Deaths from complications of pregnancy and childbirth are still high with WHO recording 295,000 maternal deaths globally in 2017(2). At that time, global maternal mortality ratio, though decreased to 196 per 100,000 from 282 per 100,000 of 1990, didn’t reach the agreed target of 75% reduction(6).
This study was conducted to identify the maternal mortality ratio and causes of maternal death in a tertiary care center of a developing country. The MMR was found to be 129.34 per 100,000 live births, which is lesser as compared to other review done in developing countries (7)(8).
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 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(8)(9)(10)(11).
An observational study conducted in a tertiary care referral center of Western Nepal found that MMR of 151 per 100,000 live births with mean age of mother being 28 years. Most of the patient had presented to the center in unstable health condition, with common cause of death being hypertension and sepsis. These findings were also comparable to our study. Most of them (73.30%) had died in postpartum period(12).
Our institute receives most of the referred complicated obstetric patients and also women can be admitted directly from home without referral. In this study almost 70% of women were referred from other health care center. Almost 30% of cases presented in state of shock at the time of admission resulting in delayed intervention and hence adverse outcome. It was similar to the findings from other studies done in developing countries(8)(13)(14).
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 (13). In our study 3 women had ruptured uterus. Among them 2 women were referred from outside after delivery in state of shock and expired during resuscitation process. Other women had ruptured uterus diagnosed during intrapartum period but we couldn’t operate on her immediately due to busy operating theater at the moment. The women who were referred from outside had difficult vaginal delivery and gave history of fundal pressure. It seems that use of fundal pressure during vaginal delivery is still being practiced in peripheral setup.
Another study conducted in India, they 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 present unlike the finding in our study where hypertensive disorder of pregnancy was the most common comorbidity. Almost 93% of death had occurred in postpartum period and 94.6 % of women were referred from another center(8).
Overall, high MMR was found in various studies which were conducted in referral center in developing countries, which reported MMR of 426 per 100,000 live births and 1513.4 per 100,000 live births(15). Comparable to several studies, most of the death (77.50%) had occurred in women of 20–34 years of age(8)(9)(11)(16). Mean gestational age at death is 36.15 ± 4.38 weeks in our study which is similar to other study(11).
In three delay model of maternal mortality, delay I (40.84%) was seen in maximum death followed by delay II in our study. Most of these cases were related to late referral from other health center. This calls for strengthening the capacity of health care worker in early recognition of danger signs and referral to appropriate center 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 center 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.