Fostering a commitment to stop maternal deaths

The Hindu

5 days ago

In childbirth in India, why should 93 women lose their life while one lakh women have a safe delivery? For the time period 2019-21, the Maternal Mortality Ratio (MMR) estimate for India was 93, in other words, the proportion of maternal deaths per 1,00,000 live births, reported under the Sample Registration System (SRS). 'Maternal death is 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'. But the MMR in India has declined over the years — it was 103 in 2017-19, then 97 in 2018-20 and now 93 in 2019-21.
To understand the maternal mortality situation better, States have been categorised into three: 'Empowered Action Group' (EAG) States that comprise Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand and Assam; 'Southern' States which include Andhra Pradesh, Telangana, Karnataka, Kerala and Tamil Nadu; and 'Other' States that cover the remaining States/Union Territories.
In the group of 'Southern' States, Kerala has the lowest MMR (20) and Karnataka the highest (63). The rest of the data is Andhra Pradesh (46) Telangana (45) and Tamil Nadu (49). In the EAG States, Assam has a very high MMR (167); the rest of the data is Jharkhand (51), and Madhya Pradesh (175). Bihar, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand are in the 100-151 range. In the category of 'Other' States. Maharashtra is 38 and Gujarat 53; the rest of the data is Punjab 98, Haryana 106 and West Bengal 109.
We need to have a differential approach in strategy to reduce maternal deaths in the different clusters of States. In this, addressing three issues is fundamental. There are 'three delays' that lead to a mother dying, according to Deborah Maine of Columbia University — I had incorporated this in the training module on 'Safe Motherhood in India' in 1992.
Key factors that endanger a life
The first delay is in recognising impending danger and making a decision to rush and seek expert care. The husband and other family members often experience inertia, thinking that all deliveries are a natural process and so the mother-to-be can wait. Or they may not have enough money or other issues at the family level that prevent them from going to a hospital. If the educational level of family members and their financial position are weak, delaying decision making is detrimental. But empowered, neighbourhood mothers and women's self-help-groups have resulted in a remarkable change; no longer is a mother-to-be neglected by lethargic family members. Ever since Accredited Social Health Activists (ASHA) began networking with Auxiliary Nurse Midwives (ANM) since 2005 (when the National Rural Health Mission (NHRM) was launched), institutional over home deliveries have become the better option. The financial incentives for the mother and ASHA were the turning point.
The second delay is in transportation. From remote rural hamlets and forest settlements or faraway islands it may take many hours, or an overnight journey for a mother-to-be to reach a health facility with a skilled birth attendant (midwife/staff nurse) or a doctor or an obstetrician. Many women die on the way. However, the 108 ambulance system and other Emergency transport mechanisms under the National Health Mission has made a difference.
Other problems
The third delay, an unpardonable one, is in initiating specialised care at the health facility. The excuses are plenty and difficult to justify — a delay in attending to a woman in the emergency room; a delay in reaching the obstetrician; a delay in getting a blood donor, in laboratory support, the operation theatre not being ready, an anaesthetist not being available is a list that can go on. The concept of the operationalisation of a 'minimum four FRUs [first referral units] per district of two million population, is crucial. The 'first level referral unit' with specialists such as an obstetrician, anaesthetist, paediatrician, blood bank and operation theatre was aimed at preventing maternal death at the doorstep of a hospital.
Unfortunately, this has not worked out as expected since 1992. There are problems such as 66% vacancies of specialists in 5,491 community health centres out of which 2,856 are supposed to be FRUs in 714 districts. The lack of blood banks or blood storage units in these designated FRUs was another reason for many mothers not receiving adequate blood transfusion within two hours of the onset of massive bleeding after delivery, leading to fatalities.
The biggest killer is bleeding after delivery. This could be due to inadequate and timely contraction of an overstretched uterus with a baby of three-kilogram weight floating in amniotic fluids. When the placenta is separated after delivery, the raw opened surfaces of the uterine wall will bleed profusely unless it immediately contracts. From a total reserve of five litres of blood, more than half is lost in such a short duration, resulting in the mother going into shock and death. If there is underlying anaemia, which has not been treated with iron folic acid supplements in pregnancy, it will also result in tragedy. Thus, there is a need for immediate blood transfusion and emergency surgical care.
The next emergency is obstructed labour where the contracted bony pelvis of an already stunted young mother (who is also malnourished and has low body mass index) does not allow the normally grown baby to emerge. Prolonged labour can lead to foetal distress and a lethal rupture of the uterus. This can be avoided by a Caesarean section. Thus, there is a need for a well-equipped operation theatre and obstetrician/ surgeon and an anaesthetist on call.
The third medical cause is hypertensive disorders of pregnancy that are not recognised and treated on time. They can result in a dire emergency with convulsions and coma and very little time to medically control high blood pressure. There are some home deliveries by untrained birth attendants which lead to trauma and puerperal infection, resulting in sepsis and death. Antibiotics could have saved their lives, but the patient is admitted to hospital late. A failure of contraceptive devices, resulting in unwanted pregnancies and crude abortion techniques by quacks, also leads to sepsis and death. In EAG States, associated illnesses such as malaria, chronic urinary tract infections and tuberculosis are also high risk factors.
The focus areas for States
The prescription for averting maternal deaths is early registration and routine antenatal care and ensuring institutional delivery. Many of these systemic deficiencies will be highlighted in the mandatory reporting and audit of all maternal deaths under the NHM. While the EAG States have to focus on the implementation of basic tasks, the southern States group and probably Jharkhand, Maharashtra and Gujarat need to fine tune the quality of their emergency and basic obstetric care.
The Kerala model of a Confidential Review of Maternal deaths, initiated by Dr. V.P. Paily, has some analytical leads on how Kerala can further reduce its already low MMR of 20. It is a model other southern States can emulate. The use of uterine artery clamps on the lower segment, application of suction canula to overcome atonicity of the uterus, and a sharp lookout for and energetic management of amniotic fluid embolism, diffused intravascular coagulation, hepatic failure secondary to fatty liver cirrhosis are strategies taught to obstetricians, which even developed countries have yet to practise routinely. They even address antenatal depression and post-partum psychosis as there were a few cases of pregnant mothers ending their life.
Finally, if there is a commitment and a will to stop preventable maternal deaths there is no limit to the varieties of proactive interventions.
Dr. K.R. Antony is a Public Health Consultant in Kochi, Kerala, and drafted the first Safe Motherhood module for the Ministry of Health on behalf of UNICEF. The writer acknowledges inputs on the Confidential Review of Maternal Deaths in Kerala from Dr. Smithy Sanel, a Spokesperson of the Kerala Federation of Obstetrics and Gynaecology