Hameed & Hassoun (2020): Epidemiology of maternal mortality Dec, 2020 Vol. 23 Issue 24

Epidemiological Study of Maternal Mortality in Al-Najaf Governor, Iraq

Ghufran Majeed Hameed*1; Suhair Mohammed Hassoun *2

1*Master degree students, Middle Technical University, Iraq

2*Assistant Professor Middle Technical University, Iraq

Abstract: Background: Mother's death is a tragic and traumatic event and it has a severe impact on the family, community and eventually the nation. Maternal mortality refers to the death of a woman who dies during pregnancy or within six weeks after delivery. Objectives: To determine the trend of maternal mortality, explore the main causes of maternal mortality and identify the factors associated with maternal mortality for ten years’ period in the Al-Najaf governorate/South of Iraq. Materials and Methods: A retrospective descriptive, cross-sectional study that utilized all maternal mortality data for the period from 2009 to 2018. Data were collected by using a structured questionnaire and get information from hospital records in the statistics departments and forensic medicine reports also contact the family by phone as needed. The duration of data collection continued for the period from December 2019 to March 2020. Reviewed (158) records of maternal death occurred in public hospitals of the Al-Najaf governorate.

Result: The maternal mortality ratio trend in the Al-Najaf increased sharply during 2016 (66.76/100.000 live births) compared to that of 2010 (18.34/100.000 live births). The most direct and indirect causes of maternal death were hemorrhage (26.58%) and heart diseases (13. 29%). Most of the maternal deaths were from women aged 20-24 years old (24.7%) with Mean±SD (Range) 29.5±7.4 (15-47), residence in urban areas (63.3%) with primary educational level (55.7%) and housewives (94.3%). Regarding the obstetrics characteristics, most of the maternal deaths were irregular antenatal care (62.3%), with gravidity ≥ 5 (27.5%), gestational age 36-42 weeks (66.0%), and (43.7%) terminate a pregnancy by cesarean section. Most of the death (60.1%) occurred after delivery or during the puerperium period.

Conclusions: According to the present findings, the trend line of maternal mortality was increasing during the period of the study. Hemorrhage and heart diseases are the main causes of maternal mortality. Educational level, gravidity and number of previous cesarean sections are factors increased risk of maternal mortality.

Recommendations: It is necessary to determine the trend of maternal mortality for all governorates of Iraq for different period to assist the authorities for proper decision-making and resource allocation to achieve the Millennium development goals in addition to strengthening and monitoring the registration system of maternal mortality and their exact causes in all health facilities of the Al-Najaf governorate are the main recommendations of the study.

Key words: Maternal mortality, MMR, Al-Najaf governorate

How to cite this article: Hameed GM, Hassoun SM (2020): Epidemiological study of maternal mortality in Al-Najaf Governor, Iraq, Ann Trop Med & Public Health; 23(S24): SP232426. DOI: http://doi.org/10.36295/ASRO.2020.232426

Introduction:

Maternal mortality is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes (1).Maternal mortality is considered a sentry event, reflecting the state of maternal health. The maternal mortality ratio (MMR) that expressed as the number of maternal deaths per 100.000 live births is one of the most important and globally-recognized indicators for measuring the state of a country’s, economy, culture, and healthcare system (2). Maternal mortality can be classified as direct and indirect mortality. It is well-known that the most important direct causes of maternal death are obstetrical hemorrhage, sepsis, hypertensive disorders of pregnancy, and abortion. Indirect maternal deaths are from non-pregnancy related causes which become aggravated by the pregnancy (for example cardiac diseases and respiratory

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232426 Hameed & Hassoun (2020): Epidemiology of maternal mortality Dec, 2020 Vol. 23 Issue 24

disorders) (3). Most maternal deaths can be prevented if pregnant women have access to good- quality of antenatal and postnatal care, and also if, certain harmful birth practices are avoided (4).

In Iraq, maternal mortality remains unacceptable and remained as high as 83 per 100,000 live births in 2015 (5). Sustainable Development Goals (SDGs) accepted by the global community set a target of less than 70 maternal deaths per 100.000 live births by the 2030s (6).In order to achieve that, more researches should be done to know the magnitude of maternal mortality, causes and determinants factors that influence maternal deaths in each area to aid prioritization of available resources and facilitate achieving the goals in decreasing maternal deaths in each country (7).

Objectives of study: To determine the trend of maternal mortality in Al-Najaf governorate for ten years’ period, to explore the main causes of maternal deaths and to identify the association between socio-demographic, obstetrics characteristics and maternal deaths. Materials and methods:

Study design: A retrospective descriptive, cross-sectional study that utilized all maternal mortality data for the period from 2009 to 2018.

Duration of the Study: The duration of data collection from all places of study continued for the period from December 2019 to March 2020.

Place of study: Maternal mortality data were obtained from statistical departments in the public hospitals of the Al-Najaf governorate.

Study Sample: This study used retrospective method to investigate (158) records of maternal death and included all live births for ten years.

Inclusion and Exclusion criteria of study:

Inclusion Criteria :( 1) Mothers who died while pregnant or within 42 days of termination of pregnancy. (2)Any gestational age or site of the pregnancy. (3)All causes related to or aggravated by the pregnancy or its management.

Exclusion Criteria: (1) Mothers who died to accidental and incidental causes. (2) Late maternal deaths.

Data Collection: To collect information about each maternal death case the researchers develop a structured questionnaire included the date of death and three parts: the first part concerned with the socio-demographic characteristics, the second was about obstetrics characteristics and the third part dealt with direct and indirect causes of maternal mortality. To filling the questionnaire and get all information the researcher depended on the following:

 File inpatient of each mother.  Hospital records in the statistics departments.  Records of maternal mortality in each hospital.  Forensic medicine reports.  Maternal death statistics form designated from the Iraqi ministry of health.  Contact the family by phone as needed especially when missing information was found in the medical records. Other statistical information (total number of live births for ten years in Al-Najaf governorate) obtained from Al-Najaf Health Directorate/ Statistics Department. Where multiple causes of death were recorded, the primary cause was identified and the time spent to fill the questionnaire required about 15-20 minutes. Statistical Analysis: Data was tabulated on Microsoft Office Excel 2016 and analyzed by using the available statistical package of SPSS-25 (Statistical Packages for Social Sciences- version 25). All variables were entered as categorical. The results were presented in simple measures frequencies, percentages, and descriptive summary statistics. To determine the trend of maternal deaths in Al-Najaf governorate for ten years the following measure is used:

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232426 Hameed & Hassoun (2020): Epidemiology of maternal mortality Dec, 2020 Vol. 23 Issue 24

Maternal mortality ratio (MMR) =

푵풐. 풐풇 풎풂풕풆풓풏풂풍 풅풆풂풕풉풔 (풑풓풆품. , 풍풂풃풐풓 풂풏풅 풑풖풆풓풑. ) 풊풏 풂 풔풑풆풄풊풇풊풄 풚풆풂풓 × ퟏퟎퟎퟎퟎퟎ 푻풐풕풂풍 풏풐. 풐풇 풍풊풗풆 풃풊풓풕풉풔 풊풏 풕풉풆 풔풂풎풆 풚풆풂풓 The Maternal Morality Ratio was calculated for each year and for the entire period of study and the evolution analysis was performed by the graphical representation of the trend curve.

Results and discussion:

1. The Trend of Maternal Mortality in Al-Najaf Governorate for Ten-Year Period (2009-2018)

MMRatio Linear (MMRatio)

80 70 66.76 60 50 35.14 37.17 40 31.81 28.22 30.45 30 23.03 25.09 22.56 18.34 20 10 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Figure 1: Maternal mortality ratio in Al-Najaf, 2009-2018

Figure 1 shows that maternal mortality ratio trend in Al-Najaf increased sharply during 2016 (66.76/100.000 live births) compared to that of 2010 (18.34/100.000 live births). Also, there was increasing in the trend line of MMR during the reference period in the study area. The reasons for this result are not clear but may have something to do with the relatively higher number of pregnancies and increased number of poor pregnancy outcomes in 2016 compared with 2010 or may be due to poor quality of maternal services and low socio-economic status that made women not receive required care during pregnancy period.

2. Causes of Maternal Mortality in Al- Najaf governorate (2009-2018):

Table 1 shows direct causes of mortality were presents in 100 cases with a percentage (63.3%) of maternal deaths in the Al-Najaf for the period (2009-2018), indirect causes were present in 49 cases accounting (31%) and unknown causes present in 9 cases (5.7%). Among the direct causes of maternal deaths, the majority (26.58%) was from postpartum and antepartum hemorrhage this result consistent with other studies were conducted in Iran and Iraq(8) (9). A major of these cases occurred may due to inappropriate diagnosis or delayed referral to hospitals with advanced complications such as obstructed labour, or major of these women were anemic and occurred delay in replacing blood and blood products when she needed it, also not managed properly during antenatal care. Heart diseases (13.29%) were the most common indirect causes of maternal mortality in the study. Same findings were reported in previous studies (9) (10), this may be explained a higher prevalence of chronic medical diseases that put women at risk for cardiac complications or by increasing number of women with congenital heart disease (CHD) reaching reproductive age (9).

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232426 Hameed & Hassoun (2020): Epidemiology of maternal mortality Dec, 2020 Vol. 23 Issue 24

Table 1: Causes of Maternal Mortality in Al-Najaf governorate (2009-2018).

Cause of death Frequency (n=158)

Direct Causes of death No. % Postpartum hemorrhage 24 15.19 Antepartum hemorrhage 18 11.39 Pulmonary embolism 30 18.99 Deep Vein Thrombosis 8 5.06 Amniotic fluid embolism 1 0.63 Hypertensive disorders 10 6.33 Maternal sepsis 8 5.06 Uterine rupture 1 0.63 Total 100 63.3 Indirect Causes of death No. % Heart diseases (Heart failure, Cardiomyopathy, 21 13.29 Myocardial infarction) Respiratory failure 13 8.23 Infection (Pneumonia, Gastroenteritis, Meningitis) 7 4.43 Renal failure 5 3.16 Hepatic failure 3 1.89 Total 49 31.0 Unknown causes of death 9 5.7%

3. Association between socio-demographic characteristics and causes of maternal mortality. In the table 2, the largest number of deaths occurred in the age group 20-34, largely because those are the ages at which women are most likely to give birth. The age distribution of maternal deaths is comparable with other studies (11) (12). Early marriage is one of the customs which is still widely practiced in Iraq. Consequently, early marriage leads to early pregnancy, which is one of the factors contributing to maternal mortality. A young pregnant carries a higher risk due to cephalopelvic disproportion and anemia. Among elder women, there are raised chances of diabetes, antepartum and postpartum hemorrhage (11). So efforts directed at this age group would most effectively to minimize the number of deaths. In the present study, 63.3% of mothers were from urban areas and 36.7% from rural areas. Similarity with a study of Jadhav et al., 2013(13) in their study on maternal mortality observed that 64.55% maternal deaths were from urban residence and 35.45% were from rural residence and different with results of WHO studies stating the death rates are usually higher in poor areas of the rural areas due to poverty and lack of access to health services. Regarding educational level, the study demonstrated that 55.7% of maternal deaths with primary education level and there is a significant association between educational level and cause of maternal deaths. This result agrees with studies done in Basrah and Erbil governorates confirmed that maternal mortality rates decrease with increasing educational level (7) (14). This result can be interpreted due to the educated women are more autonomous in decision making and use of perinatal services. Among the women died the result showed a high rate (94.3%) among housewives compared with very low rate were are working or students. This result is compatible with other studies including study of Al Hilfi et al. and study of Rane et al. (7) (15). This might be explained by the fact that working women have more chances to be educated and get more information about pregnancy care and how to avoid its risks. The study observed that not found a significant relationship between the age of women at death, residence, occupation, and the causes of maternal mortality. This result explained may due to a small sample and design of the study. Several studies have indicated to the role played by socio-demographic factors in maternal mortality (16).

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232426 Hameed & Hassoun (2020): Epidemiology of maternal mortality Dec, 2020 Vol. 23 Issue 24

Table 2: Association between socio-demographic characteristics and causes of maternal death

Cause of death Total P value Socio-Demographic Characteristics Direct Indirect Unknown No % No % No % No % Age at death 15---19 3 3.0 6 12.2 - - 9 5.7 0.184 (years) 20---24 23 23.0 14 28.6 2 22.2 39 24.7 25---29 26 26.0 7 14.3 - - 33 20.9 30---34 19 19.0 9 18.4 2 22.2 30 19.0 35---39 17 17.0 8 16.3 4 44.4 29 18.4 =>40y 12 12.0 5 10.2 1 11.1 18 11.4 Residence Urban 63 63.0 32 65.3 5 55.6 100 63.3 0.852 Rural 37 37.0 17 34.7 4 44.4 58 36.7 Educational Level Illiterate 17 17.0 6 12.2 3 33.3 26 16.5 0.042* Primary 62 62.0 21 42.9 5 55.6 88 55.7 Intermediate 12 12.0 17 34.7 - - 29 18.4 Secondary 6 6.0 3 6.1 1 11.1 10 6.3 College & higher 3 3.0 2 4.1 - - 5 3.2 Occupation Gov. employee 4 4.0 2 4.1 1 11.1 7 4.4 0.845 Housewife 95 95.0 46 93.9 8 88.9 149 94.3 Student 1 1.0 1 2.0 - - 2 1.3 *Significant difference between proportions using Pearson Chi-square test at 0.05 level.

3. Association between obstetrics characteristics and causes of maternal mortality. Table 3: Association between obstetrics characteristics of maternal deaths and causes of maternal deaths

Cause of death P Direct Indirect Unknown Total value Obstetrics Characteristics No % No % No % No % Antenatal care Regular 33 33.0 19 38.8 1 20.0 53 34.4 0.510 (4 missing information) Irregular 65 65.0 27 55.1 4 80.0 96 62.3 No ANC 2 2.0 3 6.1 - - 5 3.2 Gravidity 1 14 14.0 17 34.7 - - 31 20.3 0.035* (5 missing information) 2 17 17.0 9 18.4 2 50.0 28 18.3 3 26 26.0 6 12.2 1 25.0 33 21.6 4 11 11.0 7 14.3 1 25.0 19 12.4 =>5 32 32.0 10 20.4 - - 42 27.5 History of abortions Yes 14 14.0 6 12.2 - - 20 13.1 0.702 (5 missing information) No 86 86.0 43 87.8 4 100.0 133 86.9 No. of previous C/S 0 48 48.0 33 67.3 1 25.0 82 53.6 0.003* (4 missing information) 1 22 22.0 9 18.4 - - 31 20.3 2 9 9.0 3 6.1 3 75.0 15 9.8 3 14 14.0 3 6.1 - - 17 11.1 4 3 3.0 - - - - 3 2.0 =>5 4 4.0 1 2.0 - - 5 3.3 No. of previous N/V 0 36 36.0 18 36.7 2 50.0 56 36.6 0.275 (4 missing information) 1 15 15.0 10 20.4 - - 25 16.3 2 8 8.0 6 12.2 1 25.0 15 9.8 3 15 15.0 3 6.1 1 25.0 19 12.4 4 7 7.0 8 16.3 - - 15 9.8 Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232426 Hameed & Hassoun (2020): Epidemiology of maternal mortality Dec, 2020 Vol. 23 Issue 24

=>5 19 19.0 4 8.2 - - 23 15.0 Gestational age (weeks) (5 8---11w 4 4.0 7 14.3 - - 11 7.2 0.380 missing information) 12---23w 11 11.0 4 8.2 - - 15 9.8 24---31w 8 8.0 6 12.2 - - 14 9.2 32---35w 8 8.0 4 8.2 - - 12 7.8 36---42w 69 69.0 28 57.1 4 100.0 101 66.0 Mode of delivery NVD 32 32.0 16 32.7 3 33.3 51 32.3 0.134 CS 49 49.0 15 30.6 5 55.6 69 43.7 Curettage 9 9.0 5 10.2 - - 14 8.8 Other 10 10.0 13 26.5 1 11.1 24 15.2 Stage of death During 20 20.0 17 34.7 1 11.1 38 24.1 0.126 Pregnancy During labour 20 20.0 4 8.2 1 11.1 25 15.8 During 60 60.0 28 57.1 7 77.8 95 60.1 puerperium *Significant difference between proportions using Pearson Chi-square test at 0.05 level.

In table 3 showed the majority of women were not regular to visits the primary health care center and this result agree with the studies of Ministry of Health Iraq which refers the lack of ANC was the main cause of maternal mortality (14). The possible causes of irregularity, may attributed to low economic status, far the distance to the health center and poor the quality of health services provided to pregnant women. In this study a high rate (27.5%) of women who died that experienced pregnancy for five-time or more. This more dangerous and threatening the life of the mother and leads to an increase in maternal deaths. Also, gravidity significantly associated with the causes of maternal mortality agreed with a study done in Iran revealed that the risk of maternal death increased with gravidity (17) and a study was done in India 2019(15). A high rate of gravidity in the Al-Najaf community can be explained due to a high fertility rate or low awareness about family planning and use of contraceptives. Majority of maternal deaths without a history of abortion and not founded an association between this factor and maternal mortality. The possible reason for this difference might due to religious culture in Iraq that prohibits deliberate abortion compared with other countries. In the present study, the results showed about (20.3%) among women were done previous cesarean section (CS) for once time compared with (16.3%) among women were delivered by normal vaginal delivery for once time during their life. Also, there is a significant association between previous CS and cause of maternal mortality. Several studies that observed most cases of obstetric hemorrhage and emergency postpartum hysterectomy were associated with previous CS deliveries, including study of Abbood& Khudhair about maternal mortality after cesarean section in Iraq (18). About (66%) of maternal deaths within gestational age (36--42) weeks highest percentage compared to other pregnancy weeks. This result agreed with the study of Lili et al. It was found that increased age of pregnancy has led to an increased risk of maternal mortality (2).Compared to vaginal delivery, cesarean delivery is associated with hemorrhage, venous thromboembolism, and infection (18). According to the results obtained from this study cesarean section has possessed most interventions to end the pregnancy with percentage (43.7%). Could explain this result due to the surgical nature of CS and the risk of postpartum maternal death is almost three-fold higher than that associated with vaginal delivery (19). The majority of maternal deaths in the study occurred at the puerperium stage and recorded high rates along the period of study. These findings compatible with study of Baharuddin et al. that indicate the first few hours and days after giving birth are a critical period during which mothers should receive more attention from health care providers at the health facility to avoid catastrophic maternal deaths(20).

Conclusions:

The present study concluded the trend line of maternal mortality ratio in the Al-Najaf governorate was increasing during the period of the study due to many factors and causes such as deficiency of antenatal; postnatal care and increased cesarean sections rate. Hemorrhage and heart diseases are the main causes of maternal mortality in pregnant women of the Al-Najaf community for the period from 2009 to 2018. Educational level, gravidity, and a number of previous cesarean sections are factors increased the risk of maternal mortality.

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232426 Hameed & Hassoun (2020): Epidemiology of maternal mortality Dec, 2020 Vol. 23 Issue 24

Recommendations:

 It is necessary to determine the trend of maternal mortality for all governorates of Iraq for different periods to assist the authorities for proper decision-making and resource allocation to achieve the Millennium development goals.  Strengthening and monitoring the registration system of maternal mortality and their exact causes in all health facilities of the Al-Najaf governorate.  Intensive efforts can be made to improve the management of high- risk conditions at health facilities such as increasing the number of gynecologists in primary health care centers, increasing the availability of contraceptive information and counseling services.  Further studies are needed to better confirm the number, risk factors, and causes of maternal deaths by using other tools for data collection like verbal autopsy method.

References:

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Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232426