Comorbidities and Lack of Blood Transfusion May Negatively Affect Maternal Outcomes of Women with Obstetric Hemorrhage Treated with NASG

The Non-Pneumatic Anti-Shock Garment (NASG) is a first-aid device to reduce mortality from severe obstetric hemorrhage, the leading cause of maternal mortality globally. We sought to evaluate patient characteristics associated with mortality among a cohort of women treated with the NASG in Nigeria. Data on 1,149 women were collected from 50 facilities participating in the Pathfinder International Continuum of Care: Addressing Postpartum Hemorrhage project in Nigeria from 2007–2012. Characteristics were compared using the appropriate distributional tests, and we estimated multivariable logistic regression models to control for treatment received. There were 201 deaths (17.5%). Women who died were significantly more likely to have any co-morbidity (AOR 3.63, 95% CI: 2.41–5.48), ruptured uterus (AOR 2.79, 95% CI: 1.48–5.28), macerated stillbirth (AOR 2.96, 95% CI 1.60–5.48) and to have had 6 or more previous births, (AOR 1.53, 95% CI 1.11–2.12), after adjusting for treatment received. These results suggest certain maternal conditions, particularly the presence of another life-threatening co-morbidity or macerated stillbirth, conferred a higher risk of mortality from PPH. This underscores the need for multi-system assessment and a comprehensive approach to the treatment of women with pregnancy complications.     

Maternal Mortality in British Columbia: A Study of 145 Deaths from 1955 to 1962

Between 1955 and 1962, 145 maternal deaths were reported in the Province of British Columbia. One hundred of them were due to obstetrical causes. Of these deaths, hemorrhage was by far the commonest cause (40 cases), followed in frequency by vascular accidents (23 cases), infections (17 cases), toxemia (10 cases), anesthetic deaths (five cases), and other causes (five cases). Significant avoidable factors were noted in 80%. Indirect obstetrical deaths accounted for 29 cases, or 20% of all maternal mortalities. The most frequently encountered causes of indirect obstetrical deaths were cardiac (nine cases) and vascular accidents (six cases). Avoidable factors were considered to be present in 19 of the 29, an incidence of 65%.When all deaths were considered together, 72% were felt to have significant avoidable factors when judged against an academic standard. It was also apparent that some 40% to 50% of deaths were intimately involved with social factors.     

Maternal Mortality in India: Causes and Healthcare Service Use Based on a Nationally Representative Survey

Background

Data on cause-specific mortality, skilled birth attendance, and emergency obstetric care access are essential to plan maternity services. We present the distribution of India''s 2001–2003 maternal mortality by cause and uptake of emergency obstetric care, in poorer and richer states.

Methods and Findings

The Registrar General of India surveyed all deaths occurring in 2001–2003 in 1.1 million nationally representative homes. Field staff interviewed household members about events that preceded the death. Two physicians independently assigned a cause of death. Narratives for all maternal deaths were coded for variables on healthcare uptake. Distribution of number of maternal deaths, cause-specific mortality and uptake of healthcare indicators were compared for poorer and richer states. There were 10 041 all-cause deaths in women age 15–49 years, of which 1096 (11.1%) were maternal deaths. Based on 2004–2006 SRS national MMR estimates of 254 deaths per 100 000 live births, we estimated rural areas of poorer states had the highest MMR (397, 95%CI 385–410) compared to the lowest MMR in urban areas of richer states (115, 95%CI 85–146). We estimated 69 400 maternal deaths in India in 2005. Three-quarters of maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated live births in India. Most maternal deaths were attributed to direct obstetric causes (82%). There was no difference in the major causes of maternal deaths between poorer and richer states. Two-thirds of women died seeking some form of healthcare, most seeking care in a critical medical condition. Rural areas of poorer states had proportionately lower access and utilization to healthcare services than the urban areas; however this rural-urban difference was not seen in richer states.

Conclusions

Maternal mortality and poor access to healthcare is disproportionately higher in rural populations of the poorer states of India.     

An analysis of maternal deaths in British Columbia: 1963 to 1970

There were 132 maternal deaths in British Columbia in the years 1963 to 1970. The mean maternal mortality rate for these eight years was 0.317. Sixty of these deaths (45.5%) were due to direct obstetrical causes. Indirect and nonrelated deaths accounted for 21.2 and 33.3% of the total, respectively. The most common causes of direct obstetrical deaths were hemorrhage, infection and vascular accidents, in that order; pre-eclampsia ranked a distant fourth. Ninety-five percent of direct obstetrical deaths were probably avoidable. Approximately 27% of all direct obstetrical deaths were abortion-related. Hemorrhage continues to be a major problem, in particular among the native Indian women of the province.If further reduction in maternal mortality is to be achieved, obstetrical hemorrhage must be better managed and deaths due to abortions reduced. Future studies should reveal if the liberalized abortion laws will assist in the realization of the latter goal.     

Causes of death in the Kasekela chimpanzees of Gombe National Park, Tanzania

Understanding the rates and causes of mortality in wild chimpanzee populations has important implications for a variety of fields, including wildlife conservation and human evolution. Because chimpanzees are long-lived, accurate mortality data requires very long-term studies. Here, we analyze 47 years of data on the Kasekela community in Gombe National Park. Community size fluctuated between 38 and 60, containing 60 individuals in 2006. From records on 220 chimpanzees and 130 deaths, we found that the most important cause of mortality in the Kasekela community was illness (58% of deaths with known cause), followed by intraspecific aggression (20% of deaths with known cause). Previous studies at other sites also found that illness was the primary cause of mortality and that some epidemic disease could be traced to humans. As at other study sites, most deaths due to illness occurred during epidemics, and the most common category of disease was respiratory. Intraspecific lethal aggression occurred within the community, including the killing of infants by both males and females, and among adult males during the course of dominance-related aggression. Aggression between communities resulted in the deaths of at least five adult males and two adult females in the Kasekela and Kahama communities. The frequency of intercommunity violence appears to vary considerably among sites and over time. Intercommunity lethal aggression involving the Kasekela community was observed most frequently during two periods. Other less common causes of death included injury, loss of mother, maternal disability, and poaching.     

Surveillance system of maternal mortality in the Tunis region

In the framework of a national strategy of reduction of the maternal mortality rate. Tunisia has set up a follow up system of maternal deaths occurring in public facilities to analyse their causes, the levels of deficiency and to propose solutions for preventing them. This note aims at describing the system, its results, its efficiency and its limitations in the Tunis region for the years 1999 and 2000. The results show a maternal mortality rate estimated at 80 for 100,000 births in public facilities of the region: the main causes being haemorrhage (42.1%) followed by infection (13.2%). The proportion of avoidable deaths is 87%:74% possibly avoidable and 13% certainly avoidable, factors related to women behaviour have also contributed to 45% of cases. The system flows are however intricated, and related to organization: an underestimation of risk by the patient (33%), an inadequate watch during the postpartum period (25%), a late hospitalisation (22%) and not enough reanimation equipment. Nevertheless, this control system has achieved part of its objective by starting up a quality approach to obstetrical cares and by warning health professionals such as obstetricians, anaesthetists, blood banks in charge, hospital managers and other medical teams. The limitations of the system are tied to the follow up of the real implementation of recommendations stated in reports at a local as well as central levels.     

Maternal Mortality in Taiwan: A Nationwide Data Linkage Study

Background

To examine the changes in the maternal mortality ratio (MMR) and causes of maternal death in Taiwan based on nationwide linked data sets.

Methods

We linked four population-based data sets (birth registration, birth notification, National Health Insurance inpatient claims, and cause of death mortality data) to identify maternal deaths for 2004–2011. Subsequently, we calculated the MMR (deaths per 100,000 live births) and the proportion of direct and indirect causes of maternal death by maternal age and year.

Findings

Based on the linked data sets, we identified 236 maternal death cases, of which only 102 were reported in officially published mortality data, with an underreporting rate of 57% [(236−102) × 100 / 236]. The age-adjusted MMR was 18.4 in 2004–2005 and decreased to 12.5 in 2008–2009; however, the MMR leveled off at 12.6 in 2010–2011. The MMR increased from 5.2 in 2008–2009 to 7.1 in 2010–2011 for patients aged 15–29 years. Women aged 15–29 years had relatively lower proportion in dying from direct causes (amniotic fluid embolism and obstetric hemorrhage) compared with their counterpart older women.

Conclusions

Approximately two-thirds of maternal deaths were not reported in officially published mortality data. Routine surveillance of maternal mortality by using enhanced methods is necessary to monitor the health status of reproductive-age women. Furthermore, a comprehensive maternal death review is necessary to explore the preventability of these maternal deaths.     

An autopsy study of maternal mortality in Mozambique: the contribution of infectious diseases

Background

Maternal mortality is a major health problem concentrated in resource-poor regions. Accurate data on its causes using rigorous methods is lacking, but is essential to guide policy-makers and health professionals to reduce this intolerable burden. The aim of this study was to accurately describe the causes of maternal death in order to contribute to its reduction, in one of the regions of the world with the highest maternal mortality ratios.

Methods and Findings

We conducted a prospective study between October 2002 and December 2004 on the causes of maternal death in a tertiary-level referral hospital in Maputo, Mozambique, using complete autopsies with histological examination. HIV detection was done by virologic and serologic tests, and malaria was diagnosed by histological and parasitological examination. During 26 mo there were 179 maternal deaths, of which 139 (77.6%) had a complete autopsy and formed the basis of this analysis. Of those with test results, 65 women (52.8%) were HIV-positive. Obstetric complications accounted for 38.2% of deaths; haemorrhage was the most frequent cause (16.6%). Nonobstetric conditions accounted for 56.1% of deaths; HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis were the most common causes (12.9%, 12.2%, 10.1% and 7.2% respectively). Mycobacterial infection was found in 12 (8.6%) maternal deaths.

Conclusions

In this tertiary hospital in Mozambique, infectious diseases accounted for at least half of all maternal deaths, even though effective treatment is available for the four leading causes, HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis. These observations highlight the need to implement effective and available prevention tools, such as intermittent preventive treatment and insecticide-treated bed-nets for malaria, antiretroviral drugs for HIV/AIDS, or vaccines and effective antibiotics for pneumococcal and meningococcal diseases. Deaths due to obstetric causes represent a failure of health-care systems and require urgent improvement.     

Premature Adult Death in Individuals Born Preterm: A Sibling Comparison in a Prospective Nationwide Follow-Up Study

BackgroundClose to one in ten individuals worldwide is born preterm, and it is important to understand patterns of long-term health and mortality in this group. This study assesses the relationship between gestational age at birth and early adult mortality both in a nationwide population and within sibships. The study adds to existing knowledge by addressing selected causes of death and by assessing the role of genetic and environmental factors shared by siblings.MethodsStudy population was all Norwegian men and women born from 1967 to 1997 followed using nation-wide registry linkage for mortality through 2011 when they were between 15 and 45 years of age. Analyses were performed within maternal sibships to reduce variation in unobserved genetic and environmental factors shared by siblings. Specific outcomes were all-cause mortality and mortality from cardiovascular diseases, cancer and external causes including accidents, suicides and drug abuse/overdoses.ResultsCompared with a sibling born in week 37–41, preterm siblings born before 34 weeks gestation had 50% increased mortality from all causes (adjusted Hazard Ratio (aHR) 1.54, 95% confidence interval (CI) 1.17, 2.03). The corresponding estimate for the entire population was 1.27 (95% CI 1.09, 1.47). The majority of deaths (65%) were from external causes and the corresponding risk estimates for these deaths were 1.52 (95% CI 1.08, 2.14) in the sibships and 1.20 (95% CI 1.01, 1.43) in the population.ConclusionPreterm birth before week 34 was associated with increased mortality between 15 and 45 years of age. The results suggest that increased premature adult mortality in this group is related to external causes of death and that the increased risks are unlikely to be explained by factors shared by siblings.     

Measuring Maternal Mortality: Three Case Studies Using Verbal Autopsy with Different Platforms

Background

Accurate measurement of maternal mortality is needed to develop a greater understanding of the scale of the problem, to increase effectiveness of program planning and targeting, and to track progress. In the absence of good quality vital statistics, interim methods are used to measure maternal mortality. The purpose of this study is to document experience with three community-based interim methods that measure maternal mortality using verbal autopsy.

Methods

This study uses a post-census mortality survey, a sample vital registration with verbal autopsy, and a large-scale household survey to summarize the measures of maternal mortality obtained from these three platforms, compares and contrasts the different methodologies employed, and evaluates strengths and weaknesses of each approach. Included is also a discussion of issues related to death identification and classification, estimating maternal mortality ratios and rates, sample sizes and periodicity of estimates, data quality, and cost.

Results

The sample sizes vary considerably between the three data sources and the number of maternal deaths identified through each platform was small. The proportion of deaths to women of reproductive age that are maternal deaths ranged from 8.8% to 17.3%. The maternal mortality rate was estimable using two of the platforms while obtaining an estimate of the maternal mortality ratio was only possible using one of the platforms. The percentage of maternal deaths due to direct obstetric causes ranged from 45.2% to 80.4%.

Conclusions

This study documents experiences applying standard verbal autopsy methods to estimate maternal mortality and confirms that verbal autopsy is a feasible method for collecting maternal mortality data. None of these interim methods are likely to be suitable for detecting short term changes in mortality due to prohibitive sample size requirements, and thus, comprehensive and continuous civil registration systems to provide high quality vital statistics are essential in the long-term.     

Changing sex ratio of mortality in the Semai Senoi, 1969-1987

An excess of male over female deaths is characteristic of modern national populations, whereas in some high-mortality societies female mortality exceeds that of males. Among the Semai Senoi, a Malaysian Orang Asli ("aboriginal") population, women experienced higher mortality than males in the decades before 1969. This differential occurred in all age classes older than 15 years so that the sex ratio progressively increased with age. A recent (1987) restudy of the Semai population found that sex-specific differential mortality is much reduced. A comparison of the 1969 and 1987 life tables shows a sharp shift in the sex ratios of mortality for the post-15-year-old age classes (the geometric means of age classes 15-44 were 0.768 in 1969 and 0.997 in 1987) so that male and female expectations of further life at age 15 are now nearly identical. In contrast to the best-known cases of high female mortality (mostly in South Asia), Semai sex differential mortality does not include the childhood ages. The Semai have traditionally been relatively sexually egalitarian, and sex bias in care has not occurred. Analysis of sex-specific causes of death for the pre-1969 population suggests that maternal mortality is the major cause of the excess female deaths. The reduced number of maternal deaths seems largely due to better health care, particularly the availability of hospital services. Interestingly, the reduction in female mortality has occurred simultaneously with increased fertility, and overall mortality has continued at relatively high levels (eO less than 36). Thus, rather than forming a component of a unitary demographic transition, declining sex differences in mortality can be accounted for by a specific factor, better maternal care.     

The Scottish perinatal mortality survey.

Perinatal deaths in single births that occurred in Scotland during 1977 were investigated by case-record analysis. Causes of death were divided into nine categories, an extended version of the Aberdeen classification being used. Out of 1012 single perinatal deaths, 265 were due to fetal abnormality, which in 140 cases was malformation of the central nervous system. Of the 747 normally formed infants, 446 weighed 1500 g or more, of whom 82 died intra partum and 154 were born alive. The largest single cause of death was low birth weight in normally formed babies whose mothers had no complications of pregnancy (302 cases). Of these babies, 103 (34%) were growth-retarded. Rhesus incompatibility (16 deaths) and maternal diabetes (seven deaths) were not major causes of perinatal loss. These results were thought to be valuable in illustrating the main causes of perinatal mortality and directing attention to important issues. Hence a modified version of the study is being continued to see whether yearly audit by regional assessors is a feasible and practical way of monitoring trends in perinatal mortality.     

Analysis of factors associated with maternal mortality in Kenyan hospitals.

This paper examines the association of the sociodemographic characteristics of women and the unobserved hospital factors with maternal mortality in Kenya using multilevel logistic regression. The data analysed comprise hospital records for 58,151 obstetric admissions in sixteen public hospitals, consisting of 182 maternal deaths. The results show that the probability of maternal mortality depends on both observed factors that are associated with a particular woman and unobserved factors peculiar to the admitting hospital. The individual characteristics observed to have a significant association with maternal mortality include maternal age, antenatal clinic attendance and educational attainment. The hospital variation is observed to be stronger for women with least favourable sociodemographic characteristics. For example, the risk of maternal death at high-risk hospitals for women aged 35 years and above, who had low levels of education, and did not attend antenatal care is about 280 deaths per 1000 admissions. The risk for similar women at low-risk hospitals is about 4 deaths per 1000. To complement results from the analysis of individual patient records, the paper includes findings from hospital staff reports regarding the maternal mortality situation at the hospitals.     

The influence of antenatal and maternal factors on stillbirths and neonatal deaths in New South Wales, Australia

This study identified the influences of maternal socio-demographic and antenatal factors on stillbirths and neonatal deaths in New South Wales, Australia. Bivariate and multivariate analyses were used to explore the association of selected antenatal and maternal characteristics with stillbirths and neonatal deaths. The findings of this study showed that stillbirths and neonatal deaths significantly varied by infant sex, maternal age, Aboriginality, maternal country of birth, socioeconomic status, parity, maternal smoking behaviour during pregnancy, maternal diabetes mellitus, maternal hypertension, antenatal care, plurality of birth, low birth weight, place of birth, delivery type, maternal deaths and small gestational age. First-born infants, twins and infants born to teenage mothers, Aboriginal mothers, those who smoked during the pregnancy and those of lower socioeconomic status were at increased risk of stillbirths and neonatal deaths. The most common causes of stillbirths were conditions originating in the perinatal period: intrauterine hypoxia and asphyxia. Congenital malformations, including deformities and chromosomal abnormalities, and disorders related to slow fetal growth, short gestation and low birth weight were the most common causes of neonatal deaths. The findings indicate that very low birth weight (less than 2,000 g) contributed 75.6% of the population-attributable risks to stillbirths and 59.4% to neonatal deaths. Low gestational age (less than 32 weeks) accounted for 77.7% of stillbirths and 87.9% of neonatal deaths. The findings of this study suggest that in order to reduce stillbirths and neonatal deaths, it is essential to include strategies to predict and prevent prematurity and low birth weight, and that there is a need to focus on anti-smoking campaigns during pregnancy, optimizing antenatal care and other healthcare programmes targeted at the socially disadvantaged populations identified in this study.     

A prospective study of maternal and fetal outcome in acute Lassa fever infection during pregnancy.

Several viral infections have been reported to result in more severe disease in pregnant than non-pregnant women, but the relative risks have not been well characterised. This has now been done for Lassa fever in a prospective study of 68 pregnant and 79 non-pregnant women who were admitted to hospital in Sierra Leone with confirmed Lassa fever. Lassa fever was the main cause of maternal mortality in the hospital, accounting for 25% of maternal deaths. Twelve of 40 patients in the third trimester died, compared with two of 28 in the first two trimesters and 10 of 79 non-pregnant women. The odds ratio for death in the third trimester compared with the first two trimesters was 5.57 (95% confidence intervals 1.02 to 30.26). The condition of the mother improved rapidly after evacuation of the uterus, whether by spontaneous abortion, evacuation of retained products of conception, or normal delivery; 10 of 26 women without uterine evacuation died, but only four of 39 women with evacuation died (p = 0.0016). The odds ratio for death with pregnancy intact was 5.47 (95% confidence interval 1.35 to 22.16). Fetal and neonatal loss was 87%. The risk of death from Lassa fever in the third trimester is significantly higher than that in the first two trimesters and higher than that for non-pregnant women, but evacuation of the uterus can significantly improve the mother''s chance of survival.     

Maternal and Perinatal Mortality Associated with Cesarean Section in Alberta (1955-1959)

A province-wide study of perinatal mortality was initiated in Alberta (population 1,283,000) in 1955. The period 1955-1959 covered 182,028 total births and 4219 perinatal deaths of which 260 were from 3813 Cesarean sections.The perinatal mortality rate in Cesarean-section births in rural hospitals (101.4 per thousand Cesarean births) was compared with that for urban hospitals (55.7 per thousand).Examination of the indications for primary Cesarean section in which a perinatal death occurred showed that hemorrhage accounted for 54 out of 85 of these deaths in rural hospitals, and 49 out of 110 similar urban deaths. Of 33 perinatal deaths associated with elective repeat sections, 17 were of premature babies.Eleven of the 85 maternal deaths during 1955-1959 were associated with Cesarean section, a maternal mortality rate of 28.8 per 10,000 Cesarean section births. Preventable factors were present in 8 of the 11 cases. Hemorrhage was the primary cause of death.     

All-Cause Mortality of Low Birthweight Infants in Infancy,Childhood, and Adolescence: Population Study of England and Wales

BackgroundLow birthweight (LBW) is associated with increased mortality in infancy, but its association with mortality in later childhood and adolescence is less clear. We investigated the association between birthweight and all-cause mortality and identified major causes of mortality for different birthweight groups.ConclusionsLBW is associated with infant and later child and adolescent mortality, with perinatal factors and congenital malformations explaining many of the deaths. By understanding and ameliorating the influences of upstream exposures such as maternal smoking and deprivation, later mortality can be decreased by reducing the delivery of vulnerable infants with LBW.     

Assessing possible hazards of reducing serum cholesterol.

OBJECTIVE--To assess whether low serum cholesterol concentration increases mortality from any cause. DESIGN--Systematic review of published data on mortality from causes other than ischaemic heart disease derived from the 10 largest cohort studies, two international studies, and 28 randomised trials, supplemented by unpublished data on causes of death obtained when necessary. MAIN OUTCOME MEASURES--Excess cause specific mortality associated with low or lowered serum cholesterol concentration. RESULTS--The only cause of death attributable to low serum cholesterol concentration was haemorrhagic stroke. The excess risk was associated only with concentrations below about 5 mmol/l (relative risk 1.9, 95% confidence interval 1.4 to 2.5), affecting about 6% of people in Western populations. For noncirculatory causes of death there was a pronounced difference between cohort studies of employed men, likely to be healthy at recruitment, and cohort studies of subjects in community settings, necessarily including some with existing disease. The employed cohorts showed no excess mortality. The community cohorts showed associations between low cholesterol concentration and lung cancer, haemopoietic cancers, suicide, chronic bronchitis, and chronic liver and bowel disease; these were most satisfactorily explained by early disease or by factors that cause the disease lowering serum cholesterol concentration (depression causes suicide and lowers cholesterol concentration, for example). In the randomised trials nine deaths (from a total of 687 deaths not due to ischaemic heart disease in treated subjects) were attributed to known adverse effects of the specific treatments, but otherwise there was no evidence of an increased mortality from any cause arising from reduction in cholesterol concentration. CONCLUSIONS--There is no evidence that low or reduced serum cholesterol concentration increases mortality from any cause other than haemorrhagic stroke. This risk affects only those people with a very low concentration and even in these will be outweighed by the benefits from the low risk of ischaemic heart disease.     

Patterns of mortality in free-ranging California Condors (Gymnogyps californianus)

We document causes of death in free-ranging California Condors (Gymnogyps californianus) from the inception of the reintroduction program in 1992 through December 2009 to identify current and historic mortality factors that might interfere with establishment of self-sustaining populations in the wild. A total of 135 deaths occurred from October 1992 (the first post-release death) through December 2009, from a maximum population-at-risk of 352 birds, for a cumulative crude mortality rate of 38%. A definitive cause of death was determined for 76 of the 98 submitted cases, 70% (53/76) of which were attributed to anthropogenic causes. Trash ingestion was the most important mortality factor in nestlings (proportional mortality rate [PMR] 73%; 8/11), while lead toxicosis was the most important factor in juveniles (PMR 26%; 13/50) and adults (PMR 67%; 10/15). These results demonstrate that the leading causes of death at all California Condor release sites are anthropogenic. The mortality factors thought to be important in the decline of the historic California Condor population, particularly lead poisoning, remain the most important documented mortality factors today. Without effective mitigation, these factors can be expected to have the same effects on the sustainability of the wild populations as they have in the past.     

Perinatal deaths: analysis by clinical cause to assess value of induction of labour.

Over the 10 years 1966-75 the rate of induction of labour in the Glasgow Royal Maternity Hospital has increased from 16-3% of all births. During the same period perinatal mortality fell from 33 to 22 per 1000, mainly because of significantly fewer deaths due to antepartum haemorrhage; trauma; maternal diseases; and unknown causes in mature babies. The reduction in the number of deaths of unknown causes in mature fetuses was achieved by preventing deaths occurring after 40 weeks and was recorded in all age and parity groups. The results suggested that increased use of induction of labour has contributed to the improved perinatal mortality rate.