MATERNAL MORTALITY & MORBIDITY RATE, FERTILITY RATE - NURSING ASSIGNMENT

INTRODUCTION

        The sensitive index of the quality of the health care delivery system of a country as a whole or in part is reflected by its maternal and perinatal mortality rates. With 16% of worlds population India accounts for over 20% of worlds maternal deaths. During the last 50 years, there has been marked reduction in the maternal death rates astonishingly in the developed countries and to some extent in the developing world.

DEFINITION

        According to the World Health Organization (WHO), “A maternal death is defined as the death of a women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

MATERNAL MORTALITY RATIO

        Maternal mortality rate measures the risk of women dying from “Puerperal Causes” and is defined as

Total No. of Female deaths due to complications of pregnancy, child birth or within 42 days of delivery from “Puerperal Causes” in an area during  a given

MMR        =                                                                           X 100

Total No. of live births in the same area and year

        The MMR is expressed in terms of such maternal deaths per 100000 live births in most of the developed countries, the MMR varies from 4-40 per 100000 live births in the developing countries, it varies from 100-700 with India having about 408 per 100000 live births.

       

CLASSIFICATION

        The cause of maternal death may be classified into

·        Direct

·        Indirect

·        Non-obstetric

1)   Direct Obstetric Death (75%) are those resulting from complication of pregnancy-delivery or their management. Such conditions are abortion ectopic gestation, pre-eclampsia, eclampsia, ante-partum and post-partum  haemorrhage and puerperal sepsis.

2)   Indirect Causes (25%) included conditions present before or developed during pregnancy but aggravated by the physiological effects of pregnancy and stain of labour. These are anaemia, cardiac disease diabetes thyroid disease etc of which anaemia is the most important single causein the developing countries viral hepatitis when endemic contributes significantly to maternal death. Non-obsteric or unrelated causes include accident malaria typical and other infectious diseases.

FACTORS ASSOCIATED WITH MATERNAL MORTALITY

·        Age: The optimum reproductive efficiency appears to be between 20-25 years. In the young adolescent, pregnancy carriers a higher risk due to pre-eclampsia, cephalo-pelvic disproportion and uterine inertia. In women aged 25 years or above the risk is 3-4 lines higher.

·        Parity: The risk is slightly more in primigravida but it is 3 times greater in para 5 or above where post partum haemorrhage mal presentation and rupture uterus are more common. The risk is lowest in the second pregnancy.

·        Socio-economic Strata: Mortality ratios are higher in women belonging to low socio-economic strata as these women are likely to be less privileged in the fields of nutritions, housing, education and antenatal care.

·        Antenatal Care: The most significant factor affecting maternal mortality is the availability of antenatal care and its acceptants by the community unfortunately those very groups which have the highest mortality, like grand multiparae or the patients of lower socio-economic status are the women who least often avail themselves of this facility.

·        Social Factors: It is pertinent to find out the circumstances in which the death occurs and whether the particular deaths are avoidable rather than to know what is the immediate cause of death. An avoidable factor is a departure from the best current clinical practice preceding a maternal death.

IMPORTANT CAUSES

·        Haemorrhage: Haemorrhage is responsible for 20-25 percent of death and are mostly due to post partum haemorrhage and retained placenta, abruption placenta, placenta praevia, abortion and ectopic gestation.

·        Sepsis: Deaths due to infection associated with labour and puerperium are much less than those due to unsafe abortions and together contributing 20-25% of death. But infections from premature rupture of membranes, prolonged with labour with uterine inertia and obstructed labour are still frequent and should be guarded with antiseptic measures and antibiotics.

·        Hypertensive Disorders in Pregnancy: 5-15% of maternal death are due to preclampsia, eclampsia, and are mostly due to lack of antenatal care. Deaths from eclampsia vary from 2-10 percent.

·        Anaemia: Anaemia which accounts for 15-20% of all maternal deaths is not directly responsible for them but is usually a contributing factor. About 40% of obstetric patients in the developing countries suffer from anaemia and if it is severe, they may die from congestive cardiac failure during pregnancy or labour. All pregnant women with haemoglobin of less than 7.5gm percent should be hospitalized investigated and treated.

·        Infective Hepatitis: This is endemic in India but may sometimes present in an epidemic form with a high mortaility rate of 20-50 percent. The risk of death is mostly in the last trimester with hepatic coma and coagulation failure leading to post partum haemorrhage.

·        Thrombo-embolism: It is responsible for 15-25 percent of maternal deaths in western countries but only 2-5 percent in India.

MATERNAL MORBIDITY

        Obstetric morbidity originates from any cause related to pregnancy or its management any time during antepartum, intrapartum and postpartum period usually upto 42 days after confinement. The parameters of maternal morbidity

1.         Fever more than 100.4⁰F or 38⁰C and continuing more than 24 hours.

2.         Blood pressure more than 140/90 mm of Hg

3.         Recurrent vaginal bleeding

4.         Hb% less than 10.5 gm irrespective of gestational period.

5.         Asymptomatic bacteriuria of pregnancy.

CLASSIFICATION

1.   Direct Obstetric Morbidity

a.    Temporary

b.   Permanent

2.   Indirect Obstetric Morbidity

1) Direct Obstetric Morbidity

·        Temporary

APH, PPH, Eclampsia, obstructed labour, rupture, sepsis, ectopic pregnancy, molar pregnancy etc

·        Permanent (Chronic)

VVF, RVF, dyspareunia, CPI, prolapse secondary infertility, obstetric palsy.

2) Indirect Obstetric Morbidity

        These conditions are only expressions of aggravated previous existing disease like malaria, hepatitis, tuberculosis, anaemia etc by the changes in the various systems during pregnancy.

Reproductive Morbidity:

        Reproductive morbidity is used in a broader sense to include

a.    Obstetric morbidity

b.   Gynaecological morbidity

c.    Contraceptive morbidity

FERTIFILITY RATE

        By fertility is meant the actual bearing of children. A woman’s reproductive period is roughly from 15-45 years – a period of 30 years. A women married at 15 and living till 45 with her husband is exposed to the risk of pregnancy for 30 years and may give birth to 15 children, but this maximum is rarely achieved.

CAUSES

        The higher fertility in India is attributed to universities of marriage.

·        Lower age at marriage

·        Low level of literacy

·        Poor level of living

·        Limited use of contraceptives and traditional ways of life

FACTORS AFFECTING

1. Age at Marriage

        The age at which a female marries and enters the reproductive period of life has a great impact of her fertility. The registrar general of India collected data on fertility on a national scale and found that female who marries before the age of 18 gave birth to a larger number of children than those who married after 20.

2. Duration of Married Life

        Studies indicate that 10-25 percent of all birth occur within 1-5 years of married life. Births after 25 years of married life are very few (20)

3. Spacing of children

        Studies have shown that when all births are postponed by one year, in each age grouse there was a decline in total fertility. He follows that spacing of children may have a significant impact on the general reduction in the fertility rates.

4. Education

        There is an inverse association between fertility and educational status. The national family health survey-3 show that the total fertility rate is 1.7 children higher for illiterate women than for women with at least a high school education.

5. Economic status

        Operational research studies support the by pothesis that economic status bears an inverse relationship with fertility. The total number of children born declines with an increase in per capita expenditure of the household. The world population conference at Bucharest in fact stressed  that economic development is the best contraceptive. It will take care of population growth and bring about reductions in fertility.

6. Cast and Religion

        Muslim has a higher fertility than Hindus. The national family health survey – 3 reported a total fertility rate of 3.09 among Muslims are compared to 265 among Hindus.

        The total fertility rate among Christians was found to be 2.35. Among Hindus, the lower castes seem to have a higher fertility rate than the higher castes.

7. Nutrition

        There appears to be some relationships between nutritional status and fertility levels virtually all well fed societies have low fertility and poorly fed societies high fertility. The effect of nutrition on fertility is largely indirect.

8. Family Planning

        Family planning is another important factor in fertility reduction. In a number of developing countries, family planning has been a key factor in declining fertility. Family planning programmes can be initiated rapidly and require only limited resources, as compared to other factors.

9. Other Factors

        Fertility is affected by a number of physical, biological, social and cultural factors such as place of women in society, widow remarriage, breast-feeding, customs and beliefs, industrialization and urbanization, better health conditions, housing, opportunities for women and local community involvement. Attention to these factors requires long term government programmes and vast sum of money.

FERTILITY TRENDS

        Researches indicate that the level of fertility in India is beginning to decline. The crude birth rate which was about 49 per thousand population during 1901-11 has declined to about 29.5 per thousand population in 1991 amd 23.5 per thousand population in 2006 a decline of about 20 percent. The rural urban differential has narrowed. However, the crude birth rate has continued to be higher in rural areas as compared to urban areas in the last 3 decades.

        The total fertility rate has declined from 3.6 in 1991 to 2.8 in 2006. The TFR in rural areas has declined from 5.4 in 1971 to 3.1 in 2006. Whereas the corresponding decline in urban areas has been from 4.1 to 2.0 during the same period. There are considerable inter state variations in total fertility rate.

FERTILITY RATE

1) General Fertility Rate (GFR)

        It is the number of live births per 1000 women in the reproductive age-group (15-44 or 49 years) in a given year.

                No. of live births in an area during the year

GFR =                                                                          X 1000

Mid year female population age 15-44 in the same

area in same year

2) General Marietal Fertility Rate (GMFR)

        It is the number of live births per 1000 married women in the reproductive age group (15-44 or 49) in a given year.

                              No. of live births in a year

GMFR =                                                                        X 1000

Mid year married female population

in the age group 15-49 years

CONCLUSION

        The international federation of gynaecologists and obstetricians (FIGO) defines maternal death as one occurring during pregnancy or labour or as a consequence of pregnancy within 42 days after delivery or abortion. The World Health Organization (WHO) estimates that 585000 women die every year from pregnancy related causes.

BIBLIOGRAPHY

1.   D.C.Dutta, “A Text Book of Obstetrics”, 6^th Edition, Page No.644-648.

2.   Myles, “A Text Book of Midwives”, 13^th Edition, Page No.933-935.

3.   K.Park, “A Text Book for Community Health Nursing”, Page No.416-419.