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MATERNAL
MORTALITY

Maternal Mortality Trending Down Globally

Where Do Mothers in USA Fit?

By Dr. Rajam Ramamurthy
is striking when a man walks in alone into the Univer- • Unsafe abortion (13%)
It sity Hospital Premiere Clinic holding an infant in one • Eclampsia – very high blood pressure leading to seizures – (12%)

• Obstructed labor (8%).
arm and pushing a stroller with another infant in it. The
babies were three months old. You quickly murmur Most of the women who die from these causes do so because
greetings and scroll down the computer screen frantically to see if they had no access to skilled routine care.
there is any information on the mother. There is none on the in- Globally, approximately 1.6 percent (4,700) of all maternal deaths
fant’s chart, only her delivery record, a healthy 21 year old who de- are estimated to be AIDS-related indirect maternal deaths. In sub-
livered premature twins at 33 weeks. He was a strikingly fit, tall Saharan Africa, 2.0 percent of all maternal deaths are estimated to
handsome dad. He was comfortably bottle-feeding one of the girls. be AIDS-related indirect maternal deaths, yielding an AIDS-related
Intuitively I felt the sadness in him and as I barely got out the words indirect MMR of 11 maternal deaths per 100,000 live births. In
“and mom,” he blurted out, “she is gone when they were 6 weeks 2015, there are five countries where 10 percent or more of maternal
old – hemorrhage – too late.” Who takes care of the babies, I asked. deaths are estimated to be AIDS-related indirect maternal deaths:
He smiled, “I do, and they are good babies.” Who helps when you South Africa (32%), Swaziland (19%), Botswana (18%), Lesotho
are working? “I can’t work, and I do odd jobs on weekends when (13%) and Mozambique (11%).
my sister helps.” When a mother dies, the family unit dies with her. In 2000, the United Nations (UN) Member States pledged to
Globally, the Maternal Mortality Ratio - MMR fell by nearly 44 work towards a series of Millennium Development Goals (MDGs)
percent from 1990 to 2015. In numbers that is 532 maternal deaths Included in this was a ¾ reduction in the 1990 MMR to be achieved
per 100,000 live births in 1990 to 216 per 100,000 in 2015. The by 2015. Table 1 shows the MMR for comparable industrialized
chances of a woman dying related to pregnancy decreased from wealthy countries and the U.S. It also shows developing countries,
1:73 to 1:180. Planning and accountability for improving maternal neighboring countries and a few countries that are of interest where
health, and assessment of the World Health Organization’s pro- there is U.S. involvement. With the exception of two countries, U.S.
grams, Millennium Development Goal (MDG 5) and Sustainable and South Africa where MMR has trended up, in all others it has
Development Goal (SDG) targets, require accurate and internation- reduced significantly.
ally comparable measures of maternal mortality. In the U.S. the Center for Disease Control (CDC) has also grap-
Given the challenges of obtaining accurate and standardized di- pled with the issue and come up with a set of guidelines. In the ‘70s,
rect measures of maternal mortality, the Maternal Mortality Esti- dismantling of maternal mortality review committees in most states
mation Inter-Agency Group (MMEIG) partnered with a team at was pursued following the rapid decline of MMR. Now there is a
the University of Massachusetts Amherst (USA), the National Uni- scramble to resurrect these committees in the environment of
versity of Singapore, and the University of California at Berkeley, HIPPA regulations that have slowed progress. As per CDC, a fully
USA, to generate internationally comparable MMR estimates with functional MMR review committee should have a set of guidelines
independent advice from a technical advisory group (TAG) that in- (Figure 1). CDC developed, Maternal Mortality Review Informa-
cludes scientists and academics with experience in measuring ma- tion Application (MMRIA) a tool that is adopted by many states.
ternal mortality. Not infrequently, affluent nations that fall short of An analysis of information gathered from nine states that used
expectations invoke doubts about accuracy of data in developing MMRIA gave eye-opening information about associated factors in
countries before glancing at their own backyard. Globally five com- maternal deaths. When 237 maternal deaths from nine states who
plications arising directly from pregnancy account for 70 percent used MMRIA were analyzed; 38 percent of the mothers died during
of maternal deaths. pregnancy, 45 percent within 42 days and 18 percent within 43 days
to one year. The leading underlying causes of pregnancy related
Causes of maternal deaths globally: death are shown in (Figure 2) Slide 22 of Duah. Hemorrhage and
• Hemorrhage (25%) underlying cardiovascular condition accounted for 28 percent of
• Infection (15%) the deaths. 33.5 percent of the deaths were not preventable. 63.2

12 San Antonio Medicine • July 2018