https://imcjms.com Ibrahim Medical College Journal of Medical Science https://imcjms.com/registration/journal_full_text/226 Sun, 04 Jun 2017 13:56:36 +0000 Maternal mortality is an important indicator which reflects the health status of a community. It can be calculated by maternal mortality ratio (MMR), maternal mortality rate (MMRate), and adult life time risk of maternal death. MMR estimates are based on varieties of methods that include household surveys, sisterhood methods, reproductive-age mortality studies (RAMOS), verbal autopsies and censuses. Main causes of maternal mortality are hemorrhage, infection, unsafe abortion, hypertensive disorder of pregnancy and obstructed labour. Factors of maternal mortality have been conceptualized by three delays model. Estimates of maternal mortality ratio (MMR) trend between 1990 and 2010 (over 20 years period) suggest a global reduction (47%), with a greater reduction in developing countries (47%) including Bangladesh than in developed countries (39%). However, to meet the challenge of Fifth Millennium Development Goal (MDG5 i.e. to ensure 75% reduction of MMR by the year 2015), the annual rate of MMR decline and increase of skilled attendant at birth need to be still faster. Address for Correspondence:Dr. Sonia Shirin, Assistant Professor, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka 1000   Mothers are important constitute of a population and maternal mortality is the culmination of a series of detrimental events in a woman’s life.1 Maternal mortality ratio (MMR) represents the status of health care services and social wellbeing of a country.2 Since the launching of the Safe Motherhood Initiative in 1987, there has been a worldwide effort to reduce maternal mortality and to identify its determinants. These efforts have been directed by the outputs of a number of international conferences over the past decade such as the International Conference on Population and Development in 1994, and the Fourth World Conference on Women in 1995. The declaration of the Fifth Millennium Development Goals (MDG-5) aiming at reducing by three-quarters the MMR by 2015 has also increased the demand for measuring maternal mortality at national and subnational levels.3 There is a greater disparity in levels of maternal mortality than in any other public health indicator between developed and developing countries. While in the developing countries including Bangladesh significant progress has been made in reducing infant mortality, the same is not true for maternal mortality. Although the actions needed to reduce maternal mortality have been in place in most developing countries, 1 woman in 50 is still dying as a result of pregnancy-related complications and the figure rises to 1 in 10 in many parts of Africa. By contrast, the figure for developed countries may be as low as 1 in 8,000.5 The main causes of maternal mortality are severe bleeding, infection, unsafe abortion, eclampsia, hypertensive disorders of pregnancy and obstructed labor.8 Very little scientifically based information is available on cause-specific mortality rates for many developing countries.9 Most of the information comes from the verbal autopsy (VA), used to obtain causes of death by interviewing lay respondents on the signs and symptoms experienced by the deceased before death.10-14 In the present article, the global and regional estimates and trends of maternal mortality has been reviewed to understand the causes and factors related to maternal mortality and the challenge facing the developing world in particular in achieving MDG 5 by 2015. Maternal Mortality and its estimation: methods used The tragedy is that these women die during normal life enhancing process of procreation and not from disease.21-23 Although widely-used standardized definitions of maternal mortality exist, it is difficult to measure accurately the levels of maternal mortality in a population – for several reasons. First, it is challenging to identify maternal deaths precisely – particularly in settings where routine recording of deaths is not complete within civil registration systems. Second, even if such a death were recorded, the woman’s pregnancy status may not have been known and the death would, therefore, not have been reported as a maternal death. Third, in most developing-country settings where medical certification of cause of death does not exist, accurate attribution of female deaths as maternal death is difficult. In the absence of complete and accurate civil registration systems, MMR estimates are based upon a variety of methods namely household surveys, sisterhood methods, reproductive-age mortality studies (RAMOS), verbal autopsies, and censuses.26-28 MMR trends between 1990-2010   Fig-1. Global Reduction of MMR in Developed and Developing Countries based on WHO estimates 4 Eastern Asia ranked highest (69%) in reducing MMR between 1990 and 2010 followed by Northern Africa (66%), Southern Asia (64%), Sub-Saharan Africa (41%), Latin America and the Caribbean (41%), Oceania (38%) and finally Caucasus and Central Asia (35%) (Fig 2).       Fig-3.Region experiencing 75% reduction in MMR by 2010 The Government of Bangladesh is also committed to achieving its targets for MDG 5; reducing the maternal mortality ratio (MMR) and increasing skilled attendance at birth to improve maternal health.32 According to a WHO estimate,4 trend in decline in MMR between 1990 and 2010, in Bangladesh was highly satisfactorily (70%) with expectation to reach the target (75% reduction) by 2015 (Fig 4). Unfortunately however, the rate of skilled birth attendants of delivery remained as low as 27% against a targeted goal of 50% during the period.19 In Bangladesh, 85% of births still takes place at home. Only one in five mothers and neonates receive postnatal care from a medically trained provider within 42 days after birth.33     Evidence suggests that the direct consequences of pregnancy and childbirth continue to account for most maternal deaths in developing countries. To obtain reliable information on the individual medical causes of maternal mortality is however extremely difficult, especially for deaths that occur at home. In a systematic review of the causes of maternal mortality WHO showed severe bleeding, hypertensive diseases and infections as the dominant causes.5 There is hardly any systematic review or study about the causes of maternal deaths in Bangladesh. A study conducted by ICDDR’B at Matlab seems to be reflective of general scenario in Bangladesh. This study reviewed the major causes of maternal death, using a combination of record review and field interviews. The major causes of maternal mortality were haemorrhage (20%), complications of abortion (18%), eclampsia (12%), violence and injuries (9%), concomitant medical causes (9%), postpartum sepsis (7%), and obstructed labour (6.5%). Deaths caused by postpartum haemorrhage were positively associated with both maternal age and parity, whereas those caused by eclampsia and injuries were more common among young and low-parity women.35   Factors that contribute to a higher risk of maternal mortality include such factors as biomedical, reproductive, health service, socioeconomic and cultural factors and have been conceptualized in the ‘Three Delays Model’.This ‘Three Delays Model’ identified individual decision making, access to affordable services, and the provision of skilled personnel as the main factors which can delay access to effective interventions to prevent maternal mortality.36,37 The first delay is on the part of the mother, family, or community not recognizing a life-threatening condition. Because most deaths occur during labor or in the first 24 hours postpartum, recognizing an emergency is not easy. Most births occur at home with unskilled attendants, and it takes skill to predict or prevent bad outcomes and medical knowledge to diagnose and immediately act on complications. By the time the lay midwife or family realizes that there is a problem, it is too late. The second delay is in reaching a health-care facility, and may be due to road conditions, lack of transportation, or location. Many villages do not have access to paved roads and many families do not have access to vehicles. Public transportation may be the main transportation method. This means it may take hours or days to reach a health-care facility. Women with life-threatening conditions often do not make it to the facility in time. The third delay occurs at the healthcare facility. Upon arrival, women receive inadequate care or inefficient treatment. Resource-poor nations with fragile health-care facilities may not have the technology or services necessary to provide critical care to hemorrhaging, infected or convulsive patients. Omissions in treatment, incorrect treatment, and a lack of supplies contribute to maternal mortality.38 Cham et al utilized ‘The Three Delay’ framework in a study to identify contribution of three delays in Gambia which was mentioned as for i) seeking medical care (22%), ii) reaching an appropriate medical facility (84%) and iii) receiving required care at health facility (97%). Furthermore, 22% had all three phases of delay, 66% were subjected to two phases of delay and 9% had only one phase of delay.39 Timing of maternal mortality In Bangladesh, mortality was also highest on the first day after pregnancy. Pregnancies ending in abortions and stillbirths accounted for 50% of deaths in women within 6 weeks of the end of pregnancy, and mortality after these outcomes was between two and four times as high as mortality after a livebirth.41 In Matlab, Bangladesh, data shown that 20% of all maternal deaths occurred during pregnancy, 44% during labour and the two days following delivery, and 6% during the remaining postpartum period.35 Factors related to maternal mortality   Maternal mortality is still a major challenge to the health system worldwide. Systematic review of the ratio and trends in maternal mortality is essential for planning, resource mobilization and assessment of progress towards MDG-5, the target for 75% reduction in MMR by 2015. Estimates of ratio and trend of MMR over a 20 years’ period (1990 - 2010) suggest a global reduction with a greater reduction in developing countries including Bangladesh, than in developed countries. 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