Fewer women in both low and middle-income countries die to conditions related to pregnancy and childbirth than 10 years ago. But more mothers in Mexico than previously thought are dying of conditions that often predate pregnancies, according to a recent study published in the Bulletin of the World Health Organization (WHO). The study’s findings top mounting evidence that more than a quarter of maternal deaths worldwide are due to indirect causes, rather than direct causes during pregnancy, childbirth or within the 42 days since birth.
Direct maternal deaths result from obstetric complications during pregnancy and childbirth, according to the release. Indirect maternal deaths result from an often pre-existing disease and non-communicable conditions exacerbated by pregnancy, such as type 2 diabetes and cardiovascular disorders, as well as infectious and parasitic diseases such as HIV infection, tuberculosis, hepatitis, influenza or malaria.
“We are winning the battle against the traditional causes of maternal death—such as post-partum hemorrhage, but not against the indirect causes of maternal death,” co-author Dr. Rafael Lozano, of the National Institute of Public Health of Mexico, said in a press release to Her Report.
The authors of the study identified and re-classified 1,214 deaths as maternal deaths, revealing that such deaths in Mexico had been underestimated by about 13 percent. Thus, Mexico’s maternal mortality figures for the study period were corrected from 7,829 to 9,043, according to the release.
Additional maternal deaths were identified using a new method called Búsqueda Intencionada y Reclasificación de Muertes Maternas or BIRMM. Applying the new method to data from the eight-year study period, the researchers found that maternal deaths from direct obstetric causes declined from 46.4 to 32.1 per 100,000 live births, and that maternal deaths from indirect causes had remained relatively steady with 12.2 deaths per 100,000 live births in 2006, compared with 13.3 deaths per 100,000 live births in 2013.
“The direct maternal deaths concern women living in the poorest municipalities, but the women who died of indirect causes had fewer pregnancies, were better educated and tended to live in wealthier municipalities,” Lozano said.
Mexico has seen a rapid increase in high levels of cholesterol and obesity in recent years, putting women of reproductive age at higher risk for pre-existing hypertensive disorders and type 2 diabetes. The age-adjusted prevalence of diabetes in adult Mexicans had increased from 10.2 percent to 10.7 percent between 2010 and 2014, according to the the WHO’s Global Status Report on NCDs. In 2014, Mexico had the highest prevalence of diabetes among the Organization for Economic Cooperation and Development’s list of 34 countries. Moreover, seven out 10 Mexicans are overweight (body mass index of 25 or more), and three of those seven are obese (30 or more).
“Maternal health programs tend to focus on making skilled birth attendants and emergency obstetric care available, and on what happens at the time of the delivery,” said Dr Flavia Bustreo, Assistant Director-General for Family, Women’s and Children’s Health at the WHO. “There has been a huge improvement in the provision of these interventions in low and middle-income countries and this has reduced maternal mortality globally. But the vast majority of maternal deaths from indirect deaths cannot be averted through these delivery-focused interventions… In the absence of the intense review process by the study authors, these deaths would not have been counted and the true magnitude of maternal mortality in Mexico would have been underestimated.”
Bustreo said it is vital that governments and the international community continue to invest in civil registration systems to ensure that every maternal death is counted and that the correct cause of each death is accurately registered. The new Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) proposes key actions governments can take to prevent maternal mortality, she added—strengthening the health workforce and scaling up efforts to ensure universal coverage of essential health services, including pre-pregnancy detection and management of noncommunicable diseases and their risk factors.
“To reduce indirect maternal deaths, obstetricians and other healthcare personnel attending to women during pregnancy and the postpartum period need to be trained to care for women’s health holistically and not just her pregnancy,” Bustreo said.