WRITE UPS - MATERNAL MORTALITY

MATERNAL MORTALITY

INTRODUCTION: -

     Maternal mortality is one area in Indian obstetrics where a strong concern and consensus is seen. Obstetricians in the country have realized that half a million women dying of childbirth every year is unacceptable. This is because most of these are preventable deaths and secondly these deaths are taking place in a physiological event (of reproduction). The question that haunts the obstetric care provider in this country is confounding: Why should any one die of a physiological process?

MAGNITUDE OF THE PROBLEM: -

     500,000 women die every year in the world as a result of pregnancy and childbirth. This means that every minute of everyday there is one maternal death, 99% of these deaths occurring in the developing countries. For every maternal death, 10-15 women survive only to suffer, known as maternal morbidity. The working group of WHO in 1989 adopted a broad definition of reproductive morbidity as any morbidity or dysfunction of the reproductive tract or any morbidity which is a consequence of reproductive behavior including pregnancy, abortion and childbirth.

     It is evident that Asia accounts for about a third of a million maternal deaths annually. In no other continent in the world do so many women die as a result of pregnancy and childbirth. Out of 308,000 maternal deaths in Asia, 296 000 ( over 96% of total Asian deaths) of them take place in South Asia, South East Asia and West Asia combined.

     In India 100,000 women die every year as a result of pregnancy and childbirth, which means one maternal death every 5 minutes. 20% of the world’s total deaths take place in India every year

     Maternal mortality ratio means the number of deaths of women while being, irrespective of the duration or site of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes, per 100,000 live births. Although this statistic is often called the maternal mortality rate, it is not really a rate because the numerator (maternal deaths) is not a part of the denominator (live births).  The true maternal mortality rate indicates the number of maternal deaths per 100,000 women of reproductive age (15-49 years) per year is influenced by several factors like the risk associated with pregnancy in the population 9 i.e. maternal mortality ratio) and the fertility rate of the country.

     If we want to reduce the high maternal mortality in the developing countries, the causes are multiple, inter-related and tiered. The most superficial of all the planes are the “ direct and indirect” causes of maternal deaths. The direct causes account for 7% of maternal deaths and are the following: -

1)      Sepsis including septic abortion                20-25%

2)      Obstetric hemorrhages                            20-22%

3)      Eclampsia                                                 5-15%

4)      Accidents of labor (e.g. rupture of uterus)10-30%

     The indirect causes account for 25% cases and are due to associated medical diseases that worsen during pregnancy, the commonest being anemia followed by jaundice and heart diseases.

The causes mentioned above are only the tip of the iceberg. The underlying causes of maternal deaths in developing countries, particularly in India are the following.

1)      Ineffective health services

2)      Inadequate obstetric care

3)      Inadequate essential supplies

4)      Poor  maternal mortality audit

5)      Unregulated fertility

6)      Infection and infestations

7)      Illiteracy

8)      Early marriage

9)      Poverty

10) Malnutrition

11) Ignorance

      Many of these are classified as “avoidable” (50-80%) of maternal deaths are a avoidable) in the sense that had the care offered to the mother been better, she might not have died. Then comes the association, “ Too early, too late, too many, too close”.   This pneumonic provides an apt description of situations where various factors interplay to contribute to maternal deaths. Even more fundamental is the society’s attitude to women through infancy, adolescence and adulthood. The status of women in society and their own self-esteem remains dictated by the socio politico economic and cultural ethos of the community. Therein lies the crux of the problem. Perhaps an inadequate infrastructure and insufficient funding behave as confounding factors. Any attempt to effectively lower down maternal mortality then must address al these issues.

 FACTORS INFLUENCING MMR: -

 Female Literacy:

     It is universally accepted that the higher the female literacy rate, the lower the MMR. Studying at school /college for a longer period will prevent early marriage and early motherhood. Educated women will seek proper antenatal and intra-natal supervision. The female literacy rates in Sri-Lanka and Thailand are over 80 percent and the MMR in these two countries is 60 per 100,000 only. Although economically there is not much of difference between the MMR of these two countries –340 as compared to 60. Kerala, having the highest female literacy rate in India, has the lowest MMR, compared to Bihar < U.P. and M.P.

 Maternal Age:-

     Pregnancy even before the onset of the first menstrual period is not uncommon in the developing countries. Repeated pregnancies in the absence of any contraception, due to ignorance or religious taboo, lead to high maternal deaths. In a developing country, once a girl has reached puberty, the greatest threat to her life is thought pregnancy and childbirth. In India, although the legal age of marriage for girls is 18, it is hardly observed particularly in the villages where 70 percent of our population live. In mid-south Asia, 54 percent of teenagers are married, compared to 24 percent in Southeast Asia and 20 percent in East Asia. In Bangladesh 90 percent of girls are married before 18 years and 33 percent of those below 19 years are mothers of two. In the same country, MMR in the 15-19 years group is twice the MMR in the 20-34 years group.  A 20- year study of maternal deaths from Nagpur showed that MMR is 2.5 times higher between 35- 39 years, 5 times higher at or above 40 years than between 21-29 years.

 Socio-Economic Conditions:-

     In the lower socio-economic groups, nutrition is poor and inadequate, particularly for the girl child, long before her marriage. Those women, mostly living in rural areas, are doing hard laborious work in the fields in addition to all the housework for a large family. Most of them are poor, anaemic, undernourished and do no get adequate perinatal care.

 Access To Birth Control:

     Easy access to different birth control options leads to higher observance of family planning. India scores 73 out of 100 in different birth control options, compared to 37 for Pakistan, 77 for Bangladesh , 80 for Sri-Lanka, 83 to Singapore, 90 for China and 94 for Taiwan ( World Access to Birth Control, 1992). Effective family planning and maternal health care contribute to the reduction of maternal mortality.

 Antenatal care: -

     Safe motherhood depends on proper perinatal care. East Asia has over 90 percent perinatal care coverage, compared to only 25 percent in South Asia. Perinatal care coverage in India is around 50 percent with institution delivery of 15 percent. In India, over 95 percent of maternal deaths are of unbooked cases. Antenatal care is received by 40-50 percent of pregnant women, when calculated nationally, compared to only 12 percent in the rural areas. Trained Birth Attendants (TBA) were present in 24-30 per cent of all deliveries in India: but it was low as 13 percent in some rural areas of Uttar Pradesh.

 MCH Service: -

     The health manpower pyramid is inverted in India, Pakistan and Bangladesh. In these countries there are more physicians than nurses/midwives: the average ratio is 80:20. Although 75 percent of mothers live in rural, 75 percent of medical resources are spent in towns where 75 percent of doctors and nurses live.

 MATERNAL MORTALITY- PREVENTABLE FACTORS:-

 What is an avoidable factor?

     An avoidable factor is a departure from the best current clinical practice preceding a maternal death. Even in the developed countries where the maternal mortality has been lowered to an almost irreducible minimum, about 40-50 percent of these deaths are due to avoidable factors.

 How to avoid these deaths?

 1)      Health Policy:

The time has come for us put into practice the salient points of the national health policy. The Government should also-

·     Declare that maternal mortality is a priority public health issue.

·       Increase the health budget to about 5 percent of total plan investment.

·       Mobiles the country’s available resources to the fullest extent.

·        Improve the stand of health education using various mass media like TV, films, poster display etc. The government should aim to raise the female literacy rate throughout the country. Discrimination against the female  child in every household should be considered a punishable offence. A female child needs nutrition and care equal to, if not more than a male child. Improved health education will lead to improved antenatal, intranatal and family planning care to all women.

·        Enforce the legislation of marriage registration throughout the country, particularly in the rural areas.

·        Raise age of marriage for girls to 20, from the existing 18 years.

·        Introduce the “ Two child family norm” through legislation along with improved neonatal care throughout the country.

 2)      MCH –care :

The infrastructure of MCH care in India, particularly the rural area, is not adequate to meet the growing demands. We need a very large number of ANMs to serve the rural areas where most deliveries take place.

How to render proper MCH care?

·        Most MCH care should be provided at the most peripheral areas by Auxiliary Nurse Midwives (ANMs)

·        The ANMs should also supervise the work of the TBA s in the peripheral areas.

·        The first referral hospital should be situated in areas where the MMR is high so as to avoid delay in transporting patients in obstetric emergencies to distant district or teaching hospitals.

·        Government vehicles must be made available at all PHCs should have telephones for urgent communication with other hospitals.

·        It is a very good idea to establish either maternity homes or maternity villages, close to the district hospital so that high risk cases from the remote areas should come and stay for 10-15 days prior to the onset of labour.

·        MTP and family planning services must be available at all PHCs.

·        There should be a network of organized voluntary blood bank services.

·        Proper facilities must be provided at the PHCs. These include supply of blood pressure apparatus, weighing machine, hemoglobinometer, test tubes and acetic acid for routine urine examination for protein. Instructions should be given to all personnel, to properly record any maternal and perinatal deaths in a uniform proforma.

·        Supply of iron and folic acid to all should be ensured at the PHCs.

·        Better co-ordination between MCH field staff and hospital doctors will a long way to reduce maternal deaths.

 3)      Training programmes:-

Who needs the training? The health workers at the periphery-namely the TBAs, ANMs, Medical Officers at the PHC and first referral hospital or CHCs.

Ø      Medical officer’s training: The Medical officer at the PHC should get proper training to tackle obstetric emergencies particularly those of obstructed labour and severe hemorrhage. He should be able to perform caesarian sections and to perform manual removal of the placenta. These Medical Officers should be trained in the “Essential Obstetric Functions”

Ø      TBA –training :Though institutional delivery is safer, it is not possible to provide it to all mothers in a vast country like India. TBAs should be trained to provide minimal perinatal care. She should observe the 3 cleans”.

a)        Deliver on a clean surface.

b)        Deliver with soap-cleaned hands.

c)        Cut the cord with a clean pair of scissors.

 4) Role of professional societies: -

There should be greater involvement by professional societies in the drive for safe motherhood. A joint statement of the WHO/FIGO (1988) directed tot he FIGO and its national societies like FOGSI defines that for safe motherhood, the national societies.

a)        Should define the content of a number of prime messages to educate the public about women’s health, family planning and safe motherhood.

b)        Be actively involved in modifying the curriculum for training of undergraduate students and nurses to include problems more relevant to community obstetrics.

c)        Should establish committees to identify priority research areas and to promote public health education on women’s health and safe motherhood.

d)        Should acknowledge the role of TBAs (where they exist) and support their training and integration with health care system.

e)        Should co-ordinate with women’s organizations to promote women’s health , social and economic development.

     In a developing country, the social responsibilities of the obstetrician include participation in community obstetrics, training of MCH workers, organizing CME programmes for general practitioners and other specialists besides being available (on call or by rotation) when help is needed at the first referral level.

 5) Confidential Enquiry: -

Confidential inquiries by a committee into the causes of maternal deaths at the provincial and/or national level are useful to keep track of these deaths, ascertain their causes and recommend preventive measures. These reports are not only educative but also helpful in the better management and delivery of the health care system.

 ANALYTICAL VIEW OF THE CURRENT SCENARIO:

     There is a need to analyze this problem with solutions offered in a critical way from solid obstetric angle:

Eclampsia /Pre-eclampsia: -

·        Breaking the small nut now.

·        Reached a saturation point with magnesium Sulfate, excellent antihypertensives, competent labour inducing agents and safe anesthesia

Now what: Apply principles of critical care in areas that are refusing to budge. It is imperative to provide cardio-respiratory support for pulmonary edema and Mendelson’s syndrome. Modern methods of treatment  of intracranial catastrophe

 Labour Accidents:

-        Zero rupture after admission

-        Intra partum USG of all cases before any intervention is planned

-        Liberal judicious use of cesarean section.

-        Safety of our operative procedures:

 Sepsis: -

-        Mandatory aseptic precautions

-        Liberal use of laparotomy

-        Modern critical care methods to prevent anesthesia complications &sepsis

 Hemorrhage: -

-        Principles of modern blood banking technology.

-        Reduction in the need to give whole blood.

-        Conversion at the entire zone into one blood bank with computer

-        Satellite links.

-        Application of principles of moderns critical case management.

OBSTETRICIAN: SHED OFF THY INFERIORITY COMPLEX!

     The work done by qualified obstetricians of this country of bringing down MMR from 2000 in 1946 to 340 currently is stupendous. Let us not rest, but let us not belittle ourselves too. We have to crack the areas that have been hither to still challenge us. Obstetrician!  Thy role in preventing or reducing maternal mortality now secondary:

    Primary players in this game are:

A)      The society

B)      The government

C)      The NGOs.

Obstetrician’s role is to provide continuous, quality back up and continuos medical education. Also in his field he has to employ new technology for combating this problem. There is a need to bring new technology – out from the glamorous position to day to day life. The biggest onus is on the society. Reduction of maternal mortality must become a mass moment. If this happens soon results will be evident. The picture will not be grim if we realize this reality.

 
     

 
         
     

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