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OCR for page 1
The Relationship Between Fertility and
Maternal Mortality
Susan Zimicki
Matemal mortality is much higher in developing than in developed countries
(Mahler, 1987~. This is clearly a function of a number of factors, including the
greater risk inherent in pregnancy and delivery owing to lack of adequate medical
care; the greater prevalence of infectious diseases, which are cofactors in some
deaths; and the higher incidence of pregnancy. Because high-mortality countries
are those with the least reliable vital statistics, little information is available about
levels and risk factors.
Provision of family planning services has been proposed as one way to reduce
maternal mortality (Rosenfield and Maine, 1985~. The argument is that use of
family planning services will reduce the absolute number of pregnancies and will
allow shifts in the timing of pregnancy from high-risk to lower-risk ages and from
shorter to longer interbirth intervals.
This paper will review the information available about the effects of parity,
age, and birth intervals on maternal mortality and morbidity, with particular
attention to some of the common complications of pregnancy and the major
causes of death. Winikoff and Sullivan (1987) have examined limits of the
possible effect of family planning programs in reducing maternal mortality, and
Trussell and Pebley (1984) have quantified the possible impact of changing age
and parity distributions on fertility. In addition to including more recently
available population-based information, this paper considers in detail some of the
Susan Zimicki is research director of the HealthCom Evaluation, Annenberg School of Communi-
cations and Population Studies Center, University of Pennsylvania.
1
OCR for page 2
2 SUSAN ZlMlCKI
major mechanisms through which maternal mortality occurs and how they are
related to fertility.
DEFINITIONS AND MEASUREMENT ISSUES
Measures
A number of different measures of maternal mortality are commonly used, the
most important being the maternal mortality ratio and the maternal mortality rate.
The numerator for both is the same: the number of maternal deaths occurring in a
given period. Most studies adhere to the International Classification of Disease,
ninth revision (ICD-9), definition of maternal death in including the deaths of
women within 42 days of termination of pregnancy. Some older studies may
include deaths that occurred up to 90 days after the termination of pregnancy, in
accordance with the Guide of Maternal Deaths Studies published by the American
Medical Association (1964~.
The maternal mortality ratio is the ratio of maternal deaths per live births
(venously 1,000, 10,000, or 100,000; unless noted otherwise a metric of 1,000 is
used for ratios and rates in this paper). Although the denominator should ideally
be pregnancies, the impossibility of obtaining accurate counts of fetal losses and
stillbirths has necessitated using live births. According to the World Health
Organization (WHO) (1985), in countries with low induced-abortion rates, the
number of live births is within 10 percent of the number of pregnancies. This
ratio measures the probability of maternal death, the obstetric risk.
The maternal mortality rate is simply a cause-specific death rate: maternal
deaths/women of reproductive age (variously 10 to 49, 15 to 44, 15 to 49 years
old). This rate is a function of the incidence of pregnancy as well as the risk
inherent in pregnancy. Thus, the maternal mortality rate is linked to the maternal
mortality ratio through the general fertility rate Births/1,000 women of reproduc-
tive age).
Two extensions of the maternal mortality rate have been used as measures of
maternal mortality: (l) the proportion of all-cause mortality for women of
reproductive age that is attributable to maternal mortality and (2) the lifetime risk
of maternal mortality, calculated as reproductive-span maternal mortality rate
(Measham and Herz, cited in Fortney, 1987~.
It is important to consider the effects of age and fertility structure differences
on these measures. Obstetric risk varies greatly with age, as does the incidence of
pregnancy. Thus, populations that have different age structures andlor different
age-specific fertility rates may have different crude maternal mortality ratios even
when they have similar age-specific ratios (see Fortney, 1987, and Graham and
Airey, 1988, for examples). Whether or not the crude ratios are different depends
on whether the ages of highest obstetric risk are those in which the population or
fertility differences reside. The crude maternal mortality rate and the measures
based on it are even more sensitive to these structural differences.
OCR for page 3
FERTILITY AND MATERNAL MORTALS 3
Unfortunately, nearly all studies report only crude maternal mortality ratios
and rates, making comparisons across populations or even of the same population
at successive times questionable.
Sources of Data
Maternal mortality is underestimated even in countries with excellent vital
registration systems; official statistics from countries where maternal mortality is
high seriously underestimate the true level (WHO, 1987~. Better data are avail-
able from three sources: population-based studies, hospital population studies,
and case series. Population-based studies provide the least biased estimates of
maternal mortality. They allow nearly complete counts of live births and mater-
nal deaths. Because of their prospective nature they include deaths that occur
more than a week after delivery and probably include most of the deaths due to
induced abortion. There are very few population-based studies concerning mater-
nal mortality: six from Bangladesh (Chen et al., 1975; Lindpaintner et al.,1982;
Khan et al., 1986a; Alauddin, 1987; Koenig et al., 1988; Faveau et al., 1988~; one
from Ethiopia (Kwast et al., 1986~; one from Egypt (lPortney et al., 1985~;i one
from the Gambia (Greenwood et al., 1987~; and one from Jamaica (Walker et al.,
1985~. Preliminary results from a population-based study in India are available
(Bhatia, 1985~. Although the Medical Research Council (MRC) project in the
Gambia and the Machakos project are population laboratories that have yielded
excellent information on a number of topics, maternal mortality in both areas has
been almost completely eliminated because of care provided by the project (Lamb
et al., 1984; Voorhoeve et al., 1979), and so these studies are not included. In
addition, one hospital-based study from Lusaka, Zambia (Mhango et al., 1986),
arguably covers a sufficient portion of the population (85 percent of births, 90
percent of deaths) to be considered a population-based study. Unfortunately, the
number of deaths in each study is generally very small, so estimates by specific
cofactors are unstable.
With regard to morbidity the WHO collaborative studies on family- formation
patterns and health provide population-based information about anemia and
uterovaginal prolapse in nine countries (Omran et al., l981a,1981b). In addition,
one study from Jerusalem (Harlap et al., 1971) concerns obstetric interventions,
and one from the Philippines (Raymundo, 1987) concerns morbidity during the
last pregnancy.
Hospital population studies, particularly those from referral hospitals, provide
less accurate estimates of the incidence of maternal mortality or morbidity than do
population-based studies. They reflect the experience of only a proportion of the
population during only part of the risk period at the time of and immediately after
iThe companion study to the one carried out in Egypt was carried out in Bali. It is not included as
a population-based study because the ascertainment rate of deaths was estimated as 50 percent at most.
With that level of underestimation, it seems unlikely that the information is representative.
OCR for page 4
4 SUSAN ZIMICK]
pregnancy outcome. Many of the hospital-based studies report only the crude
maternal mortality ratio and limit further analyses to the series of deaths. A few
report case-fatality rates for various complications. If the assumption can be
made that the deaths in hospitals are representative of all maternal deaths or the
way in which they are unrepresentative can be identified, then some examination
of the proportional contribution of various causes becomes worthwhile.
Case series reports about a series of deaths, either due to any maternal cause
or to a specific cause, such as ruptured uterus, eclampsia, or hepatitis-can
provide valuable information about incidence and case-fatality rates. Unfortu-
nately, most contain no description of the population from which the cases are
drawn. However, series selected because of the presence of a risk factor (e.g., the
Arkutu, 1978, series of primigravidae) rather than an outcome and those in which
the maternal deaths are compared to a subsample of the hospitalized population
represent one of the most efficient ways of obtaining information about maternal
mortality.
Problems of Measurement
AS noted above, the maternal mortality ratio as defined by the WHO is already
an approximation of the measure of interest. However, the more serious problems
in measurement arise from incomplete ascertainment of either the number of
deaths or the number of related live births. Deaths that occur before delivery,
such as those due to ectopic pregnancy, may not be recognized as maternal deaths.
Additionally, those due to induced abortion may be misrepresented because of
shame or fear of prosecution: in one series of cases of women who came to a
hospital with tetanus "all [22] postabortal cases followed criminal abortion,
although in only 10 cases was the interference admitted by patients or their
relations" (Adadevoh and Akinla, 1970~. Another group of deaths that is easily
missed, especially in hospital-based studies, are those that occur some time after
delivery. The population-based study in Tangail (Alauddin, 1987) shows 15
percent and that in Jamalpur (Khan et al., 1986a) shows 27 percent of deaths
occurring more than a week after delivery.
Depending on the time period of interest, retrospective population-based stud-
ies may underestimate both maternal deaths and live births. A valid count of live
births is generally less of a problem for prospective population-based studies but
exists nevertheless. Comparison of the crude birth rate for the Jamalpur prospec-
tive study with the national rate suggests an underreporting of up to 10 percent of
the births (Khan et al., 1986a); the same comparison for the Tangail prospective
study suggests underreporting of 27 percent (Alauddin, 1987~.
The problem of estimation of the denominator is most crucial, however, with
regard to hospital-based studies. In developing countries many women do not
usually deliver in hospitals, although they may be brought there if the delivery is
complicated. Hospital-based maternal mortality ratios in urban areas with easy
OCR for page 5
FERTILITY AND MATERNAL MORTALS 5
access are probably overestimates because a larger proportion of more difficult
than normal deliveries is represented among deliveries. This tendency for hospi-
tal populations to overrepresent abnormal or complicated cases is exacerbated in
the case of referral or teaching hospitals in large cities, which receive not only all
the self-referred emergency deliveries but also patients referred by other health
facilities. As most hospital reports are generated by teaching or referral hospitals,
the reported maternal mortality ratios are likely to be overestimates. One study
reported two ratios, the first 16.7, calculated on the basis of hospital births, the
second, 3.9, on the basis of births in the city (Rag, 1975~.2 Unfortunately, the
number of births in the hospital catchment population often cannot be ascertained
or estimated; this might happen, for example, if there are several hospitals in a
city. The representativeness of the hospital population can be assessed using two
observations that are frequently reported: the proportion of admissions that are
emergency or unhooked and the proportion of deaths that occur soon after admis-
sion.
In areas where access to a hospital is restricted (because of distance, cost, or
social barriers), a greater proportion of women experiencing difficulty during
delivery will die at home. Ratios reported by these hospitals may represent
underestimates; in addition to the advantage of medical care at the time of
delivery, the population delivering in hospitals may have had greater than average
exposure to antenatal care and may represent a more socioeconomically advan-
taged portion of the population. One extreme example is from the Medical
Research Council (MRC) study area in the Gambia: the maternal mormlity ratio
for the period 1951-1975 was reported as about 10 (Billewicz and McGregor,
1981), but during 8 years after the establishment of a continuous medical service
there were no maternal deans, although 16 would be expected if the established
ratio had prevailed (Lamb et al., 1984~. An additional problem of smaller rural
facilities is that caseloads are often insufficient to produce stable estimates of
morality.
While estimates of maternal mortality ratios from hospital-based studies may
be biased, they provide a useful supplement to the few estimates ob~ne`1 from
population-based studies. However, because of the very small numbers of deaths
identified in population-based studies,3 using hospital-based studies is crucial for
examination of the causal mechanisms involved in high maternal mortality.
2In the light of the probable large effect of selection bias, the problem of maternal mortality ratios
calculated using deliveries rather than live births in the denominator is minor, but a number of hospital
reports (and one population-based study: Greenwood et al., 1987) use deliveries. While this is more
correct epidemiologically, as it is a better estimate of the population at nsk, it deviates from the
. . . . .
ntematlona. . c ,elmlt~on.
gibe total number of deaths reported in the nine identified population-based studies is 936; 630 of
these come from two countries Egypt and Jamaica with the lowest and third lowest reported
maternal mortality rates in the series.
OCR for page 6
6 SUSAN ZIMICK]
If all the maternal deaths from an area occur in a hospital, the proportion of
mortality associated with each cause of interest can be determined accurately
(apart from classification bias), even when the maternal mortality ratio cannot be
determined. This situation probably occurs more frequently when a large propor-
tion of the population is already delivering in a hospital for example, in Lusaka
(Mhango et al., 1986~. When it does not occur, three types of deaths are most
likely to be excluded. First, many early-pregnancy deaths occur at home: in
Addis Ababa 6 of 13 aboriion-associated deaths occurred at home. Some hospital
studies explicitly exclude all early-pregnancy deaths (e.g., Chi etal.,l981; Hartfield,
1980) as well as those occurring after the woman has been discharged from the
hospital, while a few simply do not report any (Balachandran cited in Armon,
1977; D'Cruz et al., 1986a).
The second type of death apt to be omitted from hospital statistics comprises
those due to indirect causes-not resulting from the complications of pregnancy
itself but rather from a condition that is aggravated by pregnancy or one that is
completely unrelated, such as a motor vehicle accident. Kwast et al. (1986) report
hospital deaths for 67 percent of those dying of obstetric causes but only 38
percent of those dying of indirect causes. Even if they die in hospitals, women
who die of indirect causes may, for example, die in the medical ward and never
come to the attention of those who report "maternal mortality." Finally, women
are more apt to be seen in a hospital if the delivery complication "affords relatives
the time to discuss the merits of hospital admission" (Hartfield, 1980) and the
hospital is sufficiently close to the woman's home. One way to estimate this
effect is to examine the ratio of deaths from obstructed labor and hemorrhage to
those from hypertensive disease; this ratio tends to be much higher in hospital-
based studies than in population-based ones.
In addition to these types of inclusion bias, hospital series reports are also
subject to classification bias. For example, deaths resulting from cephalopelvic
disproportion and abnormal presentations leading to prolonged labor and uterine
rupture might be classified as due to ruptured uterus if the rupture is identified, as
due to hemorrhage if extravaginal bleeding is a prominent feature, or to sepsis if
death is delayed some time after the onset of labor. Many maternal deaths are
associated with a number of complications; for example, of 219 deaths in Zaria
only 86 could be attributed to a single condition, while the rest were associated
with two or more (Harrison and Rossiter, 1985~.
This then is the situation: maternal mortality is inherently difficult to measure;
the summary measures commonly used obscure any differences between popula-
tions that might be due to fertility patterns as opposed to other sources of risk; the
best (though still flawed) data come from a few extremely small studies in
restricted geographic areas; and the largest source of data is subject to selection
and classification biases that cannot easily be controlled for because they are
unquantifiable except in He very particular circumstances of each study. Even
with these drawbacks, fairly clear patterns are apparent both in terms of the
OCR for page 7
FERTILITY AND MATERNAL MORTALl7Y 7
geography of level and causal components and with reference to the relation
between fertility and maternal mortality.
WORLD PATTERNS
Population and hospital-based studies from countries selected because they
had several studies show distinct differences in the levels of maternal mortality in
different regions CTable 1~. The highest mortality ratios are from the population-
based studies in the Gambia, where the overall ratio is probably between 10 and
20 per 1,000 births. Hospital studies from Nigeria and a population-based study
from eastern Senegal (Pison, 1989) suggest that the risk in West Africa is gener-
ally high, though perhaps closer to 10 than 20. The next highest mortality occurs
in South Asia; from the population studies in Bangladesh and the population and
hospital studies in India, a maternal mortality ratio of 4 to ~ seems most likely.
Indonesia and Ethiopia probably have similar levels. The information from
Tanzania suggests that the risk is slightly lower there, probably around 2 to 4, and
the studies from South Africa suggest the same level. The three hospital-based
studies in Lusaka, Zambia, are very consistent, and maternal mortality- at least in
the city, where rates of prenatal care and hospital delivery are very high (Mhango
et al., 1986) is most likely in the range of 1 to 2.
The ratios now seen in Lusaka are beginning to approach those seen in Latin
American countries in the early 1960s. More recent studies have shown ratios 10
times lower.
Thus, if developing country regions are ranked by risk of childbearing, West
Africa is clearly the area of highest risk, followed by South Asia, northern East
Africa, and southern Africa. Latin America is clearly the region of lowest risk.
ASPECTS OF FERTILITY AS RISK FACTORS FOR
MATERNAL MORTALITY
Fertility can be described in terms of age of first occurrence, total number of
events, and interval between them. All of these factors are susceptible to family
planning interventions; contraception can be used to delay the first pregnancy,
lengthen the interval between binhs, and reduce the total number of pregnancies.
Par ity/Gr av id ity
The event that puts a woman at risk of maternal mortality is conception.
Strictly, the relationship between fertility and maternal mortality should be de
scribed in terms of pregnancies. Some risks (e.g., hemorrhage from ruptured
ectopic pregnancy, complications of induced abortion, amplification of the risk of
infectious diseases) accrue to pregnancy well before delivery, while others are
OCR for page 8
8 SUSAN ZIMICK]
TABLE 1 Matemal Mortality Ratio Per 1,000 Binhs From Selected Countries
City Population Hospital Year Reference
Gambia
Ethiopia
Tanzania
Gambia
Indonesia
Bangladesh
India
Keneba
Mandua
North Bank
Addis
Addis Ababa
Addis Ababa
Kilimanjaro
Dar es Salaam
Moshi
Mwanza
Lusaka
Lusaka
Lusaka
South Africa Pietennantzburg
Durban
12 hospitals
Bali
Matlab
Matlab
Matlab
Tangail
Jamalpur
Calcutta
Calcutta
Madurai
Bombay urban
Bombay rural
Anantapur rural 8.7
Anantapur urban 5.5
Bogota 1.3
Call 2.2
Caracas 1.0
Cumana
Ribeirao Preto
Sao Paula
Campinas
Santiago
Santiago
Colombia
Brazil
Chile
10.5
9.5
22.0
4.6
7.2
7.7
5.7
5.1
5.7
6.2
8.4
5.9
3.9 16.5
4.0
2.4
0.6
0.9
3.2
1951-75 Billewicz and McGregor (1981)
1951-75 Billewicz and McGregor (1981)
1981-83 Greenwood et al. (1987)
7.8 1980 (Frost) cited in Kwast et al.
(1986)
1981-83
6.9 1981-83
3.2 1971-77
2.1 1974-77
2.6 198~81
2.3 1982
1.5 1974
1.6 1974-78
1.2 1982-83
1.5 1973-75
2.1 1975-82
3.9 1977-80
198~82
1967~8
1968-70
1982
0.3
0.3
Kwast et al. (1986)
Kwast et al. (1986)
Armon (1979)
M~navalye et al. (1980)
Janowitz et al. (1984)
Janowitz et al. (1984)
(Hickey) cited in Hanfield
(1980)
Parole) cited in Boerrna (1987)
Mhango et al. (1986)
Barford and Parlces (1977)
Melrose (1984)
Chi et al. (1981)
Fortney et al. (1985)
Chen et al. (1975)
Chen et al. (1975)
Iindpaintner et al. (1982)
1982-83 Alauddin (1987)
1982-83 Khan et al. (1986)
195~58 Dawn et al. (1972)
1966 68 Dawn et al. (1972)
196(}72 Rao (1975)
1961~9 Shah et al. (1971)
1961 -69 Shah et al. (1971)
1984-85 Bhatia (1985)
1984~5 Bhatia (1985)
1962~4 Puffer and Griffith (1967)
1962~4 Puffer and Griffith (1967)
1962~4 Puffer and Griffith (1967)
1978-80 Janowitz et al. (1982a)
1962-64 Puffer and Griffith (1967)
1962~6 Puffer and Griffith (1967)
1977-79 Janowitz et al. (1982b)
1962~4 Puffer and Griffith (1967)
1977-78 Janowitz et al. (1982a)
OCR for page 9
FERTI~TY AND MATERNAL MORTALS 9
inherent in delivery itself. Most of the studies concerning maternal mortality
report parity-specific mortality; a few report rates by gravidity.4
All the population-based studies indicate and results from hospital studies
generally confine that the flat birth and births of high order are strong risk factors
for maternal mortality (Table 2~. These studies indicate a I- or U-shaped risk with
parity: high during the first pregnancy, lowest during the second or third, and
high again by the fifth pregnancy. A similar pattern is found for gravidity, with an
even stronger relative risk for first pregnancies relative to later-order pregnancies
than is observed for first births.
Corroboration for the higher risk of first deliveries comes from the population-
based morbidity study carried out in West Jerusalem, where the obstetric inter-
vention rate was calculated by parity (Harlap etal., 1971~. Obstetric interventions
included any specialist intervention at any stage of labor, including surgical or
medical inductions of labor, forceps or vacuum deliveries, breech deliveries,
cesarean sections, and other major third-stage interventions; while probably an
overestimate, this measurement does indicate potential mortality in the absence of
medical care. Both the parity-specific rates and the ratios (adjusted for age,
ethnicity, and hospital) indicate about a 70 percent higher risk for first than for
second births (Table 3~.
Except for very high parity births (10+), this study does not confirm the excess
risk of multiparty. This is surprising in light of the very clear enhanced risk of
malpresentation for multiparous women noted by, for example, Faundes et al.
(1974~: 3.4 breech presentations per 1,000 women of parity 0, 10.1 for panties 1
and 2, 14.4 for parities 3 and 4, 17.5 for parities 5 and 6, and 19.0 for parity 7+. A
review of a series of 50,057 deliveries, including 5,785 to grand multiparous
(parity 7+) women in Haifa, Israel (Fuchs et al., 1985), yielded a rate of malpre-
sentation of 11.9 per 1,000 for the grand multiparous women in contrast to a rate
of 3.3 per 1,000 for women of lower parity.
A study from the Sudan (Aziz, 1980) comparing 2,049 primiparous, 3,679
multiparous, and 3,130 grand multiparous (5+) women found slightly higher rates
of abnormal presentation for grand multiparas (14 percent compared to 9 percent
for multiparas and 9.5 percent for primiparas). This same study found more
toxemia among primiparas than other women (10.8 percent vs. 7.8 percent for
multiparas and 8.5 percent for grand multiparas), more anemia among grand
multiparas (7.4 percent) than other women (4.5 percent), and a clear increase in
the risk of antepartum hemorrhage with parity (primiparas 1.3 percent, multiparas
1.9 percent, grand multiparas 4.5 percent). Al-Sayegh and Hathout (1974) in
Kuwait obtained similar results for antepartum hemorrhage (0.1 percent for
women of parities 1 to 5, 1.2 percent for parities 6 and 7, and 4.2 percent for parity
8+), but they observed lower rates of abnormal presentation-only 5.1 percent for
4Parity is the number of previous live births; gravidity is the number of previous pregnancies.
formation about parity is probably more accurate than that about gravidity.
OCR for page 10
TO SUSA}VZIMICK]
TABLE 2 Mortality Per 1,000 live Births by Parity and Gravidity Prior to Current Pregnancy
Gravidity Tangaila Jamalpuri MatlabC Matlab~ Addis AbabaC Jamaica' Gambia8
Parity G P P G P G P P P P
0 5.5 3.8 33.8 12.7 9.9 9.7 9.5 13.3 0.8 28.6
1 4.3 3.7 4.2 2.4 2.8 4.1 3.8 8.1 0.6 11.9
2 3.4 4.2 2.6 2.3 3.1 3.1 3.2 0.8
3 3.8 5.7 7.6 2.4 4.8 3.1 3.4 0.8
4 7.7 2.3 4.7 4.3 4.9 5.2 5.4 0.9
5 9.1 9.1 14.2 6.0 5.9 3.4 3.7 3.0 1.3 45.5
6 14.9 6.8 5.2 5.9 4.9
7 10.8 14.9 7.4 7.2 6.9 6.8
8 6.5 7.3 8.3 10.4
9+ 6.6 7.8 8.2
Total 5.7 5.7 6.2 5.7 5.7 5.5 5.5 4.9 1.1 22.3
Note: Close examination of the population-based studies indicates some confusion about the
definitions of parity and gravidity. Chen et al. (1975) label groups of women by their status prior to
the current pregnancy and report, as might be expected, fewer deaths and live births among women
who had never had a pregnancy than among those who had never had a live birth (but who might have
had a prior pregnancy). Alauddin (1987) also reports both parity-specific and gravidity-speciD~c
ratios, but labels women with no previous live births panty O and those with no previous pregnancies
gravidity 1. In addition, there seems to be a classification problem, as the reported ratios indicate 10
deaths among women who had no prior pregnancy but only 7 among those with no prior live birth.
Walker et al. (1985) have classified women as to parity by considering the number of prior pregnan-
cies lasting at least 28 weeks but not necessarily terminating in a live birth, including the current
pregnancy. Thus all women who have never had a prior live birth are considered parity 1; in general,
even after co'~c;ction for this difference, the panties of women in the Jamaica study will be slightly
inflated relative to reported parities of women in the other studies. This study also includes deaths
that occurred up to a year after delivery. In the population-based study from Ethiopia (Kwast et al.,
1986), a note to the parity 0 rate indicates that it has been calculated per 1,000 nulliparous women. As
the parity 1 through 5+ live births add up to the total number of live births in the study, it seems likely
that the parity classification includes the current pregnancy, with deaths to women with no prior live
birth being categorized as parity O if they did not survive to deliver and parity 1 if they delivered. This
rate has been recalculated. Rates reported by Greenwood et al. (1987) are calculated over all
pregnancies, as parity-specific numbers of live births are not available.
Sources: aAlauddin (1987), bKhan et al. (1985), CChen et al. (1985), Koenig et al. (1988), CKwast et al.
(1986),~aLker et al. (1985), and "Greenwood et al. (1987).
OCR for page 11
FERRY AND MATERNAL MORTAR ~ ~
women of parity 8 or more. Their case series is, however, quite a bit smaller,
including 2,060 women of parities 1 to 5, 494 of parities 6 and 7, and 446 of parity
8+.
In a 1958-1960 multicenter study in the United States, Israel and Blazar (1965)
reported a much higher rate of essential hypertension among grand multiparas
(7+) (without controlling either for age or race), higher rates of uterine rupture and
posq?ar~m hemorrhage, and significantly higher rates of placenta previa and
placental absorption, but no difference in maternal mortality, presumably because
of adequate hospital care.
Interaction Between Age and Gravidity/Parity
Most information about complication or mortality is couched in terms of either
age or parity: women are at greatest risk at young and old ages and at low and
high panties. Because age and parity are strongly associated, it is not clear if the
age-specif~c and panty-specific patterns reflect the same basic age-driven risk, if
they have independent effects, or if they act in combination. Contraception
provides the means of affecting timing of fertility and thus increases the impor-
tance of knowing whether there is an interaction between age and parity in their
effects on morbidity and mortality associated with fertility.
Four of the population-based studies provide information about maternal mor-
tality by age and panty. The simple I- or U-shaped relationship between panty
TABLE 3 Obstetric Interventions by Parity in Jerusalem
Parity
.
Intervention
Rate/1,000
-
Rat~o
2
3
4
5 -
7-9
10+
AB
244
138
145
116
107
103
125
159
146
84
89
81
71
73
84
100
Note: Ratio is adjusted for age, ethnic group, and hospital
Overall maternal mortality ratio in this population was 0.03
per 1,000 births.
Source: Harlap et al. (1971).
OCR for page 37
FERTILITY AND MATERNAL MORTALS 37
TABLE 19 Case-fatality Rates per 100 Hospitalized Patients With Hepatitis
Female
Place Year Male Nonpregnant Pregnant Reference
India 1949 7.8 27.3 50.5 Wahi and Arora (1953)
Saudi Arabia 53~3 4.5 11.9 46.3 Gelpi (1978)
Libya 1975 .5 1.6 13.0 Christie et al. (1976)
Bombay 65 66 - 25.6 53.8 D'Ctozand Balani (1968)
South Iran 55-70 - 18.0 44.0 Borhanmesh et al. (1973)
South Imn 67-70 - - 26.0 "
Algiers 1956 - - 61.1 Haemmerli (1966)
India 1956 - - 44.8 "
Haifa 1959 - - 30.0 "
Athens 1962 - - 25.9 "
Jerusalem 1947 - - 18.5 "
Cordoba 1957 - - 16.3 "
Ghana 62~3 - - 13.3 Morrow et al. (1968)
Haifa 5~57 _ _ 9.2 Peretzet al. (1959)
(for males, 30.9 per 100,000; for females, 34.8), but pregnant women had higher
case-fatality rates and a higher risk of serious disease.
Haemmerli (1966) raised the question of genetic susceptibility, noting the
predominance of high case-fatality rates in the circum-Mediterranean area; this
seems unlikely given the additional case series reports from India, Ghana, and
Ethiopia (Wahi and Arora, 1953; Morrow et al., 1968; Kwast and Stevens, 1987)
as well as the high proportional mortality from hepatitis reported in some of the
hospital maternal mortality series (D 'Cruz and Balani, 1968b; Shah et al., 1971;
Konar et al., 1980; Barford and Parkes, 1977; Ojo and Savage, 1974~.
The generally higher case-fatality rate for nonpregnant women than for men
has been attributed to the lower nutritional status of women, but no evidence has
been offered to support this.
Tuberculosis
Whether women with untreated tuberculosis are at higher risk of maternal
mortality is unclear. Although this was the prevailing opinion in Europe and
North America beginning in the late 19th century through the 1940s and currently
prevails in many high-mortality countries today, it is possible that pregnant
women with tuberculosis really die at no greater rate than nonpregnant women
with tuberculosis. No study from a high-mortality country that addresses this
question has been identified. However, a careful review by Hedvall (of European
OCR for page 38
3 ~ SUSAN ZIMICK]
studies) in 1953 showed about as many that demonstrate no adverse effect or even
a favorable effect of pregnancy on tuberculosis as those that show a negative
effect. In Hedvall's (1953) own prospective study of pregnant women with
pulmonary tuberculosis, 9 percent improved during pregnancy and 7 percent
worsened.
Women who are adequately treated probably have no higher risk. In a com-
panson of pregnant and nonpregnant tubercular women, with both groups having
similar severity of disease and being treated similarly for active tuberculosis,
Flanagan and Hensler (1959) showed no difference in disease progression.
Malaru:
During an epidemic of malaria in Ceylon the case fatality rate was twice as
high among pregnant (13.1 percent) as among nonpregnant (6.5 percent) women
(Wickramasuriya, cited in McGregor, 1986~. This pattern of enhanced risk of
mortality from P. falciparllm during pregnancy is probably generalizable to areas
of unstable (epidemic) transmission (Brabin, 19839. In hyperendemic areas
where immunity to the parasite is high because of repeat exposure, pregnancy
does not seem to have the same amplifying effect. However, a number of studies
have shown that in these stable-transmission areas malaria parasitemia is more
frequent and heavier during pregnancy, and particularly during the first and to a
lesser extent during the second pregnancy (McGregor et al., 1983; McGregor,
19869. One direct consequence of this for maternal health is an increased
probability of anemia (Gilles et al., 1969; McGregor, 1986; Brabin, 1983~.
CONCLUSION
The basic pattern observed for the relationship between fertility and maternal
mortality is that risk of mortality is highest for first pregnancies and for fifth and
subsequent ones. This pattern exists whatever the overall level of maternal
mortality. Extremes of age, lack of medical care, poverty, and some infectious
disease cofactors increase the risk. Thus, the lowest age-parity-specific risk in
Jamaica is only half to a third as large as that in Bangladesh or Indonesia. These
conditions also increase the relative risk of first and high-order pregnancies: the
risk of first pregnancies relative to middle pregnancies is higher in Asia and
Africa than in Jamaica. As conditions improve, the U-shaped curve of risk with
parity is not only lower but also flatter.
Given this pattern the potential for fertility reduction alone affecting maternal
mortality is limited. The possible mechanisms through which fertility reduction
can occur are contraception and provision of safe induced abortions. For first
births use of contraception or safe abortion could reduce risk of mortality either
through allowing postponement of the first birth until after age 20 or through
averting unwanted birds. Even if contraception is available, use by teenagers
OCR for page 39
FERTILITY AND MATE~~ MORTEM 39
may not be high, so provision of safe abortion is probably the most effective way
to reduce mortality associated with unwanted first pregnancies. However, in
many countries there are severe constraints to providing either contraceptives or
abortions to young unmarried women, who are the most likely to have unwanted
first pregnancies.
The potential is greater for reducing mortality associated with unwanted higher-
parity births. Family planning programs typically affect fertility mainly through
reducing the number of high-parity births. Thus, except in sub-Saharan Africa,
substitution of safe for unsafe abortions and contraception for abortion could
substantially reduce maternal mortality 20 percent to 25 percent of all maternal
deaths in some park of Asia are associated with abortion. However, this effect
will be limited by the effectiveness of programs to convince women to use
contraception.
As for the middle parities, there is as yet insufficient evidence about whether
the length of the interval between births has any effect on risk of maternal
mortality.
It is likely that maternal mortality ratios the risk of death per pregnancy-
will increase, at least in the short term, in some areas as family size decreases.
This paradoxical effect arises because of the way family planning programs
typically affect fertility. First, as the number of high-parity births decreases, high-
risk first births form a larger proportion of all births. Second, there is strong
evidence for a population of at least two segments, one of which is in contact with
the official health system, gets prenatal care, and has risks that are well below
those of the other segment. It is likely that women who elect to contracept to
postpone early childbearing, to end childbearing early, or to increase intervals
between births will initially be those at lower risk of maternal mortality. Thus,
reducing the high-parity fertility of these women may exclude those who have
higher intrinsic risks. It is important to remember, however, that even when the
risk per bird increases, the absolute number of deaths to women will probably
decrease.
Examination of the causal patterns of mortality suggests some alternative
routes to reduce-maternal mortality. For all causes whatever is measured by
"antenatal care" is important. The Zaria data show that it is not simply physical
access to a hospital, though that is clearly important. It would be helpful to know
for those living close to a hospital if having been to an antenatal clinic reduced the
interval between development of a complication during home delivery and going
to the hospital. It is unfortunate that the population-based studies have not paid
more attention to antenatal care and hospital attendance for complications as
factors in mortality.
it.
OCR for page 40
40 SUSAN ZIMICKI
APPENDIX CONTENTS OF CAUSAL CATEGORIES
The abortion category includes all abortion-associated deaths, whether in-
duced or spontaneous, because' many studies either do not mention whether
abortion was induced or indicate that it was determined indirectly. Hemorrhage
includes all deaths attributed to hemorrhage, antepartum hemorrhage, placenta
previa, placental abruption, postpartum hemorrhage, and retained placenta that
were categorized by the author as hemorrhage rather than sepsis. A few deaths
attributed to hemorrhage and ruptured uterus were classified under difficult labor,
along with deaths attributed to ruptured uterus (whether or not there was a
previous scar) and obstructed labor, including deaths due to disproportion and
malpresentation. The sepsis category includes deaths attributed to puerperal
tetanus and septicemia. If the author classified a death as due to cesarean section,
anesthesia, sepsis, or hemorrhage connected with cesarean section or to anesthe-
sia, the death was classified as operative, even if it was highly probable that the
section was performed for obstruction or abruption. It is clear that the categories
of hemorrhage, difficult labor, sepsis, and operative overlap, in that many deaths
could almost as easily be put in one category as in another.
Hypertensive disease includes deaths due to toxemia and eclampsia. Under
romboembolism are grouped deaths ascribed to pulmonary, amniotic fluid, and
air embolisms as well as those due to cerebrovascular hemorrhage. This last
category probably includes a number of deaths with toxemia as an underlying
cause.
The cardiovascular category includes mainly deaths attributed to congenital
heart disease (mitral stenosis) and rheumatic heart disease or simply to cardiovas-
cular disease. It is not clear how frequently cardiac failure due to anemia is
classified as cardiovascular. The gastrointestinal infectious category includes
amebiasis, typhoid, and cholera deaths. All deaths attributed to hepatitis, infec-
tious hepatitis, or hepatic coma when it is clear that there was an epidemic (either
because the author says so or because the proportion of deaths so indicates) were
attributed to hepatitis. Isolated hepatic or jaundice deaths that were not called
infectious hepatitis are classified as "other indirect." The "other infectious"
category includes mainly incidental deaths: anthrax (from Iran), smallpox, men-
ingiiis, tuberculosis, malaria, and pneumonia. Suicide, murder, and one motor
vehicle death make up the "violent death" category. The~"other" category
includes deaths due to epilepsy and various cancers, most of which seem to be
incidental.
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Representative terms from entire chapter:
family planning
