Maternal Deaths in Giza in the New Millennium : A Hospital Based Retrospective Study

Background: Health institutions need to contribute their quota towards the achievement of the Millennium Development Goal (MDG) with respect to maternal health. In order to do so, current data on maternal mortality are essential for health care providers and policy makers to study the burden of the problem and understand how best to distribute resources. This study presents the magnitude and distribution of the causes of the maternal deaths at the beginning of the 21 st century in an Egyptian general hospital and derives recommendations to reduce their frequency. Objectives: to identify and assess the factors contributing to maternal mortality, especially the hospital-relevant ones, and to determine the most preventable causes in order to reduce the maternal mortality ratio (MMR) calculated for Embaba General Hospital. Methods: This is a retrospective study of mortality records of obstetric cases at Embaba General Hospital during the period between (January 1 st 2001) and (December 31 st 2010). Results: There were 41 maternal deaths and 52096 live births during the study period. Thirty six mothers (87.8%) died due to direct causes while only five deaths(12.2%) were due to indirect maternal causes. The major causes of deaths were obstetric haemorrhage (56.1%), pulmonary embolization (17.0%) and eclampsia (12.2%). The maternal mortality ratio was 78.7 per 100,000 live births. Conclusion: In the first decade of the new millennium, a large number of pregnant women receiving care continued to die from preventable causes of maternal deaths. Adoption of evidence-based protocol for the management of hemorrhage and improvement in the quality of obstetric care of emergencies would go a long way to significantly reduce the frequency of maternal deaths at this hospital.


INTRODUCTION
were 1141 deaths from a total of 2,065,496 live births with maternal mortality ratio of 55 per 100,000 live births and maternal mortality rate of 5.2. (2,3).
Egypt was considered as one of the leading countries in reducing maternal mortality.This was not only done by reducing maternal deaths, but also by using an effective and a successful surveillance system.In the period between 1992 and 2000, Egypt decreased the maternal mortality ratio from 174 to 84 per 100,000 live births and this was nearly 52%. (4,5)In spite of their shortcomings, hospital-based studies are relatively easy to perform and can also provide substantial and useful information, even if the results are likely to be influenced by referral bias.Local enquiries into maternal deaths over a given period can be used to monitor as well as to indicate measures for improving the quality of obstetric care provided in a health facility.
In order for health institutions to contribute their quota towards the achievement of the MDG with respect to maternal health, current data on maternal mortality are essential for the care providers and policy makers to assess the burden of the problem and understand how best to distribute resources.(7)   This study presented the magnitude and

RESULTS
During the period of study, there were The noted differences were found to be statistically insignificant (p-value=0.5).while Europe recorded the lowest MMR of 21 maternal deaths per 100,000 live births (4).10)   Achievement of MDG5 in part requires improved provision of family planning services to enable women to have fewer, better spaced pregnancies. (11)The highest proportion of mortalities was for women belonging to the age group 24-30 (34.1%).

This is in agreement with the results of an
Indian study having 27% of their total sample in the same age group.(12)   Regarding the relation between maternal mortality and previous pregnancy status, the highest percentage of mortalities and MMR were found among women whose previous pregnancies ranged from one to four.These results are not in agreement with that reported by John and John (11) who noted that the highest mortalities were for women with 5 or more parity status.(13)   In the present study, it was noted that out of 41 cases 23 (56.1%) had received antenatal care throughout the ten years.
The present study studied blood unavailability, & consultant unavailability, as components of hospital performance, and proved that each factor separately was responsible in only one case (2.4%), which means that 4.8% of cases died due to defects in hospital care quality.The trend noted in other studies whereby the need for intensive care was strongly associated with maternal mortality similarly reflects poor health infrastructure.Health facilities must have qualified anesthesiologists to provide quality intensive care (17) .
The leading causes of maternal deaths in this study are not significantly different from those identified in the developing countries for several decades.(18)   This implies that our pregnant women are still dying from preventable causes of maternal deaths, (14) .In the present study.Obstetric hemorrhages were the commonest cause of maternal mortality (56.1%).This agrees with the national study conducted by the MOHP in 2010 which referred to obstetric hemorrhages as the leading cause of Egyptian maternal mortalities (10)   .
Pulmonary embolism was the second common cause of maternal mortality, 7 cases (17.0%).This was explained by Abdel-Aziz et al who mentioned the fact that medically assisted maternal mortalities increased by the increased risks for embolization.(10)   In the present study hypertensive disorders with pregnancy accounted for 12.2%.
Compared to the national figures in the preceding years 13% . This is in agreement with the recommendations put by Tsu 2005 maternal deaths in the developing countries.Failure of the Safe Motherhood Initiative, proposed by the World Health Organization (WHO) in 1987, and other similar programs in globally addressing the Bull High Inst Public Health Vol.41 No.3 [2011] issue of maternal mortality by the year 2000 led to setting of new goals for the present millennium.One of the key Millennium Development Goals (MDG), which the United Nations Member States pledged to meet by 2015, is improvement in maternal health by reducing the maternal mortality ratio (MMR) to three quarters of the 1990 data. (1)Among the principal obstacles to appropriate distribution of resources targeted towards improving maternal healthcare is the lack of accurate data on the number, causes and local factors influencing adverse maternal outcomes.Maternal mortality in Egypt was accurately calculated for the first time by a survey done in 1992.A second survey was done in 2000, and since then a surveillance system was established in order to determine maternal mortality annually.The 2000 maternal mortality survey showed that about three-fourths of maternal deaths in the country were due to direct obstetric causes.Haemorrhage, or severe bleeding, was the most significant direct cause, followed by hypertensive disorders of pregnancy e.g."pregnancy-induced hypertension (PIH), pre-eclampsia, and eclampsia", ruptured uterus, infection, and pulmonary embolism.Among the indirect causes, are conditions aggravated by pregnancy such as cardiovascular diseases (e.g.rheumatic heart disease ; RHD) and anemia were the most significant.The results of the surveillance study in 2007

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pregnancy.Maternal mortality ratio was defined as the number of maternal deaths per 100,000 live births.Data collection tools:Data were collected by reviewing the cases' files and database records of the Department of Obstetrics and Gynecology at Embaba General Hospital, and reviewing the database records of maternal deaths in the Ministry of Health and Population as some patients' data were incomplete especially those belonging to the first half of the study.Data were collected using a spread sheet for the n number of maternal deaths, antenatal care and diagnosis of diseases during antenatal period, birth attendant, and final cause of death, management done including; admission at intensive care unit, blood transfusion, surgical intervention and consultants' availability.Inclusion criteria: All maternal deaths during pregnancy or within 42 days after termination of pregnancy including a direct maternal death that is the result of a complication of the pregnancy, delivery, or their management, and an indirect maternal death that is a pregnancy-related death in a patient with a pre-existing or newly developed health problem.Exclusion criteria: All deaths during but unrelated to a pregnancy which are termed accidental, incidental, or non obstetrical maternal deaths, or maternal deaths after 42 days from termination of pregnancy.All data were collected under complete confidentiality and following administrative regulations by reviewing the files and the database after agreement of both the general manger and the chairman of the Medical Records Department at the hospital.Data analysis: Data were entered into a computer database using Microsoft Excel software and analyzed with SPSS version 15 and Epi info 2002 statistical package.(Results were presented in frequencies, percentages and summary statistics.MMR was determined for different age and parity groups and for each year of study.The confidence limits of the MMR for each year of study were also calculated at 95% confidence level.The relationship between maternal deaths and operative deliveries (caesarean section, instrumental delivery, destructive operations) was explored.Comparison of categorical variables was done by computing the odds ratio (OR) at 95% confidence limits.Observed differences between two samples were considered statistically significant where p < 0.05.
five (MDG5) calls for a reduction in the maternal mortality ratio by three quarters by 2015 and establishment of universal access to high quality reproductive health care.