RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALOREANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. NAME AND ADDRESS

OF THE CANDIDATE

MRS. SUSHILA KUMARI

Ist YEAR M.Sc. NURSING,

RATHNA COLLEGE OF NURSING

K.R. PURAM, HASSAN.

2.

NAME OF THE

INSTITUTION

RATHNA COLLEGE OF NURSING

K.R. PURAM, HASSAN

3.

COURSE OF STUDY

AND SUBJECT

MASTER OF SCIENCE IN NURSING

OBSTETRICS & GYNAECOLOGY

4.

DATE OF ADMISSION

TO THE COURSE

31-05-2010

5 TITLE OF TOPIC KNOWLEDGE REGARDING INDENTI-FICATION OF HIGH RISK PREGNANCY AMONG ANM STUDENTS.

5.1 STATEMENT OF THE

PROBLEM

A STUDY TO DESCRIBE THE KNOWLEDGE REGARDING IDENTIFICATION OF HIGH RISK PREGNANCY AMONG STUDENTS OF SELECTED ANM SCHOOLS OF HASSAN WITH A VIEW TO DEVELOP A INFORMATION BOOKLET.

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Let every mother and child to be counted” 1

Throughout time, care of pregnant mothers has been based on one over-riding

objective that each pregnancy should result in a healthy mother and baby. Whilst the

majority of pregnancies will progress satisfactorily with minimal intervention from the

caring professionals, there will always be the need to identify those high risk pregnancy

groups for whom a greater degree of care is required.2

A high-risk pregnancy can be defined as the gestation period in which the mother

and the child both are highly susceptible to health problems, medical complications and

may run a higher risk of spontaneous abortion. Some conditions are inevitable but a lot

can be taken care of with the help of good prenatal health care. The various complications

that one may encounter during pregnancy are heart diseases, kidney problems, sexually

transmitted diseases and diabetes etc. General awareness and a strong family support are

also the primary requisites if one needs to cope with the difficulties of a high-risk

pregnancy. It is an accepted truth that the probability of undergoing a high-risk pregnancy

increases with increasing maternal age. Even the ladies who have in the past experienced

multiple miscarriages, stillbirths, neonatal deaths or maybe pre-term deliveries also stand

a chance to suffer from a high-risk pregnancy.3

A woman is considered to have a high-risk pregnancy when health concerns exist

that may threaten the natural course of the development or birth of the baby, or that pose

a risk to the mother. In such cases, the mother may need special care, more tests and

possibly medication to ensure that she can carry the baby safely through to delivery.

While pregnancy is a natural condition, it can be complicated even in healthy woman's

body because of changes in blood volume, hormone balance, pressure, the physical

burden of pregnancy etc. Underlying medical conditions can add even more stress, while

complications caused by pregnancy itself (such as preeclampsia or gestational diabetes)

can turn a normal pregnancy into a high-risk pregnancy. Most high-risk pregnancies still

end with a healthy mother and child; it is still true that six out of 100,000 births in the

United States, the mother die, 16 babies in every 1,000 deliveries also die before, during,

or after birth. A pre-pregnancy visit with a healthcare provider is especially important for

a woman who has a medical problem.3

A woman who has not had a pre-pregnancy visit should contact a healthcare

provider as soon as she learns she is pregnant. Often, the provider will schedule the first

prenatal visit within a day or two, instead of waiting until 8-10 weeks of pregnancy. This

is because certain medical conditions can increase the risk of miscarriage. The provider

has to be sure that any medication is adjusted properly to increase the chance of having a

successful pregnancy. In addition a woman with a high-risk pregnancy may be referred to

a prenatal care center need the expert advice.3

Women die from a wide range of complications in pregnancy, childbirth or the

postpartum period. Most of these complications develop because of their pregnant status

and some because pregnancy aggravated an existing disease. The four major killers are:

severe bleeding (mostly bleeding postpartum), infections (also mostly soon after

delivery), hypertensive disorders in pregnancy (eclampsia) and obstructed labour.

Complications after unsafe abortion cause 13% of maternal deaths. Globally, about 80%

of maternal deaths are due to these causes. Among the indirect causes (20%) of maternal

death are diseases that complicate pregnancy or are aggravated by pregnancy, such as

malaria, anemia and HIV. Women also die because of poor health at conception and a

lack of adequate care needed for the healthy outcome of the pregnancy for themselves

and their babies.

The first step for avoiding maternal deaths is to ensure that women have access to

family planning and safe abortion. This will reduce unwanted pregnancies and unsafe

abortions. The women who continue pregnancies need care during this critical period for

their health and for the health of the babies they are bearing. Most maternal deaths are

avoidable, as the health care solutions to prevent or manage the complications are well

known. Since complications are not predictable, all women need care from skilled health

professionals, especially at birth, when rapid treatment can make the difference between

life and death. For instance, severe bleeding after birth can kill even a healthy woman

within two hours if she is unattended. Injecting the drug oxytocin immediately after

childbirth reduces the risk of bleeding very effectively.1

A study revealed that India and other developing countries, has a very high

perinatal mortality, with a high illiteracy, ignorance, teeming population and lack of

facilities and resources. These factors make almost 30% of pregnant mothers at high risk,

which may end their life during perinatal period. There is early identification of high risk

pregnancies and requires exemplary individualized special attention as this group is

responsible for maximum perinatal mortality and morbidity even though they form a

small proportion of the entire population. Despite recent advances in maternal and

neonatal care in India, prenatal mortality is still very high 46 per 1000 live births

compared to 5-10 per 1000 live births in developed countries. 70%-80% of perinatal

mortality in developing countries including India is accounted for by the mothers falling

in the high risk category. This need for early identification of thigh risk mothers so that

they receive timely and appropriate care.4

6.1 NEED FOR THE STUDY

Most women in the world do not have access to the health care and health

education services that they need during pregnancy. In many developing countries,

complications of pregnancy and childbirth are the leading causes of death among women

of reproductive age. More than one woman every minute and 6 lacs woman every year

die due to high risk pregnancy. 1% of these deaths occur in developed countries, could be

avoided if resources and services were made available.5

Woman can experience sudden and unexpected complications during pregnancy,

childbirth, and just after delivery. Although high-quality, accessible health care has made

maternal death a rare event in developed countries; these complications can often be fatal

in the developing world. Consequently, mothers in developing nations die in childbirth

because of risky pregnancy more than 100 times higher than the rate in developed

nations. Access to emergency obstetric care, the most important remedy for women in

these regions is not highly regarded as a priority. In countries like Bangladesh, 68.7% of

the women give birth without the assistance of trained birth attendants. Instead relatives

or traditional midwives, who are often not capable of handling complications during the

delivery, serve as birth assistants. Factors that prevent women in developing countries

from getting the health care include distance from health services, cost, and multiple

demands on their time, and women’s power within the family.5

High risk pregnancy accounts the fourth leading cause of death for women after

HIV/AIDS, malaria, and tuberculosis. 99% of these deaths occur in low-income countries

while only 1 of 4,000 women has a chance of dying in pregnancy or childbirth in a

developed nation. A woman in Sub-Saharan Africa has a 1 in 16 chance of dying in bad

maternal conditions. Furthermore, high risk pregnancy causes almost 20% of the total

burden of disease for women in developing countries. Almost 50% of the births in

developing countries take place without a medically skilled attendant to aid the mother

and the ratio is even higher in South Asia. Women in Sub-Saharan Africa mainly use

traditional birth attendants, with little or no medicinal training which largely accounts for

the high numbers of maternal deaths in this region.6

A study conducted in India shows that majority of maternal deaths are due to

direct cause (75%); due to postnatal bleeding cause 25% death, sepsis 15%, unsafe

abortion 13% and due to 12%. The direct causes for the maternal death are anemia 20%,

hypertension and cardiac diseases 04%, hepatitis/ HIV 06%. The study also revealed that

maternal mortality rate is 480 per 1 lakhs live child birth and maternal morbidity is 16

times higher than of mortality.7

A study conducted shows that India one of the six countries account for 50% of

the maternal deaths worldwide, has reduced the Maternal Mortality by four per cent a

year since 1990, more than double the global average. The study also shows that in India

still stands 127th place in maternal mortality rating. A systematic analysis of progress

toward millennium development Goal 5’ says India is one of the few countries others

being Egypt, Romania, Bangladesh and China that have recorded “substantial decline” in

maternal mortality rate. In 1980, India reported about 677 maternal deaths during

pregnancy, childbirth or after delivery per 1 lac live births but in 2008, this was down to

254 deaths. This means India has climbed from near bottom to 127th place above

Pakistan and just below Nepal. Study says that between 1980 and 2008, maternal deaths

declined worldwide. While an estimated 5.4 lacs maternal death were recorded

worldwide in 1980, the number of such deaths dropped to about 3.5 lacs in 2008.8

The investigator gone through previous study and only few studies have done

regarding identification of high risk pregnancy. So she took interest to do this study

“knowledge regarding identification of high risk pregnancy among ANM students.” This

study I hope will help ANM students to gain knowledge regarding identification of high

risk pregnant woman in hospital.

6.2 REVIEW OF LITERATURE

Review of literature is an essential step in development of research project. The

presentation of review of literature is organized under the following headings:

Studies related to:

A. Identification of high risk pregnancy.

B. Causes of high risk pregnancy.

C. Management of high risk pregnancy.

D. Knowledge of care givers regarding identification of high risk pregnancy.

A. Studies related to Identification of high risk pregnancy:

A study conducted regarding identification of high risk pregnancy at Srinagar, India

in 2005. The study shows that India and other developing countries have a very high

perinatal mortality rate with a high illiteracy, ignorance, teeming population and lack of

facilities and resources. The study concludes that perinatal mortality rate was 46.1/ 1000

live birth. The perinatal mortality rate in women with no risk factor was 5.02 per 1000

live births, which rose with the level of risk from 27 per 1000 in low risk to 96 in

moderate risk to 222 in the high risk group. The women with one or more risk factors

were 17.1 times more likely to lose their baby during the perinatal period than those with

no risk.9

A study conducted to identify the preventable factors in high risk pregnancy in

India. Over a period of one year, of total 1,600 deliveries, 1,107 were considered to be at

high risk, 33 fetal and 31 early neonatal deaths with an overall perinatal mortality rate of

40/1,000 births. The mortality was higher in mothers who had received inadequate

antenatal care or with bad obstetric history. Overall cesarean section rate was 16.9%.

Infants with a gestational age of <37 weeks and of birth weight <2,500 g contributed for

56.2% and 68.7% of the total perinatal losses respectively. Identifiable causes of perinatal

deaths observed were; asphyxia (31%), congenital anomalies (18.7%), sepsis (18.7%) and

low birth weight (25%).10

A Study conducted to find out prevalence and outcome of high risk pregnancies

in Pakistan. The sample was composed of 226 pregnancies. Out of these 226 were

delivered till December 2004. The study shows that high risk pregnancies were 69.5% as

compared to 30.5% of low risk category. This indicates high prevalence of high-risk

pregnancies in the area. It also shows that 73.24% of females with high-risk pregnancy

were illiterate as compared to 62.31% with low risk pregnancy. Literate women were

26.75% in high-risk pregnancies and 37.68% in low risk.11

A study conducted regarding the identification of high-risk pregnancy, using a

simplified risk-scoring system at Chung Ang Medical Center, Korea. The study included

4 categories demographic, obstetric, medical and miscellaneous factors. This study was

based on the 1300 pregnant women. The results of the study show that 560 infants

(42.7%) were born to mothers with risk-scores greater than 7, and 753 infants (57.3%)

were born to mothers risk scores less than 7. 2. Maternal age, parity, education level, of

the demographic factors was significant relation statistically to identify the high risk

pregnancies. Abnormal nutrition, anemia, UTI, pulmonary disease, severe influenza, and

heart disease were significant to identify the high risk pregnancies.12

A study conducted regarding near-miss and maternal mortality in maternity university

hospital, Damascus, Syria revealed that there were 28025 deliveries, 15 maternal deaths

and 901 near-miss cases. The study showed a MNMR of 32.9/1000 live births, a MMR of

54.8/1000 live births. Hypertensive disorders (52%) and haemorrhages (34%) were the

top causes of near-misses. Late pregnancy hemorrhage was the leading cause of maternal

mortality (60%) while sepsis had the highest mortality index (7.4%). Most cases (93%)

were referred in critical conditions from other facilities; namely traditional birth

attendants homes (67%), primary (5%) and secondary (10%) healthcare units and private

practices (11%). 26% of near-miss cases were admitted to Intensive Care Unit (ICU).13

B. Studies related to causes of high risk pregnancy:

A study conducted to determine the maternal mortality rate, various causes affecting

in Christian Medical College & Hospital, Ludhiana, India 2005. The study reveals that

maternal mortality rate was 1470 per lac live births. The major causes accounted for more

than three fourth of maternal deaths with hemorrhage (33%), sepsis (21.7%) and

eclampsia (7.5%) playing an important role. Anemia (44.3%) and jaundice (16.0%) were

two important indirect causes of maternal deaths. It is concluded that providing good

antenatal care, finding appropriate ways of preventing and dealing with the consequences

of unwanted pregnancies, and improving the way society looks after pregnant women are

three most important ways to reduce maternal mortality.14

A study conducted to determine factors causing high risk pregnancy and to recognize

cause of death. A total 21 pregnancy related deaths occurred during 2004 to 2006 were

studied and their age ranged from 21 year to 35 year. It was observed that maximum

numbers of deaths were recorded in the age group of 21-25 years (52.38%). Hemorrhage

remains leading cause of death (38.09%) followed by indirect causes (23.80%),

undetermined (19.04%), sepsis (9.52%) and postpartum pre eclamptic shock (9.52%).

Death records remain an important source of maternal deaths however, using only death

certificate suffers from drawback because many times cause of death is not mentioned.15

A study conducted to check prevalence and risk factors for hepatitis C virus during

high risk pregnancy, Pakistan2009. Pregnant women were screened for HCV antibodies

during antenatal visits. Detailed history of HCV positive patients was taken to find out

the risk factors. Among 3020 pregnant women, 102 were positive for HCV antibodies. Of

these 73(71.52%) were positive for HCV. Among anti-HCV positive women, 8(7.84%)

were also positive for HBSAg. The age range was 17-35. The mean parity of study group

was 0.9. Of 102 women, 10(9.8%) had delivery, 19(18.62%) previous surgery,

20(19.60%) blood transfusions, 5(4.9%) had dental surgery, 6(5.86%) received injection,

and 32(31.5%) had unknown risk factor. Prevalence of Hepatitis C virus infection in

pregnant ladies is 3.44% who are at high risk.16

An observational retrospective study was carried out in our university hospital from

January 2004 till December 2008, Egypt. The study revealed that maternal mean age of

death was 34.9 years, 59% of women came from rural areas and 41% from urban ones,

65% delivered inside the hospital while 35% delivered outside, 71% were multifarious,

65% had no antenatal care and 29.7% irregular one, 12% were complaining of

concomitant diseases, 77.5% labored with cesarean section, 17% died before labor, 36%

during and 47% after labor. Causes of death are given in the order of the most leading

cause of death to the least as follows: postpartum hemorrhage, eclampsia, pre-eclampsia,

postpartum eclampsia, ruptured uterus, amniotic fluid embolism, accidental hemorrhage,

and anesthesia.17

C. Studies related to management of high risk pregnancy:

A WHO Report 2006 says that maternal mortality in India continues to be a major

concern given the reduced social, cultural and economic status of Indian women that

inhibits them from adequate access to health facilities. The report reveals that moderate

and severe anaemia among pregnant women (28%) is almost double that of non-

pregnant women (16%). The report says that only 51% of mothers received antenatal

check up, 71% received two or more doses of tetanus toxoid and contraceptive

prevalence is 56.3% in 2006. The pregnancy pattern in India too early, too many, too

close together enhances the risk of maternal mortality. About one-fifth of fertility is

contributed by women in the age group of 15 to 19 years. The birth interval in about

one-fourth of this group is 18 months. All round improvement in the access of the

community to various services, which are commonly required to minimize the high risk

pregnancy and maternal mortality rate said in report.18

A Study conducted regarding calcium supplementation during pregnancy for

preventing hypertensive disorders and related problems in Asian countries have found an

association between maternal calcium intake and hypertension disorders of pregnancy.

Clinical trials have confirmed that calcium supplementation reduces blood pressure and

hypertension related disorders. Hypertension complicates 10% of all pregnancies

worldwide. Hypertensive disorders were reported as the cause of 16.1% of maternal

deaths in developed countries, 9.1% in Africa, 9.1% in Asia, and 25.7% in Latin

America.19

A study conducted in USA reveals that maternal glucose regulation occurs in 3-10%

of pregnancies. Study suggests that the prevalence of diabetes mellitus among women of

child bearing age is increasing in the United States. This increase is believed to be

attributable to more sedentary lifestyles, changes in diet, continued immigration from

high-risk populations, and the virtual epidemic of childhood and adolescent obesity that

is presently evolving in United States. Gestational diabetes mellitus accounts for 90% of

cases of diabetes mellitus in pregnancy. Type II diabetes mellitus accounts for 8% of

cases of diabetes mellitus in pregnancy, and given its increasing incidence.20

A study conducted in USA for pregnancy risk monitoring in certain maternal

behaviors and experiences. The study reveals that unintended pregnancy, late entry into

prenatal care, smoking cigarettes during pregnancy, and physical abuse during pregnancy

related to adverse reproductive outcomes like low birth weight, infant morbidity and

mortality, and maternal morbidity. The results of study show that across the 13 states,

11.0% to 23.9% of women reported smoking during pregnancy. Smoking was

significantly more prevalent among women who delivered a low birth weight infant.

Prevalence of physical abuse during pregnancy ranged from 2.4% to 5.6%. Findings

indicate that many women report high risk behaviors or experience high risk conditions

before, during and after pregnancy.21

D. Studies related to knowledge of care givers regarding identification of high risk

pregnancy:

A study conducted regarding knowledge of risk pregnancy among care givers

government dispensaries of south district in Delhi, India. The descriptive study interview

method used among 428 health care workers between august to December 2007. The

results of study shows 49% were knowledgeable regarding the topic.22

A study conducted regarding knowledge of nurses regarding high risk pregnancy

in U.K. The result of study suggests that knowledge of the topic was adequate but nurses

have insufficient knowledge regarding emergency management.23

A study conducted to explore obstetric health care workers knowledge regarding

influenza vaccination in pregnancy. Of 267 workers do not believe that vaccines are a

safe and effective way to decrease infections (31%) and a minority believes that vaccines

are safe in pregnancy (36%). Half of health care workers know that pregnant women are

at increased risk of complications from the flu (56.6%). Only 46% were able to correctly

identify influenza symptoms, and only 65% would recommend influenza vaccination to a

pregnant woman if indicated. A small percentage would be willing to give an avian

influenza vaccine to pregnant women during a pandemic if it had not been tested in

pregnancy (12.3%).24

STATEMENT OF THE PROBLEM

A study to describe the knowledge regarding identification of high risk

pregnancy among students of selected ANM schools of Hassan with a view to

develop a information booklet.

6.3 OBJECTIVES OF THE STUDY

To assess the knowledge of ANM students regarding identification of high risk

pregnancy.

To find out the association of knowledge with the selected demographic

variables among ANM students.

6.3.1 HYPOTHESIS

HI: There will be a significant association between the knowledge and the

selected socio demographic variables of ANM students.

6.3.2 ASSUMPTIONS

Identification of high risk pregnancy avoids complication of delivery.

Knowledge of ANM students can influence in the adaptation of

improvement of maternal care.

6.3.3 OPERATIONAL DEFINITIONS

Assess- It is the method of estimating the level of knowledge among ANM

students regarding identification of high risk pregnancy.

Knowledge- It refers to the correct response of ANM students for the

questionnaire regarding the identification of high risk pregnancy.

ANM Students- The students who are studying Auxiliary Nurse Midwives

diploma course in selected schools of Hassan.

Information Booklet- A small bound book or pamphlet having a organized

instructions regarding identification of high risk pregnancy which will be

distributed to the ANM students.

High Risk Pregnancy- A high risk pregnancy is one in which the mother or

the developing fetus has a condition that places one or both of them at a

higher than normal risk for complications, either during the pregnancy,

delivery or following the birth.

6.3.4. CONCEPTUAL FRAMEWORK

Conceptual model of this Study is based on J.W Kenny’s open

system theory.

6.3.5 DELIMITATIONS

The study is delimited to:

4 to 6 weeks of data collection.

50 ANM students.

Non experimental descriptive design.

7. MATERIAL AND METHOD OF STUDY

7.1 SOURCE OF DATA:

The data will be collected from ANM students of selected schools,

Hassan.

7.1.1 SIGNIFICANCE OF THE STUDY:

The purpose of the present study is to educate ANM students on

identification of high risk pregnancy and it will enhance the knowledge of them in

providing quality health care and in preventing complications during pregnancy, delivery

and post partum.

7.1.2 RESEARCH DESIGN:-

Non experimental descriptive research design.

7.2 METHOD OF DATA COLLECTION

Part A: Socio demographic variables of ANM students.

Part B: Structured knowledge Questionnaire on identification of high risk pregnancy.

7.2.1 SAMPLING PROCESS

CRITERIA FOR SELECTION OF SAMPLES:

INCLUSION CRITERIA

ANM students studying in selected schools of Hassan.

ANM students available during the time of study.

EXCLUSION CRITERIA

ANM students who are not willing to participate in the study.

7.2.2 SAMPLING PROCEDURE

7.2.2.1 POPULATION:

The population for the study is all ANM students of selected

schools, Hassan.

7.2.2.2 SAMPLE:

The ANM students who fulfills inclusion criteria.

7.2.2.3 SAMPLE SIZE:

In this study sample size will be 50 ANM students.

7.2.2.4 SAMPLING TECHNIQUE:

Non probability purposive sampling technique will be used.

7.2.2.5 STUDY SETTING:

Setting in general location and condition in which data collection

takes place in the study.

The setting for this study in Rajeev junior health assistant female

school, and government junior health assistant female school Hassan. ( both in

Rajeev ANM school and government ANM school 30 admission takes place per

year).

7.2.2.6 PILOT STUDY:

The pilot study is planned with 10% of the samples.

7.2.2.7 VARIABLES

Dependent Variable:

Knowledge of ANM students regarding high risk pregnancy.

Extraneous Variables:

Age, Basic Education, Type of family, dietary pattern, religion,

residence.

7.2.2.8 PLANS FOR DATA ANALYSIS

The plan for data analysis includes descriptive and inferential

statistics.

Descriptive statistics:

To describe the demographic variables and level of

knowledge,frequency (f), percentage (%), mean(x) standard deviation

(S.D) will be used.

Inferential Statistics:

chi-square’ test will be used to find out the association

between the demographic variables with knowledge scores.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION

TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?

Yes, Knowledge will be assessed through structured

questionnaire information booklet will be issued.

7.4 HAS ETHICAL CLEARANCE HAS BEEN OBTAINED FROM YOUR

INSTITUTION?

Yes, Ethical clearance has been obtained from the research

committee of Rathna college of nursing and authorities of selected ANM schools

at Hassan, informed consent will be maintained obtained from subjects who are

selected for the study and confidentiality will be maintained.

8. REFERENCES:1. WHO Report 2007, “Maternal Mortality”.

2. UK Health Departments. Why mothers die: Report on confidential enquiries into

maternal deaths in the United Kingdom 1994-96. London: HMSO, 1998.

3. http://www.faqs.org/health/topics/3/High-risk pregnancy .html 4. Samiya M, Samina M “Identification of high risk pregnancy”, Indian Journal for the

Practicing Doctor, Vol. No. 1 (2008-03 – 2008-04).

5. WHO Report 2004, “The world health report”.

6. UNICEF Report 2001, “Women’s health”.

7. Dr. Jasmine Mehta, “High Risk Pregnancy and Labour”, OBG Department, G.K.

General Hospital, Bhuj, Gujarat.

8. Dr Christopher Murray et al, “Maternal mortality rate in India”, Institute for Health

Metrics and Evaluation, University of Washington 2008.

9. Dutta S and Das XS, “Identification of high risk mothers by a scoring system and it’s

correlation with perinatal outcome”, Journal of Obstet Gynaecol India. 1990; 40: 181-

190.

10. Shahzada J. Malik and Nisar A. Mir, “identify the preventable factors in high risk

pregnancy”, Journal of obstetrics and gynecology research, May 2010.

11. Dr. MahmudaMubasher, “To find out prevalence and outcome of high risk

pregnancies”, OBG Department, MAROOF International Hospital in Pakistan.

12. Taehan Kanho, “identification of high-risk pregnancy, using a simplified risk-scoring

system at Chung Ang Medical Center, Korea”, Journal of obstetrics and gynecology,

1991 Aug; 30(3):49-65.

13. Yara Almerie et al, “Near-miss and maternal mortality” in maternity university

hospital, Syria, BMC Pregnancy and Childbirth 2010,  10.1186/1471-2393-10-65

14. Dilpreet Kaur, Vaneet Kaur and Veronica Irene Yuel, “The maternal mortality rate,

various causes affecting”, Department of Obstetrics and GynecologyChristian

Medical College & Hospital, Ludhiana, India 2005

15. R. V. Bardale MD and P. G. Dixit MD, “Factors causing high risk pregnancy and to

recognize cause of death.” Department of Forensic Medicine, Govt. Medical College

& Hospital, Nagpur, India 2006.

16. Farhana Shaikh et al, “To check prevalence and risk factors for hepatitis C virus

during high risk pregnancy”, Department of Gyne/ Obs and Pathology, Peoples

Medical College Nawabshah, Pakistan, 2009.

17. El Daba AA, Amr YM, Marouf HM, Mostafa M, “Retrospective study of maternal

mortality in a tertiary hospital in Egypt.” Anesthesia Essays Research 2010; 4:29-32.

18. WHO Report 2006, “Improve maternal health”.

19. WHO Reproductive health library 2010, “Calcium supplementation during pregnancy

for preventing hypertensive disorders”.

20. Thomas R Moore, MD, “Diabetes Mellitus and Pregnancy”, Department of

Reproductive Medicine, University of California USA 2010.

21. CDC Weekly report 2000, “Pregnancy Risk Assessment Monitoring System”.

22. Vertika Kishore, Man M Misro, and Deoki Nandan, “Knowledge of health care

workers regarding risk pregnancy”, Indian journal of community medicine, 2010

January; 35(1): 46–51

23. Barbara Mullan, PhD, lecturer in Health Psychology, School of Psychology,

University of Sydney, Sydney, Australia.

24. Broughton DE , Beigi RH and Switzer GE, “Obstetric health care workers' attitudes

and beliefs regarding influenza vaccination in pregnancy”, Obstet Gynecol. 2009

Nov;114(5):981-7