Causes And Prevention Of Maternal Mortality

The United States has one of the highest maternal mortality rates among developed countries. Interestingly enough, however, the U.S. also spends nearly twice as much on healthcare as other high-income countries. Focusing locally, Indiana isn’t doing much better, as it currently has the third-highest maternal mortality rate in the nation. 

So how can we as Hoosiers fix this disparity and solve these issues? We can start small by changing Indiana's maternal health by educating ourselves on the causes and prevention of maternal mortality. 

What Is Maternal Mortality?

The official maternal mortality definition from the Centers for Disease Control and Prevention (CDC) states that maternal mortality is the death of a person during pregnancy, at delivery, or soon after delivery. To be more specific, the World Health Organization (WHO) adds that the postpartum window is evaluated through 42 days after birth, and any deaths occurring after those 42 days, but within a year, are considered late maternal deaths. The cause of death can be related to or aggravated by the pregnancy or its management (but not accidental or incidental causes, such as homicide). 

To develop better strategies to reduce maternal mortality worldwide, we must first have a full picture of what causes maternal deaths. 

Direct and Indirect Causes of Maternal Mortality

Direct factors of maternal mortality are caused by or related to the pregnancy itself and would not have been an issue had the pregnancy never occurred. Indirect factors include health or other problems that would still exist whether or not a person is pregnant, and the pregnancy complicates or aggravates those issues. To clearly define these causes, many look to the International Classification of Diseases (ICD). The ICD “has been the basis for comparable statistics on causes of mortality and morbidity between places and overtime for the past century.” 

However, some believe that these classifications can be misleading, as pointed out in this article published in The Lancet Global Health medical journal entitled “Maternal mortality: direct or indirect has become irrelevant,” which states:

...many maternal deaths are still either not identified or misclassified. Instead of ascertainment of the primary cause, countries became fixated on grouping deaths as direct and indirect. Over the years, this classification somehow led many to believe that direct maternal deaths should receive greater attention than indirect maternal deaths…The risk of maintaining the divide between direct and indirect is that indirect maternal mortality might be regarded as less important or less urgent to tackle, since many countries have focused their efforts on a reduction of death from direct obstetric causes within the immediate realm of maternity care.

We understand there are many factors affecting maternal mortality. With that in mind, we will focus on some of those causes in this article, not by seeking to define which are more or less urgent, but instead hoping to educate on a few of the top causes of maternal death. 

What Are Some Causes of Maternal Mortality?

Some of the leading causes of maternal mortality include:

  • Cardiovascular disease

  • Severe bleeding (hemorrhaging)

  • Obstructed labor

  • Unsafe abortion

  • Infection 

We will examine a few of these causes more in-depth below. Of note, please do not use this list or any portion of this article for self-diagnosis and seek the advice of a medical professional if you have any concerns. 

Obstetric Hemorrhage 

The leading answer is usually severe bleeding when asking, “What is the major cause of maternal mortality?” the leading answer is usually severe bleeding. This includes any excessive bleeding related to the pregnancy in a person giving birth. In these situations, bleeding typically occurs vaginally but rarely in the abdominal cavity. The types of hemorrhaging can happen in:

  • Early pregnancy - From conception to 20-24 weeks

  • Antepartum - From 20-24 weeks to the onset of labor

  • Intrapartum - From the onset of labor to the delivery of the placenta

  • Postpartum - After the delivery of the placenta

Here are two specific examples of obstetric hemorrhaging:

  • Uterine Rupture - As its name suggests, uterine rupture occurs when the wall of the uterus breaks open, most commonly due to the increasing pressure of the growing baby. Those who have had a cesarean delivery (C-sections) are at increased risk, as uterine ruptures usually occur along the scar line of previous C-sections. 

  • Placenta Accreta - This condition occurs when the placenta has grown too deeply into the uterine wall. The placenta typically detaches after birth, but in these situations, part or all of the placenta remains attached, which can cause severe blood loss after delivery.

Cardiovascular Disease

Cardiovascular disease is one of the leading causes of death during pregnancy. According to the Journal of the American College of Cardiology, in the U.S., cardiovascular disease is responsible for more than 33% of pregnancy-related deaths. Sadly, it is estimated that 68.2% of these pregnancy-related deaths caused by cardiovascular issues are preventable. A couple of direct and indirect maternal death examples involving cardiovascular disease include:

  • Preeclampsia - This condition involves high blood pressure and damage to other organ systems, usually the liver and kidneys. It can lead to restricted growth for the baby, placenta abruption (separation of the placenta from the uterine wall delivery), additional organ damage, increased risk of future heart disease, and more. 

  • Cardiomyopathy - The heart chamber can enlarge, and the heart muscles can weaken during pregnancy and immediately after delivery. A pregnant person’s heart has to work harder due to the extra transfer of vital nutrients and oxygen to the baby. This means less blood flow and less oxygen for the rest of the body’s systems. 

Unsafe Abortion

According to the WHO, around 45% of all abortions are unsafe. It is also one of the leading causes of maternal mortality in developing countries, as 97% of unsafe abortions occur in developing countries. An unsafe abortion may involve:

  • Using dangerous or outdated methods, such as “sharp curettage,” which is no longer recommended by the WHO. Sharp curettage involves dilating the cervix and scraping the uterine wall. 

  • Putting foreign objects into the body.

  • Using methods like misoprostol (a drug that can be used to induce abortion) without trained medical guidance.

  • Drinking toxic fluids like turpentine or bleach.

  • Inflicting external injury, such as purposely inflicting blunt trauma to the abdomen.

What is driving pregnant people to such dangerous and risky methods? There are many reasons, but some of the more common causes include:

  • Restrictive abortion laws

  • Social, religious, and political obstacles

  • Affordability 

  • Quality healthcare accessibility  

  • Distance to facilities 

  • Lack of safe abortion education

These factors are also general reasons pregnant people may not seek other types of care during pregnancy or childbirth.  

Fortunately, this is in no way a hopeless situation, as maternal deaths can be prevented. Many steps to reducing maternal mortality are already in place and being acted upon by national and global organizations.

How Can We Prevent Maternal Mortality?

In 2015, the WHO published a report titled “Strategies toward ending preventable maternal mortality (EPMM).” This report aimed to guide global targets and strategies for reducing maternal mortality. It takes a human rights approach, focusing on “​​eliminating significant inequities that lead to disparities in access, quality and outcomes of health care within and among countries.” 

Here are some key takeaways from this report:

  • Apply a Human Rights Framework - Maternal mortality is a human rights issue and should be treated as such. A country's or state's realization of these rights is heavily indicated by whether or not they ensure equality of health results for gestational people, including efforts to reduce maternal mortality.

  • Improve Data Measurement - At the time of the report, only an estimated one-third of countries had the ability to count or register maternal deaths. The report pushes for establishing national registration and vital statistics systems in every country. Having accurate data to study is key to discovering actionable changes. 

  • Reduce Inequities - Every country should push to reach vulnerable populations with high-quality primary and emergency care in sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH). This includes all circumstances where people are at a social disadvantage over others due to the risk of stigma, discrimination, or unequal treatment. These vulnerable populations can include:

    • Lesbian, gay, bisexual, non-binary, and transgender populations

    • Urban and rural poor

    • Commercial sex workers

    • Marginalized people

    • Those living with physical and mental disabilities

    • Adolescents

    • Immigrants

    • Those living with HIV

    • Refugees

    • Those in conflict/post-conflict areas

    • Groups who experience disparities regularly

  • Ensure Universal Health Coverage - This means that all people should receive equal access to quality health services without being exposed to financial hardship in paying for the services.

  • Provide Comprehensive Education - Increasing awareness of maternal mortality is a great place to start when it comes to preventing it. Additionally, educational resources should also include comprehensive sexuality education, which is proven to reduce teen pregnancies. 

To draw the focus more locally, Indiana began developing its own Maternal Mortality Review Committee (MMRC) in 2017. In 2020, the Indiana Department of Health published its first MMRC annual report, followed by a second report in 2021. As we mentioned above, Indiana currently has the third-highest maternal mortality rate in the country, but these actions push for change, improvement, and a better future for Hoosiers. 

Women4Change: Educating and Mobilizing Hoosiers for Positive Change

If you are looking for ways to contribute to the reduction of maternal mortality, joining us personally is the perfect place to start. Our vision is to achieve equity in employment and earnings, healthcare, and political, civic, cultural, and corporate leadership. We strive toward this vision by:

  • Educating and providing resources for Hoosiers to stay informed

  • Activating and mobilizing Hoosiers to make changes

  • Collaborating and growing a diverse membership and range of partners

  • Advocating and raising awareness on key legislative issues

One recent victory we are celebrating is the passing of House Bill 1140, which called for the expansion of Medicaid protections for pregnant Hoosiers from 6 months to a full year. This expanded Medicaid coverage was a key recommendation from Indiana’s 2020 MMRC annual report, and we testified in support of its passing.

Ready to make positive changes with us? Sign up to be one of our action advocates, join our newsletter, or make a donation. Every penny and every second we receive from our volunteers allows us to see this vision through and make a difference. 

W4C