Maternal mortality

Post Graduate Student, Department of Community Medicine

1. Dr.Praseeda.B.K

2. Definition Scenario worldwide and India Statistical measures of maternal mortality Approaches to measure maternal mortality Causes in worldwide and India Preventive and social measures to reduce maternal mortality

3. “The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” Definition

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

5. 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 174 per 100,000 live births. (2015)

6. 2011 2012 2013 2014 2015 206 197 189 181 174 India

7. SRS data shows that that so far only three states Kerala with an MMR of 66 per 100,000 live births Tamil Nadu with an MMR of 90 per 100,000 live births Maharashtra with an MMR of 87 per 100,000 live births —have been able to achieve the millennium development goal.

8. Kerala

9. Maternal mortality Ratio India Kerala 2010-12 178 66 Special Bulletin on MMR 2010-12

10. Maternal mortality ratio Maternal mortality rate Adult life time risk of maternal death The proportion of Maternal Death of Women of Reproductive age (PM) Statistical measures of maternal mortality

11. Maternal mortality ratio This represents the risk associated with each pregnancy. It is calculated as the number of maternal deaths during a given year per 100,000 live births during the same period.

12. - Number of maternal deaths in a given period per 100,000 women of Reproductive age group in the same time period.. Maternal Mortality Rate

13. Number of maternal Deaths in a given time period divided by total deaths among women aged 15-49 years.. The proportion of Maternal Death of Women of Reproductive age (PM)

14. 1. Civil Registration System - Routine registration of Birth & Death - continuous registration of birth and death 2. Household Survey Approaches to measure maternal mortality

15. - interviewing a representative sample of respondents about the survival of all their adult sisters . 3 . Sisterhood Methods

16. Include 4 questions How many sisters have you ever had born to same mother who ever reached the age 15 (or those who ever married), including those who are now dead?? How many sisters who reached the age 15 are alive now ? How many of your sisters are dead ? How many of your sisters who are died during pregnancy or during child birth or during the sixth weeks after the end of pregnancy?

17. Not applicable when TFR < 4 children per family Areas of significant migration During civil war

18. - Identifying and investigating the causes of all deaths of women of reproductive age group in a defined area . Use triangulation of different sources of data on death of women of reproductive age group coupled with record review and / or verbal autopsy to identify maternal death. Best way to estimate MMR 4. Reproductive age mortality studies(RAMOS )

19. 5. Verbal Autopsy - used to assign cause of death through interview with family or community member..

20. 6. Census - National Census with addition of a limited number of questions.

21. - Representative, Re-Sampled, Routine Household Interview Of Mortality with Medical Evaluation. - enhanced form of Verbal autopsy. - included in SRS from 2002 onwards . 7. RHIME

22. Random re-sampling of field work by an independent team for maintaining. Field staff will collect major symptoms narrative of events leading to death . Two independent trained physicial will examine the report Disagreement should be referred to Senior third physician who adjudicate and find CDC 10 code

23. Maternal and peri - natal death enquiry and response Thoroughly examine and respond to social, biological & medical events that led to a maternal & Perinatal death Inquiries are conducted of the death that occur in a community over several months of time in order to identify common factors that can be acted up on to prevent further deaths. MAPEDIR

24. Conducted using a verbal autopsy interview with the families of diseased persons. Useful in areas were many deaths occur outside health facilities and for highlighting relevant social factors and health care seeking problems.

25. Causes of death and morbidity worldwide

26. Causes of death and morbidity in India

27. Causes in Kerala

28. Medical causes Non obstetric causes Social causes Determinants of Maternal mortality in India

29. Obstectric causes Toxaemias of pregnancy Haemorrhage Infection Obstructed labour Unsafe abortion Medical causes

30. Non obstetric causes Anaemia Associated diseases e.g., cardiac, renal, hepatic metabolic and infectious Malignancy Accidents

31. Age at child birth Parity Too close pregnancies Family size Malnutrition Poverty Illiteracy Ignorance Social causes

32. Prejudices Lack of maternity services Shortage of health manpower Delivery by untrained dais Poor environmental sanitation Poor communications and transport facilities Social customs. Contd...

33. Early registration of pregnancy At least three antenatal check-ups Dietary supplementation, including correction of anaemia Prevention of infection and haemorrhage during puerperium Prevention of complications, e.g., eclampsia , malpresentations . ruptured uterus Preventive and Social Measures

34. 6. Treatment of medical conditions Eg : hypertension, diabetes, tuberculosis, etc. 7. Anti-malaria and tetanus prophylaxis Clean delivery practice In India 8. Trained local dais and female health workers 9. Institutional deliveries for women with bad obstetric history and risk factors

35. 10. Promotion of family planning - to control the number of children to not more than two. and spacing of births 12. Identification of every maternal death, and searching for its cause.

36. Confidential Maternal Death Audit started in 1990’s Format and methodology revised in 2010 District level monitoring committee formed. All maternal death in Govt and Private sector are audited Kerala Federation of Obstetrics and Gynecologist published study report on maternal Death Preventive Methods in Kerala

37. In 2012, the international arm of the UK National Institute for Health and Care Excellence (NICE) partnered with the government of Kerala, the NRHM and KFOG to work to improve the obstetric care in the state through developing standards based on evidence-based clinical guidelines

38. These ten action points have been piloted in eight hos - pitals (six public and two private) in Kerala from April 2013.

39. Active Management of Third Stage of Labour 2. PPH Prevention – 4th Stage Management 3. Management of Post-Partum Haemorrhage with Blood and Blood Products 4. Obstetric Intensive Care 5. Placenta Praevia Accreta 6. Pre eclampsia 7. Anti-hypertensive Treatment 8. Severe Hypertension in pregnancy and in Immediate Postpartum Period 9. HELLP ( Hemolysis , Elevated Liver enzyme, Low Platelet) 10. Eclampsia

40. Thank you....