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An analysis of causes of maternal deaths in the Southern Highlands Zone of Tanzania, concentrating on avoidable factors contributing to these deaths, was conducted in 1983. Deaths were ascertained by forms sent to doctors in hospitals and assistants in health centers, by visiting hospital and centers regularly, and from reports to Regional Medical Officers. The majority of deaths occurred in hospitals, producing a maternal mortality rate of 2.5/1000 in hospitals, compared to 0.8/1000 for the Zone overall. Total numbers and notable cases were discussed in each of the following etiologies: ectopic pregnancy (1), sepsis after abortion (20), placenta previa (3), eclampsia (4), postpartum hemorrhage (21), anemia (3), obstructed labor (6), puerperal infection (10), sepsis after surgery (7), puerperal pulmonary embolism (2), aspiration after anesthesia (1), herbal medicines (2). The greatest number of deaths were in gravida 3 women. The main avoidable factors were lack of blood for transfusion, no partogram being kept in labor, and risk factors noted but not acted upon. Blood was not available for several reasons: blood not kept in maternity ward, equipment not available to transfuse and relatives refused to give blood. Some other avoidable risk factors were: lack of or slow transport to facility, interference abortion, no antenatal care, lack of gas gangrene serum, packing vagina with cloths to stop bleeding, staff errors. It was felt that isolation of rural doctors contributed to errors, which may possibly be avoided by holding periodic seminars and reviews.
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PMID:Preliminary report on maternal deaths in the Southern Highlands of Tanzania in 1983. 1228 47

Operational research, which was supported in part by the World Health Organization's Maternal Health and Safe Motherhood program, has shown that the risk of maternal death is decreased with the use of fully trained and supervised midwives posted in villages, when they are supported by reliable referral facilities. During a 3-year study (1987-89), 6 women died from direct obstetric causes in 39 villages covered by a community-based maternity program in the Maternal and Child Health-Family Planning (MCH-FP) project area of Matlab, Bangladesh; 20 maternal deaths occurred in a control population with an equivalent number of births. Maternal mortality was 114 per 100,000 live births in the project area and 380 in the control area. The midwives followed women throughout their pregnancies; 44% were attended in their homes at least once. The midwives attended 689 (14%) of all deliveries, and actually delivered 9% of the babies. 134 of the 689 (19%) attended deliveries were referred to the Matlab maternity clinic for assistance. 33% of the women were attended by the midwives within 4 days of delivery. 44 of the 1712 women who were attended by the midwives were referred to the clinic for postpartum complications. The program reduced deaths in the following order of importance: abortion complications, postpartum hemorrhage, postpartum sepsis, obstructed labor, and eclampsia. Due to a shortage of trained midwives in Bangladesh, extension of this program is unrealistic; however, women health workers with 18 months training in maternal and child health could be effective in managing cases referred by community health workers. This approach is under evaluation in Matlab.
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PMID:Bangladesh: village midwives save lives. 1228 32

The seminar on maternal morbidity and mortality in the Philippines held in 1991 is described. The objective of the meeting was to define the status of women's health in the country and to prepare for a more comprehensive and developed implementation of local reproductive health services. The seminar honored the International Day of Action for Women's Health. Maternal mortality statistics show a rate of 1.1.1000 live births since 1988 vs. 2.1/1000 live births in 1980. Maternal mortality is greater among young 1st time mothers, among those with 5 children, and among those 40 years regardless of the number of children. Obstetric deaths account for 85% of all maternal deaths. The common causes in 1985-89 were hemorrhage, infection, and hypertensive disorders. Pulmonary disease and acute hepatitis account for indirect obstetric mortality. The prior period from 1984 to 1985 in Manila showed the leading causes to be puerpural sepsis, septic induced abortion, postpartum hemorrhage, and eclampsia. In Manila 33% deliver at home. 65% of hospital emergency cases involve women without prenatal care, and 1 out of 4 are dying upon admission and 1 out of 5 die within 5-6 hours. 58% died within 2 days after admission. 80% of these deaths were preventable. Lack of health education and inadequate diet due to poverty account for a major predisposing role. Confounding factors are anemia, tuberculosis, and parasitism. Broad risk factors are the inadequacy of health services and socioeconomic conditions. Proposals to reduce maternal mortality by 50% include focusing health programs on both mother and child, improving knowledge about prenatal care, improving the quality of prenatal care, and improving the quality of family planning (FP) services. Medical institutions need to maintain adequate supplies of equipment and supplies. Statistics and research are needed. Contraception for the health of the child was proposed as the appropriate tool for acceptance of FP. Competition for funds was a problem. Problems were also identified as the power imbalance between the sexes. High risk screening was recommended at the local level by the health worker. Workshops were formed and issues were identified, recommendations made, activities described, and the government and nongovernmental responses given.
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PMID:The perils of motherhood. 1228 38

In 1984, 99% of abortions conducted in Bombay, India, were of female fetuses. In 1986-87, 30,000-50,000 female fetuses were aborted in India. In 1987-88, 7 Delhi clinics conducted 13,000 sex determination tests. Thus, discrimination against females begins before birth in India. Some states (Maharashtra, Goa, and Gujarat) have drafted legislation to prevent the use of prenatal diagnostic tests (e.g., ultrasonography) for sex determination purposes. Families make decisions about an infant's nutrition based on the infant's sex so it is not surprising to see a higher incidence of morbidity among girls than boys (e.g., for respiratory infections in 1985, 55.5% vs. 27.3%). Consequently, they are more likely to die than boys. Even though vasectomy is simpler and safer than tubectomy, the government promotes female sterilizations. The percentage of all sexual sterilizations being tubectomy has increased steadily from 84% to 94% (1986-90). Family planning programs focus on female contraceptive methods, despite the higher incidence of adverse health effects from female methods (e.g., IUD causes pain and heavy bleeding). Some women advocates believe the effects to be so great that India should ban contraceptives and injectable contraceptives. The maternal mortality rate is quite high (460/100,000 live births), equaling a lifetime risk of 1:18 of a pregnancy-related death. 70% of these maternal deaths are preventable. Leading causes of maternal deaths in India are anemia, hemorrhage, eclampsia, sepsis, and abortion. Most pregnant women do not receive prenatal care. Untrained personnel attend about 70% of deliveries in rural areas and 29% in urban areas. Appropriate health services and other interventions would prevent the higher age specific death rates for females between 0 and 35 years old. Even though the government does provide maternal and child health services, it needs to stop decreasing resource allocate for health and start increasing it.
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PMID:Statistics. 1228 55

This reviews 431 maternal deaths over 3 periods of 3-4 years each from January 1958 to December 1968. Trends in mortality are noted. A steady decline was noted. Associated diseases increased maternal mortality but age and parity had no significant influence. 47% of the deaths were intrapartum, 35% postpartum, and 18% antenatal. Major causes were hemorrhage, preeclampsia, eclampsia, sepsis, and anemia, in that order. Deaths due to infection diminished markedly during the period. 58.2% of the deaths were considered avoidable. Delay by patient or doctor and lack of facilities in rural areas were principle avoidable factors. Extension of obstetrical service to villages, emergency mobile squads, and periodic review of mortality statistics are recommended.
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PMID:Maternal mortality at government maternity hospital. Hyderabad, Andhra Pradesh (a review of 431 cases). 1230 76

Until the 20th century, women and families worldwide knew that it was always a possibility that women would die from childbearing (e.g., over 2000 maternal deaths/100,000 births in Europe). Increased knowledge about pregnancy and its complications and the application of that knowledge in maternal health care systems in developed countries reduced maternal mortality considerably (e.g., 20 in northern Europe). Improvements in delivery management helped greatly to reduce maternal deaths, which include aseptic techniques, appropriate use of forceps, safe blood transfusion, sulphonamides, and proper management of preeclampsia and eclampsia. Maternal mortality is still high in developing countries (e.g., 5% of women in some parts of Africa die from a pregnancy-related condition) where 99% of all maternal deaths occur. These pillars of family life die in the prime of their life and often leave other children. Their loss adversely affects social and economic development. Just 78 countries (35% of the world's population) have a vital registration system recording causes of death, thereby making it difficult to understand the extent of maternal mortality. The 1st cause of maternal death to fall in developed countries and now in developing countries is sepsis. Other causes of maternal death are obstetric hemorrhage, eclampsia, ectopic pregnancy, unsafe abortions, and obstructed labor. Lack of access to maternal health services keeps many women with pregnancy complications from receiving the care they need to survive. Trained persons help only about 50% of women worldwide with labor and delivery. Upgrading of local health centers and training midwives in recognizing complications and in aseptic delivery techniques are needed to improve the quality of maternal health care. Each health center must have the means to transport women to district hospitals. Health centers must offer contraception to prevent unwanted pregnancies. Countries need to reduce the social inequalities that women face.
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PMID:Maternity care for all. 1231 74

The University of Zimbabwe and two universities in Sweden conducted a study in Masvingo Province in Zimbabwe to examine maternal deaths. There were 168 and 85 maternal deaths per 100,000 live births in rural and urban areas, respectively. 90% and 85% of maternal deaths in rural and urban areas, respectively, were preventable. Mother-related preventable factors were no prenatal care, lack of social support, and delay in seeking help. Traditional birth attendant-related preventable factors were delay in referring mother to health care, inability to understand the severity of the complication, and administration of the wrong treatment. Local clinic-related preventable factors included inadequate resources, poor communication, and poor training of health care staff. Hospital-related preventable factors were delayed treatment, wrong diagnosis, wrong treatment, no supplies, and inadequate skills. Lack of prenatal care was common among many women who died from pregnancy- or childbirth-related complications. More than 33% of maternal deaths in rural areas occurred because there were no means for transport to the nearest clinic or hospital. Women who were single, divorced, separated, or self-supporting during pregnancy were more likely to die due to lack of social support. Other risk factors were high rate of unwanted pregnancies, age 35 or above, previous fetal death or miscarriage, and parity 7 or above. The leading causes of maternal death in rural areas included hemorrhage (25%), sepsis after unsafe abortion (15%), and puerperal sepsis (13%). In urban areas, they were eclampsia (26%), sepsis after unsafe abortion (23%), puerperal sepsis (15%), and hemorrhage (10%). 50% of the maternal deaths occurred outside of a health facility. More than 50% had already delivered 5 times. Recommendations to reduce maternal deaths were community-based health education on the risk factors of pregnancy and childbirth, improved health facilities, better training of health personnel, and improved family planning programs.
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PMID:Almost 9 in 10 maternal deaths could be prevented, Zimbabwe study shows. 1231 69

During 1981-1986, 86 maternal deaths transpired at the obstetrics department of the Jawaharlal Institute of Postgraduate Medical Education and Research in Pondicherry, India. The maternal mortality rate stood at 5.8/1000 births. 31.4% were primigravidae. The percentage of maternal deaths characterized as gravidae 2-4, 5, and multigravidae was 42.9%, 9.3%, and 16.4%, respectively. The leading causes of death were sepsis (41.9%), especially septic abortion (30.2%); eclampsia-severe preeclampsia (10.5%); ruptured uterus (9.3%); and hemorrhage and prolonged labor (8.1% each). Direct obstetric causes of death accounted for 81.4% of all maternal deaths. Indirect obstetric causes of death were hepatitis (5.8%), heart disease (4.7%), and severe anemia (2.3%). Most of the women who died were illiterate (97.6%), poor (98.8%), and had received no prenatal care (94.2%). 47.7% traveled more than 60 km to the hospital. Quacks or untrained traditional birth attendants had excessively interfered with about 33% before they reached the hospital, especially the septic induced abortion, obstructed labor, and ruptured uterus cases. Among the 48 women who delivered before dying, there were 24 live births (5 of whom died during the early neonatal period) and 24 still births. These findings indicate a need for a cooperative effort to improve and expand maternal and child health care in the community.
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PMID:Determinants of maternal mortality: a hospital based study from south India. 1231 6

To ascertain the causes of high maternal mortality in West Bengal, the author examined maternal mortality between 1964-68. It was intended that measures to improve the situation in rural areas could be suggested. Women in labor often arrive at the hospital very late and few antenatal care facilities are available in rural areas. High risk cases often are delivered at home, a situation which often results in fetal complications. Maternal deaths have declined, but not dramatically. Of the 24,265 deliveries at the Burdwan district hospital, there were 333 maternal deaths for an incidence of 13.7/1000, along with another 42 cases where death was due to pregnancy-associated causes. In contrast, the maternal mortality rate in a district hospital in Calcutta was 4/1000 in 1968. Eclampsia accounted for 42.34% (141) of maternal deaths making it the major cause of death. In Calcutta this cause of death is receding gradually but in the districts it still accounts for a heavy loss of life (an incidence of 1 in 38). Adequate antenatal care would reduce this high mortality. 2 factors which have contributed to the high mortality are the hours lost in transporting a patient from a rural area and inadequate hospital staff. Postpartum hemorrhage and/or retained placenta was responsible for 39 deaths and none of the cases admitted from outside had received antenatal care. A shortage of blood was also a contributory factor. Severe anemia was responsible for 34 deaths and abortions resulted in another 29 deaths (16 because of severe sepsis; 13 due to hemorrhage or shock). An emergency service would help reduce the number of deaths but at present such a service does not even exist in the urban areas. Ruptured uterus resulted in 29 deaths and obstructed labor in 27 deaths. Placenta previa brought about 14 deaths and the remaining 20 deaths were due to such causes as accidental hemorrhage (10), hydatidiform mole (4), puerperal sepsis (3), ectopic pregnancy (2), and uterine inversion (1). Timely admission would have helped most of these cases. In summation, the preventive measures which would help to lower maternal mortality are: 1) mass education about the need for antenatal care, 2) provision of good obstetrical service, 3) provision of quick transport, 4) adequate staffing of hospitals, 5) refresher courses for medical personnel, and 6) 24 hour blood transfusion service.
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PMID:Maternal mortality in a district hospital in West Bengal. 1233 40

A retrospective analysis of cases of caesarean section performed in Jos University Teaching Hospital between January 1994 and December 1998 was undertaken to determine the incidence, indications, perinatal and maternal outcome. There were 11,571 deliveries with 2083 caesarean sections done giving an incidence of 18%. 62.2% of the patients who had caesarean section were booked for antenatal care and delivered in the hospital, while 37.8% were unbooked seen as emergency. 90% of the operations were done as an emergency while only 10% was electively performed. There was a high caesarean section rate in all the age groups as well as the various parity distributions. The main indications for the elective section were repeat caesarean section, placenta praevia, precious baby, severe pregnancy induced hypertension and bad obstetric history while those for emergency section were cephalo-pelvic disproportion foetal distress, repeat caesarean section, antepartum haemorrhage, severe pregnancy induced hypertension/eclampsia, obstructed labour and breech presentation. The maternal mortality rate was 624.1/100,000 due mainly to haemorrhage, eclampsia and sepsis and there was one anaesthetic death amongst the booked patients. The perinatal mortality rate was 81.6/1000. The clinical causes of deaths were birth asphyxia, ante-partum haemorrhage, obstructed labour and prematurity.
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PMID:A five year appraisal of caesarean section in a northern Nigeria university teaching hospital. 1250 Dec 71


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