title: Medical disease as a cause of maternal mortality: the pre-imminence of cardiovascular pathology.
abstract: Maternal mortality ratio in low- to middle-income countries (LMIC) is 14 times higher than in high-income countries. This is partially due to lack of antenatal care, unmet needs for family planning and education, as well as low rates of birth managed by skilled attendants. While direct causes of maternal death such as complications of hypertension, obstetric haemorrhage and sepsis remain the largest cause of maternal death in LMICs, cardiovascular disease emerges as an important contributor to maternal mortality in both developing countries and the developed world, hampering the achievement of the millennium development goal 5, which aimed at reducing by three-quarters the maternal mortality ratio until the end of 2015. Systematic search for cardiac disease is usually not performed during pregnancy in LMICs despite hypertensive disease, rheumatic heart disease and cardiomyopathies being recognised as major health problems in these settings. New concern has been rising due to both the HIV/AIDS epidemic and the introduction of highly active antiretroviral therapy. Undetected or untreated congenital heart defects, undiagnosed pulmonary hypertension, uncontrolled heart failure and complications of sickle cell disease may also be important challenges. This article discusses issues related to the role of cardiovascular disease in determining a substantial portion of maternal morbidity and mortality. It also presents an algorhitm to be used for suspected and previously known cardiac disease in pregnancy in the context of LIMCs.
authors.affiliation: Instituto Nacional de Saúde and Department of Medicine, Universidade Eduardo Mondlane, Maputo, Moçambique.
authors.forename: A O
authors.initials: AO
authors.lastname: Mocumbi
authors.affiliation: Hatter Institute for Cardiovascular Research in Africa, and IDM, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa; Soweto Cardiovascular Research Unit, University of the Witwatersrand, Johannesburg; Inter-Cape Heart Group, Medical Research Council South Africa, Cape Town, South Africa. Email: karen.sliwa-hahnle@uct.ac.za.
authors.forename: K
authors.initials: K
authors.lastname: Sliwa
authors.affiliation: Inter-Cape Heart Group, Medical Research Council South Africa; University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa.
authors.forename: P
authors.initials: P
authors.lastname: Soma-Pillay
mesh_terms: D018376:Cardiovascular Abnormalities / Q000401:mortality* / Q000473:pathology; D002319:Cardiovascular System / Q000473:pathology*; D002423:Cause of Death / Q000639:trends*; D003906:Developing Countries; D005260:Female; D006801:Humans; D008428:Maternal Mortality; D011247:Pregnancy; D011295:Prenatal Care