Maternal mortality is a sensitive public health indicator, (1) After the Second World War, a sharp decline was observed in direct obstetric deaths in European countries, which was parallel to socio-economic development and improved health-care services with general access to emergency obstetric care. (2,3) In some places the decrease was accompanied by an increase in indirect obstetric deaths. (3) Today pulmonary embolism, pregnancy-induced hypertension, and haemorrhage are the main causes of maternal deaths in Europe. (2-4) The leading causes of indirect deaths are cardiovascular and psychological factors.
Reduction of maternal mortality is an important Millennium Development Goal (1) of special concern in low-income countries where one in 16 women may die of pregnancy-related complications compared to one in 2800 in high-income countries. (5) In the Russian Federation the maternal mortality ratio (MMR) varies between regions by a factor of nine. Generally, the ratio in the western part of the Russian Federation is closer to the European level, but even there it is much higher compared to the average in Western European countries. In 2000, the reported MMRs per 100 000 live births were 45 for the Russian Federation, 5 for Germany, 1.1 for Norway, 7 for the United Kingdom, 21 for Bulgaria, and 6 for the Czech Republic. (1)
According to official statistical data, in St. Petersburg the leading causes of death among women of reproductive age are injuries and poisoning (32.1%). Even though the mortality from pregnancy and obstetric complications only accounts for 0.3% of deaths in this age group, it is of great concern since most maternal deaths are of young healthy women. The present situation in the Russian Federation is further complicated by a very low fertility rate. In St. Petersburg in 2002 the fertility rate was 1.13, and this was the highest reported rate of the last decade. (6)
We collected data for a detailed analysis of levels and causes of maternal deaths in St. Petersburg over the 12-year period 1992-2003 in order to highlight some of the issues that can explain the relatively high ratio maternal mortality ratio and to assess any possible trends in causes of death.
Material and methods
We did a retrospective study of maternal mortality in St. Petersburg. For this purpose, we counted and assessed all deaths that were reported in pregnancy or within 42 days of its termination, irrespective of the duration or site of implantation. We classified deaths as direct or indirect obstetric deaths, or coincidental deaths, according to the definitions provided by International Classification of Disease (10th revision (ICD-10) and WHO. (1) Late maternal deaths (more than 42 days but less than 1 year after the termination of pregnancy) were not included in the present study.
We collected data from three sources:
1. Department of Mother and Child; St. Petersburg Public Health Committee
2. Medical Information Analytical Centre
3. St. Petersburg Statistic Committe
Information from these independent institutions is exchanged routinely. Any discrepancies that exist can be explained by administrative factors. Underreporting of maternal deaths in St. Petersburg is improbable because of strict administrative control. The St. Petersburg Public Health and Statistic Committees granted permission for the study, which used only non-identifiable data.
We built the research database from two separate forms used for mandatory registration of births and deaths: 1) "Chart of signal report for cases of maternal death"; and 2) "Report No. 32--Data of medical care during pregnancy, labor, and postpartum period". The St. Petersburg Commission of Maternal Mortality investigates every maternal death and completes the first of these forms, which contains 30 maternal characteristics, and which we used selectively. The second form is the standard statistical report to the Ministry of Health and Social Affairs--we used this for confirmation of cause of death according to ICD-10 and as a source of the total number of births in the city. …