Maternal death

Maternal death is the death of a woman while pregnant or within 42 days of the end of pregnancy, regardless of the duration and site of the pregnancy or outcome 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 death and maternal mortality mean the same thing.

Maternal deaths are divided into two categories, direct and indirect.

• Direct maternal deaths are those resulting from obstetric complications of pregnancy or its management.
• Indirect maternal deaths are those resulting from diseases or conditions that were not due to a direct obstetric cause, but were aggravated by the physiologic effects of pregnancy. Deaths considered to be causally unrelated to pregnancy are classified as coincidental.

To facilitate the identification of maternal deaths in circumstances in which cause of death attribution is inadequate, a new category has been introduced:

• Pregnancy-related death is defined by the World Health Organization as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death ¹. According to the Centers for Disease Control and Prevention (CDC), a pregnancy-related death can happen during pregnancy, at delivery, and even up to a year afterward (postpartum) ².
• Pregnancy-related death can happen up to a year after delivery:
  • 31% of pregnancy-related deaths occur during pregnancy,
  • 36% occur during delivery and up to 1 week afterward, and
  • 33% occur 1 week to 1 year after delivery.
• Pregnancy-related death covers a longer period of time than maternal death. And researchers use different methods to identify a death as pregnancy-related or maternal. The differences between pregnancy-related death and maternal death are important to health care providers and other people who keep track of patterns and trends to help scientists understand more about why women die from conditions related to pregnancy. Because pregnancy-related death covers a longer period of time after pregnancy, it helps scientists learn about and prevent these deaths for more women.

These deaths may be caused by:

• A health condition (like heart disease) that you had before pregnancy that gets worse because of pregnancy
• A pregnancy complication, like preeclampsia (a serious blood pressure condition that can happen after the 20th week of pregnancy or after giving birth)
• Treatment you get during pregnancy

A death isn’t a maternal death or a pregnancy-related death if it happens as an accident, like from a car crash or a fall.

Live birth refers to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life – e.g. beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles – whether or not the umbilical cord has been cut or the placenta is attached. Each product of such a birth is considered live born.

According to the Centers for Disease Control and Prevention (CDC), every pregnancy-related death is tragic, especially because about 60% are preventable ². About 3 in 5 pregnancy-related deaths could be prevented. Still, about 700 women die each year from complications of pregnancy. A pregnancy-related death can happen during pregnancy, at delivery, and even up to a year afterward (postpartum).

Pregnancy-related death rate for 2011-2015:

• about 1/3 of deaths (31%) happened during pregnancy;
• about 1/3 (36%) happened at delivery or in the week after; and
• about 1/3 (33%) happened 1 week to 1 year postpartum.
• Heart disease and stroke caused more than 1 in 3 deaths (34%). Other leading causes of death included infections and severe bleeding.
• Black and American Indian/Alaska Native women were about 3 times as likely to die from a pregnancy-related cause as White women.

Pregnancy-related death key findings

• From 2011-2015, of pregnancy-related deaths:
  • Nearly 1/3 (31 percent) happened during pregnancy.
  • Just over 1/3 (36 percent) happened at delivery or in the week after.
  • Exactly 1/3 (33 percent) happened 1 week to 1 year postpartum.
• Leading causes of death differed throughout pregnancy and after delivery.
  • Heart disease and stroke caused more than 1 in 3 deaths overall.
  • Obstetric emergencies, like severe bleeding and amniotic fluid embolism (when amniotic fluid enters a mother’s bloodstream), caused most deaths at delivery.
  • In the week after delivery, severe bleeding, high blood pressure, and infection were most common.
  • Cardiomyopathy (weakened heart muscle) was the leading cause of deaths 1 week to 1 year after delivery.

Who is at risk for pregnancy-related death?

About 700 women die each year in the United States from complications during or after pregnancy. Black and American Indian/Alaska Native women in this country are about 3 times as likely to die from pregnancy-related causes than white women. This difference may be because of social determinants of health. These are conditions in which you’re born and grow, work, live and age that affect your health throughout your life. For example:

• Things in your environment, like clean water and exposure to harmful chemicals
• What’s in your community, like housing, parks, schools and public transportation. It also includes influences on your community, like the police, laws, poverty and racism.
• Relationships with your partner, family and friends
• Your health and health care
• Your education and income

The risk of pregnancy-related death also increases with age. In the United States, women age 35 to 39 are about two times as likely to die from pregnancy-related causes than women age 20 to 24. The risk for women who are 40 and older is even higher ³.

The rate of pregnancy-related death in the U.S. has increased over the last 25 years and continues to rise. This increase may be because more pregnant women have health conditions like high blood pressure and diabetes that may increase the risk of complications during pregnancy. High blood pressure is when the force of blood against the walls of the blood vessels is too high. It can stress your heart and cause problems during pregnancy. Diabetes is a medical condition in which your body has too much sugar (called glucose) in your blood. This can damage organs in your body, including blood vessels, nerves, eyes and kidneys.

What is a maternal near-miss?

Some women have conditions that can cause pregnancy-related death and survive them. This is sometimes called a maternal near-miss also called severe maternal morbidity or SMM. It’s when a woman has unexpected and severe complications from labor and childbirth that cause serious short- or long-term health problems. In the United States, more women have a near-miss than die. For every death, there are about 100 women who have severe maternal morbidity. In 2014, more than 50,000 women in this country had severe maternal morbidity.

If you’ve had a near-miss, you may have lots of different feelings. You may feel like you should be happy or grateful. Or you may have trouble dealing with what happened. You may feel sad, upset, worried, scared or angry.

Some women who’ve had a near-miss have a condition called post-traumatic stress disorder (also called PTSD). This is a severe form of anxiety (strong feelings of worry or fear). PTSD may happen when you go through something shocking, scary or dangerous. If you have PTSD, you may feel stressed or scared even when you’re not in a dangerous situation.

Signs and symptoms of PTSD include:

• Serious anxiety
• Flashbacks of the event. A flashback is when you relive a traumatic (scary or troubling) event so that it feels like the event is happening again.
• Nightmares
• Physical responses (like sweating or a racing heartbeat) when you’re reminded of the event

If you think you have PTSD:

• Tell your health care provider.
• See a mental health professional. This is a person with training and education to help people with emotional or mental health conditions like PTSD. Mental health providers include social workers, therapists, counselors, psychologists, psychiatrists and psychiatric nurse practitioners. Ask your health care provider to help you find a mental health professional.
• Talk with family and friends about how you’re feeling.
• Connect with other women and families who have had experiences like yours.

Leading causes of maternal death

Leading causes of death differ throughout pregnancy and after:

• During and after pregnancy: Heart disease and stroke cause most deaths overall.
• During birth: Obstetric emergencies, like severe bleeding and amniotic fluid embolism (when amniotic fluid enters a mother’s bloodstream), cause most deaths at delivery.
• The week after giving birth: In the week after delivery, severe bleeding, high blood pressure and infection are most common.
• One week after birth to 1 year after birth: Cardiomyopathy (weakened heart muscle) is the leading cause of deaths 1 week to 1 year after delivery.

Overall, heart disease and stroke caused more than 1 in 3 (34 percent) pregnancy-related deaths. Other leading causes included infections and severe bleeding. The leading causes of death varied by timing of the pregnancy-related death ⁴.

The findings are the result of a Centers for Disease Control and Prevention analysis of 2011-2015 national data on pregnancy mortality and of 2013-2017 detailed data from 13 state maternal mortality review committees. The Centers for Disease Control and Prevention defines pregnancy-related death as the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication; a chain of events initiated by pregnancy; or the aggravation of an unrelated condition by the physiologic effects of pregnancy ⁴.

The data confirm persistent racial disparities: Black and American Indian/Alaska Native women were about three times as likely to die from a pregnancy-related cause as white women. However, the new analysis also found that most deaths were preventable, regardless of race or ethnicity.

Women in less developed countries have, on average, many more pregnancies than women in developed countries, and their lifetime risk of death due to pregnancy is higher ⁵. A woman’s lifetime risk of maternal death is the probability that a 15 year old woman will eventually die from a maternal cause. In high income countries, this is 1 in 5400, versus 1 in 45 in low income countries.

Women in less developed countries die as a result of complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy and most are preventable or treatable. Other complications may exist before pregnancy but are worsened during pregnancy, especially if not managed as part of the woman’s care. The major complications that account for nearly 75% of all maternal deaths are ⁶:

• severe bleeding (mostly bleeding after childbirth)
• infections (usually after childbirth)
• high blood pressure during pregnancy (pre-eclampsia and eclampsia)
• complications from delivery
• unsafe abortion.

The remainder are caused by or associated with infections such as malaria or related to chronic conditions like cardiac diseases or diabetes.

Heart and blood vessel conditions

Cardiomyopathy

Cardiomyopathy is a condition that affects your heart muscle. It can make your heart larger, thicker or more rigid (stiffer) than normal, so it’s harder for your heart to pump blood. Signs and symptoms of cardiomyopathy include:

• Swelling in your legs
• Fatigue (being really tired)
• Chest pressure or having a pounding, fast or fluttering heartbeat
• Fainting or feeling out of breath, dizzy or lightheaded

Heart disease

Heart disease also called cardiovascular disease. Heart disease includes conditions that affect your heart and blood vessels. They often affect the heart muscle or involve narrowed or blocked blood vessels that can lead to a heart attack or stroke. Common signs and symptoms of heart disease include:

• Chest pain, discomfort or tightness
• Dizziness or fainting
• Extreme tiredness
• Nausea (feeling sick to your stomach)
• Really fast or really slow heartbeat
• Shortness of breath
• Swelling in your legs, ankles or feet

Preeclampsia and eclampsia

Preeclampsia is a serious blood pressure condition that can happen after the 20th week of pregnancy or after giving birth (called postpartum preeclampsia). It’s when a woman has high blood pressure and signs that some of her organs, like her kidneys and liver, may not be working normally. Eclampsia is a rare and life-threatening condition. It’s when a woman with preeclampsia has seizures or goes into a coma. Tell your healthcare provider right away if you have signs or symptoms of preeclampsia, like:

• Changes in your vision
• Headache that doesn’t go away
• Nausea, vomiting or dizziness
• Pain in your upper right belly area or in your shoulder
• Sudden weight gain (2 to 5 pounds in a week)
• Swelling in the legs, hands or face
• Trouble breathing

Stroke

A stroke is when blood supply to the brain is interrupted or reduced. Stroke can happen when a blood clot blocks a blood vessel that brings blood to the brain, or when a blood vessel in the brain bursts open. Your risk of stroke increases during pregnancy. Signs and symptoms of a stroke come on suddenly and can include:

• Numbness or weakness in your face, arms or legs
• Feeling confused
• Having trouble talking and understanding what other people are saying
• Having trouble seeing or walking
• Feeling dizzy
• Having a severe headache

Thrombotic pulmonary embolism

Thrombotic pulmonary embolism is the sudden blockage of an artery in the lung. It usually happens when a blood clot in the leg travels to the lungs and blocks the flow of blood to the lungs. When a blood clot forms in a deep vein in your leg or somewhere else in your body, it’s called deep vein thrombosis (also called DVT). You’re at increased risk for thrombotic pulmonary embolism during pregnancy. Tell your  healthcare provider if you have signs or symptoms of thrombotic pulmonary embolism, including:

• Shortness of breath, chest pain and cough
• Having a fever
• Feeling dizzy or lightheaded
• Leg pain or swelling
• Having a fast heart rate
• Sweating or having clammy skin or skin that has a bluish color

Hemorrhage

Hemorrhage also called heavy bleeding. Causes of hemorrhage that can lead to pregnancy-related death include:

• Problems with the placenta, including placental abruption, placenta previa and placenta accreta, increta and percreta. The placenta grows in your uterus (womb) and supplies the baby with food and oxygen through the umbilical cord. Placental abruption is when the placenta separates from the uterus before birth. Placenta previa is when the placenta lies low in the uterus and covers all or part of the cervix. The cervix is the opening to the uterus that sits at the top of the vagina. Placenta accreta, increta, and percreta happen when the placenta grows too deeply into the wall or muscles of the uterus, or grows through the uterus. If you have vaginal bleeding during pregnancy, tell your health care provider right away. If the bleeding is severe, go to the hospital.
• Uterine rupture. This is when the uterus tears during labor. Signs and symptoms of uterine rupture include pain, bleeding, long labor and problems with the baby (called fetal distress), like having a slow heart rate during labor.
• Ruptured ectopic pregnancy. This is when an ectopic pregnancy breaks open. An ectopic pregnancy happens when a fertilized egg implants itself outside the uterus and begins to grow. An ectopic pregnancy always ends in pregnancy loss. It can cause serious problems for a woman. Most of the time, ectopic pregnancies are removed by surgery. Signs and symptoms of ectopic pregnancy include vaginal bleeding; pain in your shoulder, lower back or pelvic area (the part of your body between your stomach and your legs); and feeling dizzy or faint. If you have any of these signs and symptoms, call your provider right away.
• Retained products of conception. This is tissue from the placenta or from your baby that stays in your uterus after a pregnancy ends. Signs and symptoms include fever, bleeding, pelvic pain and tenderness of the uterus.
• Uterine atony. This is when the uterus doesn’t contract (tighten) as strongly as it should after the placenta is delivered after your baby is born. Normally, uterine contractions help stop the bleeding after the placenta separates from the uterus. But when these contractions aren’t strong enough, hemorrhage can happen. Signs and symptoms of uterine atony include heavy bleeding and not having contractions after giving birth.
• Tears in the cervix, vagina or a blood vessel in the uterus.

Infection

When you’re pregnant, your immune system isn’t as quick to respond to infections (illnesses caused by bad germs) as it was before pregnancy. So you’re more likely to get infections during pregnancy that can cause problems for you and your baby. Infections that can cause pregnancy-related death include:

• Chorioamnionitis. This is an infection of the amniotic fluid and tissue that surround a baby in the womb. Signs and symptoms of this infection include fever, fast heart rate in you or your baby, a uterus that’s tender to the touch and discharge from the vagina that smells bad.
• Flu also called influenza. The flu is a serious disease that can cause fever, chills, cough, sore throat and body aches. It’s safe to get the flu shot during pregnancy. It protects you and your baby from serious health problems during and after pregnancy.
• Genital tract infections. The genital tract includes reproductive organs, like the vulva, vagina, uterus, fallopian tubes and ovaries. Signs and symptoms of genital tract infections may include fever, chills and pain in the lower belly.
• Sepsis. Sepsis is the body’s extreme response to an infection. It can be life-threatening. Signs and symptoms of sepsis include fever, fast heart rate and fast breathing.

Non-cardiovascular medical conditions

These are medical conditions, like diabetes, kidney disease and pneumonia, that aren’t directly associated with the heart and blood vessels. You may have had the condition before you got pregnant.

Amniotic fluid embolism

This is a rare condition that can happen during or right after birth. When some of your baby’s cells or amniotic fluid gets into your bloodstream, your immune system may react. This can cause your blood to clot more than usual. Amniotic fluid is the fluid that surrounds your baby in the womb. Tell your healthcare provider if you have signs or symptoms of amniotic fluid embolism, including:

• Shortness of breath
• Feeling anxious (worried)
• Chills or a fast heart rate
• Seizures
• Bleeding from your vagina, from an incision (cut) from surgery or from the site where you have an IV (when you get fluid or medicine through a needle into a vein).

Mental health conditions

Mental health conditions affect your emotions, feelings and behaviors. They’re medical conditions that need treatment to get better. They can happen for the first during pregnancy and the postpartum period (the time right after you give birth), and they also can reoccur or happen again (called a relapse) during these times. Mental health conditions that affect pregnancy include:

• Depression also called major depression. Depression is a medical condition that causes strong feelings of sadness and a loss of interest in things you like to do. It can affect how you feel, think and act and last for a long time and can interfere with your daily life.
• Postpartum depression. Postpartum depression is a kind of depression some women get after having a baby. Depression is strong feelings of sadness, anxiety (worry) and tiredness that last for a long time after giving birth. These feelings can make it hard for you to take care of yourself and your baby.

Mental health conditions can lead to pregnancy-related death. Having an untreated mental health condition can make it hard for you to take care of yourself and your baby. You may not get the health care you need and take on unhealthy behaviors. These conditions can lead to things like substance use disorder, overdose, suicide or accidental death. Substance use disorders can happen when you use alcohol or drugs in a way that causes health problems or problems at work, school or home. An overdose is when you take too much of a drug. Overdose can cause serious medical problems and even death. Suicide is when a person kills herself.

If you think you have a mental health condition, tell your health care provider. You can get treatment to make you feel better. If you’re being treated for a mental health condition before, during or after pregnancy, talk to your provider about any medicine you take. You and your provider can work together to decide about treatment options. It’s best to talk to your prenatal care and mental health providers about a treatment plan before you get pregnant.

Maternal death prevention

Most deaths are preventable, no matter when they occur. Every death reflects a web of missed opportunities.

Factors playing a part can include:

• access to care;
• missed or delayed diagnoses;
• not recognizing warning signs.

Healthcare providers can:

• Help patients manage chronic conditions.
• Communicate with patients about warning signs.
• Use tools to flag warning signs early so women can receive timely treatment.
• During Pregnancy: Improve access to and delivery of quality prenatal care, which includes managing chronic conditions and educating about warning signs.
• At Delivery: Standardize patient care, including delivering high-risk women at hospitals with specialized providers and equipment.
• Postpartum: Provide high-quality care for mothers up to one year after birth, which includes communicating with patients about warning signs and connecting to prompt follow-up care.

Hospitals and health systems can:

• Standardize coordination of care and response to emergencies.
• Improve delivery of quality prenatal and postpartum care.
• Train non-obstetric providers to consider recent pregnancy history.

States and communities can:

• Assess and coordinate delivery hospitals for risk-appropriate care.
• Support review of the causes behind every maternal death.

Women and their families can:

• Know and communicate about symptoms of complications.
• Note pregnancy history any time medical care is received in the year after delivery.

What can you do to reduce your risk of pregnancy-related death?

Getting regular health care before, during and after pregnancy can help you and your provider identify conditions that can cause serious health problems. Learning the signs and symptoms of conditions that cause death may help you spot them early on so you can get treatment right away. Signs of a condition are things someone else can see or know about you, like you have a rash or you’re coughing. Symptoms are things you feel yourself that others can’t see, like having a sore throat or feeling dizzy.

Trust your instincts! If you’re worried about your health or your pregnancy or you have signs or symptoms of conditions that can cause problems during pregnancy, call your provider or go to the hospital. And if you know someone who’s pregnant or is a new mom, encourage them to go to their checkups and to tell their provider if they think something’s wrong. Sharing the word about how to prevent maternal death can help save moms’ lives.

If you’re planning pregnancy

• Get a preconception checkup. This is a checkup you get before pregnancy to help make sure you’re healthy when you get pregnant. Pregnancy-related death can be caused by health conditions you have before pregnancy. Finding out about them and getting treatment before you get pregnant can help prevent death.
• Tell your healthcare provider about any medicines you take. You may need to change to a medicine that’s safer for you and your baby during pregnancy. Make sure any health care provider who prescribes you medicine knows you’re trying to get pregnant.
• Protect yourself from infections. For example, talk to your provider about vaccinations (like the flu shot) that can help protect you from certain diseases. Wash your hands with soap and water after using the bathroom or blowing your nose. Stay away from people who have infections. Don’t eat raw meat, fish or eggs. Use a condom to protect yourself from sexually transmitted infections (also called STIs). And don’t touch cat poop.
• Get to a healthy weight. Eat healthy foods and do something active every day.
• Don’t smoke, or use harmful drugs. Tell your provider if you need help to quit.

During pregnancy

• Go for your first prenatal care visit as soon as you think you’re pregnant.
• Go to all your prenatal care checkups, even if you’re feeling fine. This can help your health care provider spot and treat any health problems that may affect your pregnancy.
• Tell your healthcare provider about any medicines you take. Make sure any provider who prescribes you medicine knows that you’re pregnant.
• If you’re at risk for preeclampsia, talk to your provider about taking low-dose aspirin to help reduce your risk. Preeclampsia is a serious condition that condition that can cause pregnancy-related death.
• Protect yourself from infections. For example, talk to your provider about vaccinations (like the flu shot) that can help protect you from certain diseases. Wash your hands with soap and water after using the bathroom or blowing your nose. Stay away from people who have infections. Don’t eat raw meat, fish or eggs. Use a condom to protect yourself from STIs. And don’t touch cat poop.
• Eat healthy foods and do something active every day.
• Don’t smoke, drink alcohol or use harmful drugs. Tell your provider if you need help to quit.

After pregnancy

• Tell your healthcare provider right away if you have you have any signs or symptoms of conditions that can cause pregnancy-related death. These can include chest pain, trouble breathing, dizziness and swelling in the legs, hands or face.
• If you’re worried about anything or something doesn’t seem right, call your provider.
• If you’re having a medical emergency, call your local emergency services number.

How can women’s lives be saved?

Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. All women need access to high quality care in pregnancy, and during and after childbirth. Maternal health and newborn health are closely linked. It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death for the mother as well as for the baby.

• Severe bleeding after birth can kill a healthy woman within hours if she is unattended. Injecting oxytocics immediately after childbirth effectively reduces the risk of bleeding.
• Infection after childbirth can be eliminated if good hygiene is practiced and if early signs of infection are recognized and treated in a timely manner.
• Preeclampsia should be detected and appropriately managed before the onset of convulsions (eclampsia) and other life-threatening complications. Administering drugs such as magnesium sulfate for pre-eclampsia can lower a woman’s risk of developing eclampsia.

To avoid maternal deaths, it is also vital to prevent unwanted pregnancies. All women, including adolescents, need access to contraception, safe abortion services to the full extent of the law, and quality post-abortion care.

Why do some women not get the care they need?

Poor women in remote areas are the least likely to receive adequate health care. This is especially true for regions with low numbers of skilled health workers, such as sub-Saharan Africa and South Asia.

The latest available data suggest that in most high income and upper middle income countries, more than 90% of all births benefit from the presence of a trained midwife, doctor or nurse. However, fewer than half of all births in several low income and lower-middle-income countries are assisted by such skilled health personnel ⁷.

The main factors that prevent women in less developed countries from receiving or seeking care during pregnancy and childbirth are:

• poverty
• distance to facilities
• lack of information
• inadequate and poor quality services
• cultural beliefs and practices.

To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at both health system and societal levels.

References

1. Maternal mortality ratio (per 100 000 live births). https://www.who.int/healthinfo/statistics/indmaternalmortality/en/
2. Pregnancy-related deaths. Saving women’s lives before, during and after delivery. https://www.cdc.gov/vitalsigns/maternal-deaths
3. Maternal death and pregnancy-related death. https://www.marchofdimes.org/complications/pregnancy-related-death-maternal-death-and-maternal-mortality.aspx
4. Pregnancy-Related Deaths Happen Before, During, and Up to a Year After Delivery. https://www.cdc.gov/media/releases/2019/p0507-pregnancy-related-deaths.html
5. Maternal mortality. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
6. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels JD, et al. Global Causes of Maternal Death: A WHO Systematic Analysis. Lancet Global Health. 2014;2(6): e323-e333.
7. World Health Organization and United Nations Children’s Fund. WHO/UNICEF joint database on SDG 3.1.2 Skilled Attendance at Birth. https://unstats.un.org/sdgs/indicators/database