Key words: MMR, Risk factors of MMR, Rural area, Peshawar, Pakistan.

Globally, progress in improving the survival and well being of mothers has been slow, and this holds true for the Eastern Mediterranean Region. Thus at the current pace, it is unlikely that the Millennium Development Goal related improving maternal health will be achieved in the Region by the year 2015.[1] An estimated 400,000 infant and 16,500 maternal deaths occur annually in Pakistan. These translate into an infant mortality rate and maternal mortality ratio that should be unacceptable to any state. Disease states including communicable diseases and reproductive health (RH) problems, which are largely preventable account for over 50% of the disease burden.[2] In a hospital based study in ayub teaching hospital, abbotabad, six maternal deaths were recorded during study period. The major causative factors were hemorrhage, eclampsia, sepsis, anesthetic complications and hepatic encephalopathy. Maternal mortality ratio was 12.7/1000 live births (26/2040). The age range was between 18-42 years. Most of them (69%) were grand multiparas (Parity > 5). Education, antenatal booking and socio-economic status were poor.[3] The MMRs reported from hospitals vary between 17 in a private tertiary hospital to 2,736 in a government tertiary hospital. In the community the range is from 160 in Sindh to 673 in Khuzdar. Data for different periods of time from three tertiary public hospitals, two in the south and one in the north of Pakistan, show no decrease in MMRs [4]. In a study from Aga Khan University, Karachi, The female mortality rate was 151 per 100,000 women aged 10-49 years and the maternal mortality ratio was 281 per 100,000 livebirths. The leading causes of deaths among women were complications of pregnancy (28%), infectious diseases (25%), cardiovascular diseases (21%), neoplasia (11%) and trauma (11%).[5]

Present epidemiological survey was therefore conducted in rural areas of Peshawar to determine the maternal mortality rate (MMR) and to appreciate the factors contributing to maternal mortality.

A descriptive observational survey was conducted in Palusai village near Peshawar University, Peshawar, from December 2004 to December 2005.

Two hundreds houses were included in the study. Of those houses 400 women in their reproductive ages were selected.

Inclusion criteria were all married women in their reproductive ages. Relatives were interview in case of those ladies who had died during pregnancy or cause related to pregnancy. Unmarried women in their reproductive ages were excluded.

A detailed history of the respondents was taken with the help of a pre-designed questionnaire, prepared in accordance with the objectives of this study. Questionnaire contained preliminary information regarding age, address and education of the respondents. It also contained information's about the risk factors that can lead to maternal death including socioeconomic factors, marital factors and obstetric factors.

Finally statistical analysis of the data was performed and association of risk factors with maternal mortality was studied.

This epidemiological; survey cover a total of 200 houses and 400 women in their reproductive ages. The average number of married women per house was two. A total of five maternal deaths were recorded during the survey, from December 2004 to November 2005. The total births according to the local BHU in the same period were 1056.Maternal mortality rate is the number of maternal deaths related to childbearing divided by the number of live births (or by the number of live births + fetal deaths) in that year. And is expressed as mother dying per 1000 live births. In our study the MMR will be,

MMR: 5(1000) /1056= 4.73/1000

Percentage Mortality: 5(100)/400 =1.25%

Socioeconomic factors: In Socioeconomic factors related to maternal mortality, 43% of the women living in kaccha (mud made) houses. Sixty one percent had drinking water supply from tube wells. Most of the women (49%)were living in houses with monthly income less than 5000/month. (Table No- I)

Marital factors: Sixty percent of the deliveries took place at home. Of total 57.5% women had no education. The age at marriage was less than 15 years for 17.25% of women and between 16-20 years in 47% of the clients. Thirty percent were vaccinated for TT only and 16% for both TT and MMR during pregnancy. 72% had not utilized any iron supplements during pregnancy. (Table No-II)

Obstetric factors: The interval between two childbirths was less than two years for 59% cases. Sixty two percent of the ladies missed to visit signally even to antenatal care center through out their pregnancy. In 60% of women the deliveries recorded in home environment. (Table No-III)

In order to achieve the millennium development goals (MDGs), Pakistan would require a fundamental shift in its policy and strategic directions. Along with allocation of significant additional resources for health, it needs to review and reprioritize the use of existing resources, focusing more on primary health care. Pakistan must also adopt a holistic integrated approach that views health, education, and other social sector development as intrinsically interrelated and interwoven [6]. In present study five maternal deaths were recorded as a whole. Maternal mortality ratio was 4.73/1000 live births (5/1056), and percentage mortality was 1.25%. Our finding correlates with the findings of Begum S et al [3].

In Socioeconomic factors related to maternal mortality, 43% of the women living in kaccha (mud made) houses. Sixty one percent had drinking water supply from tube wells. Most of the women (49%)were living in houses with monthly income less than 5000/month. In another study by Kazmi S, [7] from Karachi the participants were largely poor, illiterate, and of reproductive age. In the rural context of only minimal access to quality institutional care services, most rural women delivered at home with the aid of traditional birth attendants (TBA). The decision to deliver at home was reached by a combination of women's high degree of trust in the services of TBAs and their concern about costs and convenience.

The age at marriage was less than 15 years for 17.25% of women and between 16-20 years in 47% of the clients. In Germany there is a rapid decrease in infant and maternal mortality. Since the 80s of the twentieth century the average age at marriage of until then unmarried persons as well as the number of single mothers show a permanent increase. Generally, the average age of mothers increased (for live and legitimate births) [8]. Thirty percent were vaccinated for TT only and 16% for both tetanus toxoid (TT) and measles, mump and rubella (MMR) during pregnancy. 72% had not utilized any iron supplements during pregnancy. MMR is inversely related to contraceptive prevalence rates, presence of trained attendants during delivery, and adult female literacy rates.

Ninety percent of the South Asian region had coverage with BCG immunization, followed by DPT, OPV, and measles immunization. Maternal tetanus toxoid was 69%.[9] In our study sixty two percent of the ladies missed to visit signally even to antenatal care center through out their pregnancy. In a UN study from Punjab and north west frontier provinces of Pakistan, out of 170 facilities only 22 were providing basic and 37 comprehensive emergency obstetric care (EmOC) services in the areas studied. Only 5.7% of births occurred in EmOC health facilities. Met need was 9% and 0.5% of women gave birth by cesarean section. The case fatality rate was a low 0.7%, probably due to poor record keeping. Access and several indicators were better in NWFP than in Punjab. [10]

In our findings the interval between two childbirths was less than two years for 59% cases. The odds of dying in the neonatal and post-neonatal period is 2.27 and 2.12 times higher respectively for children born after preceding birth intervals of one year or less compared to children born after longer intervals. Children born within two years of a subsequent birth are at 4.09 times higher risk of dying in the second year of life than children whose mother gave birth more than 2 years after the index birth.[11]

Socioeconomic factors mainly contributing top maternal mortality in the area followed by marital and obstetric factors. There is need for more actions to decrease maternal morality by increasing awareness, improving life style of the women, and providing better health facilities at doorstep. Most maternal deaths are preventable. The provision of skilled care and timely management of complications can lower maternal mortality in our setup.