MATERNAL MORTALITY IN THE KYRGYZ REPUBLIC

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Introduction.The protection of motherhood and childhood is one of the priorities of the state policy of the Kyrgyz Republic, since the level of medical care for pregnant women and women in childbirth determines the fate and health of future generations. Despite the efforts made by the country, maternal mortality in Kyrgyzstan remains at a high level, about 38.1 cases per 100,000 live births. Realizing that the Confidential Enquiry in Maternal Deaths (CEMD) is the international gold standard for detailed investigation of the death of women, Kyrgyzstan, since 2010, has been implementing this methodology at the National level. The methodology of the World Health Organization "Beyond the numbers" allows to identify the barriers women face when receiving medical care, the reasons for their occurrence and ways to overcome them not only at the level of a medical institution, but also at the level of the family, civil society, local governments and politics[1].

           Purpose of the study: study the impact of medical and non-medical risk factors on maternal mortality in the Kyrgyz Republic.

           Materials and methods: To identify medical and  non-medical causes of maternal death, factors of poor-quality treatment, as well as social and family problems that could affect the tragic outcome, the study group included all cases of death of women during pregnancy, childbirth and within 42 days of the postpartum period from direct (associated with pregnancy, childbirth and the postpartum period) and indirect (pre-existing and  /or acquired new diseases, such as cardiovascular diseases, lung diseases, etc., the course of which was aggravated by pregnancy) causes. In addition, cases of death of women from causes not related to pregnancy were considered, which were classified as “No obstetric cause (accidents)”, and the category “No main cause has been established”, when information was insufficient to establish the cause of a woman's death. To collect information on each case of maternal death, each maternity facility/department of the Kyrgyz Republic has a local CEMD coordinator. His responsibilities include photocopying medical records, depersonalizing it (anonymizing all data on the healthcare organization, on medical workers, on the deceased woman) in order to comply with the principles of confidentiality, allowing the medical worker to express his vision of the case without fear of publicity. In addition, the local coordinator collects questionnaires that are filled out by each participant in the case and the relatives of the deceased woman (if possible) and submits a package of documents to the National Secretariat for CEMD. Further, the case is submitted to the multidisciplinary committee on CEMD, where all data are analyzed. Thus, the CMMS methodology is based on the principles of anonymity (no one knows in which medical institution this case occurred and who provided assistance to this patient), which allows the medical worker to express his vision of the case in a standard questionnaire without fear of publicity.

           All work on the confidential investigation of maternal deaths in the Kyrgyz Republic is regulated by the National Clinical Guidelines of the Ministry of Health of the country [2].

           The SPSS program calculates the Mantel-Hansel risk and provides a 95% confidence interval [4].

Results. The overall maternal mortality rate for the 2-year study period was 44.2 deaths per 100,000 live births. The number of maternal deaths from Direct causes (106 - 71.6%) significantly exceeded the number of indirect deaths (35 - 23.7%). For the first time in this Report, for the purpose of analysis, the deaths of pregnant women from accidents (2.0%) were taken into account, when the connection of their deaths with pregnancy was random.

The maternal mortality rate from direct causes was 33.2 per 100,000 live births. The most common cause of Direct Maternal Deaths was bleeding, which killed almost every second woman in this group (49 - 46.2%). Hypertensive disorders during pregnancy - 22 (20.8%) and obstetric sepsis - 21 (19.8%) ranked second and third respectively, while the difference between them was insignificant. Pulmonary embolism and amniotic fluid embolism were the cause of death in 8 (7.5%) women. The death of 6 (5.7%) women was directly related to anesthesia and resuscitation.

In the structure of Indirect causes of maternal deaths, the frequency of pre-existing maternal pathology was 40% (14 cases), while epilepsy was noted in 28.6% (4) of cases and was the most common cause of maternal death in this group. The number of oncological diseases accompanying pregnancy was 5.7% (2 cases). In the structure of infections not associated with pregnancy, community-acquired pneumonia (5-14.3%) and infectious meningitis (5-14.3%) were equally often noted as the cause of death. Tuberculosis in our country still continues to be the cause of maternal mortality (3-8.6%).

The average age of deceased women was 32.5±5.2years and was in the range of 17 - 48 years. Lowest death rate women noted in age group 20-24 years (32.9 per 100,000 births), while the relative risk of dying in the group35-39 year olds was 3 times higher (107.4 cases vs. 32.9), and in the group older than 40 years - 5 times higher (158.0 vs. 32.9).

Birth parity analysis showed that the highest risk of death was in the group nulliparous (45 - 30.4%), when RR was 3.2(95% CI: 2.54–4.77), at that time, as in the multiparous group, the indicator was less than one.

Most of the deceased women had a secondary education - 91 (61.5%). Only 11 (7.4%) women had higher education, and 10 (6.8%) women had only primary education. Despite the fact that the majority of women were married (123 - 83.1%), marriage did not make a woman less vulnerable. According to the questionnaire data, one third of the deceased (51 women or 34.5%) experienced some kind of family problems, the most significant of which was violence from the husband - in 21 cases out of 51 (41.2%), drinking by the husband / partner of alcohol and drugs - 25 (49.0%), relatives' insistence on termination of pregnancy - 15 (29.4%) cases.

Internal migration was noted in 15 cases (10.1%), external - in 9 (6.1%). The RR of maternal mortality in this group of women was 2.9% (95% 2.2-3.2, p=0.0005), i.e. the risk of dying if a migrant woman increases by more than 2.5 times. The main reason for migration is lack of work. Thus, 122 (82.4%) of the dead women were housewives, only 8 (5.4%) of the dead had a permanent job, 18 (12.2%) questionnaires indicated such categories as “self-employed, farmer, worker, has one-time job." Those only 17.6% (26) of women were employed. Along with the above, according to the National Statistical Committee of the Kyrgyz Republic for the reporting period, the share of employed in the general population of women of reproductive age was about 49%, which significantly (2.8 times) exceeds the percentage of employed women in the structure of deceased women (49% versus 17.6 %).

Most of the women died after childbirth 118 - 79.7%, without giving birth, i.e. 30 (20.3%) women died pregnant.

Noteworthy is the number of stillbirths (26 - 17.5%), while every 4th birth in the Direct Causes group ended in a stillbirth (22.6%). In the group of deaths from indirect causes, the stillbirth rate was 5.7%. In the early neonatal period, 14 children died - 15.2% of all live births. But if in the group of direct causes 6 (8.4%) newborns died, then in the group of indirect causes - 8 (40%).

An increase in the frequency of operative delivery is observed all over the world, including in the Kyrgyz Republic. According to the e-Health Center, the caesarean section rate over the past 10 years has increased from 6.3% to 13.3%, reaching up to 25% in some obstetric institutions [5, 6]. Of the 148 women who died, 118 (79.7%) were delivered. The number of births through the natural birth canal and the number of caesarean sections were almost the same: 60 (50.8%) and 58 (49.2%) women, respectively. However, the death toll per 100,000 operative births was 180 women versus 21.5 per 1,000,000 vaginal births. At the same time, the relative risk of maternal death in cases of caesarean section was 11.1 (95% CI 8.0 to 15.3, p=0.00001).

           Caesarean section, as a method of delivery, dominated in severe preeclampsia, sepsis and indirect causes. In this category of deceased women, the relative risk (OR) of bleeding during operative delivery was 8.3 (95% CI 5.0 to 13.6, p=0.00001), the risk of septic complications was 5.5 (95% CI 2.1 to 14.4), p=0 .0005. The relative risk of death in patients with severe preeclampsia delivered by caesarean section was 6.1 (95% CI 3.7 to 9.8), p=0.0001.

Discussion. Between 2000 and 2020, the maternal mortality ratio (MMR) fell by about 34% worldwide. At the same time, the largest cumulative reduction in MMR was achieved in the regions of Eastern Europe and South Asia [8]. In the Kyrgyz Republic, the total maternal mortality rate for the 2-year study period (2014-2015) was the highest among the countries of Eastern Europe and Central Asia, amounting to 44.2 deaths per 100,000 live births. While in the Republic of Uzbekistan, the MMR, in the corresponding period, was 19.3 per 100,000 live births, in Kazakhstan - 15.7 per 100,000 live births, in Tajikistan - 20 per 100,000 live births, in Turkmenistan - 6 per 100,000 live births [8, 9, 10].

The Confidential Enquiry in Maternal Deaths cases revealed the influence of social and family factors on the level of maternal mortality in the Kyrgyz Republic. The employment factor, migration, as a search for earnings, of course, had a significant impact on the deaths of women.

Older age as a risk factor for maternal mortality has been noted by a number of studies. [9, 10]. In our study, these data were confirmed, since a statistically significantly higher incidence of death in women over the age of 35 years was revealed, compared with a group of women of a younger age.

The relative risk of maternal death in cases of caesarean section remains high in the Kyrgyz Republic. This indicator is 3 times higher than, in the corresponding period, in France (11.1 versus 3.64, respectively) [7].

Maternal deaths occur as a result of complications during pregnancy and after childbirth. In some cases, complications occur before pregnancy, but are aggravated during pregnancy, especially if they do not receive due attention of medical specialists when assisting a woman.

Conclusion. Thus, the most vulnerable were women without a permanent job over the age of 35, who were about to give birth for the first time. Caesarean section is a very high risk factor for maternal mortality in the Kyrgyz Republic, with an increased likelihood of obstetric hemorrhage and sepsis in the postpartum period.

About the authors

Zhanylai Nazaralievna Amiraeva

I.K.Akhunbaev Kyrgyz state medical academy

Email: Philiya-23@mail.ru
ORCID iD: 0000-0001-6279-5548
SPIN-code: 7094-8730

assistant of the department of Obstetrics and Gynecology No. 2

Kyrgyzstan, 720020, Kyrgyzstan, Bishkek, Akhunbaev str., 92

Cholpon Askarovna Stakeeva

I.K.Akhunbaev Kyrgyz state medical academy

Email: stakeeva@bk.ru
ORCID iD: 0000-0002-2854-5956
SPIN-code: 7382-3760
ResearcherId: AGC-2233-2022

candidate of medical sciences, associate professor of the department of Obstetrics and Gynecology No. 2

Kyrgyzstan, 720020, Kyrgyzstan, Bishkek, Akhunbaev str., 92

Asel Kanybekovna Iskenderova

I.K.Akhunbaev Kyrgyz state medical academy

Author for correspondence.
Email: joldoshbekovagulnur22@gmail.com
ORCID iD: 0009-0000-3561-0384

assistant of the department of Obstetrics and Gynecology No. 2

Kyrgyzstan, 720020, Kyrgyzstan, Bishkek, Akhunbaev str., 92

Gulnur Zholdoshbekovna Zholdoshbekova

I.K.Akhunbaev Kyrgyz state medical academy

Email: bgj7777777@mail.ru
ORCID iD: 0000-0002-7601-8544
SPIN-code: 4990-2675

assistant of the department of Obstetrics and Gynecology No. 2

Kyrgyzstan, 720020, Kyrgyzstan, Bishkek, Akhunbaev str., 92

References