Background: Maternal mortality is a globally acknowledged concern by the World Health Organization.

Objectives: The purpose of this study was to analyze and document forensic fatalities caused by maternal death causes in Northern Jordan that were reported to the Forensic Medicine Teaching Centre in Irbid between 2014 and 2024.

Methods: From January 2014 to December 2024, a total of 53 maternal death cases that were brought in for postmortem examinations were examined. A retrospective study was undertaken to gather data from maternal death case profiles. Data were extracted from files and entered into functional Excel spreadsheets. Subsequently, data were examined utilizing SPSS version 21.

Results: Of the 53 maternal mortalities studied, bleeding was the leading direct cause (32.1%), followed by pneumonia as an indirect cause (15.1%). The fourth decade had the majority of maternal deaths (64.2%). The majority of fatalities (69.8%) happened in the postnatal period, with 52.8% delivered via cesarean section and 24.5% during normal vaginal delivery.

Conclusions: Maternal mortality in Northern Jordan remains largely preventable. Hemorrhage and pulmonary complications dominate as leading causes, emphasizing the urgent need for strengthened postpartum surveillance, rapid emergency response systems, reduction of unnecessary cesarean deliveries, and improved multidisciplinary management. Forensic autopsies play a vital role in identifying preventable factors and guiding public-health action.

Maternal mortality has been defined by the World Health Organization (WHO) as the death of a woman while pregnant or within 42 days of termination of pregnancy irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes [1]. A global research study published in The Lancet Global Health indicates that although maternal mortality rates (MMRs) have decreased by 34.8% over the past two decades, progress has stalled in certain regions, and in others, the rates have risen [2, 3]. In 2020, an estimated 287,000 women died from pregnancy-related causes, with sub-Saharan Africa and South Asia accounting for approximately 87% of these deaths [2]. The MMR for the same year was 223 maternal deaths per 100,000 live births, far from the UN Sustainable Development Goal (SDG) target of fewer than 70 deaths per 100,000 live births by 2030 [2]. Some high-income countries have seen rising MMRs, notably the United States, which experienced a 77.9% increase between 2000 and 2020 [2]. In Jordan, the maternal mortality rate (MMR) for 2022 was 33 per 100,000 live births, compared to a non-COVID MMR of 28 per 100,000, reduced from the previous year's non-COVID MMR of 29.8 per 100,000 [4]. According to a systematic analysis by the WHO, the worldwide leading causes include hemorrhage (27.1%), hypertensive disorders (14.0%), and sepsis (10.7%) [5]. Indirect causes, including pre-existing medical conditions exacerbated by pregnancy, accounted for 27.5% of maternal deaths [5]. Significant racial and ethnic disparities persist in maternal mortality, particularly in the United States. Black women experience maternal mortality rates 3.55 times higher than White women, with leading causes including eclampsia, preeclampsia, and postpartum cardiomyopathy [6]. This racial gap persists even when controlling for socioeconomic status and healthcare access, suggesting systemic biases in medical care and broader social determinants of health [7, 8]. Forensic investigations reveal instances of mistakes in administration, medical care, or lack of attention in healthcare situations. By finding treatment gaps or breaks from accepted standards, these studies could help professionals do their jobs better and healthcare improve [8]. Forensic autopsies specifically provide important insights into the causes of maternal deaths, help identify systemic failures, and contribute to improving healthcare policies [9].

Study objectives: The purpose of this study was to analyze and document forensic fatalities caused by maternal death causes in Northern Jordan that were reported to the Forensic Medicine Teaching Centre in Irbid between 2014 and 2024.

Subjects and Methods: This section describes the essential processes used in conducting the current inquiry. The document contained the following aspects:

Study Design and Setting: A retrospective analysis was undertaken to gather data from case files. The study was conducted over a ten-year period (2014-2024) at the Department of Legal Medicine, Toxicology, and Forensic Science in Jordan, Jordan University of Science and Technology in Irbid, Jordan, and the Ministry of Health Forensic Medicine Teaching Centre.

Study sample: A total of 5,996 medicolegal autopsy files were reviewed over a ten-year period from January 2014 to December 2024 at the Forensic Medicine Teaching Centre in Northern Jordan. Among these, 57 deaths were identified among women who were pregnant or within 42 days postpartum. After exclusion of 4 cases that did not meet the World Health Organization criteria for maternal death (three due to accidental causes and one due to homicide), 53 cases were confirmed as true maternal deaths and included in the final analysis. Thus, the study sample comprised 53 maternal death cases.

Study process: Following clearance of this study by the Faculty of Medicine's IRB at Jordan University of Science and Technology, the research team obtained data from records at the Forensic Medicine Teaching Centre. Then, a working Excel spreadsheet for cases was developed. The study factors included demographic and general data such as age, type of examination, year of occurrence, type of delivery, direct and indirect causes of mortality, and medical history. The data was analyzed using SPSS version 21, and the results were presented in tables. Data was described using descriptive statistics, such as frequencies and percentages for categorical variables, and means and standard deviations for continuous variables. The Chi-Square Test, T-test, Correlation Test, and One-Way ANOVA were used to determine the associations between variables. P-values less than 0.05 were deemed significant.  Data security was secured by storing all types of data, whether paper or electronic, in safe locations; also, the names of individuals' autopsies, as well as the entire dataset, were not accessible.

The majority of the 53 maternal fatality cases analyzed occurred in the fourth decade of life (30-39 years), accounting for 64.2% of the total. This was followed by the third decade (20-29 years) at 24.5% and the fifth decade (40-49 years) at 7.5%. Only 3.8% of instances were reported in the second decade (10-19 years). These data reveal that maternal fatalities were disproportionately concentrated among women aged 30-39 years, representing approximately two-thirds of the overall cases (Table 1).

Table 1: frequency of study participants by age.

In this study, 100% of maternal death cases had a thorough postmortem examination. This high autopsy rate is laudable, as autopsy is still the gold standard for ascertaining the precise cause of maternal mortality. 42 (79.2%) of the cases had no documented previous medical history. The most often reported comorbidities among the remaining patients were cardiac disorders (11.4%), which included cardiac muscle disease, myocardial bridging and ventricular septal defect. Other illnesses included DM type 1 which accounted for 3.8%, pre-eclampsia, leiomyomata, and mental problems, each accounted for 1.9% of cases (Table 2).

Table 2: Medical history of study participants.

2017 had the highest maternal mortality rate, with 11 fatalities (20.8%), suggesting a significant increase compared to previous years. In contrast, 2023 saw the fewest number of deaths, with only one (1.9%). Moderate  increases in maternal mortality are detected in 2015 (7 deaths, 13.2%) and 2021 (6 deaths, 11.3%), Years with relatively low and constant maternal death rates (about 7.5% or less) include 2016, 2019, 2020, 2022, and 2024. The results show oscillations rather than a consistent decrease in maternal mortality (Table 3, figure 1).

Table 3: Trends of maternal mortality rate.

Figure 1: maternal mortality by year

Obstetric Profile: In 16 instances (30.2%), moms had no history of previous cesarean section, showing that almost a third of births occurred in women who had never undergone a CS. Eight instances (15.1%) of mothers had a history of cesarean birth. The majority of cases, 29 (54.7%), had an unknown CS history (Table 4).

Table 4: The frequency of previous cesarean cases among study participants.

As shown in Table (5), 28 women (52.8%) were delivered by CS, implying that more than half of the births required surgical intervention. 13 women (24.5%) had normal vaginal births. Nine women (17.0%) were  still pregnant when they died. Two instances (3.8%) resulted in abortions. Only one example (1.9%) had an unknown delivery type, showing that this variable has a low missing data rate.

Table 5: Frequency of delivery among study participants.

The most prevalent finding in the 53 maternal fatality cases was a gravid uterus with no product of conception (66.5%), indicating that many fatalities happened in the postpartum period after birth or abortion. A gravid uterus containing a product of conception was found in 19.1% of instances, whereas 13.3% had undergone hysterectomy, indicating efforts at life-saving intervention in severe obstetric situations such as bleeding or uterine rupture. Less common observations were empty uterus (1.9%) (table 6).

Table 6: Frequency of uterus findings.

The majority of maternal fatalities occurred in the postpartum period (69.8%), followed by the antepartum interval (22.8%), with just 7.5% occurring during delivery (Table 7).

Table 7: Frequency of time death among study participants.

Table 8: Frequency of death causes.

The bulk of the 53 maternal fatalities were caused by direct causes (68%), with indirect factors accounting for 32%. Hemorrhage (32.1%) was the most common primary cause, followed by pulmonary embolism (17.0%), sepsis (7.6%), and pulmonary hemorrhage (7.6%), with a few instances associated to pulmonary edema (1.9%) and seizures (1.9%). The bulk of the 53 maternal fatalities were caused by direct causes (68%), with indirect factors accounting for 32%. Hemorrhage (32.1%) was the most common primary cause, followed by pulmonary embolism (17.0%), sepsis (7.6%), and pulmonary hemorrhage (7.6%), with a few instances associated to pulmonary edema (1.9%) and seizures (1.9%) (table 8). Among the 53 maternal death cases, the majority of women had a normal body habitus (84.9%). Obesity was documented in 11.3% of cases, while only 1.9% were classified as overweight and 1.9% as very thin. These findings indicate that most maternal deaths occurred among women within the normal weight range, suggesting that body mass index (BMI) was not a predominant contributing factor in this cohort (Table 9).

Table 9: Frequency of body status among study participants.

A total of 53 maternal death files were reviewed over a period of ten years in Northern Jordan, with the objective of describing the demographic characteristics and obstetrical features in cases where maternal mortality was involved, its causes, time distribution and medicolegal autopsy role for understanding this kind of deaths. Results show general trends that are in line with global data, and at the same place specific local findings which allow them to be planned. The majority of maternal deaths occurred among women aged 30–39 years (64.2%), followed by 20–29 years (24.5%). This pattern reflects the high fertility rates in this age group and may also be related to increased obstetric risk factors in women of advanced reproductive age. Similar trends have been observed in other middle-income countries, where advanced maternal age is associated with a higher risk of hemorrhage, embolism, and medical comorbidities [2, 10-13]. Teenage pregnancies represented only a small proportion (3.8%) of deaths in this study, indicating that maternal mortality in this region is more concentrated among multiparous or older pregnant women. Direct obstetric causes accounted for 68% of cases in this study, consistent with WHO global estimates Hemorrhage was the leading direct cause (32.1%) [5, 14-16], in contrast to a study from the United States between 2016-2017 where obstetric embolism and eclampsia/preeclampsia were tied for the leading cause of maternal death in non-Hispanic black women [6]. This was followed by pulmonary embolism (17%) and sepsis (7.6%). These findings highlight the ongoing burden of preventable obstetric emergencies. Hemorrhage-related deaths remain particularly concerning, as timely medical and surgical interventions, including active management of the third stage of labor and access to blood transfusion, can significantly reduce mortality. Obstetric hemorrhage and mortality rates have decreased in low- and middle-income countries due to improved medical treatment, while the issue is increasing in high-income settings. Factors contributing to mortality include retained placenta, obstructed labor, ruptured uterus, and unsupported cesarean sections. These issues can lead to maternal mortality when combined with limited emergency transport, long hospital delays, and shortages of specialist care. Intrapartum procedures like cesarean surgery can increase the risk of postoperative hemorrhage and abnormal placentation in subsequent pregnancies [18]. Indirect causes contributed to 32% of maternal deaths, with pneumonia (15.1%) as the leading cause, followed by cardiac conditions and metabolic disorders. The increasing proportion of indirect causes reflects an epidemiological shift toward chronic and medical conditions contributing to maternal mortality, particularly in middle-income countries [2, 5, 7]. Pulmonary causes as a group accounted for 45.4% of deaths, underscoring the need for early detection and management of respiratory complications during pregnancy and the postpartum period. The prominence of respiratory complications in our sample warrants further investigation to determine if it relates to hospital-acquired infections, undiagnosed comorbidities, or complications from surgical interventions. Eight maternal deaths from pneumonia have been reported, with over 77% of these women having no pre-existing conditions, indicating a high vulnerability to severe respiratory infections. The mode of delivery is the most significant factor, with over half of the deaths (5 out of 9) occurring in women recovering from a Cesarean section. Factors such as post-operative pain, reduced mobility, and exposure to hospital-acquired pathogens contribute to the development of fatal pneumonia. Additionally, over half of the deaths occur in the colder months of January, February, and October, suggesting that community-acquired respiratory viruses, more prevalent during these seasons in Jordan, may be a significant trigger for these tragic outcomes. Fatal pneumonia is not just a complication for the chronically ill but a significant threat to otherwise healthy women, particularly post-Cesarean patients, especially during seasons with high rates of respiratory illness. A striking 69.8% of deaths occurred in the postpartum period. This mirrors global reports from the World Health Organization (WHO), which emphasize that the majority of maternal deaths occur within 42 days after delivery, particularly in the first 48 hours [10, 18, 19-21]. The predominance of postpartum deaths suggests gaps in immediate postnatal monitoring, timely recognition of complications, and access to emergency interventions. Strengthening postpartum surveillance and early response systems could substantially reduce maternal deaths. More than half of the deceased women (52.8%) delivered by cesarean section, while 24.5?livered vaginally. Due to the scarcity of available obstetric information, it cannot be determined whether the cases delivered by the current caesarean section are first-time births or if they have previously given birth by caesarean section, to explain the increase in the number. The global trend currently reflects the rise of cesarean delivery at present, where it is common for those with previous cesarean sections as well as being an elective primary procedure [22-26]. High cesarean rates may indicate improved access to surgical obstetric services but also raise concerns regarding potential overuse and its contribution to postoperative complications such as hemorrhage and thromboembolism [27]. Careful audit of cesarean indications and outcomes may help reduce unnecessary procedures and related risks. There is a relative stability in the number of deaths from 2014 to 2024, but there is a noticeable increase in the number of maternal deaths in 2017. This can be explained by the fact that the majority of cases during the research period were of Jordanian nationality, except for 5 cases of Syrian nationality, all of which were before 2018. Out of these 5 cases, 3 occurred in 2017, and they were referred from areas outside the northern region. It is well known that the political situation in Syria had a significant impact on the large number of Syrians seeking refuge in Jordanian camps, which generally lack the primary and essential care for pregnant women, making them more susceptible to complications than others. As for the increase in 2021, it may be attributed to the impact of the Corona pandemic, as it was observed that most, if not all, maternal deaths that year were due to indirect causes, all of which had a pulmonary origin. The autopsy rate in this study was high (96.2%), which reinforces the critical role of forensic medicine in maternal mortality surveillance. Postmortem examinations provided essential insights into the timing, mechanism, and underlying medical or obstetric conditions associated with each death. Notably, a gravid uterus without product of conception was found in 66.5% of cases, indicating that many deaths occurred after delivery or abortion. Forensic investigations serve not only to establish cause of death but also to identify avoidable factors such as delays in treatment, procedural errors, or deviations from standard care. Such findings are valuable for healthcare system improvements and policy formulation [8, 9]. This aligns with previous reports emphasizing the importance of forensic autopsies in maternal death audits. Comparison with Global Data Globally, hemorrhage, embolism, hypertensive disorders, and infections remain the leading causes of maternal death [2, 5]. The high proportion of pulmonary and cardiac causes in this study mirrors trends observed in some high- and middle-income countries, where indirect medical conditions contribute increasingly to maternal deaths [6, 7]. This shift reflects changing population health profiles, with more women entering pregnancy with pre-existing comorbidities.

Implications for Policy and Practice 

The findings point to several actionable areas for intervention:

1. Strengthening postpartum care: Structured monitoring during the immediate postpartum period is critical, particularly for hemorrhage and embolism.
2. Emergency obstetric preparedness: Improving rapid access to blood transfusion, surgical interventions, and resuscitation teams can reduce direct maternal deaths.
3. Multidisciplinary management: Integrating obstetric, internal medicine, and critical care teams can improve outcomes for indirect causes such as pneumonia and cardiac disease.
4. Cesarean section audits: Reducing unnecessary cesarean sections can minimize associated complications.
5. Forensic-public health collaboration: Systematic inclusion of forensic findings in maternal death audits enhances understanding of preventable factors.

This study is retrospective and based on medicolegal autopsy records. It may lack some clinical details, particularly regarding antenatal care, referral timelines, or health system delays. Additionally, the study represents a single geographic region, and national generalization should be made cautiously.

Maternal mortality in Northern Jordan remains a significant concern. The leading causes—hemorrhage and pulmonary complications—are largely preventable with timely and coordinated obstetric and medical care. Strengthening postpartum monitoring, enhancing emergency response capacity, integrating multidisciplinary management, and utilizing forensic autopsy data in public health planning are crucial steps to reduce maternal mortality and achieve the Sustainable Development Goal targets for maternal health. To address the limitations regarding missing clinical history and antenatal data observed in this retrospective review, this study proposes the immediate adoption of a comprehensive "Maternal Mortality Investigation Form in forensic departments. 

The Jordan University of Science and Technology’s deanship of research provided funding for this project under grant number 20250239