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.
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.
Clara Menendez and colleagues analyze 139 complete autopsies following maternal deaths in Maputo, Mozambique and find a predominance of infectious and preventable causes.
Every year, half a million women—many of them living in developing countries—die during pregnancy or childbirth or within a few weeks of delivery. (The term “maternal deaths” is used to designate such deaths.) For women living in sub-Saharan Africa, the situation is particularly grim. Half of all maternal deaths occur in this region. The maternal mortality ratio (MMR)—the number of maternal deaths per 100,000 live births—in sub-Saharan Africa is nearly 1,000; in industrialized countries it is 8. The lifetime risk of maternal death in sub-Saharan Africa is 1 in 22; in industrialized countries it is 1 in 8,000. Faced with the magnitude of the global maternal death toll, in September 2000 the United Nations pledged, as its fifth Millennium Development Goal, that the global MMR would be reduced to a quarter of its 1990 level by 2015. Currently, it seems unlikely that this target will be met. Between 1990 and 2005 global maternal deaths decreased by only 1% per annum. In sub-Saharan Africa the annual reduction was even less—0.1% per annum.
Why Was This Study Done?
One reason for this slow progress is that public-health professionals in developing countries rarely have accurate data about the causes of maternal death, information that they need to guide their efforts to reduce these deaths. A detailed examination of the body after death (a medical autopsy) is the only sure way to ascertain the causes of maternal death, but in most developing countries, clinical records and verbal autopsies (asking relatives about the circumstances of the mother's death) are the main sources of these data and neither source is optimally accurate. The currently available information indicates that birth (obstetric) complications are the most frequent causes of maternal death in developing countries, in particular, hemorrhage (uncontrollable bleeding) after the baby is born. However, little is known about the impact of the HIV/AIDS epidemic (which is worst in Sub-Saharan Africa), malaria, or other infectious diseases on maternal deaths. In this study, the researchers use complete autopsies to determine the causes of maternal death in the Maputo Central Hospital, Mozambique, a tertiary-level hospital to which women with high-risk pregnancies are referred for specialized care.
What Did the Researchers Do and Find?
Between October 2002 and December 2004, there were 179 maternal deaths in the Maputo Central Hospital and 31,135 live births, corresponding to a ratio of 874 maternal deaths per 100,000 live births. (Because the hospital was a referral center, this ratio would not be expected to reflect the actual MMR for the general population of the Maputo area.) Complete autopsies were done on 139 of the women, HIV infection was measured using standard tests, and malaria was diagnosed by looking for parasites and malaria-associated changes in postmortem samples. Of these 139 women, just over one-third died because of obstetric complications; hemorrhage was the most common cause of death (one in six maternal deaths). The commonest nonobstetric causes of maternal death were HIV/AIDS- related conditions, including infections and cancers (about 1 in 8 maternal deaths; about half the women in the study were HIV positive). Other common causes were pyogenic (pus-forming) bacterial infections of the lungs and brain, and malaria. Together, these infectious diseases accounted for nearly half of the maternal deaths.
What Do These Findings Mean?
These findings indicate that infectious diseases account for a large proportion of maternal deaths at Maputo Central Hospital and identify which obstetric complications are responsible for most maternal deaths in this setting. They may not, however, accurately reflect the causes of maternal death elsewhere in Mozambique. For example, maternal deaths from some obstetric complications may be over-represented in this study because women at risk of these complications would have been referred to this hospital. Conversely, the proportion of women dying from hemorrhage may be higher in the community because this complication usually happens shortly after birth, leaving little time for women to reach a hospital for treatment. Nevertheless, these findings suggest that the implementation of effective measures to prevent and treat HIV/AIDS, malaria, and infections with pyogenic bacteria, together with improvements in health services for obstetric complications, should greatly reduce the maternal death toll in Mozambique and perhaps in other countries in sub-Saharan Africa.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050044.
UNICEF (the United Nations Children's Fund) provides information on maternal mortality including the WHO/UNICEF/UNFPA/The World Bank) estimates of maternal mortality for 2005 by country, and an article on maternal mortality in the Cabo Delgado province of Mozambique
More information on the WHO/UNICEF/UNFPA/The World Bank estimates of maternal mortality in 2005
The UK Department for International Development provides information about Millenium Development Goal 5: the improvement of maternal health
The US Centers for Disease Control and Prevention has a page on pregnancy-related deaths (in English and Spanish)
The Partnership for Maternal, Newborn and Child Health provides information on maternal deaths (in English, Spanish, French, Russian, Arabic, and Chinese)
The United Nations Development Fund for Women (UNIFEM) focuses on improving conditions for women worldwide, especially those in poverty