Maternal death refers to the demise of a woman during pregnancy, childbirth, or within 42 days after the termination of pregnancy; This includes deaths caused by factors directly related to or worsened by the pregnancy or its management, excluding accidental or incidental causes. The duration and location of the pregnancy are irrelevant in this definition [1-2], in 2017, global maternal mortality decreased by 44% compared to the levels recorded in 1990. However, even with this decline, a total of 830 women lost their lives due to complications arising from pregnancy or childbirth; the vast majority of these fatalities can be avoided entirely.   

In 2015, around 303,000 women worldwide lost their lives due to issues associated with pregnancy or childbirth; hemorrhaging and complicated childbirth are the primary factors contributing to maternal fatalities.   The global maternal mortality ratio has declined from 385 maternal deaths per 100,000 live births in 1990 to 216 maternal deaths per 100,000 live births in 2015, as women have obtained access to family planning and skilled birth attendants with backup emergency obstetric treatment; the maternal mortality rates in numerous countries have been reduced by 50% over the past decade [3].

It is essential to distinguish between direct and indirect maternal mortality, which refers to deaths caused by difficulties during pregnancy, childbirth, or medical care[4], maternal mortality primarily arises in developing nations as a result of problems during pregnancy delivery, and the postpartum phase [5]. The US maternal mortality rate experienced a significant rise of 16.8% in 2020, mainly due to the impact of the COVID-19 pandemic. The preventability of most of these deaths arises from their primary causes, which include bleeding, infection, hypertension (including eclampsia), delayed or obstructed labor, and botched abortion [6]. The maternal mortality ratio highlights the prominent disparity between established and developing nations, as well as the distinction between affluent and impoverished women within the same countries [7].                           

The leading causes of maternal mortality were postpartum hemorrhage and infection, although secondary factors such as anemia and cardiovascular issues could further complicate pregnancy, Both the mother's age and obesity are risk factors [8], Adolescent females are at a greater susceptibility to experiencing problems and mortality during pregnancy compared to elder females [9] , Adolescent moms face an elevated exposure to postpartum hemorrhage, puerperal endometritis, vaginal birth, and episiotomy, all of which can contribute to maternal death [10], Maternal mortality can be influenced by the presence of family support or the experience of social isolation [11-12] ,Unsafe abortion is a significant contributor to maternal mortality, According to the World Health Organization (W.H.O.) in 2009, a woman died every eight minutes due to complications such as bleeding, infection, and genital damage resulting from a hazardous abortion, the incidence rate is 41 instances per 100,000 live births in industrialized countries and 23 cases per 100,000 live births in poor countries [13].

Previous studies have examined mortality rates among women in various countries, but they have not specifically addressed maternal mortality among pregnant women in Diyala government. The objective of our study is to investigate the factors contributing to maternal mortality in Diyala city.

No patient was involved in this study. It was a cross-sectional study; the criteria included 75 case records of maternal deaths in Diyala governorate in the forensic medicine department from the first of January. 2017 to 31 December 2021, the Inclusive Forensic Medicine Department is the referral center for all maternal deaths in the Diyala governorate.

Data were collected from the 75 case records; Points studied included (name, age, residency, and causes of death). 

Research Ethics

Ethical approval was obtained from the University of Diyala, Baqubah Medical Faculty. Data were collected from the forensic medicine department in the Diyala government and extracted from patient records without identification of the subject. Data abstraction forms were filled in after death; therefore, study inclusion did not affect the treatment.

Tatistical Analysis

Data analysis Was performed using IBM SPSS statistics for Windows version 20. Microsoft Excel for Windows 2010, Data analysis was performed using Qualitative variables of parameters expressed as number and percent; a T-test was used to determine the significance of differences between groups composed from continuous variables; the significance level was (0.05) in all statistical testing [14].

The total number of maternal deaths during the study period was 75. The maternal mortality ratio was 37 The highest mortality was in the age group of 21-30 years 52% and the 2nd age group was 31-40  years 30.7%, as shown in the table and figure 1. According to the cause of death, cardiovascular diseases form 45.3%, followed by uterine bleeding 29.3%, as shown in table and figure 2. Rural residents form 53.4% while urban residents form 46.6% as shown in table and figure 3. The majority of maternal deaths were multigravida 76% while primigravida form 24 as shown in table and figure 4.

The maternal death ratio in Diyala governorate was 37, which aligns with research conducted in Saudi Arabia 17 per 100,000 live births 14, Jordan 46 per 100,000 live births 15, and Iran 26 per 100,000 live births [15]. The maternal mortality rate in Turkey is 17 per 100,000 live births [16].                                                                                                                                                                                       Our study finding shows the commonest age group affected is 21-30 year 52%. This high maternal mortality in this age group could be explained by the fact that this group is the most common group becoming pregnant. Another study, done in October 2018, mentioned that the age group that died during pregnancy is 35-44 years (38.5%), then the age group 25-34 years 14%[17], Another study done in April 2013 revealed that the most common age group exposed to maternal death is 20-29 years 55.6%, and the 2nd joint age group is below 20 years 33% [18]. A report on maternal death in Washington 2015 mentioned that the commonest age group affected is 20-29 years 47% because of infection and eclampsia, then the age group 30-39 years 40% [16]. In 2017 study showed the age group affected is 20-35 years 64% and then the age group 36- 50 years 18% [19]. 

The findings of our study indicate that cardiovascular reasons accounted for 45.4% of all maternal deaths, whereas uterine bleeding accounted for 29.4%.In contrast to earlier research, a study conducted in April 2006 revealed that the primary cause of the condition is uterine hemorrhage, accounting for 25% of cases, followed by cardiovascular problems at 20%, and infection at 15% [2]. 

A report in the pregnancy surveillance system C.D.C. mentions that the most common cause of maternal death is cardiovascular diseases 25.5%, followed by infection 12.8% due to unsafe abortion and then uterine bleeding 11.5%. IN 2018 Neel Shah demonstrated that the first Common causes of maternal death are cardiovascular diseases  15.2% then infection 13% and uterine bleeding (11%) [18]. While in 2017, a study done by Lachmi R-Jordan revealed that uterine bleeding is the first cause of maternal death (20%), then cardiovascular diseases (19%) [20]. In 2019, another study found that women in their 20s tend to have fewer complications during pregnancy and mostly hemorrhage. Below 20, the risk of death is high because of eclampsia and uterine bleeding [21]. The findings of our study differ from other studies in the percentage of cardiovascular causes because we have a low infection rate. Still, other studies have a high rate of infection due to the high rate of induced abortion.

Table 1: The Distribution of Maternal Deaths According To Age Group

The mean difference is significant at the 0.05 level

Table 2: The Distribution of Causes of Maternal Deaths

The Mean Difference Is Significant At the 0.05 Level

Table 3: The Distribution of the Maternal Deaths According the Residency

The Mean Difference Is Significant At the 0.05 Level

Table 4: Te Distribution of Parity in Maternal Deaths

The Mean Difference Is Significant At the 0.05 Level

Figure 1: The Distribution of Maternal Deaths According To Age Group

Figure 2: The Distribution of Causes of Maternal Deaths

Figure 3: The Distribution of the Maternal Deaths According the Residency

Figure 4: The Distribution of Parity in Maternal Deaths

Our study finds, the maternal mortality was highest 53.4% among rural resident’s women and that come from urban area is 46.6%. This is due to low education, mid wife and shortage in health care in rural area. In 2017, Lauren M. Rossen shows that 65% come from urban area this is differ from other study because high rate of induced abortion[22]. While study results that done in Pakistan 2021 reveled to, 14% of maternal mortality were comes from urban area and 61% from rural area in India. According to parity the primigravida is 24% and the multigravida is 76%. This high percent among multigravida is due to multi cesarean section make the uterine wall weak and more liable for rupture and bleeding [23]. In 2008 Rohul jabeen shah shows that 56% of maternal death is multigravida and 29% are primigravida [24]. On other side study that done by Begum S, Aziz in 2003 reveled to, 69% of maternal death is in multigravida and 31% in primigravida [25].

The primary limitations of our study are the small sample size, which was restricted to pregnant women over a period of 3 years and limited to participants from a single city. Additionally, our study focused on specific critical factors that contribute to maternal mortality, rather than examining a broader range of factors that may influence it [26-27].

A. Farhan) was involved in the conception and design of the study, carried out the analysis and wrote the first draft of the paper. 

(Mohammed T. Hamad) assisted with the conception and design of the study and contributed to the writing of the paper, All authors read and approved the final draft of the paper.

In this study, the most common age group for maternal mortality is 21-30 years (52%) and the leading cause is cardiovascular disease (45.4%), followed by uterine bleeding (29.4%). Most cases occur in rural areas (53.4%) and multigravida (76%).

Authors’ Contributions

(Youssef S. Yasin and Mohammed

Acknowledgements

The authors wish to thank the management, and the worker in the forensic medicine department in diyala government for their efforts to make this project happen. 

Financial Support and Sponsor Ship

Self -funded 

Conflicts of Interest 

There are no conflicts of interest

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