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PubMed2006

Caesarean sections and maternal mortality in Sao Paulo.

OBJECTIVES: To evaluate caesarean section in both public and private sectors; maternal mortality associated with mode of delivery in the public sector (Sistema Unico de Saude, SUS) in Sao Paulo State, Brazil. STUDY DESIGN: 610,630 births in both public and private sectors for 2003; 1,153,034 deliveries and 314 maternal deaths in the public sector for 2001-2003. The study estimated caesarean section rates and odds ratios for caesarean section in association with maternal characteristics in both public and private sectors; maternal mortality associated with mode of delivery in the public sector, adjusted for hypertension, other disorders, problems and complications, as well as maternal age. RESULTS: The caesarean section rate was 32.9% in the public sector, and 80.4% in the private sector. The odd ratio for caesarean section was 2.6 (95% CI: 2.6-2.7) for women with 12 or more years of education. The odd ratio for maternal mortality associated with caesarean section in the public sector was 3.3 (95% CI: 2.6-4.3). CONCLUSIONS: Sao Paulo presented high caesarean section rates. Caesarean section compared to vaginal delivery in the public sector presented higher risk for mortality even when adjusted for hypertension, other disorders, problems and complications, as well as maternal age.

Adult↗
PubMed2001

[Maternal mortality in France: frequency, trends and causes].

Ten years ago the first epidemiological surveys on maternal mortality in France were carried out on the national level. In 1995, a National Committee of Medical Experts was created to conduct confidential inquiries into maternal deaths. It is thus useful to examine the general picture of maternal mortality in France drawn by the routinely and permanently collected data. These statistics are collected independently of the procedure adopted by the National Committee on confidential inquiries into maternal deaths. National death and cause-of-death registries have recorded maternal death rates for several years with data by age, area of residence, nationality, and direct or indirect obstetric causes. The low and underestimated rate of 8.5 maternal deaths per 100,000 live births recorded in 1989 increased regularly up to 1992. Currently the rates have been around 9 to 13 with no evidence of a declining trend. The larger urban area around Paris (Ile-de-France) has shown a statistically significant higher rate over the last several years. Post-partum hemorrhage remains the leading cause of maternal death. Compared with other European countries, maternal mortality in France is in an average position, similar to Great Britain (12 per 100,000), but higher than in Scandinavian countries. The elevated mean age of mothers at delivery is one explanation for the lack of a decline in the rate of maternal deaths expected until 2005 although further actions should be implemented to attempt to lower the rate to that observed in Scandinavian countries. A pertinent classification of causes of maternal deaths allowing valid international comparisons would be useful for helping answer the questions raised by clinicians.

Cause of Death↗
PubMed2004

Maternal mortality in Bavaria between 1983 and 2000.

OBJECTIVE: This study was undertaken to identify the main causes of maternal mortality within a developed country to refocus and enhance the delivery of obstetric services. STUDY DESIGN: From January 1, 1983, to December 31, 2000, 309 maternal deaths occurring in Bavaria were documented and classified in a prospective observational study. The data sources were the civil registry, confidential reports by members of the Bavarian Society of Obstetrics and Gynecology, and public information. Direct obstetric death, indirect obstetric death, and coincidental death account for 164, 67, and 78 cases, respectively. They were expressed as the maternal mortality ratio (MMR: maternal deaths/100,000 live births) over the 18-year study period divided into three 6-year intervals 1983 to 1988, 1989 to 1994, and 1995 to 2000. RESULTS: The direct obstetric mortality ratio (DOMR: direct obstetric deaths/100,000 live births) decreased from 11.3 in the study period 1983 to 1988 to 5.4 in the study period 1995 to 2000 (P<.0005), mainly because of a reduction in antepartal and intrapartal deaths. The main cause of direct obstetric death was thromboembolism, including amniotic fluid embolism, which remained unchanged over the study period; other causes of direct obstetric death decreased markedly but not significantly. CONCLUSION: Careful analysis of the Bavarian maternal mortality data identified postpartum maternal deaths to be unchanged during the study period. In particular, effective prevention and treatment of thromboembolism should be a prior focus for obstetric care.

Embolism, Amniotic Fluid↗
PubMedDate not supplied

Identifying maternal mortality through networking: results from coastal Kenya.

This paper presents the results of experience in identifying maternal deaths through "networking." In a survey of child health in coastal Kenya, women of reproductive ages were asked about their knowledge of maternal deaths in the villages. Thirty-five maternal deaths were ultimately identified in the study area, which led to an estimate of maternal mortality of 6 to 7 per 1,000 live births. The leading causes of death were hemorrhage and anemia, followed by sepsis; and nulliparous women appeared to be at higher risks of dying. Special attention is given to the ethnomedical aspects of maternal mortality,which have important implications for strategies to reduce maternal mortality.

Adolescent↗
PubMed2005

Evaluating effectiveness of complex interventions aimed at reducing maternal mortality in developing countries.

BACKGROUND: Reducing the worldwide mortality ratio by 75 per cent between 1990 and 2015 is a key Millennium Development Goal. Randomized controlled trials (RCTs) are the accepted 'gold standard' to assess the effectiveness of interventions but they are not always appropriate for practical, ethical or economic reasons in developing countries. This study examines the use of cluster randomized trials and quasi-experimental (nonrandomized) study designs to evaluate complex interventions implemented to reduce maternal mortality. METHODS: We systematically searched electronic databases including MEDLINE, EMBASE, CINAHL, BNI, ASSIA, IBSS, CSA and COCHRANE. English language publications between 1990 and 2003 were included. Studies that assessed the effects of complex interventions aimed at reducing maternal mortality in developing countries were included. RESULTS: Four cluster randomized trials and eleven quasi-experimental studies were identified. Two cluster randomized trials examined reduction in prenatal visits with no adverse effects on maternal mortality. Two trials assessed the effects of vitamin A supplementation. Both trials found a significant reduction in maternal mortality ratios after vitamin A supplementation. A decline in maternal deaths was reported in eight of the nonrandomized studies. Measuring maternal mortality was a frequent problem because of insufficient sample sizes and/or poor recording methods. Other limitations include lack of suitable comparison groups and difficulties assessing the effects of confounding factors in the quasi-experimental studies. CONCLUSIONS: RCTs may not be appropriate to evaluate complex interventions in maternal mortality and cluster RCTs and quasi-experimental designs may be more suitable. However, further work is required to improve the robustness of such alternative study designs.

Developing Countries↗
PubMed2006

Maternal mortality in St. Petersburg, Russian Federation.

OBJECTIVE: To study the levels and causes of maternal mortality in St. Petersburg, Russian Federation. METHODS: We collected data about all pregnancy-related deaths in St. Petersburg over the period 1992-2003 using several sources of information. An independent research group reviewed and classified all cases according to ICD-10 and the Confidential Enquiries into Maternal Deaths in the United Kingdom. We tested trends of overall and cause specific ratios (deaths per 100,000 births) for four 3-year intervals using the chi2 test. FINDINGS: The maternal mortality ratio for the study period was 43 per 100,000 live births. A sharp decline of direct obstetric deaths was observed from the first to fourth 3-year interval (49.8 for 1992-94 versus 18.5 for 2001-03). Sepsis and haemorrhage were the main causes of direct obstetric deaths. Among the total deaths from sepsis, 63.8% were due to abortion. Death ratios from sepsis declined significantly from the first to second study interval. In the last study interval (2001-03), 50% of deaths due to haemorrhage were secondary to ectopic pregnancies. The death ratio from thromboembolism remained low (2.9%) and stable throughout the study period. Among indirect obstetric deaths a non-significant decrease was observed for deaths from cardiac disease. Death ratios from infectious causes and suicides increased over the study period. CONCLUSIONS: Maternal mortality levels in St. Petersburg still exceed European levels by a factor of five. Improved management of abortion, emergency care for sepsis and haemorrhage, and better identification and control of infectious diseases in pregnancy, are needed.

Abortion, Induced↗
PubMed1999

State-specific maternal mortality among black and white women--United States, 1987-1996.

One of the national health objectives for 2000 is to reduce the overall maternal mortality ratio ([MMR] i.e., number of maternal deaths per 100,000 live-born infants) to no more than 3.3 (objective 14.3); however, during 1982-1996, the MMR remained at approximately 7.5. In addition, the risk for maternal mortality consistently has been higher among black women than white women. This report presents state-specific MMRs for 1987-1996, focusing on persistent disparities in maternal mortality between black and white women. The findings indicate that in every state where MMRs could be reliably calculated, black women were more likely than white women to die from complications of pregnancy and that the 2000 objective will not be met; however, for white women, it has been met in three states.

Black or African American↗
PubMed1988

Maternal mortality at the Women's and Children's Hospital, South Okkalapa (1978-1982).

The maternal deaths between the years 1978 and 1982 were studied. There were 22,468 maternities and 10,623 abortion patients treated at the hospital. There were 44 maternal deaths; 22 due to abortion and 22 due to other causes. The maternal mortality rate including abortions was 1.33 per 1,000 maternities and that excluding abortions 0.98 per 1,000. The abortion was 2.0 per 1,000 abortions treated at the hospital. To reduce maternal mortality, ways and means should be found to reduce the abortion deaths, most of which were avoidable.

Abortion, Induced↗
PubMed1985

[Anesthesia-related maternal mortality during labor. Results of a survey in the Federal Republic of Germany 1971-1980].

In order to obtain figures on the anaesthesia related maternal mortality in the Federal Republic of Germany, 707 hospitals have been addressed via questionnaire. Hospitals where obstetric departments and anaesthetic departments as well were available, were investigated for maternal mortality, anaesthetic requirements, and the complications which led to the maternal deaths during the period of 1971-1980. 38% (259 general hospitals and 10 university hospitals) responded; the geographical distribution seemed to be representative. The average maternal mortality rate was at 0.21%, which ranged from 0.21% for general hospitals to 0.16% for university hospitals. The overall anaesthesia related maternal mortality was around 6.4%. 20 of the reported 21 maternal deaths occurred under general anaesthesia and 1 under local anaesthesia; 17 patients died during caesarean section and 4 during vaginal delivery. The main complications which led to the maternal deaths were cardiac arrest and aspiration of gastric content with 38,1% each and convulsions with 4.8%. In 19% of the total maternal deaths the causes could not be determined. The importance of obstetric centres and of controlled anaesthetic methods delivery will be discussed on the basis of these and other figures which have been reported in the literature.

Anesthesia, Conduction↗
PubMed2004

The impact of maternal mortality interventions using traditional birth attendants and village midwives.

Traditional birth attendants (TBAs) and village midwives have been employed in many interventions to reduce maternal mortality in developing countries. This study reviews the results of 15 TBA- and midwife-based interventions that aim to improve skilled assistance in delivery and recognition and referral of complications. Outcome measures used to evaluate the impact of the programmes varied. Five of the five programmes reviewed that evaluated their impact on maternal mortality demonstrated a decline in maternal mortality ratios, two of three studies measuring morbidity-related indicators found improvement of some but not all morbidity outcomes, six of seven showed a trend of improved referral rates, and three of three found high levels of knowledge retention among trained TBAs. Programmes with the greatest impact utilised TBAs and village midwives within multisectoral interventions. These findings suggest that TBAs and village midwives contribute to positive programme outcomes. Further investigation is needed to determine the nature of their contribution within larger programmes.

Adolescent↗
PubMedDate not supplied

Maternal mortality in rural Bangladesh: the Jamalpur District.

During the 12-month period from September 1982 to August 1983, 9,317 live births and 58 maternal deaths were recorded in Melanda and Islampur upazilas in the Jamalpur district of rural Bangladesh, giving a maternal mortality rate of 62.3 per 10,000 live births. Maternal mortality was positively related to maternal age and parity, with the mortality risk rising very sharply beyond age 35 years, and beyond parity four among women aged 25-34 years in particular. The most common causes of maternal death were eclampsia (20.7 percent), septic abortion (20.7 percent), postpartum sepsis (10.3 percent), obstructed labor (10.3 percent), and antepartum and postpartum hemorrhage (10.3 percent). These findings indicate that family planning, by decreasing the likelihood of pregnancy after age 35 and parity four, can help reduce the proportion of women at risk of maternal mortality.

Adolescent↗
PubMed2002

Active surveillance of maternal mortality in New York City.

OBJECTIVES: This study examined the usefulness of computer-assisted active surveillance in identifying maternal deaths in New York City. METHODS: Computerized searches of hospital discharge and autopsy record databases were conducted for maternal deaths occurring in 1997. RESULTS: Active surveillance revealed 14 new maternal deaths not previously reported, an 88% increase. Nine of these deaths were found through the hospital discharge database search, 1 was found through the autopsy record search, and 4 were found in both searches. Overall maternal mortality ratios associated with active surveillance and routine surveillance were 24.3 and 13.0 deaths per 100 000 live births, respectively. CONCLUSIONS: Active surveillance of maternal mortality is useful in identifying new maternal deaths. Existing databases can be used relatively easily to augment routine surveillance of maternal mortality.

Adult↗
PubMed2003

Maternal mortality in a teaching hospital in Sudan.

OBJECTIVE: Although there is a great advances in obstetrics in recent years, a hard core of maternal mortality still lingers and is considered to be an irreducible minimum. Nevertheless there has been worldwide decline in maternal mortality over the past decades. Yet maternal mortality is still the major public health problem throughout the world. METHODS: A retrospective study carried out at the Medani Teaching Hospital, Medani City, Sudan. Case notes were reviewed for all the 877 women died during the period 1985-1999. All parturients were followed for at least 6 weeks after delivery so that deaths due to sequel of delivery and puerperium were also included. The data was analyzed and the literature was reviewed to compare the results of similar studies. RESULTS: Out of the total number of deliveries in that period (N=44,605), 877 women died with a rate of 1,966 per 100,000. This rate showed a decline each year, being 2,661 per 100,000 during the period 1985-1989. The mortality rate during 1990-1994 was 2,021 per 100,000 and 1,363 per 100,000 during the last period of 1995-1999. Sepsis was the cause of death in almost one third of cases, while malaria accounted for 37.2%. The number of preventable deaths had decreased steadily. CONCLUSION: The study highlighted the existence of a serious and preventable obstetrical problem. Sepsis, malaria hemorrhage and hypertensive disorders are the main contributory factors. Poor antenatal care, poor intranatal care, and poor provision of health services add more to the problem. Research into the problem of malaria, sterilization, anesthesia, vascular accidents, and indication for cesarean section together with social and medical improvements will definitely reduce the maternal morbidity and mortality.

Adult↗
PubMed2001

Maternal mortality in Kenya: the state of health facilities in a rural district.

BACKGROUND: This study was formulated from the premise that the known causes of maternal mortality, namely haemorrhage, sepsis, obstructed labour and abortion belie the more fundamental development problems that influence it, such as the state of local medical services, quality of care and the facilities' ability to respond to reproductive health emergencies. OBJECTIVE: To document some of the underlying problems and how they were found to influence maternal mortality in Kenya, with specific reference to a rural district. DESIGN: The researchers used the Prevention of Maternal Mortality Network (PMMN) methodology/study design to assess the current state of health facilities, their level of function, and factors influencing their utilisation. Both qualitative and quantitative methods of data collection tools were used. SETTING: Siaya District in the western region of Kenya. Data were collected from thirty facilities, which provide obstetric care in the district. PARTICIPANTS: Data were collected by nurse/midwives, nursing school tutors and social scientists with experience in qualitative research methods. Respondents included health service providers and managers at the 30 health facilities. Qualitative data were obtained through focus group discussions with health facility staff as well as community members. RESULTS: All the thirty facilities studied, were grossly wanting in terms of staffing, equipment, essential drugs and supplies. Both quality of care and record keeping were well below acceptable standards. CONCLUSIONS: The study findings are a sad but a fair reflection of our situation not only in Kenya but also in sub-Saharan Africa ten years after the declaration of the Safe Motherhood Initiative (SMI). The results indicate a predictable, widening gap in basic service provision that must be urgently bridged as a prerequisite to any serious and meaningful approaches to reducing maternal mortality in Africa.

Data Collection↗
PubMed1998

Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West?

Ten years of Safe Motherhood Initiative notwithstanding, many developing countries still experience maternal mortality levels similar to those of industrialized countries in the early 20th century. This paper analyses the conditions under which the industrialized world has reduced maternal mortality over the last 100 years. Preconditions appear to have been early awareness of the magnitude of the problem, recognition that most maternal deaths are avoidable, and mobilization of professionals and the community. Still, there were considerable differences in the timing and speed of reduction of maternal mortality between countries, related to the way professionalization of delivery care was determined: firstly, by the willingness of the decision-makers to take up their responsibility; secondly, by making modern obstetrical care available to the population (particularly by encouragement or dissuasion of midwifery care); and thirdly, by the extent to which professionals were held accountable for addressing maternal health in an effective way. Reduction of maternal mortality in developing countries today is hindered by limited awareness of the magnitude and manageability of the problem, and ill-informed professionalization strategies focusing on antenatal care and training of traditional birth attendants. These strategies have by and large been ineffective and diverted attention from development of professional first-line midwifery and second-line hospital delivery care.

Developed Countries↗
PubMed2005

Maternal mortality at the Queen Elizabeth Central Teaching Hospital, Blantyre, Malawi.

BACKGROUND: Maternal mortality in Malawi continues to increase despite the global SMI and national safe motherhood programme's efforts to reduce it. OBJECTIVES: To identify the social, demographic and reproductive profiles of women suffering a maternal death, the main immediate causes and the operational factors. DESIGN: A retrospective descriptive survey. SETTING: The Gogo-Chatinkha Maternity Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi, from January 1, 1999 to December 31, 2000. SUBJECTS: All women who suffered a maternal death in the unit. RESULTS: There were a total of 204 maternal deaths and 19,859 live births, giving a Maternal mortality ratio (MMR) of 1027.2/100,000 live births. Their ages ranged from 16 to 40 years. Adolescents comprised 20.6%, while the majority, (56.4%), were aged 15 - 24 years. Almost half of the group, (43.4%), were para 1 and less, with a range of 0 to 12. The top five causes of death were puerperal sepsis, (29.4%); postabortal complications, (23.5%); other infectious conditions, (20.1%); obstetric haemorrhage, (10.6%), and eclampsia, (6.4%). Some of the identified operational factors included delay in accessing and receiving emergency obstetric care, poor quality services, HIV infection/ AIDS and unsafe induced abortion following unwanted pregnancy. CONCLUSION AND RECOMMENDATIONS: Most of the causes and operational factors for maternal deaths are easily avoidable. The country needs to make more commitment and investments necessary to mitigate these deaths.

Abortion, Illegal↗
PubMed1994

Measuring maternal mortality in developing Pacific island countries: experience with the sisterhood method in the Solomon Islands.

AIMS: To estimate the maternal mortality rate in the Solomon Islands, and to assist health planning and implementation of effective interventions. METHOD: The sisterhood method, an indirect technique for deriving population-based estimates of maternal mortality was used in interviews with 2580 randomly chosen women reporting on the fertility and mortality experience of their sisters. RESULTS: The maternal mortality ratio in this study was 549 per 100,000 (95% CI 431, 684). This equates to one maternal death in every 180 pregnancies. CONCLUSION: The sisterhood method was found to be easy to administer, inexpensive and quick, and is recommended as a measurement tool to other developing countries.

Adolescent↗
PubMed1984

An assessment of the incidence of maternal mortality in the United States.

Recent studies in several states have found that the incidence of maternal mortality is higher than traditional vital statistics reports indicate. Since no comprehensive national study has been done to evaluate the completeness of maternal mortality ascertainment through the national vital statistics reporting system, the Centers for Disease Control (CDC) undertook such a study with the assistance of the National Center for Health Statistics and state health departments. The state health departments provided CDC with death certificates for all pregnancy-related deaths occurring during 1974-78. We reviewed and classified these certificates using both International Classification of Diseases, Adapted, Eighth Revision (ICDA-8) and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) maternal death codes. We found that the actual incidence of maternal mortality for 1974-78 was approximately 20 per cent and 30 per cent greater than that published in national vital statistics reports using ICDA-8 and ICD-9-CM, respectively.

Data Collection↗