|Year : 2014 | Volume
| Issue : 3 | Page : 34-38
The evaluation of last seven years maternal mortality in Manisa, Turkey
Fatma Eskicioglu1, Burcu Artunc Ulkumen1, Pinar Solmaz Hasdemir1, Galip Koroglu2
1 Department of Obstetrics and Gynecology, Celal Bayar University, School of Medicine, Manisa, Turkey
2 Manisa Directorate of Public Health, Manisa, Turkey
|Date of Web Publication||7-Aug-2014|
Department of Obstetrics and Gynecology, Medical Faculty of Celal Bayar University, Manisa - 450 00
Source of Support: None, Conflict of Interest: None
Objective: In this study, we aimed to evaluate the last 7-year rates of maternal mortality and the causes of maternal mortality in Manisa including Aegean region in the western part of the country. Study design: Maternal mortalities in Manisa determined by Maternal Mortality Commission were examined between January 1, 2006 and December 31, 2012. The classification of maternal mortality was performed as directly, indirectly, and incidentally. The annual rates and numbers of maternal deaths, causes of death, and demographic data were obtained from the records. Maternal mortality ratio is calculated as the number of women who die during pregnancy and childbirth, per 100,000 live births. Results: A total of 32 maternal deaths cases were reviewed between 2006 and 2012. A total of seven incidental maternal deaths of 32 were not evaluated. A total of five direct maternal deaths and 20 indirect maternal deaths were recorded. Maternal mortality rate (per 100.000 per live births) was 28.86 in 2006. This ratio decreased to 10.7 in 2012. Considering the leading causes of maternal death, the diseases of the circulatory system complicating the pregnancy and puerperium (28%) rank first. When direct maternal deaths are only evaluated, the most common cause was hemorrhage, which was followed by the disseminated intravascular coagulation. In all, six over eight (42%) maternal mortality in which delay model was detected were recorded as matched with third. Conclusion: In conclusion, an incentive to demand primary pregnancy advisory service is necessary for minimizing indirect maternal deaths and the need of medical staff must be fulfilled. Postpartum monitoring will be performed during the postnatal period especially in the first 24 h. Sensitivity must be showed for the training of medical staff that will perform emergency obstetric care when required.
Keywords: Direct maternal mortality, maternal mortality, safe motherhood
|How to cite this article:|
Eskicioglu F, Ulkumen BA, Hasdemir PS, Koroglu G. The evaluation of last seven years maternal mortality in Manisa, Turkey. Sifa Med J 2014;1:34-8
|How to cite this URL:|
Eskicioglu F, Ulkumen BA, Hasdemir PS, Koroglu G. The evaluation of last seven years maternal mortality in Manisa, Turkey. Sifa Med J [serial online] 2014 [cited 2023 Mar 23];1:34-8. Available from: https://www.imjsu.org/text.asp?2014/1/3/34/138311
| Introduction|| |
Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Decrease of the maternal mortality ratio accepted as the development indicators for all the world's countries is one of the Millennium Development Goals.  Approximately 800 women lose their lives in the world due to the reasons related to pregnancy and child birth each day and 99% of these deaths are in the developing countries.  Global maternal death ratio declined by 47% between 1990 and 2010. The number of maternal mortality reached to 287.000 in 2010. Despite all of these favorable progresses, maternal death ratio in developing countries is 15 times higher than developed countries. Maternal death ratio in developed countries is on average 16 per 100.000 births versus 240 per 100.000 in 2012. 
Within a few years, the decline in maternal deaths was similarly recorded in our country. Maternal death ratio was determined as 208 per 100.000 live births during 1974 and 1975. It was recorded as 132 per live 100.000 in 1981 by State Institute of Statistics. This maternal death ratio was explained as 49 per 100.000 live births by Ministry of Health in 1998. In terms of 2005 Turkey National Maternal Mortality Study, maternal mortality ratio was 28.5 per 100.000 live births. This ratio declined to 15.5 according to 2011 Health Statistics Data. , Maternal mortality ratio shows regional differences in our country. According to 2011 Health Statistics Data, the lowest rate of maternal mortality were 8.4 in İstanbul and 8.7 per 100.000 live births in eastern part of Marmara region, the highest ratio of maternal mortality was 23.9 per 100.000 live births in Central Anatolian Region. 
In order to prevent maternal deaths, maternal mortality data system has been created by Ministry of Health since January 2007. The aim of this programis to decrease maternal mortality ratios to 15 per 100.000 live births in 2010 and 10 per 100.000 live births till 2014.  In this study, we aimed to evaluate 7-year maternal mortality ratios and the causes of those in Manisa, located in the Aegean region of Turkey.
| Materials and Methods|| |
Within the scope of Manisa Public Health department, Maternal Mortality Comission was created by two physicians from each professional field including an obstetrician and a gynecologist, a pediatrician, an anesthesia and reanimation specialist, an internist, and two physicians in Ministry of Public Health in January 2006. Between January1, 2006 and December 31, 2012, maternal mortality ratios recorded by the commission was examined. Maternal mortalities werer classified as directly, indirectly, and incidentally. Direct maternal mortality is defined as the deaths resulted from obstetric complications occurred in pregnancy, (during pregnancy, labor, and the postpartum period) as a result of the performed interventions and negligence. Indirect maternaldeaths are those relating to pre-existing medical conditions that may be aggravated by the physiologic demands of pregnancy. Incidental maternal deaths are accepted as direct and indirect deaths (e.g. accidents, suicides, and intoxication) unrelated to obstetric causes (not from any effect of pregnancy) occurred within 42 days of pregnancy, childbirth, and postnatal period. Incidental maternal deaths were not evaluated. According to records obtained from Provincial Directorate of Health, the number of annual maternal deaths, maternal age, date of death, cause of death, the health care facility that death occurred, pregnancy, childbirth, abortion, the number of live births, in which year maternal deaths occurred (during pregnancy, labor, and postnatal period or termination of pregnancy within 42 days), the region that the mother lived (village, district, or center), educational background, steps in the quality of health care facilities performed pursuit of pregnancy and maternal mortality delay models are all examined. Maternal Mortality Delay Models have been examined in three groups:
- Delay in decision to seek care has been defined as lack of information related to problems and danger signs and insufficient social factors.
- Delay in reaching care has been defined as transportation problems, economical inabilities, and inadequate number of local health organizations.
- Delay in receiving adequate health care has been identified as insuffiency of medical equipment and stuff and incapability of service providers.
Maternal mortality ratio is calculated as the number of women who die during pregnancy and childbirth, per 100,000 live births.
The statistical package Statistical Package for the Social Sciences (SPSS) for Windows 15.0 was used to analyze the data. Obtained data were analyzed by using descriptive statistical methods (mean, median, and standard deviation).
| Results|| |
According to the data obtained from Manisa Provincial Directorate of Health, a total of 32 maternal deaths were recorded between 2006 and 2012. Between 2006 and 2012, annual ratios of maternal death determined by Manisa Provincial Directorate of Health were given in [Table 1]. In all, Seven of incidental maternal deaths were not evaluated of all maternal deaths. Of all 25 maternal deaths, five of them were recorded as direct maternal death and 20 of them were recorded as indirect maternal death [Table 1]. It was determined that average maternal age was 27.1, the number of average pregnancy was 2.9, the number of abortion was 0.7, and the number of live births was 1.2 [Table 2]. Of all mothers, nine of them (36%) were in the center of Manisa and 16 of them (64%) were in the district. Among the leading causes of maternal death, the diseases of the circulatory system complicating the pregnancy and puerperium (28%) rank first, intrapartum and postpartum hemorrhage (16%) and maternal death causes related to disseminated intravascular coagulation and sepsis rank second, the causes related to cerebrovascular cases (8%) rank third [Table 3]. When direct maternal deaths were only evaluated, the most common cause was hemorrhage and following disseminated intravascular coagulation. The most common level of education in examined maternal deaths was primary school level (64%) [Table 4]. The pursuit of pregnancy of the examined cases (76%) was performed in primary and secondary care health services [Table 5]. The most rate of maternal deaths (64%) occurred in postnatal period or the termination of pregnancy within 42 days [Table 5]. Maternal deaths typically occurred in territory referral center (44%) [Table 5].
|Table 1: Manisa provincial maternal mortality ratio and distribution between 2006 and 2012|
Click here to view
|Table 2: Descriptive features related to the age and fertility of Manisa provincial direct and indirect maternal mortality cases between 2006 and 2012|
Click here to view
|Table 3: The causes of direct and indirect maternal death and the distribution between 2006 and 2012|
Click here to view
|Table 4: Descriptive features and distributions related to the education level of direct and indirect maternal mortality cases|
Click here to view
|Table 5: The pursuit of pregnancy of direct and ındirect maternal mortality and the period that maternal deaths occurred and national health ınstitute ınformations and distributions between 2006 and 2012|
Click here to view
Because delay models were not determined in 2006 by maternal mortality commission, data related to this year could not be found. Evaluation has been made over 19 maternal mortality by excluding six maternal mortality occurred in 2006. Delay was not monitored in 11 (58%) maternal mortalities. In all, six over eight (42%) maternal mortality in which delay was detected were recorded as matched with third. One was recorded as matched with first and one maternal mortality recorded as matched with both first and third delay models. Three over four maternal mortality occurred because of intrapartum and postpartum hemorrhage, the third delay model was detected.
| Discussion|| |
While rapid population growth arouses anxiety, maternal deaths are ignored for long years. In the past years, global effort to reduce maternal mortality becomes vital. Despite practiced interventions and some progresses related to maternal death, due to the complications related to pregnancy, millions of women still experience risky lives every year. Lots of women have to spend their lives by experiencing serious disability and 292200 women lose their lives due to the problems related to pregnancy, labor, and postnatal period.  Yearly distribution of maternal mortality ratios including Turkey and Manisa is given in. As it is seen in the figure, , the targets of "maternal deaths monitoring programs" determined in 2007 could not be achieved and this can not be decreased to 15 per 100.000 live birth in 2010.  According to the evaluations occurred in the country every 5 years, the rate of previous pregnancy care increased from 62 to 92%. In addition, the rate of medicine staff and pregnancy increased from 75.9 to 91.3% and the rate of delivery in health care facilities increased 59.6 to 89.7%. Despite this good progress, the desired goal of maternal mortality was not achieved. This result shows that new strategies must be performed. , Within the years, Manisa provincial maternal mortality ratios showed a decrease. An increase related to maternal deaths is observed in 2008. However, the reason of this increase resulted from indirect maternal deaths. The number 10.7 per 100.000 live births observed in 2012 is quite pleasing.
According to 2012 World Health Organization (WHO), the main reasons of maternal mortality are seen as follows: massive bleeding and infections especially observed after postnatal period, high blood pressure (preeclampsia-eclampsia), and abortions experienced in unhealthy conditions. , According to 2005 data, 58% of maternal deaths are direct and 15% of maternal death are indirect maternal death in Turkey. Bleedings related to atonic uterus and placenta abnormalities constitute 25% of direct causes. The second significant cause occurred in maternal deaths is determined as eclampsia characterized by edema, proteinuira, hypertension, and convulsion. The third most common cause is that the presence of embolism occurred in cesarean sections depending on anesthesia and surgery, and puerperial infections follow this process.  While direct maternal mortality ratio is observed as 15%, indirect causes are observed as 62% in the past 7 years in Manisa. The most common reasons related to direct maternal death in our city are bleedings and following the progress of dissemine intravascular coagulation. Among other maternal deaths, uterine rupture, postpartum depression, and embolism are observed. It is so pleasing that direct maternal mortality includes fewer shares in our city. On the other hand, relative increase observed in indirect maternal mortality demonstrates that a failure is experienced to evaluate maternal health in preconceptional consultancy service.
Poverty, living of prospective mothers far-away and in countryside, deficiency in the number of health personal staff to provide health service, deficiency of training requirement, and local and cultural practises lead to the increase in maternal mortality ratios. , Prospective mothers in poor economic condition have more disadvantage than prospective mother in high economic condition and experience risky lives more than 20 times.  The majority of maternal death ratios in our city constitutes the mothers living in the towns and the overwhelming majority of the education level (64%) includes primary school graduates. The highest rate of education level (24%) constitutes the graduates of high school level. When we evaluate in terms of advanced maternal age, we observe that only a prospective mother is 43-years old. In our city, mean and median maternal mortality age is 27. This result shows that there is no maternal deaths depending on earlier or advanced maternal age in Manisa. It is possible to associate the low numbers observed in pregnancy and live births with cultural tendencies in the western part of the country.
The most majority of maternal deaths are observed in postnatal period. In all, 54% of the maternal deaths in postnatal, 32% of the maternal deaths during pregnancy, 9% in pregnancy are observed, respectively, in our country. Fatal bleedings observed in the early period of postnatal process related to atonic uterus and placenta abnormalities lead to maternal deaths of mothers in the countryside.  A total of 64% of the maternal deaths are observed in postpartum period in our city. At this point, the deficiency of nursing services of postnatal, well-equipped, and experienced health staff draws our attention.
It is observed that the pursuit of pregnancies are performed for all of dying prospective mothers and the nursing service are obtained from primary and secondary level health care facilities. These data show the functionality of pregnancy monitoring and the system of family practice. The majority of death (76%) is observed in secondary and tertiary referral center. The condition is resulted from the referrals performed in the advanced level interventions.
It is remarkable that the delays in maternal mortality have been determined as 42% except 2006 and 87% of those matched with third delay model. In accordance with these data, mother with social complement adequate to be aware of recognizing the difficulties she has no problems in reaching the health organization, loses her life in hospital. The number of mothers who could not clear the hurdle of first delay model is limited and no mother is encountered in second delay is pleasing in terms of women's status, socio-cultural rig, economical power, and the number of health organizations. The problem is that obstetric care service cannot be supplied despite the sufficient opportunity in the number of health organization and transportation, the number of personnel giving the health service and insufficiency in their education, and inadequacy of necessary medicine and equipment, even though these whole conditions are fulfilled there is insufficiency in the performance of organization. Inadequacy of education particularly in terms of intrapartum and immediate postpartum hemorrhage treatment is obvious. It can be done via personnel who know the scheme of the treatment for the urgent conditions in case of intrapartum or postpartum hemorrhage that can occur frequently in pregnancy, labor, and postnatal period, are literate on urgent obstetric care, and by the health organizations with sufficient equipment, scheduled its performance in order to supply this service. The importance of accessibility to urgent obstetric care service in the obstetric cause of death management frequently occurred, like hemorrhage, eclampsia, and infection, has been highlighted. ,
There are a great number of problems related to maternal mortality. These mentioned problems are as follows: poverty, lack of education, deficiency in socioeconomic status of women, deficiency in hygiene and nutrition, transportation problems, inaccessibility to emergency obstetric care services and appropriate medical care, and deficiencies of consulting service during previous pregnancy, delivery, and postnatal period. If all of these above-mentioned problems had been overcome in time, maternal mortality ratio could have shown a dramatic decline prominently. But unfortunately, all of these mentioned problems cannot be solved in a restricted time. Despite all of these obstacles, in fact, the decline of maternal mortality is possible. Incentive to consulting service for previous pregnancy and the need of health staff in this mentioned field is so essential for diminishing indirect maternal death. Especially within 24 h of postpartum, by considering that maternal mortality becomes the most and postpartum monitoring will be performed and in terms of the training of health staff, it must be displayed sensivity to practise emergency obstetric intervention when required. Especially, attention must be paid to the mentioned equipment in the countryside. All these interventions are to decrease the probability of pregnancy for a woman who has a risky condition for pregnancy, to decrease the probability of serious complication that a pregnant women may experience in pregnancy or delivery period, and to decrease the probability of death that a pregnant woman may experience as a complication.
| Acknowledgment|| |
The authors received no financial support for the research, authorship, and/or publication of this article.
| References|| |
|1.||World Health Organization, UNICEF, UNFPA and The World Bank. Trends in maternal mortality: 1990 to 2010 WHO, UNICEF, UNFPA and The World Bank estimates. |
|2.||World health statistics-datas; 2013. |
|3.||Millennium Development Goals-report; 2012. |
|4.||Annual Health Statistics 2011/Turkey. Available from: www.sbu.saglýk.gov.tr/Ekutuphane/kitaplar/siy_2011.pdf [Last accessed on 2011]. |
|5.||Ministry of Health " Maternal Mortality Monitoring Program"/Turkey. Available from: www.saglik.gov.tr/TR/dosya/1-71858/h/anne-olumleri [Last accessed on 2013]. |
|6.||Turkey Population and Health Research (TNSA)/ 2008. |
|7.||Campbell OM, Graham WJ. Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: Getting on with what works. Lancet 2006;368:1284-99. |
|8.||Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, et al. Global patterns of mortality in young people: A systematic analysis of population health data. Lancet 2009;374:881-92. |
|9.||ACOG Committee Opinion. American College of Obstetrician and Gynecologist. ACOG Committee Opinion Number 283, May 2003. New US. Food and drug administration labeling on cytotec (misoprostol) use and pregnancy. Obstet Gynecol 2003;101:1049-50. |
|10.||Turkey National Maternal Mortality Study; 2005. |
|11.||Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: A systematic analysis. Lancet 2011;377:1319-30. |
|12.||Mayor S. Poorest women 20 times more likely to die in childbirth. BMJ 2001;323:1324. |
|13.||McGinn T. Monitoring and evaluation of PMM efforts: What we have learned? Int J Gynecol Obstet 1997;59:S245-51. |
|14.||Ijadunola KT, Ijadunola MY, Esimai OA, Abiona TC. New paradigm old thinking: The case for emergency obstetric care in the prevention of maternal mortality in Nigeria. BMC Womens Health 2010;10:6. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]