A C TA Obstetricia et Gynecologica
AOGS EDIT ORS M ES SAGE
Preventing maternal deaths and overcoming challenges related to disability in pregnant women GANESH ACHARYA
DOI: 10.1111/aogs.12566
According to WHO, globally, the maternal mortality ratio (MMR) has declined by 45% between 1990 and 2013, however almost 800 women still continue to die every day due to complications in pregnancy and childbirth (1). Sadly most of these deaths occur in resource-poor settings and could have been prevented by simple measures, such as availability of contraception, safe abortion services, skilled birth attendance, blood transfusion and antibiotic therapy, which we take for granted in developed countries. In this issue of AOGS (pages 148-155) Robert Goldenberg et al. from Columbia University, New York, USA using a decision tree and mathematical modeling approach report that timely diagnosis of preeclampsia, admission to hospital and delivery by induction of labor or cesarean section would reduce more maternal deaths than by increasing the use of MgSO4 in SubSaharan Africa. Although rare, maternal deaths do occur in industrialized countries and causes of death are not particularly different, commonest being preexisting medical conditions exacerbated by pregnancy, infections, hemorrhage, thromboembolic disorders and preeclampsia. Deaths due to complications related to abortion and obstructed labor are perhaps two exceptions, which are rare in developed countries. In December 2014, the latest report from the UK and Ireland Confidential Enquiries into Maternal Deaths was published and covers the period 2009–12 (2). It reported a drop in MMR in the UK from 11.39 in 2006–2008 to 10.12 per 100 000 maternities in 2010– 2012, which was mainly due to a decline in deaths caused by direct obstetric causes. However, almost three quarters of women who died had preexisting medical (physical or mental) conditions and 68% of maternal deaths were caused by indirect causes. This is alarming, considering that for every maternal death, there are likely to be many more ‘near-misses’ with similar clinical features and presentation although the final outcome is different. It highlights the importance of timely identification of preexisting medical conditions in women of reproductive age, preconceptional care and counseling, antenatal follow
up and skilled management with a view of preventing complications throughout the pregnancy, childbirth, postpartum period and beyond. Provision for better training in dealing with medical complications in pregnancy for junior doctors appears equally relevant. This report confirmed that infection (sepsis) remains a major cause of maternal mortality and revealed H1N1 influenza as a major contributor to indirect maternal deaths in that particular triennium. Therefore, measures should be taken towards raising awareness among healthcare professionals regarding how to diagnose sepsis early and treat it appropriately, and among the public regarding the safety of influenza vaccine. Immunizing pregnant women against seasonal influenza should be a public health priority, at least where resources permit. In the Nordic countries, the MMR has been reported to be lower than in the UK (3–5). However, incomplete ascertainment of maternal deaths has been a recognized problem (3,5). In 2011, a Nordic Maternal Morality Group was established under the framework of NFOG with a view of obtaining complete registration of maternal deaths in five Nordic Countries comparable to that in the UK. Initial data for the period 2005–2009 were presented at the NFOG Congress in 2012, and the MMR ranged between 7.4 and 9.4 per 100 000 maternities. Most common causes of maternal death were preeclampsia, cardiac disease, venous thromboembolism and suicide. Maternal mortality is consistently shown to be higher amongst women living in deprived areas and among some immigrants and ethnic minority groups (2,6). This problem may be on the rise in Scandinavia due to increasing immigration and social disparity. Ensuring that healthcare services reach those who are in need and are freely available to all pregnant women appears as relevant as ever. Worldwide, the prevalence of disability among women of childbearing age is estimated to be 10% (7) and numbers are perhaps increasing. Physical, sensory as well as mental impairments may lead to restrictions on activity or participation in society. However, increasing numbers of disabled women are becoming interested in having
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 123–124
123
Editors Message
children and raising them. Disabled pregnant women may have additional problems and specific needs related to their disability. Published research on interventions that may help these women and improve pregnancy outcomes is sparse (8). A qualitative study by Lisa I. Iezzoni et al. from Harvard Medical School, Boston, USA published in this issue (pages 133–140) highlights problems related to functional impairment that women with mobility disability encounter during pregnancy. More research is urgently needed to evaluate whether healthcare interventions can improve outcomes for pregnant women with disability. Social attitudes towards disabled people have been improving, and negative attitudes towards disabled parents are rare among healthcare professionals in Scandinavia. However, the awareness and knowledge of, and competence in how to meet their needs may not always be satisfactory. Maternity healthcare providers need to become more familiar with the needs of disabled pregnant women so that the important issues are not overlooked. Disabled women must have full access to health care regardless of their ability. Improving healthcare professionals’ understanding, skills and competence in this area is important to achieve fairness in healthcare service delivery to disabled pregnant women. References 1. Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. World Health Organization, 2015. 2. Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (eds.), on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons Learned to Inform Future Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-12. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2015.
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3. Vangen S, Ellingsen L, Andersgaard AB, Jacobsen AF, Lorentzen B, Nyfløt LT, et al. Maternal deaths in Norway 2005-2009. Tidsskr Nor Laegeforen. 2015;134:836–9. 4. Bødker B, Hvidman L, Weber T, Møller M, Aarre A, Nielsen KM, et al. Maternal deaths in Denmark 2002–2006. Acta Obstet Gynecol Scand. 2009;88:556–62. 5. Esscher A, H€ ogberg U, Haglund B, Ess€en B. Maternal mortality in Sweden 1988–2007: more deaths than officially reported. Acta Obstet Gynecol Scand. 2013;92:40–6. 6. Esscher A, Binder-Finnema P, Bødker B, H€ ogberg U, Mulic-Lutvica A, Essen B. Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2015;14:141. 7. World Health Organisation (WHO): World Report on Disability. Geneva: WHO Press, 2011. 8. Malouf R, Redshaw M, Kurinczuk JJ, Gray R. Systematic review of heath care interventions to improve outcomes for women with disability and their family during pregnancy, birth and postnatal period. BMC Pregnancy Childbirth. 2015;14:58.
Key messages • Although some progress has been made in reducing maternal deaths caused by direct obstetric causes, medical comorbidities and infections continue to be a major cause of maternal mortality. • Vaccinating pregnant women against seasonal influenza should be a top priority where resources permit. • Disability is not a barrier to pregnancy and parenthood. Healthcare professionals need to improve their awareness, knowledge and skills in this area to meet the expectations and needs of disabled pregnant women.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 123–124
Copyright of Acta Obstetricia et Gynecologica Scandinavica is the property of WileyBlackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
AOGS EDIT ORS M ES SAGE
Preventing maternal deaths and overcoming challenges related to disability in pregnant women GANESH ACHARYA
DOI: 10.1111/aogs.12566
According to WHO, globally, the maternal mortality ratio (MMR) has declined by 45% between 1990 and 2013, however almost 800 women still continue to die every day due to complications in pregnancy and childbirth (1). Sadly most of these deaths occur in resource-poor settings and could have been prevented by simple measures, such as availability of contraception, safe abortion services, skilled birth attendance, blood transfusion and antibiotic therapy, which we take for granted in developed countries. In this issue of AOGS (pages 148-155) Robert Goldenberg et al. from Columbia University, New York, USA using a decision tree and mathematical modeling approach report that timely diagnosis of preeclampsia, admission to hospital and delivery by induction of labor or cesarean section would reduce more maternal deaths than by increasing the use of MgSO4 in SubSaharan Africa. Although rare, maternal deaths do occur in industrialized countries and causes of death are not particularly different, commonest being preexisting medical conditions exacerbated by pregnancy, infections, hemorrhage, thromboembolic disorders and preeclampsia. Deaths due to complications related to abortion and obstructed labor are perhaps two exceptions, which are rare in developed countries. In December 2014, the latest report from the UK and Ireland Confidential Enquiries into Maternal Deaths was published and covers the period 2009–12 (2). It reported a drop in MMR in the UK from 11.39 in 2006–2008 to 10.12 per 100 000 maternities in 2010– 2012, which was mainly due to a decline in deaths caused by direct obstetric causes. However, almost three quarters of women who died had preexisting medical (physical or mental) conditions and 68% of maternal deaths were caused by indirect causes. This is alarming, considering that for every maternal death, there are likely to be many more ‘near-misses’ with similar clinical features and presentation although the final outcome is different. It highlights the importance of timely identification of preexisting medical conditions in women of reproductive age, preconceptional care and counseling, antenatal follow
up and skilled management with a view of preventing complications throughout the pregnancy, childbirth, postpartum period and beyond. Provision for better training in dealing with medical complications in pregnancy for junior doctors appears equally relevant. This report confirmed that infection (sepsis) remains a major cause of maternal mortality and revealed H1N1 influenza as a major contributor to indirect maternal deaths in that particular triennium. Therefore, measures should be taken towards raising awareness among healthcare professionals regarding how to diagnose sepsis early and treat it appropriately, and among the public regarding the safety of influenza vaccine. Immunizing pregnant women against seasonal influenza should be a public health priority, at least where resources permit. In the Nordic countries, the MMR has been reported to be lower than in the UK (3–5). However, incomplete ascertainment of maternal deaths has been a recognized problem (3,5). In 2011, a Nordic Maternal Morality Group was established under the framework of NFOG with a view of obtaining complete registration of maternal deaths in five Nordic Countries comparable to that in the UK. Initial data for the period 2005–2009 were presented at the NFOG Congress in 2012, and the MMR ranged between 7.4 and 9.4 per 100 000 maternities. Most common causes of maternal death were preeclampsia, cardiac disease, venous thromboembolism and suicide. Maternal mortality is consistently shown to be higher amongst women living in deprived areas and among some immigrants and ethnic minority groups (2,6). This problem may be on the rise in Scandinavia due to increasing immigration and social disparity. Ensuring that healthcare services reach those who are in need and are freely available to all pregnant women appears as relevant as ever. Worldwide, the prevalence of disability among women of childbearing age is estimated to be 10% (7) and numbers are perhaps increasing. Physical, sensory as well as mental impairments may lead to restrictions on activity or participation in society. However, increasing numbers of disabled women are becoming interested in having
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 123–124
123
Editors Message
children and raising them. Disabled pregnant women may have additional problems and specific needs related to their disability. Published research on interventions that may help these women and improve pregnancy outcomes is sparse (8). A qualitative study by Lisa I. Iezzoni et al. from Harvard Medical School, Boston, USA published in this issue (pages 133–140) highlights problems related to functional impairment that women with mobility disability encounter during pregnancy. More research is urgently needed to evaluate whether healthcare interventions can improve outcomes for pregnant women with disability. Social attitudes towards disabled people have been improving, and negative attitudes towards disabled parents are rare among healthcare professionals in Scandinavia. However, the awareness and knowledge of, and competence in how to meet their needs may not always be satisfactory. Maternity healthcare providers need to become more familiar with the needs of disabled pregnant women so that the important issues are not overlooked. Disabled women must have full access to health care regardless of their ability. Improving healthcare professionals’ understanding, skills and competence in this area is important to achieve fairness in healthcare service delivery to disabled pregnant women. References 1. Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. World Health Organization, 2015. 2. Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (eds.), on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons Learned to Inform Future Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-12. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2015.
124
3. Vangen S, Ellingsen L, Andersgaard AB, Jacobsen AF, Lorentzen B, Nyfløt LT, et al. Maternal deaths in Norway 2005-2009. Tidsskr Nor Laegeforen. 2015;134:836–9. 4. Bødker B, Hvidman L, Weber T, Møller M, Aarre A, Nielsen KM, et al. Maternal deaths in Denmark 2002–2006. Acta Obstet Gynecol Scand. 2009;88:556–62. 5. Esscher A, H€ ogberg U, Haglund B, Ess€en B. Maternal mortality in Sweden 1988–2007: more deaths than officially reported. Acta Obstet Gynecol Scand. 2013;92:40–6. 6. Esscher A, Binder-Finnema P, Bødker B, H€ ogberg U, Mulic-Lutvica A, Essen B. Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2015;14:141. 7. World Health Organisation (WHO): World Report on Disability. Geneva: WHO Press, 2011. 8. Malouf R, Redshaw M, Kurinczuk JJ, Gray R. Systematic review of heath care interventions to improve outcomes for women with disability and their family during pregnancy, birth and postnatal period. BMC Pregnancy Childbirth. 2015;14:58.
Key messages • Although some progress has been made in reducing maternal deaths caused by direct obstetric causes, medical comorbidities and infections continue to be a major cause of maternal mortality. • Vaccinating pregnant women against seasonal influenza should be a top priority where resources permit. • Disability is not a barrier to pregnancy and parenthood. Healthcare professionals need to improve their awareness, knowledge and skills in this area to meet the expectations and needs of disabled pregnant women.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 123–124
Copyright of Acta Obstetricia et Gynecologica Scandinavica is the property of WileyBlackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
