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Maternal mortality: national versus hospital situation
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International Journal of Gynecology & Obstetrics SO Suppl. 2 (1995) 5165-S168
Maternal mortality: national versus hospital situation A.B. Bhuiyan*, F. Hussain Department of Obstetrics and Gynaecology, Dhaka Medical College Hospital, Dhaka, Bangladesh
Abstract A retrospective analysis of the cau.es of maternal mortality in two academic hospitals of Dhaka city over a 2-year period was carried out and compared with national fig. ~::.', These are the country's chief referral institutions, where only the critically ill are admitted. Currently, the national maternal mortality ratio (MMR) is 5.6/1000 live births, while in Dhaka Medical College Hospital the case fatality ratios (CFR) were 24.4 and 17.2 in 1992 and 1993, respectively. In Mitford Hospital the CFR was 11.1 and 5.4/1000 live births, during the same periods. The most common cause of maternal death at the national level was postpartum hemorrhage and at medical college hospitals it was eclampsia. If we can strengthen emergency obstetric care at all levels, we can reduce maternal mortality both at the national level and at the referral hospitals.
Keywords: Maternal mortality; National and hospitalleveJ; Variation in causes; Bangladesh
Maternal mortality, the death of a woman from complications of pregnancy, childbirth or abortion was considered a natural part of a woman's life until the 20th century. Since then, although the industrialized world has actively challenged this fatalistic concept and sought ways to reduce maternal deaths, the figure rer ':os high in developing countries. Clearly one ...;; the most densely populated countries on earth, Bangladesh, where about 755 people live in one square kilometer, has a fertility rate of 4.8 and a contraceptive prevalence rate (CPR) of 45%. Only 37% of its people are literate, and their per capita income is U8$220 [IJ. The maternal mortality ratio (MMR) is 5.6/ 1000 live births [2J. The aim of this study was to
* Corresponding author. Department of Obstetrics and Gynaecology, Dhaka Medical College Hosp'tal, Dhaka, Bangladesh.
compare the maternal health care delivery system with that of the global situation and evaluate the variation in the level and causes of maternal mortality between medical college hospitals and the national level. 1. Materia~s and methods
This study includes women who died of pregnancy related causes between January 1992 and December 1993 in the obstetric departments of Dhaka Medical College Hospital and Mitford Hospital. Data were collected from their statistics. The total number of obstetric patients admitted (delivered and undelivered) in 1992 and 1993 in the Dhaka Medical College Hospital were 7305 and 8500, respectively. In Mitford Hospital the figures were 4297 and 5304. All maternal deaths in 1992 and 1993 in the Dhaka Medical College
0020-7292/95/$09.50 © 1995 International Federation of Gynecology and Obstetrics SSDI 0020-7292(95)02505-7
Sl66
A.B. Bhuiyan, F. Hussain / In/emotional Journal of GYII(!l'oiogy & Obstetrics 50 Suppl. 2 (1995) S/65-SJ68
Hospital amounted to 171 and 134, respectively, and in Mitford Hospital they were 45 and 26. Dhaka city has a population of some 7 million. Dhaka Medical College Hospital (DMCH). which receives referrals, is in the new town; approaches from adjoining districts are easy, therefore it caters to the complicated cases coming from distant places. On the other hand. Mitford Hospital, situated in the old town. is not easily approached by district people; it caters to urban residents more than to patients Jiving at a distance. Since both institutions are associated with a medical college, the level of care is more or less the same except that DMCH, with an intensive care unit for eclampsia patients, draws such referred cases from a larger area. Because there is no national death registry, maternal mortality is not estimated at that level. Various nongovernmental organizations (NGOs) and maternal and child health programs periodically calculate the maternal mortality on a population sample and program basis [3,4]. The Matlab population-based project in Bangladesh is the largest and most intensively studied of its kind in the developing world. They estimate the MMR as 5.6/1000 live births and this is generally accepted as the national level [2]. 2. Results The case fatality ratio (CFR) in Dhaka Medical College Hospital for 1992 and 1993 was 24.4 and 17.2/1000 live births, respectively, while in Mitford Hospital the figures were 11.1 and 5.4. The MMR at national level is estimated at 5.6/1000 live birth(s) or about 28 000 maternal deaths nationally each year [2]. Globally, this reaches the shocking figure of half a million women. In industrialized areas, MMR constitutes only 1% of this total loss; in developing countries, it is 99%, with the South Asia Region itself accounting for 44% [5]. The share of Bangladesh in these calculations is indeed great. with the highest maternal mortality '; in the world, losing one in I7 women as a result or problems associated with childbirth. As a context for this situation, it is interesting to note that Bangladesh shares only 1/3000 of the earth's sur-
Table 1 Maternity care in urban and rural areas of Bangladesh by attendant and place of delivery
Attended by trained person untrained person others Place of delivery health center home
National'%
Urban 'Yo
Rural 'JIll
1003 4803 41.6
37.2 32.2 30.7
703 50.1 42.8
4.4 95.3
25.8 74.1
2.0 97.7
face, but has a density of ]/46 of the world's population. Table I shows the status of maternity care in Bangladesh. Globally, maternal mortality is decreased by institutionalized delivery, and by trained personnel. In Bangladesh, only 10% of deliveries are conducted in this way, in contrast to more affluent countries where 99% of deliveries are attended by well trained practitioners. In Bangladesh, general health services are inadequate, with only one hospital bed per 3388 people. The physician to population ratio is I to 5000; for nurses, it is 1 to 14000 [6]. Obstetric manpower and facilities are still confined to the medica] colleges and large hospitals. Table 2 shows the health service organization in the country. The causes of maternal mortality, according to a 1993 national survey, are shown in Table 3. Postpartum hemorrhage heads the list, contributing to 26% of all deaths. Table 2 Health service organization in Bangladesh Institution
Population served, no.
Medical College Hospitals and Post graduate Institution (tertiary referral center)
132000000
District Hospital (secondary referral center) Thana Health Complex (first referral center)
1500000 200000
Union Subcenters
20000
Community level health care (wards)
4000-7000
Village level health care
1500
Source: Ref. [7].
A,B. Bhuiyan, F.
Hu.~.fl1il1 /
lmemattonal Journal of Gynecology & Obstetrics 50 Suppl. 2 (/995) S/65-SI68
Table ~ Causes of maternal death in Bangladesh, 1993 Cause
%
Postpartum hemorrhage Abortion Eclampsia Puerperal sepsis Obstructed labor Other obstetric
26 21 16 II 8 18
Table 5
Source: Ref. [8].
Table 4 shows the causes of maternal death in Dhaka Medical College Hospital and Mitford Hospital during 1992 and 1993. In both facilities eclampsia is the major cause of maternal death. The maternal mortality rate is significantly high in Bangladesh in comparison to other regions of the world. Illiteracy, poverty, a low CPR and an inadequate health care system are all considered contributory factors. The country's primary health care system is not equipped with either appropriate manpower or sufficient material resources to serve complicated obstetric cases. As a result, maternal health care cannot be properly managed. When considering the causes of maternal death, it is evident that postpartum hemorrhage is the most common at the national level, followed in frequency by abortion, eclampsia, puerperal sepsis and obstructed labor. On the other hand, in hospitals, eclampsia is the major killer of mothers, because most of the patients arrive with that complication long after the onset Table 4 Causes of maternal death in two hospitals in Dhaka Causes
Eclampsia Septicemia PPH Ruptured uterus APH Miscellaneous
Dhab Medical Colli,' .:i)h;j %,
54.4 16.4 4.7 5.3 2.3 17.0
5167
Mitford Hospital
Births
Annual no.
'x.
All At high risk Cesarean sections
3600000 540000 180000
100.0 15.0 [9] 5.0 [10]
of the first convulsion, Since our sophisticated biochemical investigations and treatment facilities are not up to the standard, we are still unable to bring about a favorable outcome. The next cause of maternal death in order of frequency in hospitals is septic abortion, which is mainly induced abortion. Death due to postpartum hemorrhage occurs less often in hospital because of blood transfusion facilities and the use of oxytocics, but also because such referrals die before reaching the hospital. There is an immense need of Emergency obstetric care (EOC) in Bangladesh, which is evident from the figures shown in Table 5. But the present situation of EOC is not at all satisfactory. At the grassroots level it is either absent or inadequate; in the district it is not properly functioning in many centers because of missing components; and in the large institutions such as the Medical College Hospital it cannot work properly because of the heavy caseload. EOC service must be upgraded to achieve the targeted goal of reducing maternal mortality from 5.6/1000 [2] Acknowledgments The authors are grateful to the authorities of Dhaka and Mitford Medical College Hospitals for permitting them to use their patients' records.
Oil)
References
i :)3
1992
1993
55.9 16.4 9.7 3.0 0.8 14.2
71.1 08,8
53.8 07.1
8.9 4.4 6.4
11.5 26.9
PPH, postpartum hemorrhage; APH. antepartum hemorrhage.
[I] Bangladesh Bureau of Statistics. Ministry of Planning, Government of the People's Republic of Bangladesh. with technical support from the United Nations Children's Fund. Progotir Pathey. Dhaka, )9~4: 1-1 S. [2] Koenig AM, Fauveau V, Chowdhury AI, Chakraborty J, Khan MA. Maternal mortality in Matlab, Bangladesh: 1976-19'85. Stud Fam Plann 1988; 19(2): 69. [3] Aluddin M. Maternal mortality in rural Bangladesh; the Tangail district. Stud Fam Plann 1986; 17(1): 13. [4] Khan AR, Jahan FA, Begum SF. Maternal mortality in
8168
A.B. Bnuiyan, F. Hussain / International Journal of Gynecology & Obstetrics 50 Suppl, 2 (1995) S165-SJ68
rural Bangladesh: the Jamalpur district. Stud Fam Plann 1986; 17: 7. [5] World Health Organization. Maternal mortality ratios and rates: a tabulation of available information. Third Edition WHO/MCH/MSM/91.6, 1991. [6] Bangladesh Bureau of Statistics. Health Information Unit, 14th edition. Dhaka: Ministry of Health and Population Control, 1993: 60S. [7] Bangladesh Ministry of Health and Family Welfare. Health Service Organization, Proceedings of the IIth Meeting of Health Ministers of the Countries of the
World Health Organization South East Asia region, Dhaka, Nov. 1-3, 1993. [8] Fauveau V, Koenig MA, Chakraborty J, Chowdhury AI. Causes of maternal mortality in rural Bangladesh, 1976- 1985. Bull World Health Organ 1988; 66(5):643. [9] Hartfield NJ. Maternal mortality in Nigeria compared with earlier international experience. Int J Gynaecol Obstet 1980; 18: 70. [10] Nordberg EM. Incidence and estimated need of caesarean section, inguinal hernia repair, and operation for strangulated hernia in rural Africa. Br Med J 1984; 289:92.
GfNDtOGf
&OB8Th1IIO
International Journal of Gynecology & Obstetrics SO Suppl. 2 (1995) 5165-S168
Maternal mortality: national versus hospital situation A.B. Bhuiyan*, F. Hussain Department of Obstetrics and Gynaecology, Dhaka Medical College Hospital, Dhaka, Bangladesh
Abstract A retrospective analysis of the cau.es of maternal mortality in two academic hospitals of Dhaka city over a 2-year period was carried out and compared with national fig. ~::.', These are the country's chief referral institutions, where only the critically ill are admitted. Currently, the national maternal mortality ratio (MMR) is 5.6/1000 live births, while in Dhaka Medical College Hospital the case fatality ratios (CFR) were 24.4 and 17.2 in 1992 and 1993, respectively. In Mitford Hospital the CFR was 11.1 and 5.4/1000 live births, during the same periods. The most common cause of maternal death at the national level was postpartum hemorrhage and at medical college hospitals it was eclampsia. If we can strengthen emergency obstetric care at all levels, we can reduce maternal mortality both at the national level and at the referral hospitals.
Keywords: Maternal mortality; National and hospitalleveJ; Variation in causes; Bangladesh
Maternal mortality, the death of a woman from complications of pregnancy, childbirth or abortion was considered a natural part of a woman's life until the 20th century. Since then, although the industrialized world has actively challenged this fatalistic concept and sought ways to reduce maternal deaths, the figure rer ':os high in developing countries. Clearly one ...;; the most densely populated countries on earth, Bangladesh, where about 755 people live in one square kilometer, has a fertility rate of 4.8 and a contraceptive prevalence rate (CPR) of 45%. Only 37% of its people are literate, and their per capita income is U8$220 [IJ. The maternal mortality ratio (MMR) is 5.6/ 1000 live births [2J. The aim of this study was to
* Corresponding author. Department of Obstetrics and Gynaecology, Dhaka Medical College Hosp'tal, Dhaka, Bangladesh.
compare the maternal health care delivery system with that of the global situation and evaluate the variation in the level and causes of maternal mortality between medical college hospitals and the national level. 1. Materia~s and methods
This study includes women who died of pregnancy related causes between January 1992 and December 1993 in the obstetric departments of Dhaka Medical College Hospital and Mitford Hospital. Data were collected from their statistics. The total number of obstetric patients admitted (delivered and undelivered) in 1992 and 1993 in the Dhaka Medical College Hospital were 7305 and 8500, respectively. In Mitford Hospital the figures were 4297 and 5304. All maternal deaths in 1992 and 1993 in the Dhaka Medical College
0020-7292/95/$09.50 © 1995 International Federation of Gynecology and Obstetrics SSDI 0020-7292(95)02505-7
Sl66
A.B. Bhuiyan, F. Hussain / In/emotional Journal of GYII(!l'oiogy & Obstetrics 50 Suppl. 2 (1995) S/65-SJ68
Hospital amounted to 171 and 134, respectively, and in Mitford Hospital they were 45 and 26. Dhaka city has a population of some 7 million. Dhaka Medical College Hospital (DMCH). which receives referrals, is in the new town; approaches from adjoining districts are easy, therefore it caters to the complicated cases coming from distant places. On the other hand. Mitford Hospital, situated in the old town. is not easily approached by district people; it caters to urban residents more than to patients Jiving at a distance. Since both institutions are associated with a medical college, the level of care is more or less the same except that DMCH, with an intensive care unit for eclampsia patients, draws such referred cases from a larger area. Because there is no national death registry, maternal mortality is not estimated at that level. Various nongovernmental organizations (NGOs) and maternal and child health programs periodically calculate the maternal mortality on a population sample and program basis [3,4]. The Matlab population-based project in Bangladesh is the largest and most intensively studied of its kind in the developing world. They estimate the MMR as 5.6/1000 live births and this is generally accepted as the national level [2]. 2. Results The case fatality ratio (CFR) in Dhaka Medical College Hospital for 1992 and 1993 was 24.4 and 17.2/1000 live births, respectively, while in Mitford Hospital the figures were 11.1 and 5.4. The MMR at national level is estimated at 5.6/1000 live birth(s) or about 28 000 maternal deaths nationally each year [2]. Globally, this reaches the shocking figure of half a million women. In industrialized areas, MMR constitutes only 1% of this total loss; in developing countries, it is 99%, with the South Asia Region itself accounting for 44% [5]. The share of Bangladesh in these calculations is indeed great. with the highest maternal mortality '; in the world, losing one in I7 women as a result or problems associated with childbirth. As a context for this situation, it is interesting to note that Bangladesh shares only 1/3000 of the earth's sur-
Table 1 Maternity care in urban and rural areas of Bangladesh by attendant and place of delivery
Attended by trained person untrained person others Place of delivery health center home
National'%
Urban 'Yo
Rural 'JIll
1003 4803 41.6
37.2 32.2 30.7
703 50.1 42.8
4.4 95.3
25.8 74.1
2.0 97.7
face, but has a density of ]/46 of the world's population. Table I shows the status of maternity care in Bangladesh. Globally, maternal mortality is decreased by institutionalized delivery, and by trained personnel. In Bangladesh, only 10% of deliveries are conducted in this way, in contrast to more affluent countries where 99% of deliveries are attended by well trained practitioners. In Bangladesh, general health services are inadequate, with only one hospital bed per 3388 people. The physician to population ratio is I to 5000; for nurses, it is 1 to 14000 [6]. Obstetric manpower and facilities are still confined to the medica] colleges and large hospitals. Table 2 shows the health service organization in the country. The causes of maternal mortality, according to a 1993 national survey, are shown in Table 3. Postpartum hemorrhage heads the list, contributing to 26% of all deaths. Table 2 Health service organization in Bangladesh Institution
Population served, no.
Medical College Hospitals and Post graduate Institution (tertiary referral center)
132000000
District Hospital (secondary referral center) Thana Health Complex (first referral center)
1500000 200000
Union Subcenters
20000
Community level health care (wards)
4000-7000
Village level health care
1500
Source: Ref. [7].
A,B. Bhuiyan, F.
Hu.~.fl1il1 /
lmemattonal Journal of Gynecology & Obstetrics 50 Suppl. 2 (/995) S/65-SI68
Table ~ Causes of maternal death in Bangladesh, 1993 Cause
%
Postpartum hemorrhage Abortion Eclampsia Puerperal sepsis Obstructed labor Other obstetric
26 21 16 II 8 18
Table 5
Source: Ref. [8].
Table 4 shows the causes of maternal death in Dhaka Medical College Hospital and Mitford Hospital during 1992 and 1993. In both facilities eclampsia is the major cause of maternal death. The maternal mortality rate is significantly high in Bangladesh in comparison to other regions of the world. Illiteracy, poverty, a low CPR and an inadequate health care system are all considered contributory factors. The country's primary health care system is not equipped with either appropriate manpower or sufficient material resources to serve complicated obstetric cases. As a result, maternal health care cannot be properly managed. When considering the causes of maternal death, it is evident that postpartum hemorrhage is the most common at the national level, followed in frequency by abortion, eclampsia, puerperal sepsis and obstructed labor. On the other hand, in hospitals, eclampsia is the major killer of mothers, because most of the patients arrive with that complication long after the onset Table 4 Causes of maternal death in two hospitals in Dhaka Causes
Eclampsia Septicemia PPH Ruptured uterus APH Miscellaneous
Dhab Medical Colli,' .:i)h;j %,
54.4 16.4 4.7 5.3 2.3 17.0
5167
Mitford Hospital
Births
Annual no.
'x.
All At high risk Cesarean sections
3600000 540000 180000
100.0 15.0 [9] 5.0 [10]
of the first convulsion, Since our sophisticated biochemical investigations and treatment facilities are not up to the standard, we are still unable to bring about a favorable outcome. The next cause of maternal death in order of frequency in hospitals is septic abortion, which is mainly induced abortion. Death due to postpartum hemorrhage occurs less often in hospital because of blood transfusion facilities and the use of oxytocics, but also because such referrals die before reaching the hospital. There is an immense need of Emergency obstetric care (EOC) in Bangladesh, which is evident from the figures shown in Table 5. But the present situation of EOC is not at all satisfactory. At the grassroots level it is either absent or inadequate; in the district it is not properly functioning in many centers because of missing components; and in the large institutions such as the Medical College Hospital it cannot work properly because of the heavy caseload. EOC service must be upgraded to achieve the targeted goal of reducing maternal mortality from 5.6/1000 [2] Acknowledgments The authors are grateful to the authorities of Dhaka and Mitford Medical College Hospitals for permitting them to use their patients' records.
Oil)
References
i :)3
1992
1993
55.9 16.4 9.7 3.0 0.8 14.2
71.1 08,8
53.8 07.1
8.9 4.4 6.4
11.5 26.9
PPH, postpartum hemorrhage; APH. antepartum hemorrhage.
[I] Bangladesh Bureau of Statistics. Ministry of Planning, Government of the People's Republic of Bangladesh. with technical support from the United Nations Children's Fund. Progotir Pathey. Dhaka, )9~4: 1-1 S. [2] Koenig AM, Fauveau V, Chowdhury AI, Chakraborty J, Khan MA. Maternal mortality in Matlab, Bangladesh: 1976-19'85. Stud Fam Plann 1988; 19(2): 69. [3] Aluddin M. Maternal mortality in rural Bangladesh; the Tangail district. Stud Fam Plann 1986; 17(1): 13. [4] Khan AR, Jahan FA, Begum SF. Maternal mortality in
8168
A.B. Bnuiyan, F. Hussain / International Journal of Gynecology & Obstetrics 50 Suppl, 2 (1995) S165-SJ68
rural Bangladesh: the Jamalpur district. Stud Fam Plann 1986; 17: 7. [5] World Health Organization. Maternal mortality ratios and rates: a tabulation of available information. Third Edition WHO/MCH/MSM/91.6, 1991. [6] Bangladesh Bureau of Statistics. Health Information Unit, 14th edition. Dhaka: Ministry of Health and Population Control, 1993: 60S. [7] Bangladesh Ministry of Health and Family Welfare. Health Service Organization, Proceedings of the IIth Meeting of Health Ministers of the Countries of the
World Health Organization South East Asia region, Dhaka, Nov. 1-3, 1993. [8] Fauveau V, Koenig MA, Chakraborty J, Chowdhury AI. Causes of maternal mortality in rural Bangladesh, 1976- 1985. Bull World Health Organ 1988; 66(5):643. [9] Hartfield NJ. Maternal mortality in Nigeria compared with earlier international experience. Int J Gynaecol Obstet 1980; 18: 70. [10] Nordberg EM. Incidence and estimated need of caesarean section, inguinal hernia repair, and operation for strangulated hernia in rural Africa. Br Med J 1984; 289:92.