Meeting the community halfway to reduce maternal deaths? Evidence from a community-based maternal death review in Uttar Pradesh, India

INTRODUCTION

Despite progress in recent decades, India has the largest number of maternal deaths of any country in the world.¹ Most maternal deaths in India are concentrated in 7 states (Assam, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttarakhand, and Uttar Pradesh). Uttar Pradesh (UP) has the second highest maternal mortality ratio (MMR) among the 7 states, at 359 maternal deaths per 100,000 live births, compared with the national average of 212 maternal deaths per 100,000 live births.²

The Government of India has placed special emphasis on improving maternal, newborn, and child health (MNCH) through policies and program guidelines.³ One major policy initiative includes increasing institutionalization of deliveries facilitated through the Janani Suraksha Yojana (JSY) program—a national conditional cash transfer scheme started in 2005 that provides eligible women with cash incentives for giving births in an institution.^4-6

Recently, the government issued national guidelines for states to carry out maternal death reviews at both community and facility levels.⁷ However, implementation on the ground has been extremely slow and challenging.⁸ Thus, expected results have not been achieved, and the country is still at a distance from achieving Millennium Development Goal 5 (MDG 5)—reducing India's MMR to 109 by 2015.^2,9

The maternal death review (MDR) is a tool used in many countries to understand the underlying factors leading to maternal deaths, providing programs with information to improve services and reduce MMR.^10,11 In an effort to analyze the reasons for maternal deaths for appropriate local intervention, the Government of India introduced Maternal Death Review guidelines in 2010,⁷ based on the experience of implementing such reviews in Kerala, Tamil Nadu, and West Bengal.¹² However, implementation has not been initiated in most of the districts.⁸

This study was conducted to highlight key operational issues in maternal death identification in Unnao District in UP and to provide an in-depth understanding of the factors and chain of events leading to maternal deaths in the community. This information can be used to advocate policies that would enable the Government of UP to take corrective measures. The relevance of this study extends to other states in India where a similar MDR process is underway.

RESULTS

Findings From the Verbal Autopsy

Verbal autopsy revealed that 16% of the maternal deaths reportedly occurred in a private facility, 30% in a government hospital, and 23% at home, while 30% died on the way to a facility (Figure 2). Our study did not identify any abortion-related deaths, which is most likely due to underreporting by the family. Even though abortion is legal in India, many studies have shown that it is still an important cause of maternal death, due to lack of access to safe abortion services.²⁵ Of the 13 maternal deaths that took place at home, 85% of these women were illiterate, 77% had illiterate husbands, and 54% belonged to the Scheduled Caste and were below the poverty line (Table 3). Of the 17 maternal deaths occurring on the way to a facility, 35% of the women and their husbands were illiterate, 41% belonged to the Scheduled Caste, and 47% were below the poverty line. Of the 27 maternal deaths that took place in the facility, about half of the women were illiterate, 41% belonged to the Scheduled Caste, and 44% were below the poverty line. Only 15 of these 27 women (56%) had sought antenatal care at least once from the facilities.

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FIGURE 2.

Reported Place of Death in Maternal Death Reviews, Unnao District, Uttar Pradesh, 2010–2011

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Table 3. Reported Place of Maternal Death by Background Characteristics

Verbal autopsies indicated that almost half of maternal deaths occurred at a health facility.

According to family responses (available for 28 cases), only 1 woman planned to deliver at home, yet 24 of the 57 women (Table 4) delivered at home. In terms of the timing of the deaths, 9 women died before delivery and the remaining 48 women died after delivery (Table 4). Of the 48 women dying after delivery, 25% died (12) at home, 27% (13) on the way to a facility, and 48% (23) in the facility, and all 48 women died within 6 weeks or 42 days of delivery.

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Table 4. Cause of Maternal Death by Reported Place of Death

Based on the verbal autopsies (and, in 2 cases, medical records available from the relatives), the major direct causes of the reported deaths were: 22 cases of hemorrhage (38%), 15 cases of anemia (26%), 8 cases of sepsis (14%), 6 cases of eclampsia (10%), 4 cases of obstructed labor (7%), and 2 cases that could not be diagnosed with available information (4%). No death certificates were available to validate the cause of death.

Table 5 shows factors contributing to the maternal deaths, which can be grouped into 3 main categories using the “3 Delays Model.”26

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Table 5. Factors Causing Delays in Accessing Appropriate Maternal Health Care (n = 57)

Delay 1 (delay in deciding to seek care): The most common reason that families cited for not seeking care sooner was lack of available transport (28%). Another reason cited was the cost of transport. The median cost of transport from home to the first facility was Rs. 100 (US$1.83); from facility 1 to facility 2, Rs. 600 (US$10.96); and from facility 2 to facility 3, Rs. 550 (US$10.04). The mean time spent deciding to take the pregnant women to a facility was 4 hours, and average time to make arrangements was 3 hours. It is easy to see how time could be lost while families weighed all these factors.

Delay 2 (delay in reaching adequate facility): According to family reports, by far the most common mode of transport to all facilities was taxi/auto rickshaw/tractor. Only during transfers from the second to third facility did the families mention travel by ambulance provided by the health facility. Being sent from one facility to another (and another) adds dangerous delay. More than half the families had to borrow money to take women to the first facility, while all the families borrowed money for treatment. Although public facilities provide free care, families still had out-of-pocket expenses, such as costs for transportation and medicines (from outside pharmacy as advised by the doctor of the visited facility). The median cost of care in the first facility was Rs. 375 (US$6.85); in facility 2, Rs. 1,500 (US$27.39); and in facility 3, Rs. 2,500 (US$45.66).

Many families had to borrow money to cover costs of transportation and medical care.

Delay 3 (delay in receiving adequate care at facility): While attention is often focused on delays 1 and 2, information provided by the MDR clearly shows that delays in receiving appropriate care once at the facility played an important role in the maternal deaths in Unnao District. Half of the women had to be taken to at least 2 facilities for management of their complications, thus losing precious time (the mean travel time between facility 1, facility 2, and facility 3 is 1.3 hours).

Half of the deceased women were taken to at least 2 facilities, causing fatal delays in receiving appropriate care.

DISCUSSION

A community-based maternal death review can be a useful tool for program planners, managers, and health advocates, provided that the data are used appropriately and strengths and weaknesses of the tool are kept in mind.²⁷ Strengths of the MDR lie in the depth of information that can be gathered on the process that the pregnant woman and her family went through and the barriers that they faced. Limitations of the MDR are directly related to its strengths, as it cannot provide maternal mortality levels in the study area.

Although the MDR conducted in Unnao District represents only 1 district in UP, we believe it is representative of the general situation of maternal care in the state. The difficulties of identifying maternal deaths have been reported in both developed and developing countries for decades. In our study, we took advantage of the extensive network of community health workers in India (ANMs and ASHAs) to report maternal deaths that might have escaped official notice. An important finding from the death identification process is the high proportion of maternal deaths reported by Anganwadi workers, who are employed by the Ministry of Women and Child Development rather than the Ministry of Health and Family Welfare.

By comparing the expected number of deaths in the study area in a year to the number reported by the community workers, we estimate that we identified about 62% of maternal deaths. This is not an unusual finding. It seems that the only way to identify nearly all maternal deaths in developing countries is to do a repeat household survey and explore the absence of any person. This has been done for many years in Matlab, Bangladesh.²⁸ Unfortunately, it is too expensive and time consuming to do this for a large area (such as an entire district in UP). Moreover, precise data on the MMR are not needed to identify and address problems in the health system, as our data show.

Clearly the ability of verbal autopsy to identify exact cause of death is limited. An unusually high level (even for India) of maternal deaths was attributed to anemia (26%), which may partly represent deaths related to hemorrhage. Our experience confirmed that of many earlier researchers who found that medical causes of many maternal deaths were not reported, even when a variety of community methods were used.²⁹ We are aware that the distribution of medical causes of death is inexact in this data set, but it does provide an idea about the major causes of maternal death in the community, for which an appropriate strategy can be formulated. This is consistent with findings in other studies that found that verbal autopsies have limited validity in the attribution of maternal deaths to single specific medical causes and that multiple causes of death should be considered in determining program priorities.^29,30

This study revealed several important findings in terms of the maternal death reporting process. One is that very few maternal deaths were reported by the government health facilities studied. A common explanation for this might be that women with complications stay at home and either die there or on the way to a facility. Our data, however, show that this is not a valid explanation, as many women are reported to have died in facilities, but the community workers—not the facilities—reported these deaths. A potential reason that facilities may underreport maternal deaths could be to avoid investigation and punitive action by higher authorities. Under the new MDR guidelines, the Government of India has clearly pronounced a “no punitive action” policy but how much this has eliminated apprehension is yet to be seen. This is clearly an area for further study.

Our study also revealed important areas of the health service delivery system that could be strengthened to reduce maternal mortality, particularly ensuring that facilities provide the appropriate level of emergency obstetric and neonatal care services and that the referral system is efficient and effective. Even First Referral Units with qualified specialists did not manage complications of pregnant women due to such factors as lack of blood or unavailability of staff, and instead transferred the women to the district hospital. In most cases, families tried desperately to obtain medical care for the women, traveling to one, then a second, and often a third, medical facility. Not only did this consume precious time and money (often borrowed), but also many women and their babies died along the way. Our data also highlight the fact that, even after recognition of a complication by health staff, women were referred to the next higher level of facility in the hierarchy—that is, from BPHC to CHC to district hospital—rather than directly to a facility where appropriate resources were available to manage the complication.

Finally, our findings indicate that a woman's family spends twice the amount in seeking care as that given by the government to pregnant women under the Janani Suraksha Yojana (JSY) scheme that aims to promote institutional deliveries. There are nearly 8.37 million JSY beneficiaries in India—about 37% of whom are in UP. In UP, institutional deliveries constitute 47%, and home deliveries 52%, of all deliveries. About 76% of women in UP were aware about the JSY scheme and 38% of the JSY beneficiaries belong to households that are below the poverty line. Among JSY beneficiaries in UP, 72% of the mothers received money (Rs. 1,400 [US$ 26.04] or more) after the institutional delivery, but only 8% of them received the amount at the time of discharge.³¹ However, our study found that families in Unnao District, UP, spent almost Rs. 500 (US$9.30) for transportation and care costs at the first facility, Rs. 2,100 (US$39.06) at the second facility, and about Rs. 3,000 (US$55.80) at the third facility.

In the case of Tamil Nadu, the government has enhanced the Muthulakshmi Reddy Maternity Benefit Scheme to Rs. 12,000 (US$223.21).32 While the top priority should be focused on improving the service delivery system, the Government of India may also consider increasing the JSY incentive while state governments can initiate and implement special schemes focused on maternal and child health to reduce maternal and infant mortality.

CONCLUSION

Combining data gathered during interviews with families of deceased pregnant women with information gathered during facility gap assessments provides a valuable picture of what families face when a woman develops a serious obstetric complication. Our findings indicate that the expense of transporting a pregnant woman to a functioning medical facility is one of the major contributing factors to maternal death. Life-saving treatment of obstetric complications is also generally not offered at the appropriate level of government facilities and an inadequate referral system contributes to fatal delays in receiving appropriate care. Therefore, the government needs to focus on strengthening facilities that provide emergency obstetric and neonatal care services and on developing a functional and effective referral system. Furthermore, we would like to thank USAID-India, for providing financial support to the study through the MCH-STAR initiative.