MATERNAL DEATHS IN JORDAN: HOSPITAL BASED FIGURES

Objective:  To calculate and analyze of the maternal mortality ratio in the hospitals of the Royal Medical Services over a five years period (2000-2005).

Methods: The data were obtained from the annual statistics reports of the Royal Medical Services, death certificates, medical records, and labor ward records.

Results:  Nineteen cases were identified .The maternal mortality ratio was calculated to be 17.08 per 100,000 live births. Age, parity and socio-economic class were the main factors affecting the ratio. Obstetric hemorrhage and thromboembolic disorders were the two major causes of maternal deaths.

Conclusions: Maternal Mortality rate is a reflection of health care system of the country. In the absence of national registry for maternal mortality ratio, hospital based statistics will be of valuable alternative. The available maternal mortality ratio of 17/100,000 live births at Royal Medical Services hospitals is accepted figure and compares favorably with the international figures, with similar contribution of different causes.

Key words: Jordan, Maternal death, Maternal Mortality Ratio.

JRMS April 2009; 16(1):26-29


Introduction

Approximately 500,000 to 1 million women die each year worldwide because of pregnancy complications.(1-4)  The vast majority of these deaths occur in developing countries. According to the World Health Organization, 55% of maternal deaths occur in Asia, 40% occur in Africa, and only 1% occurs in developed countries.(5,6) The available statistical data most likely underestimate the actual numbers of deaths because of underreporting and misclassification.(4-6)

A maternal death is defined by the World Health Organization (WHO) as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Maternal mortality is notoriously difficult to measure.(7) The most widely used measure, the Maternal Mortality Ratio (MMR), expresses maternal deaths per 100 000 live births and it rarely exceed 1000 or one per 100 live births.

Direct deaths are those that result from obstetric complications of the pregnant state (pregnancy, labour and puerperium) including deaths from interventions, omissions, inappropriate treatment, or from a chain of events resulting from any of the above.

Indirect deaths are those which result from pre-existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiological effects of pregnancy.

The aim of this study was to identify the causes of maternal deaths, the risk factors which could be related to the deaths or to the pregnancy itself.


Methods

The data were collected for a period of five years between 1st. April 2000- to 1st. April 2005 from the seven hospitals of the Royal Medical Services; these hospitals serve around 1.5 million of the Jordanian population. The largest of these hospitals is King Hussein Medical Center, which is a referral center for these hospitals and also receives referrals from any hospital in Jordan. There is an average of 22000 deliveries per year in all RMS hospitals. During this time, we identify nineteen cases of maternal deaths that occurred in the Royal Medical Services hospitals. The data obtained from the annual statistics reports of the Royal Medical Services, death certificates, and medical records, labor ward records; were vigilantly studied. In our study, we used the maternal mortality ratio.

We tried to find out the risk factors that may be related to the death.  We identify patients by personal characteristics such as age, parity, socioeconomic status, site of residency, and also by pregnancy factors such as, gestational age antenatal care, mode of delivery, place of delivery, history of medical diseases and time of death.


Results

Over a five years period there were 111,198 deliveries, resulted in 111,230 live births and 19 maternal deaths, giving a maternal mortality ratio of 17.08 per 100,000 live births.

Table I shows the distribution of maternal deaths by age, the women's ages at the time of death were grouped into standard 10-year intervals .The pregnancy-related mortality ratio differed by maternal age; the risk for pregnancy-related death increased substantially among women aged >40 years. Women aged >40 years had a pregnancy-related mortality ratio that was approximately  three times higher than that among women aged 20-30 years and approximately 4 times higher than women aged <20 years.

Table II shows the relation of maternal mortality with parity.

Table I: Realtion of maternal mortality and age

Maternal age	Live births	No. of deaths	MMR
<20	12329	1	8.11/100,000
20-30	47211	6	12.7/100,000
30-40	42266	9	21.2/100,000
>40	9424	3	31.8/100,000

Table II: Maternal mortality and parity

Parity	Live births	No. of deaths	MMR
0-2	38217	7	18.3/100,000
3-5	41615	6	14.4/100,000
6-8	19650	5	25.4/100,000
³9	11748	1	85.1/100,000

The parity of patients in our study ranges between 0 and 10.There were a relatively less number of deaths in females with their third through fifth pregnancy and a greater number of deaths in females in their sixth pregnancy and above.

The gestational age was 10-42 weeks. Only four patients were less than 28 week. Six patients (31.5%) died before delivery. Cesarean section associated with 69.2% (9/13) and vaginal delivery associated with (30.8%) of maternal deaths. The causes of death for those died before 28 weeks were HELLP syndrome, encephalitis, sickle cell crisis and intracranial hemorrhage.

Most of those patients were died at King Hussein Medical Center, as it is the referral center for the other six hospitals of the Royal Medical Services or from the hospitals all through Jordan. Only 47.3% (9/19) were booked to our hospitals, though, many of them may be booked to private doctors or to other hospitals. Two cases were referred to our hospitals on respirator.

All cases were delivered in hospitals. We do not have any case of home delivery.

The sociodemographic profile includes degree of education, family income, employment.

The highest number of deaths occur in women whose education was  below elementary school 57.8% (11/19), family income less than 200 Jordanian Dinar (JD) per month68.4% (13/19),and unemployed 84.2% (16/19). During this period, the causes of direct maternal deaths were: hemorrhage, preeclampsia, pulmonary embolism; while the cause for indirect maternal deaths was cardiovascular diseases, malignancies, sickle cell anemia, encephalitis, hepatitis, and intracranial hemorrhage. (Table III)

Table III: Causes of death

Causes of death	No. of cases	%
Hemorrhage	5	26.3
Pulmonary embolism	3	15.8
Preeclampsia and Eclampsia	2	10.5
Cardiovascular diseases	2	10.5
Malignancies	2	10.5
Infections (Hepatitis, Encephalitis)	2	10.5
Amniotic fluid embolism	1	5.3
Intracranial Hemorrhage	1	5.3
Blood transfusion reaction (Haemolysis)	1	5.3

Discussion

With the lack of national registry for maternal deaths in Jordan, hospital based statistics will remain the only source of information's regarding maternal mortality as a reflection of maternal care in Jordan.

Royal Medical Services hospitals serve more than 1.5 million of Jordanian population. The MMR in our statistics was 17.08/100000 live births, although higher than some developed countries, but they are much better than many developing countries including Arabic countries as shown in Table IV

Table IV:  (MMR by country) (5, 8)

Country	MMR (Maternal deaths per 100,000 live birth)
Australia	7
UK	6.7
USA	7.5
Israel	5.2
Italy	12.4
New Zealand	20.4
Chile	21
Mexico	60
Saudi Arabia	18
Yemen	1040
Sudan	522
Pakistan	279
Nigeria	800

Maternal mortality varies with age, and this is probably best explained by the increase frequency of hypertension and tendency for uterine bleeding with age, the risk increases for the ages of 30-40, and increase dramatically after age of 40, where 63.1% of maternal deaths occur in women older than 30 years of age.

This finding of increase MMR by age is the same in both developing countries like Saudi Arabia,(9) or developed countries like USA where MMR is 10 times more common between 40-44 years age group than 20-25 years age group.(10) Although in different countries MMR is very high among teenage mothers,(10) we had one death before 20 years of age and this is probably due to the Jordanian law that does not legitimize marriage before the age of 18.

The risk of maternal death is high in the first two pregnancies, where the risk decreases in the third, fourth and fifth pregnancies and start to increase thereafter.(11,12) This trend of variation of MMR with different parity is a wide spread in developing countries of Asia and Africa were parity above four is common compared to parity of 2-4 in other developed counties, like USA and Sweden where a 15% reduction in MMR was attributed to fewer births and lower parity.(13) In our report 69.2% of  maternal mortalities delivered by caesarean section, this probably can be explained by the fact that high parity and older patients exposed more to surgical intervention because of hypertension, diabetes, large babies, abnormal presentation and prolonged labor. The increased risk posed by caesarean on MMR is universal in both developed and developing countries. (9, 14)

Education was an important factor in MMR with more than 57% of deaths occurs in patients whose education was limited to primary education. Education will influence the level of antenatal care, where 78% of females in Jordan with university graduate use prenatal services, compared to only 24% of illiterate females.(15)  MMR in Zaire is 720 in non-educated patients compared to 130 in patients with some education.(10)

Unemployment and low-income level had the same effect on MMR as the education; this can be explained by the same fact of low attendance to antenatal care.(16) Compared to other countries obstetric hemorrhage is still the leading cause of maternal deaths in Jordan, as it is the major cause of maternal deaths world wide.(8)

Reducing maternal deaths from hemorrhage requires expensive facilities and sophisticated skills.

 In China a 50% redaction in MMR due to obstetric bleeding has been achieved in urban hospitals compared to rural areas (25% compared to 50%).(10)  Thromboembolic disorders were the leading cause of maternal mortality in developed countries.(17)  This cause ranks the second in our report, and still under reported in many countries probably due to lack of autopsy information in developing countries [18]. Hypertensive disorders in pregnancy and there complications caused two deaths, make them responsible for 10.5 % of deaths, both of them were unbooked patients who presented with eclampsia. This fact showed the effectiveness of antenatal care in early detection of pre-eclampsia and prevention of associated maternal mortality. (17)

Indirect causes were responsible for the more than 30.6% of the cases. Unfortunately, some of them were preventable like the one case with blood transfusion reaction .The other deaths although died because of non-obstetric cause, but pregnancy may have accelerate their disease to cause death, Multi-displinary team work in managing these case is of great importance to prevent such deaths.


Conclusion

Maternal Mortality rate is a reflection of health care system of the country. In the absence of national registry for MMR in Jordan, hospital based statistics will be of valuable alternative. The available MMR of 17/100,000 live births at RMS hospitals is accepted figure and compares favorably with the international figures, with almost the same contribution of different causes.


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