Special Report

Health Bulletin No, 27. Abstract of the

Report of an Inquiry into the Causes of Maternal Mortality in Calcutta

By M. I. NEAL EDWARDS, m.d., w.m.s.

Professor of Maternity and Child Welfare, All-India

Institute of Hygiene and Public Health, Calcutta

[In the introduction to this valuable report it is made clear that Calcutta was selected for this inquiry by the Maternal Mortality Advisory Committee of the

Indian Research Fund Association because of the facilities offered by the All-India Institute of Hygiene and Public Health and it does not mean that in the other cities (and the country districts) throughout India this subject is not of just as much importance. This is only the first of a series of such inquiries which it is the intention of the Research Fund Association to conduct as opportunity occurs, and no doubt other cities and rural centres will be selected for future

inquiry.] The object_ of this inquiry was to inquire into the

number and investigate the causes of maternal deaths in Calcutta. The period during which follow-up of

July, 1940] SPECIAL REPORT 431

deaths took place was 15th June, 1936, to 14th

l9The area chosen was that which is under the Contro1 of the Health Officer of the Calcutta C?^?ra,|

?

The definition of < maternal. death; which has be^

adopted for the purpose of this inquiry by the in the inquiry into maternal mortality

vpars ago

Department of Health for Scotland a

and is expressed as follows:? , v

'Maternal deaths which occurred during ?anCy or within four weeks after the termination

^ ufidbirth

or later if illness originated during pregna >,

?'t? SS'cards in use provide no information regarding any relationship there may have ^

pregnancy and childbirth, so cai^ WW identical with those in regular use by^e inauiry and but with the addition of the name of the

inquiry ana

the following questions:? Was she pregnant at the time of

death?

Did she die during labour or abortion- . ,

Did she die within three months after labour

abortion? , , ? nr(Ws

The health officer was kind enough to ajj that these duplicate cards should be filled P

j female deaths between 10 and 50 years

and that, tnes^ cards should be returned with the ordinary

g

We arranged to collect the duplicate ^deaths the health office and thereby obtained not

within one to three days of their occu 'further investigation was possible with veiy

Arrangements to receive the duplicate ̂

made about three months before the inq j.^e started and cards were coming in regular y

investigation of deaths began on 15th June. ,.

It is impossible to say how accurately ^ Caicutta represent the true maternal mortality ?

?re

during the year of the inquiry. The following are

possible sources of error:? 1. Failure to register deaths. , .

2. Failure to receive duplicate registration cards

3. Incorrect information obtained by regarding association with pregnancy

or c 1

u+nin

. 4. Failure on the part of sub-registrars o o

information relating to pregnancy and child i ?

5. Inability to trace cases of death *n ^ ̂ufful. association with childbearing was definite

o

The omissions from amongst registered deat isi w

may have arisen in the ways suggested ' 'Tnlber'of women come to Calcutta from rural

districts and distant places for confineme jjca_ Proportion of these come on account

of som

tion of pregnancy or childbirth. #

Amongs

deaths followed up there were 203 imported ?

?n Two women doctors were appointed by fniinWing

Research Fund Association for the \y>rk UP the deaths. . ,. ,??a the A weekly meeting between the investigat

<

officer in charge of the inquiry was held vm

Purpose of reaching a conclusion regarding rases

of death and the avoidable factors present 1.

for which schedules had been completed -Kc^nssed previous week. In this way each case was

while the circumstances were fresh m tne m j

or

investigators and further details could be

further inquiries made, if considered necessa y. The accurate estimation of the materna Pfpctive

rate in Calcutta is not possible on account o . j

birth registration and the fact that our. , e

maternal deaths unfortunately cannot be clai

complete. _ , . ,

The total number of registered live. bir^S Wj5th occurred during the period of the inq^-iry, ,

. acjdi- June, 193G, to 14th June, 1937, was 28,714 and n^ tion 2,889 stillbirths were registered. The g

than ?f stillbirths is believed to be even less

ac

that of live births. It seems better therefore to express the rate per live births. The figures at our

disposal, viz, 28,714 live births and 701 maternal deaths due directly to childbearing causes, give a maternal mortality rate of 24.41 per 1,000 registered live births. If imported cases are excluded the rate becomes 17.90 per 1,000 live births but the births in connection with some of the imported cases of maternal death were registered in Calcutta. The exact number of these births could not be estimated and excluded from the total registered births of the city. The rate of 17.9 must therefore be considered an under-estimate. The true maternal mortality rate in Calcutta remains unknown. In classifying the cases according to the cause of

death the International List of Causes of Death (1929 revision) has been followed as closely as possible. It has been found necessary, however, to make an addi- tional heading for

' anaemia '. The relationship between the severe anaemias, and pregnancy in India is probably an even more intimate one than exists between cardiac disease and pregnancy.

It was found that in the series of 887 maternal deaths there were 656 or 74 per cent of the total in which the registered and ascertained cause corresponded while in 231 or 26 per cent a different conclusion as to the cause of death was reached after investigation. The 887 maternal deaths investigated have been

divided into two classes:?

Cases Class I.?Deaths due directly to childbearing 701

Class II.?Deaths due to an independent disease concurrent with pregnancy or childbirth .. .. .. 186

Puerperal sepsis.?In countries where registration of maternal deaths is carried out and where special maternal mortality surveys have been made, puerperal sepsis has been consistently found to be the most

important cause of maternal death. The small amount of evidence which is so far

forthcoming in India, and all this evidence relates to urban conditions, goes to show that while the mortality rate in India is several times as high as in Western countries, the proportion of deaths from sepsis is not more than a third of the total and this in spite of the fact that a far larger number of deliveries in this

country are attended by untrained women, who make no use of modern methods of asepsis and antisepsis. Ancemia,.?The inclusion of the anaemia deaths

amongst ' childbearing' and not

' associated' causes

needs further explanation. In the first place, whenever anaemia was clearly associated with other conditions such as kala-azar, epidemic dropsy, malaria, tuberculosis, the death has been assigned to the

' associated ' group under the appropriate heading. Similarly all cases of anaemia in which other complications of childbirth were present have been assigned to their respective groups. Thus the sepsis, toxaemia, haemorrhage and accidents of labour groups contain certain cases in which anaemia was probably the more important cause of death, the other condition being secondary or terminal. The

anaemia cases which remained after, exclusion of the

above, have had to be classed with the limited information at our disposal, as due to anaemia per se. Such evidence as we have collected in the course of

this inquiry suggests that in Calcutta severe anaemias of both the macrocytic and microcytic type, and also

mixed forms, are extremely _

common and that while

many cases are associated with poverty and malnutri- tion, others occur amongst the well-to-do in families that seem healthy and well-nourished. The association between a history of dysentery or

diarrhoea and a severe pregnancy anaemia in the Calcutta

series, of cases was noticeable and the suggestion is put forward that the development of anaemia in these cases may often be the result not only of the intestinal infection but of the diet which is commonly prescribed in these cases, and often taken for long periods afterwards.

432 THE INDIAN MEDICAL GAZETTE [JULY; 1940

Table I

Maternal deaths. Distribution by cause (International List, 1929 revision)

Deaths due directly to childbearing

Abortion (septic) Abortion (non-septic) Ectopic gestation Other accidents of pregnancy Haemorrhage Puerperal sepsis Albuminuria and convulsions Other toxaemias of pregnancy Thrombosis and embolism Accidents of labour and operative

shock. Other and unspecified puerperal

conditions. Anaemia

Calcutta cases

Deaths due to associated diseases ..

Total maternal deaths

514

170

684

Per cent

25 4.86 2 0.39 4 0.78

65 12.65 172 33.46 75 14.59 11 2.14 11 2.14 15 2.92

10 1.95

124 24.12

100.00

Imported cases

2 2 7 9

52 51 4

ii

41

187

Per cent Total ' Per cent

4.28 33 4.71 1 07 4 0.57 1-07 6 0.86 3-74 7 1.00

74 10.56 27.81 224 31.95 27.27 126 17.97 214 15 2.14

i 11 1.57 5-8S 26 3.71

10 1.43

21-93 165 23.53

16 .. 186

203 | .. 887

100.00 701 i 100.00

We have no evidence of how large a part hookworm infection plays in the causation of pregnancy anaemias in Calcutta.

Eclampsia.?Primigravidae predominated and half the deaths from eclampsia occurred in women under 20 years of age. It was found that the women who died from eclampsia were relatively more from the middle class than the poor. Their diets were better, and fewer of them worked during pregnancy. It is the young newly-married woman in her first pregnancy, taking little exercise, living on a good diet, who seems more liable to develop toxaemia, of pregnancy. The most striking thing about this series of cases

is the almost total lack of antenatal supervision which these women received and the failure on the part of the patients, doctors and relations alike to realize the serious nature of the warning symptoms which were

present in a large proportion of cases and, in many, were of long standing. Haemorrhage.?Many of these deaths were un-

doubtedly preventible. The group includes _ some of

the worst cases of mismanagement, delay in getting skilled assistance and failure to treat the blood loss, that were met with during the course of the inquiry. Warning haemorrhages were present in half the cases

of death from placenta praevia, but in no case were

adequate steps taken to ensure safe delivery. Amongst the deaths from postpartum haemorrhage

the number delivered by trained attendants was rather high which raises the question as to whether such attendants are inclined to try to hurry the third stage of labour.

Abortion.?All the women who died of septic abortion were either admitted to institutions or were seen by doctors at home and it is therefore highly probable that there were other deaths from abortion which we failed to discover during the year of inquiry. Accidents of labour.?Deaths due to accidents of

labour, i.e., due to the shock of labour itself, apart from haemorrhage, made up a small proportion of maternal deaths in our series, and one is led to the conclusion that neglected cases of obstructed labour are rare in Calcutta.

Tuberculosis.?Tuberculosis was of outstanding importance in the

' associated' group and caused 41 per crent of all maternal deaths due to intercurrent diseases.

[Following this chapter there is a short one devoted to preventability, chapter 3 discusses the factors that were found to affect mortality and chapter 4 is a

review of the hospitals and institutions where women can obtain help in childbearing as well as the organiza- tions for home visiting and treatment. Unfortunately this chapter _

is headed ' The Military Services in

Calcutta' which according to the index should read 'The Maternity Services in Calcutta'. Chapter 5 is

given in exlenso.]

Chapter 5.

Recommendations suggested by the findings of the inquiry

(1) Vital statistics.?Registration of births is very defective in Calcutta, more especially in some areas

and amongst certain sections of the population. The

possession of accurate information regarding the total number of births, live and still, is a basic requirement in drawing up adequate schemes for maternal care and it is therefore urged that steps be taken to enforce the Calcutta Midwiyes Act,

_ 1923, Section 451 (which requires registration of births within eight days), if necessary by means of prosecutions for contravention of the law._ Information with regard to the age and parity of the

mother, the plasty of delivery and the attendant at delivery, are additional facts which could be collected at the time of registration of births and if available would provide most valuable information for the further elucidation of facts relating to childbirth in the city. The possession of such information would greatly facilitate the registration and control of private mid- wifery practice, private maternity homes and the work of the untrained dai, and is a most desirable supporting measure for the Bengal Nurses and Midwives Act, 1934. In the interest of greater accuracy in the registration

of deaths, it is suggested that the primary and secondary causes of deaths should be stated on the death certi- ficate and that the annual reports of deaths by cause should be prepared according to the International List of causes of death with an additional heading for ansemia in the childbirth group.

(2) Organization.?-In the interest of better co-opera- tion between the existing services, and of developing plans for future extension and improvements, it is

July, 1940] CURRENT TOPICS 433

suggested that a co-ordinating body sh maternity of representatives of (1) hospitals admig public <&ses, (2) the department of the mu P

the health service concerned with materna 'maternity voluntary organizations which are carry)?

o

service and work in Calcutta, (4) the fnt^efUthf function of other allied services. It should be tl

complete such a body to obtain in the fast P arme(i uiforraation regarding existing facilities

a ,mber of

with accurate knowledge of the total number^ ^ deliveries per annum in the city, to

con. -eS an(j

mcreasing the efficiency of the existing

making plans for their future developmen .

retence The recommendations which follow ma

^ noted

to completeness. They are outstanding .P ^ of itg during the course of this inquiry and

a taven jnto

findings and they are such as might be tai^ ^ consideration by a co-ordinating body, t:ons

suggested above, in the course of its deliberations.

(a) Staff.?Doctors and midwives eIJP ?Jfzations Public health authorities and vol"nt;| yqT.ecial training for maternity work should have

had sp rpjie iu the preventive aspects of matern

?

nQ

medical training of the sub-assistant surg j.-n^

means an adequate preparation for wor? +ra;nmg of and the same is true of the course fo

several midwives in many institutions. The fac

-dwiveS in hospitals which train medical students and , clinics Calcutta have neither antenatal nor post-natal^c !s sufficient evidence of the truth of this . .,nr :n More use should be made of the hea^up work

the existing maternity services, both lor i

jdwifery. m the homes and for the supervision , the The trained health visitor is the bac

?(jeauately Welfare centre system and at prese ?,

veme 0f staffed welfare centres are confined to ?-

Work of voluntary organizations m Caici ?

The work of midwives should be adequatelyd h; vised and refresher courses should be month dumber of cases which the midwife tak. , attend should not be greater than she can p P

SOme to in that time The number will depend extent on the area in which she works,

uot exceed 15 cases a month. e

(b) Antenatal care.?1. Systematic antena ^^

should be provided in connection wit i ^ -welfare

admitting maternity cases, maternity n '

This centres and domiciliary maternity ,,ijnics held antenatal care should include consul tatio

hy a doctor and follow-up work in the i ?

. 2. The system of booking for confinements

io ^geg

mtroduced in institutions admitting ma and and annual returns should be made for

Urgency" cases. . of welfare

3. The extension of the mtensiv *ntenatal care centre work which includes systemat ^< bribed areas (as at present carried on in small

ci -

Tndian Red m Calcutta by the welfare centres

o . centre),

Cross Society, and the Institute of Hygiene ^ The so that all areas are covered, is re

. carried on desirability of domiciliary midwifery

be? o Tl m connection with such centres is e P

ervision of makes for continuity of work, and, dn possible, the midwives by health visitors beco ?i?y,lp

i u hp availaoie 4. Milk and extra nourishment s V , who are

for pregnant women in poor circums , -

distributed enable to obtain proper food, and should

be ai

as part of welfare centre antenatal ca +;nns

5. In view of the importance of the ^^jas and of pregnancy, especially anccmia, tne

0f beds tuberculosis, the need for a generous - ^IV greatest [or antenatal cases in institutions is o

0nly that importance in Calcutta. It is necessaij greatly the number at present available shovil

^ cxist mcreased, but that closer c<?-operatl0?

'

s and the between welfare centres, domiciliary s

jnstitu- hospitals so that those cases found to Q

means of tional treatment in pregnancy may nav

obtaining it.

(c) Intranatal care.?1. More beds for confinements both in hospital and maternity homes, especially for women of the Mahommedan community, who at present take relatively less advantage of the facilities offered, are greatly needed. In addition a sufficient number of beds must be provided for those whose homes are

entirely unsuitable for confinement. 2. Regulations for the control and supervision of

maternity homes should be introduced. The prevention of overcrowding, the provision of an adequate and trained staff and the proper segregation of infected or potentially infccted cases are the outstanding require- ments.

3. More provision is necessary for beds for cases of puerperal sepsis delivered at home. Such beds should be in a separate block if possible, or at least in a

separate ward, and arrangements for the care of the infant while the mother is in hospital should be made.

4. When a case of puerperal sepsis occurs in the practice of a midwife she should not be allowed to attend normal confinements as long as she is in attendance on the septic case.

(d) Postnatal care.?Postnatal clinics (with arrange- ments for gynsecological treatment if necessary) should be held in maternity hospitals, maternity homes and welfare centres. Birth control advice should be avail- able for those women for whom rapidly repeated pregnancy is undesirable on health grounds.

(e) Special considerations. 1. Ancemia.?The diag- nosis and early treatment of anjemia in pregnancy is such a vital one in Calcutta that special methods of tackling it, apart from ordinary antenatal care, are

needed. It is suggested that (1) all antenatal clinics should have access to a central laboratory where examination of blood of anajmic women can be carried out; (2) that certain hospitals should provide special wards for the treatment of anajmia in pregnancy and (3) that the necessary treatment for milder cases as

out-patients should be available free of charge to poor patients at welfare centres, hospitals and maternity homes. The lay public, the health worker, midwives and doctors should be taught to recognize the early symptoms and signs of ansemia and to know what steps are necessary in order to get adequate treatment in pregnancy.

2. Tubercxdosis.?The problem of the tuberculous

mother, when home conditions are unfavourable, is one that can only be properly dealt with by providing institutional accommodation for her and segregation for the infant. Until such time as facilities for this are available, the provision of extra nourishment during pregnancy and lactation, and the closest possible co-

operation between the maternity services and the anti- tuberculosis service are required in order to reduce the ravages of this disease. This problem is undoubtedly the most complex of those relating to maternal

mortality in Calcutta, and raises difficulties which seem almost impossible of solution.

[The recommendations given are indications of the serious deficiencies, in the management of pregnancy and childbirth in Calcutta, revealed in this report; part II which follows is devoted to a detailed discussion of the causes of death, brought out in this inquiry.!