Maternal mortality: only 42 days?

Abstract

aObjective A maternal death is defined by WHO as 'the death of a woman while pregnant or within 42 days of termination of pregnancy. . .'. The origin of the 42 days is no longer clear. In developing countries, the burden imposed by pregnancy and birth on a woman's body may extend beyond 42 days as pregnancyrelated anaemia can persist for longer and vaginal haemorrhaging and risk of infections are not necessarily over after six weeks. We therefore examined duration of excess mortality after delivery in rural Guinea-Bissau. Design In a prospective cohort study, we followed 15,844 women of childbearing age with biannual visits over a period of six years, resulting in a total of 60,192 person-years-at-risk. To establish cause and timing in relation to termination of pregnancy, verbal autopsy was carried out for all deaths. Mortality rates were calculated for short time intervals after each delivery or miscarriage. Results During the observation period we registered 14,257 pregnancies and 350 deaths. One hundred and ninety-four deaths followed termination of a registered pregnancy and thus were eligible for the analysis. Eighty-two deaths occurred during the first 42 days after delivery/miscarriage. A further 16 women died in the period from 43 to 91 days after parturition, 16 between 92 and 182 days and 18 between 183 and 365 days after delivery. Compared with baseline mortality 7 -12 months after delivery, women who had recently delivered had 15.9 times higher mortality (95% CI 9.8-27.4). From days 43 to 91 the mortality was still significantly elevated ). Conclusion Where living conditions are harsh, pregnancy and delivery affect the health of the woman for more than 42 days. Using the WHO definition may result in an under-estimation of the pregnancy-related part of the reproductive age mortality. Extending the definition of maternal death to include all deaths within three months of delivery may increase current estimates of maternal mortality by 10 -15%.

Underreporting of Pregnancy-Related Mortality in the United States and Europe

“…20 The adequacy of this definition has been questioned. 21 In this study, the inclusion of late deaths added 17% to 49% to the pregnancy-related mortality ratio. Suicide in a context of postpartum depression and deaths due to peripartum cardiomyopathy occurred preferentially after 42 days postpartum and were the main causes of late pregnancy-related deaths in the 4 regions in our study.…”

Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting

“…It is well recognised that maternal deaths due to psychiatric illness have been under‐reported, partly because of misclassification of suicides as incidental deaths, and partly because of under‐reporting of late maternal deaths 3 . Late maternal deaths are more difficult to identify, as they often occur after women have ceased to attend maternity services.…”

“…Where linkage studies of death and birth data have been performed, they have revealed an over‐representation of maternal deaths associated with suicide or psychiatric illness. Many of these deaths are not captured by routine data collection methods because they often occur after 42 days postpartum 3 , 4 . Thus, an Office of National Statistics (ONS) linkage study in the UK identified over 40 extra maternal deaths in the 1997–1999 triennium from suicide or violent causes, making suicide the leading cause of indirect maternal deaths once these cases were added to the NICE report statistics 5 , 6 .…”

Increasing Access to Safe Abortion Services Through Auxiliary Nurse Midwives Trained as Skilled Birth Attendants

“…[3][4][5] Until 2009, manual vacuum aspiration (MVA) was the only safe abortion technology in Nepal. Based on international evidence about the safety and efficacy of medical abortion Original Article in the absence of physicians.…”