Maternal mortality: only 42 days?

A maternal death is defined by WHO as 'the death of a woman while pregnant or within 42 days of termination of pregnancy em leader '. The origin of the 42 days is no longer clear. In developing countries, the burden imposed by pregnancy and birth on a woman's body may extend beyond 42 days as pregnancy-related anaemia can persist for longer and vaginal haemorrhaging and risk of infections are not necessarily over after six weeks. We therefore examined duration of excess mortality after delivery in rural Guinea-Bissau.

In a prospective cohort study, we followed 15,844 women of childbearing age with biannual visits over a period of six years, resulting in a total of 60,192 person-years-at-risk. To establish cause and timing in relation to termination of pregnancy, verbal autopsy was carried out for all deaths. Mortality rates were calculated for short time intervals after each delivery or miscarriage.

During the observation period we registered 14,257 pregnancies and 350 deaths. One hundred and ninety-four deaths followed termination of a registered pregnancy and thus were eligible for the analysis. Eighty-two deaths occurred during the first 42 days after delivery/miscarriage. A further 16 women died in the period from 43 to 91 days after parturition, 16 between 92 and 182 days and 18 between 183 and 365 days after delivery. Compared with baseline mortality 7-12 months after delivery, women who had recently delivered had 15.9 times higher mortality (95% CI 9.8-27.4). From days 43 to 91 the mortality was still significantly elevated (RR = 2.8 [1.4-5.4]).

Where living conditions are harsh, pregnancy and delivery affect the health of the woman for more than 42 days. Using the WHO definition may result in an under-estimation of the pregnancy-related part of the reproductive age mortality. Extending the definition of maternal death to include all deaths within three months of delivery may increase current estimates of maternal mortality by 10-15%.