London School of Hygiene & Tropical Medicine

Women in sub-Saharan Africa continue to have an elevated risk of death following childbirth long after the 42-day postpartum limit the WHO uses to define pregnancy-related deaths, a new analysis shows.

Researchers analysed data from 12 sub-Saharan African countries to examine whether the 42-day definition accurately captures deaths following childbirth.

The analysis found that while the risk of death fell substantially throughout the 42-day postpartum period (relative to a comparison period of 12-17 months postpartum) the risk of death was still estimated to be 20% higher from 42 days to four months following childbirth. This has major policy implications for the improvement of maternal health in sub-Saharan Africa and other low- and middle-income countries.

The team included researchers from the London School of Hygiene & Tropical Medicine (LSHTM), the Medical Research Council Unit The Gambia at LSHTM and the Kenya Medical Research Institute-Center for Global Health Research. The research is published in The Lancet Global Health.

Ursula Gazeley, lead author from LSHTM, said: “It’s vital that we have up-to-date evidence and action to make childbirth safer for every woman. To measure pregnancy-related deaths, there must be a time limit on the definition but it is concerning that the risk of death remains 20% higher from 42 days until around four months after childbirth. In light of this, we are calling for the WHO to extend the 42-day postpartum limit currently used in the definition of pregnancy-related deaths. Our results also suggest that national and international guidelines for postpartum care should include visits beyond 42 days for women who experience chronic morbidity.”

Dr Momodou Jasseh, author from MRC Unit The Gambia at LSHTM, said: “This demonstration of an increased risk of death for mothers beyond 42 days postpartum in Sub-Saharan Africa suggests that the true burden of pregnancy-related mortality may be substantially underestimated in the region. Unless concerned governments commit to enhancing health management information systems that generate the requisite data on maternal outcomes after 42-days postpartum, the real burden will remain elusive.”

Dr Sammy Khagayi, author from the Kenya Medical Research Institute, said: “Despite the reduction in mortality around childbirth for both mothers and babies in areas with limited resources like Western Kenya, it is vital to go a step further to provide quality care for the mothers beyond the recommended postpartum period. Ante- and post-partum pregnancy monitoring would go a long way in reducing late maternal deaths. This will be achieved if we invest in data collection platforms to monitor and track women from pregnancy to 6 months postpartum."

This large, multi-country study analysed almost 30 years’ worth of data from 1991-2020, from 30 Health and Demographic Surveillance Systems (HDSS), across 12 African countries. In total 647,104 births and 1,967 deaths within one year of giving birth were recorded in the HDSS.

This analysis was based on deaths after childbirth from any cause. To plan interventions and prevent deaths, the authors call for urgent further investigation on the causes of death after 42 days postpartum in low- and middle-income settings.

Limitations of the research include that HDSS data do not always include pregnancy reports and so the analysis did not include pregnancy-related deaths before childbirth, which is likely to underestimate maternal risk. 

The research was funded by the UK Economic and Social Research Council.

Publication

Ursula Gazeley et al., Women’s risk of death beyond 42 days post partum: a pooled analysis of longitudinal Health and Demographic Surveillance System data in sub-Saharan Africa. Lancet Global Health. DOI:10.1016/S2214-109X(22)00339-4