Contraceptive Use and Controlled Fertility Health Issues for Women and Children (1989) / Chapter Skim
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The Relationship Between Fertility and Maternal Mortality
The Relationship Between Fertility and Maternal Mortality
Pages 1-47
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Because high-mortality countries are those with the least reliable vital statistics, little information is available about levels and risk factors. Provision of family planning services has been proposed as one way to reduce maternal mortality (Rosenfield and Maine, 1985~.
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The maternal mortality ratio is the ratio of maternal deaths per live births (venously 1,000, 10,000, or 100,000; unless noted otherwise a metric of 1,000 is used for ratios and rates in this paper)
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They allow nearly complete counts of live births and maternal deaths. Because of their prospective nature they include deaths that occur more than a week after delivery and probably include most of the deaths due to induced abortion.
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However, the more serious problems in measurement arise from incomplete ascertainment of either the number of deaths or the number of related live births. Deaths that occur before delivery, such as those due to ectopic pregnancy, may not be recognized as maternal deaths.
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2In the light of the probable large effect of selection bias, the problem of maternal mortality ratios calculated using deliveries rather than live births in the denominator is minor, but a number of hospital reports (and one population-based study: Greenwood et al., 1987) use deliveries.
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For example, deaths resulting from cephalopelvic disproportion and abnormal presentations leading to prolonged labor and uterine rupture might be classified as due to ruptured uterus if the rupture is identified, as due to hemorrhage if extravaginal bleeding is a prominent feature, or to sepsis if death is delayed some time after the onset of labor. Many maternal deaths are associated with a number of complications; for example, of 219 deaths in Zaria only 86 could be attributed to a single condition, while the rest were associated with two or more (Harrison and Rossiter, 1985~.
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suggest that the risk in West Africa is generally high, though perhaps closer to 10 than 20. The next highest mortality occurs in South Asia; from the population studies in Bangladesh and the population and hospital studies in India, a maternal mortality ratio of 4 to ~ seems most likely.
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8 SUSAN ZIMICK] TABLE 1 Matemal Mortality Ratio Per 1,000 Binhs From Selected Countries City Population Hospital Year Reference Gambia Ethiopia Tanzania Gambia Indonesia Bangladesh India Keneba Mandua North Bank Addis Addis Ababa Addis Ababa Kilimanjaro Dar es Salaam Moshi Mwanza Lusaka Lusaka Lusaka South Africa Pietennantzburg Durban 12 hospitals Bali Matlab Matlab Matlab Tangail Jamalpur Calcutta Calcutta Madurai Bombay urban Bombay rural Anantapur rural 8.7 Anantapur urban 5.5 Bogota 1.3 Call 2.2 Caracas 1.0 Cumana Ribeirao Preto Sao Paula Campinas Santiago Santiago Colombia Brazil Chile 10.5 9.5 22.0 4.6 7.2 7.7 5.7 5.1 5.7 6.2 8.4 5.9 3.9 16.5 4.0 2.4 0.6 0.9 3.2 1951-75 Billewicz and McGregor (1981)
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in Kuwait obtained similar results for antepartum hemorrhage (0.1 percent for women of parities 1 to 5, 1.2 percent for parities 6 and 7, and 4.2 percent for parity 8+) , but they observed lower rates of abnormal presentation-only 5.1 percent for 4Parity is the number of previous live births; gravidity is the number of previous pregnancies.
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also reports both parity-specific and gravidity-speciD~c ratios, but labels women with no previous live births panty O and those with no previous pregnancies gravidity 1. In addition, there seems to be a classification problem, as the reported ratios indicate 10 deaths among women who had no prior pregnancy but only 7 among those with no prior live birth.
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Intervention Rate/1,000 Rat~o 2 3 4 5 7-9 10+ AB 244 138 145 116 107 103 125 159 146 84 89 81 71 73 84 100 Note: Ratio is adjusted for age, ethnic group, and hospital Overall maternal mortality ratio in this population was 0.03 per 1,000 births. Source: Harlap et al.
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The authors note that the crude birth rate calculated from the number of births reported in the study is 35, about 10 percent lower than the national estimated crude birth rate of 39. If births have been missed, it seems possible that maternal deaths might also have been.
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This impression can be tested by examining several hospital series concerning primigravidfprimiparous or grand multiparous women that also take age into account in describing complication rates. Hospital Studies: Primigravid/Primiparous Women Age-specific maternal mortality ratios for primigravidas in Zaria, Nigeria (Harrison and Rossiter, 1985)
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Primigravidas below 20 years of age were also at increased risk for hemorrhage of placental origin. Except for the study in Jamaica, these hospital studies confirm the general pattern suggested by the population-based studies: young primigravidas are at higher risk of complications, especially pregnancy-related hypertensive disease, and of mortality than primigravidas age 20 to 24.
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The mortality for all multigravid women that age was 5.9 per 1,000 deliveries; for 20- to 24-yearold women of at least parity 5 it was 9.7. Risk increased with age for both groups; for all multigravid women age 30 or more mortality was 15.3, while for the grand multiparous subgroup it was 20.1.
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A referral hospital population study carried out from 1936 to 1943 in the United States (Eastman, 1944) showed no significant difference in maternal mortality ratios by length of interval since the last live birth.
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The excess risk for women who have not attended an antenatal clinic can be observed by comparing maternal mortality ratios for women who attended at least once with those for women who never attended (Table 7~. Except in the Gambia, women who never attended died at 2.6 to 22 tunes the rate of clinic attenders.
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The advantage of regular antenatal care is that women at particular risk (e.g., because of anemia, hypertensive disease, or an obviously small pelvis) can be identified and either treated to reduce the risk or advised to deliver in a hospital.
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The Zaria data provide TABLE 8 Cause-specific Mortality Ratios for Patients With and Without Prenatal Care in Lusaka, Zambia, 1982-1983 Prenatal Care No Care Relative Cause of death N MMRa N ME Risk Hypertensive disease 5 1.2 7 9.2 7.7 Hemorrhage 9 2.1 1 1.3 0.6 Puerpe~al sepsis 7 1.5 2 2.6 1.7 Amniotic fluid embolism 3 0.7 0 0 Nonobstetnc causes 8 1.9 4 5.3 2.8 All causes 32 7.4 14 18.4 2.5 aMaternal mortality ratio per 10,000 deliveries. Calculated assuming that the national rate of prenatal clinic attendance (85%)
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Since 81 percent of those living in town had antenatal care, the overall town ratio is probably lower than the true population ratio. The overall ratio for those living outside the town is probably inflated relative to the true ratio, as 83 percent of those women were emergency patients.
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Traditional Behavior Beth Practices A number of traditional birth practices contribute to higher maternal mortality, especially the use of oxytocin-con~ning medicines and the practice of"helping" delivery along by exerting extra abdominal pressure over the uterus. Whether pharmaceutical or herbal, the misuse of uterine stimulants has been implicated in deaths due to obstructed labor and ruptured uterus (Armor, 1977; Rendle-Short, 1960; Elkins et al., 1985; Groen, 1974~.
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This measure is used rather than cause-specific maternal mortality ratios mainly because of its more intuitive nature; it is easier to apprehend the meaning of a cause being responsible for 20 percent of all deaths than being responsible for 0.3/1,000 deaths, particularly when the denominator of the ratio is known to be biased, and the bias is likely to differ between hospitals. The main reason to use the cause
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Zambia, Ethiopia, and Gambia have high proportions of deaths attributed to infectious disease, which is responsible for very few deaths in Bangladesh, Jamaica, and India. The hospital studies from West Africa (Table 12)
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(1974) Overall MMR/1,000 12.1 4.5 6.3 - 4.3 8.2 N of deaths 175 624 141 155 212 183 Abortion Ectopic pregnancy 1.1 Hemorrhage 19.4 Difficult labor 21.7 Sepsis 2.9 Operative 6.3 Hypertensive disease 12.0 l~romboembolism 0.6 Over direct 1.1 6.9 0.6 1.1 17.1 1.7 5.1 10.2 Anemia Cardiovascular Hemoglobinopathies Infectious GI Hepatic Other Violent Other _ _ 24.2 25.8 8.3 0.6 11.2 0.6 4.0 7.5 1.1 15.1 3.4 11.7 25.2 17.4 9.7 17.4 8.4 9.1 1.4 8.5 21.9 9.9 9.2 9.2 7.8 31.9 6.4 17.0 5.0 7.1 5.0 _ _ 2.8 30.2 31.1 5.2 10.4 9.4 1.9 6.6 3.3 15.8 3.8 7.1 3.8 3.8 1.6 18.6 2.2 4.4 22.4 3.3 15.3 3.8 9.0 6.6 TABLE 13 Proportional Mortality in Hospital Studies in Afnca, Excluding West Afnca Place Tanzania Uganda Zambia S
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(1971) Overall MMRJ1,000 5.9 8.4 5.6 NR 2.1 4 16.7 N of deaths 80 108 637 285 27 128 1,245 Abortion 8.8 9.3 20.9 - 3.7 14.1 8.1 Ectopic pregnancy 5.0 - 0.2 - 3.7 1.6 Hemorrhage 27.5 15.7 9.4 - 40.7 14.1 18.6 Difficultlabor 11.3 4.6 - 15 1 - 7.0 21.0 Sepsis 3.8 8.3 3.3 9.1 14.8 5.5 5.2 Operative 3.8 2.8 3.3 - - 1.6 Hypertensive disease 12.5 27.8 14.3 2.5 11.1 6.3 10.7 Thromboembolism - - 6.0 - - 3.9 7.7 Other direct - - 3.8 - - - 5.0 Anemia 12.5 24.1 13.7 3.9 18.5 4.7 8.7 Cardiovascular 1.3 3.7 3.5 7.7 3.7 5.5 4.2 Infectious 10.0 1.9 15.5 20.0 - 25.0 4.8 GI - - - 8.4 - - 2.2 Hepatic 10.0 1.9 15.5 20.0 - 25.0 4.8 Other - - - 9.5 - 10.2 2.2 Violent Other 3.8 1.9 6.3 23.9 3.7 0.8 1.5
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TABLE 15 Proportional Mortality in Hospital Studies in the Middle East, ~da~esia, and Vietnam Place Lebanon Iran Saudi Arabia Indonesia Vietnam Beirut Shiraz Shiraz Riyadh 12 hasp Bali Quang Ngai Year 71-82 63-79 7~76 78-80 77-80 81-82 67-69 Author Mashini Daneshbod Borazjani Mulatto- Chi Fortney Vennema et al.
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The populationbased studies from Bangladesh and hospital studies from India suggest that in Asia most deaths are to multiparous women. This pattern is confirmed by a population-based study of abortion in Jamalpur, Bangladesh, which found that the induced-abortion/live birth case ratio increased from 32/100 for primiparous women to 37 for parities 1 to 4 and 96 for women of parity 5 or more (Khan et al., 1986b)
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They found that 25 percent reported having at least one induced abortion, and they mention that the case-fatality ratio in their hospital for induced abortions was at least 34 per 1,000. Given this reported prevalence and extremely high case-fatality rate, it is surprising that abortion figures so little in the hospital-based studies of maternal
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papers discuss induced or suspected induced abortions solely in the context of gynecologic emergency admissions. A second possibility is that behavior in the capital city Nairobi or Accra is different from that in more provincial cities and that abortion rates are higher.
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Five of the hospital studies of maternal mortality include information about cesarean section rates and about associated case fatality (Table 17~. Unfortunately, none of them report parityspecific rates or give much detail about the reasons for the cesareans, so it is difficult to assess the fertility-associated risk of disproportion.
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Only two studies cite hospital population preva Slhese are really significant only in West Africa, where they occur at low prevalences in the reproductive population. In fact, sickle cell disease (Hb SS)
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Africa Tropical Brazil 20 Colombia 22 North Guyana 55 Algeria 65 Peru 35 Egypt 75 Venezuela 52 Libya 47 Morocco 46 Temperate Tunisia 38 Argentuna 61 Chile 32 West Gambia 80 Oceania Ghana 64 Guinea-Bissau 85 Fiji 68 Ivory Coast 34 Papua New Guinea 55 Mali 50 Mauritania 24 Niger 24 Nigeria 65 Asia Sierra Leone 45 Togo 47 West East Iran 50 Ethiopia 6 Israel 29 Kenya 48 Lebanon 50 Malawi 49 Turkey 74 Mauritius 80 Uganda 35 South Tanzania S9 Bangladesh 66 Zambia 60 India 68 Zimbabwe 27 Nepal 33 Pakistan 65 South Sri Lanka 62 South Africa 25 Southeast Burma 55 Latin America Indonesia 65 Laos 62 Malaysia 77 Central America Philippines 47 Costa Rica 44 Singapore 26 E1 Salvador 15 Thailand 48 Guatemala 34 Vietnam 50 Mexico 38 Nicaragua 20 Source: Royston (1982)
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In Jamaica the maternal mortality ratios for hemorrhage increase with age up to 8.1 for those 35 to 39 and 5.1 for those 40+ (Walker et al., 1985~. In Chile most of the risk of hemorrhage, whether due to placental pathology or uterine inertia, accrued to women of panty 5 or more, except that primigravidas less than 20 were also at higher risk of placental hemorrhage (Faundes et al., 1974~.
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Hepatitis In the population and hospital studies reviewed, infectious hepatitis is the single most important disease in terms of increasing the risk of maternal mortality. It is not clear whether pregnant women are more susceptible to hepatitis than nonpregnant women, but they are at greater risk of death from the disease than nonpregnant women.
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The generally higher case-fatality rate for nonpregnant women than for men has been attributed to the lower nutritional status of women, but no evidence has been offered to support this. Tuberculosis Whether women with untreated tuberculosis are at higher risk of maternal mortality is unclear.
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The possible mechanisms through which fertility reduction can occur are contraception and provision of safe induced abortions. For first births use of contraception or safe abortion could reduce risk of mortality either through allowing postponement of the first birth until after age 20 or through averting unwanted birds.
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The potential is greater for reducing mortality associated with unwanted higherparity births. Family planning programs typically affect fertility mainly through reducing the number of high-parity births.
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The sepsis category includes deaths attributed to puerperal tetanus and septicemia. If the author classified a death as due to cesarean section, anesthesia, sepsis, or hemorrhage connected with cesarean section or to anesthesia, the death was classified as operative, even if it was highly probable that the section was performed for obstruction or abruption.
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South African Medical Journal 51(4)
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Harbin 1981 Matemal mortality at twelve teaching hospitals in Indonesia An epidemiologic analysis. International Journal of Gynaecology and Obstetrics 19:259-266.
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A 1987 File importance of family planning in reducing maternal mortality.
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Kidane-Manam 1986 Maternal mortality in Addis Ababa, Ethiopia. Studies in Family Planning 17(6)
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South African Medical Journal 50:1621-1624. Morrow, R
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Gould 1981 Maternal and abortion-related deaths in Bangladesh 1978-1979. International Journal of Gynaecology and Obstetrics 19(2)
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Winikoff, B., and M Sullivan 1987 Assessing the role of family planning in reducing maternal mortality.
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