Maternal Mortality

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Defined as death of either a pregnant woman or death of woman within 42 days of delivery, spontaneous abortion or termination providing the death is associated with pregnancy or its treatment.[1]

In the UK, maternal mortality rates can be calculated in two ways:

  • Through official death certification to the Registrars General (the Office for National Statistics and its equivalents).
  • Through deaths reported to the Centre for Maternal and Child Enquiries (CMACE).[2] This produces a report every 3 years (and this article draws its numbers from that report). The overall maternal death rate for the Enquiry is calculated from the number of deaths assessed as being due to Direct and Indirect causes.

However, it is not possible to obtain accurate data on total number of pregnancies. The alternative is to use deaths from obstetric causes/million maternities - i.e pregnancies that have been notified to a doctor.

  • Direct deaths are defined as those related to obstetric complications during pregnancy, labour or puerperium (6 weeks) or resulting from any treatment received.
  • Indirect deaths are those associated with a disorder, the effect of which is exacerbated by pregnancy.
  • Late deaths occur ≥42 days after end of pregnancy.

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In the triennium 2006-2008, 261 women in the UK died directly or indirectly related to pregnancy. The overall mortality rate was 11.39 per 100,000 maternities which is a statistically significant decline from 2003-2005.[2]

  • Deaths related directly to pregnancy decreased from 6.24 per 100,000 maternities (2003-2005) to 4.67 per 100,000 maternities. This is mainly due to the reduction in deaths from thromboembolism.
  • Cardiac disease is the most common cause of Indirect death and this has not changed significantly since 2003-2005 at 6.72 per 100,000 maternities.

There has been an increase in deaths related to genital tract sepsis, particularly from community-acquired group A streptococcal disease. The mortality rate related to sepsis increased to 1.13 deaths in 2006-2008, and sepsis is now the most common cause of Direct maternal death.[2]

The rate of deaths due to ectopic pregnancy has fallen from 0.47 to 0.26 and, although not statistically significant, suggests that the message about prompt diagnosis of this dangerous condition may have been heard. There have been no significant changes in deaths from other causes. Postpartum haemorrhage (PPH) is the most common cause of death worldwide, and new initiatives in poorer countries are called for, eg anti-shock garments and balloon tamponade.[3]

Cause of Death Rate per 100,000 Maternities
Sepsis 1.13
Pre-eclampsia and eclampsia 0.83
Thrombosis and thromboembolism 0.79
Early pregnancy/ectopic pregnancy 0.48
Haemorrhage 0.39
Other direct causes 0.17
Anaesthesia 0.31
Amniotic fluid embolism 0.57
Cause of death Rate per 100,000 maternities
Cardiac 2.27
Psychiatric 0.85
Other indirect 4.12

Most maternal mortality occurs in the developing world, with >500,000/year.[4][5] Risk factors for maternal deaths in the UK include:[6]

  • Social disadvantage: Women living in families where both partners were unemployed, where social exclusion was an associated problem, were up to 20 times more likely to die than women from the more advantaged groups. In addition, single mothers were three times more likely to die than those in stable relationships. Women living in the most deprived areas had a higher death rate than women living in the most affluent areas, but the gap has lessened since the last report.
  • Minority ethnic groups: Women from ethnic groups have higher mortality rates than Caucasian women. These groups have major problems in obtaining obstetric care. This disparity in mortality rates between ethnic groups has been noted in other affluent societies.[7]
  • Late booking or poor attendance: 26% of the women who died from Direct or Indirect causes booked for maternity care after 22 weeks of gestation, or were poor attenders at antenatal visits.
  • Delayed pregnancy: The numbers and proportion of maternities which were to women aged 35 remains high. The highest maternal mortality rates are among the older mothers.
  • Obesity: There is an increasing trend for greater BMI. 47% of mothers who died from Direct causes were either overweight or obese, as were 50% of women who died from Indirect causes.
  • Domestic violence: 12% of all the women who died declared that they were subject to violence in the home.
  • Substance abuse: Fifty-three women had problems with substance misuse. 31 were known drug addicts, 16 were noted to be occasional users and an additional six women were solely alcohol-dependent. Ten women were both drug- and alcohol-dependent.
  • Suboptimal clinical care: Substandard care was found in 70% of Direct deaths and 55% of Indirect deaths.
  • Lack of inter-professional and/or inter-agency communications:
    There were many cases where the care provided to the women who died was hampered by a lack of cross-disciplinary working. In several cases crucial clinical information, which may have affected the outcome, was not passed from the GP to the midwifery or obstetric services, or shared between consultants in other specialities.

It is the responsibility of the GP or community midwife to notify the local Director of Public Heath.

If death occurs in hospital, a co-ordinator - usually a midwife - should be appointed.
They should perform the following and keep a complete record of all actions:

  • Ensure relatives have a suitable member of staff as a single contact point.
  • The consultant on-call should see relatives as soon as possible and the woman's own consultant told of her death as soon as next in hospital.
  • The supervisor of midwives is informed.
  • The mortuary and pathologist on duty are informed.
  • Try to obtain permission from next-of-kin for postmortem examination to confirm cause of death (coroner may direct one performed if any doubt). NB: if there is a dead fetus in utero, there is no legal requirement for a death certificate but one can often be supplied if wished.
  • Ask relatives if they would like to see a culturally appropriate religious adviser.
  • All relevant documents are sent to the coroner.
  • Consider offering support to staff involved.

The following should be advised of the death:

  • CEO.
  • Clinical director/managers.
  • Consumer affairs.
  • Complaints.
  • Risk manager.
  • Community midwife.
  • GP.
  • Local Director of Public Heath - will require the Confidential Enquiry form to be completed.
  • Local Supervising Authority Officer.

Further reading & references

  1. Hoj L, da Silva D, Hedegaard K, et al; Maternal mortality: only 42 days?; BJOG. 2003 Nov;110(11):995-1000.
  2. Saving Mothers' Lives. Reviewing maternal deaths to make motherhood safer: 2006-2008; Centre for Maternal and Child Enquiries (CMACE), BJOG, Mar 2011
  3. Lalonde A, Daviss BA, Acosta A, et al; Postpartum hemorrhage today: ICM/FIGO initiative 2004-2006.; Int J Gynaecol Obstet. 2006 Jul 11;.
  4. Yayla M; Maternal mortality in developing countries.; J Perinat Med. 2003;31(5):386-91.
  5. Begum S, Aziz-un-Nisa, Begum I; Analysis of maternal mortality in a tertiary care hospital to determine causes and preventable factors.; J Ayub Med Coll Abbottabad. 2003 Apr-Jun;15(2):49-52.
  6. Chu L, Seed M, Howse E, et al; Mesenchymal hamartoma: prenatal diagnosis by MRI. Pediatr Radiol. 2010 Dec 1.
  7. Sundaram V, Liu KL, Laraque F; Disparity in maternal mortality in New York City.; J Am Med Womens Assoc. 2005 Winter;60(1):52-7.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Hayley Willacy
Current Version:
Peer Reviewer:
Dr John Cox
Document ID:
1344 (v23)
Last Checked:
19/10/2011
Next Review:
17/10/2016