Why Some Mothers Could Be Saved and Not Others? Evaluating Different Phases of Delay in Causing Maternal Near Misses and Maternal Deaths

Abstract

Introduction: The factors playing key role in determining death and survival among the Maternal Mortality (MM) and Maternal Near Miss (MNM) cases are multidetermined and interdependent. It ranges from initial illness to perception of patients to seek healthcare services and initiation of management at primary health care settings. Aim: To evaluate the factors responsible for causing delay at different phases and thereby assess the key determinants of survival and death of mothers. Materials and Methods: This cross-sectional observational study was undertaken at the tertiary care centre and teaching hospital in northern India from October 2015 to December 2016. Study population consisted of all women who were identified as MNM and MM which occurred at Centre. Attendants accompanying the patient, mostly nearest kin who were able to give details of her health were questioned. Details regarding the sequence of events that caused her severe morbidity were taken right from recognition of morbid status to landing up in the tertiary setup. Approximate duration of delay for each case of MNM and MM was assessed. Any delays in accessing or receiving medical care were recorded, if available. Data Entry was done on MicroSoft Excel spreadsheet. Proportions were calculated for qualitative data. Mean score with confidence interval was calculated for quantitative data. Qualitative data was analysed by Chi-Square test and t-test was applied for quantitative data. Results: Out of 31,111 live births during the study period, there were 249 maternal near miss cases and 131 maternal deaths. Delay in women seeking help was observed in a total of 92.36% of cases in MNM group and 97.70% of cases in MM group (p=0.034). The study discovered significant differences when referral status (p=0.4904) as well as when number of referrals (p=0.041) were considered. There was a significant difference between the women of the two groups who reported only first phase delay (p=0.033). The major pregnancy related morbidities were haemorrhage and hypertensive disorders of pregnancy. Patients with hypertensive disorders of pregnancy with delay more than 12 hours survived the acute insult but were unable to cope with dysfunction of multiple organs and passed on after prolonged intensive care whereas in cases of Postpartum Haemorrhage (PPH), delay >6 hours were observed with extremely poor prognosis. Conclusion: Delay in taking decisions to seek healthcare is a major cause of MM. There is a little difference in outcome in terms of survival and death of mothers with delay in any of three phases despite increased intervention taken in adequate referral facilities. Precious time lost in deferral and referral contributes immensely to poor prognosis of mothers as compared to direct referral to an adequate health facility.