How many die or have complications?

MEGAN KILL: So in this step, we will look at how many die or have complications. And in order to understand this question, we need to consider the fertility aspect of maternal mortality, because without pregnancy, there are no maternal deaths or complications. So when looking at the global fertility, there are 190 million pregnancies each year, and around 125 million end in a live birth and 65 million end with a miscarriage, abortion, a stillbirth. Now I just want to take a second to mention that these numbers and the numbers throughout this course are updated regularly, and it’s always advisable to check the WHO website for the latest figures.

Given the large number of pregnancies, it’s not surprising that the problem of maternal deaths is large. A woman dies every other minute, day in and day out, but if things are getting better. And in other steps this week, we’ll explore this in more detail.

Now, looking at actual numbers, WHO reported that there were 289,000 maternal deaths in 2013. And out of these deaths, 99% were in low and middle income countries, and specifically in Sub-Saharan Africa– which counted for 62% or about 179,000 of the global deaths– and southern Asia– which counted for 24% or about 69,000. What’s shocking about this large number of deaths is that most maternal deaths are avoidable. Looking at the data from maternal deaths in 2013, countries with the highest MMR– that is, having an MMR greater than or equal to 800 deaths per 100,000 live births– were Chad, Somalia, Central African Republic, Sierra Leone, and Burundi. And two countries accounted for 1/3 of the global maternal deaths.

That is India with about 19%– that is, about 56,000– and Nigeria at 14%, which counts for about 40,000. Now looking at the complication side of things, as we mentioned earlier, the situation is improving with respect to maternal mortality. And since this is happening, we need to consider maternal morbidity more. Many more pregnant or recently delivered women survive a complication than die from the complication. And some complications can lead to long-term disabilities, which can sometimes be very debilitating, as in the case of postpartum depression. And because of this shift, there’s been a major focus on severe maternal complications, including near-misses in recent years.

There’s an emerging interest on the economic and social impact of maternal morbidity, for example, the impacts of morbidity on the ability of women to work and on child development. We indicated in a previous step that the WHO definition of maternal morbidity does not just include the acute events, but also encompasses the negative impacts that it has on a woman’s life and well-being. So this negative impact can be physical. So if there’s no living child or a damaged pelvic structure. It can be social, if they have to migrate or there’s isolation or stigmatisation. There could be economic consequences, if they’re in debt from it or they have no savings, and the psychological consequences as well, so suicide or depression.

And this diagram just shows the impacts that maternal complications have. So what proportion of pregnant women have a major complication? Well, the reality is that it’s hard to know how many pregnant women have a complication, but research has shown that around 1% or 2 million pregnant women have a near-miss complication per year. This means that they nearly died during pregnancy, delivery, or the postpartum period. And programme managers estimate that around 15%, or 29 million of all pregnant women, may develop serious complications that require rapid and skilled intervention.

And this number has been used to determine the unmet or met need for complications by looking at the number of women who access services in relation to the number of expected complications at population level. But it’s really important to note that when estimating these numbers a much higher percentage of women with morbidities are obtained when surveys are conducted and women report all of the symptoms they had during and after pregnancy, including things like backache, vomiting, nausea, et cetera. So why is there an interest in near-misses? Well, they complement maternal deaths, because they’re more frequent, and it’s easier to obtain information about them as the women themselves can be at interviewed.

Morbidities are also really close to death so they have similar characteristics, and also it’s a more positive event to investigate than death. And if we assume that near-miss cases need hospital care, then these events can be captured in facility only. However, the disadvantage of studying near-misses are that the definitions are complicated and disputed.