Maternal Death Review Report for 2019 for the West Bank and Gaza Strip
Background
Reducing maternal mortality (MM) is both a global and national priority, requiring significant progress to reach the maternal mortality ratio (MMR) reduction target outlined in the United Nations Sustainable Development Goals (SDGs) by 2030. Reviewing and auditing maternal death data and improving quality of care are widely recommended interventions to reduce maternal mortality rates, particularly deaths resulting from preventable causes, and could be key to achieving certain SDGs.[1]
The Palestinian Ministry of Health (MoH) has regularly conducted maternal death reviews (MDR) since the establishment of the national surveillance system for maternal mortality and reproductive age deaths in 2009. Unfortunately, reports on MDR findings have been unreliable and sporadic with limited analysis. This report is the first to present a comprehensive MDR analysis and findings.
Purpose
This report presents the results of the 2019 maternal deaths review for the West Bank (WB) and Gaza Strip (GS). It shows the socio-demographic and health profile for the deceased women, in addition to the maternal death classification, identification of substandard factors that contributed to death, and conclusive recommendations for quality improvements in maternal and obstetric care.
Methodology
This MDR was prepared by PNIPH at the request of the Minister of Health, in close collaboration with the Primary Health Care Directorate, Community Health Department, Women’s Health Unit in the West Bank, Maternal Mortality Committee in Gaza, and the Palestinian Health Information Center (PHIC) in the West Bank and Gaza Strip.
PNIPH reviewed all maternal mortality surveillance questionnaires on maternal deaths reported through the national Maternal Mortality Surveillance System, as well as the electronic medical records of deceased women for the reporting period. This information was available through the hospital health information system. Other sources used for further data verification include the ANC record-based Maternal and Child Health (MCH) e-Registry and phone interviews with the families of the deceased women.
Due to challenges regarding reporting and data quality, the report does not provide a complete picture of maternal deaths in the country. It does provide useful information for strengthening major intervention areas for the maternal mortality surveillance system, and to avoid the needless loss of maternal lives.
Summary of Key Findings
Although the MM ratio in Palestine has improved, decreasing from 38 per 100,000 live births in 2009 to around 19.9 in 2019, a gap in MMR can be seen between the estimation and surveillance rates, which could indicate underreporting.[2]
For the period under review (January–December 2019), a total of 26 maternal deaths were reported (9 in the West Bank and 17 in the Gaza Strip) and included in this analytic review. All West Bank maternal deaths were among women aged 20 to 37 years; this age group also has the most pregnancies. Pregnancy at an early age was noticeable. The age of women at the time of their first marriage ranged from 15–26, and more than half of maternal deaths were among women who were married at or before the age of 18. Although these are proportions and not rates or ratios, it is still a valid illustration of the well-documented relationship between maternal age and maternal mortality. Unfortunately, it was not possible to obtain the sociodemographic profile for maternal deaths in the Gaza Strip, and as a result, no conclusions could be developed.
Risk of maternal death is higher among primigravida and grand multigravida, as demonstrated by the 2019 profile, particularly in the Gaza Strip. A review of the obstetric history of maternal deaths in the Gaza Strip revealed that 3 out of the 17 cases were primigravidae, and 10 were grand multigravidae. In the West Bank, none of the cases were primigravida, seven were multigravidae, and two were grand multigravidae.
Nearly all the deceased women had at least four antenatal visits, while only two had no documented antenatal visits at all. This infers that, although these women had regular antenatal visits, some of them were not aware of complications during delivery or in the postnatal period.
More than half of maternal deaths (18 out of 26) occurred in the postpartum period, three occurred in the antenatal period, and three in the intrapartum period (during delivery). Although the pregnancy-related hypertension disorder pre-eclampsia/eclampsia and pulmonary embolism were the two main causes of all maternal deaths, postpartum hemorrhage was coded as the underlying cause of death in only two cases in the West Bank and Gaza. There were probably more cases “hidden” as “volume overload,” “complication of transfusion,” or “embolism” that were closely related to or secondary to postpartum hemorrhage (PPH) and were coded as the underlying cause of maternal death. In these cases, postpartum hemorrhage would have been the appropriate underlying cause. This reflects the need to emphasize the importance of postpartum interventions to prevent such deaths.
Most maternal deaths in this study (21 out of 26) took place at a hospital while only 4 took place in the home. The place of death was not reported for the remaining case. The interpretation of this finding is linked to the severity of the condition or complication that required hospital care, and the associated higher risk of death.
Cesarean section was the most common mode of delivery among women who died during delivery or within 42 days of delivery (13 out of 21). The location of delivery for all deceased women was the hospital.
All maternal deaths that were reviewed (n=26) had an assigned underlying cause of death. More than 75% of the maternal deaths (20 out of 26) were direct maternal deaths, meaning they were due to obstetric complications. Only two cases were indirect, caused by existing medical conditions that influenced (or were influenced by) the pregnancy. The two main causes of all maternal deaths were hypertension (pre-eclampsia/eclampsia) and pulmonary embolism. Other underlying causes included sepsis and postpartum hemorrhage.
The Three Delays Model was used to analyze maternal deaths that occurred in Palestine in 2019, identifying contributing factors and profiling maternal deaths by the delay experienced by the deceased women. The analysis concluded that poor quality of services (including clinical management, communication and documentation, adherence to protocols and guidelines, availability of equipment and drugs, and referral management) was a predominant factor in maternal deaths, as were issues related to human resources for health. Other factors, such as delays in reaching an appropriate obstetric/medical facility and delays in deciding to seek medical care played less significant roles in maternal deaths. The combination of delays was an alarming issue among all maternal deaths in 2019 in Palestine.
Recommendations and Conclusion
Based on the study findings, recommendations are presented in two main categories. The first pertains to improvements to the MDR system itself, including actions needed to address weaknesses in the information collected. The second aims at preventing maternal deaths, in addition to evidence-based community interventions to address avoidable factors, such as the implementation of a well-organized health education program.
Several strategies are suggested to reduce maternal mortality. Training should be introduced for maternal health care providers at all care levels on emergency obstetric care, but also on social barriers, health rights, and adult education methods. Additionally, essential equipment should be provided. Improving and implementing MDR must be an integral part of the intervention package. These efforts will contribute to reducing maternal mortality, in line with the global initiative of Ending Preventable Maternal Mortality (EPMM) and supporting sustainable human development.
