Maternal mortality

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Chapter 43 Maternal mortality

Vivienne O’Connor

Maternal age is an important risk factor for both obstetric and perinatal outcomes. Adverse outcomes are more likely to occur in younger and older mothers. More Aboriginal or Torres Strait Islander mothers have their babies at a younger age compared with non-Indigenous mothers. One in five (19.5%) Aboriginal or Torres Strait Islander mothers is a teenager, compared with 3.5% of non-Indigenous mothers.

Background facts

Every day 1500 women die from pregnancy-related or childbirth-related conditions in the world. Most deaths occur in developing countries and are avoidable. Worldwide, 13 developing countries account for 70% of all maternal deaths. A woman living in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy or childbirth. This compares with a 1 in 2800 risk for a woman from a developed region.

The World Health Organization estimates that more than 80% of maternal deaths could be prevented through actions that have been proven to be effective and affordable, including: access to voluntary family planning to ensure that births are spaced properly, skilled attendance at delivery, aseptic birth environments, identification of maternal/fetal/neonatal complications, and minimal delay in reaching a medical facility or in receiving good quality/emergency obstetric care.

In Australia, in the triennium 2003–05, there were 65 maternal deaths (29 direct and 36 indirect) and 34 incidental deaths (see Table 43.1). There were no deaths from termination of pregnancy procedures. Over the past five trienniums, the maternal mortality rates for Indigenous women were between two and five times the maternal mortality rates for non-Indigenous women.

Table 43.1 Australian triennium 2003–05 (65 deaths)

Definitions

The World Health Organization definition of maternal mortality is the death of a woman while pregnant or within 42 days of the termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes. It also includes deaths from assisted reproduction technologies where pregnancy has not occurred, but not from incidental causes. In most Australian states and territories, incidental deaths are included in the definition.

Classifications

Direct maternal deaths

These result from obstetric complications of pregnancy, labour and puerperium (i.e. as a direct complication of pregnancy itself), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of these.

Indirect obstetric deaths

These result from pre-existing disease or disease that develops during pregnancy that is not due to a direct obstetric cause, but may have been aggravated by physiological changes in pregnancy. Common examples are complications of cardiovascular disease, renal disease and diabetes.

Incidental deaths

These are due to conditions during pregnancy where the pregnancy is unlikely to have contributed significantly to death. Examples include road accidents, homicide and malignancies.

Maternal mortality ratio

This means deaths per 100,000 confinements (including both live and stillbirths). This compares to international standards of deaths per 100,000 live births. The maternal mortality ratio in Western countries is approximately 6–10 per 100,000 (8.4 in Australia: 7.9 for non-Indigenous women and 21.5 for Indigenous women).

Contributing factors in those who died from haemorrhage were the failure to recognise the continuation and/or extent of the haemorrhage, delay in undertaking surgical treatment to arrest haemorrhage, and delay in blood transfusion.

In those with pre-eclampsia, intracerebral bleeding was the major cause of death. The reporting data in Australia can be improved. This includes variation in reporting, in referral for coronial investigation and quality of data on Indigenous status.

Reducing maternal mortality and morbidity

Increasing use of modern contraceptives have made and can continue to make an important contribution to reducing maternal mortality in the developing world by preventing high-risk, high-parity births.

It is estimated that for every maternal death in Australia, there are approximately 80 incidences of severe maternal morbidity, including haemorrhage, uterine rupture, renal failure and eclampsia.

Further reading

Callister L.C. Global maternal mortality: contributing factors and strategies for change. MCN: American Journal of Maternal / Child Nursing. 2005;30:184-192.

Laws P., Sullivan E.A.. Australia’s mothers and babies 2007. Perinatal Statistics Series No. 23. Cat. No. PER 48, 2009. AIHW National Perinatal Statistics Unit, www.preru.unsw.edu.au/PRERUWeb.nsf/page/AIHW+National+Perinatal+Statistics+Unit Available at:

Lewis G., editor. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer 2003–05. The seventh report on confidential enquiries into maternal death in the United Kingdom. London: Royal Society of Medicine Press, 2008.

Stover J., Ross J.. How increased contraceptive use has reduced maternal mortality. Maternal Child Health Journal, 2009. www.springerlink.com/content/x182m5012uk6157m/ Available at:

Sullivan E.A., Hall B., King J.F.. Maternal deaths in Australia 2003–05. 2008. AIHW National Perinatal Statistics Unit, Maternal Deaths Series No. 3 Cat. No. PER 42. www.preru.unsw.edu.au/PRERUWeb.nsf/page/AIHW+National+Perinatal+Statistics+Unit Available at:

World Health Organization (WHO). Maternal deaths disproportionately high in developing countries. www.who.int/mediacentre/news/releases/2003/pr77/en/index.html, 2003. Available at:

World Health Organization (WHO). Maternal mortality in 2005. In estimates developed by WHO. UNFPA and the World Bank: UNICEF; 2007. Available at: www.who.int/mediacentre/news/releases/2003/pr77/en/index.htmlGeneva: WHO

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