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Maternal Mortality and Its Relationship to Emergency

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Maternal Mortality and Its Relationship to Emergency Original Article Obstetric Medicine 2015, Vol. 8(2) 86–91 ! The Author(s) 2015 Maternal mortality and its relationship Reprints and permissions: sagepub.co.uk/journalsPermissions.nav to emergency obstetric care (EmOC) in DOI: 10.1177/1753495X15575949 obm.sagepub.com a tertiary care hospital in South India Papa Dasari Abstract Objective: To determine the trends in maternal mortality ratio over 5 years at JIPMER Hospital and to find out the proportion of maternal deaths in relation to emergency admissions. Methods: A retrospective analysis of maternal deaths from 2008 to 2012 with respect to type of admission, referral and ICU care and cause of death according to WHO classification of maternal deaths. Results: Of the 104 maternal deaths 90% were emergency admissions and 59% of them were referrals. Thirty two percent of them died within 24 hours of admission. Forty four percent could be admitted to ICU and few patients could not get ICU bed. The trend in cause of death was increasing proportion of indirect causes from 2008 to 2012. Conclusion: The trend in MMR was increasing proportion of indirect deaths. Ninety percent of maternal deaths were emergency admissions with complications requiring ICU care. Hence comprehensive EmOC facilities should incorporate Obstetric ICU care. Keywords Emergency obstetric care, maternal mortality, indirect causes Introduction Results The process of labour and delivery is the most common emergency in There were 106 maternal deaths among 73,935 live births. One death a woman’s life. The millennium development goal (MDG) 5 is a reduc- was misclassified as a maternal death and the record of one maternal tion of maternal mortality by 2/3 by the year 2015. The most effective death was unavailable. The overall MMR was 141 per 100,000 live strategy suggested by WHO to achieve this goal is provision of births. The MMR for the years 2008, 2009, 2010, 2011 and 2012 was Emergency Obstetric services. There is a wide regional variation in 104, 167, 187, 115 and 158, respectively (Table 1). The trend was maternal mortality rates as well as the causes of maternal deaths world- increasing MMR with increasing number of live births till 2010, and wide and also in India. Analyzing the maternal deaths helps to under- decreasing in 2011 when the live birth rate decreased, and an increase stand the profile of patients who sought the services of emergency in 2012 even though there was further reduction in the number of live obstetric care (EmOC) and informs reorganization of our EmOC ser- births. The general clinical profile of the patients at admission and vices to tackle the causes effectively. The Institutional Maternal death is shown in Table 2. All patients except two belonged to low Mortality Rate (MMR) is high when compared to the National average socioeconomic status. All patients except one (unwed pregnancy) or Global average,1 as the Institutional delivery rate is increasing grad- received the minimum antenatal care (three antenatal visits) according ually in India.2 According to the National Family Health Survey III, to WHO criteria. The mean age was 25 years and the mean gestational institutional deliveries have increased by 25% during the years 2001– age was 36 weeks. Postpartum patients constituted around 7.7%. 2006 and the national MMR decreased by 15%. The rate of decrease is There was no particular trend in the general profile of the patients not yet adequate to attain the goal of 2015. The objective of the present who died over the years. Type of admission and hospital stay is study was to determine the trend in MMR over the past five years at shown in Table 3. Overall, 90% of maternal deaths occurred in patients JIPMER (Jawaharlal Institute of Postgraduate Medical Education and who were admitted on an emergency basis. There was a gradual Research) Hospital and to find out the proportion of maternal deaths in increase in deaths among emergency admissions over the years. relation to emergency admissions. JIPMER Hospital is a tertiary care Overall, 53% of patients who died were referrals and there was an teaching centre in South India which provides free services to a large increasing trend of referral deaths from 2009 to 2012. Of the 11 preg- population all over South India and also other parts of India and is nant women who received antenatal care at our institute, five deaths equipped with all comprehensive EmOC facilities. were most probably preventable as these were due to prolonged induc- tion and late decision for caesarean section, leading to sepsis and hae- moperitoneum following caesarean section. It is difficult to comment Material and methods on the preventable factors for referrals and late arrival because of the lack of necessary details. This is a retrospective analysis of maternal deaths that occurred Overall, 32% of the patients died within 24 h of admission and 44% between January 2008 and December 2012. The maternal death rec- were admitted to ICU (Intensive Care Unit). ICU admissions showed an ords were retrieved from the medical record section of the JIPMER increasing trend from 2009. The mean duration of ICU stay was 4.2 hospital and the data were analysed with respect to the type of admis- sion, referral and cause of death. The clinical profile of the patients was also studied. MMR was expressed as the number of maternal Department of OBS & GYN, Jawaharlal Institute of Postgraduate Medical deaths per 100,000 live births. WHO classification of maternal deaths Education and Research (JIPMER), Puducherry, India was followed to classify the cause. The results are expressed as per- centages and proportions. Ethics committee/IRB approval was not Corresponding author: obtained as this was a retrospective analysis and the results were Papa Dasari, Department of OBS & GYN, WCH, JIPMER, Puducherry presented in the National conference ISMET 2013 hosted by our 605006, India. institute. Email: [email protected] Downloaded from obm.sagepub.com at UNIVERSITAET OSNABRUECK on February 3, 2016 Dasari 87 days and the longest duration was 33 days. The patient in ICU for 33 The causes of maternal deaths are shown in Table 4. The common- days was an unwed mother at term admitted with eclampsia with intra- est cause is obstetric hemorrhage followed by hypertensive disorders of uterine death at term who had persistent convulsions. Her CT brain pregnancy including eclampsia. Overall direct causes accounted for showed hydrocephalous and she was found to be HIV positive. There 60% of deaths and indirect causes for 40%. The most common indirect was lack of ICU beds for three patients. Status at death showed 58% to cause is heart disease complicating pregnancy followed by severe anae- be multiparous and 34% primiparous; 92% died after delivery and mia and jaundice. Infectious causes (malaria, tuberculosis and HIV) 8.7% died undelivered. accounted for 2%. There were two cases of liver secondaries; one from breast cancer and the other from osteogenic sarcoma of femur. Both of them occurred after primary treatment was given. The trend over the five years is a decrease from direct causes and increase in indirect Table 1. Maternal mortality rate. causes. The trends in MMR, admissions and causes are depicted in Figures 1, 2, and 3, respectively. No. of Time Total live maternal MMR per S. no period births deaths 100,000 LB Discussion 1 2008 13,501 14 104 MMR is considered to be high if it is 300 maternal deaths per 100,000 2 2009 15,551 26 167 live births and extremely high if it is 1000 maternal deaths per 100,000 3 2010 15,523 29 187 live births. India is one of the countries in the world with high maternal 4 2011 13,943 16 115 mortality and is responsible for one-third of global maternal deaths along with Nigeria. Maternal mortality in India has a wide regional 5 2012 12,036 19 158 variation; it is highest in northern Indian states like Assam and lowest in southern Indian states like Kerala.3 Mortality depends on many Table 2. Clinical profile. Profile 2008 N ¼ 14 2009 N ¼ 26 2010 N ¼ 29 2011 N ¼ 16 2012 N ¼ 19 Total N ¼ 104 Age in years 520yrs11––13 20–25 6 (43%) 14 (54%) 18 (62%) 9 (56%) 10 (53%) 57 (54.8%) 26–30 2 9 10 6 6 33 (31.7%) 31–35 4211210(9.6%) 36–40 1––––1 Mean age in years 27.6 24.6 24.8 25.3 24.9 25.44 Gestational age (GA)/ 528 weeks 113–27 status at admission 28 þ 1 to 34 weeks 578–525(24%) 34 þ 1 to 38 weeks 4 5 11 9 6 33 (32%) 38 þ 1 to 40 weeks 3712415(14%) 440 weeks 1452–12 Mean GA in weeks 36 36.2 36.3 36.6 34 Post-natal –21328(7.7%) Status at death Died undelivered 222219(8.7%) Primiparous 3 14 8 5 5 35 (34%) Multiparous 9 10 19 9 13 60 (58%) Table 3. Admission profile and hospital stay. Assessment 2008 2009 2010 2011 2012 Total Total maternal deaths 14 26 29 16 19 104 Emergency admissions 12 (85%) 25 (96%) 26 (87%) 14 (87.5%) 17 (89.5%) 94 (90%) Referrals 9 (64%) 11 (42%) 13 (45%) 7 (48%) 15 (80%) 55 (53%) Antenatal care in JIPMER 2 (14%) 2 (7.6%) Nil 4 (25%) 3 (16%) 11 (10.5%) Death 524 hrs of admission 3 (21.4%) 13 (50%) 7 (24%) 5 (31.3%) 5 (26.3%) 33 (31.7%) Number of patients requiring ICU care 8 (57%)a 8 (30.8%) 9 (31%)a 9 (56%) 12 (63%)a 46 (44.2%) Mean duration of survival after admission 3.6 days 4.2 days 4.5 days 4.1 days 4.6 days 4.2 days Longest duration of stay in ICUbefore death 33 days 17 days 15 days 16 days 14 days – aICU bed not available.
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