The mean age was 26.6 ± 5.7 years in cases and 27.2 ± 6.6 years in controls. The 25 - 35 age group was the most represented (52.17%) in cases, while the 15 - 25 group was the most common (44.57%) in controls. The majority were multiparous (39.13% versus 52.18%), and educated (82.61% versus 88.04%). Cases had fewer than 4 prenatal visits (69.57%), whereas controls had at least 4 (60.87%). The majority of patients were referred/evacuated (82.61% versus 88.04%) and came from rural areas (56.52% versus 54.35%) (Table 1).

Table 1.Sociodemographic characteristics.

The mean gestational age in the case group was 31.9 ± 6.9 weeks; it was 34.6 ± 4.4 weeks for the controls. Singleton pregnancy was more frequently represented in both groups, i.e., 100.0% versus 89.13% (Table 2).

Table 2. Clinical and paraclinical data.

The patients in the case group were more frequently admitted to the intensive care unit (86.96%) compared to the control group (38.04%). Magnesium sulfate was administered to the majority of patients (86.96% versus 38.04%) (Table 3).

Table 3. Therapeutic data.

The univariate analysis allowed for the evaluation of the crude association of each potential risk factor with death due to preeclampsia. The results are presented in Table 4.

The factors significantly associated with maternal mortality during preeclampsia were:

Fewer than 4 prenatal visits Onset of preeclampsia in the postpartum periodOccurrence of maternal complications such as eclampsia, renal failure, acute pulmonary edema, and HELLP syndromeAdmission to the intensive care unit

Table 4. Factors associated with maternal mortality due to preeclampsia. (Univariate Analysis)

A multivariate logistic regression model was constructed to adjust for the factors significant in the univariate analysis (p < 0.05). The final model includes variables that have an independent association with mortality (Table 5).

Patients who had fewer than 4 prenatal visits had a 5 times higher risk of death compared to those who had at least 4. The occurrence of acute pulmonary edema multiplied the risk of maternal death by 5.

The factor most strongly associated with death was the occurrence of eclampsia, which increased the risk of death by 31 times.

Table 5. Factors associated with maternal mortality due to preeclampsia. (Multivariate Analysis)

The univariate analysis established that inadequate prenatal care, defined as fewer than 4 prenatal visits (CPN), was associated with mortality. The multivariate logistic regression model confirmed that this factor independently increased the risk of death by 5 times.

This result is a marker of delayed or inadequate access to care [10]. Prenatal care plays a crucial role in safe monitoring and ensuring the well-being of the mother and fetus during pregnancy, ultimately leading to the best possible perinatal outcomes [11][12]. It is essential for the early screening of arterial hypertension and the initiation of preventive measures or targeted follow-up. Historically, prenatal care programs were developed to detect arterial hypertension and proteinuria [13]. The absence of regular follow-up often leads to late presentation of the disease, directly at the stage of severe complications [3]. This finding is particularly alarming in low-resource regions [14]. Kayentao et al. in Mali, and Bhutada et al. in Uganda, have reported barriers to prenatal care attendance, including financial constraints, distance from healthcare facilities, and family reluctance [15]-[18].

Improving the coverage and quality of prenatal visits therefore remains important for preventing maternal mortality in general and preeclampsia-related mortality in particular.

The occurrence of acute pulmonary edema (OAP) remained an independent risk factor, multiplying the risk of death by 5. OAP is defined as pulmonary edema caused by excessive accumulation of fluid in the interstitial and alveolar spaces of the lung due to an increase in capillary hydrostatic pressure secondary to elevated pulmonary venous pressure, itself resulting from high cardiac filling pressures [19]. It is associated with high mortality [20][21]. Several studies have established the relationship between high mortality during preeclampsia when OAP occurs [22][23]. It is most often caused by severe preeclampsia [24], which is associated with OAP in 2.9% of cases [25]. Since most cases of pulmonary edema in pregnant women are highly fatal and associated with difficult-to-control hypertension, prevention of this complication involves preventing preeclampsia to reduce maternal mortality [26].

Eclampsia proved to be the factor most strongly and independently associated with mortality, dramatically increasing the risk of death by 31 times.

This extremely high odds ratio places eclampsia at the center of survival efforts. Eclampsia is the endpoint of the pathology, representing the most severe cerebral involvement of preeclampsia, often in the form of hypertensive encephalopathy or intracranial hemorrhage [27]. Systematic reviews and studies in sub-Saharan Africa have also shown that eclampsia is the complication that confers the highest risk of mortality [28]. Adequate management and, above all, prevention of eclampsia therefore remain a key pillar in reducing maternal mortality.

Although HELLP syndrome and renal failure were significantly associated with the studied outcome in univariate analysis, they were not retained in the final multivariate model. Their low frequency may partly explain this finding. However, caution is warranted in interpreting these results. The fact that they do not remain independent predictors in the multivariate model should not lead to underestimating their clinical importance, as they remain major complications.