Sexual & Reproductive Healthcare 26 (2020) 100560
Contents lists available at ScienceDirect
Sexual & Reproductive Healthcare
journal homepage: www.elsevier.com/locate/srhc
Scoping maternal care through the lens of maternal deaths: A retrospective
analysis of maternal mortality in Georgia
Natia Skhvitaridze a, b, c, *, Erik Eik Anda a, Tormod Brenn a, Nikoloz Kintraia d,
Amiran Gamkrelidze b
a
Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Hansine Hansens veg 18, Tromsø 9037, Norway
National Center for Disease Control and Public Health, Kakheti Highway 99, Tbilisi 0198, Georgia
The University of Georgia, Kostava Street 77a, Tbilisi 0171, Georgia
d
Georgian Perinatal Association, Kostava Street 38, Tbilisi 0179, Georgia
b
c
A R T I C L E I N F O
A B S T R A C T
Keywords:
Georgia
Maternal mortality
Direct causes of death
Indirect causes of death
Substandard care
Introduction: Reduction of the maternal mortality ratio (MMR) to 12 per 100,000 live births by 2030 is a priority
target in Georgia. This study aims to assess and classify MM in Georgia by direct and indirect causes of death
from 2014 to 2017, using data from the national surveillance system and in accordance with internationally
approved criteria.
Material and methods: In this secondary study, MM data was retrieved from the Maternal and Children’s Health
Coordinating Committee and validated with data from the Vital Registry System and the Georgian Birth Registry.
The study sample comprised 61 eligible MM cases. Relevant information was transferred to case-report forms to
review and classify MM cases by direct and indirect causes of maternal death.
Results: The MMR during the study period was 26.7 per 100,000 live births. The proportion of direct causes of
maternal death exceeded that of indirect causes, at 62% and 38%, respectively. The leading direct cause of
maternal death was haemorrhage, while infection was the most frequent indirect cause. 52.5% of MM cases had
no pre-existing medical condition, 62.3% had frequent adherence to antenatal care, and 52.5% had emergency
caesarean sections.
Conclusion: In Georgia, direct causes of maternal death exceed indirect causes in MM cases, with haemorrhage
and infections, respectively, being most common. These findings are important to ensure optimal and continuous
care and to accelerate progress in the reduction of MM in the country.
Introduction
Maternal mortality ratio (MMR) is an important indicator of
maternal health and perinatal care. Although significant progress has
been made in the past decade [1–2], the global reduction of MMR remains a critical challenge. Following the United Nation’s Millennium
Development Goals by 2015, maternal health was also prioritised in the
Sustainable Development Goals, with the target to reduce MMR below
70 per 100,000 livebirths by 2030 [2–3]. Recent studies of maternal
mortality (MM) have demonstrated that 94% of all maternal deaths
occur in the developing world [4]. According to the WHO, the MMR in
low-income countries was 239 per 100,000 live births compared to 12 in
the rest of the world in 2015 [5–8]. Direct obstetric causes account for
about 86% of all maternal deaths globally, with haemorrhage being the
most common cause [7]. However, most MM cases are preventable, and
about 50% of cases are avoidable [9,10]. In order to reach the desired
reduction in MMR, efforts must focus on the improvement of all parts of
the continuum of reproductive healthcare, accurate surveillance, and
understanding the causes of maternal death [2,9,10].
Over the last decade, Georgia, a developing lower-middle-income
Abbreviations: MM, maternal mortality; MMR, maternal mortality ratio; WHO, World Health Organisation; ANC, antenatal care; MCHCC, Maternal and Children’s
Health Coordinating Committee; MoH, Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs of Georgia; NCDC,
National Center for Disease Control and Public Health; VRS, Vital Registry System; GBR, Georgian Birth Registry; ICD-10, International Classification of Diseases,
10th revision; CI, confidence interval.
* Corresponding author at: National Center for Disease Control and Public Health, Kakheti Highway 99, Tbilisi 0198, Georgia.
E-mail address: natia.skhvitaridze@uit.no (N. Skhvitaridze).
https://doi.org/10.1016/j.srhc.2020.100560
Received 26 February 2020; Received in revised form 22 September 2020; Accepted 27 September 2020
Available online 1 October 2020
1877-5756/© 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
N. Skhvitaridze et al.
Sexual & Reproductive Healthcare 26 (2020) 100560
country with a population of 3,719,300 [11], has embraced evidencebased medicine and implemented a health improvement programme
with the aim of bettering the quality of health care. State expenses for
healthcare increased 2.5 times since 2012, and these expenses currently
claim 3.7% of the country’s gross domestic product. In 2013, Georgia
launched its Universal Health Care Programme, which entitles every
citizen to a basic package of health services and is a visible demonstration of the country’s commitment to the Sustainable Development
Goals. Perinatal services are integrated into this programme, including
antenatal care (ANC). According to official statistics, from 2006 to 2016,
the MMR fluctuated between 32.1 and 23 per 100,000 live births
[11,12,13]. The health improvement programme also sought to implement relevant policy to improve perinatal health and develop national
surveillance, reporting, and registration systems and to reduce the MMR
to 12 per 100,000 live births by 2030 [13,14].
The Maternal and Children’s Health Coordinating Committee
(MCHCC), part of the Ministry of Internally Displaced Persons from the
Occupied Territories, Labour, Health, and Social Affairs of Georgia
(MoH), receives notification of each maternal death within 24 h of its
occurrence. Reporting of all medical information related to these
maternal deaths is also mandatory. The MCHCC is responsible for a
national surveillance and response system based on Confidential Enquiries into Maternal Deaths. This entails active tracking and systematic
multidisciplinary investigation of all maternal deaths occurring in
Georgia, followed by a response that aims to avoid future maternal
deaths and improve maternal health care [15,16,17]. In 2012, Georgia
implemented the WHO case-report form for death registration and
classification. In addition, under the administration of the National
Centre for Disease Control and Public Health (NCDC), the country
created the Georgian Birth Registry (GBR), enhanced Vital Registry
System (VRS), improved follow-up of maternal deaths through the
Electronic Integrated Disease Surveillance System, and implemented the
verbal autopsy methodology as part of the surveillance of MM. Moreover, specific guidelines, clinical protocols, and tailored courses for the
management of common causes of maternal death were created and
provided to medical personnel. Details of the surveillance of MM
introduced by the MoH and the reporting and registration supported by
the NCDC are described elsewhere [13,18].
So far, little attention has been given to surveillance system-based
studies. There are few studies that scrutinise persistent causes of MM
in developing countries like Georgia, where there are a shortage of
appropriate epidemiological reports based on reliable data. No study has
yet employed data from the Georgian surveillance system to evaluate
whether this data can be used by stakeholders to direct efforts to
improve maternal healthcare and thus accelerate progress toward the
reduction of MMR in Georgia. Therefore, this study aims is to assess and
classify MM in Georgia by direct and indirect causes of death from 2014
to 2017, using data from the national surveillance system and in
accordance with internationally approved criteria.
pregnancy, and which were not due to a direct obstetric cause), and
categorised by ICD-10 code [19]. If both direct and indirect causes of
death were recorded, and the starting mechanism for the chain of events
was determined to be obstetric, the case was classified as having a direct
cause of maternal death. Suicide (n = 2) was not included as a direct
cause of death in this analysis, contrary to the recommended practice of
the ICD-MM [20]. Indeed, ICD-MM recommended practice is not yet
accepted worldwide, and Georgia currently follows ICD-10 classifications. Therefore, suicide was defined as an indirect cause of maternal
death, following the ICD-10 classification of this term, excluding mental
and behavioural disorders associated with the puerperium from direct
cause of death. Final diagnoses were validated with autopsy records
when available.
Relevant information from MCHCC medical documents was transferred to a standardised case-report form, which was designed for this
particular study. The form synthesised data on demographic characteristics, health, perinatal conditions, and other diagnoses (recorded by
ICD-10 code) in order to fully ascertain the cascade of events leading to
maternal death and establish diagnoses independent of the MCHCC
decision. In MM cases with insufficient information in the MCHCC, VRS,
and GBR, demographic or obstetric data were acquired from additional
NCDC sources (Electronic Integrated Disease Surveillance System; verbal autopsy).
The MMR for the study period was defined as the number of eligible
MM cases per 100,000 live births. The confidence interval (CI) was
estimated as a Wald Interval. All analyses were performed using STATA
15 (StataCorp LLC, College Station, TX, USA). In analyses of direct and
indirect causes of maternal death, MM cases that occurred outside of
medical facilities with no autopsy or verbal autopsy could not be classified and were excluded.
Ethical consideration
The Institutional Review Board of NCDC approved the legal aspects
of the study (IRB #2017-009). In addition, regional Committees for
Medical and Health Research Ethics (REC North) approved the protocol
(Ref: 2017/404/REK nord). Personal identification remained hidden to
the investigator at all times and the data are free from personal
identifiers.
Results
Over the 4-year study period (2014–2017), there were 228,300 live
births in Georgia [11] with an MMR of 26.7 per 100,000 live births. All
MM cases reported to the MCHCC during the study period (n = 84) were
identified (including incidental, accidental, and late maternal deaths),
reviewed, and validated against MM cases in the GBR and VRS using the
unique personal identification number assigned to Georgian residents/
citizens. Pregnancy-related ICD-10 codes (O00-O95 and 98-99, A34,
B20-B24, C58, X60-X84) were used for additional validation of MM
cases or identification of possible misclassified MM cases in both registries [19], but this process did not reveal any additional MM cases for
this period in Georgia. Following the maternal death definition in the
ICD-10, and after validation in the VRS and GBR, 23 MM cases were
excluded by the study authors (12 due to late maternal death, 9 due to
accidental death, and 2 due to occurrence in occupied territories in
Georgia with lack of information). Thus, 61 eligible MM cases comprised
the study sample (Table 1). The majority of MM cases were 25–34 years
old (44.3%), married (77%), and lived in rural areas (55.7%). Medical
facilities could not be classified by the level of provided services (primary, secondary, and tertiary) during the study period, as this classification was only completed after 2017 in Georgia. A large proportion of
MM cases were multiparous (49.9%), had no pre-existing medical conditions (52.5%), and had low-risk pregnancies (73.8%). Moreover,
62.3% of MM cases adhered to obligatory ANC, 42.6% had preterm
deliveries (between 22 and 36 weeks of gestation), and 52.5% had an
Materials and methods
We defined maternal death according the International Statistical
Classification of Diseases and Related Health Problems, Tenth Revision
(ICD-10), i.e., the death of a woman while pregnant or within 42 days of
delivery or termination of pregnancy through any causes associated
with, or exacerbated by, pregnancy or its management; it did not include
deaths from incidental or accidental causes [19].
This study utilised secondary data provided by the MCHCC. All MM
cases reported to the MCHCC for the years 2014 through 2017 were
collected, reviewed, and validated by the study authors during 2018.
The final study sample comprised 61 eligible MM cases, which were
registered officially in Georgia as MM cases during the same time period.
Causes of maternal death were classified as direct (obstetric complications of the pregnant state or its management) or indirect (resulting
from a previous existing disease or a disease that developed during
2
N. Skhvitaridze et al.
Sexual & Reproductive Healthcare 26 (2020) 100560
pregnancy, and one in the late postpartum period. When considering
direct causes of maternal death, three MM cases (8.3%) died from
anaesthetic complications, two during childbirth, and one 7–42 days
postpartum after oesophageal haemorrhage and sepsis caused by a
misplaced tube during intubation. Two deaths (5.5%) were related to
ectopic pregnancies, three to amniotic fluid embolism (8%), and six to
venous thromboses (18%). Four MM cases (11.1%) were attributed to
eclampsia and the haemolysis, elevated liver enzymes, and a low platelet
count (HELLP) syndrome (Table 3).
Among all direct causes, haemorrhage was the “initiating” event in
the cascade of complications, which represented 29.5% (95% CI:
19.4–41.9) of all MM cases in our study. Nine MM cases died within 24
h, six died 2–6 days postpartum, and three died 7–42 days postpartum.
Nine of these 18 cases had neither severe maternal diseases nor any
severe pregnancy-related conditions. Fourteen of these cases had CS and
died from postpartum bleeding. Seven of those 14 had no serious
maternal- or pregnancy-related diseases recorded in their medical file.
Only one MM case was attributed to uterine rupture, whereas six cases
experienced placental abruption. Extensive blood loss was reported in
seven MM cases (≥1500 ml); blood transfusion was provided in 11 cases
(Table 4).
Hysterectomy was performed in 13 MM cases, among whom nine
ended up with disseminated intravascular coagulation. Post-caesarean
laparotomy was performed in five cases that suffered haemorrhage,
but none of these cases received uterine artery embolisation as an
alternative treatment. Pre-eclampsia was the dominant pregnancyrelated disease associated with haemorrhage, mainly in combination
with severe obesity and emergency CS. Moreover, severe obesity was
observed in five out of 18 haemorrhage cases, anaesthesia complications
in two of three, venous thromboembolism in four of six, and ectopic
pregnancy one of two MM cases (Tables 3 and 4).
Of all 22 MM cases attributed to indirect causes of maternal death,
seven died during pregnancy, three died 2–6 days postpartum, and 12
died 7–42 days postpartum (Table 5). The leading cause of indirect
maternal death was infection (10 cases, comprising 45.5%); among
them were leptospirosis (2 cases), pneumonia (2 cases), tuberculosis (2
cases), meningitis (2 cases), and hepatitis (1 case). Three became
pregnant after a cancer diagnosis (acute leukaemia) and two had a
diagnosis of malformations. Of those, four died during pregnancy and
the fifth a few days after childbirth. Three MM cases died from complications of cardiovascular disease, three from suicide, and one case
from complications due to a cholecystectomy in the postpartum period
(Table 5).
Thirty-one percent of MM cases had incomplete medical records, i.e.,
missing ANC related data, autopsy data, and histology reports.
Table 1
Selection of maternal mortality cases. Georgia, 2014–2017.
2014
2015
2016
2017
Total
Total cases
26
24
17
17
84
Excluded cases
Late maternal death
Accidental death
De facto territories
5
–
–
3
1
–
1
4
1
3
4
1
Final study sample
21
20
11
9
61
emergency caesarean section (CS) (Table 2).
Thirty-six (62%) MM cases were due to direct causes of maternal
death, and 22 were due to indirect causes (38%). Three MM cases were
unclassifiable, as the death occurred outside medical facilities with
limited medical data. Due to this issue, these cases were excluded from
the further analysis. Two of the unclassifiable cases died during
Table 2
Demographic and prenatal characteristics associated with
maternal mortality. Georgia, 2014–2017.
Total n = 61
n (%)
Age groups
18–24
25–34
35–47
Unknownb
14 (22.9)
27 (44.3)
19 (31.2)
1 (1.6)
Marital status
Married
Never married
Unknown
47 (77)
9 (14.75)
5 (8.25)
Parity
Primiparous
Multiparous
Missingc
27 (44.3)
30 (49.4)
4 (6.6)
Residency
Rural
Urban
34 (55.7)
27 (44.3)
Pre-existing medical condition
Yes
No
Unknown
15 (24.6)
32 (52.5)
14 (22.9)
Adherence to antenatal care
No care
1–4
>4
Missing
6 (9.8)
28 (45.9)
10 (16.4)
17 (27.9)
High-risk pregnancy
Yes
No
16 (26.2)
45 (73.8)
Gestational age
≤22 weeks
Preterm (22–36 weeks)
Early term (37–38 weeks)
Full term (39–40 weeks)
Late term (41–42 weeks)
Unknown
5 (8.2)
26 (42.6)
10 (16.4)
12 (19.7)
3 (4.9)
5 (8.2)
Mode of delivery
Normal vaginal
Planed CSa
Emergency CSa
Died during pregnancy
15 (24.6)
3 (4.9)
32 (52.5)
11 (18)
Discussion
This is the first study of MM that has been performed after the creation of the MCHCC in Georgia. We found that the share of direct causes
of maternal death exceeded that of indirect causes of maternal death.
Haemorrhage was the leading direct cause of maternal death, and
infection was the most common indirect cause. The estimated MMR
during our study period was 26.7 per 100,000 live births. This number
confirms the relatively stable MMR reported by the country’s official
national statistics office for the last decade [11,13]. Moreover, it reflects
the same level of MM recently reported from middle-income countries in
Europe (Romania, Russian Federation, and Turkey), Central and East
Asia (Armenia, Azerbaijan, Turkmenistan, and Uzbekistan), and Latin
America (Costa Rica) [7,10,21,22,23]. However, the observed MMR in
Georgia is double that of most high-income countries [1,24,25] and far
from the ratio being targeted for 2030 in Georgia [13,14]. Obviously,
some actions have already been taken to change the current MMR;
although, tailored solutions based on evidence should be initiated to
reach the desired goal before the deadline.
A notable finding was the proportion of direct and indirect causes of
a
Caesarean section.
Supporting medical document or data was lacking in the data
source.
c
Empty box or insufficient information in the respective data
source.
b
3
N. Skhvitaridze et al.
Sexual & Reproductive Healthcare 26 (2020) 100560
Table 3
Direct causes of maternal death - major maternal, pregnancy, and delivery related events, excluding haemorrhage. Georgia, 2014–2017.
Time of death
Maternal condition
Pregnancy-related condition
Mode of delivery
Delivery-related condition
Postpartum events
In pregnancy
In pregnancy
Delivery
Delivery
7–42 days
1st 24 h
1st 24 h
2–6 days
1st 24 h
2–6 days
2–6 days
7–42 days
7–42 days
7–42 days
1st 24 h
7–42 days
7–42 days
7–42 days
Obesity
None
None
Obesity
Obesity
None
None
Anaemia
None
Obesity
Obesity
Obesity
Obesity
None
None
None
None
None
Ectopic pregnancy
Ectopic pregnancy
Preeclampsia
None
Preeclampsia
None
Preeclampsia
None
None
None
None
Preeclampsia
None
None
Preeclampsia
Eclampsia
HELLPa
HELLPa
Not applicable
Not applicable
Emergency CSb
Emergency CSb
Emergency CSb
Emergency CSb
Emergency CSb
Vaginal
Vaginal
Emergency CSb
Emergency CSb
Emergency CSb
Planned CSb
Emergency CSb
Vaginal
Emergency CSb
Vaginal
Vaginal
Not applicable
Not applicable
Anaesthesia complications
Anaesthesia complications
Anaesthesia complications
Amniotic fluid embolism
Amniotic fluid embolism
Amniotic fluid embolism
None
None
None
None
None
None
Eclampsia
None
Haemorrhage
None
Not applicable
Not applicable
Not applicable
Not applicable
Oesophageal haemorrhage, sepsis
Hysterectomy
None
HELLPa, DICc
Venous thromboembolism
Venous thromboembolism
Venous thromboembolism
Venous thromboembolism
Venous thromboembolism
Venous thromboembolism
None
HUSd, hysterectomy, DICc
Septic shock
Septic shock
a
b
c
d
Haemolysis, elevated liver enzymes, and a low platelet count.
Caesarean section.
Disseminated intravascular coagulation.
Haemolytic-Uremic Syndrome.
Table 4
Direct causes of maternal death - major maternal, pregnancy and delivery related events, cases with haemorrhage. Georgia 2014–17.
Time of
death
Maternal
condition
Pregnancy-related condition
Mode of
delivery
Delivery-related condition
Blood loss
(ml)
Postpartum events
1st 24 h
1st 24 h
1st 24 h
1st 24 h
1st 24 h
1st 24 h
1st 24 h
None
None
None
None
None
None
Obesity
None
None
None
None
Preeclampsia
Preeclampsia /eclampsia
Preeclampsia
Emergency CSa
Emergency CSa
Emergency CSa
Vaginal
Emergency CSa
Vaginal
Emergency CSa
1300b
Unknown
Unknownb
2500b
Unknown
1800b
1200b
Hysterectomy
Hysterectomy, DICc
None
Laparotomy
Hysterectomy, DICc
Hysterectomy
Hysterectomy, DIC
1st 24 h
Obesity
Emergency CSa
600
None
1st 24 h
Obesity
Cervical cerclage,
preeclampsia
Placenta praevia
Haemorrhage
Haemorrhage
Haemorrhage,
Haemorrhage,
Haemorrhage,
Haemorrhage
Haemorrhage,
placenta
Haemorrhage
Emergency CSa
None
None
Emergency CS
2–6 days
2–6 days
2–6 days
2–6 days
None
None
None
Obesity
None
None
None
None
Emergency CSa
Vaginal
Emergency CSa
Emergency CSa
2–6 days
Obesity
Preeclampsia
Emergency CSa
7–42 days
7–42 days
None
None
None
Preeclampsia
Vaginal
Planned CSa
7–42 days
Anaemia
Preeclampsia
Emergency CSa
a
b
c
d
abrubtio
Haemorrhage, abrubtio
placenta
Haemorrhage, abrubtio
placenta
Haemorrhage, atony
Haemorrhage, deep laceration
Haemorrhage, atony
Haemorrhage, abrubtio
placenta
Haemorrhage, abrubtio
placenta
Retained products
None
a
2–6 days
uterine rupture
deep laceration
atony
Haemorrhage, abrubtio
placenta
2200b
b
Hysterectomy
2000
DICc
2100b
Unknownb
800
3500a
Hysterectomy, DICc
Hysterectomy, DICc
None
Hysterectomy, DICc
2500a
Hysterectomy, DICc
Unknownb
Unknownb
Haemorrhage, hysterectomy
HELLPd, haemorrhage,
hysterectomy
Haemorrhage, hysterectomy
Unknown
Caesarean section.
Blood transfusion.
Disseminated intravascular coagulation.
Haemolysis, elevated liver enzymes, and a low platelet count.
maternal death (62% and 38%, respectively). It is important to analyse
the distribution of these causes, as it gives an indication of the quality of
antenatal, perinatal, postpartum, and continuum of care. When direct
causes of maternal death exceed indirect causes, it suggests that obstetric care is substandard [26]. The study of global causes of maternal
death and other retrospective studies have shown results similar to ours
in other developing countries, where direct causes of maternal death
account for around 70% of MM [5,22]. The proportions we report differ
from the previous Georgian study, in which direct causes of maternal
deaths accounted for 77% of MM cases and indirect causes accounted for
23% [18]. Our results indicate that Georgia is making progress in
decreasing the MMR due to direct causes of maternal death; however,
some aspects still need attention. The notably low number of high-risk
pregnancies and co-morbidities we observed in MM cases are another
indicator of substandard care, especially on an ANC level. Timely
recognition of complications is important for correct diagnosis and
treatment, which are important if MM is to be prevented [10,27]. To
accelerate progress in the prevention of MM, Georgia should enhance
optimal obstetric care, improve ANC guidelines to detect high-risk
pregnancies and co-morbidities, and ensure that midwives and
4
N. Skhvitaridze et al.
Sexual & Reproductive Healthcare 26 (2020) 100560
Table 5
Indirect causes of maternal death - major maternal, pregnancy and delivery related events. Georgia 2014–17.
Time of death
Maternal condition
Pregnancy-related condition
Mode of delivery
Delivery-related
condition
Postpartum events
In pregnancy
In pregnancy
In pregnancy
2–6 days
7–42 days
In pregnancy
In pregnancy
In pregnancy
Acute leukaemia
Ovarian cancer
Cerebral malformation
Acute leukaemia
Cerebral malformation
None
None
None
Not applicable
Not applicable
Not applicable
Emergency CSc
Emergency CSc
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
None
None
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Cachexia
Cerebral haemorrhage
Not applicable
Not applicable
Not applicable
2–6 days
2–6 days
7–42 days
7–42 days
7–42 days
7–42 days
7–42 days
7–42 days
7–42 days
7–42 days
7–42 days
In pregnancy
7–42 days
7–42 days
Multi resistant TBa
None
None
None
None
None
Chronic hepatitis
None
CVDb
CVDb
Cardiomyopathy
Mental disorder, suicide
None
None
None
None
None
None
None
Pneumonia
Leptospirosis, pneumonia, sepsis
Leptospirosis, chorioamnionitis,
sepsis
None
TB, preeclampsia
Pneumonia
Pneumonia
None
None
None
None
None
None
None
None
None
None
Vaginal
Emergency CSc
Emergency CSc
Emergency CSc
Vaginal
Unknown
Emergency CSc
Emergency CSc
Emergency CSc
Emergency CSc
Vaginal
Not applicable
Planned CSc
Vaginal
None
None
None
None
None
None
None
None
None
None
None
Not applicable
None
Retained products
Acute respiratory distress
Acute respiratory distress
Acute respiratory distress
Acute respiratory distress
Meningitis
Bacterial meningitis
Acute liver failure, sepsis
Complicated cholecystitis
Cardiomyopathy
Severe cardiac failure
Severe cardiac failure
Not applicable
Mental disease, suicide
Haemorrhage, sepsis, hysterectomy,
suicide
a
b
c
Tuberculosis.
Cardiovascular disease.
Caesarean section.
obstetricians complete special courses within the framework of their
Continuous Medical Education. These measures could lower the proportion of MM due to direct causes of maternal death, and hence
decrease the MMR.
Haemorrhage was the foremost direct cause of maternal death in our
study. The latest study of global causes of maternal death showed that
haemorrhage accounted for 27.1% of MM cases and represented the
leading cause of maternal death worldwide [7]. In the present study,
maternal death due to haemorrhage represented 29.5% of all MM cases,
which is a common number in countries with a similar sociodevelopment index [5]. Our findings correspond to previous information about leading causes of maternal death in Georgia, which also cited
haemorrhage as the most common cause of death [13,18]. The majority
of these cases occurred in low-risk pregnancies with no severe
pregnancy-related conditions. However, the main mode of childbirth for
these cases was emergency CS, and the indication for CS was lacking.
Indeed, CS has intrinsic risks that can lead to a cascade of complications
in both non-risk and high-risk pregnancies [28]. Therefore, the high
fatality rate in these cases suggests inappropriate indications for CS,
poor diagnostic skills, and lack of follow-up by responsible medical
personnel during the post-operative period, which indicates necessity
for future studies. Our results also suggest that there is a lack of active
management in the third stage of labour to prevent haemorrhage, and
that artery embolization is under-used as an alternative treatment for
haemorrhage [28]. In general, haemorrhage is a preventable cause of
maternal death, and recent studies have outlined ways to optimise the
outcome of this condition. These publications promote a multidisciplinary team approach and the application of checklist-based protocols
for the timely management of haemorrhage [13,28], neither of which
was evidenced in our data. Additionally, the volume of blood lost or
other justifications for such treatment did not consistently accompany
reports of blood transfusion in our study. Nonetheless, study findings on
haemorrhage are an additional indication of substandard care at all
levels of reproductive services, including the inappropriate evaluation of
risks, justification for blood transfusion, detection of co-morbidities, and
lack of knowledge-based performance during obstetric emergencies. In
order to further reduce the MMR, is it important to equip medical
personnel with current knowledge and approaches to managing lifethreatening conditions. These steps must be taken if we are to improve
the quality of medical care for pregnant women and prevent haemorrhage as a major direct cause of maternal death.
Our study identified infection as the leading cause of indirect
maternal death. Contrary to national improvements in access to antibiotic treatment, preventive vaccination, and advanced diagnostic and
laboratory services, our results show a noticeably high proportion of MM
attributable to infections [13,18]. Thus it may be possible to prevent
mortality through more appropriate clinical solutions. However, our
results lead us to believe that there is a fragmentation in continuous
obstetric care, low quality of ANC, a lack of either continuous care or
communication with sub specialists, and weak multidisciplinary approaches, all of which suggest substandard care. In their study of barriers to accessing adequate maternal care in Georgia, Miteniece et al.
also indicated substandard care, along with gaps in clinical quality and
staff skills, poor communication, and lack of continuous education
programmes in the Georgian health care system [29]. After all, if a
country is looking to accelerate its progress in preventing maternal
death, it is not sufficient to improve ANC coverage; it is also necessary to
ensure high quality and continuous care. Better medical performance
and updated guidelines for provided services are needed, along with
improved collaboration with specialists and timely referrals
[10,15,23,30].
The major strength of this paper is the use of data from the MCHCC,
along with validation from and enrichment with register-based data. In
MM studies, Confidential Enquiries into Maternal Deaths and registries
give researchers a great advantage, as they allow them to obtain information, analyse non-aggregated and consistence data, validate cases,
and understand the full cascade of events [10,27]. Some of the limitations of this study include the primary data source, which was hospital
records. Because of this, some problems arose in deciphering handwriting. Additionally, 31% of our MM cases had medical records with
incomplete or missing information, which could have led to underreporting; thus our results should be interpreted with caution. Moreover,
our results showed that autopsy and forensic service are infrequent in
Georgia, which is not unique, as many other developing countries face a
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Sexual & Reproductive Healthcare 26 (2020) 100560
similar problem, especially for ANC [31,32]. However, given the
importance of decreasing the MMR, it is vital to have detailed, quality
information on this topic [25]. Under the circumstances, insufficient
medical files cannot guarantee a high-quality enquiry using MCHCC
data. Indeed, this insufficiency led to the exclusion of 3 unclassifiable
cases from our analyses as well. Furthermore, in-depth future studies on
the quality of reproductive healthcare should address some specific
questions (e.g. skills and competencies of medical personnel, quality of
care at any level, provision and access to family planning, high proportion of CS and consistent of their indications). Limitation of the
present study includes a small study sample with low MM in absolute
numbers. Thus, results cannot fully address failure of reproductive
healthcare system in specific health-related conditions (tuberculosis,
hepatitis, and leukaemia). However, provided results are important to
prioritize methodology for future studies and enhance them with the
“near-miss” approach - identification and additional assessment of cases
in which pregnant women survive certain complications [2,16].
Overall, our findings indicate the challenges Georgia faces in accelerating the reduction of MM. This evaluation of the causes of MM and
classification of cases by direct and indirect causes of death with the use
of national surveillance data may be used to generate new recommendations for clinical practice and policy improvement. This study has
important implications for the quality enhancement of reproductive
healthcare in Georgia. The present findings indicate the existence of
weaknesses and gaps in the healthcare system that can only be improved
through the collaboration of different stakeholders. Regular and systematic analyses, transparency, and involvement of professional associations, main decision makers, and healthcare authorities will
strengthen reproductive healthcare and accelerate Georgia’s progress to
decrease MM. Moreover, austerity measures should be considered to
ensure optimal obstetric care and family planning, to launch countrywide Continuous Medical Education for obstetricians, and to tailor
trainings for midwives to tackle the knowledge gap. Measures should
also be taken to trigger timely treatment or referral for multidisciplinary
care and the establishment of routine autopsies in MM cases should be
considered.
participated in the interpretation of results and in the revision of the
draft version of the article. All authors approved and agreed on the final
version of the article.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgment
We thank the Departments of Non-Communicable Disease, the Division of Maternal and Infant Health and Medical Statistics, the Division
of Population Registry under the NCDC, the Department of Health under
Ministry of Internally Displaced Persons from the Occupied Territories,
Labour, Health and the Social Affairs and Department of Controlling
under the State Regulatory Agency for helping during the study.
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Conclusion
In Georgia, contrary to high-income countries, direct causes of death
exceed indirect causes of death in MM cases, with haemorrhage and
infections, respectively, being most common. The results suggest
increasing efforts toward decreasing the MMR, where high-quality MMrelated medical data and data completeness applications are crucial to
obtain best medical measures and policies. The study findings are
important to guide stakeholders and ensure that they implement
optimal, continuous care and effective follow-up, and to accelerate
progress in the reduction of MM in the country.
Funding source
The Norwegian Agency for International Cooperation and Quality
Enhancement in Higher Education (DIKU) fully funded this study. The
funders have no responsibility for the information or opinions contained
in this paper.
Authors’ contributions
NS co-developed the core idea and study design, collected data,
reviewed all cases, conducted analyses, interpreted results, and wrote
the article. EEA co-developed the core idea, participated in study design,
in the interpretations of results, and in the revision of draft version of the
article. NK collected data, reviewed all cases, interpreted results, and
revised the draft version of the article. TB participated in the interpretations of results and in the revision of the draft version of the
article. AG co-developed the core idea, developed study design, and
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