الفهرس 
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Abstract
Child birth is a universally celebrated event for thousands of women every year. But for some women childbirth is experienced not as enjoy full event as should be, but as a hell and tragedy not only for the family but for all the community.
Maternal death is defined as death of any woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy.
The maternal mortality rate is defined as the number of maternal deaths per 100,000 women of the reproductive age (14-49), while the maternal mortality ratio is the number of maternal deaths per100.000 live births.
The WHO estimates that more than 500,000 women die each year because of conditions related to pregnancy and childbirth. Almost 99% of these deaths take place in developing countries.
The causes, maternal deaths should be divided into two groups: Direct obstetric deaths are those resulting from obstetric complications of the pregnant state (pregnancy, labor and the puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above. Indirect obstetric deaths are those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but was aggravated by physiologic effects of pregnancy (e.g., cardiac disease, psychiatric illness, hepatic disease).
In developing countries, maternal mortality has been described as a neglected tragedy. Complications of childbirth are the leading cause of death of women in the reproductive age today, accounting for 20-25% of their death.
It’s obvious that maternal mortality rates had receded in developed countries especially Sewed and USA, which are considered one of the least states of the world in the rates of maternal mortalities. The most important causes of maternal deaths in these two countries are pregnancy associated hypertension, pulmonary embolisms, heart diseases, infections, and hemorrhage.
Its noteworthy that in developed countries, regular inquiries are made on each maternal death and every attempt is made to eliminate all avoidable factors, in addition to raising awareness and interest in nutrition, increase the percentage of deliveries inside the hospitals, provision of blood banks, antibiotics and intensive care units, as well as the high level of medical competence and ongoing training with such an approach maternal mortality rates have declined to a negligible level.
In Egypt, maternal mortality in spite the recent progresses continues to be one of the existing and pressing problems. Incorrect or absent diagnosis of causes of death, elevated percent of literacy, poverty, and deliveries conducted at places rather than equipped hospitals has made the accurate measurement of the problem difficult.
Despite of the previous difficulties, Egypt is on the right track in terms of reducing maternal mortality rates according to many indicators issued by the Ministry of Health, where the national maternal mortality ratio in year 1990 was nearly 233, and the ratio is decreasing year after year, to 130 in year 2000, then 84in year 2005, to become 59 in year 2009 compared with 12 in Qatar, 15 in Saudi Arabia, 20 in Palestine, 86 in Lebanon and 366 in Yemen.
This retrospective study conducted at ain shams teaching hospital for obstetrics about maternal mortality files inside the hospital in the study period from 1/1/2014 to 31/12/2017, had revealed revealed (161) maternal deaths, the total live
births within the(4) years were (44555), and MMR (3.614) per 1000 live births.
Maternal mortality cases were distributed on the 4 years of the study period as follow; 33 cases in 2017, 48cases in 2016, 39 cases in 2015 and 41 cases in 2014.
The main underlying defects were first absence of the senior staff at the moment of admission of the seriously ill patients, whom were primarily evaluated and managed by junior staff, second was the lack and delay in getting the blood or its substitutes, medications, and medical equipments .Other causes like insufficiency of the paramedical staff from nurses technicians ,and workers in handling with the near miss patients beside the delay in cooperation with the doctors in duty in executing very critical decisions, or sending samples for the lab or the patient themselves for other diagnostic investigations like CT scan or X-ray or Dopppler.
At last it remains an important factor in all recent hospitals is the presence of a group of specialized individuals rather than workers, proficient in communicating, explaining, and assuring the relatives of near miss patients about their medical condition, this wills necessarily save the efforts of the medical staff whom are dealing with those patients.
The cases presenting with hemorrhage represented 25.5 % of the total maternal death cases ranked the 1st causative factor. from these cases, 17 cases were presented by PPH, which accounted for 10.6 % of the total maternal deaths, 10 cases were presented by APH accounted for 6.2%, 3 cases presented by internal hemorrhage which accounted 1.9 % of the total maternal deaths, 10 cases of them died due to rupture uterus and 1 case died due to placenta previa.
The cases presenting with hypertensive disorders of pregnancy represented 23.6 % of the total maternal deaths which ranked the 2nd cause of death. from these cases 14 cases were presented with Eclampsia, which accounted for 8.7% of the total maternal mortalities, 22 cases were presented by Pre-eclampsia, which accounted for 13.7 % of the total maternal deaths, and 2 case were presented by chronic hypertension which accounted for 1.2 % of the total maternal deaths.
Sepsis and infections ranked the 3rd common cause of death in this study, which accounted for 9.9% from total deaths. 10 cases were presented by septic abortion, which accounted for 6.2% of the total maternal deaths,4 cases had puerperal sepsis representing 2.5%, 3 cases were presented by acute peritonitis representing 1.8%, and 3case diagnosed as H1N1accounted for 1.8% of total mortalities.
Heart diseases ranked the 4th common cause of death in this study, which accounted for 6.2% from total deaths. 4 cases were presented by peripartum cardiomyopathy, which accounted for 2.5% of the total maternal deaths, 6 cases had history of heart disease representing 3.7%.
Other medical diseases represented in total 34.5%, 6 cases were diagnosed as AFL, 7 cases presented with liver cirrhosis due to chronic active hepatitis, and 6 case had AFE.
2 cases were presented post truama, 2cases died from anesthesia complications: succinyl choline apnea.
6 cases presented with neoplasm: one with recurrent right breast cancer, the other was acute lymphoblastic leukemia, 1.4% for each.
7 cases were without clear presentation, or unclassified because of poor data they accounted for 4.3% from total deaths.
There were two important factors can be avoided and those were the delay in seeking medical care from the mother and /or her family, perhaps the ignorance about the dangerous signs of pregnancy and birth, or mistrust in the medical institutes, from the causes. The reasons for this delay need to be explored in more depth, using quantitative and qualitative, research methods. The other factor was low standard medical care from the obstetric team.
Since most women were eventually taken to a hospital, distance from medical facilities and lack of transportation (physical accessibility) didn’t seem to be major factors. Therefore, the reasons for delay or non compliance are more likely to be: because of families and women don’t recognize the danger signs and complications of pregnancy, because those attending the birth don’t have decisions making capacities, regarding transfer, because these health facilities are not judged to be of good quality or because complying with recommendations is costly (either financially or socially).
Should part of the problem proved to be a lack of awareness of the danger signs of pregnancy, it will important to communicate with women and their families about danger signs of pregnancy, delivery, and the postpartum, so they can receive prompt care at proper time. This should be done at all possible opportunities and shouldn’t just be restricted to antenatal care.
Junior obstetricians managed many of the hospital deaths, or doctors in training with limited experience. So it’s strongly recommended that senior obstetricians be more involved in obstetric care, particularly in making early decisions for operative procedures.
There is likely a priority for training obstetricians and general practitioners providing continuing education and training that is practical and skill based. Establishment of more equipped hospitals, provision of easy transportations and both medical supplies and blood banks, and this responsibility requires the allocation of more support from the budget of GNP
However, for improving maternal heath, four essential elements should be done:
• Adequate primary health care at all levels, and an adequate share of the available food for girls from infancy to adolescence, and family planning universally available, to avoid unwanted or high risk pregnancies.
• After pregnancy begins, good prenatal care, including nutrition with efficient and early detection and referral of high risk patient.
• The assistance of a trained person for all women in child birth, at home or in the hospital.
• Women at higher risk must all have effective access to the essential elements of obstetric care.
This retrospective study on maternal mortality cases in the period from January 2014 to December 2017 revealed that:
1-Efficient and fast transfer of the pregnant ladies to the delivery unites to provide the medical services to them in proper time.
2-Providing of enough blood units and its substitutes to manage hemorrhagic cases properly.
3-Presence of recent and efficient system for patient registration; this will ensure:-
First: Recall the patient’s data with easly way from archivies.
Second: Registering the patients’ data, their medications, and medical services provided to them, to estimate the medical services later on when needed
• The importance of provision of ICU inside the hospital, as they are considered the last resource for critically ill and dangerous cases by applying the proper facilities from medications equipments and monitoring system, and more is the qualifying of the medical staff to deal with these critical cases
• Training of junior doctors on the different labor stages and dealing with dangerous cases, together with the basics of the science of obstetrics.