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Maternal Mortality

Definition Of Maternal Deaths: Death of a woman while pregnant or within 42 days of the termination of pregnancy irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

Maternal Mortality Ratio (Mmr): The MMR is expressed in terms of such maternal deaths per 100,000 live births. In most of the developed countries, the MMR varies from 4-40 per 100,000 live births. In the developing countries, it varies from 100-700 with India having about 254 per 100,000 live births. Most of the figures of the developing countries are however, based on the data from teaching hospitals as very often, the vital statistics from the whole country are not available.


Maternal Mortality Rate indicates the number of maternal deaths divided by the number of women of reproductive age (15-49). It is expressed per 100,000 women of reproductive age per year. In India, it is about 120 as compared to 0.5 of United States.

The term reproductive mortality is used currently to include maternal mortality and mortality from use of contraceptives.


Magnitude of The Problem: Worldwide, every year approximately eight million women suffer from pregnancy-related complications. Over half a million of them, die as a result. The problems of maternal mortality and morbidity are greatest (99%) for the poor women in the developing countries. One woman in 11 may die of pregnancy related complications in developing countries, compared to one in 5000 in developed countries. Here lies the major discrepancies in global health. It is further estimated that for one maternal death at least 16 more suffer from severe morbidities.



  • Direct
  • Indirect
  • Non-obstetric

Important causes of maternal deaths


Obstructed labor 8%


Hemorrhage 25%


Other direct causes 7%


Eclampsia 12%


Unsafe abortion 13%


Sepsis 15%


Indirect causes 20%

Direct obstetric deaths (75%) are those resulting from complication of pregnancy, delivery or their management. Such conditions are abortion, ectopic gestation, pre-eclampsia-eclampsia, antepartum and postpartum hemorrhage and puerperal sepsis.


Indirect deaths (25%) include conditions present before or developed during pregnancy but aggravated by the physiological effects of pregnancy and strain of labor. These are anemia, cardiac disease, diabetes, thyroid disease, etc. of which anemia is the most important single cause in the developing countries. Viral hepatitis when endemic, contributes significantly to maternal deaths.

Non-obstetric or fortuitous deaths: Accidents, typhoid and other infectious diseases.


Important Causes of Maternal Deaths and Main Interventions


Causes Percentage -Proven Interventions


Hemorrhage: Mostly due to postpartum hemorrhage. 20-25 -Treat anemia in pregnancy


Other causes are:

  1. Antepartum hemorrhage (abruptio -Skilled attendant at birth placenta, placenta previa)
  2. Retained placenta
  3. Abortion -Prevent/treat hemorrhage complications and ectopic pregnancy. Hemorrhage is more -Use oxytocics in time dangerous when the woman is anemic. -Replace fluid loss

 -Transfusion of blood, if severe hemorrhage.

Infection is associated with labor and puerperium. 15-20 -Skilled attendant at birth

Infections from premature rupture of membranes, -Clean practices during prolonged and obstructed labor are still frequent in the delivery developing world. -Antibiotics - if infection is evident.

Hypertension during pregnancy 12-15 -Early detection


Pre-eclampsia, eclampsia • Appropriate referral

 -Antiseizure prophylaxis/ treatment with MgS04


Unsafe abortion (see p. 164) 10-13 -Skilled attendant

 -Access to family planning and safe abortion services


 -Antibiotics after evacuation -Postabortion care (see p. 564).


Obstructed labor-due to cephalopelvic disproportion, 8 -Use of partoqraph-Detection in abnormal lie or malpresentation. Time, -Refer for operative delivery.

Anemia is an indirect cause of death. About 50 percent of 15-20 -Routine Iron-folic acid pregnant women worldwide suffer from anemia. Anemia supplementation -Treat hookworm, is commonly due to dietary deficiency (nutrition, iron, folic malaria, HIV, etc. acid, iodine and other micronutrients) or infections. -Admit when Hb≤7 g/dL.

Other indirect causes: Viral hepatitis is endemic in India 5-10 -Safe drinking water, with high mortality. Death is mostly in the last trimester due -Immunization to hepatic coma and coagulation failure and postpartum -Appropriate referral and hemorrhage. . supportive care.

80% of these deaths can be prevented through actions that are effective and affordable in developing country settings (WHO. UNICEF and UNFPA-2001).

Factors Associated With Maternal Mortality

Age: The optimum reproductive efficiency appears to be between 20-25 years. In the young adolescent, pregnancy carries a higher risk due to pre-eclampsia, cephalopelvic disproportion and uterine inertia. In women aged 35 years or above the risk is 3-4 times higher.

Parity: The risk is slightly more in primigravida but it is 3 times greater in para, 5 or above where postpartum hemorrhage, mal presentations and rupture uterus are more common. The risk is lowest in the second pregnancy.

Socioeconomic strata: Mortality ratios are higher in women belonging to low socioeconomic strata as these women are likely to be less privileged in the fields of nutrition, housing, education and antenatal care.


Antenatal care: Unfortunately, the women who have the highest mortality, like grand multiparae or the patients of lower socioeconomic status are the women who often do not avail the benefits of antenatal care.


Substandard care: When the care provided is below the generally accepted level, available at that circumstances. Shortage of resources (Staff) or back up facilities (Laboratory) is also included.

In the developing countries, avoidable social factors are palpably evident. These are related to: (a) Presence of social evils-illiteracy, early pregnancy, ignorance or prejudice, (b) Unregulated fertility and unsafe abortion, (c) Poor socioeconomic condition, (d) Inadequate maternity services, (e) Underutilization of the existing services, (f) Lack of communication and referral facilities. These are most often interrelated and are responsible for increased number of avoidable deaths.

Important causes of maternal death: Whereas in the organized sector (developed countries) - hypertensive disorders, hemorrhage and pulmonary embolism are the main causes, in the developing countries - hemorrhage, sepsis and pre-eclampsia-eclampsia and unsafe abortion are the main causes.

Steps to Reduce Maternal Mortality (Actions For Safe Motherhood)

It is a coordinated, long-term effort within the families, communities and the health systems. It also involves the national legislation and policy. Actions may vary in respect of an individual country. The government must make maternal mortality a priority public health issue and periodically evaluate the programs in an effort to prevent or minimise maternal deaths. Specific actions are discussed under the following groups:

  1. Health Sector Actions
    • Basic antenatal, intranatal and postnatal care (see RCH interventions). Risk assessment is a continued procedure throughout and is not once only.
    • A skilled attendant should be present at every birth. Functioning referral system is essential for integration of domiciliary and institutional services.
    • Emergency obstetric care (EmOC) is to be provided either by a field staff at the door step of a pregnant woman or preferably at the first referral unit (FRU).
    • Good quality obstetric services at the referral centers are to be ensured. Facilities for blood transfusion, laparotomy and cesarean section must be available atthe FRU level.
    • Prevention of unwanted pregnancy and unsafe abortion. All couples and individuals should have access to effective, client orien5ed and confidential family planning services.
    • Frequent joint consultation among specialists in the management of medical disorders in pregnancy particularly anemia, diabetes, cardiac disease, viral hepatitis, and hypertension.
    • Maternal mortality conferences to evaluate the cause of death and the avoidable factors.
    • Periodic refresher causes for continuing education of obstetricians, general practitioners, midwives and ancillary staff and to highlight the preventable factors.
  2. Community, Society and Family Actions
    These are essential to safe motherhood. Wide range of groups (women's groups), health care professionals, religious leaders and safe motherhood committees (regional, district) can help the woman to obtain the essential obstetric care.
  3. Health Planners/Policy Makers' Actions
    • To organize community education, motivation and formation of safe motherhood committee at the local level.
    • To strengthen the referral system for obstetric emergencies.
    • To develop written management protocols for obstetric emergencies in the hospitals.
    • To improve the standard and quality of care by organizing refresher courses for the health care personnels.
    • Periodic audit of the existing health care delivery system and to implement changes as needed.
  4. Legislative and Policy Actions
    • Girl children and adolescents should have good nutrition, education and economic opportunities. They are to be educated about the age of sex and the risks of unprotected sex.
    • Barriers to the access of health care facilities should be removed. Policies should increase women's decision making power as regard to their own health and reproduction.
    • Decentralization of services to make them available to all the women.
    • Safe abortion services and post-abortion care must be ensured by national policy (p. 562).
    • Social inequalities and discrimination on grounds of gender, age and marital status, are to be removed.

Maternal Morbidity

Although considerable attention has been given to maternal mortality, very little concern has been expressed for maternal morbidity. It has been estimated that for one maternal death at least 15 more suffer from severe morbidities. As such, about an optimistic 5-7 million women suffer a severely impaired quality of life as a result of short-term or long-term disability.


Definition: Obstetric morbidity originates from any cause related to pregnancy or its management any time during antepartum, intrapartum and postpartum period usually up to 42 days after confinement. The parameters of maternal morbidity are-(I) Fever more than 100.4°F or 38°C and continuing more than 24 hours, (2) Blood pressure more than 140/90 mm of Hg, (3) Recurrent vaginal bleeding, (4) Hb% less than 10.5 g irrespective of gestational period, and (5) Asymptomatic bacteriuria of pregnancy.


Classification: Direct obstetric morbidity: • Temporary • Permanent II. Indirect obstetric morbidity


Direct- Temporary: APH, PPH, eclampsia, obstructed labor, rupture uterus, sepsis, ectopic pregnancy, molar pregnancy, etc.


Permanent (chronic): VVF, RVF, dyspareunia, CPT, prolapse, secondary infertility, obstetric palsy, Sheehan's syndrome, etc.


Indirect: These conditions are only expressions of aggravated previous existing diseases like malaria, hepatitis, tuberculosis, anemia, etc. by the changes in the various systems during pregnancy.

Reproductive morbidity is used in a broader sense to include-

  1. Obstetric morbidity,
  2. Gynecological morbidity and
  3. Contraceptive morbidity.

Perinatal Mortality

Perinatal mortality is defined as deaths among fetuses weighing 1000 g or more at birth (28 weeks gestation) who die before or during delivery or within the first 7 days of delivery. The perinatal mortality rate is expressed in terms of such deaths per 1000 total births. The perinatal mortality rate closely reflects both the standards of medical care and effectiveness of social and public health measures. According to WHO, the limit of viability is brought down to a fetus weighing 500 g (gestational age 22 weeks) or body length (25 cm crown- heel) or more. However, for international comparisons, only deaths of fetuses or infants weighing 2: 1000 g at birth should be included as in the developing countries-many such deaths are under reported.

Worldwide nearly four million newborns die within the first week of life and another three million are born dead. Perinatal deaths could be reduced by at least 50% worldwide if key interventions are applied for the newborn. The perinatal mortality is less than 10 per 1000 total births in the developed countries while it is much higher in the developing countries (60/1000 in India). The national goal is between 30 and 35. The major health problem in the developing world arise from the synergistic effect of malnutrition, infection and unregulated fertility combined with lack of adequate obstetric care.

Majority of fetal deaths (70-90%) occur before the onset of labor. The important causes of antepartum deaths are:

  1. Chronic hypoxia (30%),
  2. Pregnancy complications (30%),
  3. Congenital malformations (15%),
  4. Infection (5%) and
  5. Unexplained (20%).

The WHO's definition, more appropriate in nations with well-established vital records of stillbirths is as follows



            Late foetal deaths (28 weeks gestation and more) + early neonatal deaths (first week) is one year

PMR = ----------------------------------------------------------------------------------------------------------------x 100

            Live births + late foetal deaths (28 weeks gestation and more) in the same year

The who's definition, more appropriate in nations with less well established vital records, is:


                                       Late foetal deaths (28 weeks of gestation) +postnatal deaths (first week) in a year

Perinatal mortality rate = ----------------------------------- -----------------------------------------------------------x 1000

                                       Live births in a year

Causes of perinatal mortality


About two-thirds of all perinatal deaths occur among infant with less than 2500 g birth weight. The causes involve one or more complications in the mother during pregnancy or about,"h1 the placenta or in the foetus or neonate.


Main causes


The main causes of death are intrauterine and birth asphyxia, low birth weight, birth, and intrauterine or neonatal infection.

Fetus, Newborn and IUGR


Important causes of perinatal mortality


Causes Percent


Infections (Sepsis, Meningitis, Pneumonia, Neonatal tetanus, Congenital syphilis) 33


Birth asphyxia and trauma Hypothermia 28


Preterm birth and/or low birth weight 24


Congenital malformations and others 15




Deaths occurring from 28 days of life to under one year are called post-neonatal death.


                                                    Number of deaths of children between 28 days and one year of age inagiven year

The post - neonatal mortality rate --------------------------------------------------------------------------------------------- x 1000

                                                    Total live births in the same year


"Whereas neonatal mortality is dominated by endogenous factors, post neonatal mortality is dominated by exogenous factors (e.g. environmental and social factors)."

  • Main causes in developing countries:
    • Diarrhoea
    • Respiratory tract infection
    • Malnutrition.
  • Main causes in developed countries:
    • Congenital anomalies

Extra Edge:


Some important Definitions:

  • Perinatal period extends from the 28th week of gestation up to the 7th day of life.
  • Extended perinatal period is the period from the 22nd week up to the 7th day of life.
  • Neonatal period extends from birth up to 28 days of life. The early neonatal period refers to the first 7 days and the late neonatal period from 7 days to 28 days.
  • Stillbirth: A stillbirth is the birth of a newborn after 28th completed week (weighing 1000 gm or more) when the baby does not breathe or show any sign of life after delivery. Such deaths include antepartum deaths (macerated) and intrapartum deaths (fresh stillbirths). Stillbirths rate is the number of such deaths per 1000 total births (live and still births).
  • Perinatal mortality rate (PNMR) : Perinatal mortality is defined as deaths among, fetuses weighing 1000 gm or more at birth (28 weeks gestation) who die before or during delivery or within the first 7 days of delivery. The perinatal mortality rate is expressed in terms of such deaths per 1000 total births. Perinatal deaths are thus the sum of stillbirths plus early neonatal deaths.

Causes: Infection> Birth asphyxia and trauma> Preterm birth and I or LBW > Congenital malformation.

  • Neonatal mortality rate (NMR): It is the death of the baby within 28 days after birth. Neonatal mortality rate is the number of such deaths per 1000 live births. Majority of the deaths occur within 48 hours of birth.

Most common cause of Neonatal mortality is Prematurity.







Respiratory effort

Heart rate

Muscle tone

Reflex irritability





No response

Blue, pale

Slow, irregular

Slow « 100)

Flexion of extremities


Body pink, extremities blue

Good, crying

> 100

Active body movement


Complete pink


Total score

No depression

Mild depression

Severe depression

In this case:

Heart rate

Respiratory effort

Muscle flaccid

Blue color

Reflex irratibility none

= 10

= 7 -10

= 4-6

= 0-3


= 110 means score of 2

= slow and irregular means a score of 1

= score 0

= score 0

= 0

Total score in this case

= 3


  • Collection of blood in between the pericranium and the flat bone of the skull due to rupture of a small emissary vein from the skull. It may be associated with fracture of the skull bone.
  • Usually unilateral.
  • Lies over a parietal bone.
  • Caused generally by forceps delivery but may also be met with following a normal labour. Ventouse application does not increase the incidence of cephalhaematoma.
  • It is never present at birth but gradually develops after 12-24 hours of birth and disappears by 6-8 weeks.
  • It is circumscribed, soft, fluctuant: and incompressible.

Caput succedaneum

This is a localised swelling of the scalp due to effusion of serum above the periosteum.


  • There is obstruction of venous and lymphatic return due to pressure by the cervix.
  • Stagnation of fluid
  • Edema over scalp
  • Site: of the caput depends upon the position of the head.
  • It is present at birth and disappears by about 24 - 36 hours.
  • The size indicates the amount of pressure on the head.

Description: 333


Caput succedaneum

Sharply circumscribed

Soft but does not pit on pressure

Under the periosteum

Does not cross suture lines

Fixed in one place

May be associated with fracture

Appears sometime after birth, grows larger

and disappears only after weeks or months


Soft and pits on pressure

Above the periosteum

Lies over and crosses suture lines/midline

Movable over dependant part

Not associated with fracture

Largest at birth, Immediately starts to

regress and disappears in a few hours

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