THE MEDICAL JOURNAL OF BASRAH UNIVERSITY

Socio-demographic characteristics of maternal deaths in Basrah or the period

(2013-2017)
Riyadh A. Al Hilfi1, Rajaa A. Mahmoud2, Nihad Q. Al Hamadi3

ABSTRACT
Introduction and Background: In Iraq, and due to the decades of wars and sunctions that affected
people’s accessibility to the health care services, maternal death was among the main health problems
over the years. Thus, studying the factors influencing this important problem is a mandatory step for a
better evidence based intervention in controlling the problem.
Objective: To analyze the socio-demographic factors that influence maternal deaths in Basrah during the
period 2013-2017.
Methodology design: The study is an observational retrospective one included information collected
from the medical records, death certificate and forensic medicine reports in addition to interviewing the
family as needed. A total of 201 deaths were included in the study.
Results: The study shows that maternal death rate in Basrah increased sharply during 2016 compared to
that of 2013 with a highest rate in Shat Al-Arab and Al-Mudiana districts. Then, a sharp decrease was
noticed in 2017 compared to 2016. Maternal mortality rates were found to be increasing with increasing
women’s age with the highest rate among women above 40 years old. But no big difference between
maternal death rates in urban and rural areas. (88.1%) of the study women died in hospital while 11.9%
of them died outside the hospital
Conclusions and recommendations: Maternal death is still a problem in Basrah in spite of the decline that
occurred between (2016-2017) compared to the rates in 2013. Strengthening of maternal mortality
monitoring system across all districts of Basrah governorate in addition to improving the quality of
registering all pregnancy related information are the main recommendations of the study.
Key words: Maternal mortality, Socio-demographic, Basrah.

)3102-3102( ‫دراسة الخصائص االجتماعية والديموغرافية لوفيات األمهات في البصرة للفترة‬

‫ كانت وفيات األمهات من بين‬،‫ ونتيجة لعقود من الحروب والعقوبات التي أثرت على حصول الناس على خدمات الرعاية الصحية‬،‫ في العراق‬:‫المقدمة‬
‫ فإن دراسة العوامل المؤثرة على هذه المشكلة هي خطوة مهمة لتقديم أفضل الطرق للمساهمة في‬،‫ لذا‬.‫المشاكل الصحية الرئيسية على مر السنين‬
.‫السيطرة على المشكلة‬
.3102-3102 ‫ تحليل العوامل االجتماعية والديموغرافية المؤثرة على وفيات األمهات في البصرة خالل الفترة‬:‫الهدف‬
‫ تضمنت الدراسة معلومات تم جمعها من السجالت الطبية وشهادات الوفاة وتقارير الطب الشرعي باإلضافة إلى إجراء مقابالت مع العائلة‬:‫المنهجية‬
.‫ حالة وفاة‬310 ‫ شملت الدراسة‬.‫حسب الحاجة‬
‫ مع أعلى‬3102 ‫ مقارنة بتلك المسجلة لعام‬3102 ‫ أظهرت الدراسة أن معدل وفيات األمهات في البصرة قد ارتفع بشكل حاد خالل عام‬:‫النتائج‬
‫ كما وجدت‬.3102 ‫ مقارنة بعام‬3102 ‫ ثم لوحظ انخفاض حاد في معدل وفيات األمهات خالل عام‬.‫معدالت في منطقتي شط العرب والمدينة‬
‫الدراسة أن معدالت الوفيات تتزايد مع زيادة عمر المرأة مع تسجيل أعلى معدل بين النساء فوق سن األربعين ولم يظهر فرق كبير بين معدالت وفيات‬
.‫األمهات في المناطق الحضرية والريفية‬

1
Ministry of Higher Education, Iraq. Basrahh University, College of Medicine, Department of Family and
Community Medicine
2
Ministry of Health. Training and Human Development Department. Basrahh Health Directorate.
3
Ministry of Health. Quality Assurance Unit. Basrahh Health Directorate
Vol. 37, No.1, 2019_______________________________________________________________

‫ مقارنة‬3102 ‫ و‬3102 ‫ ال تزال وفيات األمهات مشكلة في البصرة على الرغم من انخفاض معدالتها بين عامي‬:‫االستنتاجات والتوصيات‬
‫ وقد أوصت الدراسة بتقوية و تعزيز نظام مراقبة وفيات األمهات في جميع قطاعات محافظات البصرة باإلضافة إلى‬.3102 ‫بالمعدالت في عام‬
.‫تحسين جودة توثيق كافة المعلومات المتعلقة بالحمل و الوالدة و ما بعدها‬
‫ البصرة‬، ‫ االجتماعية والديموغرافية‬، ‫ وفيات األمهات‬:‫الكلمات المفتاحية‬
INTRODUCTION

M
aternal death as defined by the especially if the causes are multifactorial and
World Health Organization is the interrelated.[5] Among those factors, woman’s
“death of a woman while pregnant age is a big influencing factor.[6] For example,
or within 42 days of termination of pregnancy, woman’s death during early young age is due to
irrespective of the duration and site of the the physical incomplete growth of their pelvis
pregnancy, from any cause related to or while among those at older age group,
aggravated by the pregnancy or its management accumulative risk of having pregnancy related
but not from accidental or incidental causes”.[1] complications is more prominent cause of their
It is estimated that 830 women in child bearing death. Another influencing factor is maternal
age dies everyday because of pregnancy related education, which was proved in many
causes that can actually be prevented during international studies and gave an evidence that
their life. Almost all of these deaths are lower level of maternal education is associated
registered in developing countries.[2] Latest with higher rates of maternal mortality. [7] In
evidences show that there is an overall Iraq, and due to the decades of wars and
worldwide decrease in mortality rate throughout sunctions that affected people’s accessibility to
the recent years. However, still many contries - the health care services, maternal death was
especially developing ones- did not approach among the main health problems over the years.
their target for the numbers set by the Global Thus, studying the factors influencing this
Millennium Development Goals. Inorder to important problem is a mandatory step for a
achieve that, more researches should be done to better evidence based intervention in its control.
know the the socio-demographic factors that According to the Iraqi MoH strategy for
influence maternal deaths in each area to aid Maternal and Child care program in Basrahh
prioritization of the available resources and Health Directorate, death registration system is
facilitate achieving the goals in decreasing monitored continuously by a focal point in each
maternal deaths in each country.[3] Other hospital in the Basrah governorate. An
evidences show that on national levels, each immediate notification about any death during
country has in-country differences in the rates of pregnancy, labor, or perperium is mandatory to
maternal death especially in those with different the central maternal death committee in Basrah
levels of income and education. Families in Health Directorate which investigate and review
rural areas are found to be with higher rates of causes of each maternal death in Basrah.[8]
maternal deaths compared to urban areas Then, each case of maternal death has to be
because of inaccessibility to better health care reviewed and analysed first by the local/district
services in addition to other socio economic medical and gynecological committee at the
factors influencing the care they receive during hospital. Then a second review has to be done at
pregnancy, delivery and perperium.[1,4] the level of the main Health directorate by the
Knowing exactly what are the socioeconomic joint committee of Basrah health authorities and
factors that influence maternal death, is an the medical college at the governorate. The
important factor in planning the necessary “per-case” review is performed to ensure that
interventions in controlling the problem, each maternal death was analysed by experts to

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_______________________________________________________________Vol.37, No.1, 2019

define its cause of death and any associated

factors and consequently to set a future RESULTS
recommendation to avoid such a problem. (Table-1), shows that maternal death rate in
Basrah increased sharply during 2016 compared
Objective: to that of 2013. Then, a sharp decrease was
To analyze the socio-demographic factors that noticed in 2017 compared to 2016.
influence maternal deaths in Basrah during the
period 2013-2017.
Table1. Maternal Mortality rates per 100000
METHODOLOGY live birth during (2013-2017) in Basrah
The study is an observational retrospective one Death
included all of the mothers fulfilling the Number of Total live rate per
definition criteria of maternal death according to Year
deaths births 100,000
Iraqi ministry of health (MoH) during the period live birth
2013- 2017. Information was collected from the 2013 37 102351 36.15
medical records(from all hospitals in Basrah),
2014 42 106779 39.33
death certificate and forensic medicine reports
in addition to interviewing the family as needed 2015 40 101635 39.36
especially when missing information was found 2016 56 100259 55.8
in the medical records.Data were analysed using
2017 26 90266 28.80
Microsoft Excel 2010. Frequencies and
percentages of the included variables were Total 201 501290 40.09
calculated including maternal age-specific and
area-specific mortality rates per 100,000 live
births. Death rates according to the place of The present study found that the risk of death
residence, place of delivery and place of increase with increasing women’s age with the
women’s death were also calculated. In addition highest rate among women above 45 years old
to women’s education level and job. A total of and above (217 per 100000 live birth) and the
201 deaths were included in the study. Maternal lowest rate (15.2 per 100000 live) among
mortality rates were computed per 100,000 live women aged between15-19 years. (Figure-1)
births.

217
181.7

76.6
66.4 54.4
28.3
15.2 22.3

less than 19-15 24-20 29-25 34-30 39-35 44-40 45 and

15 above

Fig 1. Age specific maternal death rates in Basrah (2013-2017)

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Vol. 37, No.1, 2019_______________________________________________________________

More than half of maternal deaths (53.3%) were education level and most of the deaths (90.2%)
found by the present study to be in urban areas; were registered to be among house wives
while the highest percentage of maternal death (Figure 2, 3, 4).
(40%) was were among women with primary

Illiterate
%9
%12 Primary
107(53.
3%) 94(46.7 %39 Secondary
%)
High
%40 education

Urban Rural

Fig (2, 3). Maternal deaths according to the place of residence and Education level

[VALUE]%

[VALUE]%

House wife
Governmental work
Student
[VALUE]%

Fig 4. Maternal deaths according to her job

Figure 5, shows that the highest rate of deaths live birth), while the lowest rate was found in
(63.6/100000 live birth) is in Shat Al-Arab Al-Qurna (17.4/100000 live birth).
district followed by Al-Mudiana (53.7/100000

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_______________________________________________________________Vol.37, No.1, 2019

70 63.6
60 53.7
50
42.9
38.6 40.1
40
28.5
30

20 17.4

10

0
Shat Al- Al Center of Al-Zubair Abu Al- Al- Qurna Total
Arab Mudiana Basra kaseeb

Fig 5. Area (district) Specific maternal deaths per 100,000 live births

According to the place of delivery, (Table-2), live births at home. In addition, the study shows
shows that among the 141 women who that (88%) of the study women died in hospital
delivered (with exclusion of 60 women who did while 12% of them died outside the hospital (at
not delivered and died during pregnancy), home, in the ambulance, during a private
maternal death rate was 28.8/100000 live transportation).
birthgs at hospitals compared to 22,7 / 100000

Table 2. Maternal death rate according to the place of delivery.

At hospital At home
Year
Total Death Rate Total Death Rate
Total deaths Total deaths
deliveries (100000 LB) deliveries (100000 LB)

2013 90213 24 26.6 12138 3 24.7

2014 94641 31 32.8 12138 4 33.0

2015 92220 23 24.9 9415 2 21.2

2016 90311 32 35.4 9948 3 30.2

2017 80946 19 23.5 9320 0 0.0

129 12
448331 28.8 52959 22.7
(88% of deaths) (12% of deaths)
n= 141 (60 did not delivered and dead during pregnancy )

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DISCUSSION
According to the annual statistical report of urban and rural areas.This is different from the
Iraqi MoH, Basrah has high maternal mortality WHO results stating the death rates are usually
rate in 2016 (55/100,000 live births) which was higher in poor areas of the rural areas due to
higher than the national rate (40/100,000 [9,10]). poverty and lack of acess to health services.[1] In
Then, the rate was sharply declined in 2017 (as addition, and according to the WFP report in
found by the present study) which is lower than 2012, Shat Al-Arab and Al-Mudaina districts
the national rate. The result is similar to that are considered to have the highest poverty
which was done in Texas during 2006-2015 to indicators in Basrah.[14] Maternal death rates
study the trends in which there was an increase decrease with increasing education level. The
from 18.6/100,000 live births in 2010 to 38.7 result is in coherence with the results of a cross
/100,000 live births in 2012 followed by a sectional global survey done by the WHO in
decline to 32.5/100,000 live births in 2015.[11] 2011 on assessing the the relationship between
The sharp decline in maternal death rates that maternal education and their mortality rates.[7]
was found by the present study could be Death rates was also found to be higher among
explained by the measures taken by Basrah housewives compared to those who are working
Health Directorate to improve the quality of or students. This might be explained by the fact
intra and post natal care provided to the women. that working mothers have higher education and
These measures included increasing the number more chance to be educated about pregnancy
of Obstetric / gyneologists in rural ares, care and its associated risks. This result is
improving the performance of nursing staff at similar to a study done in Nigeria which reveals
the maternal words of the hospitals in addition that more women who are unemployed (40.6%)
to improving the referral system. However, died from maternal causes than those who were
Basrah has high maternal mortality rate, which employed (8.7%).[15] Regarding the place of
is lower than other developing countries. delivery, our study reveals that maternal deaths
Evidences provided that maternal mortality ratio for women delivered at hospitals are more than
in developing countries in 2015 is 239 per those delivered outside the hospitals. This could
100,000 live birth versus 12 per 100,000 live be explained by the risk of association between
birth in developed countries.[1] Extreme young hospital delivery and scaecarian sections.
and old mother are more risky for maternal
death and complication of pregnancy that lead CONCLUSIONS AND RECOMMENDATIONS:
to death. The study shows a “J-shape curve” for Maternal death is still a problem in Basrah in
age specific death rate with the highest rate for spite of the decline that occurred between 2016-
the women with 40 years and more. This result 2017 compared to the rates in 2013. The highest
is similar to those of a study done by the WHO rates were found in Shat Al-Arab and Al-
in 144 countries to assess maternal mortality in Mudiana districts. Level of education, woman’s
adolescents compared with women of other age, job of the mother and place of delivery are
ages,[12] and in another study done in 38 among the main socio-demographic risk factors
countries to analyze new findings for maternal influencing maternal death in Basrah.
mortality age patterns.[3] In Sweden, age was Strengthening maternal mortality monitoring
found to be the major biological determinant of across all districts of Basrah in addition to
maternal mortality rate, with a higher risk of improving the quality of registering all
death for pregnant women younger than 20 pregnancy related information are the main
years.[13] The present study found a little recommendations of the study.
difference between maternal death rates in

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REFERENCES
1. World Health Organization. Fact sheets. 8. Ministry of Health. Basrah Health Directorate.
Maternal mortality (2018). Accessed online on Health Quality management Department. 2018
February 2018: www.who.int/news-room/fact- 9. Ministry of Health. Planning and Statistical
sheets/detail/maternal-mortality department. Annual Statistical report. 2017.
2. Alkema L, Chou D, Hogan D, Zhang S, Moller 10. Ministry of Health. Basrahh Health
AB, Gemmill A, et al (2016). Global, regional, Dirrectorate. Planning and Statistical
and national levels and trends in maternal department. 2017.
mortality between 1990 and 2015, with 11. MacDorman MF, Declercq E, Thoma M (2018).
scenario-based projections to 2030: a Trends in Texas maternal mortality by
systematic analysis by the UN Maternal maternal age, race/ethnicity, and cause of
Mortality Estimation Inter-Agency Group.. death, 2006-2015. Birth. June;45(2):169-177.
Lancet; 387 (10017): 462-474. Accessed online on january 2018:
3. Blanc AK, Winfrey W, Ross J (2013). New https://www.ncbi.nlm.nih.gov/pubmed/293142
Findings for Maternal Mortality Age Patterns: 09
Aggregated Results for 38 Countries. PLoS 12. Nove A, Matthews Z, Neal S, Camacho AV
ONE 8(4): e59864. Accessed online on (2014). Maternal mortality in adolescents
February 2018: https://www.ncbi.nlm.nih.gov compared with women of other ages: evidence
/pmc/articles/PMC3629034 from 144 countries. The Lancet Global Health.
4. Wenjuan W, Alva S, Shanxiao W, Fort A March;2(3): 155-64. Accessed online on
(2011). Levels and Trends in the Use of February 2018:
Maternal Health Services in Developing https://www.ncbi.nlm.nih.gov/pubmed/251028
Countries. DHS Comparative Reports No. 26. 48
Calverton, Maryland, USA: ICF Macro. 13. Hogberg U, Wall S (1986). Age and parity as
https://dhsprogram.com/pubs/pdf/CR26/CR26. determinants of maternal mortality impact of
pdf their shifting distribution among parturients
5. Deborah M, Murat Z, Victoria W, Kamara A in Sweden from 1781 to 1980 . Bulletin of the
(1997). The Design and Evaluation of Maternal World Health Organization, 64 (1): 85-91.
Mortality Programs. Center for Population Accessed online on February 2018:
and Family Health School of Public Health http://europepmc.org/backend/ptpmcrender.fc
Columbia University. Accessed online on gi?accid=PMC2490922&blobtype=pdf
February 2018. https://www.mailman. 14. Al-Gasseer N. Common Country Assessment
columbia.edu/sites/default/files/pdf/designev Iraq. United Nations (2009). Accessed online
almm-en.pdf on February 2018:
6. Brett E, Frans W.A. (2013). Trends and risk http://www.iq.undp.org/content/dam/iraq/doc
factors of maternal mortality in late- s/CCA_Final.pdf
nineteenth-century Netherlands, The History 15. Lorretta F, Friday E, Rosemary N, Hadiza S,
of the Family, 18:4, 481-509, DOI: et.al (2018). Prevalence and risk factors for
10.1080/1081602X.2013.836457 maternal mortality in referral hospitals in
7. Karlsen S, Say L, Souza JP, Hogue CJ, Calles Nigeria: a multicenter study. International
DL, et, al (2011). The relationship between Journal of Womens Health; 10: 69–76.
maternal education and mortality among Accessed online on February 2018:
women giving birth in health care https://www.ncbi.nlm.nih.gov/pmc/articles/P
institutions: analysis of the cross sectional MC5798564/citedby/
WHO Global Survey on Maternal and
Perinatal Health. BMC Public Health.
July(29);11:606. doi: 10.1186/1471-2458-11-606.
Accessed online on january 2018:
https://www.ncbi.nlm.nih.gov/pubmed/218013
99