Causes of Maternal Mortality
Factors that contribute to a higher risk of maternal mortality can include biomedical factors, reproductive factors, health service factors, and socioeconomic and cultural factors.
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(i) Biomedical Factors
The biomedical causes of maternal mortality are well recognised (Table 1). Three quarters of maternal mortalities result from the direct obstetric complications of haemorrhage, infection, obstructed labour, hypertensive disorders of pregnancy, and septic abortion. The remainder are due to other 'direct' obstetric causes such as pulmonary embolism or ectopic pregnancy, or 'indirect' causes that are aggravated by pregnancy, such as malaria, hepatitis, diabetes mellitus and heart disease. Worldwide the most common cause of maternal mortality is haemorrhage, but the proportion due to each cause varies between regions.
It has been estimated that approximately 40% of women may suffer an acute problem in pregnancy, and 9-15% may experience a problem needing higher level care.
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Table 1. Global causes of maternal mortality
| Cause
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% of Maternal Deaths
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| Haemorrhage
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24%
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| Infection
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15%
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| Unsafe abortion
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13%
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| Hypertensive disorders of pregnancy
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12%
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| Obstructed labour
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8%
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| Other direct causes
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8%
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| Indirect causes
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20%
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*Other direct causes include: ectopic pregnancy, embolism, anaesthesia-related causes
** Indirect causes include: anaemia, malaria, heart disease
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Appropriate and timely intervention from a trained professional could prevent the majority of maternal mortalities. Table 2 illustrates that maternal mortalities do not occur instantaneously. If a system is in place to recognise problems promptly and to transport a woman to a healthcare facility where she can receive appropriate and timely treatment then the majority of maternal mortalities could be avoided.
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Table 2. Time to death for most common obstetric emergencies
| Cause of death
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Time to death
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| Postpartum haemorrhage
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2 hours
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| Antepartum haemorrhage
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12 hours
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| Ruptured uterus
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1 day
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| Eclampsia (severe hypertensive disorder of pregnancy)
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2 days
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| Obstructed labour
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3 days
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| Infection
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6 days
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Source: Maine D, 1987
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(ii) Reproductive factors
The risk of a woman dying in pregnancy and childbirth depends on the number of pregnancies she has in her lifetime. The higher the number of pregnancies the greater the lifetime risk of pregnancy related death. maternal mortality rates are also higher among very young women, those aged 35 years and older and those with four or more children.
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(iii) Health service factors
The prevention of maternal mortality requires access to healthcare services providing prompt recognition and treatment of pregnancy related complications. However in developing countries there are often inadequate facilities available and a lack of trained staff, equipment and supplies. Additionally, where services do exist, their costs may be prohibitively expensive for the majority of the population.
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(iv) Socio-economic and cultural factors
The ability of women to command resources and make independent decisions about their fertility, their health and healthcare also has an impact on maternal mortality. Where women are afforded a low status in society their health needs are often neglected, and existing health facilities may not be accessed by women in need. Additionally, lack of education and understanding around health related issues can contribute to delays in seeking care when it is needed or to the inappropriate management of life threatening pregnancy complications.
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The 'Three Delays Model'
The above issues have been conceptualised by Thaddeus and Maine in the 'Three Delays Model'. This model identifies individual decision making, access to affordable services, and the provision of skilled personnel as the main factors which can delay access to effective interventions to prevent maternal mortality (Box B).
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Box B Three Delays Model
Phase 1 delay. Delay in decision to seek care
- Failure to recognise complications
- Acceptance of maternal death
- Low status of women
- Socio-cultural barriers to seeking care: women's mobility, ability to command resources, decision-making abilities, beliefs and practices surrounding childbirth and delivery, nutrition and education
Phase 2 delay. Delay in reaching care
- Poor roads, mountains, islands, rivers - poor organisation
Phase 3 delay. Delay in decision to seek care
- Inadequate facilities, supplies, personnel
- Poor training and demotivation of personnel
- Lack of finances
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The true-life vignette below, taken from Thaddeus and Maine's monograph provides a poignant illustration of Phase 3 delay:
By the time... deadly delay
Today, Mary, the lady who helps in the house, came late to work. I told her off for being late and asked why. She said that one of her townswomen had died in the hospital while giving birth to a baby. This was her fifth delivery. She was not from a far off village but from Sokoto city itself. She had not gone too late to the hospital but rather gone on time. By the time they found a vehicle to go to hospital, by the time they struggled to get her to an admission ward, by the time she was admitted, by the time her file was made up, by the time the midwife was called, by the time the midwife had finished eating, by the time the midwife came, by the time the midwife examined the woman, by the time the bleeding started, by the time the doctor was called, by the time the doctor could be found, by the time the ambulance went to find the doctor, by the time the doctor came, by the time the husband went out to buy drugs, IV set, drip and bottle of ether, by the time the husband went round to look for blood bags all over town, by the time the husband found one, by the time the husband begged the pharmacist to reduce the prices since he had already spent all his money on swabs, dressings, drugs and fluids, by the time the haematologist was called, by the time the haematologist took blood from the poor tired husband, by the time the day and night nurses changed duty, by the time the midwife came again, by the time the doctor was called, by the time the doctor could be found, by the time the doctor came, by the time the t's had been properly crossed and all the I's dotted and the husband signed the consent form, the woman died. Today the husband wanted to sell the drugs and other things they never used to be able to carry the body of his wife back to their village, but he could never trace [the body] again in the hospital.
In practice these three phases of delay rarely operate in isolation, and delay leading to maternal death is often multifactorial. Indeed the factors are likely to be interactive and multiplicative. Thus barriers and poor care encountered at Phase 2 and 3 feed back into subsequent decision-making at Phase 1. Interventions to reduce maternal mortality must address each of the Three Delays in order to have the greatest effect.
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Koblinsky MA, CAMPBELL OMR & Harlow SD (1993). 'Mother and more: a broader perspective on women's health' in Koblinsky M, Timyan J & Gay J (eds). The health of women: a global perspective. Boulder, CO: Westview: 33-62.
WHO (2005) The World Health Report 2005: Make Every Mother and Child Count. Geneva, WHO.
Maine D: Studying maternal mortality in developing countries. A guidebook: rates and causes. Geneva. WHO 1987 (FHE 87.7).
Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994;38:1091-1110.
Tahzib F. College of Health Sciences, University of Sokoto, Nigeria, personal communication, 21 Mar 1989, from Thaddeus and Maine
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