Strategies To Reduce Maternal Mortality And Morbidity In Rural India

dilip kumarDilip Kumar Dutta

M.D., PHD, FICOG
Secretary Kalyani Obst. & Gyn. Society

 

 

INTRODUCTION:

India is the second most populous country of the world and has fast changing socio-political-demographic patterns that have been drawing global attention in recent years. Worldwide an estimated five lakh woman die as a result of pregnancy each year.  Approximately one quarter of all pregnancy and delivery related maternal deaths worldwide occur in India. This tragic picture has only gradually become clearer largely as a result of a growing number of good community surveys conducted since the mid 1970's which drew attention to the uunexpectedly  high rates of maternal mortality and serious morbidity.

WHY INDIA DRAWING WORLD ATTENTION?
India is drawing world attention, not only because of its population explosion but also for emerging health profile and profound political, economic and social transformations. Since independence during last  sixty four  years, a number of urban and growth-oriented developmental programmes have been implemented, nearly 716 million rural people (72% of the total population) half of which are below poverty line (BPL) continue to fight a hopeless and constantly losing battle for survival and health. The policies implemented so far, which concentrate only on growth of economy not on equity and equality, have widened gap between Urban & Rural and haves and have-nots. Nearly 70% of all deaths and 92% of deaths from communicable diseases, occur among the poorest 20% of the population..

THE GLOBAL PICTURE

Today's status of maternal mortality and health issue shows a far greater disparity between  developed and developing countries. As per 1993 statistics maternal mentality in devolved country is 30% per 100000 live births as compered  to 450/100000 live births in developing countries. South Eastern Asia is 420/1 Lakh as compared to Southern Asia (650/1 Lakh). Maternal mortality in India is not a chance event. It has its origins in many interwined factors, starting with the social status , position of women, greatly effected by the economic resource and infrastructure of the country, and immediately dependent on accessibility and availability of skills, materials and facilities for family planning and maternity care.

CURRENT HEALTH SCENARIO IN RURAL INDIA

The health status of Indians, is still a cause of grave concern, specially that of the rural population. This is reflected in the life expectancy (63 years), infant mortality rate (80/1000 live birth) and maternal mortality rate (438/100000live birth). Reasons why woman die in pregnancy and child birth have many layers. Beside-direct, indirect,  and co-incidental causes, there are also logistic causes that is failure in the health care system, lack of transport, lack of manpower and apathy towards patient care. And behind this are all the social  cultural and political factors which together determine the status of woman, their health, fertility and health seeking behavior. To improve this scenario, the problem of the rural health is to be addressed both at the district, regional (micro) state and national (macro) level.

STEPS  TO REDUCE HEALTH ISSUES IN RURAL WOMEN

Working for last couple of years at grass root level at rural area, following steps have been formulated by  the author for prevention of maternal mortality and morbidity rate at rural area..  Woman health issue  was divided into three 'C'(Dutta'C)i.e. crisis, care and cure.

OBJECTIVE

IN STEP – I CRISIS
Every woman should  know about the  crisis (Problem) that may come to her life from pre-reproductive period to post reproductive period.

IN STEP – II CARE

Having knowledge about the crisis - care (Prevention) should be instituted (a) to protect against child hood and adolescent health issue (b) To prevent complications of pregnancy through early detection and treatment . (c) To provide clean and safe delivery (d) To promote the implementation of family planning programme (e) Predicting the early diagnosis of post reproductive disease. (f) centpercent encouragement fo Institutional delivery

IN STEP – III CURE
Cure (immediate action) is  to be immediately implemented (a) To promote action and management of puberty and adolescent problem  if any.(b) early diagnosis of complications of pregnancy and prompt management (c) To ensure clean and safe vaginal delivery (d) To ensure immediate step to prevent third stage complications.

ACTION PLAN
To ensure success-The following important steps are to be formulated.

  1. To involve Neonatologist, Paedetrician and Physician-To ensure that childs  family  must have knowledge about  their Blood Group,Rh Factor and girl should have atleast >14gms  Haemoglobin and devoid of Malnutrition, UTI and RTI  etc.
  2. To involve Gynaecologist-To prevent and treat PCOS, Endometrosis and infection of Adolescent Girl. Before marriage.
  3. To inform Head of Family-Marriage of girl should be > 20 years of age.
  4. To involve head of the family and Husband-Before Pregnancy  wife should have  atleast above 14gms of haemoglobin, No abortion without proper knowledge of Blood Group and RH Factor ect.
  5. To involve  Obstetrician , midwife and paramedical staff-- to find out any complications of pregnancy and prompt treatment.
  6. To Involve GOVT, NGO (FOGSI), IMA- for Awareness Programme at School/ College/ Media/ Religious Places/ Marriage/ Functions-Regarding Reproductive Health Care/Sex education/Bad Effects of Drugs/ Smoking/ Alcohol etc.
  7. To Involve Health Care Staff- to perform Community studies, Household Survey, Sisterhood and other measures and reproductive age mortality surveys.
  8. To Involve Office Staff-To maintain hospital data, data from other sources and other health records.
  9. To involve DM,SDO,BDO AND PANCHAYAT SABADIPATI – Io initiate action plan and generate economic resources ect for implementation of this programme.

SELF INVESTIGATED RESULT

Maternal Mortality at Tertiary Level Hospital
J. N. M. Hospital, Kalyani, Nadia, W.B.

Year Total Delivery Maternal Death MMR/1 Lakh
2004 1986 21 263
2005 8590 40 466
2006 8265 61 738
2007 7707 30 389
2008 7867 22 280
2009 8525 18 211
2010 7672 22 302

CAUSE  OF DEATH

2004 2008 2006 2007 2008 2009 2010
N-21 N-40 N-61 N-24 N-22 N-18 N-22
1 Eclmpsia 9 15 33 7 7 6 7
2 Septicaemia 3 6 6 3 2 2 3
3 Abortion 1 1 Nil Nil 2 Nil Nil
4 Anemia 2 2 5 3 2 2 Nil
5 A.P.H. Nil 1 1 Nil 2 2 2
6 P.P.H 2 7 7 5 2 3 4
7 Ectopic Pregnancy Nil 2 1 2 2 1
8 Retained Placenta Nil 1 Nil 1 2 1 2
9 Rupture of Uterus Nil Nil 1 Nil Nil 1 Nil
10 Ammiotic fluid embolism 1 Nil Nil Nil Nil 1 Nil
11 Pulmonary Embolism 1 2 Nil 1 Nil Nil 1
12

Heart Failure due to Heart Disease

1 1 Nil Nil Nil Nil 1
13 Inversion of Uterus Nil 1 4 1 Nil Nil Nil
14 Jaundice in Pregnancy Nil 1 1 Nil Nil Nil Nil
15 Fever in Pregnancy Nil Nil 2 Nil Nil Nil Nil
16 Others
  1. CA-Ovary with Pregnancy
Nil Nil Nil Nil 1 Nil Nil
  1. Rupture of Ovarian Cyst  with Pregnancy
Nil Nil Nil 1 Nil Nil Nil
  1. CA Cervix with Pregnancy
1 Nil Nil Nil Nil Nil Nil
  1. Anesthesia Death
Nil Nil Nil Nil Nil Nil 1

Since 2007 ,involvement of obstetricians from  KALYANI OBSTETRIC AND GYNAECOLOGICAL SOCIETY,IMA,NGO and stepwise implementation-à to improve access to adolescent health problem(ANEMIA,INFECTION), pregnancy related health  services and timely interventions during intra and postpartum care, 50% to75% maternal  death and morbidity has been prevented at tertiary level hospital (JNM HOSPITAL) KALYANI ,NADIA,WB(8 TO 10 THOUSANDS DELLIVERY  PER YEAR). Observation showed that maternal mortility 738/1000000 live births during 2006 was  found to be drastically reduce to 389(2007),280(2008), 211(2009) and 302 (2010)  after implementing   stepwise measures and plan of action .  However  our aim is to reduce maternal mortality  below  150 per one lakh during 2011.

Conclusion :

Strategies to improve coverage of effective interventions during pre-reproductive  period by involving  doctor and govt and others manpower could reduce the incidence of health related complications or mortality and morbidity at rural India.

Early intensive efforts to improve family planning ,to control of fertility choices,  to provide safe abortion and integrated maternal health services  - were the most important interventions to reduce pregnancy related mortality i.e. 150,000 maternal deaths-could be prevented in next 5 years.

References:-

  • Sue J. Goldie, Steve sweet etal, Alternative strategies to reduce maternal mortality in India: A cost effectiveness Analysis-PLOSMEDICINE,APRIL 2010/Vol-7/Issue-4.
  • Ashok Vikhe Patil etal: "Current Health Scenario in Rural India", Am J. Rural Health (2002), 11,129-135.
  • CARLA ABOUZAHR AND ERICA ROYSTON-Maternal Mortality-An India Factbook, WHO, Cover,1991.
  • Dr. D. K. Dutta, Reproduction & Child health Care, FOGSI Publication,2008.

About Author

Dr Dilip Kumar Dutta  is an  ex. Teacher, Good  Academician,   Excellent clinician and dedicated  his service to rural women academic qualification

M.D. Ph.D., M.A.M.S., F.I.C.O.G., F.I.M.C.H., M.A.A.G.L., M.A.F.S. DIPLOMA HIGH RISK PREGNANCY (USA) DIPLOMA PELVISCOPIC SURGERY

AUTHOR  PREVIOUS PUBLICATIONS

  • Safe Motherhood at rural India – How we can improve it (1999).
  • Unsafe Abortion – global Emergency (1999).
  • Early Pregnancy Hemorrhage (2000).
  • Ante Partum Hemorrhage (2001)
  • Post Partum Hemorrhage (2002)
  • Caesarean Delivery (2003)
  • Update in Contraception (2004)
  • Polyestic Ovary (2004)
  • RCH (2005)
  • Manual of Births Defect & Conginatal Abnormality (2006)
  • Obstetrics Haemorrhage Made Easy (2007)
  • Laparoscopy Made Easy (2007)
  • Hysterectomy Made Easy (2007)
  • Gynae Urology Made (2007)
  • Drugs in Pregnancy – How Safe (2008)
  • Anaemia : How Safe are Indian Women – An Epidemiological Stud (2008)
  • Manual of FOETAL Medicine (2009)
  • Genital and Breast Cancer : How safe are Indian Women – an Epidemiological Study (2009).
  • High Risk Pregnancy (2010)
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