Tuesday, July 3, 2012

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 . . .

2 comments:

  1. good analysis Jeevan,,,hope the Data benefits future policy decisions...

    1.There is association between PPH and PIH/ECLAMPSIA..2 - 6 fold increase in risk (http://www.ncbi.nlm.nih.gov/pubmed/19838439),(http://www.eventkaddy.com/smfm2012/pdfs/126.pdf).it is also useful to see what was the cause of the death in the eclamptics you have seen....I think the problem with the national data might be that they might have accounted for this PPH alone without documenting the eclampsi/PIH and PIH is one of the "missed "diagnosis also which goes under the carpet while reporting...

    good points to ponder though....

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  2. The time taken to reach hospital after the first fit is an issue. The PPH patients probably die before they reach you anyway (it takes an average of 2 hours to die after PPH starts), What treatment do you follow for Eclampsia. Maybe availability of Mag Sulph in the government and with ANMs and maybe )controversial)even one dose by a local practitioner when referring would improve things, Have you talked to Madhu (Dr Madhulika of UNICEF)

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