Maternal death review in Andhra Pradesh MDR Andhra Pradesh NRHM-MDR

1. A retrospective study of Maternal Death Review (MDR) in
three districts of Andhra Pradesh
1st May 2013
Dr. P. Satya Sekhar, Dr. Neelima Singh
Indian Institute of Health and Family Welfare
Vengalrao Nagar, Hyderabad

2. What is maternal death?
The death of a woman while she
is pregnant
…. or ….
within 42 days of the
termination of the pregnancy ….
….. from any cause related to
or aggravated by the pregnancy
World Health Organization (WHO)

3. Process of Maternal death review
• Health officials conduct Verbal autopsy for each
maternal death
• Audit reports are prepared and placed before the
districts collector
• District collector invites relatives of the deceased
women for further investigation of social and
governance factors

4. Do women die immediately after developing complications in delivery?
Average time estimated from initiation of treatment in
health facility to maternal deaths
 2 hours for Postpartum Hemorrhage
 12 hours for Ante-partum Hemorrhage
 2 days for Obstructed labor
 6 days for Sepsis (Infection)
(WHO Bulletin 1998, 76(6), 591-598 based on Maharastra data)

5. A retrospective study of MDR in Andhra Pradesh
(Guntur, Anantapur and YSR Kadapa districts)
 No. of maternal deaths reported during January-December 2012 : 167
 MDR cases reported by SPHO are analysed by the District MDR team
under DM&HO
 The analysed MDR reports reviewed by the District Collector to
identify facility level gaps for corrective measures with time-lines
 IIHFW initiated the MDR analysis in 3 districts
 Data entered using EPI-Info package and analysis by using SPSS
package

6. Mandals reporting higher maternal deaths in a calendar year
3 MDs 4 -5 MDs 6 & above
Anantapur AH- Dharmavaram (3)
CHC- Nallamada (3)
GGH- Anantapur (3)
CHC-Singanamala (5)
AH- Kadiri (4)
AH- Penukonda (4)
DH- Hindupur (4)
CHC- Tadipatri (5)
YSR Kadapa
AH- Proddutur (3)
Chennur (5)
CHC- Rayachoti (4)
CHC- Porumamilla (8)
CHC- Jammalamadugu (6)
AH- Pulivendula (6)
CHC- Mydukur (6)
Guntur GGH- Guntur (3)
DH- Tenali (3)
CHC- Sattenapalle (5) AH- Narasaraopet (8)

8. 2

9. 2

10. MATERNAL DEATHS BY CHNCs
District Maternal deaths by CHNC area
Anantapur Penukonda – AH (6), Singanamala – CHC (6)
Tadipatri - CHC (5)
Dharmavaram - AH (4), Hindupur – DH (4) Kadiri – AH (4), Nallamada – CHC (4)
Anantapur -GGH (3)
YSR Kadapa Porumamilla – CHC (8), Jammalamadugu – CHC (6), Mydukur – CHC (6)
Pulivendula –AH (5), Rayachoti - CHC (5)
Chennur –(4), L.R Palli – CHC (4)
Kamalapuram – CHC (3), Proddutur – AH (3)
Guntur Guntur – GGH (9), Sattenapalle – CHC (9), Narasaraopet – AH (8), Gurazala – CHC (6)
Vinukonda – CHC (5), Kollipara – CHC (4)
Ipuru – CHC (3), Tenali – DH (3)

11. Grading of health facility and maternal deaths by geographical area
Health
facility
Guntur Anantapur YSR Kadapa
Grade-I Tenali (DH -3);
Narasaraopet (AH -8);
Sattenapalli (CHC -9);
Vinukonda (CHC-5)
Chilakaluripet (CHC-2)
Anantapur (GGH-8);
Penukonda (AH-6)
Proddutur (AH-3);
Rayachoty (CHC-5)
Grade II Gurazala (CHC-6);
I puru (CHC-3);
Amaravati (CHC-2)
Hindupur (DH-6); Kadiri (AH-4);
Dharmavaram (AH-4); Gooty (AH-4);
Tadipatri (CHC-5);
Singanamala (CHC-6);
Nallamada (CHC-4); Rayadurg (CHC-3)
Rajampet (AH-1);
Jammalamadugu (CHC-6)
Grade III Kollipara (CHC-4) Pulivendula (AH-5);
Porumamilla (CHC-8);
Mydukur (CHC-6);
Chennur (CHC-4);
L.R. Palli (CHC-4);
Kamalapur (CHC-3)

12. Maternal deaths by women age
District
Percentage of women
Below 20 yrs 21-25 yrs 26-30 yrs
Above 30
yrs
Anantapur 22.5 47.1 23.5 3.9
YSR Kadapa 26.9 46.2 19.2 7.7
Guntur 15.6 54.7 25.0 4.7
All 3 districts 22.2 49.7 22.8 5.4
70% of MDs are below 20 years of age (MDR report, Andhra Pradesh, 2008-10).
Shift in age pattern of MDs due to higher proportion of girls marring after 18 years of age

13. Seasonal trend in maternal deaths?
Maternal deaths reported during January-December 2012
1 0 1
17
26
22
19
14
25
19
12 11
0
5
10
15
20
25
30
•Rise of inflectional diseases like vector borne Dengue, Malaria and Pyrexia during
June-September months and
•Increased efforts of health staff in MDR reporting and public awareness

14. Anantapur district
In June and July months, two deaths out of six maternal deaths
was reported due to dengue. In November month, one death out
of two maternal deaths was due to Malaria.
Hence, control of vector-borne disease with measures such
as long acting insecticidal bed nets goes a long way in
averting maternal deaths due to infections

15. Timing of maternal death, 1995-96 & 2012
(No significant change in one and half decades)
0
22.7
20.4
56.8
2.4
19.2
25.7
52.7
Abortion Antenatal period Intra-natal period Post natal period
1997 2012

16. Timing of maternal deaths by district, 2012
0 20 40 60 80 100
Anantapur
YSR Kadapa
Guntur
All 3 districts
15.7
25
17.2
19.2
35.3
23.1
20.3
25.7
45.1
50.0
60.9
52.7
Abortion
Antenatal
Intranatal
Post natal
Kadapa reported 25% of MDs in Antenatal period,
Anantapur 35% during intra-natal period and Guntur 61% during postnatal period.

17. Postnatal check-ups in Andhra Pradesh (NFHS-3, 2005-06)
RCH Baseline survey (2007) also reported 60% of women delivered at home received PN check-up within one week after birth
0
10
20
30
40
50
60
70
80
90
Hadpostnatalcheckup
Lessthan4hours
4-23hours
1-2days
3-41days
Don'tknow/missing
NoPNcheckup
82.7
54
8
14
7
2
15
68.7
41
4
13
10 2
30
Urban Rural
54% in urban and 40% in rural areas
women availed PN care within 4 hours.
Less than one-third in rural areas had no
PN checkup

18. Postnatal visit by a Health Personnel
About a quarter of delivered mothers are not receiving
Postnatal care
• RCH Baseline Survey, 2006-07
–Institutional deliveries (within a day – 87%; within a
week: 90%)
– Non-institutional deliveries (within one week of
birth- 60% and within 2 weeks of birth 64.2)
• DLHS-3, 2007-08 (within 2 weeks after delivery)
Overall- 79.5%; Rural – 76.4%; Urban – 89.1%
• CES 2009 (within 10 days after delivery) – 89.4%

19. Location of Maternal Death, 1997 -2012
(Maternal deaths during transit period indicates poor management of high-risk pregnancy assessment, no
systematic referral system, non-availability of doctors in 24x7 facilities, poor transportation facility)
0
10
20
30
40
50
60
Home Transit period Govt. Hosp Private college
55.3
10.6
12.1
22
10.1
17.3
42.9
29.8

20. Place of maternal deaths by district (n=167)
3.9
19.2
7.8
10.1
19.6
15.4
15.6
17.3
37.3
40.3
49.7
42.9
39.2
25
26.6
29.8
0 10 20 30 40 50
Anantapur
YSR Kadapa
Guntur
All 3 districts
Pvt Hosp
Govt. Hosp
Transit
Home
Majority of maternal deaths in Anantapur are in RDT trust hospital

21. Women reported maternal death by birth order
Primi gravida
44%
Second Gravida
22%
More than 2
34%

22. Background characteristics of women -1
• Out of women reporting MDs
a. 12% married before legal age of 18 yrs
b. Women educational status
• Illiterate - 47%
• Up to 8th class - 30%
• Up to 12th class - 20%
• Graduate - 3.6%
c. Hindus (82.6%) and Muslims (13.8%)
e. Scheduled tribe (7.2%); Scheduled caste (29.9%);
OBC(29.9%) and Others (32.9%)

23. Background characteristics of women-2
– 62% of women are housewives
– Median distance travelled by women from home
to first health facility – 9.0 km
– Median number of institutions visited by
women before maternal death – 2 intuitions
– 9% women have previous abortion
– 44% women have no living child and 30% with
one-child
– Average age at maternal death - 24.15 yrs

24. Status of fetus of delivered women
Infant survival of women reporting MDs
• 51% live birth
• 2% new born death
• 17% still birth
• 31% not delivered
1997 MDR study reported outcome of pregnancy as live
births (62%), still births (4.5%) and not delivered (33%)

25. Distance from residence to a health facility (n=167)
43.1
17.4
12.6
6.6
20.4
0
5
10
15
20
25
30
35
40
45
50
0-5 kms 6-10 kms 11-15 kms 16-20 kms 21 +

26. Number of institutions women visited before
maternal death (n=167)
No facility
2%
one facility
21%
2 facilities
23%
3 facilities
20%
4 & above
8%
Not available
26%

27. Reasons for referral by providers to higher facility
Lack of blood
5%
Lack of staff
1%
No explanation
given
38%
Other reasons
56%
Ninety-four percent of health institutions did not indicated specific reason for referral to
higher/other facility

28. Maternal deaths reported Antenatal
care (n=32)

29. Maternal Deaths during Antenatal Care Period (n=33)
33
Mother have any problem during ANC period
Yes (26) No (6) Don’t Know (1)
Referred during ANC period
Yes (26) Not applicable (7)
Symptoms for which care sought
Anemia - 2 Bleeding p/v - 2 Edema - 2
High BP - 2 High fever - 2 Others - 16
Attended any health facility
Yes (23) No (3)
Reason for not seeking treatment
1) Other reason – 1
2) Severity of complications -2

30. Missed opportunity during ANC
• 26/33 (78%) of ANC mothers reported symptoms of
High BP, edema, bleeding p/v and high fever
referred to higher facility
• 23/26 (88%) sought treatment at referral centre
• GAP
– No follow up by the field staff /PHC MO

31. Maternal deaths during
intra-natal period

32. Maternal deaths during intra-natal period - 1
• Number of maternal deaths in intra-natal period: 43
• Preference of delivery by institution
– 38.7% Private sector
– 52.3% Govt. institutions/ medical college hospitals
– 9 % Home deliveries
• On average, 10.6 hours reported between on set of labor pain and
delivery ( 27% reported duration <= 2 hours)
• Half of deliveries (49%) attended by doctor followed by 14% by
ANM/Staff nurse/Med. Asst
• 59% of delivery ended with a live birth

33. Maternal deaths during intra-natal period -2
• Problems reported by mothers during delivery
– Severe bleeding / bleeding with clots (23.3%)
– Convulsions (11.6%)
– Severe breathlessness /Cyanosis /edema (9.3%%)
– High fever (7%)
• Out of women reported problems, only 67% availed treatment
• The reasons for non-compliance are
– Intensity of complications not known (3.7%)
– Institution far away (11.1%)
– Lack of transport (3.7%)
– Beliefs and customs (3.7%)

34. Causes of maternal deaths during intra-natal period (n=28)
Prolonged labor
7%
Severe bleeding
36%
Inversion of
uterus
4%
Retained placenta
7%
Convulsions
18%
Severe breathless
ness /edema
14%
High fever
14%

35. Missed opportunity during Intra-natal care
• Home delivery - 9%
• Institutional deliveries - 91% (52% Govt. and 38% private)
• Half of deliveries attended by doctor - 49%
• Delay-1 & 2 :
67% of mothers availed delayed treatment due to
– Institution far away (11.1%)
– Beliefs and customs (3.7%)
– Intensity of complications not known (3.7%)
– Lack of transport (3.7%)

36. Missed opportunity during Intra-natal care- continued
• Delay-3 :
– Lack of EmOC services like blood transfusion facility, USG and
mothers using 2 and more facilities during fatal illness
– More than half (53%) diseased women had residence within 5
kms from a health facility – inadequate functionality
– Lack of referral linkage
– Lack of uniform protocols and SOPs in government and private
Ex: Trial of labor in case of placenta previa, non-usage of Mg So4,
a life saving drug in Eclampsia, not using Partograph
– Lack of functioning MICU (maternal intensive care unit) in tertiary
care hospitals due to lack of specialists and team to run when
infrastructure is available.

37. Maternal deaths in postnatal
checkups (n=88)

38. Postnatal checkups by delivered mothers
5.7
20.5
19.3
54.5
0 10 20 30 40 50 60
>=4
2-3 times
One time
No postnatal care
Less than half of delivered mothers availed postnatal care.

39. Timing of maternal death after delivery
in Anantapur district (n=33)
33.0
12.1
39.7
12.2
3.0
0
5
10
15
20
25
30
35
40
45
0-6 hours 7-24 hrs 1st day - 7 days one week - 2
weeks
>2 weeks
84% of postpartam maternal deaths are in first one week after delivery
and 45% within one day

40. Identified problems reported after delivery by mothers
20.8
20.8
20.8
10.4
9
6
3.4
2.9
2.9
1.5
1.5
0 5 10 15 20 25 30
Severe bleeding
Sudden chest pain & collapse
Un consciousness/visual disturbance
Fever and foul smelling discharge
Severe anaemia
Breathlessness
Bleeding from multiple sites
Abnormal behaviour
Urinary disturbances (oliguria)
Severe leg pain & swelling
Jaundice 76% mothers had postnatal risk factors
21% had sudden chest pain & collapse
but 56% gave opportunity but “MISSED”
due to lack of postnatal care

41. Missed opportunity during post natal care
• Postnatal care (PNC) viewed as less important than Pre ANC
• CES (2009) Andhra Pradesh indicated universal PNC, but less
than half of delivered mothers received quality PN care
• 76% mothers had postnatal risk factors
• 21% had sudden chest pain & collapse but 56% gave
opportunity but “MISSED” due to lack of postnatal care
• 74% of mothers had inadequate PNC (54% had no PNC visits
and 19% had one visit.
• Majority post natal deaths (84%) occurred in first week after
delivery

42. Cause of Maternal Death Classification, 2012
Cause of death Frequency Percent
Direct obstetric cause 95 57.0
Indirect obstetric cause 45 27.0
Non obstetric cause 5 3.0
Not known cause 22 13.0
Total 167 100.0

43. Cause of Maternal Death Classification, 1997 and 2012
72
15.2
8.3
4.5
56.9
26.9
3.0
13.2
0
10
20
30
40
50
60
70
80
Direct obstetric cause Indirect obstetric cause Non obstetric cause Un-classified

44. Indirect obstetric cause
26.9%
Non obstetric cause
3.0% Not known cause
13.2%
Hemorrhage - APH
2.4%
Hemorrhage - PPH
11.4%
Hypertensive disorders of
pregnancy
15.6%
Sepsis related to pregnancies
and child birth
9.6%
Thrombo embolism (TE)
9.6%
Others - Peripartum
cardiomyopathy, surgery
complications
8.4%
Direct obstetric cause
56.9%
Causes of Maternal Death Classification

45. Indirect obstetric cause Frequency Percent
Heart diseases complicating pregnancy 12 26.7
Severe Anaemia 8 17.8
Endocrine disorders. 2 4.4
Infectious diseases. 16 35.6
Liver disorders – Jaundice 2 4.4
Renal disorders 3 6.7
Others - SOL, Cancer etc., 2 4.4
Total 45 100.0
Indirect obstetric cause of Maternal Death

46. Direct obstetric cause
56.9%
Non obstetric cause
3.0%
Not known cause
13.2%
Heart diseases complicating
pregnancy
7.2%
Severe Anaemia
4.8%
Endocrine disorders
1.2%
infectious diseases
9.6%
Liver disorders - Jaundice
1.2%
Renal disorders
1.8%
Others - SOL, Cancer etc.,
1.2%
Indirect obstetric cause
26.9%
Causes of Maternal Death Classification

47. Maternal deaths reported in Andhra Pradesh
District/Year 2009-10 2010-11 2011-12
Guntur 50 61 42
Anantapur 36 38 46
YSR Kadapa 44 50 51
Andhra Pradesh 750 N.A 691
Source: NHSRC-HMIS reports for Andhra Pradesh, 2009-10,2010-11 and 2011-12
1. 63-75 percent of maternal death reasons specified as ‘Other causes’.
2. In 2011-12, the maternal death reasons at state level are Bleeding(11.3%), Severe
Hypertension/fits (7.4%), Obstructed /prolonged labour (3%), High fever (2%), Abortion
(1.9%) and other causes (74.4%).

48. What is required for an effective MDR
implementation in A.P?
• Re-orientation/training to all Mo’s required in precisely
identifying causes of maternal deaths in CBMDR and
FBMDR
• Open history (CBMDT) written meticulously, word by
word, event by event as reported by family members
• Need to conduct sub-committee meetings regularly
• MDR trainings to all PHC medical officers
• Revise MDR formats for an user-friendly data compilation
and data analysis
• Need to initiate a systematic state level MDR analysis