[Analysis of maternal deaths in Shanghai from 2000 to 2009]

To find problems in the systematic management of maternal health and to provide evidence for developing effective interventions to reduce maternal mortality in Shanghai.

Every maternal death from 2000 to 2009 was audited by experts and relevant informations were collected and analyzed retrospectively.

(1) Number of live births. The number of live births in Shanghai rised from 84 898 in 2000 to 187 335 in 2009, which increased by 120.7%. Notably, the number of live births of migrating people increased 4.6 times. In 2000, it took up 25.5% and in 2009, it rose to 54.8%. (2) Maternal mortality ratio (MMR) and its composition. The total live births from 2000 to 2009 was 1 279 010, among which there were 262 maternal deaths, with average maternal mortality of 20.48 per 100,000 live birth (262/1,279,010). For Shanghai residents, the MMR was 8.09 per 100,000 live births (55/680,005), while the MMR of migrating people was 34.56 per 100,000 live births (207/599,005). (3) Trends of MMR. The MMR declined from 21.2 per 100,000 live births in 2000 to 9.61 per 100,000 live births in 2009. The MMR of Shanghai residents maintained below 10 per 100,000 live births with exception of year 2003 and 2004. The MMR of migrating people declined sharply. In 2002 it was 77.42 per 100,000 live births, and in 2009 it decreased to 11.69 per 100,000 live births. (4) The composition of causes of maternal deaths and rank order. The top 5 causes of deaths were obstetric hemorrhage (69 cases, 26.3% of the total deaths), pregnancy induced hypertension (27 cases, 10.3% of the total deaths), heart diseases (24 cases, 9.2% of the total deaths), liver diseases (17 cases, 6.5% of the total deaths), amniotic fluid embolism and ectopic pregnancy (15 cases respectively, 5.7% of the total deaths). (5) The changes of causes between the first 5 years and the latter 5 years. The MMR of ectopic pregnancy, heart diseases and pregnancy induced hypertension changed significantly in Shanghai residents. The MMR of ectopic pregnancy decreased from 1.36 per 100,000 live births in the first 5 years to 0.26 per 100,000 live births in the latter 5 years. The MMR of heart diseases decreased from 1.36 per 100,000 live births to 0.52 per 100,000 live births. While the MMR of pregnancy induced hypertension increased from 0 to 0.78 per 100,000 live births. For migrating population, the MMR of obstetric hemorrhage, ectopic pregnancy and pregnancy induced pregnancy deceased significantly. As the primary cause, the MMR of obstetric hemorrhage deceased from 21.85 per 100,000 live births in the first 5 years to 5.47 per 100,000 live births in the second 5 years. The MMR of ectopic pregnancy decreased from 4.37 per 100,000 live births to 0.68 per 100,000 live births. And the MMR of pregnancy induced hypertension decreased from 6.87 per 100,000 live births to 2.96 per 100,000 live births. (6) Direct obstetric causes and indirect obstetric causes of maternal deaths. Among the 262 deaths, 141 cases (53.8%) were due to Direct obstetric causes and 121 (46.2%) were due to indirect obstetric causes. (7) The trend of MMR of obstetric hemorrhage. The MMR of obstetric hemorrhage declined from 10.6 per 100,000 live births in 2000 to 1.7 per 100,000 live births in 2009. (8) The results of maternal death audit. The results of maternal death audit were classified into 3 categories: 41 cases (15.6%) belonged to the first category, i.e, avoidable deaths; 66 cases (25.2%) belonged to the second category, i.e, avoidable when creating some conditions; and 155 cases (59.2%) belonged to the third category, which means not avoidable. Among 55 deaths of Shanghai residents, 17 cases (30.9%) belonged to the first category, 14 cases (25.5%) belonged to the second, and 24 cases (43.6%) belonged to the third category. Among 207 deaths of migrating population, 24 cases (11.6%) belonged to the first category, 52 cases (25.1%) belonged to the second, and 131 cases (63.3%) belonged to the third category. (9) WHO twelve-grid classification of maternal deaths. The factors, including attitude, knowledge and skills, resources and management of the dead people and their families, the medical institutes and social supportive departments were integrated and analyzed. It showed that the main reason of maternal deaths of Shanghai residents was poor knowledge and skills of medical staffs, accounting for 80.0% of the deaths. While the main reasons of maternal deaths of migrating people were poor knowledge and skills, inappropriate attitude of the dead people and their families, which took up 54.1% and 40.1% respectively.

The MMR in Shanghai declined continuously from 2000 to 2009, especially for migrating population which reflected the interventions of maternal management in Shanghai were effective. Though obstetric hemorrhage was the first top cause of maternal death during past 10 years, it declined Sharply. 30% to 40% maternal deaths were avoidable if some conditions were created. However, in order to adapt the changes of main causes of maternal deaths and accomplish increasing service requirements, it is necessary to develop new service and management mode.