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Maternal mortality rate: a tertiary care university hospital experience

Aboul Gheit, Samah; Noah, Olfat; Shoukry, Moustapha; Sedky, Mahmoud

Journal of Evidence-Based Women’s Health Journal Society: May 2012 - Volume 2 - Issue 2 - p 64–67
doi: 10.1097/01.EBX.0000413058.28135.7f
Original articles

Objectives The aim of this study was the assessment of the causes of maternal mortality at the Kasr Al-Ainy Maternity Hospital and identification of the avoidable ones.

Study design A retrospective cohort study between 2003 and 2007.

Patients and methods Data were collected from records of patients who presented to the Kasr Al-Ainy Maternity Hospital between 2003 and 2007. Only cases of maternal mortality were included in this study. Maternal mortality has been defined as death of a woman while she is pregnant, during labor, or within 42 days after delivery. In our study, we found 55 maternal deaths at the Kasr Al-Ainy Maternity Hospital between 2003 and 2007.

Results We found that the maternal mortality rate decreased progressively from 2003 to 2007 (1.17 and 0.71%, respectively). Moreover, we found that the avoidable causes of maternal mortality accounted for 61.8% and the unavoidable causes for 38.2%. As regards the causes, obstetric hemorrhage remained the primary cause of maternal mortality from 2003 to 2007 and represented 36.4% of the avoidable causes. The second cause of maternal mortality was cardiac disease, which represented 12.7% of the avoidable causes of maternal mortality. There were two main predisposing factors for maternal mortality in the Kasr Al-Ainy Maternity Hospital. First is the substandard medical care provided, which is linked to lack of adequate supplies and communication barriers between different departments; this accounted for 47%. The second factor is the delay in seeking medical advice by the women or their families, as well as delayed referral from other hospitals; this factor accounted for 42%.

Conclusion Obstetric hemorrhage remains the first leading cause of death in one of the biggest tertiary care university hospitals in Egypt. However, there are two important avoidable predisposing factors that should be dealt with first: substandard practice; and lack of patient education and delayed transfer from other hospitals.

Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt

Correspondence to Samah Aboul Gheit, Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, 11451, Cairo, Egypt Tel: +02 2346877; fax: +02 2346068; e-mail: samahaboulgheit@gmail.com

Received December 12, 2011

Accepted January 2, 2012

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Introduction

Maternal mortality is one of the major concerns all over the world, and according to the WHO it is defined as the death of a woman while pregnant or within 42 days from termination of pregnancy, irrespective of the duration or site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Maternal mortality rate is defined as the number of women who died while pregnant or within 42 days from termination of pregnancy per 100 000 live births 1.

Maternal mortality classified as direct deaths were those related to obstetric complications during pregnancy, labor, or puerperium (6 weeks), or resulting from any treatment received. Indirect deaths are those associated with a disorder, the effect of which is exacerbated by pregnancy. Late deaths occur at least 42 days after the end of pregnancy 2.

In 1994, the Egypt National Maternal Mortality Study 1992/93 summarized the data collected, and reported an overall maternal mortality ratio of 174/100 000 (maternal deaths per live births). The five main causes of death were postpartum hemorrhage (25%), hypertensive disease (16%), antepartum hemorrhage (8%), puerperal sepsis (8%), and ruptured uterus (7%). Furthermore, the study showed that the two main avoidable factors of death were substandard care on the part of healthcare providers (59%) and delays in seeking care on the part of the patient and her family (42%) 3.

The majority of maternal deaths worldwide occur in developing countries (99%). The difference in maternal mortality between rich (mortality risk 1 in 4000–10 000) and poor countries (mortality risk 1 in 15–50) is one of the highest in public health. Postpartum hemorrhage, eclampsia, and sepsis are the leading causes of maternal deaths in developing countries. It is estimated that about 500 000 mothers die annually in the world, or that there are 1600 maternal deaths per day or about one maternal death per minute. Of these, it is estimated that 100 000–200 000 are related to poorly performed or illegal abortions. Of these, 26% are estimated to be preventable by introducing antenatal, community-based interventions 3. Access to quality, essential obstetrical care can prevent another 48% of maternal deaths. It is cost-effective to invest in policy markers that reduce maternal mortality in the most efficient manner possible 4.

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Patients and methods

This is a cross-sectional study conducted at the Kasr Al-Ainy Maternity Hospital, which is a tertiary care university hospital, between January 2003 and December 2007. Our aim was to search for the causes of maternal deaths in one of the biggest maternal tertiary care centers in Egypt and the Middle East, calculate the maternal mortality rate, and identify the avoidable causes and predisposing factors for maternal mortality. Data were collected from the files of pregnant women admitted to the Emergency Department. Inclusion criteria were death of a pregnant woman while she was pregnant or within 42 days from giving birth. Nonpregnant women who died or women who died after 42 days from delivery were excluded from the study.

Data analysis was carried out, and the maternal mortality rate was measured by dividing the number of maternal deaths by the number of women in the reproductive age group (15–50 years) during the period of the study. The data obtained were compared and analyzed using Excel database (MS cooperation, Washington, USA) and Arcus QuickStat version 1 (Research Solutions, Cambridge, United Kingdom). The χ 2-test was used to calculate the differences in proportions.

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Results

This is a cross-sectional study conducted at the Kasr Al-Ainy Maternity Hospital, which is a tertiary care university hospital. The study was conducted between 2003 and 2007. Data were collected from patient files to determine the maternal mortality rate and to survey the causes and predisposing factors for such deaths as well as determine how many of these factors can be avoided.

A total of 77 745 pregnant women were admitted to the Kasr Al-Ainy Maternity Hospital from January 2003 to December 2007. We found that the number of deliveries were 60 260, and from the total number of admissions we found 55 cases of maternal mortality in those 5 years. It is evident that the number of maternal deaths, and hence the maternal mortality rate, had decreased progressively, as in 2003 there were 17 cases of maternal mortality, which steadily decreased to seven cases in 2007 (Table 1, Fig. 1).

Table 1

Table 1

Figure 1

Figure 1

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).

Table 2

Table 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.

Table 3

Table 3

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Discussion

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.

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Conclusion

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.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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References

1. Make every mother and child count. 2005. Available at: http://www.who.int/whr/2005/whr2005_en.pdf [Accessed 3 December 2011]
2. Høj L, Da Silva D, Hedegaard K, Sandström A, Aaby P. Maternal mortality: only 42 days? BJOG. 2003;110:995–1000
3. Hamza S. The maternal mortality: Egyptian national maternal mortality study. Ain Shams J Obstet Gynecol. 2005;306:306–307
4. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367:1066–1074
5. Sexual and reproductive health. 2007. Available at: http://www.who.int/reproductivehealth/publications/en/
6. Ronsmans C, Graham WJ. Maternal mortality: who, when, where and why. Lancet. 2006;368:1189–1200
7. Bouvier Colle MH, Ould El Joud D, Varnoux N, Goffinet F, Alexander S, Bayoumeu F, et al. Evaluation of the quality of care for severe obstetrical haemorrhage in three French regions. BJOG. 2001;108:898–903
8. AbouZahr C, Wardlaw T Maternal mortality in 2000: estimates developed by WHO, UNICEF and UNFPA. 2004 Geneva Department of Reproductive Health and Research, World Health Organization (WHO)
Keywords:

labor; maternal deaths; maternal mortality; mortality rate

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