Maternal Mortality

2. MATERNAL MORTALITY

3. GOALS
1. Know the definition of maternal deaths.
2. Understand the common causes of
maternal death in Malaysia and
Sarawak.

4. MATERNAL DEATH
The death of a woman while pregnant or within 42 days of
termination of pregnancy:
◦ Irrespective of the duration and site of pregnancy
◦ From any cause related to or aggravated by the pregnancy or
its management
◦ From other causes not related or caused by the pregnancy
Termination of pregnancy:
◦ Normal delivery
◦ Miscarriage
◦ Ectopic/Molar

5. CLASSIFICATION
Direct
◦ Deaths resulting from obstetric complications in pregnancy, labour
and puerperium
Indirect
◦ Deaths resulting from previous existing disease or diseases that
developed during pregnancy and which was aggravated during
pregnancy
Fortuitous
◦ Deaths from other causes not related to or influenced by pregnancy
Late
◦ Death after 6 weeks until 1 year after delivery

6. Classification Examples
Direct Thromboembolism
Haemorrhage
Ectopics
Hypertensive disease of pregnancy
Sepsis
Amniotic fluid embolism
Indirect Cardiac disease
Suicide
Epilepsy/CNS haemorrhage
Infections
Respiratory/gastrointestinal diseases
CLASSIFICATION

7. MMR
(Maternal mortality ratio)

8. MATERAL MORTALITY RATIO
Maternal mortality ratio (MMR) is the number of women
who die from pregnancy related causes during pregnancy
and within 42 days of childbirth, per 100,000 live births.
Excluding accidental or incidental causes
Illegal immigrants are not included although each case is
investigated
◦ No of women dies
100,000 live births

9. MDG 5
(Millennium Developmental Goals)
MDG 5: improve maternal health
Target 5.A. Reduce by three quarters, between 1990 and 2015, the
maternal mortality ratio
Target 5.B. Achieve, by 2015, universal access to reproductive health

10. Trend from 1990 to 2015
Globally, MMR fell by 44%
With estimated MMR 216 maternal deaths per 100000 live
births from 385 per 100000 live births
Global lifetime risk of a maternal death fell from 1 in 73 to 1
in 180

13. Sustainable development goal
Ending preventable maternal deaths
Reducing MMR to < 70 in 100000 live births by 2030
◦ Requiring average 7.5% reduction of MMR each year from 2016 –
2030 compared to 23% each year in MDG 5

14. National MMR
National MMR have reached a plateau between 28-
30/100,000 LB the last 10 years
MMR for 2010 (26.7) & 2011 (25.4) – reaching a plateau?
MDG 5 target for state by 2015 – 11.08/100,000 LB

19. MATERNAL DEATH by Phase of
pregnancy

20. OUR STATE….
THERE IS MARKED REDUCTION IN MMR IN OUR STATE
YEAR MMR ( per 100,000 live births)
2008 30.8
2009 37.0
2010 26.7
2011 25.4
2012 26.6
2013 9.3 (***achieve MDG 5 target)
2014 16.0
2015 16.0
2016 7.3
2017 15.6

21. CEMD
(CONFIDENTIAL ENQUIRIES INTO MATERNAL
DEATH)

22. SUMMARY FROM CEMD REPORT
2009 - 2011
834 pregnancy related deaths were reported from 2009 - 2011
MMR in 2009 - 2011 were 31.0, 29.7 and 25.4 per 100,000 live births respectively
Principal cause of maternal deaths are medical disorders in pregnancy, &
hypertensive disorder, obstetric embolism, and PPH
>60% of the maternal death occurred during postnatal period
The risk of maternal death was higher in mothers who had multiparous; 40 – 65%
of death occurred in women with 2 – 5 children
Maternal death tagged with the green code increased from 32.5% in 2009 to 37.7%
in 2011
Maternal mortality rate is higher among non contraception users

23. TABLE: CAUSES OF MATERNAL DEATHS
CAUSES 2009 2010 2011
PPH 20 (13.0%) 11 (7.5%) 19 (14.6%)
HPT DISORDER 18 (11.7%) 25 (17.1%) 25 (19.2%)
OBSTETRIC
EMBOLISM
23 (14.9%) 30 (20.5%) 16 (12.3%)
MEDICAL ILLNESS 51 (33.1%) 46 (31.5%) 37 (28.5%)
APH 4 (2.6%) 3 (2.1%) 3 (2.3%)
PUERPERAL
SEPSIS
6 (3.9%) 6 (4.1%) 2 (1.5%)
ABORTION 7 (4.5%) 2 (1.4%) 2 (1.5%)
ECTOPIC 4 (2.6%) 7 (4.1%) 4 (3.1%)
UNSPECIFIED
COMPLICATION
OF PREGNANCY &
PUERPERIUM
5 (3.2%) 0 0
ASSOCIATED
WITH
ANAESTHESIA
0 0 1 (0.8%)
OTHERS 6 (3.9%) 2 (4.1%) 3 (2.3%)

24. KEY RECOMMENDATIONS
Step up the quality of maternal health care
Prepregnancy care should be provided to all women with preexisting medical
disease
Early intervention, treatment and optimization of women’s health before
embarking in pregnancy in high risk women
Ectopic pregnancy should be ruled out in any women in reproductive age gp
with abdominal pain
Cardiologist should be involved in the management of pregnant women with
heart disease
More centres with ECG service made accessible to the medical officers to refer
patients for echocardiogram

25. Senior doctors and specialist should be involved in the care of patients with medical
disease
Regular obstetric drills
Thromboprophylaxis
Postnatal nursing should focus on the ability to exclude DVT and postnatal depression
Identify psychiatric disorders, domestic violence, substance abuse and self harm
Strengthening existing referral system
Obstetric protocol, guidelines and manual should be available
All home deliveries to be conducted by trained midwives
Home visits, defaulter tracing
Prevention of teenage pregnancy
Road safety
Postmortem examination

31. More than 50% of patients who
died had some degree of
unsatisfactory management
‘Substandard care’
‘Remediable clinical factors’

32. ** INCREASE MATERNAL MORTALITY
** INCREASE PERINATAL MORTALITY