Maternal mortality at a tertiary care teaching hospital of India: a retrospective study

Introduction: Pregnancy, carries risk of maternal mortality due to various complications that may arise during pregnancy, labour and thereafter. Objectives : To assess the causes of maternal death over a period of three years at a tertiary care teaching hospital at Kolkata, India. Methods : A retrospective hospital based study of maternal deaths over a period of 3 years from January 2015 to December 2017. The information regarding demographic profile and reproductive parameters were collected and results were analyzed. Results : Over the study period, there were 25,498 live births, and 81 maternal deaths, giving MMR of 317/1,00,000 live births. Pre-eclampsia/eclampsia was the leading direct cause while liver disease was leading indirect cause. Conclusions : Maternal deaths are preventable by early identification of high risk pregnancies, standard treatment and their timely referral to higher centre.


Introduction
Maternal mortality or death is defined (as cited in International Classification of Diseases or ICD-10 [WHO, 1992]) is the death of a woman while pregnant or within 42 completed days of termination of pregnancy, irrespective of the duration or site of pregnancy, and can arise from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes [1]. Maternal Mortality Ratio(MMR) is defined internationally, as maternal death rate per 1,00,000 live births and calculated as: All maternal deaths occurring within a reference period (usually 1 year) x100,000 __________________________________________________________________ Total no. of live births occurring within the reference period Traditionally India had avery high MMR; MMR was 1000 per 1,00,000 live births by 1959; it dropped down to 540 per 1,00,000 live births in 1999 [2]. Currently it is estimated to be 167 per 1,00,000 live births (2011-2013, NItiAyog data) [3,NitiAyog] which is still above the target of 100 per 1,00,000 live births as per the objectives of Millennium Development Goals (MDGs) [1].
The most common causes of maternal mortality worldwide are postpartum bleeding (15%), complications from unsafe abortion (15%), hypertensive disorders of pregnancy (10%), postpartum infections (8%), and obstructed labour (6%).Causes of all Maternal deaths fall into two groups: Direct obstetric deaths: Direct obstetric deaths result from obstetric complications of the pregnancy, from interventions, omissions, incorrect treatment, or resulting from any of the above.

Material and Methods
Place of study: The Department of Obstetrics and Gynaecology, NRS Medical College, Kolkata which is a tertiary level health care facility over a period of three (3) years from January, 2015 to December, 2017.

Type of study:
A retrospective hospital based study.
Sample collection: A total 81 maternal deaths were noted from hospital records and analyzed depending on causes of deaths, demographic profiles of the patient, parity, admission to death time interval Statistical methods:Results were analyzed by using percentage and proportion. Inclusion criteria: All maternal deaths that were recorded included in this study.

Results
It is observed from    It indicates that age of marriage is increasing for women and teenage pregnancies are reducing in number. Kaur et al [7] revealed that 51.8% of deaths in 20-30 years, 23.3% in >30 years; Taneja P [8] showed that 78% of deaths in 20-30 years; Sengupta et al [5] observed that 61% of deaths in 20-29 years, 28.62% of deaths in >30 years and only 9.94% deaths in <19 years; Dogra et al [9] revealed that 48% deaths in 20-25 years while 10.3% in >30 years.
The reduction in the number of deaths in women <19 years of age is partly due to spreading of women education and women empowerment thus increasing the age of marriage and partly due to availability of specialist doctors for legal medical terminations, thus reducing the number of criminal abortions and subsequently the deaths associated with its complications.
In the present study, out of the 81 deaths, 18 (22.22%) deaths were among primigravidas and 63 (77.78%) among multigravidas, almost similar to that reported by other studies, Thomas et al [10] showed that primigravida contributing to 29.2% and multigravida 50.8% of deaths.
Purandare et al [11] observed that out of the 30 deaths, 21 were multigravida and 9 were primigravidas. Spacing of pregnancies is still a problem and close pregnancies adversely affect the mother's health.
In the present study, 15 women died within 6 hour of admission; 9 (11.1%) between 6-24 hours of admission; and 36 (44.4%) between 24 hours to 7 days of admission and 21 (25.9%) after 7 days of admission. Purandare et al [11] showed that among the 30 deaths,3 died within 30 minutes of admission, 14 died between 30 minutes and 6 hours, 7 died between 6 and 24 hours and remaining 6 died after 24 hours of admissions. This change in statistics shows availability of basic obstetric care in peripheral institutions and improved infrastructure in tertiary institutions which in turn either reducing the number of deaths or trying to save critical patients which shows in maximum deaths occurring after 24 hrs. In the present study, maximum 60 (74.09%) deaths occurred in post-partum period. Similar results have been reported by other studies, Purandare et al [11] showed that (73.33%) in the postpartum period followed by (26.66%) during the antepartum. Thomas et al [10] showed that maternal deaths in the 1st, 2nd and 3 rd trimester and post natal/ postabortal were 3.5%, 9.7%, 31.9% and 54.9% respectively.
Similar to that reported by the other studies. Purandare et al [11] observed that among the direct causes, hemorrhage in 70.83% of deaths; followed by septicemia (3.3%) and among the indirect causes, anemia in 55.3%; hepatic disorders in 3.3% and pulmonary embolism accounting for 6.67%. Thomas et al [10] noticed that among the direct causes, hemorrhage in 20.15% and sepsis in 17.4% and among the indirect causes, hepatitis in 11.9%.
In the present study deaths due to hemorrhage are less; it indicates better availability of blood products and rapid surgical intervention following admission. Also availability of newer generations of anti-microbials are reducing deaths due to sepsis.