DISCUSSION
In the present study, which was done over a period of 18 months,
incidence of ICU admission was 0.77% which is comparable to the results
of Begum and Padmavat8. However, Ozumba et
al9 in 2018 in their study found a higher incidence of
1.7% probably due to different admission criteria or due to a large
catchment area.
It is obvious that booked status of the patients is associated with
better outcome as is also reflected in the present study. In contrast to
the present study, Joseph et al10 found increased ICU
admission among booked cases. Probably this was due to the referral of
these booked cases in complicated stages.10
In the present study, referred cases comprised the major part (55.6%)
of the ICU admissions and their outcomes were significantly worse than
the direct admissions.
This may be attributed to the fact that the patients who are referred
are generally high risk or in critical condition as they could not be
managed at the periphery hospital. If this factor is also associated
with delay in the transport then the outcome of the referred patients
further deteriorates.
Maternal health behavior varies with socioeconomic status and it is also
affected by education level. Low socioeconomic status is usually
associated with low education status, poor health seeking behavior,
unintended and unplanned pregnancy, inadequate antenatal visits, lack of
knowledge regarding available health facility benefits and their
cultural stigma. These issues are clubbed with logistic problems like
inaccessibility to health care and form a vicious circle in this strata.
The same is clearly reflected in the present study where patients of
lower socioeconomic strata had worse outcomes. Concordant results were
found by Panda et al, 64.13% of the patients admitted to ICU in their
study belonged to lower socioeconomic status.11
To improve the medical care in obstetric emergency, time is a crucial
factor in life threatening conditions. Delay at any level worsens the
prognosis of patients because life-threatening conditions may develop
without any warning and require prompt treatment.
In the present study, first level delay was present in 65.4% cases
admitted in ICU.
Similar to present study, Ghumare et al found that 27% delays were at
the first level. In 19% cases mixed delay was
present.12 Kumari K et al also observed that first
delay was present in 81.8% of cases and level 1 delay was the most
common delay found.13
In the present study most, common delay found was the delay at level 1,
which is the delay in deciding to seek care. It was mainly due to
socioeconomic and cultural characteristics. They were also not educated
about the warning sign of any complication by the front-line provider
(ASHA) in some cases. An accredited social health activist
(ASHA ) is a community health worker instituted by the
government of India’s Ministry of Health and Family Welfare (MOHFW) as a
part of the National Rural Health Mission (NRHM). Their antenatal visits
were limited to nutritional supplements and a general check up at the
ground level, which might have missed preexisting medical and also
obstetrical complications like malpresentation and cephalopelvic
disproportion.
The hesitation to seek health care was compounded by cultural taboos and
gender bias which further increased the duration of delay. The outcomes
worsened significantly with increasing duration of level 1 delay. This
again emphasizes the importance of intervention in the first few golden
hours.
Second level delay is the delay in reaching the appropriate health care
facility and in the present study, it was present in 50% cases.
Similar to our study Kumari K, et al also found that contribution of
second level delay was present in 54.5% cases.13
Second level delay of <4hr is present in 33.1% which was
mainly due to geographic distribution of referral center, cost of
transportation and unavailability of transport. Second level delay of
>4hr was found in 16.9% and was associated with delayed
decision of referral by peripheral hospital. Main reasons of referral
were non availability of NICU, blood bank, ICU facility and facility of
cesarean section (lack of functional operation theatre or trained
personnel). This results in lack of active intervention in the first few
golden hours thus worsening the condition of the patients. Increased
duration of level 2 delay was significantly associated with worse
outcome.
Third level delay was present in 9.7% cases in the present study.
Presence of third level delay in our tertiary care hospital could
probably be explained by disproportionate infrastructural facility in
comparison to the patient load. (only single functional emergency
operation theatre, no availability of dedicated obstetric ICU facility,
a smaller number of beds available in general ICU).
In contrast to present study, Ghumare et al found that third level delay
was present in 21% cases12 and Kumari K et al also
found third level delay in 45.5% cases.13 It was
higher than the present study which may have been contributed by
superadded effect of inadequate specialist services and inadequate blood
component transfusion facility.12,13
Presence of any delay was significantly associated with worse outcomes.
In a multicentric cross sectional study done by Pacagnella et al, any
type of delay was observed in 53.8% of subjects and there was positive
association between the presence of any delay and severity of maternal
outcome.14Kumari K et al observed that most of the
deaths were associated with multiple levels of
delay.13
It was observed that the most common indication for ICU admission was
obstetrical hemorrhage (37.1%), followed by hypertensive disorder of
pregnancy (25.8%). In concordance with the present study, Sodhi et
al15 and Joseph et al10 had similar
results but Ozumba et al 9 found that rupture uterus
was the most common indication of ICU admission. Uterine rupture has
been remarkably eliminated in most parts of the world but probably low
socioeconomic status and poor health-seeking behavior of the subjects in
the study (South Ease Nigeria) contributed to this
finding.9
Mean APACHE II score was 14.77±6.85, According to this predicted
mortality was 25% but observed mortality was found to be higher i.e.
30.6%. %. This was probably due to the infrastructure and logistic
constraints of our study area, which is a government organization. There
was significant (p<0.01) difference in APACHE II score in the
presence of 1st and 2nd level delay.
APACHE II score was significantly (p<0.05) high in patients
having delay of ≥24 hrs. Also, APACHE II score was significantly higher
in the presence of 2nd level delay and it was
significantly increased as the duration of delay increased (p=0.0001).
In contrast to the present study, Sodhi et al found observed mortality
rate (OMR) to be too low as compared to the predicted mortality of
24%.15 This variability can probably be explained as
this study was conducted in a private hospital having most of the modern
equipment. Our study was conducted in a government setup having limited
and conventional resources.
Strengths: It is one of the few studies conducted in a tertiary
center of northern India correlating all three levels of delay to
fetomaternal outcome thus allowing a genuine root cause analysis at the
ground level.