Maternal mortality- one of the main criteria for the quality and level of organization of the work of obstetric institutions, the effectiveness of the implementation of scientific achievements in health care practice. However, most leading experts consider this indicator more broadly, considering maternal mortality an integrating indicator of the health of women of reproductive age and reflecting the population outcome of the interactions of economic, environmental, cultural, socio-hygienic and medical-organizational factors.
This indicator allows us to evaluate all losses of pregnant women (from abortion, ectopic pregnancy, obstetric and extragenital pathology during the entire gestation period), women in labor and postpartum women (within 42 days after termination of pregnancy).
In the International Classification of Diseases and Related Health Problems, 10th revision (1995), the definition of “maternal mortality” has remained virtually unchanged compared to ICD-10.
Maternal death is defined as pregnancy-related (regardless of its duration and location) death of a woman that occurs during pregnancy or within 42 days after its end from any cause related to pregnancy, aggravated by it or its management, but not from an accident or by accident the reason that arose.
At the same time, a new concept was introduced - “late maternal death”. The introduction of this new concept is due to the fact that there are known cases of death of women that occurred later than 42 days after the termination of pregnancy from causes directly related to it and especially indirectly related to pregnancy (purulent-septic complications after intensive care, decompensation of cardiovascular pathology, etc. .d.). Accounting for these cases and analyzing the causes of death allows us to develop a system of measures to prevent them. In this regard, the 43rd World Health Assembly in 1990 recommended that countries consider including items on the death certificate regarding current pregnancy and pregnancy in the year preceding death, and adopt the term “late-term pregnancy.” maternal death."
Maternal deaths are divided into two groups: deaths directly attributable to obstetric causes: deaths resulting from obstetric complications, pregnancy conditions (i.e. pregnancy, childbirth and the puerperium), and as a result of interventions, omissions, improper treatment or chain of events following any of the above reasons.
Death indirectly related to obstetric causes: death as a result of a pre-existing disease or disease that developed during pregnancy, not due to a direct obstetric cause, but aggravated by the physiological effects of pregnancy.
Along with the indicated reasons (the main ones), it is advisable to analyze random causes of death (accidents, suicides) of pregnant women, women in labor and postpartum within 42 days after completion of pregnancy.
The maternal mortality rate is expressed as the ratio of maternal deaths from direct and indirect causes to the number of live births (per 100,000).
Every year, more than 200 million women in the world become pregnant, which in 137.6 million ends in childbirth. The share of births in developing countries is 86% of the number of births worldwide, and maternal mortality is 99% of all maternal deaths in the world.
The number of maternal deaths per 100,000 live births varies sharply by part of the world: Africa - 870, South Asia - 390, Latin America and the Caribbean - 190, Central America - 140, North America - 11, Europe - 36, Eastern Europe - 62 , Northern Europe -11.
In economically developed countries, low maternal mortality rates are due to the high level of economic development, sanitary culture of the population, low birth rate, and high quality of medical care for women. In most of these countries, childbirth is carried out in large clinics equipped with modern diagnostic and treatment equipment and qualified medical personnel. The countries that have achieved the greatest success in protecting the health of women and children are characterized, firstly, by the full integration of the components of maternal and child health and family planning, balance in their provision, financing and management, and secondly, by the full availability of assistance in planning families within health services. At the same time, the reduction in the maternal mortality rate was mainly achieved through improving the situation of women, providing maternal health and family planning within the framework of primary health care and creating a network of district hospitals and perinatal centers.
About 50 years ago, countries in the European Region first formalized health care systems for pregnant women based on routine screening and visits to a doctor or midwife at regular intervals. With the advent of more sophisticated laboratory and electronic technology, a greater number of tests have been introduced and the number of visits has changed. Today, every country in the European Region has a legally established or recommended system of visits for pregnant women: for uncomplicated pregnancies, the number of visits varies from 4 to 30, with an average of 12.
In recent years, the obstetric service strategy has been built on two principles: identifying pregnant women at high risk of perinatal pathology and ensuring continuity in the provision of obstetric care. The great attention that was paid to perinatal risk in the 70s began to wane in the 90s.
Another important characteristic of systems of care during pregnancy is continuity of care. In Europe, the vast majority of systems treat pregnancy, childbirth and the puerperium as three separate clinical situations requiring a variety of clinical expertise, different medical personnel and different clinical settings. Therefore, in almost all countries there is no continuity of care provided during pregnancy and childbirth, i.e., a pregnant woman is cared for by one specialist, and the birth is carried out by another who has not previously observed her. Moreover, changing personnel every 8 hours of work also does not ensure continuity of care during childbirth.
The Netherlands, a developed European country with a highly organized home birth service (36%), has the lowest maternal and newborn mortality rates. Monitoring of low-risk pregnant women and birth at home is carried out by a midwife and her assistant, who assists during childbirth and stays in the house for 10 days to help the birthing mother.
Maternal mortality is unacceptably high. About 830 women worldwide die every day from complications related to pregnancy or childbirth. In 2015, an estimated 303,000 women died during and after pregnancy and childbirth. Almost all of these deaths occur in low-income countries, and most are preventable.
In several countries in sub-Saharan Africa, maternal mortality rates have halved since 1990. Other regions, including Asia and North Africa, have made even greater progress. Between 1990-2015 The global maternal mortality rate (that is, the number of maternal deaths per 100,000 live births) fell by only 2.3% per year. However, since 2000, there has been a higher rate of accelerated decline in maternal mortality. In some countries, maternal mortality fell annually between 2000 and 2010. was above 5.5%, the level required to achieve the MDGs.
Sustainable Development Goals and the Global Strategy for Women's and Children's Health
Convinced that it is possible to accelerate this decline, countries are now united around a new goal - to further reduce maternal mortality. One of the targets of Sustainable Development Goal Three is to reduce the global maternal mortality rate to less than 70 per 100,000 births, with no country having a maternal mortality rate more than twice the global average.
Where do maternal deaths occur?
High maternal mortality rates in some parts of the world reflect inequities in access to health services and highlight the huge gap between rich and poor. Almost all maternal deaths (99%) occur in developing countries. More than half of these cases occur in sub-Saharan Africa and almost one third in South Asia. More than half of maternal deaths occur in places with fragile conditions and humanitarian problems.
The maternal mortality rate in developing countries was 239 per 100,000 live births in 2015, compared with 12 per 100,000 in developed countries. There are significant differences in rates between countries. There are also large disparities within countries between high- and low-income women and between women living in rural and urban areas.
The highest risk of maternal death is among adolescent girls under 15 years of age. Complications during pregnancy and childbirth are the leading cause of death among adolescent girls in most developing countries. 2.3
Women in developing countries have, on average, many more pregnancies than women in developed countries, and face a higher risk of pregnancy-related death throughout their lifetime: a 15-year-old girl is about to die from a maternity-related cause. 1 in 4,900 in developed countries compared to 1 in 180 in developing countries. In countries designated as fragile states, the risk is 1 in 54; this is a testament to the consequences of collapsing health systems.
Why do women die?
Women die as a result of complications during and after pregnancy and childbirth. Most of these complications develop during pregnancy and can be prevented. Other complications may exist before pregnancy but become worse during pregnancy, especially if they are not monitored. The main complications that lead to 75% of all maternal deaths are: 4
- heavy bleeding (mostly postpartum hemorrhage);
- infections (usually after childbirth);
- high blood pressure during pregnancy (preeclampsia and eclampsia);
- postpartum complications;
- unsafe abortion.
In other cases, diseases such as malaria and HIV/AIDS during pregnancy or related problems are the causes.
How can mothers' lives be saved?
Most maternal deaths are preventable because medical methods to prevent or manage complications are well established. All women need access to antenatal care during pregnancy, skilled care during labour, and care and support in the weeks after birth. Maternal health and newborn health are closely linked. An estimated 2.7 million newborn infants died in 2015 5 and an additional 2.6 million were stillborn 6 . It is especially important that all births are attended by trained health professionals, as timely care and treatment can make the difference between life and death for both mother and baby. It is especially important to ensure the presence of qualified health professionals during all births, since timely care and treatment can depend on life.
Heavy postpartum bleeding: a healthy woman can die within 2 hours if she does not receive medical attention. An injection of oxytocin given immediately after birth is effective in reducing the risk of bleeding.
Infection: After childbirth, infection can be ruled out by maintaining proper hygiene and identifying early signs and promptly treating it.
Preeclampsia: must be identified and managed appropriately before seizures (eclampsia) and other life-threatening complications occur. By administering medications such as magnesium sulfate, the risk of women developing eclampsia can be reduced.
To prevent maternal deaths, preventing unwanted and too early pregnancies is also vital. All women, including adolescent girls, need access to contraception, safe abortion services to the full extent permitted by law, and quality post-abortion care.
Why aren't mothers getting the help they need?
Poor women in remote areas are least likely to receive adequate health care. This is especially true in regions with low numbers of skilled health workers, such as sub-Saharan Africa and South Asia. Despite increased levels of antenatal care in many parts of the world over the past decade, only 51% of women in low-income countries receive skilled care during childbirth. This means that millions of births occur without a midwife, doctor or trained nurse.
In high-income countries, almost all women attend at least four antenatal clinics, receive care from a skilled health worker during childbirth, and receive postnatal care. In 2015, in low-income countries, only 40% of all pregnant women attended at least four antenatal clinics.
Other factors that prevent women from seeking medical care during pregnancy and childbirth include the following:
- poverty;
- distance;
- lack of information;
- inadequate services;
- cultural characteristics.
To improve maternal health care, it is necessary to identify barriers to access to quality maternal health services and take action to eliminate them at all levels of the health system.
WHO activities
Improving maternal health is one of WHO's main priorities. WHO works to reduce maternal mortality by providing evidence-based clinical and programmatic guidance, setting global standards and providing technical support to Member States. In addition, WHO promotes more affordable and effective treatments, develops training materials and guidelines for health workers, and supports countries in implementing policies and programs and monitoring progress.
In addition, WHO promotes more affordable and effective treatments, develops training materials and guidelines for health workers, and supports countries in implementing policies and programs and monitoring progress.
During the 2015 United Nations General Assembly in New York, UN Secretary-General Ban Ki-moon launched the Global Strategy on Women's, Children's and Adolescents' Health 2016–2030. 7 This strategy is a roadmap for the post-2015 agenda, as described in the Sustainable Development Goals, and aims to end all preventable deaths of women, children and adolescents, and to create an environment in which these groups not only survive , but also successfully develop and see changes in the environment, health and well-being.
Life expectancy
Natural population growth rate
Natural increase population is considered as the difference between the birth rate and death rate.
Natural increase= (number of live births – number
population died in a given year) x 1000
average annual population
Natural increase= birth rate - indicator
population mortality
The indicator of natural population growth is a fairly general characteristic of population growth and does not always reflect the demographic situation in society, since the same indicators of population growth can be obtained with different indicators of fertility and mortality. In this regard, natural increase must be assessed only in relation to fertility and mortality rates. High natural increase can be considered as a favorable demographic phenomenon only if mortality is low. Positive population growth with high mortality despite a relatively high birth rate characterizes an unfavorable type of population reproduction. Negative natural growth (population decline), observed in recent years, both in Russia and in the Sverdlovsk region, indicates a clear problem in society. This fact is commonly called unnatural population decline. Currently, the population mortality rate exceeds the birth rate by 1.6 times.
Life expectancy is an integral indicator for assessing public health and social well-being of society. Under the indicator life expectancy should be understood as the hypothetical number of years that a given generation of those born or a number of peers of a certain age will live, provided that throughout their lives, mortality in each age group will be the same as it was in the year for which the calculation was made. This indicator
characterizes the viability of the population as a whole and does not depend on the characteristics of the age structure of the population. The life expectancy indicator is calculated on the basis of age-specific mortality rates by constructing special mortality (survival) tables. They show the order of successive extinction of a set of persons born at the same time.
Life expectancy is one of the most important indicators recommended by WHO as an indicator of the health and standard of living of the population of a particular region. National programs “Health for All” recommend focusing on the value of this indicator, equal to 75 years.
On average for Russia and the Sverdlovsk region, this figure is significantly lower than that recommended by WHO, especially for the male population. In the modern period, both in Russia and in the Sverdlovsk region, the difference between the expected life expectancy of women and men is on average 12 years. So, for example, in the Sverdlovsk region in 2004, the expected life expectancy of the female urban population was 70.79 years, while that of the male population was 57.43 years; for rural residents, the characteristics of this indicator are more unfavorable.
Maternal mortality is defined by WHO as pregnancy-related, regardless of duration and location, death of a woman that occurs during pregnancy or within 42 days after its end, from any cause related to pregnancy, aggravated by it or its management, but not from an accident accident or accidental cause.
Maternal mortality= number of women who died at the beginning
pregnancy, women in labor,
postpartum women 42 days after
end of pregnancy x100000
number of live births
Maternal mortality refers to demographic indicators that clarify the overall mortality rate. Due to its low level, it does not have a noticeable impact on the demographic situation, but at the same time, it fully reflects the state of the maternal and child health system in the region.
The dynamics of maternal mortality over several years, both in Russia and in the Sverdlovsk region, has been trending downward. However, compared to economically developed countries, the maternal mortality rate in our country is significantly higher (5-10 times).
Important in assessing the maternal mortality rate is the analysis of causes of death - the frequency of death from individual causes and the percentage of individual causes of death. All cases of maternal mortality are divided into 2 groups:
1. Death, directly related to obstetric causes, i.e. death as a result of obstetric complications, pregnancy (pregnancy, childbirth and the puerperium), as well as as a result of interventions, omissions, improper treatment and chain of events arising from any other of these causes.
2. Death, indirectly related to obstetric causes, i.e. death as a result of a pre-existing illness, an illness that occurred during pregnancy, not related to
direct obstetric cause, but aggravated by the effects of pregnancy.
To assess the structural distribution of causes of maternal mortality, the following formula is used:
Structure of reasons= abs. number of women who died at the beginning
maternal mortality
42 days after graduation
pregnancy, from a certain
reasons, for example, abortion x 100
abs. number of women who died at the beginning
pregnancy, women in labor, postpartum women
42 days after graduation
pregnancy, for all reasons
In the modern period, the following lead in the structure of causes of maternal mortality in Russia and the Sverdlovsk region:
1. Bleeding during pregnancy and childbirth.
2. Abortion.
3. Preeclampsia and eclampsia.
4. Extragenital pathology (indirect cause of obstetric death).
It should be noted that in most foreign countries, death from bleeding after abortion is reduced to zero.
Along with the maternal mortality rate, when conducting an in-depth analysis, an indicator such as late maternal mortality. Late maternal mortality is defined as the death of a woman from a direct or indirectly related obstetric cause that occurs more than 42 days after delivery but less than 1 year after delivery. This indicator is not considered separately to characterize the medical and demographic situation.
According to the WHO definition, maternal mortality is the death of a woman caused by pregnancy (regardless of its duration and location) and occurring during pregnancy or within 42 days after its end from any cause related to pregnancy, aggravated by it or its management, but not from an accident or a random cause.
This indicator allows us to evaluate all losses of pregnant women (from abortion, ectopic pregnancy, from obstetric and extragenital pathology during the entire gestation period), as well as women in labor and postpartum within 42 days after the end of pregnancy. The concept of “maternal mortality” does not include deaths resulting from murder, suicide, poisoning, injury and other violent causes.
Maternal mortality rate:
number of deaths of pregnant women (from the beginning of pregnancy), women in labor, women giving birth within 42 days after termination of pregnancy? 100,000 / number of live births.
The maternal mortality rate should be calculated at the level of district, city, region, region, and republic. In the institution where the death occurred, a detailed analysis of each case (without calculating the indicator) of death should be carried out from the perspective of its preventability.
When assessing the dynamics of maternal mortality in areas with low birth rates, in order to avoid errors, statistical methods should be used,
in particular, the alignment of the dynamic series using the moving average method, which allows you to replace each level of the series with the average value from this level and two adjacent ones, eliminate the influence of random fluctuations on the level of the dynamic series and helps to identify the main trend.
Analysis of the structure of the causes of maternal mortality allows us to establish the place of one or another cause among all deceased women.
Structure of causes of maternal mortality:
number of women who died from this cause? 1000 / total number of women who died from all causes.
Of essential importance in the analysis of maternal mortality is the calculation of the frequency of death from individual causes.
Maternal mortality from selected causes:
number of women who died from this cause? 100 / number of live births.
In the structure of causes of maternal mortality, the majority (80%) are obstetric causes, and approximately 20% are caused by causes related to pregnancy and childbirth only indirectly (in particular, extragenital diseases).
Among obstetric causes, 70% are complications of pregnancy and childbirth, 25% are consequences of abortion, and 5% are ectopic pregnancies. Among extragenital diseases, diseases of the cardiovascular system predominate.
The country's high maternal mortality rate is due to a number of reasons. In recent years, there has been an increasing deterioration in the health indicators of pregnant women, the rate of early coverage of their medical supervision, the quality of medical examination of pregnant women are decreasing, and there is a high prevalence of abortions.
Health statistics currently allows you to calculate the formula for maternal mortality, the main indicators of the performance of the maternal and child health service, as well as the methodology for their calculation.
Maternal mortality is one of the most important criteria for assessing not only the activities of a maternity hospital, but also socio-economic factors that affect the health of the population and reflect many aspects of public life:
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- level of economic development,
- political situation in the country or region,
- level of healthcare development,
- state of ecology,
- cultural and religious characteristics of society.
Performance indicators of the maternal and child health system
One of the indicators characterizing the activities of the maternal and child health system is the provision of obstetric beds per 10 thousand women of fertile age, as well as the total number of maternity hospitals.
The number of maternity hospitals in the Russian Federation has been steadily declining over recent years. Thus, in the period from 2001 to 2005, the total number of obstetric and gynecological beds decreased by 12% (by more than 20 thousand), including obstetric beds - by 7.5% (by 6.7 thousand beds) ), gynecological – by 16.1% (by 14.6 thousand beds). The reduction is mainly due to low-capacity institutions with 60–70 beds.
At the same time, more powerful modern ones are developing, constituting a high-risk group. Simultaneously with the reduction in the network of institutions and the reduction in the number of beds intended to provide inpatient care to women, the structure of the bed fund is changing in favor of beds for pregnancy pathologies.
The provision of obstetric beds per 10 thousand women of fertile age in a country or region is largely determined by the birth rate, as well as the level of organization of obstetric care.
The availability of obstetric beds is calculated as follows (1):
Currently, the availability of obstetric beds in Russia is 13.2.
