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Maternal death

Maternal death

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Maternal death, or maternal mortality, also "obstetrical death" is the death
Death
Death is the permanent termination of the biological functions that sustain a living organism. Phenomena which commonly bring about death include old age, predation, malnutrition, disease, and accidents or trauma resulting in terminal injury....

 of a woman during or shortly after a pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...

. In 2010, researchers from the University of Washington and the University of Queensland in Brisbane, Australia, estimated global maternal mortality in 2008 at 342,900 (down from 526,300 in 1980), of which less than 1% occurred in the developed world
Developed country
A developed country is a country that has a high level of development according to some criteria. Which criteria, and which countries are classified as being developed, is a contentious issue...

. However, most of these deaths have been medically preventable
Preventive medicine
Preventive medicine or preventive care refers to measures taken to prevent diseases, rather than curing them or treating their symptoms...

 for decades, as treatments to avoid such deaths have been well-known since the 1950s.

Maternal Mortality definition


According to the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

 (WHO), "A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes."

Generally there is a distinction between a direct maternal death that is the result of a complication of the pregnancy, delivery, or their management, and an indirect maternal death that is a pregnancy-related death in a patient with a preexisting or newly developed health problem. Other fatalities during but unrelated to a pregnancy are termed accidental, incidental, or nonobstetrical maternal deaths.

Maternal mortality is a sentinel event
Sentinel event
A Sentinel Event is defined by The Joint Commission as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness...

 to assess the quality of a health care system. However, a number of issues need to be recognized. First of all, the WHO definition is one of many; other definitions may also include accidental and incidental causes. Cases with "incidental causes" include deaths secondary to violence against women
Violence against women
Violence against women is a technical term used to collectively refer to violent acts that are primarily or exclusively committed against women...

 that may be related to the pregnancy and be affected by the socioeconomic and cultural environment. Also, it has been reported that about 10% of maternal deaths may occur late, that is after 42 days after a termination or delivery,
thus, some definitions extend the time period of observation to one year after the end of the gestation. Further, it is well recognized that maternal mortality numbers are often significantly underreported.

Reducing the maternal mortality by three quarters between 1990 and 2015 is a specific part of Goal 5 -Improving Maternal Health - of the eight Millennium Development Goals
Millennium Development Goals
The Millennium Development Goals are eight international development goals that all 193 United Nations member states and at least 23 international organizations have agreed to achieve by the year 2015...

; its progress is monitored at mdgmonitor.org

Major causes


As stated by the WHO in its 2005 World Health Report
World Health Report
The World Health Report is a series of reports produced regularly by the World Health Organization . First published in 1995, the World Health Report is WHO's leading publication...

 "Make Every Mother and Child Count", they are: severe bleeding/hemorrhage (25%), infections (13%), unsafe abortions (13%), eclampsia
Eclampsia
Eclampsia , an acute and life-threatening complication of pregnancy, is characterized by the appearance of tonic-clonic seizures, usually in a patient who had developed pre-eclampsia...

 (12%), obstructed labour (8%), other direct causes (8%), and indirect causes (20%). Indirect causes such as malaria
Malaria
Malaria is a mosquito-borne infectious disease of humans and other animals caused by eukaryotic protists of the genus Plasmodium. The disease results from the multiplication of Plasmodium parasites within red blood cells, causing symptoms that typically include fever and headache, in severe cases...

, anaemia, HIV/AIDS and cardiovascular disease
Cardiovascular disease
Heart disease or cardiovascular disease are the class of diseases that involve the heart or blood vessels . While the term technically refers to any disease that affects the cardiovascular system , it is usually used to refer to those related to atherosclerosis...

, complicate pregnancy or are aggravated by it.

Forty-five percent of postpartum deaths occur within 24 hours. Over 90% of maternal deaths occur in developing countries. In comparison, pregnancy-associated homicide
Homicide
Homicide refers to the act of a human killing another human. Murder, for example, is a type of homicide. It can also describe a person who has committed such an act, though this use is rare in modern English...

 accounts for 2 to 10 deaths per 100000 live births, possibly substantially higher due to underreporting.

In developing countries, the most common cause of maternal death is obstetrical hemorrhage
Obstetrical hemorrhage
Obstetrical hemorrhage refers to heavy bleeding during pregnancy, labor, or the puerperium. Bleeding may be vaginal and external, or, less commonly but more dangerously, internal, into the abdominal cavity...

, followed by deep vein thrombosis
Deep vein thrombosis
Deep vein thrombosis is the formation of a blood clot in a deep vein. Deep vein thrombosis commonly affects the leg veins or the deep veins of the pelvis. Occasionally the veins of the arm are affected...

, in contrast to developed countries, for which the most common cause is thromboembolism.

Unintended pregnancy
Unintended pregnancy
Unintended pregnancies are those in which conception was not intended by the female sexual partner. Worldwide, 38% of pregnancies were unintended in 1999 . Unintended pregnancies are the primary cause of induced abortion, resulting in about 42 million induced abortions per year...

 is a major cause of maternal deaths. Worldwide, unintended pregnancy resulted in almost 700,000 maternal deaths from 1995 to 2000 (approximately one-fifth of the maternal deaths during that period). The majority (64%) resulted from complications from unsafe or unsanitary abortion.

Maternal Mortality Ratio (MMR)


Maternal Mortality Ratio is the ratio of the number of maternal deaths per 100,000 live births. The MMR is used as a measure of the quality of a health care system. Sierra Leone
Sierra Leone
Sierra Leone , officially the Republic of Sierra Leone, is a country in West Africa. It is bordered by Guinea to the north and east, Liberia to the southeast, and the Atlantic Ocean to the west and southwest. Sierra Leone covers a total area of and has an estimated population between 5.4 and 6.4...

 has the highest maternal death rate at 2,000, and Afghanistan
Afghanistan
Afghanistan , officially the Islamic Republic of Afghanistan, is a landlocked country located in the centre of Asia, forming South Asia, Central Asia and the Middle East. With a population of about 29 million, it has an area of , making it the 42nd most populous and 41st largest nation in the world...

 has the second highest maternal death rate at 1900 maternal deaths per 100,000 live births, reported by the UN based on 2000 figures. According to the Central Asia Health Review, Afghanistan
Afghanistan
Afghanistan , officially the Islamic Republic of Afghanistan, is a landlocked country located in the centre of Asia, forming South Asia, Central Asia and the Middle East. With a population of about 29 million, it has an area of , making it the 42nd most populous and 41st largest nation in the world...

's maternal mortality rate was 1,600 in 2007. Lowest rates included Ireland
Ireland
Ireland is an island to the northwest of continental Europe. It is the third-largest island in Europe and the twentieth-largest island on Earth...

 at 0 per 100,000 and Austria
Austria
Austria , officially the Republic of Austria , is a landlocked country of roughly 8.4 million people in Central Europe. It is bordered by the Czech Republic and Germany to the north, Slovakia and Hungary to the east, Slovenia and Italy to the south, and Switzerland and Liechtenstein to the...

 at 4 per 100,000. In the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...

, the maternal death rate was 11 maternal deaths per 100,000 live births in 2005. This rose to 13.3 per 100,000 in 2006.
"Lifetime risk of maternal death" accounts for number of pregnancies and risk. In sub-Saharan Africa the lifetime risk of maternal death is 1 in 16, for developed nations only 1 in 2,800.

In 2003, the WHO
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

, UNICEF and UNFPA produced a report with statistics gathered from 2000. The world average per 100,000 was 400, the average for developed regions was 20, and for developing regions 440. Countries with highest maternal mortality were:
Sierra Leone
Sierra Leone
Sierra Leone , officially the Republic of Sierra Leone, is a country in West Africa. It is bordered by Guinea to the north and east, Liberia to the southeast, and the Atlantic Ocean to the west and southwest. Sierra Leone covers a total area of and has an estimated population between 5.4 and 6.4...

 (2,000), Afghanistan
Afghanistan
Afghanistan , officially the Islamic Republic of Afghanistan, is a landlocked country located in the centre of Asia, forming South Asia, Central Asia and the Middle East. With a population of about 29 million, it has an area of , making it the 42nd most populous and 41st largest nation in the world...

 (1,900), Malawi
Malawi
The Republic of Malawi is a landlocked country in southeast Africa that was formerly known as Nyasaland. It is bordered by Zambia to the northwest, Tanzania to the northeast, and Mozambique on the east, south and west. The country is separated from Tanzania and Mozambique by Lake Malawi. Its size...


(1,800), Angola
Angola
Angola, officially the Republic of Angola , is a country in south-central Africa bordered by Namibia on the south, the Democratic Republic of the Congo on the north, and Zambia on the east; its west coast is on the Atlantic Ocean with Luanda as its capital city...

 (1,700), Niger
Niger
Niger , officially named the Republic of Niger, is a landlocked country in Western Africa, named after the Niger River. It borders Nigeria and Benin to the south, Burkina Faso and Mali to the west, Algeria and Libya to the north and Chad to the east...

 (1,600), Tanzania
Tanzania
The United Republic of Tanzania is a country in East Africa bordered by Kenya and Uganda to the north, Rwanda, Burundi, and the Democratic Republic of the Congo to the west, and Zambia, Malawi, and Mozambique to the south. The country's eastern borders lie on the Indian Ocean.Tanzania is a state...

 (1,500), Rwanda
Rwanda
Rwanda or , officially the Republic of Rwanda , is a country in central and eastern Africa with a population of approximately 11.4 million . Rwanda is located a few degrees south of the Equator, and is bordered by Uganda, Tanzania, Burundi and the Democratic Republic of the Congo...

 (1,400), Mali
Mali
Mali , officially the Republic of Mali , is a landlocked country in Western Africa. Mali borders Algeria on the north, Niger on the east, Burkina Faso and the Côte d'Ivoire on the south, Guinea on the south-west, and Senegal and Mauritania on the west. Its size is just over 1,240,000 km² with...

 (1,200), Somalia
Somalia
Somalia , officially the Somali Republic and formerly known as the Somali Democratic Republic under Socialist rule, is a country located in the Horn of Africa. Since the outbreak of the Somali Civil War in 1991 there has been no central government control over most of the country's territory...

, Zimbabwe
Zimbabwe
Zimbabwe is a landlocked country located in the southern part of the African continent, between the Zambezi and Limpopo rivers. It is bordered by South Africa to the south, Botswana to the southwest, Zambia and a tip of Namibia to the northwest and Mozambique to the east. Zimbabwe has three...

, Chad
Chad
Chad , officially known as the Republic of Chad, is a landlocked country in Central Africa. It is bordered by Libya to the north, Sudan to the east, the Central African Republic to the south, Cameroon and Nigeria to the southwest, and Niger to the west...

, Central African Republic
Central African Republic
The Central African Republic , is a landlocked country in Central Africa. It borders Chad in the north, Sudan in the north east, South Sudan in the east, the Democratic Republic of the Congo and the Republic of the Congo in the south, and Cameroon in the west. The CAR covers a land area of about ,...

, Guinea Bissau (1,100 each), Mozambique
Mozambique
Mozambique, officially the Republic of Mozambique , is a country in southeastern Africa bordered by the Indian Ocean to the east, Tanzania to the north, Malawi and Zambia to the northwest, Zimbabwe to the west and Swaziland and South Africa to the southwest...

, Burkina Faso
Burkina Faso
Burkina Faso – also known by its short-form name Burkina – is a landlocked country in west Africa. It is surrounded by six countries: Mali to the north, Niger to the east, Benin to the southeast, Togo and Ghana to the south, and Côte d'Ivoire to the southwest.Its size is with an estimated...

, Burundi
Burundi
Burundi , officially the Republic of Burundi , is a landlocked country in the Great Lakes region of Eastern Africa bordered by Rwanda to the north, Tanzania to the east and south, and the Democratic Republic of the Congo to the west. Its capital is Bujumbura...

, and Mauritania
Mauritania
Mauritania is a country in the Maghreb and West Africa. It is bordered by the Atlantic Ocean in the west, by Western Sahara in the north, by Algeria in the northeast, by Mali in the east and southeast, and by Senegal in the southwest...

 (1,000 each).

Associated risk factors


High rates of maternal deaths occur in the same countries that have high rates of infant mortality
Infant mortality
Infant mortality is defined as the number of infant deaths per 1000 live births. Traditionally, the most common cause worldwide was dehydration from diarrhea. However, the spreading information about Oral Re-hydration Solution to mothers around the world has decreased the rate of children dying...

, reflecting generally poor nutrition and medical care.

Low birth weight of the child is correlated with maternal death from cardiovascular disease
Cardiovascular disease
Heart disease or cardiovascular disease are the class of diseases that involve the heart or blood vessels . While the term technically refers to any disease that affects the cardiovascular system , it is usually used to refer to those related to atherosclerosis...

. Subtracting one pound of infant birth weight is correlated with the doubling of the risk of maternal death. Conversely, heavier child birth weight is correlated with lower risk of maternal death.

Another issue that is associated with maternal mortality is the lack of access to skilled medical care during childbirth
Birth attendant
A birth attendant, also known as “skilled birth attendant” , is a midwife, physician, obstetrician, nurse, or other health care professional who provides basic and emergency health care services to women and their newborns during pregnancy, childbirth and the postpartum period...

 and the distance of traveling to the nearest clinic to receive proper care. In developing nations, as well as rural areas, this is especially true. Traveling to and back from the clinic is very difficult and costly, especially to poor families when time could have been used for working and providing incomes. Even so, the nearest clinic may not provide decent care because of the lack of qualified staff
Health Human Resources
Health human resources — also known as “human resources for health” or “health workforce” — is defined as “all people engaged in actions whose primary intent is to enhance health”, according to the World Health Organization's World Health Report 2006. Human resources for health are identified as...

 and equipment such as ones in the Guatemalan highlands.

Maternal death rates in the 20th century


The death rate for women giving birth plummeted in the 20th century.

The historical level of maternal deaths is probably around 1 in 100 births. Mortality rates reached very high levels
Historical mortality rates of puerperal fever
Dr. Ignaz Semmelweis worked at the Vienna General Hospital's maternity clinic on a 3-year contract from 1846-1849. There, as elsewhere in European and North American hospitals, puerperal fever, or childbed fever, was rampant, sometimes climbing to 40 percent of admitted patients...

 in maternity institutions in the 1800s, sometimes climbing to 40 percent of birthgiving women. At the beginning of the 1900s, maternal death rates were around 1 in 100 for live births. The number in 2005 in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...

 was 11 in 100,000, a decline by two orders of magnitude, although that figure has begun to rise in recent years, having nearly tripled over the decade up to 2010 in California. The increase may be due to a change in reporting methods by the CDC in 1999.

The decline in maternal deaths has been due largely to improved asepsis
Asepsis
Asepsis is the state of being free from disease-causing contaminants or, preventing contact with microorganisms. The term asepsis often refers to those practices used to promote or induce asepsis in an operative field in surgery or medicine to prevent infection...

, fluid management and blood transfusion
Blood transfusion
Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood...

, and better prenatal care
Prenatal care
Prenatal care refers to the medical and nursing care recommended for women before and during pregnancy. The aim of good prenatal care is to detect any potential problems early, to prevent them if possible , and to direct the woman to appropriate specialists, hospitals, etc...

. Recommendations for reducing maternal mortality include access to health care, access to family planning
Family planning
Family planning is the planning of when to have children, and the use of birth control and other techniques to implement such plans. Other techniques commonly used include sexuality education, prevention and management of sexually transmitted infections, pre-conception counseling and...

 services, and emergency obstetric care, funding and intrapartum care.

A recent study showed that patients older than 34 yr and non-Hispanic black women were disproportionately represented. Common comorbidities included hypertensive disorders of pregnancy, previous Caesarean delivery, diabetes mellitus, preexisting hypertension, and multiple gestation. In this study, the authors examined both near-miss morbidity and actual mortality to increase numbers for analysis of morbidity and mortality associated with delivery. This article was also discussed on that journal's blog.

See also

  • Endometritis
    Endometritis
    Endometritis refers to inflammation of the endometrium, the inner lining of the uterus. Pathologists have traditionally classified endometritis as either acute or chronic: acute endometritis is characterized by the presence of microabscesses or neutrophils within the endometrial glands, while...

  • List of women who died in childbirth
  • Maternal health
    Maternal health
    Maternal health refers to the health of women during pregnancy, childbirth, and the postpartum period. It encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to reduce maternal morbidity and mortality.Preconception care can include...

  • Maternal near miss
    Maternal near miss
    A maternal near miss is an event in which a pregnant woman comes close to maternal death, but does not die – a "near-miss". Traditionally, the analysis of maternal deaths has been the criteria of choice for evaluating women’s health and the quality of obstetric care...

  • Obstetrical Dilemma
    Obstetrical Dilemma
    The Obstetrical Dilemma refers to the evolutionary development of the human species through a number of biological changes, specifically the shifting of the females' pelvic bones, thereby shortening the fetal incubation period....

  • Perinatal mortality
    Perinatal mortality
    Perinatal mortality , also perinatal death, refers to the death of a fetus or neonate and is the basis to calculate the perinatal mortality rate. Variations in the precise definition of the perinatal mortality exist specifically concerning the issue of inclusion or exclusion of early fetal and...

  • Puerperal fever
    Puerperal fever
    Puerperal fever or childbed fever, is a bacterial infection contracted by women during childbirth or miscarriage. It can develop into puerperal sepsis, which is a serious form of septicaemia. If untreated, it is often fatal....

  • Reproduction
  • Reproductive health
    Reproductive health
    Within the framework of the World Health Organization's definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene, addresses the reproductive processes, functions and system...

  • Stillbirth
    Stillbirth
    A stillbirth occurs when a fetus has died in the uterus. The Australian definition specifies that fetal death is termed a stillbirth after 20 weeks gestation or the fetus weighs more than . Once the fetus has died the mother still has contractions and remains undelivered. The term is often used in...

  • Unintended pregnancy
    Unintended pregnancy
    Unintended pregnancies are those in which conception was not intended by the female sexual partner. Worldwide, 38% of pregnancies were unintended in 1999 . Unintended pregnancies are the primary cause of induced abortion, resulting in about 42 million induced abortions per year...

  • Maternal mortality in fiction
    Maternal mortality in fiction
    Maternal death in fiction is a common theme encountered in literature, movies, and other media.The death of a mother during pregnancy, childbirth or puerperium is a tragic event. The chances of a surviving child to survive are compromised...

  • Global Library of Women's Medicine

External links