Abstract
Background: The current United Nations sustainable development goal 3 sets to reduce maternal mortality to less than 70 per 100 000 live births by 2030. To monitor whether India is on track to attaining sustainable development goals, it is essential to routinely assess trends of health indicators.
Objectives: This study was conducted to assess trends of maternal mortality and cause-specific maternal death in tertiary care hospitals in Southern India.
Methods: This is a retrospective study of hospital records and death summaries of all maternal deaths between January 1, 2009, and December 31, 2018, at the tertiary care hospital in Southern India. The demographic, clinical, and delivery details of all the maternal deaths were collected. Causes of maternal deaths were classified as direct, indirect, and nonspecific. To observe trends of maternal death, the maternal mortality ratio was calculated for each year, and Pearson’s chi-square test was used.
Results: Maternal mortality ratio was 555/100000 and had a decreasing trend from its highest in 2010 of 1230/100000 to its lowest of 229/100000 in 2017 (t = 7.71 p = 0.02). The majority of women who died were aged 21-35 years, resided in rural, were primigravidae, and had operative delivery. Most of the maternal deaths had been referred to our facility (90.8%) from other healthcare units. Obstetric hemorrhage (27.8%) and puerperal sepsis (37.7%) among direct causes; H1N1 pneumonia (34.8%) among indirect causes were the major causes of maternal death. The number of maternal deaths due to sepsis increased from the beginning until the end of the study from 10% to 50% (t = 5.9, p = 0.01). On the contrary, there was a decline in maternal deaths due to obstetric hemorrhage from 50% to 25% (t = 4.2, p = 0.03).
Conclusion: Although the maternal mortality ratio has reduced over the years, sepsis was an important cause of maternal deaths.
Graphical Abstract
[1]
World Health Organization. Global health observatory country views: India statistics summary (2002 - present). 2016. Available from: http://apps.who.int/gho/data/node.country.country-IND
[2]
World Health Organization. Maternal mortality. 2018. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
[3]
MDG, Monitor MDG 5: Improve maternal health. Available from: https://www.mdgmonitor.org/mdg-5-improve-maternal-health/
[4]
Singh, P.K. India has achieved groundbreaking success in reducing maternal mortality. 2019. Available from: http://www. searo.who.int/mediacentre/features/2018/india-groundbreaking-sucess-reducing-maternal-mortality-rate/en/
[5]
WHO, UNICEF, UNFPA, The world bank and the united nations population division. the world trends in maternal mortality: 1990 to 2013. 2014. Available from: http://reliefweb.int/sites/relief web. int/files/resources/WHO_RHR_14.13_eng.pdf
[6]
Office of registrar general of India. Special bulletin on maternal mortality in India, 2010-12. Sample registration system, office of registrar general of india, ministry of home affairs, government of india, New Delhi. 2013. Available from: http://www.censusindia. gov.in/vital_statistics/SRS_Bulletins/MMR_Bulletin-2010-12.pdf
[7]
Ministry of statistics and programme implementation (MoSPI). Millennium development goals: India country report 2015. Social statistics division, ministry of statistics and programme implementation 2015. Available from: http://mospi.nic.in/Mospi_New/upload/mdg_26feb15.pdf
[8]
United Nations. Sustainable development goal 3 ensure healthy lives and promote well-being for all at all ages. Available from: https://sustainabledevelopment.un.org/sdg3#targets
[9]
State/UT-wise institutional births during 2015-16. Available from: https://community.data.gov.in
[10]
Say, L.; Chou, D.; Gemmill, A.; Tunçalp, Ö.; Moller, A.B.; Daniels, J.; Gülmezoglu, A.M.; Temmerman, M.; Alkema, L. Global causes of maternal death: A WHO systematic analysis. Lancet Glob. Health, 2014, 2(6), e323-e333.
[http://dx.doi.org/10.1016/S2214-109X(14)70227-X] [PMID: 25103301]
[http://dx.doi.org/10.1016/S2214-109X(14)70227-X] [PMID: 25103301]
[11]
Mgawadere, F.; Unkels, R.; Kazembe, A.; van den Broek, N. Factors associated with maternal mortality in Malawi: Application of the three delays model. BMC Pregnancy Childbirth, 2017, 17(1), 219.
[http://dx.doi.org/10.1186/s12884-017-1406-5] [PMID: 28697794]
[http://dx.doi.org/10.1186/s12884-017-1406-5] [PMID: 28697794]
[12]
Health Protection Surveillance Centre (HPSC). What is disease surveillance? 2019. Available from: https://www.hpsc.ie/abouthpsc/whatisdiseasesurveillance/
[13]
Observer Research Foundation. An analysis of maternal health condition across parliamentary constituencies in India. 2019. Available from: https://www.orfonline.org/expert-speak/an-analysis-of-maternal-health-condition-across-parliamentary-constituencies-in-india50535/
[14]
Kasturba Medical College, Manipal. Kasturba Hospital, Manipal. 2019. Available from: https://manipal.edu/content/dam/manipal/mu/kmc-manipal/Documents/Magazines-Newsletters/Kasturba%20Hospital-Overview%20CGM.pdf
[15]
Health statistics and information systems: Maternal mortality ratio (per 100 000 live births). Available from: https://www.who.int/healthinfo/statistics/indmaternalmortality/en/
[16]
World Health Organization. The WHO application of ICD-10 to deaths during pregnancy, childbirth and puerperium: ICD MM. 2012. Available from: https://www.who.int/reproductivehealth/publications/monitoring/9789241548458/en/
[17]
Bruce, N.G.; Pope, C.; Stanistreet, D. Quantitative methods for health research: A practical interactive guide to epidemiology and statistics 2008.
[http://dx.doi.org/10.1002/9780470725337]
[http://dx.doi.org/10.1002/9780470725337]
[18]
United Nations. Millenium development goals indicators. Available from: https://millenniumindicators.un.org/unsd/mdg/Metadata.aspx?IndicatorId=0&SeriesId=553
[19]
World Health Organization. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: executive summary. 2019. Available from: https://apps.who.int/iris/handle/10665/327596
[20]
India records 22% drop in maternal mortality rate. Available from: https://thewire.in/health/maternal-mortality-ratio-india-decline
[21]
Tayade, S.; Bagde, M.; Shivkumar, P.V.; Tayade, A.; Bagde, N. Maternal death review to know the determinants of maternal mortality in a District Hospital Of Central India. Int. J. Biomed. Res., 2012, 3(3), 157-163.
[http://dx.doi.org/10.7439/ijbr.v3i3.366]
[http://dx.doi.org/10.7439/ijbr.v3i3.366]
[22]
Shah, R.; Ali, I.; Banday, A.; Fazili, A.; Khan, I. Analysis of maternal mortality in a small teaching hospital attached to tertiary care hospital (a 10 yr review). Indian J. Community Med., 2008, 33(4), 260-262.
[http://dx.doi.org/10.4103/0970-0218.43234] [PMID: 19876502]
[http://dx.doi.org/10.4103/0970-0218.43234] [PMID: 19876502]
[23]
Paul, B.; Sen, M.; Kar, K.; Mohapatra, B. Facility based maternal death review: learning from maternal deaths in a teaching hospital of Eastern India. Int. J. Biomed. Res., 2013, 4, 12-20.
[24]
Bedi, N.; Kambo, I.; Dhillon, B.S.; Saxena, B.N.; Singh, P. Maternal deaths in India: Preventable tragedies (An ICMR Task Force Study). J. Obstet. Gynaecol. India, 2001, 51, 86-92.
[25]
Rao, K.B. Maternal mortality in a teaching hospital in southern India. A 13-year study. Obstet. Gynecol., 1975, 46(4), 397-400.
[PMID: 1080844]
[PMID: 1080844]
[26]
Shah, P.; Shah, S.; Kutty, R.V.; Modi, D. Changing epidemiology of maternal mortality in rural India: Time to reset strategies for MDG-5. Trop. Med. Int. Health, 2014, 19(5), 568-575.
[http://dx.doi.org/10.1111/tmi.12282] [PMID: 24533443]
[http://dx.doi.org/10.1111/tmi.12282] [PMID: 24533443]
[27]
Ngwenya, S. Postpartum hemorrhage: Incidence, risk factors, and outcomes in a low-resource setting. Int. J. Womens Health, 2016, 8, 647-650.
[http://dx.doi.org/10.2147/IJWH.S119232] [PMID: 27843354]
[http://dx.doi.org/10.2147/IJWH.S119232] [PMID: 27843354]
[28]
Kansal, A.; Kandpal, S.D. India’s story of reducing maternal mortality-achievement so far and commitments ahead. Indian J. Community Health, 2018, 30(2), 107-110.
[http://dx.doi.org/10.47203/IJCH.2018.v30i02.002]
[http://dx.doi.org/10.47203/IJCH.2018.v30i02.002]
[29]
Global Sepsis Alliance. WHO Statement on Maternal Sepsis. 2018. Available from: https://www.global-sepsis-alliance.org/news/2018/1/9/who-statement-on-maternal-sepsis
[30]
Ngonzi, J.; Tornes, Y.F.; Mukasa, P.K.; Salongo, W.; Kabakyenga, J.; Sezalio, M.; Wouters, K.; Jacqueym, Y.; Van Geertruyden, J.P. Puerperal sepsis, the leading cause of maternal deaths at a Tertiary University Teaching Hospital in Uganda. BMC Pregnancy Childbirth, 2016, 16(1), 207.
[http://dx.doi.org/10.1186/s12884-016-0986-9] [PMID: 27495904]
[http://dx.doi.org/10.1186/s12884-016-0986-9] [PMID: 27495904]
[31]
Maharaj, D. Puerperal pyrexia: A review. Part I. Obstet. Gynecol. Surv., 2007, 62(6), 393-399.
[http://dx.doi.org/10.1097/01.ogx.0000265998.40912.5e] [PMID: 17511893]
[http://dx.doi.org/10.1097/01.ogx.0000265998.40912.5e] [PMID: 17511893]
[32]
Leth, R.A.; Møller, J.K.; Thomsen, R.W.; Uldbjerg, N.; Nørgaard, M. Risk of selected postpartum infections after cesarean section compared with vaginal birth: A five-year cohort study of 32,468 women. Acta Obstet. Gynecol. Scand., 2009, 88(9), 976-983.
[http://dx.doi.org/10.1080/00016340903147405] [PMID: 19642043]
[http://dx.doi.org/10.1080/00016340903147405] [PMID: 19642043]
[33]
Smaill, F.M.F.; Gyte, G.M.G. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Syst. Rev., 2010, (1), CD007482.
[PMID: 20091635]
[PMID: 20091635]
[34]
Paruk, F. Infection in obstetric critical care. Best Pract. Res. Clin. Obstet. Gynaecol., 2008, 22(5), 865-883.
[http://dx.doi.org/10.1016/j.bpobgyn.2008.06.011] [PMID: 18693141]
[http://dx.doi.org/10.1016/j.bpobgyn.2008.06.011] [PMID: 18693141]
[35]
Acosta, C.D.; Knight, M. Sepsis and maternal mortality. Curr. Opin. Obstet. Gynecol., 2013, 25(2), 109-116.
[http://dx.doi.org/10.1097/GCO.0b013e32835e0e82] [PMID: 23385771]
[http://dx.doi.org/10.1097/GCO.0b013e32835e0e82] [PMID: 23385771]
[36]
Kodan, L.R.; Verschueren, K.J.C.; Kanhai, H.H.H.; van Roosmalen, J.J.M.; Bloemenkamp, K.W.M.; Rijken, M.J. The golden hour of sepsis: An in-depth analysis of sepsis-related maternal mortality in middle-income country Suriname. PLoS One, 2018, 13(7), e0200281.
[http://dx.doi.org/10.1371/journal.pone.0200281] [PMID: 29990331]
[http://dx.doi.org/10.1371/journal.pone.0200281] [PMID: 29990331]
[37]
Acosta, C.D.; Harrison, D.A.; Rowan, K.; Lucas, D.N.; Kurinczuk, J.J.; Knight, M. Maternal morbidity and mortality from severe sepsis: A national cohort study. BMJ Open, 2016, 6(8), e012323.
[http://dx.doi.org/10.1136/bmjopen-2016-012323] [PMID: 27554107]
[http://dx.doi.org/10.1136/bmjopen-2016-012323] [PMID: 27554107]
[38]
Puvanalingam, A.; Rajendiran, C.; Sivasubramanian, K.; Ragunanthanan, S.; Suresh, S.; Gopalakrishnan, S. Case series study of the clinical profile of H1N1 swine flu influenza. J. Assoc. Physicians India, 2011, 59, 14-16, 18.
[PMID: 21751659]
[PMID: 21751659]
[39]
Singhal, S.; Sarda, N.; Arora, R.; Punia, N.; Jain, A. Clinical profile & outcome of H1N1 infected pregnant women in a tertiary care teaching hospital of northern India. Indian J. Med. Res., 2014, 139(3), 454-458.
[PMID: 24820841]
[PMID: 24820841]
[40]
Jamieson, D.J.; Honein, M.A.; Rasmussen, S.A.; Williams, J.L.; Swerdlow, D.L.; Biggerstaff, M.S.; Lindstrom, S.; Louie, J.K.; Christ, C.M.; Bohm, S.R.; Fonseca, V.P.; Ritger, K.A.; Kuhles, D.J.; Eggers, P.; Bruce, H.; Davidson, H.A.; Lutterloh, E.; Harris, M.L.; Burke, C.; Cocoros, N.; Finelli, L.; MacFarlane, K.F.; Shu, B.; Olsen, S.J. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet, 2009, 374(9688), 451-458.
[http://dx.doi.org/10.1016/S0140-6736(09)61304-0] [PMID: 19643469]
[http://dx.doi.org/10.1016/S0140-6736(09)61304-0] [PMID: 19643469]
[41]
Nair, M.; Nelson-Piercy, C.; Knight, M. Indirect maternal deaths: UK and global perspectives. Obstet. Med., 2017, 10(1), 10-15.
[http://dx.doi.org/10.1177/1753495X16689444] [PMID: 28491125]
[http://dx.doi.org/10.1177/1753495X16689444] [PMID: 28491125]
[42]
Cirelli, J.; Surita, F.; Costa, M.; Parpinelli, M.; Haddad, S.; Cecatti, J. The burden of indirect causes of maternal morbidity and mortality in the processof obstetric transition: A cross-sectional multicenter study. Rev. Bras. Ginecol. Obstet., 2018, 40(3), 106-114.
[http://dx.doi.org/10.1055/s-0038-1623511] [PMID: 29609192]
[http://dx.doi.org/10.1055/s-0038-1623511] [PMID: 29609192]
