Addressing Maternal Mortality in Selected Districts of Madhya Pradesh, India - A Human Rights-based Approach.

BACKGROUND: Maternal mortality is an indicator of state of maternal health services, status of women, women's health, and above all developments of nation.
OBJECTIVES: The objectives of the study were to identify the patterns and causes, medical as well as sociocultural, of maternal death as well as consider and list out the rights realization perspective of the mothers, their immediate families and the community at large.
MATERIALS AND METHODS: A cross-sectional study was conducted in three districts of Madhya Pradesh, India, for 1 year. One hundred and two maternal deaths were covered, and verbal autopsy was conducted. Human right perspective was assessed using questionnaire.
RESULTS: Majority (64.7%) of maternal deaths occurred between 18 and 25 years of age. About 50.9% were primigravida, and postpartum hemorrhage was the most common cause. Nearly 53.9% had visited more than one facility before death.
CONCLUSION: Poor antenatal care and lack of human resources posed major reasons for death in all facilities. Rights realization among the beneficiaries was found to be very poor.

INTRODUCTION

Maternal mortality is an indicator of state of maternal health services, status of women, women's health, and above all developments of nation. India alone contributed 15% of global maternal deaths.[1] Lifetime risk of maternal death in India is 1 in 220 as compared to 1 in 5800 in the UK. The major burden of maternal mortality is in the Empowered Action Group (EAG) states. As per recent SRS data, 2014–2016 Maternal mortality rate (MMR) was observed in Madhya Pradesh (MP) as 173.[2]

Realizing maternal health as one of the greatest impediments in human development, it has also been considered as a human rights issue, affecting the rights to life, equality of women, and right to health among other social and economic rights. There is clearly a great global concern demanding focused local solutions and persistent efforts.[345]

The reasons that women die in pregnancy and childbirth are many layered. Apart from medical causes are logistic causes, failure in the health-care system, lack of transport, etc., and behind these are social, cultural, and political factors which together determine the status of women, their health, fertility, and health-seeking behavior.[6]

The Government of India is committed to tackling the horrific health statistics of the rural poor and of the scheduled caste and tribal peoples, which significantly contribute to the global mortality rates of mothers and children under the age of 5 years.[7]

Maternal deaths are violation of women's human rights as these deaths reflect violations of the rights to life, rights to health, and rights against nondiscrimination based on sex, as childbirth is unique to females only, and if there is a neglect on this front, then it is considered that this is an outcome of systematic denial of equality for women in terms of providing assistance to them, as their rights are often ignored or considered less important.[8910]

Objectives

The objectives of the study were to identify the patterns and causes, medical as well as sociocultural, of maternal death as well as consider and list out the rights realization perspective of the mothers, their immediate families and the community at large.

MATERIALS AND METHODS

This was a cross-sectional study of maternal deaths conducted in Shahdol, Tikamgarh and Indore districts of MP between January 1, 2016, and December 31, 2016. Relatives of the deceased mothers were enrolled.

Three districts were selected from the division having high, medium, and low maternal mortality ratio, based on AHS survey 2012–2013.[11] District-wise list of reported maternal deaths was obtained from the National Health Mission, MP, India, for the duration of January 2016–December 2016. A nongovernmental organization (NGO) was identified in each district to validate the enlisted deaths as well as to find more number of unreported deaths, if any, during the defined period.

The study tool consisted of two sets of instruments through a community-based verbal autopsy questionnaire for investigation of maternal death which is a standard pro forma taken from maternal death review guidebook of the Government of India.[12] The second set of instruments was the human rights-based approach questionnaire.[13]

The team of two investigators reached the respective house of the deceased, conducted verbal autopsy and house-to-house survey from the identified list of maternal deaths from the best respondents, who were present with the deceased during the entire episode of the last journey. Additional information was also gathered from ANM/ASHA regarding the antenatal, intranatal, and postnatal care of the mother.

The second set of instrument was human rights-based approach questionnaire which was pretested and predesigned. Information was gathered mainly regarding the rights realization of the antenatal mother regarding her nutrition, antenatal care, physical activity during her pregnancy, and also as a community member, what do they think are the provision for giving special health assistance for pregnant women.

Apart from that, all the stakeholders, whether formal or informal, were also inquired regarding any unreported maternal deaths, namely Kotwar, ANM, ASHA, Sarpanch, and medical officer by the team members. Similarly, the team visited three districts and covered 102 maternal deaths. The obtained data were compiled using MS Excel and analyzed using Epi Info™ version 7.2.2.6 software (CDC). Epi Info™ is a trademark of the Centers for Disease Control and Prevention (CDC). The software is in the public domain and freely available for use, copying translation and distribution.

OBSERVATIONS

As per 2011 census population data and 2012–2013 AHS data, the expected number of maternal deaths at Shahdol, Tikamgarh, and Indore is 92, 121, and 102, respectively, out of which 60 deaths were investigated at Shahdol, 16 at Tikamgarh, and 26 at Indore district. A total of 102 deaths were covered in our study.

Table 1 shows that, of 102 females death, 65 (63.7%) were married at the age of 18–25 years and 24 (23.5%) got married below the age of 18 years.

Table 1

Distribution of the maternal deaths on the basis of sociodemographic characteristics

Background characteristics	Frequency (n=102), n (%)
Age at marriage (years)
<18	24 (23.5)
18-25	65 (63.7)
26-30	11 (10.7)
31-35	2 (1.9)
Age at death (years)
<18	1 (0.9)
18-25	66 (64.7)
26-30	20 (19.6)
31-35	11 (10.7)
>35	4 (3.9)
Religion
Hindu	99 (97.0)
Muslim	3 (2.9)
Community
OBC	45 (44.1)
SC	15 (14.7)
ST	42 (41.1)
Education of mother
Illiterate	34 (33.3)
Up to 8th standard	51 (49.9)
Up to 12th standard	13 (12.7)
Graduate	4 (3.9)
Occupation of mother
Agricultural laborer	19 (18.6)
Government employee	2 (1.9)
Homemaker	75 (73.5)
Nonagricultural daily wages	4 (3.9)
Private employee	2 (1.9)

Majority of deceased mothers 52 (50.9%) were primigravida, which were found to be due to poor antenatal care and no birth preparedness at all. About 57.9% of the deceased mothers left behind one or more children. Illiteracy and underage of marriage were also the sociocultural factors contributing to maternal death.

Majority of deaths occurred in postnatal period (49.01%), followed by antenatal (30.3%) and intranatal (20.5%) deaths. Overall, in our study, a high number of deaths were in postpartum period which indicates the need for continuous vigilance in postpartum period and prompt action in case of problems.

Table 2 shows that of 102 maternal deaths encountered in our study, 26 (25.4%) were home deaths. The reasons observed mainly were subjective to various sociocultural and environmental factors such as heavy rains, difficult terrains, nonavailability of vehicle, underestimation of seriousness of health conditions, strictly following the rituals and traditions. Hence leading to acceptance of prevailing situation and acceptance of death as fate.

Table 2

Distribution of the maternal deaths according to place of death

Place of death	Type of deaths, n (%)			Total, n (%)
	Antenatal	Delivery	Postnatal
Medical college hospital	6 (19.3)	3 (14.2)	10 (20)	19 (18.6)
DH	11 (35.4)	7 (33.3)	9 (18)	27 (26.4)
Private Hospital	2 (6.4)	2 (9.5)	9 (18)	13 (12.7)
CHC	2 (6.4)	4 (19)	1 (2)	7 (6.8)
PHC	0	1 (4.7)	2 (4)	3 (2.9)
In transit	1 (3.2)	2 (9.5)	4 (8)	7 (6.8)
Home	9 (29.0)	2 (9.5)	15 (30)	26 (25.4)
Total	31 (30.3)	21 (20.5)	50 (49.0)	102 (100)

DH: District hospital, CHC: Community health centre, PHC: Primary health centre

Deaths occurring during antenatal period within the first 6 h of onset of fatal illness were due to eclampsia, anemia, and non-obstetric causes in 6.5% of deceased mothers and antepartum hemorrhage in 3.2% of deceased mothers. Eclampsia and nonobstetric causes were major contributing cause of deaths occurring during this period [Table 3].

Table 3

Distribution of causes of deaths according to the time gap between onset of illness and death

Cause of death
Time Gap (hr)	Antenatal (n=31)	Intranatal (n=21)	Postnatal (n=50)
0-6	Anemia - 2 (6.5)	PPH - 7 (33.3)	PPH - 2 (4)
	Eclampsia - 2 (6.5)		SD - 4 (8)
	NOC - 2 (6.5)		Eclampsia - 1 (2)
	APH - 1 (3.2)		Anemia - 2 (4)
			NOC - 1 (2)
7-12	Anemia - 3 (9.7)	PPH - 1 (4.7)	PPH - 2 (4)
		SD - 2 (9.5)	SD - 1 (2)
		Anemia - 3 (14.3)	Eclampsia - 1 (2)
13-24	SD - 2 (6.5)	PPH - 3 (14.3)	PPH - 2 (4)
	Eclampsia - 2 (6.5)	Eclampsia - 1 (4.7)	SD - 1 (2)
	APH - 1 (3.2)	SD - 1 (4.7)	DIC - 1 (2)
	NOC - 1 (3.2)	Uterine rupture - 2 (9.5)
	Malaria - 1 (3.22)
>24	Eclampsia - 5 (16.1)	SD - 1 (4.7)	PPH - 4 (8)
	Anemia - 2 (6.5)		Puerperal sepsis - 12 (24)
	SD - 2 (6.5)		Eclampsia - 5 (10)
	APH - 1 (3.22)		SD - 1 (2)
	NOC - 4 (12.9)		Anemia - 7 (14)
			NOC - 3 (6)

APH: Antepartum hemorrhage, PPH: Postpartum hemorrhage, NOC: Non obstretic causes, DIC: Disseminated intravascular coagulation, SD: Sudden death

Majority of delivery deaths are in the first 6 h of onset of illness, which are due to postpartum hemorrhage (PPH). Of them, 5 (27.8) were home deliveries. This is due to the underlying fact that many of deceased mothers had preexisting anemia, slight bleeding during delivery, precipitated into severe anemia, thus making them more vulnerable to death [Table 3].

Death due to PPH in the first 24 h calls for an urgent action for effective management of PPH during postnatal period. Deaths due to puerperal sepsis were 24% after 24 h of delivery which shows that routine postnatal home visits are not being done by health worker [Table 3].

Human rights approach

During the study, our teams came across certain cases where we observed a violation of human rights pertaining to maternal health and delivery outcomes of the women.

Case study 1

She was 25 years old, gravida 2, Hindu by religion belonging to scheduled tribe caste and educated up to 8th standard. It was the second pregnancy of the woman. The first child died after 14 days of delivery. As this was her precious pregnancy, the deceased mother was even more vigilant and had gone for regular antenatal checkup (ANC) at Community Health Centre (CHC). During her antenatal period, her hemoglobin levels fluctuated from 9 gm% to 6 gm%. On May 30, 2016, when she reached CHC for her routine ANC checkup at 12 noon, she was told by the staff to get admitted as her cervical os was dilated. With the help of staff nurse, she delivered a male child through normal vaginal delivery at 6 pm same day. The mother was bleeding profusely after delivery and in spite of the treatment (oxytocin and misoprostol), bleeding could not be controlled. She went into hypovolemic shock and died after 3 hours. Upon realizing the seriousness of the case, the staff immediately wrapped her body in a cloth and even though the relatives requested to wait for the husband, hurriedly transferred her to District Hospital (DH). When brought to DH, the staff declared her brought dead, and because of this, she was not issued the death certificate by either of the institutes.

In the above scenario, the woman had undergone proper ANC throughout her pregnancy, and even for delivery, she had reached hospital well on time, even without any symptoms, for normal checkup. This definitely tells that the woman was conscious and concerned about her pregnancy. The violation is on the part of hospital staff that brought down the meaning of a lost life to mere escape from declaration of the death in their institute. The mistake of the staff left the bewildered family in a state where they have been denied of death certificate from both the institutes.

Case study 2

She was 25 years old, primi, 7 months pregnant, Hindu by religion belonging to scheduled tribe caste and educated up to 5th standard. She had proper antenatal care at her respective primary health-care facility and had 2-3 ante natal checkups. She developed high fever with rigor of 1 day and complained of no fetal movement. She was taken to a private hospital where she was told that the child had died in utero. She was referred to government medical college hospital stating that she was anemic and would cost much. Hence, 108 was called but it arrived 1–2 h late. On reaching medical college hospital, she was admitted soon. The relatives kept on pursuing for early operation since it was intrauterine death but they did not get a prompt response from the service providers. She was fully conscious and well oriented, but with time, her condition deteriorated.

After death, she was taken back to home, and according to the customs and their society, the dead fetus was extracted from the deceased mother then burnt and buried them separately.

Delayed attention to the patient leads to loss of the golden hour of saving a life.

Recommendations

Quality antenatal care should be provided by ANM with support of ASHA so that problems related to anemia and blood pressure can be detected truly at field level

Postnatal care should be routinely carried out by ANMs which should include baby and mother both so that many complications can be detected timely during this period

Specialist availability and blood storage facility should be made available at CHC and civil hospital as per Indian Public Health standards (IPHS) norms so that many high-risk cases can be dealt at this level only and thereby decrease the load at tertiary care centers

Service providers at the periphery should timely refer the high-risk patients, and transport facilities should be made available for them on time

Every left out child's right to life, right to nutrition, and right to education should be Ensured by developing some support system either at the family and community level for these children

The human rights principles must be integrated into programs at the clinical, facility management, and national policy levels. For example, a human rights “audit” can help identify ways to encourage respectful, nondiscriminatory treatment of patients, providers, and staff in the clinical setting.

Financial support and sponsorship

Study was supported by the National Health Mission, MP, India.

Conflicts of interest

There are no conflicts of interest.