A retrospective study of Maternal Death Review

(MDR) in three districts of Andhra Pradesh

1st May 2013

Dr. P. Satya Sekhar, Dr. Neelima SinghIndian Institute of Health and Family Welfare

Vengalrao Nagar, Hyderabad

What is maternal death?

The death of a woman while she is pregnant

…. or ….within 42 days of the

termination of the pregnancy ….….. from any cause related to

or aggravated by the pregnancy

World Health Organization (WHO)

Process of Maternal death review

• Health officials conduct Verbal autopsy for each maternal death

• Audit reports are prepared and placed before the districts collector

• District collector invites relatives of the deceased women for further investigation of social and governance factors

Do women die immediately after developing complications in delivery?

Average time estimated from initiation of treatment in health facility to maternal deaths 2 hours for Postpartum Hemorrhage 12 hours for Ante-partum Hemorrhage 2 days for Obstructed labor 6 days for Sepsis (Infection)

(WHO Bulletin 1998, 76(6), 591-598 based on Maharastra data)

A retrospective study of MDR in Andhra Pradesh (Guntur, Anantapur and YSR Kadapa districts)

No. of maternal deaths reported during January-December 2012 : 167

MDR cases reported by SPHO are analysed by the District MDR team under DM&HO

The analysed MDR reports reviewed by the District Collector to identify facility level gaps for corrective measures with time-lines

IIHFW initiated the MDR analysis in 3 districts

Data entered using EPI-Info package and analysis by using SPSS package

Mandals reporting higher maternal deaths in a calendar year

3 MDs 4 -5 MDs 6 & above

Anantapur AH- Dharmavaram (3)CHC- Nallamada (3)GGH- Anantapur (3)

CHC-Singanamala (5)AH- Kadiri (4)

AH- Penukonda (4)DH- Hindupur (4)CHC- Tadipatri (5)

YSR Kadapa AH- Proddutur (3)

Chennur (5)CHC- Rayachoti (4)

CHC- Porumamilla (8)CHC- Jammalamadugu (6)

AH- Pulivendula (6) CHC- Mydukur (6)

Guntur GGH- Guntur (3)DH- Tenali (3)

CHC- Sattenapalle (5) AH- Narasaraopet (8)

2

2

MATERNAL DEATHS BY CHNCs

District Maternal deaths by CHNC area

Anantapur Penukonda – AH (6), Singanamala – CHC (6) Tadipatri - CHC (5)

Dharmavaram - AH (4), Hindupur – DH (4) Kadiri – AH (4), Nallamada – CHC (4) Anantapur -GGH (3)

YSR Kadapa Porumamilla – CHC (8), Jammalamadugu – CHC (6), Mydukur – CHC (6)Pulivendula –AH (5), Rayachoti - CHC (5)

Chennur –(4), L.R Palli – CHC (4)Kamalapuram – CHC (3), Proddutur – AH (3)

Guntur Guntur – GGH (9), Sattenapalle – CHC (9), Narasaraopet – AH (8), Gurazala – CHC (6) Vinukonda – CHC (5), Kollipara – CHC (4)

Ipuru – CHC (3), Tenali – DH (3)

Grading of health facility and maternal deaths by geographical area

Health facility

Guntur Anantapur YSR Kadapa

Grade-I Tenali (DH -3); Narasaraopet (AH -8); Sattenapalli (CHC -9);

Vinukonda (CHC-5)Chilakaluripet (CHC-2)

Anantapur (GGH-8);Penukonda (AH-6)

Proddutur (AH-3); Rayachoty (CHC-5)

Grade II Gurazala (CHC-6);I puru (CHC-3);

Amaravati (CHC-2)

Hindupur (DH-6); Kadiri (AH-4); Dharmavaram (AH-4); Gooty (AH-4);

Tadipatri (CHC-5); Singanamala (CHC-6);

Nallamada (CHC-4); Rayadurg (CHC-3)

Rajampet (AH-1);Jammalamadugu (CHC-6)

Grade III Kollipara (CHC-4) Pulivendula (AH-5);Porumamilla (CHC-8);

Mydukur (CHC-6); Chennur (CHC-4); L.R. Palli (CHC-4);

Kamalapur (CHC-3)

Maternal deaths by women age

DistrictPercentage of women

Below 20 yrs 21-25 yrs 26-30 yrs Above 30 yrs

Anantapur 22.5 47.1 23.5 3.9

YSR Kadapa 26.9 46.2 19.2 7.7

Guntur 15.6 54.7 25.0 4.7

All 3 districts 22.2 49.7 22.8 5.4

70% of MDs are below 20 years of age (MDR report, Andhra Pradesh, 2008-10). Shift in age pattern of MDs due to higher proportion of girls marring after 18 years of age

Seasonal trend in maternal deaths?Maternal deaths reported during January-December 2012

Jan,2012 Feb Mar Apl May June July Aug Sept Oct Nov Dec,20120

5

10

15

20

25

30

1 0 1

17

26

22

19

14

25

19

12 11

Trend line

Rise of inflectional diseases like vector borne Dengue, Malaria and Pyrexia during June-September months andIncreased efforts of health staff in MDR reporting and public awareness

Anantapur district

In June and July months, two deaths out of six maternal deaths was reported due to dengue. In November month, one death out of two maternal deaths was due to Malaria.

Hence, control of vector-borne disease with measures such as long acting insecticidal bed nets goes a long way in averting maternal deaths due to infections

Timing of maternal death, 1995-96 & 2012 (No significant change in one and half decades)

Abortion Antenatal period Intra-natal period Post natal period0

22.7 20.4

56.8

2.4

19.2

25.7

52.7

1997 2012

Timing of maternal deaths by district, 2012

Anantapur

YSR Kadapa

Guntur

All 3 districts

0 10 20 30 40 50 60 70 80 90 100

15.7

25

17.2

19.2

35.3

23.1

20.3

25.7

45.1

50.0

60.9

52.7

AbortionAntenatalIntranatalPost natal

Kadapa reported 25% of MDs in Antenatal period,Anantapur 35% during intra-natal period and Guntur 61% during postnatal period.

Postnatal check-ups in Andhra Pradesh (NFHS-3, 2005-06) RCH Baseline survey (2007) also reported 60% of women delivered at home received PN check-up within one week after birth

Had

post

nata

l che

ckup

Less

than

4 h

ours

4-23

hou

rs

1-2

days

3-41

day

s

Don'

t kno

w/m

issin

g

No

PN c

heck

up

0102030405060708090 82.7

54

8

14

72

15

68.7

41

4

1310

2

30

Urban Rural

54% in urban and 40% in rural areas women availed PN care within 4 hours. Less

than one-third in rural areas had no PN checkup

Postnatal visit by a Health PersonnelAbout a quarter of delivered mothers are not receiving

Postnatal care• RCH Baseline Survey, 2006-07– Institutional deliveries (within a day – 87%; within a

week: 90%)– Non-institutional deliveries (within one week of

birth- 60% and within 2 weeks of birth 64.2)• DLHS-3, 2007-08 (within 2 weeks after delivery)

Overall- 79.5%; Rural – 76.4%; Urban – 89.1% • CES 2009 (within 10 days after delivery) – 89.4%

Location of Maternal Death, 1997 -2012(Maternal deaths during transit period indicates poor management of high-risk pregnancy assessment, no

systematic referral system, non-availability of doctors in 24x7 facilities, poor transportation facility)

Home Transit period Govt. Hosp Private college0

10

20

30

40

50

60 55.3

10.612.1

22

10.1

17.3

42.9

29.8

Place of maternal deaths by district (n=167)

Anantapur

YSR Kadapa

Guntur

All 3 districts

0 5 10 15 20 25 30 35 40 45 50

3.9

19.2

7.8

10.1

19.6

15.4

15.6

17.3

37.3

40.3

49.7

42.9

39.2

25

26.6

29.8

Pvt HospGovt. HospTransitHome

Majority of maternal deaths in Anantapur are in RDT trust hospital

Women reported maternal death by birth order

Primi gravida44%

Second Gravida22%

More than 233%

Background characteristics of women -1

• Out of women reporting MDs

a. 12% married before legal age of 18 yrs

b. Women educational status• Illiterate - 47% • Up to 8th class - 30%• Up to 12th class - 20%• Graduate - 3.6%

c. Hindus (82.6%) and Muslims (13.8%)e. Scheduled tribe (7.2%); Scheduled caste (29.9%);

OBC(29.9%) and Others (32.9%)

Background characteristics of women-2– 62% of women are housewives – Median distance travelled by women from home

to first health facility – 9.0 km– Median number of institutions visited by

women before maternal death – 2 intuitions – 9% women have previous abortion – 44% women have no living child and 30% with

one-child – Average age at maternal death - 24.15 yrs

Status of fetus of delivered women

Infant survival of women reporting MDs• 51% live birth• 2% new born death• 17% still birth• 31% not delivered

1997 MDR study reported outcome of pregnancy as live births (62%), still births (4.5%) and not delivered (33%)

Distance from residence to a health facility (n=167)

0-5 kms 6-10 kms 11-15 kms 16-20 kms 21 +0

5

10

15

20

25

30

35

40

45

50

43.1

17.4

12.6

6.6

20.4

Number of institutions women visited before maternal death (n=167)

No facility2%

one facility21%

2 facilities23%3 facilities

20%

4 & above8%

Not available26%

Reasons for referral by providers to higher facility

Lack of blood5% Lack of staff

1%

No ex-planation

given38%

Other reasons

56%

Ninety-four percent of health institutions did not indicated specific reason for referral to higher/other facility

Maternal deaths reported Antenatal care (n=32)

Maternal Deaths during Antenatal Care Period (n=33)

33

Mother have any problem during ANC period

Yes (26) No (6) Don’t Know (1)Referred during ANC period

Yes (26) Not applicable (7)

Symptoms for which care sought

Anemia - 2 Bleeding p/v - 2 Edema - 2High BP - 2 High fever - 2 Others - 16

Attended any health facility

Yes (23) No (3)

Reason for not seeking treatment

1) Other reason – 12) Severity of complications -2

Missed opportunity during ANC

• 26/33 (78%) of ANC mothers reported symptoms of High BP, edema, bleeding p/v and high fever referred to higher facility

• 23/26 (88%) sought treatment at referral centre

• GAP– No follow up by the field staff /PHC MO

Maternal deaths during intra-natal period

Maternal deaths during intra-natal period - 1• Number of maternal deaths in intra-natal period: 43

• Preference of delivery by institution– 38.7% Private sector– 52.3% Govt. institutions/ medical college hospitals– 9 % Home deliveries

• On average, 10.6 hours reported between on set of labor pain and delivery ( 27% reported duration <= 2 hours)

• Half of deliveries (49%) attended by doctor followed by 14% by ANM/Staff nurse/Med. Asst

• 59% of delivery ended with a live birth

Maternal deaths during intra-natal period -2• Problems reported by mothers during delivery

– Severe bleeding / bleeding with clots (23.3%)

– Convulsions (11.6%)

– Severe breathlessness /Cyanosis /edema (9.3%%)

– High fever (7%)

• Out of women reported problems, only 67% availed treatment

• The reasons for non-compliance are

– Intensity of complications not known (3.7%)

– Institution far away (11.1%)

– Lack of transport (3.7%)

– Beliefs and customs (3.7%)

Causes of maternal deaths during intra-natal period (n=28)

Prolonged labor7%

Severe bleeding36%

Inversion of uterus4%

Retained placenta7%

Convulsions18%

Severe breathless

ness /edema

14%

High fever14%

Missed opportunity during Intra-natal care• Home delivery - 9%

• Institutional deliveries - 91% (52% Govt. and 38% private)

• Half of deliveries attended by doctor - 49%

• Delay-1 & 2 :

67% of mothers availed delayed treatment due to

– Institution far away (11.1%)

– Beliefs and customs (3.7%)

– Intensity of complications not known (3.7%)

– Lack of transport (3.7%)

Missed opportunity during Intra-natal care- continued• Delay-3 :

– Lack of EmOC services like blood transfusion facility, USG and mothers using 2 and more facilities during fatal illness

– More than half (53%) diseased women had residence within 5 kms from a health facility – inadequate functionality

– Lack of referral linkage

– Lack of uniform protocols and SOPs in government and private Ex: Trial of labor in case of placenta previa, non-usage of Mg So4, a life saving drug in Eclampsia, not using Partograph

– Lack of functioning MICU (maternal intensive care unit) in tertiary care hospitals due to lack of specialists and team to run when infrastructure is available.

Maternal deaths in postnatal checkups (n=88)

Postnatal checkups by delivered mothers

>=4

2-3 times

One time

No postnatal care

0 10 20 30 40 50 60

5.7

20.5

19.3

54.5

Less than half of delivered mothers availed postnatal care.

Timing of maternal death after deliveryin Anantapur district (n=33)

0-6 hours 7-24 hrs 1st day - 7 days one week - 2 weeks

>2 weeks0

5

10

15

20

25

30

35

40

45

33.0

12.1

39.7

12.2

3.0

84% of postpartam maternal deaths are in first one week after delivery and 45% within one day

Identified problems reported after delivery by mothers

Severe bleeding

Sudden chest pain & collapse

Un consciousness/visual disturbance

Fever and foul smelling discharge

Severe anaemia

Breathlessness

Bleeding from multiple sites

Abnormal behaviour

Urinary disturbances (oliguria)

Severe leg pain & swelling

Jaundice

0 5 10 15 20 25 30

20.8

20.8

20.8

10.4

9

6

3.4

2.9

2.9

1.5

1.5 76% mothers had postnatal risk factors21% had sudden chest pain & collapse but 56% gave opportunity but “MISSED” due to lack of postnatal care

Missed opportunity during post natal care

• Postnatal care (PNC) viewed as less important than Pre ANC

• CES (2009) Andhra Pradesh indicated universal PNC, but less than half of delivered mothers received quality PN care

• 76% mothers had postnatal risk factors

• 21% had sudden chest pain & collapse but 56% gave opportunity but “MISSED” due to lack of postnatal care

• 74% of mothers had inadequate PNC (54% had no PNC visits and 19% had one visit.

• Majority post natal deaths (84%) occurred in first week after delivery

Cause of Maternal Death Classification, 2012

Cause of death Frequency Percent

Direct obstetric cause 95 57.0

Indirect obstetric cause 45 27.0

Non obstetric cause 5 3.0

Not known cause 22 13.0

Total 167 100.0

Cause of Maternal Death Classification, 1997 and 2012

Direct obstetric cause Indirect obstetric cause

Non obstetric cause Un-classified0

10

20

30

40

50

60

70

80

72

15.2

8.34.5

56.9

26.9

3.0

13.2

Indirect obstetric cause26.9%

Non obstetric cause3.0%

Not known cause13.2%

Hemorrhage - APH2.4%

Hemorrhage - PPH11.4%

Hypertensive disorders of pregnancy

15.6%

Sepsis related to pregnancies and child birth

9.6%

Thrombo embolism (TE)9.6%

Others - Peripartum cardiomyopathy, surgery com-plications

8.4%

Causes of Maternal Death Classification

Indirect obstetric cause Frequency Percent

Heart diseases complicating pregnancy 12 26.7

Severe Anaemia 8 17.8

Endocrine disorders. 2 4.4

Infectious diseases. 16 35.6

Liver disorders – Jaundice 2 4.4

Renal disorders 3 6.7

Others - SOL, Cancer etc., 2 4.4

Total 45 100.0

Indirect obstetric cause of Maternal Death

Direct obstetric cause56.9%

Non obstetric cause3.0%

Not known cause13.2%

Heart diseases complicating pregnancy

7.2%

Severe Anaemia4.8%

Endocrine disorders1.2%

infectious diseases9.6%

Liver disorders - Jaundice1.2%Renal disorders

1.8% Others - SOL, Cancer etc.,1.2%

Causes of Maternal Death Classification

Maternal deaths reported in Andhra Pradesh

District/Year 2009-10 2010-11 2011-12

Guntur 50 61 42

Anantapur 36 38 46

YSR Kadapa 44 50 51

Andhra Pradesh 750 N.A 691

Source: NHSRC-HMIS reports for Andhra Pradesh, 2009-10,2010-11 and 2011-12

1. 63-75 percent of maternal death reasons specified as ‘Other causes’.2. In 2011-12, the maternal death reasons at state level are Bleeding(11.3%), Severe

Hypertension/fits (7.4%), Obstructed /prolonged labour (3%), High fever (2%), Abortion (1.9%) and other causes (74.4%).

What is required for an effective MDR implementation in A.P?

• Re-orientation/training to all Mo’s required in precisely identifying causes of maternal deaths in CBMDR and FBMDR

• Open history (CBMDT) written meticulously, word by word, event by event as reported by family members

• Need to conduct sub-committee meetings regularly

• MDR trainings to all PHC medical officers

• Revise MDR formats for an user-friendly data compilation and data analysis

• Need to initiate a systematic state level MDR analysis

Thank You