Maternal Mortality

MATERNAL MORTALITY, mortality associated with motherhood and caused by pregnancy, childbirth, and the postpartum period. Both maternal mortality and maternal morbidity have recently attracted special attention from obstetricians, pediatricians, and representatives of social hygiene. In 1927, a special commission was organized at the State Scientific Institute of Social Hygiene (to prepare materials for an international conference) to develop issues regarding the causes of general mortality. Issues of mortality in individual groups were analyzed in special subcommissions. The international nomenclature includes eight points of maternal mortality: 1) Complications of pregnancy: a) miscarriage, b) ectopic pregnancy, c) other complications of pregnancy, d) premature birth, e) bleeding in pregnant women; intractable vomiting of pregnancy, chorea of pregnancy. 2) Puerperal hemorrhage; placenta praevia, premature detachment of the placenta. 3) Other complications of the act of childbirth: pathological labor, malpresentation, perineal rupture, uterine rupture. Childbirth (without other indications) in cases ending in the mother's death. 4) Puerperal septicemia (childbed fever). 5) Puerperal venous thrombosis (phlegmasia alba dolens), postpartum and sudden embolism; death in connection with childbirth. 6) Puerperal albuminuria and eclampsia: a) postpartum albuminuria, b) eclampsia of pregnant women and women in labor, c) inflammation of the kidneys and renal pelves in pregnant women and women in labor, d) uremia of women in labor; postpartum tetanus, postpartum coma. 7) Consequences of childbirth (without other indications). Postpartum insanity. 8) Puerperal diseases of the mammary gland. This nomenclature cannot be considered final, on the one hand, because it is not strictly consistent, and on the other, because it needs greater detail and differentiation of diseases and complications of pregnancy, childbirth, and the postpartum period. The nomenclature proposed by the subcommission on obstetrics and women's diseases on January 15, 1928: Childbirth and abortions. 1. Complications of pregnancy. 2. Toxicosis of pregnancy. 3. Complications of the act of childbirth. 4. Postpartum (and post-abortion) diseases. 5. Other causes (psychoses, mastitis, etc.). In proposing the above nomenclature, the subcommission was based on the desirability of disaggregating mortality depending on diseases and complications of pregnancy, childbirth, and the postpartum period, accidental diseases, and isolating abortions into a special category. Of course, this nomenclature cannot be considered final either. Authors who have studied the causes of maternal mortality consider it possible, for the sake of simplifying accounting in practical life, to adhere to a more simplified and abbreviated nomenclature of the causes of mortality. Thus, Antonov (1928) considers it possible to accept two main causes of maternal mortality: 1) from septicemia and 2) from causes in connection with pregnancy and childbirth; Selitsky (1930), however, suggests adhering to three main groups: 1) Maternal mortality due to complications of pregnancy (e.g., toxicosis, hemorrhage), 2) Maternal mortality from postpartum diseases (so-called septic mortality), and 3) Maternal mortality from accidental diseases arising during pregnancy or worsened under the influence of the puerperal state. The latter group includes cases of mortality primarily from general acute and chronic diseases, injuries of a traumatic nature, etc. Although we encounter references to maternal mortality and attempts to clarify its causes in Russian and foreign sources as early as the 1870s and 1880s, the term maternal mortality itself was introduced relatively recently, both here and in the West. In those years, in an era of incessant, widespread epidemics of childbed fever, accompanied by colossal mortality, clinicians could not help but focus on clarifying the causal factors of postpartum diseases and the possibility of their prevention. Thus, in the reports of maternity institutions (Bidder, Hugenberger, Sutugin), the difference in the percentage of morbidity and mortality between primiparas and multiparas is noted, and the influence of age, the number of previous pregnancies, and even the importance of the physique of the women in labor is pointed out. It was statistically proven that mortality begins to gradually increase from the fifth birth, and it is highest after the ninth birth, after which twice as many die as after the first birth. Likewise, the dependence of the mortality percentage on age and its increase with advancing years was confirmed. Along the way, the influence of the duration of the woman's stay in the hospital, the influence of the total number of births in it in the sense of the possible harm of overcrowding the institution, and finally, the influence of general diseases and the mental state of the woman herself were noted. This shows that clinicians 50 years ago paid sufficient attention to the issue of maternal mortality in connection with pregnancy and childbirth, but it is quite understandable that much could not be taken into account by them due to insufficient knowledge and the lack of a preventive direction in obstetrics, and the lack of protection of motherhood and infancy. At the present time, the comprehensive study of the causes and factors of maternal morbidity and mortality is at the center of attention, as is the desire to create such conditions that not only reduce it to minimal figures, but also ensure that motherhood does not cause complications during pregnancy and childbirth, proceeds without postpartum diseases, and does not affect the subsequent life of the woman. This study is necessary because even in our time, despite the indicated shifts, maternal mortality continues to remain at a high level in all countries, and all authors who have touched upon the question of its causes unanimously note that for many decades it has remained at the same level and not only has no tendency to decrease, but in some years even an increase is observed. Campbell (1928) pointed out the need to take measures to combat maternal mortality, since under modern conditions one death is observed for every 250 births, and female morbidity due to injuries caused directly by the act of childbirth is high. It was also pointed out that maternal mortality represents a serious socio-pathological phenomenon and deserves the deepest and most thorough study, since it is not only an indicator of the state of maternity protection, but also an indicator of antenatal infant protection (Antonov, Stuke) (according to Woodbury, the mortality of children whose mothers died shortly after childbirth is almost six times higher than the mortality of children with living mothers). In the report of the League of Nations (1930), based on the latest statistical data, it is indicated that the minimum maternal mortality is 2‰. Its main causes are septic postpartum diseases and toxic processes caused by pregnancy (Tables 1 and 2). An analysis of reports from various Russian clinics and maternity institutions in different cities from the 1870s to the present day also shows what significance not only the rational organization of obstetric care and sufficient coverage of the population with it, but also the prevention of maternal morbidity and mortality during pregnancy has for the fluctuation of the percentage of maternal mortality. Especially thorough in this regard are the data of Nikitin. Nikitin, having comprehensively analyzed the material on maternal mortality in Moscow for 1914–1931, noted a definite decrease in maternal mortality in the post-revolutionary years. Undoubtedly, the noted decrease in maternal mortality in Moscow and other cities of the Union must be linked to the bringing of obstetric care closer to the population, a significant increase in the number of obstetric beds after the October Revolution compared to the pre-revolutionary period, and more in-depth preventive work in the network of consultations for women that has emerged. The concept of maternal mortality must be significantly expanded, its causes must be deeply worked out and studied, because in fact it is the result of many and diverse factors. One cannot consider maternal mortality without taking into account the environment and the situation in which the pregnant woman lives, and carry out individual preventive principles outside of this. Likewise, one cannot approach maternal mortality only from the point of view of the rational organization of maternity care alone, without taking into account the environment, working conditions, and the nature of the profession.

Based on the study of factual material (from both Russian and foreign clinics) over many years, one can come to the conclusion that maternal morbidity and mortality do not always depend on the organization of affairs in an individual institution or the current state of obstetric science, but can depend on the factors indicated above and predominantly on conditions of labor and daily life. Analysis and comparison of the percentages of maternal mortality for various years in individual institutions have shown that maternal morbidity and mortality, even with the most ideal organization of obstetric care, cannot represent a constant value, but is a value, at least under the conditions of modern reality, that is continuously fluctuating depending on a whole series of variable, combining harmful influences and factors. Differentiating maternal mortality by causes of death, Nikitin showed that, excluding postpartum infections, maternal mortality most often occurs during childbirth and least often during pregnancy. A second, no less significant factor influencing to a significant degree the fluctuations in the percentage of maternal mortality (regardless of the degree and nature of obstetric care) is a large group of diseases, which includes, firstly, general chronic and acute infections and, secondly, local inflammatory diseases of the genital sphere. Diverse processes included in this group (such as, for example, tbc, lues, chronic sepsis, typhus, scarlet fever, etc.; local processes have a lesser influence) serve not only as a direct cause of maternal mortality, but also contribute to the emergence of puerperal infection in the literal sense of this word (mortality which must be considered as "secondary septic mortality"). A special place in terms of significant influence on complications of pregnancy and the act of childbirth must be assigned to influenza and the periodically observed influenza epidemics. This influence can also be of a mass character, can serve as a cause of outbreaks of general diseases in maternity institutions, increase maternal morbidity and mortality, and furthermore influence morbidity among the staff of a given institution with all the consequences flowing from this. In this regard, the data of Vaudescal on the epidemic of severe influenza (Spanish flu) of 1916–18, during which mortality from influenza among pregnant women reached up to 40%, are interesting. To subsequent factors, one must attribute the possible harmful influence of operations undergone in the past. This influence is observed not only after operations performed directly on the genital sphere, but also on other organs of the abdominal cavity or outside it. On this issue, there are only isolated casuistic reports; it has not yet been discussed in its full breadth, and in the future, a detailing of the question and an accounting of the influence of individual operations for the purpose of prophylaxis are necessary, since clinical observations show that even such innocent operations as discissio or excisio colli uteri can be the cause of difficult childbirth and the maternal morbidity and mortality associated with them. A significant factor for ensuring the normal course of pregnancy, the normal act of childbirth, the lowering of morbidity and mortality, and the obtaining of healthier offspring are definite intervals between pregnancies. Clinical observations point out to us quite clearly that a woman cannot be in the phase of motherhood all the time—carrying, giving birth, nursing—and that there must be definite intervals between individual pregnancies, since we know that pregnancies following one after another negatively affect the weakened organism, lower its resistance, and furthermore produce weak, inferior offspring. Antonov, regarding this, points out that infant mortality is greatest in cases where the interval is equal to one year, and significantly decreases with intervals of 2 to 4 years. To no lesser degree, one must also take into account the environment, social factors, conditions of daily life, and professional labor. Just as a departure from the basic rules of aseptic conduct of childbirth leads to severe and inevitable consequences, so an inevitable consequence of diseases in the family, diseases of the nurse, midwife, or doctor are diseases of the pregnant woman, the woman in labor, and the woman in the puerperium. To the same extent, domestic factors and especially the character of this or that profession can also have an influence. As an example, one can cite the indications of George Gedd that a possible source of puerperal infection can be not only this or that production as such, but the various possible accidental injuries associated with it. A. P. Gubarev also attaches great importance to these factors. Gedd points out that the percentage of postpartum morbidity is in full correspondence with the number of accidental injuries observed in production. Nikitin, having developed data on age-specific maternal mortality, showed their close connection, explaining which, he rejected the biologization of this concept, viewing it as an expression of that social burden in the past, the magnitude of which is determined by the number of years lived. One must not lose sight of the influence of the time of year. Just as before in individual reports, so now in American statistics, for example, there are indications that the highest maternal mortality falls in the last winter months and early spring (February–April). Indicative in this regard are the data of Eichel (1924), who, when studying maternal mortality for the years 1914–20, noted that the lowest mortality from childbirth falls in September, while the highest percentage of septic diseases and mortality is observed in March; in February, the highest percentage of mortality from septic processes is encountered in connection with the bad influence of the time of year on renal and pulmonary diseases. The seasonality of maternal mortality is depicted in the same way in the material from Moscow (Nikitin). These data show that the question of the influence of the time of year must be worked out additionally, that it must be studied not in isolation, and that when accounting for the percentage of mortality at this or that time of year, a breakdown of the causes of mortality by individual categories must be performed. Given the diversity of causes of maternal morbidity and mortality, the measures for combating them must also be diverse. Among contemporary authors who have touched upon both the analysis of available data and preventive measures, two directions can be noted. Representatives of one direction consider it necessary, mainly, to expand antenatal consultations, to conduct more in-depth prophylaxis for the pregnant woman, to perform prophylactic treatment of the birth canal, to conduct childbirth rationally, etc. Others, however, are not limited only to these preventive factors and believe that the prophylaxis of maternal mortality must be conducted significantly earlier and that, in view of its exceptional state importance, the issues connected with it must be subjected to broad public discussion. Antonov believes that in the fight against maternal mortality, a large role belongs to 1) antenatal protection of the woman, 2) a widely developed network of obstetric care, 3) raising the well-being of the population and increasing its cultural level, and 4) a series of corresponding legislative measures for the protection of the woman. Stuke, believing that maternal mortality is caused by insufficient observance of asepsis during childbirth, points out that under appropriate conditions, maternal mortality can be reduced to figures close to zero. But even he recognizes as necessary, along with a general raising of the cultural level of the population, maximum hospitalization of childbirth, and raising the qualifications of obstetric personnel, the unconditional hospitalization of those pregnant women and women in the puerperium whose home conditions may present a danger in the sense of the emergence of infection in them. Interesting are the conclusions of Campbell regarding the necessity, along with improving the teaching of obstetrics, better qualification of personnel, expansion of obstetric care in the countryside, and public education of future mothers, of sanitary-educational work in the form of "hygiene weeks." The basic condition is, of course, the rationalization and expansion of obstetric care, especially in the countryside. Rationalization must pursue the goals not only of expanding the bed system, but also of improving the quality of obstetric care by raising the qualifications of obstetric personnel. The following measures are necessary: the fight against childhood infections, paying special attention to post-infectious complications with periodic control, examination of the functions of individual organs, and dispensary care. This is important, since infections affect the development of the girl, cause the insufficiency of her organism for performing the act of motherhood, and give a greater percentage of complications during pregnancy. Rational upbringing of the girl, reasonable physical culture appropriate to sex and age, more strictly conducted labor protection of the adolescent, especially in domestic life, prohibition of early physical labor, and hygiene of mental labor of the school period. Greatest care in relation to girls in the phases of puberty and sexual development. Sanitary education about the harm of early sexual life. Prohibition of early marriages, the fight against them as a phenomenon not yet fully eradicated among national minorities. A detailed, comprehensive study of the intervals of motherhood is necessary.

Directly connected with this point is the question of contraceptives and their possible influence on the reproductive sphere. They must be such that the possibility of subsequent harmful influence and the emergence, on the basis of their use, of postpartum morbidity and the maternal mortality associated with it is excluded. Special attention should be paid to acute and chronic infections. Careful isolation of the pregnant woman from the harmful influence of the environment and from harmful factors of daily life must be carried out. In view of the insufficiency of obstetric care for this type of disease and the absence of appropriate institutions, it is necessary to create special wards for acute infections, at least at scientific institutes for the protection of motherhood and infancy. The fight against acute infections, their treatment, and the provision of qualified obstetric care during them is the main preventive factor in the fight against secondary septic mortality. An additional essential preventive measure is the medical examination of all personnel in obstetric institutions. For a more thorough study of the causes of maternal mortality, it is necessary to register every case of maternal mortality on special questionnaires.