Maternal deaths in Mozambique : An audit approach with special reference to adolescence, abortion and violence

Abstract: The main purpose of the present thesis was to elucidate the causes and circumstances that surround maternal deaths occurring in Hospital Central de Maputo (HCM). The specific aims were 1: to identify the major causes of direct and indirect matemal deaths, and by utilizing the audit approach, to address the avoidability aspect in each case, 2: to estimate the contribution of malaria to matemal mortality, 3: to compare the main causes of direct and indirect matemal death in adolescents with those in non- adolescents, and the prevalence of risk factors used in antenatal cards with the intention to identify "high risk pregnancy" among such women, 4: to review pregnancy-related deaths due to injuries in HCM, and to elucidate the contribution of violence (homicide and suicide) to these deaths, 5: to estimate the trends of matemal mortality in a ten year period, with special reference to adolescents, and to compare the contribution of induced abortion to matemal mortality in two periods in which different policies regarding abortion were applied. Methods: The matemal mortality ratio (MMR) by age and parity was calculated for matemal deaths divided by live newborns in the same period collected from the delivery room record book of HCM. Analysis of the circumstances of death, antenatal care, care in other health centres and in the HCM was carried out in order to detect any avoidable factor. Matemal deaths due to malaria were assessed by clinical audit and autopsy results and the proportion of these deaths to all maternal deaths were estimated. Maternal deaths among adolescents were compared with those of non-adolescents. The Department of Forensic Medicine at HCM, provided data on all autopsies performed during 1991-1995, in women of reproductive age. Data from maternal deaths occurring in HCM during the period 1989-1993 was used to compare the characteristics of women suffering a maternal death with those of women suffering a pregnancy-related death due to violence. To estimate the trends in matemal mortality in HCM, a retrospective study on matemal deaths occurring during the period of 1997-1999 was performed and MMR compared to the corresponding figure in the period 1989 to 1993. Results: During the period 1989-1993 a total of 239 matemal deaths identified at HCM gave a MMR of 320 per 100,000 live births. The main cause of matemal death, all ages, was haemorrhage, (27%). Malaria contributed with 37 cases to matemal mortality (16%). Associated with anaemia the contribution grows to 21% of all maternal deaths. Adolescent deaths comprised 52/239 matemal deaths (22%). The main causes of adolescent death were malaria ( 27%), pregnancy-induced hypertension (PIH) and eclampsia (21%), puerperal sepsis (15%), and septic abortion (10%). A higher proportion of adolescents than non- adolescents died from abortion, spontaneous or provoked, (29% versus 15%, p<0.01) and in the second trimester of pregnancy (23% versus 11%, p<0.05 ). Only half the adolescent maternal deaths were booked for antenatal care (29152, 56%). Fewer adolescent women (2%), than non-adolescent women (12%), p<0.01, were classified as "at risk" in antenatal cards. The audit classified as avoidable 78 % of all matemal deaths. Twenty-seven pregnancy-related deaths due to injuries were identified during the period 1991-95. Induced abortion was clearly an underlying contributing factor in almost one fifth of violence-related maternal deaths. Institutional matemal mortality ratio showed a significant numerical increase from 320 to 432 per 100,000 livebirths, from the first (1989-93) to the second period (1997-99), respectively (p=0.002). Compared with non-adolescents, adolescents showed a 30% increase in the risk of dying from complications of pregnancy in HCM. The institutional abortion- related MMR showed an increase from 24 to 53 per 100,000 livebirths, between first and second period (p=0.013). Conclusions: Lack of transport and poor quality of antenatal and intrapartum care in peripheral maternity units implied that women with complications arrived late. Risk factors used in antenatal cards to classify women "at risk" show a low sensitivity to prevent maternal death. The study addresses the need of malaria prophylaxis for certain categories of pregnant women such as adolescent primigravidae and HIV-positive pregnant women. Unsafe abortion is an important cause of death in adolescents. Screening for domestic violence should be introduced in antenatal and post-abortion care. The study has demonstrated a trend of increasing maternal mortality ratios in HCM. Family planning, sex education, adequate antenatal services, improving the access to abortion services, and strengthen the emergency obstetric care are suggested for a successful Safe Motherhood programme in Maputo.