Maternal mortality is still a serious global public health problem, but a new study on women in rural Bangladesh finds that almost half of all adult female deaths were actually caused by non-contagious diseases, not complications of pregnancy.

The study, say researchers from the Johns Hopkins Bloomberg School of Public Health, is one of the first population-based studies to investigate causes of adult female mortality that were unrelated to pregnancy.

Its findings could help refocus public health efforts toward preventing conditions like heart disease and stroke among rural South Asian, which may pose a greater threat to them than maternal mortality.

Surveying Rural Women in Bangladesh

The researchers used data from a nutritional intervention trial called JiVitA-1, which aimed to find out whether taking weekly supplements of vitamin A, also known as beta-carotene, could help reduce pregnancy-related mortality.

That survey included data from over 133,617 married Bangladeshi women, aged 14 to 45 years old, in the rural districts of Gaibandha and Rangpur in northwest Bangladesh.

From 2001 to 2007, field workers visited the women every five weeks to ask about their pregnancy status in order to see if they would be eligible for the vitamin A trial. They also kept track of deaths, so epidemiologists could see what factors contributed to eventual mortality among the rural women.

Over the course of those six years, 1,107 of the surveyed women died of various causes. Trained physicians visited the women's relatives and neighbors soon after, and used verbal autopsy interview methods adapted from the World Health Organization (WHO) to find out what circumstances preceded each death.

An obstetrician and an epidemiologist then independently reviewed the verbal autopsy reports to confirm a primary cause of death.

Causes of Mortality Among Bangladeshi Women

The results, published in this month's edition of the British Journal of Obstetrics & Gynecology, showed that 48 percent of the women's deaths were attributed to non-communicable diseases.

19 percent of those were from circulatory diseases like heart failure, stroke, or other cardiovascular conditions. Another 15 percent was from cancer, and the rest resulted from various conditions like gastrointestinal disorders, diabetes, and kidney disorders.

22 percent of the other deaths were classified as pregnancy-related, since they occurred while the women were pregnant or within six weeks of the pregnancy's ending. Another 17 percent were caused by endemic infectious diseases like diarrhea, tuberculosis, or malaria. 9 percent resulted from injuries, including assaults, suicides, homicides, or accidents.

Implications for Rural South Asia

"While reducing mortality from pregnancy remains a high priority, these findings highlight the need to address and reduce the risk of death unrelated to pregnancy among women of reproductive age," said lead author Dr. Alain Labrique in a news release.

Many of the non-communicable disease deaths were preventable, suggests Labrique, resulting from lifestyle factors that could have been altered by early interventions.

Risk for cardiovascular diseases, for example, can often be identified with early screening. Health education can also play a major role, empowering women to make decisions about nutrition before risk factors for disease begin to build up.

Previous population-based studies in South Asia have found high rates of risk factors for cardiovascular disease, like high blood pressure and cholesterol, poor diet, and sedentary lifestyle.

The findings are likely to be generalizable to the rest of rural Bangladesh and much of India, say the researchers.

The women in this sample have similar socioeconomic and demographic characteristics as rural adult females throughout South Asia-a region that, including India, Pakistan, and Bangladesh, comprises almost one-sixth of the world population.

"The causes and risk factors need to be better understood to design interventions to reduce risk," added Labrique "for rural women in their prime of life."

Source: Labrique A, Sikder S, Wu L, Rashid M, Ali H, Ullah B, Shamim A, Mehra S, Klemm R, Banu H, West K Jr, Christian P. Beyond pregnancy - the neglected burden of female mortality in young women of reproductive age in Bangladesh: a prospective cohort study. British Journal of Obstetrics & Gynecology. 2013.