causes, those that are aggravated by pregnancy but may be present even before pregnancy, such as diabetes, malaria, or hepatitis. Approximately 80 percent of all maternal deaths are estimated to be due to direct causes (World Health Organization, 1996). The World Health Organization (WHO) (1993c) estimates that hemorrhage is the most common direct cause, followed by sepsis and complications of unsafe abortion, hypertensive disorders of pregnancy (including eclampsia), and obstructed labor. The relative importance of different direct causes of mortality varies among studies, due in part to differences in reporting and definitions, and in part to real differences in the quality and accessibility of delivery care.

Although the definition of a maternal death includes a woman's death while pregnant or up to 42 days postdelivery from any cause (except accidental), most maternal deaths, excluding abortion-related deaths, occur during labor and delivery or soon thereafter. In a rural area of Bangladesh, for example, more than 70 percent of the nonabortion deaths occur in this short time span: 40 percent during labor or within 48 hours of delivery (primarily due to eclampsia and postpartum hemorrhage) and 30 percent between 3 and 42 days postdelivery, with sepsis and associated diseases leading the list of causes (Fauveau et al., 1988). Extending the definition of maternal death to 90 days postpartum, as has been proposed, would only have increased the number of maternal deaths by 6 percent. The critical period as that of labor and delivery is also supported by a nationally representative study in Egypt (Ministry of Health, 1994): 39 percent of deaths took place during delivery or within the first 24 hours, and 36 percent occurred within 42 days postpartum; only 25 percent took place during pregnancy itself.

Maternal Disability

Between 30 and 40 percent of pregnant women, or over 54 million women in developing countries, are estimated to experience a pregnancy-related complication annually (World Health Organization, 1993b; Koblinsky, Campbell, and Harlow, 1993). WHO estimates that 15 million women per year develop long-term disabilities from such complications as obstetric fistula, prolapse, severe anemia, pelvic inflammatory disease, and reproductive tract infections, as well as infertility.

At the country level, these estimates vary widely. For example, in community-based studies, Guatemalan women reported one in five pregnancies as complicated (Bailey, Szaszdi, and Schieber, 1994); in West Java, one in three women reported complications, not including those experienced in the postpartum period (Alisjahbana et al., 1995); and in Ghana, two of every three pregnant women had some complication, although the



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