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Dhaka Tribune

The battle against indirect maternal mortality

Uncovering the differential burdens and dissecting the root causes and systemic failures that have resulted in the often overlooked issue of indirect maternal deaths

Update : 05 Apr 2024, 09:09 AM

Maternal mortality is an issue that often flies under the radar but deserves our attention. Maternal deaths -- defined as when a woman dies during pregnancy, while giving birth, or within 42 days after giving birth -- has a lasting impact on families and communities across the world. According to the World Health Organization, about 287,000 women died globally during and following pregnancy and childbirth in 2020. However, the complexity and depth of this issue extends far beyond simple numbers. Each time a life is lost, it leaves behind broken dreams, a family forever altered, and a community struggling with emptiness.

Despite significant advances in healthcare and technology, maternal mortality serves as a stark reminder of the work that still lies ahead. Maternal deaths can be classified as direct maternal deaths (DMDs) linked directly to pregnancy or childbirth, or indirect maternal deaths (IMDs) due to health issues unrelated to pregnancy. Eclampsia and hemorrhaging are well-known, usual suspects of DMDs, but IMDs often get overlooked. 

Globally, in 2013, approximately 293,000 mothers lost their lives, 33,000 of those were due to IMD. In general, DMDs are the primary burden in low- and middle-income countries while IMDs more often impact high-income countries. This differential between the DMDs and IMDs is known as the “obstetric transition,” which is particularly noticeable in high-income countries with advanced obstetric care. Countries like Sweden and England experienced this shift a long time ago, but it’s only recently surfaced in nations like Sri Lanka. This indicates the need to modify maternal health care to meet these shifting needs.

The etiology of IMD varies by timing and geography. For instance, in Brazil, H1N1 influenza caused many maternal deaths from 2009 to 2010. In sub-Saharan Africa, HIV/AIDS has been a considerable cause of IMDs since the 1990s. On the other hand, in the United Kingdom, cardiovascular diseases impacted maternal mortality. Other significant reasons around the world include infections, anemia, diabetes, liver and kidney diseases, cancer, and mental disorders. 

One-fifth of pregnant women die because of indirect reasons related to pregnancy, making IMDs the third most common cause for mothers dying in the country

According to the Bangladesh Maternal Mortality and Healthcare Survey (BMMS) 2016, strokes, cancer, heart disease, and asthma cause 80% of IMDs. A recent paper published at the Journal of Global Health reveals that, in Bangladesh, women who died due to IMDs had preexisting health issues and frequently reported symptoms like headaches, difficulty in breathing, fever, cough, abdominal and chest pain, edema, and blurred vision during their respective pregnancies. Therefore, to prevent IMDs, it is important that all symptoms and pre-existing conditions are presented during pregnancy -- no matter how mundane it appears -- by both providers and women (including family), and they must be taken seriously. 

Pre-pregnancy health check-ups can provide crucial guidance on managing pregnancy. For example, high blood pressure is linked to strokes and heart disease. Based on the Bangladesh Demographic and Health Survey 2017-18 around 28% women ages 18 and above have high blood pressure, making them vulnerable to high-risk pregnancies, requiring more advanced obstetric care and attention. According to a 2023 paper by Haider et al, most of the women who died due to IMDs went to a doctor or hospital at least once and almost half sought services from more than two different locations for their respective symptoms. For these women, public hospitals were the preferred choice of health facility; however, system failures like long waiting hours, less consultation time from doctors, unprepared facilities, coupled with delay in decision making delayed appropriate care and contributed to women dying. 

Now let’s look at the demand side issue of deaths. According to the paper by Moin et Al, three out of five women in the study waited at home for too long before going to any health facility. One possible reason for this delay could be the lack of “danger sign” counseling during the ANC sessions. Additionally, husbands often do not attend ANC sessions, resulting in not identifying the danger signs on time.

According to the 2016 Bangladesh Maternal Mortality and Health Care Survey, one-fifth of pregnant women die because of indirect reasons related to pregnancy, making IMDs the third most common cause for mothers dying in the country. A significant portion of these deaths occur early in pregnancy or soon after childbirth. This highlights the need to provide better care for women before they plan to become pregnant, during pregnancy, and in the postpartum phase.

The battle against maternal mortality is a collective effort. It’s not just about doctors’ interventions; it requires a multifaceted approach that goes beyond medical measures. Comprehensive efforts in maternal health in policy making, continuum of care, localized engagement, and strengthened health system are required to fight this battle. By addressing these essential components, we can drastically reduce maternal mortality rates and ensure the well-being of mothers globally. In an era of so many medical innovations, it is time to ensure every woman’s right to a healthy life. 



Dr Sumaiya Nusrat is a medical doctor with a passion for data, holding both an MBBS and a Master's in Applied Statistics. Currently serving as a Project Research Physician at icddr,b, aspiring to become a public health researcher. Shusmita Khan is a Knowledge Management and Communications Specialist with Data for Impact (D4I). This article was produced with the support of the USAID under the terms of the D4I associate award, which is implemented by the Carolina Population Centre at the University of North Carolina at Chapel Hill, in partnership with Palladium International, LLC; ICF Macro, Inc; John Snow, Inc; and Tulane University. The views expressed do not necessarily reflect the views of USAID or the United States Government. To learn more, please email Shusmita Khan at [email protected]

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