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: -
Sepsis including septic abortion
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.
Ineffective health services
Inadequate obstetric care
Inadequate essential supplies
Poor maternal mortality audit
Infection and infestations
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: -
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.
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
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
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
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
How to avoid these deaths?
The time has come for us put into practice the salient
points of the national health policy. The Government should
· 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.
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
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
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.
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.
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”
–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”.
Deliver on a clean surface.
Deliver with soap-cleaned hands.
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
Should define the content of a number of prime messages to educate the
public about women’s health, family planning and safe
Be actively involved in modifying the curriculum for training of
undergraduate students and nurses to include problems more
relevant to community obstetrics.
Should establish committees to identify priority research areas and to
promote public health education on women’s health and safe
Should acknowledge the role of TBAs (where they exist) and support their
training and integration with health care system.
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
Eclampsia /Pre-eclampsia: -
Breaking the small nut now.
Reached a saturation point with magnesium Sulfate, excellent
antihypertensives, competent labour inducing agents and safe
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
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:
Mandatory aseptic precautions
Liberal use of laparotomy
Modern critical care methods to prevent anesthesia complications &sepsis
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
Application of principles of moderns critical case management.
OBSTETRICIAN: SHED OFF THY INFERIORITY
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:
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.