Background- India is among those countries which have very high Maternal Mortality Rate (301/100,000 live birth) .In Madhya Pradesh MMR is much higher (379/100,000/live birth). About 78,000 women die each year due to pregnancy related causes. Social factors play important role in maternal morbidity and mortality. Research Question –What is the magnitude of Maternal Mortality and its social determinants in a Community Development Block of District Satna (MP.). Objective– To assess the magnitude of Maternal Mortality and its social determinants. Study Design-Retrospective epidemiological study. Setting and Participants - The subjects included were female deaths of reproductive age group (15-45 years) of a Community Development Block Satna (MP.). Methodology- The data were collected from available health records, by house to house survey and verbal autopsy in study area. Results - A total of 27 maternal deaths were gathered from deferent sources during one year study period, thus giving, MMR of 550/100,000 live birth. Maximum 24 maternal deaths (88.8%) occurred in the age group of 18-30years.Around 55% maternal deaths took place in low socio economic group. Around 44.44% mothers did not take any antenatal care during their pregnancies. Around twelve maternal deaths (44%) were due to direct obstetrical causes and remaining 15 maternal deaths (54%) were due to indirect causes. The reason in 62.96% mothers for non- availing hospital treatment were financial constraints, ignorance, illiteracy, late decision, male dominance in family matters

Joshi, K P

Kushwah, S S

English

Indian Journal of Community Health

Indian Journal of Community Health, Vol. 23, No. 2, July 2011- Dec. 2011                                                                                                                                            ( 78)Joshi & Kushwah: Epidemiological study of social factors associated with maternal mortality in community development block of Madhya Pradesh  Original     ArticleAN EPIDEMIOLOGICAL STUDY OF SOCIAL FACTORSASSOCIATED WITH MATERNAL MORTALITY IN A COMMUNITYDEVELOPMENT BLOCK OF MADHYA PRADESHDr K P Joshi1, Prof. S S Kushwah21Associate Prof., Department of Community Medicine, SVSMC, Yenugonda, Mahabubnagar, (A.P.), 2Prof & Head, Dept. of Community Medicine, S.S. Medical college,Rewa (M.P.)AbstractBackground- India is among those countries which have very high Maternal Mortality Rate (301/100,000 live birth) .In Madhya Pradesh MMR is muchhigher (379/100,000/live birth). About 78,000 women die each year due to pregnancy related causes. Social factors play important role in maternalmorbidity and mortality.Research Question –What is the magnitude of Maternal Mortality and its social determinants in a Community Development Block of   District Satna (MP.).Objective–  To assess the magnitude of Maternal Mortality and its social determinants. Study Design-Retrospective epidemiological study. Setting andParticipants - The subjects included were female deaths of reproductive age group (15-45 years) of a Community Development Block Satna (MP.).Methodology- The data were collected from available health records, by house to house survey and verbal autopsy in study area. Results - A total of 27maternal deaths were gathered from deferent sources during one year study period, thus giving, MMR of  550/100,000 live birth. Maximum 24 maternaldeaths (88.8%) occurred in the age group of 18-30years.Around 55% maternal deaths took place in low socio economic group. Around 44.44% mothers didnot take any antenatal care during their pregnancies. Around twelve maternal deaths (44%) were due to direct obstetrical causes and remaining 15 maternaldeaths (54%) were due to indirect causes. The reason in 62.96% mothers for non- availing hospital treatment were financial constraints, ignorance,illiteracy, late decision, male dominance in family matters.Key Words- MMR,  SES, Social Factors.Introduction  More than half million women die in developing countrieseach year during pregnancy, childbirth or from related causes, makingat least one million children motherless. The risk of dying of mother dueto pregnancy or childbirths in developing countries is 300 times higherthan in developed countries. For example, a women in Eastern Africafaces the highest risk of maternal death 1 in 12, compared with only 1 in3700 for women in North America. No other health indicator varies sodramatically between developed and developing countries1. Accordingto WHO, a maternal death is defined as “the death of women whilepregnant or 42 days of termination of pregnancy, irrespective of theduration and site of pregnancy, from any cause related to or aggravatedby the pregnancy or its management but not from accidental or incidentalcauses”2.Every one minute one female die and EVERY 5 MINUTES…one woman somewhere in India dies from a pregnancy relatedcomplication. When a woman dies, her new born baby has 6 to 10 timesgreater chance of dying as well, that comes to more than 100,000 maternaland 10,00,000 newborn deaths each year. India accounts for one in fiveof all maternal deaths around the globe every year3. According to census2001, Madhya Pradesh is the 2nd largest state in terms of its geographicalarea after Rajasthan and is 7th in terms of population and contributes5.88% of India’s total population . Evidence from various rural surveyssuggests that maternal deaths account for more than 2% of total deathsand about 4% of total female deaths (Department of Economics andStatistics GOMP, 1996). In Madhya Pradesh, MMR is high (379/100,000live births) and in Satna district it is much higher4.Determinants of maternal mortality in India are medical causesand social factors. A large number of social factors influences maternalmortality like age of the mother, age of marriage, parity, birth spacing,family size, malnutrition, poverty, illiteracy especially in rural areas.Hence present study was undertaken to assess the Magnitude of MaternalMortality and its social determinants in study area5.MethodologyAll female deaths (> 10 yrs age) during the period from 01-10-2002 to30-09-2003 of study area were identified and investigated throughAddress for Correspondence:Dr K P Joshi, Department of community medicine, SVSMC, Yenugonda, Mahabubnagar, E-mail drkp_joshi@rediffmail.com. Received: 12/09/2011 Accepted: 14/12/2011different sources by pre-designed, pre-tested questionnaire so that allmaternal deaths could be identified. The data were re- investigated andcross checked to avoid any duplication.Data collection1. Records-a) Police Records.b) Records from Panchayat & Kotwar.c) Records of health Workers.d) Hospital Records.e) PHC-Records.2. Door to door survey through personal visits by PGresident and health worker.3. Verbal autopsy using a specified semi-structured pre-testedquestionnaire by a group of PG resident of department of communitymedicine. SSMC Rewa(MP).  All the data collected were tabulated in Microsoft Excel 2000 softwareand then the analysis was done using Pivot tables. The coverage of variouscomponents related to female health is expressed in percentages. Results          Physical mapping of study area revealed that the totalpopulation of the study area was 2,01,236  with majority  91.90%population in Rural and 8.10% in Urban area Sex ratio in area was949 female per1000 male. Female literacy was much lower (51% )than male literacy (77.80%). Birth rate of study area was 32/1000population and total fertility rate was 3.The study area was having 2community health centres,4 primary health centres and 32 sub healthcentres .Proportionate population of SC, ST and others in the studyarea was 12.1%, 11.5% and 76.4% respectively. Total 110 deaths offemale in reproductive age group (15-45 years) were reported in thestudy area. Out of these female deaths, 27(24.54%) deaths were dueto pregnancy related causes (maternal deaths).                During the study period, total 7062 pregnancies were reported;out of this, only 5064 (71%) pregnancies were registered for antenatalcare, in any govt or private health institutions. Total 4905 live birthswere reported in the study area, so the maternal mortality rate was 550/100,000 live births. Out of 27 maternal deaths, 26 deaths (96.3%) werefrom rural area and only one (3.7%) death reported in urban area. In thecaste wise distribution of maternal deaths, 33.33% were from SC,Indian Journal of Community Health, Vol. 23, No. 2, July 2011- Dec. 2011                                                                                                                                            ( 79)11.11%ST and remaining 55.55% were from other caste. Maximum 24maternal deaths (88.8%) occurred in the age group of 18-30years.TABLE- 1EDUCATIONAL STATUS OF MOTHERSAbout 33.0% of mothers were illiterate, 40.74% studied upto 8th class, 18.51% studied up to 12th standard and 7.42% were graduate.On other hand educational status of the husband of the mother wereilliterate-40%, 8th standard-30.50%, 12th standard 20.57%, graduates-8%.TABLE- 2SOCIO-ECONOMIC STATUS OF MOTHERAround 55% maternal deaths took place in low socioeconomic group ( class IV). Maximum (15) maternal death (55.60%) inproportion to pregnancies was observed in multipara (more than 3children). Around 60% of  mother were having the birth interval of 1year only. Around 44.44% mothers did not take any antenatal care duringtheir pregnancies and only 14.81% mothers attended 3 or more ANCvisits. Remaining 40.25% women attended less than 3 antenatal visits.This signifies that maximum deaths were reported among those motherswho did not avail any antenatal care during their pregnancy. Out of   thefamily total 27 mothers, in 95% families decision taking power was inmales. As per the verbal autopsy report, nutritional status of 80% motherwas poor. More than 70% mother did not consume any iron folic acidand calcium tablets,  and did not have TT vaccination during theirpregnancy. Out of total 27 mother, 20 (74%) mothers were delivered athome and in  the 41.67% of cases ,delivery were attended by trainedbirth attendants followed by 16.66% by family members and relatives.Educational Status No. of Maternal deaths Percentage Illiterate 9 33.33% Up to Middle 11 40.74% Higher Secondary 5 18.51% Graduate & above 2 7.42% Total 27 100% Socio-economic Status No. Of Maternal deaths Percentage I 0 0.0 II 4 14.80 III 8 29.60 IV 15 55.60 V 0 0.0 Total 27 100%  No. Of Maternal Deaths ( n=27) History of Treatment  Number Percentage % Treatment received Did not received                        21 06 77.78 22.22 Place of Treatment  Home                        21  19    90.50%     Hospital, PHC ,CHC 02 9.50% Person consulted  Doctor (Qualified)   04   19.00% Doctor (Unqualified) 11 52.40% Health Worker 03 14.30% Family Members 03 14.30% Referral/Advice To take  PHC/higher Centre                        21  Advice Followed 07 33.30% Not Followed 14 66.70%  Around 22.22% of mothers did not consult to any doctor forpregnancy related problems. Among the mothers those who took thetreatment, 90.50% were treated at home only by the unqualified doctors,and only 10% reached to hospital for treatment.TABLE- 4Causes of non-availing referral servicesTABLE- 5CAUSES OF MATERNAL DEATHAround   44% (12 maternal deaths) were due to directobstetrical causes and remaining 54%(15 maternal deaths ) were causedby indirect obstetrical causes. The direct causes of maternal death werehaemorrhage- 29.63%, obstructed labour-7.40%, toxaemia-7.40%.Among the indirect causes of maternal deaths, anaemia was the leadingcause in 33.33% mother ,followed by 22.24% other associated diseasesin pregnancy like malaria, heart diseases,  infectious diseases, accidentsetc.TABLE- 3 ANALYSIS OF TREATMENTCauses Before intervention (N = 14) Financial constraints 08 (57.1%) Did not realized to be important, ignorance 03 (21.4%) No body at home to accompany 01 (7.1%) Could not make immediate arrangements 02 (14.3%) Total 14 (100.0%)  SN Causes No. of Maternal deaths  1.  Direct Obstetrical 12 (44.4%) percentage   Haemorrhage 08 66.67%  Obstructed labour - --  Eclampsia 01 8.33%  Abortions - --  Intrauterine Death 03 25.00% 2  Indirect Obstetrical  15(55.6%)         100%   Anaemia 09 60.0%  Tuberculosis - --  Pneumonia 03 20.0%  Hepatitis - --  Pulmonary embolism 03 20.0%  Jaundice - --  Typhoid - --  Heart Disease - --  Malaria / Fever - --  Total 27 100%  Joshi & Kushwah: Epidemiological study of social factors associated with maternal mortality in community development block of Madhya PradeshNo.44.4%1255.6%15Indian Journal of Community Health, Vol. 23, No. 2, July 2011- Dec. 2011                                                                                                                                            ( 80)Around 11.10% deaths occurred in ante partum period andremaining 88.90% deaths took place in postpartum period. No deathwas reported in intrapartum period. 62.96% mothers died at home, only25.92% mothers died in various hospitals and remaing11.11% mothersdied on the way from home to hospital.Discussion       Health cannot be isolated from its social context. The lastfew decades have shown that social and economic factors have as muchinfluence on health as medical intervention. A number of social factorinfluence maternal mortality. The important ones are : a) Women’s age: The optimal child bearing years are betweenthe ages of 20 and 30 years. The further away from this age range, thegreater the risks of woman dying from pregnancy and child-birth.Similarly maximum 24 maternal deaths (88.8%) occurred in the agegroup of 18-30 years in this study. b) Birth interval: Short birth intervals are associated with anincreased risk of maternal mortality. Around 60% of mothers having thebirth interval of 1 year only.C) Parity: High parity contributes to high maternal mortality.Same factors were observed in this study. Around 15 maternal death(55.60%) in proportion to pregnancies was observed in   multipara (morethan 3 children).Not only are these three variables interrelated, but there are alsoother factors which are involved, e.g., economic circumstances, culturepractices and beliefs, nutritional status, environmental conditions. Thesocial factors often precede the medical causes and make pregnancy andchild-birth a risky venture5.Most maternal deaths are preventable. The low status of womenin the society coupled with their low literacy levels prevent the womenfrom taking antenatal care even if services are available .Most deliveriestakes place at home with out the services of the trained midwiferypersonnel. In present study out of total 27 mothers, 20 (74%) motherswere delivered at home and 41.67% of cases delivered by trained birthattendants.In the present study area, maternal mortality rate was high, 550per 100,000 live birth as compared to the national level data which is407 per 100,000 live birth probably because of  selection of rural areapopulation for study, and low  literacy among females, low socioeconomicstatus,  unavailability  of health care services in rural areas. Ante natal services were not given properly for pregnant women;as around 45% of maternal deaths occurred due to this reason. Therewas direct relation between ANC visits attendance and education statusof women and her husband. Those  mothers  (18.51%) who were educatedup  to higher secondary level, from them also only 14.81% mothersattended 3 or more ANC visits.One very important social factor played crucial role that was maledominance in the family regarding decision   taking for the birth spacing,use of contraceptives, ANC care and treatment of any complication duringpregnancy.The causes of the maternal mortality in the study were quite similaras the national statistics. According to 2001-2003 SRS survey, majorcauses of maternal mortality in India are haemorrhage (38%), sepsis(11%),  hypertension (pre-eclampsia/eclampsia) (5%), obstructed labour(5%), unsafe abortion (8%) and other conditions (34%)6. Veena Yesikar(1996)7. in a retrospective study in Sassoon General Hospital Pune (M.S.),reported haemorrhage (33.3%), eclampsia (14.3%), Sepsis (4.3%),Anaemia (4.8%) and other indirect causes (38.0%).In the study done by Brijbala Singh (2004)8, in GMH Rewa, mostcommon age group in maternal deaths was 15 – 20 years (37%) followedby 21 – 25 years (29%) and 26  - 30 years (18%). That means majordeaths (84%) are within the age group of 15 – 30 years. These results aresimilar to the one observed in the present study. Alok Ranjan (2004)9, according to his extensive study (1998-99)of status of obstetric care in undivided Madhya Pradesh, the risk ofmaternal death decreases sharply with the increase in education of mother.According to him the lifetime risk of maternal death is estimated to behighest in illiterates and lowest in high-educated females and these resultsare  quite similar to the  present study.Abdul Salam et al (1998)10  (study in northern rural Tanzania), intheir study on maternal mortality and morbidity reported that socio-economic status of the family was a major factor for/of maternal deaths.80% of deaths occurred in the income group below Rs. 700/- per month.Women’s poor socio-economic status and education level in the societyis directly or indirectly associated to the high maternal mortality. Thiswas also observed in present study.ConclusionMaternal Mortality rate in rural area of Madhya Pradesh is quitehigh. Most of the maternal deaths are preventable. The low literacy levelsand low socio economic level contributing in maximum number of cases.Social status of women in family and society play crucial role in women’shealth as well as in maternal   mortality. Most maternal deaths can beprevented if pregnant women have access to good- quality of ante nataland post natal care, and also if, certain harmful birth practices are avoided.References.1.World Health Organization (1997). Coverage of Maternity Care:A listing of Available Information. World Health Organization, Geneva.WHO / RHT / MSMI 96.28.2. WHO (2005), Regional health forum,Vol.9,No 1,20053 . SRS, RGI (1998).4. Record from CM &HO Office 2001, District Satna.5 .  K.PARK - Textbook of Preventive & Social Medicine-21stedition Pg 481.6. Govt. of India (sample Registration system), Maternal Mortalityin India :1997-2003, Trends, causes and risk factor, registrar General,India, New Delhi in collaboration with center for global Health ResearchUniversity of Toronto, Canada.7. Veena Yesikar (1996): Evaluation of verbal autopsy techniquein women of reproductive  age group. A report.8. Brijbala Singh (2004): A retrospective study of maternalmortality among females admitted at G.M. Hospital, Rewa – ProjectReport submitted to Bhoj University, Bhopal for PGDMCH.9. Alok Ranjan, R William Stones, Obstetric care in Central India,University of Southampton 2004, pg. 62.10. Olsen BE, Hinderaker SC, Gasheka P, Bergsj P, Lie RT andKvale G – Assessing estimates and sources of information of maternalmortality in northern rural Tanzania, Studies in HSO&P, 17, 2001.Joshi & Kushwah: Epidemiological study of social factors associated with maternal mortality in community development block of Madhya Pradesh

AN EPIDEMIOLOGICAL STUDY OF SOCIAL FACTORS ASSOCIATED WITH MATERNAL MORTALITY IN A COMMUNITY DEVELOPMENT BLOCK OF MADHYA PRADESH

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Indian Journal of Community Health