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Indian Journal of Community Medicine

Outcome of Antenatal Care in an Urban Slum of Delhi

Author(s): S. Sinha

Vol. 31, No. 3 (2006-07 - 2006-09)

S. Sinha1

Introduction

Most of the studies on pregnancy outcomes, maternal mortality and early neonatal mortality in India are hospital based and do not reflect the true picture of the situation in the community. Recently there have been few communitybased inquiries into this problem in this subcontinent5-7. However, no detailed community analysis is available from an area where maternal care us an integral component of reproductive health has been implemented by a nongovernment organisation. The present analysis provides information about maternal death, pregnancy outcomes, early neonatal deaths and their correlation with the extent of antenatal care in an urban slum.

Material and Methods

A project on reproductive health and child survival funded by McArthur Foundation and USAID was implemented from mid 1995 to January 2000 in Sangam Vihar, an urban slum of Delhi. The project works with 55000 population, which is divided, into three administrative units. Being an unauthorised slum it is denied basic amenities like sanitation, road, water supply, electricity, health post etc. The population comprises of migrants mainly from Bihar, UP and Rajasthan. The problems faced by the people residing in this area are poverty, illiteracy, overcrowding and inadequate housing. Maternal care is one of the interventions of this project. This intervention is addressed by clinic and community based service delivery strategies. The aim of these strategies is to ensure early registration of all pregnant women in antenatal clinic, timely identification and referral of complicated or high risk cases. Women are educated by community health guides about hygiene, nutrition, immunisation, breast-feeding, family planning, and danger signs of pregnancy and labour. The community runs ambulance service for emergencies. Trained health guides provide domiciliary antenatal checkup and counseling under supervision of project staff. All births and deaths are registered by the community health guides and subsequently recorded in the field office. Verbal autopsy is performed for all stillbirths, maternal and infant deaths to assess the cause of death.

The present analysis was done in one of the administrative units, which covers 17500 population. All births that occurred during August 97 to September 98 (14 months) were analyzed retrospectively from the records. Aside from births, early neonatal deaths among this group and maternal mortalities during that period were also analyzed retrospectively. Thus, data on 799 births were analyzed to know the current scenario of maternal care. Analysis was done in terms of live births, still births, low birth weight babies and early neonatal deaths. Maternal deaths were also probed.

Results

Out of 799 births, in 737 cases mothers were registered in antenatal clinic and 19 terminated into still births giving a still birth rate of 23.78/1000 births, (92.24 %), out of 780 live births, 150 babies had birth weight below 2500 gms. (19.2%), 11 babies died within 7 days after birth giving the no. of total perinatal deaths 30 and perinatal death rate of 37.54/1000 births. Out of 780 live births 2 pregnancies ended into maternal deaths (maternal mortality rate 2.56/1000 live births).

Table I: Relationship of Antenatal Checkup with Perinatal Mortality

No. of check up Perinatal deaths Total births
> 2 15 (2.3%) 651
< 2 15 (10.1%)* 148*
P < 0.01

Table I shows that women who had undergone two or more ANC had significantly lesser number of perinatal deaths as compared to those with one or no ANC. (P< 0.01).

Table II: Distribution of Still Births in Relation to Danger Signs

Danger signs Still births Live births
No fetal movement 3 1
Breech 3 18
Past history of still birth 2 11
IUGR 2 19
Pregnancy with fulminant hepatitis 1 0
P I H with PET 1 0
Post dated pregnancy 1 3
Prolonged labour 1 34
Severe Anemia 1 51
Short stature 1 73
Unknown 3

Breech, absent fetal movement experienced by mother, previous history of still birth and IUGR were associated with higher number of still births (Table 2).

Leading cause of early neonatal death among 11 deaths is low birth weight and prematurity (27.27%), followed by congenital anomaly, (18.2%), sudden infant death syndrome (SIDS) (18.2%) and perinatal anoxia (18.2%) and sepisis and accident were 9% each. Both deaths due to SIDS were weighing less than 2500 gms. Thus babies weighing less than 2500 gms., contributed 45.45% of total mortality. 45.45% of early neonatal deaths occurred within 24 hours.

Table III: Relationship of Low Birth Weight with Early Neonatal deaths

Birth weight Early neonatal deaths Total live births
< 2500 gms 9 (6%) 150
> 2500 gms 2 (0.3%)* 630
*P< 0.01

Table 3 shows incidence of early neonatal deaths among low birth weights is 6% as compared to 0.32% among normal weighing babies. Thus low birth weight babies have significantly poor chance of survival (P< 0.01).

Table IV: Risk associated with first order births

Birth order Perinatal deaths Total births Perinatal mortality rate
One 10 159 62.9*
Two and more 20 640 31.2
Total 30 799 37.5

About a third perinatal deaths (33.3%) occurred in first order births and another 23.3% in fifth and above order births. Table 4 shows that first order births have twice the risk of perinatal deaths as compared to that of others. Out of the two maternal deaths, the first was an unregistered recent migrant who expired due to post partum hemorrhage at home. The other case died due to fulminant hepatitis.

Discussion

The present analysis shows that very high 92.24%, of births mothers were registered in the project area, compared to other studies in the country. Where it ranged from 44% to 82%4,8,9,10.

The perinatal mortality was 37.54 per 1000 total births, compared to 44.2 in India (1993)4 and 55 for the developing countries11. So the present study shows a markedly lower figure. It is also much lower than another study in ICDS urban slums in Lucknow where the perinatal mortality rate was 596. An 1CMR study reported a perinatal mortality rate of 65 in ICDS project areas in urban slums of Delhi12. The present study with a perinatal mortality rate of 37 is close to envisaged goal of 30-35 by year 2000 AD.

The still birth rate in the present analysis was 23.78 per 1000. It is slightly lower than the still birth rate of 26 reported by a multicentric study of ICMR12. The NFHS (1992-93) has reported still birth rate of 23 per 1000 for India. So the still birth rate of the area is comparable with this report. However another study from urban slums of Lucknow reported a still birth rate of 37.266, which is much higher than the present study.

Maternal mortality rate was found to be 2.56 per 1000 live births in the present study. It is much lower than 4 as reported by the Ministry of Health and Family Welfare for India and 3.97 for urban sector. Another estimate from an econometric model quotes maternal mortality rate of 5.5513. Thus maternal mortality in the study area is much lower than the above reports and close to the national goal of 2 per thousand live births by the year 2000 AD.

The incidence of tow birth weight babies (those weighing less than 2500 gms.) in the present study is 19.2 %. Ministry of Health and Family Welfare quotes a figure of 30% for India (1992)4. This rate indicates the status of pregnant mothers and is the single most important determinant of effectiveness of antenatal care.

The present analysis shows that outcome of pregnancies in terms of perinatal deaths, low birth weight and maternal deaths improve significantly for women who have at least two antenatal check ups. Thus it justifies the objective of the project which states that the pregnant mothers should have at least two antenatal checkups. Other studies have also reported a higher mortality in cases with no antenatal checkup6,14-16.

Out of the noted risk factors for malpresentations delivered at home and complaint of no fetal movement carried the greatest number of still births. Next in order is previous history of still births and IUGR cases. Out of all causes noted for early neonatal deaths, prematurity is the leading cause. This result is in conformity with other studies6,17,18. In the present study all babies who died due to prematurity and SIDS were low birth weight babies. Thus low birth weight was associated with 45% of early neonatal deaths. About 45% of early neonatal deaths occurred within 24 hours of delivery and 63% within 48 hours of delivery. One third of perinatal deaths occurred in cases of first pregnancies. Grandmultipara forms the second highest group, which contributes 23% of perinatal deaths. Thus primi and grandmultipara together make 56% of perinatal deaths.

A limitation of the present analysis is that spontaneous abortions and medical termination of pregnancies could not be incorporated because of lack of detailed information.

References

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  14. Sachar RK, Soni RK, Singh WP, Dhot, Gill PJS, Arora Sona, Singh, Dhiman B. Perinatal mortality and pregnancy wastage in ten Punjab villages during 1991-96. A population based study. Ind. Jr. of Comm. Med. 1998; 23:3: 99-104.
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1 Medical Officer,
CASP-PLAN Project on Reproductive Health and Child Survival, New Delhi. 1998.
E-mail: [email protected]

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