MATERNAL MORTALITY AND MORBIDITY 1. JOHN R. FRASER, M.D.

MONTREAL

1.

Since this article does not have an abstract, we have provided the first 150 words of the full text. Excerpt The meeting this year is one of peculiar importance, marking as it does the first occasion on which these two great national medical associations have met in joint session. These are anxious times, great problems of economic and social import are in process of solution, and much thought is being expended on the development of schemes for social betterment. It is only natural that some reflection of these activities should be manifested in the proceedings of these meetings. The world over, if one may judge by published reports, there is an awakening to the fact that obstetrics has failed to keep pace with the progress attained by other branches of medicine in lowering the death rate. Eardley Holland,1 recently addressing the Royal Sanitary Institute in London, put the situation fairly before the country when he said: The failure of the mortality rate to yield one decimal point to the Footnotes Read before the Section on Obstetrics, Gynecology and Abdominal Surgery at the Eighty-Sixth Annual Session of the American Medical Association, Atlantic City, N: J., June 12, 1935

Maternal Mortality and Morbidity Sanjay Datta, Bhavani Shankar Kodali and Scott Segal

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Book Chapter Airway Management and Mechanical Ventilation in Pregnancy Uma Munnur, Venkata Dp Bandi and Michael A. Gropper Respiratory Medicine, 2009, Pulmonary Problems in Pregnancy, 3, Pages 1-19
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Journal of Anesthesia, 2008, Volume 22, Number 1, Pages 38-48

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Maternal mortality and serious morbidity from obstetric anesthesia are rare. Although this is reassuring, important lessons can still be learned to continue to reduce the incidence toward zero. Moreover, changing demographics of the obstetric population are likely to challenge obstetric anesthesiologists to maintain the impressive safety record they have

increasingto epidemic levels. Fulltext Preview

major coexisting disease to bear children. Obesity is attained. Assisted reproductive technologies have allowed older women and those with

Maternal Mortality and Morbidity

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References (16) Export Citation About

Abstract
Maternal mortality and morbidity have always been important matters for discussion in obstetric anesthesia. Confidential inquires into maternal mortality in England and Wales have been used for international comparison because of strict record keeping.1 However, in recent past several important statistics regarding maternal mortality and morbidity have been published in the American literature.25

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10

Severe maternal morbidity in a tertiary care centre of northern Italy: a 5-year review.
Zanconato G, Cavaliere E, Iacovella C, Vassanelli A, Schweiger V, Cipriani S, Franchi M.

Source
University of Verona, Department of Life Science and Reproduction, Verona, Italy.

11

Abstract
Abstract Objective: To assess prevalence and causes of severe acute maternal morbidity cases and evaluate their impact on feto-maternal wellbeing and on facility resources. Study Design: Observational retrospective study adopting managementbased criteria in a tertiary care public hospital during a 5-year period. Criteria adopted were: intensive care unit admission; blood transfusion? 4 units; emergency peripartum hysterectomy and arterial embolization at any time during pregnancy. Results: A total of 80 cases were identified; most of them (97.5%) through a combination of two criteria; ICU admission and blood transfusion. Commonest severe obstetric morbidities were major obstetric haemorrhage (48.8%) and hypertensive disorders (27.5%). Immigrant status (OR 1.68; 95% CI 1.03-2.7); pre-term birth (OR 4.15; 95% CI 2.5-6.8); Caesarean section (OR 7.74;95% CI 4.2-14.3) were factors significantly associated with SAMM cases. Major abdominal surgery was necessary in 26 women (32.5%); with emergency peripartum hysterectomy in 11 (13.5%). These events led to an average blood consumption per woman of 6.5 12.8 units and a mean hospital stay of 8.9 5.0 days; significantly longer (p<0.001) than the average duration of post-delivery care. Maternal mortality to morbility ratio was 1:80. Conclusion: An integrated interventionbased approach proved to be effective in finding severe acute maternal morbidity cases. Information on underlying causes and associated risk factors may improve prevention and treatment of obstetric morbidities; thus reducing feto-maternal adverse effects and hospital expenditures.

Bothrops jararaca Peptide with Anti-Hypertensive Action Normalizes Endothelium Dysfunction Involved in Physiopathology of Preeclampsia.
Benedetti G, Morais KL, Guerreiro JR, de Oliveira EF, Hoshida MS, Oliveira L, Sass N, Lebrun I, Ulrich H, Lameu C, de Camargo AC.

Source
Center for Applied Toxinology-Centros de Pesquisa, Inovacio e Difusao, Instituto Butantan, Sao Paulo, Brazil.

Abstract
Preeclampsia, a pregnancy-specific syndrome characterized by hypertension, proteinuria and edema, is a major cause of fetal and maternal morbidity and mortality especially in developing countries. Bj-PRO-10c, a proline-rich peptide isolated from Bothrops jararaca venom, has been attributed with potent anti-hypertensive effects. Recently, we have shown that Bj-PRO-10cinduced anti-hypertensive actions involved NO production in spontaneous hypertensive rats. Using in vitro studies we now show that Bj-PRO-10c was able to increase NO production in human umbilical vein endothelial cells from hypertensive pregnant women (HUVEC-PE) to levels observed in HUVEC of normotensive women. Moreover, in the presence of the peptide, eNOS expression as well as argininosuccinate synthase activity, the key rate-limiting enzyme of the citrulline-NO cycle, were enhanced. In addition, excessive superoxide production due to NO deficiency, one of the major deleterious effects of the disease, was inhibited by Bj-PRO-10c. Bj-PRO-10c induced intracellular calcium fluxes in both, HUVEC-PE and HUVEC, which,

12

however, led to activation of eNOS expression only in HUVEC-PE. Since Bj-PRO-10c promoted biological effects in HUVEC from patients suffering from the disorder and not in normotensive pregnant women, we hypothesize that Bj-PRO-10c induces its anti-hypertensive effect in mothers with preeclampsia. Such properties may initiate the development of novel therapeutics for treating preeclampsia.

MATERNAL, INFANT, AND CHILD HEALTH IN RURAL AREAS: A LITERATURE REVIEW

by Jennifer Peck and Kristie Alexander

SCOPE OF PROBLEM

Infant mortality is higher in rural areas in the South and Western regions.3 Adolescent mortality is higher in rural areas in all four regions of the country.3

GOALS AND OBJECTIVES Improving the health of women, infants, children, and families, a Healthy People 2010 goal, involves identifying and eliminating health disparities in underserved populations. The key Healthy People 2010 objectives addressed in this review are as follows:

16-1. Reduce fetal and infant deaths. 16-6. Increase the proportion of pregnant women who receive early and adequate prenatal care. 16-8. Increase the proportion of very low birth weight (VLBW) infants born at Level III hospitals or subspecialty perinatal centers. 16-11. Reduce preterm births.

Differences across these key indicators of maternal and infant health have been observed across urban and rural locations. This article reviews the current state of these indicators of maternal and infant health as highlighted in Healthy People 20101 and identifies the extent of inequality by urban and rural residence. Several definitions are utilized to examine maternal and infant health:

Fetal Mortality refers to the death of a fetus between 20 weeks of gestation and birth. There are two measures for this indicator of perinatal health: fetal death rates (the number of deaths reported for every 1,000 live births and fetal deaths combined) and fetal death ratios (the number of fetal deaths for every 1,000 live births in the same year). Neonatal Mortality includes deaths within the first 28 days of life. Postneonatal Mortality identifies deaths from day 29 to one year of age. Infant Mortality is defined as the death of an infant before one year of age.

IDENTIFIED BY PEOPLE LIVING IN RURAL AREAS AS A HIGH PRIORITY HEALTH ISSUE FOR THEM According to the Rural Healthy People 2010 survey, maternal, infant, and child health was ranked as the ninth highest rural health priority and was nominated by 25 percent of state and local rural health respondents as a rural health priority. Maternal, infant, and child health was in a virtual tie with substance abuse, and educational and community-based programs for the seventh, eighth, and ninth place rankings.2 Unlike most of the higher-ranking

13

priorities, no significant differences were noted in frequency of nominations for maternal, infant, and child health either across four different types of state and local rural health respondent groups or across the four geographic regions of the country.29

PREVALENCE AND DISPARITIES IN RURAL AREAS Disparities in Infant Mortality

The infant mortality rate is an indicator of a populations health, reflecting the well being of infants, children, and pregnant women and the general state of maternal health, prenatal care, and public health practices.1 Among industrialized nations, the United States ranked 26th in infant mortality in 1996.9 The national infant mortality rate for the year 2000 was 6.9 infant deaths per 1,000 live births, down slightly from the 1999 rate of 7.130 but still well above the national target of 4.5.1 Twice as many infant deaths occur during the neonatal period compared to the postneonatal period (4.6 versus 2.3 per 1,000 live births in 2000).30 Neonatal deaths commonly result from congenital anomalies, prematurity, or complications of pregnancy and delivery; in contrast, postnatal deaths are less often the result of genetic or pregnancy-related causes and more often the result of infectious disease and injuries.11, 31 National infant death rates by area of residence show rates to vary across urban and rural regions.3 According to national data from 1996 through 1998,3 infant mortality rates for nonmetropolitan counties appear similar to metropolitan counties, with the exception of fringe counties of large metropolitan areas. The rates for these suburban counties are 20 percent lower (6.1 deaths per 1,000 live births) than other levels of urbanization (7.5 per 1,000 live births for other metropolitan counties and 7.7 per 1,000 live births for nonmetropolitan counties). When evaluated for regional variations, infant mortality rates are highest in the South, followed by the Midwest, Northeast, and West, respectively. Rates in the Northeast and Midwest regions are highest in central metropolitan counties, while nonmetropolitan counties have the highest rates in the South and West regions. Nonmetropolitan counties in the South exhibit higher infant mortality rates (8.7 per 1,000 live births) than nonmetro areas in all other geographic regions. When compared to metropolitan rates, the rate for the nonmetropolitan South is exceeded only by the infant mortality rate for large central metropolitan counties in the Midwest (9.6 per 1,000 live births).29 A study based on 1985 and 1987 national data reports higher rates of postneonatal mortality among nonmetropolitan county residents.32 Controlling for other risk factors such as race, maternal age, parity, marital status, maternal education, and prenatal care, rural residence is independently associated with increased rates of postneonatal mortality but not with rates of neonatal mortality. In addition to national infant mortality estimates, a number of state-based studies have examined the association between infant death and rural residence. In an Illinois study,4 researchers found that rural residents have a slightly higher, though not statistically significant, rate of neonatal mortality (6.9 per 1,000 births) compared to the rest of the state (6.7 per 1,000 births). The most rural counties with populations less than 2,500, however, have a rate of neonatal death that far exceeds all other areas (11.3 per 1,000 births). Postneonatal deaths are also higher in rural counties (3.7 per 1,000 births) than in the rest of the state (2.6 per 1,000). Using records from 1988, the neonatal mortality rate for all rural counties dropped and became lower than the rate for the state (4.8 versus 5.9, respectively). However, the neonatal death rate in the most rural counties (7.6 per 1,000) continued to exceed that of all nonmetropolitan counties (4.8) or the rest of the state (5.9). Postneonatal mortality rates remained higher among rural women (3.5 versus 2.8) but not statistically different. In Alabama, rural residents with normal birth weight infants have higher rates of postneonatal mortality than urban residents. The differential in postneonatal mortality rates between blacks and whites is also greater for rural residents. Among rural residents, the postneonatal mortality rate for blacks is 2.5 times higher than rural whites, while urban blacks have rates 2.1 times higher than urban whites.5 A Washington state study6 reports that rural residents who delivered infants in urban facilities between 1984-1988 had higher rates of neonatal mortality (10.2 per 1,000 births) than rural women delivering in rural facilities (3.7 per

14

1,000 births) or urban women delivering in urban facilities (5.2 per 1,000 births). In this study, rural and urban designations are based on the distance to hospitals officially designated as rural or urban. The higher rates of adverse pregnancy outcomes among rural residents delivering in urban hospitals may be evidence that high-risk pregnancies are appropriately referred to regional facilities with the appropriate resources. However, this finding may also be a reflection of poor access to local care. A Florida study documents that the rates of infant mortality in rural residents (9.3 per 1,000) compare unfavorably to rates for urban residents (7.5 per 1,000 births).7 The authors conclude that rural residence influences infant death indirectly through its association with other risk factors such as poverty, race/ethnicity, age, education, and availability and access to medical resources. In a study of access to care in a rural area in Indiana, availability of obstetrical services in nonmetropolitan counties is negatively correlated with infant mortality (r=-0.38, p=0.02).17 Furthermore, 14 percent (R2=14.44) of the variability in infant mortality in nonmetropolitan counties is explained by physician availability. Thus, lack of access to local care may explain some portion of disparate infant mortality rates in rural communities. As a whole, a number of state-based studies have found increased rates of infant mortality among rural residents. When other known social and biological risk factors are taken into account, there is evidence that rural residence may have an indirect effect on infant mortality rather than a direct association. Thus, disparities in infant mortality by area of residence may result from the disproportionate distribution of poverty, race/ethnicity, age, education, and availability and access to medical resources. Disparities in Adverse Pregnancy Outcomes Total fetal mortality rates in 1990 were reported to be slightly lower for metropolitan (6.8 per 1,000 live births and fetal deaths) than nonmetropolitan (7.1 per 1,000 live births and fetal deaths) populations.33 Rates were inversely associated with the mothers educational attainment, revealing an increase to 8.4 fetal deaths per 1,000 live births for mothers with less than 12 years of schooling. Fetal death ratios in 1992 were approximately 4 percent higher in nonmetropolitan areas (7.6 per 1,000 live births) than in metropolitan areas (7.3 per 1,000).34 Higher fetal death ratios were consistently observed in nonmetropolitan areas across racially defined groups; however, fetal death ratios were approximately two times higher among blacks than whites.34 Reports of pregnancy outcomes, such as low birth weight and premature birth, have had mixed results when rates are compared for rural and urban populations. A study of Iowa women, who delivered live-born infants by cesarean section, found rural residents to have poorer birth outcomes than women residing in urban counties.8 These rural residents had lower birth weights, shorter gestations, lower Apgar scores, longer hospital stays, higher costs, and greater distances to travel for delivery than urban women or women living in rural areas adjacent to urban areas.8 In Illinois, low birth weight and fetal death rates were found to be slightly higher in rural counties compared to the rest of the state, but these differences were not statistically different (low birth weight, 6 percent versus 5 percent; fetal death rate, 6.7 versus 6.3).4 A Wisconsin study35 found that although rural women are more likely to have inadequate prenatal care, rates of low birth weight outcomes do not differ between urban and rural residents. However, urban women have higher rates of very low birth weight outcomes (< 1000 grams) than their rural counterparts (10.8 per 1,000 compared to 7.6 per 1,000). Furthermore, low prenatal care utilization is positively associated with low birth weight in urban counties, but this association was not observed in rural counties. A comparison of birth outcomes for women attending public health department prenatal clinics found rural women deliver infants with lower average birth weights despite entering prenatal care earlier than urban women.36 However, rural residence does not significantly predict infant birth weight patterns when adjusting for race, education, total prenatal visits, weeks gestation at first prenatal visit, and prepregnancy weight/weight gain. Crude analyses of metropolitan and nonmetropolitan differences show slightly lower percentages of low birth weight, very low birth weight, and neonatal death rates among nonmetropolitan residents but higher rates of postneonatal deaths. The differences in low and very low birth weight persist among blacks and American Indians when the data are stratified by race, but rural whites have higher rates of low birth weight than urban whites. When

15

other risk factors such as race, maternal age, parity, marital status, maternal education, and prenatal care are controlled in the analysis, neonatal mortality and low birth weight no longer differ by metro-nonmetro residence. However, rural residence is independently associated with postneonatal mortality rates.

Disparities in Prenatal Care

Among several national and state-based studies of prenatal care utilization, the majority of studies report less adequate prenatal care among rural women than among urban women. There is a plethora of evidence from studies using data from the late 1980s that prenatal care among rural residents compares unfavorably with care received by urban populations. The few reports from 1990s data suggest that prenatal care remains inadequate in both urban and rural locations but may be most lacking in urban areas. Thus, prenatal care for rural women may be approaching rates for urban women, but care in both groups remains inadequate and below the national goal of 90 percent initiating care in the first trimester.1 Analysis of the National Linked Birth Death Data Set for the 1985-1987 study period reveals that non-metropolitan residents in the United States are more likely than their urban counterparts to delay prenatal care until the third trimester.32 This result persists after controlling for other risk factors such as race, maternal age, parity, marital status, and maternal education. Using the Adequacy of Prenatal Care Utilization Index37 to combine information on timing and amount of care, disparities by residence become apparent. Significantly more nonmetropolitan women (16.8 percent) receive inadequate prenatal care compared to metropolitan women (12.5 percent). When evaluated by race/ethnicity, the disadvantage among nonmetropolitan residents persists for each racial/ethnic group; however, the difference by residence is greatest among Hispanic women (19 percent metro and 32 percent nonmetro), notable among whites (8 percent metro and 13 percent nonmetro), and alarmingly high for both groups of African Americans (25 percent metro and 29 percent nonmetro). When comparing the proportion of women with adequate prenatal care, there is no difference by residence, with roughly one-third of all women classified as receiving adequate care. A number of state-based studies conducted in Washington, Illinois, Wisconsin, and Virginia found comparable trends in inadequate prenatal care among rural women.4, 6, 35, 36 Analysis of the 1988 National Maternal and Infant Health Survey shows that U.S. women residing in nonmetropolitan areas were more likely to receive inadequate prenatal care than metropolitan residents, irrespective of race/ethnicity or socioeconomic status.15 However, differences by race/ethnicity are also observed. When comparing white, black, and Hispanic women by residence, Hispanics who live in nonmetropolitan areas are the most likely to receive inadequate care.15 The probability of inadequate care is highest for high-risk Hispanic women living in rural areas. The high-risk profile includes those who are poor, have no insurance, have an unwanted pregnancy, live alone and unmarried, are young, have low educational attainment, have no previous pregnancies, use a public provider, drive an hour or more to provider, and do not take prenatal classes. Inadequate prenatal care is defined, according to the Kotelchuck Adequacy of Prenatal Care Index, as entry later than the fourth month of pregnancy or receiving less than 50 percent of the expected number of visits.37 In contrast, a study of Hispanic women in San Diego County, California, found rural women to enter prenatal care earlier than urban women. Those delivering in urban county hospitals in 1991-1992 were twice as likely to delay prenatal care beyond 24 weeks gestation than women who delivered in rural hospitals, independent of other factors such as income, education, marital status, language, pregnancy wantedness, and total number of barriers to care.38 The most frequent barriers to prenatal care were the same for urban and rural women: lack of money, distance to care, lack of transportation, and depression. The most current comparison of urban and rural prenatal care comes from the 1995 National Survey of Family Growth. This survey indicates that more nonmetropolitan than suburban women receive delayed or no prenatal care.16 However, urban central city residents have the highest percentage of prenatal care delayed beyond the first trimester. More suburban residents initiate prenatal care early, followed by nonmetropolitan residents and central city residents.

16

Disparities in Obstetrical Care Pregnant women residing in rural areas with fewer available obstetric services in their communities frequently opt to deliver outside their communities.18 Seeking services outside the community is considered an indicator of inadequate access to care. Rural women seeking obstetrical services outside their local community hospital experience more complications during delivery and higher rates of preterm birth compared to rural mothers who deliver at local facilities.18 The infants treated in facilities outside the community also have longer and more expensive stays. According to data from the 1995 National Survey of Family Growth, fewer nonmetropolitan mothers have insurance to cover all expenses associated with labor and delivery.16 Thus, a higher percentage of nonmetropolitan residents pay out-of-pocket expenses for all or part of their labor and delivery charges.16 Another study examines whether use of high-technology services differs for urban or rural women in the U.S.39 Among women with high-risk pregnancies, including those with preterm births or who receive a high-risk medical diagnosis, urban women are two to three times more likely to deliver at facilities with high technology capabilities compared to rural women.39

IMPACT OF THE CONDITION ON MORBIDITY AND MORTALITY

Adverse Pregnancy Outcomes

There were over four million births in the United States in the year 2000, and the crude birth rate was 14.8 per 1,000 population.40 Adverse pregnancy outcomes such as fetal death, low birth weight, and preterm birth, however, were a major source of perinatal morbidity and mortality. The leading causes of infant mortality in 2000 included congenital malformations, low birth weight and preterm birth, and sudden infant death syndrome (SIDS), accounting for 20.7, 15.4 and 7.7 percent, respectively, of all infant deaths.30 After the first month of life, the leading cause of infant death is SIDS, representing approximately one-third of postneonatal deaths in 1997.30 Low birth weight and premature birth are major sources of infant morbidity and mortality. Preterm birth accounts for the majority of neonatal deaths not associated with birth defects.1 Long-term impairments associated with low birth weight and preterm birth include cerebral palsy, autism, mental retardation, vision and hearing difficulties, learning disabilities, and delayed development.10 Respiratory distress is the most common cause of death among low birth weight infants.11 The introduction of surfactant in the early 1990s for the treatment of respiratory distress contributed to improved survival of premature and very low birth weight infants.41 Although survival of the preterm or low birth weight infant has improved along with medical advancements, rates of long-term disabilities associated with these birth outcomes have not experienced a similar decline.

Prenatal Care and Obstetrical Care

Lack of available local prenatal and obstetrical care in rural areas is reported to be associated with higher rates of preterm delivery, infant mortality, and complications during delivery.17-20 Overall, fewer preterm and low birth weight infants are born to women who receive early and comprehensive prenatal care.42 Hypotheses for the association between access to care and pregnancy outcome include longer travel time for routine care, which is associated with poor compliance for prenatal care due to factors such as transportation problems.43 Other explanations include lack of adherence to prenatal protocols prescribed by providers in distant locations, delayed hospital arrival following onset of labor, and the stresses associated with travel and delivery in an unfamiliar setting.18 Maternal mortality can potentially be reduced through quality prenatal and obstetrical care. Maternal deaths from complications such as ectopic pregnancy, infection, and hemorrhage can be prevented. It is estimated that early diagnosis and effective treatment of pregnancy complications may prevent over half of all maternal deaths.27, 28

17

BARRIERS Access to available prenatal and obstetrical care is necessary to ensure the health and well being of mother and baby. Although there has been recent progress with technological advancements in perinatal medicine, access to such services has concurrently deteriorated for rural residents. One reason for decreased access is the number of family practitioners dropping obstetrics from their practice, most often due to the high cost of medical malpractice insurance and increasing fear of litigation.44 A total of 9 percent of all physicians practice medicine in rural areas.45 The number of rural obstetric providers in the United States has been decreasing since the early 1980s,46, 47 with a 20 percent decrease in obstetric providers between 1984 and 1989 alone.47 The number of rural family physicians providing obstetric or neonatal care has also declined in recent decades.11 In 1992, only 37 percent of rural family physicians offered obstetric services, and only 65 percent provided care for newborns.48 Thus, the decline in access to maternity care is accompanied by declining access to neonatal services. A decrease in obstetric services in rural areas has created a barrier to prenatal and obstetric care, particularly for women with high-risk pregnancies. In the 1980s, there was a transition to regionalized systems of perinatal care to provide access to tertiary care for high-risk, rural mothers and their infants. Regionalization led to marked improvements in birth weight-specific infant mortality rates among rural infants,6, 18 but regional variation remains.32 Furthermore, interhospital transport has been associated with excess morbidity49 as well as additional expense, stress, and inconvenience.50 Other barriers to prenatal care for women living in rural communities include less access to health insurance,21 greater distance and travel time to providers,22 transportation problems,11, 23, 24 and child-care difficulties for larger families.23, 24 However, a study of predictors of distance traveled for prenatal care showed that up to 50 percent of rural Alabama women bypassed the nearest rural hospital to obtain obstetrical care, with approximately one-third delivering in metropolitan hospitals.22 Rural women with higher incomes and insurance coverage are more likely to travel further to seek obstetrical services from larger hospitals with neonatal intensive care units.22 KNOWN CAUSES OF THE CONDITION OR PROBLEM SO EFFECTIVE INTERVENTIONS OR SOLUTIONS CAN BE IDENTIFIED Fetal Mortality Risk factors for infant death include low birth weight, preterm birth, delayed or lack of prenatal care, mother under age 20 or over age 40, low educational attainment of mother, maternal smoking during pregnancy, and more than three previous births.12 Additionally, maternal and infant morbidity and mortality more commonly result from unintended pregnancies.13, 14 It is estimated that one-third to one-half of all pregnancies in the U.S. are unplanned.13, 51, 52 This estimate increases to 75 percent of all pregnancies among women under 20 years of age.13 Women with unintended pregnancies are more likely to engage in high-risk behaviors, such as smoking, alcohol intake, and poor nutrition,13 and delay prenatal care beyond the first trimester.13 In addition to reflecting disparities by racial/ethnic composition and poverty, higher infant mortality rates among the nonmetropolitan South may result from disproportionately low maternal ages and risk behaviors, such as smoking during pregnancy. Birth rates among adolescents 15 to 19 years of age are highest among residents of nonmetropolitan counties in the South (70.4 per 1,000 female adolescents).3 According to the National Center for Health Statistics, the percentage of births among teenagers (less than 20 years of age) in 1992 was higher for nonmetropolitan mothers (16 percent) than metropolitan mothers (12 percent).53 The difference by geographic location is even more pronounced when examined by race. Among nonmetro blacks, 27 percent of live-born infants are born to mothers under 20 years of age. The corresponding figure for nonmetro white infants is 14 percent. Both adolescents and adults who live in the most rural counties are more likely to smoke than those living in other levels of urbanization.3 According to national birth certificate data from 1996, young women age 1519 also have the highest rates of smoking during pregnancy.54 Although the rate of smoking during pregnancy dropped slightly between 1990 and 1996, 17.2 percent of women in the 15-19 age group continued to smoke during pregnancy in 1996.54

Adverse Pregnancy Outcomes

18

Fetal deaths are commonly associated with maternal complications including amniotic fluid levels and maternal blood disorders.55 Risk factors associated with low birth weight include younger and older maternal age, high parity, low socioeconomic status, low educational attainment, inadequate prenatal care, low pregnancy weight gain, previous low birth weight infant, multiple births, smoking, alcohol intake, and illicit drug use.36, 56 Less is currently known about the risk factors for preterm birth. Predictors identified to date include previous preterm delivery; multiple gestation; the use of alcohol, tobacco, and illicit drugs during pregnancy; low prepregnancy weight; low weight gain during pregnancy; vaginal infections; and domestic violence.1, 56, 57 Studies have shown that demographic composition and behavioral risk factors differ for rural and urban women in ways that influence pregnancy outcomes, such as low birth weight.36 Rural women receive approximately one year less of formal education than urban women.58 Poverty rates in rural areas are reportedly 30 percent higher than in urban areas.59 Rural women are less likely to be married, lacking the social, emotional, and financial support that marriage may offer, which may have a link to adverse pregnancy outcomes.60 A lack of social support or tangible assistance is previously shown to be associated with poor birth outcomes, particularly among those who are very young, unmarried, or have less than a high school education.61

Inadequate Prenatal Care The percentage of women delaying prenatal care or receiving no prenatal care has improved during the period of 1989-1997 from 25 to 18 percent. The top three reasons for not initiating early care include not knowing they are pregnant, inability to pay for care, and inability to obtain an earlier appointment.25 Twice as many non-Hispanic blacks (28 percent) and Hispanic women (26 percent) delay or receive no prenatal care compared to white women (12 percent).25 Furthermore, over 32 percent of mothers under age 20 and 32 percent of mothers with less than a high school education receive delayed or no prenatal care.25 Of note, most of the characteristics that predict prenatal care utilization such as age, race, ethnicity, marital status, income, education, and rurality are the same as those associated with adverse pregnancy outcomes, such as low birth weight.

PROPOSED SOLUTIONS OR INTERVENTIONS THAT ARE FEASIBLE IN RURAL COMMUNITIES

Prenatal care is regarded as a successful approach for improving pregnancy outcomes. However, close to 20 percent of pregnant women in the United States continue to refuse or delay prenatal care.25 Women who do not receive prenatal care or who delay prenatal care beyond the first trimester are at risk of severe maternal morbidity and possible mortality due to undetected complications of pregnancy.25 The effectiveness of prenatal care is believed to be due to three primary components: early and continuous risk assessment, health education, and medical and psychological intervention.26 COMMUNITY MODELS KNOWN TO WORK See the Models for Practice Section in Volume 1 for a catalog of models. SUMMARY AND CONCLUSIONS Rural mothers and their children comprise a large segment of the U.S. population. Thus, health disparities between rural and urban groups are of national concern. Increased rates of adverse pregnancy outcomes in rural areas, such as preterm birth and low birth weight have been observed, as well as higher rates of infant mortality. Access to prenatal care is critical for reducing maternal and infant morbidity and mortality, though rural women tend to receive less adequate prenatal care than their urban counterparts. Although the risk factors for these conditions tend to disproportionately affect women in rural areas, the health status of rural mothers and infants can be largely improved by eliminating existing barriers to high quality, comprehensive prenatal care. Improving the health of rural mothers and infants, from preconception to pregnancy to birth and beyond, advances the health of the next generation.

19

REFERENCES 1. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000, 16-12 16-62. 2. Gamm, L.; Hutchison, L.; Bellamy, G.; et al. Rural healthy people 2010: Identifying rural health priorities and models for practice. Journal of Rural Health 18(1):9-14, 2002. 3. Eberhardt, M.; Ingram, D.; Makuc, D.; et al. Urban and Rural Health Chartbook, Health, United States, 2001. Hyattsville, MD: National Center for Health Statistics, 2001. 4. Rock, S., and Straub, L. Birth outcomes to rural Illinois residents: Is there a crisis? Journal of Rural Health 10(2):122-130, 1994. 5. Druschel, C.M., and Hale, C.B. Postneonatal mortality among normal birth weight infants in Alabama, 1980 to 1983. Pediatrics 80(6):869-872, 1987. 6. Larson, E.; Hart, L.; and Rosenblatt, R. Rural residence and poor birth outcome in Washington state. Journal of Rural Health 8(3):162-170, 1992. 7. Clarke, L., and Coward, R. A multivariate assessment of the effects of residence on infant mortality. Journal of Rural Health 7(3):246-265, 1991. 8. Hulme, P., and Blegen, M. Residential status and birth outcomes: Is the urban/rural distinction adequate? Public Health Nursing 16(3):176-181, 1999. 9. U.S. Department of Health and Human Services. Briefing book fiscal year 2000: Infant mortality. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, 2001, 50-54. 10. McCormick, M. The contribution of low birth weight to infant mortality and childhood morbidity. New England Journal of Medicine 312:80-90, 1985. 11. Lishner, D.; Larson, E.; Rosenblatt, R.; et al. Rural Maternal and Perinatal Health. In Ricketts, T. (ed.), Rural Health in the United States. New York: Oxford University Press, 134-149, 1999. 12. Mathews, T.; Curtin, S.; and MacDorman, M. Infant mortality statistics from the 1998 period linked birth/infant death data set. National Vital Statistics Reports 48, 2000. 13. Centers for Disease Control and Prevention (CDC). Healthier mothers and babies. Morbidity and Mortality Weekly Report 48(38):849-858, 1999. 14. Brown, S., and Eisenberg, L. The best intentions: Unintended pregnancy and the well-being of children and families. Washington, DC: National Academy Press, 1995. 15. Miller, M.K.; Clarke, L.L.; Albrecht, S.L.; et al. The interactive effects of race and ethnicity and mothers residence on the adequacy of prenatal care. Journal of Rural Health 12(1):6-18, 1996.

Chapter Suggested Citation

Peck, J., and Alexander, K. (2003). Maternal, Infant, and Child Health in Rural Areas: A Literature Review. Rural Healthy People 2010: A companion document to Healthy People 2010. Volume 2. College Station, TX: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.

Severe maternal morbidity and near misses in a regional reference hospital.

20

[Article in English, Portuguese] Morse ML, Fonseca SC, Gottgtroy CL, Waldmann CS, Gueller E.

Source
Instituto de Sade da Comunidade, Universidade Federal Fluminense, Niteri, RJ. marcialait@bol.com.br

Abstract
OBJECTIVE:
To investigate severe maternal morbidity/near misses in a tertiary public maternity in the state of Rio de Janeiro, using different identification criteria.

METHODS:
This is a cross-sectional study, performed in a regional reference hospital between June and October 2009, on severe maternal morbidity/near miss cases identified from the log books of the maternity hospital and review of medical records. This study focused on women who, during pregnancy, delivery, or the postpartum period, showed no clinical symptoms compatible with the defining criteria for severe maternal morbidity/near miss of Waterstone et al, Mantel et al. and the World Health Organization (WHO).

RESULTS:
Among the 1,544 admissions during the period studied, 89 women with severe maternal morbidity were identified, considering all criteria. The occurrence of severe maternal morbidity/near misses ranged from 81.4 to 9.4 per 1,000 live births (LB), depending on the criterion used. The mortality rate was 3.2%, reaching 23% in the WHO criteria. Only 40% of these women had more than six prenatal visits and 10% did not have any visit at all. The most common markers found were severe preeclampsia, followed by severe hemorrhage, ICU admissions, HELLP syndrome, and eclampsia. There were three maternal deaths with a MMR = 280/100.000 LB and one late death. The WHO criterion showed greater specificity, identifying more severe cases, while the Waterstone criterion was more sensitive.

CONCLUSIONS:
The study of severe maternal morbidity/near misses in a regional reference hospital can contribute to the knowledge of this event's magnitude, as well as to identify its most frequent characteristics and clinical conditions, being essential for dealing with maternal morbidity and mortality.

Maternal and perinatal health

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Causes of maternal death

Haemorrhage and hypertensive disorders together account for the largest proportion of maternal deaths in developing countries, according to an HRP study, believed to be the first to use the systematic review approach to analyse causes of maternal mortality. The results of the review, which was published in The Lancet,(Khan KS et al. WHO analysis of causes of maternal death: a systematic review. Lancet, 2006, 367:10661074.) are based on an analysis of 160 datasets, or studies, that came from a multiplicity of sources including general and specialized databases, reference lists from studies produced by a search of these databases, personal contacts with WHO country representatives, nongovernmental organizations, journal articles and vital registry data. These sources produced 64 585 titles of reports, from which 1143 potentially usable datasets were identified and finally whittled down to the 160 that were used for the analysis.

Table 1. Maternal conditions most frequently reported in sudies included in the WHO/HRP systematic review
Morbidity Hypertensive disorders of pregnancy Stillbirth Preterm delivery Induced abortion Haemorrhage (antepartum, intrapartum, postpartum, unspecified) Anaemia Placenta anomalies (pravia, abruptio, etc.) Spontaneous abortion Gestational diabetes Ectopic pregnancy Premature rupture of membranes Perineal laceration Uterine rupture Obstructed labour Depression (postpartum, during pregnancy) Puerperal infection Violence during pregnancy Urinary tract infection Malaria Other conditions Overall Number of studies (%) 885 (14.9) 828 (13.9) 489 (8.2) 400 (6.7) 365 (6.2) 267 (4.5) 245 (4.1) 235 (4.0) 224 (3.8) 146 (2.5) 140 (2.4) 139 (2.3) 116 (2.0) 102 (1.7) 96 (1.6) 86 (1.5) 77 (1.3) 66 (1.1) 54 (0.9) 973 (16.4) 593

Three important criteria for inclusion of a dataset or study were that: (i) the data had to cover the period 19972002; (ii) the study participants had to be pregnant women or women who had ended a pregnancy over the previous year; and (iii) the deaths reported had to have occurred during the pregnancy or within one year of termination of the pregnancy. The systematic review found that the distribution of causes of maternal death varies by United Nations region. Haemorrhage, for example, is the leading cause of maternal mortality in Africa (Table 2), accounting for 34% of maternal deaths, and also in Asia (Table 3), where it accounts for 31% of maternal deaths. In Latin America and the Caribbean, hypertensive disorders, causing 26% of maternal deaths, top the list of causes (Table 4). In developed countries, the most important cause of maternal death is "other direct causes" (21%), which includes largely complications during interventions such as those related to caesarean section and anaesthesia, followed by hypertensive disorders and embolism (Table 5). 22

Table 2. Causes of maternal death in Africa

Morbidity Haemorrhage Other indirect causes of deaths Sepsis Hypertensive disorders HIV/AIDS Unclassified deaths Other direct causes of deaths Obstructed labour Abortion Anaemia Embolism Ectopic pregnancy Percentage 33.9 16.7 9.7 9.1 6.2 5.4 4.9 4.1 3.9 3.7 2 0.5

Table 3. Causes of maternal death in Asia

Morbidity Haemorrhage Anaemia Other indirect causes of deaths Sepsis/infection Obstructed labour Hypertensive disorders Unclassified deaths Abortion Other direct causes of deaths Embolism Ectopic pregnancy HIV/AIDS Percentage 30.8 12.8 12.5 11.6 9.4 9.1 6.1 5.7 1.6 0.4 0.1 0

Estimates of maternal mortality

Estimates of maternal mortality ratios (MMRs), namely, the number of maternal deaths per 100 000 live births, calculated for 141 countries included in the systematic review showed a strong association with three factors: (i) the proportion of deliveries assisted by a skilled attendant; (ii) the infant mortality rate; and (iii) national per capita expenditure on health. The estimates were based mainly on vital registration data and on survey data for the period 19972002. The estimated MMRs varied considerably between countries, even countries within a region or countries grouped by development status. MMRs ranged from 127 to 1289 in the least developed countries and from two to 695 in the less developed countries. Development status clearly showed an inverse relationship with MMR: generally speaking, the higher the level of development, the lower the MMR. Source: Betrn AP, Wojdyla D, Posner SF, Glmezoglu AM. National estimates for maternal mortality: an analysis based on the WHO systematic review of maternal mortality and morbidity. Biomed Central Public Health, 2005, 5:131 (doi:10.1186/1471-2458-5-131).

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Prevalence of severe acute maternal morbidity

A situation in which a "very ill pregnant or recently delivered woman would have died had it not been for luck and good care" has entered the obstetric literature under the term severe acute maternal morbidity (SAMM), more commonly known as a near miss. Of the studies included in the overall systematic review, 30 included reports of SAMM cases for the period 19972002. An HRP analysis of these reports showed prevalence rates ranging from 0.38% to 8.23% for the period of interest. Complicating the analysis is the existence of several definitions of SAMM. One common definition is based on the disease or disorder that caused the near miss, such as preeclampsia, haemorrhage, and so on. A second common definition focuses more on how the problem was managed, such as by hysterectomy or admission to an intensive care unit. A third, more exact, definition is based on failure of specific body organs as a result of pregnancy-related conditions. As per this last definition, the study showed that, of pregnant women who deliver in hospitals in resource-poor areas, 4%8% will experience SAMM, versus about 1% for women delivering in more developed areas.

Key facts

Every day, approximately 1000 women die from preventable causes related to pregnancy and childbirth. 99% of all maternal deaths occur in developing countries. Maternal mortality is higher in rural areas and among poorer and less educated communities. Adolescents face a higher risk of complications and death as a result of pregnancy than older women. Skilled care before, during and after childbirth can save the lives of women and newborn babies. Between 1990 and 2008, maternal mortality worldwide dropped by one third.

Maternal mortality is unacceptably high. About 1000 women die from pregnancy- or childbirth-related complications around the world every day. In 2008, 358 000 women died during and following pregnancy and childbirth. Almost all of these deaths occurred in developing countries, and most could have been prevented.

Progress towards achieving the fifth Millennium Development Goal

Improving maternal health is one of the eight Millennium Development Goals (MDGs) adopted by the international community in 2000. Under MDG5, countries committed to reducing maternal mortality by three quarters between 1990 and 2015. Since 1990, maternal deaths worldwide have dropped by 34%. In sub-Saharan Africa, a number of countries have halved their levels of maternal mortality since 1990. In other regions, including Asia and North Africa, even greater headway has been made. However, between 1990 and 2008, the global maternal mortality ratio (i.e. the number of maternal deaths per 100 000 live births) declined by only 2.3% per year. This is far from the annual decline of 5.5% required to achieve MDG5.

Where do maternal deaths occur?

The high number of maternal deaths in some areas of the world reflects inequities in access to health services, and highlights the gap between rich and poor. Almost all maternal deaths (99%) occur in developing countries. More than half of these deaths occur in sub-Saharan Africa and one third occur in South Asia. The maternal mortality ratio in developing countries is 290 per 100 000 births versus 14 per 100 000 in developed countries. There are large disparities between countries, with some countries having extremely high maternal mortality ratios of 1000 or more per 100 000 live births. There are also large disparities 24

within countries, between people with high and low income and between people living in rural and urban areas. The risk of maternal mortality is highest for adolescent girls under 15 years old.1 Complications in pregnancy and childbirth are the leading cause of death among adolescent girls in most developing countries.2 Women in developing countries have on average many more pregnancies than women in developed countries, and their lifetime risk of death due to pregnancy is higher. A womans lifetime risk of maternal death the probability that a 15-year-old woman will eventually die from a maternal cause is 1 in 4300 in developed countries, versus 1 in 120 in developing countries.

Why do women die?

Women die as a result of complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy. Other complications may exist before pregnancy but are worsened during pregnancy. The major complications that account for 80% of all maternal deaths are:

severe bleeding (mostly bleeding after childbirth) infections (usually after childbirth) high blood pressure during pregnancy (pre-eclampsia and eclampsia) obstructed labour unsafe abortion.

The remainder are caused by diseases such as malaria, anaemia and HIV/AIDS during pregnancy. Maternal health and newborn health are closely linked. More than three million newborn babies die every year, and an additional three million babies are stillborn.3

How can womens lives be saved?

Most maternal deaths are avoidable, as the health-care solutions to prevent or manage complications are well known. All women need access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth. It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death. Severe bleeding after birth can kill a healthy woman within two hours if she is unattended. Injecting oxytocin immediately after childbirth effectively reduces the risk of bleeding. Infection after childbirth can be eliminated if good hygiene is practised and if early signs of infection are recognized and treated in a timely manner. Pre-eclampsia should be detected and appropriately managed before the onset of convulsions (eclampsia) and other life-threatening complications. Administering drugs such as magnesium sulfate for pre-eclampsia can lower a womans risk of developing eclampsia. Obstructed labour occurs when the baby's head is too big for the mothers pelvis or if the baby is abnormally positioned for birth. A simple tool for identifying these problems early in labour is the partograph a graph of the progress of labour and the maternal and fetal condition. Skilled practitioners can use the partograph to identify and manage a slow labour before the lives of the mother and baby are threatened. If necessary, a caesarean section can be performed.

25

To avoid maternal deaths, it is also vital to prevent unwanted and too-early pregnancies. All women, including adolescents, need access to family planning, safe abortion services to the full extent of the law, and quality post-abortion care.

Why do women not get the care they need?

Poor women in remote areas are the least likely to receive adequate health care. This is especially true for regions with low numbers of skilled health workers, such as sub-Saharan Africa and South Asia. While levels of antenatal care have increased in many parts of the world during the past decade, only 66% of women in developing countries benefit from skilled care during childbirth. This means that millions of births are not assisted by a midwife, a doctor or a trained nurse. In high-income countries, virtually all women have at least four antenatal care visits, are attended by a skilled health worker during childbirth and receive postpartum care. In low- and middle-income countries, less than half of all pregnant women have a minimum of four antenatal care visits. Other factors that prevent women from receiving or seeking care during pregnancy and childbirth are:

poverty distance lack of information inadequate services cultural practices.

To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at all levels of the health system.

WHO response
Improving maternal health is one of WHOs key priorities. WHO is working to reduce maternal mortality by providing evidence-based clinical and programmatic guidance, setting global standards, and providing technical support to Member States. In addition, WHO advocates for more affordable and effective treatments, designs training materials and guidelines for health workers, and supports countries to implement policies and programmes and monitor progress. During the United Nations MDG summit in September 2010, UN Secretary-General Ban Ki-moon launched a Global strategy for women's and children's health, aimed at saving the lives of more than 16 million women and children over the next four years. WHO is working with partners towards this goal.

Vitamin A supplementation in postpartum women

Maternal dietary intake is an important determinant of maternal vitamin A status and vitamin A concentrations in breast milk. A variety of programmes have been used for improving women's vitamin A status and to increase the vitamin A content of breast milk to indirectly provide more vitamin A to breastfed infants, who usually are born with low vitamin A. In infants, vitamin A is essential to support rapid growth and to help combat infections. Informed by the available evidence, the WHO does not recommend vitamin A supplementation for postpartum women as a public health intervention for the prevention of maternal and infant morbidity and mortality.

26

Accelerating efforts to save the lives of women and newborns

Joint statement on behalf of the UNICEF, United Nations Population Fund, the World Bank and WHO
25 September 2008 During the next five years, we will enhance support to the countries with the highest maternal mortality. We will support countries in strengthening their health systems to achieve the two MDG 5 targets of reducing the maternal mortality ratio by 75% and achieving universal access to reproductive health by 2015. Our joint efforts will also contribute to achieving MDG 4: To reduce child mortality. Every minute a woman dies in pregnancy or childbirth: over 500 000 every year. And every year over one million newborns die within their first 24 hours of life for lack of quality care. Maternal mortality is the largest health inequity in the world; 99% of maternal deaths occur in developing countries half of them in Africa. A woman in Niger faces a 1 in 7 chance during her lifetime of dying of pregnancy related causes, while a woman in Sweden has 1 chance in 17 400. Fortunately, the vast majority of maternal and newborn deaths can be prevented with proven interventions to ensure that every pregnancy is wanted and every birth is safe. We will work with governments and civil society to strengthen national capacity to:

Conduct needs assessments and ensure that health plans are MDGdriven and performance based; Cost national plans and rapidly mobilize required resources; Scale up quality health services to ensure universal access to reproductive health, especially for family planning, skilled attendance at delivery and emergency obstetric and newborn care, ensuring linkages with HIV prevention and treatment; Address the urgent need for skilled health workers, particularly midwives; Address financial barriers to access, especially for the poorest; and Tackle the root causes of maternal mortality and morbidity, including gender inequality, low access to education especially for girls, child marriage and adolescent pregnancy; Strengthen monitoring and evaluation systems.

In the countdown to 2015, we call on Member States to accelerate efforts for achieving reproductive, maternal and newborn health. Together we can achieve Millennium Developments Goals 4 and 5.

Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality

1. Margaret Oates + Author Affiliations 1. Nottingham University Medical School, Nottingham, UK 1. Correspondence to: Dr Margaret Oakes, Nottingham University Medical School, Division of Psychiatry, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA, UK. E-mail: Margaret.Oates@nottingham.ac.uk

Abstract
The Confidential Enquiry into Maternal Deaths 1997 to 1999 finds that psychiatric disorder, and suicide in particular, is the leading cause of maternal death. Suicide 27

accounted for 28% of maternal deaths. Women also died from other complications of psychiatric disorder and a significant minority from substance misuse. Some of the findings of the Confidential Enquiry confirm long established knowledge about postpartum psychiatric disorder. The findings highlight the severity and early onset of serious postpartum mental illness and of the risk of recurrence following childbirth faced by women with a previous history of serious mental illness either following childbirth or at other times. These findings led to the recommendation that all women should be asked early in their pregnancy about a previous history of serious psychiatric disorder and that management plans should be in place with regard to the high risk of recurrence following delivery. Other findings of the Enquiry were new and challenged some of the accepted wisdoms of obstetrics and psychiatry. It is likely that the suicide rate following delivery is not significantly different to other times in womens lives and for the first 42 days following delivery may be elevated. This calls into question the so-called protective effect of maternity. The overwhelming majority of the suicides died violently, contrasting with the usual finding that women are more likely to die from an overdose of medication. Compared to other causes of maternal death, the suicides were older and socially advantaged. The Enquiry findings suggest that the risk profile for women at risk of suicide following delivery may be different to that in women at other times and in men. None of the women who died had been admitted at any time to a Mother and Baby Unit and their psychiatric care had been undertaken by General Adult Services. None of the women who died had had a previous episode correctly identified and none had had adequate plans for their proactive care. The conclusion is that there is a need for both Psychiatry and Obstetrics to acknowledge the substantial risk that women with a previous psychiatric history of serious mental illness face following delivery.
British

Medical Bulletin, Vol. 67 The British Council 2003; all rights reserved

Maternal deaths drop by one-third from 1990 to 2008: a United Nations analysis
John Wilmoth a, Colin Mathers b, Lale Say c & Samuel Mills d
a. Department of Demography, University of California at Berkeley, Berkeley, CA, United States of America (USA). b. Department of Health Statistics and Informatics, World Health Organization, Geneva, Switzerland. c. Department of Reproductive Health and Research, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland. d. Human Development Network, The World Bank, Washington DC, USA. Correspondence to Lale Say (e-mail: sayl@who.int). Bulletin of the World Health Organization 2010;88:718-718A. doi: 10.2471/BLT.10.082446 28

With only five years left until the 2015 deadline to achieve the United Nation's Millennium Development Goals (MDGs), slow progress in MDG 5 (Improve maternal health) has been of concern to the international community. The latest estimates issued by the World Health Organization (WHO), the United Nations Population Fund (UNFPA), the United Nations Childrens Fund (UNICEF) and The World Bank in September 2010 provide evidence of progress in all regions of the world, including in sub-Saharan Africa where data had previously shown limited change.1 According to estimates presented for 172 countries and territories in the interagency report, approximately 358 000 maternal deaths occurred worldwide in 2008. There was a steady decline in the maternal mortality ratio, which relates the number of maternal deaths to the number of live births. At the global level, the maternal mortality ratio fell by 34% from 1990 to 2008. The biggest declines in this ratio were seen in eastern Asia and northern Africa (63% and 59%, respectively). Although such progress is encouraging, it will be insufficient to meet the MDG target of reducing the maternal mortality ratio by three quarters between 1990 and 2015. This would require an average annual decline of 5.5%. Improvements documented in this study fell short of this goal for the world as a whole with an annual decline of 2.3%, and for sub-Saharan Africa, in particular, where the estimated rate of decline was only 1.7%. The effect of HIV/AIDS in sub-Saharan Africa is likely to have contributed to the slow pace of decline in maternal mortality. Overall, it was estimated that there were 42 000 deaths due to HIV/AIDS among pregnant women in 2008. About half of those were assumed to be maternal. The contribution of HIV/AIDS was highest in sub-Saharan Africa where 9% of all maternal deaths were estimated to be due to HIV/AIDS. There was much variability between countries in 2008, with a maternal mortality ratio of 290 deaths (per 100 000 live births) in developing regions as compared to 14 deaths (per 100 000 live births) in developed regions. Not surprisingly, 99% of maternal deaths in 2008 occurred in developing countries. Levels and trends of maternal mortality varied widely within regions as well. For example, in subSaharan Africa, where an overall reduction was noted for the first time, some countries (e.g. Benin, Cape Verde, Equatorial Guinea, Eritrea, Ethiopia, Mozambique and Rwanda) experienced declines in maternal death rates since 1990, whereas in other countries (e.g. Botswana, Kenya, Lesotho, South Africa, Swaziland and Zimbabwe) death rates increased. WHO, UNICEF, UNFPA and The World Bank have published periodic estimates of maternal mortality every five years since 1990.2,3 Earlier this year, a study by the Institute of Health Metrics and Evaluation reported a different set of estimates based on an alternative methodology, which showed a faster pace of progress than earlier estimates.4 This study estimated a total of 342 900 maternal deaths for 2008 and a rate of annual decline of 1.3% between 1990 and 2008. The estimates summarized here were derived using a larger data set and an improved method than that used for the previous rounds of interagency estimates. The estimation methods were reviewed by an external technical advisory group and will be published separately. We used all available national data on maternal mortality from the late 1980s to the present, analysed the variability of such data over time and space and included formal estimates of uncertainty. We adjusted the data, where appropriate, for the incomplete recording of maternal deaths and for over-counting in cases where a data source includes deaths that occur during pregnancy but are due to incidental or accidental causes. The country consultation that was done while developing these estimates has helped identify increased data collection efforts in recent years, including special systems to capture data on maternal deaths. However, the global database on which estimates are based remains weak: it is crucial to develop improved mechanisms for counting maternal deaths so that we may better understand the true magnitude of maternal mortality. 29

These new estimates show a decline in maternal mortality greater than expected during 19902008. The study is the first to suggest that there has been a decline in sub-Saharan Africa. Several factors could account for this observation. Countries are increasingly adopting strategies and policies, such as free obstetric care or risk-pooling mechanisms, with the goal of increasing the coverage of effective health services. During the same period, the proportion of deliveries attended by skilled health personnel rose from 53% to 63% and the proportion of women who report using a method of contraception increased from 52% to 62% in developing countries.5 However, there is still much work to be done in improving health systems to prevent maternal deaths in developing countries.

Acknowledgements
This editorial was written on behalf of the members of the Maternal Mortality Estimation Interagency group: Carla Abou Zahr, Mohamed Ali, Ties Boerma, Eduard Bos, Liliana Carvajal, Doris Chou, Ralph Hakkert, Sara Hertog, Mie Inoue, Michael Mbizvo, Holly Newby, Mikkel Oestergaard, Armando Seuc, Emi Suzuki, Tessa Wardlaw. Nobuko Mizoguchi, Sarah Zureick and Reid Hamel helped with the analysis.

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