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Maternal mortality means the death of a woman during pregnancy (i.e. conception to delivery) and the puerperium (i.e. up to 42 days after delivery). It includes deaths due to miscarriages (abortions) and ectopic pregnancies.
A maternal death is defined as the death of a woman at any time between the conception of her infant and 42 days after the delivery of the infant.
The maternal mortality ratio (MMR) is defined as the number of women dying between conception and 6 weeks (42 days) after delivery per 100 000 deliveries. The maternal mortality ratio is calculated as follows:
Total number of maternal deaths ÷ Total number of live births × 100 000
The maternal mortality ratio is usually given for a specific area and a specific period of time. For example, if 10 women die in Cape Town where the annual delivery rate is 50 000, then the maternal mortality rate is:
10 ÷ 50 000 × 100 000 = 20
Note that the maternal mortality ratio is expressed per 100 000 deliveries.
The maternal mortality ratio is the number of maternal deaths per 1000 000 deliveries.
Because pregnancy effects the mother’s body soon after the start of pregnancy. Problems which occur early in pregnancy, such as ectopic pregnancies and septic abortions, can result in the mother’s death.
Because the effects of pregnancy on the mother’s body take up to 6 weeks to disappear. Deaths during the puerperium (6 weeks after delivery) are often as a result of complications of pregnancy.
It is a very important method of assessing both the standard of health of pregnant women and the standard of care being provided to pregnant women. The maternal mortality ratio can also be compared between different areas or between different periods of time in the same area.
A high maternal mortality ratio usually indicates either poor maternal health or inadequate care during the pregnancy and puerperium or both. In contrast, a low maternal mortality ratio indicates that both maternal health and health care are good.
The maternal mortality ratio reflects both the general health of women as well as the standard of care during pregnancy and the puerperium.
In industrialised countries, or privileged areas in poor countries, the maternal mortality ratio is usually about 10 per 100 000 deliveries. Therefore, it is very uncommon for a woman to die during pregnancy or the puerperium.
In poor countries the maternal mortality ratio is usually above 50 per 100 000 deliveries. The maternal mortality ratio varies widely between poor countries with some very undeveloped communities having a ratio as high as 1000 per 100 000.
In many poor areas of industrialised countries the maternal mortality ratio is also increased. Worldwide, most maternal deaths occur in poor countries where the death is usually related to poverty and inadequate access to good health care services.
In most poor developing countries the collection of mortality information is very incomplete, making it difficult to calculate the accurate maternal mortality rate.
The exact maternal mortality ratio in South Africa is not known, as many maternal deaths are still not registered. However, the estimated maternal mortality ratio is about 200/100 000 deliveries. The maternal mortality ratio varies between different districts from as low as 50 to as high as 300. Unlike many other developing countries, the maternal mortality ratio has increased over the past few years.
The estimated maternal mortality ratio for South Africa is 200 / 100 000.
Each maternal death must be discussed in detail to determine the cause and decide whether it could have been prevented. This is usually done at the regular ‘perinatal mortality meeting’ which also includes any maternal deaths. It is important to discuss the maternal death as soon as possible while the details of the clinical problems and care are still remembered. The findings of each death must be carefully summarised and included in the maternal mortality report. This is usually prepared annually for each health region.
Yes. All maternal deaths are notified by law in South Africa. This includes maternal deaths at home and in private institutions. It is important to include maternal deaths which occur outside the maternity services, e.g. women who have not yet started antenatal care and women who die in medical, surgical or emergency departments.
The primary cause of maternal death is the obstetric factor or condition which lead to the death, i.e. it is the reason why the death occurred. Knowing the primary causes of death helps to identify clinical practices which need to be improved. Deaths can be prevented if the primary causes are well managed.
The final cause of maternal death is the event which actually caused the death (a final complication of the disease process), i.e. how the patient died. Knowing the final causes of death helps to identify facilities and resources which need to be improved. It also helps to prevent or improve the management of conditions which can be final causes of death.
For example, if a pregnant woman has a severe antepartum haemorrhage from a placenta praevia and dies of hypovolaemic shock, the primary cause of death is antepartum haemorrhage and the final cause of death is hypovolaemic shock. Similarly, if a woman has eclampsia and dies of a brain haemorrhage, the eclampsia is the primary cause and the brain bleed is the final cause of death.
The primary cause of maternal death is the obstetric factor or condition which lead to the death.
The primary causes of maternal deaths are subdivided into 3 groups:
Usually a forth group called ‘Unknown’ is added. These are maternal deaths where the cause of death cannot be identified.
These are deaths which are a direct result of the woman being pregnant. They result from complications of pregnancy or the puerperium, or the management of the pregnancy or puerperium. These deaths would not have happened if the woman had not been pregnant. An example of a direct cause of maternal death is eclampsia.
A direct cause of maternal death would not have happened if the woman had not been pregnant.
These are deaths are caused by diseases that existed before the pregnancy or developed during the pregnancy or puerperium. Although not a result of pregnancy or puerperium complications, the pregnant state aggravated the condition. If the woman had not been pregnant, she may not have died from the disease. An example of an indirect cause of maternal death is rheumatic heart disease which became worse during the pregnancy, leading to heart failure.
A woman may have died of an indirect cause even if she was not pregnant.
These are deaths that were unrelated to the pregnancy or puerperium and just happened to occur at this time. The condition causing the death was not aggravated by the pregnancy and would have killed the women even if she had not been pregnant. Examples of fortuitous causes of maternal death include motor vehicle accidents and assault.
Although fortuitous causes of maternal death are recorded in South Africa, they are not included in calculating the maternal mortality rate. Fortuitous deaths are counted to document the extent of violence against women, accidents and suicides.
No. Unfortunately the underlying cause sometimes is unknown. This is often because the history is incomplete and a post mortem examination was not done.
Most maternal deaths are due to direct causes, especially the hypertensive disorders, haemorrhage and infection.
The commonest direct causes of maternal death in South Africa are hypertension, haemorrhage and infection.
AIDS is the commonest indirect cause of maternal death in South Africa.
Non-pregnancy-related infection is the commonest indirect cause of maternal death in South Africa.
When all direct and indirect causes of maternal death in South Africa are considered together, the following are the commonest (the ‘big five’ causes) in order of frequency:
These five causes are responsible for 85% of all maternal deaths. In South Africa in 1999 the most common single cause of maternal death was AIDS.
AIDS is the commonest cause of maternal death in South Africa.
Non-pregnancy related infections were the commonest cause of death at all levels of care. However:
The high maternal mortality rate in poor countries is not due to the lack of knowledge of how to manage ill pregnant women, but due to women not being able to receive adequate care.
Although some reasons may be obvious, this question is often not easy to answer unless a detailed investigation into causes of maternal death is carried out. Such as investigation is best done as a confidential enquiry. Important reasons why some women do not have access to good care are distance to the nearest clinic or hospital, lack of transport and inadequate staffing or equipment at health care facilities.
In a confidential enquirer of maternal deaths, the deaths of as many pregnant women as possible are identified by an appointed committee. The case record of each woman is then carefully investigated by an independent team of experts to identify the likely cause and reason for the death. This information is kept confidential to protect the staff involved with the care of the case. If this were not done, it would be difficult to obtain the full story.
Yes. This is a most important enquiry into the number and causes of maternal death in South Africa. It attempts to identify avoidable factors, missed opportunities and substandard care, and gives recommendations as to how these causes can be prevented or effectively managed. The aim of the report is to make recommendations aimed at reducing the maternal mortality rate. It is important that the findings and recommendations of the confidential enquiry are made available to all services and health care workers responsible for maternal care.
The Saving Mothers report is the official report of the confidential enquiry into maternal deaths in South Africa. The first Saving Mothers Report to be published in South Africa reviewed maternal deaths in 1998.
An avoidable factor is something which could have caused the maternal death and yet was potentially avoidable. If that event or condition was not present, the death may not have occurred.
A missed opportunity is a potentially avoidable maternal death where an opportunity was present to prevent the death but the opportunity was missed.
Substandard care is poor care which may have resulted in the woman’s death.
In any enquiry into a maternal death, it is very important to identify possible and probable avoidable factors and missed opportunities as much can be learned from these events. This knowledge helps to avoid similar deaths in future.
Avoidable factors, missed opportunities and substandard care must be looked for in each maternal death.
Maternal deaths where avoidable factors, missed opportunities or substandard care was present. Maternal deaths are not classified into avoidable or not, only into deaths where avoidable factors were or were not present. Therefore, the report identifies deaths which were potentially avoidable.
Avoidable factors can be grouped into the following 3 categories:
In South Africa, avoidable factors due to patient related problems were present in half, administrative problems were associated with a third, and health worker related problems with a quarter of the maternal deaths. Many deaths had more than one avoidable factor. Therefore, all three categories of avoidable factors are commonly associated with maternal deaths.
In South Africa, avoidable factors associated with patient, administrative and health worker related problems are commonly associated with maternal deaths.
In South Africa the commonest patient related problem associated with maternal death is not attending antenatal care or only attending late in pregnancy. This probably true for in many other developing countries.
Poor attendance for antenatal care is the commonest patient related factor associated with maternal death in South Africa.
There are many underlying social factors to patient related problems such as poor education of women, women not being allowed to decide for themselves whether to report to clinic or hospital, fear and ignorance, and traditional taboos on disclosing a pregnancy. Many women do not seek care because care is not easily available. They may have to travel long distances, face long queues and be turned away from overcrowded clinics.
While some patients may not seek care because they are lazy or disinterested, usually there are social conditions which prevent or do not encourage access to health care. Perhaps patient related problems should be called community related problems.
Problems resulting in these administrative factors include poor planning and supervision of maternal services, little emphasis on health funding for women and a general lack of funds. In rural areas, deliveries are often conducted by untrained members of the family. Having a skilled assistant to monitor labour and conduct the delivery is important.
Lack of well trained midwives is an important administrative related factor in maternal mortality.
As a result, level 3 (intensive) care is often not available to very ill women.
Major health care worker related problems include:
The administrative problems of staff shortages and excessive patient load often contribute to problems experienced by health care workers (both nursing and medical staff).
Negligence, laziness and an attitude of not caring are very complex problems which are influenced by attitudes in the home, community, schools, tertiary education centres and places of employment. Social and environmental problems affect the way health workers relate to both their work and their patients. Salaries, management styles, opportunities for further training and promotion, and personal beliefs all influence the motivation of health workers. A caring attitude is often not rewarded and encouraged at all levels of society. Understaffing and overwork are important causes of poor care.
Substandard care may be the result of inadequate training or a lack of personal motivation and commitment to patient care.
An honest error is a mistake in management of the patient where the health worker has done his or her best but it was not the correct diagnosis or treatment and, as a result, the woman died. Honest errors are often the result of an excessive patient load and inadequate staffing. Examples of honest errors are forgetting to enter an important observation on the partogram or forgetting to give a newborn infant vitamin K after delivery.
Many health workers are not appropriately trained for the work they are expected to perform. This is often due to a lack of suitable training opportunities. Basic midwifery and medical training may not equip the nurse or doctor to function in a primary care situation where supervision by an experienced person is not available. Most advanced courses are expensive and require the health worker to leave their home and place of employment to travel to a regional centre for a period of time. Few distance-learning courses are available which enable health workers to take responsibility for some of their own continuing education.
A ‘near miss’ occurs when a woman is very ill and almost dies of one of the conditions which can cause maternal death. The avoidable factors in a near miss are usually the same as those where the patient dies. There are more near misses than maternal deaths in a service. As with an audit of causes of maternal deaths, an audit of near misses can also be very useful in identifying avoidable factors and substandard care.
Maternal mortality index = Number of maternal deaths ÷ Number of maternal deaths and near misses
The maternal mortality index gives a measure of the standard of care of women who present with serious complications. With good management, most severely ill women will be near misses rather than deaths. Therefore, a low maternal mortality index indicates a high standard of care while a high index suggests poor care.
At present the maternal mortality index for the whole of South Africa is not known.
Yes. There is a reduction in the direct causes and an increase in the indirect causes of maternal death. The increase in indirect causes is due to more deaths resulting from AIDS. As the testing for HIV increases in patients where there has been maternal death, the percentage of HIV positive maternal deaths will probably increase. In 1999, two thirds of HIV tests in maternal deaths were positive.
The Perinatal Problem Identification Programme (PPIP) is a software package used mainly for recording data on perinatal deaths. However PPIP is also very useful to record information and analyse maternal deaths. PPIP data helps to collect the documentation needed for the national confidential enquiry into maternal deaths.
In a large maternity service consisting of one small hospital and six clinics, there have been 10 000 liveborn deliveries and 35 maternal deaths in the past year. These deaths include women who died as a result of septic abortions as well as women who died of sepsis following delivery.
Maternal mortality consists of all the women who died between conception and the end of the puerperium (6 weeks after delivery).
Because both conditions are related to pregnancy. Neither would have occurred if the women had not been pregnant. Maternal deaths are, therefore, all deaths where the cause of death is related to pregnancy. Deaths after 6 weeks are excluded as the physiological changes of pregnancy have returned to the pre-pregnancy state by 6 weeks after delivery.
There were 35 maternal deaths out of 10 000 live births. The maternal death ratio is traditionally expressed as a proportion of 100 000 deliveries. Therefore, the maternal mortality ratio is 35/10 000 x 100 000 = 350/100 000. Usually maternal mortality is expressed as an annual ratio and it is best expressed for a whole health region.
The maternal mortality ratio in industrialised countries is usually about 10/100 000 while that in poor countries is usually above 50/100 000. Therefore, this maternal mortality ratio of 350/100 000 is high, even for a poor country.
The exact maternal mortality ratio is not known as accurate mortality statistics as many maternal death are still not reported, especially in rural areas. The estimated maternal mortality ratio is 200/100 000. However, it is probably much higher than this in many poor areas.
Because it gives a good idea of both the standard of maternal health during pregnancy and the puerperium, as well as the standard of health care available for pregnant women in the community.
In a large maternity hospital in a city, both the number and causes of maternal deaths are carefully recorded after they have been discussed at the monthly mortality meeting. The primary and direct cause of each death is noted in order to find the commonest causes of death at the hospital.
Yes. All maternal deaths must be notified. This includes not only deaths in the state health service but also deaths at home and in private hospitals.
The primary cause of death is the obstetric factor or condition which lead to the death. In other words, it is the reason why the death occurred. Important primary causes of death include pre-eclampsia, antepartum and post partum haemorrhage, and pregnancy related infection such as septic abortion and puerperal sepsis.
Because steps can then be made to avoid these primary causes by managing them better. By doing this, many maternal deaths can be prevented. It is difficult to reduce the maternal mortality if the primary causes are not known.
The final cause of maternal death is the event which actually resulted in the death. In other words, it is the final complication of the disease process which killed the woman. For example, the final cause of death in antepartum or post partum haemorrhage is usually hypovolaemic shock while the final cause in eclampsia may be a brain haemorrhage.
Because the final cause of death can often be prevented with adequate facilities and the correct management of these complications. For example, death from hypovolaemic shock can often be avoided if women with severe antepartum haemorrhage are correctly managed in an intensive care unit which has adequate staffing and facilities.
Fortuitous causes are not related to pregnancy at all but just happened to occur during pregnancy or the puerperium. Examples are motor car accidents, assault and suicide. Fortuitous causes are not included when the maternal mortality rate is calculated.
In recent years the main causes of maternal death have become better known in each province. Information is also being collected on the main causes at each level of care within health districts and regions. The findings of the Confidential Enquiry into Maternal Deaths are presented in the Saving Mothers report. From this publication, funding is being made available to address specific problems in the care of pregnant women.
AIDS has become the leading cause of maternal death in the past few years.
Non pregnancy related infection (i.e. AIDS).
Obstetric haemorrhage, especially post partum haemorrhage.
Complications of pregnancy related hypertension such as eclampsia.
Because accurate information on the number and causes of maternal death in South Africa is now available for the first time. This will result in better planning of maternity services.
This is the official report of the Confidential Enquiry into Maternal Deaths.
During a monthly mortality meeting in a regional hospital, all the maternal and perinatal deaths are presented. The possible avoidable factors and missed opportunities associated with each of the two maternal deaths are discussed and documented in the mortality report. A near miss maternal death was also described. Neither the medical superintendent of the hospital nor the maternity matron was at the meeting.
These are factors, events or conditions which may have prevented the maternal death if they had not been present. For example, if fast, efficient transport had been available a mother might not have died from a post partum haemorrhage.
This is an opportunity for providing good care which was missed and, as a result, led to the woman’s death? For example, not testing a woman’s urine for sugar during antenatal care was a missed opportunity which may have prevented her dying from a complication of diabetes during labour.
Deaths where avoidable factors, missed opportunities or substandard care were present.
The commonest patient related factors are not attending antenatal care or booking late, not recognising important warning signs and not seeking help when warning signs are present.
The commonest administrative related factors are lack of staff, inadequate staff training, poor transport, lack of primary care clinics and hospitals in the community, and inadequate intensive care facilities for seriously ill women.
The commonest staff related factors are poor care, honest errors and lack of appropriate training.
Not recognising problems, a delay or failure in referring sick patients, not following standard protocols of care, and inadequate monitoring of ill patients.
A very ill woman who nearly died from a condition which often causes maternal deaths. Good lessons on how to improve maternal care can be learned from near misses.
Many women still die in poor countries, not because of the lack of knowledge of how to manage ill pregnant women, but due to women not being able to receive adequate care. This is usually due to great distances to the nearest clinic or hospital, lack of transport and inadequate staffing, equipment and training.
Yes. As the managers of the service, it is very important that they are aware of problems, avoidable factors and recommended ways of improving the service and preventing further maternal deaths.
These are included as a reference only.
The most important subdivisions are:
A more detailed classification of primary causes of maternal death is given in the Perinatal Problem Identification Programme. Each subdivision is given a specific code.