Maternal Death Review in Andhra Pradesh,2013

INDIAN INSTITUTE OF HEALTH AND FAMILY WELFARE

August 2013

A RETROSPECTIVE STUDY ON

MATERNAL DEATH REVIEW IN

ANDHRA PRADESH [An analysis of data

from Anantapur, Guntur and YSR Cuddapah districts]

Dr. P. Satya Sekhar

Dr. Neelima Singh

Mr. Ch. V. S. Sitarama Rao


August 2013

A RETROSPECTIVE STUDY ON

MATERNAL DEATH REVIEW IN

ANDHRA PRADESH [An analysis of data

from Anantapur, Guntur and YSR Cuddapah districts]

Dr. P. Satya Sekhar

Dr. Neelima Singh

Mr. Ch. V. S Sitarama Rao

2

A RETROSPECTIVE STUDY ON MATERNAL DEATH REVIEW IN

ANDHRA PRADESH:

ANALYSIS OF DATA FROM ANANTAPUR, GUNTUR AND YSR CUDDAPAH

DISTRICTS

Dr. P. Satya Sekhar

Dr. Neelima Singh

Mr. Ch.V.S.Sitarama Rao


VENGALARAO NAGAR, HYDERABAD-38

August 2013

3

ACKNOWLEDGEMENTS

Maternal Death Review (MDR) has been identified as one of the tools to understand the systemic

obstacles and address them locally. Government of India has included MDR as one of the key

intervention approaches under National Rural Health Mission. Andhra Pradesh, a non-high focus

state, in collaboration with UNICEF and IIPH, Hyderabad operationalized MDR in 10 districts and

later it was expanded to all the districts by Indian Institute of Health and Family Welfare (IIHFW),

Hyderabad. MDR provides detailed information on various factors at facility, community, district,

state levels that is needed to be addressed to reduce maternal mortality ratio. The present

retrospective study of MDR in three specially selected districts was successfully completed, thanks

to the efforts and involvement of state and district authorities and individuals at different stages of

study. We would like to thank each and every one who was involved in it and contributed to its

success.

First of all, we are grateful to Sri Ajay Sawhney, IAS, Principal Secretary to Government (HM&FW) for

suggesting analysis of MDR data collated by the department. We are grateful to our former director

Sri D.S. Lokesh Kumar, IAS, who had been constantly guiding us and lent full support. We are

grateful to Smt. Poonam Malakondaiah, IAS, former commissioner, Health and Family Welfare, for

comments on an earlier presentation and Smt. Y.V. Anuradha, IAS, present Commissioner, Health

and Family Welfare and Director (FAC), IIHFW for her keen interest.

We are also thankful to the Department of Health and Family Welfare particularly Dr. G. Gowardhan

Reddy, Retired Regional Director (RCH), Dr. Tarachand Naidu, Additional Director, CHFW, Dr. P.

Rajendra Prasad, JD(Trainings), District Medical and Health Officers (DM&HO) and District MDR

Nodal officers (ADM&HO) of Anantapur, YSR Cuddapah and Guntur districts.

We appreciate the immense technical help received from Dr. V. Jayasankaraiah, Medical consultant

and Multi-skilled Technical Assistants, Mr. Mir Wajahat Ali, Mr. PVSN Kumar and Mr. K. Ravindra

Babu for compilation, data structure preparation, careful data entry and helping in data analysis.

We are very thankful to Dr. N.V.Rajeswari, faculty member for comments and suggestions on an

earlier draft.

Last but not the least, our sincere thanks to all family members and relatives of the women who

responded to the questionnaire and medical doctors of CHNCs for an efficient data collection work.

Dr. P. Satya Sekhar

Dr. Neelima Singh

Mr. Ch.V.S. Sitarama Rao

4

A RETROSPECTIVE STUDY ON MATERNAL DEATH REVIEW IN ANDHRA PRADESH:

Analysis of data from Anantapur, Guntur and YSR Cuddapah districts

CONTENTS

ACKNOWLEDGEMENTS

FACTSHEET

EXECUTIVE SUMMARY

LIST OF ACRONYMS

CHAPTER 1 INTRODUCTION

CHAPTER 2 WOMEN PROFILE AND BACKGROUND CHARACTERISTICS

CHAPTER 3 GEOGRAPHICAL LOCATION AND SEASONALITY OF

MATERNAL DEATHS

CHAPTER 4 TIMING OF MATERNAL DEATHS AND HEALTH SERVICE

UTILIZATION

CHAPTER 5 MEDICAL CAUSES OF MATERNAL DEATHS AND THREE DELAYs

IN SEEKING CARE

CHAPTER 6 SUMMARY, CONCLUSIONS AND FUTURE SETTING

REFERENCES

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LIST OF TABLES

Table: 1 Maternal mortality in India by states

Table-2 District-wise maternal deaths in Andhra Pradesh

Table 3 Socio-Demographic characteristics of women

Table: 4 Percentage distribution of maternal deaths by social group

Table-5 Distance from residence to the nearest health facility providing EmOC services

LIST OF APPENDICES

Appendix: 1 Five approaches for reviewing maternal deaths

Appendix-2 Studies on maternal mortality in Andhra Pradesh

Appendix-3 Maternal death review training strategy at district and sub-district levels

Appendix-4 List of causes of maternal mortality

LIST OF FIGURES

Figure-1 Training strategy of maternal death review

Figure-2 Women education levels and survival of live births

Figure-3 Women reporting place of maternal deaths by district

Figure-4 Timing of maternal deaths by districts

Figure-5 Number of antenatal care visits

Figure-6 Women reporting maternal deaths by parity

Figure-7 Pregnancy outcome of women whose maternal death was reported

Figure-8 Grading of health facilities and maternal deaths reported during 2012

Figure-9 Seasonality of maternal deaths January-December 2012

Figure-10 Timing of maternal deaths

Figure-11 Maternal deaths reported during antenatal period – treatment sought for symptoms

Figure-12 Problems faced by women during labour /delivery

Figure-13 Postnatal check-ups reported by women

Figure-14 Postnatal period maternal deaths in Anantapur district

Figure-15 Reasons for referral by providers to higher level facility

Figure-16 Medical causes of maternal death

Figure-17 District-wise cause of death by districts

Figure-18 Direct obstetric causes of maternal deaths

Figure-19 In-direct causes of maternal deaths

Figure-20 Maternal death causes by timing of death by districts

Figure-21 Three types of delay model in seeking health care

Figure-22 Decision making at household level by districts

Figure 23 Delay in reaching first level health facility

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LIST OF ACRONYMS

1 ADM&HO Additional District Medical Health Officer

2 AH Area Hospital

3 APNA Andhra Pradesh Nursing Association

4 APVVP Andhra Pradesh Vaidya Vidhana Parishad

5 ASHA Accredited Social Health Activist

6 AWW Anganwadi Worker

7 BCC Behavior Change Communication

8 CBMDR Community Based Maternal Death Review

9 CES Coverage Evaluation Survey

10 CESS Centre for Economic & Social Sciences

11 CHC Community Health Centre

12 CHNC Community Health and Nutrition Centre

13 DC District Collector

14 DCHS District Community Health Officer

15 DH Director of Health

16 DM&HO District Medical Health Officer

17 DME Director of Medical Education

18 DPHNO District Public Health Nursing Officer

19 EAG Empowered Action Group

20 EMOC Emergency Obstetric Care

21 EMRI Emergency Management Research Institute

22 FBMDR Facility Based Maternal Death Review

23 FOSGI Federation of Obstetric and Gynaecological Societies of India

24 GOAP Government of Andhra Pradesh

25 GOI Government of India

26 HIV/AIDS Human Immune Virus / Acquired Immune Deficiency Syndrome

27 HM&FW Health Medical and Family Welfare

28 HPN Health Professions Network

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29 ICPD International Conference on Population and Development

30 IEC Information, Education and Communication

31 IFA Iron Folic Acid

32 IIHFW Indian Institute of Health and Family Welfare

33 IIPH Indian Institute of Public Health

34 JSSK Janani Shishu Suraksha Karyakram

35 JSY Janani Suraksha Yojana

36 KAP Knowledge Attitude Practice

37 LSAS Life Saving Anesthetic Skills

38 MAPEDIR Maternal and Perinatal Death Inquiry and Response

39 MDG Millennium Development Goals

40 MMR Maternal Mortality Ratio

41 MO Medical Officer

42 MVA Manual Vacuum Aspiration

43 NFHS National Family Health Survey

44 NNMR Neo-Natal Mortality Rate

45 NRHM National Rural Health Mission

46 OB&GY Obstetrics and Gynecology

47 PHC Primary Health Centre

48 PPH Post-Partum Haemorrhage

49 RCH Reproductive and Child Health

50 SNO State Nodal officer

51 SPHO Senior Public Health Officer

52 SPSS Statistical Package for Social Sciences

53 TBA Trained Birth Attendant

54 UNICEF United Nations Children Education Fund

55 VHND Village Health Nutrition Day

56 WHO World Health Organization

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A RETROSPECTIVE STUDY ON MATERNAL DEATH REVIEW IN ANDHRA PRADESH:

ANALYSIS OF DATA FROM ANANTAPUR, GUNTUR AND YSR CUDDAPAH DISTRICTS

FACT SHEET

S. NO INDICATOR ALL 3

DISTRICTS

ANANTAPUR GUNTUR YSR

CUDDAPAH

1 Number of maternal deaths 167 51 64 52

2 Number of CHNCs 69 18 17 14

3 Number of PHCs 232 80 82 70

BACKGROUND INFORMATION (according to maternal death data)

4 % Women married before 18 years of age 12.0 17.6 4.7 12.0

5 % Women married at 18-25years of age 80.8 80.4 79.5 80.8

6 % Women belonging to Hindu religion 82.6 94.1 81.3 73.6

7 % Women belonging to SC&ST community 37.1 35.3 50.0 23.1

8 % Women reporting house activities as

occupation

61.7 52.9 60.9 71.2

9 % Women with no formal education 46.7 43.1 54.7 40.4

10 % women with zero and one parity 64.6 64.7 70.4 57.7

11 Mean age of women reporting age at death 24.15 23.94 24.25 24.2

12 % women reporting maternal death in 19-25

years group

70.1 72.5 67.2 71.2

13 % women reporting at pregnancy

• < 16 weeks 1.8 - 1.6 3.8

• 17-28 weeks 16.2 15.7 17.2 15.4

• >=29 weeks 45.5 39.2 37.5 61.5

• No information 36.5 45.1 43.8 19.2

14 % Women reporting type of maternal death

• Abortion 2.4 3.9 1.6 1.9

• Antenatal 19.2 15.7 17.2 25.0

• Delivery (Intra-natal) 25.7 35.3 20.3 23.1

• Post natal 52.7 45.1 60.9 50.0

15 % Women reporting place of maternal death

• Home 12.6 7.8 7.8 23.1

• Transit period 16.8 17.6 17.2 15.4

• Government facility 41.3 37.3 48.4 36.5

• Private facility 29.4 37.3 26.6 25.0

16 Time duration of fatal illness between

admission to first institution to final

institution

• One day 76.6 80.4 87.5 59.6

• 2-5 days 16.2 15.7 9.4 24.9

• 6 & above days 7.2 3.9 3.1 15.5

17 Time duration between maternal death and

admission to final institution

• One day 38.3 45.1 35.9 34.6

• 2-5 days 40.2 39.2 42.2 38.5

• 6 & above days 21.5 15.7 21.9 26.9

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DISTRICTS


CUDDAPAH

INFANT SURVIVAL STATUS

18 % newborn status of survival

• Alive 50.8 45.0 59.4 46.2

• Newborn death 1.8 2.0 3.1 -

• Stillbirth 17.4 21.6 14.1 17.3

• Not reported 29.9 31.3 23.4 36.5

AVAILABILITY OF HEALTH FACILITIES, SERVICES AND TRANSPORT

19 % women reporting nearest health facility

providing EmOC services

• No facility 13.8 13.7 17.2 9.6

• PHC 15.6 23.5 10.9 13.5

• Government hospital 55.0 47.1 62.5 53.8

• Private hospital 15.6 15.7 9.4 23.1

20 % Number of institutions visited by women

before death

• One facility 49.1 41.2 64.0 38.5

• 2-3 facilities 42.6 53.0 29.7 60.1

• 4 & above facilities 8.3 5.8 6.3 14.0

21 % health institutions not provided reason for

referral to higher/other health facility

93.4 86.2 98.4 94.3

CURRENT PREGNANCY

22 % women who availed antenatal care 88.0 88.2 84.4 92.3

23 % women reporting place of ANC

• Sub-center 59.9 62.7 59.4 57.7

• Private hospital 15.3 9.8 18.8 17.3

24 % women who availed 4 & above ANC

checkups

49.3 50.0 42.6 56.0

DEATHS DURING THE ANTENATAL PERIOD (N=32)

25 % Women reporting problems during ANC 81.3 66.7 100.0 69.2

26 Out of women reporting problems, % women

who attended hospital

71.9 62.5 90.9 61.5

DEATHS DURING INTR-ANATAL SERVICES (N=43)

27 % Women delivered in health facility 81.3 83.3 84.6 75.0

28 % women attended by a health personnel 62.8 66.7 53.4 66.6

29 % Women who had normal delivery 51.1 55.5 38.5 58.3

30 % Women delivered a live birth 58.1 72.2 61.5 33.3

DEATHS DURING POSTNATAL PERIOD

31 % Women reporting at least 2 postnatal

checkups

26.1 30.4 20.5 30.8

32 % Women reporting problems following

delivery

82.9 82.6 79.5 88.5

33 % Women who sought treatment during post

natal period

83.5 78.3 74.2 86.9

34 % women seeking treatment from

MO/SN/ANM (Govt. sector)

45.9 75.0 56.5 45.0

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DISTRICTS


CUDDAPAH

35

Medical causes of death

• Direct obstetric causes 56.9 62.7 53.1 55.8

• In-direct obstetric causes 26.9 27.4 25.0 28.8

• Non-obstetric & Unknown causes 13.1 9.8 21.9 15.4

36 Major direct obstetric causes

• Hemorrhage –APH 2.4 3.9 1.6 1.9

• Hemorrhage –PPH 11.4 9.8 14.1 9.6

• Hypertensive disorders during

pregnancy

15.6 19.6 10.9 17.3

• Sepsis 9.6 13.7 7.8 7.7

• Thrombo embolism 9.6 11.8 7.8 9.6

37 Major in-direct obstetric causes

• Severe anemia 4.8 5.9 4.7 3.8

• Endocrine disorders 1.2 2.0 - 1.9

• Infectious diseases 9.6 11.8 10.9 5.8

• Liver disorders 1.2 - 3.1 -

• Renal disorders 1.8 - 3.1 1.9

38 Major non-direct obstetric & unknown

causes

• Non-Obstetric surgical causes 0.6 - - 1.9

• Injury due to burns 1.2 - - 3.8

• Injury due to accidents 0.6 - - 1.9

• Snakebite 0.6 - - 1.9

• Un-known causes 13.2 9.8 21.9 5.8

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EXECUTIVE SUMMARY

GOAP undertook CBMDR and FBMDR initiatives, effectively since 2011 with appropriate authorities

for data collection from every CHNC/district. The purpose of maternal death audit was to identify

inadequacies and shortcomings in the work system and to provide future directions at district level.

The IIHFW was given an opportunity to analyze the MDR formats for the first time by the

Department of HM&FW, GOAP. After careful scrutiny by Gy & OB specialists and statistical

personnel, the 167 MDR formats from Anantapur, Guntur and YSR Cuddapah districts were

analyzed using SPSS package.

Out of 167 maternal deaths covered in the study (January-December 2012) most of the deaths

(80%) happened at health institutions while others happened at home. About 53% of the maternal

deaths occurred after the child birth which denotes that poor post-partum care and complications

accentuated after the child birth because of three types of delays. There were 52.7% postpartum,

25.7% intra-partum and 19.2% antenatal period deaths while 2.4% deaths occurred due to medical

abortion.

While investigating socio-economic status of the women who succumbed to maternal death, it was

found that 33% were from scheduled castes and scheduled tribes communities. More than half of

women were in the age group of 19-24 years and 12% women married before legal age of 18 years.

Most of the deceased women were illiterate (47%) and nearly 62% were housewives.

Most of the deaths took place at health facility namely, private institutions (31.1%) followed by

medical college hospitals (28.2%) and government district/sub-district hospitals(13.7%). A

substantial proportion occurred during transit period (16.8%) and home (10.2%).

Across the three districts more than one-third (37%) women died belonged to zero parity and 23%

of women in first parity. The birth interval, which is an important factor of safe pregnancy and

delivery, needs to be included in the CBMDR formats.

When asked on the antenatal care, it was found that only 49% of the deceased had taken 4 and

above ANC checkups. However, the MDR formats did not provide information on quality aspects of

ANC services availed (TT injections received, receipt of IFA tablet/syrup supply and consumption,

investigations done, high risk identification etc). Hence, we are unable to comment on full ANC

care (3 ANC + one TT injection and consumption of 100 IFA tablets) coverage during pregnancy.

The section 5 of CBMDR format requires modifications by incorporating the above aspects.

The factors, namely unawareness of danger signs (38.4%), illiteracy and ignorance (38.1%), delay in

decision-making (27.4%), delay in mobilizing funds (19.9%), and lack of birth preparedness (15.2%)

are found to be the areas of concern in the study.

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In case of postnatal deaths, the columns of delivery particulars were not collected in the format by

majority of the investigating teams. In future training/re-orientation, these aspects need to be

emphasized.

Only 4 numbers of maternal deaths out of abortion were reported. One abortion happened at

home, 2 cases took place in private health institutions. Three of the four abortions are spontaneous

abortions.

77% of the deceased family members sought care as soon as complications were found, but 51%

women died within 24 hours after final institutional admission.

50.9% of cases were referred to two or more health facilities but still maternal death happened for

lack of delay and inappropriateness of facility / services.

The present analysis suggests that maternal deaths are geographically concentrated in specific

pockets of a district. Health facilities with Grade-1 and Grade-II level performance indicators

reported higher number of maternal deaths indicating a mis-match of service availability and

deployment of health personnel. Anantapur and YSR Cuddapah districts require fulfillment of IPHS

norms in health facilities along with support by specialist doctors or medical officers, who are

trained in Life Saving Anesthetic Skills (LSAS) and staff nurses / maternity assistants who are trained

in SBA and NSSK. In Guntur district, majority of the health facilities are ranked as Grade-1 reporting

maternal deaths in the referral jurisdiction area. Upgradation of 2 to 3 strategically located FRUs

with EmOC facilities along with blood bank / blood storage units and surgical operation facilities (C-

section) is required.

The causes of death due to fatal illness like PPH, hypertension disorders, sepsis, heart disease

complicated pregnancy and severe anemia were also assessed in each maternal death review. The

direct medical causes that contributed to maternal mortality were observed in 95 cases (56.9%). In

the direct causes group, hypertensive disorders (27.4%), hemorrhage (24.2%), sepsis (17%) and

thrombo embolism (17%) were the contributors. In the indirect causes group, infection diseases

(35.6%), heart disease complicated pregnancy (27%); severe anemia (17.8%) and renal disorders

(6.7%) were the reasons. Control of vector borne diseases in tribal and backward areas with

medicated mosquito nets goes a long way in preventing maternal deaths.

Though NRHM is providing unprecedented resources to states to address the ‘Continuum of Care’

issues, studies have indicated a slow progress with wide inter-state and inter-district variations on

maternal and child health indicators. The SBCC strategy of ‘Amma Kongu’, brand of CARE and DARE

strategy can be effectively implemented to fasten the slow reduction of maternal mortality.

1

Chapter 1

INTRODUCTION

Background

Every maternal death is a tragedy. What is an even greater tragedy

is failing to learn from why a mother died - Matthews Mathai

Maternal Mortality Ratio (MMR) which measures number of women of reproductive age (15–49

years) dying due to maternal causes per 1,00,000 live births, is a sensitive indicator of the

quality of the health care services. At national level, MMR declined to 212 per 100,000 live

births in 2007-09 from 254 in 2004-06 indicating a decline of 5.8 per cent per year which is well

short of the Eleventh Plan goal of 100. Across states, Kerala (81), Tamil Nadu (97) and

Maharashtra (104) have reached MDG targets, while Andhra Pradesh (134), West Bengal

(145), Gujarat (148) and Haryana (153) are in closer proximity (Table-1). The maternal death

reviews in the Empowered Action Group (EAG) states which had higher rates of MMR identified

gaps in Ante-natal care, skilled birth attendance and Emergency obstetrical care as major

factors (Planning Commission, 2013).

Every year in India, around 28 million women experience pregnancy and 26 million have a live

birth. Of these an estimated 54,000 maternal deaths and one million newborn deaths occur

each year (WHO, 2012). It is not enough to know the level of maternal deaths to prevent further

deaths, but one should understand responsible causes (medical and socio-behavioral factors)

that led to deaths.

Based on the recommendations of the International Conference on Population and

Development (ICPD, 1994), the Government of India (GOI) reoriented the family planning and

maternal and child health programs into the Reproductive and Child Health (RCH) Programs.

The program’s second phase, RCH-II was initiated in 2005 with an objective of reducing MMR

by expanding quality services at delivery points by offering ‘safe delivery, emergency obstetric

care and quality services’ (NRHM, 2005).

Table-1: Maternal Mortality in India by States

India and major states Maternal mortality ratio (MMR) Drop in MMR

(2004-06) to

(2007-09) 2004-06 2007-09

Assam 480 390 90

Bihar, including Jharkhand 312 261 51

Madhya Pradesh, including

Chhattisgarh

335 269 66

2

India and major states Maternal mortality ratio (MMR) Drop in MMR

(2004-06) to

(2007-09) 2004-06 2007-09

Orissa 303 258 45

Rajasthan 388 318 70

Uttar Pradesh, including Uttaranchal 440 359 81

Andhra Pradesh 154 134 20

Karnataka 213 178 35

Kerala 95 81 14

Tamil Nadu 111 97 14

Gujarat 160 148 12

Haryana 186 153 33

Maharashtra 130 104 26

Punjab 192 172 20

West Bengal 141 145 -4

India 254 212 42

Source: Registrar General of India, Ministry of Home Affairs (SRS Estimates)

In 2005, the GOI launched the National Rural Health Mission (NRHM) subsuming RCH-II. After

completing seven years of NRHM, the Eleventh Five Year Plan (2007-12) revealed that four

innovations namely Janani Suraksha Yojana (JSY), ‘Dial 108’ ambulance system to address

emergency transport, multi-tasking of non-specialist medical officers for the provision of EmOC

and the Janani Shishu Suraksha Karyakram (JSSK) in order to reduce financial barriers in

accessing care by Indian states significantly contributed for the reduction of MMR and IMR

(Planning Commission, 2013).

Among several alternative techniques available to estimate MMR are the direct household

survey method, sisterhood method, reproductive age mortality studies, verbal autopsy and

census (Rai et al, 2012) [ see Appendix-1]. Currently no standard method has been adopted

worldwide to document the burden of maternal mortality and these acts as a major hurdle in

making global comparisons. Gauging the progress of MDG-5 is challenging due to lack of civil

registration systems in more than 181 countries and half (51%) of maternal deaths go un-

reported (WHO, 2012).

Maternal Death Review (MDR) as a strategy has been spelt out clearly in the RCH-II National

Programme Implementation Plan document. It is an important strategy to improve the quality of

obstetric care and reduce maternal mortality and morbidity. MDR provides detailed information

on various factors at facility, community, district, regional and state level that is needed to be

addressed to reduce maternal deaths. MDR analysis will identify the delays that contribute to

maternal deaths at various levels and the information can be used to adopt measures to fill the

gaps in service delivery (IIPH-UNICEF, 2012). The UNICEF- MAPEDIR (2006) initiated a

3

confidential inquiry to examine causes of maternal death, generate local evidence, sensitize

communities and health officials and galvanize necessary actions (UNICEF, 2008). MDR has

been conducted as an established intervention strategy for the last few years in Tamil Nadu,

West Bengal and Kerala and significantly reduced MDR.

Maternal death audit in Andhra Pradesh

The GOI adopted the MDR by recommending Community Based Maternal Death Review

(CBMDR) and the Facility Based Maternal Death Review (FBMDR) to every state in identifying

gaps in the existing health delivery systems, prioritization and plan for intervention strategies

under NRHM initiatives. Andhra Pradesh also initiated the MDR review in the state since 2011

to identify the factors responsible for maternal deaths.

There have been three attempts in the past to introduce MDR in the state during 2002 and

2005 ( Ref:1 G.O. Ms. No. 287 HM&FW (D1) Dept dated 9-7-2002; Ref:2 G.O. Ms. No, 60,

HM&FW (D1) Dept. dated 21-2-2004 and Ref:3 G.O. Rt. No. 1016 HM&FW (D1) Dept dated

23-9-2005) but the pace of implementation remained slow due to non-adaptation of GOI

guidelines, systemic gaps in availability of human resources and lack of clear roles and

responsibilities at state and district level key stakeholders.

Review of literature

Innovative approaches and low-cost solutions save millions of lives of mothers and newborns

by accessing basic health care services - before, during and after delivery. Knowing the

magnitude of MMR in a region/district is not sufficient for local interventions and it must be

supported by an in-depth analysis of each maternal death for providing practical solutions. A

number of studies have been conducted on maternal mortality in Andhra Pradesh. A summary

of the studies is presented in Appendix-2.

The review of literature indicates the crucial observations on maternal mortality review in

Andhra Pradesh. Higher percent of maternal deaths reported among households with illiterate

mothers, low economic status and scheduled caste and scheduled tribe communities.

Seasonality of maternal deaths and concentrated among backward and un-reachable areas in

a district. Studies reported maternal deaths among teen ages and 35 and above age group

women. More than half of deaths reported among women in higher birth order. Home and

transit period (from home to health facility / higher referral) were important place of maternal

deaths. Most common time of maternal deaths was during post natal period. The major direct

and indirect causes of maternal death were post partum hemorrhage, hypertension disorders in

pregnancy, sepsis and severe anaemia.

4

NRHM made a commitment in 2005 to provide good quality maternity services within Indian

Public Health standards. However, studies conducted on service availability of health facility

indicated a sub-optimal achievement (DLHS-3, 2007-08; Satya Sekhar et al, 2009; CHFW,

2010).

The findings of present review indicates the need for a) a well structured awareness campaign

on female literacy, age at marriage, delay in teenage pregnancy and steps to correct wrong

cultural practices; b) provision of EmOC care to address direct and indirect maternal causes; c)

steps to correct persisting anemia related problems among women and children; d) re-

deployment of skilled personnel to higher workload facilities, round-the-clock availability of

specialists (private doctors on per-call basis or PHC doctors trained on LSAS training) in

backward and tribal areas; e) BCC campaign on micro-birth planning for pregnant women and

post partum care to delivered mothers.

Need for the study

• Maternal mortality is a useful indicator not only to capture the reproductive health status

of women but also to get an idea of the adequacy of maternal services provided to

women in health facilities. Of the 5.8 percent decline per annum at national level,

maternal mortality will touch 139 by 2015 and 123 by 2017. An achievement of the

Millennium Development Goal (MDG) of reducing MMR to 109 by 2015 would require

acceleration of new innovations.

• Recent projections in Andhra Pradesh that MMR expected to reach 115 per lakh by

2015. The same across districts indicate special attention particularly in Srikakulam,

Vizianagaram, Visakhapatnam in Coastal Andhra region, Anantapur and Kurnool in

Rayalaseema region and Mahabubnagar, Khammam and Adilabad in Telangana region.

It may be observed that with around sixteen lakh deliveries per annum in the state, with

an MMR of 134 per lakh live births (2007-09), about 2100 to 2140 maternal deaths are

expected per annum in the state. However, disagreement prevailed between CBMDR

maternal deaths reported by HMIS and above 2140 maternal deaths (a margin of 40-

50% respectively) (Table-2). A significant increase in reporting of maternal deaths from

974 maternal deaths in 2012-13 against 510 during 2008-09 was evident, recording a

fifty percent increase in four years period.

During 2008-12 period, less than 20 maternal deaths were reported from Warangal, Adilabad

and East Godavari districts. A higher number of maternal deaths are generally expected in

backward and tribal districts due to inadequate EmOC services. This may be explained due to

punitive actions against health personnel by higher authorities or timely referral to higher health

facility /private nursing home require further evidence.

5

Table-2 District-wise maternal deaths in Andhra Pradesh

S. No. District 2008-09 2009-10 2010-11 2011-12 2012-13

1 Srikakulam 13 21 33 29 30

2 Vizianagaram 44 36 44 29 32

3 Visakhapatnam 38 63 60 64 72

4 East Godavari 15 27 26 44 24

5 West Godavari 13 14 23 17 38

6 Krishna 11 23 24 23 33

7 Guntur 40 49 61 53 87

8 Prakasam 23 39 35 32 32

9 Nellore 3 26 27 54 38

10 Chittoor 21 30 48 51 80

11 YSR Cuddapah 4 46 50 55 65

12 Anantapur 18 42 38 51 54

13 Kurnool 26 51 54 96 60

14 Mahabubnagar 36 20 20 30 53

15 Rangareddy 2 11 32 27 34

16 Hyderabad 55 9 9 7 35

17 Medak 54 38 31 36 31

18 Nizamabad 21 37 20 25 33

19 Adilabad 4 13 13 7 16

20 Karimnagar 2 4 13 20 42

21 Warangal 21 31 16 23 20

22 Khammam 32 31 32 23 26

23 Nalgonda 14 20 25 16 39

Andhra Pradesh 510 681 734 812 974

Source: Commissionerate of Health and Family Welfare, Hyderabad

From the beginning of year 2011, MDR information has been collected in CBMDR and FBMDR

formats in all districts of the state. In MDR review, ASHA /ANM identify the maternal death in

the village and inform the PHC medical officer and CHNC. In the second step, an investigating

team collects information from the family members of the deceased woman about medical

causes and three delays related to seeking care along with family background characteristics.

In the case of health facility, the medical officer in charge intimates the death to facility nodal

officer and district MDR authorities. The review formats after scrutiny at the CHNC, district

nodal officer duly submits to the District Collector for a review with a team of medical experts

along with family members/relatives of the deceased woman for verification of the correctness

of the collected information.

6

The present study is an attempt to analyze the causes and factors that led to maternal mortality

at district level using CBMDR and FBMDR formats collected by the three district nodal officers.

The specific objectives of the study were as follows:

a) To assess the direct, indirect and non-medical causes of maternal deaths

b) To assess the influence of socio-economic, demographic and other factors that led

to death

c) To identify mandals reporting higher number of maternal deaths in a calendar year

and suggest corrective measures

d) To identify gaps in three delays model

Materials and methods

CHFW entrusted the analysis of district-level MDR to the Indian Institute of Health and Family

Welfare (IIHFW) and on a priority basis requested analysis of data from Anantapur, Guntur and

YSR Cuddapah districts by first fortnight of May 2013. The original CBMDR and FBMDR

formats were collected by IIHFW from Anantapur, Guntur and YSR Cuddapah district nodal

officers. The IIHFW with due permissions from the CHFW, Hyderabad, intimated the authorities

of Anantapur, YSR Cuddapah and Guntur districts to submit the original CBMDR formats

reviewed by the District Collector/Magistrate during January-December 2012. The original

questionnaires were handed over to IIHFW through a messenger in April 2013.

In the first stage, the filled-in questionnaires were scrutinized by a team of medical experts for

triangulation of information from cause of death particulars and open review narrated by family

members. The IIHFW computer center developed the data structure in EPInfo-6 and entered

the data in the structured format. After manual and computer consistency checks, uni-variate

and cross tabulation analysis was carried out using SPSS Version 16.0.

The chapterisation of the report is given below. Chapter 1 covers the aspects of problem

setting, review of literature and materials & methods, analysis of maternal deaths based on

background variables (Women profile, socio-demographic characteristics) is presented in

Chapter 2. Chapter 3 deals with geographical location and seasonality aspects of maternal

deaths. Chapter 4 includes timing of maternal deaths and health seeking behavior. Chapter 5

includes medical causes of maternal deaths and three delays in seeking care. Last section

presents an overview of the study in the form of discussion and conclusions.

7

Chapter 2

WOMEN PROFILE AND BACKGROUND CHARACTERISTICS

Knowing just the level of maternal mortality is not enough to prevent further deaths; there is a

need to understand causes/factors that led to the deaths. The maternal mortality ratio in India

has declined to 212 per lakh live births in 2007-09 by 89 deaths since 2001-03. However, the

same (SRS, 2007-09 estimates) demonstrate wide inter-state disparities from 390 in Assam

state as compared to 81 in Kerala state. Several studies indicate that the progress made in

maternal and child health indicators is uneven and inequitable, and many women still lack

access to maternal and reproductive health care (NFHS-3, 2005-06; CES 2010).

Retrospective analysis of 167 maternal deaths reported from the three selected districts

Anantapur (51), YSR Cuddapah (52) and Guntur (64) formed as the basic information for the

study. IIHFW collected original CBMDR and FBMDR formats from the districts with the

permission of the State MDR Nodal officer, CHFW, Hyderabad.

Women’s age at marriage

It was found in the study that only 12% of women married below 18 years of age. About 81%

women married in the age group 18 to 25 years. Only 7.2% women married after 26 and above

age (Table-3).

Women’s age and maternal death

The mean age of women who reported maternal deaths was 24.15 years. About 37 (22.2%)

women died below 20 years of age. About half (49.7%) of women reported maternal deaths in

21-25 age group and remaining 28.1% above 26 years respectively. Research studies on

maternal mortality showed that 61% of reported maternal deaths in Medak (Singh, 2010) and

71% in Mahabubnagar (CESS, 2012) women were less than 18 years of age. The shift from

teenage deaths from earlier studies is a welcome sign and attributed due to increase of median

age at marriage to 16.1 years among women age in 2005-06 (NFHS-3) from 15.6 years in

1998-99 (NFHS-2) in the state. This may be one of the possible reasons for decline of teenage

deaths in the study.

8

Table 3 Socio-Demographic characteristics of women

S. No

Characteristic Number (%) Chi-Square & significance

1 Age at marriage (yrs)

Below 18 20 12.0

18-25 135 80.8 20.18 (.010)

26 & above 12 7.2

2 Age of women at the time of death (yrs)

Below 20 37 22.2

21-25 83 49.7 3.63 (.725)

26-29 32 19.2

30 & abobe 15 9.0

3 Social Group

SC&ST 62 37.1

OBC 50 29.9 18.49 (.005)

Other groups 55 32.9

4 Education of woman

Illiterate 78 46.7

Up to 8th 50 29.9 12.446 (.053)

Up to 12th 33 19.8

Graduate 6 3.6

5 Parity

0 62 37.1

1 46 27.5

2 30 18.0 15.654 (.110)

3 & above 16 9.6

Not reported 13 7.8

6 Infant survival

Alive 85 50.8

Newborn death 3 1.8 7.790 (.454)

Still birth 29 17.4

Not applicable 50 30.0

7 Number of Antenatal checkups during last pregnancy

1 8 4.8

2-3 66 39.5 4.49 (.610)

4& above 75 44.9

Not known (undelivered gestation including abortions)

18 10.8

8 Place of maternal death

Home 16 10.2

Medical college hospital/APVVP facility 74 41.9 6.245 (.396)

Private 49 31.1

Transit 28 16.8

9

Caste and maternal deaths

Research studies indicated that 50-54 percent of women reporting maternal deaths were from

scheduled castes and scheduled tribe communities (IIHFW, 1997; CESS, 2012 and Singh,

2010). However, contrary to above observations, the present CBMDR study conducted in year

2012 showed maternal deaths among women from scheduled caste and tribes as 37.1%, other

backward castes (30%) and other caste groups (32.9%) (Table-4). Across the districts, the

Janani Suraksha Yojana (NRHM-JSY) intervention made a significant impact in improving the

institutional deliveries among SC&ST (particularly BPL group) communities (GOAP-PIP, 2013-

14) but the higher percent (50%) of maternal deaths in Guntur district was among SC &ST

communities requiring further probing.

Table: 4 Percentage distribution of maternal deaths by social group

District S.C & S. T OBC Other Castes All

Anantapur 35.3 43.1 21.6 100(51)

Guntur 50.0 15.6 34.4 100 (64)

YSR Cuddapah 23.1 34.6 42.3 100 (52)

All 3 districts 37.1 29.9 32.9 100 (167)

Chi-square (6 df) - 18.48 (p=.005)

Education level of woman and maternal deaths

It was revealed from the study that

46.7% were illiterate women died

due to pregnancy related

complications and rest are literate.

Among the latter nearly 29.9% of

respondents have studied up to 8th

standard and 19.8% had studied

up to 2+ level (Figure-2). Because

of poor educational status of

women, several BCC strategies

undertaken by the government

from time to time did not inculcate

or enhanced health seeking behavior.

10

Occupation status

Occupation is determined by level of education and literacy of the families. Since most of the

respondents are illiterate, 61.7% reported maternal deaths were among housewives doing only

household works.

Place of death

It was revealed

from the study that

a relatively higher

proportion of

deaths took place

at medical college

hospital (29.2%)

private institutions

(29.8%) and this is

followed by

government

district/sub-district

hospitals (13.7%)

(Figure-3). About

17.3% reported

death during transit and 10% at their home. As per Mahabubnagar district study (CESS (2012)

maternal deaths at government facility were (34%), private facility (26%), home (29%) and

transit from home to health facility / between referral places (11%) respectively. However,

Medak district study (Singh, 2010) reported deaths at home (22%) and transit (66.7%) due to

late referral. There is a substantial improvement of institutional deliveries (63.4%) in 2002-04

(DLHS-2) to 75% in 2007-08 (DLHS-3) in Medak district due to successful RCH-I, RCH-II and

NRHM interventions in the state. About 43% of maternal deaths are in government health

facilities (medical college hospitals and APVVP institutions) indicate better community

awareness of delivery care services and also due to shifting of referral cases from private

sector. In Anantapur district, enquiries showed that the RDT private hospital was largely

catering the delivery care services and thus reflected high reports of maternal deaths. About

15-20 percent of maternal deaths during transit from home to referral and from referral to higher

level facility indicate poor situation assessment and lack of confidence among health staff or

intentionally referring to higher facility to avoid death in their hospital. Seventy seven percent of

women with fatal illness/complication were shifted within a day to a referral hospital. Out of the

women admitted in the health facility, one third (35%) reported death on the same day of

admission. This may be due to lack of birth preparedness, transport facilities, lack of existing

referral mechanism and low awareness of family members.

with fatal illness/complications were admitted in the hospital at the eleventh hour and

consequently more number of maternal deaths occur at tertiary/private/government hospitals.

Stages of Pregnancy at the time of

When asked about the time of

death of the deceased, it was

found that 52.7% deaths took

place after delivery while only

25.7% deaths took place

during labour or delivery

(intra-natal) period. Similarly

about 19.2% of women died

during antenatal period and

only 2% of women died during

or after abortion (Figure-4). It

is interesting to note that after

the postnatal deaths, Anantapur recorded the highest 35.3% deaths during intra natal period

whereas in YSR Cuddapah district

The safe motherhood programmes emphasize

recommend medical checkup o

showed that 90% of women delive

received postnatal care within one week period (Satya Sekhar et al, 2007). More so, the CES

(2009) estimate reported that only 60% of women received postnatal check

10 days after delivery in Andhra

delivering in a health facility, 22 to 41 percent women stayed one day after delivery in

facility. Hence duration of stay of 48 hours at health facility is also to b

findings indicate that to reduce

essential to provide cent percent post partum care

an immediate initiative by the NRHM in

Antenatal status of the deseased

Antenatal care generally implies that either a

doctor, ANM or any other trained health

personnel provides pregnancy related health

care so as to avoid complications during

pregnancy and child birth. Proper and effective

counseling is also an integral part of antenatal

11

awareness of family members. Due to all these factors women



Pregnancy at the time of Death

When asked about the time of

death of the deceased, it was

% deaths took

while only

% deaths took place

labour or delivery

period. Similarly

died

and

only 2% of women died during

It

is interesting to note that after


district deaths in antenatal period (25%) occupied second place.

safe motherhood programmes emphasize the importance of postnatal care

heckup of their health within two days after delivery. Research stud

showed that 90% of women delivered in a health facility and 60% women in domiciliary delivery


only 60% of women received postnatal check

after delivery in Andhra Pradesh. The KAP study (2012) showed that among women

alth facility, 22 to 41 percent women stayed one day after delivery in

Hence duration of stay of 48 hours at health facility is also to be insisted.

to reduce higher percent of maternal deaths during postnatal period

cent percent post partum care to every delivered woman and neonate

immediate initiative by the NRHM in order to meet MDG goals.

status of the deseased women

Antenatal care generally implies that either a

doctor, ANM or any other trained health

personnel provides pregnancy related health

id complications during

d birth. Proper and effective

o an integral part of antenatal

Due to all these factors women




antenatal period (25%) occupied second place.

importance of postnatal care and

their health within two days after delivery. Research studies

red in a health facility and 60% women in domiciliary delivery


only 60% of women received postnatal check-ups within the first

KAP study (2012) showed that among women

alth facility, 22 to 41 percent women stayed one day after delivery in the health

e insisted. Different study

postnatal period, it is

to every delivered woman and neonate as

care such as preventive care, diet during pregnancy, delivery and post natal care.

guidelines envisaged in RCH programme, ANC should include at least 3 health check

measurement of weight, height and blood pressure, administration of 2 TT injections,

consumption of IFA tablets and preventive measures

It was reported in three districts,

ANC check-ups followed by 44% with 2

monthly Village Health and Nutrition Days (VHNDs) at Anganwadi centre by ANM/ASHA and

AWW in every village, contrary

identified as high risk had early

partum care.

Parity of women and maternal deaths

Against the general concept that higher

parity women had higher number of

maternal deaths, the Medak district study

reported 50% maternal deaths among

teenaged primigravidae women

2010). It is interesting to note that majority

of the NRHM interventions namely JSY,

JSSK are extended only to first two

children. The present study reveals that

65% of zero and one parity women are at

high risk (Figure 6). We observe that

45% of mothers availed 4 & more ANC visits; b) three

center/PHC; c) more than half of women are ho

that the NRHM program interventions require

PNC services.

Survival status of newborn

Out of 167 mothers who were victims of maternal

death, 85 (51%) had delivered live and healthy

babies before they died and 29 (17.4%) had still

births (Figure 7). The infant survival was 88.3%

among women who had studied 8

above as compared to 44.4% among women with

no formal education.

12

care such as preventive care, diet during pregnancy, delivery and post natal care.

guidelines envisaged in RCH programme, ANC should include at least 3 health check


consumption of IFA tablets and preventive measures against malaria.

in three districts, that about 49% of pregnant women underwent 4 and above

44% with 2-3 visit (Figure-5). Even with compulsory


contrary to the expectation, in less than half of mothers (

early micro birth planning, had safe delivery practices

Parity of women and maternal deaths

Against the general concept that higher

parity women had higher number of

maternal deaths, the Medak district study

maternal deaths among

women (Singh,

note that majority

ions namely JSY,

extended only to first two

study reveals that

65% of zero and one parity women are at

observe that a)

more ANC visits; b) three-fifth (60%) availed ANC care from Sub

than half of women are home makers /agricultural labour clearly

interventions requires a re-look in terms of delivering quality ANC and

f 167 mothers who were victims of maternal

death, 85 (51%) had delivered live and healthy

babies before they died and 29 (17.4%) had still

survival was 88.3%

studied 8th class and

above as compared to 44.4% among women with

care such as preventive care, diet during pregnancy, delivery and post natal care. According to

guidelines envisaged in RCH programme, ANC should include at least 3 health checkups,


% of pregnant women underwent 4 and above

compulsory conducting of


half of mothers (45%) that were

practices and had post

fifth (60%) availed ANC care from Sub

me makers /agricultural labour clearly indicating

look in terms of delivering quality ANC and

13

In a nutshell, the NRHM interventions like Janani suraksha yojana (JSY), Janani Sishu

Suraksha Karyakram (JSSK) which are aimed at first two children are not even ensuring safe

delivery and a healthy newborn. There is a need to revamp the NRHM in the state towards

reaching cent percent antenatal care, feasible strategies for consumption of required number of

IFA tablets by every pregnant woman, assured referral system from PHC to higher level health

facility, availability of 24x7 services for C-section delivery care, blood bank/ blood storage

facility in all 24x7 PHCs and APVVP hospitals.

14

Chapter 3

GEOGRAPHICAL LOCATION AND SEASONALITY OF MATERNAL DEATHS

In this section an attempt is made to answer the question - whether maternal deaths are

concentrated in certain pockets of the district and indicate any seasonality? From the available

district CBMDR formats, we would like to resolve the above questions. In addition we have

supplemented the health facility information on the availability of obstetric and neonatal care

services from Satya Sekhar et al. 2009, CHFW presentation (2011) and GOAP-NRHM-PIP

(2013-14).

Of the 167 maternal

deaths, in the three

districts, the detailed

information is provided in

Appendix-4 and

consolidated information

of mortality information by

CHNC is given below

(Figure 8). In YSR

Cuddapah district, eight

maternal deaths in a

calendar year were

reported from

Porumamilla Mandal and six each in the mandals of Jammalamadugu, Pulivendula and

Mydukur. Both Chennur and Rayachoti mandals recorded four maternal deaths each during

2012. In Guntur district, eight maternal deaths were reported from Narasaraopet mandal

followed by five in Sattenapalle mandal and three each from Guntur and Tenali mandals. In

Anantapur district, 4-5 maternal deaths in a calendar year were reported in Singanamala,

Kadiri, Penukonda, Hindupur and Tadipatri mandals.

The health facility assessment survey (CHFW, 2011) conducted public health facility

information from every district of Andhra Pradesh. The survey collected information on

availability of specialist doctors (Obstetrics, Paediatrics and Anaesthesia and general doctors),

conduct of normal and C-section deliveries and minimum 100 deliveries conducted in the facility

per annum. Health facilities with three attributes (availability of specialist doctors, facility

conducting C-section delivery, and minimum 100 deliveries per annum) classified as Grade-1.

Those with any two of the attributes were marked as Grade-II and those with only one attribute

as Grade-III. The study did not cover the Government General Hospital, Guntur and RIMS,

YSR Cuddapah in the survey.

15

It is interesting to note that many health facilities (CHC, Sub-district and District hospital) are in

Grade-II and Grade-III categories. In Anantapur district, out of 14 health facilities (Govt. general

hospital, one district hospital, six Area hospitals, and six CHCs) only GGH Anantapur and

Penukonda Area hospital ranked as Grade-1 with all three attributes. In the Anantapur map, 15

women reported death from the group of nearby mandals Singanamala (CHC), Anantapur

(GGH) and Tadipatri (AH). In second group of mandals, Penukonda (AH), Madakasira (CHC)

and Hindupur (DH) reported 12 maternal deaths. The Penukonda Area hospital was in Grade-I

category and others are in Grade-II. The third group of mandals comprising Kadiri (AH) and

Nallamada (CHC) reported 8 maternal deaths and both are in Grade-II category. The above

four groups require specialist health personnel or medical officers trained in advanced OB care,

availability of staff nurses trained in SBA would be a feasible strategy in lowering maternal

deaths.

16

In YSR Cuddapah district, out of 14 health facilities (two Area hospitals, Twelve CHC facilities),

only Proddutur Area hospital and Rayachoti CHC are in Grade-I with all three attributes. Except

for two Area hospitals and two CHCs, 10 facilities have poor infrastructure for carrying out C-

sections and normal deliveries. In the first group of mandals, Porumamilla and Budwel mandals

reported 10 maternal deaths with CHCs at mandal headquarters. In the second group,

Jammalamadugu with Grade-I and Proddutur with Grade-II recorded 9 maternal deaths. In the

third group, Lakkireddipalli CHC (Grade-III) and Rayachoti (Grade-I) reported 8 maternal deaths

in the calendar year. In fourth group, Pulivendula (AH) recorded 5 maternal deaths. An

overview of the four groups, a) health facilities in Porumamilla, Budwel, and Pulivendula require

full fledged advanced maternity care centers and NICUs and b) Jammalamadugu and

Rayachoti health facilities require full-fledged IPHS up gradation. With an availability of 24x7

maternity services in the other five health facilities, a substantial reduction in maternal deaths

may be achieved.

17

In Guntur district, out of 11 health facilities, 5 hospitals are in Grade-I (Tenali District hospital,

Narasaraopet Area hospital, three CHCs in Sattenapalli, Vinukonda and Chilakaluripet). The

Government general hospital reported 9 maternal deaths from the urban and peri-urban areas

of Guntur town. A different situation was reported from Guntur district. Higher maternal deaths

were reported from Grade-1 category mandal headquarters hospitals. In first group both

Chilakaluripet and Narasaraopet facilities are in Grade-I and reported 10 maternal deaths. In

second group, Tenali, T. Sundur, Kollipara and Duggirala mandals recorded 9 maternal deaths.

It is surprising to observe that Tenali had District hospital with all specialities and GGH Guntur

and Vijayawada are nearby. Still higher maternal deaths were reported which requires an in-

depth survey. In third group, Vinukonda (CHC) and near by mandals recorded four maternal

deaths. Strengthening the health facilities in Vinukonda, Sattenapalli and Ipuru CHCs into full-

fledged FRUs and strengthening the first three groups to maintain Indian public health

standards can reduce maternal mortality in the district.

Thus the geographical density / concentration of maternal deaths in the districts require

immediate fulfillment of Indian public health standards in all the health facilities especially those

that are far away from the district headquarters. In Anantapur district Rayadurg, Tadipatri,

Kadiri, Penukonda, Hindupur and Madakasira which are far away places from district

headquarters have to ensure IPHS norms in order to reduce maternal deaths. In YSR

Cuddapah district, Porumamilla, Budwel, Pulivendula and Rayachoti require immediate IPHS

level facilities with human resources and functional NICU facilities. In Guntur district, Grade-I

and Grade-II health facilities are available but high maternal deaths are reported, indicating lack

of responsibility of specialists/health staff or running of private nursing homes by government

doctors near the health facilities may be the reason. International evidence showed that

18

adequate referral facilities with EmOC are required for dealing with complications effectively to

reduce maternal mortality further rather simply ensuring institutional delivery (Padmanabhan et

al, 2009).

Seasonality in maternal deaths

A review of month-wise MDR records showed that three-fourths (74%) women died in the

months April to September. This period is well known for epidemics, malaria and seasonal

diseases. The infectional diseases like Dengue, Malaria and Pyrexia are main causes of

maternal deaths. Figure 9 depicts occurrence of two maternal deaths due to Dengue in

Anantapur district during reference period. The district MDR review committee recommended i)

immediate control of vector-borne diseases and ii) lack of functional FRUs due to shortage of

specialists in Ob & GY and Anaesthesia has to be overcome by increasing training in EmOC

and LSAS as observed in Tamil Nadu, Karnataka and Gujarat states.

In a nutshell, analysis of data on maternal deaths suggests that maternal deaths are

geographically concentrated in a few pockets in the district. Mandals catered by Grade-1 and

Grade-II level facilities are reporting higher maternal deaths in their coverage referral area. In

Anantapur and YSR Cuddapah districts achievement of IPHS norms in all the health facilities

and strengthening with specialist doctors are required. In Guntur district, majority of the health

facilities are ranked as Grade-1 with high maternal deaths in the referral areas during a

calendar year. Ensuring the availability of specialist doctors and staff is a prime requirement

along with a supporting supervision.

19

Anantapur district

In the month of June and July, there were two deaths from

dengue out of the total six maternal deaths reported and

reviewed i.e. 1/3rd . In the month of November, one death of the

two maternal deaths due to Malaria i.e. ½ .

Henceforth, control of vector-borne disease with measures of

mosquito nets goes a long way in preventing such maternal deaths

contributing to a major portion of averting deaths.

20

CHAPTER 4

TIMING OF MATERNAL DEATHS AND HEALTH SERVICE UTILIZATION

The investigating team constituted by the SPHO of the CHNC, collect the maternal death

information in a structured format CBMDR developed by the Government of India from a close

relative, preferably female, and the birth attendant if the death was associated with delivery.

The interview consisted of a questionnaire which first addressed common issues like place of

death, care-seeking behavior and the respondent’s relationship to the deceased. In case the

death occurred during pregnancy or within 42 days of child birth, the interviewer fills the 3

modules of the questionnaire according to the type of death occurred- post abortion period,

antenatal period, death during delivery and postnatal period as prescribed by the GOI-MDR

guidelines.

Most common time of

maternal deaths observed

was the postnatal period

(53%) followed by intra-natal

period (26%), antenatal

period (19%) and abortion

(2%). Out of 53% post natal

deaths, 37% were in the

immediate post natal period,

i.e. within first seven days of

delivery and 16% were

reported between 7-42 days

after delivery (Figure 10). In the subsequent sections we analyze socio-demographic and

medical (direct and indirect) causes of maternal death in detail.

Abortion deaths

Out of total, 4 reported deaths due to

abortion, only 3 cases are due to

induced abortion and one

spontaneous in nature. Out of three

abortions one took place at home

and the remaining in a private clinic.

The health service providers

attended abortions - one by a doctor

another by a nurse.

21

In India about 9% of total maternal deaths are caused by unsafe abortions but medical experts

put the figure at almost 18%, higher than global average of 13%. Most women in India can not

obtain legal abortion due to high doctor fees, shortage of trained providers and adequate

equipment, poor access to facilities, lack of confidentiality and informal demand for spousal

consent etc (Centre for Reproductive Rights, 2008).

Recent survey findings reported in Bihar and Jharkhand states in India that nurses are as

skilled as doctors in performing manual vacuum aspiration (MVA) abortion. Ten members each

were selected from medical officers and staff nurses with no previous experience in providing

surgical or medical abortion, conducting of pelvic examination or assessing gestational age.

Both categories underwent MVA training using national guidelines and were supervised by a

trained abortion provider. The overall failure rates are low and two provider groups are equally

acceptable to women who underwent the procedure (98%). These findings demand

amendments to existing regulations to expand the MVA provider base for increasing access to

safe abortion in India (Jejeebhoy et al, 2011).

Maternal deaths reported during Antenatal period

About 34 women died during

antenatal care period. The

CBMDR death information

indicated that 26 (76%)

women had problem during

antenatal care period and

were referred to health

facility/doctor for symptomatic

treatment. The women sought

treatment for the symptoms

given in Figure- 11. The

major symptoms reported are

high blood pressure (15%),

heart related problems (15%), breathlessness (15%), anaemia (12%) and high fever, bleeding

P/V, edema each by 8% respectively. Eighty-eight percent (23 out of 26) women attended

hospital for treatment.

Maternal deaths reported during Intra-natal period

Forty-three women died during intra-natal period. Out of them, 37.5% women delivered at

private health facility followed by 23.3% at medical college hospital, 21% at Government health

facilities and 18.5% at home. On mean time interval between onset of pain and delivery was

4.30 +2.12 S.D. Among 43 maternal deaths, the time gap between onset of pain and delivery

22

was reported as a minimum of 2 hours and a maximum of 10 hours. Fifty-nine percent of

deliveries ended with a live birth.

As for the major problems reported

during labour / delivery of women

about 39.5% had not been

classified by the CBMDR

investigating teams (Figure-12).

About 23.3% women reported

severe bleeding / bleeding clots,

convulsions (11%), severe

breathlessness /edema (9.3%) and

high fever (7%). Out of the women

reported complications, only 67%

availed medical assistance.

Maternal deaths reported during postnatal period

The early postnatal period is a highly vulnerable time for mothers – 60% of maternal deaths

occur in the first week after birth, and nearly half of those deaths occur in the first day after

delivery. There is a need to enhance counseling by midwives and community workers on new

born care practices, immediate and exclusive breast feeding and recognize health problem

among mothers and newborn care practices. Recent study pointed that postnatal care costs

less than half the amount required for skilled care during child birth to scale up and has a

potential to prevent 20 to 50 percent of newborn deaths (Save the children, 2013).

Out of 88 women who died in the

postnatal period death, 54.6% had

not received postnatal care visits

(34% did not avail and 20.5% did not

know about post natal visits). Slightly

less than aggregate, 47.8% were

reported in Anantapur and 53.9%

reported in YSR Cuddapah district

respectively (Figure-13). Across three

districts, two or more postnatal visits

availed by 30% in Anantapur and

YSR Cuddapah districts and 20.5% in

Guntur district respectively.

23

Most common time of

maternal deaths was

immediate postpartum

period. Analysis of 53

maternal deaths in

Anantapur district

revealed that, one-

third (33%) of maternal

deaths occurred within

6 hours after delivery

and 12% between 7 to

24 hours of duration.

About 40% of maternal

deaths were reported between one day and 7 days (Figure-14). The findings indicate that

duration of stay after delivery is an important factor to minimize the incidence of maternal

deaths. Though the proportion of institutional deliveries is on rising trend but the duration of 48

hours stay in the health facility after delivery needs to be insisted.

Availability of health facilities services and transport

In the case of 167 deceased women, the nearest health facility providing emergency obstetric

care services are APVVP hospitals (55%), private nursing home (15.6%) and primary health

centers (15.6%). However, the EmOC services provided by APVVP hospitals are 62.5% in

Guntur, 53.8% in YSR Cuddapah and 47.1% in Anantapur districts (Table-5). Juxtaposing the

information of YSR Cuddapah district given in previous section, majority of health facilities are

in Grade-III category, higher proportion of women preferred EmOC services from private health

facilities. In general more than half (52-62 percent) deceased women were at location 6

kilometers or farther from their residence. Half (49%) of the women reported maternal death

have visited one health facility (64% in Guntur followed by 41% in Anantapur and 38.5% in YSR

Cuddapah). Interestingly, across three districts, 59-61% women in Anantapur and YSR

Cuddapah districts visited two or more number of health facilities before death as compared to

36% in Guntur district.

24

Table-5 Availability of EmOC based health facility from women residence

District APVVP&GGH Private PHC Not available All (%)

Anantapur 47.1 15.7 23.5 13.7 100 (51)

Guntur 62.5 9.4 10.9 17.2 100 (64)

YSR

Cuddapah

53.8 23.1 13.5 9.6 100 (52)

All 55.1 15.6 15.6 13.8 100 (167)

Chi-square with 8 df =10.83 (p=.212)

Distance of health facility from residence

District Below 2 km 3 to 5 km 6 & above All

Anantapur 29.4 11.8 58.8 100 (51)

Guntur 34.4 14.1 51.6 100 (64)

YSR Cuddapah 32.7 5.8 61.5 100 (52)

All 32.3 10.8 56.9 100 (167)


Number of facilities woman visited before death

District Number of facilities visited before death

Below one 2 3 4 5 and

above

All

Anantapur 41.2 27.5 25.5 3.9 2.0 100 (51)

Guntur 64.1 20.3 9.4 4.7 1.6 100 (64)

YSR

Cuddapah

38.5 21.2 26.9 7.7 5.8 100 (52)

All 49.1 22.8 19.8 5.4 3.0 100 (167)


Ninety-three percent of health

institutions did not indicate specific

reason for referral to higher / other

facility. Only six percent informed

about lack of blood in the health facility

(Figure-15). These observations

suggest that the working conditions of

medical and paramedical staff are poor

and supporting supervision lacking at

all levels. The results revealed that

25

once a woman was referred, no responsibility was taken by the referring institution to ensure

she was accompanied by a staff person for care during transit or that she reached the next

institution safely (multiple referrals with no specified referral pattern). Hence there were a higher

number of maternal deaths during transit period (17%), which indicate partly the negligence of

health personnel in facility and anxiety among patient’s relatives. According to survey findings,

the hierarchical system and culture of public health system, apportions the blame to the lowest

possible level, led to the attitude “do not take any risk, pass the buck to the next level” (Subha

Sri et a,, 2012).

The early postnatal period is a highly vulnerable time for mothers as well - 85% of maternal

deaths occur in the first seven days after birth, and nearly half (45%) among those deaths occur

in the first day after delivery. Studies indicated that postnatal care advices to delivered mothers

include only newborn care and breast feeding. Quantitative and qualitative information revealed

that lactating mother’s health is not considered as important as the child, not only by the women

but also by the health workers (Murthy and Satya Sekhar, 2012). Post natal care is required to

be provided to the new born with special emphasis to post partum care of mother too.

26

Chapter 5

MEDICAL CAUSES OF MATERNAL DEATHS AND THREE DELAYs IN SEEKING CARE

Since mid-60s, when GOI introduced Maternal care, Family planning later modified as Family

welfare programme, Maternal and child health, (MCH), Child survival and safe delivery program

(CSSM), Reproductive and child health (RCH-1) and RCH-2 programs finally re-named as

National rural health mission (NRHM) in Indian states. Research studies showed that except

for the obstetric care and delivery, major emphasis was laid in all the above programs from

antenatal care to in-facility delivery and child immunization aspects (Kumar, 2010).

The historical interventions like trained birth attendants (TBA), antenatal care screening of

healthy women for health (maternal) education, screening of women for signs of high/low risk of

pregnancy did not yield significant reduction in maternal mortality rate because ‘every

pregnancy is considered as at risk, if not proved, otherwise’. The risk approach does not

assume that women classified as ‘low risk’ have a false sense of security and at the other end,

women classified as ‘high risk’ undergo unnecessary inconvenience and cost.

The following interventions under NRHM namely a) Mother and Child Tracking of pregnant

women, quality ANC services, early identification of pregnancy (Nischay test card) and four

checkups during pregnancy; b) Implementation of comprehensive emergency obstetric services

at FRUs, ensuring access to blood bank in all district hospitals and blood storage facility at

FRUs, training of different health personnel on obstetric care at every delivery point c) utilization

of partograph, Oxytocin, magnesium sulphate, strengthening post-partum care at community

and facility level and d) interventions of FMNDR and CBMDR review substantially reduced the

MMR and NNMR in different states depending on the intensity of implementation of the

program (various NRHM-CRM reports, Planning Commission, 2013).

Studies under Safe Motherhood initiatives found lack of association between obstetric

complications and background characteristics like demographic, behavioral risk factors,

antenatal care complications. Moreover, issues related to reduction of maternal mortality had to

be designed and looked at as secondary prevention. Any amount of safe screening methods

and improving living conditions would decrease the need of emergency obstetric care

(Pacagnella, 2012).

27

Medical causes of maternal death

Understanding the causes of maternal

mortality is crucial in addressing the

challenge of high rates of maternal

mortality. Important medical causes of

death across three districts were

classified into direct, indirect and

unclassified categories. In the three

districts aggregate, 57% of deaths

were due to direct causes, 27% of

deaths due to indirect causes and 3%

due to non-obstetric causes (for

detailed classification see Appendix-4)

(Figure-16). In about 22 deaths (13%) across three districts, the investigating team did not

indicate appropriate cause of death in the CBMDR.

Figure-17 shows that

direct obstetric causes

accounted for 62.7% of

maternal deaths in

Anantapur district;

whereas 55.8% in YSR

Cuddapah and 53.1%

reported in Guntur district.

Slightly more than a

quarter (25-29 percent) of

cases was reported to be

due to indirect causes

across the three districts.

About 10% of deaths in YSR Cuddapah district were reported due to non-obstetric causes

(accidental or incidental causes) where as nil report were filed in the other two districts.

28

Direct causes that

contributed to maternal

mortality were observed in 95

cases (56.9%). In the direct

cause group, 26 cases died

due to hypertensive

disorders during pregnancy

(27.4%), 19 cases due to

hemorrhage (PPH -20%), 16

cases each due to

thromboembolism and sepsis

related to pregnancy and

child birth, 14 cases due to other factors (Peripartum cardio-myopathy and surgery

complications (14.7%) (Figure- 18). The deaths from pregnancy-induced hypertension are

preventable. Early prenatal care subsequent detection of pregnancy-induced hypertension, and

careful monitoring and treatment are essential to prevent serious complications from this

problem.

Indirect causes that

contributed to maternal

mortality were observed in

45 cases (26.9%)., about

16 cases due to infectious

diseases (35.6%), 12

cases due to heart disease

complicating pregnancy

(26.7%), 8 cases due to

severe anaemia (17.8%).

Two cases each were

reported to be due to

endocrine disorders, liver

disorders (jaundice), renal disorders etc (Figure-19).

Maternal death causes were classified by timing of death (pre-to-post delivery period) and by

district is presented in Figure-20. The direct and indirect medical causes showed that infectious

diseases and ‘un-classified cases’ were reported in both categories. In future trainings at grass

root level and in re-orientation trainings emphasis should be laid on minimizing un-reported

category. Across the three districts, PPH, hypertensive disorder of pregnancy, sepsis and

thrombo embolism were reported as major factors.

29

Causes of maternal deaths – Three Delays

Methods for collecting information on delays have ranged from verbal autopsies to in-depth

review of family members by the MDR investigating team. Maternal mortality is extremely

sensitive to standards of obstetric care, and many pregnant women reach health facilities in

poor condition which cannot be saved and require immediate care by a skilled health

personnel. Thaddeus and Maine have offered a new approach to examine maternal mortality,

using a three-phase framework to understand the gaps in access to adequate management of

obstetric emergencies. The three delay model includes:

• Delay-1: Delay in decision making at household level due to unawareness of danger

signs, illiteracy and ignorance, lack of birth preparedness and beliefs and customs;

• Delay-2: Delay in reaching first level health facility due to delay in getting transport,

mobilization of funds, poor transport conditions;`

• Delay-3: Delay in initiating appropriate care at the health facility due to delay in initiating

treatment, sub-standard care in hospital, lack of blood, equipment and lack of adequate

funds.

Delay in seeking care was seen in 64 of 167 cases (39%). Reasons for delay in seeking care

included ignorance and lack of awareness of danger signs (38.4%), illiteracy and ignorance (38,

1%), delay in decision making (27.4%) and lack of birth preparedness (15.9%).

30

Once the decision to go

to a health facility was

made, there was delay

in reaching the first

facility because of

mobilization of funds

(19.9%), delay in

transport (5.4%) and

delay in reaching

second facility in time

(4.2%). The last Delay-

3 on receiving quality

health care services

reported delay in

initiating treatment

(8.3%) followed by substandard care (8.8%). Important reason was either delay in referring the

patient by the previous organization or to in-appropriate referrals; precious time was lost in

these cases before right treatment could be initiated (Figure-21).

However, the three-delay model refers only to emergency obstetric care and identify gaps in

reaching appropriate obstetric care but did not address primary prevention or early detection of

pregnancy complications during antenatal care, socio-demographic factors and attitude of

family members etc (Pacagnella et al. 2012).

The delays in decision

making at household level

were assessed by five

components (unawareness

of danger signs, illiteracy

and ignorance, delay in

decision making, no birth

preparedness and beliefs

and customs). Each

correct response was

given a score of one mark,

otherwise zero. We made

three groups, Grade-1 correct answers to four and above score, Grade-2 correct answers of 2-

3 score and Grade-3 score for less than one. In the aggregate of 3 districts, eleven percent in

Grade-1 indicated 4 to 5 causes for delay. More than half (57%) family members of the women

reported death indicated 2 to 3 reasons for the delay at household level. Across three districts,

31

all four types of delays at household level were reported in YSR Cuddapah (69.4%) followed by

Anantapur (50%) and less than 10 percent in Guntur district. An in-depth analysis of Guntur

district family members reported unawareness of danger signs (73%), illiteracy and ignorance

(86%), delay in decision making (61%), no birth preparedness (11%) and customs and beliefs

(34%) respectively.

Delay in reaching first level

of health facility was

assessed by three

components (delay in

getting transport, delay in

mobilizing funds and not

reaching appropriate facility

in time). Each correct

response was given a score

of one mark, otherwise

zero. We made three

groups, Grade-1 (all 3

factor score), Grade-2 (two score) and Grade-3 (less than one score). Among 51 (30%)

respondents 24.7% reported both reasons namely getting transport and mobilizing funds as a

major reason. No wide variations were reported across three districts.

To sum up, about 45% maternal deaths occurred within 48 hours of admission reflecting that

majority of the patients came late to the hospital when the complications had already set in.

Provision and utilization of emergency obstetric care services at peripheral center can help in

reducing maternal mortality in referred cases. Fifty-seven percent maternal deaths were due to

direct causes. Haemorrhage and hypertension were the major direct causes. Sepsis related to

pregnancies and child birth and thrombo embolism were indicated in seventeen percent each.

In the present study, indirect causes of maternal mortality were quite high (26.9%). This means

that the women died as a result of a disease that she already had, or one which developed

during pregnancy though not directly due to pregnancy. Infectious diseases (16, 35.6%) and

heart diseases complicating pregnancy (12, 26.7%) which were leading indirect causes which

can be prevented.

32

Chapter 6

SUMMARY, CONCLUSIONS AND FUTURE SETTING

The purpose of maternal death audit was to identify inadequacies and shortcomings in the

working systems and to provide valid facts and data to regulate future developments. Among

the MDR evaluation techniques, direct household survey, sisterhood method, reproductive age

mortality studies, verbal autopsy and census, the GOI recommended CBMDR and FBMDR

approach to all states under the flagship programme of NRHM. The GOAP effectively

implemented it since early 2012. The CHFW appointed ADMHO at district level and Additional

Director, CHFW as the State and district level nodal officers. ASHA in the habitation village,

ANM at sub-center, medical officer at PHC level, SPHO at CHNC are responsible for collecting

information for CBMDR questionnaire. While, the FBMDR questionnaire is filled by facility

medical officer and scrutinized by the facility MDR nodal officer and information sent to ADMHO

in specified time lines. Both the CBMDR and FBMDR formats were reviewed at district level by

the district collector and for recommendation and initiating steps to overcome problems at local

level.

The IIHFW was given the opportunity to analyze the CBMDR and FBMDR formats for the first

time by the Department of HM&FW, GOAP. Prior permissions were obtained from the CHFW

and 167 MDR schedules were collected from Anantapur, Guntur and YSR Cuddapah districts.

Strict scrutiny of data was conducted by medical and statistical teams by way of cross checks,

filling data gaps, consistency of information besides the task of exactly identifying the cause of

death from open history information and investigators notes/observations.

On analysis of maternal deaths (n=167) in three districts, there were 88 (52.7%) postpartum,

25.7% intra-partum, 13.2% antenatal periods and 4 deaths occurred due to medical abortion.

Studies reported less importance given to postnatal care as compared to antenatal care (by

community and by health staff) and poor dissemination of postpartum care related to mother.

As against the earlier studies, more than half of the women are in 19-24 age. Majority of studies

indicated women deaths among scheduled caste and scheduled tribe communities, however

the present study reported 37.1% in scheduled caste and tribes, 30% among other backward

castes and 32.9% belong to other caste groups. More than 43% women were illiterate and 32%

had read up to 8th standard and 22% up to 10+2 level. Most of the deaths took place at health

facility namely, medical college hospitals (28.2%) followed by private institutions (31.1%), and

13.7% in government district/sub-district hospitals. A substantial proportion occurred during

transit period (16.8%) and home (10.2%). Majority of the NRHM interventions like JSY, JSSK

are directed only at families with two children only. The CBMDR study reveals that a) 45%

pregnant women availed 4 ANC visits; b) sixty percent of pregnant women availed ANC

services from Sub center/PHC; c) about 65% of women belong to parity zero and one; d) 73%

of postnatal women reported maternal death after availing 2 to 3 postnatal checkups. As

majority of the NRHM interventions were limited to first two children (JSY and JSSK), one has

to question the quality of antenatal services available at sub-centre/PHC, highlighting the need

33

for improving IPHS norms in all EmOC health delivery points especially in backward and tribal

pockets by ensuring safe deliveries to all and in particular to zero and first parity women. There

is a need to gear up the postnatal care across the districts as suggested by DARE to CARE of

community and health providers as envisaged in ‘AMMA KONGU’ Strategic behavior change

communication (SBCC) strategy (Murthy et al, 2012).

Meta analysis (Kalter et. al, 2011) of maternal mortality studies emphasized lack of correlation

between socio-economic, geographical, seasonality factors with the occurrence of maternal

deaths factors. The present analysis of one calendar year information suggests that, maternal

deaths are geographically concentrated in specific pockets of a district. Health facilities with

Grade-1 and Grade-II level performance indicators, reported higher number of maternal deaths

indicating a mis-match of service availability and deployment of health personnel. Anantapur

and YSR Cuddapah districts require fulfillment of IPHS norms in health facilities and supported

by specialist doctors or medical officers with LSAS training. In Guntur district, majority of the

health facilities are ranked as Grade-1 reporting maternal deaths in the referral jurisdiction area.

Ensuring the availability of specialist doctors and staff is a prime requirement along with

supportive supervision.

Ninety-three percent of health institutions did not indicate specific reason for referral to

higher/other facility. Only six percent informed about lack of blood in the health facility. This

reflects the low morale of medical and paramedical staff and lack of effective supervision at all

levels. CBMDR revealed that once a woman was referred onwards, no responsibility is taken by

the referring institution to ensure that she was accompanied by a staff person for care during

transit or that she reached the next institution safely. Hence there were a higher number of

maternal deaths during transit period (17%), which indicate partly the negligence of health

personnel in facility and anxiety among patient relatives.

The direct medical causes that contributed to maternal mortality were observed in 95 cases

(56.9%). In the direct causes group, hypertensive disorders (27.4%), hemorrhage (24.2%),

sepsis (17%) and thrombo embolism (17%). In the indirect causes group, infection diseases

(35.6%), heart disease complicated pregnancy (27%), severe anemia (17.8%) and renal

disorders (6.7%). Control of vector borne diseases with medicated mosquito nets goes a long

way in preventing maternal deaths.

Less than half (45%) deaths occurred within 48 hours of admission indicating that majority of

the patients came late to the hospital when the complications had already set in. Provision and

utilization of emergency obstetric care services at peripheral center can help in reducing

maternal mortality in referred cases. Fifty-seven percent maternal deaths were due to direct

causes. Hypertension and hemorrhage were the major direct causes. Seventeen percent each

had sepsis problem related to pregnancies and child birth and thrombo embolism. In the

present study, indirect causes of maternal mortality were quite high (26.9%). This means that

34

the women died as a result of a disease that she already had, or one which developed during

pregnancy and was not directly due to pregnancy.

Future Setting

1. Systematic monitoring of MCTS information on components of ANC, place of delivery,

mode of transport from home to health facility and post partum care and post natal care

of every delivered women in the lines of ‘Amma Lalana’ intervention in Karimnagar

district

2. In the lines of Tamil Nadu, identify two or more health facilities in each district to provide

round the clock comprehensive emergency obstetric and new born care services with

radial distance of less than two hours to reach the facility

3. Need to gear up and complete trainings on LSAS, NSSK and SBA trainings to medical

officers, staff nurses, ANMs / Maternal assistants in labour rooms and placed at every

delivery point.

4. Half of the mothers (51%) reported maternal deaths in 21-25 years age particularly with

zero and one parity gestation. Delaying the 1st pregnancy after marriage and

identification of high risk woman in prime gravid provide opportunity to reduce maternal

deaths.

5. Half of maternal deaths were in post natal period (51%) followed by antenatal period

23%. Re-emphasize the continuum of care (Amma Kongu brand strategy), the complete

post partum care to every mother and new born.

6. Focus to be laid on no punitive action shall be taken by authorities based on the MDR

reports (No name – No blame principle) and commitment to act on the findings will go a

long way in bringing down maternal deaths.

35

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(2005) National Rural Health Mission- Andhra Pradesh Programme Implementation Plan, 2013-

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(annexure 2). Available at: http://nrhm.gov.in/nrhm-in-state/state-program-implementation-plans-

pips/andhra-pradesh.htm/ap-pips-13-14.zip (accessed: 17th August, 2013).

Government of India, Ministry of Health and Family Welfare (2009) Coverage Evaluation Survey

Report - Andhra Pradesh, New Delhi: UNICEF.

Indian Institute of Public Health, Hyderabad (2012) Maternal death review in Andhra Pradesh:

Standard operating procedures, Hyderabad: Department of Health and Family Welfare, GOAP

and UNICEF.

International Institute of Population Sciences (2006) National Family Health Survey: Andhra

Pradesh, Mumbai: International Institute of Population Sciences.

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Indian Journal of Public Health, 54(2).

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National Rural Health Mission (2005) Framework for implementation 2005-2012, New Delhi: Ministry

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37

Appendix-1: Five approaches for reviewing maternal deaths

Facility-based maternal death review:

• In-depth investigation of the causes of and associated factors in maternal deaths that occur in health

facilities.

• Entails interviews of health personnel who attended to the deceased. Can also be extended to

interviews of family members who accompanied the mother to the facility

• The review is nonjudgmental to encourage the cooperation of the health workers involved.

• Provides information for improving obstetric care.

Community-based maternal death review (verbal autopsy):

• In-depth nonjudgmental investigation of the causes and the associated factors of maternal deaths

that occur outside health facilities.

• Entails interviews of family members who cared for the deceased. This requires a community

informant to let local authorities know whenever there is a death of a reproductive-age female in the

community.

• The interviewer, who is usually not a health worker, should be sensitive when probing the

circumstances leading to the death. In some cultures, the interview is done after the mourning period.

• A team of physicians then examines the interview notes to determine the cause of death.

• When this is combined with the facility-based review described above, a more complete picture of

maternal deaths emerges in a given local jurisdiction.

Confidential enquiries into maternal deaths

• A national or sub-national multidisciplinary committee meets periodically to systematically investigate

a representative sample of (or all) maternal deaths to identify the causes and associated factors; the

committee then gives written guidelines to health personnel and administrators on how to prevent

similar deaths in future.

• The investigation is carried out in a confidential manner (“No blame, no shame”).

• Requires a complete and functioning civil registration or health management information system.

• A sub-national or district-level panel might be more appropriate in countries with high mortality, so

that the guidelines issued can be tailored to local situations.

Survey of severe morbidity (near misses)

• A near-miss event refers to one in which a woman has nearly died but survived a complication that

occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy.

• This survey is an in-depth investigation of the factors that led to the near miss, what worked well in

the treatment of the life-threatening complications, and the lessons learned.

• Unlike the other approaches, in this survey the pregnant woman herself is also interviewed, creating

the opportunity to obtain more insight into the circumstances.

• This survey is less threatening to health personnel than the others, since the women have survived.

Clinical audit

• Entails a systematic review or audit of the obstetric care provided to pregnant women against

established protocols or criteria aimed at improving the quality of care.

• Protocols for the management of obstetric complications will have to be established prior in order to

ascertain whether cases are properly being managed at health facilities.

• If well implemented, it leads to standardized and improved care across health facilities.

Source: S. Mills,” Maternal Death Audit as a Tool Reducing Maternal Mortality,” HNP Notes, (Washington, DC: HDNHE, the World Bank, March 2011).

38

Appendix-2: Studies on maternal mortality in Andhra Pradesh

S. No

Agency/ author

Year of

study

State/region/ district

MMR and medical and non-medical causes

1 Bhatia JCA 1984 Anantapur MMR=830; Major cause reported was puerperal sepsis (30.5%). Authors reported it in one-third of maternal deaths in SC/PHC records

2 Mahapatra et al

2000 Districts of AP

(n=52158)

MMR=256; Haemorrhage reported as an important reason. Abortion and sepsis are two major causes for 52,158 deaths of women aged 15-44 years.

3 IIHFW (Prakasamma et al)

1995-96

Five districts of AP (Adilabad, Anantapur, Karimnagar, Mahabubnagar, Vizianagaram)

MMR=712 [Adilabad (972); Anantapur (400); Karimnagar (237); Mahabubnagar (1088); Vizianagaram (709)].

About 56% of women reported maternal deaths during post natal period. 50% of maternal deaths reported from SC&ST communities. September to November is the peak periods for maternal deaths in the study area. Obstetric factors were the largest (72%) leading causes of maternal deaths. Haemorrhage (21%), Eclampsia (18%) and Puerperal sepsis (14%) are leading causes.

4 Prakasamma 2004 Medak MMR=431; Pregnancy induced hypertension, Eclampsia (29%) and sepsis (15%)

5 ANS 2001 Medak & Mahabubnagar

(n=50)

Compared 100 normal child births with 100 survivors of maternal complications and 50 cases of maternal death.

70% of women who died had no formal education, and 48% women belonged to SC&ST communities

6 Centre for Reproductive Rights –ANS

2007 Andhra Pradesh

(n=30 sub-sample of a major study)

Median age of women who died was below 25 years. Half of the women were married at 18 years or younger. Postpartum deaths higher than prenatal period reported.

Delay or poor management is the main cause of death. Lack of awareness of health needs and risks during pregnancy and child birth. Poor quality of care in first level institutions, multiple referrals, lack of blood availability added to the delays in treatment.

7 MAPEDIR (UNICEF)

2007-08

Medak district,

(N=59)

Half of the women who died are in teenage and prime gravid. 61% were married before 17 years of age. Majority of women are illiterate (72%) and seasonal agricultural labour. About 56% delivered in health facility followed by 22% at home and remaining 22% died undelivered. The medical causes reported were Eclampsia (33%), sepsis (17%), rupture uterus (11%), embolism (5.5%). More than two-third (66%) were anemic. Auto-rickshaw was the main transport (94%) from home to the health facility.

8 GoAP-CESS study

2009 Mahabubnagar

(n=35)

71% of women who died were married below 18 years of age. At the time of first delivery, 40% mothers were below 18 yrs and 16% older than 23 years. Half of women who died have no formal education, 63% belonged to SC&ST communities. 80% of maternal deaths reported during postnatal period (within 7 days). Among the medical causes reported PPH (20%), Eclampsia (12%), surgical complications (14%), septicemia (17%) and thrombo-embolism (11%)?

9 IIHFW (CHFW web site on MDR)

2013 Andhra Pradesh

(n=333) during 2012-13

Analyzed 333 maternal deaths information entered on-line from the MDR-CHFW web-site. 51% of women who died were in 21-25 years age group. 42% maternal deaths occurred at government facilities due to late referrals. Maternal deaths by region indicate that rural (45%), urban (50%) and 5% from tribal areas. Few districts reported more than 35 maternal deaths requiring validation by expert group. In three types are delays, positioning of health personnel in remote and tribal delivery points, popularizing referral health system information to mothers and their families during ANC visits. Re-emphasized that post natal care will be as essential and important as prenatal care.

39

Appendix-3: Maternal death review training strategy in district and sub-district level

Workshop/ Training

Duration of Workshop

Participants Facilitators Number of

participants per batch

Number of workshops

Venue

District level Sensitization workshop

Half-a-day District level officials from health and related depts., Panchayat raj, pvt. health facilities

State & District level resource

persons trained in MDR

30 23 (One in each

district)

District Hqrs.

District level orientation training on FBMDR

One day Ob & Gyn., Spl. From AH, CHC, pvt. Medical colleges and other facilities conducting more than 500 deliveries per year


persons trained in FBMDR

20 23 (One in each

district)

District Hqrs.

District level TOT – CBMDR*

One day SPHOs*, PODTT, and DPHNO


persons trained in CBMDR

20 23 (One in each

district)

District Hqrs.

Cluster level CBMDR (way forward)

One day 4-5 PHC MOs with LHV and MPHEO

ADMHO/ PODTT/

DPHNO and SPHO

20 360 (one workshop at each cluster)

CHNC

PHC level CBMDR

(way forward)

One day All staff of PHC SPHO,PHC MO, LHV

20 1500 (one workshop at each PHC)

PHC

Sub Centre CBMDR notification and sensitization

One day MPHA, AWW, ASHA

PHC MO and LHV

10 12200 (one at each

sub centre)

SC of the PHC

• SPHO will conduct CBMDR as a team of 3 persons including MO PHC, LHV/MPHEO to

impart hands-on training to conduct CBMDR interview, handling sensitive issues and format

filling.

• All SPHOs in turn, will orient and sensitize PHC Medical Officers

• PHC Medical officer will sensitize and orient MPHEO, MPHS, and ANMs with emphasis on

dispelling misconception of notification.

• ANMs will sensitize AWWs and ASHAs regarding MDR notification and the process

40

APPENDIX - 4

Government of India - Cause of Maternal Death Classification

DIRECT OBSTETRIC CAUSE: Resulting from Obstetric complications of the pregnant state

Hemorrhage – APH

1. Hemorrhage –PPH

2. Hypertensive disorders of pregnancy

3.1. Severe Pre-Eclampsia

3.2. Eclampsia

3.3. HELLP Syndrome.

3.4. CVA

3.5. Chr.HTN with superimposed Pre eclampsia

4. Sepsis related to pregnancies and child birth

4.1. Chorioamnionitis

4.2. Puerperal sepsis following normal delivery

4.3. Puerperal sepsis following caesarean section

4.4. Peritonitis

5. Thrombo embolism (TE)

5.1 Pulmanary TE

5.2 Aminiotic fluid embolism

6. Abortions

6.1 Spontaneous

6.2. Induced

7. Others

7.1. Peripartum cardiomyopathy

7.2. Complications of surgery.

7.3. Complications of anaesthesia

7.4. Transfusion reactions

7.5. Ectopic pregnancy

7.6. Rupture Uterus

7.7. Others

INDIRECT CAUSES: Resulting from Pre-existing disease or disease that developed during pregnancy but

is aggravated by the physiological effects of pregnancy.

8. Heart diseases complicating pregnancy

8.1. Congenital Heart Disease.

8.2. Rheumatic Heart Disease.

8.3. Complications following valve replacement.

8.4. Myocardial infarction.

8.5. Undiagnosed heart disease

9. Severe Anaemia

10. Endocrine disorders.

10.1. Diabetes mellitus

10.2. Thyroid disease

10.3. Other endocrine disorders

41

11. Infectious diseases.

11.1. Meningitis/encephalitis

11.2. Maternal tetanus

11.3. HIV/AIDS

11.4. Malaria

11.5. Tuberculosis.

11.6. H1N1 (Swine flu)

11.7. Others

12. Liver disorders – Jaundice

13. Renal disorders

14. Br. Asthma

15. Others - SOL, Cancer etc.,

NON-OBSTETRIC CAUSES

(FROM ACCIDENT OR INCIDENTAL CAUSES)

16. Non Obst. Surgical cause

17. Injury due to burns

18. Injury due to accident

19. Snakebite

20. Suicide

21. Cause not known

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Additional Tabulations

Table-A1 Percentage distribution of social status of women reporting maternal death by district

Characteristics Maternal death reported during

Scheduled caste Scheduled tribe OBCs Other classes Total

District

Anantapur 29.5 4.5 45.5 20.5 100

Guntur 29.3 14.6 24.4 31.7 100

YSR Cuddapah 19.2 3.8 34.6 42.3 100

All 25.5 7.3 35.0 32.1 100

Chi-Square with 6 degrees of freedom = 11.877

Table-A2 Percentage distribution of education status of women reporting maternal death by district

Characteristics Maternal death reported during

Illiterate Up to 8th Up to 12th (Inter) Graduate Total

District

Anantapur 38.6 40.9 18.2 2.3 100

Guntur 51.2 22.0 19.5 7.3 100

YSR Cuddapah 40.4 32.7 26.9 - 100

All 43.1 32.1 21.9 2.9 100


Table-A3 Percentage distribution of women reporting maternal death

Characteristics

Maternal death reported during

Abortion Antenatal period Intra natal period Postnatal period Total

District

Anantapur 2.3 15.9 36.4 45.5 100

Guntur 2.4 19.5 19.5 58.5 100

YSR Cuddapah 1.9 25.0 23.1 50.0 100


Woman’s age at death (yrs)

Below 18 - 5.6 33.3 61.1 100

19-25 1.8 22.7 25.5 50.0 100

25 & above 11.1 22.2 22.2 44.4 100


Social group

SC&ST - 13.3 24.4 62.2 100

OBC 2.1 22.9 33.3 41.7 100

Other groups 4.5 25.0 20.5 50.0 100

All 2.2 20.4 26.3 51.1 100


43

Table-A4 Percentage distribution of number of antenatal care visits made by women before maternal death by district, woman age and social group

Characteristics Number of antenatal check ups

1 2-3 4 & above Not known Total

District

Anantapur 6.3 41.7 50.0 2.1 100

Guntur 7.4 46.3 42.6 3.7 100

YSR Cuddapah 2.0 42.0 56.0 - 100


Woman’s age at death (yrs)

<18 - 50.0 50.0 - 100

19-25 2.8 43.0 51.4 2.8 100

26 & above 11.6 44.2 44.2 - 100


Social group

SC&ST 5.4 41.1 48.2 5.4 100

OBC 2.0 49.9 53.1 - 100

Other castes 8.5 44.7 50.1 1.2

All 5.3 43.4 49.3 2.0 100


Table-A5 Percentage distribution of distance from home to first referral health facility of woman reporting maternal death by district and social group

Characteristics Women reporting distance from home to a nearest health facility

<5 km 6-10 11-15 16-25 26 + Total

District

Anantapur 43.2 15.9 11.4 18.2 11.4 100

Guntur 39.0 17.1 9.8 14.6 19.5 100

YSR Cuddapah 38.5 23.1 17.3 11.5 9.6 100


Social group

SC&ST 28.7 17.7 9.7 21.0 12.9 100

OBC 36.0 22.0 14.0 10.0 18.0 100

Other groups 54.5 12.7 14.5 7.3 10.9 100

All 40.1 19.0 13.1 14.6 13.1 100


Table-A6 Percentage distribution of infant survival status of woman reporting maternal death by district

Characteristics Status of infant survival of women reported maternal death

Alive Newborn dead Still birth Not applicable Total

District

Anantapur 45.5 2.3 22.7 29.5 100

Guntur 63.4 2.4 9.8 24.4 100

YSR Cuddapah 46.2 - 17.3 36.5 100

All 51.1 1.5 16.8 30.6 100


44

Table-A7 Percentage distribution of women in age groups by district, woman’s age and social group

Characteristics Woman’s age at death (years)

Below 18 19-24 25-29 30-34 35 + Total

District

Anantapur - 54.9 39.2 3.9 2.0 100

Guntur 3.1 50.0 35.9 7.8 3.1 100

YSR Cuddapah 1.9 55.8 32.7 3.8 5.8 100


Social group

SC&ST 1.6 55.2 35.5 6.5 3.2 100

OBC 4.0 62.0 32.0 2.0 - 100

Other groups - 45.5 40.0 7.3 7.3 100


Illiterate 1.3 46.2 29.7 7.7 5.1 100

Up to 8th std 2.0 58.0 34.0 2.0 4.0 100

Up to 12th

std 3.0 69.7 24.2 3.0 - 100

Graduate - 16.7 66.7 16.7 - 100

All 1.8 53.3 35.9 5.4 3.6 100


Table-A8 Percentage distribution of health facilities visited by women reporting maternal death by district, woman’s age and social group

Characteristics Number of institutions visited before maternal death

None 1 2 3 4 & above Total

District

Anantapur 2.5 22.5 35.0 32.5 7.5 100

Guntur 4.8 40.5 31.0 14.3 9.5 100

YSR Cuddapah

- 21.4 28.6 33.3 16.7 100


Woman’s age at death (Yrs)

Below 18 - 50.0 - 50.0 - 100

19-25 1.1 29.9 26.4 32.2 10.3 100

25 & above 5.7 22.9 45.7 11.4 14.3 100


Social group

SC&ST 2.0 34.7 32.7 20.4 10.2 100

OBC 5.1 28.2 25.6 38.5 2.6 100

Other groups - 19.4 36.1 22.2 22.2 100

All 2.4 28.2 31.5 26.6 11.3 100


45

Table-A9 Percentage distribution of direct maternal causes of death, according to type of health facility/ Home/ En-route to medical facility, 2012

Characteristics

Place of death

Home Medical college hospital

Private Sub district

hospital (DH/AH/CHC)

En-route to medical facility

All

Direct Obstetric cause 10.5 27.4 35.8 11.6 14.7 100

Indirect Obstetric causes 6.7 26.7 31.1 20.0 15.6 100

Non-Obstetrics / Unknown causes

13.6 22.7 18.2 13.6 31.8 100

All 10.2 28.1 31.1 13.8 16.8 100

Table-A10 Percentage distribution of antenatal care registration, and place of availing antenatal services by district, woman’s age and social group

Characteristics ANC registered

Place of antenatal checkup

Govt & Pvt.

Govt. Hosp.

PHC/CHC Private hosp.

S.C/PHC Don’t know /Others

All

District

Anantapur 88.2 - 2.0 11.8 9.8 62.7 13.7 100

Guntur 84.4 - 3.1 3.1 18.8 59.4 15.6 100

YSR Cuddapah 92.3 9.6 1.9 9.6 17.3 57.7 39.0 100



< 18 yrs 66.7 33.3 - - - 33.3 33.3 100

18-25 yrs 88.9 2.6 0.9 6.8 13.7 65.8 10.2 100

26 + yrs 87.2 2.1 6.4 10.6 21.3 46.8 12.8 100


Social group

SC&ST 87.1 1.6 3.2 12.9 11.3 59.7 11.3 100

OBC 96.0 6.0 2.0 4.0 12.0 72.0 4.0 100

Other castes 81.8 1.8 1.8 5.5 23.6 49.1 18.2 100

All 88.0 3.0 2.4 7.8 15.6 59.9 11.3 100


46

Table- A11 Percentage distribution of place of death (according to type of health facility/Home/En-route to medical facility) by district, woman’s age and social group

Characteristics Place of death

Home En-route to medical facility

DH/SDH CHC Private Medical college hosp

All

District

Anantapur 3.9 17.6 15.8 2.0 37.3 23.5 100

Guntur 7.8 17.2 14.0 - 26.6 34.4 100

YSR Cuddapah 19.2 15.4 11.6 - 26.9 26.9 100



< 18 33.3 - - - 33.3 33.3 100

19-25 9.4 15.4 12.8 - 28.2 29.9 100

26 + 10.6 21.3 6.4 2.1 34.0 25.5 100


Social group

SC&ST 4.8 16.1 17.8 1.6 24.2 35.5 100

OBC 18.0 14.0 14.0 - 30.0 24.0 100

Other castes 9.1 20.0 9.1 - 36.4 25.5 100

All 10.2 16.8 13.8 0.6 29.9 28.7 100


Table-A12: Distribution of maternal deaths in Anantapur, Guntur and YSR Cuddapah districts, 2012

S.

No

Cause of Death Medical cause of maternal deaths

Anantapur Guntur YSR

Cuddapah

All

1 Hemorrhage -AH 3.9 1.6 1.9 2.4

2 Hemorrhage -PPH 9.8 14.1 9.6 11.4

3 Hypertensive disorders of pregnancy 19.6 10.9 17.3 15.6

4 Sepsis related to pregnancy and child birth 13.7 7.8 7.7 9.6

5 Thrombo embolism (TE) 11.8 7.8 9.6 9.6

6 Others – Peripartum cardiomyopathy, surgery

complications

3.9 10.9 9.6 8.4

7 Heart disease complications during pregnancy 7.8 3.1 11.5 7.2

8 Severe Anaemia 5.9 4.7 3.8 4.8

9 Endocrine disorders 2.0 - 1.9 1.2

10 Infectious diseases 11.8 10.9 5.8 9.6

11 Liver disorders – Jaundice - 3.1 - 1.2

12 Renal disorders - 3.1 1.9 1.8

13 Others – SOL, Cancer etc., - - 3.8 1.2

14 Non-obst. Surgical causes - - 1.9 0.6

15 Injury and burns - - 3.8 1.2

16 Injury due to accidents - - 1.9 0.6

17 Snakebite - - 1.9 0.6

18 Un-known causes 9.8 21.9 5.8 13.2

All 100

(51)

100

(64)

100

(52)

100

(167)

INDIAN INSTITUTE OF HEALTH AND

Vengalrao Nagar, Hyderabad


Vengalrao Nagar, Hyderabad – 500 038

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Maternal Death Review in Andhra Pradesh,2013

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