Many a discussion and debate arose in the wake of the death of a woman at  Malappuram, following a home delivery or domiciliary delivery. It's been many years since Kerala, known for its educated citizens, achieved a Maternal Mortality Rate (MMR-Rate of maternal death per 1 lakh delivery ) at par with Western countries. We boast of an MMR of 19. This is while India as a country is  97 and the United States of America is  22.3. MMR is an indicator of the quality of the health care system and also reflects the capacity of the health system to prevent and address complications during pregnancy and childbirth.

The credit for achieving the lowest MMR in India goes to the government of Kerala, the central health department for women and child Development, and the association of gynaecologists of Kerala -Federation of Obstetrics and Gynaecology (KFOG). Kerala achieved the rate with much hard work and is close to that of most of the developed countries of the world, and stands sky high compared to the entire nation. That is why the state has been fretting over a single maternal death which occurred following domiciliary delivery, most probably due to bleeding. Let us look at the top-performing countries of the world .

As compared to other modes of workout, yoga is often considered the best exercise regime for expecting women as it is gentle and low-impact. Photo: iStock/NataliaDeriabina
The MMR is lowest in countries where a health professional attends labour. Photo: iStock/NataliaDeriabina

MMR of the top performers in the world
Norway - 0
Switzerland - 1
Sweden - 3
Canada - 8
China - 14
New Zealand - 14
Kerala - 19
US - 22

The MMR is lowest in countries where a health professional attends labour. The low maternal mortality rate of 19/100,000 in Kerala is pretty low compared to other states of India, which amounts to 118/100,000 in Bihar. This is achieved by the high rate of institutional deliveries in Kerala, 99%. The Kerala Government and the Kerala Federation of Obstetrics and Gynaecology (KFOG) are working hard to fulfil the vision of improving the health of the common people.

The government and KFOG together are conducting training programs for health personnel periodically, thereby increasing the awareness among the general population regarding the causes of maternal death and the remedies to prevent the adversities that can happen during childbirth. Presently, all pregnant women are getting antenatal care even from the start of pregnancy, so that screening for several complications of pregnancy is resorted to and remedial measures are started early. Labour is the most dangerous journey for the fetus. By proper monitoring in labour, the lack of oxygen supply to the fetus can be detected, and an appropriate decision can be taken. There will be situations where we have to decide on a cesarean delivery as an emergency. All these are possible only if the pregnant woman delivers in an institution.

The incident at Malappuram is tragic and unfortunate.  It is stated in the mother’s autopsy report that excessive blood loss is the sole cause of her demise. The fact that the mother who had given birth to the four babies in the past could’ve been easily saved if the delivery had been conducted in a hospital setup. Due to the ignorance of the people involved, all five kids are now motherless.

Representational image: Onmanorama/Canva
It is stated in the Malappuram mother’s autopsy report that excessive blood loss is the sole cause of her demise.Representational image: Onmanorama/Canva

The most common preventable conditions for a pregnant lady, which can result in her death if not adequately managed, are bleeding following delivery, high blood pressure, which can occur in about 7% of pregnant women and infection. All the hospitals in Kerala that regularly conduct deliveries are well equipped and capable of effectively combating these conditions, thereby saving many lives. 

In addition, well-trained staff and better infrastructure assure the perfect package to achieve the golden goal of single-digit MMR. All maternal deaths are thoroughly scrutinised by the district health administration and the KFOG so that the underlying cause and other contributory factors of the death can be identified and lessons can be learned about remediable factors that might save the lives of more mothers in the future. The Kerala Federation releases periodicals every few years to enlighten the practising obstetricians in the state about safe motherhood.

Neonatal Mortality Rates (NMR- Rate of death in a neonate within 28 days of delivery per 1000 live births ) is yet another indicator of the quality of healthcare. The NMR is also drastically affected by the unattended domiciliary delivery services by trained professionals. The major conditions which can affect the NMR are infections, asphyxia(lack of oxygen supply) and birth defects.

Regular prenatal checkups of pregnant ladies, addressing maternal health conditions effectively, and institutionalising childbirth are a multipronged approach that the health sector of Kerala has adopted to reduce MMR and NMR. Prompt antenatal visits and prenatal screening tests, including double marker tests and sonological markers, can effectively diagnose congenital anomalies and thereby help in improving NMR. Major congenital abnormalities are detected in the early months of pregnancy, 3rd-5th month, so that they are aborted if the couple wishes so. That is why we do not see as many abnormal children as we used to a few decades ago.

Exposure to stress hormones in utero can affect children's brain development. Photo: IANS
Only a trained professional in a hospital can tackle all the preventable adversities that cannot be handled by untrained personnel conducting the delivery in a domiciliary setting. Photo: IANS

Termination of pregnancy is done for fetuses with lethal congenital anomalies; if born, they can increasingly affect the neonatal mortality rates. Birth asphyxia, if not properly managed, can lead to short-term and long-term poor outcomes of the baby, resulting in neurological sequelae like cerebral palsy and behavioural abnormalities. In labour, fetal and maternal monitoring should be done to diagnose fetal jeopardy early and to prevent the occurrence of hypoxic-ischaemic encephalopathy, cerebral palsy, seizures and even death,  which can occur as a result of fetal hypoxia.

Only a trained professional in a hospital can tackle all the preventable adversities that cannot be handled by untrained personnel conducting the delivery in a domiciliary setting. The Government should take proper measures to prevent such mishaps as those that occurred in Malappuram, and unconventional practices should not be encouraged for the betterment of society.
(The author was a former professor of the Trivandrum Medical College and is also the Chairperson of the Safe Motherhood Committee of KFOG). 

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