Dr.Praseeda.B.K

Definition

Scenario worldwide and India

Statistical measures of maternal mortality

Approaches to measure maternal mortality

Causes in worldwide and India

Preventive and social measures to reduce maternal mortality

“The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”

Definition

Global burden 5,29,000 deaths / yr or 400/ 1 lakh live births

1 death per minute

1% in developed countries

Range – 24 to 830 / 100,000 live births

Scenario in India

An Indian woman dies from complications related to pregnancy and childbirth. Every seven minutes

The maternal mortality ratio in India stands at 174 per 100,000 live births.

(2015)

2011 2012 2013 2014 2015

206 197 189 181 174

India

SRS data shows that that so far only three states

Kerala with an MMR of 66 per 100,000 live births

Tamil Nadu with an MMR of 90 per 100,000 live births

Maharashtra with an MMR of 87 per 100,000 live births

—have been able to achieve the millennium development goal.

Kerala

Maternal mortality Ratio

India Kerala

2010-12 178 66

Special Bulletin on MMR 2010-12

Maternal mortality ratio

Maternal mortality rate

Adult life time risk of maternal death

The proportion of Maternal Death of Women of Reproductive age (PM)

Statistical measures of maternal mortality

Maternal mortality ratio

This represents the risk associated with each pregnancy.

It is calculated as the number of maternal deaths during a given year per 100,000 live births during the same period.

- Number of maternal deaths in a given period per 100,000 women of Reproductive age group in the same time period..

Maternal Mortality Rate

Number of maternal Deaths in a given time period divided by total deaths among women aged 15-49 years..

The proportion of Maternal Death of Women of Reproductive age (PM)

1. Civil Registration System

- Routine registration of Birth & Death - continuous registration of birth and

death

2. Household Survey

Approaches to measure maternal mortality

- interviewing a representative sample of respondents about the survival of all their adult sisters.

3. Sisterhood Methods

- Include 4 questions

- How many sisters have you ever had born to same mother who ever reached the age 15 (or those who ever married), including those who are now dead??

- How many sisters who reached the age 15 are alive now?

- How many of your sisters are dead?

- How many of your sisters who are died during pregnancy or during child birth or during the sixth weeks after the end of pregnancy?

Not applicable when

- TFR < 4 children per family

- Areas of significant migration

- During civil war

- Identifying and investigating the causes of all deaths of women of reproductive age group in a defined area.

- Use triangulation of different sources of data on death of women of reproductive age group coupled with record review and / or verbal autopsy to identify maternal death.

- Best way to estimate MMR

4. Reproductive age mortality studies(RAMOS)

5. Verbal Autopsy

- used to assign cause of death through interview with family or community member..

6. Census

- National Census with addition of a limited number of questions.

- Representative, Re-Sampled, Routine Household Interview Of Mortality with Medical Evaluation.

- enhanced form of Verbal autopsy. - included in SRS from 2002 onwards.

7. RHIME

- Random re-sampling of field work by an independent team for maintaining.

- Field staff will collect major symptoms narrative of events leading to death .

- Two independent trained physicial will examine the report

- Disagreement should be referred to Senior third physician who adjudicate and find CDC 10 code

Maternal and peri-natal death enquiry and response

Thoroughly examine and respond to social, biological & medical events that led to a maternal & Perinatal death

Inquiries are conducted of the death that occur in a community over several months of time in order to identify common factors that can be acted up on to prevent further deaths.

MAPEDIR

Conducted using a verbal autopsy interview with the families of diseased persons.

Useful in areas were many deaths occur outside health facilities and for highlighting relevant social factors and health care seeking problems.

25%

15%12%8%

13%

8%

20%severe bleeding Infectioneclampsiaobstructed labourUnsafe abortionother direct causesindirect causes

Indirect causes- Eg: Anemia, Malaria, Heart disease

Other direct causes – Eg: Ectopic pregnancy, embolism, aneasthesia related

Causes of death and morbidityworldwide

38%

11%

5%5%

8%

34%heakorrhaagesepsisHypertensive dis-orderobstructed labourabortionother coditions

Causes of death and morbidityin India

Causes in Kerala

Medical causes

Non obstetric causes

Social causes

Determinants of Maternal mortality in India

Obstectric causes

- Toxaemias of pregnancy- Haemorrhage - Infection - Obstructed labour - Unsafe abortion

Medical causes

Non obstetric causes

- Anaemia

- Associated diseases e.g., cardiac, renal, hepatic metabolic and

infectious Malignancy Accidents

Age at child birth Parity

Too close pregnancies Family size

Malnutrition

Poverty

Illiteracy

Ignorance

Social causes

Prejudices

Lack of maternity services Shortage of health manpower

Delivery by untrained dais

Poor environmental sanitation

Poor communications and transport facilities

Social customs.

Contd...

1. Early registration of pregnancy

2. At least three antenatal check-ups

3. Dietary supplementation, including correction of anaemia

4. Prevention of infection and haemorrhage during puerperium

5. Prevention of complications, e.g., eclampsia, malpresentations. ruptured uterus

Preventive and Social Measures

6. Treatment of medical conditions Eg: hypertension, diabetes, tuberculosis, etc.

7. Anti-malaria and tetanus prophylaxis Clean delivery practice In India

8. Trained local dais and female health workers

9. Institutional deliveries for women with bad obstetric history and risk factors

10. Promotion of family planning - to control the number of children to not more than two. and spacing of births

12. Identification of every maternal death, and searching for its cause.

Confidential Maternal Death Audit started in 1990’s

Format and methodology revised in 2010

District level monitoring committee formed.

All maternal death in Govt and Private sector are audited

Kerala Federation of Obstetrics and Gynecologist published study report on maternal Death

Preventive Methods in Kerala

In 2012, the international arm of the UK National Institute for Health and Care Excellence (NICE) partnered with the government of Kerala, the NRHM and KFOG to work to improve the obstetric care in the state through developing standards based on evidence-based clinical guidelines

These ten action points have been piloted in eight hos- pitals (six public and two private) in Kerala from April 2013.

1. Active Management of Third Stage of Labour 2. PPH Prevention – 4th Stage Management

3. Management of Post-Partum Haemorrhage with Blood and Blood Products

4. Obstetric Intensive Care

5. Placenta Praevia Accreta

6. Pre eclampsia

7. Anti-hypertensive Treatment

8. Severe Hypertension in pregnancy and in Immediate Postpartum Period

9. HELLP ( Hemolysis, Elevated Liver enzyme, Low Platelet)

10. Eclampsia

Thank you....