CHAPTER 2

VITAL HEALTH INDICATORS

MATERNAL VITAL STATISTICS

Understanding how a population is coping with the burdens of reproduction is vital. High-quality population based data are essential in the interpretation of obstetric and maternal care. This valuable insight can provide populations with the opportunity to intervene for improved outcomes for women and infants.

MATERNAL MORTALITY RATIO (MMR)

• The maternal mortality ratio is the number of women who die from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespectiveof the duration and site of the pregnancy, per 100,000 live births.
• MMR in India is 130 per 100,000 live births (2018).

MATERNAL DEATH

Maternal death is ‘death of a woman while pregnant or within 42 days (6 weeks) of termination of pregnancy, irrespective of the duration or site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental cause.

No. of maternal deaths in a given year

Total no. of live births in the same year× 100,000

MMR=

MATERNAL MORTALITY RATE

It can be obtained by dividing the average annual number of maternal deaths in a population by the average number of women of reproductive age (15- 49 years of age) who are alive during the observation period.

CLASSIFICATION

The causes of maternal death may be classified into

MENTAL ILLNESS

When an individual is not able to view himself/ herself clearly or has a distorted view about self, is unable to maintain satisfying personal relationships with others, and is unable to adapt his/her environment, a mental illness occurs.

FACTORS ASSOCIATED WITH MATERNAL MORTALITY

Five Clearly Defined Global and National Targets for 2025

The Ending Preventable Maternal Mortality (EPMM) initiative, which includes a broad coalition of partners working in maternal and newborn health, has established new coverage targets and milestones that need to be achieved by 2025 if the SDGs are to be met.

MILESTONES TOWARDS PROGRESS

STEPS TO REDUCE MATERNAL MORTALITY

1. Policy Initiatives
2. Programme Initiatives
3. Family Planning Counseling
4. Essential Obstetric Care

INFANT MORTALITY RATE

It is the number of deaths under one year of age per 1000 live births in one year.

Infant mortality rate is the ratio of infant deaths registered in a given year to the total number of live births registered in the same year.

Number of deaths under one year of age

Total live births in the year

IMR =

× 1000

THE CAUSES OF INFANT MORTALITY ARE AS FOLLOW:

Biological factors:

Birth weight (BW)

Age of mother

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Birth order :

Birth spacing

Multiple births

High fertility

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Economic factors

Socio-economic status (SES)

Cultural and social factors:

Breastfeeding

Religion and caste

Early marriages

MEASURES TAKEN TO REDUCE INFANT MORTALITY RATE

• Promotion of Institutional Delivery through Janani Suraksha Yojana (JSY)

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• Emphasis on facility-based new-born care at different levels to reduce infant Mortality

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• Capacity building of health care providers

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• Management of Malnutrition

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• Appropriate Infant and Young Child Feeding (IYCF)

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• Universal Immunization Programme (UIP)

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• Janani Shishu Suraksha Karyakaram (JSSK)

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• Home based new born care (HBNC)

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• Mother and Child Tracking System (MCTS)

NEONATAL MORTALITY RATE (NNMR)

• Neonatal deaths: Deaths occurring within 4 weeks or 28 days of birth are called neonatal deaths.”
• Neonatal mortality rate (NNMR): Is the number of neonatal deaths (deaths within completed 28 days after birth) per 1000 live births in that year.

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• NNMR =

× 1000

No. of neonatal deaths in a given year

Total no. of live births in the same year

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EARLY NEONATAL MORTALITY

LATE NEONATAL MORTALITY (LNNM)

CAUSES OF NEONATAL MORTALITY (0-4 WEEKS)

MEASURE TO REDUCE IMR

• Promotion of Institutional Delivery through Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK)

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• Strengthening Facility based newborn care

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• Home-based Newborn Care (HBNC)

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• Ensuring a single dose of Injection Vitamin K prophylaxis

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• Capacity building of healthcare providers

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• Management of Malnutrition

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• Village Health and Nutrition Days (VHNDs)

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PERINATAL MORTALITY RATE

Perinatal mortality is defined as deaths among fetuses weighing over 1000 gm at birth who die before and during delivery or within the first 7 days of delivery. The perinatal mortality rate is expressed in terms of such deaths per 1000 total births.

Perinatal mortality rate =

Number of deaths occurring from 28 weeks of Gestation or under one week after birth

Total no. of live births in the same year

× 1000

Predisposing Factors of Perinatal Mortality

• Epidemiological: Age over 30 years, parity above 5, low socio-economic condition, poor maternal nutritional status; etc.

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• Medical disease: In anemia with (Hb% <8g/dL), diabetes mellitus, syphilis, acute fever and infection. The total risk of death increases due to hypoxia, intrauterine growth restrictions, prematurity and infection. Hypertensive disorders of pregnancy

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• Obstetric Complications :

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Causes of Perinatal Mortality

• Related clinical conditions: In about 25% deaths are related to prolonged and difficult labour, in about 20% related to pregnancy complications and in about 40% deaths remain undermined. Direct causes of death as revealed by autopsy.
• Direct causes of deaths: About 80% of the perinatal deaths are related to perinatal hypoxia, low birth weight, infection and intracranial hemorrhage. The undetermined group is reduced to 15%.

Prevention of Perinatal Mortality

• Pre-pregnancy healthcare counseling.
• Genetic counseling in high-risk cases and the role of prenatal diagnosis to detect genetic, chromosomal or structural abnormalities are essential.
• Termination of an affected fetus is a positive step in the reduction of deaths due to congenital malformations.
• Regular antenatal care, with advice regarding health, diet and rest.
• Improvement of maternal nutrition.
• Immunization against tetanus should be done as a routine.
• Screening of high-risk patients

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FERTILITY RATES

The general fertility rate is the number of resident live births for a specified geographic area (nation, state, county, etc.) during a specified period (usually a calendar year) divided by the female population aged 15-44/49 years (usually estimated for a mid-year) for that area, and the resulting fraction multiplied by 1,000.

GFR =

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Number of live births in an area during the year

Total Female population aged 15-44/49 in the same area in the same year

× 1000

OTHER IMPORTANT HEALTH INDICATORS

Under-Five Mortality Rate

It is the annual number of deaths of children aged under 5 years, expressed as a rate per 1000 live births.

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Under-five mortality rate =

Number of deaths of children less than 5 years of age in a year

Number of live births in the same year

× 1000

Birth Rate

The Birth rate is defined as the number of live births during a year per 1000 estimated mid-year population. It is given by the formula:

Number of live births during the year

Estimated midyear population

× 1000

Birth rate =

Death Rate

The death rate is defined as the number of deaths per 1000 population estimated mid-year population in one year. It is given by the formula:

Death rate =

× 1000

Number of deaths during the year

Estimated midyear population

STILL BIRTH

A stillbirth is a birth of a newborn after the 28th completed week when the baby does not breathe or show any sign of life after delivery. Such deaths include antepartum deaths and intrapartum deaths. The stillbirth rate is the number of such deaths per 1000 births.

Antepartum deaths �Intrapartum deaths �Acute fetal distress �Traumatic vaginal delivery leading to asphyxia or intracranial hemorrhage. �Asphyxia-premature babies are more vulnerable. �Congenital malformation of the fetus.

Causes

MATERNAL DEATH AUDIT/REVIEW

• Maternal Death Review (MDR) as a strategy has been spelled out clearly in the RCH – II National Programme Implementation Plan document.
• It is an important strategy to improve the quality of obstetric care and reduce maternal mortality and morbidity.

Different Approaches to the Investigation of Maternal Deaths

• Community-based maternal death review (Verbal autopsy).
• Facility based maternal deaths review
• Confidential enquiries into maternal deaths
• Surveys of severe morbidity (near miss)
• Clinical audit

STEPS IN CONDUCTING MDR