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P.A. 4 MATERNAL MORTALITY Maternal mortality is a negative demographic phenomenon, with major social and health-related implications. It is a true indicator of a population’s health-state, which reflects both the socio-economic development of a country and the development of the health-care system, as well as the health-related cultural and educational level of the population. As it also reflects the involvement of states and governments in achieving social welfare (by the percentage of GDP allocated to health), maternal mortality is, as recommended by UN experts in populations, an indicator that may be used for the synthetic characterization a country’s level of socio-economic development. Definition: maternal mortality refers to the death of a woman during pregnancy or within a period of 42 days after the end of it, whatever the duration or location of pregnancy, by any cause determined or aggravated by pregnancy, which is neither accidental nor coincidental. Deaths may be divided into two groups: 1. Deaths associated with direct obstetric causes - those resulting from obstetric complications (pregnancy, childbirth, confinement), interventions, omissions, incorrect treatment, or a concatenation of events resulting from one of the above-mentioned factors. 2. Deaths associated with indirect obstetric causes - those resulting from preexisting diseases or a disorder occurring during pregnancy, without its being due to direct obstetric causes, but aggravated by the physiological effects of pregnancy. Direct obstetric causes of death: - abortion - obstetrical risk from complications of pregnancy complications of labor and birth complications during confinement Death by abortion and, respectively, by obstetrical risk, is studied separately, given the fact that their determinants quite different. International statistics and those obtained in our country take into account only deaths from direct obstetric causes (mortality from complications of pregnancy, birth and confinement). Way of calculation: The index is calculated in relation to the number of live births registered within a certain period and a certain territory: dsnl Msnl = x 1000 nv For analysis-related purposes, the index is calculated in relation with the age groups of the deceased: dsnlx Msnlx = x 1000 nvx Msnl = the index of mortality associated with complications of pregnancy, birth and confinement dsnl = number of persons having died of these complications nv = live births The elements marked with “X” also refer to the age group of the dead persons and to the live infants of mothers having died at the respective age. Causes of maternal mortality by obstetrical risk are: toxemia, hemorrhage, puerperal infection. The most frequent causes are: - in developed countries: hemorrhage, toxemia; in some countries many deaths caused by abortion are not reported as such, due to religious or moral reasons. - in underdeveloped countries: infection, bleeding, injuries at birth Causes of bleeding: - uterine rupture - disseminated intravascular coagulation - incomplete placenta deliverance - placenta praevia - abortion Puerperal infections can be puerperal, nosocomial, etc. The evolution of maternal mortality through obstetrical risk and abortion In Romania: During the prewar period, maternal mortality used to be high, especially in rural areas, due to women’s limited education for health and to a very high birth rate. After that period, the evolution of maternal mortality has been associated with a particular aspect, namely the poorly implemented demographic policy (Decree 770/1966 and regulations concerning the interruption of the normal pregnancy course, in 1985). Between 1967 and 1990, in parallel with an increase in natality (associated with the above-mentioned decree), an increase in maternal mortality was also recorded, so that, in 1989, there were 1.7 ‰ live births (0.22 ‰ from obstetrical risk and 1.48 ‰ from abortion). After the liberalization of abortions, maternal mortality decreased to 0.83 ‰ in 1990, to 0.53 ‰ in 1992, and to 0.48 ‰ in 1995. In Europe In 1995 the average level of maternal mortality was of 60/0000 in Western Europe, of 180/0000 in Central and Eastern Europe and of 410/0000 in NEI (independent countries). In the 90s, the level of maternal mortality stabilized in Western European countries and NEI. In Central and Eastern European countries, it continued to decline slightly after the collapse of the 1990 indicator, mainly due to the particular evolution in Romania. Although Romania records decreasing values, these continue to be the highest in Europe. Induced abortion remains the main contraception means in Central and Eastern European countries and the NEI, though being the main cause of maternal mortality in these countries.