Saving Mothers and Babies: Maternal mortality

2
Maternal
mortality

Before you begin this unit, please take the due to miscarriages (abortions) and ectopic
corresponding test at the end of the book to pregnancies.
assess your knowledge of the subject matter.

Objectives A maternal death is defined as the death of a
woman at any time between the conception of her
infant and 42 days after the delivery of the infant.
When you have completed this unit you
should be able to: 2-2 What is the maternal mortality ratio?
• Define and calculate maternal mortality The maternal mortality ratio (MMR) is defined
ratio. as the number of women dying between
• List the important causes of maternal conception and 6 weeks (42 days) after
delivery per 100 000 deliveries. The maternal
mortality.
mortality ratio is calculated as follows:
• Interpret maternal mortality rates.
• Separate direct and indirect causes of Total number of maternal deaths
× 100 000
maternal death. Total number of livebirths
• Describe the confidential enquiry into The maternal mortality ratio is usually given
maternal deaths. for a specific area and a specific period of time.
For example, if 10 women die in Cape Town
where the annual delivery rate is 50 000, then
MORTALITY RATIO the maternal mortality rate is:

10
× 100 000 = 20
2-1 What is maternal mortality? 50 000

Maternal mortality means the death of a Note that the maternal mortality ratio is
woman during pregnancy (i.e. conception expressed per 100 000 deliveries.
to delivery) and the puerperium (i.e. up to
42 days after delivery). It includes deaths

24 SAVING MOTHERS AND BABIES

The maternal mortality ratio is the number of 2-6 What is the maternal mortality ratio in
industrialised countries?
maternal deaths per 1000 000 deliveries.
In industrialised countries, or privileged areas
NOTE ‘Ratio’ rather than ‘rate’ used as the in poor countries, the maternal mortality ratio
denominator does not include all pregnancies or is usually about 10 per 100 000 deliveries.
deliveries, only livebirths. Therefore, it is very uncommon for a woman
to die during pregnancy or the puerperium.
2-3 Why does maternal mortality include
NOTE For example, in 1994–1996 the MMR for the
the deaths of women during the first few United Kingdom was 12.2 / 100 000.
months of pregnancy?
Because pregnancy effects the mother’s body 2-7 What is the maternal mortality ratio in
soon after the start of pregnancy. Problems poor countries?
which occur early in pregnancy, such as
In poor countries the maternal mortality ratio
ectopic pregnancies and septic abortions, can
is usually above 50 per 100 000 deliveries. The
result in the mother’s death.
maternal mortality ratio varies widely between
poor countries with some very undeveloped
2-4 Why does the maternal mortality ratio communities having a ratio as high as 1000
include the deaths of women during the 6 per 100 000.
weeks after delivery?
In many poor areas of industrialised countries
Because the effects of pregnancy on the the maternal mortality ratio is also increased.
mother’s body take up to 6 weeks to disappear. Worldwide, most maternal deaths occur in
Deaths during the puerperium (6 weeks after poor countries where the death is usually
delivery) are often as a result of complications related to poverty and inadequate access to
of pregnancy. good health care services.

2-5 What is the importance of the maternal In most poor developing countries the
mortality ratio? collection of mortality information is very
incomplete, making it difficult to calculate the
It is a very important method of assessing both accurate maternal mortality rate.
the standard of health of pregnant women
and the standard of care being provided to 2-8 What is the maternal mortality ratio in
pregnant women. The maternal mortality ratio South Africa?
can also be compared between different areas
or between different periods of time in the The exact maternal mortality ratio in South
same area. Africa is not known, as many maternal deaths
are still not registered. However, the estimated
A high maternal mortality ratio usually maternal mortality ratio is about 200/100 000
indicates either poor maternal health or deliveries. The maternal mortality ratio varies
inadequate care during the pregnancy and between different districts from as low as 50 to
puerperium or both. In contrast, a low as high as 300. Unlike many other developing
maternal mortality ratio indicates that both countries, the maternal mortality ratio has
maternal health and health care are good. increased over the past few years.

The maternal mortality ratio reflects both the The estimated maternal mortality ratio for South
general health of women as well as the standard Africa is 200 / 100 000.
of care during pregnancy and the puerperium.
NOTE Estimates of maternal mortality in
South Africa vary widely but suggest 200 to

MATERNAL MOR TALITY 25

400 / 100 000. An accurate ratio will only be know The final cause of maternal death is the event
when most pregnancies and maternal deaths are which actually caused the death (a final
recorded. It is important to know the maternal complication of the disease process), i.e. how
mortality ratio in the country where you work. the patient died. Knowing the final causes of
death helps to identify facilities and resources
which need to be improved. It also helps
CAUSES OF MATERNAL to prevent or improve the management of
DEATH conditions which can be final causes of death.
For example, if a pregnant woman has a severe
antepartum haemorrhage from a placenta
2-9 When are the causes of a maternal praevia and dies of hypovolaemic shock,
death determined? the primary cause of death is antepartum
Each maternal death must be discussed in haemorrhage and the final cause of death is
detail to determine the cause and decide hypovolaemic shock. Similarly, if a woman has
whether it could have been prevented. This eclampsia and dies of a brain haemorrhage,
is usually done at the regular ‘perinatal the eclampsia is the primary cause and the
mortality meeting’ which also includes any brain bleed is the final cause of death.
maternal deaths. It is important to discuss the
maternal death as soon as possible while the The primary cause of maternal death is the
details of the clinical problems and care are
obstetric factor or condition which lead to the
still remembered. The findings of each death
must be carefully summarised and included in
death.
the maternal mortality report. This is usually
prepared annually for each health region. 2-12 How can the primary causes of
maternal deaths be subdivided?
2-10 Are maternal deaths notifiable? The primary causes of maternal deaths are
Yes. All maternal deaths are notified by law in subdivided into 3 groups:
South Africa. This includes maternal deaths 1. Direct.
at home and in private institutions. It is 2. Indirect.
important to include maternal deaths which 3. Fortuitous.
occur outside the maternity services, e.g.
women who have not yet started antenatal care Usually a forth group called ‘Unknown’ is
and women who die in medical, surgical or added. These are maternal deaths where the
emergency departments. cause of death cannot be identified.
NOTE In South Africa in 1977 all maternal deaths
were made notifiable. 2-13 What are direct causes of maternal
death?
2-11 What are primary and final causes of These are deaths which are a direct result
maternal death? of the woman being pregnant. They result
from complications of pregnancy or the
The primary cause of maternal death is the
puerperium, or the management of the
obstetric factor or condition which lead to
pregnancy or pueperium. These deaths would
the death, i.e. it is the reason why the death
not have happened if the woman had not been
occurred. Knowing the primary causes of
pregnant. An example of a direct cause of
death helps to identify clinical practices which
maternal death is eclampsia.
need to be improved. Deaths can be prevented
if the primary causes are well managed. NOTEDirect deaths result from obstetric
complications of the pregnancy state, from


interventions, omissions, incorrect treatment or 2-16 Is a cause found for all deaths during
from a chain of events of any of these. pregnancy and the puerperium?
No. Unfortunately the underlying cause
A direct cause of maternal death would not have sometimes is unknown. This is often because
happened if the woman had not been pregnant. the history is incomplete and a post mortem
examination was not done.

2-14 What are indirect causes of maternal 2-17 What are the important direct causes
death? of maternal death in South Africa?
These are deaths are caused by diseases that 1. Hypertension.
existed before the pregnancy or developed 2. Postpartum haemorrhage.
during the pregnancy or puerperium. 3. Antepartum haemorrhage.
Although not a result of pregnancy or 4. Pregnancy related infection, such septic
puerperium complications, the pregnant state abortion and puerperal sepsis
aggravated the condition. If the woman had
NOTE Other causes are anaesthetic related, acute
not been pregnant, she may not have died
collapse and pulmonary embolism, abortion and
from the disease. An example of an indirect
ectopic pregnancy.
cause of maternal death is rheumatic heart
disease which became worse during the Most maternal deaths are due to direct
pregnancy, leading to heart failure. causes, especially the hypertensive disorders,
haemorrhage and infection.
NOTE Indirect deaths result from previous existing
disease or disease that developed during NOTE The common final causes of death in the
pregnancy which were not due to direct obstetric hypertensive category are cerebral haemorrhage
causes but which were aggravated by the and pulmonary oedema.
physiological effects of pregnancy.

The commonest direct causes of maternal death
A woman may have died of an indirect cause even in South Africa are hypertension, haemorrhage
if she was not pregnant. and infection.

2-15 What are fortuitous causes of 2-18 What are the important indirect
maternal death? causes of maternal death in South Africa?
These are deaths that were unrelated to the 1. Non pregnancy related infections, such as
pregnancy or puerperium and just happened AIDS, TB and malaria.
to occur at this time. The condition causing 2. Pre-existing maternal disease, such as
the death was not aggravated by the pregnancy cardiac disease.
and would have killed the women even if she
had not been pregnant. Examples of fortuitous AIDS is the commonest indirect cause of
causes of maternal death include motor vehicle maternal death in South Africa.
accidents and assault. NOTE The common final causes of deaths in
women with AIDS are pneumonia, meningitis
Although fortuitous causes of maternal and tuberculosis.
death are recorded in South Africa, they
are not included in calculating the maternal
mortality rate. Fortuitous deaths are counted Non-pregnancy-related infection is the commonest
to document the extent of violence against indirect cause of maternal death in South Africa.
women, accidents and suicides.


2-19 What are the most common causes of 2. Complications of hypertension in
maternal death in South Africa? pregnancy resulting in maternal death was
most common in level 2 hospitals (staffed
When all direct and indirect causes of
by full-time specialists) and in level 3
maternal death in South Africa are considered
hospitals (having intensive care facilities).
together, the following are the commonest (the
‘big five’ causes) in order of frequency:
2-21 Why do so many pregnant women still
1. Non-pregnancy related infection, especially die in poor countries?
AIDS.
2. Complications of hypertension in The high maternal mortality rate in poor
pregnancy. countries is not due to the lack of knowledge of
3. Obstetric haemorrhage, including how to manage ill pregnant women, but due to
antepartum and postpartum haemorrhage. women not being able to receive adequate care.
4. Pregnancy related infection, especially
septic abortions and puerperal sepsis. 2-22 Why do many pregnant women in poor
5. Non-pregnancy related diseases (pre- countries not have access to adequate care?
existing medical conditions), especially Although some reasons may be obvious, this
heart disease. question is often not easy to answer unless a
These five causes are responsible for 85% of all detailed investigation into causes of maternal
maternal deaths. In South Africa in 1999 the death is carried out. Such as investigation is
most common single cause of maternal death best done as a confidential enquiry. Important
was AIDS. reasons why some women do not have access
to good care are distance to the nearest clinic
NOTE Many women who died of pregnancy
related sepsis were not screened for HIV/AIDS. It
or hospital, lack of transport and inadequate
is highly likely that many were positive. Therefore, staffing or equipment at health care facilities.
many deaths classified as pregnancy related
infection, non-pregnancy related disease and
possibly post partum haemorrhage should CONFIDENTIAL ENQUIRY
probably be re-classified as non-pregnancy
related infection.
2-23 What is a confidential enquiry into
AIDS is the commonest cause of maternal death maternal deaths?
in South Africa. In a confidential enquirer of maternal deaths,
the deaths of as many pregnant women
as possible are identified by an appointed
2-20 Which causes of maternal deaths are committee. The case record of each woman is
most common at different levels of care? then carefully investigated by an independent
Non pregnancy related infections were the team of experts to identify the likely cause and
commonest cause of death at all levels of care. reason for the death. This information is kept
However: confidential to protect the staff involved with
the care of the case. If this were not done, it
1. Obstetric haemorrhage, especially post would be difficult to obtain the full story.
partum haemorrhage, as a cause of maternal
NOTE The aim of a confidential enquiry is
death was most common in level 1 hospitals
to reduce maternal mortality by collecting,
(small hospitals staffed by doctors but analysing and interpreting information, reporting
without any full-time obstetric specialists) findings and making recommendations for
or clinics where there are no doctors. evidence based decisions.


2-24 Is there a confidential enquiry into yet was potentially avoidable. If that event or
maternal deaths in South Africa? condition was not present, the death may not
have occurred.
Yes. This is a most important enquiry into the
number and causes of maternal death in South A missed opportunity is a potentially
Africa. It attempts to identify avoidable factors, avoidable maternal death where an
missed opportunities and substandard care, and opportunity was present to prevent the death
gives recommendations as to how these causes but the opportunity was missed.
can be prevented or effectively managed. The
Substandard care is poor care which may
aim of the report is to make recommendations
have resulted in the woman’s death.
aimed at reducing the maternal mortality
rate. It is important that the findings and In any enquiry into a maternal death, it
recommendations of the confidential enquiry is very important to identify possible and
are made available to all services and health probable avoidable factors and missed
care workers responsible for maternal care. opportunities as much can be learned from
these events. This knowledge helps to avoid
NOTE In South Africa a National Committee on
Confidential Enquiries into Maternal Deaths is similar deaths in future.
responsible for reviewing all maternal deaths.
Avoidable factors, missed opportinities and
2-25 What is the Saving Mothers report? substandard care must be looked for in each
The Saving Mothers report is the official report maternal death.
of the confidential enquiry into maternal
deaths in South Africa. The first Saving
Mothers Report to be published in South 2-27 Which maternal deaths are potentially
Africa reviewed maternal deaths in 1998. avoidable?
NOTE The first interim report on maternal deaths Maternal deaths where avoidable factors,
in South Africa was published in 1988. This was missed opportunities or substandard care was
followed by the first comprehensive confidential present. Maternal deaths are not classified
enquiry into maternal deaths in South Africa, into avoidable or not, only into deaths where
conducted in 1998 and published as the ‘Saving avoidable factors were or were not present.
Mothers: Report on Confidential Enquiry into Therefore, the report identifies deaths which
Maternal Deaths in South Africa 1998’. It is planned
were potentially avoidable.
to produce a full report every 3 years. In addition
there will be annual interim reports to track
changes in the number and causes of maternal 2-28 What are the categories of avoidable
death at different levels of care in each province. factors for maternal mortality?
The information for these reports, and practical
and affordable recommendations based on the Avoidable factors can be grouped into the
reports, are produced by the National Committee following 3 categories:
for Confidential Enquiries into Maternal Deaths.
1. Patient related problems.
2. Administrative problems.
3. Health worker related problems.
AVOIDABLE FACTORS
In South Africa, avoidable factors due to
patient related problems were present in half,
2-26 What are avoidable factors, missed administrative problems were associated with
opportunities and substandard care? a third, and health worker related problems
with a quarter of the maternal deaths. Many
An avoidable factor is something which deaths had more than one avoidable factor.
could have caused the maternal death and Therefore, all three categories of avoidable


factors are commonly associated with or do not encourage access to health care.
maternal deaths. Perhaps patient related problems should be
called community related problems.
In South Africa, avoidable factors associated
2-31 What administrative factors
with patient, administrative and health worker
contribute to maternal mortality?
related problems are commonly associated with
maternal deaths. These include:
1. Lack of staff.
2. Lack of availability of adequate training.
2-29 What patient related problems 3. Lack of adequate transport.
contribute to maternal mortality? 4. Lack of good clinics and hospitals close to
These include: the community.
5. Lack of intensive care facilities for seriously
1. Not attending or booking late for antenatal ill women.
care.
2. Not recognising important warning Problems resulting in these administrative
symptoms and signs such as a severe factors include poor planning and supervision
headache or vaginal bleeding. of maternal services, little emphasis on health
3. Not seeking help when warning signs were funding for women and a general lack of
present. funds. In rural areas, deliveries are often
conducted by untrained members of the
In South Africa the commonest patient related family. Having a skilled assistant to monitor
problem associated with maternal death is not labour and conduct the delivery is important.
attending antenatal care or only attending late
in pregnancy. This probably true for in many
other developing countries. Lack of well trained midwives is an important ad-
ministrative related factor in maternal mortality.
Poor attendance for antenatal care is the
commonest patient relatedfactor associated with 2-32 Why is lack of staff a common
maternal death in South Africa. problem?
1. Funding is often not available. Often this
2-30 Are patient related problems the fault is because maternity care is not viewed as
of the patient? a priority.
2. Suitably qualified staff may not be available
There are many underlying social factors due to inadequate numbers of staff being
to patient related problems such as poor trained, staff moving from the state into
education of women, women not being the private service or staff leaving to work
allowed to decide for themselves whether to in other countries.
report to clinic or hospital, fear and ignorance, 3. Staff do not want to work in some areas far
and traditional taboos on disclosing a from towns and cities, areas with a high
pregnancy. Many women do not seek care crime rate or areas with poor transport and
because care is not easily available. They may few facilities such as schools.
have to travel long distances, face long queues
and be turned away from overcrowded clinics.
2-33 Why is a lack of adequate training a
While some patients may not seek care common problem?
because they are lazy or disinterested, usually
1. School education and basic nurse training
there are social conditions which prevent
may be poor.


2. Medical school training may not include 2-36 Why are intensive care facilities often
enough time in maternal care. not available?
3. Opportunities for continuing training or
1. The equipment is expensive and needs
special (advanced) courses for both nursing
skilled and costly maintenance. Often the
and medical staff are often not available.
equipment is available but not kept in good
4. Obstetric specialists or medical officers,
working order.
general practitioners with additional
2. It is expensive to employ staff who are
training in maternal care, and advanced
adequately trained and regularly attend
midwives are often not available to teach
further training courses.
their junior colleagues.
5. Nursing staff who have attended advanced As a result, level 3 (intensive) care is often not
courses are often placed in areas where this available to very ill women.
knowledge cannot be best used.
6. Routine staff rotation prevents individuals 2-37 What health care worker related
acquiring enough experience in maternal problems contribute to maternal
care. mortality?
These include:
2-34 Why is transport often inadequate?
1. Negligent or substandard care (they knew
1. Transport is often not available to get
what to do but did not do it).
patients to antenatal clinic or to a clinic or
2. Honest errors.
hospital when labour starts or danger signs
3. Lack of appropriate training (they did not
present.
know what to do).
2. Patient transport is often worse in poor or
rural areas and at night. Major health care worker related problems
3. Transport is often expensive. include:
4. Transport to move patients from a clinic 1. Not recognising clinical problems.
to hospital or between hospitals is often 2. Delay in referral or not referring.
not available or the delay time is very long. 3. Not following standard protocols.
This may be due to lack of vehicles, lack 4. Inadequate monitoring of sick women after
of staff, or due to maternity cases being admission.
viewed as less important than other cases
such as trauma. The administrative problems of staff shortages
5. Telephones may not be available to call for and excessive patient load often contribute to
transport. problems experienced by health care workers
6. It may be dangerous to go to clinic or (both nursing and medical staff).
hospital at night in areas with a lot of crime.
2-38 Why are health care workers some-
2-35 Why are clinics and hospitals often not times negligent or offer substandard care?
available? Negligence, laziness and an attitude of not
1. It is very expensive to provide enough caring are very complex problems which
clinics and hospitals within easy reach of are influenced by attitudes in the home,
all pregnant women, especially in very community, schools, tertiary education
mountainous areas or areas with a low centres and places of employment. Social
population density. and environmental problems affect the way
2. Clinics and hospital are often built far from health workers relate to both their work
the community they serve. and their patients. Salaries, management
styles, opportunities for further training and
promotion, and personal beliefs all influence


the motivation of health workers. A caring very useful in identifying avoidable factors and
attitude is often not rewarded and encouraged substandard care.
at all levels of society. Understaffing and NOTE A ‘near miss’ is more correctly referred to as
overwork are important causes of poor care. severe acute maternal morbidity (SAMM).
Substandard care may be the result of
inadequate training or a lack of personal 2-42 What is the maternal mortality index?
motivation and commitment to patient care.
Number of maternal
Maternal deaths
2-39 What are honest errors? mortality =
index Number of maternal
An honest error is a mistake in management deaths and near misses
of the patient where the health worker has
done his or her best but it was not the correct The maternal mortality index gives a measure
diagnosis or treatment and, as a result, the of the standard of care of women who present
woman died. Honest errors are often the result with serious complications. With good
of an excessive patient load and inadequate management, most severely ill women will be
staffing. Examples of honest errors are near misses rather than deaths. Therefore, a
forgetting to enter an important observation low maternal mortality index indicates a high
on the partogram or forgetting to give a standard of care while a high index suggests
newborn infant vitamin K after delivery. poor care.
At present the maternal mortality index for the
2-40 What training may be inappropriate?
whole of South Africa is not known.
Many health workers are not appropriately
NOTE The maternal mortality index for the
trained for the work they are expected to Bloemfontein, Pretoria and Soweto areas are 22.8,
perform. This is often due to a lack of suitable 14.0 and 30.8 respectively.
training opportunities. Basic midwifery and
medical training may not equip the nurse or
2-43 Are the causes of maternal death in
doctor to function in a primary care situation
South Africa changing over time?
where supervision by an experienced person
is not available. Most advanced courses are Yes. There is a reduction in the direct causes
expensive and require the health worker to and an increase in the indirect causes of
leave their home and place of employment maternal death. The increase in indirect causes
to travel to a regional centre for a period is due to more deaths resulting from AIDS. As
of time. Few distance-learning courses are the testing for HIV increases in patients where
available which enable health workers to there has been maternal death, the percentage
take responsibility for some of their own of HIV positive maternal deaths will probably
continuing education. increase. In 1999, two thirds of HIV tests in
maternal deaths were positive.
2-41 What is a ‘near miss’?
2-44 What is the role of the Perinatal
A ‘near miss’ occurs when a woman is very
Problem Identification Programme in
ill and almost dies of one of the conditions
recording maternal deaths?
which can cause maternal death. The avoidable
factors in a near miss are usually the same The Perinatal Problem Identification
as those where the patient dies. There are Programme (PPIP) is a software package used
more near misses than maternal deaths in a mainly for recording data on perinatal deaths.
service. As with an audit of causes of maternal However PPIP is also very useful to record
deaths, an audit of near misses can also be information and analyse maternal deaths.
PPIP data helps to collect the documentation


needed for the national confidential enquiry in poor countries is usually above 50/100 000.
into maternal deaths. Therefore, this maternal mortality ratio of
350/100 000 is high, even for a poor country.

CASE STUDY 1 5. What is the maternal mortality ratio in
South Africa?
In a large maternity service consisting of one The exact maternal mortality ratio is not
small hospital and six clinics, there have been known as accurate mortality statistics as many
10 000 liveborn deliveries and 35 maternal maternal death are still not reported, especially
deaths in the past year. These deaths include in rural areas. The estimated maternal mortality
women who died as a result of septic abortions ratio is 200/100 000. However, it is probably
as well as women who died of sepsis following much higher than this in many poor areas.
delivery.
6. Why is it important to know the maternal
1. What is the definition of maternal mortality ratio in a health service?
mortality?
Because it gives a good idea of both the
Maternal mortality consists of all the women standard of maternal health during pregnancy
who died between conception and the end of and the puerperium, as well as the standard of
the puerperium (6 weeks after delivery). health care available for pregnant women in
the community.
2. Why are abortions and postpartum
deaths also included in maternal mortality?
Because both conditions are related to CASE STUDY 2
pregnancy. Neither would have occurred if
the women had not been pregnant. Maternal In a large maternity hospital in a city, both
deaths are, therefore, all deaths where the the number and causes of maternal deaths
cause of death is related to pregnancy. Deaths are carefully recorded after they have been
after 6 weeks are excluded as the physiological discussed at the monthly mortality meeting.
changes of pregnancy have returned to the The primary and direct cause of each death is
pre-pregnancy state by 6 weeks after delivery. noted in order to find the commonest causes
of death at the hospital.
3. What is the maternal mortality ratio in
this health service? 1. Are maternal deaths notifiable?
There were 35 maternal deaths out of Yes. All maternal deaths must be notified. This
10 000 livebirths. The maternal death ratio includes not only deaths in the state health
is traditionally expressed as a proportion of service but also deaths at home and in private
100 000 deliveries. Therefore, the maternal hospitals.
mortality ratio is 35/10 000 × 100 000 =
350/100 000. Usually maternal mortality is 2. What are primary causes of maternal
expressed as an annual ratio and it is best death?
expressed for a whole health region.
The primary cause of death is the obstetric
factor or condition which lead to the death.
4. How do you interpret this maternal
In other words, it is the reason why the death
mortality ratio?
occurred. Important primary causes of death
The maternal mortality ratio in industrialised include pre-eclampsia, antepartum and
countries is usually about 10/100 000 while that post partum haemorrhage, and pregnancy


related infection such as septic abortion and province. Information is also being collected
puerperal sepsis. on the main causes at each level of care within
health districts and regions. The findings of
3. Why is it important to know the common the Confidential Enquiry into Maternal Deaths
primary causes of maternal death? are presented in the Saving Mothers report.
From this publication, funding is being made
Because steps can then be made to avoid these available to address specific problems in the
primary causes by managing them better. care of pregnant women.
By doing this, many maternal deaths can be
prevented. It is difficult to reduce the maternal
1. What are the four main causes of
mortality if the primary causes are not known.
maternal death in South Africa?
4. What are final causes of maternal death? 1. AIDS.
2. Complications of hypertension in
The final cause of maternal death is the event pregnancy.
which actually resulted in the death. In other 3. Antepartum and post partum haemorrhage.
words, it is the final complication of the disease 4. Infections such as septic abortion and
process which killed the woman. For example, puerperal sepsis.
the final cause of death in antepartum or post
partum haemorrhage is usually hypovolaemic AIDS has become the leading cause of
shock while the final cause in eclampsia may maternal death in the past few years.
be a brain haemorrhage.
2. What is the commonest cause of
5. Why is it important to identify the final maternal deaths at all levels of care?
cause of maternal death? Non pregnancy related infection (i.e. AIDS).
Because the final cause of death can often be
prevented with adequate facilities and the 3. What is the commonest direct cause of
correct management of these complications. maternal death in primary care clinics?
For example, death from hypovolaemic
Obstetric haemorrhage, especially post partum
shock can often be avoided if women with
haemorrhage.
severe antepartum haemorrhage are correctly
managed in an intensive care unit which has
adequate staffing and facilities. 4. What is the commonest direct cause of
maternal death in level 2 and 3 hospitals?
6. What are fortuitous causes of maternal Complications of pregnancy related
death? hypertension such as eclampsia.
Fortuitous causes are not related to pregnancy
at all but just happened to occur during 5. Why is the notification of all maternal
pregnancy or the puerperium. Examples deaths and the Confidential Enquiry into
are motor car accidents, assault and suicide. Maternal Deaths so important?
Fortuitous causes are not included when the Because accurate information on the number
maternal mortality rate is calculated. and causes of maternal death in South Africa
is now available for the first time. This will
result in better planning of maternity services.
CASE STUDY 3
6. What is the Saving Mothers Report?
In recent years the main causes of maternal
This is the official report of the Confidential
death have become better known in each
Enquiry into Maternal Deaths.


CASE STUDY 4 recognising important warning signs and not
seeking help when warning signs are present.
During a monthly mortality meeting in The commonest administrative related factors
a regional hospital, all the maternal and are lack of staff, inadequate staff training, poor
perinatal deaths are presented. The possible transport, lack of primary care clinics and
avoidable factors and missed opportunities hospitals in the community, and inadequate
associated with each of the two maternal intensive care facilities for seriously ill women.
deaths are discussed and documented in
The commonest staff related factors are poor
the mortality report. A near miss maternal
care, honest errors and lack of appropriate
death was also described. Neither the medical
training.
superintendent of the hospital nor the
maternity matron was at the meeting.
6. What common errors are made by health
care workers?
1. What are avoidable factors in maternal
deaths? Not recognising problems, a delay or failure in
referring sick patients, not following standard
These are factors, events or conditions which
protocols of care, and inadequate monitoring
may have prevented the maternal death if
of ill patients.
they had not been present. For example, if
fast, efficient transport had been available
a mother might not have died from a post 7. What is a ‘near miss’?
partum haemorrhage. A very ill woman who nearly died from a
condition which often causes maternal deaths.
2. What is a missed opportunity? Good lessons on how to improve maternal
care can be learned from near misses.
This is an opportunity for providing good
care which was missed and, as a result, led to
the woman’s death? For example, not testing a 8. Why do so many mothers still die in poor
woman’s urine for sugar during antenatal care countries?
was a missed opportunity which may have Many women still die in poor countries, not
prevented her dying from a complication of because of the lack of knowledge of how
diabetes during labour. to manage ill pregnant women, but due to
women not being able to receive adequate care.
3. Which maternal deaths are potentially This is usually due to great distances to the
avoidable? nearest clinic or hospital, lack of transport and
inadequate staffing, equipment and training.
Deaths where avoidable factors, missed
opportunities or substandard care were present.
9. Should the medical superintendent
and maternity matron attend mortality
4. What are the three categories of
meetings?
avoidable factors in maternal mortality?
Yes. As the managers of the service, it is very
1. Patient related factors.
important that they are aware of problems,
2. Administration related factors.
avoidable factors and recommended ways of
3. Health worker related factors.
improving the service and preventing further
5. Can you give an example of each of the maternal deaths.
three categories?
The commonest patient related factors are not
attending antenatal care or booking late, not


PPIP CLASSIFICATION OF 7. Pre-existing maternal disease

MATERNAL DEATHS • Cardiac disease e.g. rheumatic valve disease.
• Endocrine e.g. diabetes.
• Central nervous system e.g. epilepsy.
These are included as a reference only.
• Skeletal e.g. kyphoscoliosis.
Primary causes of maternal death 8. Postpartum haemorrhage
The most important subdivisions are: • Retained placenta.
• Uterine atony.
1. Abortion • Ruptured uterus.
• Septic abortion. • Inverted uterus.
• Uterine trauma. 9. Anaesthetic complication
2. Ectopic pregnancy 10. Embolism
3. Antepartum haemorrhage 11. Acute collapse – cause unknown
• Abruptio placenta. 12. Non obstetric cause
• Abruptio placenta with hypertension.
• Placenta praevia. • Motor vehicle accident.
• Assault.
4. Hypertensive disorders of pregnancy • Suicide.
• Chronic hypertension.
• Proteinuric hypertension. Final causes of maternal death
• Eclampsia.
1. Hypovolaemic shock.
• HELLP syndrome.
2. Septic shock.
• Ruptured liver.
3. Respiratory failure.
5. Pregnancy related sepsis 4. Cardiac failure.
5. Renal failure.
• Amniotic fluid infection with ruptured
6. Liver failure.
membranes.
7. Cerebral complication.
• Amniotic fluid infection without ruptured
8. Disseminated intravascular coagulation.
membranes.
9. Multiorgan failure.
• Puerperal sepsis following normal delivery.
• Puerperal sepsis following caesarean A more detailed classification of primary
section. causes of maternal death is given in the
Perinatal Problem Identification Programme.
6. Non-pregnancy related sepsis
Each subdivision is given a specific code.
• AIDS.
NOTE Codes and descriptions of causes
• Pneumonia. of maternal death can be viewed at and
• Tuberculosis. downloaded from www.ppip.co.za.
• Bacterial endocarditis.
• Pyelonephritis.
• Malaria.

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