This is a guest article by Silvio Aladjem MD.
I approach this topic with some trepidation. Its magnitude is staggering and the discrepancies between countries and/or world areas, is painful. Worldwide, the latest WHO (World Health Organization) data estimates that 343000 women die every year as a result of pregnancy. To put it in context, that means that over 900 women die every day, year round, as a consequence of pregnancy. Maternal mortality is defined as total maternal deaths per 100,000 births. The best rates, according to the WHO, are in the Western world. (less than 20 per 100,000 births) The worst rates are in the Sub-Saharan Africa (over 1000 per 100,000 births). Otherwise stated, in the Western world a woman has a life-time risk of dying following pregnancy of 1 in 4300, while in Sub-Saharan Africa that risk is 1 in 31. These figures speak for themselves.
From all maternal mortalities, 99% occur in the developing world, where poverty is rampant, illiteracy is the rule and compounded by tribal superstitions and “cultural” bias.
These figures do not take into account delivery related injuries or other diseases, which affect another 10 million women each year.
The three main causes for maternal deaths in the Western world are: hemorrhage, infections and eclampsia (high blood pressure -pre-eclampsia- leading to seizures –eclampsia-). In other parts of the world one has to add unsafe abortions with their deadly complications and obstructed labor (when the maternal pelvis is abnormal or too small or the baby is too big or in an undeliverable position in the uterus).
In the United States, maternal mortality has decreased from 850/100000 births in 1900 to 12.7 in 2010. It is still too high. Unless we reduce maternal mortality to an irreducible minimum, we should not claim victory. An irreducible minimum is a concept which takes into account that certain deaths are unavoidable.
Postpartum hemorrhage is unpredictable. Its management has improved significantly but not to the point that it will ever be a non-cause. Same is true of preeclampsia-eclampsia. It will be with us for the foreseeable future. It is unlikely that it will ever be a non-cause either, but its treatment has improved dramatically. As for infections, while a sterile surgical environment has decreased the dreaded “puerperal fever”, it is also still with us. The bacterial flora that we used to control with antibiotics has been replaced by antibiotic-resistant strains for which we do not have enough new drugs.
If we were to do away with all the main causes of maternal death, we will still have a small number of unpredictable complications which may lead to death. Pulmonary embolus, cardiac arrest or a sudden exacerbation of a pre-pregnancy existing disease, like lupus or hyperthyroidism, are a few examples. Our goal, at least in the US and Western world, is to decrease those deaths that may be preventable. We have made significant progress in controlling pre-existing conditions like diabetes, lupus and other diseases. Today, women that would have never been able to have a pregnancy without putting their lives on the line, now carry a pregnancy to term without fear.
In the rest of the world WHO has been campaigning to bring the minimum of care that would significantly decrease the high maternal mortality. Their efforts have made an impact. In fact a few years ago maternal mortality was estimated to be 500,000 deaths each year. It has come down to 334,000, thanks to a mortality reduction in the developing world. There is still a long way to go before it will reach the rates of the Western world. WHO fight is hampered by lack of transportation, lack of roads, lack of education, superstitions, old engrained traditions, poverty, and a slew of other social problems.
We, on the other hand, are committed to reducing mortality from 12.7/100000 births to the lowest denominator possible. What would that acceptable low rate be? Ideally we should not lose a single mother as a result of a pregnancy. It’s not going to happen. But we can aim to improve. The day we will understand what causes preeclampsia, we could do away with almost a` third of all maternal deaths. New drugs should improve the risk of infections. That would leave us with hemorrhage as a major cause of death. With time even death from postpartum hemorrhage will probably improve. But we will never reach zero. Life is what it is, and we cannot change it or fully control its turns. But we should try aiming to as close as possible to zero deaths. No woman should ever have to die because she wants to be a mother.
SILVIO ALADJEM MD, an obstetrician/gynecologist and Maternal Fetal Medicine (high risk obstetrics) specialist, is Professor Emeritus in obstetrics and gynecology at Michigan State University, College of Human Medicine, in Lansing, MI. He is the author of “10,000 babies: my life in the delivery room” now available on Amazon, Barnes and Noble and other book stores. Dr. Aladjem published extensively in Scientific Medical Journals and wrote several textbooks in the specialty. He can be reached through his website, www.drsilvio.com