Maternal mortality rate in

Yazd-Iran during 10 years

(2002-2011)

DR.Karimi Zarchi M

Gynecological oncology felloship, shahid sadoughi

university of Medical Sience

Definitions

Maternal deathThe death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

Death must be attributed directly or indirectly to pregnancy or childbirth

Requires medical certification or verbal autopsy

Cannot be obtained through surveys or censuses

No deaths beyond 42 days due to pregnancy complications accounted for

Definition Implications

Pregnancy-related deathThe death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.

Cause of death certification not needed

Can be obtained through surveys or censuses

UN Interagency maternal mortality estimates conform to the definition of maternal death

Maternal Mortality: A Global Tragedy

• Annually, 536,000 women die of pregnancy related complications

– 99% in developing world

– ~ 1% in developed countries

– 25% global burden by India

Every minute one Maternal Death occur

Current Approach to Reduction of Maternal Mortality

3

Maternal Death Watch• 380 women become pregnant

• 190 women face unplanned or unwanted pregnancy

• 110 women experience a pregnancy related complication

• 40 women have an unsafe abortion

• 1 woman dies from a pregnancy-related complication

Current Approach to Reduction of Maternal Mortality

4

The fifth MDG(Millennium Development Goal) aims to improve maternal health, with a target of reducing the MMR by 75% between 1990 and 2015.

The percentage reductions for the 10 countries that have already achieved MDG 5 by 2010 are:

Estonia(95%), Maldives(93%), Belarus(88%), Romania(84%), Bhutan(82%), Islamic Republic of Iran(81%), Equatorial Guinea(81%), Lithuania(78%), Nepal(78%) and Viet Nam(76%)

Estimates of maternal mortality ratio,number of maternal deaths by United National Millennium Development Goal region,2013

Region MMR Range of MMR uncertainty

Number of maternal deaths

Lower estimate

Upper estimate

World 210 160 290 289000

Developed regions 16 12 23 2300

Developing regions 230 180 320 286000

Northern Africa 69 47 110 2700

Sub-Saharan Africa 510 380 730 179000

Eastern Asia 33 21 54 6400

Southern Asia 190 130 280 69000

Oceania 190 100 380 510

Trends in estimates of maternal mortality ratio(maternal deaths per 100000 live births), 1990-2013, by country

Country MMR % Change in MMR between 1990 and

20131990 1995 2000 2005 2010

Afghanistan 1200 1200 1100 730 400 -67

India 560 460 370 280 190 -65

Indonesia 430 360 310 250 190 -56

Iraq 110 84 71 77 67 -37

Egypt 120 96 75 62 45 -62

Iran 83 60 44 31 23 -72

Saudi Arabia 41 31 24 19 16 -65

Bahrain 21 22 27 16 22 3

Maternal mortality ratio in Iran (2002 – 2011)

Birth and maternal mortality in some Iranian universities(2007-20011)

University Birth(5 years)

Maternal mortality(5 years)

Percent of all births in 5

years

Percent of all deaths in 5

years

Tehran(Shahid Beheshti,Tehran)

913791 145 17.14 9.45

Esfahan 332849 57 6.24 3.71

Kashan 29033 9 0.54 0.59

Sistan & Balochestan

374611 173 7.02 11.27

Zabol 40350 21 0.76 1.37

Kerman 190903 60 3.72 4.91

Kohkeloieh & Boyer Ahmad

74040 23 1.39 1.50

Hormozgan 168263 67 2.53 4.36

Yazd 113015 29 1.72 1.89

Birth and maternal mortality in Yazd(2002-2011)

Birth (2002-2011) 222433

Maternal Death (2002-2011) 40

Maternal Mortality Ratio 17.9

The most common causes of maternal death in 2011,Iran

The most common causes of maternal death in Yazd, 2002-2011

Percent of maternal deaths by place of birth, Iran

Percent of maternal deaths by place of birth in Yazd,2002-2011

Percent of maternal deaths by type of delivery, Iran

Percent of maternal deaths by type of delivery in Yazd, 2002 - 2011

Percent of delays leading to maternal death, Iran

According to the results, it seems necessary considering the quality of services provided in the hospital emergency obstetric,92.5% of mothers had died in childbirth in hospitals(92.5% in Yazd & 94% in Iran).

55% of mothers had died giving birth by cesarean section in Yazd (63% in Iran). As of Huchon and Heyl study.Therefore reducing cesarean rates can also reduce maternal mortality.

In most studies, the most common cause of maternal death is hemorrhage. Rajai and et al study was one of these cases,the hemorrhagy was reported by 34.1% as the most common cause of maternal mortality in Hormozgan.

Hemorrhage is one of the reasons that are preventable. Improving care before,during and after delivery is effective in contrlling bleeding.

And finally providing timely emergency obstetric will result in saving the lives of mothers(41% in 2011).

Interventions to Reduce Maternal Mortality

Historical Review

• Traditional Birth Attendants-3 percent

• Antenatal Care -11 percent

• Risk Screening About 15 %

Current Approach

• Reduce Unwanted Fertility

• Skilled Attendant at Delivery

• Emergency Obst. Care

Current Approach to Reduction of Maternal Mortality

20

Risk Screening

• Conclusion: Cannot identify those at risk of maternal mortality — Every pregnancy is at risk, if not proved, otherwise.

Do women die immediately after developing complications in delivery?

Average Complications to death interval

• Hemorrhage PPH: 2 Hours ( 5.7 hrs*) APH: 12 Hours(11.5 hrs)

• Ruptured uterus 1 Day • Eclampsia 2 Day (1.7 Days)• Obstructed Labour 3 Days• Infection 6 Days (2.4 Days)• (* Study in Maharashtra – Ganatra et al. WHO bulletin 1998, 76(6):591-598.

Current Approach to Reduction of Maternal Mortality

22

Current Approach to Reduction of Maternal Mortality

23UN

Maternal deaths averted through Maternal deaths averted through access to services access to services (World (World Bank, 2004)Bank, 2004)

Maternal Health Services

• Good quality maternal health services are not universally available and accessible

– > 39% receive no antenatal care

– ~ 40% of deliveries unattended by skilled provider

– ~ 60% receive no postpartum care during 1st 6 weeks following delivery

– 15% unmet need of FP

Current Approach to Reduction of Maternal Mortality

24

Are there populations who are rich, well nourished and educated but have high

maternal mortality?

• Yes in USA there are such populations – eg. Faith Assembly of God who are rich, well nourished, and educated : their MMR was 872 in 1982 while in that year MMR in US general population was only 8 per 100,000 live births.

• What is the key difference between these two groups? Use of modern obstetric care.

25 Current Approach to Reduction of Maternal

Mortality

SoAll pregnant women

need Access to*

Emergency Obstetric Care

(EmOC)

* Not the same as Institutional Delivery [ID]

26 Current Approach to Reduction of Maternal

Mortality

Thanks a lotThanks a lot

Current Approach to Reduction of Maternal Mortality

28

REFRANCE:

Maine D. 1999. What's So Special about Maternal Mortality?, in Safe Motherhood Initiatives: Critical Issues. Berer M et al (eds). Blackwell Science Limited: London.

World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: Geneva.