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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Changing Trends of Maternal Mortality in a Rural Medical College in Eastern India: A 23-Year Retrospective Study
Correspondence Address :
Dr. BC Kameswari,
Room no-312, New building, Ladies Hostel, Lokepur-722101, Bankura, West Bengal, India.
E-mail: bhairavabhatla@gmail.com
Introduction: Maternal mortality in a region is a measure of reproductive health of women in that area. The direct causes of maternal deaths are largely preventable. A new era of more comprehensive, international development agenda-the Sustainable Development Goals (SDG 3.1) was launched by the United Nations General Assembly 2015, New York for ending preventable maternal deaths.
Aim: To determine the causes and changing trends of maternal mortality in at a rural centre in Eastern India.
Materials and Methods: A retrospective observational study was carried out in the Department of Obstetrics and Gynaecology of Bankura Sammilani Medical College in West Bengal in Eastern India. Individual hospital records of all the maternal deaths, from January 1998 to December 2020 were collected. Data regarding demographic profile and reproductive parameters like gravida, parity, antenatal care and cause of death were collected. The records were divided into two four yearly periods, to compare the changing trends (1998-2001) vs (2017-2020) and three five yearly (2002-2006), (2007-2011), (2012-2016) periods. The first term (1998-2001) was taken as the reference period.
Results: Comparison between first (1998-2001) and last term (2017-2020) shows significant declining trend of Maternal Mortality Ratio (MMR) (364 vs 148)/100000 live birth (p-value <0.00001). Majority of deaths occurred in primigravida (57.5% vs 60.6%). Direct obstetric causes accounted for majority of the deaths, but with a declining trend (74.7% vs 66.9%). Eclampsia remained the leading direct cause (35.5% vs 32.2%) followed by haemorrhage (20.4% vs 18.8%) and sepsis (18.8% vs 15.7%) in the first term (1998-2001) vs last term (2017-2020). Jaundice 6.45% vs 10.3%, heart disease 2.15% vs 7.1%, embolism 4.3% vs 0.8%, anaemia 6.45% vs 1.6% and other diseases 5.91% vs 13.4% in the first vs last term were the indirect causes of maternal mortality.
Conclusion: There is a declining trend of maternal mortality since 1998, which can be attributed to improvement at all levels of healthcare. Eclampsia/preeclampsia and its complications remain the leading cause of maternal mortality. Majority of these maternal deaths can be prevented by regular screening of highrisk cases, integrated antenatal and postnatal care, institutional deliveries, timely referral, and proper implementation of national health programmes.
Eclampsia, Institutional delivery, Maternal death surveillance and response, Maternal mortality ratio, Preventable causes
Maternal mortality is defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes (1). Direct causes of maternal deaths due to obstetric haemorrhage, sepsis, hypertensive disorders of pregnancy or due to complication of anaesthesia or Caesarean section are largely preventable (2). Indirect obstetric deaths are due to pre-existing disease like anaemia, cardiac disease, liver or kidney disease (2). One of the key indicators of maternal mortality is MMR (3), which shows marked variation due to variety of geographical and cultural regions in India (4),(5). In recent years, increasing attention is given to maternal mortality trends in developing countries, especially in context of the United Nations Millennium Declaration (6),(7). Thus, this study aimed to determine the changing trends of maternal mortality over a 23- year period in this rural centre.
A retrospective analysis was carried out in the Department of Obstetrics and Gynaecology, B.S. Medical College and Hospital, Bankura, West Bengal, India from January 1998 to December 2020. Data collection and analysis was done from July 2021- January 2022. This institution is a rural based teaching cum referral government hospital, catering almost exclusively to the under privileged rural pregnant women of Bankura, as well as neighbouring three to four districts, with total annual delivery of 23,000 approximately. All the case records of maternal deaths from the Medical Record Section of this hospital were obtained after taking permission from the Institutional Ethical Committee (IEC) (BSMC/Aca:-2126, dated 05/07/2021).
Inclusion criteria: All maternal deaths in this institution that occurred during pregnancy or within 42 days of its termination irrespective of the site or duration of pregnancy.
Exclusion criteria: Brought dead mothers and accidental or incidental maternal deaths were excluded from the study.
Demographic data including age, parity, literacy, residential area, antenatal care, admission-death interval were recorded to review the changing trends of maternal mortality in this rural area.The records were divided into two four yearly periods, to compare the changing trends i.e.(1998-2001) vs (2017-2020) and three five yearly i.e. (2002-2006), (2007-2011), (2012- 2016) periods. The first term (1998-2001) was taken as the reference period.
Statistical Analysis
The percentages for all variables were calculated and analysed using Microsoft Excel, 2007 and Statcalc statistical software (version: 8.1). Z test for proportion was used, to calculate p-value for MMR in first term (1998-2001) vs last term (2017-2020).
During the study period from January 1998 to December 2020, 960 maternal deaths and 4,02,743 live births were reported in this hospital with a cumulative (Cum) MMR of 238/100000 live births over a span of 23 years. There was an increase in institutional delivery and the MMR was 364 (1998-2001), 385 (2002-2006) and 227 (2007-2011), 157(2012-2016), and 148/100000 live births during 2017-2020 (Table/Fig 1). Comparison between first (1998-2001) and last term (2017-2020) show a statistically significant declining trend of MMR (364 vs 148)/100000 live birth (p-value <0.00001) using Z test for proportion. A significant declining trend of maternal mortality over the last two decades from 1998 to 2020 was observed (Table/Fig 2).
Majority belonged to 20-29 years primigravida. A declining death trends within 24 hours of admission (72% in the first term vs 31% in the last term) was noted, but increasing incidence in deaths after 72 hours of admission i.e.from 4% (1998-2000) to 45% in recent years (Table/Fig 3) (8).
There was a declining trend in the deaths due to eclampsia, preeclampsia (35.5% vs 32.2%), haemorrhage (20.4% vs 18.8%), sepsis (18.8% vs 15.7%) in the first term (1998-2001) vs last term (2017-2020) (Table/Fig 4).
MMR is defined as the number of maternal deaths in a given year per 100000 live births during the same period, and measures the obstetric risk in a particular area. Comparison of the MMR in different institutions of India is shown in (Table/Fig 5) (9),(10),(11),(12),(13),(14),(15). In India, the Sample Registration Survey (SRS) Bulletin of Register General of India of 1997-98 to 2016-2018, shows that the MMR has declined from 398/100000 live births during 1997-98 to 113/100000 live births in 2016-2018 (2),(3),(16). The ratio tends to be less in urban areas which reflects easy access of city dwellers to medical services (6).
The Millennium Development Goal-5 (MDG-5) had set a desired target of reducing maternal mortality ratio by 75% between1990-2015 (6). India’s share among global deaths has declined significantly, as per latest MMEIG report and 71% births are assisted by Skilled Birth Attendants (7),(16). In this era of SDG, India is committed to reduce its MMR to less than 70/100000 live births by 2030 (17).
The MMR in our state, West-Bengal has substantially declined from 218/100000 live births during 1999-2001 to 98/100000 live births during 2016-2018 as per SRS (3). In this study, the cumulative MMR was 238/100000 live births over a period of 23 years. Comparison between the first term (1998-2001) and the last term (2017-2020) showed a statistically significant declining trend of MMR (364 vs 148/100000 live births; p-value<0.00001. Being a tertiary referral centre, the number of institutional deliveries has increased significantly to 23,000 per year recently. Admission of moribund cases at BSMCH Bankura referred from the periphery have inflated the mortality ratio. Similar studies from other teaching institutions, reported MMR ranging from 185-3906/100000 livebirths (9),(10),(11),(12),(13),(14),(15). Majority belonged to the age group of 20-29 years consistent with other studies (9),(10),(11),(12),(13),(14),(15),(18),(19),(20),(21). There is reduction in teen-age maternal deaths over the years with 34% (1998-2001) vs 25% (2017-2020) as observed in this study, similar to that of Yadav S and Tiwari D (9) and Soni M et al., (20). This is partly, due to liberalization of abortion, increased age at marriage and availability of the drugs-misoprostol and mifepristone. Maternal deaths of referred cases, have decreased from 80% to 65% in recent years due to upgradation and improvement of peripheral health centres. In the first period of this study, 72% deaths occurred within 24 hours of admission in unbooked primigravida mothers, similar to the other reports (18),(19),(20),(21) probably due to lack of qualified medical attention in remote areas, poor communication and delayed referral, resulting in late intervention.
Here, it was observed that maternal deaths within 24 hours of admission have decreased by 40% due to timely referral, proper operative and High Dependency Unit (HDU) management, blood transfusion facilities and improved transportation and implementation of national maternity programmes. Studies show that eclampsia, haemorrhage and sepsis are the direct causes of maternal death whereas anaemia, embolism, jaundice and heart disease are important indirect causes in the recent days in our country (9),(10),(11),(12),(13),(14),(15). In this institution, the direct causes were responsible for 74.7% (1998- 2001) vs 66.7% (2017-2020) deaths, the leading cause being eclampsia consistent with Kachhwaha KP and Jain M (15) and Ashraf Ali M et al., (21) from Karnataka, who reported hypertensive disorders as the leading cause of death followed by haemorrhage. Singh R et al., from Bihar reported, a very high MMR (3906/100000 live births) in their study, with eclampsia as the leading cause (24%) followed by sepsis and haemorrhage (11). Regular availability and widespread use of magnesium sulphate in eclampsia in our tertiary centre along with antihypertensive, termination of pregnancy within 24 hours of last fit, facility of Obstetrics HDU, round the clock monitoring, 24 hours on call anaesthetist team and implementation of LaQshya programme by training our faculties, postgraduates and nursing staff have resulted in the declining trend of maternal as well as perinatal mortality in this tertiary referral centre.
Although obstetric haemorrhage was vigorously tackled, the prevalence of nutritional anaemia and poor general condition failed to prevent the maternal tragedy in moribund cases. Jaundice, heart disease, anaemia are important indirect causes in rural areas (12),(13). Pre-existing anaemia worsens as pregnancy advances, leading to congestive cardiac failure, inability to resist infection or cope with haemorrhage. Most of the deaths due to septicaemia, had history of septic abortion or home delivery. The availability of misoprostol, mifepristone and antibiotics have reduced such deaths in the recent years. Periodical study and analysis of maternal mortality are therefore important to monitor progress and the trend.
Various programmes have been launched by the Government of India viz. JSY(Janani Suraksha Yojana-April 2005), with nationwide emergency referral system to promote institutional delivery, JSSK (Janani Sishu Suraksha Karyakram-June 2011) with free maternal services for delivery and free services to sick newborn, EmOC (Emergency Obstetric Care) services, menstrual hygiene scheme, peer education programme and Rashtriya Kishor Swasthya Karyakram (RKSK) for adolescents, prevention and control of anaemia with Iron and folate supplementation, monthly Village Health Nutrition Days (VHND), to provide maternal and child care, setting up of skilled labs, engagement of Accredited Social Health Activists (ASHA) to facilitate healthcare services to pregnant women, screening of high-risk cases, setting up obstetric HDU, Pradhan Mantri Surakshit Matritya Abhiyan (PMSMA), to provide fixed day assured comprehensive quality antenatal care universally to all pregnant women on the ninth of every month, LaQshya Programme, to prevent maternal death (17),(18),(19),(20),(21),(22). Maternal Death Review (MDR) was adopted in 2010 by RCH Programme, but certain gaps have prompted a paradigm shift towards Maternal Death Surveillance and Response (MDSR) in 2017 (22),(23). This focuses on surveillance and response, and identifying the gaps as per the “Three-delay model” of seeking care (Delay1), reaching care (Delay2) or receiving care (Delay3), and taking action on information obtained, from every maternal death with detailed analysis on various factors at community, facility, regional and national level, to prevent further maternal deaths (23),(24).
Limitation(s)
As this was a retrospective study over last 23 years, some data like duration of gestation, mode and place of delivery could not be collected. Reliable study on the trends of maternal mortality requires large sample size, confidential community based verbal autopsy, surveillance and response which is lacking to some extent in present study. Moreover, the effect of Coronavirus Disease-2019 (COVID-19) on maternal health outcome, in health facilities in rural areas remain poorly understood.
There was a significant declining trend in MMR and increase in institutional delivery in this institution since 1998, which can be attributed to improvement at all levels of healthcare. Eclampsia/preeclampsia, and its complications remain the leading cause of maternal mortality followed by haemorrhage and sepsis. Majority of these direct causes of maternal deaths can be prevented by regular screening of high-risk cases at the periphery centres. Implementation of effective community and facility based maternal death audits, and regular maternal death surveillance and response should be carried out to eliminate preventable maternal mortality.
DOI: 10.7860/JCDR/2022/57151.17053
Date of Submission: Apr 17, 2022
Date of Peer Review: May 26, 2022
Date of Acceptance: Aug 17, 2022
Date of Publishing: Oct 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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