OR Interventions for Reducing Maternal Mortality in MP-DANIDA Project

Introduction:

The principal goal of a reproductive health programme is to reduce unwanted fertility safely & to provide high quality health services. There by satisfying the needs of the individuals, as well as, stabilizing the population. Under Reproductive Child Health (RCH) project various interventions were carried out to enable clients to make informed choice, to receive counseling & education which is responsible for healthy sexual behaviour, to access user-friendly services for preventing unwanted pregnancy & safe abortion, maternity care & child survival and management of reproductive tract infections (RTI) and sexually transmitted diseases (STD). Even after these interventions the desired changes in maternal mortality could not be achieved at country level in general and MP state in particular.

In Rajgarh district where the problem is greatest, most maternal deaths go unregistered; either entirely so or their cause is not specified. There has been the tendency to underestimate the gravity of the situation. It is estimated that as many as ¼ to 1/3 of these deaths may be a consequence of complications of unsafe abortion procedures. This is also a major cause for high level of MMR in the district. In addition to this the major causes of maternal deaths are Anaemia, Hemorrhage, Eclampsia, Obstructed Labour and Infection. About 72% of all maternal deaths are preventable. Therefore it has become very necessary to identify the local causes of maternal deaths in Rajgarh & recommend appropriate interventions for preventing the causes. Therefore an operation research study was carried out in Rajgarh.

About project district:

The Rajgarh district is the most backward district in the state with lowest literacy & poor health indicators. The maternal deaths due to Abortion, Anaemia, Hemorrhage, Eclampsia, Obstructed labour & Infection are at higher side due to ignorance in the community. Being culturally associated with neighbouring Rajsthan the desire for male child is very strong among the general population. For want of male child women risk themselves for pregnancies leading to higher maternal mortality.

Health infrastructure in the district is adequate but poorly manned. There are 1 District Hospital, 2 Civil Hospitals, 6 CHCs/BPHCs, 34 PHCs and 159 Sub Health centers in the district. This study was carried out in two blocks namely Bioara and Khilchipur. Firstly Narsinghgarh block was selected instead of Khilchipur but as per suggestion of CMHO and DWCDO of Rajgarh district during workshop for finalization of research tools Narsinghgarh block was replaced by Khilchipur block.

There are 30 Sub Health Centres in Bioara block and 24 Sub Health Centres are in Khilchipur block.
Facilities available in villages:
The information regarding facilities were collected from each village and the inquiry was made either from ANM or AWW or JSR or Sarpanch or Teacher or any other influential person who has every information regarding their village.
In India almost 60-70 percent population resides in villages. For assessment of cause for maternal mortality it is necessary to study about facilities available in villages. In this study we gathered information from all villages of both the blocks.

In case of emergency every person calls his neighbour first. If village habitation is dense then the aid will be available early but in case of sparse habitation the neighbour takes time to attend the call while the condition may become critical and deteriorate further.

In both the blocks more than 85 percent villages were densely populated and 12.5 percent villages were sparsely populated. In both the block highest percent (Bioara 63.8 percent and Khilchipur 75.3 percent) of houses were of Other Backward Classes. Lowest percent (4.4 percent) of houses were of Scheduled Tribes. As highest percentage of other backward class houses, the percentage of population was also highest (68.4 percent) of other backward class and lowest percent (4.5) of population was of Scheduled Tribe caste. Almost 60 percent (59.7 percent) families had agriculture as their occupation. Only 2.3 percent families rely on business. In Bioara block only 5.6 percent families were non-farm labours where as in Khilchipur block 32.0 percent families were in this group. Unfortunately 71.1 percent villages were located more than 2 Km away from road. Only 7.6 percent villages were situated on road and about 6.2 percent villages do not have any road linked with the village. In both the blocks almost 70.0 percent (69.0 percent in Bioara block and 72.7 percent in Khilchipur block) villages do not have any access to road.
Only 20.4 percent villages had accessed through Govt. or private bus. 85.2 percent villages had facility of other mode (vehicle) i.e., bullock cart, tractor or motorcycle.

In 84.9 percent villages some or other transport facility was available during night. In Bioara block 92.9 percent villages had transport facility available.
Although government as well as private health institutions have facility of ambulance and in case of emergency any one can call it to get early treatment, but these facilities are available only in urban areas and not a single respondent gave response in favour of availability of ambulance to any village. In 79.5 percent villages tractors were available in emergency where as in 5.8 percent villages government or private buses were also available during night. 82.0 percent villages had facility of bullock carts and 27.5 percent villages had other transport facility i.e., motorcycle or manual carriage (cot) as mode of transport. 341 villages have access to private tractor.

In both the blocks more than 95 percent villages had electricity connectivity.
In India almost 80.0 percent deliveries are conducted at home. For safe delivery and to safe life of women it is necessary that every village had atleast one trained dai. 82.0 percent villages had atleast one trained dai. Where as 59.7 percent villages had untrained dai also. 18.9 percent villages had unregistered private practitioners. In Khilchipur block only 2.9 percent villages where as in Bioara block 36.3 percent villages had unregistered private practitioners.
51.6 percent villages relied on neighbours, relatives, other known persons and influential persons to get money on credit. In Bioara block 59.7 percent villages got help from self help groups in case of emergency. 26,5 percent villages rely on local money lenders for getting money on interest.
Facility of fast communication also helps in reduced casualty in case of emergency. But only 20.8 percent villages had facility of STD/PCO. Only 3.0 percent villages had medical shops available.

Research objectives:

This study mainly aimed at to ascertain the causes of maternal morbidity and mortality in Rajgarh. To carry out interventions for reducing maternal morbidity and mortality.

Therefore it tried to determine causes of maternal mortality and morbidity, determine awareness and knowledge in the community regarding maternal morbidity and mortality i.e. in terms of awareness and recognition of danger signals of pregnancy related complications, when and where to seek care and reasons for failure to seek care. Study infrastructure facilities available for maternal care, particularly Emergency Obstetric Care, its accessibility and utilization by the community, Study service providers’ (government, NGO, private) perception of maternal morbidity and mortality, Creating awareness among community, government employees and local opinion leaders for initiating steps for reduction of maternal morbidity and mortality and Empower women members of PRIs for reduction of maternal mortality.

Research Methodology:

The study was designed in two phases. The first phase was designed to assess the causes of mortality and the 2nd phase was designed to conduct certain interventions by community themselves to reduce maternal mortality. The first phase was further divided into two parts. In the part I we conducted retrospective data collection and 2nd part we collected data on prospective cases of mortality.
Retrospective study:


During this study the data about the deceased mothers were collected by verbal autopsy with their relatives.

The data were collected for the mortality cases of past 2 years which the relatives could easily recall. The data were also collected from attending health institutions. For this purpose we studied 48 cases in Bioara block and 66 cases in Khilchipur block.
The profile of cases studied in terms of their caste, religion, monthly income of the family, educational status and occupation of deceased women are given in table below


48.2 percent mortality cases were from OBC category. Almost 96.5 percent females were hindus where as only 3.5 percent cases were from Muslim community. None of the deceased women were Sikh or Christian. Almost half (48.2 percent) of the pregnant women were from low income group (upto Rs. 750/- P.M.). It was very difficult to assess the correct income of their family. In both the blocks majority of deceased women were illiterate. Only 2.6 percent were educated up to the primary level. Low level of awareness about health, early marriage and maternal care are due to low level of literacy among the community. Thus we can say that the low literacy rate & poverty were also responsible for maternal mortality. More than half (52.6 percent) of the deceased women were housewives and 40.4 percent were agricultural labour. In Khilchipur block all women were either house wife or agriculture/non farm labour. On the analysis of data on age at marriage it was observed that the death took place in 95.6 percent mothers who were married below 20 years. The younger age at marriage appears one of the causes of mortality. The interventions were required on these issues. In all about 63.2 percent women were registered either with ANM or AWW of their respective area.

As per the information given by relatives 42.1 percent deceased women consumed IFA tablets and 38.6 percent women had not consumed it. In this study almost half (49.1% women) died in first delivery (Primy Para). Above 60 percent women died were less than twenty-five years. 14.3 percent relatives of deceased women affirmed the cause of death was abortion. In almost 62.3 percent cases the women died either at home or on the way to hospital before getting any treatment.

Major disorders during pregnancy were (75.4 percent) fever, body ache, nausea, and other disorders. 26.3 percent women died due to hemorrhage. Whereas in Khilchipur block 24.2 percent women died due to anaemia. 14.0 percent respondents revealed that one of major causes of death for woman was delay in arranging money. A major group (39.6 percent) could not specify whether any delay was responsible for the death of a woman.

Prospective study:

We understand that in case of retrospective study the responses may not be very reliable because of longer time gap after the event has taken place, as the respondent had to recollect the event and then respond. To overcome this shortcoming we designed prospective study for collecting the required data from the conception stage. During this study 2026 pregnant women from Bioara block and 1480 women from Khilchipur block were studied. Highest proportion (59.6 percent) of the respondents were OBC.

The occupation of 48.6 percent families of pregnant women was agriculture and 33.5 percent women were from the farm labour family. Highest 34.6 percent women were from the families having income in between Rs. 750/- to 1,000/- and only 8.5 percent families had income more than Rs. 5,000/- per month.

More than half (51.5 percent) of the respondents were housewives. 78.1 percent respondents were illiterate where as 11.0 percent respondents had formal education. Only 1.5 percent of the respondents had more than middle level education. Age at the time of marriage and gauna plays an important role in reproductive life of a woman. Government promulgated Sharda Act to restrain marrying a girl before the age of 18 years. But in Khilchipur block 33.4 percent respondents got married before 16 years of their age. Whereas in Bioara block 37.0 percent respondents got married in same age bracket.

To see the pattern of morbidity it is necessary to observe full gestation period carefully. ANM of the area were instructed to visit every pregnant women atleast thrice the whole gestation period. The ANMs and AWWs of the project blocks were trained by us and their role in the research was also clarified.

In this study 34.2 percent cases had their first pregnancy where as 21.9 percent cases had fourth or higher parity. Even after the involvement of service providers only 21.3 percent women got either three or more ANC check ups.

51.8 percent of the respondents got two vaccines or booster vaccines against tetanus. High blood pressure leads to eclampsia and eclampsia claims 17 percent of the maternal deaths. But 15.7 percent women did not have their blood pressure measured. Edema during pregnancy is risky. 5.9 percent respondents had suffered from edema. Pregnancy burdens the functioning of heart. It leads risk to women's life. 4.7 percent of the respondents complained that they had some trouble in their heart. During this study haemoglobin estimation of 52.4 percent respondents was not performed.

In 7.6 percent respondents pregnancy was terminated either due to miscarriage or abortion.

In 97.8 percent cases pregnancy terminated as live birth. In 0.4 percent cases (9 in number) mothers died during delivery. In 2.1 percent cases of neonate deaths and in 2.6 percent cases of the maternal deaths the delivery was assisted by untrained dai. Similar trend was observed in case of deliveries attended by relatives with respect to still births (3.3 percent) and maternal deaths. Our study shows that 88.8 percent deliveries were conducted at home. Only 10.7 percent of the deliveries were conducted either at government or private hospital (Institutional deliveries).
In case of 8.8 percent respondents the delivery was conducted by untrained dai. In


For safe deliveries it is essential to use five cleans or disposable delivery kit or use of new blade to protect mother and baby from tetanus. But during this study we found that only in 61.8 percent cases disposable delivery kits were used. Only in 1.2 percent cases old blade was used to separate placenta. 73.1 percent respondents did not face any complication during delivery. 21.4 percent respondents faced excessive labour pain. 3.0 percent respondents faced excessive bleeding. Only 0.1 percent respondent complained about fighting eclampsia.

One of the main object of this study was to find morbidity pattern among pregnant women. We found that 2.4 percent respondents had high blood pressure. 5.9 percent respondents had suffered edema. 4.7 percent of the respondents complained that they had some trouble in their heart. In 7.6 percent respondents pregnancy was terminated either due to miscarriage or abortion.

Facilities available at health institutions:

Availability of generator/inverter is very essential for O.T. in case of emergency but in Bioara block only 1 and in Khilchipur block only 3 health institutions had generator/inverter available with them.

Availability of atleast one separate labour room was essential to ensure privacy at the time of delivery. Therefore the data were collected on this aspect also.
4 health institutions in Bioara block and 3 institutions in Khilchipur block had 3 or more rooms. 2 institutions in Khilchipur block and one institution in Bioara block did not have labour room. Half of the health institutions had sanctioned bed strength of six to ten beds. Whereas 4 institutions had beds capacity in between ten to thirty.
6 health institutions did not have proper waste disposal facility. It is hygienic to have incinerator facility for disposal of medical waste but only one health institution (Sultania Hospital Bhopal) had facility of incinerator. One health institution in Bioara block which had facility of open pit did not functional at the time of survey.


Information regarding availability of vehicle in functional state was also collected from the health institutions. 8 health institutions did not have any type of vehicle. Rest of 6 health institutions had 12 jeeps 8 ambulance and 1 mobile van. All of the vehicles were found functional.

In Bioara block only 1 Medical Officer was available for Caesarian and anesthesia. Whereas in Khilchipur block no Medical Officer was found available for Caesarian and anesthesia. Sufficient number of Health Workers were available for conducting deliveries and in handling of emergency. The status of training in the field of maternal health, such as conducting deliveries, safe motherhood, MTP, Caesarian section etc. and information regarding application in the same fields was also collected from Medical Officers as well as health workers. It was found inadequate.
32 Medical Officers were found trained in conducting deliveries and 23 in performing MTP. In Khilchipur block no Medical Officer was trained in performing MTP or Caesarian section or anesthesia. Sufficient number of health workers were available in conducting deliveries and checking blood pressure.

In the rural areas around 80 percent deliveries are conducted at home. In such cases availability of trained dai in villages would have helped in safe delivery and low maternal mortality. The information regarding number of trained dais available in health centers was also collected. The availability of trained dais in the field was inadequate and there was a need for imparting training to more dais. So that the home deliveries may be attended by these dais. In both the blocks 2 health institutions did not have any trained dais in their area. Only 3 health institutions had more than 10 trained dais available in their area.

Stock availability of some medicines required in case of emergency, TT vaccines, IFA tablet, Disposable delivery kit etc., was also obtained from health institutions. 12 health institutions had adequate stock of IFA tablets. District hospital Rajgarh and Sultania hospital at Bhopal had adequate medicines. The information about workload at health institutions was also obtained in the form of number of registered or treated cases at the center. The data was obtained only for the activities related to safe delivery and emergency.

Total 20877 cases were registered for ANC, out of these 2473 high-risk pregnant women were diagnosed. Number of pregnant women treated for anaemia were 8320. In Khilchipur block only 367 pregnant women were treated for anaemia. 5843 home deliveries in the field of Bioara and Khilchipur block were assisted by ANM. Total 9086 institutional deliveries were registered.

The use of bio-medical equipments is very essential for diagnosing the diseases. Even in routine check-up the equipments like sphygmomanometer, weighing machine, torch, thermometer, etc. are extensively used. The specific check-ups like antenatal check-ups or for conducting deliveries, immunization, MTP, etc. need specific equipments. These are very common equipments used in health institutions. Therefore it was felt essential to know the status of these equipments. The data regarding the status of equipments used in above stated activities were collected.

Interventions for reduction of maternal mortality:

The second phase of this study was more important, because in this phase we carried out interventions to reduce maternal mortality. For these interventions 5 panchayats in each block were selected. Major role of this part was to sensitize the stakeholders. So that they should get involved in process consultation and developing action plan.

The criteria for selecting the intervention villages was the maternal morbidity. Before proceeding to these interventions the Study Findings were summarized and then shared with the participants. The PRI members and VHC members for each gramsabha were called for 2 days workshop at each Block Head Quarter. These workshops were carried out using process consultation, confrontation and problem solving approaches. In the month of December and January five members from each panchayats were called for interventions. In all these workshops the VHC members, Anganwadi workers, ANMs, PRI members, opinion leaders, local citizens were involved. The team building interventions were also planned among these groups. The group members chalked out the activity plan for reduction of maternal morbidity and mortality. The follow-up activities were carried out at these intervention villages. For determining awareness and knowledge about maternal morbidity and mortality we conducted focus group discussions in both the blocks. These intervention workshops were conducted in two phases.

In these workshops awareness among stakeholders about causes of maternal mortality were pointed out. After finding awareness among stakeholders the activities for reduction of maternal mortality and morbidity were designed by themselves. Next follow up activities were carried out for these intervention villages. The problems in administering those interventions will be assessed and were solved in next round of workshops. As an outcome of these interventions in some of the villages self help groups were formed to save money for loaning for transportation at the time of delivery. The awareness creation and ANC registration increased to a great extent resulting into lower morbidity of diseases among pregnant women.