Causes and prevention of maternal mortality

1. MATERNAL MORTALITY
 Introduction
 Definition
 Determinants
 Prevention

2. SOME FACTS
 85 % women will deliver normally
 10-15 % women will develop complications
 3-5 % women will need surgical interventions
(blood/Cesarean etc.)
More chances of women having a normal delivery
However delivery complications can occur suddenly, without any
warning signals
2

3. SOME FACTS
 20-25% deaths occur during pregnancy.
 40-50% deaths occur during labour and
delivery
 25-40% deaths occur after childbirth
(More during the first seven days)
It is important to focus attention during pregnancy and also
after childbirth
3

4. GLOBAL BURDEN
 5,29,000 deaths / yr or 400/ 1 lakh live births
 1 death per minute
 1% in developed countries
 Range – 24 to 830 / 100,000 live births
 19/20 countries with high MMR – Sub
Saharan Africa

5. LIFETIME RISK FOR A WOMAN
Continent Risk of Losing a Risk of dying due to
neonate maternal cause
AFRICA 1 In 5 1 in 16
ASIA 1 in 11 1 in 132
LATIN AMERICA 1 in 21 1 in 188
DEVELOPED 1 in 125 1 in 2976
COUNTRIES

6. SCENARIO IN INDIA
 An Indian woman dies from
complications related to pregnancy
and childbirth.
 Every seven minutes
 The maternal mortality ratio in India
stands at approx 200 per 100,000 live
births.
 It has some high performing states
like Kerala with MMR of 110 and
poorly doing states like Uttar Pradesh

7. MATERNAL MORTALITY
Death of a woman who is pregnant or within
42 days of termination of
pregnancy, irrespective of the site or duration
of pregnancy, from any cause related to or
aggravated by the pregnancy or its
management

8. MATERNAL MORTALITY
Death of a woman who is pregnant or within
42 days of termination of
pregnancy, irrespective of the site or duration
of pregnancy, from any cause related to or
aggravated by the pregnancy or its
management

9. MATERNAL MORTALITY
Death of a woman who is pregnant or within
42 days of termination of pregnancy,
irrespective of the site or duration of
pregnancy, from any cause related to or
aggravated by the pregnancy or its
management

10. MATERNAL MORTALITY
Death of a woman who is pregnant or within
42 days of termination of pregnancy,
irrespective of the site or duration of
pregnancy, from any cause related to or
aggravated by the pregnancy or its
management

11. MATERNAL MORTALITY
Death of a woman who is pregnant or within
42 days of termination of
pregnancy, irrespective of the site or duration
of pregnancy, from any cause related to or
aggravated by the pregnancy or its
management

12. DIRECT OBSTETRIC DEATHS
 The deaths resulting from obstetric
complications of the pregnant state
(pregnancy, labour and the puerperium), from
interventions, omissions, or incorrect
treatment, or from a chain of events
resulting from any of the above are called
direct obstetric deaths.
 Indirect obstetric deaths
Those resulting from previous existing disease or disease that
developed during pregnancy and that was not due to direct
obstetric causes but was aggravated by the physiological effects
of pregnancy.

13.  Late maternal death
Late maternal is death of a woman from direct or indirect obstetric
causes, more than 42 days but less than one year, after
termination of pregnancy.
 Pregnancy related death
defined as : the death of a woman while pregnant or within
42 days of termination of pregnancy, irrespective of the
cause of death.
To facilitate the identification of maternal death in circumstances
in which cause of death attribution is inadequate, ICD-10
introduced a new category, that of “pregnancy-related death”.

14. MEASUREMENT OF MATERNAL MORTALITY
There are three main measures of maternal
mortality-
 maternal mortality ratio,
 maternal mortality rate
 lifetime risk of maternal death.

15. MATERNAL MORTALITY RATIO
 This represents the risk associated with each
pregnancy, i.e. the obstetric risk.
 It is calculated as the number of maternal
deaths during a given year per 100,000 live
births during the same period. This is usually
referred to as rate though it is a ratio.

16. NOTE - MMR
 The appropriate denominator for the maternal
mortality ratio would be the total number of
pregnancies (live births, fetal deaths or stillbirths,
induced and spontaneous abortions, ectopic and
molar pregnancies).
 However, this figure is seldom available and thus
number of live births is used as the denominator.
 In countries where maternal mortality is high
denominator used is per 1000 live births but as this
indicator is reduced with better services, the
denominator used is per 1,00,000 live births to avoid
figure in decimals.

17. ‘DELAY’ MODEL
 Delay in seeking care
 Delay in transport to appropriate health
facility
 Delay in provision of adequate care

18. DELAY
 Onset, time and death
 APH-12 hours
 PPH – 02hours
 Rupture uterus- 24 hours
 Eclampsia – 48 hours
 Infection – 06 days

19. CAUSES OF MATERNAL MORTALITY
20 % - indirect
80 % - direct
Four Major causes
 Haemorrhage
 Infection (sepsis)
 Eclampsia
 Obstructed
Labour

20. Source- Registrar General India. Causes of Maternal
Mortality in Rural India

21. UNDER LYING FACTORS
 Socio-economic
 Nutritional

22. WOMEN ARE DYING IN INDIA DUE TO
 Marriage and childbirth at an early age.
 Lack of access to Emergency Obstetric Care
(EmOC).
 Inadequate nutrition
 Due to six medical causes-
Hemorrhage, sepsis, unsafe abortion, obstructed
labour, eclampsia, pre-existing anemia, malaria
 Absence of skilled personnel at delivery
 Short birth intervals- 30% births at < 24 months
interval
 High parity- 25% births in parity 4 or more
 Lack of blood transfusion facilities in rural areas

23. IMPACT OF MATERNAL DEATHS
 Children who lost their mothers are more likely
to die within two years of maternal death
 10 times the chance of death for the neonate
 7 times the chance of death for infants older
than one month
 3 times the chance of death for children 1 to5
years
 Enrolment in school for younger children is
delayed and older children often leave school to
support their family.

24. WHAT IS COMMON TO ALL THESE
CAUSES ?
They all are preventable to a great extent

25. IF THEY ARE ALL PREVENTABLE THEN
WHY NOT?
The reasons are
Social
Economical
Medical

26. SOCIAL ISSUES
 Early marriage
 Gender discrimination
 Illiteracy
 Desire for selective sex of child- female feticide
 Domestic violence

27. ECONOMIC ISSUES
 Lack of money
 Lack of timely transport and communication
 Delay in taking decision to shift
 Improper dietary habits

28. MEDICAL ISSUES
 Lack of ANC
 Lack of emergency obstetric care
 Lack of blood and blood products
 Lack of essential drugs
 Junior staff dealing with high risk cases without
supervision
 Delay in diagnosis / wrong diagnosis

29. PREVENTION OF MATERNAL MORTALITY
 Health Education
 Age at marriage
 Utilization of RCH services
 Awareness of antenatal care
 Nutritional education
 Importance of Immunization
 Spacing / Limitation of births

30. PREVENTION OF MATERNAL MORTALITY
 Safe Abortion services
 Sex education and contraception
(Adolescent clinics)
 Roleof MVA
 MTP under LA
 Teaching MTP to RMP

31. PREVENTION OF MATERNAL MORTALITY
 Health delivery infrastructure
 Provision of RCH services at remote rural areas /
urban slums
 Improved staffing
 Facilities for Essential / Emergency obstetric
care
 Training of traditional birth attendants (
TBAs )

32. PREVENTION OF MATERNAL MORTALITY
 Health care delivery
 Emergency management of Eclampsia / Third
stage complications at PHC level
 Flying squad services

33. PREVENTION OF MATERNAL MORTALITY
 Adoption of small family norm

34. PREVENTION OF MATERNAL MORTALITY
Prevention of anaemia
 Concept of 100 tablets
 at puberty
 at the time of marriage
 during pregnancy
 during lactation

35. PREVENTION OF MATERNAL MORTALITY
 Non health strategies
 Povertyeradication
 Improvement of literacy
 Women‟s empowerment measures
 Improved communications
 Improved transport facilities

36. ACTIONS FOR SAFE MOTHERHOOD
 Legislative & Policy actions
 Society & Community
 Health sector

37. LEGISLATIVE & POLICY ACTIONS
 MTP Act
 Sharda Act
 Janani Suraksha Yojna
 Adolescent education
 Decentralization
 Protocols

38. SOCIETY & COMMUNITY
 National, regional and district safe motherhood
committees
 Health facility and community committee
 Raising awareness on danger signs
 provisioning of DDK for clean deliveries
 TBAs - remote and inaccessible areas.
 Improving maternal nutrition
 Addressing certain diseases like malaria, TB,
RTI/STI, HIV/AIDS and Hepatitis.
 Preventing unwanted births and reducing unsafe
abortions

39. HEALTH SECTOR ACTIONS
 Antenatal clinics
 EOC -Skilled Birth attendance
 Postnatal care
 Abortion services
 FRUs –EmOC
 Iron & FA, inj TT
 Family planning services

40. FIRST LEVEL MATERNAL CARE
Such care has three functions-
 birth takes place in the best of circumstances
 resolve complications as they arise
 To respond to life-threatening emergencies
organized in midwife led birthing
centres, combining cultural proximity in a non-
medicalized setting, with professional skilled
care, the necessary equipment, and the
potential for emergency evacuation.

41. BACKUP CARE
 ideally provided in a hospital where doctors –
specialists, skilled general practitioners or mid-
level technicians with the appropriate skills
 Linked with first level care
 24 hrs availability
 Emergency & non-emergency conditions
Both 1st level services & backup care to be
rolled out simultaneously

42. INITIATIVES IN INDIA
 FP program – 1952
 AIHPP - 1969
 MTP Act -1971
 Family welfare -1977
 CSSM -1992
 RCH
 JSY
 Vandemataram scheme
 EmOC
 EOC

43. ESSENTIAL OBSTETRIC CARE
 Registration of pregnancy in the first 12-
16 wks
 At least 3 prenatal check ups
 Assistance during delivery.( Skilled Birth
Attendant)
 At least 3 postnatal check ups.

44. EMERGENCY OBSTETRIC CARE
 Inputs
 A total of 1748 FRUs - provisioning of drug kits, laparoscope, blood
transfusion and employing contractual staff like PHN/ANM/Lab Asst and
anaesthesiologist.
 24 Hour Delivery Services at PHCs/CHCs
For this doctor could be paid Rs 200/- per delivery & other staff could be hired on contractual
basis.
 Referral Transport to Indigent Families through Panchayats
In category C districts of eight weakly performing states, issue addressed by providing financial
assistance to Panchayats through District Family Welfare Officers.
 Blood Supply to FRUs/PHCs
 MTP services
Inputs
(a) Need based training in MTP by NIHFW.
(b) Supply of MTP equipment to District Hospitals, CHCs & PHCs where trained staff is
available.
(c) Assistance for engaging doctors trained in MTP to the PHCs once a week on fixed
days for performing MTP (Pay Rs 500/- day). These doctors will also provide ANC
and PNC services to patients during their visit.
(d) Supply of MTP equipment to Private clinics if they have OT & trained doctors.

45. JSY

46. JSY- ELIGIBILITY
LPS States All pregnant women delivering in Government
health centres like Sub-centre, PHC/CHC/ FRU /
general wards of District and state Hospitals or
accredited private institutions
HPS States BPL pregnant women, aged 19 years and above
LPS & HPS All SC and ST women delivering in a
government health centre like Sub-centre,
PHC/CHC/ FRU / general ward of District and
state Hospitals or accredited private institutions

47. Cash Assistance
Cat Rural Area Total Urban Area Total
Mother’s ASHA’s Rs. Mother’s ASHA’s Rs.
Package
Package Package Package
LPS 1400 600 2000 1000 200 1200
HPS 700 700 600 600

48. SPECIAL DISPENSATION FOR LPS STATES:
 Age restriction removed
 Restricting benefits of JSY up to 2 births
removed
 No need for any marriage or BPL certification

49. MICRO BIRTH PLAN
-
Inform the mother and the family about 4 Is, namely
 Inform dates of 3 ANC & TT Injection (s) and
ensure these are provided,
 Identify the health centre for all referral,
 Identify the Place of Delivery,
 Inform expected date of delivery

50. VANDE MATARAM SCHEME
 Public Private Partnership with the involvement of
Federation of Obstetric and Gynachological Society of India
and Private Clinics.
 Voluntary scheme wherein any Obstetric and Gynaecologist,
maternity home, nursing home can volunteer themselves in
joining the scheme. Any lady doctor/MBBS doctor providing
safe motherhood services can also volunteer to join this
scheme.
 The enrolled „Vandematram‟ doctors will display
„Vandematram‟ logo in their clinic. Iron and Folic Acid
Tablets, oral pills, TT injections etc. will be provided by the
respective District Medical Officers to the „Vandematram‟
doctors/clinics for free distributions to beneficiaries.

51. CHALLENGES IN MATERNAL HEALTH
 Establishing data base on maternal mortality
 High risk pregnancy behavior-too early, too
many, too close
 Urban-Rural divide
 Poor rate of institutional deliveries
 Lack of skilled care at birth
 Poor implementation of programs
 Lack of women empowerment

52. TEN ACTION MESSAGES FOR SAFE MOTHERHOOD
 Advance Safe Motherhood Through Human Rights
 Empower Women: Ensure Choices
 Safe Motherhood is a Vital Economic and Social
Investment
 Delay Marriage and First Birth
 Every Pregnancy Faces Risks
 Ensure Skilled Attendance at Delivery
 Improve Access to Quality Reproductive Health
Services
 Prevent Unwanted Pregnancy and Address Unsafe
Abortion
 Measure Progress
 The Power of Partnership

53. FINAL MESSAGE
Child birth – a miracle of life should not
become a nightmare of death

54. Tribute to maternal mortality

55. Perinatal Mortality Rate : This includes both late foetal deaths (stillbirths)
and early neonatal deaths. The important thing to consider is the weight 1000gm
and more at birth or a gestation of 28 weeks if birth weight is not available and if
both weight
and gestation are not available, body length (Crown to heel) of at least 35 cm
should be used.
The preferred criterion is birth weight. The denominator used in calculation of
perinatal mortality is 1000 live births (suits nations with poor recording of still
births) but for more precise comparison the denominator includes all live births
weighing
1000 gm or more. Perinatal mortality is a sensitive indicator of essential maternal
and newborn care provided at childbirth.
The factors responsible for stillbirths and early neonatal deaths are often similar.
This indicator also assumes importance in view of the fact that many of the early
neonatal deaths are recorded as stillbirth in developing nations thereby inflating
figures for stillbirths but showing figures for early neonatal deaths lower than the
factual. This anomaly is taken care of by Perinatal Mortality Rate. The Perinatal
period comprises just 0.5 % of the average lifespan but has more deaths in this
period than next 30-40 years of life.