ALSO Korogwe 2009

Causes of Maternal and Neonatal Deaths

Why mothers and newborns die

The aim of maternal health care

to prevent death and disability of women, related to pregnancy and birth

The decades of irresponsible commitments

The decades of irresponsible commitments

”Maternal mortality will be reduced by 50% by the year 2000”

World Summit for children, New York, 1990

The decades of irresponsible commitments

”Maternal mortality will be reduced by 50% by the year

2000”

ICPD, Cairo, 1994

The decades of irresponsible commitments

”Maternal mortality will be reduced by 50% by the year

2000”

Women’s Conference, Beijing, 1995

The decades of irresponsible commitments

”Maternal mortality will be reduced by 50% by the year

2000”

World Summit for Social Development, Copenhagen, 1995

So, what happened by the year 2000?

Maternal mortality

1995

Maternal deaths

MMR(Maternal deaths per 100.000 live births)

WORLDWIDE

WESTEN

LOWINCOME

Africa

Asia

Latin America

515.000

2.800

512.000

273.000

217.000

22.000

400

21

440

1.000

280

190

Maternal mortality

1995 2000

Maternal deaths

MMR(Maternal deaths per 100.000 live births)

Maternal deaths

MMR

Maternal deaths per 100.000 live births)

WORLDWIDE

WESTEN

LOWINCOME

Africa

Asia

Latin America

515.000

2.800

512.000

273.000

217.000

22.000

400

21

440

1.000

280

190

529.000

2.500

527.000

251.000

253.000

22.000

400

20

440

830

330

190

UN Millenium Development Goal 5

by 2015

75% reduction of maternal deaths90% skilled delivery attendance

Tanzania:MMR 950/100,000 live birthsincreased from 1996 to 2004

46% deliveries in health facilities

The cause of maternal deaths Poverty• More than ½ million women die every year in

relation to pregnancy and delivery. • That is one every minute. • In Denmark one out of 17.000 women die in

relation to childbearing.• In Subsaharan Africa one out of 15.• In Afghanistan one out of six.• Ninety nine percent of all maternal deaths occur

in low income countries reflecting the greatest disparity between rich and poor countries of any health indicator

Developing countries that reduced MMR

Kigoma Region, Tanzania

Clinical causes of maternal deaths

Direct obstetric causes: 75%• Haemorrhage 21%• Abortion 14%• Eclampsia 13%• Obstructed labor 8%• Infection 8%Indirect obstetric causes 25%Malaria, anemia, hepatitis, HIV/AIDSCauses vary from place to place

Components of Maternal health care

• Ante natal care

• Post partum care

• Traditional birth attendants

• Skilled delivery attendance

• Emergency obstetric care

Ante natal careScreening for mother and child morbidity and risc, f.ex:• Obstetric history • Hypertension• Anemia• Number, position and growth of fetus(es)Preventive administering of drugs, f.ex:• Iron, folic acid, antimalaria-drugs, tetanus-immunizationTreatment or referral of certain complications, f.ex:• Malposition• Preeclampsia• Infection (including malaria)• Ante partum bleedingPlanning of delivery

Ante natal care has not been able to reduce maternal morbidity and mortality significantly as most complications occur unexpected during or after birth

Post partum care

A significant share of maternal deaths happen in the postpartum period (the 6 weeks after birth) – bleeding, infection, eclampsia

The majority of delivered women don’t get postpartum care.

Training of traditional birth attendants

Training of Traditional birth attendants in safe delivery and referral at complications has been tried

It has proven difficult to align western and traditional

health concepts; results have been disappointing and the strategy has largely been abandoned

Training of TBAs has been criticized for not

respecting the skills of traditional birth attendants and not considering that most TBAs are illiterate

Women’s satisfaction of maternal care by TBAs is

higher than by modern health services

Skilled delivery attendants

The main strategy for the last ten years to reduce maternal mortality:

90% of all births by skilled delivery attendants A skilled attendant is trained in midwifery skills (2 yrs.+)Problems:• Human and economical ressources - Brain drain• Skilled attendants are not necessarily able to treat

obstetric complications due to lack of training or supplies• Many women don’t recognize the importance of skilled

attendants and prefer to deliver at home

Skilled delivery attendants

Skilled delivery attendants – doctors

Skilled delivery attendants - midwives

Emergency obstetric care 1

• Most complications occur unexpected and sudden in low risk pregnant women

• 75% of complications occur around the time of birth

• Skilled delivery attendants must be able to perform adequate life saving emergency obstetric care at all deliveries

Emergency obstetric care 2

UN signal functionsBasic emergency obstetric care (2 hrs)1. Administration of parenteral antibiotics Infection, abortion2. Administration of parenteral oxytocic drugs Bleeding3. Administration of anticonvulsant drugs Eclampsia4. Manual removal of placenta Bleeding, infection,

abortion

5. Removal of retained products Bleeding, infection, abortion

6. Assisted vaginal delivery Obstructed labour

Comprehensive emergency obstetric care (12 hrs)7. Cesarean section Obstructed labour8. Blood transfusion Bleeding

Emergency obstetric care 3

Delays in receiving life saving treatment

• 1st Delay: Delay in deciding to seek medical assistance

• 2nd Delay: Delay in reaching health facility

• 3rd Delay: Delay in receiving adequate treatment once at the health facility

Emergency obstetric care 3

Delays in receiving life saving treatment

• 1st Delay: Delay in deciding to seek medical assistance

• 2nd Delay: Delay in reaching health facility

• 3rd Delay: Delay in receiving adequate treatment once at the health facility

The National Road Map Strategic Plan To Accelerate The Reduction of

Maternal and Newborn Deaths In Tanzania (2006 -2010)Tanzanian Ministry of Health

By 2010

Reduce MMR from 578 to 265

Increase deliveries by skilled attendantsfrom 46% in 2004 to 80%

The road map EmOC objective• Basic EmOC at all Health Facilities by 2010• Comprehensive EmOC at half Health Centres and all

Hospitals

Newborns

Under five mortality

• Each year 11 million children under the age of 5 years die

• 4 million die within the first month

• 3 million within the first week

• 1 million within the first day

The UN MDG 4 is to reduce under five mortality by 2/3 by 2015

Neonatal mortality

World Africa E. AfricaTanzania

Live births 133 mio. 30.3 mio. 10.6 mio. 1423000

Stillbirths 3.3 mio. 1.0 mio. 0.3 mio. 56000

Neonatal deaths 4.0 mio. 1.24 mio 0.44 mio. 113000

NMR (/1000 LB) 30 41 42 62

Neonatal mortality

Neonatal mortality

A home-based study on neonatal mortality in Gadchiroli, India

NMR was reduced 70%

by

Asphyxia management

Supportive care in LBW

Sepsis management

ALSO in Kagera

Impact on neonatal mortality

Before: No=577 After: No=565

Stillborn15 2,5% 15 2,7%

Assisted ventilation17 3,0% 13 2,4%Cardio-Pulmonary Resuscitation 7 1,2% 6 1,1%With mother <10 minutes:32 5,8% 394 72,0%

Born alive Apgar 4-10 but died before discharge 6/528 1,1% 0/521 0,0%