Determinants of Maternal Mortality: A Thorn Remains in Our Side
Almost every woman in her reproductive life gets an opportunity to become pregnant, which is a normal healthy event, sometimes marred by complications which can be prevented mostly. Identification of determinants of maternal mortality (MM) is important to improve maternal health which has been a major global concern.
The Millennium Development Goals (MDGs) are eight international goals proposed by World Health Organization (WHO) in order to improve the health status of the people. Out of these MDGs, improvment of maternal health is the 5th leading goal, which is targeted to be achieved by 2015. Currently, Pakistan is off-track and lags behind for any progress in MDG 5 .
However, we still have 2 years remaining in order to fulfill this goal. Hence, it is important to analyse the determinants of MM and to work accordingly. Maternal Mortality defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental cause . MM is the culmination of series of detrimental events and considered as major public health problem, not only in developing countries, but also in developed countries and varies across the globe.
According to WHO, United Nations (UN) and The World Bank (2010) estimates, Maternal mortality rate (MMR) in developed regions is 16 deaths/100, 000 live births, whereas in developing countries, this ratio is estimated at 240 deaths/ 100, 000 live births . There are countries within the South Asia like Pakistan, India, Bangladesh and Nepal that are contributing major shares in maternal deaths worldwide. Pakistan ranks third highest in the entire world in account for the increased maternal mortalities . In Pakistan, this rate is very high 220 deaths/100,000 live births.
Perhaps, this is not the exact number; the actual figures are more alarming than official figures, which are unreported. Such a high MM indicates an urgent need for addressing women’s health in Pakistan. I still remember the day when I visited at the northern area of Pakistan and we had a discussion with one of the community women about the increasing prevalence of MM.
Many international agencies like (WHO, UN, UNFDP, and World Bank) are striving hard to reduce the MM in different parts of the world. Despite of their efforts and initiatives, MM is still a major global public health concern. Several researches at international and national level have been done to identify various existing causes of MM.
Despite significant investments in maternal and child health care, there are countries like Pakistan that have highest burden that has not been reduced at the expected and desired level. Death of mothers has a severe impact on the lives of their family, community, and surviving children . The risk of women dying due to pregnancy related causes is 1:40 in developing countries, as compared to the developed countries . Above evidences suggested that MM is a public health issue which needs to be rectified.
This paper provides in-depth analysis of the major determinants of maternal mortality in Pakistani context. Determinants of Maternal Mortality is a major global concern which paints a dismal picture in our country. Globally, numerous studies have been done to explore the determinants of MM. These determinants are well defined in various national and international papers.
Identification of these determinants is a valid endeavor to improve maternal health. These determinants include socioeconomic, cultural, physical, human and medical factors.
Analysis of the Determinants
1. Socio-Economic Factors: Socio-economic conditions play a more significant role in causing maternal deaths than any other medical cause . It includes poverty, lack of education, and lack of empowerment. A descriptive, cross-sectional study was conducted at Dow Medical College and Civil hospital, Karachi to explore the maternal mortality and morbidity of unsafe abortions.
The findings concluded that most of the women (22/43; 51.2%) belonged to the poor-socioeconomic status, which results in increasing frequency of unsafe abortions . This reflects the overall situation of poverty in Pakistan. The huge economical burden in our country exerts a significant reduction in providing the basic health care facilities to the people of our society.
(a) Poor Educational Status: Another very important reason contributing to high maternal mortality is the poor educational status of women especially in rural settings of Pakistan. Women’s access to the primary level of education is very low. The literacy rate of Pakistan is one of the lowest in the world that is 59 that keeps women ignorant and unaware about their reproductive health. Low literacy also keeps women at the level where they are totally unaware about their rights and the facilities provided , , .
They are unable to decide where and when to contact in case of any complication related to their pregnancy. As a result, rate of abortions and maternal mortality increases. Improving literacy rates among females can reduce the prevalence of abortions in female population . Lack of empowerment, especially in rural women results in seeking medical attention, is often too late .
2. Cultural Factors: Cultural factors also promote MM in many areas. These factors include male dominance, non-availability of males, absence of husbands from home, devaluing of females, family traditions of not seeking health care facilities, hesitancy to go to hospital without head of the family or on their own are some very important contributing factors , . In another study, author highlighted factors like low neglected status of women and early marriages contribute to increasing the statistics of MM especially in developing countries . 35% of women under gone for induced abortions in first trimester due to their husband’s influence and due to the lack of empowerment of the women of our society to make their own decisions . In this case, it is very difficult for women to deal with such rigid socio-cultural constraints.
(a). Caste Based Hierarchy: Despite the range of maternal health care services available, the monopoly paradigm of cultural difference such as class and caste based hierarchy difference contributes to tragic outcomes in a community.
(b). Gender Inequalities: Gender inequality is another important feature that exists in many developing countries mostly in South Asia. Gender inequality is found to have destructive effects and strongly associated with maternal health. The cultural and gender inequality perpetuate women to have little autonomy to take decisions about their own reproductive health choices. Women have no right to decide when to have children.
The pressure of giving birth to a son by the in-laws, puts women at risk of deteriorating their own health. Another important aspect because of gender inequality is women’s increasing vulnerability to physical, verbal, and sexual abuse by the family , .
3. Physical Factors: Majority of the women living in rural areas, do not have access to receive adequate antenatal, intra-natal and postnatal care because of the unavailability of the adequate health facilities to provide the care during pregnancy. One of the important reasons behind this factor is the physical delay in arrival to an appropriately equipped medical facility e.g. poor or no transportation and long distance .
Delay in seeking health care due to lack of transport (30.7%), poverty and inability to afford the cost, (26.9%), familial taboos, (38.4%), ignorance about health care facilities (3.8%), inadequate and insufficient maternal health services leads to delay in getting the maternal services , , . Moreover, three delay model of maternal mortality proposed by literature highlighted the overall role of health system and community in maternal deaths. These delays are responsible for causing maternal mortality. (1) Delay in deciding to seek care, (2) delay in reaching the healthcare facility, where obstetric care is available, and (3) delay in initiation of treatment after arrival at obstetric services .
4. Human Factors: (a). Lack of Skilled Birth Attendants (SBAs): WHO refers SBAs as educated, trained, and accredited health professionals such as midwives, doctors or nurses who have proficient knowledge and have been trained in dealing with all sorts of normal versus complicated pregnancies, childbirth and immediate postnatal period. SBAs are considered important in reducing maternal and neonatal mortalities. Only 39% births were attended by SBAs and 61% deliveries take place at home conducted by unskilled care providers that is TBAs and dais .
(b). Influence of TBAs: Most of the deliveries in rural settings of Pakistan takes place at their home by untrained health personnel such as TBAs and dais. The influence of TBAs is 38.5% and majority of the deliveries are conducted at home by them . Because of their limited knowledge and due to financial resources, community prefers TBA for their deliveries, which end up in creating complications for the women. Most of the abortions occurred due to untrained providers 84.6% .
(c). Unsafe abortions: Unsafe abortions are the third major determinant of maternal mortality . They’re responsible for 13% of maternal mortality and cause 70, 000 maternal deaths each year in developing countries. It depends upon the training of the health care personnel, who is performing deliveries . Several unhygienic practices performed by unskilled workers put women at high risk of developing uterine perforation and septicemia , , . In a study, it has been reported that the frequency of unsafe abortions was 1.35% in two tertiary care settings, whereas the frequency of maternal death due to unsafe abortions was 9.7%.
The reasons of unsafe abortions include poor socioeconomic status, illiteracy, and domestic violence. The most common complications associated were septicemia (34.79%), uterine perforation with or without bowel perforation (30.2%), hemorrhage (20.9%) and pus in abdominal cavity (18.6%) .
5. Medical Factors A variety of medical factors could lead to maternal mortality. Various studies have been done and show statistical features of medical problems associated with maternal mortality.
Direct and indirect causes. Several authors have identified , ,  direct and indirect causes of maternal mortality rates in government and private tertiary hospitals of Pakistan. Major determinants of maternal mortality under the category of direct causes include hemorrhage, hypertensive disorders, eclampsia, sepsis, obstructed labour, ruptured uterus, and unsafe abortions , , , , , . Authors mentioned in their study that hemorrhage (34.6%), eclampsia (30.7%), sepsis (19.2%), anesthetic complications (11.5%), and hepatic encephalopathy (3.8%).
Other causes reported were pulmonary embolism and anesthetic complications . On the other hand, indirect causes were severe anemia (39%), hepatitis (9.7%), and heart diseases (9%). It has been concluded that 78.1% of maternal deaths are due to direct causes and 21.9% are indirect causes .
(a). Hemorrhage: It has been found in several researches that hemorrhage is the most common cause of death in Pakistan , . A study conducted by in Abbottabad from Jan 2000 to Dec 2001 reported that twenty-six maternal deaths occurred due to hemorrhage during this study period . Globally, eclampsia accounts as a major cause of maternal morbidity and mortality in Pakistan , .
Approximately, 10-15% of the maternal deaths occurred due to hypertensive disorders and eclampsia. All maternal deaths in eclampsia mothers are due to poverty and illiteracy. They delay in seeking medical advice or noncompliance due to their unaffordability .
(b). Sepsis: Sepsis is considered as another common cause of maternal mortality in European, Western and Asian countries. In Pakistan, unhygienic, unsafe practices by TBAs during the process of delivery are the leading cause of sepsis, which increases the proportion of maternal mortality , . Various literature explores the prevalence of sepsis in developing and developed countries.
The contribution of sepsis related deaths during maternal life was 19.2% , 66.6% , (57%) , (19.2%) , 13.8% , and (33.3%) . Maternal mortality due to sepsis has been almost same since last eighteen years . On the other hand, the incidence of sepsis in developed countries is quite controlled and low. The reason for this control is due to the proper implementation of aseptic techniques and trained health professionals .
Puerperal sepsis is the second most common cause of maternal mortality in developing countries , . The associated factors leading to develop sepsis include maternal anemia, prolonged labour, premature membrane rupture, frequent vaginal examination and use of unsterilized/unwashed instruments during delivery process and domestic delivery , . According to Pakistan demographic and health survey (2007), 65% of women delivered at home. These deliveries are conducted in unsafe settings by untrained TBAs under unhygienic conditions .
To conclude, maternal mortality is still a very challenging public health issue in Pakistan. It constitutes a major health problem, which not only affects the women but their entire families and community. The objective of this paper is to analyze the determinants that contribute to one of the major public health issue of maternal mortality in Pakistan. These determinants have been analyzed using various available resources including research based published articles and scientific reports.
These determinants include socio-economic, cultural, physical, human and medical factors which need to be addressed successfully. To combat this major public health issue, we need to work diligently in order to meet the challenging task of MDGs. It requires active participation of community, governmental and non-governmental agencies including doctors, registered nurses, and midwives to look for various innovative strategies addressing this huge burden at all the levels.
1. Call for increase in health budget. Dawn Newspapers. Available from: http://dawn.com/2012/10/17/call-for-increase-in-health-budget. 2012 October 16.
2. WHO: Safe Abortion: technical and policy guidance for health systems (2nd ed.). 2012. (Online April 2013), Available from http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf
3. World Bank Data. Literacy Rate of 2008-2012. (Online) April 2013. Available from http://data.worldbank.org/indicator/SE.ADT.1524.LT.ZS
4. Maternal deaths Pakistan ranks third: expert. Available from http://www.brecorder.com/generalnews/ 172/1244514/. Business recorder news; October 25, 2012
5. Nisar, N., & Sohoo, N. Maternal mortality in rural community: a challenge for achieving millennium development goal. (2010). JPMA; 60: 20-24
6. Drife J. Maternal Mortality: National and International perspectives. (2000) In P. Shaughn, The Yearbook of Obstetrics and Gynaecology.
7. Jafarey SN. Maternal Mortality in Pakistan – Compilation of available Data. (2002). Journal of Pakistan Medical Association; 52(12), 539-544.
8. Shah N, Hossain N, Noonari M, Khan H. Maternal mortality and morbidity of unsafe abortion in a university teaching hospital of Karachi, Pakistan.(2011). JPMA; 61: 582.
9. World Health Organization: Maternal Mortality in 2000: Estimates developed by WHO, UNICEF, and UNFPA. (Online) 2013 (Cited 2013 April 15). Available from URL: www.who.int 2000.
10. Begum S, Nisa A, & Begum I. Analysis Of Maternal Mortality In A Tertiary Care Hospital To Determine Causes And Preventable Factors. (2003). Journal of Ayub Medical Abbottabad; 15: 2.
11. Iftikhar R. A Study of Maternal Mortality. (2009). Journal of Surgery Pakistan; 14(4): 176-178.
12. Fawad A, Naz H, Khan K, Aziz-un-Nisa. Septic Induced Abortions. (2008). Journal of Ayub Medical College Abbottabad; 20 (4): 145- 148.
13. Pal, SA. Haemorrhage and Maternal Morbidity and Mortality in Pakistan. (2007). Journal of Pakistan Medical Association; 57(12): 576-577.
14. Stokoe U. Determinants of maternal mortality in the developing world. (1991). Aust N Z J Obstet Gynaecol; Feb; 31 (1): 8-16.
15. Mumtaz, Z., Salway, S., Shanner, L., Bhatti, A., & Laing, L. Maternal deaths in Pakistan: intersection of gender, caste, and social exclusion. (2011). British Medical Centre; 11(2): S2-S4
16. Osmani S, Sen Amartya. The Hidden penalties of gender inequality: Fetal origins of ill-health. (2003). Economics and Human Biology; 105-121
17. Jabeen, S., Ahmed, A., Zaman, B. S., & Bhatti, S.-u.-Z. Maternal Mortality. (2010). Professional Medicine Journal; 17(4): 679-685.
18. Fikree, F. F., Midhet, F., Sadruddin, S., & Berendes, H. Maternal Mortality in different Pakistani sites: ratios, clinical causes and determinants. (1997). Acta Obstet Gynecology Scand; 7: 637-45.
19. Thaddeus & Maine. Too far to walk: Maternal mortality in context. (1994). Soc Sci Med; 38 (8): 1091-110.UNICEF: Pakistan Annual Report 2010 (Online April 2013). Available from www.unicef.org/pakistan.
20. WHO: Safe Abortion: technical and policy guidance for health systems (2nd ed.). 2012. (Online April 2013), Available from http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf
21.Okonofua F. Abortion and maternal mortality in the developing world. (2006). Journal of Obstetric Gynecology Can; 28: 974-9.
22. Korejo R, Noorani KJ, Bhutta S. Sociocultural determinants of induced abortion. (2003). Journal of College of Physician Surg Pakistan; 13: 260-2.
23. Haddad L.B. & Nour N. M. Unsafe Abortion: Unnecessary Maternal Mortality. (2009). Rev Obstetrics Gynecology; 2(2): 122-6.
24. Hafeez M & Siddique S. Demographic and clinical profile of patients with complicated unsafe abortion. (2007). Journal of College Physicians Surg Pakistan; 17(4): 203-6.
25. Safdar, S. S., & Omair, I. A. (2002). Maternal Health Care in a rural area of Pakistan. JPMA, 52, 308.
26. Shaheen, B. I., & Obaid, H. M. Eclampsia,a Major Cause of Maternal and Perinatal Mortality: a prospective analysis at a tertiary care hospital of Peshawar. (2003). JPMA; 53: 346
27. Duley L. Maternal Mortality associated with hypertensive disorders of pregnancy. (1992). British Journal of Obstetrics Gynaecology; 99: 547-553. DOI: 10.1111/j.1471-0528.1992.tb13818.x
28. Ashraf R, Gul A, Noor R, Nasin T, Chohan A. Sepsis Induced abortion, maternal mortality and morbidity.(2004). Ann King Edward Med Coll; 10:346-7.
29. Farooq N, Jadoon H, Masood T, Wazir, M, Farooq U, Lodhi, M. An assessment study of maternal mortality ratio databank in five districts of Northern Western Frontier Province Pakistan. (2006). J Ayyub Med Coll Abbottabad; 10 (2): 64-8.
30. Ayhan A, Bilgin F, Tuncer Z, Tuncer R, Klesnisa H. Trends in maternal mortality at University hospital in Turkey. Int Journal Obstetric Gynecology (1994): 44: 223-8. DOI 10.1016/0020-7292(94)90170-8.
31. Madhudas C, Khurshid F, Sirichand P. Maternal Morbidity and Mortality Associated with Puerperal Sepsis. (2011). JLUMHS; 10 (3): 121- 123.
32. Abbasi, M., Rizwan, N., & Qazi, Y. Puerperal Sepsis: an outcome of suboptimal care. (2009). JLUMHS; 8 (1): 72-75.
33. USAID Pakistan: Pakistan Demographic and Health Survey 2006-07. National Institute of Population studies Islamabad
About the Author: Mehtab Qutbuddin Jaffer is a final year student in Masters of Nursing program at the Aga Kahn Univeristy. Pakistan. She had vast experience of working in several positions and capacities at the Aga Khan University, School of Nursing and Midwifery, ranging from registered nurse, clinical nurse instructor, in emergency department, medicine unit, and out-patient services. Mehtab can be reached [email protected]
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