Reducing Maternal Deaths

What Is Maternal Death?What Is Maternal Death?

The death of a woman while she is pregnant

The death of a woman while she is pregnant

…From any cause related to

or aggravated by the pregnancyWorld Health Organization (WHO)

within 42 days of the

termination of the pregnancy…

within 42 days of the

termination of the pregnancy…

…or…

Maternal Mortality: Scope of Problem

• 180–200 million pregnancies per year• 75 million unwanted pregnancies1 • 50 million induced abortions2

• 20 million unsafe abortions (same as above)

• 600,000 maternal deaths (1 per min.)• 1 maternal death=30 maternal morbidities

1 Sadik 1997.2 WHO 1998.

Newborn Mortality: Scope of Problem

• 3 million newborn deaths (first week of life)• 3 million stillbirths

India-latest trends in MMR• MMR of India:212 per 100,000 live births -2007-2009(The Special

Bulletin for Maternal Mortality Ratio (MMR) in India- Office of the Registrar General of India)

• MMR of India has shown a decline of around 17 percent points from 254 in 2004-06

• Eleven states show decline of more than 15 percentage points, notable being Maharashtra, Madhya Pradesh/Chhattisgarh, Assam, Uttar Pradesh/Uttaranchal and Rajasthan

• Assam with MMR of 390 per 100,000 live births is the worst state and Kerala is the best state recording MMR of 81 in 2007-09

• West Bengal is the only state which has shown an increase in MMR from 141 in 2004-06 to 145 in 2007-09

India & WB- Neonatal MortalityINDICATOR INDIA WEST BENGAL

Infant Mortality Rate 50 33

Neonatal Mortality Rate 34 25

Early Neonatal Mortality Rate 27 19

Perinatal Mortality Rate 35 30

Under-5 Mortality Rate 64 40

Source-SRS Annual Report 2009

What Do Women Die Of?What Do Women Die Of?

They Die of Obstetric Complications

that Need Not Be Fatal

They Die of Obstetric Complications

that Need Not Be Fatal

Infection14.9%

Hemorrhage24.8%

Indirect causes19.8%

Other direct causes

7.9%Unsafe abortion

12.9%

Obstructed labor6.9%

Eclampsia12.9%

Causes of Maternal Death

WHERE DO WOMEN DIE TODAY?WHERE DO WOMEN DIE TODAY?

99% of Maternal Deaths Today Occur in

Africa, Asia and Latin America

99% of Maternal Deaths Today Occur in

Africa, Asia and Latin America

Most Obstetric Complications Occur Suddenly

Most Obstetric Complications Occur Suddenly

If women do not receive medical treatment on time,

they will probably suffer disability…

If women do not receive medical treatment on time,

they will probably suffer disability…

Or DieOr Die

Without WarningWithout Warning

Most Obstetric ComplicationsMost Obstetric Complications Can Neither

Be Predicted Nor Prevented…

Can Neither Be Predicted Nor Prevented…

But if Women Receive Effective Treatment in Time, But if Women Receive Effective Treatment in Time,

…Almost All Can Be Saved…Almost All Can Be Saved

How Much Time Do We Have?

How Much Time Do We Have?

It is estimated that, if untreated, death occurs on average in: It is estimated that, if untreated, death occurs on average in:

2 hours from Postpartum Hemorrhage12 hours from Antepartum Hemorrhage 2 days from Obstructed Labor 6 days from Infection

2 hours from Postpartum Hemorrhage12 hours from Antepartum Hemorrhage 2 days from Obstructed Labor 6 days from Infection

The Three Delays

• Delay 1: Delay in decision to seek care

• Delay2: Delay in reaching care

• Delay3: Delay in receiving care

Interventions to Reduce Maternal Mortality

Historical review

• Traditional birth attendants

• Antenatal care

• Risk screening

Current approach

• Skilled provider at childbirth

• Emergency Obstetric Care (EmOC)

Interventions: Antenatal Care• Antenatal care clinics started in US, Australia, Scotland

between 1910–1915• New concept—screening healthy women for signs of disease• By 1930s large number (1,200) antenatal care clinics opened

in UK• No reduction in maternal mortality• But, widely used as a maternal mortality reduction strategy

in 1980s and early 1990s • Is antenatal care important? YES!!• Early detection of problems and birth preparation

Interventions: Risk Screening • Disadvantages• Very poorly predictive• Costly—removes woman to maternity waiting

homes• If risk-negative, gives false security

• Conclusion: Cannot identify those at risk of maternal mortality—every pregnancy is at risk

Why Change the Focus of Antenatal Care

• Every pregnancy faces risks• It is almost impossible to predict accurately which

woman will face life- threatening complications• Antenatal risk assessment has not reduced

maternal mortality• Many antenatal routines have not been effective

in preventing complications

Risk Approach Does Not Work

• Large number of women classified as “high risk” never develop any complications

• Most women who develop complications do not have risk factors and were classified as “low risk”

Implications of Risk Approach

• Women classified as “low risk” have a false sense of security

• Women classified as “high risk” undergo unnecessary inconvenience and cost

• Health systems overburdened by unnecessary management of “high risk” mothers and resources for dealing with actual emergencies reduced

Interventions: Traditional Birth Attendants

Advantages• Community-based• Sought out by women• Low tech• Teach clean childbirth

Disadvantages• Technical skills limited• May keep women away

from life-saving interventions due to false reassurance

There will no substantial reduction in maternal mortality by TBAs providing clinical services

Maternal Mortality ReductionSri Lanka, 1940–1985

Health System Improvements:• Introduction of system of health facilities• Expansion of midwifery skills• Decreased use of home childbirth and

births by untrained birth attendants• Spread of family planning

Maternal Mortality ReductionSri Lanka, 1940–1985

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200

400

600

800

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1940-45 1950-55 1960-65 1970-75 1980-85

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85% births attended by trained personnel

Maternal Mortality: UK 1840–1960

050

100150200250300350400450500

MaternalDeaths

Improvements in nutrition, sanitation

Antibiotics, banked blood, surgical improvements

Antenatal care

R2 = 0.5609

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500

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% Skilled Attendant at DeliverySource: Safe Motherhood Initiative website and Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA 2001.

Relationship between Skilled Attendant at Delivery and MMR for countries with MMR<500

Source: Safe Motherhood Initiative website and Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA 2001.

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% Skilled Attendant at Delivery

Relationship between Skilled Attendant at Delivery and MMR for countries with MMR>500

R2 = 0.0687

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500

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Country n=47

AbouZahr and Wardlaw 2001.

Good Quality Maternity Services Will Save the Lives of Newborns

0

20

40

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Africa Asia Latin America &Caribbean

More developedcountries

0

10

20

30

40

50Skilled provider at childbirth

Newborn deaths

Interventions: Skilled Provider at Childbirth

• Has relevant training, range of skills• Recognizes onset of complications• Observes woman, monitors newborn• Performs essential basic interventions• Refers mother and newborn to higher level of

care if complications arise requiring further interventions

• Has patience and empathyWHO 1999.

Interventions: Emergency Obstetric Care

• From late 1930s, MMR in West started to show a steady & steep decline, which is still sustained

• The main reason: Effective treatment for obstetric complications was developed and used, e.g., antibiotics for infection, blood transfusions for hemorrhage & other EmOC interventions

• To Avert Death and Disability We Need to Ensure that Women have Access To Emergency Obstetric Care (EmOC)

How Can We Improve Access

to EmOC?

How Can We Improve Access

to EmOC?

By making sure health facilities provide the

services needed to save women’s lives.

By making sure health facilities provide the

services needed to save women’s lives.

Eight key functions “signal” a facility’sability to provide EmOC

Eight key functions “signal” a facility’sability to provide EmOC

EmOC Key FunctionsCover These Services:

EmOC Key FunctionsCover These Services:

• Antibiotics (intravenous or by injection)

• Oxytocic Drugs (intravenous or by injection)

• Anticonvulsants (intravenous or by injection)

• Manual Removal of Placenta

• Removal of Retained Products• Assisted Vaginal Delivery• Surgery (Cesarean Section)• Blood Transfusion

Basic and Comprehensive EmOC FacilitiesBasic and Comprehensive EmOC Facilities

• Antibiotics (intravenous or by injection)• Oxytocic Drugs (intravenous or by injection)• Anticonvulsants (intravenous or by injection)• Manual Removal of Placenta• Removal of Retained Products• Assisted Vaginal Delivery

• Antibiotics (intravenous or by injection)• Oxytocic Drugs (intravenous or by injection)• Anticonvulsants (intravenous or by injection)• Manual Removal of Placenta• Removal of Retained Products• Assisted Vaginal Delivery

BASICBASICEmOC Facilities Provide the First Six Services

Basic and Comprehensive EmOC FacilitiesBasic and Comprehensive EmOC Facilities

• Antibiotics (intravenous or by injection)• Oxytocic Drugs (intravenous or by injection)• Anticonvulsants (intravenous or by injection)• Manual Removal of Placenta• Removal of Retained Products• Assisted Vaginal Delivery

COMPREHENSIVECOMPREHENSIVEEmOC Facilities Provide All Eight Services

• Surgery (Cesarean Section)• Blood Transfusion

Access to…Access to…

THE 6 PROCESS INDICATORSTHE 6 PROCESS INDICATORS

tell us about changes in:tell us about changes in:

Utilization of…Utilization of… and Quality of…and Quality of…

EmOC ServicesEmOC Services

EmOC Process Indicators1. For every 500,000 population, there should be at least: 1

Comprehensive EmOC Facility & 4 Basic EmOC Facilities

2. Geographical Distribution of EmOC Facilities: EmOC Facilities should be well-distributed to serve 500,000 people

3. Proportion of All Births in EmOC Facilities: At Least 15% of All Births in the Community Should Take Place in EmOC Facilities

4. Met Need for EmOC Services: At Least 100% of Women Estimated to Have Obstetric Complications Should Be Treated in EmOC Facilities

5. Cesarean Sections as a Percentage of All Births

1. Minimum: 5% Maximum: 15%

6. Case Fatality Rate: Proportion of Women with Obstetric Complications Admitted to a Facility Who Die: Maximum Acceptable Level: 1%

Solutions for Maternal and Newborn Survival

• Delay in decision to seek care– Lack of understanding of

complications– Acceptance of maternal death– Low status of women– Socio-cultural barriers to seeking

care• Delay in reaching care

– Mountains, islands, rivers—poor organization

• Delay in receiving care– Supplies, personnel, finances– Poorly trained personnel with

punitive attitude

• Community involvement and social mobilization– Mother-friendly services– Community education

• Taking care to the community– Skilled provider at every birth– EmOC– Innovative community programs

• Improved standards of care– Developing guidelines– Preservice training– Performance improvement

strategies– Periodic audits, e.g., near miss

audits

Identifying the problem: Maternal and newborn death

Embracing the solution: Maternal and newborn survival

MULTI-PRONGED

APPROACH..

MATERNAL HEALTH STRATEGIES-NRHM

Demand Promotion-

( Janani Suraksha Yojana)

Provision of services Public sector

1. Essential and Emergency Obstetric Care•Quality ANC, INC, Safe and Institutional delivery•Skilled birth attendance•Multi-skilling 2.Operationalize FRU s & 24*7 PHCs 3. Services for RTIs & STIs –convergence

with the NACP4. Safe abortion services- New

Guidelines5. Strengthen referral systems6.Village Health and Nutrition Day..

Mother-Child Protection Card

Provision of Services : Private sector•Accreditation of Pvt. Health Facilities for RCH services and SBA training•Fixed package for outsourcing services

• Maternal Death Review• Pregnancy and Child Tracking –web based system• Prioritising resources for identified “delivery points” or MCH Centres

New

Continuum of Care

• From Mother to Newborn• From EmOC to EmONC• From Community to Facility• MCH Centres under NRHM:– level 1 (24x7 delivery)– Level 2 (BEmONC)– Level 3 (CEmONC)

Some ongoing maternal health activities in the state

• Capacity building : SBA training; EmOC training; Anesthesia training; MVA training

• Operationalization of facilities: Infrastructure, Equipments & HR- for 24x7 PHCs, BEmOC & CEmOC centres, Blood Storage Units

• Maternal Death Review• Referral transport (Matri Yan)• JSY• Training of ASHAs on maternal & newborn care • Nischay-kit (early registration)

Thank You