Maternal Mortality . . . Struggling

The press has reported a United Nations Report saying that India is going to miss the Millennium Development Goal (MDG) related to maternal health. We had targeted to reach a Maternal Mortality Rate (MMR) of 109 per 100,000 live births by 2015. However, the MMR as of today is about 212 per 100,000 live births . . . a far cry from what we want to achieve. . .

If you had been following my blog, the state of poor maternal and child health has been something I had been trying to portray. Recently, I had been trying to put some statistics from where I could look at what we may need to do extra to bring down the high maternal mortality rate. 

Thanks to Mr. Luke, a visiting student who has been helping us with computerizing our data, we have been able to look at maternal deaths. So far, we have been able to data for the last 3 years. Considering the way we keep our statistics, I'm sure that the data is incomplete. 

However, below is data related to diagnosis of the 89 maternal deaths which happened over the last 3 years - 2009-12. 

Diagnosis	Nos.
Anemia	8 (10%)
Eclampsia	48 (57%)
Malaria	1 (1%)
Unknown	3 (4%)
Obstructed labour	1 (1%)
Pneumonia	1 (1%)
PPH	5 (6%)
Rupture uterus	4 (5%)
Sepsis	10 (12%)
Unknown	3 (4%)
TOTAL	84 (100%)

Table 1

We had been suspecting it for some time. Although this is institutional based data, a diagnosis of Eclampsia causing death in 57% of the Maternal Deaths over the last 3 years is a major finding.

Well, for the uninitiated, according to the 2005 World Health Report, the following are the causes of maternal deaths - - - 

Causes of MM	%
Hemorrhage	25%
Infections	13%
Unsafe abortions	13%
Eclampsia	12%
Obstructed labour	8%

Table 2

I did some calculations for the populations that we serve. I hope the following table is self-explanatory . . .

	Total pop.	Pop. catered	Birth Rate	Births	MMR	Maternal Deaths
Palamu	1936319	1452239	0.026	37758	0.0021	80
Garhwa	1322387	661194	0.026	17191	0.0021	36
Latehar	725673	362837	0.026	9434	0.0021	20
TOTAL	3984379	2476269		64383		136

Table 3

According to our rough calculations, NJH caters to about 75% of the Palamu district and 50% of Latehar and Garhwa districts - this means that in our catered population, we would have a total of 136 deaths every year . . . 

There are documents putting the institutional delivery rates as low as 18% as well as those putting it at 50%. We estimate that about 30% of deliveries happen in institutions. Therefore, we recalculated and got the following statistics . . . 

	Maternal Deaths	Institution Del Rate	Maternal Deaths
Palamu	80	0.3	24
Garhwa	36	0.3	11
Latehar	20	0.3	6
TOTAL	136		41

Table 4

So, it means that 41 maternal deaths occurs in hospitals. However, this can be an underestimation as most of them had been trying for home delivery and reach hospital quite late after realizing of possibility of a complication.

I thought about re-looking the statistics for 2011 alone . . . We, at NJH had a total of 29 maternal deaths in 2011 . . . Below is the table showing the diagnosis of the maternal deaths. . .

Diagnosis	Nos (%)
Anemia	2 (7%)
Eclampsia	10 (34%)
Malaria	1 (3%)
Unknown	2 (7%)
Obstructed labour	1 (3%)
Pneumonia	1 (3%)
PPH	3 (10%)
Rupture uterus	2 (7%)
Sepsis	4 (14%)
Unknown	3 (10%)
TOTAL	29 (100%)

Table 5


The predominance of Eclampsia being the commonest diagnosis in a maternal death remains. For the 29 maternal deaths that happened at NJH in 2011, I have put an additional column in Table 5 and looked at where the 29 maternal deaths came from . . .

	Maternal Deaths in target community	Institution Del Rate	Maternal Deaths in institutions (calculated)	Maternal Deaths at NJH (2011)
Palamu	80	0.3	24	16
Garhwa	36	0.3	11	4
Latehar	20	0.3	6	7
Others	-	-	-	2
TOTAL	136		41	29

Table 6

2 of the patients had come from Gaya district. Well, table nos. 6 speaks volumes of the influence NJH has in the Maternal and Child Health Care in the region.

Well . . . there is quite a lot that we need to learn. We had looked at the possibility of a community based survey about maternal health care. Unfortunately, the clinical load has prevented us from doing it . . .

There are quite a lot of people who has put in their input behind this post . . .and I'm indebted to them. Just a couple of names without whom this would not have been possible. First of all, for a discussion with Dr Anil Cherian, the Director at Community Health, Emmanuel Hospital Association which stimulated me to look at this and Mr. Luke Gray who computerised all the records . . .

So, at the end of it . . . questions remain. . . The major ones being . . . 

1. Is hemorrhage the commonest cause of maternal death in the country?

2. Eclampsia is a major problem in many of our rural areas . . .Does nutrition have a role in the pathophysiology of hypertensive diseases of pregnancy?

3. How serious is our public healthcare about maternal health? 

To answer the last question . . . The saddest part remains that at least our local public healthcare authorities are hardly bothered about maternal deaths . . . We had been filling up the Institutional Maternal Death Review Forms since last August. It is going to be one year. I'm yet to be called for at least one meeting about this . . .

Praise and Prayer Bulletin . . . July 1, 2012

It has been a quite busy time at the hospital. In addition to the increase in patients accessing the hospital, we had also been busy with preparations for our Annual General Body meeting which was held at Ramnagar, Uttarakhand. Below are praise and prayer items. Kindly uphold us in prayers . . .

a. During the AGB meetings of the Emmanuel Hospital Association at Ramnagar, I realized that the services that we provide in our 20 odd hospitals and work happening through 32 community health programmes are on the increase. We thank the Lord for using us for the upliftment of the poor. Along with the work load comes increased requirements of adequate and qualified manpower to provide quality services in each of our locations. Kindly pray that the Lord will move the hearts of more people to come and join the movement we are involved in. 

b. EHA has been able to influence government policies and programmes such that they benefit more of the marginalised and poor in this country. Kindly pray as our different units are involved in programmes such as the Revised National Tuberculosis Control Programme (RNTCP), the Rashtriya Swasthya Bima Yojana (RSBY), Janani Suraksha Yojana (JSY) etc. The Clinical Establishment Act is something that is going to influence healthcare in the country over the years. Please pray for the efforts EHA is providing in the implementation of CEA. 

c. NJH has done good over the last one year. We suffered a loss of around 2 million INR over the last year. However, we are thankful that we have been a agent of transformation and relief to many a poor patient. There are quite a lot of need both in terms of personnel and infrastructure at NJH. Kindly pray that in 2012-13 we would continue to be blessing to the communities around us.

d. The spectre of a poor progress in Maternal and Child Health continues to haunt India. At NJH, we see quite a few maternal deaths. Please pray that we would be able to make progress in our care for the mother and the child so that we are assured of a healthy tomorrow. 

e. We had been blessed with heavy rains couple of weeks back for a continuous period of about 5 days. Unfortunately, it has been hot ever since. Kindly pray that the rains would continue so that there is not any remote possibility of a drought.

f. Kindly pray for the new project, 'Injot' which has been initiated in the Koel Karo region of Khunti district of Jharkhand. There are quite a lot of challenges, but the expectations are huge. Please remember the team serving the project in your prayers.

g. The invocation of the occult is something we commonly find in the region especially when there are cases of snake bites, cerebral malaria, eclampsia. Please pray that the people in the region will realize the futility of such beliefs. Many patients die as they come late to hospital after having been managed by such practices.

h. Kindly pray for protection of the staff at NJH as many a time they deal with patients whose relatives expect too much from us. 

i. There are initial discussions on couple of our doctors planning to move out for various reasons. Kindly pray as we have clarity on how and why we need to take such decisions. Do remember that we may be needing a surgeon towards the beginning of the next year (2013-14) along with already needed consultants in Internal Medicine and Pediatrics. 

j. We have received clearance and a promise of funding for couple of Community Health projects in disability, climate change and community monitoring of Rashtriya Swasthya Bima Yojana. We thank the Lord. Please pray that the Lord will send us committed staff for these projects.

k. We thank the Lord that over the last week we have been having a fairly good electricity supply. However, we would still need to purchase couple of generators to tide over periods of unsure supply of electricity in the future. The expected costs are upto 1 million INR. (approx 20000 USDs / 12500 GBPs). Please also uphold the need for funds to purchase a new school bus 1.2 million INR (approx 24000 USDs / 15000 GBPs). 

l. Kindly remember the construction of the burns unit. There has been a lull in the construction because of local contractors pleading inability to facilitate the construction citing lack of equipment enough for the area of building being constructed. Please pray that we would find a breakthrough in finding the right contractors. 

Dear friends, we really value your prayers. I hope that you've seen the blog copy of our Annual Report 2012. If you would like to get a PDF copy of the same, please send me a e-mail at jeevan53@gmail.com. And if you wish to have a hard copy of the Annual Report 2012-13, if you could send me your postal addresses, we shall send the same to you.

Corbett . . . Assorted snaps . . .

Snaps taken at Ramnagar, Uttarakhand . . .On the fringes of the Corbett National Park.


A contraption found inside the AC compartment in the train from Delhi to Ramnagar. Most probably, a thing to keep rat poison. Did not look like a rat trap. However, complex name - RODENT BAIT STATION

The cute Ramnagar railway station

A wild elephant seen outside the National Park areas

On the way to the safari . . .

One of the many peacokcks we saw . . .

Langurs . . . Looked more healthy and graceful than the ones at NJH . . .

Roads . . .

Wild fowl . . .

Driving under a fallen tree . . .

Tiger footprints . . .

Peacock footprints . . . Looked like a scene in Jurassic park . . .

Tiger claw marks . . . Marking the territory . . .

Monitor lizard . . . Going after the brandy bottle. Littering . . .a major problem in National Parks all over the world

Although we scoured the park for the elusive tiger, we could not spot one. . . Well, you can get more pictures of the place especially those of birds from one of my very senior colleagues who is an avid photographer . . .