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Maternal Mortality - PG Obstetrics & Gynaecology (25 Marks)

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1. DEFINITION

• Late maternal death: Death from direct or indirect obstetric causes, after 42 days but less than 1 year after termination of pregnancy (ICD-10 codes O96 and O97).
• Pregnancy-related death: Death of a woman while pregnant or within 42 days, from any cause including accidental/incidental causes (used where cause-of-death data is unreliable).
• Comprehensive maternal deaths (ICD-11): Maternal deaths + late maternal deaths combined.

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2. CLASSIFICATION OF MATERNAL DEATHS

A. Direct Obstetric Deaths

• Obstetric haemorrhage
• Hypertensive disorders (pre-eclampsia/eclampsia)
• Sepsis/infection
• Obstructed labour
• Complications of anaesthesia
• Amniotic fluid embolism

B. Indirect Obstetric Deaths

• Cardiac disease (commonest cause in UK/USA now)
• Renal disease
• Hepatic disease
• Anaemia (severe)
• Epilepsy, stroke
• HIV/AIDS

C. Coincidental (Fortuitous) Deaths

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3. INDICES / MEASUREMENT

Maternal Mortality Ratio (MMR)

The most commonly used measure globally and SDG indicator (SDG 3.1.1).

Maternal Mortality Rate

Lifetime Risk of Maternal Death

Case Fatality Rate

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4. GLOBAL AND NATIONAL DATA

• India accounted for approximately 35,000 maternal deaths (2017 data), one of the highest absolute numbers globally along with Nigeria.
• India's MMR has declined from 130 (2014-16) to 97 per 100,000 live births (2018-20), reflecting significant progress.
• Racial disparities (USA): Non-Hispanic Black women have MMR of 69.9 vs 26.6 in non-Hispanic White women (nearly 4-fold difference).
• ~50-70% of maternal deaths occur in the postpartum period; 45% within first 24 hours of delivery; >2/3 within the first week.

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5. CAUSES OF MATERNAL MORTALITY

In Developing Countries (including India) - "HAVE"

A meta-analysis (PMID: 38017449, 2023) using ICD-MM classification found hemorrhage and hypertensive disorders consistently among the top causes of maternal mortality globally.

In Developed Countries (UK/USA)

• Cardiovascular disease (peripartum cardiomyopathy, structural heart disease) - now the leading cause in the USA (23-33% of deaths)
• Thromboembolism (16% UK, 9.7% USA)
• Sepsis and infection (10-12%)
• Mental health conditions (UK: 10%)
• Preeclampsia/eclampsia (UK: 2%, USA: 6.6%)
• Haemorrhage (UK: 8%, USA: 10.7%)
• Amniotic fluid embolism (8.7%)

Note: Cardiovascular and indirect medical deaths now outnumber direct obstetric deaths in resource-rich countries - in UK data 2009-12, 68% of maternal deaths were from medical/mental health causes vs only 32% from direct obstetric causes.

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6. AVOIDABLE/CONTRIBUTING FACTORS - THE THREE DELAYS MODEL (Thaddeus & Maine, 1994)

Delay 1 - Decision to Seek Care

• Failure to recognise danger signs
• Low female literacy and autonomy
• Financial constraints
• Cultural barriers, family decision-making by males
• Previous bad experiences with health system

Delay 2 - Reaching Care

• Long distances to facility
• Poor roads, lack of transport
• Geographic isolation
• Inadequate referral system

Delay 3 - Receiving Adequate Care

• Shortage of skilled personnel
• Inadequate drugs and blood
• Poor quality emergency obstetric care (EmOC)
• Overcrowded facilities
• Inappropriate management

Other Contributing Factors

• Patient factors: Late booking, non-attendance at ANC, unbooked cases, grand multipara, elderly primigravida, poor nutritional status
• Obstetric factors: APH, PPH, eclampsia, obstructed labour, sepsis
• Medical factors: Anaemia, cardiac disease, diabetes
• Health system factors: Lack of skilled birth attendants, lack of blood transfusion, poor EmOC

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7. MATERNAL DEATH AUDIT (MDA) / MATERNAL DEATH REVIEW (MDR)

Types of MDR

1. Facility-based MDR - audit of deaths occurring in health facilities
2. Community-based MDR - verbal autopsy to capture deaths at home (important in India where many deliveries still occur at home)

Process of MDR

1. Notification of every maternal death
2. Collection of information (verbal autopsy, medical records)
3. Classification of cause of death
4. Identification of avoidable factors
5. Development of recommendations
6. Dissemination and implementation of recommendations
7. Monitoring the impact

Classification used

• Substandard care: Avoidable factors including delays and deficiencies in care
• Coincidental: Deaths due to unrelated causes

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8. PREVENTION STRATEGIES AND NATIONAL PROGRAMMES (India)

Key Interventions

1. Antenatal care - Early registration, minimum 8 ANC contacts (WHO 2016), detection of high-risk pregnancies
2. Skilled birth attendance - Trained midwives/doctors at every delivery
3. Emergency Obstetric Care (EmOC)
   • Basic EmOC: signal functions at PHC level
   • Comprehensive EmOC: surgery, blood transfusion at FRU/CHC level
4. Postnatal care - At least 3 visits in first 6 weeks
5. Family planning - Spacing births, limiting family size
6. Safe abortion services - Preventing unsafe abortions

National Programmes in India

Components of Active Management of Third Stage of Labour (AMTSL)

• Oxytocin 10 IU IM within 1 minute of delivery of baby
• Controlled cord traction (optional)
• Uterine massage after placenta delivery

WHO Safe Childbirth Checklist

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9. SUSTAINABLE DEVELOPMENT GOALS (SDG)

• SDG 3.1: Reduce global MMR to less than 70 per 100,000 live births by 2030
• SDG 3.1.2: At least 80% of births attended by skilled health personnel by 2030
• India's MMR target: <70 per 100,000 by 2030 (India is close with current MMR of 97)

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10. NEAR-MISS CONCEPT (Severe Acute Maternal Morbidity)

• For every maternal death, there are approximately 20 near-miss cases (WHO estimate)
• Near-miss review is complementary to MDR - more cases available for analysis, staff more willing to discuss
• Indicators: Near-miss ratio, mortality index = deaths/(near-miss + deaths) x 100

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11. KEY FORMULAE FOR EXAM

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SUMMARY TABLE - QUICK REVISION

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