Maternal mortality: nothing but the truth | Gilbert Gravino, Isabel Stabile

the major difficulties in relying on maternal mortality to demonstrate excellence in health care are that maternal deaths remain generally under-reported, and that considerable statistical variation results from the small numbers of births recorded in Malta

File photo
File photo

The Maltese healthcare system has collected and reported statistics on maternal deaths since 1995. In these records, maternal death refers to any person who dies either during pregnancy, or within 42 days (six weeks) of being pregnant (including after a miscarriage, an ectopic pregnancy, an induced abortion, or a birth) from any cause related or aggravated by the pregnancy or its management. This excludes death due to incidental or accidental causes. 

The accuracy of these data depends on how precisely doctors complete death certificates. So, if for example, the doctor writing the death certificate is not aware that the person was pregnant six weeks before her death, they would have no reason to suspect the death is related to pregnancy. We are not suggesting that any doctor would knowingly do so, only that it is possible and that there would be no way of knowing for sure. 

Over a period of 27 years (1995-2021), eight women in Malta have died during or within six weeks of the pregnancy. It is possible that some of these deaths could have been prevented if the law did not ban abortion completely. Unfortunately, we do not know the exact cause of death because our statistics do not keep record of the reason for a maternal death.

Since maternal death is fortunately so rare, the maternal mortality rate (or ratio) is reported as the number of deaths per 100,000 live births. This is less than 10 per 100,000 in most European countries. Given that in Malta there are approximately 4,000 births per year (and 92,402 births between 2000 and 2021), one would quickly realise that for such a small country, it takes many years to gather enough births to report rates per 100,000 live births. 

Moreover, countries with small numbers of annual births, such as Malta, will experience greater year-to-year random fluctuations and will have wider confidence intervals around rates. For example, if we calculate the rate of deaths each year we might find years with a rate of 0 (2011), whereas in the previous year (2010) because we had one death, the rate would be 25.65 which is five times greater than the EU average for that year (5.51/100,000).

It is precisely because there are so few maternal deaths, that the EU reports maternal deaths as a running average with data for five years (2011-2015) and with 95% confidence intervals. However, even with data for five years, the number of deaths is still very low in the smallest countries in Europe.

This is why countries such as Iceland, Luxembourg, and Malta, all with fewer than 100 000 births per year, would need to collect maternal deaths for over half a century or more to provide data as robust as those of the French or UK confidential enquiries into maternal deaths.

Even if it were possible to go back 50 years (the earliest recorded statistical data pertaining to Malta is from 1995), it would still not be meaningful because of the social and medical changes that have occurred over so many years.

If maternal mortality rates are to be quoted, one should never cherry-pick the last 11 years to make the numbers look more palatable and fit the narrative that obstetric care in Malta is flawless. We cannot rely on short-term rates. Reviewing a long time-frame is important, especially considering the small population, and therefore, the smaller number of total pregnancies per year relative to other countries. Although obstetric care in Malta has improved greatly in the last 27 years, we should not be falsely reassured about our obstetric health services by low maternal death rates.

When reflecting on this death rate, bear in mind that an estimated 400 pregnancies in Malta are already being aborted by using pills ordered online or by having an abortion abroad in a clinical setting. Had abortion been completely inaccessible, the rate of maternal death (and avoidable serious complications) would likely be greater. The current situation masks this fact and is making the lives of pregnant people difficult and potentially dangerous. For example, in the US, the Commonwealth Fund (an independent organisation researching health policy) has reported that in 2020, those states that have restricted and/or banned abortion have maternal death rates which were 62% higher than they were in states where abortion was more accessible.

Let us consider a thought experiment: what if Andrea Prudente or Marion Mifsud Mora had left Malta too late? What if they had died after leaving Malta? Their deaths (which fortunately did not happen) would not have been included in our statistics. We have effectively been exporting our problems, and in turn, importing solutions in the form of medical abortion pills. Ironically, the only women who cannot access these pills are those who are hospitalised in Malta. This is why the current amendment to the Criminal Code is essential.

Moreover, maternal death is a very low bar to set when discussing women’s reproductive health. Firstly, many who could not access an abortion in a timely manner go on to develop complications that could have otherwise been prevented. We must not forget that apart from death, there are a number of poor maternal outcomes in pregnancy, including near-misses, severe morbidity, and long-term consequences. Secondly, it is hypocritical to find solace in a low maternal death rate, only to then put women’s lives at risk by depriving them of autonomy over decisions that have a direct impact on their health.

Abortion aside, Malta’s healthcare in general is acknowledged by the WHO as being exemplary. However, considering the tremendous impact that the lack of abortion access has on the holistic wellbeing of our families and friends, it is not an over-exaggeration to conclude that the current law is no longer fit for purpose. This is why 135 medical doctors in Malta signed a judicial protest in June 2022 requesting the government to review the current legislation. They are calling on the government to eliminate any possibility that doctors might be reluctant to intervene in clinical situations that put women at risk for fear they might fall foul of the law. 

In summary, the major difficulties in relying on maternal mortality to demonstrate excellence in health care are that maternal deaths remain generally under-reported, and that considerable statistical variation results from the small numbers of births recorded in Malta. 

This proposed amendment is about access to essential life-saving healthcare. Claiming that our present law suffices because no one has died as a result of it is disingenuous at best, and negligent at worst.