European Journal of Cardiovascular Medicine

According to the World Health Organization (WHO), “A maternal death is defined as death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to  or aggravated by pregnancy or its management, but not from accidental or incidental causes.” (ICD-10). Though pregnancy is a physiological state it always carries high risk of maternal mortality and morbidity. Number of maternal death per 100000 live birth in a particular year within the antenatal period, intra-natal period and post-natal period excluding homicidal and suicidal causes is called maternal mortality ratio. Maternal mortality ratio for the study period was calculated by using the formula

This is an institution-based, retrospective study in the Department of Obstetrics and Gynaecology at Jorhat Medical College And Hospital, Jorhat, Assam for a period of 10 years from January, 2011 to December, 2020.
Demographic and other data are collected from bed head tickets, case records, maternal death register and maternal death review register from office of O&G and MRD of Jorhat Medical College And Hospital.
Necessary ethical clearance for this study is taken from institutional ethical committee of Jorhat Medical College and Hospital. A total no of 275 deaths were analysed with the special emphasis on social demographic profile, antenatal check-up, parity, cause of death, time interval from admission to death, trimester of pregnancy at the time of death, communication facility and type of delay in reaching tertiary care centre from periphery.
Inclusion criteria
• Death from complications during the pregnancy itself, during labour or the puerperium, or within 42 days of the pregnancy's termination, regardless of the location or length of the pregnancy.
•Death caused by a condition that existed prior to pregnancy or developed during pregnancy and was exacerbated by pregnancy-related physiological changes.
Exclusion criteria
•Deaths from reasons other than those listed above, such as homicide and suicide.
Type of delay according to maternal death review form-

In our study, total life Birth were 69,685 and total number of maternal deaths was 275. Year wise distribution of maternal mortality rate shows maximum death occurred in 2011 and minimum death occurred in 2019 out of 275 maternal death (Table 1).

Socio-demographic characteristics of patients showed that a total of 233(84.72%) came from rural area and 42 (15.27) cases came from urban area. Most of the maternal death occurred in the age between 19 to 24 years which is 153 (55.56%) and death occurred in more than 35 years of age which is 19{6.9%}. Also, it is observed that most of the deaths occurred among low social economic status which is 184 (66.90%). Moreover, as much as 54.18% (149) were illiterate and only 12 (4.36%) received higher education. These findings are depicted in Table 2.

Out of total 275, 132 (48%) were primigravida, 107 (38.90%) multigravida, and 36 (13.09%) grand multiparas.
From our study, it shows that maximum death which is 211 (76.72%) were un booked cases. Majority of death occurred in postpartum period which is 141 (51.2%) followed by 3rd trimester which is 76 (27.6%).
If we consider time interval from admission to death, it shows that out of 275, 149 (54.1%) where died within 6 hours of admission, 42 (15.2%) died between 7 to 12 hours, 48 (17.4%) died between 13 to 24 hours and 36 (13.1%) died after 24 hours of admission. These findings are shown in Table 3.

Referral characteristics showed that most of the patients were referred from district hospitals (137, 50.2%). Only a few (3,1.1%) were referred from private hospital. Also, as much as 40% (110) took more than 12 hours to reach Jorhat Medical college (Table 4)

When we consider type of delay it observed that out of 275 cases, 94 (34.2%) cases have type-1 delay, 158 (57.4%) cases had type-2 delay and 23 (8.36%) cases had type-3 delay (Fig 1)

Unexpectedly high rates of maternal mortality are found in developing nations like India. A mother's death is a sad occasion. In real life, it negatively affects the family, the community, and ultimately the country. The young survivor who is left motherless is more likely to die since they are unable to handle day-to-day life.In the national level, India has an MMR of 167/1,00,000 in 2012 and 103/100000 in 2018-2020 and recently reduced to 97/100000 live birth, in our study, there are 275 maternal deaths among 71,843 delivery and 69,685 live births with an MMR of 394.63 per 1,00,000 live births which is higher than the national average. Jorhat Medical College is being a teaching institution and a tertiary care centre get complicated cases referred from peripheral Hospital have inflated in this mortality ratio like being other teaching institution of India. Like this study, other similar study from the tertiary care institution reported MMR of range between 213 to 879 per 1,00,000 live birth as described by A.verma et al, N.Purandare and A Pal et all [3,4,5]. and Goswami et al [6] from Guwahati Medical College in 1994 which showing MMR 1234/1,00,000 and also by S.K Bera [7] from Kolkata in 1990 showing MMR of 1023/1,00,000.
In the present study, maximum maternal death seen in age below 25 years which is 60% (165). Due to the common practice of early marriage in rural areas, the majority of pregnant women present at an early age. Our study shows maximum maternal death 132(48%) out of 275 were primigravida,107(38%) were multigravida and 36(13%) were grand multipara. This is due to the fact that the majority of eclampsia patients were primigravida, and eclampsia is the leading cause of maternal death. Similar study also published by Dogra and Purandare in 2007 and 2007[4]
If ANC registration were taken into consideration, it shows that maximum maternal deaths occurred among un booked case which was 211 (76.7%) and 64 (23.3%) were booked cases, similar reports also published by S. Kulkarni et al in 1996. It demonstrates how important prenatal care is in ensuring safe motherhood. If we can somehow enhance attendance at antenatal check-ups, we can at least pick up the high-risk cases and provide good care to them.
Our study revealed that the marginalized and poor population, who live in distant and rural areas with limited access to healthcare services, had the greatest maternal death rate. A study done by Bhutta Z A et all [9] in 2013 shows similar results. Lack of ANC, emergency obstetric care facilities, illiteracy, certain social beliefs and customs, poverty, and a shortage of medical workers in rural and outlying locations could all be contributing factors to this.
In our study 149(54.1%) women died within 6 hours of admission, 42 (152%) died between 6-12 hours of admission, 48(17.4%) died between 13-24 hours of admission and only 36(13%) women died 24 hours after admission. When we compare our study with study done by Purandare in 2007 [4] which shows about 74(84%) died within 12 hours of admission suggesting majority of patients reach the tertiary care hospital quite late. It may be possible to save the lives of many mothers by strengthening the provision of comprehensive and basic emergency obstetrics care at the primary healthcare level and first referral unit.
Our study showed maximum maternal deaths 141(51.2%) occurred in the postpartum period, followed by 3rd trimester which is (27.6%) if we compare our results with study done by Dogra K and Purandare [8,4] also shows similar results. High number of deaths in postpartum period indicate that need continuous monitor during postpartum period and prompt action in case of problems. Intra-natal care by skilled attendant, timely management and replacement of lost blood volume can reduced the deaths in the postpartum period.
Leading cause of death in our study is eclampsia which in 28.4%, though eclampsia is a preventable cause of death if good obstetrics care given. It is mainly due to high incidence of eclampsia in this area and delayed referral mostly after 12 hours of the incidence. Roy et all study [10] also shows same findings.
Most of the patients in our study were low socioeconomic status, low level of education, and poor prenatal and antenatal care. Higher maternal mortality in our study was caused by inadequate prenatal and antenatal care, delayed early diagnosis, progression to severe disease, delay in treatment, lack of access to health care facilities, inadequate transportation, lack of properly trained staff and personnel, inadequate resources, and intensive care unit. This outcome were equivalent to the study conducted by Bangal in 2011[12].
When we look at the types of delays (Fig. 2), we see that the most maternal deaths occurred as a result of type 2 delays, which suggest late referral to Jorhat Medical College. Several issues contribute to this, including insufficient staff, facilities, or patient poverty, as well as illiteracy or ignorance of their illness. As a result, referrals from the primary referral centre are delayed. Type 1 delay accounted for 94 instances. Patients delayed seeking medical care due to illiteracy, ignorance, poverty, household norms, and a lack of transportation. Type 3 delays totalled 23 cases, which could be decreased by making emergency medications and blood available. Adequate ICU and HDU care can also help to decrease the delay

Our study's MMR is higher than the national average. The majority of maternal deaths may have been avoided with good antenatal care, early referral, better transportation facilities and better-equipped tertiary care. Even today, the majority of maternal mortality occur in rural locations, among un booked, illiterate patients, and those from low socioeconomic backgrounds. Eclampsia, haemorrhage, sepsis are the leading causes of maternal mortality. Improvement in primary health care in rural areas and implementing basic and comprehensive emergency obstetrics care at peripheral level can definitely bring down the number of maternal deaths.
Conflict of interest: None.
Disclaimer: Nil

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