Indirect causes of maternal death
Authors: Frederikke Storm, Suneth Agampodi, Michael Eddleston, Jane Brandt Sørensen, Flemming Konradsen, Thilde Rheinländer
Journal: The Lancet Global Health (2014)

Comprehensive analyses of the causes of maternal mortality have been published by WHO1Say L Chou D Gemmill A et al.Global causes of maternal death: a WHO systematic analysis.Lancet Glob Health. 2014; 2: e323-e333Summary Full Text Full Text PDF PubMed Scopus (2716) Google Scholar and the Institute for Health Metrics and Evaluation.2Kassebaum NJ Bertozzi-Villa A Coggeshall MS et al.Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Institute for Health Metrics and Evaluation.Lancet. 2014; (published online May 2.)http://dx.doi.org/10.1016/S0140-6736(14)60696-6PubMed Google Scholar These analyses strikingly show the increasing importance of indirect causes of maternal death. Say and colleagues1Say L Chou D Gemmill A et al.Global causes of maternal death: a WHO systematic analysis.Lancet Glob Health. 2014; 2: e323-e333Summary Full Text Full Text PDF PubMed Scopus (2716) Google Scholar noted that 27·5% of all maternal deaths result from these indirect causes, with the highest proportion of such deaths in south Asia and sub-Saharan Africa. Kassebaum and colleagues2Kassebaum NJ Bertozzi-Villa A Coggeshall MS et al.Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Institute for Health Metrics and Evaluation.Lancet. 2014; (published online May 2.)http://dx.doi.org/10.1016/S0140-6736(14)60696-6PubMed Google Scholar similarly show the growing direct and indirect effects of non-communicable diseases on maternal mortality. The authors conclude that indirect causes of maternal deaths cannot be ignored and that efforts should be focused on their reduction. The greater relative importance of indirect causes could be a result of successful addressing of direct complications of pregnancy and childbirth, and of a change in risk factors and disease patterns.1Say L Chou D Gemmill A et al.Global causes of maternal death: a WHO systematic analysis.Lancet Glob Health. 2014; 2: e323-e333Summary Full Text Full Text PDF PubMed Scopus (2716) Google Scholar, 2Kassebaum NJ Bertozzi-Villa A Coggeshall MS et al.Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Institute for Health Metrics and Evaluation.Lancet. 2014; (published online May 2.)http://dx.doi.org/10.1016/S0140-6736(14)60696-6PubMed Google Scholar Indirect causes of death include the effects of pre-existing disorders, such as HIV infection, mental disease, and diabetes, when aggravated by pregnancy. Unfortunately, this range of indirect causes is yet to be fully explored. Prompt action to thoroughly understand these causes of death and develop appropriate responses is crucial to continue worldwide progress in maternal mortality reduction. Despite the importance of these indirect causes, key policy and strategy documents of leading international maternal health non-governmental organisations and UN organisations do not focus much on indirect causes3WHOReproductive health strategy to accelerate progress towards the attainment of international development goals and targets. World Health Organization, Geneva2004Google Scholar, 4WHOAccelerating progress towards the attainment of international reproductive health goals: a framework for implementing the WHO Global Reproductive Health Strategy. World Health Organization, Geneva2006Google Scholar, 5International Planned Parenthood FederationStrategic framework 2005–2015. International Planned Parenthood Federation, London2007Google Scholar, 6Marie Stopes InternationalGlobal impact report 2013: the client as our compass. Marie Stopes International, London2014Google Scholar, 7Population CouncilAnnual report 2013. Population Council, New York2014Google Scholar of maternal mortality, except for HIV infection. Predominant attention is still given to direct causes of adverse pregnancy outcomes. In particular, poor mental health as an underlying causal factor for maternal mortality and morbidity has been ignored and remains outside the stated agenda of these organisations. This omission is despite the fact that many studies8Rahman A Surkan PJ Cayetano CE Rwagatare P Dickson KE Grand challenges: integrating maternal mental health into maternal and child health programmes.PLoS Med. 2013; 10: e1001442Crossref PubMed Scopus (150) Google Scholar, 9Patel V Rahman A Jacob KS Hughes M Effect of maternal mental health on infant growth in low income countries: new evidence from south Asia.BMJ. 2004; 328: 820-823Crossref PubMed Scopus (248) Google Scholar have shown that poor maternal mental health has far-reaching adverse effects on mother and infant. Furthermore, suicide, as the most severe effect of poor mental health, is a leading contributor to maternal mortality worldwide and is strongly associated with violence and abuse.8Rahman A Surkan PJ Cayetano CE Rwagatare P Dickson KE Grand challenges: integrating maternal mental health into maternal and child health programmes.PLoS Med. 2013; 10: e1001442Crossref PubMed Scopus (150) Google Scholar The situation might be helped by the WHO guidelines10WHOThe WHO application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD-MM. World Health Organization, Geneva2012Google Scholar on recording of maternal mortality cause: the International Classification of Disease—Maternal Mortality. These guidelines now deem suicides during pregnancy and 12 months postpartum as direct maternal deaths, even if underlying obstetric psychiatric disorders are not diagnosed. This revision provides hope for improved future data on suicide as a cause of maternal death and provides reason for organisations to add mental health to their agenda. Implementation of several internationally ratified human rights conventions that require governments to take action to address maternal mental health as part of health services could improve the situation somewhat. Maternal mental health is essential to safe motherhood. The worldwide maternal health community should update their agendas to ensure programme effectiveness by giving attention to indirect causes of maternal death, including mental health. We declare no competing interests.