RISK FACTORS FOR MATERNAL MORTALITY IN DELHI SLUMS: A COMMUNITY-BASED CASE-CONTROL STUDY.

Aggarwal A, Pandey A, Bhattacharya BN. Risk factors for maternal mortality in Delhi slums: A community-based case-

control study. Indian J Med Sci 2007;61:517-26

INTRODUCTION: In order to develop, implement and evaluate

policy for reducing maternal mortality, it is essential to study risk factors.

Pregnancy complications and childbirth-related complications are the major causes.

India is far from the desired level of 100 by 2012 set by the National Rural Health Mission (NRHM) and 109 by 2015 as per millennium development goals (MDG).

LEARNING OBJECTIVES To learn about maternal mortality indicators.

OBJECTIVE OF STUDY: To determine the epidemiological risk factors

and its related causes associated with maternal deaths in Delhi slums.

METHODOLOGY

929 slums

Source of information

21 health centers (50000)

105 health post (10000)

6 maternity homes

(2 million)

328 slums (1.25 million)

Community-based case-control study

Definitions of Cases and Controls: Case : A woman who was pregnant and whose

pregnancy's outcome was a live birth but the woman died within 42 days of delivery.

Control: a woman who was pregnant and whose pregnancy's outcome was a live birth and the woman was surviving at the time of survey.

Method of identifying Cases and Controls: Cases: Snowball-sampling method was used to identify

the maternal deaths (cases) in the community. Controls: Circular systematic random sampling

procedure was used to select the controls from the same area where a maternal death was found.

Exclusion criteria: pregnancy outcome SB/abortion.

Identify household of

maternal death

Ask about similar event occurred to respondent.

ANM/ basti sevika

Snow ball sampling

Circular systematic random sampling for selection of controls:

1 case= 3 controls

1.1Total no of households with a live birth/ no of controls(384)

1.2Means 3 times cases were foundThen every kth household of live birth was selected as control.

STUDY POPULATION:

131

70(61)

cases

393

384(9)

controls

DATA COLLECTION: BY PRE-TESTED QUESTIONNAIRS

• type of house , family, separate kitchen, type of toilet, woman’s and husband education.

Socioeconomic variables

• Current age, age at marriage, parity c/x during pregnancy

• verbal autopsy

Biological variables

• Utilization of health facilities • ANC, delivery care, distance of

residence from HF.

Environmental variables

RESULTS

TABLE 1: CAUSES OF MATERNAL DEATHSCAUSES OF MATERNAL DEATHS

PERCENTAGE

NUMBER PERCENTAGE

Direct causes 61.4

PPH 15 21.4Retain placenta

12 17.2

Sepsis 8 11.4Obstructed labour

1 1.4

Embolism 1 1.4Indirect causes

38.6

Anaemia 15 21.4Post op 6 8.6Other 12 17.2

TABLE 2

No significant difference was found in household characteristics.

TABLE 3:SE & REPRODUCTIVE CHARACTERSTICSVariables Case (%)

(n=70)Control( %)(n=384)

P Value

Education Level

Illiterate 54 (77.1) 234(60.9) 0.005

Literate 16(22.9) 150(39.1) Ns

Husband’s Education

Illiterate 31(44.3) 113(29.5) 0.007

Literate 39(55.7) (70.5) Ns

Type of Family

Nuclear 40(57.1) 262(68.2) 0.03

Joint 30(42.9) 122(31.8) Ns

Current Age

> 35 13(18.6) 26(6.8) 0.0006

Parity

2 10(14.3) 106(27.6) 0.0107

TABLE 4:UTILIZATION OF HEALTH FACILITIES

VARIABLES CASES(%) CONTROL(%) P VALUEANC registrationYes 54(77.1) 349(90.9) NS no 16(22.9) 35(9.1) 0.0004Received TT injectionNo 15(21.7) 37(9.7) 0.002Consumed IFA< 100 33(47.1) 250(65.1) 0.006Distance of Health Facility> 5 km 37(61.7) 56(19.1) 0.00003Mode of transportby walking 5(8.1) 56(20.1) 0.025Auto-rickshaw 41(66.1) 85(30.6) 0.001manual rickshaw 5(8.1) 95(34.2) 0.001Place of deliveryhome 39(55.7) 268(69.8) 0.02hospital 31(44.3) 116(30.2) 0.02

TABLE 5: C/X DURING PREG & DELIVERYVARIABLE CASE(%) CONTROL

(%)P VALUE

Complications during pregnancyAnaemia 33(47.1) 27(7.0) <0.001

High BP 3(4.3) 4(1) NS

Jaundice 6(8.6) 5(1.3) <0.001

Fever 13(18.6) 50(13.0) 0.1062

Abn +nt of child 14(20.0) 20(5.2) <0.001

Complications during delivery

Exce. bleeding 5(7.1) 2(0.5) <0.001

Retained placenta 5(7.1) 1(0.3) <0.001Delivery by untrained dai 37(94.9) 194(72.4) <0.001Institutional death 47(67.2)

Death <24 hrs 23(48.9)

UNIVARIATE LOGISTIC REGRESSION ANALYSIS:

Independent V cases controls OR CI P valueCurrent age 20-29 yrs

38 127 2.4 1.43-4.03 0.001

Illiterate women 54 234 2.16 1.19-3.92 0.011

Parity 2/ 3 24 193 1.94 1.14-3.30 0.001

Distance >5 km 56 237 6.81 3.75-12.36 0.0001

Delivery conducted by untrained dai

37 94 6.87 1.61-29.2 0.009

MULTIPLE LOGISTIC REGRESSION ANALYSISCOMPLICATION

ODDS RATIO 95% C I P VALUE

Anaemia 11.76 6.09, 22.71 <0.001

Ex. bld during delivery

12.82 2.08, 79.04 0.006

Abn + of child 2.85 1.14, 7.12 0.025

R. placenta 41.92 4.5,3 88.75 0.001

Jaundice 1.99 0.47, 8.4 0.346

RESULTS FROM OTHER STUDIES :INSTITUTE

YR MMR Causes of Mat ernal Deaths in %Hge Toxemia Se

psisAnaemia

jaundice

others

Present study

2007 - 21.4 - 11.4 21.4 - -

Bera and Sengupta (K)

79-80 1009 23.8 17 16 5 19 16

Ramteke and Pajai 3 (Y)

92-94 1048 29 12 12 12 5 27

Sapre and Joshi (G)

71-96 1448 17 25 12 25 4 14

Pal and ray (WB)

94-04 623 9.7 50 18 4 2 15

SRS 1998 540(NFHS)

30 - 16 19 - 8

DISCUSSION:

Use of a cost-effective snowball-sampling technique. The major direct causes - PPH, F.B. retained placenta

and sepsis. As per the report of the sample registration system

(SRS) –hemorrhage 38%, which is much higher than our estimate.

Hypertensive disorders are one of the causes of maternal deaths, our study did not find any such case.

Maternal deaths d/t retained placenta was found to be marginally higher than those reported elsewhere. anemia -major cause of maternal death in the present study

CONT….. Entire study population was from urban slums,

socioeconomic characteristics do not show statistically significant differences between cases and controls.

Investing in training of untrained dies should be considered by policy makers and donor agencies.

A high proportion of maternal deaths occurred in hospital set up - deliveries were conducted at home by untrained dais and were rushed to a hospital at the last minute.

CONCLUSION: Mass education about the importance of

antenatal registration and regular ANC checkups.

Focus on training of dais. Encouragement for institutional

deliveries to reduce maternal mortality at the community level.