Indirect Maternal Deaths Research Articles

A Spotlight on Obstetric Anesthesia in the Developing World

(Anesth Analg. 2015;120(6):1179–1181) Despite a 47% decrease in maternal mortality worldwide since 1990, direct and indirect maternal deaths are still at an unacceptably high, 287,000 deaths per year. The majority of these take place in low-income countries and reports on possible interventions to reduce mortality further are scarce.

Pregnancy-associated Deaths: 31-year Experience.

The aim of the present study was to elucidate the clinical characteristics of pregnancy-associated maternal deaths. We performed a retrospective analysis with medical records and autopsy reports of cases of pregnancy-associated deaths. We collected information on all maternal deaths related to pregnancy that occurred in 3 hospitals affiliated with Nippon Medical School in Japan from January 1, 1984, to December 31, 2014. Data analyzed were maternal age, past medical history, parity, gestational age, clinical signs and symptoms, cause of death, and maternal autopsy findings. A total of 26 maternal deaths occurred during the 31-year study period. Autopsies were performed for 16 patients (61.5%). The 26 deaths included 19 (73.1%) classified as direct maternal deaths and 7 (26.9%) classified as indirect maternal deaths. The mean maternal age at death was 33.1±4.3 years (range, 26-41 years). The highest percentage of women was aged 35 to 39 years (38.5%). Of the 26 maternal deaths, 69% occurred at 32 to 41 weeks of gestation. In cases of direct maternal death, the leading causes were amniotic fluid embolism (7 cases, 27.0% of all deaths) and hemorrhage (6 cases, 23.1% of all deaths). In cases of indirect obstetric deaths, the causes included cardiovascular disorders, cerebrovascular disorders, sepsis due to group A streptococcal infection, and hepatic failure of unknown etiology. Amniotic fluid embolism was the leading cause of maternal deaths and was followed by obstetric hemorrhage. To prevent and reduce the number of maternal deaths in Japan, further basic and clinical research on amniotic fluid embolism is required.

Analysis of the Causes and Trends of Maternal Mortality in Korea: 2009-2014

Purpose: This study was conducted to analyze recent trends and causes of maternal mortality in Korea between 2009 and 2014. Methods: We investigated trends and causes of maternal death using the data from Complementary Investiga­ tions on the Infant, Maternal, and Perinatal Mortality carried out by Statistics Korea between 2009 and 2014. Maternal age, administrative district, causes of death and gestational age at the time of death were collected from data. Statistics including maternal mortality ratio (MMR) and maternal mortality rate were calculated. We also analyzed MMR according to the age, and administrative districts. The causes of maternal death were sorted and classified using International Classification of Diseases and World Health Organization recommendations. Results: The average MMR during 6 years was 13.16 and maternal mortality rate was 0.45. MMR was highest in 2011 (17.2) and lowest in 2012 (9.9). The average MMR of the administrative districts varied greatly from 7.51 (Gwangju) to 26.84 (Jeju). The average MMR during the study period was lowest in maternal age of 20­ 24 (6.9), and highest in 45-49 (143.7). On average, direct and indirect maternal deaths accounted for 66.2% and 29.9% of total maternal death, respectively. The three most common causes of maternal deaths were obstetrical embolism (24.4%), postpartum hemorrhage (18.3%), and hypertensive disease of pregnancy (5.5%) in decreasing order of frequency. Conclusion: Although MMR is decreasing during the study period, it fluctuates widely according to maternal age, districts, and constant effort for improvements is necessary. To reduce maternal deaths, solution to control preventable causes of maternal deaths, careful management of pregnancies with advanced maternal age, and policy to solve the discrepancy in the medical services among diverse regions in the country are needed.

Attitudes of midwives and maternal child health nurses towards suicide: A cross-sectional study.

Perinatal women are at risk of depression and/or suicidality. Suicide is the highest cause of indirect maternal deaths in the perinatal period. Midwives and maternal child health nurses (MCHN), as key clinicians, need to be able to detect these mental health issues. Little is known about these clinicians' attitudes to suicide. In this paper, we report on the results of a cross-sectional study of midwives' and MCHN attitudes to suicide. A convenience sample of midwives (n = 95) and MCHN (n = 86) from south-eastern Victoria, Australia, was recruited into the study. Participants completed the Attitudes to Suicide Prevention Scale. The results showed that MCHN have more positive attitudes towards suicide prevention than midwives, and younger participants have more positive attitudes to suicide prevention compared to older participants. Midwives and MCHN could benefit from continuing professional education to build their knowledge and skills in assessing suicide risk for childbearing women and their families, increasing positive attitudes, improving detection, and mental health referrals.

Grossesse chez les patientes ayant un antécédent de cardiopathie ischémique – Série de cas et revue de la littérature

Heart diseases complicate 1 to 3% of pregnancies and are the leading cause of indirect maternal deaths. Prior ischaemic heart event in pregnant patients is increasing. Most knowledge is based on few reports and there are no French nor international recommendations about the specific management of these patients. The specificity of the management of these patients during pregnancy, delivery and post-partum depends on the severity of the prior cardiac event and its consequences. This will be illustrated by the report of four recent cases managed in our hospital. First patient had myocardial infarction with normal left ventricular ejection fraction (LVEF). Second patient had a Tako-Tsubo syndrome with LVEF 45%. Third patient had ischemic cardiopathy with LVEF 30%. Fourth patient had myocardial infarction with LVEF 20%. A multidisciplinary follow-up should be required, especially in patients with severe ventricular dysfunction. The risk of fetal growth restriction appears to be increased, suggesting that closer ultrasound monitoring is necessary.

Mortalidad materna 1958-1996. Experiencia en el Hospital Nacional Edgardo, Rebagliati Martins - 38 años

OBJETIVO: Examinar la tendencia de la mortalidad materna ocurrida en un Hospital Nacional del Instituto Peruano de Seguridad Social. DISEÑO: Estudio epidemiológico descriptivo retrospectivo de las muertes maternas registradas en los archivos del Hospital. SUJETO: 202 mujeres que fallecieron durante la gestación, el parto o el puerperio. LUGAR: Departamento de Obstetricia y Ginecología del Hospital Nacional Edgardo Rebagliati Martins, IPSS. RESULTADOS: La muerte obstétrica directa representó el 73,3% (148 casos), incluyendo 26,2% (53 casos) por hipertensión inducida por la gestación, 24,8% (50 casos) por infecciones, 14,9% (30 casos) por hemorragias y 7,4% (15 casos) por otras causas obstétricas directas. La obstétrica indirecta fue 26,2% (53 casos) y la no relacionada 0,5% (1 caso). La tasa de mortalidad materna fue 40,3/100 000 nv. CONCLUSION: Se hace énfasis en la importancia del estudio de las muertes maternas, la mayoría de ellas prevenibles, de manera de contribuir a la disminución de las mismas. Así mismo, se hace mención de los problemas institucionales que repercuten en las tasas de mortalidad materna en los niveles registrados.

Maternal mortality and distance to facility-based obstetric care in rural southern Tanzania: a secondary analysis of cross-sectional census data in 226 000 households.

Access to skilled obstetric delivery and emergency care is deemed crucial for reducing maternal mortality. We assessed pregnancy-related mortality by distance to health facilities and by cause of death in a disadvantaged rural area of southern Tanzania. We did a secondary analysis of cross-sectional georeferenced census data collected from June to October, 2007, in five rural districts of southern Tanzania. Heads of georeferenced households were asked about household deaths in the period June 1, 2004, to May 31, 2007, and women aged 13-49 years were interviewed about birth history in the same time period. Causes of death in women of reproductive age were ascertained by verbal autopsy. We also asked for sociodemographic information. Multilevel logistic regression was used to analyse the effects of distance to health facilities providing delivery care on pregnancy-related mortality (direct and indirect maternal and coincidental deaths). The study included 818 583 people living in 225 980 households. Pregnancy-related mortality was high at 712 deaths per 100 000 livebirths, with haemorrhage being the leading cause of death. Deaths due to direct causes of maternal mortality were strongly related to distance, with mortality increasing from 111 per 100 000 livebirths among women who lived within 5 km to 422 deaths per 100 000 livebirths among those who lived more than 35 km from a hospital (adjusted odds ratio 3·68; 95% CI 1·37-9·88). Neither pregnancy-related nor indirect maternal mortality was associated with distance to hospital. Among women who lived within 5 km of a hospital, pregnancy-related mortality was 664 deaths per 100 000 livebirths even though 72% gave birth in hospital and 8% had delivery by caesarean section. Large distances to hospital contribute to high levels of direct obstetric mortality. High pregnancy-related mortality in those living near to a hospital suggests deficiencies in quality of care. Bill & Melinda Gates Foundation.

MORTALIDAD MATERNA. EXPERIENCIA DE 4 AÑOS EN EL HOSPITAL NACIONAL CAYETANO HEREDIA

OBJETIVO: Determinar la variación en el tiempo del tipo de muerte materna y las patologías responsables. MATERIAL Y METODOS: Estudio descriptivo, retrospectivo, tipo serie de casos, en base a datos de todos los casos de muerte materna ocurridas en el Hospital Nacional Cayetano Heredia, entre 1998 y 2001. RESULTADOS: Se registró 12446 nacidos vivos y 14 muertes maternas, obteniéndose una tasa de muerte materna de 112,5 por 100 nacidos vivos. El principal tipo de muerte materna fue la indirecta, con 57,1% (8 casos), siendo la causa principal el síndrome de inmunodeficiencia adquirida (SIDA) en 21,4% (3 casos). L a muerte directa represento 42,9% (6 casos), predomino el aborto séptico con 28% (4 casos). En los últimos dos años ocurrió solo un caso de muerte materna de tipo directa causada por eclampsia; sin embargo, ocurrieron cinco casos de muerte materna de tipo indirecta, 3 de ellas por SIDA. CONCLUSIÓN: La mortalidad por causas tuvo un comportamiento irregular, con una tendencia al descenso en las causas directas y un incremento marcado en las indirectas.

The maternal death autopsy

The post-mortem examination of maternal deaths can be one of the more complicated investigations in forensic pathology and there is no Australia-wide register of maternal deaths in Australia. Pregnancy-related deaths are traditionally defined as being a death that occurs during pregnancy or within 6 weeks of parturition. They are usually categorised into direct, indirect, coincidental and late maternal deaths. These categories attempt to delineate and define those conditions that are specifically related to pregnancy. Various case studies will be presented, along with a discussion of some of the complex medicolegal issues that may arise in specific cases. The potential value of a national registry will be discussed.

Pregnancy-related mortality in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System sites

Background Women continue to die in unacceptably large numbers around the world as a result of pregnancy, particularly in sub-Saharan Africa and Asia. Part of the problem is a lack of accurate, population-based information characterising the issues and informing solutions. Population surveillance sites, such as those operated within the INDEPTH Network, have the potential to contribute to bridging the information gaps. Objective To describe patterns of pregnancy-related mortality at INDEPTH Network Health and Demographic Surveillance System sites in sub-Saharan Africa and southeast Asia in terms of maternal mortality ratio (MMR) and cause-specific mortality rates. Design Data on individual deaths among women of reproductive age (WRA) (15–49) resident in INDEPTH sites were collated into a standardised database using the INDEPTH 2013 population standard, the WHO 2012 verbal autopsy (VA) standard, and the InterVA model for assigning cause of death. Results These analyses are based on reports from 14 INDEPTH sites, covering 14,198 deaths among WRA over 2,595,605 person-years observed. MMRs varied between 128 and 461 per 100,000 live births, while maternal mortality rates ranged from 0.11 to 0.74 per 1,000 person-years. Detailed rates per cause are tabulated, including analyses of direct maternal, indirect maternal, and incidental pregnancy-related deaths across the 14 sites. Conclusions As expected, these findings confirmed unacceptably high continuing levels of maternal mortality. However, they also demonstrate the effectiveness of INDEPTH sites and of the VA methods applied to arrive at measurements of maternal mortality that are essential for planning effective solutions and monitoring programmatic impacts.

Using the new ICD-MM classification system for attribution of cause of maternal death--a pilot study.

Understanding the causes of and factors contributing to maternal deaths is critically important for development of interventions that reduce the global burden of maternal mortality and morbidity. The International Classification of Diseases-Maternal Mortality (ICD-MM) classification of cause of death during pregnancy, childbirth and the puerperium was applied to data obtained from maternal death reviews (MDR) for 4558 maternal deaths from five countries in sub-Saharan Africa. None of the data sets identified type of maternal death. Information obtained via MDR is generally sufficient to agree on classification of cause of death to the levels of type and group. The terms 'underlying cause of death' and 'contributing conditions' were used differently in different settings and a specific underlying cause of death was frequently not recorded. Application of ICD-MM resulted in the reclassification of 3.1% (9/285) of cases to the group 'unanticipated complications of management', previously recorded as obstetric haemorrhage or unknown. An increased number of cases were assigned to the groups pregnancy-related infection (5.6-10.2%) and pregnancies with abortive outcome (3.4-4.9%) when a clear distinction was made between women who died 'with' HIV/AIDS of obstetric causes (direct maternal death) and AIDS-related indirect maternal deaths (group 'non-obstetric complications'). Similarly, anaemia and obstructed labour were more frequently identified as contributing factors than underlying cause of death. It would be helpful if MDR forms could have explicitly stated variables called: type, group and underlying cause of death as well as a dedicated section to the most frequently occurring contributing conditions recognised in that setting.

PMM.06 Five-year experience of maternal cardiac disease in a district general hospital 2008–2012

CMACE 2008 has shown that the overall rate of mortality from cardiac disease has tripled over the last two decades being, the largest cause of indirect maternal death; mainly due...

PMM.78 Pregnancies in women with cardiac disease- experience of a tertiary centre following establishment of obstetrics-cardiology services

The incidence of cardiac disease in pregnancy is increasing and cardiac disease remains the leading cause of indirect maternal deaths. Management in pregnancy is highly specialised and requires early diagnosis,...

Pregnancy and Maternal Outcomes in Women With Prior or Current Gastrointestinal Malignancies

ObjectivesTo review the fetal and maternal outcomes of women with a diagnosis of gastrointestinal (GI) cancer before or during pregnancy. MethodsWe conducted a retrospective cohort study of pregnant women referred to a single tertiary care centre with a current or previous diagnosis of GI malignancy. Maternal, obstetric, and infant data were recorded. ResultsWe identified 18 pregnancies in 13 women. Nine women were found to have a GI malignancy during pregnancy (group 1). There was an indirect maternal death in this group in a woman with advanced gastric adenocarcinoma. Nine unique pregnancies occurred in eight women with diagnosis and management of GI malignancies before their pregnancies (group 2). ConclusionGI malignancies are difficult to diagnose and manage during pregnancy and are usually advanced at the time of diagnosis. Surgery can be performed during pregnancy if necessary, with chemotherapy and radiotherapy usually deferred to the postpartum period. Women who have had a prior GI malignancy have special circumstances related to the type of surgery performed and previous exposure to chemotherapy. These patients may benefit from a multidisciplinary team effort to optimize their care.

The evaluation of last seven years maternal mortality in Manisa, Turkey

Objective: In this study, we aimed to evaluate the last 7-year rates of maternal mortality and the causes of maternal mortality in Manisa including Aegean region in the western part of the country. Study design: Maternal mortalities in Manisa determined by Maternal Mortality Commission were examined between January 1, 2006 and December 31, 2012. The classification of maternal mortality was performed as directly, indirectly, and incidentally. The annual rates and numbers of maternal deaths, causes of death, and demographic data were obtained from the records. Maternal mortality ratio is calculated as the number of women who die during pregnancy and childbirth, per 100,000 live births. Results: A total of 32 maternal deaths cases were reviewed between 2006 and 2012. A total of seven incidental maternal deaths of 32 were not evaluated. A total of five direct maternal deaths and 20 indirect maternal deaths were recorded. Maternal mortality rate (per 100.000 per live births) was 28.86 in 2006. This ratio decreased to 10.7 in 2012. Considering the leading causes of maternal death, the diseases of the circulatory system complicating the pregnancy and puerperium (28%) rank first. When direct maternal deaths are only evaluated, the most common cause was hemorrhage, which was followed by the disseminated intravascular coagulation. In all, six over eight (42%) maternal mortality in which delay model was detected were recorded as matched with third. Conclusion: In conclusion, an incentive to demand primary pregnancy advisory service is necessary for minimizing indirect maternal deaths and the need of medical staff must be fulfilled. Postpartum monitoring will be performed during the postnatal period especially in the first 24 h. Sensitivity must be showed for the training of medical staff that will perform emergency obstetric care when required.

Recognition of Postpartum Psychosis; Obstetricians, Gps, Midwives, Community Psychiatric Nurses and Psychiatrists Working Together

Psychiatric illness remains one of the leading causes for indirect maternal deaths in the United Kingdom. CMACE Report 2006-2008 reported 13 maternal deaths attributed to psychiatric illness compared to 18 deaths in the previous triennial report. This significant improvement highlights the importance of early recognition, appropriate referrals and multidisciplinary approach for dealing with Psychiatric illness during pregnancy and puerperium. Puerperal Psychoses or Postpartum Psychosis is characterized by sudden onset and rapid deterioration. Therefore, early recognition should be an essential skill for Obstetricians and midwives working together with Psychiatrists; Understanding the incidence, risk factors and symptoms are integral in early recognition of the disorder, and consequently patients receiving the proper treatment.

Maternal deaths in Norway 2005-2009.

Norway has low maternal mortality, but such deaths are underreported even in high-income countries. Our goal was to identify the exact number of maternal deaths, the causes of death and the potential for improvement through medical care in Norway. We traced maternal deaths in the period from 1 January 2005 to 31 December 2009 by linking the Medical Birth Registry and the Cause of Death Registry, supplemented with data from maternity clinics. We identified the cause of death and the lessons that could be learned by a meticulous review of each case. We found 26 maternal deaths during the period, 14 of which were due to direct causes and 12 to indirect causes. The maternal mortality ratio was 8.7/100,000 live births. Fourteen of the deaths were registered in official statistics. Of the 12 deaths that were not included in the statistics, 11 were found through matching the registers and one had been reported directly by the hospital. The most common causes of death were hypertensive disorders during pregnancy (n = 6), thromboembolism (n = 4) and mental illness (n = 4). None of the deaths due to thromboembolism appeared in official statistics. The same applied to nine of the 12 indirect maternal deaths. We found a potential for improved medical care in 14 of 26 cases. Half of these were deaths due to hypertensive disorders during pregnancy or thromboembolism. Maternal death was considerably underreported in Norwegian official statistics during the period studied. Greater attention should be given to better blood-pressure treatment, stabilisation and timely delivery in the case of hypertension during pregnancy, and to screening for possible pulmonary embolism. The same applies to mental illness and internal medical disorders in pregnant women.

Facility‐based review of 296 maternal deaths at a tertiary centre in India: Could they be prevented?

The aim of this study was to identify causes of maternal mortality at the facility and to assess the standard of care, deficiencies in health services and preventability of these deaths using facility-based maternal death reviews. This was a prospective study at a tertiary care hospital that included all women who died during pregnancy or within 42 days of being pregnant during 2005-2010. A review of 296 maternal deaths revealed that 59% of these occurred in medical wards. Indirect maternal deaths (54%) outnumbered the direct deaths (46%). Main causes were hepatitis (18%), hemorrhage (10%) and puerperal sepsis (10%). Only 5% of the women had received antenatal care at the facility. One-third (34%) were referred from other centers. The majority (74%) were critically sick at admission. Most of the women (62%) died postpartum. Substandard care and deficient health services were identified in 8% and 20% of the cases, respectively. Sixteen (5%) maternal deaths were deemed preventable and another 36 (12%) possibly preventable. Since most of the preventable deaths (12/16) were due to hemorrhage, measures to control postpartum hemorrhage were promoted at the facility. Findings of the maternal death reviews were regularly conveyed to the State Health Department for prioritization and resource allocation to prevent maternal mortality. More maternal deaths occurred in the medical than in the obstetrics wards at the facility. The leading causes were hepatitis, hemorrhage and puerperal sepsis. Most of the deaths were non-preventable as the women were critically sick at admission; however, substandard care and health service deficiency were contributory in some of the cases.

Causas externas e mortalidade materna: proposta de classificacao

To analyze deaths from external causes and undefined causes in women of childbearing age occurring during pregnancy and early postpartum. The deaths of 399 women of childbearing age, resident in Recife, Northeastern Brazil, in the period 2004 to 2006, were studied. The survey utilized the Reproductive Age Mortality Survey method and a set of standardized questionnaires. Data sources included reports from the Institute of Legal Medicine, hospital and Family Health Strategy records and interviews with relatives of the deceased women. External causes of death during pregnancy were classified according to the circumstance of death, using the O93 code (ICD) and maternal mortality ratios before and after the classification were calculated. Eighteen deaths during pregnancy were identified. The majority were aged between 20 and 29, had between 4 and 7 years of schooling, were black and single parents. Fifteen deaths were classified using the O93 code as pregnancy related death (13 for homicide - code 93.7; 2 by suicide - code 93.6) and three were classified as indirect obstetric maternal deaths (one homicide - code 93.7 and two by suicide - code 93.6). There was an average increment of 35% in the RMM after classification. Deaths from undefined causes in and in early postpartumdid not occur by chance and their exclusion from the calculations of maternal mortality indicators only increases levels of underreporting.

826: The effect of factors of social exclusion on access to antenatal care and the subsequent impact on foetal outcomes

Delayed and erratic access to antenatal care are linked to direct and indirect maternal deaths and morbidity. Social deprivation also accounts for much maternal and child ill-health, with much national and regional health data showing discrepancies in the access and utilisation of care by groups of women who differ by ethnicity, age and socioeconomic status.