Maternal death

Maternal death or maternal mortality is defined by the World Health Organization (WHO) as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes."[1][2]

Maternal death
Other namesMaternal mortality
A mother dies and is taken by angels as her new-born child is taken away, A grave from 1863 in Striesener Friedhof in Dresden.
SpecialtyObstetrics 

Adding to the WHO definition, the CDC extends the period of consideration to include up to 1 year within the end of a pregnancy regardless of the outcome.[3]

There are two performance indicators that are sometimes used interchangeably: maternal mortality ratio and maternal mortality rate, which confusingly both are abbreviated "MMR".[4] By 2017, the world maternal mortality rate had declined 44% since 1990, but still every day 830 women die from pregnancy or childbirth related causes.[5] According to the United Nations Population Fund (UNFPA) 2017 report, this is equivalent to "about one woman every two minutes and for every woman who dies, 20 or 30 encounter complications with serious or long-lasting consequences. Most of these deaths and injuries are entirely preventable."[5]

UNFPA estimated that 303,000 women died of pregnancy or childbirth related causes in 2015.[5] These causes range from severe bleeding to obstructed labour,[6] for which there are highly effective interventions. As women have gained access to family planning and skilled birth attendance 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, and many countries halved their maternal death rates in the last 10 years.[5]

Although attempts have been made in reducing maternal mortality, there is much room for improvement, particularly in impoverished regions. Over 85% of maternal deaths are from impoverished communities in Africa and Asia.[5] The effect of a mother's death results in vulnerable families. Their infants, if they survive childbirth, are more likely to die before reaching their second birthday.[5]

Causes

Factors that increase maternal death can be direct or indirect. In a 2009 article on maternal morbidity, the authors said, that generally, there is a distinction between a direct maternal death that is the result of a complication of the pregnancy, delivery, or management of the two, and an indirect maternal death,[7] that is a pregnancy-related death in a patient with a preexisting or newly developed health problem unrelated to pregnancy. Fatalities during but unrelated to a pregnancy are termed accidental, incidental, or nonobstetrical maternal deaths.

According to a study published in the Lancet which covered the period from 1990 to 2013, the most common causes are postpartum bleeding (15%), complications from unsafe abortion (15%), hypertensive disorders of pregnancy (10%), postpartum infections (8%), and obstructed labour (6%).[6] Other causes include blood clots (3%) and pre-existing conditions (28%).[8] Maternal mortality caused by severe bleeding and infections are mostly after childbirth. Indirect causes are malaria, anaemia,[9] HIV/AIDS, and cardiovascular disease, all of which may complicate pregnancy or be aggravated by it.[10] 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.[11][12]

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:[3] cardiovascular diseases (15.2%.), non-cardiovascular diseases (14.7%), infection or sepsis (12.8%), hemorrhage (11.5%), cardiomyopathy (10.3%), thrombotic pulmonary embolism (9.1%), cerebrovascular accidents (7.4%), hypertensive disorders of pregnancy (6.8%), amniotic fluid embolism (5.5%), and anesthesia complications (0.3%).

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,[13] especially adolescents aged 15 years or younger.[14] Adolescents have higher risks for postpartum hemorrhage, puerperal endometritis, operative vaginal delivery, episiotomy, low birth weight, preterm delivery, and small-for-gestational-age infants, all of which can lead to maternal death.[14] 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 fifteen-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.[13] However, in the United States, as many women of older age continue to have children, trends have seen the maternal mortality rate to rise in some states, especially among women over 40 years old.[11]

Structural support and family support influences maternal outcomes.[15] Furthermore, social disadvantage and social isolation adversely affects maternal health which can lead to increases in maternal death.[16] 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.

Unsafe abortion

Unsafe abortion is another major cause of maternal death. According to the World Health Organization in 2009, every eight minutes a woman died from complications arising from unsafe abortions. Unsafe abortion practices include drinking toxic fluids such as turpentine or bleach, More physical methods include physical injury to the female genitalia. Complications include hemorrhage, infection, sepsis and genital trauma.[17]

By 2007, globally, preventable deaths from improperly performed procedures constitute 13% of maternal mortality, and 25% or more in some countries where maternal mortality from other causes is relatively low, making unsafe abortion the leading single cause of maternal mortality worldwide.[18]

Abortions are more common in developed regions than developing regions of the world. It is estimated that 26% of all pregnancies that occur in the world are terminated by induced abortions. Out of these, 41% occur in developed regions and 23% of them occur in developing regions.[18]

Unsafe abortion practices are defined by the WHO as procedures that are “carried out by persons either lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both."[18][19] 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. Also, 97% of these unsafe abortions occur in developing countries.[18][20]

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]

Associated Factors

Social factors impact a woman's decision to seek abortion services, and 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.[20]

Rates

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.[20]

There are four primary types of data sources that are used to collect abortion-related maternal mortality rates. These four sources are 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 lay-people and not medical professionals.[21]

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 30-50% of all maternal deaths.[21] 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.[21] 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.[21]

Prevention

Providing safe services for pregnant women within family planning facilities is applicable to all regions. This is an important fact to consider since abortion is legal in some way in 189 out of 193 countries worldwide.[20] Promoting effective contraceptive use and information distributed to a wider population, with access to high-quality care, can significantly make strides towards reducing the number of unsafe abortions. Reproductive education and health for women should also be incorporated in schools. For nations that allow contraceptives, programs should be instituted to allow the easier accessibility of these medications.[17] However, this alone will not eliminate the demand for safe services.[22]

Three delays model

The three delays model addresses three critical factors that inhibit women from receiving appropriate maternal health care.[23] These factors include:

  1. Delay in seeking care
  2. Delay in reaching care
  3. Delay in receiving adequate and appropriate care[24]

Delays in seeking care are due to the decisions made by the women who are pregnant and/or other decision-making individuals. Decision-making individuals can include the woman's spouse and family members.[24] Examples of reasons for delays in seeking care include lack of knowledge about when to seek care, inability to afford health care, and women needing permission from family members.[23][24]

Delays in reaching care include factors such as limitations in transportation to a medical facility, lack of adequate medical facilities in the area, and lack in confidence in medicine.[25]

Delays in receiving adequate and appropriate care may result from an inadequate number of trained providers, lack of appropriate supplies, and the lack of urgency or understanding of an emergency.[23][24]

The three delays model illustrates that there are a multitude of complex factors, both socioeconomic and cultural, that can result in maternal death.[23]

Measurement

The four measures of maternal death are the maternal mortality ratio (MMR), maternal mortality rate, lifetime risk of maternal death and proportion of maternal deaths among deaths of women of reproductive years (PM).

Maternal mortality ratio (MMR): the ratio of the number of maternal deaths during a given time period per 100,000 live births during the same time-period.[26] The MMR is used as a measure of the quality of a health care system.

Maternal mortality rate (MMRate): the number of maternal deaths in a population divided by the number of women of reproductive age, usually expressed per 1,000 women.[26]

Lifetime risk of maternal death: a calculated prediction of a woman's risk of death after each consecutive pregnancy.[27] The calculation pertains to women during their reproductive years.[27] The adult lifetime risk of maternal mortality can be derived using either the maternal mortality ratio (MMR), or the maternal mortality rate (MMRate).[26]

Proportion of maternal deaths among deaths of women of reproductive age (PM): the number of maternal deaths in a given time period divided by the total deaths among women aged 15–49 years.[28]

Approaches to measuring maternal mortality includes civil registration system, household surveys, census, reproductive age mortality studies (RAMOS) and verbal autopsies.[28]

The United Nations Population Fund (UNFPA; formerly known as the United Nations Fund for Population Activities) have established programs that support efforts in reducing maternal death. These efforts include education and training for midwives, supporting access to emergency services in obstetric and newborn care networks, and providing essential drugs and family planning services to pregnant women or those planning to become pregnant.[5] They also support efforts for review and response systems regarding maternal deaths.

According to the 2010 United Nations Population Fund report, developing nations account for ninety-nine percent of maternal deaths with the majority of those deaths occurring in Sub-Saharan Africa and Southern Asia.[28] Globally, high and middle income countries experience lower maternal deaths than low income countries. The Human Development Index (HDI) accounts for between 82 and 85 percent of the maternal mortality rates among countries.[29] In most cases, high rates of maternal deaths occur in the same countries that have high rates of infant mortality. These trends are a reflection that higher income countries have stronger healthcare infrastructure, medical and healthcare personnel, use more advanced medical technologies and have fewer barriers to accessing care than low income countries. Therefore, in low income countries, the most common cause of maternal death is obstetrical hemorrhage, followed by hypertensive disorders of pregnancy, in contrast to high income countries, for which the most common cause is thromboembolism.[30]

Between 1990 and 2015, the maternal mortality ratio has decreased from 385 deaths per 100,000 live births to 216 maternal deaths per 100,000 live births.[5][31]

Some factors that have attributed to the decreased maternal deaths seen between this period are in part to the access that women have gained to family planning services and skilled birth attendance, meaning a midwife, doctor, or trained nurse), with back-up obstetric care for emergency situations that may occur during the process of labor.[5] This can be examined further by looking at statistics in some areas of the world where inequities in women's access to health care services reflect an increased number of maternal deaths. The high maternal death rates also reflect access to health services between the poor communities compared to women who are rich.[13]

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 . 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.[28] 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.[32]

Until the early 20th century developed and developing countries had similar rates of maternal mortality.[33] Since most maternal deaths and injuries are preventable,[12] 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.[2]: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.[34] 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.[35] 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.[5]

The WHO has also developed a global strategy and goal to end preventable death related to maternal mortality.[13] 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

There are significant maternal mortality intracountry 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[36] 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.[37] There are also racial and ethnic disparities in maternal health outcomes which increases maternal mortality in marginalized groups.[38]

United States

Main article: Maternal mortality in the United States

The US has the "highest rate of maternal mortality in the industrialized world."[39] In the United States, the maternal death rate averaged 9.1 maternal deaths per 100,000 live births during the years 1979–1986,[40] but then rose rapidly to 14 per 100,000 in 2000 and 17.8 per 100,000 in 2009.[3] In 2013 the rate was 18.5 deaths per 100,000 live births.[41] It has been suggested that the rise in maternal death in the United States may be due to improved identification and misclassification resulting in false positives.[42] The rate has steadily increased to 18.0 deaths per 100,000 live births in 2014.[3] Between 2011 and 2014, there were 7,208 deaths that were reported to the CDC that occurred for women within a year of the end of their pregnancy. Out of this there were 2,726 that were found to be pregnancy-related deaths.[3]

Since 2016, ProPublica and NPR investigated factors that led to the increase in maternal mortality in the United States. They reported that the "rate of life-threatening complications for new mothers in the U.S. has more than doubled in two decades due to pre-existing conditions, medical errors and unequal access to care."[39] According to the Centers for Disease Control and Prevention, c. 4 million women who give birth in the US annually, over 50,000 a year, experience "dangerous and even life-threatening complications."[39]

According to a report by the United States Centers for Disease Control and Prevention, in 1993 the rate of Severe Maternal Morbidity, rose from 49.5 to 144 "per 10,000 delivery hospitalizations" in 2014, an increase of almost 200 percent. Blood transfusions also increased during the same period with "from 24.5 in 1993 to 122.3 in 2014 and are considered to be the major driver of the increase in SMM. After excluding blood transfusions, the rate of SMM increased by about 20% over time, from 28.6 in 1993 to 35.0 in 2014."[43]

The past 60 years have consistently shown considerable racial disparities in pregnancy-related deaths. Between 2011 and 2014, the mortality ratio for different racial populations based on pregnancy-related deaths were as follows: 12.4 deaths per 100,000 live births for white women, 40.0 for black women, and 17.8 for women of other races.[44] This shows that black women have between three and four times greater chance of dying from pregnancy-related issues. It has also been shown that one of the major contributors to maternal health disparities within the United States is the growing rate of non-communicable diseases.[44] In addition, women of color have not received equal access to healthcare professionals and equal treatment by those professionals.[45]

“Black women’s poor reproductive outcomes are often seen as a women’s personal failure. For example, Black women’s adverse birth outcomes are typically discussed in terms of what the women do, such as drinking alcohol, smoking, and having less than optimal eating habits that lead to obesity and hypertension. They may be seen to be at risk based on the presumption that they are ‘single,’ when in fact they have a partner- but are unmarried.”.[46] Black women in the United States are dying at higher rates than white women in the United States. The United States has one of the worst maternal mortality rates despite it being a developed nation.[47] The health care system in the United States is flawed by a systematic bias against people of color dating back to centuries of oppression and racism dating back to slavery.[48]

It is unclear why pregnancy-related deaths in the United States have increased. It seems that the use of computerized data servers by the states and changes in the way deaths are coded, with a pregnancy checkbox added to death certificates in many states, have been shown to improve the identification of these pregnancy-related deaths. However, this does not contribute to decreasing the actual number of deaths. Also, errors in reporting of pregnancy status have been seen, which most likely leads to overestimation of the number of pregnancy-related deaths.[3] Again, this does not contribute to explaining why the death rate has increased, but does show complications between reporting and actual contributions to the overall rate of maternal mortality.[44]

Even though 99% of births in the United States are attended by some form of skilled health professional, the maternal mortality ratio in 2015 was 14 deaths per 100,000 live births[5] and it has been shown that the maternal mortality rate has been increasing. Also, the United States is not as efficient at preventing pregnancy-related deaths when compared to most of the other developed nations.[44]

The United States took part in the Millennium Development Goals (MDGs) set forth from the United Nations. The MDGs ended in 2015 but were followed-up in the form of the Sustainable Development Goals starting in 2016. The MDGs had several tasks, one of which was to improve maternal mortality rates globally. Despite their participation in this program as well as spending more than any other country on hospital-based maternal care, however, the United States has still seen increased rates of maternal mortality. This increased maternal mortality rate was especially pronounced in relation to other countries who participated in the program, where during the same period, the global maternal mortality rate decreased by 44%.[44] Also, the United States is not currently on track to meet the Healthy People 2020 goal of decreasing maternal mortality by 10% by the year 2020, and continues to fail in meeting national goals in maternal death reduction.[44] Only 23 states have some form of policy that establishes review boards specific to maternal mortality as of the year 2010.[44]

In an effort to respond to the maternal mortality rate in the United States, the CDC requests that the 52 reporting regions (all states and New York City and Washington DC) to send death certificates for all those women who have died and may fit their definition of a pregnancy-related death, as well as copies of the matching birth or death records for the infant.[3] However, this request is voluntary and some states may not have the ability to abide by this effort.

The Affordable Care Act (ACA) provided additional access to maternity care by expanding opportunities to obtain health insurance for the uninsured and mandating that certain health benefits have coverage. It also expanded the coverage for women who have private insurance. This expansion allowed them better access to primary and preventative health care services, including for screening and management of chronic diseases. An additional benefit for family planning services was the requirement that most insurance plans cover contraception without cost sharing. However, more employers are able to claim exemptions for religious or moral reasons under the current administration. Also under the current administration, the Department of Health and Human Services (HHS) has decreased funding for pregnancy prevention programs for adolescent girls.[11]

Those women covered under Medicaid are covered when they receive prenatal care, care received during childbirth, and postpartum care. These services are provided to nearly half of the women who give birth in the United States. Currently, Medicaid is required to provide coverage for women whose incomes are at 133% of the federal poverty level in the United States.[11]

Prevention

The death rate for women giving birth plummeted in the twentieth century. During the Georgian era the average level of maternal deaths was around 1 in 100 births.[49] Mortality rates reached very high levels in maternity institutions in the 1800s, sometimes climbing to 40 percent of patients (see Historical mortality rates of puerperal fever). At the beginning of the 1900s, maternal death rates were around 1 in 100 for live births.[50] Public health, technological and policy approaches are steps that can be taken to drastically reduce the global maternal death burden. For developing regions, where it has been shown that maternal mortality is greater than in developed nations, antenatal care has increased from 65% in 1990 to 83% in 2012.[35]

It was estimated that in 2015, a total of 303,000 women died due to causes related to pregnancy or childbirth.[5] The majority of these causes were either severe bleeding, sepsis, eclampsia, labor that had some type of obstruction, and consequences from unsafe abortions. All of these causes are either preventable or have highly effective interventions.[5] Another factor that contributes to the maternal mortality rate that have opportunities for prevention are access to prenatal care for women who are pregnant. Women who do not receive prenatal care are between three and four times more likely to die from complications resulting from pregnancy or delivery than those who receive prenatal care. For women in the United States, 25% do not receive the recommended number of prenatal visits, and this number increases for women among specific demographic populations: 32% for African American women and 41% for American Indian and Alaska Native women.[44]

Four elements are essential to maternal death prevention, according to UNFPA.[5] First, prenatal care. It is recommended that expectant mothers receive at least four antenatal visits to check and monitor the health of mother and fetus. Second, skilled birth attendance with emergency backup such as doctors, nurses and midwives who have the skills to manage normal deliveries and recognize the onset of complications. Third, emergency obstetric care to address the major causes of maternal death which are hemorrhage, sepsis, unsafe abortion, hypertensive disorders and obstructed labour. Lastly, postnatal care which is the six weeks following delivery. During this time, bleeding, sepsis and hypertensive disorders can occur, and newborns are extremely vulnerable in the immediate aftermath of birth. Therefore, follow-up visits by a health worker to assess the health of both mother and child in the postnatal period is strongly recommended.

Women who have unwanted pregnancies who have access to reliable information as well as compassionate counseling and quality services for the management of any issues that arise from abortions (whether safe or unsafe) can be beneficial in reducing the number of maternal deaths.[18] Also, in regions where abortion is not against the law, then abortion practices need to be safe in order to effectively reduce the number of maternal deaths related to abortion.

Maternal Death Surveillance and Response is another strategy that has been used to prevent maternal death. This is one of the interventions proposed to reduce maternal mortality where maternal deaths are continuously reviewed to learn the causes and factors that led to the death. The information from the reviews is used to make recommendations for action to prevent future similar deaths.[51] Maternal and perinatal death reviews have been in practice for a long time worldwide, and the World Health Organization (WHO) introduced the Maternal and Perinatal Death Surveillance and Response (MPDSR) with a guideline in 2013. Studies have shown that acting on recommendations from MPDSR can reduce maternal and perinatal mortality by improving quality of care in the community and health facilities.

Medical technologies

The decline in maternal deaths has been due largely to improved aseptic techniques, better fluid management and quicker access to blood transfusions, and better prenatal care.

Technologies have been designed for resource poor settings that have been effective in reducing maternal deaths as well. The non-pneumatic anti-shock garment is a low-technology pressure device that decreases blood loss, restores vital signs and helps buy time in delay of women receiving adequate emergency care during obstetric hemorrhage.[52] It has proven to be a valuable resource. Condoms used as uterine tamponades have also been effective in stopping post-partum hemorrhage.[53]

Medications

Some maternal deaths can be prevented through medication use. Injectable oxytocin can be used to prevent death due to postpartum bleeding.[8] Additionally, postpartum infections can be treated using antibiotics. In fact, the use of broad-spectrum antibiotics both for the prevention and treatment of maternal infection is common in low-income countries.[54] Maternal death due to eclampsia can also be prevented through the use of medications such as magnesium sulfate.[8]

Public health
In April 2010 Sierra Leone launched free healthcare for pregnant and breastfeeding women

A public health approach to addressing maternal mortality includes gathering information on the scope of the problem, identifying key causes, and implementing interventions, both prior to pregnancy and during pregnancy, to combat those causes.[55]

Public health has a role to play in the analysis of maternal death. One important aspect in the review of maternal death and its causes are Maternal Mortality Review Committees or Boards. The goal of these review committees are to analyze each maternal death and determine its cause. After this analysis, the information can be combined in order to determine specific interventions that could lead to preventing future maternal deaths. These review boards are generally comprehensive in their analysis of maternal deaths, examining details that include mental health factors, public transportation, chronic illnesses, and substance use disorders. All of this information can be combined to give a detailed picture of what is causing maternal mortality and help to determine recommendations to reduce their impact.[56]

Many states within the US are taking Maternal Mortality Review Committees a step further and are collaborating with various professional organizations to improve quality of perinatal care. These teams of organizations form a "perinatal quality collaborative," or PQC, and include state health departments, the state hospital association and clinical professionals such as doctors and nurses. These PQCs can also involve community health organizations, Medicaid representatives, Maternal Mortality Review Committees and patient advocacy groups. By involving all of these major players within maternal health, the goal is to collaborate and determine opportunities to improve quality of care. Through this collaborative effort, PQCs can aim to make impacts on quality both at the direct patient care level and through larger system devices like policy. It is thought that the institution of PQCs in California was the main contributor to the maternal mortality rate decreasing by 50% in the years following. The PQC developed review guides and quality improvement initiatives aimed at the most preventable and prevalent maternal deaths: those due to bleeding and high blood pressure. Success has also been observed with PQCs in Illinois and Florida.[57]

Several interventions prior to pregnancy have been recommended in efforts to reduce maternal mortality. Increasing access to reproductive healthcare services, such as family planning services and safe abortion practices, is recommended in order to prevent unintended pregnancies.[55] Several countries, including India, Brazil, and Mexico, have seen some success in efforts to promote the use of reproductive healthcare services.[58] Other interventions include high quality sex education, which includes pregnancy prevention and sexually-transmitted infection (STI) prevention and treatment. By addressing STIs, this not only reduces perinatal infections, but can also help reduce ectopic pregnancy caused by STIs.[59] Adolescents are between two and five times more likely to suffer from maternal mortality than a female twenty years or older. Access to reproductive services and sex education could make a large impact, specifically on adolescents, who are generally uneducated in regards to carrying a healthy pregnancy. Education level is a strong predictor of maternal health as it gives women the knowledge to seek care when it is needed.[55] Public health efforts can also intervene during pregnancy to improve maternal outcomes. Areas for intervention have been identified in access to care, public knowledge about signs and symptoms of pregnancy complications, and improving relationships between healthcare professionals and expecting mothers.[59]

Access to care during pregnancy is a significant issue in the face of maternal mortality. "Access" encompasses a wide range of potential difficulties including costs, location of healthcare services, availability of appointments, transportation services, and cultural or language barriers that could inhibit a woman from receiving proper care.[59] For women carrying a pregnancy to term, access to necessary antenatal (prior to delivery) healthcare visits is crucial to ensuring healthy outcomes. These antenatal visits allow for early recognition and treatment of complications, treatment of infections and the opportunity to educate the expecting mother on how to manage her current pregnancy and the health advantages of spacing pregnancies apart.[55] Access to birth at a facility with a skilled healthcare provider present has been associated with safer deliveries and better outcomes.[55] The two areas bearing the largest burden of maternal mortality, Sub-Saharan Africa and South Asia, also had the lowest percentage of births attended by a skilled provider, at just 45% and 41% respectively.[60] Emergency obstetric care is also crucial in preventing maternal mortality by offering services like emergency cesarean sections, blood transfusions, antibiotics for infections and assisted vaginal delivery with forceps or vacuum.[55] In addition to physical barriers that restrict access to healthcare, financial barriers also exist. Close to one out of seven women of child-bearing age have no health insurance. This lack of insurance impacts access to pregnancy prevention, treatment of complications, as well as perinatal care visits.[61]

By increasing public knowledge about pregnancy, including signs of complications that need addressed by a healthcare provider, this will increase the likelihood of an expecting mother to seek help when it is necessary.[59] Higher levels of education have been associated with increased use of contraception and family planning services as well as antenatal care.[62] Addressing complications at the earliest sign of a problem can improve outcomes for expecting mothers, which makes it extremely important for a pregnant woman to be knowledgeable enough to seek healthcare for potential complications.[55] Improving the relationships between patients and the healthcare system as a whole will make it easier for a pregnant woman to feel comfortable seeking help. Good communication between patients and providers, as well as cultural competence of the providers, could also assist in increasing compliance with recommended treatments.[59]

Another important preventive measure that is being put in is specialized education for mothers. Doctors and medical professionals providing simple information to women, especially women in lower socioeconomic areas will decrease the miscommunication that often occurs between doctors and patients.[63] Training doctors will be another important aspect in decreasing the rate of maternal death,[64] “The study found that white medical students and residents often believed incorrect and sometimes “fantastical” biological fallacies about racial differences in patients. For these assumptions, researchers blamed not individual prejudice but deeply ingrained unconscious stereotypes about people of color, as well as physicians’ difficulty in empathizing with patients whose experiences differ from their own.”[65]

Policy

The biggest global policy initiative for maternal health came from the United Nations' Millennium Declaration which created the Millennium Development Goals. In 2012, this evolved at the United Nations Conference on Sustainable Development to become the Sustainable Development Goals (SDGs) with a target year of 2030. The SDGs are 17 goals that call for global collaboration to tackle a wide variety of recognized problems. Goal 3 is focused on ensuring health and well-being for people of all ages.[66] A specific target is to achieve a global maternal mortality ratio of less than 70 per 100,000 live births. So far, specific progress has been made in births attended by a skilled provider, now at 80% of births worldwide compared with 62% in 2005.[67]

Countries and local governments have taken political steps in reducing maternal deaths. Researchers at the Overseas Development Institute studied maternal health systems in four apparently similar countries: Rwanda, Malawi, Niger, and Uganda.[68] In comparison to the other three countries, Rwanda has an excellent recent record of improving maternal death rates. Based on their investigation of these varying country case studies, the researchers conclude that improving maternal health depends on three key factors: 1. reviewing all maternal health-related policies frequently to ensure that they are internally coherent; 2. enforcing standards on providers of maternal health services; 3. any local solutions to problems discovered should be promoted, not discouraged.

In terms of aid policy, proportionally, aid given to improve maternal mortality rates has shrunken as other public health issues, such as HIV/AIDS and malaria have become major international concerns.[69] Maternal health aid contributions tend to be lumped together with newborn and child health, so it is difficult to assess how much aid is given directly to maternal health to help lower the rates of maternal mortality. Regardless, there has been progress in reducing maternal mortality rates internationally.[70]

In countries where abortion practices are not considered legal, it is necessary to look at the access that women have to high-quality family planning services, since some of the restrictive policies around abortion could impede access to these services. These policies may also affect the proper collection of information for monitoring maternal health around the world.[18]

Epidemiology
See also: List of countries by maternal mortality ratio and Maternal mortality in India
Maternal mortality ratio (with Sustainable Development Goal target) as of 2015[71]

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.[50] The global rate (2017) is 211 maternal deaths per 100,000 live births. Forty-five percent of postpartum deaths occur within 24 hours.[72] Ninety-nine percent of maternal deaths occur in developing countries.[8]

Country Countries by maternal mortality ratio in the year 2017. All data is from the World Bank.[73][74]
Australia 6
Canada 10
France 8
Germany 7
Japan 5
Sweden 4
UK 7
US 19
New Zealand 9
South Korea 11
Italy 2
Spain 4
Russia 17
Mexico 33
China 29

Severe maternal morbidity

Severe maternal morbidity (SMM) is an unanticipated acute or chronic health outcome after labor and delivery that detrimentally affects a woman's health. Severe Maternal Morbidity (SMM) includes any unexpected outcomes from labor or delivery that cause both short and long-term consequences to the mother's overall health.[75] There are nineteen total indicators used by the CDC to help identify SMM, with the most prevalent indicator being a blood transfusion.[76]  Other indicators include an acute myocardial infarction ("heart attack"), aneurysm, and kidney failure. All of this identification is done by using ICD-10 codes, which are disease identification codes found in hospital discharge data.[77] Using these definitions that rely on these codes should be used with careful consideration since some may miss some cases, have a low predictive value, or may be difficult for different facilities to operationalize.[12] There are certain screening criteria that may be helpful and are recommended through the American College of Obstetricians and Gynecologists as well as the Society for Maternal-Fetal Medicine (SMFM). These screening criteria for SMM are for transfusions of four or more units of blood and admission of a pregnant woman or a postpartum woman to an ICU facility or unit.[12]

The greatest proportion of women with SMM are those who require a blood transfusion during delivery, mostly due to excessive bleeding. Blood transfusions given during delivery due to excessive bleeding has increased the rate of mothers with SMM.[75] The rate of SMM has increased almost 200% between 1993 (49.5 per 100,000 live births) and 2014 (144.0 per 100,000 live births). This can be seen with the increased rate of blood transfusions given during delivery, which increased from 1993 (24.5 per 100,000 live births) to 2014 (122.3 per 100,000 live births).[75]

In the United States, severe maternal morbidity has increased over the last several years, impacting greater than 50,000 women in 2014 alone. There is no conclusive reason for this dramatic increase. It is thought that the overall state of health for pregnant women is impacting these rates. For example, complications can derive from underlying chronic medical conditions like diabetes, obesity, HIV/AIDs, and high blood pressure. These underlying conditions are also thought to lead to increased risk of maternal mortality.[78]

The increased rate for SMM can also be indicative of potentially increased rates for maternal mortality, since without identification and treatment of SMM, these conditions would lead to increased maternal death rates. Therefore, diagnosis of SMM can be considered a “near miss” for maternal mortality.[12] With this consideration, several different expert groups have urged obstetric hospitals to review SMM cases for opportunities that can lead to improved care, which in turn would lead to improvements with maternal health and a decrease in the number of maternal deaths.

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gollark: Oh right. Sorry. Let's try and get the annoying one to move.
gollark: I mean, Anavrins was saying that they're the same account.
gollark: Not really.
gollark: Darn you to heck, Wyatt.

See also

References
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