Maternal mortality in India.

Authors worked on maternal mortality in India from 1992-94. This article is a review article on the basis of authors' experience. The article starts with the brilliant sentence, 'Maternal mortality in India is unacceptably high' and ends with the suggested strategies to solve the problem.

Evaluating contraceptive choice through the method-mix approach. An Indian Council of Medical Research (ICMR) task force study.

The method-mix approach was used to evaluate informed contraceptive choices in the present study. A total of 8,077 potential clients were given a balanced presentation of all available contraceptive methods in the national program, ie, the CuT 200 intrauterine device (IUD), low-dose combined oral pills (OC), condom, and sterilization (female/male) along with a new method, Norplant(R).(1) The majority of women opted for spacing methods; among them, the IUD was preferred by about 60% of clients, followed by condoms (9%), OC (6%), and Norplant (5%). Sterilization, mainly female, was accepted by about 17% of the women making an informed choice. The economic status of couples did not influence the contraceptive choices, as all the methods were offered free of cost in the present study, which is the current practice in the national program. Illiterate women more often accepted sterilization (about 25%) than did literate women (15%). This is because illiterate women had more children; about 30% of illiterate women had three or more children, as opposed to 16.2% of literate women. However, literacy status did not influence the choice of any specific spacing method. The study also revealed that, by encouraging potential clients to make an informed choice, they could override the provider's bias while accepting a particular type of spacing method. This is evident from the observation that Norplant was the first choice of the provider for 35% of the women, whereas only 5% of women preferred and accepted Norplant. The present study stresses an urgent need to promote the practice of informed choices in the national program with a variety of contraceptive options-especially, spacing methods for improving contraceptive prevalence and reproductive health in the country.

Return of fertility following discontinuation of Norplant-II subdermal implants. ICMR Task Force on Hormonal Contraception.

A total of 627 women who had discontinued the use of the Norplant-II implants for various reasons and were exposed to the risk of pregnancy were followed-up for two years for return of fertility. The cumulative conception rates in women who had discontinued due to planning pregnancy were 80.3 per 100 women at one year and 88.3 per 100 women at two years. The majority of women who did conceive (90 percent), had full-term normal live births; about 4 percent of women had spontaneous abortions, the remaining 6 percent decided on elective termination of pregnancy (ETP). The cumulative conception rates in women who discontinued due to bleeding irregularities and 'other reasons' were 64.5 and 55.8 per 100 women at one year and 77.9 and 75.1 per 100 women at two years, respectively. These rates were significantly lower as compared to those observed in women who discontinued due to planning pregnancy. A large proportion, about 40 percent, of women who conceived after discontinuation of the method due to bleeding irregularities and "other reasons," opted for ETP indicating that many women in these two groups did not desire another child and that such women need to be counselled for adopting another method of contraception. The spontaneous abortion rates observed in ex-users of Norplant-II implants (1.7 to 4.4% pregnancies) were comparable to the spontaneous abortion rates prior to Norplant-II implant use (3.6% pregnancies) indicating that ex-users of Norplant-II implants were not at a higher risk of spontaneous abortion.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Researchers at 15 Human Reproduction Centres of the Indian Council of Medical Research followed 627 women aged 18-35 who stopped using the subdermal Norplant-II system for different reasons, and thus were exposed to the risk of pregnancy, for 2 years to determine return of fertility. 20% conceived within 1 month of Norplant-II implant removal. The 6-month, 1-year, and 2-year pregnancy rates were 63.4%, 80.3%, and 88.3%, respectively. Neither duration of Norplant-II implant use nor bleeding patterns had an adverse effect on return of fertility. The 1-year and 2-year cumulative pregnancy rates for women who stopped due to bleeding irregularities and other reasons were lower than those who stopped due to planning a pregnancy. Return of fertility was delayed in women whose implants were removed after age 30 compared to those younger than 30 (1-year pregnancy rate, 66.3% vs. 83%; median time to conception, 6 vs. 3.8 months; p 0.05). The difference was not significant at 2 years, however. 89.7% of women who wanted pregnancy and became pregnant after discontinuation delivered full-term live infants. 4.4% had a spontaneous abortion. Women who discontinued the implant system to conceive were less likely to opt for an induced abortion than those who discontinued for irregular bleeding and other reasons (5.9% vs. 36.4-41.6%), suggesting that many women did not want another child and need to be counseled about adopting and offered another contraceptive method. The spontaneous abortion rates for women who discontinued for irregular bleeding and other reasons were 1.7% and 2.7%. No group of former Norplant II users suffered a spontaneous abortion rate greater than the pre-Norplant II use rate (3.6%). These findings show that the Norplant-II implant system does not delay return to fertility in women who stop using it to become pregnant.

Birth outcomes by birth order and maternal nutritional status.

PIP: Birth weights were studied of infants born to 432 women who delivered at SSG Hospital and Medical College in Baroda, India, in 1993 to determine whether birth order and maternal age have effects on birth weight independent of social disadvantages, as measured by maternal height, weight, and hemoglobin level. The weight-height product index (WHPI) (kg x cm x 100/45 kg x 150 cm) was used as one of the indicators for maternal nutrition. Mean WHPI was 101.83. Mean maternal weight and height were 46.56 kg and 147.49 cm, respectively. The hemoglobin level stood at 9.5 g/dl. Mean gestational age was 38.02 weeks. Even though the birth weight of newborns of women in the C nutritional status group (i.e., WHPI = 101.83) were significantly smaller than those born to mothers in the next higher nutritional status group (WHPI = 133.49) (2283 vs. 2381 g; Z = 1.99), the proportion of low birth weight ( 2.5 k) infants in the C group was not significantly different from those in the B group (54.54% vs. 53.08%). The proportion of low birth weight newborns was higher in the birth order 1 group than higher birth order groups (61.04% vs. 50.23% for birth order 2-3 and 37.7% for birth order =or 4). Yet, there was no significant difference in mean birth weight by birth order. When comparing birth weights within the same age group, mean birth weight was significantly greater after birth order 1 regardless of maternal age. Among 16.5-34.5 year old mothers, the percentage of low birth weight newborns was much higher in birth order 1 than higher birth orders (60.45% vs. 48.79%; p 0.02). Thus, within the same age group, first order births have a lower birth weight and a higher incidence of low birth weight than higher order births.^ieng

Bishop's score and induction of labor in prelabor rupture of membrane.

PIP: At the obstetrics department of SSG Hospital in Baroda, India, data was compared on 79 pregnant women at or near term presenting with prelabor rupture of membranes (PROM) with data on 79 pregnant women presenting with intact membranes to determine whether induction of labor contributes to maternal complications. Women in the study group were observed for 1 hour for uterine contractions and then received oxytocin to induce labor. Women in the control group were observed for spontaneous progress of labor. Operative deliveries (e.g., forceps/vacuum) were more common in the study group than the control group (10-36.58% vs. 5.55-16.22%). The difference in assisted deliveries was significant for Bishop's score categories 4-6 and 6-8 (p 0.05). The lowest Bishop's score (4-6) yielded the highest assisted delivery rates (e.g., among primigravidae, 36.58% for study group and 16.22%). 78.78% of PROM women who crossed the alert line and all of those who crossed the action line required operative delivery compared to 50% and 81.82%, respectively, for the control group. PROM women experienced a longer latent phase of labor than did the control group (12.06 vs. 8.42 hours). The duration of other labor phases was comparable. The likelihood of spontaneous vaginal delivery was greater when the latent period lasted more than 12 hours. Based on these findings, induction should not be done on PROM women with no obvious infection or obstetric hazard. If induction is indicated, it should not be done until the Bishop's score reaches 6-8.^ieng

Adolescent sexuality education and sources of information.

PIP: A survey of 959 young females (ages 10-21 years) from India highlighted the importance of educational attainment to fertility-related behaviors. Respondents represented a spectrum of educational levels: school drop-outs (32%), primary and secondary school attendees (41%), and college students (27%). The mean age at menarche was 13.6 years. School drop-outs were most likely to have obtained information about sexuality from films and other mass media, while students cited friends and neighbors as primary sources. There was an positive association between educational level and both preferred age at marriage and intended interval from marriage to first birth. 42% of adolescents with a secondary or college education planned to marry after 23 years of age and 84% wanted to defer childbearing for at least two years after marriage. The desire for formal sex education was strong in all educational subgroups (about 62%), however. It has been estimated that postponement of the marriage age from 16 years to 20-21 years would result in a 20-30% decrease in the annual number of births in India. School-based sex education represents a feasible mechanism for helping to achieve this goal.^ieng

Postabortal sepsis.

A review of postabortal sepsis following a 2-year study undertaken at the Department of Obstetrics and Gynaecology, SSG Hospital, Baroda is presented here with a view to know the incidence of postabortal sepsis and septic induced abortions and to re-evaluate the effectiveness of the MTP services in reducing its impact on maternal morbidity and mortality, since the implementation of the MTP Act in 1972. It has been observed that postabortal sepsis is a major cause of maternal mortality even now and MCH service is to be improved to reduce the same.

Maternal manifestations of malaria in pregnancy: a review.

PIP: Malaria is a major cause of maternal and fetal morbidity and mortality, and this risk is highest in the areas of unstable malaria transmission. In 1990 and 1991 the Department of Obstetrics and Gynecology of Sir Sayajirao General Hospital in central Gujarat, India, has cared for a total of 445 urban as well as rural patients with malaria in pregnancy: 232 were labor ward admissions and 213 were antenatal ward admissions. Plasmodium falciparum infection affected 97.27% of patients, both primigravidae and multigravidae. Heavy parasitemia was observed in 27.14% of primigravidae and 48.57% in secundigravidae, however, this was not statistically significant. Out of the 260 (58.42.) cases who had various degrees of anaemia, 59 (22.69) had severe anaemia with haemoglobin of less than 6.0 gm O/dl. Within this group, 71.16% women were primigravidae or secundigravidae, the rest were multigravidae. Out of the 6 patients in first trimester, the miscarriage rate was 100%. In the second trimester, out of 52 patients 74.99 pregnancies were discontinued, whereas in the third trimester, the miscarriage rate was 18.17%. This observation was statistically significant (p 0.05). 178 patients who were admitted antenatally were discharged, their pregnancy outcome was not known, and accordingly they were excluded. There were 11 patients in the first trimester, 139 in the second trimester, and 295 in the third trimester. The known pregnancy losses were 54.54% in the first trimester. 28.05% in the second trimester, and 12.88% in the third trimester. 75.59% of those with minor parasitemia and 47.36% with heavy parasitemia had a normal pregnancy outcome. The overall fetal loss was 31.08%, which was almost twice that of the miscarriage rates among the general population. Maternal deaths attributed to malaria in pregnancy were 15, with cerebral malaria accounting for 5 deaths. 46.66% of the deaths occurred in primigravidae and secundigravidae. The other causes of mortality were postpartum hemorrhage, acute pulmonary edema, and hypoglycemia.^ieng

Pregnancy outcome in short statured women.

Three hundred and forty short statured mothers (height less than 145 cm) were compared with 680 mothers (height more than 145 cm) who served as control to isolate problems associated with pregnancy and labour in the former. Short statured mothers hailed from poorer social class and had an unhealthy family and past history and higher incidence of pelvic deformities and abnormal presentations. They had a lower possibility of delivering vaginally and higher incidence of instrumental deliveries. Their offsprings were likely to be less in weight and suffered from a significantly higher incidence of stillbirth and neonatal death. All this made a short statured mother a high-risk patient.

Randomized clinical trial with intrauterine devices (levonorgestrel intrauterine device (LNG), CuT 380Ag, CuT 220C and CuT 200B). A 36-month study. Indian Council of Medical Research Task Force on IUD.

A total of 1905 subjects were randomly allocated to four types of intrauterine devices (IUDs) and were observed for 45,683 woman-months of use. While no method failure was observed with levonorgestrel (LNG) IUD, 11 women became pregnant with other devices; 4 with Copper T 380Ag, 1 with Copper T 220C, and 6 while using Copper T 200B, indicating method failure rates of 1.0, 0.3 and 1.6, respectively, at 36 months of use. These rates were within acceptable range. Continuation rates were significantly lower with LNG IUD (74.5, 58.7, 38.8 at 1 year, 2 years and 3 years, respectively) as compared to other copper devices, which ranged between 82.4 to 84.4 at 1 year, 66.6 to 69.9 at 2 years and 45.4 to 50.4 at 3 years. The difference in continuation rates was mainly due to menstrual disturbances (e.g. amenorrhoea, irregular bleeding) which were higher with LNG IUD (27.9 per 100 users) as compared to the copper devices (13.4-15.4 per 100 users) at 36 months of use. The risk of expulsion ranged between 8.3 to 10.6 per 100 users and was comparable for all the devices. The observations from the present study based on 36 months of experience with different intrauterine devices do not indicate the need to replace CuT 200, the device currently in use in the National Programme.

Phase III-clinical trial with Norplant-2 (covered rods). Report of a 24-month study. National Programme of Research in Human Reproduction. Division of Human Resource Development Research Indian Council of Medical Research Ansari Nagar, New Delhi, India.

In a phase III multicentre clinical trial, the subdermal implant NorplantR-2 was studied for its clinical use effectiveness, safety and bleeding pattern. A total of 1466 healthy volunteers, with no contraindication to steroid use, were observed for 29,669 woman-months of use. One method failure was reported at 18 months of NorplantR-2 use. The method was associated with altered menstrual pattern with a trend towards reduced blood loss. The continuation rates were 88.1 and 73.5 per 100 users at 12 and 24 months of use, respectively. Menstrual disturbance, mainly prolonged bleeding, accounted for the majority of the discontinuations. Removal of NorplantR-2 due to local infection was rare (0.4 per 100 users at 24 months). In similar clinical trial conditions, the continuation rate with NorplantR-2 is significantly higher than those observed with LNG IUD and injectable contraceptives, norethisterone oenanthate 200 mg given every 60 +/- 5 days, and is comparable to that of CuT 200 IUD.

Liver stores of vitamin A in human fetuses in relation to gestational age, fetal size and maternal nutritional status.

1. Studies were made on liver stores of retinol in aborted human fetuses and stillborn babies in relation to gestational age, fetal size and maternal retinol status. The mothers belonged to low- and high-income groups (LIG and HIG respectively) in urban Baroda. 2. Fetal weights were less than those reported by Widdowson (1968) for similar gestational ages and the deficits were greater in LIG. 3. The combined mean values (microgram/l) for maternal serum retinol for all gestational ages were 193 for LIG and 261 for HIG. They were found to decline in late pregnancy in the former but not significantly in the latter. 4. Fetal liver retinol concentrations were much lower than those reported for healthy Thai subjects by Montreewasuwat & Olson (1979) in early pregnancy but showed complete 'catch up' in late pregnancy for HIG and to a considerable extent for LIG. 5. Significant correlations were found between maternal serum retinol, fetal liver retinol and fetal growth. 6. These findings stress the importance of adequate vitamin A supplies during pregnancy to prevent vitamin A deficiency and intra-uterine growth retardation in the newborn.

Vitamin E status of the newborn in relation to gestational age, birth weight and maternal vitamin E status.

1. Studies were made on the vitamin E status of the newborn as judged by cord serum vitamin E and erythrocyte haemolysis in vitro in relation to gestational age, birth weight and maternal vitamin E status in subjects belonging to low (LIG)- and high (HIG)-income groups in urban Baroda. 2. In the case of full-term infants, the mean values for maternal serum vitamin E (mg/l) for LIG (n 73) and HIG (n 43) were 9.9 (SE 0.4) and 11.6 (SE 0.5). The corresponding values for cord serum vitamin E were 3.6 (SE 0.2) and 4.6 (SE 0.2) mg/l. 3. Serum vitamin E levels (mg/l) were lower in premature infants (2.3 (SE 0.2); n 20) and low-birth-weight full-term infants (2.9 (SE 0.2); n 25) than in full-term normal infants (4.2 (SE 0.1); n 91). This was associated with differences in maternal serum vitamin E levels (7.4 (SE 0.5), 8.2 (SE 0.5) and 11.1 (SE 0.3) respectively). The differences were more marked for LIG. 4. A negative correlation was found between serum vitamin E and erythrocyte haemolysis in vitro in the case of maternal blood but not in cord blood. 5. These results suggest that maternal vitamin E deficiency is one of the features associated with prematurity and intra-uterine growth retardation.

Electrolyte studies after intra-amniotic instillation of 20 per cent sodium chloride.

PIP: Electrolyte studies following intraamniotic instillation of 200 ml of 20% sodium chloride are reported. In 300 cases of second trimester termination of pregnancy, sodium, potassium, and chloride in the blood, urine, and liquor were analyzed over 24 hours. There was no marked difference in blood electrolytes though abnormally elevated serum sodium concentrations were occasionally noted but no adverse effects were observed. The excretion of sodium and chloride in the urine increased slowly and most was excreted in 24 hours. Urinary potassium increased in the 1st 2 hours, followed by a progressive fall to lower than baseline values at the end of 24 hours. The data showed rapid clearance of instilled hypertonic saline without adverse effects. It is suggested that this method is simple, sure, and safe when a careful assessment of patients is made before induction, and when precautions are taken for proper instillation of saline.^ieng