Community Health Department, SEWA-Rural, Jhagadia, India.
Trop Med Int Health. 2014 May;19(5):568-75. doi: 10.1111/tmi.12282. Epub 2014 Feb 18.
To understand changes in epidemiology of maternal mortality in rural India in the context of increasing institutional deliveries and implementation of community-based interventions that can inform policies to reach MDG-5.
This study is a secondary analysis of prospectively collected community-based data of every pregnancy and its outcomes from 2002 to 2011 in a rural, tribal area of Gujarat, India as part of safe-motherhood programme implemented by voluntary organisation, SEWA Rural. The programme consisted of community-based interventions supported by a first referral unit, and promotion of institutional deliveries. For every maternal death, a verbal autopsy was conducted. The incidence rates for maternal mortality according to place, cause and timing of maternal deaths in relation to pregnancy were computed. Annual incidence rate ratios (IRR) and 95% confidence intervals, adjusted for caste and maternal education, were estimated using Poisson regression to test for linear trend in reduction in mortality during the study period.
Thirty-two thousand eight hundred and ninety-three pregnancies, 29,817 live births and 80 maternal deaths were recorded. Maternal mortality ratio improved from 607 (19 deaths) in 2002-2003 to 161 (five deaths) in 2010-2011. The institutional delivery rate increased from 23% to 65%. The trend of falling maternal deaths was significant over time, with an annual reduction of 17% (adjusted IRR 0.83 CI 0.75-0.91, P-value <0.001). There were significant reductions in adjusted incidence rate of maternal deaths due to direct causes, during intrapartum and post-partum periods, and those which occurred at home. However, reductions in incidence of maternal deaths due to indirect causes, at hospital and during antepartum period were not statistically significant. Most maternal deaths are now occurring at hospitals and due to indirect causes.
Gains in institutional deliveries and community-based interventions resulting in fewer maternal deaths due to direct causes should be maintained. However, it would be essential to now prioritize management of indirect causes of maternal mortality during pregnancy at community and hospitals for further reduction in maternal deaths to achieve MDG-5.
了解印度农村地区产妇死亡率在不断增加的情况下，其流行病学变化。这一变化的背景是，越来越多的产妇选择在医疗机构分娩，同时实施了以社区为基础的干预措施，以便为实现千年发展目标 5 提供政策依据。
本研究对 2002 年至 2011 年期间，在印度古吉拉特邦一个农村部落地区，由 SEWA Rural 志愿组织实施的安全孕产项目中，每一次妊娠及其结局的前瞻性社区基础数据进行二次分析。该项目由社区为基础的干预措施和一级转诊单位共同支持，并促进产妇在医疗机构分娩。对每一例产妇死亡，均进行口头尸检。根据产妇死亡地点、死因和妊娠时间，计算产妇死亡率的发生率。采用泊松回归法，调整种姓和产妇教育因素后，计算每年产妇死亡率的调整发病率比（IRR）和 95%置信区间，以检验研究期间死亡率下降的线性趋势。
记录了 32893 次妊娠、29817 例活产和 80 例产妇死亡。产妇死亡率从 2002-2003 年的 607（19 例死亡）提高到 2010-2011 年的 161（5 例死亡）。机构分娩率从 23%提高到 65%。产妇死亡人数随时间的推移呈显著下降趋势，每年下降 17%（调整后的发病率比为 0.83，95%置信区间为 0.75-0.91，P 值 <0.001）。在产时、产后和在家分娩期间，直接原因导致的产妇死亡调整后发病率显著降低。然而，在医院分娩期间和产前期间，间接原因导致的产妇死亡调整后发病率没有统计学意义。目前大多数产妇死亡发生在医院，死因是间接原因。
应保持因直接原因导致的产妇死亡人数减少而带来的机构分娩率和以社区为基础的干预措施方面的优势。然而，现在的当务之急是在社区和医院层面，优先管理妊娠期间间接原因导致的产妇死亡，以进一步降低产妇死亡率，从而实现千年发展目标 5。
