Maternal health in Emergencies and Beyond

1. Maternal health in Emergencies and Beyond Deepti Thomas-Paulose MD, MPH Global Health Division St. Luke’s Roosevelt Hospital Center http://www.youtube.com/watch?v=oHjwc4a57Vo http://www.youtube.com/watch?v=5g0vzs8bC8s

2. Outline • Definitions • Some sobering numbers • Direct and Indirect Causes • EmOC • Crisis • Post-Emergency Phase • References

3. Definitions • Maternal Mortality – death of a woman while she is pregnant, or within 42 days of termination of pregnancy regardless of the site or duration of the pregnancy.

4. Definitions • Maternal Mortality Ratio – the number of maternal deaths per 100,000 live births per year. The numerator includes deaths to women during their pregnancy or in the first six weeks after delivery.

5. Definitions • Maternal Mortality Rate – the number of maternal deaths per 100,000 women of reproductive age (15-49). This measures the impact of maternal deaths on the population of women as a whole but is generally not used in public health since not all women are at risk for maternal mortality—only those that are pregnant.

6. Definitions • Lifetime Risk of Maternal Death – the probability of dying as a result of pregnancy cumulative across pregnancies in a woman's life

7. Obtaining accurate maternal death data is challenging in the developing world because accurate vital statistics are not available in many areas (particularly rural areas), and because the majority of births take place outside of health facilities. Instead of using vital statistics to track pregnancy related deaths, survey data is used instead. Thus, these data significantly underestimate the actual number of pregnancy-associated deaths.

8. Recent 2008 data estimated 342,900 maternal deaths worldwide in 2008 down from 536,000 in 2005. They estimate that more than 50% of all maternal deaths in 2008 occurred in six countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo

9. Sobering facts Based on 2005 data, the average lifetime risk of a woman in a least developed country dying from complications related to pregnancy or childbirth is more than 300 times greater than for a woman living in an industrialized country. No other mortality rate is so unequal.

10. Beyond Pregnancy and Childbirth For every woman who dies from causes related to pregnancy or childbirth, it is estimated that there are 20 others who suffer pregnancy-related illness or experience other severe consequences. An estimated 10 million women annually who survive their pregnancies experience such adverse outcomes.

11. Beyond Pregnancy and Childbirth Almost 40 per cent of under-five deaths – or 3.7 million in 2004, according to the latest World Health Organization estimates – occur in the first 28 days of life. Three quarters of neonatal deaths take place in the first seven days, the early neonatal period; most of these are also preventable.

12. Beyond Pregnancy and Childbirth Lowering a mother’s risk of mortality and morbidity directly improves a child’s prospects for survival. In a study conducted in Afghanistan, 74 per cent of infants born alive to mothers who died of maternal causes also subsequently died.

13. Quality of Health Systems Maternal mortality ratios strongly reflect the overall effectiveness of health systems, which in many low income developing countries suffer from weak administrative, technical and logistical capacity, inadequate financial investment and a lack of skilled health personnel.

14. Somalia Chad Sudan Zimbabwe Dem. Rep. of the Congo 6. Afghanistan 7. Iraq 8. Central African Republic 9. Guinea 10. Pakistan Top Ten Failed States 2010* *http://www.foreignpolicy.com/articles/2009/06/22/2009_failed_states_index_interactive_map_and_rankings

15. Source-UNFPA

16. Maternal health – as epitomized by the risk of death or disability from causes related to pregnancy and childbirth – has scarcely advanced in decades is the result of multiple underlying causes.

17. The root cause may lie in women’s disadvantaged position in many countries and cultures, and in the lack of attention to, and accountability for women’s rights.

18. A human rights-based approach to improving maternal and neonatal health focuses on enhancing healthcare provision, addressing gender discrimination and inequities in society through cultural, social and behavioral changes, among other means, and targeting those countries and communities most at risk.

19. MDG 5 • The reduction of maternal mortality is a leading Millennium Development Goal (MDG), which calls for a 75% reduction in maternal mortality by the year 2015. • http://www.youtube.com/watch?v=mW20VfDz6rE

20. Causes of Maternal Mortality • Direct Causes are those related to obstetric complications of pregnancy, labor and delivery, and the post-partum periods. Direct causes account for 80% of maternal death. • Indirect causes are those relating to pre-existing medical conditions that may be aggravated by the physiologic demands of pregnancy.

21. Direct Causes Hemorrhage • Accounts for approximately 25% of maternal deaths and is the single most serious risk to maternal health. • Blood loss during pregnancy, labor, or post-partum. • Can rapidly lead to death without medical intervention. • Can be treated with blood transfusions, oxytocics and/or manual removal of the placenta.

22. Direct Causes Sepsis • Accounts for approximately 15% of maternal deaths. • Related to poor hygiene and infection control during delivery or to the presence of untreated sexually transmitted infections during pregnancy. • Can be prevented or managed with high standards for infection control, appropriate prenatal testing and treatment of maternal infection, and appropriate use of intravenous or intramuscular antibiotics during labor and post-partum period.

23. Direct Causes Hypertensive Disorders • Accounts for approximately 12% of maternal deaths • Pre-eclampsia is characterized by hypertension, proteinurea general edema, and sudden weight gain. If left untreated, can lead to eclampsia. • Eclampsia is characterized by kidney failure, seizures, and coma during pregnancy or post-partum. Can lead to maternal and/or infant death. • Pre-eclampsia can be identified in the prenatal period by monitoring blood pressure, screening urine for protein, and through physical assessment. • Treatment available during childbirth includes the use of sedative or anti-convulsant drugs.

24. Treatment of Hypertension in Pregnancy • Unclear benefit in mild to moderate HTN • In severe HTN, use any anti-HTN drug available • Load with 4 grams of IV magnesium then 1-2 grams per hour to prevent eclampsia and also to treat seizures

25. Cardiac arrest Pulmonary edema (lungs fill with fluid; can be fatal) Chest pain Cardiac conduction defects Low blood pressureLow calcium Increased urinary calcium Visual disturbances Decreased bone density Respiratory depression (difficulty breathing) Muscular hyperexcitability Magnesium overdose

26. Direct Causes Prolonged or Obstructed Labor • Accounts for 8% of maternal deaths. • Caused by cephalopelvic disproportion (CPD), a disproportion between the size of the fetal head and the maternal pelvis; or by the position of the fetus at the time of delivery. • Increased incidence among women with poor nutritional status • Use of assisted vaginal delivery methods such as forceps, vacuum extractor, or performing a Caesarean Section can prevent adverse outcomes. • CPD is the leading cause of obstetrical fistula

27. Direct Causes Unsafe Abortion • Accounts for approximately 13% of maternal deaths. • In some parts of the world unsafe abortion accounts for 1/3 of maternal deaths. • Approximately 67,000 cases of abortion related deaths occur each year. • Can be prevented by providing safe abortion, quality family planning services, and competent post-abortion care.

28. Indirect Causes • Accounts for approximately 20% of maternal deaths. • Pre-existing medical conditions such as anemia, malaria, hepatitis, heart disease, and HIV/AIDS can increase the risk of maternal death. • Risk of adverse outcomes can be reduced through prenatal identification and treatment as well as the availability of appropriate basic emergency obstetric care (EmOC) at the time of delivery.

29. EmOC

30. Reproductive Health in Crisis • There are multiple competing health priorities in an emergency, such as addressing diarrhea, measles, acute respiratory infections, malaria and malnutrition • Reproductive health needs should not be ignored

31. Reproductive Health in Crisis • In any displaced population, approximately 4 percent of the total population will be pregnant at a given time.* • Of these pregnant women, 15 percent will experience an unpredictable obstetric complication, such as obstructed or prolonged labor, pre-eclampsia or eclampsia, sepsis, ruptured uterus, ectopic pregnancy or complications of abortion.* *UNFPA, UNICEF, WHO

32. What causes women to die from obstetric complications? • delay in deciding to seek care; • delay in reaching care due to transportation difficulties; and • delay in having appropriate care available at the facility once reached.

33. The Minimum Initial Service Package (MISP) • A series of actions needed to respond to the reproductive health needs of populations in the early phase of a refugee situation (which may or may not be an emergency). The MISP is not just kits of equipment and supplies; it is a set of activities that must be implemented in a coordinated manner by appropriately trained staff. It can be implemented without any new needs assessment since documented evidence already justifies its use.

34. MISP • Prevents excess neonatal and maternal morbidity and mortality, reduces HIV transmission, prevents and manages the consequences of sexual violence, and includes planning for the provision of comprehensive reproductive health services integrated into the primary health program in place.

35. MISP objectives and activities • 1. Identify an organization(s) and individual(s) to facilitate the coordination and implementation of the MISP by: ensuring the overall RH Coordinator is in place and functioning under the health coordination team; ensuring RH focal points in camps and implementing agencies are in place; making available material for implementing the MISP and ensuring its use.

36. MISP objectives and activities • 2.Prevent sexual violence and provide appropriate assistance to survivors by: ensuring systems are in place to protect displaced populations, particularly women and girls, from sexual violence; ensuring medical services, including psychosocial support, are available for survivors of sexual violence.

37. MISP objectives and activities • 3.Reduce the transmission of HIV by: enforcing respect for universal precautions; guaranteeing the availability of free condoms; ensuring that blood for transfusion is safe.

38. MISP objectives and activities • 4.Prevent excess maternal and neonatal mortality and morbidity by: providing clean delivery kits to all visibly pregnant women and birth attendants to promote clean home deliveries; providing midwife delivery kits (UNICEF or equivalent) to facilitate clean and safe deliveries at the health facility; initiating the establishment of a referral system to manage obstetric emergencies.

39. The New Emergency Health Kit • The kit provides the drugs and medical supplies for 10,000 people for approximately 3 months. It is designed to meet the primary health care needs of a displaced population without medical facilities, or a population with disrupted medical facilities in the immediate aftermath of a disaster. • The kit includes supplies for professional midwifery care and emergency contraception.

40. Clean Delivery Kits • Clean Delivery Kits consist of a square meter of plastic sheet, a bar of soap, a razor blade, a length of string, and a pictorial instruction sheet

41. MISP objectives and activities • 5. Plan for the provision of comprehensive reproductive health services, integrated into primary health care (PHC), as the situation permits by: collecting basic background information identifying sites for future delivery of comprehensive RH services; assessing staff and identifying training protocols; identifying procurement channels and assessing monthly drug consumption.

42. Post-Emergency Phase The main methods of reducing maternal and newborn mortality and morbidity are well established and understood.

43. Post-Emergency Phase • Quality antenatal care providing a comprehensive package of health and nutrition services. • Preventing mother-to-child transmission of HIV and offering antiretroviral treatment for women in need.

44. Post-Emergency Phase • Basic preventive and curative interventions, including immunization against neonatal tetanus for pregnant women, routine immunization, distribution of insecticide treated mosquito nets and oral rehydration salts, among others.

45. Post-Emergency Phase • Access to improved water and sanitation, and adoption of improved hygiene practices, especially at delivery. Clean water for hygiene and drinking is essential for safe delivery

46. Post-Emergency Phase Access to skilled health personnel –a doctor, nurse or midwife – at delivery.

47. A strong referral system, skilled health workers and well equipped facilities are pivotal to reducing maternal and newborn deaths resulting from complications during childbirth. Health workers treat babies in the Sick Newborn Care Unit, India.

48. Post-Emergency Phase • Basic emergency obstetric care at a minimum of four facilities per 500,000 population – adapted to each country’s circumstances – for women who experience some complication. • Comprehensive emergency obstetric care at a minimum of one facility in every district or one per 500,000 population.

49. Post-Emergency Phase • A post-natal visit for every mother and newborn as soon as possible after delivery, ideally within 24 hours, with additional visits towards the end of the first week and at four to six weeks.

50. Post-Emergency Phase • Knowledge and life skills for pregnant women and families on the danger signs of maternal and newborn health and about referral systems. • Maternal nutrition counseling and supplementation as needed as part of routine antenatal, post-natal and neonatal care.