The main cause of death as an overall percentage in the 5 years was uncontrolled obstetric hemorrhage (36.4%). The second cause was cardiac arrest with a percentage of 23.6%, and the rest of the causes accounted for 40%. However, during the year 2007 there were no cases of obstetric hemorrhage (Tables 1 and 2).
When we analyzed the place of delivery we found that only three of the 55 cases of maternal death were of women who delivered at home. This may give a false impression that the rest of the 52 cases were delivered at the Kasr Al-Ainy Hospital; however, this was not the case as there were 22 patients transferred from private hospitals in the terminal stage, some of whom delivered there.
As seen from Table 3 the avoidable causes accounted for 61.8% of maternal mortalities between 2003 and 2007; moreover, the maternal mortality in patients who had undergone a cesarean section was one and a half times that in patients who had undergone vaginal deliveries. One of the major difficulties we faced while conducting this study was the improper documentation and lack of information from the registers.
The WHO gives high priority to maternal health as reflected from the report published in 2005, according to which 99% of maternal deaths occur in developing countries and the maternal mortality ratio in developing countries is 450 maternal deaths per 100 000 live births. Furthermore, according to that report there were four major causes for maternal death: obstetric hemorrhage (mainly postpartum hemorrhage), infections, hypertensive disorders, and obstructed labor. In addition, it was found that women also die from poor nutritional status at conception and from the substandard care provided to them 5.
This coincides with the results obtained from our study, as we found that the main cause of death as an overall percentage in the 5 years was uncontrolled obstetric hemorrhage (36.4%). Second came cardiac arrest, with a percentage of 23.6%, and the rest of the causes accounted for 40%.
A recent report published by the United Nations in the year 2000 shows that there is considerable disparity in maternal mortality in different parts of the world. The highest rates of maternal mortality are found in Africa, more specifically in sub-Saharan Africa, followed by Asia, Latin America, and Oceania. During the last 50 years, this overall trend in maternal mortality has also been observed in transitional countries, with some achieving a decline of almost 75%. In Thailand, a decreased maternal mortality ratio from 400 deaths per 100 000 live births in 1960 to 50 per 100 000 live births in 1984 was seen. Similar declines were observed in Malaysia, Sri Lanka, Matlab, Egypt, Honduras, and Bangladesh 6.
In a study conducted by Khan and colleagues, hemorrhage was found to be the leading cause of maternal death in Africa and Asia. Hypertensive disorders represented the highest cause of death in Latin America and in the Caribbean. Within regions also, there was some significant variability. In South America, Peru had the highest incidence of maternal death from hemorrhage, whereas China, Afghanistan, and Iran had the highest incidence in Asia. In Africa, Egypt, Senegal, and Zambia had the highest incidence of maternal death from hemorrhage. In Europe, Poland had the highest rate of maternal death from hemorrhage 4.
We detected two main factors that contributed to these maternal deaths in the Kasr Al-Ainy Hospital, and both could be avoided: first was the substandard care provided in the form of inadequate supplies and drugs and difficulties in communication between departments involved in the management of these cases, such as the intensive care unit, anesthesiology department, and blood bank. The second factor was delayed transfer from the private sector, either from clinics, small centers, or unequipped hospitals.
Bouvier Colle and colleagues found that the management of postpartum hemorrhage in France was substandard, contributing substantially to the death rate among French women. This finding was evident in hospitals in which there was no anesthetist available for 24 h, as these places had a low rate of deliveries 7. In the study conducted by Abou Zahr and Wardlaw 8, the difference between developed and developing countries as regards the maternal mortality ratio was 13 per 100 000 live births and 440 per 100 000 live births, respectively.
The maternal mortality ratio decreased in the Kasr El-Aini Hospital over the period of the study. This can be attributed to increase in manpower to include three running rooms with five obstetricians working daily under supervision of a senior staff and equipped with an ultrasound machine. An intensive care unit was established with eight beds equipped with all facilities with intensive monitoring and highly skilled nurses and residents available 24 h/day. Regulations were established to guarantee the availability of a senior staff 24 h/day, 7 days/week, in the Obstetric Emergency Unit to help save time when emergency cases are received. The availability of a senior anesthesiologist 24 h/day (12-h shift) has also been ensured. Improvements have been made in the full reporting of maternal deaths and maternal mortality surveillance systems have been installed. In addition, a review committee was established in early 2003 for analysis and discussion of any maternal mortality and also for developing strategies for prevention of avoidable factors of maternal mortality. All the above factors have led to a significant decrease in the maternal mortality ratio.
The maternal mortality rate in the Kasr Al-Ainy Maternity Hospital decreased from 2003 to 2007; nevertheless, 61.8% of causes of maternal deaths are avoidable. Moreover, there were two major contributing factors in these deaths: the substandard care and delayed transfer of cases; both are avoidable.
Conflicts of interest
There are no conflicts of interest.
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Keywords:© 2012 Lippincott Williams & Wilkins, Inc.
labor; maternal deaths; maternal mortality; mortality rate