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Response to Dr Muula's comment ("Maternal mortality in Mozambique: Methodologic issues")

Posted by plosmedicine on 31 Mar 2009 at 00:26 GMT

Author: Clara Menendez
Position: Research Professor
Institution: Barcelona Center for International Health Research (CRESIB)
Submitted Date: May 13, 2008
Published Date: May 14, 2008
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

We included in the analysis all consecutive maternal deaths occurring at the Maputo Central Hospital (MCH) during the period of study, independently of whether the patients delivered at the MCH or elsewhere, but not patients brought in dead at the hospital. Although the number of women that delivered elsewhere was low, we may have slightly overestimated the maternal mortality, as we compared the number of maternal deaths with the number of live births in the MCH.
The WHO defines maternal death as: “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”. [1] In this definition, all “direct” (obstetrical) deaths should be included, but the inclusion of “indirect” (non-obstetrical) deaths, relies on a rather subjective decision on whether a particular disease could be or not aggravated by the physiological effects of pregnancy. Interestingly, the majority (59.5%) of the women in our study died of “indirect” causes and therefore, might have been excluded by some investigators, although we do know that many infectious diseases (that caused 86% non-obstetrical deaths) can be aggravated by pregnancy. The WHO 2005 report on maternal mortality states that “accurate identification of the causes of maternal death by differentiating the extent to which they are due to direct or indirect obstetric causes or even to accidental or incidental events is not always possible”. It has therefore proposed in the ICD-10 classification an alternative definition of maternal death, namely “pregnancy-related death”, [1] which includes all maternal death irrespective of its cause that we consciously used in our study. Although we acknowledge with Dr. Muula that this may render the findings difficult to compare with some other studies (most published studies include all deaths as ours), definitely avoids subjective and sometimes aprioristic decisions on what is or what is not a maternal death, and may thus make easier the comparisons.

We agree that the numbers are small to carry out more sophisticated statistical analysis, but what we are dealing here with are maternal deaths and not infant or child mortality.


1. WHO. Maternal mortality in 2005: estimates developed by WHO, UNICEF UNFPA and the world bank. WHO Press, Geneva, Switzerland

Competing interests declared: I am the first and corresponding author of this paper.