Maternal Mortality at a Teaching Hospital of Rural India: A Retrospective Study

Introduction: Pregnancy, although being considered a physiological state, carries risk of serious maternal morbidity and at times death. This is due to various complications that may occur during pregnancy, labour or thereafter. Maternal death has serious implications on the family, the society and the nation. Maternal Mortality Ratio (MMR) is a very sensitive index that reflects the quality of health care provided by the country to the women population. Objectives: To assess the maternal mortality ratio and the causes of maternal death over a period of five years at a tertiary care teaching hospital of rural India. Methods: A retrospective hospital based study of 256 maternal deaths over a period of 5 years from January 2008 to December 2012. The information regarding demographic profile and reproductive parameters were collected and results were analyzed by using percentage and proportion. Results: Over the study period, there were 52413 deliveries, giving a MMR of 518.48 per 1,00,000 live births. The leading direct cause (81.64%) was Eclampsia (43.75%), while indirect (18.35%) leading cause was heart disease (6.64%). Most of the women (60.92%) died within 12 hours of admission suggesting majority patients reach the tertiary care hospital quite late. The age group of below 25 years (67.17%), primigravida (63.28%) and unbooked cases (89.84%) were mainly affected. Conclusions: Most maternal deaths are preventable by optimum antenatal, intranatal and postnatal care. Early referral, quick and well equipped transport facilities and promotion of overall safe motherhood is essential to reduce maternal deaths.


Discussion
Maternal mortality is unacceptably high in developing countries including India. Death of mother is a tragic event. In practical life, it has a severe impact on the family, community and eventually, the nation. The young surviving children left motherless, are unable to cope with daily living and are at an increased risk of death. Reduction of maternal mortality is the objective of MDGs, especially in low income countries, where one in 16 women die of pregnancy related complications 4 .
Recent assessment of global statistics suggests that despite major gains, among the 75 so-called Countdown countries that have 98% of all maternal deaths and deaths among children younger than 5 years of age, only 17 are on track to reach the MDG 4 target for child mortality and only 9 are on track to reach the MDG 5 target for maternal mortality. However, estimates from the Institute for Health Metrics and Evaluation suggest that 31 countries will achieve MDG 4, 13 countries will achieve MDG 5, and only 9 countries will achieve both targets 5 .
In the present study, there were 256 maternal deaths amongst 52413 deliveries, giving a MMR of 518.48 per 1,00,000 live births, which is higher than the national averages. Malda medical college and hospital being a teaching institution and a tertiary care centre, get complicated cases from rural areas. Admissions of moribund cases referred from peripheral hospital have inflated this mortality ratio, like other teaching institutions of India. Like our study, other similar studies from tertiary care institution reported MMR ranged between 213 to 879 per 1,00,000 live births 6,7,8 .
No discussion of global maternal, newborn, and child health is complete without addressing basic issues of social determinants 9 . Marmot notes that, according to the World Health Organization, -Social determinants of health are the conditions in which people are born, grow, live, work, and age; these circumstances are shaped by the distribution of money, power and resources at global, national, and local levels‖ 10 . In the present study, Maximum deaths (67.17%) were in the age group of below 25 years. Maternal deaths in age <19 years is 30.85% & over the age of 30 years is 11.70%. A study done by Dogra also showed similar age distribution like our study 11 . With the prevailing custom of early marriage in rural area, majority of the women present with their pregnancy in the early age group. In the present study, out of 256 deaths, 162 (63.28%) were primigravidas and 85 (33.20%) were multigravidas. In our study 9 (3.51%) women were grand multipara. Dogra and Purandare also published similar report in their studies 11,12 . In the current study, maximum maternal deaths occurred in primigravidas. This is because most of the eclamptic patients were primigravida and eclampsia took the highest toll of maternal deaths. Too many and too close pregnancies also adversely affect the mother's health. The incidence of unbooked cases was 89.84%. In our study, majority of maternal deaths seen in unbooked cases. High incidence of deaths among the unbooked cases has also been observed in study done by Roy et al 13 .
Much of the burden of maternal and child mortality and ill health is concentrated among the poorest populations in countries of sub-Saharan Africa and South Asia. In many of these countries, the highest mortality is observed among the marginalized and poor, who frequently reside in remote and rural areas with limited access to health care services 9 . A delay in accessing care can occur at three time points. This has been described as the three-delay model: the first delay refers to a woman or her family delaying the decision to seek care; the second is the delay in reaching that care; and the third is the delay in receiving care once a healthcare provider is reached 14 .
In the present study, 30.85% women died within 6 hours of admission and 30.07% died between 6-12 hours of admission. In our study 24.21% women died between 13-24 hours of admission and 14.84% women died after 24 hours of admission. Similar reports have also been published by Purandare in their study 12 . About 60.92% deaths occurred within 12 hours of admission suggesting majority patients reach the tertiary care hospital quite late. Strengthening of both basic and comprehensive emergency obstetrics care at primary health centre level and first referral unit could possibly save many mothers lives.
In the present study, maximum deaths (48.82%) occurred in the post-partum period, followed by (30.46%) in the 3rd trimester. Similar results have also been reported by other studies 11,12 . High numbers of deaths in post-partum period indicate the need for continuous vigilance in post-partum period and prompt action in case of problems. Intranatal care by skilled attendant, timely management and replacement of lost blood volume can reduce deaths in post-partum period. It is clear that interventions that have a relatively narrow delivery channel and separate management, such as immunizations, do achieve high coverage, whereas those that require functional health systems and facilities, such as skilled birth attendance and postnatal care, reach barely half the population in need 9 . Despite wide recognition of evidence-based interventions and the availability of information and guidelines, major gaps remain in implementation In the present study, direct causes contributed to 81.64% of maternal deaths, of which eclampsia (43.75%) is the most Common cause. Other direct causes were haemorrhage (21.87%), sepsis (13.28%) and pulmonary embolism (2.74%). Indirect causes contributed to 18.35% maternal deaths, of which heart disease (6.64%), cerebro vascular accident (5.85%), renal failure (3.12%), and anaemia (2.74%) were the most common causes. Though eclampsia is preventable in almost all cases by good obstetrics care, it was found to be the leading cause of deaths (43.75%) in our institution. It is mainly due to high incidence of eclampsia in this area and delayed referral mostly after 12 hours of the incidence. Eclampsia, as seen in our study was found to be the leading cause of death in study done by Roy 13 .
Despite the availability of magnesium sulphate for the prophylaxis and treatment of eclamptic seizures, the rates of eclampsia and maternal complications remain very high. This is because magnesium sulphate will only prevent eclamptic seizures in women who are hospitalized with severe preeclampsia during labour and immediately postpartum. The high maternal mortality reported from the developing countries was noted primarily among patients who had multiple seizures outside the hospital and those without prenatal care 15,16,17 . In addition, this high mortality rate could be attributed to the lack of resources and intensive care facilities needed to manage maternal complications from eclampsia. In the developing countries, most women will not be identified early, as most cases of eclampsia develop at home and/or during transport. Not surprisingly, the rate of preeclampsia and eclampsia is higher in the developing countries because of absent prenatal care and lack of access to proper hospital care.
The socioeconomic status, level of education, the quality of patients' nutrition and antenatal care of the patients in our study were very low. Lack of and/or poor prenatal care, delay in early diagnosis, progression to severe disease, delay in treatment, lack of access to hospital care, lack of access to transportation to clinic, lack of transport from clinic to hospital, lack of transport from hospital to tertiary facility, lack of welltrained staff and personal, lack of proper resources and, Intensive care unit were responsible for high maternal mortality in our study. These results are comparable with the study done by Bangal 18 .
Although the focus during the past decade has been on the saving of lives, it is also important to look beyond survival to issues of reducing morbidity and disability and improving long-term outcomes of relevance to human development. The close links among poverty, inequity, under nutrition, and human deprivation are well known, and all these factors have been shown to reduce the potential for human development considerably 9 . There are promising interventions that can benefit survival as well as human development 19 and there is a huge public health need to integrate the two issues. Linking the agenda for maternal and child health and nutrition with the emerging issues of long-term development, human capital, and economic growth may well be the most appropriate strategy to ensure that we stay the course in solving one of the most important moral dilemmas of our times. Although the MDG target dates are in 2015, the need to keep a sustained focus on maternal and child health should remain.

Conclusion
The MMR in our study is higher than the national averages. Most deaths could have been avoided with the help of good antenatal, intranatal and postnatal care, early referral, quick, efficient and well equipped transport facilities, availability of adequate blood and blood components, and by promoting overall safe motherhood. To reduce the maternal mortality and morbidity the main thrust should be on implementing basic and comprehensive emergency obstetrics care. Analysis of every maternal death through maternal death audit, either at community level (verbal autopsy) or at the institutional level should be carried out. It will help in identifying the actual cause of maternal deaths and deficiencies in health care delivery system that might contribute in formulating preventive measures to reduce pregnancy related deaths.