1. Aggarwal A, Pandey A, Bhattacharya BN. Risk factors for maternal mortality in Delhi slums: A community-based case- control study. Indian J Med Sci 2007;61:517-26

2.  To learn about maternal mortality indicators.

3.  In order to develop, implement and evaluate policy for reducing maternal mortality, it is essential to study risk factors.  Pregnancy complications and childbirth- related complications are the major causes.  MMR in India is far from the desired level of 100 by 2012 set by the National Rural Health Mission (NRHM) and 109 by 2015 as per millennium development goals (MDG).

4.  To determine the epidemiological risk factors and its related causes associated with maternal deaths in Delhi slums.

5. 929 slums 328 slums (1.25 million) 21 health centers (50000) 105 health post (10000) 6 maternity homes (2 million) Source of information Community-based case-control study

6. Definitions of Cases and Controls:  Case : A woman who was pregnant and whose pregnancy's outcome was a live birth but the woman died within 42 days of delivery.  Control: A woman who was pregnant and whose pregnancy's outcome was a live birth and the woman was surviving at the time of survey. Method of identifying Cases and Controls:  Cases: Snowball-sampling method was used to identify the maternal deaths (cases) in the community and hospital recods.  Controls: Circular systematic random sampling procedure was used to select the controls from the same area where a maternal death was found.  Exclusion criteria: pregnancy outcome SB/abortion.

7. Identify household of maternal death Ask about similar event occurred to respondent. ANM/ basti sevika Snow ball sampling

8. 1 case= 3 controls 1.1 Total no of households with a live birth/ no of controls (384) 1.2 controls were found i.e. 3 times cases. Then every k th household of live birth was selected as control.

9. 131 70(61) cases 393 384(9) controls

10. type of house, family, separate kitchen, type of toilet, woman’s and husband education. Socioeconomic variables Current age, age at marriage, parity c/x during pregnancy Biological variables Utilization of health facilities ANC, delivery care, distance of residence from HF. Environmental variables

11. RESULTS

12. CAUSES OF MATERNAL DEATHS total PERCENTAG E (%) NUMBERPERCENTAG E Direct causes 43 (61.4) PPH1521.4 Retain placenta1217.2 Sepsis811.4 Obstructed labour 11.4 Embolism11.4 Indirect causes27(38.6) Anaemia1521.4 Post op68.6 Other1217.2

13.  No significant difference was found in household characteristics.

14. VariablesCase (%) (n=70) Control( %) (n=384) P Value Education Level Illiterate54 (77.1)234(60.9)0.005 Literate16(22.9)150(39.1)Ns Husband’s Education Illiterate31(44.3)113(29.5)0.007 Literate39(55.7)(70.5)Ns Type of Family Nuclear40(57.1)262(68.2)0.03 Joint30(42.9)122(31.8)Ns Current Age > 3513(18.6)26(6.8)0.0006 Parity 210(14.3)106(27.6)0.0107

15. VARIABLESCASES(%)CONTROL(%)P VALUE ANC registration Yes54(77.1)349(90.9)NS no16(22.9)35(9.1)0.0004 Received TT injection No15(21.7)37(9.7)0.002 Consumed IFA < 10033(47.1)250(65.1)0.006 Distance of Health Facility > 5 km37(61.7)56(19.1)0.00003 Mode of transport by walking5(8.1)56(20.1)0.025 Auto-rickshaw41(66.1)85(30.6)0.001 manual rickshaw5(8.1)95(34.2)0.001 Place of delivery home39(55.7)268(69.8)0.02 hospital31(44.3)116(30.2)0.02

16. VARIABLECASE(%)CONTROL (%) P VALUE Complications during pregnancy Anaemia33(47.1)27(7.0)<0.001 High BP3(4.3)4(1)NS Jaundice6(8.6)5(1.3)<0.001 Fever13(18.6)50(13.0)0.1062 Abn +nt of child14(20.0)20(5.2)<0.001 Complications during delivery Exce. bleeding5(7.1)2(0.5)<0.001 Retained placenta5(7.1)1(0.3)<0.001 Delivery by untrained dai37(94.9)194(72.4)<0.001 Institutional death47(67.2) Death <24 hrs23(48.9)

17. Independent VcasescontrolsORCIP value Current age 20-29 yrs 381272.41.43-4.030.001 Illiterate women542342.161.19-3.920.011 Parity ¼241931.941.14-3.300.001 Distance >5 km562376.813.75-12.360.0001 Delivery conducted by untrained dai 37946.871.61-29.20.009

18. COMPLICATI ON ODDS RATIO95% C IP VALUE Anaemia11.766.09, 22.71<0.001 Ex. bld during delivery 12.822.08, 79.040.006 Abn + of child2.851.14, 7.120.025 R. placenta41.924.5,3 88.750.001 Jaundice1.990.47, 8.40.346

19. INSTITU TE YRMMRCauses of Mat ernal Deaths in % HgeToxemiaSe psis Anae mia jaun dice others Present study 2007-21.4-11.421.4-- Bera and Sengupta (K) 79-80100923.8171651916 Ramteke and Pajai 3 (Y) 92-9410482912.2512.2 4 12.9 4 527 Sapre and Joshi (Gw) 71-96144817251225414 Pal and ray (WB) 94-046239.750184215 SRS1998540(N FHS) 3081619-8 WHO report 2005-25-1520-8

20.  Use of a cost-effective snowball-sampling technique.  The major direct causes - PPH, F.B. retained placenta and sepsis.  As per the report of the sample registration system (SRS) –hemorrhage 38%, which is much higher than this study’s estimate.  Hypertensive disorders are one of the causes of maternal deaths, our study did not find any such case.  Maternal deaths d/t retained placenta was found to be marginally higher than those reported elsewhere. Anemia -major cause of maternal death in the present study

21.  Entire study population was from urban slums, socioeconomic characteristics do not show statistically significant differences between cases and controls.  Investing in training of untrained dies should be considered by policy makers and donor agencies.  A high proportion of maternal deaths occurred in hospital set up - deliveries were conducted at home by untrained dais and were rushed to a hospital at the last minute.

22.  Mass education about the importance of antenatal registration and regular ANC checkups.  Focus on training of dais.  Encouragement for institutional deliveries to reduce maternal mortality at the community level.