Maternal and perinatal indicators
Maternal and perinatal health indicators, with emphasis on Pakistan
Health indicators turn deaths and births into comparable numbers, and each has a precise numerator and denominator that CPSP tests. Pakistan still has high maternal and newborn mortality, driven mainly by haemorrhage, hypertension, infection and delays in reaching skilled care.
Defining a maternal death
- Maternal death: death of a woman while pregnant or within 42 days of the end of pregnancy, from any cause related to or aggravated by the pregnancy or its management, irrespective of duration or site, but not from accidental or incidental causes.
| Category | Meaning | Example |
|---|---|---|
| Direct | Obstetric complication of pregnancy, labour or puerperium | PPH, eclampsia, sepsis, unsafe abortion, obstructed labour, ectopic |
| Indirect | Pre-existing or new disease aggravated by pregnancy | Rheumatic mitral stenosis, anaemia, hepatitis |
| Late maternal death | Direct or indirect cause, 42 days to 1 year after pregnancy | Peripartum cardiomyopathy death at 11 weeks |
| Pregnancy-related death | Any cause while pregnant or within 42 days, including accidents | Road traffic death at 30 weeks (not a maternal death) |
- Maternal near-miss: a woman who nearly died but survived a severe complication (organ failure, ICU admission, massive transfusion). Near-misses outnumber deaths, so they are valuable for audit.
Maternal mortality measures
| Indicator | Numerator | Denominator |
|---|---|---|
| Maternal mortality ratio (MMR) | Maternal deaths | Per 100,000 live births |
| Maternal mortality rate | Maternal deaths | Per 100,000 women aged 15–49 |
| Lifetime risk | Chance of a maternal death over a woman's reproductive life | Rises with both MMR and number of pregnancies |
- Example: 30 maternal deaths and 15,000 live births give an MMR of 200 per 100,000 live births.
- The rate rises with fertility; two places with equal MMR differ in lifetime risk if the total fertility rate differs, which is why family planning lowers maternal deaths.
- Risk by age is J-shaped: lowest at 20–29 years; teenagers risk obstructed labour and eclampsia, older women hypertension and placental problems.
Perinatal, neonatal and child measures
| Indicator | Definition | Denominator |
|---|---|---|
| Stillbirth rate | Babies born without signs of life (WHO comparison: 28 weeks or 1,000 g, or 35 cm) | Per 1,000 total births |
| Perinatal mortality rate | Stillbirths + early neonatal deaths (first 7 days) | Per 1,000 total births (live + still) |
| Neonatal mortality rate | Deaths under 28 days (early: days 0–6, the first 7 days; late: days 7–27) | Per 1,000 live births |
| Post-neonatal mortality rate | Deaths 28 days to under 1 year | Per 1,000 live births |
| Infant mortality rate | Deaths under 1 year | Per 1,000 live births |
| Under-five mortality rate | Deaths under 5 years | Per 1,000 live births |
- Example: 1,960 live births, 40 stillbirths and 20 deaths in the first week give a PMR of 60 ÷ 2,000 = 30 per 1,000 total births; deaths on days 7–27 (late neonatal) are excluded.
- A baby dying on day 5 counts in perinatal, neonatal and infant rates.
- Perinatal mortality is the best index of the quality of antenatal, intrapartum and newborn care (asphyxia, prematurity, infection). Post-neonatal deaths reflect the environment (diarrhoea, pneumonia), and the infant mortality rate is a broad index of a community's health and socioeconomic state.
Pakistan's position
- Pakistan Maternal Mortality Survey 2019: MMR about 186 per 100,000 live births, higher in rural areas and Balochistan.
- Pakistan Demographic and Health Survey 2017–18: neonatal mortality about 42, infant about 62, under-five about 74 per 1,000 live births, and perinatal mortality about 57 per 1,000 pregnancies; total fertility rate about 3.6.
- Leading direct causes of maternal death: obstetric haemorrhage (mainly PPH, which can kill within 2 hours), then hypertensive disorders, sepsis, unsafe abortion and obstructed labour. Anaemia contributes to many deaths.
- Sustainable Development Goal 3.1: global MMR below 70 per 100,000 live births by 2030; SDG 3.2: neonatal mortality 12 or fewer and under-five mortality 25 or fewer per 1,000 live births.
Why women die: the three delays
| Delay | Where | Example |
|---|---|---|
| First: deciding to seek care | Household | Waiting hours for the husband's permission; not recognising danger signs |
| Second: reaching care | Transport and distance | No vehicle, poor roads, cost |
| Third: receiving adequate care | Inside the facility | No blood, absent obstetrician, no theatre or drugs |
Programmes and coverage
- Lady Health Workers (since 1994) provide household-level primary care: family planning, maternal and child health, immunisation and nutrition, each covering about 1,000 people. Community midwives add skilled birth attendance in villages.
- Key coverage indicators: antenatal visits, skilled birth attendance, institutional delivery, contraceptive prevalence and postnatal care. Skilled attendance at birth and access to emergency obstetric care are the strongest levers on maternal mortality.
- Immunisation: tetanus toxoid (Td) in pregnancy protects the newborn by placental IgG. Live vaccines (MMR, BCG, OPV, varicella, yellow fever, rotavirus) are avoided in pregnancy and immunosuppression; MMR fever and rash appear 6–11 days later as the vaccine virus replicates.
- Child nutrition: severe acute malnutrition in children aged 6–59 months is a mid-upper arm circumference below 115 mm, weight-for-height below −3 SD, or nutritional oedema; low height-for-age (stunting) reflects chronic undernutrition.
Remember Maternal mortality ratio: per 100,000 live births. Perinatal mortality: per 1,000 total births. Get the denominator right and the sum follows.
Exam trap Accidental deaths in pregnancy are not maternal deaths, and deaths after 42 days are late maternal deaths outside the standard MMR.
Exam trap The perinatal denominator includes stillbirths; neonatal and infant rates use live births only.
Test yourself on this topic
5 of the 24 questions in our bank on this topic. Choose an answer to see why every option is right or wrong.
Two districts have the same maternal mortality ratio, but in district B women have twice as many pregnancies on average. A researcher divides maternal deaths by the number of women aged 15–49 years in each district. Which indicator has she calculated?
Answer: Maternal mortality rate
The maternal mortality rate uses women of reproductive age (15–49 years) as the denominator, usually per 100,000. It therefore reflects both the obstetric risk per pregnancy and how often women become pregnant. District B, with higher fertility, will have a higher maternal mortality rate even though its ratio (deaths per 100,000 live births) is the same. The ratio isolates the risk per birth; the rate shows the burden on the female population.
Ratio vs rate
- Ratio: per 100,000 live births
- Rate: per 100,000 women 15–49
- Rate rises with fertility
- Ratio = risk per birth
Remember Women in the denominator makes it a rate.
Exam trap Exam stems often call the ratio a rate; check the denominator before answering.
Why the other options are wrong
- Maternal mortality ratio The ratio uses live births as the denominator.
- General fertility rate This is live births per 1,000 women aged 15–49, not deaths.
- Lifetime risk of maternal death Lifetime risk is the probability of one woman dying of maternal causes over her reproductive life.
- Proportional maternal mortality This is maternal deaths as a percentage of all deaths of women 15–49.
For international comparison of stillbirth rates, a WHO report counts a baby born without signs of life only if it reaches which threshold?
Answer: 28 weeks or 1,000 g
Countries define stillbirth differently, often from 20, 22 or 24 weeks, which makes rates impossible to compare. For international comparison WHO uses late fetal deaths: babies born with no signs of life at or after 28 weeks' gestation, or with birth weight of at least 1,000 g (or body length 35 cm or more). These babies are also the ones most reliably recorded in low-resource settings such as rural Pakistan, where earlier losses are often unreported.
Stillbirth thresholds
- WHO comparison: 28 weeks or 1,000 g
- Alternative: 35 cm body length
- National definitions vary (20–24 weeks)
- Improves comparability between countries
Remember 28 weeks, 1 kg for world comparison.
Exam trap The UK 24-week definition is not the WHO international comparison threshold.
Why the other options are wrong
- 20 weeks or 350 g Used by some national systems, not for WHO international comparison.
- 24 weeks of gestation The UK national definition starts at 24 weeks, but WHO comparison uses 28.
- 22 weeks or 500 g The ICD threshold for national perinatal reporting, not the international comparison cut-off.
- 37 weeks or 2,500 g These define term birth and low birth weight, not stillbirth.
Country X and country Y have the same maternal mortality ratio, yet a woman in country X has a much higher lifetime risk of dying from a maternal cause. Which difference best explains this?
Answer: Higher total fertility rate in X
Lifetime risk of maternal death is the probability that a 15-year-old girl will eventually die from a maternal cause. It depends on the risk per pregnancy (reflected by the MMR) and on the number of times she is exposed to that risk, which is captured by the total fertility rate. With the same MMR, the country where women have more children has the higher lifetime risk. This is why family planning lowers lifetime maternal risk even without changes in obstetric care.
Lifetime maternal risk
- Depends on risk per pregnancy (MMR)
- And number of pregnancies (TFR)
- High fertility raises lifetime risk
- Family planning lowers it
Remember More pregnancies, more chances to die.
Exam trap Equal MMR does not mean equal lifetime risk; fertility multiplies the exposure.
Why the other options are wrong
- Higher crude death rate in X General mortality does not directly change maternal risk per pregnancy or the number of pregnancies.
- Lower stillbirth rate in X Fewer stillbirths would not raise maternal lifetime risk.
- Higher infant mortality in Y Infant deaths do not enter the calculation.
- Lower female literacy in Y A social factor, but it would change the MMR itself rather than explain the difference.
A 24-year-old woman with known rheumatic mitral stenosis is admitted at 32 weeks with acute pulmonary oedema and dies despite treatment. There were no obstetric complications. How is this death classified?
Answer: Indirect maternal death
Indirect obstetric deaths result from a pre-existing disease, or one that developed during pregnancy, that was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy. Mitral stenosis worsens in pregnancy because the 40–50% rise in blood volume and the faster heart rate shorten diastolic filling and raise left atrial pressure. Direct deaths arise from obstetric complications such as haemorrhage, eclampsia, sepsis or obstructed labour, or from their treatment.
Direct vs indirect
- Direct: obstetric complications (PPH, eclampsia, sepsis)
- Indirect: existing disease aggravated by pregnancy
- Heart disease is a key indirect cause
- Both count in the MMR
Remember Old disease made worse by pregnancy is indirect.
Exam trap Both direct and indirect deaths enter the MMR; only incidental deaths are excluded.
Why the other options are wrong
- Direct maternal death No obstetric complication caused this death.
- Late maternal death She died during pregnancy, not 42 days to 1 year after.
- Incidental death The cause was aggravated by pregnancy, so it is not incidental.
- Maternal near-miss Near-miss describes a woman who survived.
A tertiary hospital records 1,960 live births and 40 stillbirths in a year. Of the live-born babies, 20 die in the first 7 days and 10 more between day 8 and day 28. What is the perinatal mortality rate?
Answer: 30 per 1,000 total births
Perinatal mortality = stillbirths plus early neonatal deaths (first 7 days), divided by total births (live births plus stillbirths), expressed per 1,000. Here (40 + 20) ÷ 2,000 × 1,000 = 30. Total births are used because stillbirths appear in the numerator, so they must also be in the denominator. Deaths between day 8 and day 28 are late neonatal deaths and belong to the neonatal mortality rate, not the perinatal rate.
Perinatal mortality rate
- Numerator: stillbirths + deaths in first 7 days
- Denominator: total births (live + still)
- Per 1,000
- Late neonatal deaths excluded
Remember Stillbirths on top, so stillbirths below too.
Exam trap Late neonatal deaths (day 8–28) do not enter the perinatal rate.
Why the other options are wrong
- 35 per 1,000 total births Wrongly adds the 10 late neonatal deaths.
- 30.6 per 1,000 live births Uses live births as the denominator, which is incorrect when stillbirths are counted.
- 15.3 per 1,000 live births This is the neonatal mortality rate (30 ÷ 1,960).
- 20 per 1,000 total births Counts only stillbirths.
Where this sits in the CPSP syllabus
- Obstetrics & Gynaecology, Paper 2: Statistics and epidemiology, Maternal and perinatal health indicators, especially in Pakistan