1. Identifying Factors Associated with Maternal Deaths in Jharkhand, India: A Verbal Autopsy Study Nizamuddin Khan, Manas Ranjan Pradhan J HEALTH POPUL NUTR 2013 Jun;31(2):262-271 By Dr Pranali Kothekar Moderator- Dr Chetna Maliye

2. Framework Learning objective Presentation of journal paper Critical appraisal

3. Learning objective Role of verbal autopsy for identifying social cause of maternal deaths

4. In Jharkhand State Total fertility rate was 3.3 31% using contraceptive method while 23% had an unmet need for contraception 57% received antenatal care, 17% of the mothers had a postnatal check-up Four out of every five births at home 43% were underweight, and 70% were anemic MMR in the state was 312—much higher than the national average of 254 (2006) Introduction

5. Objectives 1. understand the missed opportunities to save maternal lives 2. explore social dimensions contributing to maternal mortality 3. support the Government and other agencies to develop need- based area-specific strategies to addressing these issues.

6. Material and Method A cross-sectional study was carried out in 2008 in two phases. A multistage sampling design 1. Five districts, representing five divisions of the state, were selected using simple random sampling. 2. Three blocks from each district were selected using systematic random sampling. 3. Maternal deaths that occurred during the last one year prior to the study were considered for verbal autopsy.

7. The verbal autopsy tool 1. Background information 2. Brief obstetric history of the woman’s illness that led to death 3. General information about events preceding the deaths 4. Information regarding general illness leading to death and specific questions on symptoms and signs of the last illness 5. Information regarding treatment and care-seeking behavior of the deceased women 6. Additional information on rituals during pregnancy, childbirth, and after delivery performed by the communities

8. The verbal autopsies on maternal deaths were designed to provide interventions leading to prevent maternal deaths, besides giving an understanding of the causes of maternal deaths. Informed verbal consent conducted by trained research investigators who were postgraduates in social science and received a one-week intensive training verified by a team of doctors, including one obstetrician, before determining the actual cause of death

9. Analysis The analytical approach includes bivariate analysis through SPSS (version 15), besides triangulation of both qualitative and quantitative findings. For MMR, live births have been projected from the 2001 Census data for the same periods. Study follows WHO definition of maternal mortality.

10. Results Context of deceased women 85% of them had no education 74% were housewives, and 16% were working in agricultural sector 72% did not receive any antenatal care 16% had given birth in health facilities 81% died at home, 12% died in hospital, and the rest 7% died on their way to the hospital 45% of the women died within six weeks after delivery, 28% died during pregnancy, 26% died during delivery, and the rest died within six weeks after abortion

11. Results Factors associated with maternal death Deaths immediately after onset of complication Delays that resulted in maternal deaths Adherence to traditional rituals Unsafe abortion Poverty Poor health infrastructure

12. Delay in decision-making Time required to recognize Complication ≤1 day 2-7 days ≥8 days Never detected 5.8 (16) 65.3 (181) 25.3 (70) 3.6 (10) Delays in the search for, access to, and provision of adequate care Characteristics Percentage(Number)

13. Time between realizing a complication and seeking help Within one day 2-3 days ≥4 days 34.2 (91) 39.4 (105) 26.5 (73) Delay in travel time for arranging the transport <1 hour 1-<2 hours 2-5 hours >5 hours 38.9 (61) 30.6 (48) 22.9 (36) 7.6 (12)

14. Time to reach hospital <1 hour 1-<2 hours 2-5 hours >5 hours 20.4 (32) 22.3 (35) 40.8 (64) 16.6 (26) Delay in treatment Immediately/within 30minutes 31-59 minutes <5 hours >5 hours 46.5 (73) 28.0 (44) 17.8 (28) 7.6 (12) Number of facilities visited 1 2 3 or more 63.1 (99) 31.2 (49) 5.7 (9)

15. Discussion Medical and socioeconomic factors leading to maternal mortality are largely preventable. But, it remains a major public-health challenge. Most of the deceased were poor; non-literate, and housewives, indicating that certain sections of the society are more prone to maternal mortality. Provision of quality obstetric care and capacity-building of the existing health workforce is more important than improving health infrastructure. Community mobilization to increase the use of obstetric care and programmes addressing awareness-generation are equally important.

16. Critical appraisal Study follows most of the STROBE Checklist of criteria that should be included in reports of cross-sectional studies. In results details of each factor associated with maternal death not given.

17. Role of verbal autopsy for identifying social cause of maternal deaths The Verbal Autopsy is a technique whereby family members, relatives, neighbors or other informants and care providers are interviewed to elicit the information on the events leading to the death of the mother during pregnancy/abortion/delivery/after delivery in their own words to identify the medical and non- medical (including socio-economic) factors for the cause of death of the mother.

18. It involves three steps 1.data collection by interviewing relatives or others familiar with the circumstances of the death and who ideally were with the deceased during the events leading to death 2.assignment of cause of death using either individual or multiple physician reviews, expert algorithms or data driven algorithms 3.coding and tabulation of causes, ideally using the ICD

19. Uses 1. research tool in the context of longitudinal population studies, intervention research or epidemiological studies. 2. a source of cause of death and this cause-specific mortality data to be used in policy, planning, priority setting. 3. source of cause of death statistics to be used for monitoring progress and evaluation.

20. Advantages In contexts where most deliveries and deaths take place outside of health facilities, it can be the only way of ascertaining the cause of death In addition to medical causes of death, to provide important information on social and community factors associated with a maternal death and identifies barriers to accessing obstetric care

21. Limitations assumes most causes of death have distinct symptom complexes (and that can be recognized, and that is possible to classify causes into meaningful categories) causes of death have limited reliability when reported by lay- persons and can be subjective causes of death may be subject to under or over-reporting data collection is subject to the quality of training provided to interviewers as well as the quality of the VA questionnaire

22. Measurement issues can be supplemented with information from medical documents if available in the household or from health facilities Measurement requirements duplicate deaths need to be excluded sub-causes of maternal deaths must be coded and classified as maternal deaths data on births are needed

23. Social causes of maternal deaths Maternal death is often directly or indirectly influenced by various sociodemographic, economic and cultural issues. A. Delays that resulted in maternal deaths Verbal autopsy reports of all maternal deaths were examined to illustrate the delays in obtaining appropriate emergency obstetric care. 1. Delay in decision-making 2. Delay in travel 3. Delay in treatment

24. B. Adherence to traditional rituals some existing traditional practices lack scientific logic and often adversely affect the maternal health. Examples- women are discouraged to have adequate food during pregnancy, enhancing the risk of anemia and associated maternal complications. Pregnant women consume locally-available alcohol to avoid any pain. Again, delivering the baby with the help of relatives or at most by a traditional dai is quite common.

25. C. Unsafe abortion Important determinant of maternal death. Many were not only unaware of the consequences of unsafe abortion but also lacked knowledge about the facilities providing safe abortion. D. Poverty Poverty many a times, responsible for delay in treatment-seeking for any maternal health complications. E. Poor health infrastructure The available health facilities are inadequate, inaccessible, without required staff and, are providing poor-quality services.

26. Primary components to reduce maternal death 1.Enabling and Mobilizing individual and communities Improve individual, household, and community behaviors and norms Improve equity of access to and use of services by the most vulnerable

27. 2. Advancing quality and respectful care Strengthen integration of maternal health services with family planning Scale up quality maternal and fetal health care Prevent, diagnose, and treat the indirect causes of maternal mortality and poor birth outcomes Increase focus on averting and addressing maternal morbidity and disability Advance choice and respectful maternity care and improve working conditions for providers

28. 3. Strengthening health systems Strengthen and support health systems Promote data for decision-making and accountability Promote innovation and research for policy and programs

29. Thank you