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Saving Mothers and Babies: Maternal mortality

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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: An essential tool in the initial and ongoing training and teaching of any healthcare worker – Miriam Adhikari, South African Journal of Child Health, Primary Newborn Care was written specifically for nurses, midwives and doctors who provide primary care for newborn infants in level 1 clinics and hospitals. It covers: Mother and Baby Friendly Care describes gentler, kinder, evidence-based ways of caring for women during pregnancy, labour and delivery. It also presents improved methods of providing infant care with an emphasis on kangaroo mother care and exclusive breastfeeding. It covers: Saving Mothers and Babies was developed in response to the high maternal and perinatal mortality rates found in most developing countries. Learning material used in this book is based on the results of the annual confidential enquiries into maternal deaths and the Saving Mothers and Saving Babies reports published in South Africa. It addresses: the basic principles of mortality audit, maternal and perinatal mortality, managing mortality meetings, ways of reducing maternal and perinatal mortality rates, This book should be used together with the Perinatal Problem Identification Programme (PPIP).

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Saving Mothers and Babies: Maternal mortality

  1. 1. 2 Maternal mortalityBefore you begin this unit, please take the due to miscarriages (abortions) and ectopiccorresponding test at the end of the book to pregnancies.assess your knowledge of the subject matter. Objectives 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. When you have completed this unit you should be able to: 2-2 What is the maternal mortality ratio? • Define and calculate maternal mortality The maternal mortality ratio (MMR) is defined ratio. as the number of women dying between • List the important causes of maternal conception and 6 weeks (42 days) after delivery per 100 000 deliveries. The maternal mortality. mortality ratio is calculated as follows: • Interpret maternal mortality rates. • Separate direct and indirect causes of Total number of maternal deaths × 100 000 maternal death. Total number of livebirths • Describe the confidential enquiry into The maternal mortality ratio is usually given maternal deaths. 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, thenMORTALITY RATIO the maternal mortality rate is: 10 × 100 000 = 202-1 What is maternal mortality? 50 000Maternal mortality means the death of a Note that the maternal mortality ratio iswoman during pregnancy (i.e. conception expressed per 100 000 deliveries.to delivery) and the puerperium (i.e. up to42 days after delivery). It includes deaths
  2. 2. 24 SAVING MOTHERS AND BABIES The maternal mortality ratio is the number of 2-6 What is the maternal mortality ratio in industrialised countries? maternal deaths per 1000 000 deliveries. In industrialised countries, or privileged areas NOTE ‘Ratio’ rather than ‘rate’ used as the in poor countries, the maternal mortality ratio denominator does not include all pregnancies or is usually about 10 per 100 000 deliveries. deliveries, only livebirths. Therefore, it is very uncommon for a woman to die during pregnancy or the puerperium.2-3 Why does maternal mortality include NOTE For example, in 1994–1996 the MMR for thethe deaths of women during the first few United Kingdom was 12.2 / 100 000.months of pregnancy?Because pregnancy effects the mother’s body 2-7 What is the maternal mortality ratio insoon after the start of pregnancy. Problems poor countries?which occur early in pregnancy, such as In poor countries the maternal mortality ratioectopic pregnancies and septic abortions, can is usually above 50 per 100 000 deliveries. Theresult in the mother’s death. maternal mortality ratio varies widely between poor countries with some very undeveloped2-4 Why does the maternal mortality ratio communities having a ratio as high as 1000include the deaths of women during the 6 per 100 000.weeks after delivery? In many poor areas of industrialised countriesBecause the effects of pregnancy on the the maternal mortality ratio is also increased.mother’s body take up to 6 weeks to disappear. Worldwide, most maternal deaths occur inDeaths during the puerperium (6 weeks after poor countries where the death is usuallydelivery) are often as a result of complications related to poverty and inadequate access toof pregnancy. good health care services.2-5 What is the importance of the maternal In most poor developing countries themortality ratio? collection of mortality information is very incomplete, making it difficult to calculate theIt is a very important method of assessing both accurate maternal mortality rate.the standard of health of pregnant womenand the standard of care being provided to 2-8 What is the maternal mortality ratio inpregnant women. The maternal mortality ratio South Africa?can also be compared between different areasor between different periods of time in the The exact maternal mortality ratio in Southsame area. Africa is not known, as many maternal deaths are still not registered. However, the estimatedA high maternal mortality ratio usually maternal mortality ratio is about 200/100 000indicates either poor maternal health or deliveries. The maternal mortality ratio variesinadequate care during the pregnancy and between different districts from as low as 50 topuerperium or both. In contrast, a low as high as 300. Unlike many other developingmaternal mortality ratio indicates that both countries, the maternal mortality ratio hasmaternal health and health care are good. increased over the past few years. The maternal mortality ratio reflects both the The estimated maternal mortality ratio for South general health of women as well as the standard Africa is 200 / 100 000. of care during pregnancy and the puerperium. NOTE Estimates of maternal mortality in South Africa vary widely but suggest 200 to
  3. 3. MATERNAL MOR TALITY 25 400 / 100 000. An accurate ratio will only be know The final cause of maternal death is the event when most pregnancies and maternal deaths are which actually caused the death (a final recorded. It is important to know the maternal complication of the disease process), i.e. how mortality ratio in the country where you work. the patient died. Knowing the final causes of death helps to identify facilities and resources which need to be improved. It also helpsCAUSES OF MATERNAL to prevent or improve the management ofDEATH conditions which can be final causes of death. For example, if a pregnant woman has a severe antepartum haemorrhage from a placenta2-9 When are the causes of a maternal praevia and dies of hypovolaemic shock,death determined? the primary cause of death is antepartumEach maternal death must be discussed in haemorrhage and the final cause of death isdetail to determine the cause and decide hypovolaemic shock. Similarly, if a woman haswhether it could have been prevented. This eclampsia and dies of a brain haemorrhage,is usually done at the regular ‘perinatal the eclampsia is the primary cause and themortality meeting’ which also includes any brain bleed is the final cause of death.maternal deaths. It is important to discuss thematernal death as soon as possible while the The primary cause of maternal death is thedetails of the clinical problems and care are obstetric factor or condition which lead to thestill remembered. The findings of each deathmust be carefully summarised and included in death.the maternal mortality report. This is usuallyprepared annually for each health region. 2-12 How can the primary causes of maternal deaths be subdivided?2-10 Are maternal deaths notifiable? The primary causes of maternal deaths areYes. All maternal deaths are notified by law in subdivided into 3 groups:South Africa. This includes maternal deaths 1. Direct.at home and in private institutions. It is 2. Indirect.important to include maternal deaths which 3. Fortuitous.occur outside the maternity services, e.g.women who have not yet started antenatal care Usually a forth group called ‘Unknown’ isand women who die in medical, surgical or added. These are maternal deaths where theemergency departments. cause of death cannot be identified. NOTE In South Africa in 1977 all maternal deaths were made notifiable. 2-13 What are direct causes of maternal death?2-11 What are primary and final causes of These are deaths which are a direct resultmaternal death? of the woman being pregnant. They result from complications of pregnancy or theThe primary cause of maternal death is the puerperium, or the management of theobstetric factor or condition which lead to pregnancy or pueperium. These deaths wouldthe death, i.e. it is the reason why the death not have happened if the woman had not beenoccurred. Knowing the primary causes of pregnant. An example of a direct cause ofdeath helps to identify clinical practices which maternal death is eclampsia.need to be improved. Deaths can be preventedif the primary causes are well managed. NOTEDirect deaths result from obstetric complications of the pregnancy state, from
  4. 4. 26 SAVING MOTHERS AND BABIES interventions, omissions, incorrect treatment or 2-16 Is a cause found for all deaths during from a chain of events of any of these. pregnancy and the puerperium? No. Unfortunately the underlying cause A direct cause of maternal death would not have sometimes is unknown. This is often because happened if the woman had not been pregnant. the history is incomplete and a post mortem examination was not done.2-14 What are indirect causes of maternal 2-17 What are the important direct causesdeath? of maternal death in South Africa?These are deaths are caused by diseases that 1. Hypertension.existed before the pregnancy or developed 2. Postpartum haemorrhage.during the pregnancy or puerperium. 3. Antepartum haemorrhage.Although not a result of pregnancy or 4. Pregnancy related infection, such septicpuerperium complications, the pregnant state abortion and puerperal sepsisaggravated the condition. If the woman had NOTE Other causes are anaesthetic related, acutenot been pregnant, she may not have died collapse and pulmonary embolism, abortion andfrom the disease. An example of an indirect ectopic pregnancy.cause of maternal death is rheumatic heartdisease which became worse during the Most maternal deaths are due to directpregnancy, leading to heart failure. causes, especially the hypertensive disorders, haemorrhage and infection. NOTE Indirect deaths result from previous existing disease or disease that developed during NOTE The common final causes of death in the pregnancy which were not due to direct obstetric hypertensive category are cerebral haemorrhage causes but which were aggravated by the and pulmonary oedema. physiological effects of pregnancy. The commonest direct causes of maternal death A woman may have died of an indirect cause even in South Africa are hypertension, haemorrhage if she was not pregnant. and infection.2-15 What are fortuitous causes of 2-18 What are the important indirectmaternal death? causes of maternal death in South Africa?These are deaths that were unrelated to the 1. Non pregnancy related infections, such aspregnancy or puerperium and just happened AIDS, TB and malaria.to occur at this time. The condition causing 2. Pre-existing maternal disease, such asthe death was not aggravated by the pregnancy cardiac disease.and would have killed the women even if shehad not been pregnant. Examples of fortuitous AIDS is the commonest indirect cause ofcauses of maternal death include motor vehicle maternal death in South Africa.accidents and assault. NOTE The common final causes of deaths in women with AIDS are pneumonia, meningitisAlthough fortuitous causes of maternal and tuberculosis.death are recorded in South Africa, theyare not included in calculating the maternalmortality rate. Fortuitous deaths are counted Non-pregnancy-related infection is the commonestto document the extent of violence against indirect cause of maternal death in South Africa.women, accidents and suicides.
  5. 5. MATERNAL MOR TALITY 272-19 What are the most common causes of 2. Complications of hypertension inmaternal death in South Africa? pregnancy resulting in maternal death was most common in level 2 hospitals (staffedWhen all direct and indirect causes of by full-time specialists) and in level 3maternal death in South Africa are considered hospitals (having intensive care facilities).together, the following are the commonest (the‘big five’ causes) in order of frequency: 2-21 Why do so many pregnant women still1. Non-pregnancy related infection, especially die in poor countries? AIDS.2. Complications of hypertension in The high maternal mortality rate in poor pregnancy. countries is not due to the lack of knowledge of3. Obstetric haemorrhage, including how to manage ill pregnant women, but due to antepartum and postpartum haemorrhage. women not being able to receive adequate care.4. Pregnancy related infection, especially septic abortions and puerperal sepsis. 2-22 Why do many pregnant women in poor5. Non-pregnancy related diseases (pre- countries not have access to adequate care? existing medical conditions), especially Although some reasons may be obvious, this heart disease. question is often not easy to answer unless aThese five causes are responsible for 85% of all detailed investigation into causes of maternalmaternal deaths. In South Africa in 1999 the death is carried out. Such as investigation ismost common single cause of maternal death best done as a confidential enquiry. Importantwas AIDS. reasons why some women do not have access to good care are distance to the nearest clinic NOTE Many women who died of pregnancy related sepsis were not screened for HIV/AIDS. It or hospital, lack of transport and inadequate is highly likely that many were positive. Therefore, staffing or equipment at health care facilities. many deaths classified as pregnancy related infection, non-pregnancy related disease and possibly post partum haemorrhage should CONFIDENTIAL ENQUIRY probably be re-classified as non-pregnancy related infection. 2-23 What is a confidential enquiry into AIDS is the commonest cause of maternal death maternal deaths? in South Africa. In a confidential enquirer of maternal deaths, the deaths of as many pregnant women as possible are identified by an appointed2-20 Which causes of maternal deaths are committee. The case record of each woman ismost common at different levels of care? then carefully investigated by an independentNon pregnancy related infections were the team of experts to identify the likely cause andcommonest cause of death at all levels of care. reason for the death. This information is keptHowever: confidential to protect the staff involved with the care of the case. If this were not done, it1. Obstetric haemorrhage, especially post would be difficult to obtain the full story. partum haemorrhage, as a cause of maternal NOTE The aim of a confidential enquiry is death was most common in level 1 hospitals to reduce maternal mortality by collecting, (small hospitals staffed by doctors but analysing and interpreting information, reporting without any full-time obstetric specialists) findings and making recommendations for or clinics where there are no doctors. evidence based decisions.
  6. 6. 28 SAVING MOTHERS AND BABIES2-24 Is there a confidential enquiry into yet was potentially avoidable. If that event ormaternal deaths in South Africa? condition was not present, the death may not have occurred.Yes. This is a most important enquiry into thenumber and causes of maternal death in South A missed opportunity is a potentiallyAfrica. It attempts to identify avoidable factors, avoidable maternal death where anmissed opportunities and substandard care, and opportunity was present to prevent the deathgives recommendations as to how these causes but the opportunity was missed.can be prevented or effectively managed. The Substandard care is poor care which mayaim of the report is to make recommendations have resulted in the woman’s death.aimed at reducing the maternal mortalityrate. It is important that the findings and In any enquiry into a maternal death, itrecommendations of the confidential enquiry is very important to identify possible andare made available to all services and health probable avoidable factors and missedcare workers responsible for maternal care. opportunities as much can be learned from these events. This knowledge helps to avoid NOTE In South Africa a National Committee on Confidential Enquiries into Maternal Deaths is similar deaths in future. responsible for reviewing all maternal deaths. Avoidable factors, missed opportinities and2-25 What is the Saving Mothers report? substandard care must be looked for in eachThe Saving Mothers report is the official report maternal death.of the confidential enquiry into maternaldeaths in South Africa. The first SavingMothers Report to be published in South 2-27 Which maternal deaths are potentiallyAfrica reviewed maternal deaths in 1998. avoidable? NOTE The first interim report on maternal deaths Maternal deaths where avoidable factors, in South Africa was published in 1988. This was missed opportunities or substandard care was followed by the first comprehensive confidential present. Maternal deaths are not classified enquiry into maternal deaths in South Africa, into avoidable or not, only into deaths where conducted in 1998 and published as the ‘Saving avoidable factors were or were not present. Mothers: Report on Confidential Enquiry into Therefore, the report identifies deaths which Maternal Deaths in South Africa 1998’. It is planned were potentially avoidable. to produce a full report every 3 years. In addition there will be annual interim reports to track changes in the number and causes of maternal 2-28 What are the categories of avoidable death at different levels of care in each province. factors for maternal mortality? The information for these reports, and practical and affordable recommendations based on the Avoidable factors can be grouped into the reports, are produced by the National Committee following 3 categories: for Confidential Enquiries into Maternal Deaths. 1. Patient related problems. 2. Administrative problems. 3. Health worker related problems.AVOIDABLE FACTORS In South Africa, avoidable factors due to patient related problems were present in half,2-26 What are avoidable factors, missed administrative problems were associated withopportunities and substandard care? a third, and health worker related problems with a quarter of the maternal deaths. ManyAn avoidable factor is something which deaths had more than one avoidable factor.could have caused the maternal death and Therefore, all three categories of avoidable
  7. 7. MATERNAL MOR TALITY 29factors are commonly associated with or do not encourage access to health care.maternal deaths. Perhaps patient related problems should be called community related problems. In South Africa, avoidable factors associated 2-31 What administrative factors with patient, administrative and health worker contribute to maternal mortality? related problems are commonly associated with maternal deaths. These include: 1. Lack of staff. 2. Lack of availability of adequate training.2-29 What patient related problems 3. Lack of adequate transport.contribute to maternal mortality? 4. Lack of good clinics and hospitals close toThese include: the community. 5. Lack of intensive care facilities for seriously1. Not attending or booking late for antenatal ill women. care.2. Not recognising important warning Problems resulting in these administrative symptoms and signs such as a severe factors include poor planning and supervision headache or vaginal bleeding. of maternal services, little emphasis on health3. Not seeking help when warning signs were funding for women and a general lack of present. funds. In rural areas, deliveries are often conducted by untrained members of theIn South Africa the commonest patient related family. Having a skilled assistant to monitorproblem associated with maternal death is not labour and conduct the delivery is important.attending antenatal care or only attending latein pregnancy. This probably true for in manyother developing countries. Lack of well trained midwives is an important ad- ministrative related factor in maternal mortality. Poor attendance for antenatal care is the commonest patient relatedfactor associated with 2-32 Why is lack of staff a common maternal death in South Africa. problem? 1. Funding is often not available. Often this2-30 Are patient related problems the fault is because maternity care is not viewed asof the patient? a priority. 2. Suitably qualified staff may not be availableThere are many underlying social factors due to inadequate numbers of staff beingto patient related problems such as poor trained, staff moving from the state intoeducation of women, women not being the private service or staff leaving to workallowed to decide for themselves whether to in other countries.report to clinic or hospital, fear and ignorance, 3. Staff do not want to work in some areas farand traditional taboos on disclosing a from towns and cities, areas with a highpregnancy. Many women do not seek care crime rate or areas with poor transport andbecause care is not easily available. They may few facilities such as schools.have to travel long distances, face long queuesand be turned away from overcrowded clinics. 2-33 Why is a lack of adequate training aWhile some patients may not seek care common problem?because they are lazy or disinterested, usually 1. School education and basic nurse trainingthere are social conditions which prevent may be poor.
  8. 8. 30 SAVING MOTHERS AND BABIES2. Medical school training may not include 2-36 Why are intensive care facilities often enough time in maternal care. not available?3. Opportunities for continuing training or 1. The equipment is expensive and needs special (advanced) courses for both nursing skilled and costly maintenance. Often the and medical staff are often not available. equipment is available but not kept in good4. Obstetric specialists or medical officers, working order. general practitioners with additional 2. It is expensive to employ staff who are training in maternal care, and advanced adequately trained and regularly attend midwives are often not available to teach further training courses. their junior colleagues.5. Nursing staff who have attended advanced As a result, level 3 (intensive) care is often not courses are often placed in areas where this available to very ill women. knowledge cannot be best used.6. Routine staff rotation prevents individuals 2-37 What health care worker related acquiring enough experience in maternal problems contribute to maternal care. mortality? These include:2-34 Why is transport often inadequate? 1. Negligent or substandard care (they knew1. Transport is often not available to get what to do but did not do it). patients to antenatal clinic or to a clinic or 2. Honest errors. hospital when labour starts or danger signs 3. Lack of appropriate training (they did not present. know what to do).2. Patient transport is often worse in poor or rural areas and at night. Major health care worker related problems3. Transport is often expensive. include:4. Transport to move patients from a clinic 1. Not recognising clinical problems. to hospital or between hospitals is often 2. Delay in referral or not referring. not available or the delay time is very long. 3. Not following standard protocols. This may be due to lack of vehicles, lack 4. Inadequate monitoring of sick women after of staff, or due to maternity cases being admission. viewed as less important than other cases such as trauma. The administrative problems of staff shortages5. Telephones may not be available to call for and excessive patient load often contribute to transport. problems experienced by health care workers6. It may be dangerous to go to clinic or (both nursing and medical staff). hospital at night in areas with a lot of crime. 2-38 Why are health care workers some-2-35 Why are clinics and hospitals often not times negligent or offer substandard care?available? Negligence, laziness and an attitude of not1. It is very expensive to provide enough caring are very complex problems which clinics and hospitals within easy reach of are influenced by attitudes in the home, all pregnant women, especially in very community, schools, tertiary education mountainous areas or areas with a low centres and places of employment. Social population density. and environmental problems affect the way2. Clinics and hospital are often built far from health workers relate to both their work the community they serve. and their patients. Salaries, management styles, opportunities for further training and promotion, and personal beliefs all influence
  9. 9. MATERNAL MOR TALITY 31the motivation of health workers. A caring very useful in identifying avoidable factors andattitude is often not rewarded and encouraged substandard care.at all levels of society. Understaffing and NOTE A ‘near miss’ is more correctly referred to asoverwork are important causes of poor care. severe acute maternal morbidity (SAMM).Substandard care may be the result ofinadequate training or a lack of personal 2-42 What is the maternal mortality index?motivation and commitment to patient care. Number of maternal Maternal deaths2-39 What are honest errors? mortality = index Number of maternalAn honest error is a mistake in management deaths and near missesof the patient where the health worker hasdone his or her best but it was not the correct The maternal mortality index gives a measurediagnosis or treatment and, as a result, the of the standard of care of women who presentwoman died. Honest errors are often the result with serious complications. With goodof an excessive patient load and inadequate management, most severely ill women will bestaffing. Examples of honest errors are near misses rather than deaths. Therefore, aforgetting to enter an important observation low maternal mortality index indicates a highon the partogram or forgetting to give a standard of care while a high index suggestsnewborn infant vitamin K after delivery. poor care. At present the maternal mortality index for the2-40 What training may be inappropriate? whole of South Africa is not known.Many health workers are not appropriately NOTE The maternal mortality index for thetrained for the work they are expected to Bloemfontein, Pretoria and Soweto areas are 22.8,perform. This is often due to a lack of suitable 14.0 and 30.8 respectively.training opportunities. Basic midwifery andmedical training may not equip the nurse or 2-43 Are the causes of maternal death indoctor to function in a primary care situation South Africa changing over time?where supervision by an experienced personis not available. Most advanced courses are Yes. There is a reduction in the direct causesexpensive and require the health worker to and an increase in the indirect causes ofleave their home and place of employment maternal death. The increase in indirect causesto travel to a regional centre for a period is due to more deaths resulting from AIDS. Asof time. Few distance-learning courses are the testing for HIV increases in patients whereavailable which enable health workers to there has been maternal death, the percentagetake responsibility for some of their own of HIV positive maternal deaths will probablycontinuing education. increase. In 1999, two thirds of HIV tests in maternal deaths were positive.2-41 What is a ‘near miss’? 2-44 What is the role of the PerinatalA ‘near miss’ occurs when a woman is very Problem Identification Programme inill and almost dies of one of the conditions recording maternal deaths?which can cause maternal death. The avoidablefactors in a near miss are usually the same The Perinatal Problem Identificationas those where the patient dies. There are Programme (PPIP) is a software package usedmore near misses than maternal deaths in a mainly for recording data on perinatal deaths.service. As with an audit of causes of maternal However PPIP is also very useful to recorddeaths, an audit of near misses can also be information and analyse maternal deaths. PPIP data helps to collect the documentation
  10. 10. 32 SAVING MOTHERS AND BABIESneeded for the national confidential enquiry in poor countries is usually above 50/100 000.into maternal deaths. Therefore, this maternal mortality ratio of 350/100 000 is high, even for a poor country.CASE STUDY 1 5. What is the maternal mortality ratio in South Africa?In a large maternity service consisting of one The exact maternal mortality ratio is notsmall hospital and six clinics, there have been known as accurate mortality statistics as many10 000 liveborn deliveries and 35 maternal maternal death are still not reported, especiallydeaths in the past year. These deaths include in rural areas. The estimated maternal mortalitywomen who died as a result of septic abortions ratio is 200/100 000. However, it is probablyas well as women who died of sepsis following much higher than this in many poor areas.delivery. 6. Why is it important to know the maternal1. What is the definition of maternal mortality ratio in a health service?mortality? Because it gives a good idea of both theMaternal mortality consists of all the women standard of maternal health during pregnancywho died between conception and the end of and the puerperium, as well as the standard ofthe puerperium (6 weeks after delivery). health care available for pregnant women in the community.2. Why are abortions and postpartumdeaths also included in maternal mortality?Because both conditions are related to CASE STUDY 2pregnancy. Neither would have occurred ifthe women had not been pregnant. Maternal In a large maternity hospital in a city, bothdeaths are, therefore, all deaths where the the number and causes of maternal deathscause of death is related to pregnancy. Deaths are carefully recorded after they have beenafter 6 weeks are excluded as the physiological discussed at the monthly mortality meeting.changes of pregnancy have returned to the The primary and direct cause of each death ispre-pregnancy state by 6 weeks after delivery. noted in order to find the commonest causes of death at the hospital.3. What is the maternal mortality ratio inthis health service? 1. Are maternal deaths notifiable?There were 35 maternal deaths out of Yes. All maternal deaths must be notified. This10 000 livebirths. The maternal death ratio includes not only deaths in the state healthis traditionally expressed as a proportion of service but also deaths at home and in private100 000 deliveries. Therefore, the maternal hospitals.mortality ratio is 35/10 000 × 100 000 =350/100 000. Usually maternal mortality is 2. What are primary causes of maternalexpressed as an annual ratio and it is best death?expressed for a whole health region. The primary cause of death is the obstetric factor or condition which lead to the death.4. How do you interpret this maternal In other words, it is the reason why the deathmortality ratio? occurred. Important primary causes of deathThe maternal mortality ratio in industrialised include pre-eclampsia, antepartum andcountries is usually about 10/100 000 while that post partum haemorrhage, and pregnancy
  11. 11. MATERNAL MOR TALITY 33related infection such as septic abortion and province. Information is also being collectedpuerperal sepsis. on the main causes at each level of care within health districts and regions. The findings of3. Why is it important to know the common the Confidential Enquiry into Maternal Deathsprimary causes of maternal death? are presented in the Saving Mothers report. From this publication, funding is being madeBecause steps can then be made to avoid these available to address specific problems in theprimary causes by managing them better. care of pregnant women.By doing this, many maternal deaths can beprevented. It is difficult to reduce the maternal 1. What are the four main causes ofmortality if the primary causes are not known. maternal death in South Africa?4. What are final causes of maternal death? 1. AIDS. 2. Complications of hypertension inThe final cause of maternal death is the event pregnancy.which actually resulted in the death. In other 3. Antepartum and post partum haemorrhage.words, it is the final complication of the disease 4. Infections such as septic abortion andprocess which killed the woman. For example, puerperal sepsis.the final cause of death in antepartum or postpartum haemorrhage is usually hypovolaemic AIDS has become the leading cause ofshock while the final cause in eclampsia may maternal death in the past few years.be a brain haemorrhage. 2. What is the commonest cause of5. Why is it important to identify the final maternal deaths at all levels of care?cause of maternal death? Non pregnancy related infection (i.e. AIDS).Because the final cause of death can often beprevented with adequate facilities and the 3. What is the commonest direct cause ofcorrect management of these complications. maternal death in primary care clinics?For example, death from hypovolaemic Obstetric haemorrhage, especially post partumshock can often be avoided if women with haemorrhage.severe antepartum haemorrhage are correctlymanaged in an intensive care unit which hasadequate staffing and facilities. 4. What is the commonest direct cause of maternal death in level 2 and 3 hospitals?6. What are fortuitous causes of maternal Complications of pregnancy relateddeath? hypertension such as eclampsia.Fortuitous causes are not related to pregnancyat all but just happened to occur during 5. Why is the notification of all maternalpregnancy or the puerperium. Examples deaths and the Confidential Enquiry intoare motor car accidents, assault and suicide. Maternal Deaths so important?Fortuitous causes are not included when the Because accurate information on the numbermaternal mortality rate is calculated. and causes of maternal death in South Africa is now available for the first time. This will result in better planning of maternity services.CASE STUDY 3 6. What is the Saving Mothers Report?In recent years the main causes of maternal This is the official report of the Confidentialdeath have become better known in each Enquiry into Maternal Deaths.
  12. 12. 34 SAVING MOTHERS AND BABIESCASE STUDY 4 recognising important warning signs and not seeking help when warning signs are present.During a monthly mortality meeting in The commonest administrative related factorsa regional hospital, all the maternal and are lack of staff, inadequate staff training, poorperinatal deaths are presented. The possible transport, lack of primary care clinics andavoidable factors and missed opportunities hospitals in the community, and inadequateassociated with each of the two maternal intensive care facilities for seriously ill women.deaths are discussed and documented in The commonest staff related factors are poorthe mortality report. A near miss maternal care, honest errors and lack of appropriatedeath was also described. Neither the medical training.superintendent of the hospital nor thematernity matron was at the meeting. 6. What common errors are made by health care workers?1. What are avoidable factors in maternaldeaths? Not recognising problems, a delay or failure in referring sick patients, not following standardThese are factors, events or conditions which protocols of care, and inadequate monitoringmay have prevented the maternal death if of ill patients.they had not been present. For example, iffast, efficient transport had been availablea mother might not have died from a post 7. What is a ‘near miss’?partum haemorrhage. A very ill woman who nearly died from a condition which often causes maternal deaths.2. What is a missed opportunity? Good lessons on how to improve maternal care can be learned from near misses.This is an opportunity for providing goodcare which was missed and, as a result, led tothe woman’s death? For example, not testing a 8. Why do so many mothers still die in poorwoman’s urine for sugar during antenatal care countries?was a missed opportunity which may have Many women still die in poor countries, notprevented her dying from a complication of because of the lack of knowledge of howdiabetes during labour. to manage ill pregnant women, but due to women not being able to receive adequate care.3. Which maternal deaths are potentially This is usually due to great distances to theavoidable? nearest clinic or hospital, lack of transport and inadequate staffing, equipment and training.Deaths where avoidable factors, missedopportunities or substandard care were present. 9. Should the medical superintendent and maternity matron attend mortality4. What are the three categories of meetings?avoidable factors in maternal mortality? Yes. As the managers of the service, it is very1. Patient related factors. important that they are aware of problems,2. Administration related factors. avoidable factors and recommended ways of3. Health worker related factors. improving the service and preventing further5. Can you give an example of each of the maternal deaths.three categories?The commonest patient related factors are notattending antenatal care or booking late, not
  13. 13. MATERNAL MOR TALITY 35PPIP CLASSIFICATION OF 7. Pre-existing maternal diseaseMATERNAL DEATHS • Cardiac disease e.g. rheumatic valve disease. • Endocrine e.g. diabetes. • Central nervous system e.g. epilepsy.These are included as a reference only. • Skeletal e.g. kyphoscoliosis.Primary causes of maternal death 8. Postpartum haemorrhageThe most important subdivisions are: • Retained placenta. • Uterine atony.1. Abortion • Ruptured uterus.• Septic abortion. • Inverted uterus.• Uterine trauma. 9. Anaesthetic complication2. Ectopic pregnancy 10. Embolism3. Antepartum haemorrhage 11. Acute collapse – cause unknown• Abruptio placenta. 12. Non obstetric cause• Abruptio placenta with hypertension.• Placenta praevia. • Motor vehicle accident. • Assault.4. Hypertensive disorders of pregnancy • Suicide.• Chronic hypertension.• Proteinuric hypertension. Final causes of maternal death• Eclampsia. 1. Hypovolaemic shock.• HELLP syndrome. 2. Septic shock.• Ruptured liver. 3. Respiratory failure.5. Pregnancy related sepsis 4. Cardiac failure. 5. Renal failure.• Amniotic fluid infection with ruptured 6. Liver failure. membranes. 7. Cerebral complication.• Amniotic fluid infection without ruptured 8. Disseminated intravascular coagulation. membranes. 9. Multiorgan failure.• Puerperal sepsis following normal delivery.• Puerperal sepsis following caesarean A more detailed classification of primary section. causes of maternal death is given in the Perinatal Problem Identification Programme.6. Non-pregnancy related sepsis Each subdivision is given a specific code.• AIDS. NOTE Codes and descriptions of causes• Pneumonia. of maternal death can be viewed at and• Tuberculosis. downloaded from www.ppip.co.za.• Bacterial endocarditis.• Pyelonephritis.• Malaria.