Abstract: Background and Objective: The occurrence of maternal death would threaten the family foundation and children’s health. The aim of this study was to determine the causes of maternal deaths during childbirth in Tehran province, Iran in 2011-2015. Materials and Methods: All Maternal Mortality Ratio (MMR) in Tehran province from 2011-2015 were considered in this cross-sectional study. Data were recorded for demographic characteristics, autopsy findings, medical and obstetric histories. The data were then analyzed with a z-test to identify differences in the rate of MMR during the study period. Results: The mean MMR was 15.8 in 100,000 live births (95% CI, 1.076-13.546) during the 5 years study period and the highest MMR was 19.1 in 2011 and the lowest proportion was 13 in 2015. Most deaths (23.6%) occurred in the preeclampsia-eclampsia period and the lowest autoimmune disease and addiction (1.8%). High-risk mothers accounted for 79.2% of maternal deaths. Among the mothers who died, 50.45% received satisfactory prenatal care and at least 2 years elapsed between successive pregnancies in 23.8%. Vaginal bleeding was the main cause of death (33.8%). Conclusion: The MMR has been declining over the years, due to the identified factors associated with maternal death, proposed strategies, such as improving the quality of hospital services.
INTRODUCTION
An estimated 300,000 women died globally in 2015 as a result of pregnancy-related conditions1. Although maternal mortality ratios remain elevated in many areas, the maternal mortality ratio has decreased by 1.3% per year globally since 1990, with the greatest annualized rate of reduction in developed countries (1.3% versus 1.4% in developing countries)2. During the same time period, however, the maternal mortality ratio in the United States increased2. Globally, reduction in maternal mortality has been attributed to reduction in the total fertility rate, increase in maternal education and increased access to skilled birth attendants2. Other factors associated with maternal mortality reduction include the promotion of policies to reduce anemia and malnutrition, prevent malaria in pregnancy, provide calcium and micro-nutrient supplementation, encourage delivery in facilities properly resourced for emergency obstetric care, discourage early motherhood and reduce unsafe pregnancy termination3.
World Health Organization (WHO) in version 10 of International Classification of Diseases (ICD-10) defined maternal mortality as maternal death during pregnancy or within 24 h after delivery irrespective of the duration and place of delivery from any cause related to pregnancy or aggravated by the pregnancy or its management4. Maternal Mortality (MM) is a term used when a mother dies due to complications of pregnancy within 42 days after delivery5. It is estimated that over 500,000 maternal deaths occur annually, i.e., approximately one death per minute6,7. Overall, 15% of all pregnancies are complicated by mostly preventable and manageable obstetric conditions8. The main contributing factors of nearly 75% of maternal deaths are hemorrhage, infections, hypertensive disorders, obstructed labor and unsafe abortion6,7. Other no obstetric disorders that play a role in MM include severe anemia, sickle cell disease and cardiovascular diseases7. Aside from medical causes, several non-medical issues also play key roles in MM such as socioeconomic, cultural, religious and biological factors (age and parity)7. The risk of MM is 200 times higher in developing countries compared to develop ones8. This is equal to 1 death in every 18 pregnancies, compared to 1 in every 2228 conceptions in developed countries9. Disparities in MM between developed and developing countries have highlighted the need for global attention to this important issue; therefore, the goal to achieve a 75% reduction in MM in all countries by the end of 2015 has been set as part of millennium development goal number 58. Since then, some progress has been made in developed countries; however, the problem persists in Asia and Africa, where the status is more hazardous10,11. In Iran, a developing country in the Middle East region, MMR has fluctuated from 47.2 per 100,000 live births in 1993 to 34.3 per 100,000 in 1995, 45.7 per 100,000 in 1997, 34 per 100,000 in 1999, 38.7 per 100,000 in 2004 and 34 per 100,000 live births in 200812. Despite some overall progress in MMR trends, the rate is far from ideal and needs to be lowered. The MM refers to deaths due to complications from pregnancy or childbirth. From 1990-2015, the global MMR declined by 44% from 385 deaths to 216 deaths per 100,000 live births, according to UN inter-agency estimates (Fig. 1). This translates into an average annual rate of reduction of 2.3%. While impressive, this is less than half the 5.5% annual rate needed to achieve the three-quarters reduction in maternal mortality targeted for 2015 in millennium development goal 513.
| Fig. 1: | Causes of MMR fell by almost half between 1990, 2000 and 2015 in the world12-15 |
| Table 1: | Trends in estimates of MMR, maternal deaths per 100,000 live births in Iran1990-201512-15 |
| MMR: Maternal mortality ratio | |
| Table 2: | Causes of maternal mortality fell by almost half between 1990 and 2015 in Iran12-15 |
| Table 3: | Causes of decrease MMR in Iran 1990-201512-15 |
In Iran causes of maternal mortality fell by almost half between 1990 and 201512-15 (Table 1-3).
Every region has advanced, although levels of MM remain unacceptably high in sub-Saharan Africa. Almost all maternal deaths can be prevented as evidenced by the huge disparities found between the richest and poorest countries. The lifetime risk of maternal death in high-income countries is 1 in 3,300, compared to 1 in 41 in low-income1. Given the importance of identifying the causes, prevention and the need to continue the process of reducing the MMR, this study was conducted the causes of MMR in Tehran-Iran from 2011-2015 to identify and prioritize the factors affecting MMR by presenting the results and providing it to the authorities and planners which took a step to further reduce MMR.
MATERIALS AND METHODS
The present study was a descriptive-analytic cross-sectional study of maternal deaths was conducted in Tehran province during 5 years from 2011-2015. This study was approved by the Ethical Committee of Tehran University of Medical Sciences (TUMS) (Approval code: IR.TUMS.REC.1394-1561).
The cause of death for each case was recorded from the autopsy report and verbally from the woman’s family. After a verbal explanation of the aims of present study verbal consent to use this information was obtained from the woman’s next of kin. Information regarding each case of Maternal Mortality (MM) was recorded by a team of trained experts who were members of the Maternal Mortality Committee. This team consisted of a gynecologist, an anesthesiologist, a midwife, a nurse, a coroner, a representative of the University Clinical Affairs section and a representative of the Vice Chancellery of Health. They recorded the cause of death based on a review of available documents, i.e., prenatal care records, hospital admission files, verbal reports and pathological autopsies.
Data collection form consisted of two parts: Demographic and obstetric. In the demographic part information such as the mothers ‘first and last name, date of death, hospital file code, residential area (Urban, rural and nomadic), age and underlying diseases were recorded. Obstetric information consisted of past and present obstetric histories. Information, regarding the number of pregnancies, number of living children and number of abortions were recorded from the past history. The present obstetric history comprised date of death, delivery or postpartum period, type of previous delivery (normal vaginal delivery, cesarean delivery or abortion), quality of prenatal care according to the attached prenatal care card, quality of care during labor (by reviewing the hospital file) and time between the two previous pregnancies in multiparous mothers. Prenatal care was considered appropriate when it matched the standard of care, quantitatively and qualitatively. At least 14 care events during pregnancy are required for women with no medical or obstetric problems. Quality of care was categorized into appropriate or inappropriate according to follow-up, appropriate administration of drugs (if needed), supplements such as folic acid, iron and multi-vitamins and acceptable par clinical interventions (lab tests and ultrasound examinations). Care during labor and in the recovery room was considered appropriate if the type of drug, dosage and time of administration were suitable and if vital signs were recorded and acceptable measures were taken for those women who were unstable.
Checklist for evaluating care during puerperium had two parts: Quantity and quality. Mothers with no postpartum complications should be visited by an obstetrician or a midwife at least 3 times: The day after delivery, 1 week later and in the following 6 weeks. In these visits, mothers should be evaluated for any abnormal bleeding, infection, quality of married life, appropriate training for breast-feeding and appropriate administration of supplements.
The Maternal Mortality Committee categorized deceased mothers into two groups: High-risk and low-risk. Mothers were considered high-risk if they met at least one of the criteria related to their age (younger than 17 or older than 35 years), presence of underlying diseases or poor obstetric history. The poor obstetric history category included mothers with four or more previous deliveries, <2 years between pregnancies or antenatal vaginal bleeding in the previous or present pregnancy. Statistical analysis the data were analyzed with a z-test to identify differences in the rates of MM that occurred between 2011-2015. Differences with a p<0.05 were considered statistically significant. The data are reported as Mean±SD. All data were analyzed with SPSS v.22 software.
RESULTS
Maternal deaths (109) were reported in Tehran province from 2011-2015. The ratio of maternal deaths was 15.8 in 100,000 of live births during this period. The highest MMR was 19.1 in 2011 and the lowest proportion was 13 in 2015.
Table 4 showed there were significant relationship between age, place of residence and maternal deaths (p>0.05). Most deaths occurred during the postpartum period (71.3%) and 23.7% occurred in the antepartum period. Analysis of the quality of care revealed that almost 50.45% of the mothers who died had received appropriate prenatal care. According to the delivery room quality of care checklist, most mothers (90%) received appropriate quality of care during labor.
| Table 4: | Frequency distribution the causes of maternal death during childbirth in Tehran-Iran in 2011-2015 (N = 109) |
Because no medical records were generated for postpartum care, so this period could not be evaluated. Results of the present study revealed that 79.2% of the mothers who died were at high-risk during the perinatal period. Table 5 compares demographic and clinical factors between high-risk and low-risk mothers. Table 6 revealed that 70.64% of the mothers died during childbirth due to "Wrong in treatment" and 55.04% of the mother died during childbirth due to "Delays in treatment".
DISCUSSION
This study was undertaken to determine the causes of maternal mortality in Tehran province, Iran from 2011-2015. According to the findings, 109 pregnant women in Tehran in this study period, with an average of 15.8 deaths per 100,000 live births have died and the highest maternal mortality ratio in 2011 was equal to 19.1 and the lowest proportion was 13 in 2015 which is the same as the calculated MMR index over the years.
| Table 5: | Comparison of high-risk versus low-risk mothers in different subgroups (N = 109) |
Generally, maternal mortality has declined during these years indicating an improvement in the services provided to the mother. But according to the conducted studies in Sistan-Baluchistan province from 2002-2009, maternal mortality was 82.616. In Hormozgan province from 2005-2011, maternal mortality was 39.717, in Kermanshah province from 2001-2012, maternal mortality was 25.918. In Fars province from 2003-2010, maternal mortality was 22.1819 and this shows better situation in Tehran in the field of maternal health as compared to other provinces.
In relation to maternal age and death, the findings showed that 55.96% of women who died were 36-57 years old, while 15.59% were 17-26 years old. Maternal mortality rate was higher in Iran than in some developed countries; however, the gap seems to be narrowing20. For example, the MMR in England was estimated at 15 per 100,000 deliveries during 2003-200520 and a study conducted by Schutte et al.21 showed that in the Netherlands, MMR was approximately 12.1 per 100, 000 live birth during 1993-2005.
Iran’s MMR is much lower than in other developing countries in Asia and Africa9.
| Table 6: | Causes of maternal death during childbirth in Tehran-Iran in 2011-2015 (N = 109) |
For example, in India MMR was estimated at about 519 per 100,000 live births8 and in Northern Nigeria the figure was reported to be about 2849 per 100,000 deliveries over 5 years period from 2003-20079. Differences in MMR between developing countries can be attributed to several factors including local topography, cultural factors, health resources and quality of obstetric care8,7,22.
Between 2011 and 2015 the trend in MMR in the studied population was generally downward clinically, with the lowest rate appearing in 2015, followed by a slight upward trend. At the end of the study period, MMR was lower than at the start of the present study period. This tendency of MMR to fluctuate has been observed in other countries, such as the Netherlands and the UK21. According to Schutte et al.21, changes in MMR may reflect better registration and data recording along with demographic changes, with age and parity playing the largest roles. A correlation between MMR and maternal age is consistent with findings reported by Maharlouei et al.19, who have shown that older mothers need higher rates of assisted reproduction, which might contribute to higher MMR. Pregnancy-related complications, another important factor are more frequent in older women who are more often considered at high-risk23. The highest MMR was seen in mothers who were 35 years of age or older, where as the rate in women aged between 18 and 35 years was much lower. Kullima et al.9 found significant differences in mortality rates among different age groups; however, Kullima et al.9 and Schutte et al.21 found no such differences. In the studied population most deaths occurred during the postpartum period, followed by pregnancy and were less frequent during labor. Although Bashour et al.24 found labor to be the most critical time followed by the postpartum period, other studies found the postpartum period to account for the most maternal deaths6. One of the most important reasons may be the lack of adequate follow-up care during puerperium, a phase as important as pregnancy or labor. In this survey, care during puerperium was not documented in the medical record, so the quality of care in comparison to pregnancy and labor could not be evaluated. This was a potential limitation in the analysis of the present study. Good care during the prenatal period and labor did not necessarily result in a better delivery outcome. Almost all mothers who died (50.45%) received the full package of prenatal care. Based on the results of this study it is suggest that the quality of postnatal care is as important as care during pregnancy and labor in preventing maternal deaths.
The present study identified hemorrhage to be the main cause of maternal death, followed by eclampsia and sepsis. Few studies have identified other main causes of maternal death in developed countries9,21. For example, Schutte et al.21 and Kullima et al.9 reported that the most common causes of MM were preeclampsia and eclampsia, respectively. Overall, results of the present study were congruent with most studies in developing countries6,24. In some settings, the main cause of death and the order of relative contributions of different causes were the same as in the studied population. Similarly, Gupta et al.8 and Tsu and Coffey25 found postpartum hemorrhage and eclampsia to be the two leading causes of maternal mortality. Cesarean delivery was involved in more than half (56.88%) of maternal deaths in our setting. This was not unexpected, because in Tehran province as in other developing areas, more than half of all deliveries are cesarians26. In addition, cesarean delivery is the procedure of choice in most high-risk pregnancies23. In this study, 79.2% of the mothers who died were identified as high-risk. In the study by Schutte et al.21, 49% of the mothers who died had undergone cesarean delivery, although this mode of delivery was the direct cause of death in only four cases21. Several limitations might affect the studied data and analysis. The most important limitation of the present study was retrospective design and use of previously recorded data. Because, design of the present study was cross-sectional, therefore, predictors of maternal mortality could not be identified. On the other hand, using community-based data for the entire Tehran province helped ensure the reliability of the data analysis. All maternal mortality cases were recorded by an expert team and the Maternal Mortality Committee, thus the likelihood of information bias was reduced. The prolonged study period ensured that the trends observed in MMR were accurate. The size, demographic and ethnic diversity of this study population mean that findings of the present study may be applicable, with appropriate reservations, to the general population of Iran.
CONCLUSION AND FUTURE RECOMMENDATIONS
Maternal mortality has been declining over the years, due to the identified factors associated with maternal death, proposed strategies, such as improving the quality of hospital services in the field of obstetric emergencies, improving the quality and coverage of prenatal care, avoidance of selective cesarean sections, identifying high-risk pregnancies and referrals to specialized centers, training of experienced and expedite forces and facilitating the process of efficient and professional services to reduce maternal mortality should be used. This study will help in:
| • | Improving skills and knowledge of doctors, midwives and nurses and strengthening educational programs for the illiterate are the most effective measures to reduce maternal mortality |
| • | Improving the quality and coverage of prenatal care |
| • | Safe delivery by trained individuals |
| • | Identification of high risk pregnancies and referrals to specialized centers |
| • | Efficient and experienced personnel and speeding up the process of education services by increasing equipment such as blood products used to reduce the mortality rate of pregnant women |
| • | Also, due to constraints, such as lack of some records, lack of access to families to complete information and in some cases illegible answers in the case |
SIGNIFICANT STATEMENTS
This study identifies several points that are critical for health policy makers who aim to decrease MMR. The present study also highlight the need to focus on and document the quality of postpartum care, which is as important as prenatal care. Efforts to decrease MMR should focus on high-risk mothers not only during pregnancy and delivery but also during the postpartum period. Because preeclampsia-eclampsia were the most frequent cause of death in our setting, closer postpartum surveillance to detect this potentially worrisome complication is warranted.
This study discovers the possible synergistic effect of intervention in improving the quality of hospital services has a significant effect on the reduction of the number of maternal deaths and since more >99% of the deliveries take place in hospitals of the province, it is necessary to pay attention to hospital services and the part they play in maternal death.
ACKNOWLEDGMENTS
This article is a part of a MPH thesis entitled "Assessing factors related to maternal mortality in Tehran province 2011-2015" that has been supported by Tehran University of Medical Sciences, Faculty of Health. The authors thank all those who have helped researchers at all stages of the project.