Factors Associated with Maternal Mortality in India: A scoping review of research publications from 2015 – 2020
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Background: Many women still die from preventable causes such as haemorrhage, sepsis and hypertensive disorders of pregnancy which are aggravated by broader socio-political, socio-economic, individual-level, community-level and health system factors. India has made great strides in reducing its maternal mortality in the last two decades, however, wide inter and intra-state disparities persist. Rigorous research can help identify the determinants of maternal mortality in these states to inform evidence-based interventions. This review aims to map the determinants of maternal mortality that have been assessed in empirical studies in India in order to identify gaps and inform future research. Methodology: This scoping review followed the Joanna Briggs Institute (JBI) approach. An electronic search was conducted in PubMed, Scopus, Web of Science, Cochrane, Proquest, CINAHL, Research gate, Reliefweb and Google Scholar for articles published between 2015 and 2020. Additional articles were handpicked from references. Seventy-seven articles were retrieved for full-text screening with 68 articles retained for the study. The data was extracted into the Mendeley reference manager and analysed using Epi InfoTM version 18.104.22.168 software. The Commission on Social Determinants of Health (CSDH) and the World Health Organisation (WHO) application of the 10th revision of the International Classification of Diseases and Related Health Problems to deaths during pregnancy, childbirth, and the puerperium (ICD-MM) frameworks were used to organise our review and respond to the research question which was: What health system factors associated with maternal mortality in India have been assessed in empirical literature between 2015 and 2020? Results: The studies were conducted in four union territories and 19 states with the majority of studies in Maharashtra (n=11), Karnataka (n=7) and Uttar Pradesh (n=5). Most were descriptive studies (79.41%) using quantitative methods (87.69%) to collect data in urban (69.84%) tertiary care teaching hospitals (80.88%). Biomedical causes classified as direct and indirect causes of maternal mortality (95.45%) were the most prevalent factor assessed followed by individual-level factors (88.24%), health system factors (72.06%) community-level factors (52.94%) and socio-economic factors (50%). Socio-political factors were not assessed. The main health system factors assessed in the studies were: availability of ANC services (n=36), referral status of the client (n=26), length of stay in a health facility (n=22), number of ANC attended (n=15), the three delays (n=13) and the place of delivery (n=11). Conclusion: Empirical studies on factors associated with maternal mortality in India have mostly replicated the same study design in different states with minimal consideration of socio-economic and community-level factors and no exploration of socio-political factors. Studies assessing health system factors have not been adequately exploratory, leaving many of the factors such as distance to a health facility, cost of health services, means and cost of transportation, the quality of health personnel, proper diagnosis and management, and monitoring and evaluation unexplored. Therefore, more qualitative studies should be conducted to assess the socio-political, socio-economic, community-level and health system factors associated with maternal mortality in India.