Prepregnancy obesity and the risk of gestational diabetes mellitus

Background

Investigation of maternal near-miss is a useful complement to the investigation of maternal mortality with the aim of meeting the United Nations' fifth Millennium Development Goal. The present study was conducted to investigate the frequency of near-miss events, to calculate the mortality index for each event and to compare the socio-demographic and obstetrical data (age, parity, gestational age, education and antenatal care) of the near-miss cases with maternal deaths.

Methods

Near-miss cases and events (hemorrhage, infection, hypertensive disorders, anemia and dystocia), maternal deaths and their causes were retrospectively reviewed and the mortality index for each event was calculated in Kassala Hospital, eastern Sudan over a 2-year period, from January 2008 to December 2010. Disease-specific criteria were applied for these events.

Results

There were 9578 deliveries, 205 near-miss cases, 228 near-miss events and 40 maternal deaths. Maternal near-miss and maternal mortality ratio were 22.1/1000 live births and 432/100 000 live births, respectively. Hemorrhage accounted for the most common event (40.8%), followed by infection (21.5%), hypertensive disorders (18.0%), anemia (11.8%) and dystocia (7.9%). The mortality index were 22.2%, 10.0%, 10.0%, 8.8% and 2.4% for infection, dystocia, anemia, hemorrhage and hypertensive disorders, respectively.

Conclusion

There is a high frequency of maternal morbidity and mortality at the level of this facility. Therefore maternal health policy needs to be concerned not only with averting the loss of life, but also with preventing or ameliorating maternal-near miss events (hemorrhage, infections, hypertension and anemia) at all care levels including primary level.     

Factors associated with antenatal mental disorder in West Africa: A cross-sectional survey

Background

The maternal mortality ratio in Sudan was estimated at 750/100,000 live births. Sudan was one of eleven countries that are responsible for 65% of global maternal deaths according to a recent World Health Organization (WHO) estimate. Maternal mortality in Kassala State was high in national demographic surveys. This study was conducted to investigate the causes and contributing factors of maternal deaths and to identify any discrepancies in rates and causes between different areas.

Methods

A reproductive age mortality survey (RAMOS) was conducted to study maternal mortality in Kassala State. Deaths of women of reproductive age (WRA) in four purposively selected areas were identified by interviewing key informants in each village followed by verbal autopsy.

Results

Over a three-year period, 168 maternal deaths were identified among 26,066 WRA. Verbal autopsies were conducted in 148 (88.1%) of these cases. Of these, 64 (43.2%) were due to pregnancy and childbirth complications. Maternal mortality rates and ratios were 80.6 per 100,000 WRA and 713.6 per 100,000 live births (LB), respectively. There was a wide discrepancy between urban and rural maternal mortality ratios (369 and 872\100,000 LB, respectively). Direct obstetric causes were responsible for 58.4% of deaths. Severe anemia (20.3%) and acute febrile illness (9.4%) were the major indirect causes of maternal death whereas obstetric hemorrhage (15.6%), obstructed labor (14.1%) and puerperal sepsis (10.9%) were the major obstetric causes. Of the contributing factors, we found delay of referral in 73.4% of cases in spite of a high problem recognition rate (75%). 67.2% of deaths occurred at home, indicating under utilization of health facilities, and transportation problems were found in 54.7% of deaths. There was a high illiteracy rate among the deceased and their husbands (62.5% and 48.4%, respectively).

Conclusions

Maternal mortality rates and ratios were found to be high, with a wide variation between urban and rural populations. Direct causes of maternal death were similar to those in developing countries. To reduce this high maternal mortality rate we recommend improving provision of emergency obstetric care (Emoc) in all health facilities, expanding midwifery training and coverage especially in rural areas.     

La mortalité maternelle en France est-t-elle toujours plus élevée que dans les autres pays européens ? Mise au point avec des données de routine

Background

In 1996, an European study showed that maternal mortality and frequency of deaths due to hemorrhages were higher in France than in other countries. This study aims to update with routine data.

Methods

We compared the maternal mortality ratio and the frequency of causes during the period 2000–2004 among France, United Kingdom (UK), and the Netherlands. The data were collected from WHO and the demographic yearbooks. Direct standardization, Z-test, and Chi-square statistics were used.

Results

The standardized maternal mortality ratios were 7.5, 7.5, and 6.7 per 100,000 live births in France, UK, and the Netherlands, respectively. In France, the ratio decreased between 1990–1994 and 2000–2004 from 11.2 to 7.5 per 100,000 live births. However, the hemorrhages are persisting as the predominant obstetrical cause in France, whereas they are the indirect causes in the UK, and the hypertensive complications are the cause in the Netherlands.

Conclusion

France seems to fill up its delay, thanks to the implementation of the confidential inquiries into maternal death recommendations, launched since 1996. More studies are needed to deal with the hemorrhages.     

National maternal mortality ratio for Jordan, 2007-2008

Objective

To estimate the number of maternal deaths per 100 000 live births during 2007-2008 among Jordanian women; to identify the causes of maternal mortality; and to compare the results with those of the last report for 1995-1996.

Methods

Reproductive-age mortality study of maternal deaths among women aged 15-49 years in Jordan in 2007-2008.

Results

Among 1406 identified deaths of reproductive-aged women, 76 maternal deaths were identified out of 397 588 live births, for a maternal mortality ratio of 19.1 deaths per 100 000 live births. Forty-three (56.6%) deaths were attributable to hemorrhage, thrombosis and thromboembolism, and sepsis. Avoidable factors were present in 53.9% of women, 52.6% had substandard care, and 31.5% had 3 or fewer antenatal visits. Of those with available information on family planning, only 29.4% had ever used any form of contraception.

Conclusions

Maternal deaths in Jordan are declining. The maternal mortality ratio of 19.1 deaths per 100 000 live births reported for 2007-2008 showed a remarkable reduction of 53.9% achieved in the 12 years since the 1995-1996 report (a 4.5% annual reduction), which is approaching the 75% reduction recommended by Millennium Development Goal 5.     

Estimation of maternal and neonatal mortality at the subnational level in Liberia

Objective

To establish representative local-area baseline estimates of maternal and neonatal mortality using a novel adjusted sisterhood method.

Methods

The status of maternal and neonatal health in Bomi County, Liberia, was investigated in June 2013 using a population-based survey (n = 1985). The standard direct sisterhood method was modified to account for place and time of maternal death to enable calculation of subnational estimates.

Results

The modified method of measuring maternal mortality successfully enabled the calculation of area-specific estimates. Of 71 reported deaths of sisters, 18 (25.4%) were due to pregnancy-related causes and had occurred in the past 3 years in Bomi County. The estimated maternal mortality ratio was 890 maternal deaths for every 100 000 live births (95% CI, 497–1301]. The neonatal mortality rate was estimated to be 47 deaths for every 1000 live births (95% CI, 42–52). In total, 322 (16.9%) of 1900 women with accurate age data reported having had a stillbirth.

Conclusion

The modified direct sisterhood method may be useful to other countries seeking a more regionally nuanced understanding of areas in which neonatal and maternal mortality levels still need to be reduced to meet Millennium Development Goals.     

Maternal mortality in an urban tertiary care hospital of north India

Objectives

The aims of the study were to help generate information and knowledge regarding the causes and complications leading to maternal deaths (MDs) in an urban tertiary care hospital, to find if any of them are potentially preventable, and to use information thus generated to save lives.

Methods

The medical records of all MDs occurring over a period of 4 years between January 2003 and December 2006 were reviewed and correlated with maternal age, antenatal registration, mode of delivery, parity, admission death interval, and causes of death.

Results

The maternal mortality rate (MMR) ranged between 926 and 377/100,000 births in the study period. The causes of deaths were sepsis 23.84%, eclampsia /pregnancy-induced hypertension 17.69%, hemorrhage 13.84%, hepatitis 13.84%, anemia 13.07%, respiratory infections 8.46%, other indirect obstetrical causes 6.15%, and unrelated causes 4.61%. Maximum deaths (71.53%) occurred in women between 21 and 30 years of age while multigravida had MMR of 51.53%. Mortality was highest in postnatal mothers 63.06%.Unbooked cases constituted 92.31% of MDs and included 25% referred cases.

Conclusion

Overall maternal mortality was 690/100,000. MDs due to direct obstetric causes were 55.38%, indirect obstetric deaths 40%, and unrelated deaths 4.61%. The causes of potentially preventable deaths include deaths due to anemia, sepsis, hemorrhage, DIC, and anesthesia complication, and accounted for 25.38% of all deaths.     

Maternal Mortality and Its Causes in a Tertiary Center

Objectives

To study the maternal mortality and the complications leading to maternal death.

Methods

A retrospective study of hospital records and death summaries of all maternal deaths over the period from January 2000 to August 2009 was carried out.

Results

There were a total of 80 maternal deaths out of 88,443 live births giving maternal mortality rate (MMR) of 90.45 per 100,000 live births. Unbooked and late referral accounted for 77.5 % of maternal deaths. The majority of the deaths was in 30–40-year age group and around term. Hemorrhage was the commonest cause of death (52.5 %), followed by sepsis (13.75 %) and pregnancy-induced hypertension including eclampsia (10 %).

Conclusions

Hemorrhage, sepsis, and pregnancy-induced hypertension including eclampsia were found to be the direct major causes of death. Anemia and cardiac disease were other indirect causes of deaths.     

The joint influence of marital status, interpregnancy interval, and neighborhood on small for gestational age birth: a retrospective cohort study

Background

Birth weight for gestational age is a widely-used proxy for fetal growth. Although the need for different standards for males and females is generally acknowledged, the physiologic vs pathologic nature of ethnic differences in fetal growth is hotly debated and remains unresolved.

Methods

We used all stillbirth, live birth, and deterministically linked infant deaths in British Columbia from 1981 to 2000 to examine fetal growth and perinatal mortality in Chinese (n = 40,092), South Asian (n = 38,670), First Nations, i.e., North American Indian (n = 56,097), and other (n = 731,109) births. We used a new analytic approach based on total fetuses at risk to compare the four ethnic groups in perinatal mortality, mean birth weight, and "revealed" (< 10^th percentile) small-for-gestational age (SGA) among live births based on both a single standard and four ethnic-specific standards.

Results

Despite their lower mean birth weights and higher SGA rates (when based on a single standard), Chinese and South Asian infants had lower perinatal mortality risks throughout gestation. The opposite pattern was observed for First Nations births: higher mean birth weights, lower revealed SGA rates, and higher perinatal mortality risks. When SGA was based on ethnic-specific standards, however, the pattern was concordant with that observed for perinatal mortality.

Conclusion

The concordance of perinatal mortality and SGA rates when based on ethnic-specific standards, and their discordance when based on a single standard, strongly suggests that the observed ethnic differences in fetal growth are physiologic, rather than pathologic, and make a strong case for ethnic-specific standards.     

Evaluation of Severe Maternal Outcomes to Assess Quality of Maternal Health Care at a Tertiary Center

Background

Maternal mortality and near-miss index reflect the quality of care provided by a health facility. The World Health Organization recently published near-miss approach where strict near- miss criteria based on markers of organ dysfunction are defined.

Objectives

The aim of the study was to determine the frequency of severe maternal complications, maternal near-miss cases and maternal deaths, to analyze causes of near-miss and maternal mortality and to determine the values of maternal near-miss indicators.

Methods

This was a prospective observational study conducted at a tertiary care centre in North India from January 2012 – March 2013. WHO's near-miss approach was implemented for evaluation of severe maternal outcomes and to assess the quality of maternal health care.

Results

The number of women attending our facility with severe maternal complications was low (205 in 6,767 live births); as a result maternal near-miss ratio (MNMR) was low; 3.98/1,000 live births; Overall Maternal near-miss mortality ratio (MNM:1MD) was also low, 3.37:1, because of strict criterion of labeling near-miss and delay in referral to the hospital. Hypertensive disorder (37.5 %) was the commonest underlying cause for maternal mortality.

Conclusion

Basic implementation of WHO near-miss approach helped in the systematic identification and evidence-based management of severe maternal complications thereby improving the quality of maternal health in a developing country.

     

Estimating maternal mortality and causes in South Africa: National and provincial levels

Objectives

maternal mortality estimates for South Africa have methodological weaknesses. This study uses the Growth Balance Method to adjust reported household female deaths and pregnancy-related deaths and the relational Gompertz model to adjust reported number of live births and estimate maternal mortality in South Africa at national and provincial level; examines the potential impact of HIV/AIDS prevalence; and investigates the recorded direct causes of maternal mortality.

Design

data from the 2001 Census, 2007 Community Survey and death registrations were utilised. Information on household deaths, including pregnancy-related deaths was collected from the aforementioned census and survey.

Setting

enumerated households in the 2001 Census and a nationally representative sample of 250,348 households in the 2007 Community Survey.

Participants

information about members of households who died in the preceding 12 months was collected, and of these deaths whether there were women aged 15–49 who died while pregnant or within 42 days after childbirth.

Findings

maternal mortality ratio of 764 per 100,000 live births in 2007, ranging from 102 per 100,000 live births in the Western Cape province to 1639 in the Eastern Cape. Maternal infections and parasitic diseases as well as other maternal diseases complicating pregnancy, childbirth and the puerperium are the major causes. The study found a weak correlation between provincial HIVprevalence and maternal mortality ratio.

Conclusion

despite strategies to improve maternal and child health, maternal mortality remains high in South Africa and it is unlikely that the Millennnium Developmemnt Goal of reducing maternal will be achieved.     

Trends in perinatal deaths from 2010 to 2013 in the Guatemalan Western Highlands

Background

While progress has been made in reducing neonatal mortality in Guatemala, stillbirth and maternal mortality rates remain high, especially among the indigenous populations, which have among the highest adverse pregnancy-related mortality rates in Guatemala.

Methods

We conducted a prospective study in the Western Highlands of Guatemala from 2010 through 2013, enrolling women during pregnancy with follow-up through 42-days postpartum. All pregnant women were identified and enrolled by study staff in the clusters in the Chimaltenango region for which we had 4 years of data. Enrolment usually occurred during the antenatal period; women were also visited following delivery and 42-days postpartum to collect outcomes. Measures of antenatal and delivery care were also obtained.

Results

Approximately four thousand women were enrolled annually (3,869 in 2010 to 4,570 in 2013). The stillbirth rate decreased significantly, from 22.0 per 1000 births (95% CI 16.6, 29.0) in 2010 to 16.7 (95% CI 13.5, 20.6) in 2013 (p-value 0.0223). The perinatal mortality rate decreased from 43.9 per 1,000 births (95% CI 36.0, 53.6) to 31.6 (95% CI 27.2, 36.7) (p-value 0.0003). The 28-day neonatal mortality rate decreased from 28.9 per 1000 live births (95% CI 25.2, 33.2) to 21.7 (95% CI 17.5, 26.9), p-value 0.0004. The maternal mortality rate was 134 per 100,000 in 2010 vs. 113 per 100,000 in 2013. Over the same period, hospital birth rates increased from 30.0 to 50.3%.

Conclusions

In a relatively short time period, significant improvements in neonatal, fetal and perinatal mortality were noted in an area of Guatemala with a history of poor pregnancy outcomes. These changes were temporally related to major increases in hospital-based delivery with skilled birth attendants, as well as improvements in the quality of delivery care, neonatal care, and prenatal care.

     

Determinants of perinatal mortality in Nigeria

Objective

To determine risk factors for perinatal mortality among hospital-based deliveries in Nigeria.

Methods

The WHO Global Maternal and Perinatal Health Survey was implemented in Nigeria as a first step in establishing a global system for monitoring maternal and perinatal health. Twenty-one health facilities with more than 1000 deliveries annually were selected by a stratified multistage cluster sampling strategy. Information was recorded on all women who delivered and their neonates within a 3-month period.

Results

Overall, there were 9208 deliveries, comprising 8526 live births, 369 fresh stillbirths, 282 macerated stillbirths, 70 early neonatal deaths, and 721 perinatal deaths. The stillbirth and perinatal mortality rates were, respectively, 71 and 78 per 1000 deliveries; the early neonatal death rate was 8 per 1000 live births. Approximately 10% of all newborns weighed less than 2500 g, and 12.3% were born at less than 37 weeks of gestation. Predictors of perinatal mortality were mother's age, lack of prenatal care, unbooked status, prematurity, and birth asphyxia.

Conclusion

The perinatal mortality rate remains unacceptably high in Nigeria. Fresh stillbirth accounted for most perinatal deaths. Interventions to improve the utilization and quality of prenatal care, in addition to the quality of intrapartum care, would considerably reduce perinatal death.     

Pilot community-mobilization program reduces maternal and perinatal mortality and prevents obstetric fistula in Niger

Objective

To assess the impact of a pilot community-mobilization program on maternal and perinatal mortality and obstetric fistula in Niger.

Methods

In the program, village volunteers identify and evacuate women with protracted labor, provide education, and collect data on pregnancies, births, and deaths. These data were used to calculate the reduction in maternal mortality, perinatal mortality, and obstetric fistula in the program area from July 2008 to June 2011.

Results

The birth-related maternal mortality fell by 73.0% between years 1 and 3 (P < 0.001), from 630 (95% confidence interval [CI] 448–861) to 170 (95% CI 85–305) deaths per 100 000 births. Early perinatal mortality fell by 61.5% (P < 0.001), from 35 (95% CI 31–40) to 13 (95% CI 10–16) deaths per 1000 births. No deaths due to obstructed labor were reported after the lead-in period (February to June 2008). Seven cases of community-acquired fistula were reported between February 2008 and July 2009; from August 2009 to June 2011 (23 months; 12 254 births), no cases were recorded.

Conclusion

Community mobilization helped to prevent obstetric fistula and birth-related deaths of women and infants in a large, remote, resource-poor area.     

Maternal mortality ratio in selected rural communities in Kebbi State,Northwest Nigeria

Background

Maternal mortality remains a topical issue in Nigeria. Dearth of data on vital events posed a huge challenge to policy formulation and design of interventions to address the scourge. This study estimated the lifetime risk (LTR) of maternal death and maternal mortality ratio (MMR) in rural areas of Kebbi State, northwest Nigeria, using the sisterhood method.

Methods

Using the sisterhood method, data was collected from 2917 women aged 15–49?years from randomly selected rural communities in 6 randomly selected local government area of Kebbi State. Retrospective cohort of their female siblings who had reached the childbearing age of 15?years was constructed. Using the most recent total fertility rate for Kebbi State, the lifetime risk and associated MMR were estimated.

Result

A total of 2917 women reported 8233 female siblings of whom 409 had died and of whom 204 (49.8%) were maternal deaths. This corresponds to an LTR of 6% (referring to 11?years before the study) and an estimated MMR of 890 deaths/100,000 live births (95% CI, 504–1281).

Conclusion

The findings provide baseline information on the MMR in rural areas of the State. It underscores the need to urgently address the bane of high maternity mortality, if Kebbi State and Nigeria in general, will achieve the health for all by year 2030 as stated in the Sustainable Development Goals (SDGs).

     

Insights into maternal mortality in Madang Province,Papua New Guinea

Objective

To assess the frequency, causes, and reporting of maternal deaths at a provincial referral hospital in coastal Papua New Guinea (PNG), and to describe delays in care.

Methods

In a structured retrospective review of maternal deaths at Modilon General Hospital, Madang, PNG, registers and case notes for the period January 2008 to July 2012 were analyzed to determine causes, characteristics, and management of maternal death cases. Public databases were assessed for underreporting.

Results

During the review period, there were 64 maternal deaths (institutional maternal mortality ratio, 588 deaths per 100 000 live births). Fifty-two cases were analyzed in detail: 71.2% (n = 37) were direct maternal deaths, and hemorrhage (n = 24, 46.2%) and infection (n = 16, 30.8%) were the leading causes of mortality overall. Women frequently did not attend prenatal clinics (n = 34, 65.4%), resided in rural areas (n = 45, 86.5%), and experienced delays in care (n = 45, 86.5%). Maternal deaths were underreported in public databases.

Conclusion

The burden of maternal mortality was found to be high at a provincial hospital in PNG. Most women died of direct causes and experienced delays in care. Strategies to complement current hospital and national policy to reduce maternal mortality and to improve reporting of deaths are needed.     

Maternal mortality in Denmark, 1985–1994

Objectives

In Denmark, maternal mortality has been reported over the last century, both locally through hospital reports and in national registries. The purpose of this study was to analyze data from national medical registries of pregnancy-related deaths in Denmark 1985–1994 and to classify them according to the UK Confidential Enquiry into Maternal Deaths (CEMD).

Study design

All deaths of women with a registered pregnancy within 12 months prior to the death were identified by comparing the Danish medical registries, death certificates, and relevant codes according to International Classification of Diseases (ICD-10). All cases were classified using the UK CEMD classification. Cases of maternal death were further evaluated by an audit group.

Results

311 cases were classified. 92 deaths (29.6%) occurred ≤42 days after termination of pregnancy. Of these, 30 were classified as direct obstetric deaths, 30 as indirect obstetric deaths, and 32 as fortuitous deaths. Among the late pregnancy-related deaths (>42 days), 1 woman died from a direct obstetric cause, 46 from indirect causes, and 172 from fortuitous causes. Hypertensive disorders of pregnancy were the major cause of direct maternal deaths. The rate of maternal deaths constituted 9.8/100,000 maternities (i.e. the number of women delivering registrable live births at any gestation or stillbirths at 24 weeks of gestation or later).

Conclusion

This is the first systematic report on deaths in Denmark based on data from national registries. The maternal mortality rate in Denmark is comparable to the rates in other developed countries. Fortunately, statistics are low, but each case represents potential learning.Obstetric care has changed and classification methods differ between countries. Prospective registration and registry linkage seem to be a way to ensure completion. This retrospective study has provided the background for a prospective study on registration and evaluation of maternal mortality in Denmark.     

Geographic accessibility to obstetric care and maternal mortality in a large metropolitan area of Brazil

Objective

To assess maternal mortality and its association with accessibility to obstetric care in the metropolitan region of Rio de Janeiro, Brazil.

Methods

Maternal mortality was assessed from 2 national databases, one administrative and the other designed for epidemiologic purposes. Distances traveled from residence to hospital via the transit network were calculated using a specialized information system. Deaths were grouped by area of residence, and maternal mortality ratios (number of deaths per 100,000 live births) as well as death incidence ratios (deaths/live births in 2 regions or hospital types) were calculated for these areas.

Results

We identified 236 deaths and estimated under-reporting at 30%. The most common causes of death were hypertension-related disorders, “other obstetric conditions,” and complications from abortion; the longest traveled distance was 66.43 km (mean, 13.65 km); and maternal mortality ratios varied between 25.54% and 56.45%, the highest values being for areas with the lowest municipal human development index. The highest death incidence ratios were found at general hospitals without specialized obstetric care.

Conclusion

Maternal mortality is still a serious problem in the studied region. The wide variations among areas of different socioeconomic conditions suggest the need for a better allocation of health care resources.     

Maternal mortality in Greece, 1996-2006

Objective

To present retrospective data for maternal deaths in Greece from 1996 to 2006.

Methods

Demographic information and information on the causes of death was provided by the Hellenic Statistical Authority. Maternal deaths were assessed by cause of death, maternal age, and place of residence. The maternal mortality ratio (MMR) was estimated and expressed as the number of deaths per 100 000 live births.

Results

From 1996 to 2006, 29 deaths were attributed to pregnancy and childbirth, yielding a total MMR of 2.63. The leading cause of direct deaths was hemorrhage and that of indirect deaths was cardiac disease. There was a borderline significant decline in the MMR during the study period. The MMR was significantly higher at the extremes of the reproductive age range.

Conclusion

Maternal mortality in Greece is low; however, no formal data have been published since 1996. Knowledge of the causes of maternal death can lead to the prevention of maternal deaths and safer motherhood.