Deaths from complications of pregnancy and childbirth are high with WHO recording 295,000 maternal deaths globally in 2017 [2].
This study was conducted to identify the maternal mortality ratio and causes of maternal death in a tertiary care center in a developing country. The MMR was found to be 129.34 per 100,000 live births, which is lesser as compared to other reviews done in developing countries [6, 7]. The MMR is very much less in our center as compared to the rate as mentioned by NDHS 2016 (MMR of 239) as this is a hospital based study [5].The common causes of maternal mortality in our center were obstetric hemorrhage, hypertension, sepsis, and anemia which is similar to the findings from other studies [7,8,9,10].
An observational study conducted in a tertiary care referral center of Western Nepal found that MMR of 151 per 100,000 live births with the mean age of the mother being 28 years. Most of the patients had presented to the center in unstable health conditions, with a common cause of death being hypertension and sepsis. These findings were also comparable to our study. Most of them (73.30%) had died in the postpartum period [11].
In this study, almost 70% of women were referred from other health care centers. Almost 30% of cases presented in a state of shock at the time of admission resulting in delayed intervention and hence adverse outcomes. It was similar to the findings from other studies done in developing countries [7, 12, 13].
In a study conducted in Nigeria, six leading causes of maternal mortality were hemorrhage, eclampsia/ preeclampsia, sepsis, ruptured uterus, complications of abortion, and prolonged obstructed labor. Among these causes, 43.4% accounted for hemorrhage followed by 36.0% of preeclampsia and eclampsia which coincides with the finding seen in our study [12]. In our study 3, women had ruptured uterus. Among them, 2 women were referred from outside after delivery in a state of shock and expired during the resuscitation process. Other women had ruptured uterus diagnosed during the intrapartum period. The women who were referred from outside had a difficult vaginal delivery and gave history of fundal pressure. It seems that the use of fundal pressure during vaginal delivery is still being practiced in peripheral setup.
Another study conducted in India, had found MMR of 802 per 100,000 live births which was very much higher than the finding of our study. In this study, maternal anemia (53.57%) was the most common morbidity unlike the finding in our study where hypertensive disorder of pregnancy was the most common comorbidity. Almost 93% of death had occurred in the postpartum period and 94.6% of women were referred from another center [7].
Overall, high MMR was found in various studies which were conducted in a referral centers in developing countries, which reported MMR of 426 per 100,000 live births and 1513.4 per 100,000 live births [14]. Comparable to several studies, most of the death (77.50%) had occurred in women of 20- 34 years of age [7, 8, 10, 15]. The mean gestational age at death is 36.15 ± 4.38 weeks in our study which is similar to another study [10].
Evidence has suggested that three delays are important factors for maternal morbidity and mortality in Nepal. The delay I (40.9%) was seen in maximum death followed by delay II in our study. Most of these cases were related to late referrals from other health centers. This calls for strengthening the capacity of the health care workers in early recognition of danger signs and referral to the appropriate centers on time.
This study has highlighted the gaps between the community to the tertiary care center. Those women who had delivered at home or primary care center are being referred to many other centers before reaching tertiary care center or not referred on time due to lack of skills/ knowledge to identify the high-risk patient. Furthermore, delays in interventions and inadequate supply of equipment, inadequate skills of providers had also contributed to the deaths.
The following significant strategies have been adopted to reduce risk during pregnancy and childbirth and address factors associated with mortality and morbidity at national level:
Promoting birth preparedness and complication readiness including awareness- raising and improving preparedness for funds, transport and blood transfusion.
Expansion of 24 h birthing facilities alongside a safe motherhood program, which also promotes the continuum of care from antenatal care (ANC) to post-natal care (PNC). The expansion of 24 -hour emergency obstetric care services (basic and comprehensive) at selected health facilities in all districts.
The steps taken by government are commendable. However, there is unequal distribution of health care services throughout the country based upon population distribution. Also, only selected health facilities give BEONC and CEONC, easy access to those facilities is far from reality due to difficult transport system especially in hilly and mountainous areas. Having said so, more than half of our study population were from Terai. This may be because our hospital is in vicinity of Terai region. In addition to that, even though the transport in Terai region is easy, the awareness regarding reproductive health care, right of women on deciding about their own health is lacking. Also, because of patriarchal society, there is tendency of multiparity till a woman delivers a son. Another aspect responsible for increased maternal mortality is unavailability of trained health care workers in all facilities. Though the provision of easy transport and social reform will take time, providing training to the health care workers to increase their skills in prevention, detection, and management of the leading causes of maternal deaths through an obstetric drill, refresher course may help in reducing maternal morbidity and mortality to some extent. In our study, few deaths were related to delay in providing intervention, inadequate supply of the instruments (delay 3) which need to be addressed by the hospital management in coordination with the province and national government.
The government can also plan on establishing a confidential maternal death enquiry (CMDE) which is already started in many countries like England and Wales, Malaysia, Ireland. The aim of CMDE is not just to ascertain the numbers of deaths but principally to promote safer pregnancy by learning how such tragedies could be avoided in the future. This could make a major contribution to informing and improving standards of care in maternity services and the use of guidelines and recommendations would help to ensure all the pregnant and recently delivered women receive the best possible care.
Our institute routinely conducts a maternal-perinatal death audit, a surgical audit and identifies the lacunae in management that has led to the mortality. Such audits are helping us to formulate short term and long term plans to act properly if such conditions arise in future and to reduce MMR.
Strengths and limitations
This hospital-based study provides little representation of what is happening in the community and may lead to under-reporting. However, this study done over 5 years of duration provides trends of maternal mortality in our population. Also, this sample may not represent the general population as this is a referral center where patients were self-referred or referred by another center. As this is a descriptive study that lack a comparison group, it may not provide a causative association for maternal deaths. The contributory factors leading to delay I and II were also not studied separately.
As this is a retrospective study with less sample size, a more extended study period with a large sample size would give meaningful data. However, we have ensured accurate data using multiple approaches to identify all cases of maternal deaths in the hospital.
