Discuss maternal mortality with its causes and prevention.

Measurement and Causes

• Each element of that definition does work — the 42-day window, the requirement of a causal relationship, and the exclusion of accidental death; a woman killed in a road crash while pregnant is not a maternal death
• A late maternal death occurs between 42 days and one year; and pregnancy-related death is any death during pregnancy or within 42 days irrespective of cause, which is easier to measure and is what many surveys actually capture
• The ratio uses live births as the denominator and measures obstetric risk; the maternal mortality rate uses women of reproductive age and reflects both obstetric risk and fertility; and the lifetime risk combines the two — which is why a country with moderate MMR but high fertility can have a very high lifetime risk
• Maternal mortality IS the indicator showing the widest disparity between rich and poor countries of any health measure, which makes it a powerful indicator of both health system quality and of equity
• India has reduced its MMR substantially, but with wide inter-state variation — Kerala and Tamil Nadu approach developed-country levels while several central and eastern states remain far higher
• The direct obstetric causes, which account for the majority:
• Haemorrhage — the leading cause in India, chiefly postpartum haemorrhage, of which the commonest cause is uterine atony
• Sepsis — puerperal, and following unsafe abortion
• Hypertensive disorders — pre-eclampsia and eclampsia
• Obstructed labour and ruptured uterus
• Unsafe abortion
• The indirect causes, which are rising as a proportion as direct deaths fall — anaemia, which is a major contributor in India both directly and by reducing tolerance of haemorrhage; heart disease, particularly rheumatic mitral stenosis; malaria, tuberculosis, hepatitis and HIV
• The mnemonic for the classical causes is the "five" — haemorrhage, sepsis, hypertensive disease, obstructed labour and unsafe abortion
• The social and system factors underlying these — early marriage and adolescent pregnancy; high parity and short birth intervals; malnutrition and anaemia; illiteracy and low status of women; poverty; lack of transport; delivery by untrained attendants; and inadequate emergency obstetric care

The Three Delays and Prevention

• The three delays model is the most useful framework in this topic, because it locates the failure precisely and points to a different remedy for each:
• Delay 1 — delay in deciding to seek care, caused by failure to recognise danger signs, low status of the woman so that she cannot decide for herself, cost, previous poor experience of services, and cultural beliefs
• Its remedies — health education on danger signs, birth preparedness, women’s empowerment and education, and removing user fees
• Delay 2 — delay in reaching the facility, caused by distance, absent or unaffordable transport, poor roads and terrain
• Its remedies — free ambulance services such as 102 and 108, referral transport schemes, maternity waiting homes near facilities, and better roads
• Delay 3 — delay in receiving adequate care AT the facility, caused by absent staff, lack of blood, drugs or equipment, non-functioning operation theatre, and poor referral onward
• Its remedies — functional emergency obstetric care available 24 hours, blood storage units, trained staff, protocols and audit
• The value of the model is that it shows a woman may die despite deciding promptly and reaching a facility, if the facility cannot help her — so raising institutional delivery rates alone does not reduce mortality unless the institutions can actually manage emergencies
• That is the single most important lesson from India’s experience, where institutional delivery rose dramatically after JSY while MMR fell more slowly
• The interventions that reduce maternal death, in order of impact:
• Skilled attendance at every birth, by a person trained to manage normal labour and to recognise and refer complications
• Active management of the third stage of labour, which substantially reduces postpartum haemorrhage — comprising a uterotonic (oxytocin, or misoprostol where cold chain and skills are lacking) within one minute of delivery, controlled cord traction, and uterine massage
• Misoprostol deserves mention because it is heat-stable and oral, and can therefore be used at home births where oxytocin cannot
• Magnesium sulphate for eclampsia and severe pre-eclampsia, which is clearly superior to diazepam and phenytoin for preventing and treating convulsions
• Emergency obstetric care, classified as basic and comprehensive
• Basic (BEmOC) provides seven signal functions — parenteral antibiotics, parenteral uterotonics, parenteral anticonvulsants, manual removal of the placenta, removal of retained products, assisted vaginal delivery, and neonatal resuscitation
• Comprehensive (CEmOC) adds two more — caesarean section and blood transfusion
• The recommended provision is at least four basic and one comprehensive facility per 500,000 population
• Safe abortion services under the Medical Termination of Pregnancy Act, since unsafe abortion is an entirely preventable cause of death
• Family planning, which reduces maternal deaths simply by reducing the number of pregnancies and avoiding high-risk ones — too early, too late, too many and too close
• Antenatal and postnatal care, and treatment of anaemia
• Maternal death review (audit) — reviewing every maternal death to identify avoidable factors and act on them
• Its essential principle is that it must be conducted in a NO-blame, confidential manner focused on system failure, because a punitive audit produces concealment of deaths rather than improvement
• The INDIAN programmes — JANANI suraksha YOJANA (JSY), a conditional cash transfer promoting institutional delivery; JANANI SHISHU suraksha karyakram (JSSK), entitling free delivery including caesarean, free drugs, diagnostics, diet, blood and transport for mother and sick newborn; PMSMA; SUMAN, assuring dignified, respectful and zero-tolerance care; and LaQshya for labour room quality improvement
• Institutional delivery alone does not reduce death; the institution must actually be able to manage the emergency
• India proved that point itself, as facility delivery rose sharply while mortality fell more slowly
• Give oxytocin within one minute of delivery, with controlled cord traction and uterine massage
• Misoprostol is heat-stable and oral, so it can be used at home births where oxytocin cannot
• Magnesium sulphate beats diazepam and phenytoin for preventing and treating eclamptic convulsions
• Haemorrhage is the leading cause in India, most often postpartum and most often from uterine atony
• Anaemia kills both directly and indirectly, by reducing tolerance of the haemorrhage that follows
• The three delays each need a different remedy, which is what makes the model useful rather than merely descriptive
• Basic emergency care has seven signal functions and comprehensive adds caesarean section and blood transfusion
• Four basic and one comprehensive per five hundred thousand is the recommended provision to quote
• Maternal death review must be no-blame, since a punitive audit produces concealment rather than improvement
• Family planning prevents maternal deaths simply by reducing the number of pregnancies and avoiding risky ones
• Too early, too late, too many, too close summarises the pregnancies that family planning should prevent
• Unsafe abortion is entirely preventable, which makes safe abortion services a maternal mortality intervention
• The ratio uses live births and measures obstetric risk, while the rate uses women and reflects fertility too
• Lifetime risk combines risk and fertility, which is why high-fertility countries fare worse than their MMR suggests
• Maternal mortality shows the widest global disparity of any health indicator, which makes it a measure of equity
• A road death in pregnancy is not maternal, since the definition excludes accidental and incidental causes
• JSSK entitles free delivery and transport, including caesarean, drugs, diagnostics, diet and blood
• JSY is a conditional cash transfer, which raised institutional delivery substantially and rapidly
• Indirect causes rise as a proportion as direct obstetric deaths fall, which changes what services must provide
• Inter-state variation is enormous, with Kerala approaching developed-country levels and others far behind