Maternal Death Review in Andhra Pradesh An analysis of data from Anantapur, Guntur and YSR Cuddapah districts

Dr. P. Satya Sekhar, Dr. Neelima Singh and Ch.V.S. Sitarama RaoIndian Institute of Health and Family Welfare, Hyderabad

Introduction & Background

Maternal Mortality Ratio (MMR) is a sensitive indicator reflecting the availability of health care facilities and prevailing socio-economic scenario. India contributes to 20% of global maternal deaths. Around 54,000 maternal deaths and one million newborn deaths occur each year (WHO, 2012). Nationwide, the MMR has dropped by 34 points from 212 in 2007-09 to 178 in 2010-12; Andhra Pradesh has managed to reduce it by another 24 points from 134 in 2007-09 to 110 in 2010-12 (6% per year). Andhra Pradesh becomes the fourth best state in the country with the lowest MMR rate after Kerala (66), Tamil Nadu (90) and Maharashtra (87). There is a wide interstate and intrastate variation in MMR reported with 390 in Assam and 81 in Kerala state (RGI, 2013 and AHS (2011-12) in EAG states).

Maternal Death Review (MDR) is a new initiative introduced under NRHM and the GOI recommended to collect the information in two formats namely CBMDR (Community Based Maternal Death Report) and FBMDR (Facility Based Maternal Death Report) in every state in order to identify gaps, which can be classified into three delay model (medical, socio-economic and health system-related factors) both at state and district level. The IIHFW, the apex training institute of the Government of Andhra Pradesh (GoAP) conducted both sensitization work shop to district officials and systematic training on filling the CBMDR and FBMDR formats to medical specialists and hospital administrators.

Data Collection Procedure

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.

From the beginning of year 2011, MDR information has been collected in CBMDR and FBMDR formats in all districts of the state. The ANM line lists all deaths of women of age 15-49 years during the month (Format-5) irrespective of cause of pregnancy status and submits by 25th of the month to the MO PHC. In CBMDR, the ASHA/AWW provides information to ANM and PHC MO about the suspected maternal death in the village. After cross checking every death according to Format-5, the MO PHC submits maternal death information to the SPHO. The SPHO on receipt of information about maternal death, initiates community based investigation (verbal autopsy) according to guidelines and collect information as per Format-2 and Format-3 within three weeks after death.

The SPHO of the PHC jurisdiction area submits CBMDR formats along with a Case Summary Sheet (Format-3) to the District Nodal officer (ADM&HO). The SPHO of every CHNC would maintain a register (Format-4) of maternal deaths in a chronological order and update it every month. In case of any occurrence of maternal death reported in the jurisdiction area, the SPHO attends the monthly District MDR sub-committee meeting chaired by DM&HO.

In FBMDR, on any maternal death in a health facility, medical officer on duty, informs the Facility MDR Nodal officer, DCHS and District Nodal officer (ADM&HO) within 24 hours of occurrence. The facility nodal officer in the health facility prepares a list (Format-4) of any maternal deaths in the facility and submits to the ADM&HO every month. The facility nodal officer submits two copies of MDR summary formats in a sealed cover to Facility MDR Committee and to District Nodal officer within 48 hours of occurrence of maternal death. Every maternal death occurring in the facility is given a yearly serial number and all corrective actions initiated in the facility are reported to District nodal officer in a separate format-4.

The DM&HO constitutes the district MDR sub-committee consisting of DCHS, Senior Obstetrician from the district/ teaching hospital, Anesthetist, Officer-in charge blood bank /storage center /senior nurse/EMRI district representative/ FOGSI/ invited members from health facilities / Block PHCs as members and District nodal officer MDR (ADM&HO) as member secretary. On a prefixed day, the ADM&HO conducts the District MDR sub-committee meeting under the chairmanship of DM&HO.

The District Collector (DC) conducts the District MDR Committee meeting every month convened by DM&HO and assisted by District nodal officer of MDR along with members of District Health Society identified by the District MDR committee members including family members of the deceased who were present with the woman during the treatment of complications at the time of maternal death. The DC reviews a sample of maternal deaths by listening to relatives of the deceased. Based on the narration of relatives of the deceased, correctness of information gathered through CBMDR and FBMDR formats verified and plan for corrective steps.

The State Nodal Officer (SNO) for4 MDR will be responsible for overall supervision and monitoring of MDR implementation in the state and coordinates district MDR activities. A serial record of every maternal death received from all districts during the calendar year will be maintained at the office of the Director, FW according to Format 7 and made available along with HMIS data set.

Review of literature

There are about 9 research studies enquired about the maternal deaths in Andhra Pradesh and first study conducted by Bhatia (1984) in Anantapur district and the latest by Centre for Economic and Social Studies (CESS, 2009) in Mahabubnagar district. In case of maternal death analysis in the state, significant contribution were made by Dr. M. Prakasamma, Academy of Nursing Studies (ANS), Hyderabad.

A cross-section of the literature showed that a higher proportion of maternal deaths were reported among households having illiterate mothers, low economic status and scheduled caste and scheduled tribe communities (Prakasamma, 1997). Higher proportion of maternal deaths reported from women below 19 years and women with 35 and above age group (ANS, 2007). More than half of maternal deaths were reported among women with birth order 3 and above. Home and transit (travel of pregnant women from home to health facility / higher referral) were important places of maternal deaths (ANS, 2007). The most common time of maternal deaths was during postnatal period (ANS, 2007, Singh (2012), CESS (2012). The direct and indirect causes of maternal death were post partum hemorrhage, hypertension disorders in pregnancy, sepsis and severe anaemia. Studies reported low or sub-optimal quality health care services in health facilities.

The review of studies showed 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) availability of EmOC care to address direct and indirect causes of maternal deaths; c) steps to correct persisting anemia related problems among women and children; d) health campaign on micro-birth planning for pregnant women and importance of postpartum care to delivered mothers.

The Indian Institute of Health and Family Welfare (IIHFW) made an attempt to analyze the CBMDR and FBMDR formats for an in-depth analysis in Anantapur (51), Guntur (52) and YSR Cuddapah (64) districts covering January to December 2012. A team of medical experts scrutinized the CBMDR formats for data consistency and correctness including causes of death. IIHFW also developed data structure in EPinfo-6 and entered the data in a structured format. After manual and consistency validation checks, uni-variate and cross tabulation analysis was carried out using SPSS package.

Thus the retrospective study attempted to fill the gap by analyzing the CBMDR formats during 2012 period from Anantapur, Guntur and Kadapa districts. The specific objectives of the study are a) to assess the direct, in-direct and non-medical causes of maternal deaths; b) to assess the influence of socio-economic, demographic and other factors that led to maternal death; c) to identify mandals/CHNCs reporting maximum number of maternal deaths and suggest corrective measures and d) to identify gaps in three delays model.

Discussion

a) Age a marriage and maternal deaths

Out of women reported maternal deaths, about 61-71% married before legal age at marriage in Medak district (Singh, 2010) and Mahabubnagar (CESS, 2012) district. Contrary to the observation, only 12% (5% in Guntur, 15% in Kadapa and 18% in Anantapur) women married before legal age at marriage. Shift from teenage maternal deaths is a welcome sign and attributed due to increase in median age at marriage to 16.1 years (NFHS-3, 2005-06) from 15.6 years (NFHS-2, 1998-99) in the state.

b) Caste and maternal deaths

More than half (51-54%) women reported maternal deaths were belonged to scheduled caste and scheduled tribe communities (IIHFW, 1997; CESS, 2012; and Singh (2010). The three districts CBMDR data revels that slightly above one-third (37%) belonged to scheduled groups and backward castes (30%) and other castes (33%). The Janani Suraksha Yojana (JSY) made a significant impact in improving the hospital deliveries among scheduled communities, however about half (50%) maternal deaths reported from scheduled groups in Guntur district.

c) Education level of women and maternal deaths

Less than half (46%) women died due to pregnancy related complications are illiterate women. 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.

d) Place of death

Less than three quarters (73%) women seek admitted in medical facilities (43% in public and 30% in private) and remaining 27% died either at home (10%) or during transit period (17%). The Medak study (Singh 2010) reported deaths at home (22%) and transit (66%) due to poor referral facilities available in the district. The Mahabubnagar study (CESS, 2012) showed that majority of maternal deaths occurred in government facility (34%) followed by private (26%), at home/residence (29%) and during transit from one facility to other referral (11%). However, evidence from Medak district (Singh, 2010) showed that two-fifths (67%) of maternal deaths occurred during transit (67%) period and at home (22%) due to delayed /late referral by health institutions. In the present study, about 15-20% maternal deaths reported during transit period which indicates poor assessment and lack of confidence in health staff or intentionally referring to higher facility to avoid death in their premises. About one-third (35%) of the women admitted in a health facility died within 24 hours indicating lack of birth preparedness, transport facilities, lack of existing referral mechanism and low awareness of family members.

The common time of maternal deaths in the three districts observed was the postnatal period (53%), followed by intra-natal period (26%) antenatal period (19%) and abortion (2%).

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. Half of mothers (51%) reported maternal deaths in 21-25 years age particularly with zero and one parity gestation. 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 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).

Of the 167 maternal deaths in the three districts, consolidated information of maternal deaths by mandals (CHNC area) presented in Figure. In YSRB 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. 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 ina calendar year were reported in Singanamala, Kadiri, Penukonda, Hindupur and Tadipatri mandals.

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 in the health facilities is the prime requirement along with strict supportive supervision.

Ninety-three percent of health institutions did not indicate specific reason for referral to higher/other institution facility. Only six percent of health facilities indicated lack of blood as main reason. This reflects the low morale of medical and paramedical staff and lack of effective supervision at each level. 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 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

Systematic monitoring of MCTS information on the components of ANC, institutional delivery, birth planning, post partum care and post natal care in the lines of ‘Amma Lalana’ intervention in Karimnagar district of Andhra Pradesh

In the lines of Tamil Nadu, identify two or more health facilities in each district with comprehensive emergency obstetric and newborn care services with radial distance of less than two hours to reach the facility.

Need to gear-up trainings on LSAS, NSSK and SBA trainings to medical officers, staff nurses and ANMs / maternal assistants working in labour rooms at every delivery point.

Half of the mothers 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

Half of maternal deaths were in post natal period (51%) followed by antenatal period (23%). Re-emphasize the continuum of care, the complete post partum care to every mother and newborn.

Focus to be lain 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.

MATERNAL DEATH REVIEW IN ANDHRA PRADESHANALYSIS 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 364 18 17 14

3 Number of PHCs 1624 80 82 70

BACKGROUND INFORMATION

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

S. NO INDICATOR ALL 3 DISTRICTS

ANANTAPUR GUNTUR YSR Cuddapah

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

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

S. NO INDICATOR ALL 3 DISTRICTS

ANANTAPUR GUNTUR YSR Cuddapah

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

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)

Source:

A Retrospective study on maternal death review in Andhra Pradesh- An analysis of data from Anantapur, Guntur and YSR Cuddapah districts, (Mimeo), Indian Institute of Health and Family Welfare, Vengalarao Nagar, Hyderabad-38. (Authors: Dr. P. Satya Sekhar (psekhar9@gmail.com); Dr. Neelima Singh and Mr. Ch.V.S. Sitarama Rao).

Need to develop 3 or more FRUs (as per Tamil Nadu criteria) along with IPHS norms for a comprehensive 24-hour emergency obstetric and new born care services in remote and backward mandals of the districts