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Panorama general de la mortalidad materna

Autores: Haywood L Brown, MD, Maria J. Small, MD, MPH
Redactor de sección: Lynn L. Simpson, MD
Redactor adjunto: Dra. Alana Chakrabarti

Todos los temas se actualizan a medida que se dispone de nueva evidencia y se completa nuestro proceso de
revisión por pares .

Revisión de la literatura actual hasta:  octubre de 2022. | Última actualización de este tema:  03 de
noviembre de 2022.

INTRODUCCIÓN

A nivel mundial, la mortalidad materna ha ido disminuyendo, con una variación sustancial
entre países y dentro de los países [ 1,2 ]. En contraste con la tendencia mundial, la
mortalidad materna en los Estados Unidos ha ido en aumento en las últimas décadas [ 3 ].

Este tema discutirá temas relacionados con la mortalidad materna, incluidos los enfoques
para la reducción de riesgos en países ricos en recursos (a veces categorizados como países
de "altos ingresos" o "desarrollados").

Los países de recursos limitados (a veces categorizados como países de "ingresos bajos" o
"ingresos bajos y medianos" o países "en desarrollo") tienen problemas adicionales que
afectan la reducción del riesgo, que se revisan por separado. (Consulte "Enfoques para la
reducción de la mortalidad materna en entornos de recursos limitados" .).

Los temas relacionados con la morbilidad materna severa también se revisan por separado.
(Ver "Morbilidad materna grave" .)

TERMINOLOGÍA

Las definiciones de muerte materna y sus subclasificaciones de la Clasificación Internacional

de Enfermedades de la Organización Mundial de la Salud (OMS), décima revisión (ICD-10) y del
Comité de Revisión de Mortalidad Materna (MMRC) de los Centros para el Control y la
Prevención de Enfermedades (CDC) son las siguientes [ 4, 5 ]:
● Muerte materna : la muerte de una paciente durante el embarazo o dentro de los 42
días posteriores a la terminación del embarazo, independientemente de la duración y
el lugar del embarazo, por cualquier causa relacionada o agravada por el embarazo o
su manejo, pero no por causas accidentales o incidentales. [ 6 ].

● Muerte materna tardía : la muerte de una paciente por causas obstétricas directas o
indirectas más de 42 días, pero menos de un año, después del final del embarazo.

● Muerte asociada al embarazo : una muerte durante o dentro de un año del

embarazo, independientemente de la causa. Esto se compone de lo siguiente:

• Muerte relacionada con el embarazo : una muerte durante o dentro de un año del
embarazo debido a una complicación del embarazo, una cadena de eventos
iniciados por el embarazo o el agravamiento de una condición no relacionada por
los efectos fisiológicos del embarazo.

• Muerte asociada con el embarazo, pero no relacionada : una muerte durante o

dentro de un año del embarazo por una causa que no está relacionada con el
embarazo.

● Muerte obstétrica directa : una muerte obstétrica directa resulta de complicaciones

obstétricas del embarazo, trabajo de parto, parto o puerperio, y de intervenciones,
omisiones, tratamiento incorrecto o una cadena de eventos relacionados con la
complicación obstétrica. Las muertes obstétricas directas son más comunes que las
muertes obstétricas indirectas (86 y 12 por ciento, respectivamente) [ 7,8 ].

● Muerte obstétrica indirecta : una muerte obstétrica indirecta resulta de una

enfermedad preexistente (p. ej., diabetes, enfermedad cardíaca, paludismo,
tuberculosis, VIH) o una nueva enfermedad que se desarrolla durante el embarazo y no
está relacionada con las condiciones relacionadas con el embarazo, pero se ve
agravada por los efectos fisiológicos de embarazo (p. ej., gripe). El término muerte
obstétrica indirecta se usa indistintamente con los términos muerte no materna, no
obstétrica y materna indirecta.

● Razón de mortalidad materna (MMR) : la RMM se refiere al número de muertes

maternas durante un período de tiempo determinado por cada 100.000 nacidos vivos.
Esta es la medida de mortalidad materna más utilizada y sirve como un indicador del
riesgo de muerte una vez que la paciente ha quedado embarazada. El denominador es
nacidos vivos en lugar de todos los embarazos debido a la dificultad de determinar el
número de abortos espontáneos y abortos en la población.

● Tasa de mortalidad materna: la tasa de mortalidad materna se define como el número

de muertes maternas en un período determinado por cada 100.000 mujeres en edad
 reproductiva (15 a 49 años de edad) durante el mismo período. Dado que la frecuencia
de embarazos en mujeres en edad fértil es un factor en el cálculo de esta tasa, se ve
afectada por las diferencias en la frecuencia de embarazos o partos en la población,
aunque el riesgo de muerte materna por embarazo/parto se mantiene sin cambios.

● Tasa de mortalidad relacionada con el embarazo (PRMR) : el número de muertes

relacionadas con el embarazo por cada 100 000 nacidos vivos, donde una muerte
relacionada con el embarazo se define como la muerte de una paciente durante el
embarazo o dentro de 1 año del final de un embarazo (independientemente de el
resultado, la duración o el lugar del embarazo) por cualquier causa relacionada o
agravada por el embarazo o su manejo, pero no por causas accidentales o incidentales.
Esta es la métrica reportada por los Centros para el Control y la Prevención de
Enfermedades (CDC) en los Estados Unidos; es diferente a la RMM reportada por
organismos internacionales.

● Riesgo de muerte materna a lo largo de la vida: el riesgo de muerte materna a lo

largo de la vida tiene en cuenta la probabilidad acumulada de morir como resultado
del embarazo a lo largo de los años reproductivos de una mujer. Se calcula
multiplicando la tasa de mortalidad materna por la duración del período reproductivo
(aproximadamente 35 años; (1 – [1-tasa de mortalidad materna]) [ 9 ].

● Prevenibilidad : una muerte se considera prevenible si hubo al menos alguna

posibilidad de que la muerte se evitara mediante uno o más cambios razonables en el
paciente, la familia, el proveedor, el centro, el sistema o los factores de la comunidad.
Los MMRC utilizan esta definición para determinar si una muerte que revisan se puede
prevenir.

The United States employs two national approaches to maternal mortality surveillance and
reporting: The CDC's National Vital Statistics System (NVSS) and the Pregnancy Mortality
Surveillance System (PMSS). The NVSS provides MMRs for national and international use
based on information provided in death certificates and follows the WHO guidelines using
death certificate information; late maternal deaths (occurring 43 days to one year
postdelivery) are not included in these guidelines. The PMSS performs epidemiologic
surveillance of pregnancy-related deaths; in the United States, all states voluntarily submit
deidentified death certificate data for females ages 12 to 55 who died within one year of
pregnancy, linked birth or fetal death certificates, and additional sources of data, when
available [10]. Medical epidemiologists review the data to determine if a pregnancy-related
death has occurred. For each pregnancy-related death, the PMSS includes pregnancy
outcome, associated conditions, demographic, and obstetric variables.

METHODOLOGY
The absence of high-quality, population-based data is one of the challenges of measuring
maternal mortality [11-13]. Maternal deaths are relatively rare events, even in countries
where maternal mortality rates are high. Thus, large sample sizes are needed to estimate
both maternal mortality risks and contributors to maternal deaths.

Globally, several measures and surveillance methods are used to ascertain the magnitude of
maternal mortality in a given region. These include medical certification in vital registration,
household surveys (including sisterhood method), census records, and reproductive age
mortality studies (RAMOS) [6]. Although many of these methods are imprecise, they provide
some baseline information on the causes and magnitude of maternal deaths.

Resource-limited countries often apply their limited resources toward implementation of

processes to decrease maternal mortality rather than toward improvement of surveillance
programs. Resource-rich countries have more options. In the United States, the Centers for
Disease Control and Prevention's Pregnancy Mortality Surveillance System combines data
from state health departments, maternal mortality review committees, media, and individual
providers, in addition to death certificates, to provide the best available assessment of
maternal mortality in the United States.

● Vital registration – Few resource-limited countries have the ability to employ vital
registration systems to assess levels and trends in maternal mortality. In resource-rich
countries, information about maternal mortality is determined primarily from vital
registrations (eg, death certificates) of deaths by causes. Nevertheless, maternal
mortalities are still underreported and frequently misclassified. In one study from the
United States, 38 percent of maternal deaths were unreported on death certificates,
and at least 50 percent of maternal deaths were unreported among patients who were
undelivered at the time of death, experienced a fetal death or therapeutic abortion,
died more than a week after delivery, or died as a result of a cardiovascular disorder
[11]. Confidential enquiries, such as the longstanding surveillance system in the United
Kingdom, are often used to determine the extent of misclassification of maternal death
[14-18].

● Direct household surveys – In areas where vital registration data are not available or
reliable, household surveys provide an alternative method of maternal mortality
assessment. However, surveys for direct estimation of maternal death are expensive
and require large sample sizes to provide statistically reliable estimates. The sisterhood
method is the most common method for household survey.

The sisterhood method asks four simple questions about survival of the respondents'
adult sisters:
 • How many sisters have you ever had, born to the same mother, who ever reached
the age 15 (or who were ever married), including those who are now dead?

• How many of these sisters reaching age 15 are alive now?

• How many of these sisters are dead?

• How many of these dead sisters died during pregnancy or during childbirth, or
during the six weeks after the end of the pregnancy?

In high-fertility populations, this approach is useful because sample size requirements

(and thus costs) can be reduced. At high levels of maternal mortality (over 500 maternal
deaths per 100,000 live births), a sample size of ≤4000 households is acceptable [19].
The method is not appropriate for use in settings where the total fertility rate is less
than four children per family; in areas of significant migration, civil strife, or war; or
where other social disruptions exist. Because deaths occurring over a large time
interval are being documented, the overall estimate of maternal mortality is
determined for a period of 10 to 12 years before the survey [19]. Although this is a
limitation, the method is still useful since maternal mortality generally changes slowly
and it provides some data for settings where there are no alternative means of
generating estimates.

Demographic health surveys may also employ the indirect sisterhood approach, which
utilizes more in-depth questions. The indirect sisterhood method relies on fewer
assumptions than the original sisterhood method but requires a larger sample size;
information gathering and analyses are also more complex. This method also does not
provide a current estimate of maternal mortality, but the greater specificity of
information allows for calculation of ratios for seven years prior to the survey.

● RAMOS – The RAMOS method involves investigation of the cause of death for all
females of reproductive age. It has been used to calculate the degree of
misclassification of maternal deaths in countries with and without well-developed vital
registration systems. Multiple methods and sources are applied to obtain a
comprehensive sample. In countries without vital registration systems, interviews with
household members and medical providers enable further classification of deaths as
possibly maternal. This method is one of the most complete determinations of
maternal deaths; however, it can be complicated and time-consuming to perform.

● Verbal autopsy – Where medical classification of cause of death is limited or

unavailable, some studies establish cause of death using verbal autopsy methodology.
However, the reliability and validity of this method for determining the cause of death
have not been established. The method may fail to address certain maternal deaths,
 such as first trimester deaths (ectopic, abortion-associated) or medical causes resulting
from complications of terminations (eg, sepsis) and indirect causes (eg, HIV infection).

● Census – Census level data may include questions on household deaths during an
established reference period followed by more detailed questions that identify
maternal deaths based on timing of death in relation to pregnancy, similar to verbal
autopsy methodology. The advantage of this method is that it can generate national
data relative to household characteristics.

● Death certificates – In the United States, a 2003 revision of the death certificate added
a pregnancy checkbox to connect death certificates and ICD-10 coding for maternal
death. The five standard questions asked in the death certificate (if female) include: (1)
not pregnant within the past year; (2) pregnant at the time of death; (3) not pregnant,
but pregnant within 42 days of death; (4) not pregnant, but pregnant 43 days to one
year before death; (5) unknown if pregnant within last year. To be classified as a
maternal mortality, the death must be related to the pregnancy and not be a result of
an accidental or incidental cause. The addition of these questions resulted in increased
ascertainment of maternal deaths, particularly late maternal deaths [20,21]. For
example, when reported with and without use of the checkbox, maternity mortality
rates in 2014 and 2015 more than doubled (20.9 versus 8.7 deaths per 100,000 live
births) [22]. Thus, caution should be exercised when comparing maternal mortality
rates calculated before and after implementation of the pregnancy checkbox, as
maternal mortality was greatly underreported prior to its implementation.

Although the revisions were recommended in 2003, they were not universally adopted
by all states until 2017, and one state does not use these standard questions [23]. The
nationwide adoption of the checkbox enabled the National Center for Health Statistics
to report a nationwide maternal mortality ratio in 2018 [22]. To further mitigate
misclassification of maternal deaths using death certificate data alone, further criteria
(eg, including decedents ages 10 to 44 years [rather than 10 to 54 years], assignment of
maternal codes to underlying cause of death if the checkbox is the only indication of
pregnancy in the death certificate) were applied [24,25].

Even with these additions, state surveillance programs suggest that maternal death is
underreported and often misclassified. For example:

• A study in Maryland found that checkboxes on death certificates were effective in

identifying deaths resulting from maternal causes but were far less effective in
identifying deaths resulting from nonpregnancy-related causes, such as homicide,
accidental death, and substance use, which represented three of the four leading
causes of pregnancy-associated death in Maryland [26].
 • An observational study of United States death certificate maternal mortality data
reported the estimated maternal mortality rate rose by nearly 27 percent between
2000 and 2014 in 48 states and the District of Columbia (maternal mortality rate per
100,000 live births: 18.8 in 2000 to 23.8 in 2014) [27]. The authors concluded that
their analysis of measurement change suggested that maternal mortality rates were
higher than reported during the early 2000s.

● Other methods – In low-income countries, other benchmark or process indicators,

such as the number of deliveries with skilled attendants and minimum (below 15
percent) cesarean birth rates, have been proposed as proxy measures for health
system progress in maternal mortality reduction efforts. (See "Approaches to reduction
of maternal mortality in resource-limited settings".)

INCIDENCE AND TRENDS

Maternal mortality ratios (MMR) worldwide for 1990 and 2015 have been compiled by the
World Health Organization, United Nations International Children's Emergency Fund
(UNICEF), United Nations Population Fund (UNFPA), World Bank Group, and the United
Nations Population Division and are available online.

Globally, the MMR was 216 maternal deaths per 100,000 live births in 2015 [1,2,8]. MMR fell
44 percent between 1990 and 2015 but with significant variation by the country’s income
level: 13 deaths per 100,000 live births in high-income countries, 180 deaths per 100,000 live
births in middle-income countries, and 479 deaths per 100,000 live births in low-income
countries [28]. Country-specific MMR estimates ranged from 3 (Finland) to 1360 (Sierra
Leone) maternal deaths per 100,000 live births. There were 24 countries with an MMR of
more than 400 maternal deaths per 100,000 live births [8].

The need for continued efforts to eliminate preventable maternal deaths is highlighted by
the gap between the Sustainable Development Goal of fewer than 70 maternal deaths per
100,000 live births globally by 2030 and the recent MMR of low-performing regions, which is
nearly 20 times the goal MMR. However, the gap can be closed, even in resource-limited
regions. As an example, from 1996 to 2015, the county-level MMRs across China, where 25
percent of all maternal deaths are due to hemorrhage, declined by an annualized rate of 8.5
percent per year (from 108.7 to 21.8 per 100,000 live births), with significant declines
reported by both developed and less-developed counties [29]. Simulation training for
management of hemorrhage has played a significant role in the reduction in maternal
mortality due to hemorrhage in China [30].

In contrast to the global trend of decreasing MMR, the Centers for Disease Control and
Prevention reports that maternal mortality in the United States has been increasing in recent
decades: from 10 deaths per 100,000 live births in 1990 to a high of 18 deaths per 100,000
live births in 2014 [3,31]. In a 2019 report from the National Center for Health Statistics, the
United States MMR was 20 deaths per 100,000 live births [24]. The MMR for non-Hispanic
Black females was 44 deaths per 100,000 live births or 2.5 times the rate for non-Hispanic
White females and 3.5 times the rate for Hispanic females.

Equally concerning, it has been estimated that up to 80 percent of maternal deaths are
preventable (see 'Risk reduction' below). Improved identification of pregnancy-related deaths
and changes in coding and classification may account for most of this rise [32-34]. However,
increases in maternal age, body mass index, and comorbidities have increased and may also
account for part of the rise. Although the cause(s) for increasing MMR are not clear, factors
that do not appear to contribute significantly to the increase include changes in the
proportion of rural females, immigration rate, cesarean birth rate, and rates of medical
conditions [35].

TIMING

Worldwide, approximately one-quarter of maternal deaths occur antepartum, another one-

quarter occur intrapartum and immediately postpartum, approximately one-third are
subacute and delayed postpartum deaths, and the remainder are late deaths [32]. In a
United States study of data from 2017 to 2019, approximately 22 percent of pregnancy-
related deaths occurred during pregnancy, 13 percent on the day of delivery, 12 percent on
days 1 to 6 postpartum, 23 percent occurred within days 7 to 42 of delivery, and 30 percent
occurred 43 days to one year after delivery [36]. Thus, more than half of maternal deaths
occurred during the postpartum period. In another study performed by the Centers for
Disease Control and Prevention (CDC) including 1480 maternal inpatient deaths from 2017
to 2019, rates of death were highest during delivery (6.1 per 100,000 hospital deliveries)
compared with postpartum (4.5) and antepartum (2.9) [37]. However, while antenatal and
postpartum hospitalizations accounted for <10 percent of all perinatal hospitalizations, they
contributed to over half (56 percent) of the inpatient deaths during these periods.

Patient safety initiatives and standardizing obstetric care for high-risk patients (eg, patient
safety bundles for maternal severe hypertension, thromboembolism, and obstetric
hemorrhage) have likely contributed to the reduction in antepartum and intrapartum
maternal deaths. Additional initiatives directed toward postpartum hospitalizations are
needed [37].

CAUSES
Overview — Circumstances leading to maternal death are both complex and multifactorial,
often involving at least four contributing factors [38] and patient/family, provider, and/or
facility delay. The "Three Delays" model has been widely applied in the global context to
understand and investigate complex social, cultural, and medical events contributing to
maternal deaths [38-40]. These delays involve:

● Delay in the decision to seek care (eg, lack of knowledge of warning signs, lack of
knowledge of symptoms requiring health care assessment, unrecognized life-
threatening illness, women needing to seek permission from family members before
obtaining care).

● Delay in arrival to an appropriate medical care facility (eg, poor or no transportation,

long distance from care facility).

● Delay in receiving adequate care once a patient arrives to the medical facility (eg, lack
of assessment resulting in misdiagnosis, delayed or ineffective treatment,
unrecognized or undertreated life-threatening condition, inadequate facilities for
severity of disease, lack of patient care coordination and poor communication between
providers). For example, in the United States, women residing in rural compared with
nonrural areas experience higher maternal mortality due to lack of access to obstetric
care or subspecialists (eg, maternal-fetal medicine specialists) [41].

This framework enables assessment of patient, provider, and social/cultural practices that
contribute to maternal death, which are key components of maternal mortality surveillance
audits [39,40].

Specific disorders

Worldwide — The proportion of maternal mortality attributable to various causes varies

worldwide. In a systematic analysis performed by the World Health Organization in 2014, the
leading causes of maternal death were [7]:

● Obstetric hemorrhage (27 percent)

● Hypertensive disorders (14 percent)
● Pregnancy-related sepsis (11 percent)
● Abortion (8 percent)
● Embolism (3 percent)
● Other direct causes (10 percent; complications of delivery, obstructed labor, and all
other direct causes)
● Indirect causes (28 percent; preexisting medical disorders, HIV-related maternal
deaths, and all other indirect causes)
In subgroup analysis of the "other direct causes" of death, complications of delivery and
obstructed labor each accounted for 2.8 percent of all maternal deaths. Obstructed labor as
a cause of death was much more common in resource-limited than resource-rich regions
(2.9 versus 0.6 percent of all maternal deaths). Among "indirect causes of death," preexisting
medical conditions accounted for 14.8 percent and HIV for 5.5 percent of all maternal
deaths. Although an analysis of the preexisting medical disorders was not performed, an
earlier systematic review noted that cardiovascular disease was the most common medical
condition among the indirect causes of maternal death [42].

Obesity, which is increasing in prevalence globally, contributes to an increased risk for

venous thromboembolism-related maternal death and deaths associated with cesarean
birth, preeclampsia, and cardiovascular disease [17].

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus the
causes coronavirus disease 2019 (COVID-19) has become a new cause of maternal mortality
worldwide. In a cohort study including 43 institutions in 18 countries evaluating the risks
associated with COVID-19 on maternal and neonatal outcomes, pregnant patients with (706
patients) versus without (1424 patients) a diagnosis of COVID-19 were at higher risk for
preeclampsia/eclampsia (relative risk [RR] 1.8, 95% CI 1.3-2.4), infection requiring antibiotic
therapy (RR 3.4, 95% CI 1.6-7), intensive care unit admission (RR 5.1, 95% CI 3.1-8.1), and
maternal mortality (RR 22.3, 95% CI 2.9-1.7) [43]. In addition, asymptomatic women with a
diagnosis of COVID 19 remained at higher risk for maternal morbidity (RR 1.2, 95% CI 1-1.5)
and preeclampsia (RR 1.6, 95% CI 1-2.6).

Further discussion regarding COVID-19 and pregnancy, and vaccines to prevent SARS-CoV-2
infection are discussed in detail separately. (See "COVID-19: Overview of pregnancy issues".)

United States — The Centers for Disease Control and Prevention (CDC) issued a report
using data from over 1000 maternal deaths from 36 states from 2017 to 2019 and reported
the causes of pregnancy-related death including pregnancy and up to one year postpartum;
more than 80 percent of such deaths were determined to be preventable [36].

The most common causes of pregnancy-related death were [36]:

● Mental health conditions (eg, deaths of suicide, overdose/poisoning related to

substance use disorder; 22.7)
● Hemorrhage (13.7 percent)
● Cardiovascular conditions (12.8 percent)
● Infection (9.2 percent)
● Embolism (8.7percent)
● Cardiomyopathy (8.5 percent)
● Hypertensive disorders of pregnancy (6.5 percent)
 ● Amniotic fluid embolism (3.8 percent)
● Injury (eg, homicide, overdose/poisoning deaths not related to substance use disorder;
3.6 percent)
● Cerebrovascular accidents (2.5 percent)

These data are the first to be released under the Enhancing Reviews and Surveillance to
Eliminate (ERASE) Maternal Mortality program and reflect an updated, more robust set of
data, with information from more Maternal Mortality Review Committees (MMRCs) than ever
before.

The causes of maternal death have shifted in frequency since recording began in 1987
[31,33,44-46]. When compared with maternal mortality data from prior to 2017, data from
2017 onward indicate there has been an increase in deaths from mental health conditions
(eg, suicide, opioid use disorder) and hemorrhage, but a reduction in deaths from
cardiovascular disease, hypertensive disorders of pregnancy, pulmonary embolism, and
cardiomyopathy [10,31,44,45,47].

Furthermore, racial differences in the causes of maternal death exist. In the CDC report
discussed above, Black patients had a higher proportion of deaths from cardiac and
coronary conditions, while White patients had more deaths from mental health conditions
[36]. Differences in causes of maternal mortality are also seen in patients who identify as
American Indian or Alaska Native. In a separate CDC report, American Indian and Alaska
Native patients had a higher proportion of deaths from mental health conditions and
hemorrhage; however, the data are limited because of the small number of patients
included [48].

As discussed above, trauma (eg, suicide, homicide, motor vehicle accidents, homicide) is a
major contributor to maternal mortality but is excluded as a cause from the calculation of
most national maternal mortality ratios [6,49-53]. In addition to the CDC study reported
above [36], representative studies include:

● In an analysis of the 2018 to 2019 National Center for Health Statistics database,
homicide-related maternal deaths were a leading cause of pregnancy-associated
deaths with 3.6 homicides per 100,000 live births during pregnancy or within one year
postpartum and 2.2 homicides per 100,000 live births up to 42 days postpartum [54].
The prevalence of pregnancy-associated homicide was highest among non-Hispanic
Black females and females <25 years of age. Overall, pregnancy was associated with a
nearly doubled risk for homicide among non-Hispanic White and non-Hispanic Black
females ages 10 to 24.

● In a cross-sectional analysis including pregnancy-related deaths from 2008 to 2017 and

reviewed by 14 maternal mortality review committees (MMRCs), there were 421
 pregnancy-related deaths of which 46 (11 percent) were due to maternal mental health
conditions including suicide (63 percent), unintentional poisonings/overdoses (24
percent), and other means or fatal injuries (13 percent) [55]. These deaths were most
likely to occur in non-Hispanic White females (86 percent) and between 43 and 365
days postpartum (63 percent). All pregnancy-related maternal mental health deaths
were deemed preventable.

● In an analysis from the National Violent Death Reporting System examining deaths
during pregnancy and up to one year postpartum among females ages 15 to 54 from
16 states reporting complete data from 2003 to 2007, there were 94 pregnancy-
associated suicides and 139 pregnancy-associated homicides, yielding maternal death
rates of 2.0 and 2.9 deaths per 100,000 live births [56].

● An MMRC review from Colorado from 2004 to 2012 reported self-harm (eg, accidental
overdose, suicide) was the leading cause of pregnancy-associated death [57]. Of the
211 maternal deaths, 63 (30 percent) were classified as self-harm of which the majority
(90 percent) occurred postpartum and were associated with substance use and/or
psychiatric disorders (depression being the most common). The pregnancy-associated
mortality ratio was 34 per 100,000 live births. Pregnancy-associated maternal death
ratios for overdose and suicide were 5 and 4.6 per 100,000 live births, respectively.

● In a retrospective study including over 11,700 pregnancy-associated deaths from 2010

to 2019 in the United States, drug-related deaths, suicide, and homicide accounted for
22 percent of the pregnancy-associated deaths [58]. All three causes of death increased
in frequency during the study period.

Specific disorders that may lead to maternal death are discussed in detail separately:

● (See "Pregnancy in women with congenital heart disease: General principles".)

● (See "Acquired heart disease and pregnancy".)
● (See "Peripartum cardiomyopathy: Etiology, clinical manifestations, and diagnosis" and
"Peripartum cardiomyopathy: Treatment and prognosis".)
● (See "Sudden cardiac arrest and death in pregnancy".)
● (See "Critical illness during pregnancy and the peripartum period".)
● (See "Overview of postpartum hemorrhage".)
● (See "Deep vein thrombosis in pregnancy: Epidemiology, pathogenesis, and
diagnosis".)
● (See "Deep vein thrombosis and pulmonary embolism in pregnancy: Prevention".)
● (See "Treatment of hypertension in pregnant and postpartum patients".)
● (See "Preeclampsia: Antepartum management and timing of delivery".)
● (See "Eclampsia".)
● (See "Amniotic fluid embolism".)
 ● (See "Acute respiratory failure during pregnancy and the peripartum period".)
● (See "Initial evaluation and management of major trauma in pregnancy".)
● (See "Anesthesia for cesarean delivery".)

MAJOR DEMOGRAPHIC RISK FACTORS

Race and ethnicity — There is significant disparity in maternal mortality in the United

States for Black females compared with White females and females of other races, and this
disparity appears to be worsening [31,35,44,47,59,60]. The Centers for Disease Control and
Prevention's (CDC) Pregnancy Mortality Surveillance System reported that, from 2011
through 2015, the pregnancy-related mortality ratio (PRMR) per 100,000 live births were
approximately 3.3 and 2.5 times higher for Black and American Indian/Alaska Native (AI/AN)
females, respectively, compared with White females (42.8 for Black females, 32.5 for AI/AN
females, 14.2 for Asian/Pacific Islander females, 13 for White females, and 11.4 for Hispanic
females) [31].

Subsequent reports confirm this finding [61,62]. In an expanded analysis from 2007 to 2016,
the PRMR for Black and AI/AN women ≥30 years of age were four to five times greater than
those for White women [61]. Mortality differences persisted at all education levels, which
suggests that factors beyond education are involved. Among women with a college
education or higher, the PRMR for Black women was 5.2 time that of White women. This
racial disparity is one of the largest perinatal health disparities in the United States and does
not appear to be related to changes in data collection [31,63,64] (see 'Methodology' above).
Similarly, in an analysis of 2016 to 2017 vital statistics mortality data, the all-cause maternal
mortality ratio was over three times higher for non-Hispanic Black females than for non-
Hispanic White females (mortality rate ratio [MRR] 3.55, 95% CI 2.94-4.28); the MRR for the
four most common causes of death were, in descending order [62]:

● Eclampsia and preeclampsia (MRR 5.06, 95% CI 3.16-8.21)

● Postpartum cardiomyopathy (4.86, 95% CI 2.93-8.12)
● Obstetric embolism (2.58, 95% CI 1.55-4.23)
● Obstetric hemorrhage (2.27, 95% CI 1.22-4.11)

Although increasing educational and socioeconomic levels and prenatal care are protective
against maternal death, at all educational and socioeconomic levels, PRMR for Black women
are three to five times higher than ratios for White women, and the reduction in maternal
death associated with prenatal care is greater for White women than for Black women who
receive prenatal care [61,63,65]. Although PRMR increase with maternal age for all women,
Black women aged ≥25 years have a fourfold greater risk of dying from pregnancy than
White women, and the excess risk of death is highest among Black women aged 40 years or
older [44,61].
Social and structural determinants rather than biological factors contribute to these racial
inequities and the disparity gap between Black and White individuals [66]. A disparity bundle
has been added to the Alliance for Innovation on Maternal Health (AIM) safety bundle to
address this disparity gap [67,68].

Maternal mortality and severe morbidity are also higher among non-White women in the
United Kingdom and Canada [17,69-71]. Similar findings have been observed globally in
countries where ethnicity and immigrant status are included in national surveillance systems
and studies of adverse maternal health outcomes [13,72-74]. (See "Racial and ethnic
disparities in obstetric and gynecologic care and role of implicit biases".)

Younger and older maternal age — Several studies have linked younger and older
maternal age with an increased risk of maternal mortality [31,75-80]; patients must be
counseled about these risks during preconception counseling visits.

● Younger maternal age – A large international multicenter study found that

adolescents had a higher maternal mortality ratio (MMR; 260 maternal deaths per
100,000 live births) compared with females ages 20 to 24 years, who had the lowest
MMR (190 maternal deaths per 100,000 live births) [76]. However, age-specific MMRs
varied among countries and regions; in Southeast Asia, for example, adolescents had
the lowest MMR of any age group.

● Older maternal age – In the large international multicenter study mentioned above,
females >35 years had a higher MMR compared with females in any younger age group
(>700 maternal deaths per 100,000 live births) [76]. In a second study, females ages ≥45
compared with females <35 years had a higher risk of death (odds ratio [OR] 9.90, 95%
CI 5.6-15.98); cardiac events, including heart failure and myocardial infarction, were the
primary contributing factors (OR 8.42, 95% CI 6.48-10.93 and OR 21.38, 95% CI 11.46-
39.88, respectively) [79].

In a United Kingdom database study of maternal deaths for women age ≥35 years,
each additional one-year increase in age was associated with a 12 percent increased
odds of maternal death [81]. Adjusted risk factors associated with increased likelihood
of death included, in descending order:

• Inadequate use of antenatal care (adjusted OR [aOR] 23.62, 95% CI 8.79-63.45)

• Medical comorbidities (aOR 5.92, 95% CI 3.56-9.86)
• Previous complication of pregnancy (aOR 2.06, 95% CI 1.23-3.45)
• Maternal smoking during pregnancy (aOR 2.06, 95% CI 1.13-3.75)

Furthermore, causes of maternal mortality in older females may differ from that of
younger females. In the United States, the leading cases of maternal mortality for
 females ≥35 compared with <35 years between the years 2016 to 2017 included, in
descending order [80]:

• Obstetric hemorrhage (increased risk: approximately fourfold)

• Postpartum cardiomyopathy (threefold)
• Obstetric embolism (twofold)
• Eclampsia/preeclampsia (twofold)
• Other complications of obstetric surgery (twofold)

RISK REDUCTION

Forty to 80 percent of maternal deaths are considered preventable [31,36,38,82-84]. One

report suggested the following interventions to reduce maternal mortality, in order of
significance [85]:

● Family planning with birth spacing and contraception (30 percent reduction)
● Safe abortion (13 percent reduction)
● Hemorrhage prevention and treatment (8 to 9 percent reduction)
● Cesarean section when indicated (7 percent reduction)
● Prevention of eclampsia and treatment of preeclampsia (7 percent reduction)

General approach — In the United States, deficient medical care, medical comorbidities,
structural barriers and social determinants of health appear to be strong contributors to
maternal mortality, especially for Black women who continue to have a higher case-fatality
rate than White women (see 'Race and ethnicity' above). In the United States, better use of
resources, rather than increase of resources, is a major focus for reducing maternal
mortality. Efforts have focused on team and individual training; simulations and drills;
development of protocols, guidelines, and checklists; use of information technology; and
education [86-89]. The goal of many of these activities is to achieve early diagnosis and
appropriate medical care of pregnancy complications [82]. (See "Reducing adverse obstetric
outcomes through safety sciences" and "Safety in the operating room".)

For example, hospitals can implement multidisciplinary (eg, obstetric providers, anesthesia,
nursing) huddles to assess and review each obstetric patient's risk factors, identify those at
high risk for complications, and develop a shared mental model of how the needs of those
patients can be met [90]. Huddles among the surgeon, anesthetist, nurses, and scrub
technicians for all patients undergoing scheduled or nonurgent cesarean deliveries develop
shared understanding of the patient and the procedure and clarify what additional resources
might be needed for the surgery, especially in the event of an unexpected complication. As
part of this process, safety concerns that are identified should be communicated to the
patient. Shared decision making by the patient and the obstetric team may reduce any
potential institutional biases that affect disparities in maternal morbidity and mortality.

Discharge planning and postpartum follow-up are essential for women with obstetric near-
miss morbidity. For example, guidelines for follow-up of women with preeclampsia,
especially those with severe features, should include blood pressure surveillance for up to 72
hours and at seven days, depending on severity [91]. In addition, the American College of
Obstetricians and Gynecologists (ACOG) recommends that all postpartum patients have an
initial encounter within three weeks after delivery followed by a comprehensive visit
between four and 12 weeks postpartum and ongoing follow-up as needed [92]. (See
"Overview of the postpartum period: Normal physiology and routine maternal care", section
on 'Follow-up visits'.)

CMQCC — The California Maternal Quality Care Collaborative (CMQCC) was formed as a

public-private partnership to lead maternal quality improvement activities. The CMQCC's
review of 207 pregnancy-related deaths in California concluded there was a good-to-strong
chance that 41 percent could have been prevented and that 60 to 70 percent of deaths
related to hemorrhage and preeclampsia could be prevented [93]. Based on these and other
data, they initiated several activities, including linking public health surveillance to actions;
mobilizing a broad range of public and private partners; developing a rapid-cycle Maternal
Data Center to support and sustain quality improvement initiatives; and implementing a
series of data-driven, large-scale quality improvement projects [94]. These interventions
have been associated with a 50 percent reduction in maternal deaths (three-year average of
7 maternal deaths per 100,000 live births) at a time when maternal deaths in other states
were increasing.

Key clinical and systems issues are rapid and systematic responses to (1) hemorrhage, (2)
severe hypertension, and (3) infection/fever/sepsis. The CMQCC has created toolkits to help
providers reduce morbidity/mortality from obstetric hemorrhage, preeclampsia, venous
thromboembolism, and cardiovascular disease, as well as to reduce cesarean birth rates and
eliminate early elective deliveries. Other potential areas to reduce risk for maternal death
include improvements in preconception counseling and pregnancy care (eg, availability of
tertiary care, multidisciplinary care, specialized equipment) for women with medical
comorbidities, including obesity [82,95].

AIM — The Alliance for Innovation on Maternal Health (AIM), a collaboration led by ACOG
and involving 30 other organizations representing the spectrum of women's health care, has
helped to implement consistent maternity care practices by creating bundles of best
practices for improving safety in maternity care. The bundles help clinicians, the obstetric
team, and facilities consistently manage the care of high-risk pregnant women, and include:

● Maternal venous thromboembolism prevention

 ● Postpartum care basics for maternal safety
● Obstetric care for women with opioid use disorder
● Obstetric hemorrhage
● Reduction of peripartum racial/ethnic disparities
● Safe reduction of primary cesarean birth
● Severe hypertension in pregnancy
● Severe maternal morbidity review
● Support after a severe maternal event
● Maternal mental health: Depression and anxiety

A transition-to-care postpartum AIM bundle from hospital discharge to postpartum follow-

up is under development. This is important to improving postpartum follow-up especially for
patients with pregnancy complications and those with near-miss maternal morbidity.

Maternal mortality review committees — Maternal mortality review committees (MMRCs)

use multiple sources of data from clinical and nonclinical sources (eg, vital records, social
services information, police reports) to perform in-depth reviews to determine the following:
(1) Was the death pregnancy-related? This determination is based on the response to the
question, "Would she have died if she had not been pregnant?" After review of multiple data
sources, if the answer to that question is no, the death is considered pregnancy related. The
committees then address additional questions: (2) What was the underlying cause of death?,
(3) Was the death preventable?, (4) What were the factors that contributed to the death?, (5)
What are the recommendations and actions that address those contributing factors?, and (6)
What is the anticipated impact of those actions if implemented? [38]. They also determine
factors that contributed to death (eg, patient/family, provider, facility, systems of care, or
community), and analyze the impact of social determinants of health on maternal outcomes
[96]. MMRCs must be multidisciplinary and include health care providers beyond
obstetrician-gynecologists, such as emergency medicine clinicians, pathologists,
cardiologists, psychiatrists/mental health providers, advocacy groups, and violence/injury
prevention specialists.

Recommendations for maternal mortality reduction in resource-rich countries are based, in

part, on confidential inquiries of maternal deaths and evaluations of maternal deaths and
severe maternal morbidities by MMRCs [31,84,97,98]. Their findings can enable development
of referral systems for appropriate transfer or consultation, in addition to providing
education and feedback on management of scenarios or cases that result in high near-miss
maternal morbidity and/or mortality. To facilitate discussions, the proceedings of
committees reviewing severe maternal morbidities and maternal mortalities should have
protection by state statute to shield them from liability or discovery. At least one review has
suggested that the process of confidential inquiry and resultant change in clinical
management have contributed to the substantial reduction in maternal mortality in the
United Kingdom over the past 60 years (from 200 deaths in England and Wales in 1952 to
1954 to 3 deaths in the entire United Kingdom from 2013 to 2015) [99].

In 2018 the United States Preventing Maternal Deaths Act established federal legislation for
states to create MMRCs to review all maternal deaths. The legislation authorizes the Centers
for Disease Control and Prevention (CDC) to assist states to create or expand MMRCs, collect
consistent data to help understand what causes maternal mortality, and recommend locally
relevant strategies for state Departments of Public Health to prevent pregnancy deaths and
reduce disparities. The legislation asked for a follow-up report to Congress on maternal
mortality data to track successes and setbacks. Finally, Congress asked the Department of
Health and Human Services to research disparities in maternal health outcomes.

After review of data from nine MMRCs in the United States, the authors of a 2018 report
recommended the following interventions to reduce maternal deaths and estimated their
potential impact, which varies by cause of death:

● Large impact likely:

• Adopt levels of maternal care/ensure appropriate level of care determination

• Improve policies regarding prevention initiatives, including screening procedures
and substance use prevention or treatment programs
• Enforce policies and procedures
• Improve policies related to patient management, communication and coordination
between providers, and language translation
• Improve access to care

● Small to medium impact likely:

• Improve patient management for mental health conditions

• Improve training
• Improve standards regarding assessment, diagnosis, and treatment decisions
• Improve procedures related to communication and coordination between providers
• Improve patient/provider communication

To build upon this momentum, the CDC has expanded its investment in efforts to eliminate
preventable maternal mortality, with awards to support MMRCs in 39 states and one US
territory [100].

Recommendations of national organizations — Recommendations of selected national

organizations are described below.

● ACOG has developed many resources for its members regarding patient safety [101]
and maternal mortality [102]. ACOG also supports use of Maternal Health Compacts in
 which a tertiary care hospital provides services to its referring lower-resource hospitals
for high-risk patients [103]. The connection can be activated by lower-resource
hospitals, especially in rural areas, to get immediate consultation in the event of an
unexpected obstetric emergency whose care demands exceed their resources. The
tertiary hospital may also run simulations of obstetric emergencies and assist with
quality-improvement activities.

● Joint Commission – The United States Joint Commission suggestions to help hospitals
reduce the risk of maternal death include [97]:

• Good communication between all members of the health care delivery team,
consultants, the patient, and the patient's family.

• Education of clinicians about the potential additional risks in pregnant women with
underlying medical conditions. These risks should be discussed during
preconception care and counseling, and appropriate contraception should be
offered. High-risk patients should be referred to obstetricians with expertise in and
resources for caring for these patients.

• Development of written protocols and drills for promptly responding to changes in

maternal vital signs with best practices. Common scenarios are management of
severe hypertension or hypotension, treatment of pulmonary edema in
preeclampsia, and early response to postpartum hemorrhage.

• Instituting measures (pneumatic compression devices, low molecular weight

heparin) to reduce the frequency of pulmonary embolism in high-risk patients.

Hospitals should review and report severe maternal morbidities [104]. In addition, they
should collect data on race/ethnicity and institute processes for individual providers
and teams to recognize and address implicit bias and the impact of social determinants
of health on maternal outcomes [67].

● UK Confidential Enquiries Commission – The Eighth Report of the Confidential

Enquiries into Maternal Deaths in the United Kingdom had similar recommendations as
those described above, and also included [83]:

• Access to professional interpreter services for ethnic minorities

• Emphasis on prevention and treatment of infection
• Consistent reporting of serious incidents and maternal deaths
• Performance of autopsies by pathologists with expertise in this area

Resource-limited countries — Specific recommendations for reducing maternal mortality

in resource-limited countries are discussed in detail separately. (See "Approaches to
reduction of maternal mortality in resource-limited settings".)

SUMMARY AND RECOMMENDATIONS

● Incidence – Maternal mortality ratios (MMR) worldwide are available online. In contrast
to the global trend of decreasing MMR, maternal mortality in the United States has
been increasing in recent decades. (See 'Incidence and trends' above.)

● Timing – Worldwide, approximately one-quarter of maternal deaths occur antepartum,

another one-quarter occur intrapartum and immediately postpartum, and the
remainder occur up to one year postpartum. (See 'Timing' above.)

● Causes – According to the World Health Organization, the leading causes of maternal
death worldwide are (see 'Worldwide' above):

• Obstetric hemorrhage (27 percent)

• Hypertensive disorders (14 percent)
• Pregnancy-related sepsis (11 percent)
• Abortion (8 percent)
• Embolism (3 percent)
• Other direct causes (10 percent; complications of delivery, obstructed labor, and all
other direct causes)
• Indirect causes (28 percent; preexisting medical disorders, HIV-related maternal
deaths, and all other indirect causes)

● Risk factors

• Race and ethnicity – In the United States, Black, American Indian, and Alaska
Native women have higher maternal mortality compared with White women. (See
'Race and ethnicity' above.)

• Older age – Pregnant patients of all races ages ≥45 years compared with <35 years
are at greater risk for cardiac maternal mortality. (See 'Younger and older maternal
age' above.)

● Risk reduction – Forty to 80 percent of maternal deaths are considered preventable.

(See 'Risk reduction' above.)

• In the United States, deficient medical care, medical comorbidities, and social
determinants of health appear to be strong contributors to maternal mortality. As
such, better use of resources rather than lack of resources is a major focus for
reducing maternal mortality. Efforts have focused on team and individual training;
 simulations and drills; development of protocols, guidelines, and checklists; use of
information technology; and education. The goal of many of these activities is to
achieve early diagnosis and appropriate medical care of pregnancy complications.
Strategies that address implicit bias and social determinants of health focus on
reducing racial and ethnic disparities in maternal mortality. (See 'Risk reduction'
above.)

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Topic 6713 Version 63.0

Contributor Disclosures
Haywood L Brown, MD Consultor/Juntas asesoras: Cook Medical [hemorragia posparto]; Acceso a la
Coalición Ampliada de Detección de Portadores [Pruebas prenatales]. Otro interés financiero:
Colaborador del Manual Merck. Todas las relaciones financieras relevantes enumeradas han sido
mitigadas. Maria J Small, MD, MPH No hay relación(es) financiera(s) relevante(s) con compañías no
elegibles para revelar. Lynn L Simpson, MD No hay relación(es) financiera(s) relevante(s) con
compañías no elegibles para revelar. Alana Chakrabarti, MD No hay relación(es) financiera(s)
relevante(s) con compañías no elegibles para revelar.

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