European Journal of Cardiovascular Medicine

Maternal mortality remains one of the most pressing indicators of health disparities around the world. Defined as the death of a woman during pregnancy, childbirth, or within 42 days of delivery from causes related to or aggravated by the pregnancy, maternal mortality is both a public health concern and a reflection of the quality of healthcare systems globally 5.

Most maternal deaths stem from conditions that are well understood and, in many cases, avoidable. These include hemorrhage, pre-eclampsia and eclampsia, infections, and complications from unsafe abortions 2.The most common cause of maternal mortality is Obstetric haemorrhage 3, 5. Factors such as poverty, lack of education, inadequate healthcare access, and cultural practices often exacerbate the risk 3.

The global maternal mortality rate has seen a gradual decline over the past two decades due to increased investment in maternal health services, better-trained birth attendants, and improved access to prenatal and postnatal care. However, progress has been uneven.

Recent years have also witnessed setbacks. The COVID-19 pandemic disrupted essential health services worldwide, and subsequent reductions in foreign aid threaten to further strain healthcare systems in vulnerable regions.

India has made notable progress in reducing maternal deaths, dropping its maternal mortality ratio significantly in the last two decades. However, the country still faces challenges in rural and underserved areas, where access to timely medical care remains inconsistent 4. Efforts to strengthen institutional deliveries and community health programs have contributed positively, but more work is needed to ensure no woman dies while giving life.

The aim of this study is to analyse the regional trends in Maternal Mortality rate over the past 5 years in Kakinada region and to evaluate statistical patterns in Maternal Mortality Rates and distribution of their causes.

It is a retrospective observational study conducted in the Department of Obstetrics and Gynaecology, Government General Hospital attached to Rangaraya Medical College for a period of 60 months from December 2019 to December 2024. Over 171 cases in the past 5 years were studied and were redistributed according to the cause of death.

Inclusion criteria:

·         Maternal deaths in the Government General Hospital, Kakinada.

Exclusion criteria:

·         Maternal deaths >6 weeks after delivery.

·         Deaths in non-pregnant females.

Relevant data was collected using documented case record forms. Collected information included maternal age, gravidity, parity, number of antenatal visits, gestational age at delivery, mode of delivery, maternal outcomes. Maternal outcomes were further classified based on the primary cause of mortality.

Statistical Analysis:

Data were analyzed using standard statistical methods to evaluate the association between various maternal parameters and maternal mortality. Categorical variables such as cause of maternal mortality were analyzed using chi-square or Fisher’s exact tests, as appropriate.

Continuous variables such as gestational age and birth weight were summarized using means and standard deviations, and differences were analyzed using independent t-tests or

Mann-Whitney U tests, depending on the data distribution. A p-value <0.05 was considered statistically significant.

Informed Consent:

Implied consent was obtained from all participants at the time of admission to the hospital, ensuring their voluntary participation in the study.

Ethical Approval:

The study protocol was reviewed and approved by the Institutional Ethics Committee (IEC) of Rangaraya Medical College, Kakinada. Ethical approval was obtained prior to the commencement of the study, and all procedures adhered to the ethical standards.

A total of 171 cases were analysed in this study. The most common cause of maternal deaths is hemorrhage followed by covid pneumonia followed by sepsis. In the year 2020, COVID deaths preceded number of maternal deaths caused due to sepsis. This is due to the global pandemic which had occurred earlier. About 69 cases (40.3%) have hemorrhage as their primary cause of death, followed by 34 Covid pneumonia cases which accounts for 19.8%, followed by sepsis (30%). Hypertensive disorders in pregnancy accounts for 23 cases which adds up to 13.4% of the total cases. Cardiac disorders in pregnancy such as peripartum cardiomyopathy, chronic rheumatic heart disease complicating pregnancy accounts for six cases which adds up to 3.5% of the total cases. Amniotic fluid embolism, which is a rare phenomena accounts for 1.7% of the cases. Other medical disorders like pneumonia, jaundice, renal failure, and anemia sums up the list.

Among the deaths due to hemorrhage, the leading cause is atonic PPH which involves 44 cases(63.7%) followed by hemorrhage which is a result of Ruptured ectopic which includes 10 cases (14%). Antepartum hemorrhage accounts for 7 cases (9%). Incomplete abortion leading to haemorrhage accounts for six cases that is 8% of the total cases which has mortality due to haemorrhage. The least common cause leading to haemorrhage which leads to maternal mortality is molar pregnancy which accounts for 1% of cases.

Following hemorrhage, Covid pneumonia is the second leading cause of death in pregnant women accounting for 34 cases of the total 171 cases which adds up to 19.8% of cases.

The third most common cause of maternal mortality is sepsis which is most commonly due to sepsis after Caesarean section.12 cases (40%) accounts for puerperal sepsis as aetiology of death after cesarean section. About 11 cases that that is about 36.6% up at accounts for puerperal success after vagina delivery. Five cases of post abortal sepsis are observed in the study. About 6.6% of cases that is around two cases accounts for antenatal causes of sepsis.

In the cases with hypertensive disorders complicating pregnancy, the most common cause of death is due to renal failure, which accounts for 20 cases that is 86% of the total maternal deaths in the hypertensive disorders of pregnancy category. The next leading cause in the spectrum is HELLP syndrome which accounts for 11 cases that is 47%. Cerebral haemorrhage accounts for one case 4% of the total cases. HIE accounts for four cases which adds up to 17% of the total spectrum.

The next leading cause of death in pregnant woman is cardiac diseases complicating pregnancy in which peripartum cardiomyopathy is major cause accounting for 66% of the cases totalling to 4 cases. One case of Chronic rheumatic heart disease, which presented with severe mitral stenosis with the hypertension accounts for 16% of cases. The one death due to the cyanotic congenital heart disease has occurred due to improper preconceptional counselling for avoidance of pregnancy and antenatal checkups in private hospital till 9th month of gestation and patient present it to Government General Hospital Kakinada at term deteriorated progressively and death after delivery.

Out of all cases, the most common age group is 20 to 40 years which accounts for 89.4% of cases that is 153 to be precise and 16 cases (9.3%) were patients with less than 19 years of age. Patients which are aged more than 40 years or least common accounting for one case (0.5%).

Deaths occurred more commonly in multipara. About 106 cases(61.9%) were are multiparous women, followed by 61 cases (35.6%) or primigravidas and only four cases (2.3%) were grand multipara.

In regard to demographic distribution of maternal deaths, they occurred more commonly in women belonging to rural areas and low social economic status.

About in 82 cases(47.9%), deaths occur following 48 hours of admission even after primary resuscitating measures and prompt treatment.

More deaths occurred in the postpartum period which are a result of postpartum hemorrhage. About 69% of patients were shown to be anemic, while 20% to be having elevated serum creatinine levels. 21% of cases were having elevated serum bilirubin and 10% of cases had deranged coagulation profile.

About 72.5% of patients required PRBC transfusion, 49% needed platelet transfusion and 51% had FFPs transfusion. 11% of patients were treated with magnesium sulphate. 15% were given antihypertensives. 43% were treated with higher antibiotics like Pipericillin and sulbactam. 41% of patients were treated with inotropic agents and 30% of them required ventilatory support. 23% of patients had undergone dialysis. 12% of patients required emergency surgical intervention like emergency laparotomy. 26% had SR cannula inserted.

Our study highlights the causes of the maternal mortality and discusses the regional trends of the maternal deaths. There are several strengths to this study. Most importantly, the timely topic with the relevance to SDGs. This study aligns with the national and global goals, such as the SDG target of reducing MMR to 70 per one lakh by 2030 1,5. The substantial sample size and time frame is also an added advantage for this study. The inclusion of 171 maternal deaths over five years provides a decent data set for observational trends. The categorical analysis of causes that is the breakdown of the aetiology into haemorrhage, hypertensive disorders, sepsis, cardiac disease gives a clear clinical perspective and helps in planning the improvement of the future management options. This study enables us to recognise the need for multidisciplinary perspective and shows an awareness of maternal mortality as a complex and systemic issue. It gives a holistic view of contributing factors as it doesn’t just list medical causes, it also looks at demographics, parity, social, economic status and time of death giving a fuller picture of maternal mortality beyond just clinical variables 4. It also helps us to recognise the rural and urban divide. This study acknowledges the disparity in maternal outcomes based on geography and social economic status which are important for targeting public health interventions. The recognition of Covid pneumonia as leading cause of maternal mortality in 2020 shows responsiveness to recent global events and reflects adaptability in clinical awareness. It also helps us to recognise the importance of postpartum period as the most vulnerable time for mother and acts as a crucial phase which reflects current global understanding of maternal health risks.

he study concludes that maternal mortality is one of the most crucial indicator of development of the present health care. There are certainly gaps to be filled to improve the present medical trends in regard to maternal mortality. MMR can further be decreased by high index of suspicion, early diagnosis of high-risk cases and timely referral and intervention. Availability of various specialised doctors like cardiologist, nephrologist and intensivist round the clock will also help. Availability of blood and blood products and their easy procurement is also necessary. Arrangement of blood donation camps and donation from kin and kith should be encouraged.

Improving awareness about early detection of most common causes of maternal deaths and sensitisation of healthcare personnels like ASHA and ANM is also necessary. Routine Cardiac evaluation like 2D Echo for all antenatal women during 30 to 34 weeks of gestation age should be made compulsory which helps us to decrease the incidence of peripartum cardiomyopathy. Internal audit should be done monthly to assess the lacunae to be corrected and necessary actions should be taken to prevent the evitable deaths. Educating all pregnant women about danger signs during and after pregnancy helps an early approach to health care personnel and early seeking of the treatment. Improving the cleanliness and maintaining sterile conditions within and around the hospital reduces the chances of sepsis in the hospital.

1.       A global analysis of the determinants of maternal health and transitions in maternal mortality, Prof João Paulo Souza MD a , Louise Tina Day MRCOG c, Ana Clara Rezende-Gomes MSc a, Prof Jun Zhang MD d, Prof Rintaro Mori MD e, Adama Baguiya MD f, Kapila Jayaratne MD g, Alfred Osoti MD h I, Prof Joshua P Vogel MD j, Prof Oona Campbell PhD c, Kidza Y Mugerwa MD k, Prof Pisake Lumbiganon MD l, Özge Tunçalp MD m, Jenny Cresswell PhD m, Lale Say MD m, Allisyn Carol Moran PhD n, Olufemi T Oladapo MD m. The Lancet Global Health Volume 12, Issue 2,February 2024, pages e306-e316 https://doi.org/10.1016/S2214-109X(23)00468-0

2.       Trends in maternal mortality in India over two decades in nationally representative surveys C Meh, A Sharma, U Ram, S Fadel, N Correa, JW Snelgrove, P Shah, R Begum, M Shah, T Hana, SH Fu, L Raveendran, B Mishra, P Jha First published: 29 August 2021 https://doi.org/10.1111/1471-0528.16888

3.       International Journal of Reproduction, Contraception, Obstetrics and Gynecology Vol. 5 No. 1 (2016): January 2016 A cross sectional study to assess the pattern of maternal mortality in a tertiary level government hospital of a city in north India Akanksha Lamba, Sakshi Agarwal, Apurba Kumar Dutta

4.       DOI:https://doi.org/10.18203/2320-1770.ijrcog20151629

5.       International Journal of Reproduction, Contraception, Obstetrics and Gynecology Vol. 9 No. 9 (2020): September 2020 Trends of maternal mortality at a tertiary health care centre in India Authors Deepali S. Kapote, Anam B. Syed, Swati C. Gawai, Ashwini S. Desai, Apeksha M. Mohite DOI:https://doi.org/10.18203/2320-1770.ijrcog20203851

6.       International Journal of Reproduction, Contraception, Obstetrics and Gynecology Vol. 13 No. 4 (2024): April 2024 Maternal mortality in a tertiary hospital of North India- analysis of causes and risk factors Authors Urvashi Miglani, Jasmine K. Kohli, Poonam Laul, Monika S. Grover, Richa Madan DOI:https://doi.org/10.18203/2320-1770.ijrcog20240779