Maternal health in a resource poor setting: The challenge of delivering effective obstetric care in rural West Bengal.

ca Moretti1

Luca Moretti

Introduction

Despite significant progress in the attempt to satisfy the fifth Millennium Development Goal, reducing maternal mortality by two-thirds between 1990 and 2015, India remains a work-in-progress1. Over 50’000 maternal deaths were reported in India during 2011, accounting for 18.5% of all maternal deaths worldwide and 57% of all maternal deaths in South Asia2.

Resource poor, remote, rural hospitals constitute the frontline in the fight against maternal mortality3. Remote hospitals and satellite clinics provide access to obstetric care for the most marginalised members of society. The delivery of effective obstetric care in rural populations remains a vital aspect in the attempt to reduce maternal mortality4.

Setting

Khristiya Seva Niketan Hospital (KSN) is a charitable, non-government organisation, 150-bed general hospital in the Santal tribal belt of West Bengal. It is the only major hospital within a radius of 60 km. The hospital is deprived by means of resources, finances and staff. Over 70% of the hospital’s patients live below the poverty line.

Resources

There is no access to ultrasonography or cardiotocography at the hospital. Ultrasound scan centres exist in towns further afield and the patient must cover the costs. Drugs used in pregnancy are limited and their preparation is often substandard. The pathology lab can process only the most basic of tests. Notable omissions include: Urea and Electrolytes, Liver Function Tests and Blood Gases. There is no blood bank at the hospital and there is no access to an anaesthetist.

Data Collection

Retrospective data was collected for every delivery within the year 2012. The total sample size (n) was 1804 deliveries. This included 691 deliveries by mothers classed as general, 701 deliveries by mothers of a scheduled caste and 412 deliveries by mothers of a scheduled tribe.

Results

All births, regardless of general, caste or tribe status, showed male to female ratios in favour of the male sex. This was most established in the General cohort. When compared to scheduled tribes, women from the general cohort showed a 3.64% increase in the rate of male births; rising further to a 6.79% increase compared to schedule castes. Over three quarters of all deliveries were registered as booked. Women from scheduled tribes showed a 48.81% increase in the rate of unbooked deliveries compared to general and a 62.14% increase in unbooked deliveries compared to scheduled caste.

Mothers from a scheduled tribe reported an increased rate of premature deliveries when compared to general (37.98% increase) and scheduled castes (14.29% increase). Mothers from a scheduled caste reported an increased rate of stillborn births; the rates of stillborn birth were 430% greater than mothers from the general cohort, and 90.72% greater when compared to standard tribes. Mothers from a scheduled tribe reported higher rates of eclampsia during or after their pregnancy.

Eclampsia in scheduled tribes was 69.23% greater than the scheduled castes cohort; and 52.20%greater when compared to the general cohort. There was also a significant difference in the weeks of gestation at birth for deliveries between 33-36 weeks and deliveries >40 weeks gestation. Mothers from scheduled tribe had the highest rates of deliveries within both 33-36 weeks and >40 weeks.

Table 1A breakdown of 12 months maternity data classified by the mother’s ethnic status.n = 1804.

General / Scheduled Caste / Scheduled Tribe / P value
Booked / Y / 76.89% / 78.89% / 65.61% / 0.04
N / 23.11% / 21.21% / 34.39% / 0.01
Parity / Null / 55.90% / 53.44% / 58.01% / 0.60
Multi / 44.11% / 46.56% / 41.99% / 0.53
Gestation / <33 / 2.49% / 2.88% / 4.17% / 0.30
33-36 / 13.66% / 15.71% / 21.08% / 0.01
37-39 / 54.19% / 51.73% / 43.63% / 0.06
40 / 22.03% / 19.74% / 17.89% / 0.32
>40 / 7.64% / 9.94% / 13.24% / 0.02
Pre Eclampsia / 1.59% / 1.43% / 2.42% / 0.45
Mode of delivery / SVD / 86.88% / 88.92% / 85.82% / 0.85
Emergency CS / 3.20% / 3.45% / 4.65% / 0.46
Elective CS / 6.71% / 3.45% / 5.62% / 0.03
Breech / 0.87% / 1.15% / 1.47% / 0.67
Forceps / 2.33% / 3.02% / 2.45% / 0.71
Episiotomy / 50.50% / 46.37% / 46.44% / 0.52
Infant Sex / Male / 55.22% / 51.71% / 53.28% / 0.67
Female / 44.78% / 48.29% / 46.72% / 0.63
M:F / 1.23 / 1.07 / 1.14
Birthweight (grams) / <1000g / 0% / 0.43% / 0% / 0.09
≥1000g <1500g / 0.58% / 1% / 0.97% / 0.65
≥1500g <2000g / 2.47% / 4.57% / 4.87% / 0.06
≥2000g <2500g / 12.77% / 16.14% / 15.82% / 0.22
Livebirth / 99.57% / 98% / 98.78% / 0.96
Stillbirth / 0.43% / 2.00% / 1.22% / 0.03
Neonatal Death / 1.16% / 1.14% / 0.73% / 0.77

ca Moretti1

Discussion

The results of the present study provide a useful insight into the challenge of providing effective obstetric care in a resource poor setting. A retrospective analysis of the maternity records from 2012 has helped to identify key trends and patterns that can be used to identify mothers most in need of essential and comprehensive obstetric care. Robust statistical analysis is required if the results are to be used to comment on likelihood ratios or cause and effect arguments.

Mothers from the general cohort had the highest rates of male births. The M:F of 1.23 for mothers classed as general is much higher than the M:F of 1.06 reported for 0-6 year old during the 2011 India census. This is a genuine cause for concern. Despite strict laws, gender discrimination and foetal genocide remain an active problem in India. Wealth and access resources may explain the difference between general, standard castes and standard tribes. Mothers from a general background are likely to come from families with greater levels of income and greater access to resources. It is conceivable that mothers from the general cohort, who can afford to pay for ultra sound scans, can also afford to pay brides to determine the sex of the baby. The result of which may affect their decision to continue with the pregnancy.

Mothers from a scheduled tribe had the lowest rates of antenatal visits prior to delivery. It is unclear as to whether this represents an unwillingness to use antenatal care, or difficulties in accessing antenatal care. Mothers from standard tribes are more likely to live in remote rural locations where regular access to antenatal services may be difficult. Tribal mothers may be deterred from antenatal support by a perceived lack of benefit, compounded by concerns regarding transport costs. Consequently, it is plausible that even in the tribal mothers who attend antenatal care, their presentation may be much later into pregnancy than mothers of general or standard caste cohorts. This may limit the effectiveness of the antenatal care that they receive and increase their risk of experiencing difficulties during pregnancy.

The results show that mothers from standard tribes experience higher rates of premature delivery. This increase was almost 38% when compared to general mothers alone. Furthermore, mothers from standard tribes experienced more eclampsia than mothers from general (over 50% more) or standard castes (almost 70% more). The situation may be compounded by the observation that mothers from a scheduled tribe were less likely to have attended at least four antenatal clinics before delivery.

It is plausible that the lack of antenatal visits may affect the accuracy of the estimated weeks of gestation. Thus, the higher rates of premature and deliveries greater than weeks may be indicative of a cumulative calculative error. However, this seems unlikely to be the only explanation. Mothers from a scheduled tribe also reported lower birth weights compared to their general mother counterparts.A combination of social, physical and genetic factors may be adversely affecting the maternal health of mothers from Santali descent.

There was also a significant difference in the rates of stillborn deliveries. It is not entirely clear why mothers of a scheduled caste had the highest rates of stillborn births. More research is required to collect and analyse data into the circumstances surrounding the stillborn births.

Conclusion

A significant challenge in providing effective obstetric care in a resource poor setting is identifying those members of society most at risk of difficulties during pregnancy and providing suitable levels of support for them. The results of the present study report higher rates of unbooked deliveries, premature deliveries and eclampsia in mothers from a scheduled tribe. In 1987 Mahler described the victims of maternal mortality as those with the least influence in society, adding, “they are poor, rural peasants, and female”5. This statement succinctly explains the need for effective obstetric care in rural areas. KSN may be resource poor but it provides a vital lifeline for those women most in need of obstetric support.

References

1 Rosenfield A, Maine D, Freedman L. Meeting MDG-5: an impossible dream? The Lancet 2006; 368: 1133-1134.

2 Lozano R, Wang H, Foreman K et al. Progress towards Millenium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. The Lancet 2011; 378: 1139-65.

3 Kongnyuy E, Hofman J, van de Broek N. Ensuring essential obstetric care in resource poor settings. BJOG An International Journal of Obstetrics and Gynaecology 2009; 116(suppl. 1): 41-47.

4 Drost E, Lonkhuijzen LRCW, Meguid T et al. Implementing safe motherhood: a low-cost intervention to improve the management of eclampsia in a referral hospital in Malawi. BJOG An International Journal of Obstetrics and Gynaecology 2010; 117: 1553-1557.

5 Mahler H. The safe motherhood initiative: a call to action. The Lancet 1987; 365: 668-70.

Appendix

Government of India. Ministry of Home affairs. Office of the register general and the census commissioner India. Census 2011. Accessed February 5th 2013.

Supervisors

Dr Elizabeth Serle

Khristiya Seva Niketan Hospital (KSN)

Sarenga

West Bengal

India

Dr Majory MacLean

Crosshouse Hospital

Kilmarnock

East Ayrshire

ca Moretti1