every pregnancy is at risk: current approach to reduction of maternal mortality

1. �Every Pregnancy Is at Risk:�Current Approach to Reduction of Maternal Mortality Advances in Maternal and Neonatal Health

2. 2 Current Approach to Reduction of Maternal Mortality We will review the magnitude of maternal mortality and its causes. Then, we will review past interventions aimed at reducing maternal mortality, and focus on the most recent development, having a skilled attendant at childbirthWe will review the magnitude of maternal mortality and its causes. Then, we will review past interventions aimed at reducing maternal mortality, and focus on the most recent development, having a skilled attendant at childbirth

3. 3 Current Approach to Reduction of Maternal Mortality What Is Safe Motherhood? High maternal mortality has gone on too long. It�s time for initiatives that are proven effective.High maternal mortality has gone on too long. It�s time for initiatives that are proven effective.

4. 4 Current Approach to Reduction of Maternal Mortality Maternal Health: Scope of Problem 180�200 million pregnancies per year 75 million unwanted pregnancies 50 million induced abortions 20 million unsafe abortions (same as above) 600,000 maternal deaths (1 per minute) 1 maternal death = 30 maternal morbidities For each woman who dies during pregnancy, 30 women suffer complications. Initiatives should include: Family planning Management of complications of abortion Management of complications of pregnancy and childbirthFor each woman who dies during pregnancy, 30 women suffer complications. Initiatives should include: Family planning Management of complications of abortion Management of complications of pregnancy and childbirth

5. 5 Current Approach to Reduction of Maternal Mortality Neonatal Health: Scope of Problem 3 million neonatal deaths (first week of life) 3 million stillbirths

6. 6 Current Approach to Reduction of Maternal Mortality Maternal Mortality: A Global Tragedy Annually, 585,000 women die of pregnancy related complications 99% in developing world ~ 1% in developed countries Maternal mortality is a global tragedy, but if affects the developing world. Almost all of the deaths from pregnancy-related complications occur in the developing world.Maternal mortality is a global tragedy, but if affects the developing world. Almost all of the deaths from pregnancy-related complications occur in the developing world.

7. 7 Current Approach to Reduction of Maternal Mortality Maternal Death Watch 380 women become pregnant 190 women face unplanned or unwanted pregnancy 110 women experience a pregnancy related complication 40 women have an unsafe abortion 1 woman dies from a pregnancy-related complication

8. 8 Current Approach to Reduction of Maternal Mortality Global Causes of Maternal Mortality The most common cause of maternal mortality is hemorrhage (24.8%), followed by infection (14.9%), obstructed labor (6.9%) and unsafe abortion (12.9%). Indirect causes account for 19.8%.The most common cause of maternal mortality is hemorrhage (24.8%), followed by infection (14.9%), obstructed labor (6.9%) and unsafe abortion (12.9%). Indirect causes account for 19.8%.

9. 9 Current Approach to Reduction of Maternal Mortality But WHY Do These Women Die? 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 Poorly trained personnel with punitive attitude Finances Multiple factors affect WHY a woman dies during pregnancy. The �three delays� model�: Delay in decision to see care: lack of information about problems/warning signs, social factors Delay in reaching care: having transportation, road conditions Delay in receiving care: lack of equipment or personnel at facility, lack of funding, poor attitude of personnelMultiple factors affect WHY a woman dies during pregnancy. The �three delays� model�: Delay in decision to see care: lack of information about problems/warning signs, social factors Delay in reaching care: having transportation, road conditions Delay in receiving care: lack of equipment or personnel at facility, lack of funding, poor attitude of personnel

10. 10 Current Approach to Reduction of Maternal Mortality Maternal Health Services Good quality maternal health services are not universally available and accessible > 35% receive no antenatal care ~ 50% of deliveries unattended by skilled provider ~ 70% receive no postpartum care during 1st 6 weeks following delivery

11. 11 Current Approach to Reduction of Maternal Mortality Interventions to Reduce Maternal Mortality Historical Review Traditional birth attendants Antenatal care Risk screening Current Approach Skilled attendant at delivery There have been many interventions implemented to try to improve maternal mortality. We will review the ones used to date. TBAs and antenatal care still play a role, but the role needs clarification.There have been many interventions implemented to try to improve maternal mortality. We will review the ones used to date. TBAs and antenatal care still play a role, but the role needs clarification.

12. 12 Current Approach to Reduction of Maternal Mortality Historical Review of Interventions The flawed assumption: Most life-threatening obstetric complications can be predicted or prevented Certain interventions can help prevent problems: active management of third stage of labor and clean delivery. Should be routine, however, pre-eclampsia and uterine atony cannot be prevented.Certain interventions can help prevent problems: active management of third stage of labor and clean delivery. Should be routine, however, pre-eclampsia and uterine atony cannot be prevented.

13. 13 Current Approach to Reduction of Maternal Mortality Interventions: Traditional Birth Attendants Advantages Community-based Sought out by women Low tech Teaches clean delivery Disadvantages Technical skills limited May keep women away from life-saving interventions due to false reassurance Traditional birth attendants: use has many advantages and disadvantages. The biggest disadvantage is that their skills are limited and may delay a woman getting to an appropriate level of care.Traditional birth attendants: use has many advantages and disadvantages. The biggest disadvantage is that their skills are limited and may delay a woman getting to an appropriate level of care.

14. 14 Current Approach to Reduction of Maternal Mortality Maternal Mortality ReductionSri Lanka 1940�1985 Health system improvements: Introduction of system of health facilities Expansion of midwifery skills Decreased use of home delivery and delivery by untrained birth attendants Spread of family planning Midwifery skills: provision of emergency obstetric care. Untrained birth attendants are unable to provide emergency obstetric care.Midwifery skills: provision of emergency obstetric care. Untrained birth attendants are unable to provide emergency obstetric care.

15. 15 Current Approach to Reduction of Maternal Mortality Maternal Mortality ReductionSri Lanka 1940�1985 Even with TBA�s and other interventions, maternal mortality decreased in Sri Lanka. The reduction, however, was the greatest (maternal mortality was the lowest) after having births attended by skilled providers The government�s commitment to this intervention was crucial.Even with TBA�s and other interventions, maternal mortality decreased in Sri Lanka. The reduction, however, was the greatest (maternal mortality was the lowest) after having births attended by skilled providers The government�s commitment to this intervention was crucial.

16. 16 Current Approach to Reduction of Maternal Mortality Interventions: Traditional Birth Attendants Conclusion: TBAs are useful in the maternal health network, but there will not be a substantial reduction in maternal mortality by TBAs delivering clinical services alone TBAs are useful, but more skilled attendants are needed to substantially reduce maternal mortality.TBAs are useful, but more skilled attendants are needed to substantially reduce maternal mortality.

17. 17 Current Approach to Reduction of Maternal Mortality Interventions: Antenatal Care Antenatal care clinics started in US, Australia, Scotland between 1910�1915 New concept - screening healthy women for signs of disease By 1930�s large number (1200) ANC clinics opened in UK No reduction in maternal mortality However, widely used as a maternal mortality reduction strategy in 1980�s and early 1990�s Is ANC important? YES!! Early detection of problems and birth preparation Wide use of antenatal care in UK, US and Australia. Still maternal mortality in US 700/100.000 in 1940s.Wide use of antenatal care in UK, US and Australia. Still maternal mortality in US 700/100.000 in 1940s.

18. 18 Current Approach to Reduction of Maternal Mortality Maternal Mortality: UK 1840�1960 Other interventions can make a difference, but not as substantial as skilled attendants. For example, in this graph, the implementation of antenatal care did not reduce maternal mortality in the UK. Improvements came only with skilled attendants who could provide surgical intervention if needed, and who had access to and could use appropriate antibiotics and blood products. Nevertheless, antenatal care remains an important intervention in maternal care because it provides an opportunity to detect problems and be prepared to handle them.Other interventions can make a difference, but not as substantial as skilled attendants. For example, in this graph, the implementation of antenatal care did not reduce maternal mortality in the UK. Improvements came only with skilled attendants who could provide surgical intervention if needed, and who had access to and could use appropriate antibiotics and blood products. Nevertheless, antenatal care remains an important intervention in maternal care because it provides an opportunity to detect problems and be prepared to handle them.

19. 19 Current Approach to Reduction of Maternal Mortality 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 Risk screening is another intervention that has been used. It is problematic because only about 10-15% of women who are thought to be �at risk� for a complication actually go on to have a problem. And most women who do develop complications have no risk factors. If �risk factors� are ruled out, the patient and provider develop a false sense of security, and are then not prepared when complications arise. All women, therefore, should be considered at risk.Risk screening is another intervention that has been used. It is problematic because only about 10-15% of women who are thought to be �at risk� for a complication actually go on to have a problem. And most women who do develop complications have no risk factors. If �risk factors� are ruled out, the patient and provider develop a false sense of security, and are then not prepared when complications arise. All women, therefore, should be considered at risk.

20. 20 Current Approach to Reduction of Maternal Mortality Interventions: Skilled Attendant at Childbirth Proper training, range of skills Assess risk factors Recognize onset of complications Observe woman, monitor fetus/infant Perform essential basic interventions Refer mother/baby to higher level of care if complications arise requiring interventions outside realm of competence Have patience and empathy A skilled attendant should have a good range of skills, be able to identify problems, recognize complications early, be able to perform essential basic interventions and make referrals to appropriate levels of care when necessary.A skilled attendant should have a good range of skills, be able to identify problems, recognize complications early, be able to perform essential basic interventions and make referrals to appropriate levels of care when necessary.

21. 21 Current Approach to Reduction of Maternal Mortality Interventions: Skilled Attendant at Childbirth Proven effective Malaysia: basic maternity services 320 ? 157 Cuba: national priority 118 ? 31 China: facility based childbirth 1500 ? 50 Malaysia vs. Indonesia: Trained community midwives (2 years) vs. untrained midwives (4 years)

22. 22 Current Approach to Reduction of Maternal Mortality As shown in this graph, there appears to be a relationship between having skilled attendants at childbirth and a reduction in maternal mortality. We believe the association is real. So far, it appears to be the most effective intervention.As shown in this graph, there appears to be a relationship between having skilled attendants at childbirth and a reduction in maternal mortality. We believe the association is real. So far, it appears to be the most effective intervention.

23. 23 Current Approach to Reduction of Maternal Mortality Summary Skilled attendant at childbirth is the most effective intervention

24. 24 Current Approach to Reduction of Maternal Mortality References Maine D. 1999. What's So Special about Maternal Mortality?, in Safe Motherhood Initiatives: Critical Issues. Berer M et al (eds). Blackwell Science Limited: London. World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: Geneva.