Maternal death

Direct obstetric deaths Overview Direct obstetric deaths are due to complications of pregnancy, birth, termination, or complications arising from their management. Descriptions by condition Postpartum bleeding happens when there is uncontrollable bleeding from the uterus, cervix, or vaginal wall after birth. This can happen when the uterus does not contract correctly after birth, there is leftover placenta in the uterus, or there are cuts in the cervix or vagina from birth. Hypertensive disorders of pregnancy happen when the body does not regulate blood pressure correctly. In pregnancy, this is due to changes at the level of the blood vessels, likely because of the placenta. This includes medical conditions like gestational hypertension and pre-eclampsia. Postpartum infections are infections of the uterus or other parts of the reproductive tract after the resolution of a pregnancy. They are usually bacterial and cause fever, increased pain, and foul-smelling discharge. Obstructed labor happens when the baby does not properly move into the pelvis and out of the body during labor. The most common cause of obstructed labor is when the baby's head is too big or angled in a way that does not allow it to pass through the pelvis and birth canal. Blood clots can occur in different vessels in the body, including vessels in the arms, legs, and lungs. They can cause problems in the lungs and travel to the heart or brain, thereby leading to complications. Unsafe abortion When abortion is legal and accessible, it is widely regarded as safer for the mother than carrying a pregnancy to term and delivery. In fact, a study published in the journal Obstetrics & Gynecology reported that in the United States, carrying a pregnancy to term and delivering a baby comes with a 14 times increased risk of death for the mother as compared to a legal abortion. However, in many regions of the world, abortion is not legal and can be unsafe for the mother. Maternal deaths caused by improperly performed procedures are preventable and contribute 13% to the maternal mortality rate worldwide. This number is increased to 25% in countries where other causes of maternal mortality are low, such as in Eastern European and South American countries. This makes unsafe abortion practices the leading cause of maternal death worldwide. Unsafe abortion is another major cause of maternal death worldwide. In regions where abortion is legal and accessible, abortion is safe and does not contribute greatly to overall rates of maternal death. According to the World Health Organization in 2009, every eight minutes a woman died from complications arising from unsafe abortions. The WHO defined unsafe abortion practices as procedures performed by someone without the appropriate training and/or ones that are performed in an environment that is not considered safe or clean. Using this definition, the WHO estimates that out of the 45 million abortions that are performed each year globally, 19 million of these are considered unsafe, and 97% of these unsafe abortions occur in developing countries. Rates Four primary types of data sources are used to collect abortion-related maternal mortality rates: confidential enquiries, registration data, verbal autopsy, and facility-based data sources. A verbal autopsy is a systematic tool that is used to collect information on the cause of death from laypeople and not medical professionals. Confidential enquiries for maternal deaths do not occur very often on a national level in most countries. Registration systems are usually considered the "gold standard" method for mortality measurements. However, they have been shown to miss anywhere between 30 and 50% of all maternal deaths. Indirect obstetric deaths Indirect obstetric deaths are caused by preexisting health problem worsened by pregnancy or newly developed health problem unrelated to pregnancy . HIV/AIDS, and cardiovascular disease, all of which may complicate pregnancy or be aggravated by it. Risk factors associated with increased maternal death include the age of the mother, obesity before becoming pregnant, other pre-existing chronic medical conditions, and cesarean delivery. Risk factors According to a 2004 WHO publication, sociodemographic factors such as age, access to resources, and income level are significant indicators of maternal outcomes. Young mothers face higher risks of complications and death during pregnancy than older mothers, especially adolescents aged 15 years or younger. Adolescents have higher risks for postpartum hemorrhage, endometritis, operative vaginal delivery, episiotomy, low birth weight, preterm delivery, and small-for-gestational-age infants, all of which can lead to maternal death. Structural support and family support influence maternal outcomes. Furthermore, social disadvantage and social isolation adversely affects maternal health which can lead to increases in maternal death. Additionally, lack of access to skilled medical care during childbirth, the travel distance to the nearest clinic to receive proper care, number of prior births, barriers to accessing prenatal medical care and poor infrastructure all increase maternal deaths. By 2020, maternal mortality rates were 62 % higher in abortion-restriction states than in abortion-access states (28.8 vs. 17.8 per 100,000 births). Analysis of CDC data (2019–2023) indicates that mothers in abortion-ban states are twice as likely to die during pregnancy, childbirth, or postpartum than those in states with legal abortion access. Three delays model The three delays model describes three critical factors that prevent women from receiving appropriate maternal health care. These factors include: • Delay in seeking care • Delay in reaching care • Delay in receiving adequate and appropriate care Delays in seeking care are due to decisions made by pregnant women and/or other individuals. Decision-making individuals can include a spouse and family members. Delays in receiving adequate and appropriate care may result from an inadequate number of trained providers, a lack of appropriate supplies, and a lack of urgency or understanding of an emergency. The three delays model illustrates that there are a multitude of complex factors, both socioeconomic and cultural, that can result in maternal death. ==Measurement==

The four measures of maternal death are the maternal mortality ratio (MMR), maternal mortality rate, lifetime risk of maternal death, and proportion of maternal deaths among deaths of women of reproductive age (PM). Maternal mortality ratio (MMR) is the ratio of the number of maternal deaths during a given time period per 100,000 live births during the same time period. The MMR is used as a measure of the quality of a health care system. Maternal mortality rate (MMRate) is the number of maternal deaths in a population divided by the number of women of reproductive age, usually expressed per 1,000 women. The calculation pertains to women during their reproductive years. The most common household survey method, recommended by the WHO as time- and cost-effective, is the sisterhood method. Trends The United Nations Population Fund (UNFPA; formerly known as the United Nations Fund for Population Activities) has established programs that support efforts in reducing maternal death. These efforts include education and training for midwives, supporting access to emergency services in obstetric and newborn care networks, and providing essential drugs and family planning services to pregnant women or those planning to become pregnant. In most cases, high rates of maternal deaths occur in the same countries that have high rates of infant mortality. These trends reflect that higher-income countries have stronger healthcare infrastructure, more doctors, use more advanced medical technologies, and have fewer barriers to accessing care than low-income countries. In low-income countries, the most common cause of maternal death is obstetrical hemorrhage, followed by hypertensive disorders of pregnancy. This is in contrast to high-income countries, for which the most common cause is thromboembolism. Between 1990 and 2015, the maternal mortality ratio decreased from 385 deaths per 100,000 live births to 216 maternal deaths per 100,000 live births. Some factors that have been attributed to the decreased maternal deaths seen between this period are in part to the access that women have gained to family planning services and skilled birth attendance, meaning a midwife, doctor, or trained nurse), with back-up obstetric care for emergencies that may occur during the process of labor. In 2023, just over 90 % of maternal deaths occurred in low- and lower-middle-income countries. The maternal mortality ratio in these countries was 346 per 100,000 live births, compared with 10 per 100,000 live births in high-income countries. In high-income settings, racial, ethnic, and income disparities continue to impact maternal outcomes. ==Prevention==

According to UNFPA, there are four essential elements for preventing maternal death. Maternal and perinatal death reviews have been in practice for a long time worldwide, and the World Health Organization (WHO) introduced the Maternal and Perinatal Death Surveillance and Response (MPDSR) with a guideline in 2013. Studies have shown that acting on MPDSR recommendations can reduce maternal and perinatal mortality by improving the quality of care in the community and health facilities. According to a 2023 systematic review published by the Patient Centered Outcomes Research Institute (PCORI) and the Agency for Healthcare Research and Quality (AHRQ), "More than 60 percent of pregnancy-related deaths are considered preventable". The World Health Organization (WHO) has developed a global goal to end preventable death related to maternal mortality. Prenatal care It was estimated that in 2015, a total of 303,000 women died due to causes related to pregnancy or childbirth. In 2023, a study reported that deaths among Native American women were three-and-a-half times that of white women. The report attributed the high rate in part to the fact that Native American women are cared for under a poorly funded Federal Health Care System that is so stretched that the average monthly visit lasts only from three to seven minutes. Such a short visit allows neither time for performing an adequate health assessment nor time for the patient to discuss any problems she may be experiencing. Medical technologies The decline in maternal deaths has been due largely to improved aseptic techniques, better fluid management and quicker access to blood transfusions, and better prenatal care. Technologies have been designed for resource-poor settings that have been effective in reducing maternal deaths as well. The non-pneumatic anti-shock garment is a low-technology pressure device that decreases blood loss, restores vital signs and helps buy time in delay of women receiving adequate emergency care during obstetric hemorrhage. It has proven to be a valuable resource. Condoms used as uterine tamponades have also been effective in stopping post-partum hemorrhage. Medications and surgical management Some maternal deaths can be prevented through medication use. Injectable oxytocin can be used to prevent death due to postpartum bleeding. Maternal death due to eclampsia can also be prevented through the use of medications such as magnesium sulfate. Public health launched free healthcare for pregnant and breastfeeding women. A public health approach to addressing maternal mortality includes gathering information on the scope of the problem, identifying key causes, and implementing interventions, both before pregnancy and during pregnancy, to combat those causes and prevent maternal mortality. Public health has a role to play in the analysis of maternal death. One important aspect in the review of maternal death and its causes are Maternal Mortality Review Committees or Boards. The goal of these review committees is to analyze each maternal death and determine its cause. After this analysis, the information can be combined to determine specific interventions that could prevent future maternal deaths. These review boards are generally comprehensive in their analysis of maternal deaths, examining details that include mental health factors, public transportation, chronic illnesses, and substance use disorders. All of this information can be combined to give a detailed picture of what is causing maternal mortality and help determine recommendations to reduce its impact. Many states in the US are taking Maternal Mortality Review Committees a step further and are collaborating with various professional organizations to improve the quality of perinatal care. These teams of organizations form a "perinatal quality collaborative" (PQC) and include state health departments, the state hospital association, and clinical professionals such as doctors and nurses. These PQCs can also involve community health organizations, Medicaid representatives, Maternal Mortality Review Committees, and patient advocacy groups. By involving all of these major players within maternal health, the goal is to collaborate and determine opportunities to improve the quality of care. Through this collaborative effort, PQCs can aim to make an impact on quality both at the direct patient care level and through larger system devices like policy. It is thought that the institution of PQCs in California was the main contributor to the maternal mortality rate decreasing by 50% in the years following. The PQC developed review guides and quality improvement initiatives aimed at the most preventable and prevalent maternal deaths: those due to bleeding and high blood pressure. Success has also been observed with PQCs in Illinois and Florida. Several interventions before pregnancy have been recommended in efforts to reduce maternal mortality. Increasing access to reproductive healthcare services, such as family planning services and safe abortion practices, is recommended to prevent unintended pregnancies. Other interventions include high quality sex education, which includes pregnancy prevention and sexually transmitted infection (STI) prevention and treatment. By addressing STIs, this not only reduces perinatal infections, but can also help reduce ectopic pregnancy caused by STIs. Adolescent mothers are between two and five times more likely to die than a female twenty years or older. Access to reproductive services and sex education could make a large impact, specifically on adolescents, who are generally uneducated regarding carrying a healthy pregnancy. Education level is a strong predictor of maternal health as it gives women the knowledge to seek care when it is needed. Emergency obstetric care is also crucial in preventing maternal mortality by offering services like emergency cesarean sections, blood transfusions, antibiotics for infections, and assisted vaginal delivery with forceps or vacuum. By increasing public knowledge and awareness through health education programs about pregnancy, including signs of complications that need addressed by a healthcare provider, this will increase the likelihood of an expecting mother to seek help when it is necessary. Addressing complications at the earliest sign of a problem can improve outcomes for expecting mothers, which makes it extremely important for a pregnant woman to be knowledgeable enough to seek healthcare for potential complications. Training health care professionals will be another important aspect in decreasing the rate of maternal death, "The study found that white medical students and residents often believed incorrect and sometimes 'fantastical' biological fallacies about racial differences in patients. For these assumptions, researchers blamed not individual prejudice but deeply ingrained unconscious stereotypes about people of color, as well as physicians' difficulty in empathizing with patients whose experiences differ from their own." Policy The largest global policy initiative for maternal health came from the United Nations' Millennium Declaration, which created the Millennium Development Goals. In 2012, this evolved at the United Nations Conference on Sustainable Development to become the Sustainable Development Goals (SDGs) with a target year of 2030. The SDGs are 17 goals that call for global collaboration to tackle a wide variety of recognized problems. Goal 3 focuses on ensuring health and well-being for women of all ages. A specific target is to achieve a global maternal mortality ratio of less than 70 per 100,000 live births. So far, specific progress has been made in births attended by a skilled provider, now at 80% of births worldwide compared with 62% in 2005. Countries and local governments have taken political steps to reduce maternal deaths. Researchers at the Overseas Development Institute studied maternal health systems in four apparently similar countries: Rwanda, Malawi, Niger, and Uganda. In comparison to the other three countries, Rwanda has an excellent record of improving maternal death rates. Based on their investigation of these varying country case studies, the researchers conclude that improving maternal health depends on three key factors: • reviewing all maternal health-related policies frequently to ensure that they are internally coherent; • enforcing standards on providers of maternal health services; • any local solutions to problems discovered should be promoted, not discouraged. In terms of aid policy, proportionally, aid given to improve maternal mortality rates has shrunken as other public health issues, such as HIV/AIDS and malaria, have become major international concerns. Maternal health aid contributions tend to be lumped together with newborn and child health, so it is difficult to assess how much aid is given directly to maternal health to help lower the rates of maternal mortality. Regardless, there has been progress in reducing maternal mortality rates internationally. In countries where abortion practices are not considered legal, it is necessary to look at the access that women have to high-quality family planning services, since some of the restrictive policies around abortion could impede access to these services. These policies may also affect the proper collection of information for monitoring maternal health globally. Significant progress has been made since the United Nations made reducing maternal mortality part of the Millennium Development Goals (MDGs) in 2000. Bangladesh, for example, cut the number of deaths per live births by almost two-thirds from 1990 to 2015. A further reduction of maternal mortality is now part of the Agenda 2030 for sustainable development. The United Nations recently developed a list of goals termed the Sustainable Development Goals. Some of the specific aims of the Sustainable Development Goals are to prevent unintended pregnancies by ensuring more women have access to contraceptives, as well as providing women who become pregnant with a safe environment for delivery with respectful and skilled care. This initiative also included access to emergency services for women who developed complications during delivery.. In 2022, President Joe Biden signed the “Data Mapping to Save Moms’ Lives Act” into law, just before Christmas, and with the support of the AMA (American Medical Association). The law called for the Federal Communications Commission—in consultation with the Centers for Disease Control and Prevention (CDC) to incorporate publicly available data on maternal mortality and severe maternal morbidity for at least one year postpartum into its Mapping Broadband Health in America platform Regardless, a concerted study on the policy outcome on black women’s mortality rate is a rarity. Additionally, in February of 2021, Senator Cory Booker and Representatives Lauren Underwood and Alma Adams reintroduced the Black Maternal Health Momnibus Act. It consisted of thirteen bills aimed at improving maternal health. Six of the bills specifically target Black maternal health or related factors that impact it. The legislation aimed to save lives, reduce health care disparities, and ensure all mothers received proper care, regardless of race or circumstances. The Momnibus is a set of laws focused on improving maternal health in the United States. However, the bill was only introduced, not passed. There have been varying policies regarding maternal mortality that have aimed to prevent or lower the rate of maternal mortality for women in the U.S. during and post-partum. An example of such policies is the IMPROVE initiative, started by the National Institutes of Health (NIH) in 2019 to address maternal health issues. The initiative aimed to reduce preventable maternal deaths, lower serious health problems during pregnancy, and promote health equity. It then examined various factors—biological, behavioral, social, and structural—to create better care and outcomes for specific groups and areas. The initiative emphasized the importance of collaborating with new partners and communities to find solutions to the problem of maternal health crisis. The NIH also started the Connecting the Community for Maternal Health Challenge to help community groups build their research skills. They offered training and support to create research proposals that address local needs. Before the IMPROVE initiative in 2019, other past policies were either passed or made regarding maternal mortality. An example of this was in 2014, when the US Department of Health and Human Services funded the American College of Obstetrics and Gynecology to create the Alliance for Innovation on Maternal Health (AIM) program. The point of AIM was to collaborate with state and hospital partners for the purpose of implementing safety measures aimed at improving maternal care quality and outcomes. Through evidence-based practices, such as a toolkit for managing hemorrhage and hypertension in pregnancy, AIM had helped reduce maternal morbidity rates from 22.1% to 8.3%. California could be used as an exemplar of how to implement policies regarding maternal health. California implemented three measures to battle maternal mortality: (1) Increase funding for federal programs to address social determinants of maternal health (2) Support health care strategies to improve maternal health, including developing national standards and goals for health care systems (3) Increase investments in maternal health monitoring and surveillance. For the first measure, an example was how California created the Black Infant Health Program (BIH) to support black mothers, reduce their stress, and build social support. The program was funded by Federal Title V Maternal and Child Health Block Grant, Federal Title XIX Medicaid Funds, and State General Funds. Some policies regarding maternal health are nuanced. For example, it was discovered that states with stricter abortion laws had a 7% higher maternal mortality rate than states with much less strict laws. Access to healthcare for pregnant individuals from low-income backgrounds is very crucial. ==Epidemiology==

Maternal mortality and morbidity are leading contributors to women's health. It is estimated that 303,000 women are killed each year in childbirth and pregnancy worldwide. The global rate in 2017 is 211 maternal deaths per 100,000 live births and 45% of postpartum deaths occur within 24 hours. Whereas in 2020, the global rate was 223 deaths per 100,000 live births. Democratic Republic of the Congo, Pakistan, Sudan, Indonesia, Ethiopia, United Republic of Tanzania, Bangladesh and Afghanistan accounted for between 3 and 5 percent of maternal deaths each. In 2017, countries in Southeast Asia and Sub-Saharan Africa accounted for approximately 86% of all maternal deaths worldwide. As of 2020, Sub-Saharan African countries such as South Sudan, Chad, and Nigeria had the highest maternal deaths per 100,000 live births. Since 2000, Southeast Asian countries have seen a significant decrease in maternal mortality of almost 60%. Sub-Saharan Africa also saw an almost 40% decrease in maternal mortality between 2000 and 2017. The maternal mortality ratio (MMR) is the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes). Prevalence by race and ethnicity In the United States In the United States, women who are black and non-Hispanic experience pregnancy-related death at a significantly higher rate. They are three to four times as likely to succumb to maternal mortality than non-Hispanic white women. In the United States between the years of 2007 and 2014, women who identify as non-Hispanic and black had a significant increase in death related to pregnancy. This is significantly higher than the rates in 2020, defined as 23.8 deaths per 100,000 live births and 20.1 in 2019. In 2021, the maternal mortality rate for non-Hispanic Black women was 69.9 deaths per 100,000 live births, which is 2.6 times higher than non-Hispanic White women. The mortality rate for women over the age of 40 was 6.8 times higher than the rate for women under the age of 25. Research indicates that these disparities in the U.S. are not due to genetic differences, but rather systemic factors, including racial bias in healthcare, inadequate access to high-quality maternity care, and higher rates of chronic conditions like hypertension and preeclampsia. Implicit bias among healthcare providers has been documented as a contributing factor to these disparities, leading to the dismissal of Black women's pain and symptoms, resulting in delayed or inadequate treatment. Studies have found that some healthcare providers incorrectly believe that Black patients feel less pain, which has been linked to delays in diagnosing and managing pregnancy-related complications like preeclampsia and hemorrhage Additionally, Black women face barriers to high-quality maternal care, including living in maternity care deserts, a lack of access to midwifery and doula services, and financial challenges due to inadequate insurance coverage. Many states have restrictive policies on midwifery care, which further limits Black women's access to alternatives that have been shown to improve maternal outcomes The disparities in maternal health outcomes are also present among racial groups. Black and American Indian/Alaska Native (AI/AN) women experience pregnancy-related mortality rates over three times those of White women. In 2020, rates were 55.9 and 63.4 per 100,000 live births for Black and AI/AN women, respectively, versus 18.1 for White women; Native Hawaiian/Pacific Islander women had a rate of 62.8. In 2023, the CDC's Pregnancy Mortality Surveillance System reported pregnancy-related mortality ratios of 49.4 for Black women and 14.9 for White women per 100,000 live births. In the United States, black women are 3-4 times more likely to die from maternal mortality than white women. Unequal access to quality medical care, socioeconomic disparities, and systemic racism by health care providers are factors that have contributed to the high maternal mortality rates among black women. The COVID-19 pandemic heightened maternal mortality rates, disproportionately impacting communities of color. Multiple factors contribute to this widening disparity, notably, social factors such as implicit bias, repeated racial discrimination, and limited access to healthcare. All issues are further exacerbated for people of color who face systemic barriers to adequate medical care. Overall, the maternal mortality rate increased from 23.8 deaths per 100,000 live births in 2020, to 32.9 deaths per 100,000 live births in 2021. An apparent spike in this rate can be noted in 2021. For non-hispanic black women the rate of maternal deaths per 100,00 live births increased from 44.0 in 2019 to 69.9 in 2021. Elsewhere Similar patterns exist in other countries. In Brazil, women who are not white were 3.5 times as likely to die because of obstetric mortality compared to white women. The maternal mortality ratio is larger in women who are from Sub-Saharan Africa in France. According to The Lancet Global Health, their search, which included over 40 studies, identified significant increases in stillbirth and maternal death during the pandemic versus before the pandemic. This drives the urgent global need to prioritize safe, equitable, and accessible maternal care in future healthcare crises. those living in wealthier households, having higher education, or living in urban areas, have higher use of healthcare services than their poorer, less-educated, or rural counterparts. There are also racial and ethnic disparities in maternal health outcomes which increases maternal mortality in marginalized groups. == Related terms ==

Severe maternal morbidity Severe maternal morbidity (SMM) is an unanticipated acute or chronic health outcome after labor and delivery that detrimentally affects a woman's health. Severe Maternal Morbidity (SMM) includes any unexpected outcomes from labor or delivery that cause both short and long-term consequences to the mother's overall health. There are nineteen total indicators used by the CDC to help identify SMM, with the most prevalent indicator being a blood transfusion. Other indicators include an acute myocardial infarction ("heart attack"), aneurysm, and kidney failure. All of this identification is done by using ICD-10 codes, which are disease identification codes found in hospital discharge data. Using these definitions that rely on these codes should be used with careful consideration since some may miss some cases, have a low predictive value, or may be difficult for different facilities to operationalize. The increased rate for SMM can also be indicative of potentially increased rates for maternal mortality, since without identification and treatment of SMM, these conditions would lead to increased maternal death rates. Therefore, diagnosis of SMM can be considered a "near miss" for maternal mortality. With this consideration, several different expert groups have urged obstetric hospitals to review SMM cases for opportunities that can lead to improved care, which in turn would lead to improvements with maternal health and a decrease in the number of maternal deaths. == See also ==