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From January 1973 to December 1975, 26 018 women were delivered at Edendale Hospital. During the same period, 4 478 patients aborted there. Maternal deaths during this period numbered 118, a mortality of 4,5/1 000 total births. Avoidable factors influencing the mortality may have been present in 28 (2387%).
Comparisons of crude and standardized rates of maternal mortality show that changes in age and parity distributions of births had some influence on maternal mortality trends for the years 1919-1969 in the United States. Changes in the age and parity distributions of births for cohorts of U.S. women also influenced crude cohort maternal mortality rates to some extent.
The maternal mortality rate of 22.4 per 100,000 live births in 1973 is the lowest recorded in Austria. The figures for Austria are compared with the data from other European countries with similar health systems. Austria reflects the overall trend of a decreasing maternal mortality rate. 10 cases of maternal death recorded per 16,447 live births in the 2nd Department of Obstetrics, University of Vienna are presented and discussed with respect to the clinical diagnosis and compared with the main causes of maternal death in the national and international literature. As in other countries, haemorrhage in 3 out of the 10 cases ranks first, whilst in Austria generally, toxaemia has been the most common cause of death in recent years. The main cause of the bleeding is undetected rupture of the uterus, which is frequently concealed behind the clinical diagnosis of circulatory failure with cardiac arrest. 2/3 of the observed cases in the present series are considered to have been avoidable. It is recommended that in future every single reported case of maternal death in Austria is analyzed and the cause of death and the degree of avoidability discussed as is done in England.
Caesarean section-rates of more than 10% in our days are not seldom; the reasons are the changed and enlarged indications for Caesarean section. The increase of the Caesarean section-frequency is parallel to the decrease of maternal mortality. The authors' investigations came to the same results. From 1963-1974 they examined 29534 deliveries (28184 spontaneous deliveries and 1350 Caesarean sections). In the examined years the Caesarean section-frequency increased from 3.6% to 5.7%. The maternal mortality of all deliveries was 5.47% (14 from 29534);the maternal mortality of the spontaneous vaginal deliveries was 0.14% (4 from 28184), in the Caesarean sections the maternal mortality was 7.41% (10 from 1350). The different causes of exitus in Caesarean section are discussed. Even "adjusted statistics" show that maternal mortality in Caesarean section is until today 10 to 15 times as high as in vaginal deliveries. Therefore Caesarean section means a ten times higher risk than a spontaneous delivery. For these reasons Caesarean section should not develop to the delivery's "method of choice" and we should keep our intentions also in future to the vaginal methods of delivery.
The sociocultural, psychological, and medical effects of maternal death are described and analyzed for the purpose of appraising the value of the given death as a measure of the quality of medical care. The work of the Maternal Mortality Committee of the Hospital de Gineco-Obstetetricia No. 1 of the Mexican Social Security Institute over its three years of operation and some results on responsiblity for death and its possible predictabilty are presented. The results show that it is necessary to broaden the Committee's functions in a social, professional, and institutional context so that the indicated factors may be objectively assessed and also that the Committee be transformed into a dynamic organism that will contribute to solving the problem. Recommendations for the operation of the Maternal Mortality Committees are given.
Eighty maternal deaths occurring at the University Teaching Hospital (UTH) Lusaka, from 1974-1976 have been reviewed. The maternal mortality rate was 1.5 per 1000 births. The commonest causes of death were pre-eclampsia and eclampsia (23), septicaemia (14), haemorrhage (13) and ruptured uterus (11). Avoidable hospital factors were present in 52 percent of cases, while avoidable outside factors were noted in 27 percent. Thirty two per cent had no antenatal care. The mortality rate may be reduced by increased awareness of high risk patients by medical staff in the central hospital. Improvements in community maternal health services and better transport and communications are essential.
This is the fourth review on the maternal mortality and obstetrics in the federal state of Hamburg comprising, this time, the years 1968 to 1972. 70 cases of maternal mortality are described classified, and discussed. All cases of maternal death with a temporal relationship to pregnancy, labour and delivery and puerperium were analyzed individually. There were 70 maternal deaths in 113, 564 deliveries. 10 or 8.8/100,000 cases were due to embolism. 1 or 0.9/100,000 cases were due to amniotic fluid embolism. 10 or 8.8/100,000 cases were due to infection. 9 or 7.9/100,000 cases were due to hemorrhage. 8 or 7.0/100,000 cases were due to toxemia of pregnancy. 5 or 4.4/100,000 cases were due to criminal abortions. 1 or 0.9/100,000 cases were due to chorio-carcinoma and 26 or 23/100,000 cases were due to non-obstetric causes. Our experience over many years shows that maternal mortality, stillbirth and death during the first year of life should be considered an epidemiologic entity.
In the period 1953 - 1977 there were 223 maternal deaths among 291 800 patients delivered in hospitals under the aegis of the Department of Obstetrics and Gynaecology of the University of Cape Town. A sudden decrease in the maternal mortality rate to below 100/100,000 deliveries occurred in 1956, largely due to the greater use of the obstetric 'flying squad'. Since 1975 maternal mortality rates have been available for the various ethnic groups. For the period 1975 - 1977 the rates were 69/100,000 for Blacks, 40/100,000 for Coloureds and 27/100000 for Whites. Of the deaths, 48% occurred in women aged 21 - 30 years and 29% in those aged 35 years or more. While 28% of deaths were associated with the first pregnancy, grand multiparity (parity 5 or more) accounted for 39%. Nearly half of the patients who died were unbooked. The 7 commonest causes (grouped) of maternal deaths (obstetric as well as non-obstetric) were, in rank order: proteinuric hypertension, haemorrhage, cardiac disease, pulmonary embolism, sepsis, trauma and anaesthetic complications. Proteinuric hypertension is the most important obstetric problem in Cape Town, in terms of numbers of patients, maternal and perinatal deaths, and socio-economic implications for the community. Slightly more than 33% of the infants whose mothers died also succumbed. Major avoidable factors associated with maternal deaths were booking status, grand multiparity, cardiac disease and late or incorrect use of the 'flying squad'.
The Sisterhood Method, a community-based survey technique, was used to estimate the Life Time Risk of a woman dying a maternal death in Southern Malawi. With this figure, the maternal mortality ratio for that area was calculated to be 409 deaths per 100,000 live births. The 4124 adults interviewed reported 150 maternal deaths in sisters. An in-depth questionnaire was then used to determine that 56% of these deaths occurred outside a health facility, largely due to lack of transportation or poor access to fixed health care facilities; 25% died from excessive hemorrhage; 20% from obstructed labour; 18% from abortion; 13% from sepsis; while eclampsia accounted for only 4% of the maternal deaths. This field experience with the Sisterhood Method technique combined with an in-depth questionnaire for determining causes of maternal deaths has provided useful information in a simple and cost-effective manner for use in planning intervention strategies designed to decrease maternal mortality.
Statistics covering deaths directly due to pregnancy in the Commonwealth of Australia have been available since the turn of the century. However, those for deaths associated with pregnancy have not. Over the past two decades each State in the Commonwealth has set up Maternal Mortality Committees to collect confidential information on each maternal death, both direct (where the death is directly attributable to pregnancy or childbirth) and associated (where the death is associated with but not directly due to pregnancy or childbirth). New South Wales had set up the first such Committee in the 1930's, and this has since been followed by the other States. Most of the States have published reports from time to time but, owing to the small numbers involved, these reports have been limited in the conclusions that could be made. Confidential information on each maternal death is obtained and is considered by the State Maternal Mortality Committee. The cause of death is confirmed and classified. A necropsy is usually performed in each instance, the pathologist travelling to the town where the death has occurred, if requested.
Maternal mortality in the C.H.U. of Rennes from the 1st January 1969 to the 1st January 1979 consisted of 8 deaths in 24.911 deliveries and 1.381 Caesarean sections, which gives a mortality of 32 per 100.000 deliveries. There was 1 death due to hyperemesis gravidarum, 1 due to toxaemia of pregnancy, 3 due to haemorrhage, 1 due to puerperal sepsis, 1 due to cerebral haemorrhage and lastly 1 due to cancer of the pancreas. 2 women died during Caesarean section, which works out at 1 death per 690 Caesareans. Of these 8 deaths, 4 were possibly avoidable, and 3 of their children survived. In spite of continual progress since the end of the second world war, maternal mortality should decrease still further and tend down to the figures for Scandinavia or England (10 deaths for 100.000 deliveries).
During the 13 years 1960-1972, in a teaching hospital that serves a predominantly rural and semiurban population in southern India, there were 74,384 deliveries and 1245 maternal deaths, a maternal mortality rate of 16.7 per 1000 births. Direct obstetric factors caused 854 (65.5%) of these deaths. The leading indirect or associated causes of maternal deaths were anemia, cerebrovascular accidents, and infectious hepatitis. During the past 13 years, monthly maternal mortality meetings have helped to reduce the incidence of avoidable factors in maternal deaths among patients from the city but not among those brought from the surrounding countryside. The important causes of maternal deaths in this developing country, and their prevention, are individually discussed.
In spite of great strides in obstetrics, maternal mortality has been completely eliminated. Possible changes in the causes of mortality are examined for three periods of time (1954-1961, 1962-1971 and 1972-1976). The overall incidence was 3.6/10 000, changing through the three periods from 4.9 to 4.3 and finally to 3.0/10 000. Vascular accidents were the cause of death in almost one third of the cases, emerging as the most important etiologic factor. Older age and higher parity did not seem to influence the incidence of obstetric deaths. Cesarean section was involved in ten of 23 cases in which the death was directly related to the pregnancy and delivery. In six patients there was a rupture of the uterus. The number of preventable deaths has decreased steady, but research into the problem of vascular accidents and dampening of the enthusiasm for cesarean sections may further improve the situation.
Over the past 50 years, maternal mortality for the pregnant diabetic has been reduced by half. In the period from 1957 to 1974, 24 pregnant diabetic women died in Los Angeles County. Seven deaths were directly attributed to the metabolic complications of diabetes. Fatal ketoacidosis occurred in the second and third trimesters, while hypoglycemia led to death in the first trimester or postpartum period. Of 15 patients alive at the onset of labor, 8 were delivered by cesarean section. Four of these women died from sepsis and 3 from hemorrhage. In contrast to other reports, vascular disease contributed to only 1 fatality.
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A 15-year survey of maternal mortality in a large urban hospital revealed an overall rate of 2.95 deaths per 10,000 pregnancies (3.44 per 10,000 live births), representing 31 maternal deaths among approximately 105,000 deliveries and spontaneous and therapeutic abortions. This rate showed marked improvement during the 15-year period, ie, 6.56 per 10,000 pregnancies for the first 5 years as compared to only 1.37 per 10,000 pregnancies for the last 10 years. In contrast to the classic triad of causes of maternal death--toxemia, hemorrhage, and spesis--the principal cause of death in this series was amniotic fluid embolism. Other aspects of the causes of death and of the findings are discussed. Among the 32 fetuses, total fetal wastage was 63%, with a neonatal mortality of 8% and a fetal mortality of 46%.