Maternal Mortality and COVID-19 Pandemic: Looking Beyond SARS CoV-2 Infection

Ratna Biswas¹ · Manju Puri² · Abha Singh³ · Reena Yadav⁴ · Kiran Aggarwal⁵ · Anuradha Singh⁶ · Keerti Chandra⁷

Ratna Biswas is a Director Professor, Manju Puri is a Director Professor, Abha Singh is a Director Professor, Reena Yadav Director Professor and Head, Kiran Aggarwal is a Director Professor, 5, Anuradha Singh is a Professor, and Keerti Chandra is a Senior Resident.

Ratna Biswas

drratnabiswaspaul@yahoo.co.in

1 Director Professor, Department of Obstetrics and Gynecology, Lady Hardinge Medical College & Sucheta Kriplani Hospital (LHMC & SSKH), Shahid Bhagat Singh Marg, New Delhi 110001, India

2 Director Professor, Department of Obstetrics and Gynecology, Lady Hardinge Medical College, New Delhi, India

3 Director Professor, Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India

4 Director Professor and Head, Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India

5 Director Professor, Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India

6 Professor, Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India

7 Senior Resident, Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India

Objective To study the impact of COVID-19 pandemic on maternal mortality ratio, aetiological and modifiable factors for maternal mortality and key interventions performed.

Method Retrospective exploratory study evaluating maternal mortality between April to November 2020 (study group) and 2019 (control group).

Results Demographic variations existed in the two groups. Increased maternal age and illiteracy were significantly more in the study group. Maternal mortality ratio (MMR) was significantly high in the study group (792 vs. 296 p value = 0.0). Hemorrhage accounted for 20% and COVID-19-related maternal deaths accounted for 15% deaths in the study group. Level 3 delay (delay in receiving care/inadequate care) was observed in 35% in the study group and 28% in control group (p value = 0.349). 17.5% of mothers in the study group as compared to 8% of control group were dead on arrival to hospital though not statistically significant (p value = 0.28). Significantly more women in study group died within 24 h of admission (45% vs. 20%, p value 0.04). Among the key interventions, the use of supplemental oxygen was significantly high in study group (p value = 0.02).

Conclusion Maternal mortality ratio was high in the pandemic year because of a significant decline in hospital delivery rate. The lesson learnt from this pandemic needs to be documented to guide better planning in the future to face similar situations.

Keywords : Maternal Mortality · ICD-10MM (International Classification of Disease-10 Maternal Mortality) · Levels of delay · Key interventions · Maternal mortality ratio (MMR)

Maternal mortality is defined by the World Health Organization (WHO) as "Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” [1].

Maternal mortality ratio (MMR) is a yardstick to measure the health status of a nation. Availability of integrated health facilities, skilled health personnel and optimal utilization of services are benchmark of good health care system.

But despite having world class infrastructure and highly advanced health services many countries reeled under the impact of the unexpected COVID 19 pandemic. The COVID SARS -2 pandemic affected millions of people and overburdened the existing health care facilities in most countries. In India, many tertiary care centers were converted to COVID care centers and the routine medical services including obstetric care were disrupted.

Antenatal visits were reduced due to the fear of spread of infection. Further, lockdown imposed restrictions on movement leading to delays in access to health care. There was a change in admission policy, many hospitals admitted patients only after a COVID RTPCR negative report and other COVID-dedicated hospitals admitted patient only after a COVID positive report leading to a delay in receiving care awaiting the report. Women often had multiple referrals before admission because of refusal on grounds of non-availability of COVID report, lack of facilities and/ or manpower.

The COVID SARS-2 infection affected the maternal mortality in more ways than one. There was a decline in institutional delivery rate. Non-obstetric maternal deaths increased consequent to COVID-19. This study was undertaken to the assess the impact of COVID-19 pandemic on maternal health by comparing the maternal deaths during COVID-19 pandemic with maternal deaths in pre-pandemic period.

Declarations
Conflict of interest There is no conflict of interest.

Ethical Approval The study was approved by the institute’s ethical committee.

Informed Consent Waiver of consent was sought as it is retrospective study on maternal mortality and all data were deidentified.

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