The fundamental aim of the obstetrician is to deliver healthy women of healthy children. It is a recurring tragedy therefore that pregnancy and its complications still contribute, on a worldwide scale, to death of women in the reproductive age group. In the developed world enormous advances have been made in the care of women in general and in pregnancy in particular. These have resulted in a reduction in maternal mortality though death in childbirth or pregnancy remains a risk for all women embarking on pregnancy.
DEFINITIONS OF MATERNAL MORTALITY
Maternal deaths
Direct
Indirect
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Maternal and Perinatal Mortality
The Maternal Mortality Rate (MMR) is now commonly quoted as the number of deaths per 100000 maternities, i.e. the number of pregnancies that result in a live birth at any gestation or stillbirths occurring at or after 24 weeks completed gestation. In the United Kingdom these must be notified by law. The total number of maternities for 1997–1999 was 2123614.
Special Enquiries into maternal deaths have been carried out in the United Kingdom since the 1930s. A consultant obstetrician in each region was appointed to act as assessor and subsequently assessors in anaesthesia were added. The importance of thorough evaluation of reports was emphasised with the addition of assessors in pathology, psychiatry and midwifery.
Assessors were asked to consider the circumstances of each death and identify, if possible, avoidable factors. The identification of deficiencies by the Enquiries has, over the years, helped to improve the quality of the maternity services. Mortality rates are published by the Departments of Health of the United Kingdom on a three yearly basis. There has been an enormous reduction in MMR over the 80 years since data have been collected.
An important development has been in the introduction of a psychiatric assessor since a common theme in maternal mortality reports is of the problems presented by social exclusion, domestic violence and mental illness.
In the United Kingdom, responsibility for enquiring into maternal (and perinatal) mortality falls with the remit of the Confidential Enquiry into Maternal and Child Health (CEMACH). Included within CEMACH’s overall remit are the work programmes of two previous national confidential enquiries – the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) and the Confidential Enquiry into Maternal Deaths (CEMD). These two enquiries were dissolved on 31 March 2003.
‘the death of a woman while pregnant or within 42 days of delivery, miscarriage or termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes’.
Deaths are subdivided into Direct, Indirect and Fortuitous, but only Direct and Indirect deaths are counted for statistical purposes.
The latest revision, ICD10, recognises that some women die as a consequence of Direct or Indirect obstetric causes after this period and has introduced a category for Late maternal deaths defined as ‘those deaths occurring between 42 days and one year after abortion, miscarriage or delivery that are due to Direct or Indirect maternal causes’.
Deaths of women while pregnant or within 42 days of delivery, miscarriage or termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
Deaths resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above.
Deaths resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiologic effects of pregnancy.
