Risk factors for maternal mortality among 1.9 million women in nine empowered action group states in India: secondary analysis of Annual Health Survey data.

Geneviève Horwood,Saswati Sanyal Choudhury,Charles Opondo,Anjali Rani,Manisha Nair

doi:10.1136/bmjopen-2020-038910

Abstract

ObjectiveTo examine the risk factors for pregnancy-related death in India’s nine Empowered Action Group (EAG) states.DesignSecondary data analysis of the Indian Annual Health Survey (2010–2013).SettingNine states: Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand.Participants1 989 396 pregnant women.MethodsMaternal mortality ratio (MMR), overall and for each state, with 95% CI was calculated. Stepwise multivariable logistic regression was used to investigate the association of risk factors with maternal mortality. Area under the receiver-operating characteristic (AUROC) curve was used to assess the prediction of the model.Outcome measuresMMR adjusted for survey design, adjusted OR (aOR)with 95% CI and C-statistic with 95% CI.ResultsMMR calculated for the nine states was 383/100 000 live births (95% CI 346 to 423 per 100 000). Age exhibited a U-shaped association with maternal mortality. Not having a health scheme and belonging to a scheduled caste or scheduled tribe group were significant risk factors for maternal death with aOR of 2.72 (95% CI 2.41 to 3.07), 1.10 (95% CI 1.02 to 1.18) and 1.43 (95% CI 1.31 to 1.56), respectively. Socioeconomic status and rural residence were not associated with maternal mortality after adjusting for access to a healthcare facility. Complications of pregnancy and medical comorbidities were the strongest risk factors for maternal death (aOR 50.2, 95% CI 44.5 to 56.6). Together, the risk factors identified accounted for 89% (95% CI 0.887 to 0.894) of the AUROC.ConclusionsMaternal mortality in India’s EAG states greatly exceeds the national average. The identified risk factors demonstrate the importance of improving the quality of pregnancy care. Notably, the study showed that the risk conferred by poor socioeconomic status could be mitigated by universal access to healthcare during pregnancy and childbirth.

Highlights

Despite advances in modern medicine, pregnancy and childbirth remain one of the leading causes of mortality worldwide for women of reproductive age.[1]
Of the women surviving pregnancy, 53.1% accessed a health facility compared with only 36.1% of women dying in pregnancy
Maternal mortality ratio The overall maternal mortality ratio (MMR) was 383 per 100 000 live births

Summary

Introduction

Despite advances in modern medicine, pregnancy and childbirth remain one of the leading causes of mortality worldwide for women of reproductive age.[1] The question of safe motherhood is not merely one of public health concern but has been widely recognised as an issue of social injustice.[2 3] According to the Sustainable Development Goals (SDGs), the global target is to reduce the maternal mortality ratio (MMR) to less than 70 per 100 000 live births by 2030 and to provide universal access to reproductive healthcare.[4]. India is responsible for the second-h ighest number of maternal deaths worldwide.[5] India’s MMR has been steadily declining since the 1990s.1 5 6. India’s MMR has been steadily declining since the 1990s.1 5 6 According to the Sample Registration System, a household survey conducted by the Indian government, the Horwood G, et al BMJ Open 2020;10:e038910. doi:10.1136/bmjopen-2020-038910

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Conclusion