This document summarizes a 5-year study of maternal mortality in Faisalabad City, Pakistan from 1989-1993. The study found 215 maternal deaths during this period, giving a maternal mortality rate of 0.77 deaths per 1,000 live births. The main causes of death were postpartum hemorrhage (23.3%), pregnancy induced hypertension/eclampsia (15.8%), and non-obstetric causes (15.8%). Efforts like traditional birth attendant training, community education, antenatal checkups, and improved obstetric care were found to help reduce the maternal mortality rate in the region over this time period.

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International Journal of Gynecology & Obstetrics 50 Suppl, 2 (1995) S93-596
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A 5-year study of maternal mortality in Faisalabad
City Pakistan
"Department of Obstetrics and Gynaecology, Allied Hospital of Punjab Medical College, Faisalobad, Pakistan
bDepartment of Pediatrics, Allied Hospital of Punjab Medical College, Faisalabad, Pakistan
Abstract
A 5-year study(1989-1993) of215 maternal deaths in Faisalabad (third largest city of Pakistan) is presented. There
were 276717 live births recorded by the Municipal Corporation during that period, giving a maternal mortality of
0.77/1000 live births. These deaths included 88 (40.9%) in teaching hospitals, 70 (32.6%) at home and 57 (26.5%) in
private hospitals. The main causes of maternal death were postpartum hemorrhage, 50 (23.3%), followed by
pregnancy induced hypertension/eclampsia and non-obstetric causes, 34 (15.8%) each. The study reveals that
traditional birth attendant (TBA) training/refresher courses, intensive community education, antenatal checkup in
local areas, free obstetric flying squad service, better linkage between formal and informal health services, home
maternal death condolence camps and improvement of obstetric care in hospital, offered free for deserving cases have
played major roles in reducing maternal mortality.
Keywords: Maternal mortality; Eclampsia; TBA training; Obstetric Flying Squad; Community education
Maternal death is defined as the loss of a woman
while she is pregnant or within 42 days of termination of her pregnancy irrespective of its duration and site, from any cause related to or
aggravated by the pregnancy or its management,
but not from accidental causes [1]. In developing
countries maternal mortality (MM) accounts for
about one quarter of all deaths of women of
childbearing age in contrast to the United States
with less than 1% [2]. In the industrialized world,
there are only 2.9 maternal deaths per 100 000
live births compared to developing countries,
where the figure ranges from 300 to 1000 or
.,Corresponding author, Fax: 92411 711 439.
more. Thus, women in economically deprived societies run 50-100-times the risk of dying than
those in more affluent countries [3]. There, such
a result of pregnancy is at least 100-times smaller
than the same risk in the poorest nations of
Africa and Asia [4]. The very high MM in
Faisalabad in 1977 (10.1/1000 live births) provided us with the incentive to embark on a program that would help to reduce these numbers
[5]. Traditional Birth Attendant (TBA) refresher/
training courses were initiated for these practitioners in urban and rural areas of Faisalabad
[6]. After 10 years, another study was conducted
(1987) in the same areas; we found a drop in
MM to 1.9/1000 live births [7J.
0020.7292/95/$09.50 © 1995 International Federation of Gynecology and Obstetrics
SSDI 0020·7292(95)02494-W

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A. llu/;llr et al. / Intemational Journal of Gynecology & Obstetrics 50 Suppl. 2 (1995) S93-S96
To further reduce MM, a campaign of community education, TBA. training/refresher courses,
antenatal check-up in local areas and distribution
of iron pills, an obstetric flying squad, free services in hospital and home, and MM survey was
undertaken in Faisalabad city in 1989. The objectives of the survey were to: estimate maternal
mortality in the city; determine the age, parity and
education of deceased mothers; diagnose causes of
their deaths; compare our data with previous
years; assess the impact of the mother and child
health/family planning (MCH/FP) program; and
suggest measures to improve antenatal care and
further reduce maternal mortality.
The MM survey was carried out by an investigating physician who visited the home of deceased
mothers as well as all involved health centers and
hospitals (public and private). Information was
obtained from TBAs, Municipal Corporation vaccinators, lady health visitors (LHVs) midwives
and the public. Specially designed questionnaires
were filled out by the investigator with the help of
the TBA, LHV or doctor or whoever was present
at the time of delivery, e.g., relatives or friends.
There were 215 maternal deaths in the city
during the 5 years from 1989 to 1993. Seven were
between the ages of 14 and 19 (3.3%), 134 (62.3%)
were 20-34 years old and 74 (34.4%) were more
than 35 years of age [8-12]. While studying the
literacy levels of the deceased mother and her
husband it was found that 131 (60.9%) of the
women had no education and 64 (29.8%) had only
attended primary school; most of their husbands,
89 (41.4%), were also uneducated.
When gravidity of deceased mothers was reviewed, it was observed that 116 (54.0%) had been
pregnant more than five times, 55 (25.6%) had
had from two to four pregnancies and 44 (20.5%)
were primigravidae [8-12]. When phase of pregnancy during which the death occurred was studied, it was found that 133 (61.9%) of the women
had died during the postpartum period, 33
(15.4%) antepartum and 37 (17.2%) at the time of
an abortion. For these women 123 (57.2%) had no
antenatal care but 38 (17.6%) were seen at Allied
Hospital or other hospitals.
When the mode of delivery of these women was
studied it was found that 88 (40.9%) were vaginal,
12 (5.6%) instrumental vaginal and 35 (16.3%) by
cesarean section. In regard to the person conduct"
ing the delivery, our data revealed that 61 (28.4%)
were managed by TBAs, 56 (26.0%) by general
practitioners and 13 (6.1%) by obstetricians.
Of the 215 deaths, 88 (40.9%) occurred in
teaching hospitals, 70 (32.6%) at home and 57
(26.5%) in private hospitals and clinics. The most
common cause of death was postpartum hemorrhage (PPH), 50 (23.3%), followed by preeclampsia/eclampsia and indirect conditions, 34 (15.8%),
each, and abortion 20 (9.3%). There were 163
(75.8%) direct and 36 (16.7%) indirect obstetric
deaths.
Table 1 shows the declining trend in maternal
mortality over the 5-year period. Table 2 shows a
comparison of our study with some others. As
would be expected, most causes are lower for the
United Kingdom [17] but is it notable that the
two industrialized areas, the UK and Israel [15]
have the highest anesthesia deaths.
An understanding of the determinants of maternal mortality (MM) is of paramount importance in the developing world where MM varies
widely both between and within countries, depending upon the level of socioeconomic development, education, living conditions and. access to
maternal care. Low income, illiteracy, ignorance
and cultural factors result in nutritional deficiency
of girls and expectant mothers. Various unhealthy
customs regarding confinement, contraception
and the preference of women to be delivered at
home, even when hospital facilities are available,
lead to high MM. Short birth interval and high
infant mortality further aggravate the situation. A
Table I
Maternal mortality in Faisalabad city: 1989-1993
Year
Live births
Maternal death
Maternal
mortality per
1000 live births
1989
1990
1991
1992
1993
Tot.,
55454
57960
56364
53957
52982
276717
48
55
41
37
34
215
0.86
0.94
0.73
0.67
0.64
0.77

3. A. Basllir et al. / Intenuuional Joumal of Gynecology & Obstetrics 508uppl. 2 (1995) 893-896
S95
Table 2
Causes of maternal mortality in this study compared with others (percentage)
Study
(country)
APH
PPH
PIHjedampsia
Sepsis
Faisalabad
(Pakistan)
Adetoro
(Nigeria) (13)
Hartfield
(Nigeria) (14)
Kessler
(Israel) (15)
Karchmer
(Morocco) (16)
Confidential inquiries
(UK) (17)
Bhatia
(India) (18)
'rarook
(India) (19)
7.0
23.3
15.8
18.6
6.5
3.7
8.2
16.0
U.2
8.3
13.9
0.6
6.0
11.9
IIA
0.4
0.5
1.1
0.0
11.4
14.1
18.5
0.0
11.0
0.0
22.0
30.0
31.0
0.0
6.0
1.7
3.0
12.0
5.0
1.3
9.7
1.1
6.3
9.2
31.0
5.3
0.0
6.6
8.3
20.2
27.4
6.0
2.4
Ruptured
uterus
Anesthesia
I
APH, antepartum hemorrhage; PPH, postpartum hemorrhage; PIH pregnancy induced hypertension.
current but perhaps optimistic estimate of MM in
Pakistan is 400/100000 live births [19]. This ;g in
marked contrast to the 80/100000 recorded in
Faisalabad city. The latter figure also shows considerable improvement compared with 190 for
1987 in selected rural and urban areas [7].
In our series, postpartum hemorrhage (PPH)
was responsible for 23.3% of maternal deaths, and
may be due to mismanagement of the third stage
of labor. This figure compares favorably with
results of Karchmer and Adetoro, but not to the.
3.0% in a recent report of Confidential Inquiries
into Maternal Deaths in England and Wales during 1979-1981 [17].
The second important cause of maternal death
was sepsis (18.6%), whether due to abortion or
puerperal. A similar trend was shown by Kessler
(18.5%) quite distinct from reports of Bhatia and
Karchmer (31.0%) and Farook (27.4%).
Pregnancy induced hypertension (PIH)/edampsia and its complications was responsible for
15.8% of maternal death in our series which was
one half the Karchmer figure (30.0%) and compares favorably with results of Adetoro, Hartfield,
Kessler and the Confidential Inquiries. The PIH/
eclampsia has increased risk owing to lack of
antenatal care, grand multiparity and pregnancy
at a young age. One cause of relatively high sepsis
in our study could be that most of the deliveries
were managed at home by TBAs who might not
observe aseptic measures. Another is probably
illegal termination of unwanted pregnancy.
We found 7% of maternal deaths were due to
antepartum hemorrhage (APH). This figure is
similar to that reported by Hartfield and Farook
and is very high when compared with Kessler,
Karchmer, Bhatia and the Confidential Inquiries.
Rupture of the uterus contributed 6.5% to our
maternal deaths but there was great improvement,
from 12.5% in 1989 to none at all in 1993, and the
same trend was shown by Bhatia and Farook.
However, Adetoro reported 13.9% cases of ruptured uterus which is almost double our figure.
Deaths due to anesthesia were 3.7% a very low
figure compared to studies by Kessler, the Confidential Inquiries and Karchmer.
We believe that the important causes of our
maternal deaths i.e., PPH, sepsis, PIH/ec1ampsia,
APR and ruptured uterus are avoidable. The
patient's insistence on home delivery, hesitation
about hospital admission and delay in transfer to
hospital lead to poorly treated complications and
deaths. Thus, public awareness, community education, transportation and good personal relation-

4. 596
A. Bashir et al. / lnternational Journal of Gynecology & Obstetrics 50 Sup 2 (/995) 593-596
pl.
ships can be very useful in reducing MM. Eclampsia and PPH can be managed with competent
antenatal care and hospital confinement for the
cases likely to have these dreadful complications.
Our obstetric flying squad service has played an
important role in saving lives by resuscitating the
patient at home and transferring her to hospital
under supervision.
Maternal mortality in Faisalabad city in 1993 is
recorded as 0.6/1000. This has been achieved by
an intensive TBA training/refresher course program, community education, opening of MCH/
FP centers, obstetric flying squad servic-, free
services in hospital, antenatal examinations in
street and safe motherhood camps. All these factors have played a role in reducing MM. In case
of any gross mistake, the responsible person is
caned for an explanation and instructed on correct procedure. Repeated refresher courses have
had a considerable impact on MM as revealed in
the 1O-year study in Faisalabad district, where it
was reduced from 10.1 in 1977 to 1.9 in 1987 to
0.8/1000 over the 5 years of this research [5,7].
Greater numbers of people are being made
aware of the importance of antenatal care, the
need for timely hospitalization and provision of
free maternity services in hospital. All these are in
fact the practical application of the suggestions
offered by Bashir to reduce maternal mortality
about 16 years ago when refresher courses of
TBAs were started as the foundation ;~one [6].
Community education programs include direct
communication via street camps (corner meetings)
with TBAs, LHVs, all women of the area, free
antenatal check-up and distribution of iron pills
in their respective areas. Various media, i.e., radio, television, cinema slides and the newspapers
(local and national) have been utilized to convey
the message to the public. Display charts in the
city have been installed. Handbills about mother
and child health care have been distributed in
Faisalabad.
We are especially gratified with the results of
the obstetric flying squad service which answered
394 calls from 1989-1992 in Faisalabad city [20],
preventing a considerable number of avoidable
deaths. However, this service, which was started
as an independent venture, should be planned on
a large scale by the national Government, thereby
reducing maternal mortality throughout Pakistan
as has been done in Faisalabad.
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