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."
There are two performance indicators that are sometimes used interchangeably: maternal mortality ratio and maternal mortality rate, which confusingly both are abbreviated "MMR". 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. 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."
UNFPA estimated that 303,000 women died of pregnancy or childbirth related causes in 2015. These causes range from severe bleeding to obstructed labour, 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.
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. 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.
|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.|
According to a 2003 article in the British Medical Bulletin, maternal death was first defined 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 " in the tenth revision of the International Classification of Diseases (ICD-10) which was completed in 1992. It is the definition still in use by the World Health Organization (WHO), which defines maternal mortality 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."
The 2003 article "Global burden of maternal death and disability" noted that the definition leaves out a segment of the population. According to the Centers for Disease Control, during the period 1974-75 in Georgia, US, 29% of maternal deaths "occurred after 42 days of pregnancy termination and 6% occurred after 90 days post-partum." This may explain the CDC’s definition, extending the period of consideration “within 1 year of the end of pregnancy.” Adding to the WHO definition, the CDC also mentions that this death can be irrespective of the outcome of the pregnancy.
Severe maternal morbidity or 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. There are nineteen total indicators used by the CDC to help identify SMM, with the most prevalent indicator being a blood transfusion. 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. 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. 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.
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. 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).
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.
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. 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.
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, 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%). Other causes include blood clots (3%) and pre-existing conditions (28%). Maternal mortality caused by severe bleeding and infections are mostly after childbirth. Indirect causes are malaria, anaemia, HIV/AIDS, and cardiovascular disease, all of which may complicate pregnancy or be aggravated by it. 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.
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: 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, especially adolescents aged 15 years or younger. 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. 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. 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.
Structural support and family support influences maternal outcomes. Furthermore, social disadvantage and social isolation adversely affects maternal health which can lead to increases in maternal death. 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 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. Complications include hemorrhage, infection, sepsis and genital trauma.
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.
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.
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." 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.
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.
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.
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.
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.
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. 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. 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.
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. 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. However, this alone will not eliminate the demand for safe services.
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. 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.
Lifetime risk of maternal death: refers to the probability that a 15-year-old female will die eventually from a maternal cause if she experiences throughout her lifetime the risks of maternal death and the overall levels of fertility and mortality that are observed for a given population. The adult lifetime risk of maternal mortality can be derived using either the maternal mortality ratio (MMR), or the maternal mortality rate (MMRate). 
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.
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. 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. 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. 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.
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. 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. 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.
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. 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.
Until the early 20th century developed and developing countries had similar rates of maternal mortality. Since most maternal deaths and injuries are preventable, 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.: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. 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. 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.
The WHO has also developed a global strategy and goal to end preventable death related to maternal mortality. 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.
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 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. There are also racial and ethnic disparities in maternal health outcomes which increases maternal mortality in marginalized groups.
The US has the "highest rate of maternal mortality in the industrialized world." In the United States, the maternal death rate averaged 9.1 maternal deaths per 100,000 live births during the years 1979–1986, but then rose rapidly to 14 per 100,000 in 2000 and 17.8 per 100,000 in 2009. In 2013 the rate was 18.5 deaths per 100,000 live births. 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. The rate has steadily increased to 18.0 deaths per 100,000 live births in 2014. 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.
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." 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."
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."
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. 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.
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. 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.
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 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.
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%. 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. Only 23 states have some form of policy that establishes review boards specific to maternal mortality as of the year 2010.
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. 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.
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.
The death rate for women giving birth plummeted in the twentieth century. The historical level of maternal deaths is probably around 1 in 100 births. 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. Currently, there are an estimated 303,000 maternal deaths each year. 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.
It was estimated that in 2015, a total of 303,000 women died due to causes related to pregnancy or childbirth. 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. 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.
Four elements are essential to maternal death prevention, according to UNFPA. 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. 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. 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.
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. It has proven to be a valuable resource. Condoms used as uterine tamponades have also been effective in stopping post-partum hemorrhage.
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.
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.
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.
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. Several countries, including India, Brazil, and Mexico, have seen some success in efforts to promote the use of reproductive healthcare services. 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. 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. 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.
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. 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. Access to birth at a facility with a skilled healthcare provider present has been associated with safer deliveries and better outcomes. 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. 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. 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.
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. Higher levels of education have been associated with increased use of contraception and family planning services as well as antenatal care. 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. 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.
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. 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.
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. 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, have become major international concerns. 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.
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.
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. In 2011, there were approximately 273,500 maternal deaths (uncertainty range, 256,300 to 291,700). Forty-five percent of postpartum deaths occur within 24 hours. Ninety-nine percent of maternal deaths occur in developing countries.
|Country||Maternal mortality rate per 100,000 live births (2015)|
Abortion in Paraguay is illegal except in case of the threat to the life of the woman. Anyone who performs an abortion can be sentenced to 15 to 30 months in prison. If the abortion is done without the consent of the woman, the punishment is increased to 2 to 5 years. If the death of the woman occurred as a result of the abortion, the person who did the procedure can be sentenced to 4 to 6 years in prison, and 5 to 10 years in cases in which she did not consent.In Paraguay, 23 out of 100 deaths of young women are the result of illegal abortions. Concerning this death rate, Paraguay has one of the highest in the region.In April 2015, a story about a 10-year-old Paraguayan girl who was 22 weeks pregnant as a result of having allegedly been raped and impregnated by her stepfather came to light. The pregnancy had been discovered that same month upon the girl’s mother having brought her to a local hospital in order to receive medical treatment for abdominal pain, which was found to have been related to the pregnancy. Calls from her mother as well as outraged members of the public throughout the world for permission to allow the girl the ability to undergo an abortion procedure were ultimately denied. The girl had given birth to the child via a caesarean section in a Red Cross hospital in Paraguay’s capital city of Asunción later that year. The girl’s stepfather has since been prosecuted for the rape and her mother had also been charged with negligence for her alleged role in the circumstances surrounding the rape and pregnancy of her daughter. The high-profile nature of this case has led opposition leftist parties to push for less restrictive abortion laws in Paraguay, such as in cases of child pregnancies and in cases of sexual assault. Despite these efforts and the international attention, current government officials have neglected to support or act on any proposed changes to Paraguayan abortion law. Following this case, Paraguayan president Horacio Cartes instead attempted to justify denying the 10-year-old legal access to an abortion, arguing that, “We did what our conscience dictated, what the Constitution commands, and what our religious convictions command”. The United Nations has found that the maternal death rate is four times higher for girls under the age of 16 in Latin America. The 10-year-old girl has reportedly survived the birth, and her mother and grandmother have both requested legal custody of the newborn child.Abortion in the Dominican Republic
Abortion in the Dominican Republic is completely illegal. The Dominican Republic is one of the few countries of the world which have a complete ban on abortion, without an exception for saving maternal life.Abortion has been constitutionally prohibited since September 18, 2009, when a constitutional amendment declaring the right to life as "inviolable from conception until death" was approved in Congress by a majority vote of 128 to 34. Up until October 2012, women could come forward for treatment without fear of being arrested. Dr. Milton Cordero has been working since 1980 in the republic's public hospitals, treating women who have abortions: he estimates that there are 90,000 illegal abortions per year. These illegal abortions are self-induced or done by a back-alley practitioner. Since the law was passed, abortion has risen to the third leading cause of maternal death in the country.Female genital mutilation in Nigeria
Female genital mutilation (FGM), also known as Female Genital Cutting (FGC) in Nigeria accounts for the most female genital cutting/mutilation (FGM/C) cases worldwide. The practices is customarily a family tradition that the young female of the age 0-15 would experience. It is a procedure that involves partial or completely removing the external females genitalia or other injury to the female genital organs whenever for non-medical reasons. The practice is considered harmful to girls and women and a violation of human rights. FGM causes infertility, maternal death, infections, and the loss of sexual pleasure.Nationally, 27% of Nigerian women between the ages of 15 and 49 were victims of FGM, as of 2012. In the last 30 years, prevalence of the practice has decreased by half in some parts of Nigeria.In May 2015, then President Goodluck Jonathan signed a federal law banning FGM. Opponents of the practice cite this move as an important step forward in Africa, as Nigeria is the most populous country and has set an important precedent. Though the practice has declined, activists and scholars say a cultural shift is necessary to abolish the practice, as the new law will not singularly change the wider violence against women in Nigeria.Health in Djibouti
In Djibouti, malnutrition is severe and the incidence of tuberculosis is high. Malaria is low.Health in Senegal
Expenditure on health in Senegal was 4.7% of GDP in 2014, US$107 per capita.
Life expectancy at birth was estimated as 65 years for men in 2016 and 69 for women.In 2001 data, 54% of the population of Senegal was below the poverty line, which has implications on people's wellbeing. Common medical problems in Senegal include child mortality, maternal death, malaria, and sexual diseases including HIV/AIDS. There is a high disparity in both the quality and extent of health services between urban and rural areas. The greatest problems in public health are in the East and South (Louga, Kaolack, and Tambacounda) and the region of Casamance.List of countries by maternal mortality rate
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." The maternal mortality rate, on the other hand, is the number of maternal deaths per 100,000 births. The maternal mortality is used as a criterion for the quality of medical care in a country.Maternal health
Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. It encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience, in most cases, and reduce maternal morbidity and mortality, in other cases.Maternal health in Angola
Maternal health in Angola is a very complicated issue. In the Sub-Saharan region of Africa where Angola is located, poor maternal health has been an ongoing problem contributing to the decreased level of health in the population in the early 21st century.
According to the World Health Organization (WHO), maternal health refers to the health of women during pregnancy, childbirth, and the postpartum period. Maternal health is an important factor in determining the status of health in all countries as the health of newborns, which depends on the health of the mother, has an effect on the developmental stages of each individual. In Angola, maternal health is affected by many different factors, including the country's history, economic state, and overall prevalence of infectious diseases.
The WHO lists the leading causes of maternal death as severe bleeding, infections, high blood pressure during pregnancy, obstructed labor, and unsafe abortions. These causes compose approximately 80 percent of all maternal mortalities worldwide with the vast majority occurring in developing countries. The other remaining factors that contribute to maternal death include malaria, anemia, and HIV/AIDS during pregnancy. The WHO also states that the reasons why so many women die during childbirth are usually poverty, long distance to care, lack of information, inadequate service, and cultural practices. All of these causes of maternal death, and the corresponding reasons, are very familiar among women in Angola.Maternal mortality in fiction
Maternal death in fiction is a common theme encountered in literature, movies, and other media.
The death of a mother during pregnancy, childbirth or puerperium is a tragic event. The chances of a child surviving such an extreme birth are compromised. In fictional literature the death of a pregnant or delivering mother is a powerful device: it removes one character and places the surviving child into an often hostile environment which has to be overcome.Maternal mortality in the United States
Maternal mortality refers to the death of a woman during her pregnancy or up to a year after her pregnancy has terminated; this only includes causes related to her pregnancy and does not include accidental causes. Some sources will define maternal mortality as the death of a woman up to 42 days after her pregnancy has ended, instead of one year. In 1986, the CDC began tracking pregnancy related deaths to gather information and determine what was causing these deaths by creating the Pregnancy-Related Mortality Surveillance System. Although the United States was spending more on healthcare than any other country in the world, more than two women died during childbirth every day, making maternal mortality in the United States the highest when compared to 49 other countries in the developed world. The CDC reported an increase in the maternal mortality ratio in the United States from 18.8 deaths per 100,000 births to 23.8 deaths per 100,000 births between 2000 and 2014, a 26.6% increase; It is estimated that 20-50% of these deaths are due to preventable causes, such as: hemorrhage, severe high blood pressure, and infection.Maternal mortality ratio
The maternal mortality ratio is a key performance indicator for efforts to improve the health and safety of mothers before, during, and after childbirth per country worldwide. Often referred to as MMR, it is the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes). It is not to be confused with the maternal mortality rate, which is the number of maternal deaths (direct and indirect) in a given period per 100,000 women of reproductive age during the same time period. The statistics are gathered by WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. The yearly report started in 1990 and is called Trends in Maternal Mortality. As of the 2015 data published in 2016, the countries that have seen an increase in the maternal mortality ratio since 1990 are the Bahamas, Georgia, Guyana, Jamaica, Dem. People’s Rep. Korea, Serbia, South Africa, St. Lucia, Suriname, Tonga, United States, Venezuela, RB Zimbabwe. But according to Sustainable Development Goals report 2018, the overall maternal mortality ratio has declined by 37 percent since 2002. Nearly 303,000 women died due to complications during pregnancy.
With an exceptionally high mortality ratio compared to other U.S. states, the government of Texas created the Maternal Mortality and Morbidity Task Force in 2013.Maternal near miss
A maternal near miss (MNM) is an event in which a pregnant woman comes close to maternal death, but does not die – a "near-miss". Traditionally, the analysis of maternal deaths has been the criteria of choice for evaluating women's health and the quality of obstetric care. Due to the success of modern medicine such deaths have become very rare in developed countries, which has led to an increased interest in analyzing so-called "near miss" events.Mother
A mother is the female parent of a child. Mothers are women who inhabit or perform the role of bearing some relation to their children, who may or may not be their biological offspring. Thus, dependent on the context, women can be considered mothers by virtue of having given birth, by raising their child(ren), supplying their ovum for fertilisation, or some combination thereof. Such conditions provide a way of delineating the concept of motherhood, or the state of being a mother. Women who meet the third and first categories usually fall under the terms 'birth mother' or 'biological mother', regardless of whether the individual in question goes on to parent their child. Accordingly, a woman who meets only the second condition may be considered an adoptive mother, and those who meet only the first or only the third a surrogacy mother.
An adoptive mother is a female who has become the child's parent through the legal process of adoption. A biological mother is the female genetic contributor to the creation of the infant, through sexual intercourse or egg donation. A biological mother may have legal obligations to a child not raised by her, such as an obligation of monetary support. A putative mother is a female whose biological relationship to a child is alleged but has not been established. A stepmother is a female who is the wife of a child's father and they may form a family unit, but who generally does not have the legal rights and responsibilities of a parent in relation to the child.
The above concepts defining the role of mother are neither exhaustive nor universal, as any definition of 'mother' may vary based on how social, cultural, and religious roles are defined. The parallel conditions and terms for males: those who are (typically biologically) fathers do not, by definition, take up the role of fatherhood. Motherhood and fatherhood are not limited to those who are or have parented. Women who are pregnant may be referred to as expectant mothers or mothers-to-be, though such applications tend to be less readily applied to (biological) fathers or adoptive parents. The process of becoming a mother has been referred to as "matrescence".The adjective "maternal" refers to a mother and comparatively to "paternal" for a father. The verb "to mother" means to procreate or to sire a child from which also derives the noun "mothering". Related terms of endearment are mom (mama, mommy), mum, mumsy, mamacita (ma, mam) and mammy. A female role model that children can look up to is sometimes referred to as a mother-figure.Obstetric labor complication
An obstetric labor complication is a difficulty or abnormality that arises during the process of labor or delivery.
The Trust for America's Health reports that as of 2011, about one third of American births have some complications; many are directly related to the mother's health including increasing rates of obesity, type 2 diabetes, and
physical inactivity. The U.S. Centers for Disease Control and Prevention (CDC) has led an initiative to improve woman's health previous to conception in an effort to improve both neonatal and maternal death rates.Prenatal care
Prenatal care, also known as antenatal care, is a type of preventive healthcare. Its goal is to provide regular check-ups that allow doctors or midwives to treat and prevent potential health problems throughout the course of the pregnancy and to promote healthy lifestyles that benefit both mother and child. During check-ups, pregnant women receive medical information over maternal physiological changes in pregnancy, biological changes, and prenatal nutrition including prenatal vitamins. Recommendations on management and healthy lifestyle changes are also made during regular check-ups. The availability of routine prenatal care, including prenatal screening and diagnosis, has played a part in reducing the frequency of maternal death, miscarriages, birth defects, low birth weight, neonatal infections and other preventable health problems.
The World Health Organization (WHO) reported that in 2015 around 830 women died every day from problems in pregnancy and childbirth. Only 5 lived in high-income countries. The rest lived in low-income countries.A study examined the differences in early and low-weight birth deliveries between local and immigrant women and saw the difference caused by prenatal care received. The study, between 1997 and 2008, looked at 21,708 women giving birth in a region of Spain. The results indicated that very preterm birth (VPTB) and very low birth weight (VLBW) were much more common for immigrants than locals (Castelló et al., 2012). The study showed the importance of prenatal care and how universal prenatal care would help people of all origins get proper care before pregnancy/birth (Castelló et al., 2012).
The WHO recommends that pregnant women should all receive four antenatal visits to spot and treat problems and give immunizations. Although antenatal care is important to improve the health of both mother and baby, many women do not receive four visits.There are many ways of changing health systems to help women access antenatal care, such as new health policies, educating health workers and health service reorganisation. Community interventions to help people change their behavior can also play a part. Examples of interventions are media campaigns reaching many people, enabling communities to take control of their own health, informative-education-communication interventions and financial incentives. A review looking at these interventions found that one intervention helps improve the number of women receiving antenatal care. However interventions used together may reduce baby deaths in pregnancy and early life, lower numbers of low birth weight babies born and improve numbers of women receiving antenatal care.Traditional prenatal care in high-income countries generally consists of:
monthly visits during the first two trimesters (from the 1st week to the 28th week)
fortnightly visits from the 28th week to the 36th week of pregnancy
weekly visits after 36th week to the delivery, from the 38th week to the 42nd week
Assessment of parental needs and family dynamicsThe traditional form of antenatal care has developed from the early 1900s and there is very little research to suggest that it is the best way of giving antenatal care. Antenatal care can be costly and uses a lot of staff. The following paragraphs describe research on other forms of antenatal care, which may reduce the burden on maternity services in all countries.Self-induced abortion
A self-induced abortion (or self-induced miscarriage) is an abortion performed by the pregnant woman herself or with the help of other, non-medical assistance. Although the term includes abortions induced with legal over-the-counter medication, it also refers to efforts to terminate a pregnancy through alternative, sometimes more dangerous means. Such practices may present a threat to the health of women. If the abortion does not result in termination of the pregnancy, damage to the fetus can occur.
Self-induced abortion is often attempted during the earliest stages of pregnancy (the first eight weeks from the last menstrual period). In recent years, significant reductions in maternal death and injury resulting from self-induced abortions have been attributed to the growing use of misoprostol (known commercially at "Cytotec"), an inexpensive, widely available drug with multiple uses, including the treatment of post-partum hemorrhage, stomach ulcers, and induction of labor. The World Health Organization has endorsed a standardized regimen of misoprostol to induce abortion up to 9 weeks of pregnancy. This regimen has been shown to be up to 83% effective in terminating a pregnancy.Victoria Joyce Ely
Victoria Joyce Ely (September 12, 1889 – May 12, 1979) was an American nurse who served in World War I in the Army Nurse Corps and then provided nursing services in the Florida Panhandle in affiliation with the American Red Cross. To address the high infant and maternal death rates in Florida in the 1920s, she lectured and worked at the state health office. Due to her work, training improved for birth attendants and death rates dropped. After 15 years in the state's service, she opened a rural health clinic in Ruskin, Florida, providing both basic nursing services and midwife care. The facility was renamed the Joyce Ely Health Center in her honor in 1954. In 1983, she was inducted into Florida Public Health Association's Hall of Memory and in 2002 was inducted into the Florida Women's Hall of Fame.Wasp waist
Wasp waist is a women's fashion silhouette, produced by a style of corset and girdle, that has experienced various periods of popularity in the 19th and 20th centuries. Its primary feature is the abrupt transition from a natural-width rib cage to an exceedingly small waist, with the hips curving out below. It takes its name from its similarity to a wasp's segmented body. The sharply cinched waistline also exaggerates the hips and bust.
In the 19th century, while average corseted waist measurements varied between 23 to 31 inches, wasp waist measurements of 16 to 18 inches were uncommon and were not considered attractive. Ladies' magazines told of the side effects of tight lacing, proclaiming that "if a lady binds and girds herself in, until she be only twenty-three inches, and, in some cases, until she be only twenty-one inches, it must be done at the expense of comfort, health, and happiness." Instead, fashions created the illusion of a small waist, using proportion, stripe placement, and color. Extreme tight lacing (15"-18") was a "fad" during the late 1870s/'80s, ending in around 1887. Among the multitude of medical problems women suffered to achieve these drastic measurements were deformed ribs, weakened abdominal muscles, deformed and dislocated internal organs, and respiratory ailments. Displacement and disfigurement of the reproductive organs greatly increased the risk of miscarriage and maternal death.Women in Peru
Women in Peru represent a minority in both numbers and legal rights. Although historically somewhat equal to men, after the Spanish conquest the culture in what is now Peru became increasingly patriarchal. The patriarchal culture is still noticeable. Women receive less pay than men, have fewer employment and political opportunities, and are at times abused without repercussion. Contraceptive availability is not enough for the demand, and over a third of pregnancies end in abortion. Maternal death rates are also some of the highest in South America.The Peruvian Government has begun efforts to combat the high maternal mortality rate and lack of female political representation, as well as violence against women. However, the efforts have not yet borne fruit.