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This article reports the results of a review of all maternal deaths occurring in Jamaica in 1981-83. A total of 192 maternal deaths were identified, yielding a maternal mortality rate of 10.8/10,000 live births, which was considerably higher than the official rate of 4.8. 15% of these deaths were associated with abortion or ectopic pregnancy. The most common causes of death were hypertensive diseases of pregnancy (26%), hemorrhage (20%), ectopic pregnancy (10%), pulmonary embolus (8%), and sepsis (8%). Maternal mortality was closely related to both age and parity. Lowest rates were noted among women of para 2-4 aged 20-24 years and para 3-4 aged 25-29 years. Avoidable factors were judged to be present in 68% of the deaths. The largest categories of avoidable factors were: nonuse of and deficiencies in antenatal care; inadequacy in ensuring the delivery in hospital of high-risk women; and delays in taking action when signs of complications developed before, during, and after delivery. In response to these findings, the Ministry of Health's Maternal Mortality Committee has called for the following actions: measures to encourage women to seek antenatal care early in pregnancy; improvements in antenatal monitoring; the referral of high-risk women for hospital delivery; the definition of standard procedures for dealing with specific complications of pregnancy, e.g., eclampsia and hemorrhage; regionalization of obstetric services and criteria for referring patients to hospital; and review of provision of blood and plasma for emergency transfusions.
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PMID:Maternal mortality in Jamaica. 286 18

Cesarean deliveries are increasing in both developed countries and less developed countries (LDCs). Recent studies in the U.S. have revealed a significantly higher mortality risk for women who delivered abdominally than for those who delivered vaginally, even when the effect of the conditions which necessitated cesarean delivery was taken into account. We chose for study from an international maternity monitoring network, five centers from two LDCs that reported an in-hospital maternal mortality rate (MMR) of around 10 per 1000 parturient women. The pooled data revealed an MMR of 5.1 per 1000 women with vaginal deliveries. For women with cesarean delivery, the total MMR was 36.2 and the MMR attributable to cesarean section was estimated to be 12.8; both rates were per 1000 procedures. The leading cause of death was eclampsia for the vaginal deliveries and sepsis for the cesarean deliveries. The risk of maternal mortality inherent with the cesarean section procedure per se (not counting the risk associated with the labor and delivery complications that necessitated cesarean section) as well as the practical avoidability of maternal deaths for either mode of delivery in these LDC hospitals are discussed.
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PMID:In-hospital maternal mortality risk by cesarean and vaginal deliveries in two less developed countries--a descriptive study. 287 80

A retrospective analysis of 27 maternal deaths associated with cesarean section and occurring at Nigeria's University of Ilorin Teaching Hospital in 1982-86 was performed. The cesarean section rate for the 48,974 deliveries that took place at the hospital during the study period was 4.1%. The death rate was 18.1/1000 cesarean sections compared with 1.89/1000 vaginal deliveries. Maternal sepsis was responsible for 22 (82%) of the cesarean section-associated maternal deaths; the remaining deaths were attributed to hemorrhage (1 primary and 3 secondary) and eclampsia (1 case). Obstructed labor was the single most important indicator for cesarean section (67%) and the most significant predisposing factor to maternal sepsis (63%). Most deaths from sepsis occurred on the 2nd-4th postoperative days. The skill of the surgeon was not a significant factor in maternal deaths. The most common antibiotic used to combat sepsis was a combination of ampicillin and gentamicin--a regimen that does not cover anaerobic organisms. Some patients did not receive antibiotics until the 3rd postoperative day because they were not on stock in the hospital pharmacy. Administrative difficulties, most notably inadequate laboratory backing and funding, also played some role in the high maternal death rate in this series.
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PMID:Characteristics of maternal deaths following cesarean section in a developing country. 290 81

The maternal mortality rate in 10 hospitals scattered all over Anambra State, Nigeria, in a 5-year period were studied. The hospitals covered urban, semi-urban and rural areas. The maternal mortality rate varied from 1.8 to 13/1000 with a mean of 4.97/1000. This mean is 45 times the rate in England in 1978 and also compared less favorably with some other figures from third world sources. Attributable causes included obstetric hemorrhage (23%), ruptured uterus (27.6%), obstructed labor (13%), sepsis (12.1%), eclampsia (7.9%), anemia (2.9%), septic abortion (2.1%) and other causes. 16.7% of deaths were among 16-20 year olds; 14.6% among 21-25 year olds, 27.2% among 26-30 year olds; 18.8% among 31-35 year olds; and 22.6% among women older than 35. 87.5% of the women were unbooked. Of the 239 cases, 51 delivered vaginally, 162 by cesarean section, 12 by breech, 5 by TOP and 5 by destruction. Parity and age were important influences; at highest risk were primigravida and the grandmultipara, especially between para 4 and para 5. All the major causes of death are avoidable--either by obtaining prenatal and intrapartal care or by anticipating fetopelvic disproportion or abnormal lie. Lack of access to health facilities, especially in the rural areas, poor transportation, great distances to nearest health facility, are all implicated in obstructed labor deaths. Most cases of hemorrhage are avoidable through early diagnosis and recognition of high risk cases, prophylactic measures and availablity of blood transfusion and surgical delivery. Lack of antibiotics and non-adherence to normal aseptic precautions were also problems, especially in the 5 deaths from illegal abortions. Changes in the mortality rate can be made by accurate data collection, improved health facilities, improved socioeconomic status and basic education.
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PMID:Maternal mortality in Anambra State of Nigeria. 290 99

There were 37 maternal deaths among the 109,221 livebirths registered during the period 1977-86 in Bahrain, Arabian Gulf. The maternal mortality rate was 33.9/100,000 for the 10-year study period; however, disaggregation reveals a decline in this rate from 42.3/100,000 in 1977-81 to 26.9/100,000 in 1982-86. This decline presumably reflects streamlining of the Ministry of Health's maternity services, including a central maternity hospital with all modern facilities that serves as a referral center for all of Bahrain, 2 peripheral hospitals with provision for blood transfusion and surgical deliveries, and 3 maternity units managed by fully qualified midwives. About 80% of deliveries are covered by these maternity services; only 2.5% of deliveries occur in the home. Despite this highly developed maternity care system, 18 of the maternal deaths were due to direct obstetric cause: hemorrhage, 7; pre-eclampsia and eclampsia, 5; abortion septicemia, 2; bowel perforation during cesarean section, 1; thromboembolism, 2; and amniotic fluid embolism, 1. The causes of the 19 indirect maternal deaths were: pulmonary embolism, 5; infection, 7; cardiac failure, 2; cerebrovascular accident, 2; pulmonary hypertension, 1; and uncertain, 2. Of interest is the finding that sickle cell disease was the underlying cause of maternal death in 12 of the 37 deaths in this series. Sickle cell disease was implicated in 3 of the deaths from hemorrhage, all 5 deaths from pulmonary embolism, 2 deaths from septicemia, and the 2 cases of cardiac failure. In this series, 50% of the patients with sickle cell disease had thromboembolic crises following treatment of anemia with packed cell transfusion. Blood transfusion, especially of packed cells, should be given with caution to these patients since it may precipitate vaso-occlusive crisis by increasing blood viscosity. Since sickle cell disease represents a high risk during pregnancy in this Arab population, such patients should have frequent prenatal check-ups and deliver in a well-equipped hospital.
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PMID:Maternal mortality in Bahrain with special reference to sickle cell disease. 321 81

Of a total of 1037 women of reproductive age who died during the period 1976-85 in the Matlab area that was under demographic surveillance, 387 (37%) were maternal deaths. The mean maternal mortality over the 10-year period was 5.5 per 1000 live births (101 per 100 000 women of reproductive age). Major causes of maternal death, which were assessed using a combination of record review and field interviews, included postpartum haemorrhage (20%), complications of abortion (18%), eclampsia (12%), violence and injuries (9%), concomitant medical causes (9%), postpartum sepsis (7%), and obstructed labour (6.5%). Deaths caused by postpartum haemorrhage were positively associated with both maternal age and parity, whereas those caused by eclampsia and injuries were more common among young and low-parity women. If maternal deaths arising from complications of abortion are disregarded, 20% of all maternal deaths occurred during pregnancy, 44% during labour and the two days following delivery, and 36% during the remaining postpartum period.These findings support the need to develop a service strategy to address the risks of childbearing and childbirth in areas such as rural Bangladesh, where almost all deliveries take place at home. This strategy must be based not only on preventive and educational interventions, including family planning and antenatal care, but also on systematic attendance at home deliveries by trained professional midwives, backed up by an effective chain of referral.
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PMID:Causes of maternal mortality in rural Bangladesh, 1976-85. 326 66

Spontaneous adrenal hemorrhage is rare during pregnancy. Most reported cases have been associated with preeclampsia-eclampsia, trauma or septicemia. A woman was treated for recurrent unilateral adrenal hemorrhage during pregnancy.
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PMID:Spontaneous adrenal hemorrhage in pregnancy. A case report. 335 26

After a general discussion of the factors contributing to maternal mortality and morbidity, a solution to both of these problems is suggested for India: an initiative at the district level to improve support, supervision, training, essential midwifery and obstetric care. The general causes of the 200 or more times higher maternal morality risks in developing countries act throughout the woman's lifetime: powerlessness, illiteracy, malnutrition, deficiency of calcium, vitamin D and iron, heavy physical labor, unchecked fertility, lack of prenatal and obstetric care and illegal abortion. The most common causes of maternal morality and morbidity, eclampsia, obstructed labor, hemorrhage and sepsis, have been prevented in developed countries and in China. We know how to prevent them, by technical support and management at the district level. 4 elements are required: 1) adequate primary health care, food and universal family planning; 2) prenatal care and nutrition with referral if needed; 3) assistance of a trained person at every childbirth; 4) access to obstetric care for those at high risk. Rather than spend money or urban specialized hospital centers, half to 2/3 of all fatal complications of childbirth can be eliminated by local hospitals with the ability to do basic obstetrics such as caesareans and blood transfusions. There is a need for further health systems research in the given locale, but what we need now is an initiative on making pregnancy and childbirth safe for all women.
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PMID:On safe motherhood. 342

This study was conducted to determine: the present rate, demographic correlates, and major causes of maternal mortality in rural Bangladesh; the pattern of health practices in relation to maternal mortality; the rate and pattern of neonatal mortality in rural areas; and the reliability of traditional birth attendants as reporters of maternal mortality-related data. During the 12-month period from September 1982 to August 1983, 9,317 live births and 58 maternal deaths were recorded in Melanda and Islampur upazilas in the Jamalpur district of rural Bangladesh, giving a maternal mortality rate of 62.3/10,000 live births. The age-specific maternal mortality rate is lowest in the 20-24 year old age group. Mortality risk increases with age after 29 years, particularly in the 35-39 and the 40-and-over groups. For all ages combined, mortality rates show a positive relation to parity. Although a positive relationship between parity and mortality is visible in the 25-34 group, the relationship is negative in the 35-and-over group. The single most common cause of death was septic abortion. Other causes include eclampsia (20.7%), delivery complications including obstructed labor, retained placenta (17.2%), postpartum sepsis (10.3%), and hemorrhage (10.3%). The classic triad of causes of infection--eclampsia--hemorrhage, accounted for 68.9% of all maternal deaths in the study area; direct obstetric causes accounted for 86.2% of all maternal deaths. The positive correlation between maternal age and maternal mortality risk found in the study indicates that childbearing in women aged above 35 years is significantly more hazardous than in younger women. A high mortality risk was also found among high parity (4) women. Family planning can reduce the risk of maternal mortality.
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PMID:Maternal mortality in rural Bangladesh: the Jamalpur District. 348 42

During approximately a 9-year period, 37 severe preeclamptic-eclamptic patients had pulmonary edema for an incidence of 2.9%. The incidence was significantly higher in older patients (p less than 0.0001) and in multigravid patients (p less than 0.05). Eleven (30%) had antepartum edema with 10 (90%) of the 11 having preexisting chronic hypertension. Twenty-six (70%) had postpartum edema with an average onset of 71 hours post partum. The majority of these patients had excessive colloid and crystalloid infusions for various medical, surgical, and obstetric complications. There were four maternal deaths and morbidity was significant. Eighteen patients had disseminated intravascular coagulopathy, 17 had sepsis, 12 had abruptio placentae, 10 had acute renal failure, six had hypertensive crisis, five had cardiopulmonary arrest, two had rupture of the liver, and two had ischemic cerebral damage. The overall perinatal mortality was 530/1000 and neonatal morbidity was significant. Pulmonary edema is infrequent in severe preeclampsia-eclampsia without associated medical, surgical and obstetric complications. The occurrence of pulmonary edema in such patients is associated with high maternal and perinatal mortality and morbidity.
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PMID:Pulmonary edema in severe preeclampsia-eclampsia: analysis of thirty-seven consecutive cases. 357 33


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