2 Maternal mortality

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Contents

• Objectives
• Mortality ratio
• Causes of maternal death
• Confidential enquiry
• Avoidable factors
• Case studies

Objectives

When you have completed this unit you should be able to:

• Define and calculate maternal mortality ratio.
• List the important causes of maternal mortality.
• Interpret maternal mortality rates.
• Separate direct and indirect causes of maternal death.
• Describe the confidential enquiry into maternal deaths.

Mortality ratio

2-1 What is maternal mortality?

Maternal mortality means the death of a woman during pregnancy (i.e. conception to delivery) and the puerperium (i.e. up to 42 days after delivery). It includes deaths due to miscarriages (abortions) and ectopic pregnancies.

A maternal death is defined as the death of a woman at any time between the conception of her infant and 42 days after the delivery of the infant.

2-2 What is the maternal mortality ratio?

The maternal mortality ratio (MMR) is defined as the number of women dying between conception and 6 weeks (42 days) after delivery per 100 000 deliveries. The maternal mortality ratio is calculated as follows:

Total number of maternal deaths ÷ Total number of live births × 100 000

The maternal mortality ratio is usually given for a specific area and a specific period of time. For example, if 10 women die in Cape Town where the annual delivery rate is 50 000, then the maternal mortality rate is:

10 ÷ 50 000 × 100 000 = 20

Note that the maternal mortality ratio is expressed per 100 000 deliveries.

The maternal mortality ratio is the number of maternal deaths per 100 000 deliveries.

Note

‘Ratio’ rather than ‘rate’ used as the denominator does not include all pregnancies or deliveries, only live births.

2-3 Why does maternal mortality include the deaths of women during the first few months of pregnancy?

Because pregnancy effects the mother’s body soon after the start of pregnancy. Problems which occur early in pregnancy, such as ectopic pregnancies and septic abortions, can result in the mother’s death.

2-4 Why does the maternal mortality ratio include the deaths of women during the 6 weeks after delivery?

Because the effects of pregnancy on the mother’s body take up to 6 weeks to disappear. Deaths during the puerperium (6 weeks after delivery) are often as a result of complications of pregnancy.

2-5 What is the importance of the maternal mortality ratio?

It is a very important method of assessing both the standard of health of pregnant women and the standard of care being provided to pregnant women. The maternal mortality ratio can also be compared between different areas or between different periods of time in the same area.

A high maternal mortality ratio usually indicates either poor maternal health or inadequate care during the pregnancy and puerperium or both. In contrast, a low maternal mortality ratio indicates that both maternal health and health care are good.

The maternal mortality ratio reflects both the general health of women as well as the standard of care during pregnancy and the puerperium.

2-6 What is the maternal mortality ratio in high-income countries?

In high-income countries, or privileged areas in low-income countries, the maternal mortality ratio is usually about 10 per 100 000 deliveries. Therefore, it is very uncommon for a woman to die during pregnancy or the puerperium.

Note

For example, in 2015 the MMR for the United Kingdom was 9 / 100 000.

2-7 What is the maternal mortality ratio in low-income countries?

In low-income countries the maternal mortality ratio is usually above 200 per 100 000 deliveries. The maternal mortality ratio varies widely between low-income countries with some very undeveloped communities having a ratio as high as 1000 per 100 000.

In many poor areas of high-income countries the maternal mortality ratio is also increased. Worldwide, most maternal deaths occur in low-income countries where the death is usually related to poverty and inadequate access to good health care services.

In most low- and middle-income developing countries the collection of mortality information is very incomplete, making it difficult to calculate the accurate maternal mortality rate.

2-8 What is the maternal mortality ratio in South Africa?

The exact maternal mortality ratio in South Africa is not known, as many maternal deaths are still not registered. However, the institutional maternal mortality ratio is about 135/100 000 deliveries. The maternal mortality ratio varies between different districts from as low as 70 to as high as 170. The maternal mortality ratio has decreased in the past few years, mainly due to less women dying from complications of AIDS after the national roll-out of anti-retroviral therapy.

The estimated maternal mortality ratio for South Africa is 135 / 100 000.

Note

Estimates of the true maternal mortality in South Africa vary widely but suggest 200 to 400 / 100 000. An accurate ratio will only be known when most pregnancies and maternal deaths are recorded. It is important to know the maternal mortality ratio in the country where you work.

Causes of maternal death

2-9 When are the causes of a maternal death determined?

Each maternal death must be discussed in detail to determine the cause and decide whether it could have been prevented. This is usually done at the regular perinatal morbidity and mortality meeting which also includes any maternal deaths. It is important to discuss the maternal death as soon as possible while the details of the clinical problems and care are still remembered. The findings of each death must be carefully summarised and included in the maternal mortality report. This is usually prepared annually for each health region.

2-10 Are maternal deaths notifiable?

Yes. All maternal deaths are notified by law in South Africa. This includes maternal deaths at home and in private institutions. It is important to include maternal deaths which occur outside the maternity services, e.g. women who have not yet started antenatal care and women who die in medical, surgical or emergency departments.

Note

In South Africa in 1977 all maternal deaths were made notifiable.

2-11 What are primary and final causes of maternal death?

The primary cause of maternal death is the obstetric factor or condition which lead to the death, i.e. it is the reason why the death occurred. Knowing the primary causes of death helps to identify clinical practices which need to be improved. Deaths can be prevented if the primary causes are well managed.

The final cause of maternal death is the event which actually caused the death (a final complication of the disease process), i.e. how the patient died. Knowing the final causes of death helps to identify facilities and resources which need to be improved. It also helps to prevent or improve the management of conditions which can be final causes of death.

For example, if a pregnant woman has a severe antepartum haemorrhage from a placenta praevia and dies of hypovolaemic shock, the primary cause of death is antepartum haemorrhage and the final cause of death is hypovolaemic shock. Similarly, if a woman has eclampsia and dies of a brain haemorrhage, the eclampsia is the primary cause and the brain bleed is the final cause of death.

The primary cause of maternal death is the obstetric factor or condition which lead to the death.

2-12 How can the primary causes of maternal deaths be subdivided?

The primary causes of maternal deaths are subdivided into 3 groups:

1. Direct.
2. Indirect.
3. Co-incidental.

Usually a fourth group called ‘Unknown’ is added. These are maternal deaths where the cause of death cannot be identified.

2-13 What are direct causes of maternal death?

These are deaths which are a direct result of the woman being pregnant. They result from complications of pregnancy or the puerperium, or the management of the pregnancy or puerperium. These deaths would not have happened if the woman had not been pregnant. An example of a direct cause of maternal death is eclampsia.

Note

Direct deaths result from obstetric complications of the pregnancy state, from interventions, omissions, incorrect treatment or from a chain of events of any of these.

A direct cause of maternal death would not have happened if the woman had not been pregnant.

2-14 What are indirect causes of maternal death?

These are deaths are caused by diseases that existed before the pregnancy or developed during the pregnancy or puerperium. Although not a result of pregnancy or puerperium complications, the pregnant state aggravated the condition. If the woman had not been pregnant, she may not have died from the disease. An example of an indirect cause of maternal death is rheumatic heart disease which became worse during the pregnancy, leading to heart failure. Suicide during pregnancy were previously counted as a co-incidental death but are now regarded as an indirect cause of maternal death.

Note

Indirect deaths result from previous existing disease or disease that developed during pregnancy which were not due to direct obstetric causes but which were aggravated by the physiological effects of pregnancy.

A woman may have died of an indirect cause even if she was not pregnant.

2-15 What are co-incidental causes of maternal death?

These are deaths that were unrelated to the pregnancy or puerperium and just happened to occur at this time. The condition causing the death was not aggravated by the pregnancy and would have killed the women even if she had not been pregnant. Examples of co-incidental causes of maternal death include motor vehicle accidents and assault.

Although co-incidental causes of maternal death are recorded in South Africa, they are not included in calculating the maternal mortality rate. Co-incidental deaths are counted to document the extent of violence against women as well as accidents.

2-16 Is a cause found for all deaths during pregnancy and the puerperium?

No. Unfortunately the underlying cause sometimes is unknown. This is often because the history is incomplete and a post mortem examination was not done.

2-17 What are the important direct causes of maternal death in South Africa?

1. Hypertension.
2. Obstetric haemorrhage (antepartum or postpartum).
3. Pregnancy related sepsis.
4. Miscarriage

Note

Other causes are anaesthetic related, acute collapse and pulmonary embolism, abortion and ectopic pregnancy.

Most maternal deaths are due to direct causes, especially the hypertensive disorders, haemorrhage and infection.

Bleeding during and after Caesarean section are the biggest cause of deaths due to postpartum haemorrhage.

2-18 What are the important indirect causes of maternal death in South Africa?

1. Non-pregnancy related infections (NPRI), such as HIV, TB and malaria.
2. Pre-existing maternal disease, such as cardiac disease.

AIDS is the commonest indirect cause of maternal death in South Africa.

Note

The common final causes of deaths in women with AIDS are pneumonia, meningitis and tuberculosis.

Non-pregnancy-related infection is the commonest indirect cause of maternal death in South Africa.

2-19 What are the most common causes of maternal death in South Africa?

When all direct and indirect causes of maternal death in South Africa are considered together, the following are the commonest (the ‘big five’ causes) in order of frequency:

1. Non-pregnancy related infection, especially AIDS.
2. Complications of hypertension in pregnancy.
3. Obstetric haemorrhage, including antepartum and postpartum haemorrhage.
4. Non-pregnancy related diseases (pre-existing medical conditions), especially heart disease.
5. Pregnancy related infection, especially septic abortions and puerperal sepsis.

These five causes are responsible for more than 80% of all maternal deaths. In South Africa in 2014-2016 the most common single cause of maternal death was NPRI.

Note

Many women who died of pregnancy related sepsis were not screened for HIV/AIDS. It is highly likely that many were positive. Therefore, many deaths classified as pregnancy related infection, non-pregnancy related disease and possibly post-partum haemorrhage should probably be re-classified as non-pregnancy related infection.

NPRI is the commonest cause of maternal death in South Africa.

2-20 Which causes of maternal deaths are most common at different levels of care?

Non-pregnancy related infections were the commonest cause of death at all levels of care. However:

1. Obstetric haemorrhage, especially post-partum haemorrhage, as a cause of maternal death was most common in level 1 hospitals (small hospitals staffed by doctors but without any full-time obstetric specialists) or clinics where there are no doctors.
2. Complications of hypertension in pregnancy resulting in maternal death was most common in level 2 hospitals (staffed by full-time specialists) and in level 3 hospitals (having intensive care facilities).

2-21 Why do so many pregnant women still die in low- and middle-income countries?

The high maternal mortality rate in poor countries is not due to the lack of knowledge of how to manage ill pregnant women, but due to women not being able to receive adequate care.

2-22 Why do many pregnant women in poor countries not have access to adequate care?

Although some reasons may be obvious, this question is often not easy to answer unless a detailed investigation into causes of maternal death is carried out. Such as investigation is best done as a confidential enquiry. Important reasons why some women do not have access to good care are distance to the nearest clinic or hospital, lack of transport and inadequate staffing or equipment at health care facilities.

Confidential enquiry

2-23 What is a confidential enquiry into maternal deaths?

In a confidential enquiry of maternal deaths, the deaths of as many pregnant women as possible are identified by an appointed committee. The case record of each woman is then carefully investigated by an independent team of experts to identify the likely cause and reason for the death. This information is kept confidential to protect the staff involved with the care of the case. If this were not done, it would be difficult to obtain the full story.

Note

The aim of a confidential enquiry is to reduce maternal mortality by collecting, analysing and interpreting information, reporting findings and making recommendations for evidence based decisions.

2-24 Is there a confidential enquiry into maternal deaths in South Africa?

Yes. This is a most important enquiry into the number and causes of maternal death in South Africa. It attempts to identify avoidable factors, missed opportunities and substandard care, and gives recommendations as to how these causes can be prevented or effectively managed. The aim of the report is to make recommendations aimed at reducing the maternal mortality rate. It is important that the findings and recommendations of the confidential enquiry are made available to all services and health care workers responsible for maternal care.

Note

In South Africa a National Committee on Confidential Enquiries into Maternal Deaths is responsible for reviewing all maternal deaths.

2-25 What is the Saving Mothers report?

The Saving Mothers report is the official report of the confidential enquiry into maternal deaths in South Africa. The first Saving Mothers Report to be published in South Africa reviewed maternal deaths in 1998.

Note

The first interim report on maternal deaths in South Africa was published in 1988. This was followed by the first comprehensive confidential enquiry into maternal deaths in South Africa, conducted in 1998 and published as the ‘Saving Mothers: Report on Confidential Enquiry into Maternal Deaths in South Africa 1998’. Since then a full report has appeared every 3 years. In addition there will be annual interim reports to track changes in the number and causes of maternal death at different levels of care in each province. The information for these reports, and practical and affordable recommendations based on the reports, are produced by the National Committee for Confidential Enquiries into Maternal Deaths (NCCEMD). The last triennial (three-yearly) report was published in 2017 and covered the years 2014-2016.

Avoidable factors

2-26 What are avoidable factors, missed opportunities and substandard care?

An avoidable (or modifiable) factor is something which could have caused the maternal death and yet was potentially avoidable. If that event or condition was not present, the death may not have occurred.

A missed opportunity is a potentially avoidable maternal death where an opportunity was present to prevent the death but the opportunity was missed.

Substandard care is poor care which may have resulted in the woman’s death.

In any enquiry into a maternal death, it is very important to identify possible and probable avoidable factors and missed opportunities as much can be learned from these events. This knowledge helps to avoid similar deaths in future.

Avoidable factors, missed opportunities and substandard care must be looked for in each maternal death.

2-27 Which maternal deaths are potentially avoidable?

Maternal deaths where avoidable factors, missed opportunities or substandard care was present. Maternal deaths are not classified into avoidable or not, only into deaths where avoidable factors were or were not present. Therefore, the report identifies deaths which had potentially avoidable factors.

2-28 What are the categories of avoidable factors for maternal mortality?

Avoidable factors can be grouped into the following 3 categories:

1. Patient related problems.
2. Administrative problems.
3. Health worker related problems.

In South Africa, avoidable factors due to patient related problems were present in 52.9%, administrative problems were present in 47%, and health worker related problems with 39% of the maternal deaths. Many deaths had more than one avoidable factor. Therefore, all three categories of avoidable factors are commonly associated with maternal deaths.

In South Africa, avoidable factors associated with patient, administrative and health worker related problems are commonly associated with maternal deaths.

2-29 What patient related problems contribute to maternal mortality?

These include:

1. Not attending or booking late for antenatal care.
2. Not recognising important warning symptoms and signs such as a severe headache or vaginal bleeding.
3. Not seeking help when warning signs were present.

In South Africa the commonest patient related problem associated with maternal death is a delay in accessing medical help (present in 27% of avoidable cases) or not attending antenatal care or only attending late in pregnancy (25% of avoidable cases). This probably true for in many other low and middle income countries.

Delay in accessing medical help is the commonest patient related factor associated with maternal death in South Africa.

2-30 Are patient related problems the fault of the patient?

There are many underlying social factors to patient related problems such as poor education of women, women not being allowed to decide for themselves whether to report to clinic or hospital, fear and ignorance, and traditional taboos on disclosing a pregnancy. Many women do not seek care because care is not easily available. They may have to travel long distances, face long queues and be turned away from overcrowded clinics.

While some patients may not seek care because they are not motivated, usually there are social conditions which prevent or do not encourage access to health care. Perhaps patient related problems should be called community related problems.

2-31 What administrative factors contribute to maternal mortality?

These include:

1. Lack of staff.
2. Lack of availability of adequate training.
3. Lack of adequate transport.
4. Lack of good clinics and hospitals close to the community.
5. Lack of intensive care facilities for seriously ill women.

Problems resulting in these administrative factors include poor planning and supervision of maternal services, little emphasis on health funding for women and a general lack of funds. In rural areas, deliveries are often conducted by untrained members of the family. Having a skilled assistant to monitor labour and conduct the delivery is important.

Lack of well trained skilled birth attendants is an important administrative related factor in maternal mortality.

2-32 Why is lack of staff a common problem?

1. Funding is often not available. Often this is because maternity care is not viewed as a priority.
2. Suitably qualified staff may not be available due to inadequate numbers of staff being trained, staff moving from the state into the private service or staff leaving to work in other countries.
3. Staff do not want to work in some areas far from towns and cities, areas with a high crime rate or areas with poor transport and few facilities such as schools.

2-33 Why is a lack of adequate training a common problem?

1. School education and basic nurse training may be poor.
2. Medical school training may not include enough time in maternal care.
3. Opportunities for continuing training or special (advanced) courses for both nursing and medical staff are often not available.
4. Obstetric specialists or medical officers, general practitioners with additional training in maternal care, and advanced midwives are often not available to teach their junior colleagues.
5. Nursing staff who have attended advanced courses are often placed in areas where this knowledge cannot be best used.
6. Routine staff rotation prevents individuals acquiring enough experience in maternal care.

2-34 Why is transport often inadequate?

1. Transport is often not available to get patients to antenatal clinic or to a clinic or hospital when labour starts or danger signs present.
2. Patient transport is often worse in poor or rural areas and at night.
3. Transport is often expensive.
4. Transport to move patients from a clinic to hospital or between hospitals is often not available or the delay time is very long. This may be due to lack of vehicles, lack of staff, or due to maternity cases being viewed as less important than other cases such as trauma.
5. Telephones may not be available to call for transport.
6. It may be dangerous to go to clinic or hospital at night in areas with a lot of crime.

2-35 Why are clinics and hospitals often not available?

1. It is very expensive to provide enough clinics and hospitals within easy reach of all pregnant women, especially in very mountainous areas or areas with a low population density.
2. Clinics and hospital are often built far from the community they serve.

2-36 Why are intensive care facilities often not available?

1. The equipment is expensive and needs skilled and costly maintenance. Often the equipment is available but not kept in good working order.
2. It is expensive to employ staff who are adequately trained and regularly attend further training courses.

As a result, level 3 (intensive) care is often not available to very ill women.

2-37 What health care worker related problems contribute to maternal mortality?

These include:

1. Negligent or substandard care (they knew what to do but did not do it).
2. Honest errors.
3. Lack of appropriate training (they did not know what to do).

Major health care worker related problems include:

1. Not recognising clinical problems.
2. Delay in referral or not referring.
3. Not following standard protocols.
4. Inadequate monitoring of sick women after admission.

The administrative problems of staff shortages and excessive patient load often contribute to problems experienced by health care workers (both nursing and medical staff).

2-38 Why are health care workers some­times negligent or offer substandard care?

Negligence, laziness and an attitude of not caring are very complex problems which are influenced by attitudes in the home, community, schools, tertiary education centres and places of employment. Social and environmental problems affect the way health workers relate to both their work and their patients. Salaries, management styles, opportunities for further training and promotion, and personal beliefs all influence the motivation of health workers. A caring attitude is often not rewarded and encouraged at all levels of society. Understaffing and overwork are important causes of poor care.

Substandard care may be the result of inadequate training or a lack of personal motivation and commitment to patient care.

2-39 What are honest errors?

An honest error is a mistake in management of the patient where the health worker has done his or her best but it was not the correct diagnosis or treatment and, as a result, the woman died. Honest errors are often the result of an excessive patient load and inadequate staffing. Examples of honest errors are forgetting to enter an important observation on the partogram or forgetting to give a newborn infant vitamin K after delivery.

2-40 What training may be inappropriate?

Many health workers are not appropriately trained for the work they are expected to perform. This is often due to a lack of suitable training opportunities. Basic midwifery and medical training may not equip the nurse or doctor to function in a primary care situation where supervision by an experienced person is not available. Most advanced courses are expensive and require the health worker to leave their home and place of employment to travel to a regional centre for a period of time. Few distance-learning courses are available which enable health workers to take responsibility for some of their own continuing education.

2-41 What is a ‘near miss’?

A ‘near miss’ occurs when a woman is very ill and almost dies of one of the conditions which can cause maternal death. The avoidable factors in a near miss are usually the same as those where the patient dies. There are more near misses than maternal deaths in a service. As with an audit of causes of maternal deaths, an audit of near misses can also be very useful in identifying avoidable factors and substandard care.

Note

A ‘near miss’ is more correctly referred to as severe acute maternal morbidity (SAMM).

2-42 What is the maternal mortality index?

Maternal mortality index = Number of maternal deaths ÷ Number of maternal deaths and near misses

The maternal mortality index gives a measure of the standard of care of women who present with serious complications. With good management, most severely ill women will be near misses rather than deaths. Therefore, a low maternal mortality index indicates a high standard of care while a high index suggests poor care.

At present the maternal mortality index for the whole of South Africa is not known.

2-43 Are the causes of maternal death in South Africa changing over time?

Yes. The last two Saving Mothers Reports (2011-2013 and 2012-2014) showed that there was a decline in deaths from 2009. The main reason is the decrease in deaths due to AIDS after the national roll-out of antiretroviral drugs for all pregnant women. There was a decline in deaths due to obstetric haemorrhage but the deaths due to hypertensive conditions remains high.

Case study 1

In a large maternity service consisting of one small hospital and six clinics, there have been 10 000 liveborn deliveries and 35 maternal deaths in the past year. These deaths include women who died as a result of septic abortions as well as women who died of sepsis following delivery.

1. What is the definition of maternal mortality?

Maternal mortality consists of all the women who died between conception and the end of the puerperium (6 weeks after delivery).

2. Why are abortions and postpartum deaths also included in maternal mortality?

Because both conditions are related to pregnancy. Neither would have occurred if the women had not been pregnant. Maternal deaths are, therefore, all deaths where the cause of death is related to pregnancy. Deaths after 6 weeks are excluded as the physiological changes of pregnancy have returned to the pre-pregnancy state by 6 weeks after delivery.

3. What is the maternal mortality ratio in this health service?

There were 35 maternal deaths out of 10 000 live births. The maternal death ratio is traditionally expressed as a proportion of 100 000 deliveries. Therefore, the maternal mortality ratio is 35/10 000 x 100 000 = 350/100 000. Usually maternal mortality is expressed as an annual ratio and it is best expressed for a whole health region.

4. How do you interpret this maternal mortality ratio?

The maternal mortality ratio in high income countries is usually about 10/100 000 while that in poor countries is usually above 50/100 000. Therefore, this maternal mortality ratio of 350/100 000 is high, even for a poor country.

5. What is the maternal mortality ratio in South Africa?

The exact maternal mortality ratio is not known as accurate mortality statistics as many maternal death are still not reported, especially in rural areas. The estimated maternal mortality ratio is 135/100 000. However, it is probably much higher than this in many poor areas.

6. Why is it important to know the maternal mortality ratio in a health service?

Because it gives a good idea of both the standard of maternal health during pregnancy and the puerperium, as well as the standard of health care available for pregnant women in the community.

Case study 2

In a large maternity hospital in a city, both the number and causes of maternal deaths are carefully recorded after they have been discussed at the monthly mortality meeting. The primary and direct cause of each death is noted in order to find the commonest causes of death at the hospital.

1. Are maternal deaths notifiable?

Yes. All maternal deaths must be notified. This includes not only deaths in the state health service but also deaths at home and in private hospitals.

2. What are primary causes of maternal death?

The primary cause of death is the obstetric factor or condition which lead to the death. In other words, it is the reason why the death occurred. Important primary causes of death include pre-eclampsia, antepartum and post-partum haemorrhage, and pregnancy related infection such as septic abortion and puerperal sepsis.

3. Why is it important to know the common primary causes of maternal death?

Because steps can then be made to avoid these primary causes by managing them better. By doing this, many maternal deaths can be prevented. It is difficult to reduce the maternal mortality if the primary causes are not known.

4. What are final causes of maternal death?

The final cause of maternal death is the event which actually resulted in the death. In other words, it is the final complication of the disease process which killed the woman. For example, the final cause of death in antepartum or post partum haemorrhage is usually hypovolaemic shock while the final cause in eclampsia may be a brain haemorrhage.

5. Why is it important to identify the final cause of maternal death?

Because the final cause of death can often be prevented with adequate facilities and the correct management of these complications. For example, death from hypovolaemic shock can often be avoided if women with severe antepartum haemorrhage are correctly managed in an intensive care unit which has adequate staffing and facilities.

6. What are co-incidental causes of maternal death?

Co-incidental causes are not related to pregnancy at all but just happened to occur during pregnancy or the puerperium. Examples are motor car accidents and assault. Co-incidental causes are not included when the maternal mortality rate is calculated.

Case study 3

The main causes of maternal death are now known for each province. Information is also being collected on the main causes at each level of care within health districts and regions. From the findings and recommendations of the Confidential Enquiry into Maternal Deaths, funding is being made available to address specific problems in the care of pregnant women.

1. What are the five main causes of maternal death in South Africa?

1. Non-pregnancy related infection, especially AIDS.
2. Complications of hypertension in pregnancy.
3. Obstetric haemorrhage, including antepartum and postpartum haemorrhage.
4. Non-pregnancy related diseases (pre-existing medical conditions), especially heart disease.
5. Pregnancy related infection, especially septic abortions and puerperal sepsis.

2. What is the commonest cause of maternal deaths at all levels of care?

Non pregnancy related infection (i.e. AIDS).

3. What is the commonest direct cause of maternal death in primary care clinics?

Complications of pregnancy related hypertension such as eclampsia.

4. What is the commonest direct cause of maternal death in level 2 and 3 hospitals?

Non-pregnancy related infections.

5. Why is the notification of all maternal deaths and the Confidential Enquiry into Maternal Deaths so important?

Because accurate information on the number and causes of maternal death in South Africa will result in better planning of maternity services.

6. What is the Saving Mothers Report?

This is the official report of the Confidential Enquiry into Maternal Deaths.

Case study 4

During a monthly mortality meeting in a regional hospital, all the maternal and perinatal deaths are presented. The possible avoidable factors and missed opportunities associated with each of the two maternal deaths are discussed and documented in the mortality report. A near miss maternal death was also described. Neither the medical superintendent of the hospital nor the maternity matron was at the meeting.

1. What are avoidable factors in maternal deaths?

These are factors, events or conditions which may have prevented the maternal death if they had not been present. For example, if fast, efficient transport had been available a mother might not have died from a post-partum haemorrhage.

2. What is a missed opportunity?

This is an opportunity for providing good care which was missed and, as a result, led to the woman’s death? For example, not testing a woman’s urine for sugar during antenatal care was a missed opportunity which may have prevented her dying from a complication of diabetes during labour.

3. Which maternal deaths are potentially avoidable?

Deaths where avoidable factors, missed opportunities or substandard care were present.

4. What are the three categories of avoidable factors in maternal mortality?

1. Patient related factors.
2. Administration related factors.
3. Health worker related factors.

5. Can you give an example of each of the three categories?

The commonest patient related factors are not attending antenatal care or booking late, not recognising important warning signs and not seeking help when warning signs are present.

The commonest administrative related factors are lack of staff, inadequate staff training, poor transport, lack of primary care clinics and hospitals in the community, and inadequate intensive care facilities for seriously ill women.

The commonest staff related factors are poor care, honest errors and lack of appropriate training.

6. What common errors are made by health care workers?

Not recognising problems, a delay or failure in referring sick patients, not following standard protocols of care, and inadequate monitoring of ill patients.

7. What is a ‘near miss’?

A very ill woman who nearly died from a condition which often causes maternal deaths. Good lessons on how to improve maternal care can be learned from near misses.

8. Why do so many mothers still die in low-income countries?

Many women still die in poor countries, not because of the lack of knowledge of how to manage ill pregnant women, but due to women not being able to receive adequate care. This is usually due to great distances to the nearest clinic or hospital, lack of transport and inadequate staffing, equipment and training.

9. Should the medical superintendent and maternity matron attend mortality meetings?

Yes. As the managers of the service, it is very important that they are aware of problems, avoidable factors and recommended ways of improving the service and preventing further maternal deaths.

PPIP classification of maternal deaths

These are included as a reference only.

Primary causes of maternal death

The most important subdivisions are:

1. Pre-existing maternal disease Cardiac disease e.g. rheumatic valve disease. Endocrine e.g. diabetes. Central nervous system e.g. epilepsy. Skeletal e.g. kyphoscoliosis.

2. Non-pregnancy related sepsis AIDS. Pneumonia. Tuberculosis. Bacterial endocarditis. Pyelonephritis. Malaria.

3. Ectopic pregnancy

4. Abortion Septic abortion. Uterine trauma.

5. Pregnancy related sepsis Amniotic fluid infection with ruptured membranes. Amniotic fluid infection without ruptured membranes. Puerperal sepsis following normal delivery. Puerperal sepsis following Caesarean section.

6. Antepartum haemorrhage Abruptio placenta. Abruptio placenta with hypertension. Placenta praevia.

7. Postpartum haemorrhage Retained placenta. Uterine atony. Ruptured uterus. Inverted uterus.

8. Hypertensive disorders of pregnancy Chronic hypertension. Proteinuric hypertension. Eclampsia. HELLP syndrome. Ruptured liver.

9. Anaesthetic complication

10. Embolism

11. Acute collapse – cause unknown

12. Non obstetric cause Motor vehicle accident. Assault.

Final causes of maternal death

1. Hypovolaemic shock.
2. Septic shock.
3. Respiratory failure.
4. Cardiac failure.
5. Renal failure.
6. Liver failure.
7. Cerebral complication.
8. Disseminated intravascular coagulation.
9. Multiorgan failure.

A more detailed classification of primary causes of maternal death is given in the Perinatal Problem Identification Programme. Each subdivision is given a specific code.

Note

Codes and descriptions of causes of maternal death can be viewed at and downloaded from www.ppip.co.za.