International Journal of Gynecology and Obstetrics (2006) 93, 164 — 170
www.elsevier.com/locate/ijgo
SPECIAL ARTICLE
Maternal mortality among Palestinian women in the
West Bank
N. Al-Adili a,b, A. Johansson a, S. Bergström a,*
a
Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet,
Stockholm, Sweden
b
Al-Quds University School of Public Health, Jerusalem
Received 15 August 2005; received in revised form 23 November 2005; accepted 23 November 2005
KEYWORDS Abstract
Maternal mortality;
West Bank; Objective: To assess maternal mortality and determine the most common causes of
Avoidability; maternal death among Palestinian women. Methods: Available data on the 431
Audit; women who died between the ages of 15 and 49 years in the West Bank in 2000 and
Quality of care 2001 were reviewed. The data were collected from official agencies and, using the
verbal autopsy approach, interviews of the deceased women’s relatives. The
interviews were conducted in all 10 districts of the West Bank over 30 months.
Results: Maternal mortality ratios for 2000 and 2001 were 29.2 and 36.5 per 100,000
live births, respectively. Cardiovascular diseases and hemorrhage were the most
common causes of death. Misclassification was found in 38% of the deaths. A
tentative analysis of avoidability indicated that 69% of maternal deaths could be
classified as avoidable. Conclusion: A majority of the maternal deaths identified
were avoidable. Substandard classification of maternal deaths is hampering efforts
to reduce maternal mortality.
D 2005 International Federation of Gynecology and Obstetrics. Published by
Elsevier Ireland Ltd. All rights reserved.
1. Introduction Still, nearly 600,000 women die every year as a result
of pregnancy and childbirth complications, and
Emphasis has been placed worldwide on protecting many more experience serious pregnancy complica-
women’s fundamental right to life and reducing the tions, many resulting in permanent disability [3,4].
unacceptably high rates of maternal deaths [1,2]. Moreover, the negative impact on the survival and
well being of the deceased mothers’ young children,
* Corresponding author. IHCAR, Karolinska Institutet, SE 171 76
particularly their infants, has been documented [5].
Stockholm, Sweden. Tel.: +46 8 5177 6470; fax: +46 8 311590. While socio-cultural, economic, and gender factors
E-mail address: staffan.bergstrom@phs.ki.se (S. Bergström). have been identified as contributors to maternal
0020-7292/$ - see front matter D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.
All rights reserved.
doi:10.1016/j.ijgo.2005.11.009
, Maternal deaths in the Palestinian territory 165
morbidity and mortality [6,7], poverty, the low 2002 MMR for the Palestinian area was estimated at
status of women, pregnancies that occur too early, 24 [9].
too frequently, or too late, and unsafe abortions The purpose of this study was to determine the
continue to increase the risk of maternal death. In MMR and elucidate the causes of death among
some regions, a low awareness of danger signs and a women of reproductive age in the West Bank.
lack of decision-making power prevent women from Maternal death was defined as bthe death of a
seeking medical care personally, while transporta- woman while pregnant, during labor, or within
tion problems can further delay needed help [7]. 42 days of termination of pregnancy, irrespective
Although considerable international efforts and of the duration or site of pregnancy, from any cause
commitment toward safe motherhood have been related to or aggravated by the pregnancy or its
made, the levels of maternal mortality remained management but not from accidental or incidental
globally stable between 1995 and 2000 [8]. Accord- causes.Q
ing to more recent estimates, in the 22 countries of
the Eastern Mediterranean Region, approximately
53,000 mothers die every year because of pregnan- 2. Subjects and methods
cy and childbirth complications, and the World
Health Organization (WHO) reported that the mean The subjects were women aged 15 to 49 years who
maternal mortality ratios (MMR) per 100,000 live were reported dead in the 10 districts in the West
births were 465 and 377 in 1990 and 2002, Bank. The planned duration of the study was 2 years
respectively. Moreover, WHO reported that for (January 2000 through December 2001). However,
2002, the MMR ranged from zero in Qatar to 1600 because of political unrest and mobility restric-
in Afghanistan and Somalia [9]. tions, data collection was extended until the end of
Substandard reporting and classification of ma- June 2002 in order not to miss any delayed death
ternal deaths also remain a problem. For example, notification.
in Taiwan, under-reporting has been shown to occur The authors assessed notification adequacy using
58% of the time and correct classification merely 3 sources. First, the Village Health Workers who run
53% of the time [10]; and in Mozambique, a 68 Ministry of Health (MOH) Village Health Rooms in
community-based study on the quality of registra- the largest district in the West Bank (Hebron
tion of maternal deaths reported that up to 86% of district) were requested to report all female deaths
maternal deaths were unregistered [11]. during the study duration. Second, the United
The majority of maternal deaths in both high- Nations Relief and Works Agency (UNRWA) list of
and low-income countries can be avoided [12]. In all registered maternal deaths among refugee
Cape Verde, for example, 72% of women’s deaths women in the West Bank for the year 2000 was
with known causes were considered avoidable using checked. Third, the summary sheets on all deaths
locally available resources [13]. In Mozambique, of women aged from 15 to 49 years that occurred in
75% of all maternal deaths were classified as 2000 and 2001 in 7 of 8 governmental hospitals
avoidable following an audit procedure [14]. Data were checked. The hospitals visited were those of
from Zimbabwe also show that, in 90% of cases Beit Jala, Alia, Jericho, Ramallah, Watani, Rafidia,
maternal deaths in a rural area and 85% of maternal and Tulkarm.
deaths in an urban area, 1 or more of the factors This validation exercise revealed that the deaths
contributing to death were avoidable [15]. The of 24 women of reproductive age, including 1
main contributing factors in the latter study were maternal death, were reported as per the hospi-
the unavailability or inaccessibility of health serv- tals’ records, but the districts’ public health
ices and substandard curative and obstetric care. departments were not notified. These cases were
In the West Bank and Gaza strip, 22% of the included in the study.
almost 3.5 million population are women of child- A structured questionnaire was developed con-
bearing age and the overall fertility rate in the sisting of 4 parts: (1) general questions applying to
West Bank is 3.3 [16]. Data on maternal mortality in all deaths; (2) questions identifying whether the
this area are scant and based on estimates [8]. In death was maternal death; (3) questions revealing
their joint reports, WHO, the United Nations whether the deceased woman had children younger
Population Fund (UNFPA), and United Nations Child- than 5 years; and (4) a verbal autopsy inquiring
ren’s Fund (UNICEF) estimated the MMR per about circumstances related to the woman’s death.
100,000 live births to be between 70 and 80 in The questionnaire was piloted, with 15 women
1995 and 100 in 2000 for the West Bank and Gaza before finalization.
combined [8]. The range of uncertainty for the All data collectors attended a 4-day training
latter estimate was between 25 and 190 [8]. The program. All but 1 interview with the families/
