Obstetric Causes Of Death Research Articles

Spatiotemporal patterns and surveillance artifacts in maternal mortality in the United States: a population-based study

Reports of high and rising maternal mortality ratios (MMR) in the United States have caused serious concern. We examined spatiotemporal patterns in cause-specific MMRs, in order to obtain insights into the cause for the increase. The study included all maternal deaths recorded by the Centers for Disease Control and Prevention from 1999 to 2021. Changes in overall and cause-specific MMRs were quantified nationally; in low-vs high-MMR states (i.e., MMRs <20 vs≥26 per 100,000 live births in 2018-2021); and in California vs Texas (populous states with low vs high MMRs). Cause-specific MMRs included those due to unambiguous causes (e.g., selected obstetric causes such as pre-eclampsia/eclampsia) and less-specific/potentially incidental causes (e.g., "other specified pregnancy-related conditions", chronic hypertension, and malignant neoplasms). MMRs increased from 9.60 (n=1543) in 1999-2002 to 23.5 (n=3478) per 100,000 live births in 2018-2021. The temporal increase in MMRs was smaller in low-MMR states (from 7.82 to 14.1 per 100,000 live births) compared with high-MMR states (from 11.1 to 31.4 per 100,000 live births). MMRs due to selected obstetric causes decreased to a similar extent in low-vs high-MMR states, whereas the increase in MMRs from less-specific/potentially incidental causes was smaller in low- vs high-MMR states (MMR ratio (RR) 5.57, 95% CI 4.28, 7.25 vs 7.07, 95% CI 5.91, 8.46), and in California vs Texas (RR 1.67, 95% CI 1.03, 2.69 vs 10.8, 95% CI 6.55, 17.7). The change in malignant neoplasm-associated MMRs was smaller in California vs Texas (RR 1.21, 95% CI 0.08, 19.3 vs 91.2, 95% CI 89.2, 94.8). MMRs from less-specific/potentially incidental causes increased in all race/ethnicity groups. Spatiotemporal patterns of cause-specific MMRs, including similar reductions in unambiguous obstetric causes of death and variable increases in less-specific/potentially incidental causes, suggest misclassified maternal deaths and overestimated maternal mortality in some US states. This work received no funding.

Non-Obstetric Maternal Mortality Trends by Race in the United States.

Public health interventions to reduce maternal mortality have largely focused on obstetric causes of death. However, previous studies have noted that non-obstetrics factors, such as motor vehicle accidents, substance overdoses, homicides, and suicides, may account for a large proportion of maternal deaths. The study objective was to examine trends in maternal deaths from non-obstetric causes across races in the United States (US). A population-based cross-sectional study was conducted on 80,710,348 live births using data from the "Birth Data" and "Mortality Multiple Cause" files compiled by the Centers for Disease Control and Prevention from 2000 to 2019. The annual incidence of maternal deaths attributed to non-obstetric causes (/100,000 live-births) during pregnancy and up to 42 days postpartum were calculated across racial groups. Then the effects of race on the risk of non-obstetric maternal mortality and temporal changes over the study period were examined using logistic regression models. From 2000 to 2019, a total 7,334 women died during pregnancy, childbirth, and within 42 days postpartum from non-obstetric causes, representing 34.5% (7,334/21,241) of all maternal mortality. Of non-obstetric deaths, 31.3% were caused by transport accidents and 27.3% by accidental poisoning. American Indian women were found to have the highest risk of non-obstetric maternal mortality (OR 2.20,95% CI 1.90-2.56), and 46.1% (176/382) of all deaths among pregnant American Indian women were caused by non-obstetric complications. Risk of non-obstetric maternal mortality increased overall during the 20-year study period, with a greater increase among Black (1.15, 1.13-1.17) and American Indian women (1.17, 1.13-1.21). Non-obstetric causes of death have become increasingly prevalent in the US, especially in American Indian women. Novel interventions to address these non-obstetric factors should especially target American Indian women to improve maternal outcomes.

Audit of maternal deaths at the Saint Louis regional hospital from 2017 to 2019

Objective: To audit maternal deaths at the regional hospital center of Saint-Louis. Materials and methods: This was a retrospective cross-sectional study of all maternal deaths that occurred between January 1, 2017 and December 31, 2019 at the Saint-Louis regional hospital center. Data were entered on EXCEL 2013 software. Analysis was performed on Epi Info version 3 software. Results: During our study, 73 cases of maternal death were collected. Maternal mortality was 520 per 100 000 live births. The mean age of the patients was 28.1 years±6.8. Multiparous women accounted for 43.8% and nulliparous women for 1.3%. The causes of maternal death were obstetric hemorrhage (28.77%), hypertension and its complications (20.55%), labour dystocia (15.07%) and anemia (6.85%). Direct obstetric causes of death were responsible for 64.38% of cases and indirect obstetric causes were seen in 35.62%. Death occurred postpartum in 68% of cases, during pregnancy in 25% and during labor in 7%. Death was preventable in 77.5% of cases. Conclusion: Maternal mortality is a real health problem in our practice. It affects young women. Indirect causes of death are becoming more significant causes of death in our practice. Maternal mortality is avoidable in the majority of cases.

Maternal death analysis based on data from the nationwide registration system in Japan (2010-2018).

The maternal mortality rate in Japan was 3.5 per 100 000 live births in 2017, similar to that reported in other developed countries. To reduce the number of maternal deaths, a Japanese nationwide registration and analysis system was implemented in 2010. Between January 2010 and April 2018, 367 maternal deaths were reported. Among them, by reviewing 80 autopsy records, the direct obstetric causes of death were identified in 52 women. The major causes of deaths were amniotic fluid embolism and acute pulmonary thromboembolism. The other 26 maternal deaths were associated with indirect obstetric causes including invasive Group A Streptococcus infection, aortic dissection, cerebral stroke and cardiomyopathies. This review highlights the importance of autopsy in maternal deaths. On analyzing 42 autopsy specimens obtained from registered cases of maternal death during 2012–2015, the 36% of causes of death by autopsy were discordant with the clinical diagnosis. Moreover, of the 38% of non‐autopsied maternal death, the cause of death could not be clarified from the clinical chart. We emphasized that detailed autopsies are necessary to clarify the precise pathologic evidence related to pregnancy and delivery, especially causes of unexpected death such as amniotic fluid embolism.

Сравнительный анализ материнской смертности в Дальневосточном и Сибирском федеральном округах

Objective. To perform comparative analysis of parameters and structure of maternal mortality (MM) in the Far Eastern Federal District (FEFD) and Siberian Federal District (SFD) in 2014–2019. Materials and methods. The database for analysis was generated using map-based emergency notifications of maternal deaths (69 in FEFD and 180 in SFD). We used methods of descriptive statistics, Pearson's χ2-test, and calculated odds ratios (ORs) with 95% confidence intervals (95% CIs). Results. Between 2014 and 2018, the dynamics of MM in the FEFD and SFD had a one-way trend: it decreased in 2014–2017, but dramatically increased in 2018 primarily due to social factors. In 2019, we observed a significant growth of MM in the FEFD, while the SFD demonstrated a reduction of MM. The most common cause of maternal death in both districts was extragenital diseases. However, there were some differences in the structure of obstetric causes: in FEFD, preeclampsia and obstetric hemorrhage were the most frequent obstetric causes of death, while in SFD, women primarily developed embolism and placental abruption. Conclusion. The dynamics and structure of MM in the FEFD and SFD require management decisions aimed at improving medical care with the consideration of clinical guidelines, organization of continuous audit, systematic development of practical teamwork skills both in simulation training centers and healthcare institutions. Key words: Far Eastern Federal District, maternal mortality, Siberian Federal District

A Study of Causes and Factors Responsible for Maternal Mortality in a Tertiary Care Institute of Central Gujarat

Maternal mortality is still a big health concern in developing world. The state of maternal health represents overall state of women’s right in health, social and economic realms. If the causes of death can be addressed and are found to be preventable it indicates negligence on the part of government and the entities that have the power to implement the changes. To determine factors and causes of maternal mortality this retrospective observational study was conducted in the department of obstetrics and gynaecology, BJ medical college. Maternal mortalities from October 2016 to March 2018 (18 months) were analysed with respect to factors like locality, literacy, parity, ANC care, time after admission, type of delay (according to maternal death review form) and causes of death (direct and indirect causes of MMR). Total 92 maternal deaths were studied and that gave a MMR of 468 per 1,00,000 live births. Maximum deaths occurred in patients who were in the age group of 20-34 (83.1%), rural locality (71%), Irregular with ANC visits (74%), multigravida (56.5%), within 24 hours of delivery (46.7%) and those who had type 1 delay (delay in decision making to seek help, 78.3%). More of deaths occurred in post partum (84.8%) and in vaginal mode of delivery (47.4) Vs Caesarean section (46.3). Direct obstetric causes of death (57.6%) were of deaths which included hypertensive disorders (29.3%), haemorrhage (19%) and others. Indirect causes accounted for 42.4% deaths which included hepatitis (21.7%), heart diseases (9.8%) etc. Early intervention and diagnosis with timely management are essential to reduce morbidity and hence maternal mortality. Special attention should be given to Routine Antenatal care (RANC) and more specifically to Focussed Antenatal Care (FANC)). Lack of expertise at primary level with lack of proper referral system adds to the cause.

Maternal death review and outcomes: An assessment in Lagos State, Nigeria.

The objective of the study was to investigate the results of Maternal and Perinatal Death Surveillance and Response (MPDSR) conducted in three referral hospitals in Lagos State, Nigeria over a two-year period and to report the outcomes and the lessons learned. MPDRS panels were constituted in the three hospitals, and beginning from January 2015, we conducted monthly MPDSR in the three hospitals using a nationally approved protocol. Data on births and deaths and causes of deaths as identified by the MPDSR panels were collated in the hospitals. The results show that over a 21-month period (January 1, 2015 –September 30, 2016), maternal mortality ratio (MMR) remained high in the hospitals. Although there was a trend towards an increase in MMR in Lagos Island Maternity Hospital and Gbagada General Hospital, and a trend towards a decline in Ajeromi Hospital, none of these trends were statistically significant. Eclampsia, primary post-partum haemorrhage, obstructed labour and puerperal sepsis were the leading obstetric causes of death. By contrast, delay in arrival in hospital, the lack of antenatal care and patients’ refusal to receive recommended treatment were the patients’ associated causes of death, while delay in treatment, poor use of treatment protocols, lack of equipment and lack of skills by providers to use available equipment were the identified facility-related causes of death. Failure to address the patients and facility-related causes of maternal mortality possibly accounted for the persistently high maternal mortality ratio in the hospitals. We conclude that interventions aimed at redressing all causes of maternal deaths identified in the reviews will likely reduce the maternal mortality ratios in the hospitals.

Validity of a minimally invasive autopsy for cause of death determination in maternal deaths in Mozambique: An observational study.

BackgroundDespite global health efforts to reduce maternal mortality, rates continue to be unacceptably high in large parts of the world. Feasible, acceptable, and accurate postmortem sampling methods could provide the necessary evidence to improve the understanding of the real causes of maternal mortality, guiding the design of interventions to reduce this burden.Methods and findingsThe validity of a minimally invasive autopsy (MIA) method in determining the cause of death was assessed in an observational study in 57 maternal deaths by comparing the results of the MIA with those of the gold standard (complete diagnostic autopsy [CDA], which includes any available clinical information). Concordance between the MIA and the gold standard diagnostic categories was assessed by the kappa statistic, and the sensitivity, specificity, positive and negative predictive values and their 95% confidence intervals (95% CI) to identify the categories of diagnoses were estimated. The main limitation of the study is that both the MIA and the CDA include some degree of subjective interpretation in the attribution of cause of death.A cause of death was identified in the CDA in 98% (56/57) of cases, with indirect obstetric conditions accounting for 32 (56%) deaths and direct obstetric complications for 24 (42%) deaths. Nonobstetric infectious diseases (22/32, 69%) and obstetric hemorrhage (13/24, 54%) were the most common causes of death among indirect and direct obstetric conditions, respectively. Thirty-six (63%) women were HIV positive, and HIV-related conditions accounted for 16 (28%) of all deaths. Cerebral malaria caused 4 (7%) deaths. The MIA identified a cause of death in 86% of women. The overall concordance of the MIA with the CDA was moderate (kappa = 0.48, 95% CI: 0.31–0.66). Both methods agreed in 68% of the diagnostic categories and the agreement was higher for indirect (91%) than for direct obstetric causes (38%). All HIV infections and cerebral malaria cases were identified in the MIA. The main limitation of the technique is its relatively low performance for identifying obstetric causes of death in the absence of clinical information.ConclusionsThe MIA procedure could be a valuable tool to determine the causes of maternal death, especially for indirect obstetric conditions, most of which are infectious diseases.The information provided by the MIA could help to prioritize interventions to reduce maternal mortality and to monitor progress towards achieving global health targets.

Temporal Analysis of Maternal Mortality in Kano State, Northern Nigeria: A Six-Year Review

To determine the incidence of maternal mortality associated with non utilization of obstetric services and how socio-demographic and medical factors influence the deaths of pregnant women. A retrospective study of information extracted from hospital records on live birth, antenatal attendance, age at death, parity, educational level and cause of death was reviewed, the study covered data from thirty General hospitals in both urban and rural areas in Kano state for a period of 6 years from 1<SUP>st</SUP> January 2005 to 31<SUP>st</SUP> December 2010. Data collected was analyzed for pattern of antenatal care, hospital live delivery, age at death, obstetric causes of death and maternal mortality ratio. There were 2,310,727 antenatal attendance 1,886,932 live deliveries and 3,062 maternal death during the period under review given a maternal mortality ratio (MMR) of 1625/100,000 live deliveries. It was also discovered that mean age at death for pregnant women for urban areas was 28.8 years and rural 27.6 years. Both antenatal and hospital live deliveries had irregular pattern. The major direct causes of death in urban area was eclampsia and bleeding cases while in rural areas bleeding cases followed by eclampsia and obstructed labor and then anemia were more prevalent.

Trends in maternal mortality in Hungary between 1978 and 2010

ObjectiveWe evaluated the trends of the last decades in maternal mortality in Hungary and compared Hungarian results with those of other European countries. Study designCases of maternal death in Hungary during the study period from calendar year 1978 to 2010 were analyzed in a retrospective manner to characterize mortality distribution and to identify potential clinical or demographic predictors. Data in all cases were extracted both from the national Obstetric Registry operated by the National Institute of Gynecology and Obstetrics, from the Hungarian Central Bureau of Statistics and from the National Public Health and Medical Officer Service. Detailed clinical data were obtained based on obligatory reporting by individual clinical institutions. ResultsThe annual maternal mortality rate (MMR) was 26.7 per 100,000 live births in the period 1978–1987 and declined significantly to 10.9 per 100,000 live births in the period 1997–2010. In the period 1988–1996 (with missing associated clinical and demographic data) the MMR was 16.4 per 100,000 live births. The proportion of delivery-associated causes of death increased significantly between the two study periods from 49.4% to 62.9% (p<0.05). Among obstetric causes of death, the rate of thromboembolism showed a significant increase, while there was a trend toward a decline in rate of maternal deaths attributable to hemorrhagic shock. Among medical causes of death not directly attributable to obstetric complications, the rate of renal and gastrointestinal etiologies declined significantly throughout the study periods. ConclusionsWe observed a marked decline in maternal mortality during the last few decades in Hungary. Recent changes in mortality distribution highlight current characteristics of pregnancy care in Hungary and may help identify strategies for future improvement.

Neonatal mortality in South Africa: How are we doing and can we do better?

While there has been a worldwide call for a two-thirds reduting in childhood mortality Millennium Development Goal 4 (MDG$0 is unlikely to be reached by that deadline. The highest rates of infant and child mortality are found in sub-Saharan Africa where little progress has been made in the last 15 years towards reducing the number of deaths. Although good progress has been made in Africa towards reducing under-five mortality preventable causes continue to take the lives of children. In South Africa the neonatal death rate is 21 per 1000 births. A retrospective descriptive audit conducted over a 1-year period at Steve Biko Academic Hospital As neonates continue to die in South Africa offers important insights into the causes of neonatal mortality. The top five primary obstetric causes of death at the hospital included spontaneous preterm labor fetal anomaly hypertensive disorders intrapartum asphyxia and antepartum hemorrhage. The top four causes of neonatal death were immaturity-related infections congenital abnormalities and hypoxia. Research supports that cost-effective and inexpensive interventions such as antibiotics antenatal corticosteroids hypothermia prevention breastfeeding and clean delivery practices can reduce neonatal deaths by a 41-72%. As neonates continue to die in South Africa the question needs to be raised whether the deaths occurring outside of the referral hospital is due to limited availability of beds in the region (which probably reflects similar regions in the country) or inadequate referral systems and problematic transport systems. Community educational programs outreach programs improved hospital staff training and the implementation of cost-effective techniques and supplies are suggestions for South Africa and other sub-Saharan African countries to make progress towards MDG4. Though this may not be possible by 2015 the focus should be on the implementation of sustainable measures to improve neonatal mortality and ultimately reducing child mortality.

English

AIMS : This study aimed to study the determinants, common causes and possible prevention of maternal mortality. MATERIALS AND METHODS: Maternal mortalities in Department of Obstetrics and gynecology, Gandhi medical college, Sultania Zanana Hospital, Bhopal during 5 year period from Jan 2007- Dec 2011 were studied. The individual records of all maternal deaths occurring during the study period of 5 years were extracted from patient's case notes and hospital record registers. Total deliveries for the period were extracted from the delivery registers. RESULTS : In the year 2007-2011 total live births were 43,683 of which 338 mothers died giving cumulative maternal mortality ratio of 773.75 per 1,00,000 live births. Among 338 total maternal deaths, the maximum deaths were in the age group 20-30 years (88.16%).The death rate of mothers from rural areas was higher (65.68%).The highest number of maternal death occurred among multigravidae (46.74%) . A total of 91.72% of maternal death occurred in unbooked patients. Most were referred patients (74.55%). Most of them were illiterate (61.8%).76.62% patients died within 24 hours of admission.33.13% women died in antenatal period while 64.49% died in postnatal period. Direct obstetric causes of death accounted for 76.03% of all maternal deaths. Among the direct causes 39.64% died due to hypertensive disorder of pregnancy, 18.93% due to hemorrhage. Indirect causes accounted for 23.96% in which anemia (8.57%), malaria (3.55%) hepatitis (2.66%) were the leading causes . CONCLUSIONS : This study has shown higher maternal mortality due to being a tertiary care hospital based study where more complicated and referred cases are admitted. Most maternal deaths can be prevented by providing care at grass root level, linkage between primary, secondary and tertiary care, strengthening of referral services and instituting emergency obstetric services.

Total perinatally related losses at Tygerberg Hospital – a comparison between 1986, 1993 and 2006

To determine the leading causes of perinatal deaths and to evaluate any changes, with the inclusion of placental histology. At perinatal mortality meetings, primary and final causes of death were assigned for the period 1 July 2006 - 30 June 2007. All singleton babies born to women residing in the metropolitan area serviced by Tygerberg Hospital were included in the prospective descriptive study. The total number of singleton births was 10 396. The total of perinatally related losses (TPRL) rate was 26.2 per 1,000 births. The leading primary obstetric causes of death were: infections (47 - 17.3%), spontaneous preterm labour (PTL) (41 - 15.1%), antepartum haemorrhage (APH) (40 - 14.7%), intra-uterine growth restriction (IUGR) (40 - 14.7%), fetal abnormality (31 - 11.4%), hypertensive disorders (25 - 9.2%), unexplained intra-uterine deaths (IUD) (20 - 7.4%), intrapartum hypoxia (12 - 4.4%) and maternal disease (9 - 3.3%). A total of 162 placentas were sent for histology; 58 reports changed the primary cause of death. The TPRL rate for singleton pregnancies was 26.2 per 1,000 births for the study period. The TPRL rates in 1986 and 1993 were 36.7 and 30.5 per 1,000 deliveries. Infection is now the leading primary cause of death, followed by spontaneous PTL, APH and IUGR. During the previous two study periods, APH was the leading primary cause of death, followed by spontaneous PTL. Unexplained IUDs ranked third in 1986, fourth in 1993 and seventh in this study because of the availability of placental histology. Placental histology reports changed 21.3% of the primary causes of death.

Neonatal mortality, risk factors and causes: a prospective population-based cohort study in urban Pakistan.

To evaluate the prevalence, sex distribution and causes of neonatal mortality, as well as its risk factors, in an urban Pakistani population with access to obstetric and neonatal care. Study area women were enrolled at 20-26 weeks' gestation in a prospective population-based cohort study that was conducted from 2003 to 2005. Physical examinations, antenatal laboratory tests and anthropometric measures were performed, and gestational age was determined by ultrasound to confirm eligibility. Demographic and health data were also collected on pretested study forms by trained female research staff. The women and neonates were seen again within 48 hours postpartum and at day 28 after the birth. All neonatal deaths were reviewed using the Pattinson et al. system to assign obstetric and final causes of death; the circumstances of the death were determined by asking the mother or family and by reviewing hospital records. Frequencies and rates were calculated, and 95% confidence intervals were determined for mortality rates. Relative risks were calculated to evaluate the associations between potential risk factors and neonatal death. Logistic regression models were used to compute adjusted odds ratios. Birth outcomes were ascertained for 1280 (94%) of the 1369 women enrolled. The 28-day neonatal mortality rate was 47.3 per 1000 live births. Preterm birth, Caesarean section and intrapartum complications were associated with neonatal death. Some 45% of the deaths occurred within 48 hours and 73% within the first week. The primary obstetric causes of death were preterm labour (34%) and intrapartum asphyxia (21%). Final causes were classified as immaturity-related (26%), birth asphyxia or hypoxia (26%) and infection (23%). Neither delivery in a health facility nor by health professionals was associated with fewer neonatal deaths. The Caesarean section rate was 19%. Almost all (88%) neonates who died received treatment and 75% died in the hospital. In an urban population with good access to professional care, we found a high neonatal mortality rate, often due to preventable conditions. These results suggest that, to decrease neonatal mortality, improved health service quality is crucial.

Perinatal mortality at Frontier Hospital, Queenstown - a 6-year audit using the Perinatal Problem Identification Programme (PPIP)

The objectives were to determine the perinatal mortality rate (PNMR) the neonatal mortality rate (NNMR) the major obstetric and neonatal causes of death the occurrence of avoidable factors in perinatal deaths and syphilis serology at the time of delivery at Frontier Hospital Queenstown. The study was an audit of perinatal deaths with retrospective and prospective periods. Frontier Hospital is a designated Regional Hospital in the Northern Region of the Eastern Cape South Africa. All perinatal deaths of infants weighing more than 499 g occurring from 1 January 1995 to 31 December 2000. Methods: A retrospective hospital records review from 1 January 1995 to 30 June 1996 and a prospective assessment of perinatal deaths from 1 July 1996 to 31 December 2000. Measures: PNMR NNMR causes of perinatal and neonatal death avoidable factors and syphilis serology. The retrospective PNMR was 33/1 000 deliveries and the NNMR 7/1 000. The prospective PNMR started at 51/1 000 deliveries and the NNMR at 19/1 000. The prospective data then showed a downward trend. The leading obstetric cause of death was unexplained stillbirths and the leading neonatal cause of death labour-related hypoxia. Health personnel-related avoidable factors occurred frequently. Of these intrapartum care-related avoidable factors made the largest contribution. Syphilis serology at delivery was unknown in over 80% of deaths and declined to 56% over the 6-year period. Both the PNMR and the NNMR dropped during the audit period. This may have been due to the general audit and feedback process itself as well as to specific responses to problems that were identified through the audit process. (authors)

Causes of stillbirths and early neonatal deaths: data from 7993 pregnancies in six developing countries

To report stillbirth and early neonatal mortality and to quantify the relative importance of different primary obstetric causes of perinatal mortality in 171 perinatal deaths from 7993 pregnancies that ended after 28 weeks in nulliparous women. A review of all stillbirths and early newborn deaths reported in the WHO calcium supplementation trial for the prevention of pre-eclampsia conducted at seven WHO collaborating centres in Argentina, Egypt, India, Peru, South Africa and Viet Nam. We used the Baird-Pattinson system to assign primary obstetric causes of death and classified causes of early neonatal death using the International classification of diseases and related health problems, Tenth revision (ICD-10). Stillbirth rate was 12.5 per 1000 births and early neonatal mortality rate was 9.0 per 1000 live births. Spontaneous preterm delivery and hypertensive disorders were the most common obstetric events leading to perinatal deaths (28.7% and 23.6%, respectively). Prematurity was the main cause of early neonatal deaths (62%). Advancements in the care of premature infants and prevention of spontaneous preterm labour and hypertensive disorders of pregnancy could lead to a substantial decrease in perinatal mortality in hospital settings in developing countries.

Maternal Mortality in the First Year of the New Millennium at the University of Port Harcourt Teaching Hospital, Nigeria

Aim: To highlight the tragedy posed by unbooked obstetric emergencies. Method: All the obstetric deaths in the year 2000 were recorded. Analyses were made of such aspects as distribution of death according to booking status, major direct obstetric causes of death, state of mother and baby on admission, duration of stay and mode of delivery in hospital before death occurred and source of admission of the unbooked mothers. Results: In a period of 12 months from January 1 to December 31, 2000, a total of 1809 mothers delivered at the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt. One thousand five hundred and sixty two (86.3%) were booked while 247 (13.7%) were unbooked. There were 18 maternal deaths; 2 among the booked mothers and 16 among the unbooked mothers, constituting a maternal mortality ratio of 128 and 6,478 per 100,000 deliveries respectively. The combined maternal mortality ratio for both booked and unbooked mothers was 995.0 per 100,000 deliveries. The major avoidable social factor in maternal mortality here is the lack of antenatal care and also the unorganized maternity referral system in Port Harcourt. Conclusion: Any intervention to reduce maternal mortality here should be directed towards eliminating poverty, illiteracy and ignorance which are the major factors that create the unbooked mothers. Key Words: First year, New millennium, maternal mortality, Port Harcourt Journal of College of Medicine Vol.9(1) 2004: 25-27

Can enquiries into severe acute maternal morbidity act as a surrogate for maternal death enquiries?

To assess whether severe acute maternal morbidity (SAMM, 'near misses') can be used as a surrogate of an analysis of maternal deaths to describe the pattern of severe maternal disease and avoidable factors related to it. Prospective, descriptive study. A SAMM and maternal mortality audit was conducted in three clearly defined geographical areas, consisting of rural and urban settings in South Africa. Indigent black African pregnant women. Cases of SAMM and maternal deaths were collected in the areas and a comparison was made of the disease profiles and avoidable factors, missed opportunities and substandard care. The proportion of primary obstetric causes and avoidable factors in women with SAMM and maternal deaths, and the mortality indices of the primary obstetric causes of death and organ system dysfunction. A total of 423 women with SAMM and 128 maternal deaths were collected over two years. Demographic factors were similar between the groups except that significantly more maternal deaths had not attended any antenatal care. The primary obstetric causes of SAMM and maternal death did not correlate. The four most common causes of SAMM were complications of hypertension (27.2%), postpartum haemorrhage (18.0%), antepartum haemorrhage (12.8%) and abortion (11.3%), whereas the four most common causes of maternal death were non-pregnancy related sepsis (26.6%), complications of hypertension (23.4%), pre-existing medical disease (14.1%) and abortion (10.9%). The types of avoidable factors were similar between both groups although administrative factors occurred significantly more frequently in the maternal death group as did poor problem identification and monitoring. Review of SAMM gives a different disease pattern to that obtained from maternal death audits. However, in diagnosing inadequacies in the health system, similar information was obtained.

Why babies die--a perinatal care survey of South Africa, 2000-2002.

To identify the major causes of perinatal mortality in South Africa. Seventy-three state hospitals throughout South Africa representing metropolitan areas, cities and towns and rural areas. Users of the Perinatal Problem Identification Programme (PPIP) amalgamated their data to provide descriptive information on the causes of perinatal death and the avoidable factors, missed opportunities and substandard care in South Africa. A total of 8,085 perinatal deaths among babies weighing 1,000 g or more were reported from 232,718 births at the PPIP user sites. The perinatal mortality rates for the metropolitan, city and town, and rural groupings were 36.2, 38.6 and 26.7/1,000 births, respectively. The neonatal death rate was highest in the city and town group (14.5/1,000 live births) followed by the rural and metropolitan groups (11.3 and 10.0/1,000 live births respectively). The low birth weight rate was highest in the metropolitan group (19.6%), followed by the city and town group (16.5%) and the rural group (13.0%). The most common primary cause of perinatal death in the rural group was intrapartum asphyxia and birth trauma (rate 6.92/1,000 births) followed by spontaneous preterm delivery (5.37/1,000 births). The most common primary cause of death in the city and town group was spontaneous preterm delivery (6.79/1,000 births) followed by intrapartum asphyxia and birth trauma (6.21/1,000 births) and antepartum haemorrhage (5.7/1,000 births). The metropolitan group's most common primary causes were antepartum haemorrhage (7.14/1,000 births), complications of hypertension in pregnancy (5.09/1000 births) and spontaneous preterm labour (4.01/1,000 births). Unexplained intrauterine deaths were the most common recorded primary obstetric cause of death in all areas. Complications of prematurity and hypoxia were the most common final causes of neonatal death in all groups. Intrapartum asphyxia, birth trauma, antepartum haemorrhage, complications of hypertension in pregnancy and spontaneous preterm labour account for more than 80% of the primary obstetric causes of death.

Can enquiries into severe acute maternal morbidity act as a surrogate for maternal death enquiries?

Objective To assess whether severe acute maternal morbidity (SAMM, ‘near misses’) can be used as a surrogate of an analysis of maternal deaths to describe the pattern of severe maternal disease and avoidable factors related to it. Design Prospective, descriptive study. Setting A SAMM and maternal mortality audit was conducted in three clearly defined geographical areas, consisting of rural and urban settings in South Africa. Population Indigent black African pregnant women. Method Cases of SAMM and maternal deaths were collected in the areas and a comparison was made of the disease profiles and avoidable factors, missed opportunities and substandard care. Main outcome measures The proportion of primary obstetric causes and avoidable factors in women with SAMM and maternal deaths, and the mortality indices of the primary obstetric causes of death and organ system dysfunction. Results A total of 423 women with SAMM and 128 maternal deaths were collected over two years. Demographic factors were similar between the groups except that significantly more maternal deaths had not attended any antenatal care. The primary obstetric causes of SAMM and maternal death did not correlate. The four most common causes of SAMM were complications of hypertension (27.2%), postpartum haemorrhage (18.0%), antepartum haemorrhage (12.8%) and abortion (11.3%), whereas the four most common causes of maternal death were non-pregnancy related sepsis (26.6%), complications of hypertension (23.4%), pre-existing medical disease (14.1%) and abortion (10.9%). The types of avoidable factors were similar between both groups although administrative factors occurred significantly more frequently in the maternal death group as did poor problem identification and monitoring. Conclusion Review of SAMM gives a different disease pattern to that obtained from maternal death audits. However, in diagnosing inadequacies in the health system, similar information was obtained.