and an awareness of the signs and symptoms is therefore important.

Maternal mortality

The process of audit standardizes protocols in departments and has long-term benefits. Maternal autopsies though routinely performed, deserve a special attention. This study was carried out to calculate the maternal mortality ratio (MMR) in a tertiary care hospital and to correlate final cause of death with the clinical diagnosis. An audit of maternal autopsies was carried out to evaluate current practices, identify fallacies and suggest corrective measures to rectify them. Eighty-nine autopsies of maternal deaths in the period 2003 to 2007 were studied in detail along with the clinical details. There were 158 maternal deaths and 13940 live births in this five-year period. Maternal mortality rate was found to be very high (1133/ 100000 live births) in our institution with a high number of complicated referral cases (68/89 cases, 76%). Of the 89 autopsies, acute fulminant viral hepatitis was the commonest cause of indirect maternal deaths (37 cases, 41.5%). This was followed by direct causes like pregnancy-induced hypertension (12 cases, 13.4%) and puerperal sepsis (10 cases, 11.2%). Certain fallacies were noted during the audit process. During the audit it was realized that in maternal mortality autopsies, special emphasis should be given to clinicopathologic correlation, microbiological studies, identification of thromboembolic phenomenon and adequate sectioning of relevant organs. We found difficulty in identification of placental bed in the uterus in postpartum autopsies. A systematic approach can help us for better understanding of the pathophysiology of diseases occurring in pregnancy.

Maternal mortality in South Africa in 2001: From demographic census to epidemiological investigation.

BackgroundMaternal mortality remains poorly researched in Africa, and is likely to worsen dramatically as a consequence of HIV/AIDS.MethodsThe 2001 census of South Africa included a question on deaths in the previous 12 months, and two questions on external causes and maternal mortality, defined as "pregnancy-related deaths". A microdata sample from the census permits researchers to assess levels and differentials in maternal mortality, in a country severely affected by high death rates from HIV/AIDS and from external causes.ResultsAfter correcting for several minor biases, our estimate of the Maternal Mortality Ratio (MMR) in 2001 was 542 per 100,000 live births. This level is much higher than previous estimates dating from pre-HIV/AIDS times. This high level occurred despite a relatively low proportion of maternal deaths (6.4%) among deaths of women aged 15–49 years, and was due to the astonishingly high level of adult mortality, some 4.7 times higher than expected from mortality below age 15 or above age 50. The main reasons for these excessive levels were HIV/AIDS and external causes of deaths. Our regional estimates of MMR were found to be consistent with other findings in the Cape Town area, and with the Agincourt DSS. The differentials in MMR were considerable: 1 to 9.2 for population groups (race), 1 to 3.2 for provinces, and 1 to 2.4 for levels of education. Relationship with income and wealth were complex, with highest values for middle income and middle wealth index. The effect of urbanization was small, and reversed in a multivariate analysis. Higher risks in provinces were not necessarily associated with lower income, lower education or higher proportions of home delivery, but correlated primarily with the prevalence of HIV/AIDS.ConclusionDemographic census microdata offer the opportunity to conduct an epidemiologic analysis of maternal mortality. In the case of South Africa, the level of MMR increased dramatically over the past 10 years, most likely because of HIV/AIDS. Indirect causes of maternal deaths appear much more important than direct obstetric causes. The MMR appears no longer to be a reliable measure of the quality of obstetric care or a measure of safe motherhood.

Cardiac disease in pregnancy. Part 1: congenital heart disease

Key content Heart disease is now the most common indirect cause of maternal death in the United Kingdom. Neonatal morbidity and mortality from fetal growth restriction and prematurity are markedly increased in women with heart disease. Women with congenital heart disease should ideally have a planned pregnancy managed by a multidisciplinary team which includes obstetricians, cardiologists, anaesthetists, neonatologists and midwives. Learning objectives To understand the changes to cardiovascular physiology during pregnancy. To recognise the risk factors for poor pregnancy outcome in cardiac disease. To understand the general management principles for women with cardiac disease in pregnancy. Ethical issues Should we be recommending termination of pregnancy in women with high risk cardiac lesions? How do we manage women who become pregnant against medical advice? What is the role of surrogacy in women with high risk cardiac lesions? Please cite this article as: Gelson E, Johnson M, Gatzoulis M, Uebing A. Cardiac disease in pregnancy. Part 1: congenital heart disease. The Obstetrician &amp; Gynaecologist 2007;9:15–20.

La contribución de la violencia a la mortalidad materna en Morelos, México

To document the under-registration of violent deaths related to pregnancy and the importance of considering these violent deaths within the definition of maternal mortality. The study was carried out in the state of Morelos, based on the review of all death certificates (394) of reproductive aged women (12-49 years) who died during 2001. Based on a list of diagnostic criteria we eliminated 167 certificates that were neither violent deaths nor maternal deaths. The remaining 227 certificates were further evaluated through verbal autopsy and/or review of medical charts. Fifty-one violent deaths were found. Eighteen maternal deaths were officially reported in 2001, however, our study identified 23 direct maternal deaths and four violent deaths during pregnancy and the post-partum period. We found that this reproductive event was the direct trigger for the homicide or suicide of these four women, and only one of these cases was documented officially. Violent deaths related to pregnancy should be included in official maternal mortality statistics as indirect causes of maternal deaths. This would allow for a greater and more accurate understanding of violent maternal deaths and guide appropriate prevention and care policies, programs and services. Verbal autopsy is a useful technique for identifying cases of violent maternal deaths.

Moederlike mortaliteitskoers in Potchefstroom Hospitaal, 2000–2002: hoe kan hierdie risiko's vir moeders verlaag word?

Maternal mortality rate in Potchefstroom Hospital, 2000 - 2002: How can these risks for mothers be reduced? Background The aim of this study was to determine the maternal mortality ratio (MMR) in Potchefstroom Hospital, situated in North-West Province, for 2000-2002. The main causes of maternal deaths in Potchefstroom Hospital were determined and compared to the main causes for maternal deaths nationally. Methods Data were collected in a retrospective manner from Potchefstroom Hospital's yearbooks and statistics, 2000-2002. The number of deliveries per month, the total number of maternal deaths and the main causes for these deaths were recorded. Results The MMR for Potchefstroom Hospital in 2000-2002 was 354.7/100000 live births, compared to the estimated MMR for SA in 1999-2001 of 170-200/100 000 live births. The main causes of maternal deaths in Potchefstroom Hospital include non-pregnancy-related infection (mainly AIDS), complications of hypertension in pregnancy, obstetrical haemorrhage, preexisting maternal disease and pregnancy-related sepsis. Conclusions ,br> The main causes for maternal deaths in Potchefstroom Hospital correlated well with the main causes nationally. Of interest was that, compared to national statistics, there was a higher percentage of indirect causes of maternal death (mainly due to HIV/AIDS) than direct causes of deaths in Potchefstroom Hospital. However, it has been observed nationally that the percentage of indirect deaths compared to direct deaths is on the increase. This national trend is caused by the HIV/AIDS pandemic. General recommendations are made, which can be instituted to help lower the MMR in Potchefstroom Hospital and nationally. Keywords: Maternal mortality; hypertension; HIV; postpartum bleeding; maternal deaths For full text, click here: SA Fam Pract 2005;47(9):63-66