Depression and obesity are major causes of maternal death in Britain
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7476.1205 (Published 18 November 2004) Cite this as: BMJ 2004;329:1205
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The SA Yearbook states obsetric haemorrhage to be the most common direct cause of death in level one institutions and that there was a significant decline in the number of women dying as a result of complications of abortion (1998:32 cases 5.7% of all maternal deaths and in 1999: 37 cases 5.2%. For 2000: 26 cases 3.9%.) Access to abortion is not available countrywide and many backstreet abortions continue.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor:
While I have not yet read the it seems evident that either the RCOG
or the BMJ have failed to report on the association between abortion and
elevated mortality rates.
Four large, record-based studies have found a significant and strong
association between abortion and elevated mortality rates compared to
women who carry to term. Three examined the population of Finland (1-3),
one of which was published in the BMJ (2). The fourth examined low income
women in California and found that the elevated risk of death associated
with abortion persisted over several years and may effect maternal
mortality rates of subsequent pregnancies.(4) A fifth study published in
BMJ’s letters (5) found that the elevated risk of attempted suicide
following abortion is can not be explained by prior suicide attempts, for
the rate of prior suicide attempts is not higher among women who have
abortions.
There have yet to be any studies that contradict these findings.
Given this literature, it seems unlikely that the RCOG researchers failed
to look at the association between abortion and maternal mortality in this
British population. This leads me to fear that the findings in this
regard may have been obscured or suppressed either in the RCOG report or
in the BMJ’s summary of it’s findings.
As previously suggested, much additional research needs to be done to
explore the association between abortion and elevated mortality rates,
including the finding of higher deaths associated with heart disease (6),
which may be related to higher rates of anxiety (7) and depression (8).
This requires a closer examination including complete reproductive
histories. It appears that RCOG has access to data that may help to shed
light on these associations. I hope there will be an additional report
forthcoming.
Sincerely,
David C. Reardon, Ph.D.
(1) Gissler M, Berg C, BouvierColle MH, Buekens P.
Pregnancyassociated mortality after birth, spontaneous abortion or induced
abortion in Finland, 19872000. Am J Ob Gyn 2004; 190:422427.
(2) Gissler M, Hemminki H, Lonnqvist J. Suicides after pregnancy in
Finland: 198794: register linkage study. BMJ 1996; 313:14314.
(3) Gissler M, Kauppila R, Merilainen J, Toukomaa H, Hemminki E.
Pregnancy-associated deaths in Finland 1987-1994 — definition problems and
benefits of record linkage. Acta Obsetricia et Gynecolgica Scandinavica
1997; 76:651-657.
(4) Reardon DC, Ney PG, Scheuren F, Cougle JR, Coleman, PK, Strahan
TW. Deaths associated with pregnancy outcome—a record linkage study of
low income women. Southern Medical Journal 2002; 95(8):834841.
(5) Morgan CM, Evans M, Peter JR, Currie C: Mental health may
deteriorate as a direct effect of induced abortion. Br Med J, 1997; 314:
902. (Letters)
(6) Reardon DC, Coleman PK. Pregnancyassociated mortality after
birth. American Journal of Obstetrics and Gynecology, 2004
191(40):15061507.
(7) Cougle JR, Reardon DC, Coleman PK. Generalized anxiety following
unintended pregnancies resolved through childbirth and abortion: a cohort
study of the 1995 national survey of family growth. Journal of Anxiety
Disorders, 2005 19(1):137142.
(8) Reardon DC, Cougle JR. Depression and unintended pregnancy in the
National Longitudinal Survey of Youth: a cohort study. BMJ. 2002;
324:1512.
Competing interests:
None declared
Competing interests: No competing interests
Haemorrhage, hypertension, sepsis, anaemia and medical disorders continue to be major maternal killers in developing world
The article on maternal mortality by Brettingham that depression and
obesity are emerging as major causes of maternal mortality in UK shows a
changing trend in causes of maternal deaths in all developed world.
Unfortunately maternal mortality continues to be unacceptably high in
developing countries like India due to avoidable causes.
In an Indian
Council of Medical Research Task Force Study by Bedi et al (1) in 31
teaching hospitals from 16 states and Union Territories of India and over
1,66,996 live borths, there were 973 maternal deaths with maternal
mortality ratio of 582 per 100,000 live births. As expected maternal
mortality was higher in rural areas (53%), in uneducated women (62%) and
was highest in women admitted in postnatal period and 70 % deaths were due
to direct causes.
The main causes of mortality were hypertension(24%),
haemorrhage (23.6%), abortion (12.2%)(septic abortion was responsible for
83% of abortion deaths), anaemia (11%), viral hepatitis (7.1%)and
puerperal sepsis (3.7%). India has one of the highest maternal mortalities
in the world with 100,000 maternal death per year with maternal mortality
rate of 437 per 100,000 births(2). However,mortalitie only repreent tip of
iceberg. For every death, many more live with permanent injury and chronic
disability. Thus in an Indian study for each death, there were 541
morbidities: 46% were life threatening and 25% women suffered chronic
illnesses(3).
Maternal education and empowerment are two most important
tools to reduce maternal mortality as an educated woman is more likely to
accept contraception and small family norm, is more likely to eat
nutritious diet and is more amenable to receive antenatal and labour care
as has been the case with Sri Lanka and Kerala state in India which have
one of the best maternal and perinatal outcomes of developing world(4-6).
There is a need to create social,economical and cultural environment in
which freedom and choice are given concrete meaning(4). Government and non
-goverment organisations,donor and society must work together to design
delivery systems to make the services more responsive to the need of the
women(4). Safe motherhood is an achievable and worthwhile goal and is the
right of every woman(6).
References:
1. Bedi N, Kambo I, Dhillon BS, Saxena BN, Singh P. Maternal deaths
in India-Preventable Tragedies. An ICMR Task Force Study. J Obstet Gynec
India 2001;51:86-92.
2.International Institute for Population Sciences. National Family
Health Survey,1992-93,India Introductory Report. Mumbai: International
Institute of Population Sciences,1994.
3.Fortney JA,Jason BS (eds). The base of the iceberg. Prevalence and
perceptions of maternal morbidity in four developing countries. The
Maternal Morbidity Network. Research Triangle Park:Family
International,1996.
4. Pachauri S. Preventing maternaal mortality:Right to safe
pregnancy. Nat Med J Ind 2003;16 Suppl 2:24-27.
5.Sharma JB. Nutritional anaemias during pregnancy in non-
industrialised countries. In Studd J (ed) Progres in Obstetrics and
Gynaecology, 15th edition, Edinburgh, Churchill Livingstone, 2003:103-122.
6. Pitroff R, Johanson R. Safe motherhood:an achievable and
worthwhile aim. In Studd J (ed) Progress in Obstetrics and Gynaecology,
13th edition,Edinburgh, Churchill Livingstone, 1996:47-57.
Competing interests:
None declared
Competing interests: No competing interests