Maternal Death, Autopsy Studies, and Lessons from Pathology
Authors: Sebastian Lucas
Journal: PLoS Medicine (2008)

Pathology is quality control—it confirms, refutes, or elaborates on clinical diagnoses. Globally, the most important fatal condition for which there is a lack of autopsy evaluation is maternal death. One reason for this lack may be that everyone supposedly knows why mothers die in pregnancy and childbirth. In resource-poor or developing countries, where the World Health Organization (WHO) estimates that over 99% of the 500,000 or more global maternal deaths occur annually, the stated main causes are (in descending order): post-partum haemorrhage, puerperal sepsis, hypertensive disorders, obstructed labour, and abortion. These are the so-called direct conditions, i.e., they would not happen if the woman were not pregnant. But WHO admits that it cannot reliably estimate these, nor the additional morbidity and mortality burden of the indirect conditions that lead to maternal death, i.e., pre-existing diseases that are worsened by pregnancy and delivery. These conditions include HIV, malaria, anaemia, tuberculosis, cardiac disease, and post-partum suicide; globally they are estimated to be less frequent than the direct causes [1].

In the United Kingdom, where maternal deaths are exhaustively evaluated (including through many autopsies), the indirect causes are more common than the direct ones by a ratio of more than 1.2. Overall the causes are (in descending order): maternal cardiac disease (acquired and congenital), pulmonary thromboembolism, central nervous system disorders, hypertensive disorders, sepsis, psychiatric disorder and suicide, haemorrhage, amniotic fluid embolism, and infectious diseases (of which HIV is a small proportion) [2].

A second reason for the global lack of autopsy data relates to the circumstances of maternal death in resource-poor countries. Most deliveries and deaths occur not in hospitals but in rural areas, where there may be no midwives or traditional birth attendants, let alone obstetricians [3]. So as well as being less well counted, maternal deaths will not be regularly evaluated by pathologists.

A third possible reason might be ministerial embarrassment. Whilst road traffic collisions leading to death are routinely examined by autopsy (though the information gained is generally small), there may be less desire to investigate deaths that collectively represent the greatest contrast in health outcomes between poor and rich countries. The lifetime risk of maternal death for a female in north-western Europe is one in 30,000, whilst in Afghanistan and Sierra Leone it is one in six [3]. And in many countries, maternal deaths are partly the outcome of policy and legislation, such as the criminalisation of therapeutic abortion, which makes so many women seek unsafe termination of pregnancy [4].

Linked Research Article
This Perspective discusses the following new study published in PLoS Medicine:

Menendez C, Romagosa C, Ismail MR, Carrilho C, Saute F, et al. (2008) An autopsy study of maternal mortality in Mozambique: The contribution of infectious diseases. PLoS Med 5(2): e44. doi:10.1371/journal.pmed.0050044

Menendez and colleagues conducted a prospective study on the causes of maternal death in a tertiary-level referral hospital in Maputo, Mozambique, using complete autopsies with histological examination.