emergency obstetric complications; a risk of maternal

Emergency Obstetric Complications; a risk of

maternal health outcomes in India

Author’s Name

Miss. Komal Sureshrao Gajbhiye

Research Scholar

Department of Population Policy & Programmes

International Institute for Population Sciences

Mumbai, India

Abstract: Background: Emergency Obstetric complications (EmOC) become a significant health problem resulting in poor maternal and

neonatal health outcomes. The significant deaths due to direct obstetric complications are convulsions, prolonged labor, excessive

bleeding, massive vaginal bleeding, and very high fever. In this study, we examine the socioeconomic differentials in the

prevalence of EmOC and examine the determinants of the EmOC during pregnancy, at delivery, and post-delivery.

Methods: This study used data from the National Family Household Survey (2014-15) for empirical assessment. The study used

Univariate, bivariate, and multilevel logistic regression analyses were applied to examine the determinants of EmOC and the

association between during pregnancy, at delivery, and post-delivery of mothers aged 15-45yrs.

Results: The result revealed that there is 42.3% mother who experienced prolonged labor. The mother who did a full ANC

experienced fewer pregnancy complications reported 21% (OR: 0.79; 95% CI: 0.70-0.89) than no ANC. The women who assisted

delivery by skilled (doctor/nurse/midwife) reported 43% (OR: 0.57; 95% CI: 0.50-0.66) less likely to experience complications at

delivery than unskilled health providers. The mother who experienced complications during pregnancy reported 1.99 times (OR:

1.99; 95% CI: 1.90-2.07) more likely to experience a high risk of complications at delivery.

Conclusion: Women below 20 years of age have experienced high complications during pregnancy and delivery. Illiterate women

have a high risk of EmOC complications. We should focus more on the protective factors for the pregnancy complications such as

full ANC, PNC, skilled ANC provider, and making our women healthier to enter in pregnancy without anemia and with normal

BMI. We should do more to strengthen the public hospitals to reduced complications and by available and accessible emergency

obstetric care.

Keywords: Emergency Obstetric Complications, pregnancy, delivery, and post-delivery complications, Reproductive health care

utilizations

Background:

Obstetric complications have become a significant health

problem resulting in poor maternal and perinatal outcomes.

The major causes of maternal deaths due to direct obstetric

complications are hemorrhage, sepsis, prolonged and

obstructed labor, hypertensive disorders, and abortion

complications. Globally, about 800 women die every day

due to pregnancy and childbirth-related preventable causes,

where India accounts for 20%, and 44,000 deaths are

estimated annually in the country. MMR of 174 (2015) and

130/lakh live births in (2016) was below the MDG target for

India (Dakhode & Gaidhane, 2020). 19% of global

pregnancy-related deaths occur in India, making it the first

most unsafe country to deliver babies (Banke-Thomas,

Maua, & Madaj, 2020). The Sustainable Development Goal

target is MMR below 70 by 2030. Since the 1990s, WHO,

UNICEF, and UNFPA have recognized that Emergency

Obstetric Care (EmOC) is a cost-effective strategy for

reducing maternal death? India accounts for a fifth of annual

global maternal deaths (56,000), and the Maternal Mortality

Ratio (MMR) is estimated to be 167/100,000 live births

(SRS-2011-13) (Singh, Doyle, & Campbell, 2013). In India,

EmOC services were started under the RCH-II program to

reduce MMR to less than 100 and increase institutional

deliveries to at least 80% by 2010. The implemented

strategy was to enhance the availability of facilities and

increase access to EmOC.

The study revealed that age showed a U-shaped association

with maternal mortality (Horwood & Opondo, 2020). The

analysis shows that the women age groups 35-44 and aged

45 and older were likely to experience obstetric

complications compared to women less than 35 and a higher

risk of deaths (Grotegut & Chisholm, 2014). In contrast, the

analysis shows that as the age increases, the prevalence of

any obstetric health complication decreases a bit (Mousumi,

2015).

The study found that almost all the variables such as age,

education, occupation, parity, type of family, socioeconomic

status (SES) had a significant association with awareness

about ANC, and variables such as education and SES had a

significant association with practices about ANC (Jain &

Upadhyay, 2019). The socioeconomic status and rural

residence were not associated with maternal mortality when

available and accessible health care facilities (Horwood &

Opondo, 2020). The mother not having a health scheme and

belongs to a scheduled caste and scheduled tribe group were

significant factors for maternal death (Horwood & Opondo,

2020). The studies show that variables such as parental

education, child's gender, sibling effects, birth-spacing,

economic characteristics, religion, and caste are essential in

influencing child mortality outcomes (Rommohan, 2013).

According to the maternal education status, the mother who

is highly educated reported fewer health complications than

not educated and medium-class educated mother, While the

household standard of living has also shown a positive

attitude towards reporting health complications as women

belong to higher wealth quintile reported having fewer

obstetric health complications (pregnancy, delivery, and

after delivery) as compared to women that belong to a poor

wealth quintile (Mousumi, 2015). The study explained a

significant association between mothers receiving ANC 4-9

visits had experienced a lower risk of neonatal mortality.

Mothers who received antenatal care visits from the first

trimester experienced minor pregnancy outcomes and

neonatal deaths (Gupta R. , 2003). Qualitative studies

suggested that most women experienced direct benefit from

ANC in various pregnancy complications. Neither urban nor

rural women were sure about the benefits of ANC for their

health or their unborn child in Zimbabwe (Mathole, 2004).

Similarly, ANC was not seen as essential unless there was

physical discomfort during pregnancy and complications in

a previous pregnancy or childbirth (Chaudhari AMR., 2003).

The study found that birth order and interval were

significantly associated with ANC visits (Magadi, Madise,

& Rodrigues, 2000). Results also show that women with less

education, belonging to lower wealth quintiles, were more

vulnerable to health complications because of lack of use of

services or lack of knowledge regarding complications

(Mousumi, 2015). Our results show that national programs

can be implemented in low-income countries without

significant external funding and that they can rapidly

improve the coverage of obstetric services and significantly

reduce the risk of death associated with obstetric

complications (Pierre & Alexandre, 2008). Complications of

pregnancy and medical comorbidities were the most

substantial risk factors for maternal death (Horwood &

Opondo, 2020). The study found that live pregnancies with

the first trimester bleeding and the subchorionic hematoma

was associated with a similar risk of miscarriage and

antepartum hemorrhage while an increased risk of

preeclampsia, fetal growth restrictions, preterm birth, non-

reassuring fetal heart pattern, cesarean delivery, and low

birth weight baby when compared to patients with the first

trimester bleeding without subchorionic hematoma

(Agarwal, Ritu, & Singh, 2020). Women's perceptions of the

risk factors associated with adverse obstetric outcomes were

significantly related to the probability of seeking ANC.

Women who had a prior fetal loss or neonatal death are

more likely to receive ANC (Bhatia & Cleland, 1995). It is

clear from the studies that there is no strong positive

correlation between pregnancy complications and delivery

complications (Mousumi, 2015). During delivery, access to

emergency obstetric care and postnatal care (PNC) are cost-

effective and lifesaving investments for mothers. This is

clear from the study that women face many complications

during their reproductive period, leading to future

complications and maternal mortality. In general, maternal

and reproductive morbidity is an outcome of not just

biological factors but also women's poverty, powerlessness,

and lack of control over resources. The use of maternal

health care services may reduce the probability of

developing many complications during pregnancy, delivery,

and after delivery.

Figure No. 1 shows, 16.5% of the total women reported

experiencing a convulsion, not from fever. When it comes to

delivery complications, 12.7% of the total mothers reported

a breech presentation, 42.3% of the mother’s experienced

prolonged labor, and 33.9% had excessive bleeding. With

regards to the post-delivery complications, it was found that

19.7% of the mothers reported experiencing massive vaginal

bleeding, and 15.2% reported very high fever.

Figure 1: Magnitude of various pregnancy-related

complications among women's age between 15-49 years in

India

Figure 1: Magnitude of various pregnancy-related

complications among women’s age between 15-49 years

in India

Methods:

Data source: The analysis has been done by using the

Individual data of the fourth round of NFHS-4, which was

conducted during 2015-2016 under the stewardship of the

Ministry of Health and Family Welfare (MoHFW),

Government of India, and coordinated by the International

Institute of Population Sciences (IIPS), Mumbai. National

Family Health Survey is a large-scale multi-round survey

conducted in a nationally representative sample of

households. The survey provided national and state-level

data for India on Emergency Obstetric Complications,

reproductive health, maternal and child health, nutrition,

anemia, and family planning services. The NFHS 4 collected

information from the nationally representative sample of

601,509 households from which 699,686 women aged 15-

49- and 1, 12,122 -men aged 15-54 were surveyed (IIPS,

2017). I have worked on a sample of 1 90,898 who were

asked questions about complications during pregnancy,

delivery, and post-delivery of their recent birth. Unit of

analysis - a mother who experienced Emergency Obstetric

Complications at the time of pregnancy, delivery, and post-

delivery.

Statistical analysis:

All analyses of this study were done using STATA-14

software. Frequencies and percentages were used to describe

socioeconomic and demographic characteristics. Bivariate

analysis has been carried out to investigate the relationship

between dependent and independent variables. A Chi-square

test is done for each pair to find out the p-value which is

statistically significant or not. Prevalence showing by Map

at the state level by using Arc-GIs.

A brief description of the study is given below; this section

includes the definition of terms used for the study, variables

used for the study, and various techniques used for analysis.

Bivariate analysis: To see the impact of the independent

variable on the dependent variable (Cross tabulation)

Multivariate analysis: To see the impact of an independent

variable on the dependent variable (Binary Logistic

Regression analysis) Chi-square test: It is a common

bivariate statistic used to test whether the distribution in the

categorical variables is statistically different in two or more

groups. The chi-square test gives the Yes/No answer P-value

less than Level of Significance means there are statistically

significant differences between the two groups.

Variable description:

For Objective 1: Response Variables: Pregnancy

Complication- We have included convulsions from fever as

the complications arising before delivery. Delivery

Complication- We have included Breech Presentation,

Prolonged Labour, and Excessive bleeding as the

complications arising during delivery. Post-Delivery

Complication- We have included very high fever after

delivery and massive vaginal bleeding as the complications

arising after delivery Exposure Variables: Socioeconomic

variables such as Place of residence, age, Wealth index,

religion, caste, and education of mothers were used.

Univariate analysis was carried out to estimate the

magnitude of pregnancy-related complications. In

comparison, bivariate analysis (Chi-Square test) has been

performed to find an association between the responses as

mentioned above variables with the socioeconomic

variables.

For Objective 2: Response Variables: Pregnancy

Complication- We have included convulsions from fever as

the complications arising before delivery. Delivery

Complication- We have included Breech Presentation,

Prolonged Labour, and Excessive bleeding as the

complications arising during delivery. Post-Delivery

Complication- We have included very high fever after

delivery and massive vaginal bleeding as the complications

arising after delivery Exposure variables: Socioeconomic

variables such as age, education, parity, wealth, and

residence. Antenatal care variables include full ANC, ANC

provider, Place of ANC, body mass index, Anaemia. Natal

care variables are a place of delivery, performed C-section

delivery, who assisted delivery. Postnatal care variables are

PNC check-ups after delivery and PNC provider.

Results:

Prevalence of emergency obstetric complications: Indian

states

During pregnancy: States of India

The prevalence of emergency obstetric complications for the

states and UTs of India ranges from (0.41-29.06) percent,

with a wide range of EmOC in various states of India

(Figure No. 2). According to the reporting, the exceptionally

high prevalence of pregnancy complications is in the Uttar

Pradesh state and Bihar and Madhya Pradesh. In contrast,

16

.48

12

.68

42

.32

33

.88

19

.68

15

.21

P R E G N A N C Y - R E L A T E D C O M P L I C A T I O N S

the lowest is in the Dadra & Nagar Haveli, Mizoram,

Andhra Pradesh, Chandigarh, and West Bengal. Other states

have approximately average prevalence, such as Sikkim,

Chhattisgarh, Nagaland, Delhi, Rajasthan, etc.

At the time of delivery: States of India

The level of prevalence of EmOC in the states of India

which are in ranges from during the time of delivery 0.19

percent to 33.56 percent, which has a wide range for the

emergency obstetric complications in various geographically

in states of India (Figure No. 3), from that very high

prevalence states are Pondicherry, Tamil Nadu, Meghalaya

and Goa whereas the lowest prevalence pattern showing in

Mizoram, Daman & Diu, Lakshadweep, Dadar & Nagar

Haveli, Manipur and Kerala which has most of Union

Territories region of India.

During the time of post-delivery: States of India

Prevalence of emergency obstetric complications in India

has less occurred after delivery than pregnancy and delivery

complications (Figure No. 4). The high prevalence is in the

Punjab state and followed by Pondicherry, Chandigarh,

Bihar states of India, whereas the lowest prevalence is in the

states of Mizoram, Lakshadweep, Manipur, Kerala, and

Tripura.

Figure 2: State-wise prevalence of emergency obstetric

complications during the time of pregnancy


complications during the time of delivery


complications during the time of post-delivery

Presents socio-demographic characteristics of a mother.

The pregnancy complication is the convulsion, not from

fever. So we categories them into any complications and no

complications. At the same time, the delivery complications

are breech presentation, prolonged labor, and excessive

bleeding. So based on the literature, we divided it into life-

threatening complications and non-life-threatening

complications. The life-threatening complications are

prolonged labor and excessive bleeding, whereas the non-

life-threatening complications are breech presentations,

similarly for the post-delivery complications. The life-

threatening complications are massive vaginal bleeding, and

non-life-threatening complications are very high fever.

The result shows that as the age increases, the level of

complications decreases during pregnancy and delivery,

whereas it increases post-delivery. 17.5% of mothers

experienced pregnancy complications below 20 years of age,

and the complications decreasing by the increasing age. At

the delivery complications, the prevalence of life-

threatening complications is 79.2% high below the 20 yrs of

a mother aged compared to the other aged groups, whereas

post-delivery complications, the prevalence of life-

threatening complications 42.1% high at the above-aged

35yeras. The mother who is not educated reported a high

prevalence of complications during pregnancy, delivery, and

low post-delivery. The first parity of the mother shows a

high prevalence of complications during pregnancy (16.3%),

at delivery (77.9%), and post-delivery (77.6%) and low at

the second parity; again, the complications will occur high

after the third parity of mother. The mother who belongs to a

rural area shows a high prevalence of complications.

Table 1: Socio-economic differentials in the prevalence of Emergency Obstetric Complications during pregnancy among women’s

aged between 15-49 years in India: NFHS-4 (2015-16)

Socio-economic

characteristics

Pregnancy complications Delivery complications Post-delivery complications

Any

Complicatio

ns

No

Complic

ations

N Life-

threatening

Complicatio

ns

Non-Life

threatening

Complicatio

ns

N Life-

threatening

Complications

Non-Life

threatening

Complications

N

Maternal age in yrs. *** *** *** *** *** ***

<20 yrs. 17.5 82.5 88,509 79.2 21.8 44,021 39.8 60.2 22,592

20-34 yrs. 16.4 83.6 98,715 76.5 23.5 50,007 43.7 56.3 25,140

>35 yrs. 11.8 87.2 1,081 75.1 25.0 513 42.1 57.9 221

Total 16.9 83.1 1,88,305 77.7 22.3 94,541 41.8 58.2 47,953

Education *** *** *** **** *** ***

No education 29.7 80.3 55,016 81.2 18.8 25,974 33.8 66.2 14,804

Primary education 17.7 82.4 26,656 79.6 20.4 13,303 39.0 61.0 6,864

Secondary education 15.4 84.6 88,768 76.0 24.0 45,865 46.0 54.0 21,917

Higher education 15.1 85.0 20,132 74.4 25.7 10,559 50.5 49.5 5,012

Total 16.9 83.1 1,90,572 77.7 22.3 95,701 41.8 58.2 48,597

Parity *** *** *** *** *** ***

1 16.3 83.7 86,568 77.9 22.4 44,390 77.6 22.4 22,572

2 15.8 84.2 62,406 75.5 24.5 31,928 75.5 24.5 15,568

3 17.4 82.7 32,992 78.8 21.2 15,731 78.8 21.2 8,214

4 19.0 81.0 8,606 81.0 19.0 3,652 81.0 19.0 2,243

More than 5 20.6 79.4 1,500 82.4 17.6 1,500 82.4 17.6 1,500

Total 16.9 83.1 1,90,572 82.4 17.6 95,701 77.7 22.3 48,597

Residence *** *** *** *** *** ***

Rural 17.8 82.2 1,42,796 78.8 21.3 71,818 40.3 59.8 37,243

Urban 14.3 85.7 47,776 74.6 25.4 23,883 46.7 53.3 11,354

Total 16.9 83.1 1,90,572 77.7 22.3 95,701 41.8 58.2 48,597

Head of Household n.s. n.s. n.s. n.s. n.s. n.s.

Male 16.9 83.1 1,67,625 77.7 22.4 84,239 41.6 58.4 42,642

Female 17.0 83.0 22,947 78.2 21.8 11,462 42.6 57.4 5,955

Total 16.9 83.1 1,90,572 77.7 22.3 95,701 41.8 58.2 48,597

Religion *** *** *** *** *** ***

Hindu 17.4 82.6 1,38,154 78.3 21.7 71,965 42.0 57.8 35,856

Muslim 20.1 79.9 29,270 79.0 21.0 13,548 34.0 66.1 7,659

Christian 10.5 89.6 15,130 62.3 37.7 5,603 47.7 52.3 2,413

Sikh 11.6 88.4 3,230 85.1 14.9 2,507 55.9 44.1 1,752

Buddhist 8.0 92.0 2,089 80.4 19.6 950 50.1 49.9 411

other 10.6 89.4 2,699 82.4 17.6 1,128 47.0 53.0 506

Total 16.9 83.1 1,90,572 77.7 22.3 95,701 41.8 58.2 48,597

Caste *** *** *** *** *** ***

SC 18.3 81.7 35,126 77.7 22.3 19,236 42.2 57.8 10,062

ST 13.5 86.5 37,753 75.4 24.6 16,505 42.0 58.1 7,872

OBC 18.9 81.1 73,979 77.3 22.7 38,455 40.1 59.9 19,565

other 15.9 84.1 167 82.3 17.7 18,269 41.1 59.0 9,428

Total 17.1 82.9 1,82,693 78.2 21.9 92,465 41.3 58.7 46,927

Wealth Index *** *** *** *** *** ***

Low 19.2 80.8 90,323 81.1 18.9 43,988 36.1 63.9 23,758

Middle 15.7 84.3 38,331 74.3 25.7 19,530 44.4 55.6 9,351

High 14.4 85.6 61,918 75.2 24.8 32,183 48.9 51.1 15,488

Total 16.9 83.1 1,90,572 77.7 22.3 95,701 41.8 58.2 48,597

Determinants of Emergency Obstetric Complications

during pregnancy, at delivery, and post-delivery:

Table 2 shows logistic regression models that were used to

examine the determinants of EmOC during pregnancy.

Model 1 showed the association of EmOC and community-

level characteristics. Model 2 examines the determinants of

EmOC during pregnancy from Individual-level

characteristics and complications. Model 3 showed the

determinants of EmOC between reproductive and child

health service and complications during pregnancy.

In Model 1, community-level characteristics were

considered; in Model 2, individual-level characteristics were

added; in Model 3, RCH services were added; In Model 4,

two sets of variables are considered, and in Model 5, three

sets of variables are considered. The results indicated a

statistically significant association between community-level

characteristics and pregnancy complications. The results

revealed that the mother belongs to an urban region reported

18% (OR: 0.82; 95% CI: 0.79-0.85) less likely to experience

pregnancy complications than rural region mothers. The

mother who has high wealth reported 25% (OR: 0.75; 95%

CI: 0.73-0.78) less likely to experience pregnancy

complications than low wealth.

In Model 2, individual-level characteristics were included.

In this model, the mother's age is above 35 years reported

38% (OR: 0.62; 95% CI: 0.50-0.77) less likely to experience

pregnancy complications. As the level of education

increases, the level of complications decreases. The BMI of

the mother is the average reported 7% (OR: 0.93; 95%

C.I.:0.90-0.96) less likely to experience complications than

underweight mother. In Model 3, RCH services were

included. This model found that the mother who did a full

ANC reported 33% (OR: 0.67; 95% CI: 0.61-0.73) less

likely to experience pregnancy complications than no ANC.

The mother went to the private health facility for antenatal

check-up reported 1.10 times (OR: 1.10; 95% CI: 1.03-1.19)

more likely to experience than a public health facility. The

antenatal check-up from a skilled provider reported 1.26

times (OR: 1.26; 95% C.I.:1.17-1.35) more likely to

experience pregnancy complications than the unskilled

providers. In model 4, Individual characteristics and RCH

services were considered. It was found that maternal age,

education, BMI, ANC services, Place of ANC, and type of

ANC provider are the same as those in Model 2 and Model

3. In Model 5, community-level characteristics, individual-

level characteristics s, and RCH services were considered. It

was found that the religion, caste, residence, wealth index,

maternal age, education, BMI, ANC services, Place of ANC,

and type of ANC provider are the same significance as those

in Model 1, Model 2, and Model 3.

Results of multivariate logistic regression were applied

to understand the adjusted effect of all selected variables

at the time of delivery complications. In Table 3, in Model

1, community-level characteristics were included. It was

found that religion, caste, residence e, and wealth index are

all variables that are statistically significant determinants.

Moreover, the wealth index with middle and high were 1.37

and 1.40 times, respectively, more likely to experience

delivery complications than the low wealth index. In Model

2, individual characteristics were included. It is found that

all variables are statistically significant determinants of

delivery complications. Moreover, the mother education

with primary, secondary, and higher education was reported

1.11, 1.32, and 1.18 times respectively, more likely to

experience delivery complications. The mother with normal

and obese BMI reported 1.10 and 1.16 times more likely to

experience delivery complications than underweight. In

Model 3, RCH services were included. The mother delivered

at the private hospital reported 16% (OR: 0.84; 95% CI:

0.72-0.86) less likely to experience delivery complications

than a public health facility. The mother who had C-section

delivery reported 13% less likely to experience delivery

complications than normal delivery. In Model 4, individual

characteristics and RCH services were considered. The only

Place of delivery, type of delivery, and type of assisted

delivery were statistically significant as those same in Model

2 and 3. In model 5, community characteristics, individual

characteristics, and RCH services were considered. It was

found that religion, caste, Place of delivery, type of delivery,

and type of assisted delivery were statistically significant as

those same in Model 1, Model 2, and Model 3.

Results of multivariate logistic regression were applied

to understand the adjusted effect of all selected variables

at post-delivery complications. In Table 4, Model 1,

community-level characteristics were adjusted. It is found

that all the factors statistically significant determinants of

postnatal complications. The Sikh religion reported 3.05

times (OR: 3.05; 95% CI: 2.77-3.36) more likely to

experience postnatal complications among others religion.

As the wealth index increases, fewer complications are

experienced during the postnatal period. In Model 2,

maternal education found that as the level of education

increases, the complications decrease. The mother who’s

primary, secondary, and higher educated reported 10%,

20%, and 25% less likely to experience postnatal

complications than not educated mothers. The mother whose

BMI is obese and not anaemic shows less experienced

complication in the postnatal period. In Model 3, it is found

that the mother who delivered at a private hospital reported

26% (OR: 0.74; 95% C.I.:0.69-0.79) less likely to

experience postnatal complications than public hospitals.

The mother who performed C-section delivery reported 1.30

times (OR: 1.30; 95% CI: 1.21-1.40) more likely to

experience postnatal complications than normal delivery.

The mother who check-up within two days after delivery

reported 10% less likely to experience postnatal

complications than no PNC after delivery. In Model 4,

individual characteristics and RCH services were

considered. The factors are all statistically significant same

as in Models l 2 & 3. In Model 5, Model 1, 2 & 3 were

considered. It was found that religion, residence, wealth

index, education, Place of delivery, type of delivery, type of

assisted delivery, PNC services, and type of PNC provider

were statistically significant as those same in Model 1,

Model 2, and Model 3.

Table 2: Results of Multilevel logistic regression showing the likelihood of determinates of emergency obstetric

complication during pregnancy. Results from Logistic Regression Analysis, 2015-16 India.

Background Variables Model 1 Model 2 Model 3 Model 4 Model 5

OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI

Community-level Characteristics

Religion

Hindu® 1.40*** (1.35 1.45) - - - - - - 1.46*** (1.29 1.64)

Muslim 0.69*** (0.65 0.73) - - - - - - 0.60*** (0.49 0.72)

Christian 0.73*** (0.65 0.81) - - - - - - 0.89 (0.68 1.17)

Sikh 0.48*** (0.41 0.56) - - - - - - 0.64 (0.42 0.98)

Buddhist 0.64*** (0.57 0.73) - - - - - - 0.50*** (0.31 0.81)

Other 1.40*** (1.35 1.45) - - - - - - 1.46*** (1.29 1.64)

Caste

Schedule caste®

Schedule tribe 0.77*** (0.73 0.80) - - - - - - 0.78*** (0.68 0.91)

OBC 1.01 (0.97 1.04) - - - - - - 1.00 (0.89 1.12)

don't know 0.86*** (0.82 0.89) - - - - - - 0.89* (0.78 1.02)

Residence

Rural®

Urban 0.82 *** (0.79 0.85) - - - - - - 0.89** (0.81 0.98)

Wealth Index

Low ®

Middle 0.80*** (0.78 0.83) - - - - - - 0.87** (0.77 0.98)

High 0.75*** (0.73 0.78) - - - - - - 0.90* (0.80 1.02)

Individual-level characteristics

Maternal Age in years

<20 yrs. ®

20-34 yrs. - - 0.96*** (0.93 0.99) - - 0.96 (0.88 1.05) 0.99 (0.91 1.08)

>35 yrs. - - 0.62*** (0.50 0.77) - - 0.59** (0.37 0.96) 0.68* (0.42 1.11)

Maternal Education

No education®

Primary education - - 0.89*** (0.93 0.83) - - 0.86** (0.74 1.00) 0.92** (0.79 1.08)

Secondary education - - 0.80*** (0.77 0.83) - - 0.77*** (0.69 0.87) 0.86* (0.76 0.98)

Higher education - - 0.81*** (0.77 0.86) - - 0.85** (0.73 0.99) 0.98** (0.83 1.16)

Maternal parity

1®

2 - - 0.93*** (0.90 0.97) - - 0.98 (0.90 1.08) 0.97 (0.88 1.06)

3 - - 1.00 (0.96 1.04) - - 1.01 (0.89 1.14) 1.02 (0.90 1.16)

4 - - 1.06** (1.00 1.11) - - 0.98 (0.82 1.18) 0.98 (0.81 1.19)

5 and more - - 1.14*** (1.08 1.20) - - 0.91 (0.73 1.13) 0.95 (0.75 1.19)

Body Mass Index

Underweight®

Normal - - 0.93*** (0.90 0.96) - - 0.87*** (0.79 0.97) 0.90** (0.81 1.00)

Obese - - 0.88*** (0.84 0.92) - - 0.91 (0.80 1.03) 0.95 (0.83 1.08)

Anaemia

Severe®

Moderate - - 1.01 (0.91 1.12) - - 0.93 (0.68 1.29) 0.92 (0.66 1.27)

Mild - - 0.86 (0.78 0.95) - - 0.86 (0.63 1.19) 0.85 (0.61 1.18)

Not anemic - - 0.84 (0.75 0.93) - - 0.78 (0.57 1.08) 0.79 (0.57 1.10)

Reproductive and child health services

ANC services

No ANC®

Full ANC - - - - 0.67*** (0.61 0.73) 0.76*** (0.67 0.85) 0.79*** (0.70 0.89)

Place of ANC

Public health facility®

Private health facility - - - - 1.10*** (1.03 1.19) 1.15*** (1.05 1.25) 1.08** (0.99 1.19)

Other - - - - 1.52* (0.95 2.42) 1.74** (1.03 2.93) 1.57 (0.93 2.66)

Type of ANC provider

Unskilled®

Skilled - - - - 1.26*** (1.17 1.35) 1.23*** (1.13 1.33) 1.23*** (1.13 1.34)

Other - - - - 4.92*** (2.58 9.39) 4.94*** (2.41 10.12) 5.42*** (2.60 11.30)

Table 3: Results of Multilevel logistic regression showing the likelihood of determinates of emergency obstetric complication at the time of delivery. Results from Logistic

Regression Analysis, 2015-16 India.



Community-level characteristics

Religion

Hindu®

Muslim 0.93*** (0.87 0.99) - - - - - - 0.97 (0.84 1.12)

Christian 1.30*** (1.20 1.40) - - - - - - 1.36*** (1.14 1.63)

Sikh 1.30*** (1.14 1.47) - - - - - - 1.17 (0.92 1.51)

Buddhist 0.86 (0.71 1.04) - - - - - - 0.58** (0.37 0.91)

other 0.77*** (0.64 0.93) - - - - - - 0.69 (0.42 1.13)

Caste

Schedule caste®

Schedule tribe 0.88*** (0.82 0.94) - - - - - - 0.60*** (0.51 0.70)

OBC 0.91*** (0.86 0.95) - - - - - - 0.97 (0.86 1.09)

don't know 0.72*** (0.68 0.77) - - - - - - 0.63 (0.55 0.73)

Residence

Rural®

Urban 0.94** (0.90 0.99) - - - - - - 0.94 (0.85 1.04)

Wealth Index

Low ®

Middle 1.37*** (1.30 1.44) - - - - - - 1.05 (0.92 1.19)

High 1.40*** (1.34 1.48) - - - - - - 1.02 (0.89 1.16)



<20 yrs. ®

20-34 yrs. - - 1.08*** (1.03 1.13) - - 0.95 (0.87 1.04) 0.96 (0.87 1.05)

>35 yrs. - - 0.93 (0.69 1.24) - - 0.64 (0.37 1.11) 0.69 (0.40 1.18)

Maternal Education

No education®

Primary education - - 1.11*** (1.03 1.20) - - 0.95 (0.80 1.12) 0.93 (0.78 1.10)

Secondary education - - 1.32*** (1.24 1.39) - - 1.06 (0.93 1.20) 1.03 (0.90 1.18)

Higher education - - 1.18*** (1.09 1.28) - - 0.88 (0.74 1.04) 0.87 (0.72 1.05)

Maternal parity

1®

2 - - 1.02 (0.97 1.07) - - 1.08 (0.98 1.19) 1.06 (0.96 1.17)

3 - - 0.85*** (0.80 0.91) - - 1.01 (0.88 1.15) 0.98 (0.86 1.13)

4 - - 0.74*** (0.67 0.81) - - 0.83* (0.67 1.03) 0.80** (0.65 1.00)

5 and more - - 0.67*** (0.60 0.74) - - 0.92 (0.72 1.17) 0.93 (0.72 1.19)

Body Mass Index

Underweight®

Normal - - 1.10*** (1.05 1.16) - - 1.05 (0.94 1.17) 1.05 (0.94 1.18)

Obese - - 1.16*** (1.08 1.25) - - 0.96 (0.83 1.11) 0.97 (0.83 1.12)

Anaemia

Severe®

Moderate - - 1.27*** (1.06 1.53) - - 1.2 (0.82 1.76) 1.25 (0.84 1.85)

Mild - - 1.24** (1.03 1.49) - - 1.2 (0.82 1.75) 1.24 (0.83 1.83)

Not anemic - - 1.1 (0.92 1.32) - - 0.98 (0.67 1.44) 1.02 (0.69 1.51)


ANC services

No ANC®

Full ANC - - - - 0.95 (0.86 1.05) 0.94 (0.84 1.06) 0.97 (0.86 1.10)

Place of delivery


Private health facility 0.79*** (0.72 0.86) 0.82*** (0.74 0.91) 0.79*** (0.71 0.88)

Other - - - - 0.84** (0.71 0.99) 0.82** (0.68 0.99) 0.88 (0.73 1.06)

Type of delivery - - - -

Normal®

Caesarean - - - - 0.87*** (0.79 0.95) 0.88** (0.79 0.99) 0.88** (0.79 0.98)

Type of assisted at delivery

Unskilled®

Skilled - - - - 0.59*** (0.52 0.67) 0.57*** (0.50 0.66) 0.57*** (0.50 0.66)

Other - - - - 0.54*** (0.35 0.81) 0.54** (0.33 0.87) 0.55** (0.34 0.89)

Table 4: Results of Multilevel logistic regression showing the likelihood of determinates of emergency obstetric complication at post-delivery. Results from Logistic Regression

Analysis, 2015-16 India.



Community-level characteristics

Religion

Hindu®

Muslim 1.16*** (1.10 1.22) - - - - - - 1.05 (0.95 1.17)

Christian 0.51*** (0.46 0.56) - - - - - - 0.45*** (0.36 0.55)

Sikh 3.05*** (2.77 3.36) - - - - - - 2.82*** (2.44 3.26)

Buddhist 0.69*** (0.56 0.84) - - - - - - 0.8 (0.56 1.14)

other 0.57*** (0.47 0.69) - - - - - - 0.70* (0.49 1.00)

Caste

Schedule caste®

Schedule tribe 0.87*** (0.82 0.93) - - - - - - 0.83*** (0.74 0.92)

OBC 0.96* (0.92 1.01) - - - - - - 0.96 (0.88 1.04)

don't know 0.89*** (0.84 0.95) - - - - - - 0.94 (0.85 1.04)

Residence

Rural®

Urban 0.85*** (0.81 0.90) - - - - - - 0.89*** (0.82 0.97)

Wealth Index

Low ®

Middle 0.83*** (0.79 0.87) - - - - - - 0.90** (0.83 0.99)

High 0.79*** (0.76 0.83) - - - - - - 0.87*** (0.79 0.96)



<20 yrs. ®

20-34 yrs. - - 0.99 (0.95 1.03) - - 0.95* (0.89 1.01) 0.94* (0.88 1.00)

>35 yrs. - - 0.78* (0.58 1.05) - - 0.84 (0.54 1.32) 0.88 (0.55 1.40)

Maternal Education

No education®

Primary education - - 0.90*** (0.85 0.96) - - 0.91** (0.82 1.00) 0.93 (0.98 1.14)

Secondary education - - 0.80*** (0.76 0.84) - - 0.81*** (0.74 0.87) 0.86*** (0.79 0.94)

Higher education - - 0.75*** (0.69 0.81) - - 0.79*** (0.70 0.90) 0.89* (0.78 1.02)

Maternal parity

1®

2 - - 0.99 (0.95 1.04) - - 1.07* (1.00 1.16) 1.05 (0.98 1.14)

3 - - 0.97 (0.91 1.03) - - 1 (0.91 1.10) 1 (0.90 1.10)

4 - - 0.95 (0.88 1.03) - - 1.01 (0.89 1.15) 1.01 (0.89 1.15)

5 and more - - 0.90*** (0.83 0.97) - - 0.87* (0.76 1.00) 0.89 (0.77 1.03)

Body Mass Index

Underweight®

Normal - - 0.99 (0.94 1.04) - - 1.08* (1.00 1.16) 1.08** (1.00 1.17)

Obese - - 0.91*** (0.85 0.97) - - 0.91* (0.82 1.01) 0.92 (0.83 1.03)

Anaemia

Severe®

Moderate - - 1 (0.86 1.16) - - 1.11 (0.87 1.42) 1.13 (0.87 1.45)

Mild - - 0.91 (0.78 1.05) - - 1.04 (0.81 1.33) 1.06 (0.82 1.36)

Not anemic - - 0.88* (0.76 1.02) - - 1.07 (0.83 1.36) 1.11 (0.86 1.43)


Place of delivery


Private health facility - - - - 0.74*** (0.69 0.79) 0.80*** (0.74 0.87) 0.80*** (0.73 0.87)

Other - - - - 0.90** (0.82 1.00) 0.88** (0.79 0.98) 0.92 (0.82 1.03)

Type of delivery

Normal®

C-section - - - - 1.30*** (1.21 1.40) 1.38*** (1.27 1.50) 1.38*** (1.27 1.51)

Type of assisted delivery

Unskilled®

Skilled - - - - 1.06 (0.98 1.15) 1.06 (0.98 1.16) 1.08** (0.99 1.18)

Other - - - - 0.99 (0.81 1.22) 1.02 (0.81 1.27) 1.02 (0.81 1.29)

PNC services - - - -

No check-up®

Within 2 days 0.90** (0.84 0.98) 0.91** (0.83 0.99) 0.88*** (0.80 0.96)

Type of PNC provider

Unskilled®

Skilled - - - - 0.99 (0.92 1.07) 0.98 (0.90 1.06) 0.95 (0.87 1.03)

Other - - - - 0.81 (0.51 1.30) 0.79 (0.47 1.32) 0.77 (0.46 1.29)

Association between pregnancy complications, delivery

complications, and post-delivery complications

Results show that if the mother who has experienced

complications during pregnancy reported 99% (OR 1.99, CI

1.90-2.07) more likely to experience a high risk of

complications at the time of delivery. That mother who has

complications at the time of delivery reported 3.92 times

(OR 3.92, 95% CI 3.78-4.06) more likely to experience a

high risk of complications occurring after delivery. The

mother who has complications during pregnancy reported

4.28 times (OR 4.28, 95% CI 4.08-4.48) more likely to

experience a high risk of complications after the delivery.

Based on the results of all the complications are statistically

highly significant to each other.

Table 5: Association between Pregnancy complications, delivery complications, and post-delivery complications

Association between pregnancy complication and delivery complications

OR 95% C. I.

Pregnancy complications Delivery Complications

No®

Yes 1.99*** (1.90 2.07)

Association between pregnancy complication and post-delivery complications

Pregnancy complications Post-delivery complications

No®

Yes 3.92*** (3.78 4.06)

Association between delivery complications and post-delivery complications

Delivery Complications Post-delivery complications

No®

Yes 4.28*** (4.08 4.48)

Discussion:

This study analysed the prevalence of emergency obstetric

complications in India and its determinants during

pregnancy, delivery, and post-delivery. The socioeconomic

variables like maternal age, education, parity, residence,

religion, and caste are important in influencing maternal

mortality and morbidity health outcomes. In this study, the

age group of mothers below 20 years and 20-34 years

experienced a high risk of complications than the 35-45

years of age group. In contrast, the study analysed that the

mother's age groups 35-45 yrs. Furthermore, older

experienced obstetric complications compared to the less

than 35 and a higher risk of death (Grotegut et al., 2014). As

the level of education increases, the complication level is

decreasing.

Similarly, the findings of (Mousumi G et al., 2015). The first

parity of the mother experiencing high risk of complications

than the second parity bit as the parity increases means four

and more than four the level of complications is also

increases during pregnancy, at delivery, and post-delivery.

The sex of the household is not significant for emergency

obstetric complications. Muslim religion reported high

prevalence of complications than the other religion, whereas

the Sikh reported high risk of complications at post-delivery,

and Buddhists show a low risk of complications. In our

findings, the scheduled tribes reported less risk of

complication, but in contrast, the literature shows that

scheduled caste or scheduled tribe groups were significant

risk factors for maternal deaths (Horwood G et ., Al., 2020).

The mother who are poor shows a high prevalence of

emergency obstetric complications than the rich mother.

Similarly, the findings from the literature standard of living

have also shown a positive attitude towards reporting health

complications as women belong to higher wealth quintile

reported having fewer obstetric health complications

(pregnancy, delivery, and after delivery) as compared to

women that belong to a poor wealth quintile (Mousumi, G.,

2015).

The various factors are affected to the emergency obstetric

complications such as Antenatal care visits or not, natal care

and postnatal care; the Place of delivery, who assisted the

delivery, is the factors that play a main role in the

pregnancy, delivery, and post-delivery complications. The

mother who had done the full antenatal and postnatal care

reported fewer complications, and similarly, the finding

shows form (Rishabh G et al. 2017). The skilled attendance

during delivery and post-delivery are highly statistically

significant, and the literature is also said that skilled

attendance during delivery, access to emergency obstetric

care, and postnatal care (PNC) are cost-effective lifesaving

investments for mothers. In our results, the pregnancy

complications are highly associated with the delivery and

post-delivery complication, but in contrast, the literature

shows no strong positive correlation between pregnancy

complications and delivery complications (Mousumi G et

al., 2015).

Conclusion:

There is a need to focus more on the protective factors for

the pregnancy complications such as full ANC, PNC, skilled

ANC provider, and making our women healthier to enter

pregnancy without anemia and with normal BMI. Public

hospitals should be strengthened by enabling easy

availability and accessibility of emergency obstetric care to

reduced complications.

Policy Implications:

Based on the findings of this study, some policy

implications which help to reduce adverse maternal and

neonatal health outcomes are as follows:

1. The states like Uttar Pradesh, Bihar, and Madhya

Pradesh reported a high prevalence of pregnancy

complications compared to the national level

(India), and the rate of consumption of Iron folic

tablets is also low in that states. In such states, the

government should form policies and implement

awareness about antennal care services.

2. To more strengthen the equipment for the

emergency obstetric care on the sub-canter,

primary center, community level, and district level

hospitals. To more strengthen the referral services.

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