MATERNAL MORTALITY

MMR remains high in the developing world India has the highest number of maternal deaths in the world (136,000 per annum) and accounts for 26% of all maternal deaths

The baseline data period only covers 36 weeks. Maternal mortality is a relatively rare event. To have a more accurate picture of the current situation regarding maternal mortality in this population 60 weeks of data have been analysed.

Definitions Maternal death - Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Maternal mortality rate – Maternal deaths per 100,000 live births. Pregnancy related death - The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. Late maternal death - The death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after the termination of pregnancy.

Maternal Outcome Crude Birth Rate 28 Number of live births 7278 Number of deaths to women of reproductive age (15-49) 148 Maternal Mortality Ratio per 100 000 live births (n) 770 (56) Number of late maternal deaths 4

Cause of death

Timing of maternal death

Place of death of Suru Lohar in Kuida, West Singhbhum 55% died at home 37% died in hospital 8% died in transit (3% to & 5% from facility) Place of death of Suru Lohar in Kuida, West Singhbhum

3 Three delay model Delays prior to maternal deaths . . . 1. Delay in seeking care 2. Delay in reaching care 3. Delay in receiving care

1. Delay in Seeking Care Reason for Delay No. Consulted village doctor ‘quack’ 22 Delay in recognising there was a problem / did not think it was necessary 16 Consulted a traditional healer ‘ojha’ / ‘kabiraj’ 15 Consulted a traditional birth attendant ‘dai’ 11 Consulted a private doctor / nurse 6 Unable to afford treatment Mother was too ill to be transported 4 No means of transport / poor roads / facility too far away Didn’t know where to go 2 Wait until traditional birth rituals are over 1 Husband was unavailable to give permission No one able to accompany Wait until festival was finished

2. Delay in Reaching Care Reasons for Delay No. Had to arrange transport 7 Too late at night to travel 6 Had to arrange finance 3

3. Delay Receiving Care Reasons for Delay No. Unable to treat complication 9 Referred to another facility 7 No blood available 6 No doctor available 4 Unable to afford treatment 1

Neonatal outcome for maternal and late maternal deaths

Balema “Balema’s labour pains started at around midnight on 31st January 2006. Her husband wanted to call the dai, but Balema would not allow it, saying that they should wait until the pains had increased. At 4:30am the pain increased and the dai was called, who arrived at 6am. She delivered the baby without any problems, but the placenta did not come out. The private nurse was called who gave her two injections, but when the placenta did not deliver she asked them to take her to the hospital. It took until 11:30 am before they were able to arrange transport and transferred her to hospital. One woman was already undergoing a caesarean section so no one was able to assist Balema. She was eventually examined by the doctor at 2:45pm. He said she needed oxygen and medicines but he could not give her any because the tube was cracked and there were no medicines in the hospital. The relatives tried to buy medicines from outside but all of the medical shops were closed. She was put on an intravenous drip but she died at 4pm on 1st February.”

Suryamani “Suryamani went into labour at around 10pm on 27th May 2005. She had still not delivered by 7am the following day, so a local private nurse was called. The nurse gave her two injections to induce labour and told her to wait until 12noon. When she had still not delivered, she was referred to the ‘village doctor’ at around 4pm. He gave her intravenous fluid and two more injections to induce labour and asked her to wait half an hour. At 7pm 28th May she delivered a stillborn baby boy. After the placenta had come out she tried to get up from the bed but she fell down and started bleeding profusely. She was given an oxytocic injection to try to stop the bleeding but when the bleeding did not stop, she was referred to a private qualified doctor. The doctor refused to see her as she had been referred by a village doctor. She was taken to a nursing home where she was told that she had lost a lot of blood and she would need five units of blood. The nursing home did not have a blood bank so she was referred to the medical college hospital. Suryamani reached the hospital at around midnight on 28th May but she was pronounced dead on arrival.”

Conclusion 5 Key Findings

Husband and children of Suru Lohar who died in Kuida, West Singhbhum First … Maternal death rates are extremely high in this largely tribal population. Husband and children of Suru Lohar who died in Kuida, West Singhbhum

Place of death of Mecho Tubid Dharamsai, West Singhbhum Second … Most maternal deaths in this population occur at home (55%) rather than at a facility (37%). Place of death of Mecho Tubid Dharamsai, West Singhbhum

Husband and child of Basanti Munda, Gajapur, Keonjhar Third … The findings contradict the widely held belief that two-thirds of maternal deaths occur around the intra- partum period. Husband and child of Basanti Munda, Gajapur, Keonjhar

Fourth … Verbal autopsies highlighted serious delays in seeking or receiving care for all maternal deaths. Husband, mother-in-law and 2 daughters of Moko Rautiya, who died in Tendrauli, West Singhbhum

Fifth … Sarkudar village, Keonjhar, Orissa Our study suggests a poor outcome for infants whose mothers suffer a maternal death, especially for girls.

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