Maternal mortality due to hemorrhage: population-based study in Turkey

Abstract

Objective: The aim of this study was to determine the epidemiological characteristics of maternal mortality due to postpartum hemorrhage, and to investigate whether national preventative measures of the Maternal Mortality Program have been successful in Turkey.

Design: A population-based cohort study.

Setting: Turkish National Maternal Mortality Data collected by the Turkish Ministry of Health.

Participants: Women who died due to hemorrhage during pregnancy or after delivery within the initial 42 days, from 2012 to 2015, throughout Turkey (N?=?812/146).

Main outcome measures: The preventability and problems in each maternal death due to hemorrhage.

Results: A total of 779 maternal deaths were identified during the study period. Our estimate of the Maternal Mortality Ratio (MMR) in the 3-year period was 19.7 per 100,000 live births. Of the 779 deaths, the report listed 411 as direct and 285 as indirect deaths. Direct obstetric complications were the leading causes of maternal deaths, the most common of which was maternal cardiovascular diseases (21%) and obstetric hemorrhage (20.6%).

Conclusion: Improving data surveillance and implementing national guidelines for the prevention and management of major complications of pregnancy, childbirth, and puerperium is necessary to reduce MMR. The healthcare authorities of Turkey should continue to set a sustainable development goal of ≤70 maternal deaths per 100,000 live births by 2030. We believe our results may provide useful information for other developing countries that are aiming to reduce maternal mortality, as well as mobilize global efforts to improve women’s health.     

Maternal and perinatal outcomes of uterine rupture in a tertiary care hospital: a cross-sectional study

Objective: The current study aims to evaluate the incidence, maternal and perinatal outcomes in cases presented with uterine rupture (UR) and to explore the differences in presentation, management and outcome of UR in patients with scarred versus unscarred uterus.

Materials and methods: A cross-sectional study conducted in a tertiary care hospital over a period of 2 years. The study included all women diagnosed with UR and admitted to the emergency unit between January 2016 and December 2017. A structured questionnaire was used to collect the preoperative demographic and clinical data. An observation checklist was used for intraoperative findings and management. Postoperative data were collected about maternal and fetal outcomes. Data were analyzed using SPSS software. Qualitative variables were compared between groups using chi-square test while quantitative variables were compared using the Mann–Whitney test.

Results: Sixty two women were diagnosed with uterine rupture (0.32% of all deliveries). The mean age of the included patients was 29.6?±?5.6 years while the mean parity was 3.0?±?1.8. Uterine repair was successful in 52 cases (83.9%). There were four (6.5%) maternal deaths and 42 (67.8%) perinatal deaths. Ten patients (16.1%) were transferred to the postoperative intensive care unit (ICU). Re-exploration was carried out in three cases. The most common complication of UR was disseminated intravascular coagulopathy (DIC) occurred in eight women (12.9%). Maternal and perinatal mortality were significantly higher in patients with unscarred uterus (p?=?.0001 and .026, respectively).

Conclusions: The incidence of UR is 32/10,000 deliveries in our tertiary hospital. Rupture of unscarred uterus is associated with more maternal and fetal mortality. However, rupture of scarred uterus was more common due to the rising rate of cesarean sections.     

How many maternal deaths are there in Portugal?

Introduction: Maternal mortality is a public health issue, internationally considered an indicator of women’s status in society, indirectly translating access to health facilities. However, it is difficult to measure and is usually underestimated by official records. Methods: Maternal deaths missed by the official statistics in Portugal between 2001 and 2006 were estimated by multiple-recapture methods using three different data sources. An upper limit to the number of deaths was derived from the application of the mortality function of women in reproductive age to the estimated annual number of pregnancies. Results: Maternal mortality decreased from 40 to less than 10 deaths per 100?000 live births between 1978 and 1986. Between 2001 and 2006, it varied from 2.5 to 19 and was underestimated by 9%–26%. Nevertheless, within the same age range, the risk of a pregnant women to die was four times less than a women in the general population. Conclusion: Like in other developed countries, official statistics in Portugal have systematically underestimated maternal deaths. These deaths are a rare event, but the consistent increase in the average age at pregnancy may exacerbate the main causes of death, raising concerns for the future and prompting the need for emergency facilities nearby maternities.     

Effects of family conversation on health care practices in Ethiopia: a propensity score matched analysis

Background

Maternal and newborn mortality rates in Ethiopia are among the highest in sub-Saharan Africa. The majority of deaths take place during childbirth or within the following 48 h. Therefore, ensuring facility deliveries with emergency obstetric and newborn care services available and immediate postnatal follow-up are key strategies to increase survival. In early 2014, the Family Conversation was implemented in 115 rural districts in Ethiopia, covering about 17 million people. It aimed to reduce maternal and newborn mortality by promoting institutional delivery, early postnatal care and immediate newborn care practices. More than 6000 Health Extension Workers were trained to initiate home-based Family Conversations with pregnant women and key household decision-makers. These conversations included discussions on birth preparedness, postpartum and newborn care needs to engage key household stakeholders in supporting women during their pregnancy, labor and postpartum periods. This paper examines the effects of the Family Conversation strategy on maternal and neonatal care practices.

Methods

We used cross-sectional data from a representative sample of 4684 women with children aged 0–11 months from 115 districts collected between December 2014 and January 2015. We compared intrapartum and newborn care practices related to the most recent childbirth, between those who reported having participated in a Family Conversation during pregnancy, and those who had not. Propensity score matched analysis was used to estimate average treatment effects of the Family Conversation strategy on intrapartum and newborn care practices, including institutional delivery, early postnatal and immediate breastfeeding.

Results

About 17% of the respondents reported having had a Family Conversation during their last pregnancy. Average treatment effects of 7, 12, 9 and 16 percentage-points respectively were found for institutional deliveries, early postnatal care, clean cord care and thermal care of the newborn (p < 0.05).

Conclusion

We found evidence that Family Conversation, and specifically the involvement of household members who were major decision-makers, was associated with better intrapartum and newborn care practices. This study adds to the evidence base that involving husbands and mothers-in-law, as well as pregnant women, in behavior change communication interventions could be critical for improving maternal and newborn care and therewith lowering mortality rates.

     

Maternal deaths: initial report of an on-going monitoring of maternal deaths at the Federal Medical Centre Katsina,Northwest Nigeria

Abstract

Objectives: To assess the maternal mortality ratio (MMR) from data collected as maternal deaths occurred over a 4-year period.

Methods: A Departmental database established in 2008 was used to keep data on deliveries and maternal deaths as they occurred. The causes of death were decided after a meeting reviewed the case. Analysis was done using Microsoft Excel software and results presented in means and frequencies.

Results: Eight thousand two hundred and twenty live deliveries that occurred were complicated by 68 maternal deaths. The MMR was 827/100?000 live births. The MMR for unbooked women was four times higher than for booked women. Obstetric haemorrhage was the main (21.6%) direct cause of death followed by preeclampsia/eclampsia (18.9%). While anaemia was the leading (8.1%) indirect cause of death, tetanus in the puerperium reared its head as an emerging (5.4%) indirect cause of maternal death. None of the women ever used contraceptives. Most deaths occurred in teenage mothers (23.5%), unbooked women (86%) and in the postpartum period (69%).

Conclusion: The MMR was high and tetanus in puerperium emerged as an indirect cause of maternal deaths. There is a need to curb the emergence of tetanus in the puerperium as a cause of maternal death.     

A ten-year retrospective review of maternal cardiac arrest: Incidence,characteristics, causes,and outcomes in a tertiary-care hospital in a developing country

ObjectiveMaternal cardiac arrest is rare. We retrospectively reviewed and reported (1) the incidence of maternal cardiac arrests during admissions for delivery; (2) the characteristics and causes of cardiac arrest; and (3) the mortality rate and outcomes in a referral, single-university, teaching hospital in Thailand.Materials and methodsData on 23 cardiac arrests during admissions for delivery in the decade January 2006–December 2015 were retrospectively chart-reviewed. Patients with gestational ages under 24 weeks or cardiac arrests and death occurring before hospital arrival were excluded. The clinical characteristics of the arrests and outcomes were collected.ResultsOf 89,368 deliveries during the decade, 23 women suffered cardiac arrest (incidence, 1:3885), with 3 of those arrests occurring before delivery (incidence, 1:29,789). One patient underwent a perimortem cesarean delivery in the operating theatre. The most common reasons for the arrests were hypertension during pregnancy and cardiovascular causes (30.4% and 21.7%, respectively). Amniotic fluid embolisms were suspected for 2 patients (8.7%) with unidentified causes. The incidence of maternal deaths in peripartum cardiac arrests was 20/23, representing 86.9% (95% CI, 67.9–95.5) or 1:4468 of deliveries. Three patients suffering cardiac arrests after delivery survived to discharge.ConclusionsWe found a high maternal mortality rate following cardiac arrests during hospitalization for delivery. To decrease the incidence of arrests during the peripartum period and diminish the maternal mortality rate, identification of the causes and precipitating factors is vital. High-risk pregnant women require multidisciplinary care to improve the survival-to-discharge rate.     

Maternal mortality in Pernambuco, Brazil: what has changed in ten years?

This study examines changes in levels and patterns of maternal mortality in Pernambuco, Brazil, in 1994 and 2003. The research was carried out in five sub-regions of Pernambuco using the Reproductive Age Mortality Survey (RAMOS) method and based on death certificates of women of reproductive age registered in the local System of Information on Mortality. In-depth interviews with family members were also conducted for the abortion-related deaths. Of the 1,258 female deaths investigated, 54 maternal deaths were identified, corresponding to a maternal mortality ratio of 77 per 100,000 live births. The estimated level of under-reporting (46%) corresponds to an upward adjustment factor of 1.9. The illegal status of abortion in Brazil remains an important contributory factor for the abortion-related deaths. Approximately 94% of the maternal deaths were judged to be avoidable with improvements in health care. Maternal mortality declined by 30% over the ten-year period but the level of misclassification of maternal deaths remains. Improvements in maternity care for women and reporting of maternal deaths are still urgently needed.     

Maternal mortality from cardiac disease in Turkey: a population-based study

Objective: Population-based studies on maternal deaths in Turkey are rare. The aim of the present study was to analyze the cardiac causes of all maternal deaths in Turkey between 2007 and 2009. Materials and methods: In this retrospective study, case files of all pregnancy-associated deaths recorded in Turkey between 2007 and 2009 were reviewed. Records for all pregnancy-associated deaths were reviewed by five authors to identify 129 cases in which a cardiac disease seemed to be the reason. For each of the 129 cases, maternal age, gravidity, parity, antenatal care attendance, district of residence, year of death, mode of delivery, perinatal outcome, and clinical history preceding death were recorded. Results: During the study period, 779 maternal deaths were identified. Our estimate of the maternal mortality ratio (MMR) in 3-year period was 19.7 per 100,000 live births. The report lists 779 deaths, 411 direct and 285 indirect. Indirect obstetric causes of maternal death were primarily cardiac disorders and cerebrovascular diseases. Maternal mortality due to cardiac disease was 15.5% in 2007 and 18.4% in 2008. Valvular heart disease was the leading cause of maternal death from cardiac reasons (25.6%). Maternal mortality due to cardiac disease increased with age. Conclusion: The main cause of indirect maternal death has been cardiac disease in 3-year period.     

Maternal mortality in the United States: report from the Maternal Mortality Collaborative

To better define the incidence, causes, and risk factors associated with maternal deaths, the Maternal Mortality Collaborative in 1983 initiated national voluntary surveillance of maternal mortality. The Maternal Mortality Collaborative reported 601 maternal deaths from 19 reporting areas for 1980-1985, representing a maternal mortality ratio of 14.1 per 100,000 live births. Overall, 37% more maternal deaths were reported by the Maternal Mortality Collaborative than by the National Center for Health Statistics for these reporting areas. Older women and women of black and other races continued to have higher mortality than younger women and white women. The five most common causes of death for all reported cases were embolism, nonobstetric injuries, hypertensive disease of pregnancy, ectopic pregnancy, and obstetric hemorrhage. Compared with national maternal mortality for 1974-1978, ratios were lower for all causes except for indirect causes, anesthesia, and cerebrovascular accidents. Fatal injuries among pregnant women are not commonly reported to maternal mortality committees. As maternal mortality from direct obstetric causes continues to decline, clinicians will need to emphasize preventing deaths from nonobstetric causes.     

Maternal mortality and maternity care from 1990 to 2005: uneven but important gains

Maternal mortality continues to be the major cause of death among women of reproductive age in many countries. Data from published studies and Demographic and Health Surveys show that gains in reducing maternal mortality between 1990 and 2005 have been modest overall. In 2005, there were about 536,000 maternal deaths, and the maternal mortality ratio was estimated at 400 per 100,000 live births, compared to 430 in 1990. Noteworthy declines took place in east Asia (4% per year) and north Africa (3% per year). Maternal deaths and mortality ratios were highest in sub-Saharan Africa and southeast Asia and low in east Asia and Latin America/Caribbean. In 11 of 53 countries with data, fewer than 25% of women had had at least four antenatal visits. About 63% of births were attended by a skilled attendant: from 47% in Africa to 88% in Latin America/Caribbean. In 16 of 23 countries with data, less than 50% of the recommended levels of emergency obstetric care had been fulfilled. Only 61% of women who delivered in a health facility in 30 developing countries received post-partum care, and far fewer who gave birth at home. Countries with maternal mortality ratios of 750+ per 100,000 live births shared problems of high fertility and unplanned pregnancies, poor health infrastructure with limited resources and low availability of health personnel. The task ahead is enormous.     

Maternal health-related behaviours during pregnancy: a critical public health issue

Aim: The aim of the study was to investigate the health-related behaviours of pregnant women. Maternal health-related habits, use of psychoactive medicines, diet, prevention of neural tube defects, oral cavity hygiene, chronic diseases and physical activity were analysed in a group of pregnant women attending antenatal classes.

Methods: Hundred pregnant women recruited from various antenatal classes in Poznań, Poland, were investigated using a questionnaire based on the Pregnancy Risk Assessment Monitoring System.

Results: The results showed that 29% of pregnancies were unplanned. In women with higher education, 62% reported that they were taking folic acid supplements during pregnancy, in contrast with 35% women with a lower level of education (p?=?.012). The study showed that 24% of women were exposed to second-hand smoke during pregnancy, and this was more common among younger study participants (p?=?.038). Nine percentage of women admitted drinking alcohol during pregnancy. Pre-pregnancy alcohol consumption was more frequent among women with higher education (p?=?.011). Only 46.7% of women informed their dentist about their pregnancy, and these were more often older participants (p?=?.023).

Conclusion: The study found low maternal awareness regarding health-related behaviours, which presents a serious challenge to public health care in Poland. Pregnant women and those who wish to conceive need to be educated effectively about preventive measures in order to maintain optimal maternal and reproductive health, as well as normal fetal development.     

Trends in maternal mortality over 29 years in a Kuwait Tertiary Teaching Hospital: signs of progress?

This study aims at (1) Assessing trends in maternal mortality in kuwait (2) Define strategies for prevention. Methods: Retrospective analysis of maternal deaths that occurred among, 55,979 live births at a tertiary hospital, between 1980 and 2009. Results: There were 14 maternal deaths, and 55,979 live births, giving a maternal mortality rate of 25 per 100,000 live birth. In terms of decades maternal mortality declined from 54.8 in 1980–90 to 28.4 in 1990–2000 and continued to decline to 12.2 in 2000–2009. Thromboembolism (28.6%), Obstetric haemorrhage (21.5%) and Eclampsia (14.3%) were the leading causes of direct deaths. Cardiac disease is the most common cause of indirect deaths (14.3%) followed by H1N1 pneumonia 7.1%. Eclampsia contributed to 40% of deaths, only in the 1980s. Thromboembolism caused 28.6% of deaths, 50% of which were in the last 9 years. Indirect deaths from cardiomyopathies (66.7%) gained prominence in the 1990s. No deaths from puerperal sepsis were reported after the 1980s (14.3%). Conclusions: Maternal mortality rates are decreasing significantly (p?<?0.01) at our institution over the last 29 years. Obstetric haemorrhage and thromboembolism remain important causes of maternal mortality. Substandard care was identified in 70% of Direct and 55% of indirect deaths.     

Maternal asthma: pregnancy course and outcome

Objective: To evaluate the association between maternal asthma and perinatal outcome.

Study design: In this retrospective population-based cohort study, all pregnancies between 1991 and 2014 in a tertiary medical center, were included. Multiple pregnancies and congenital malformations were excluded. Pregnancy course and outcomes were compared between women with and without asthma, and multivariable generalized estimating equations were used to control for confounders.

Results: During the study period, 243,363 deliveries met the inclusion criteria, 1.35% of which (n?=?3283) occurred in women diagnosed with asthma. Multiple perinatal complications were found to be associated with maternal asthma, including hypertensive disorders, preterm delivery, and cesarean delivery. However, no significant differences between the groups were noted in neonatal outcomes, including perinatal mortality rates and low Apgar scores. In the regression model, maternal asthma was noted as an independent risk factor for preterm delivery, hypertensive disorders of pregnancy, and cesarean delivery (aOR?=?1.21, 95%CI 1.1–1.4, p?=?.007; aOR?=?1.35, 95%CI 1.2–1.6, p?p?Conclusions: Maternal asthma is associated with an increased risk for adverse pregnancy outcome. This association remains significant while controlling for variables considered to coexist with maternal asthma. Nevertheless, perinatal outcome is generally favorable.