Asia-Oceania J . Obstet. Cynaecol. Vol. 18, No. I : 1-6 1992
Role of Antenatal Care in Reducing Maternal Mortality
Ramesh D. Pandit Department of Obstetrics and Gynaecology,Nowrosjee Wadia Maternity Hospital, G. S. Medical College, Bombay, India
Abstract Maternal mortality in the developed nations has been considerably reduced, but it still is very high in developing nations. I carried out an indepth study of maternal mortality at N. Wadia Maternity Hospital, Bombay. India, from 1929 to 1988, which revealed that the MMR which was 1920 per 100,000 live births during 1929-1939 period has declined to 82 per 100,000 live births during 1980-1988 period. This achievement in reduction of maternal mortality over the decades was due to multiple factors like increased and effective antenatal, intranatal, and postnatal care. This study shows the apathy of pregnant women to come forward to avail of antenatal care though available even free of charge nearby. To give maximum benefits to pregnant women specially in the developing nations, we have to carry the antenatal care at the doorsteps of the community.
Key words: antenatal care, reduced maternal mortality Introduction Antenatal care is the strategy and intranatal care is the tactics to reduce the maternal mortality and morbidity. The practice of obstetrics has been revolutionised over the number of decades. The utopian objective of obstetrics is that every pregnancy should culminate in a healthy mother in possession of a healthy baby. The obstetrician of today considers pregnant woman as two patients, not only the mother but her fetus too. When Ballantyne in 1901 published his plea for a promaternity hospital, antenatal care had its begining. This now has been established as a branch of therapeutic and preventive medi-
cine throughout the world. The present concept of antenatal care goes beyond the medical supervision, including the education of girls and women to understand the potential benefits of antenatal care, and the provision of dietary and social conditions. conducive to health so that when a woman becomes pregnant she is already prepared physically, and psychologically to undergo medical care from the very early stage of pregnancy.
Observations and Discussion Maternal mortality in the most developed nations has now been reduced to as much as 5 to 20 per 100,000 L.B., while in the develop-
, Received: Sep. 11, 1991 Reprint request t o : Dr. R. D. Pandit, Sagar Mahal, GI, 65, Walkeshwar Road, Bombay-400 006, India
1
R.D. PANDIT
Table 1. Maternal mortality rates (Year 1929-1988) at Nowrosjee Wadia Maternity Hospital, Bombay, India -~
Total No. of deliveries Total No. of maternal deaths M.M.R./100,000 L.B.
1929-39
1940-49
1950-59
1960-69
1970-79
1980-88
47,310
90,783
122,135
120,348
72,202
84,894
909
857
476
355
135
70
1,920
940
390
290
190
82
Table 2. Classification of maternal mortality rate/100,000 live birthes, N. Wadia Maternity Hospital, Bombay, India
Total M.M.R. 1. Obstetric death rate (O.D.R.) a) Direct Obst. death rate b) Indirect Obst. death rate 2. Non-Obst. death rate
1929-39
1940-49
1950-59
1960-69
1970-79
1980-88
(%)
(%)
(%)
(%I
(%I
(%)
1,920 940 390 290 190 82 1,360(70.82) 780 (82.98) 350 (89.75) 270 (93.10) 180 (94.73) 70 (85.30) 670 (49.25) 400 (51.14) 200 (57.14) 170 (62.97) 130 (72.22) 41 (58.50) 690 (50.75) 380 (48.72) 150 (42.86) 100 (37.03) 50 (27.78) 29 (41.50) 560 (29.18) 160 (17.02) 40 (10.25)
ing countries it still ranges from even 50 to 2,000 per 100,000 L.B. (WHO, 1985).') The main reason for such high rate of maternal mortality is due to poor socioeconomic status, illiteracy, ignorance, and apathy. Table 1 shows the maternal mortality rates at Nowrosjee Wadia Maternity Hospital, Bombay, India, from 1929 to 1988 in the indepth study of maternal mortality carried out by me. This reveals that the maternal mortality rate which was 1920 per 100,000 live births during 1929-1939 period has declined to 82 per 100,000 live births during 1980-1988 period. Table 2 reveals the obstetric death rate, direct obstetric death rate, indirect obstetric death rate, and non-obstetric death rate from 1929-1988 period at N. Wadia Maternity Hospital, Bombay. There is a gradual decline in all these death rates. The direct obstetric death rate which was 670 per 100,000 L.B. during 1929-1939 period, was reduced to 41 per 100,000 L.B. during 1980-1988 period, and the indirect obstetric death rate which was 690 per 100,000 L.B. during 1929-1939 period has come down to 29 per 100,000 L.B. during 1980-1988 period, a very substantial reduc2
20 ( 6.90)
10 ( 5.27) 12 (14.70)
tion. This achievement in reduction of maternal mortality over the decades was due to multiple factors like increased and effective antenatal, intranatal and postnatal care, various new biochemical and biophysical methods of investigations, newer diagnostic and therapeutic measures and effective management of labour. Table 3 shows that about 52% of the births are attended by trained personnel in the developing countries as compared to 99% in the developed countries (WHO, 1989).2) The percentage of prenatal care differs from continent to continent, and may even differ from country to country in the same continent (WHO, 1989).a) Table 4 shows that at N. Wadia Maternity Hospital, Bombay, India, during the period January 1981-December 1983, 5%, 69.7%, and 25.3% patients registered during the first, second and the third trimester of pregnancy respectively. While during the January 1987 to December 1988 period, 6.1%, 64.7% and 29.2% patients registered during the first, second and the thivl trimester of pregnancy respectively.
ANTENATAL CARE I N RBDUCINC MATERNAL MORTALITY
Table 3. Estimate of Coverage of Maternity Care (W.H.O. 1989)*). Current estimates compared to those made in 1985 Percent of births with trained attendant
Region or area
Current Previous estimate estimate World Developed countries Developing countries Africa Northern Africa Eastern Africa Middle Africa Western Africa Southern Africa Asia* Southern Asia Western Asia East Asia* Latin America Middle America Caribbean Tropical S. America Temperate S. America Oceania*
58 99 52 38 30 37 22 38 64 49 25 63 94
86 80
78 73 93 42
55 98 48 34 31 29 29 36 65 49 20 61 93 64 51 58 69 89 34
* Japan, Australia and New Zealand have been excluded from the regional estimates, but, are included in the total for developed countries. No data are available for USSR. Table 4. Period of gestation at first booking in Antenatal Department at N. Wadia Maternity Hospital, Bombay, India -
Third First Second trimester trimester trimester
(%I
(%I
5%
69.7%
25.3%
6.1%
64.7%
29.2%
(%I
January 1981 to December 1983 January 1987 to December 1988
Such is the condition existing in public hospitals in metropolitan city like Bombay, India, where medical facilities are available even free of charge, hardly at a distance, of about a kilometer from the patient’s residence. It is probably the general illiteracy, and especially the female illiteracy which is the root cause, as community does not recognise the benefits
which can accrue by regular antenatal visits right from the first trimester of pregnancy. Majority of patients have the notion that to obtain the antenatal card after registration is the passport for admission to hospital at any time, and hence they register themselves late during pregnancy. This notion has to be completely dispelled by proper education. It is amply evident from Table 5 that at N. Wadia Maternity Hospital there has been considerable decline in maternal mortality in booked cases. In the period 1929-1939, there were 109 maternal deaths in booked cases comprising of 11.99% while during the said period 800 maternal deaths occurred in unbooked cases comprising of 88.01%. During the periods 1970-1979 and 1980-1988, maternal deaths amongst booked cases were 43 and 29 respectively comprising of 31.85% and 41.Myo respectively. While in unbooked cases during the periods 1970-1979 and 1980-1988, maternal deaths were 92 and 41 respectively comprising of 68.14% and 58.60% respectively. Table 6 shows the relation of antenatal visits and Medical/Surgical and obstetric complications amongst booked and emergency cases, at N. Wadia Maternity Hospital, Bombay, from January 1981 to December 1983. It is interesting to note that amongst the booked patients 36.2% had less than 3 antenatal visits and 63.8% had more than 3 antenatal visits. I n this group 0.41% had medical or surgical complications, while 1.67% had obstetric complications. Amongst the emergency (unbooked) patients 1.29% had medical or surgical complications and 4.49% had obstetric complications, which is a very significant finding. Table 7 reveals the incidence of normal deliveries and operative deliveries amongst booked and emergency cases, at N. Wadia Maternity Hospital from January 1981-December 1988. It will be seen that amongst the booked group 87.3% had normal deliveries and 12.7% operative deliveries while in emergency group, 89.9% had normal deliveries and 10.1% had operative deliveries. The incidence of destructive operations, and caeserean hysterectomy is
3
R. D. PANDIT
Table 5. Maternal deaths related to booked and emergency cases at N. Wadia Maternity Hospital, Bombay, India Years
Total No. of maternal deaths
1929-39 1940-49 1950-59 1960-69 1970-79 1980-88
909 857 476 355 135 70
Booked
%
Unbooked
%
109
-
11.99
-
800
-
88.01
80 88 43 29
16.91 24.78 31.85 41.40
396 267 92 41
83.09 75.22 68.14 58.60
-
Table 6. Relation of antenatal visits and medical/surgical and obstetric complications amongst booked and emergency cases. N. Wadia Maternity Hospital, Bombay, India, January 1981 to December 1983
- ---- Nn - .-.
Tn+nl
Nature of antenatal care A. Booked
24,053
B. Emergency (Unbooked)
No. of antenatal visits
of deliveries
2,156
3
8,707 (36.2%)
15,346 (63.8%)
-
-
Complications Medical or surgical 98 (0.41%) 28 (1.29%)
Obstetric 401 (1.67%) 97 (4.49%)
Table 7. Incidence of normal deliveries and operative deliveries amongst booked and unbooked (emergency) cases. N. Wadia Maternity Hospital, Bombay, India, January-1981-December-1988 Operative deliveries Nature of antenatal care A. Booked B. Emergency (Unhooked)
Total No. of deliveries deliveries
71,538 (93.9%) 4,633 (06.1%)
62,458 (87.3%) 4,184 (89.9%)
Total 9,080 (12.7%) 469 (10.1%)
much higher in emergency group. Table 8 shows the major admission diagnosis of patients admitted in antenatal ward between January 1981 to December 1983 and January 1987 to December 1988 at N. Wadia Maternity Hospital, Bombay. Patients admitted for obstetric complications comprised of 26.62% and 25.1% with hypertensive disorder, 4.42% and 6.9% for incompetent OS, 3.44% and 4.5% for premature onset oflabour, 3.28% and2.5% for I.U.G.R., 2.13% and 1.1% for decreased or absent fetal movements, 2.78% and 3.3% for postdatism, 1.46% and 1.9% for third trimester bleeding, 4
!:touse TFor:
caeCae. serean hysteresection ctomy
3,699 (5.2%) 179 (3.7%)
5,317 (7.4%) 259 (5.5%)
12 (0.02%) 19 (0.4%)
DestrucI.P.V.
ogations
46 (0.06%) 7 (0.2%)
6 (0.01%) 15 (0.3%)
2.62% and 2.60% for elective caeserean section. The other conditions comprised of diabetes mellitus, threatened abortion, leaking P.v., I.U.F.D., abnormal presentations, hydrocephalus, RH negative for observation and investigations, anaemia comprised 22.62% and 19.8% cases, oedema in 2.62% and 2.3%, heart disease in 2.45% and 2.9%. Other medical conditions comprised of rheumatoid arthritis, epilepsy, convulsions and abdominal pain, fever due to urinary tract infection, upper respiratory tract infection and Malaria. These figures itself reveal how the patients
ANTENATAL CARE I N REDUCING MATERNAL MORTALITY
Table 8. Major admission diagnosis of patients admitted in antenatal wards N. Wadia Maternity Hospital, Bombay, India Jan. 1981 to Dec. 1983
I. Admission diagnosis 1. Hypertensive disorder 2. Threatened abortion 3. Incompetent 0 s 4. Premature onset of labour 5. Leaking P.V. (PROM) 6. I.U.G.R. 7. Decreased or absent fetal movements 8. I.U. fetal death 9. Abnormal presentation 10. Postdatism 11. Third trimester bleeding 12. Elective L.S.C.S. 13. Hydrocephalus 14. Rh negative for observation 15. Unmarried primi 16. B.O.H. 17. Multiple gestation 18. Hyperemesis gravidarum 19. Malformations 11. Medical etc. 1. Qedema 2. Anaemia 3. Heart disease 4. Rheumatoid arthritis 5. Epilepsy/convulsions 6. Abdominal pain (including degeneration of fibroid) 7. Fever (URTI, UTI, Malaria) 8. Bronchial asthama 9. Abnormal glucose tolerance 10. Koch's 111. For observation or investigation IV. Patients delivered during stay V. Patients delivered after discharge
are being followed up in antenatal clinics and are admitted for various ailments. This not only helps in requisite and adequate treatment, but also results in lesser maternal mortality and morbidity as well as lesser perinatal mortality and morbidity. The 1,125 patients (20.49%) were admitted for observation and or investigation. The 1,422 patients (25.90%) delivered during stay in antenatal ward, while 4,068 (74.10%) patients delivered after their discharge.
Jan. 1987 to Dec. 1988
No.
%
No.
%
1,467 54 27 1 211 21 180 117 27 45 153
26.72 0.98 4.42
1,329 56 366 240 39 130 58 26
25.1 1.1 6.9 4.5 0.7 2.5 1.1 0.5
173 101 138
3.3 1.9 2.6
42 13 189 29 20 10
0.8 0.2 3.6 0.7 0.4 0.2
121 1,017 152
2.3 19.8 2.9
10 17
0.2 0.3
61 25 10 6 926 1,716
1.2 0.5 0.2 0.1 17.4 32.4
3.44
134 9 36 9
0.32 3.28 2.13 0.49 0.82 2.78 1.46 2.62 0.16 0.64 0.16
136 1,242 135 9 9 36
2.62 22.62 2.45 0.16 0.16 0.64
90
-
-
-
9
0.16
1,125 1,422 4,068
20.49 25.90 74.10
-
-
-
-
-
-
-
-
Thus we have seen-how antenatal care has been responsible for reduction of maternal mortality in N. Wadia Maternity Hospital, Bombay, India. Besides the care that is taken by the medical personnel, it is also important to realise about the care that is imparted by midwives, paramedical personnel, health visitors, and social workers, who are also part and parcel of the whole team. . In most of developing countries the urban 5
R.D. PANDIT
population comprises of about 25% while the rural population comprises of about 75%. But the medical personnel comprise of about 75% in urban area, and only 25% in rural areas. Attempts are being made in developing countries to establish primary Health Centres, subcentres, Maternity and Child Welfare Centres along with Family Planning Centres, with attached under 5 clinics in many parts of the country. But there is lack of medical and nursing personnel to man these centres especially in rural areas. I n such circumstances it would be advisable to delegate responsibility to trained midwives to screen the patients in the antenatal department in rural as well as some overcrowded urban clinics. The doctors can then periodically check up all antenatal patients and concentrate more on abnormal cases. Patients requiring specialised investigations should be referred to fullfledged nearest Maternity and Child Welfare Centre, or district hospital, or if necessary transferred to teaching hospital and they should have close liaison amongst them. There should be physician and surgeon attached to the antenatal clinics to check up medical or surgical disorders. The health team comprising of obstetrician and gynaecologist, paediatrician, and doctor from department of preventive and social medicine, medical students both undergraduate and postgraduate, interns, nursing and paramedical personnel should regularly visit the primary health centre as well as maternity and child welfare centre. The medical student of today has to be taught and oriented to the concept of social obstetrics. Community should be made aware of the benefits of antenatal care by home visits by health visitors, also giving them fundamentals
6
of health education, hygienic measures, proper dietetic advice, removal of notions regarding superstitions, and ingraining in them the benefits of institutional deliveries. In the rural areas, still the traditional birth attendant also plays an important role. It would be better not to discard the T.B.A., but to utilise their services by giving them proper orientation in fundamentals of antenatal care and conducting normal delivery, and giving them sterile delivery kits to reduce the complication. I would like to suggest the idea of mobile antenatal clinic van, manned by obstetrician, midwife, health visitor, and social worker and pathology technician visiting periodically the rural areas as well as slum areas in cities, not only to check up pregnant women but also encouraging them to deliver in hospital. By this way they gain confidence in the team of doctors who come for antenatal check-ups, and we thus give health services at the doorstep of the community. This I think is the only way in the developing countries to give maximum benefits of antenatal care and the hospital deliveries to pregnant women.
Acknowledgement I thank the Dean, N. Wadia, Maternity Hospital, Bombay, India, for allowing me to use the hospital data. References 1. Maternal Mortality Rates-FHE/85.2 W.H.O. 1985 2. Coverage of Maternity Care-WHO/FHE/89.2 W.H.O. 1989
Role of Antenatal Care in Reducing Maternal Mortality
Ramesh D. Pandit Department of Obstetrics and Gynaecology,Nowrosjee Wadia Maternity Hospital, G. S. Medical College, Bombay, India
Abstract Maternal mortality in the developed nations has been considerably reduced, but it still is very high in developing nations. I carried out an indepth study of maternal mortality at N. Wadia Maternity Hospital, Bombay. India, from 1929 to 1988, which revealed that the MMR which was 1920 per 100,000 live births during 1929-1939 period has declined to 82 per 100,000 live births during 1980-1988 period. This achievement in reduction of maternal mortality over the decades was due to multiple factors like increased and effective antenatal, intranatal, and postnatal care. This study shows the apathy of pregnant women to come forward to avail of antenatal care though available even free of charge nearby. To give maximum benefits to pregnant women specially in the developing nations, we have to carry the antenatal care at the doorsteps of the community.
Key words: antenatal care, reduced maternal mortality Introduction Antenatal care is the strategy and intranatal care is the tactics to reduce the maternal mortality and morbidity. The practice of obstetrics has been revolutionised over the number of decades. The utopian objective of obstetrics is that every pregnancy should culminate in a healthy mother in possession of a healthy baby. The obstetrician of today considers pregnant woman as two patients, not only the mother but her fetus too. When Ballantyne in 1901 published his plea for a promaternity hospital, antenatal care had its begining. This now has been established as a branch of therapeutic and preventive medi-
cine throughout the world. The present concept of antenatal care goes beyond the medical supervision, including the education of girls and women to understand the potential benefits of antenatal care, and the provision of dietary and social conditions. conducive to health so that when a woman becomes pregnant she is already prepared physically, and psychologically to undergo medical care from the very early stage of pregnancy.
Observations and Discussion Maternal mortality in the most developed nations has now been reduced to as much as 5 to 20 per 100,000 L.B., while in the develop-
, Received: Sep. 11, 1991 Reprint request t o : Dr. R. D. Pandit, Sagar Mahal, GI, 65, Walkeshwar Road, Bombay-400 006, India
1
R.D. PANDIT
Table 1. Maternal mortality rates (Year 1929-1988) at Nowrosjee Wadia Maternity Hospital, Bombay, India -~
Total No. of deliveries Total No. of maternal deaths M.M.R./100,000 L.B.
1929-39
1940-49
1950-59
1960-69
1970-79
1980-88
47,310
90,783
122,135
120,348
72,202
84,894
909
857
476
355
135
70
1,920
940
390
290
190
82
Table 2. Classification of maternal mortality rate/100,000 live birthes, N. Wadia Maternity Hospital, Bombay, India
Total M.M.R. 1. Obstetric death rate (O.D.R.) a) Direct Obst. death rate b) Indirect Obst. death rate 2. Non-Obst. death rate
1929-39
1940-49
1950-59
1960-69
1970-79
1980-88
(%)
(%)
(%)
(%I
(%I
(%)
1,920 940 390 290 190 82 1,360(70.82) 780 (82.98) 350 (89.75) 270 (93.10) 180 (94.73) 70 (85.30) 670 (49.25) 400 (51.14) 200 (57.14) 170 (62.97) 130 (72.22) 41 (58.50) 690 (50.75) 380 (48.72) 150 (42.86) 100 (37.03) 50 (27.78) 29 (41.50) 560 (29.18) 160 (17.02) 40 (10.25)
ing countries it still ranges from even 50 to 2,000 per 100,000 L.B. (WHO, 1985).') The main reason for such high rate of maternal mortality is due to poor socioeconomic status, illiteracy, ignorance, and apathy. Table 1 shows the maternal mortality rates at Nowrosjee Wadia Maternity Hospital, Bombay, India, from 1929 to 1988 in the indepth study of maternal mortality carried out by me. This reveals that the maternal mortality rate which was 1920 per 100,000 live births during 1929-1939 period has declined to 82 per 100,000 live births during 1980-1988 period. Table 2 reveals the obstetric death rate, direct obstetric death rate, indirect obstetric death rate, and non-obstetric death rate from 1929-1988 period at N. Wadia Maternity Hospital, Bombay. There is a gradual decline in all these death rates. The direct obstetric death rate which was 670 per 100,000 L.B. during 1929-1939 period, was reduced to 41 per 100,000 L.B. during 1980-1988 period, and the indirect obstetric death rate which was 690 per 100,000 L.B. during 1929-1939 period has come down to 29 per 100,000 L.B. during 1980-1988 period, a very substantial reduc2
20 ( 6.90)
10 ( 5.27) 12 (14.70)
tion. This achievement in reduction of maternal mortality over the decades was due to multiple factors like increased and effective antenatal, intranatal and postnatal care, various new biochemical and biophysical methods of investigations, newer diagnostic and therapeutic measures and effective management of labour. Table 3 shows that about 52% of the births are attended by trained personnel in the developing countries as compared to 99% in the developed countries (WHO, 1989).2) The percentage of prenatal care differs from continent to continent, and may even differ from country to country in the same continent (WHO, 1989).a) Table 4 shows that at N. Wadia Maternity Hospital, Bombay, India, during the period January 1981-December 1983, 5%, 69.7%, and 25.3% patients registered during the first, second and the third trimester of pregnancy respectively. While during the January 1987 to December 1988 period, 6.1%, 64.7% and 29.2% patients registered during the first, second and the thivl trimester of pregnancy respectively.
ANTENATAL CARE I N RBDUCINC MATERNAL MORTALITY
Table 3. Estimate of Coverage of Maternity Care (W.H.O. 1989)*). Current estimates compared to those made in 1985 Percent of births with trained attendant
Region or area
Current Previous estimate estimate World Developed countries Developing countries Africa Northern Africa Eastern Africa Middle Africa Western Africa Southern Africa Asia* Southern Asia Western Asia East Asia* Latin America Middle America Caribbean Tropical S. America Temperate S. America Oceania*
58 99 52 38 30 37 22 38 64 49 25 63 94
86 80
78 73 93 42
55 98 48 34 31 29 29 36 65 49 20 61 93 64 51 58 69 89 34
* Japan, Australia and New Zealand have been excluded from the regional estimates, but, are included in the total for developed countries. No data are available for USSR. Table 4. Period of gestation at first booking in Antenatal Department at N. Wadia Maternity Hospital, Bombay, India -
Third First Second trimester trimester trimester
(%I
(%I
5%
69.7%
25.3%
6.1%
64.7%
29.2%
(%I
January 1981 to December 1983 January 1987 to December 1988
Such is the condition existing in public hospitals in metropolitan city like Bombay, India, where medical facilities are available even free of charge, hardly at a distance, of about a kilometer from the patient’s residence. It is probably the general illiteracy, and especially the female illiteracy which is the root cause, as community does not recognise the benefits
which can accrue by regular antenatal visits right from the first trimester of pregnancy. Majority of patients have the notion that to obtain the antenatal card after registration is the passport for admission to hospital at any time, and hence they register themselves late during pregnancy. This notion has to be completely dispelled by proper education. It is amply evident from Table 5 that at N. Wadia Maternity Hospital there has been considerable decline in maternal mortality in booked cases. In the period 1929-1939, there were 109 maternal deaths in booked cases comprising of 11.99% while during the said period 800 maternal deaths occurred in unbooked cases comprising of 88.01%. During the periods 1970-1979 and 1980-1988, maternal deaths amongst booked cases were 43 and 29 respectively comprising of 31.85% and 41.Myo respectively. While in unbooked cases during the periods 1970-1979 and 1980-1988, maternal deaths were 92 and 41 respectively comprising of 68.14% and 58.60% respectively. Table 6 shows the relation of antenatal visits and Medical/Surgical and obstetric complications amongst booked and emergency cases, at N. Wadia Maternity Hospital, Bombay, from January 1981 to December 1983. It is interesting to note that amongst the booked patients 36.2% had less than 3 antenatal visits and 63.8% had more than 3 antenatal visits. I n this group 0.41% had medical or surgical complications, while 1.67% had obstetric complications. Amongst the emergency (unbooked) patients 1.29% had medical or surgical complications and 4.49% had obstetric complications, which is a very significant finding. Table 7 reveals the incidence of normal deliveries and operative deliveries amongst booked and emergency cases, at N. Wadia Maternity Hospital from January 1981-December 1988. It will be seen that amongst the booked group 87.3% had normal deliveries and 12.7% operative deliveries while in emergency group, 89.9% had normal deliveries and 10.1% had operative deliveries. The incidence of destructive operations, and caeserean hysterectomy is
3
R. D. PANDIT
Table 5. Maternal deaths related to booked and emergency cases at N. Wadia Maternity Hospital, Bombay, India Years
Total No. of maternal deaths
1929-39 1940-49 1950-59 1960-69 1970-79 1980-88
909 857 476 355 135 70
Booked
%
Unbooked
%
109
-
11.99
-
800
-
88.01
80 88 43 29
16.91 24.78 31.85 41.40
396 267 92 41
83.09 75.22 68.14 58.60
-
Table 6. Relation of antenatal visits and medical/surgical and obstetric complications amongst booked and emergency cases. N. Wadia Maternity Hospital, Bombay, India, January 1981 to December 1983
- ---- Nn - .-.
Tn+nl
Nature of antenatal care A. Booked
24,053
B. Emergency (Unbooked)
No. of antenatal visits
of deliveries
2,156
3
8,707 (36.2%)
15,346 (63.8%)
-
-
Complications Medical or surgical 98 (0.41%) 28 (1.29%)
Obstetric 401 (1.67%) 97 (4.49%)
Table 7. Incidence of normal deliveries and operative deliveries amongst booked and unbooked (emergency) cases. N. Wadia Maternity Hospital, Bombay, India, January-1981-December-1988 Operative deliveries Nature of antenatal care A. Booked B. Emergency (Unhooked)
Total No. of deliveries deliveries
71,538 (93.9%) 4,633 (06.1%)
62,458 (87.3%) 4,184 (89.9%)
Total 9,080 (12.7%) 469 (10.1%)
much higher in emergency group. Table 8 shows the major admission diagnosis of patients admitted in antenatal ward between January 1981 to December 1983 and January 1987 to December 1988 at N. Wadia Maternity Hospital, Bombay. Patients admitted for obstetric complications comprised of 26.62% and 25.1% with hypertensive disorder, 4.42% and 6.9% for incompetent OS, 3.44% and 4.5% for premature onset oflabour, 3.28% and2.5% for I.U.G.R., 2.13% and 1.1% for decreased or absent fetal movements, 2.78% and 3.3% for postdatism, 1.46% and 1.9% for third trimester bleeding, 4
!:touse TFor:
caeCae. serean hysteresection ctomy
3,699 (5.2%) 179 (3.7%)
5,317 (7.4%) 259 (5.5%)
12 (0.02%) 19 (0.4%)
DestrucI.P.V.
ogations
46 (0.06%) 7 (0.2%)
6 (0.01%) 15 (0.3%)
2.62% and 2.60% for elective caeserean section. The other conditions comprised of diabetes mellitus, threatened abortion, leaking P.v., I.U.F.D., abnormal presentations, hydrocephalus, RH negative for observation and investigations, anaemia comprised 22.62% and 19.8% cases, oedema in 2.62% and 2.3%, heart disease in 2.45% and 2.9%. Other medical conditions comprised of rheumatoid arthritis, epilepsy, convulsions and abdominal pain, fever due to urinary tract infection, upper respiratory tract infection and Malaria. These figures itself reveal how the patients
ANTENATAL CARE I N REDUCING MATERNAL MORTALITY
Table 8. Major admission diagnosis of patients admitted in antenatal wards N. Wadia Maternity Hospital, Bombay, India Jan. 1981 to Dec. 1983
I. Admission diagnosis 1. Hypertensive disorder 2. Threatened abortion 3. Incompetent 0 s 4. Premature onset of labour 5. Leaking P.V. (PROM) 6. I.U.G.R. 7. Decreased or absent fetal movements 8. I.U. fetal death 9. Abnormal presentation 10. Postdatism 11. Third trimester bleeding 12. Elective L.S.C.S. 13. Hydrocephalus 14. Rh negative for observation 15. Unmarried primi 16. B.O.H. 17. Multiple gestation 18. Hyperemesis gravidarum 19. Malformations 11. Medical etc. 1. Qedema 2. Anaemia 3. Heart disease 4. Rheumatoid arthritis 5. Epilepsy/convulsions 6. Abdominal pain (including degeneration of fibroid) 7. Fever (URTI, UTI, Malaria) 8. Bronchial asthama 9. Abnormal glucose tolerance 10. Koch's 111. For observation or investigation IV. Patients delivered during stay V. Patients delivered after discharge
are being followed up in antenatal clinics and are admitted for various ailments. This not only helps in requisite and adequate treatment, but also results in lesser maternal mortality and morbidity as well as lesser perinatal mortality and morbidity. The 1,125 patients (20.49%) were admitted for observation and or investigation. The 1,422 patients (25.90%) delivered during stay in antenatal ward, while 4,068 (74.10%) patients delivered after their discharge.
Jan. 1987 to Dec. 1988
No.
%
No.
%
1,467 54 27 1 211 21 180 117 27 45 153
26.72 0.98 4.42
1,329 56 366 240 39 130 58 26
25.1 1.1 6.9 4.5 0.7 2.5 1.1 0.5
173 101 138
3.3 1.9 2.6
42 13 189 29 20 10
0.8 0.2 3.6 0.7 0.4 0.2
121 1,017 152
2.3 19.8 2.9
10 17
0.2 0.3
61 25 10 6 926 1,716
1.2 0.5 0.2 0.1 17.4 32.4
3.44
134 9 36 9
0.32 3.28 2.13 0.49 0.82 2.78 1.46 2.62 0.16 0.64 0.16
136 1,242 135 9 9 36
2.62 22.62 2.45 0.16 0.16 0.64
90
-
-
-
9
0.16
1,125 1,422 4,068
20.49 25.90 74.10
-
-
-
-
-
-
-
-
Thus we have seen-how antenatal care has been responsible for reduction of maternal mortality in N. Wadia Maternity Hospital, Bombay, India. Besides the care that is taken by the medical personnel, it is also important to realise about the care that is imparted by midwives, paramedical personnel, health visitors, and social workers, who are also part and parcel of the whole team. . In most of developing countries the urban 5
R.D. PANDIT
population comprises of about 25% while the rural population comprises of about 75%. But the medical personnel comprise of about 75% in urban area, and only 25% in rural areas. Attempts are being made in developing countries to establish primary Health Centres, subcentres, Maternity and Child Welfare Centres along with Family Planning Centres, with attached under 5 clinics in many parts of the country. But there is lack of medical and nursing personnel to man these centres especially in rural areas. I n such circumstances it would be advisable to delegate responsibility to trained midwives to screen the patients in the antenatal department in rural as well as some overcrowded urban clinics. The doctors can then periodically check up all antenatal patients and concentrate more on abnormal cases. Patients requiring specialised investigations should be referred to fullfledged nearest Maternity and Child Welfare Centre, or district hospital, or if necessary transferred to teaching hospital and they should have close liaison amongst them. There should be physician and surgeon attached to the antenatal clinics to check up medical or surgical disorders. The health team comprising of obstetrician and gynaecologist, paediatrician, and doctor from department of preventive and social medicine, medical students both undergraduate and postgraduate, interns, nursing and paramedical personnel should regularly visit the primary health centre as well as maternity and child welfare centre. The medical student of today has to be taught and oriented to the concept of social obstetrics. Community should be made aware of the benefits of antenatal care by home visits by health visitors, also giving them fundamentals
6
of health education, hygienic measures, proper dietetic advice, removal of notions regarding superstitions, and ingraining in them the benefits of institutional deliveries. In the rural areas, still the traditional birth attendant also plays an important role. It would be better not to discard the T.B.A., but to utilise their services by giving them proper orientation in fundamentals of antenatal care and conducting normal delivery, and giving them sterile delivery kits to reduce the complication. I would like to suggest the idea of mobile antenatal clinic van, manned by obstetrician, midwife, health visitor, and social worker and pathology technician visiting periodically the rural areas as well as slum areas in cities, not only to check up pregnant women but also encouraging them to deliver in hospital. By this way they gain confidence in the team of doctors who come for antenatal check-ups, and we thus give health services at the doorstep of the community. This I think is the only way in the developing countries to give maximum benefits of antenatal care and the hospital deliveries to pregnant women.
Acknowledgement I thank the Dean, N. Wadia, Maternity Hospital, Bombay, India, for allowing me to use the hospital data. References 1. Maternal Mortality Rates-FHE/85.2 W.H.O. 1985 2. Coverage of Maternity Care-WHO/FHE/89.2 W.H.O. 1989
