|Year : 2014 | Volume
| Issue : 1 | Page : 35-37
Maternal mortality in Andaman and Nicobar group of islands: 10 years retrospective study
Indu Chawla1, Mrinmoy Kumar Saha2, Anis Akhtarkharvi3
1 Department of Obstetrics and Gynaecology, Senior Gynaecologist, Central Health Service, Ministry of Health and Family Welfare, Ram Manohar Lohia Hospital, New Delhi, India
2 Department of Obstetrics and Gynaecology, Consultant Gynaecologist, Govind Ballabh Pant Hospital, Port Blair, Andaman and Nicobar Islands, India
3 Department of Obstetrics and Gynaecology, Medical Officer, Govind Ballabh Pant Hospital, Port Blair, Andaman and Nicobar Islands, India
|Date of Submission||16-May-2013|
|Date of Acceptance||23-Nov-2013|
|Date of Web Publication||4-Feb-2014|
J-5/169, Rajouri Garden, New Delhi - 110 027
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Maternal mortality ratio (MMR) is an indicator of effectiveness of health care facilities for women of child bearing age group. Andaman and Nicobar (A&N) group of islands are unique as they are situated 1200 km from the mainland India. Healthcare delivery for the these islands is exclusively provided and controlled by only one authority, Directorate of Health Services, A&N Islands. GB Pant Hospital, Port Blair is the only referral hospital with round the clock specialists and surgical services. Aims: To estimate the MMR in A&N islands from 2001 to 2010, and study the causes of maternal mortality. Settings and Design: Retrospective. Materials and Methods: Data for the estimation of MMR were collected from office of Registrar of Births and Deaths, Hospital and Peripheral Health Centres. Case records of maternal deaths in GB Pant Hospital were reviewed to study the causes of death. Statistical analysis used: Proportions and Ratios. Results: Ten years average MMR for the entire island was 85.42. Analysis of 30 maternal deaths in GB Pant Hospital showed that 63.3% were due to direct obstetric causes (eclampsia 30%, hemorrhage 23.33%, sepsis 6.66%, and 3.33% amniotic fluid embolism). Of the indirect causes, anemia was the commonest (16.66%). Conclusions: The MMR of A&N islands is much lower than the national average of 250. Direct obstetric causes accounted for more than half of maternal deaths 63.33%.
Keywords: Maternal health, MMR, obstetrics deaths
|How to cite this article:|
Chawla I, Saha MK, Akhtarkharvi A. Maternal mortality in Andaman and Nicobar group of islands: 10 years retrospective study. Indian J Community Med 2014;39:35-7
|How to cite this URL:|
Chawla I, Saha MK, Akhtarkharvi A. Maternal mortality in Andaman and Nicobar group of islands: 10 years retrospective study. Indian J Community Med [serial online] 2014 [cited 2020 Feb 25];39:35-7. Available from: http://www.ijcm.org.in/text.asp?2014/39/1/35/126356
| Introduction|| |
World Health Organization WHO estimates that globally 358,000 women die every year due to pregnancy-related complications and India is home to one fourth of these maternal deaths.  The Millennium Development Goals(MDG) of the United Nations has set the target of achieving 109 maternal deaths per lakh of live births by 2015.  Maternal mortality ratio MMR in India, though far from the target, has declined from 254 in 2004-2006 to 212 in 2007-2009. In some of the North Indian states, Uttar Pradesh and Rajasthan MMR are still very high, that is, 359 and 318, respectively. 
Maternal mortality is an index of effectiveness of health care services prevailing in a place. Andaman and Nicobar islands are group of islands situated in Bay of Bengal more than 1000 km away from mainland India with an estimated population of 3.81 lakhs, of which 62.3% is rural. Overall, literacy rate is 86.6% and female literacy is 74.71. Per capita income is Rs. 74340 per annum. 
Healthcare delivery for these islands is exclusively controlled by Directorate of Health Services(DHS), Andaman and Nicobar (A&N) islands and is provided free of cost. The referral hospital 473 bedded with round the clock availability of surgeons, obstetricians, anaesthetists, operation room facilities, and blood bank is situated in Port Blair. There are 2 district hospitals, 5 urban health centers, 4 community health centres, 20 primary health centers, and 115 subsidiary health centers situated across the island. Antenatal coverage in these islands primarily carried byAuxiliary nurse midwifes (ANMs) is 98%as per data collected by management information system, National Rural Health Mission, for monthly submission to Ministry of health and family welfare. As per the above data, institutional delivery rate is 88%. Evacuation of patients by sea plane, helicopter, ferry boat, and ambulance services is very efficiently provided by A&N administration free of cost. The present study was undertaken to estimate the MMR in A&N islands and to analyze the causes of maternal deaths in GB Pant hospital over a period of 10 years from 2001 to 2010.
| Materials and Methods|| |
This descriptive study included maternal deaths which occurred anywhere in A&N islands during the study period of 10years from year 2001 to 2010. Maternal death was defined as death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.  Data were collected from the office of Registrar of Births and Deaths A&N islands,  hospital, peripheral health centres, and NRHM office Port Blair. Details of maternal deaths which occurred in GB Pant Hospital, Port Blair were taken from the case records kept in the medical record section of the hospital. Data thus collected were analyzed.
| Results|| |
Between Jan 2001 and Dec 2010, there were total 60870 live births and 52 maternal deaths making the overall MMR 85.42 for the entire island territory. Year-wise distribution of live births, maternal deaths, and MMR is shown in [Table 1]. Exact number of home deliveries in previous 10 years and data on exact cause of maternal deaths from peripheral institutions were not available for analysis. Hence, analysis in this study has been done based on all those maternal deaths (30) that took place in G B Pant Hospital in last ten years (2001-2010).
|Table 1: Year-wise distribution of births and maternal deaths in Andaman and Nicobar Islands*|
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Primigravida constituted the largest group (40%). A total of 60% of maternal deaths (n = 18) took place during postpartum period, whereas 30% deaths occurred in the antenatal patients. Two patients died during delivery and one died due to septicaemia following abortion. Out of 18 postpartum maternal deaths 72.22% (n = 13) were following vaginal delivery and 27.78% (n = 5) following LSCS (Lower segment caesarean section). More than 60% patients died within 48 h of admission.
Among direct causes, death due to eclampsia was the leading cause being 30% (n = 9), followed by hemorrhage 23.33% (n = 7) [Table 2]. Septicaemia accounted for 6.66% (n = 2) maternal deaths and 3.33% (n = 1) died because of suspected amniotic fluid embolism. Among indirect causes 16.66% (n = 5) woman died because of severe anaemia with intractable cardiac failure and 6.66% (n = 2) because of cardiac disease. In four patients death was due to medical complications of pregnancy namely hepatitis, malaria, and leptospirosis.([Table 2])
Haemorrhage accounted for 22.33% of deaths (n = 7) and included 28.57% (2/7) of deaths by atonic postpartum haemorrhage ( PPH,) 14.29% (1/7) because of traumatic PPH following normal vaginal delivery and 57.14% (4/7) deaths because of haemorrhage following LSCS.
| Discussion|| |
Ten year MMR (2001-2010) for the entire A&N islands was found to be 85.42 (range: 94.54 in 2001 and 51.85 in 2010). This is lower than most of the states in India except Kerala MMR 81 and comparable to the MMR of Tamil Nadu and Maharashtra, 97 and 104, respectively. These are the three states in India which have realized the MDG target in 2007-2009.  At global level, WHO studies show there is much variability between countries, with MMR of 290 in developing regions as compared with14 in developed regions. 
A&N islands though more than 1000 km away from mainland India have been able to achieve MDG target. Health care system is exclusively controlled by single authority DHS; hence, there is better control and accountability. WHO recommends that all pregnant should be registered, should have minimum four antenatal visits, and all births should be attended by skilled health professionals.  In A&N islands, there is 98% registration of antenatal cases and presence of skilled health personnel at the time of delivery is more than 88% as against the national average of 52%.
In the present study, the most common cause of death was eclampsia 30%, followed by hemorrhage 23.33%. In a systematic review by WHO, hemorrhage was the leading cause of maternal death in Africa and Asia 33.9% and 30.8%, respectively.  In Latin America and the Caribbean, hypertensive disorders were the commonest cause of deaths 25.7%. In developed countries, most deaths are due to other direct causes, mainly complication of anesthesia and surgery.  In studies from India by Purandre et al.,  and Priya et al.,  hemorrhage was the leading cause of maternal mortality 35.05% and 70.83%,respectively. Hypertensive disorders of pregnancy were the major cause of maternal mortality in studies by Singh et al.,  and Paul et al.,  being, 24.01% and 32.6%, respectively. Murthy et al., reported equal contribution by hemorrhage and eclampsia (26.6% each). Overall, direct obstetrical causes accounted for 60.33% of deaths in the present study. In the present study deaths due to anemia were 20%, while in other studies from India it ranged between7% and 25.7%. 
An effective health care structure, in the form of high antenatal registration rate, presence of skilled health attendants at time of delivery, and minimum delays in referrals and transport because of clear cut guidelines by single controlling authority have all been the contributory factors to low maternal mortality in A&N islands.
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[Table 1], [Table 2]