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International Journal of Gynecology & Obstetrics 50 Suppl, 2 (1995) S93-596
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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. Basllir et al. / Intenuuional Joumal of Gynecology & Obstetrics 508uppl. 2 (1995) 893-896

S95

Table 2
Causes of mater...
596

A. Bashir et al. / lnternational Journal of Gynecology & Obstetrics 50 Sup 2 (/995) 593-596
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INTERNATIONAL PUBLICATION International journal of gynecology & obstetrics volume 50 issue supp s2 1995 [doi 10.1016 0020-7292(95)02494-w] a. bashir; m. aleem; m. mustansar -- a 5-year study of maternal

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INTERNATIONAL PUBLICATION International journal of gynecology & obstetrics volume 50 issue supp s2 1995 [doi 10.1016 0020-7292(95)02494-w] a. bashir; m. aleem; m. mustansar -- a 5-year study of maternal

  1. 1. .IIIItrnI(iQIIIIMMI.. G 'fNDLOGY &OBSTETRI£S International Journal of Gynecology & Obstetrics 50 Suppl, 2 (1995) S93-596 ;_:;;;;;;;;;;;;;:_;;;;;;;;;;;;; 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
  2. 2. 594 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. 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. 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. References [I] World Health Organization. Studying maternal mortality in developing countries, a guidebook. Geneva: WHO, 1987: 28. [2J World Health Organization, Childbirth, a matter of life and death. Geneva: WHO, 1987. [3] Compiled by WHO, 1987. In: Preventing the tragedy of maternal deaths: a report of the International Safe Motherhood Conference. Nairobi, Kenya, 1987. [4J World Health Organization. Maternal mortality ratios and rates, 3rd edn. Geneva: WHO, 1991: 4. [5] Bashir A. Survey of maternal mortality: A retrospective study. Bulletin 1979; 12(7-9): 47. [6J Bashir A. Refresher courses of TBAs. J Pakistan Med Assoc 1982; 32(1): 37. [71 Bashir A. TBA training and maternal mortality in Faisalabad district. Pakistan Med Res 1989; 28: 117. (8) Bashir A, Cheema MA. Mustansar M. Prevalence of maternal mortality in Faisalabad. Gynaecologist 1993; 3(2,3): 114. [9] Bashir A. Cheema MA, Mustansar M. Maternal mortality 1990: Result of a survey of Metropolitan Faisalabad. Gynecologist 1991; 1,2 (6,1): 375. [10] Bashir A, Cheema MA, Mustansar M. Maternal mortality 1991. Specialist 1992; 9 (I): 47. [11] Bashir A, Cheema MA, Mustansar M. Maternal mortality 1992 Specialist (in press). [12] Bashir A, Shafique A, Mustansar M. Maternal mortality 1993, Specialist (in press). [13] Adetoro 00. Maternal mortality.A twelve-year survey at the University of llorin Teaching Hospital (U.I.T.H) llorin, Nigeria. Int J Gynaecol Obstet 1987: 25: 93, (I4J Hartfield VJ. Maternal mortality in Nigeria compared with earlier international experience. Int J Gynaecol Obstet 1980; 18: 70. [15] Kessler I, Lancet M, Rozenman D. Maternal mortality in an Israeli Hospital: A review of 23 years. Int J Gynaecol Obstet 1979; 17: 154. [16] Karchmer S, Armas-Dominguez J, Chavez-Azuela J, Shor-Pinsker V, MacGregor C. Studies on maternal mortality in Mexico. Int J Gynaecol Obstet 1976; 141: 443. [17J Turnbull AC, Tindall VR, Robson G. Dawson IMP, Cloake EP, Ashley JSA. Report on confidential enquiries into maternal deaths in England and Wales 1979-1981. London: Her Majesty's Stationery Office, 1986. [18] Bhatia C. Level and causes of maternal mortality in Southern India. Stud Fam Plann 1993; 24,5: 310. [19] Farook SM. Maternal mortality at Liaquat Medical College Hospital, Hyderabad in 1986-1990. J Coli Phys Surg Pakistan 1993: 3: 8. [20] Beshir A. Mustansar M,Shafique A. Faisalabad Obstetric Flying Squad: a 4-yeu,r study. Specialist 1994; 10(4): 311.

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