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Journalism of Courage
It was only when 23-year-old Dhaanu* succumbed to heart failure during childbirth at a village in Tamil Nadu that her family realised that she had an undiagnosed congenital heart defect. Neither did they know that her death could have been prevented had she been screened in the early stages of her pregnancy. The primary health care centre in her village lacked diagnostics or a skilled obstetrician to read the warning signs.
All that’s set to change with the Indian Council of Medical Research (ICMR) now funding a study to analyse the number of maternal deaths because of heart diseases and develop a treatment protocol to prevent future mortality. This is needed to further arrest India’s maternal mortality because the most common risk factors, like infections and excessive bleeding, have been controlled well while heart disease is emerging to be the next big risk factor.
Maternal mortality rate (MMR) is an important concern for any country since it is a key indicator of women’s health and childcare. Since deaths during childbirth are preventable, MMR is also an indication of basic public health preparedness. Over the last two decades, India’s MMR has gone down by 70 per cent, according to a 2022 study. Government data pegs it at 97 deaths per lakh live births between 2018 and 2020.
But now that it has reached a plateau, ICMR is planning to tackle the underlying risk factor of heart disease. The Rs 8-crore study, which will be held across 50 centres and AIIMS, will not only identify the 10 most common heart diseases in pregnant women but also develop their treatment protocol that can be accessed in remote rural pockets.
“Obstetricians are doing a great job in managing haemorrhage and septic complications. Now, unless we focus on improving care for heart diseases in pregnancy, the maternal mortality cannot come down further. India has a specific plan for improving care of women with heart disease,” said Dr Justin Paul, professor at the Institute of Cardiology at Madras Medical College and the lead investigator of the proposed study. “We will then randomise participants and study the outcome of using the newly-developed protocol care versus the usual care,” he added.
Pregnancy carries an increased risk of cardiovascular events because of several metabolic changes in the body. Significant cardiovascular changes happen in the mother within the first eight weeks of pregnancy. As per a Lancet study, the risk of heart failure increases steadily by 24 weeks, plateaus at 30 weeks and peaks again around delivery. Sometimes pregnant women, according to Dr Paul, especially those belonging to the lower economic strata, may have an underlying problem, like congenital heart disease, that is diagnosed for the first time.
He has studied trial data from 2016 to 2019 in Tamil Nadu and found valvular heart diseases (conditions in which the heart valves do not function normally) to be the most common in India, making up around two-thirds of the maternal deaths. “Congenital heart diseases (problems of heart structure present by birth) comprised 33 per cent of maternal deaths,” he added.
The data also showed that 60 per cent of the women came to know of a heart disease for the first time during their pregnancy. “Most of them were never diagnosed before, but some were also never informed of their condition by family members due to existing stigma. A woman with heart disease is unlikely to get married. And, when they do get married — and sometimes may not even know that they have had a heart surgery with parents hiding it from them — they face complications. These women tend to not do very well because their disease has not been optimised before pregnancy,” said Dr Paul.
It is essential that women during their pregnancy and obstetricians treating them are aware of complications of heart disease and identify them at the earliest. “That’s why cardiologists and obstetricians need to work together to bring down maternal deaths caused by heart disease. These cases have to be managed by two different specialities who otherwise would not meet or discuss with each other. So what really happens is that the cases get ignored. This is the reason it is important to have cardio-obstetrics teams in hospitals. In fact, this should become a new super-speciality,” suggested Dr Paul.
According to a 2022 study, that looked at trends over two decades, the leading causes of maternal deaths were haemorrhage or uncontrolled bleeding (47 per cent), pregnancy-related infection (12 per cent), and hypertensive disorders of pregnancy (seven per cent).
The proposed trial will include sites across India — from Kashmir to Tamil Nadu, and from Assam to Rajasthan to be representative of the Indian population. Around seven All India Institute of Medical Sciences will also participate in the study, according to Dr Paul. “This is a wonderful type of study that hasn’t been done anywhere in the world,” he added.
(*Name changed)
| Kerala | 19 |
| Maharashtra | 33 |
| Telangana | 43 |
| Andhra Pradesh | 45 |
| Tamil Nadu | 54 |
| Jharkhand | 56 |
| Gujarat | 57 |
| Karnataka | 69 |
Top three causes of maternal mortality*:
*Between 1997-2020
(Source: Sample Registration System 2018-20, analysis of Million Death Study data)
