Two maternal deaths due to PPH and A

ntepartum eclampsia on two consecutive days, immediately on arrival to hospital casualty, from same block of the district prompted me to write this post.

As such maternal mortality ratio is showing declining trend in the country. Maternal death surveillance and response (MDSR) is being conducted all over the country to find out the reasons behind the maternal deaths, so that corrective steps can be taken to prevent its occurrence. Postpartum haemorrhage and complications of hypertensive diseases of pregnancy still take up the top positions among the causes of maternal deaths. Fortunately, deaths due to both these causes are largely preventable by adopting various means.

MDSR meetings often reveal that one or the other type of delay, has a major contribution in causation of maternal deaths. The "Three Delays" model proposes that pregnancy-related mortality is overwhelmingly due to delays in: (1) deciding to seek appropriate medical help for an obstetric emergency; (2) reaching an appropriate obstetric facility; and (3) receiving adequate care when a facility is reached. In cases of PPH, delay in identifying haemorrhage, delays in transport to facilities from home or from primary health centres, and delays in receiving definitive therapies upon arrival at secondary or tertiary facilities contribute to high rates of maternal mortality and morbidity. Time interval between occurrence of PPH and arrival of case to tertiary care facilities determines the outcome. Unfortunately, there is very narrow margin of safety as regards to time in postpartum haemorrhage. Treatment received in first two hours, following PPH determines the survival. At times, patients are transferred as per transfer protocols of the health care centres, resulting into delay in reaching to tertiary care centres, as small health facilities, including primary health centres and rural hospitals are not equipped and often do not have specialist doctors and blood transfusion facilities. Delay in transfer is often seen even in private nursing homes.

Study of 18 maternal deaths due to PPH conducted at Pravara Rural Hospital, Loni revealed that the average distance from referring hospital to referral hospital was 25-30 kilo-meters with actual travel time of 30-40 minutes. Not a single case reached to the referral hospital within one hour of PPH, which is considered as golden hour. The time between occurrence of PPH and admission to referral hospital was up to two hours in twenty seven percent cases, was up to three hours in twenty seven percent cases and was more than three hours in forty six percent cases.

High risk pregnancy identification and timely referral to higher centre is of prime importance to avoid severe maternal morbidity and mortality in these cases. As per Pareto principle, eighty percent of the complications and the maternal deaths occur in twenty percent of pregnancies, mainly high risk pregnancies. Upgrading the emergency obstetric services at lower level facilities, so that immediate care can be provided to women with complications like PPH and Eclampsia will go a long way in preventing maternal deaths.