Global Headway in Maternal Mortality

Peter Kovacs, MD, PhD

Authors and Disclosures

Posted: 05/27/2010

 

Maternal Mortality for 181 Countries, 1980-2008: A Systematic Analysis of Progress Towards Millennium Development Goal 5

Hogan MC, Foreman KJ, Naghavi M, et al
Lancet. 2010;375:1609-1623

Background

During pregnancy, women are at increased risk for certain medical complications. The body undergoes numerous physiologic adaptations to be able to care for the growing pregnancy. The cardiovascular, urinary, respiratory, immune, and other systems all undergo these adaptive changes. Because pregnant women are typically young and healthy, these changes occur easily. The case is different for women who have preexisting medical conditions. Even when these conditions are well-controlled before conception, the physiologic changes may lead to abnormal function and place the future mother at risk. In addition, women respond differently to medical problems during pregnancy. For example, viral infections tend to be more severe, as was clearly seen with the recent H1N1 outbreak.
With adequate preconception care, medical conditions that require careful management before and during pregnancy can be identified, and the risks associated with pregnancy can be minimized.
Data on maternal mortality help healthcare authorities systematically identify medical problems that require special attention in pregnancy. These data also help clinicians identify the main causes for maternal mortality, and allow them to attack these problems actively before women become pregnant. In addition, international organizations can use such data to find intervention programs that must be coordinated at an international level (eg, research, education, screening). This article analyzed maternal mortality data for a 28-year period in 181 countries.

Study Summary

Maternal mortality is defined as death of the mother during pregnancy, during delivery, or within 42 days postpartum. The maternal mortality ratio (MMR) is the number of maternal deaths for every 100,000 births. For this analysis, data were collected from several sources: vital registration systems, sibling histories, censuses, and published national and subnational data. International Classification of Diseases codes were used for data identification.
The number of maternal deaths worldwide was down to 342,900 (uncertainty range: 302,100-394,300) from 526,300 (uncertainty range: 446,400-629,600) between 1980 and 2008. The annual rate of decline in the MMR was 1.85% between 1980 and 1990, and then slowed down to 1.4% after 1990. The slowing of the decline in MMR is believed to be a consequence of the HIV epidemic in the early 1990s. The MMR was reduced to 251 (uncertainty range: 221-289) from 320 (uncertainty range: 272-388) for the same time period. Most maternal deaths were seen in sub-Saharan Africa (52% of all maternal deaths in 2008). The MMR was less than 20/100,000 in 5 regions: Australasia, western Europe, central Europe, high-income North America, and high-income Asia-Pacific. The MMR was more than 200/100,000 in the following regions: south Asia, Caribbean, Oceania, and sub-Saharan Africa (central/east/south/west). The region with the highest MMR was west sub-Saharan Africa (629), and the country with the highest MMR was Afghanistan (1575). MMR increased in sub-Saharan Africa in the 1990s, mainly because of HIV infection.
Of the 181 countries analyzed, 21 countries with the highest maternal mortality were responsible for almost 80% of the maternal deaths and 60% of all live births. In the United States, Canada, Norway, and Afghanistan, MMR increased slightly.

Viewpoint

Maternal mortality is defined as the death of the mother during pregnancy, delivery, or up until 42 days postpartum. Reporting and coding differences may partially explain the findings of this study, especially when the numbers from developed countries (United States, Canada, and Norway) are considered, but other potential explanations also exist for the findings of this study.
The investigators noted that the total fertility rate is positively associated with maternal mortality, whereas gross domestic product (GDP per head) negatively influences the MMR. The overall health status of the population continuously changes as well. Obesity is becoming more prevalent and is known to be associated with adverse pregnancy outcomes.^[1] Women who delay childbearing and pregnancy (especially over the age of 40) are at higher risk for morbidity (hypertensive complications, gestational diabetes, operative delivery) and death. In developed countries, infertility is a growing problem, and more and more patients use infertility services. In Europe, 1%-4% of live births are conceived through assisted reproductive technology (ART). The number of multiple gestations is higher after ART, and maternal risks are more common with multifetal gestations.^[2]
The quality of healthcare and access to healthcare in general correlate with a country's GDP. In countries where access to healthcare is limited, maternal morbidity and mortality are higher. In countries with well-functioning screening and vaccination programs, maternal mortality is less likely to be related to infections. In the 1990s, the decline in the MMR slowed down as a result of the rise in the number of HIV infections. In countries where access to antiretroviral drugs is limited, MMR rates remained high (eg, sub-Saharan Africa). The recent H1N1 epidemic highlighted the importance of effective vaccination programs.
The data presented in this article could be very useful for healthcare authorities by helping them identify the regions where the most improvement could be achieved with the introduction of patient and provider education programs, screening programs, drug distribution, and vaccination. It is reassuring to see that in most countries the figures are improving, but it is also obvious that there is room for further improvement. The biggest improvement can be expected in the developing countries. Managing pregnancy complications caused by infections, malnutrition, and lack of available medical care (both before and during pregnancy) could result in substantial improvement within a short period of time. On the other hand, in the developed world, it is going to be difficult to further improve the numbers. More emphasis must be put on preconception care, and patients must be informed about the adverse effects of factors such as delayed childbearing, obesity, and inappropriate nutrition. This certainly is a challenging task for health authorities in most countries.