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Maternal Morbidity And Mortality Pak Armed Forces Med J 2017; 67 (4): 635-40
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
making, for advocacy and for determining trends risk pregnancies (such as those to grand-
over a period of time. multiparous women); lack of family planning,
In Pakistan each year over 5 million women poor access to health services, deliveries
become pregnant, out of these 0.7 million (15% of conducted by non-professionals, lack of antenatal
all pregnant women) are likely to experience and postnatal care, poverty, and illiteracy.
some obstetrical and medical complication. The Women's health is a neglected area in developing
major causes of maternal mortality world over countries. Despite at least 50% maternal deaths
are hemorrhage, hypertensive disorders, sepsis, occurring during the postpartum period, very
obstructed labor and abortions. It has been limited research has been carried out to assess
estimated that around 15% of women during morbidities. In developing countries, the role of
child birth develop potentially life threatening traditional health practitioners and their practices
complications and 1-13% will die in the absence have a strong influence during the antepartum,
of major surgical or medical intervention. While a and postpartum period.
couple of years ago most of the research was MATERIAL AND METHODS
focused on maternal mortality, now there is an This descriptive study was conducted in Jun
evolving concept of MMR as with new advances 2014. Data were collected in different time
in health, mortality is a rarer event in developed periods from articles published between 01
world as is examplified by UK confidential January 2005 to 31 December 2012 in medical
enquiries into maternal deaths. According to a journals, proceedings of workshops/conferences
recent WHO systematic review, the global as well as from newsletters of the NCMH along
prevalence of MMR varies from 0.01%-8.23%, with GBD 2013 to estimate MMR. Data were later
with an inverse trend with the development tabulated accordingly in June 2014.
status of the country2. RESULTS
Pakistan has a specific traditional culture of To estimate maternal mortality, for the cause
childbirth in its rural areas. Thus, high levels of of death database GBD 2013 was used. It extends
maternal mortality and morbidity in Pakistan are from 1990 to 2013, Naghavi and collegues the
a direct result of the interplay between a variety lancet 2014 provide substantial detail about
of factors such as low status of women in society; inclusion criteria and data processing of studies
poor nutrition; a significant proportion of high-
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Maternal Morbidity And Mortality Pak Armed Forces Med J 2017; 67 (4): 635-40
across all causes. It shows data of 188 countries, mean of 8.5%. Anaesthetic complications are a
MMR of Pakistan is stated in table-I. significant cause of death ranging from 2.6 to
Five tertiary hospitals and global perspective 10.5% (mean 5.6%). Among the indirect causes
have reported figures over different periods of two early reports, show severe anemia as the
time. This shows very little change in trends. most common cause of death (39% and 18.1%).
Community based data were not sufficient to be Hepatitis too contributes significantly (2 to 9.7%)
tabulated, though the trends there also shows (table-III).
equally little change as shown in table-II. The most common cause of death amongst
Information, which was not clearly stated, the women as personally experienced is
has been excluded. The cause of death has been hemorrhage (63%, of which 42% were
based on clinical features alone as post mortems postpartum hemorrhage) followed by eclampsia
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Maternal Morbidity And Mortality Pak Armed Forces Med J 2017; 67 (4): 635-40
deaths i.e. 52.9%. The second most common cause information about the causes as well as trends
was sepsis (16.3%) followed by eclampsia (14.4%) over the years. However hospital studies need to
and obstructed labor (6.5%). Abortion caused conform to a standard uniform pattern of
5.2% of the deaths. Among the indirect causes reporting. Studies in the community are few and
hepatitis was the most common (14%) followed on small scales. More data, which are nationally
by heart disease (9.3%) (table-IV). representative, are necessary. It is of vital
A study was carried out to establish the importance that all births and deaths throughout
factors that caused delay in women reaching the country are registered.
hospital in time. The reasons for delay were Three major public teaching hospitals from
economic, like non-availability of transport and which data are available, the maternal deaths are
lack of finances (3.6%), socio-cultural factors due to direct causes, an indication of the poor
including absence of husband from home (34%), maternal health status and inadequate health
inadequate and inefficient maternal health care. Hemorrhage is the overall leading cause
services (2.1%). In 9% the reason for delay could followed by eclampsia and sepsis, though a few
not be determined. hospitals report sepsis and one reports eclampsia
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Maternal Morbidity And Mortality Pak Armed Forces Med J 2017; 67 (4): 635-40
number of deaths (11.8%) again. Is this a result of however not supervised in their work and there
increasing malnutrition, or is it just a sporadic is no back up support in time of need. A review
finding? There are anecdotal accounts that of TBA training and utilization of programs in 70
anemia is on the increase. countries over the past three decades shows that
Of other medical disorders, hepatitis is also a there are limited examples of their successful
significant cause accounting for between 2.5 to utilization. In countries where the TBA’s have
9.7% of the deaths. Data on the type of hepatitis been adequately supervised the strategy has
are not available, though it is known that shown some positive results. In other words for
hepatitis E during pregnancy is associated with a effective functioning, TBAs require constant
high maternal mortality4. supervision, more than other health care
providers do.
Community data reveals that more than half
of the deaths were due to hemorrhage (52.9%). A different policy approach is now required
The high proportion of deaths due to hemorrhage which is comprehensive and comprises of short
among women who die in the community and and long term goals. The time has come for a
also among those who died before reaching critical evaluation of all safe motherhood
hospitals (63%) indicates the urgent need for help programs, both in the public and private sector,
in cases that are bleeding. Immediate help if not be conducted to form the foundation of a national
forth coming kills the women5. Misoprostol, an safe motherhood strategy. In the meantime, the
essential lifesaving drug, can be used for both potential strategy of preparing a cadre of
prevention and treatment of postpartum appropriately trained midwives for maternal care
hemorrhage. during pregnancy, labor and the postpartum
period should be pursued. In Europe particularly
What do the continuing high MMR figures
Sweden, even before the advent of modern
from the hospitals indicate? Is it that the
technology, professionally trained midwives
proportion of women who are dying has now
helped reduce maternal morbidity and mortality.
increased? Is it that the proportion of deaths has
decreased in the community and increased in the In Pakistan midwifery is a neglected
hospitals? Is it that as a result of greater profession. Though there are more than 10,000
awareness of pregnancy related complications by nurses who have been trained in midwifery, very
both the community and the health care few are practicing as midwives7. Moreover their
providers, and more facilities for transport, a training, especially in skills, is deficient. The lady
greater number of women are now reaching health visitors (LHVs), a cadre of health care
hospitals but not in time to be saved? Is it that providers who are trained to deliver women in
sub-standard care is given to women who come the community, do practice midwifery both in
with complications to the hospitals? Is it that health facilities and in the community but their
more accurate data is now being collected by the exact numbers are not known. Their training too,
hospitals? Unfortunately, most of these questions especially skills’ training leaves much to be
cannot be answered as the trend in the number of desired. Moreover back up support to them is
deaths in the community is not known. lacking.
In Pakistan over 80% of the deliveries are Midwifery training needs to be geared
still taking place at home, majority of them being towards competency based skills. Midwives need
conducted by the traditional birth attendants to be motivated to work in the rural areas and
(TBAs). A large number of these TBAs, about their roles and career pathways well defined.
40,000 to 50,000, have undergone training under They should, as a short-term measure, supervise
one of the many initiatives for safe motherhood existing trained TBAs in their work. As a long-
taken by the Government6. The TBAs are
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Maternal Morbidity And Mortality Pak Armed Forces Med J 2017; 67 (4): 635-40
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