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User:HeidiCarpenter23/Maternal death

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Maternal death or maternal mortality is defined in slightly different ways by several different health organizations. The World Health Organization (WHO) defines maternal death as the death of a pregnant person due to complications related to pregnancy, underlying conditions worsened by the pregnancy or management of these conditions. This can occur either while the person is pregnant or within six weeks of resolution of the pregnancy.[1] The CDC definition of pregnancy-related deaths extends the period of consideration to include one year from the resolution of the pregnancy.[2] [3] Pregnancy associated death, as defined by the American College of Obstetricians and Gynecologists (ACOG), are all deaths occurring within one year of a pregnancy resolution. [4] Identification of pregnancy associated deaths is important for deciding whether or not the pregnancy was a direct or indirect contributing cause of the death.

There are two main measures used when talking about the rates of maternal mortality in a community or country. These are the maternal mortality ratio and maternal mortality rate, both abbreviated as "MMR".[5] By 2017, the world maternal mortality rate had declined 44% since 1990; however, everyday 808 women die from pregnancy or childbirth related causes.[6] According to the United Nations Population Fund (UNFPA) 2017 report, about every 2 minutes a woman dies because of complications due to child birth or pregnancy. For every woman who dies, there are about 20 to 30 women who experience injury, infection, or other birth or pregnancy related complication.[6]

UNFPA estimated that 303,000 women died of pregnancy or childbirth related causes in 2015.[6] [7] The WHO divides causes of maternal deaths into two categories: direct obstetric deaths and indirect obstetric deaths. Direct obstetric deaths are causes of death that due to complications of pregnancy, birth or termination. For example, these could range from severe bleeding to obstructed labor, for which there are highly effective interventions.[8][1] Indirect obstetric deaths are caused by pregnancy interfering or worsening an existing condition, like a heart problem.[1]

As women have gained access to family planning and skilled birth attendant with backup emergency obstetric care, the global maternal mortality ratio has fallen from 385 maternal deaths per 100,000 live births in 1990 to 216 deaths per 100,000 live births in 2015[6][7]. Many countries halved their maternal death rates in the last 10 years.[6] Although attempts have been made to reduce maternal mortality, there is much room for improvement, particularly in low-resource regions. Over 85% of maternal deaths are in low-resource communities in Africa and Asia.[6] In higher resource regions, there are still significant areas with room for growth, particularly as they relate to racial and ethnic disparities and inequities in maternal mortality and morbidity rates.[4][7]

Overall, maternal mortality is an important marker of the overall health of the country and reflects on its health infrastructure.[4] Lowering the amount of maternal death is an important goal of many health organizations world-wide.

Article body edit

Causes edit

Direct Obstetric Deaths edit

Overview edit

Direct obstetric deaths are due to complications of pregnancy, birth, termination or complications arising from their management. [1]

The causes of maternal death vary by region and level of access. According to a study published in the Lancet which covered the period from 1990 to 2013, the most common causes of maternal death world-wide are postpartum bleeding (15%), complications from unsafe abortion (15%), hypertensive disorders of pregnancy (10%), postpartum infections (8%), and obstructed labor (6%).[9] Other causes include blood clots (3%) and pre-existing conditions (28%).[10]

Descriptions by Condition edit

Postpartum bleeding happens when there is uncontrollable bleeding from the uterus, cervix or vaginal wall after bleeding. This can happen when the uterus does not contract correctly after birth, there is left over placenta in the uterus, or there are cuts in the cervix or vagina from birth. [11]

Hypertensive disorders of pregnancy happen when the body does not regulate blood pressure correctly. In pregnancy, this is due to changes at the level of the blood vessels, likely because of the placenta. [12]This includes medical conditions like gestational hypertension and pre-eclampsia.

Postpartum infections are infections of the uterus or other parts of the reproductive tract after the resolution of a pregnancy. They are usually bacterial and cause fever, increased pain, and foul-smelling discharge. [13]

Blood clots can occur in different vessels in the body, including vessels in the arms, legs, and lungs. They can cause problems in the lung, as well as travel to the heart or brain, leading to complications. [14]

Unsafe abortion edit

When abortion is legal and accessible, is widely regarded as safer than carrying a pregnancy to term and delivery. In fact, a study published in the journal Obstetrics & Gynecology reported that in the United States, carrying a pregnancy to term and delivering a baby comes with 14 times increased risk of death as compared to a legal abortion. [15] However in many regions of the world, abortion is not legal and can be unsafe.[15][16][17] Maternal deaths caused by improperly performed procedures are preventable and contribute 13% to the maternal mortality rate worldwide. This number is increased to 25% in countries where other causes of maternal mortality are low, such as in Eastern European and South American countries. This makes unsafe abortion practices the leading cause of maternal death worldwide.[18]

Unsafe abortion is another major cause of maternal death worldwide. In regions where abortion is legal and accessible, abortion is safe and does not contribute greatly to overall rates of maternal death. [7] [16][15] However, in regions where abortions are not legal, available, or regulated, unsafe abortion practices can cause significant rates of maternal death. [19] According to the World Health Organization in 2009, every eight minutes a woman died from complications arising from unsafe abortions.[20]

Unsafe abortion practices are defined by the WHO as procedures that are performed by someone without the appropriate training and/or ones that are performed in an environment that is not considered safe or clean. [18][21] Using this definition, the WHO estimates that out of the 45 million abortions that are performed each year globally, 19 million of these are considered unsafe, and 97% of these unsafe abortions occur in developing countries.[18][22] Complications include hemorrhage, infection, sepsis and genital trauma.[23]

Associated factors edit

Social factors impact a woman's decision to seek abortion services. These can include fear of abandonment from the partner, family rejection and lack of employment. Social factors such as these can lead to the consequence of undergoing an abortion that is considered unsafe.[22]

Rates edit
 
Infographic - History of Maternal Mortality in India

One proposal for measuring trends and variations in risks to maternal death associated with maternal death is to measure the percentage of induced abortions that are defined unsafe (by the WHO) and by the ratio of deaths per 100,000 procedures, which would be defined as the abortion mortality ratio.[22]

There are four primary types of data sources that are used to collect abortion-related maternal mortality rates: confidential enquiries, registration data, verbal autopsy, and facility-based data sources. A verbal autopsy is a systematic tool that is used to collect information on the cause of death from laypeople and not medical professionals.[24]

Confidential enquires for maternal deaths do not occur very often on a national level in most countries. Registration systems are usually considered the "gold-standard" method for mortality measurements. However, they have been shown to miss anywhere between 30 and 50% of all maternal deaths.[24] Another concern for registration systems is that 75% of all global births occur in countries where vital registration systems do not exist, meaning that many maternal deaths occurring during these pregnancies and deliveries may not be properly record through these methods. There are also issues with using verbal autopsies and other forms of survey in recording maternal death rates. For example, the family's willingness to participate after the loss of a loved one, misclassification of the cause of death, and under-reporting all present obstacles to the proper reporting of maternal mortality causes. Finally, an potential issue with facility-based data collection on maternal mortality is the likelihood that women who experience abortion-related complications to seek care in medical facilities. This is due to fear of social repercussions or legal activity in countries where unsafe abortion is common since it is more likely to be legally restrictive and/or more highly stigmatizing.[24] Another concern for issues related to errors in proper reporting for accurate understanding of maternal mortality is the fact that global estimates of maternal deaths related to a specific cause present those related to abortion as a proportion of the total mortality rate. Therefore, any change, whether positive or negative, in the abortion-related mortality rate is only compared relative to other causes, and this does not allow for proper implications of whether abortions are becoming more safe or less safe with respect to the overall mortality of women.[24]

Prevention edit
 
SDG 3

The prevention and reduction of maternity death is one of the United Nation's Sustainable Development Goals, specifically Goal 3, "Good health and well being". Promoting effective contraceptive use and information distributed to a wider population, with access to high-quality care, can make steps towards reducing the number of unsafe abortions. For nations that allow contraceptives, programs should be instituted to allow the easier accessibility of these medications.[23] However, this alone will not eliminate the demand for safe services, awareness on safe abortion services, health education on prenatal check ups and proper implementation of diets during pregnancy and lactation also contributes to its prevention.[25]

Indirect Obstetric Deaths edit

Indirect obstetric deaths are caused by preexisting health problem worsened by pregnancy or newly developed health problem unrelated to pregnancy .[26] [1] Fatalities during but unrelated to a pregnancy are termed accidental, incidental, or non-obstetrical maternal deaths.

Indirect causes include malaria, anemia,[27] HIV/AIDS, and cardiovascular disease, all of which may complicate pregnancy or be aggravated by it.[28] Risk factors associated with increased maternal death include the age of the mother, obesity before becoming pregnant, other pre-existing chronic medical conditions, and cesarean delivery.[29][30]

Risks Factors edit

According to a 2004 WHO publication, sociodemographic factors such as age, access to resources and income level are significant indicators of maternal outcomes. Young mothers face higher risks of complications and death during pregnancy than older mothers,[31] especially adolescents aged 15 years or younger.[32] Adolescents have higher risks for postpartum hemorrhage,endometritis, operative vaginal delivery, episiotomy, low birth weight, preterm delivery, and small-for-gestational-age infants, all of which can lead to maternal death.[32] The leading cause of death for girls at the age of 15 in developing countries is complication through pregnancy and childbirth. They have more pregnancies, on average, than women in developed countries, and it has been shown that 1 in 180 15-year-old girls in developing countries who become pregnant will die due to complications during pregnancy or childbirth. This is compared to women in developed countries, where the likelihood is 1 in 4900 live births.[31] However, in the United States, as many women of older age continue to have children, the maternal mortality rate has risen in some states, especially among women over 40 years old.[29]

Structural support and family support influences maternal outcomes.[33] Furthermore, social disadvantage and social isolation adversely affects maternal health which can lead to increases in maternal death.[34] Additionally, lack of access to skilled medical care during childbirth, the travel distance to the nearest clinic to receive proper care, number of prior births, barriers to accessing prenatal medical care and poor infrastructure all increase maternal deaths. [31]


Epidemiology edit

Maternal deaths and disabilities are leading contributors in women's disease burden with an estimated 303,000 women killed each year in childbirth and pregnancy worldwide.[35] The global rate (2017) is 211 maternal deaths per 100,000 live births. Forty-five percent of postpartum deaths occur within 24 hours.[36] Ninety-nine percent of maternal deaths occur in developing countries.[37]

At a country level, India (19% or 56,000) and Nigeria (14% or 40,000) accounted for roughly one third of the maternal deaths in 2010.[38] Democratic Republic of the Congo, Pakistan, Sudan, Indonesia, Ethiopia, United Republic of Tanzania, Bangladesh and Afghanistan accounted for between 3 and 5 percent of maternal deaths each.[39] These ten countries combined accounted for 60% of all the maternal deaths in 2010 according to the United Nations Population Fund report. Countries with the lowest maternal deaths were Greece, Iceland, Poland, and Finland.[40]

As of 2017, countries in Southeast Asia and Sub-Saharan Africa account for approximately 86% of all maternal death in the world. Sub-Saharan African countries accounted for about two-thirds of the global maternal deaths and Southeast Asian countries accounted for approximately one-fifth. Since 2000, Southeast Asian countries have seen a significant decrease in maternal mortality with an overall decrease in maternal mortality of almost 60%.[41] Sub-Saharan Africa also saw an almost 40% decrease in maternal mortality between 2000 and 2017. As of 2017, the countries with the highest maternal mortality rates included South Sudan, Somalia, Central African Republic, Yemen, Syria, South Sudan, and the Democratic Republic of the Congo. The numbers for maternal mortality in these countries are likely affect by the political and civil unrest that these countries are facing.[41]

Until the early 20th century developed and developing countries had similar rates of maternal mortality.[42] Since most maternal deaths and injuries are preventable,[43] they have been largely eradicated in the developed world.

A lot of progress has been made since the United Nations made the reduction of maternal mortality part of the Millennium Development Goals (MDGs) in 2000.[44]: 1066  Bangladesh, for example, cut the number of deaths per live births by almost two-thirds from 1990 to 2015. However, the MDG was to reduce it by 75%. According to government data, the figure for 2015 was 181 maternal deaths per 100,000 births. The MDG mark was 143 per 100,000.[45] A further reduction of maternal mortality is now part of the Agenda 2030 for sustainable development. The United Nations has more recently developed a list of goals termed the Sustainable Development Goals. The target of the third Sustainable Development Goal (SDG) is to reduce the global maternal mortality rate (MMR) to less than 70 per 100,000 live births by 2030.[46] Some of the specific aims of the Sustainable Development Goals are to prevent unintended pregnancies by ensuring more women have access to contraceptives, as well as providing women who become pregnant with a safe environment for delivery with respectful and skilled care during delivery. This also includes providing women with complications during delivery timely access to emergency services through obstetric care.[47]

The WHO has also developed a global strategy and goal to end preventable death related to maternal mortality.[48] A major goal of this strategy is to identify and address the causes of maternal and reproductive morbidities and mortalities, as well as disabilities related to maternal health outcomes. The collaborations that this strategy introduces are to address the inequalities that are shown with access to reproductive, maternal, and newborn services, as well as the quality of that care. They also ensure that universal health coverage is essential for comprehensive health care services related to maternal and newborn health. The WHO strategy also implements strengthening health care systems to ensure quality data collection to better respond to the needs of women and girls, as well as ensuring responsibility and accountability to improve the equity and quality of care provided to women.

Variation within countries edit

There are significant maternal mortality intra country variations, especially in nations with large equality gaps in income and education and high healthcare disparities. Women living in rural areas experience higher maternal mortality than women living in urban and sub-urban centers because[49] those living in wealthier households, having higher education, or living in urban areas, have higher use of healthcare services than their poorer, less-educated, or rural counterparts.[50] There are also racial and ethnic disparities in maternal health outcomes which increases maternal mortality in marginalized groups.[51]

By country edit

See also: Maternal mortality in the United States
Country Maternal Mortality Ratio (2017) by Country All data is from the World Bank.[52][53]
Italy 2
Spain 4
Sweden 4
Japan 5
Australia 6
Germany 7
UK 7
France 8
New Zealand 9
Canada 10
South Korea 11
Russia 17
US 19
Mexico 33
China 29
South Africa 119
India 145
Ghana 308

In the year 2017, 810 women died from preventable causes related to pregnancy and birth per day which totaled to approximately 295,000 maternal deaths that year alone. It was also estimated that 94% of maternal deaths occurred in low-resource countries in the same year.[54]

In a retrospective study done across several countries in 2007, the cause of death and causal relationship to the mode of delivery in pregnant women was examined from the years 2000 to 2006. It was discovered that the excess maternal death rate of women who experienced a pulmonary embolism was casually related to undergoing a cesarean delivery. There was also an association found between neuraxial anesthesia, more commonly known as an epidural, and an increased risk for an epidural hematoma. Both of these risks could be reduced by the institution of graduated compression, whether by compression stockings or a compression device. There is also speculation that eliminating the concept of elective cesarean sections in the United States would significantly lower the maternal death rate.[54]


Causes of Maternal Death in the US edit

Pregnancy-related deaths between 2011 and 2014 in the United States have been shown to have major contributions from non-communicable diseases and conditions, and the following are some of the more common causes related to maternal death:[55] cardiovascular diseases (15.2%.), non-cardiovascular diseases (14.7%), infection or sepsis (12.8%), hemorrhage (11.5%), cardiomyopathy (10.3%), pulmonary embolism (9.1%), cerebrovascular accidents (7.4%), hypertensive disorders of pregnancy (6.8%), amniotic fluid embolism (5.5%), and anesthesia complications (0.3%).

References edit

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