Elsevier

The Lancet

Volume 367, Issue 9516, 1–7 April 2006, Pages 1066-1074
The Lancet

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WHO analysis of causes of maternal death: a systematic review

https://doi.org/10.1016/S0140-6736(06)68397-9Get rights and content

Summary

Background

The reduction of maternal deaths is a key international development goal. Evidence-based health policies and programmes aiming to reduce maternal deaths need reliable and valid information. We undertook a systematic review to determine the distribution of causes of maternal deaths.

Methods

We selected datasets using prespecified criteria, and recorded dataset characteristics, methodological features, and causes of maternal deaths. All analyses were restricted to datasets representative of populations. We analysed joint causes of maternal deaths from datasets reporting at least four major causes (haemorrhage, hypertensive disorders, sepsis, abortion, obstructed labour, ectopic pregnancy, embolism). We examined datasets reporting individual causes of death to investigate the heterogeneity due to methodological features and geographical region and the contribution of haemorrhage, hypertensive disorders, abortion, and sepsis as causes of maternal death at the country level.

Findings

34 datasets (35 197 maternal deaths) were included in the primary analysis. We recorded wide regional variation in the causes of maternal deaths. Haemorrhage was the leading cause of death in Africa (point estimate 33·9%, range 13·3–43·6; eight datasets, 4508 deaths) and in Asia (30·8%, 5·9–48·5; 11, 16 089). In Latin America and the Caribbean, hypertensive disorders were responsible for the most deaths (25·7%, 7·9–52·4; ten, 11 777). Abortion deaths were the highest in Latin America and the Caribbean (12%), which can be as high as 30% of all deaths in some countries in this region. Deaths due to sepsis were higher in Africa (odds ratio 2·71), Asia (1·91), and Latin America and the Caribbean (2·06) than in developed countries.

Interpretation

Haemorrhage and hypertensive disorders are major contributors to maternal deaths in developing countries. These data should inform evidence-based reproductive health-care policies and programmes at regional and national levels. Capacity-strengthening efforts to improve the quality of burden-of-disease studies will further validate future estimates.

Introduction

The reduction of maternal deaths is a high priority for the international community, especially in view of the increased attention on the Millennium Development Goals.1 Maternal deaths arise from the risks attributable to pregnancy and childbirth as well as from the poor-quality care from health services.2 Effective services to improve overall maternal health need targeted health and social policies that are informed by reliable and valid epidemiological data. A comprehensive summary of the magnitude and distribution of the causes of maternal deaths is critical to inform reproductive health policies and programmes. The most widely referred source that is currently available3 dates back to the 1990s, although its methodology is not clear and it assumes a fixed distribution across all regions. Regional variations are likely to exist, although their magnitude and direction are unknown. A more recent WHO Global Burden of Disease estimate gave a breakdown by cause and region but the methodology and the data sources for cause attribution and regional differences were not reported.4

Systematic reviews are increasingly used to summarise descriptive epidemiological evidence to provide summary estimates for the extent of important public-health problems.5, 6 We undertook a systematic review that aimed to estimate incidence and prevalence of a range of maternal conditions, including maternal mortality and its causes.7 The aim of this study was to ascertain and map the distribution of causes of maternal deaths, to identify data gaps in regional coverage, and to explore the extent to which countries' development status, geographical location, and datasets' methodological features explain variable distribution of causes of deaths.

Section snippets

Methods

Our systematic review followed an a-priori protocol developed with a widely recommended methodology7, 8, 9 to generate a comprehensive, standardised, and reliable evidence summary for conditions contributing to maternal deaths worldwide. This process included the breakdown of causes of maternal deaths and examination of heterogeneity of causes.

Results

The search strategy yielded 64 585 citations for all defined maternal morbidity conditions and maternal mortality, of which 4606 were assessed in full-text form. Of these, 2581 reporting on a range of morbidities or mortality were included in the systematic review. 305 datasets provided information on causes of maternal deaths for 1 or more years or geographical locations (or both), with 1143 datasets (for a particular time or location) potentially eligible for this analysis. Figure 1 shows the

Discussion

As expected, our systematic analysis of the causes of maternal deaths, showed variation both across and within geographical regions. Our findings confirm the prominent role of haemorrhage as a cause of maternal death in developing countries. Hypertensive disorders are among the leading causes of deaths in Latin America and the Caribbean. In developed countries, most deaths are due to other direct causes, mainly complications of anaesthesia and caesarean sections. The contributions of sepsis and

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