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Averting Maternal Death and Disability (AMDD)

Averting Maternal Death and Disability (AMDD). Program Orientation A Tool for Self-Learning. Developed for use in AMDD-partnered projects February 2002 By Nadia Hijab & Czikus Carriere. This Presentation Covers:. Causes of Maternal Death and Disability

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Averting Maternal Death and Disability (AMDD)

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  1. Averting Maternal Death and Disability (AMDD) Program Orientation A Tool for Self-Learning Developed for use in AMDD-partnered projectsFebruary 2002 By Nadia Hijab & Czikus Carriere

  2. This Presentation Covers: • Causes of Maternal Death and Disability • Evolution of Understanding of the Problem • Central Role of Emergency Obstetric Care • UN Process Indicators • The AMDD Program

  3. What Is Maternal Death? …or… The death of a woman while she is pregnant within 42 days of the termination of the pregnancy… …From any cause related to or aggravated by the pregnancy World Health Organization (WHO)

  4. WHO Estimates 515 000 Maternal Deaths Each Year MORE THAN ONE WOMAN DIES EVERY MINUTE from pregnancy-related causes

  5. What Is Maternal Disability? Short- or Long-term Illness Caused by Obstetric Complications The Most Serious Is Obstetric Fistula (An Abnormal Passage Between Vagina and Bladder or Rectum Often Caused by Obstructed Labor when it is Not Treated with Cesarean Section)

  6. What Do Women Die Of? They Die Of Obstetric Complications That Need Not Be Fatal

  7. OBSTETRIC COMPLICATIONS DIRECT • Hemorrhage 21% • Unsafe Abortion 14% • Eclampsia 13% • Obstructed Labor 8% • Infection 8% • Other 11% Account for about 3/4 of Maternal Deaths

  8. OBSTETRIC COMPLICATIONS INDIRECT • Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis • And Increasingly HIV / AIDS Account for about 1/4 of Maternal Deaths

  9. Most Obstetric Complications Occur Suddenly Without Warning If women do not receive medical treatment on time, they will probably suffer disability… Or Die

  10. WHERE DO WOMEN DIE TODAY? 99% of Maternal Deaths Today Occur in Africa, Asia and Latin America

  11. WHAT ABOUT THE REST OF THE WORLD? Maternal Mortality Used to be Very High in Europe and the U.S. So was Infant Mortality. In 1915, Maternal and Infant Mortality Rates Were as High in the U.S. As They Are in Africa Today

  12. WHAT HAPPENED NEXT? Better Living Conditions Reduced Infant Mortality in the U.S. By over 40% Between 1915 and 1933

  13. BUT MATERNAL MORTALITY REMAINED THE SAME “The well known triad of fever, haemorrhage and toxaemia predominated…” (Irvine Loudon)

  14. …Until the late 1930s There was then a “steep and sustained decline which has continued in most Western countries at much the same rate for over fifty years” (Irvine Loudon)

  15. What Happened To Reduce Maternal Mortality In The West? Effective treatment for obstetric complications was developed and used, e.g., antibiotics for infection, blood transfusions for hemorrhage

  16. Can Neither Be Predicted Nor Prevented… But If Women Receive Effective Treatment In Time, Most Obstetric Complications …Almost All Can Be Saved

  17. It is estimated that, if untreated, death occurs on average in: 2 hours from Postpartum Hemorrhage 12 hours from Antepartum Hemorrhage 2 days from Obstructed Labor 6 days from Infection How Much Time Do We Have?

  18. To Avert Death and Disability… …We Need To Ensure That Women have Access To… Emergency Obstetric Care (EmOC)

  19. How Can We Improve Access To EmOC? By making sure health facilities provide the services needed to save women’s lives. Eight key functions “signal” a facility’s ability to provide EmOC

  20. Antibiotics (intravenous or by injection) Oxytocic Drugs(ditto) Anticonvulsants(ditto) Manual Removal of Placenta Removal of Retained Products Assisted Vaginal Delivery Surgery (Cesarean Section) Blood Transfusion EmOC Key FunctionsCover These Services:

  21. Antibiotics (intravenous or by injection) Oxytocic Drugs (ditto) Anticonvulsants (ditto) Manual Removal of Placenta Removal of Retained Products Assisted Vaginal Delivery Basic and Comprehensive EmOC Facilities BASIC EmOC Facilities Provide The First Six Services

  22. Antibiotics (intravenous or by injection) Oxytocic Drugs (ditto) Anticonvulsants (ditto) Manual Removal of Placenta Removal of Retained Products Assisted Vaginal Delivery Basic and Comprehensive EmOC Facilities COMPREHENSIVE EmOC Facilities Provide All Eight Services • Surgery (Cesarean Section) • Blood Transfusion

  23. Not all these functions need hospitals and doctors Well-trained nurses and midwives can perform most functions at Basic EmOC Facilities THE GOOD NEWS An Important Point For Resource Poor Areas

  24. If we know we have provided enough EmOC… …and if we know that these services are being used by women suffering obstetric complications… How Can We Tell We Are Making a Difference? WE CAN BE CONFIDENT THAT WE ARE SAVING WOMEN’S LIVES

  25. How Do We Know Which Women Will Experience Complications? WE DON’T

  26. …But we do know that of any population of pregnant women at least 15% will experience an obstetric complication …This is as true of pregnant women in the US and Europe as of women in Africa, Asia and Latin America Nobody Knows Why This Happens. It Is a Fact of Life

  27. In 1991, UNICEF and Columbia University developed 6 Process Indicators to do just that Can We Really TellIf Services Are Functioning? …And Are Being Used? These were issued by UNICEF/WHO/UNFPA in 1997: Guidelines for Monitoring Availability and Use of Obstetric Services

  28. In general, process indicators show you the changes in the conditions that lead to an outcome (such as death or disability) Process Indicators

  29. Access to… THE 6 PROCESS INDICATORS tell us about changes in: Utilization of… and Quality of… EmOC Services

  30. INDICATOR # 1 For every 500,000 population, there should be at least: 1 Comprehensive EmOC Facility 4 Basic EmOC Facilities

  31. INDICATOR # 2 Geographical Distribution of EmOC Facilities EmOC Facilities should be well-distributed to serve 500,000 people Minimum: 1 Comprehensive and 4 Basic EmOC Facilities

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

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

  34. INDICATOR # 5 Cesarean Sections As a Percentage of All Births Minimum: 5% Maximum: 15%

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

  36. CALCULATING ALL 6 INDICATORS • Gives you an indication of where the problems lie and where action is needed. • Also, these indicators are sensitive to change: within months, you can know if your project is making a difference

  37. ACCESS TO EmOC • Problems: • Does Indicator # 1 show you need more EmOC facilities? • Does Indicator # 2 show you need better distributed EmOC facilities? • Action: • Most countries already have enough facilities; they may just need to upgrade services to ensure 1 Comprehensive and 4 Basic EmOC facilities per 500,000 population

  38. UTILIZATION OF EmOC Problems • Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population? • Does Indicator # 4 show that “Met Need” is less than 100%? (I.e. that not all women who experience obstetric complications are using EmOC facilities) • Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section?

  39. UTILIZATION OF EmOC Action: Collect More Info First • Do you have enough qualified staff? • Do you need to train staff on management of emergency obstetric complications? • Does hospital management need improvement? • What’s the supply situation like? • What’s the equipment situation like? If all the above is in place, conduct focus groups in the community to find out why women are not coming for care

  40. QUALITY OF EmOC Problem: Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities?

  41. QUALITY OF EmOC Action: Get More Info • Find out if your EmOC facilities are really functioning • Check staff numbers, skills, management capacity, supplies and equipment • Lobby your health ministry for more support – and get the community to lobby with you

  42. Any Country Can Avert Maternal Death And Disability If It Makes Good EmOC Available And Accessible on Time

  43. The AMDD Program • The AMDD Program Was Established in 1999 at Columbia University’s School of Public Health, Heilbrunn Department of Population and Family Health • The AMDD Program Is Dedicated to Improving the Availability, Quality and Utilization of Life-saving Obstetric Services in Developing Countries • AMDD Partners Projects in Close to 50 Countries, Within a Framework That Links Technical Know-How With Management Capacity and Human Rights • AMDD Is Funded by a Generous Grant From the Bill and Melinda Gates Foundation

  44. AMDD Partners Project Partners: • United Nations Children’s Fund(UNICEF):projects in Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka • United Nations Fund for Population Activities (UNFPA): projects in India, Morocco, Mozambique and Nicaragua • Regional Prevention of Maternal Mortality (RPMM) Network: teams and projects in19 sub-Saharan African countries • CARE: projects in Ethiopia, Rwanda, Tanzania, Peru and Tajikistan • Save the Children: projects in Mali and Vietnam • Reproductive Health for Refugees (RHR) Consortium: projects in 12 countries

  45. AMDD Partners Technical Partners: • Family Health International • John Snow International • Indian Institute of Management at Ahmedabad (IIMA) • JHPIEGO • Engender Health (formerly AVSC International)

  46. RESOURCES UNICEF/WHO/UNFPA, Guidelines for Monitoring the Availability and Use of Obstetric Services, UNICEF, New York, October 1997 Maine, Deborah, Safe Motherhood Programs: Options and Issues, Columbia University, New York, 1991 UNFPA and AMDD, Reducing Maternal Deaths: Selecting Priorities, Tracking Progress, Distance Learning Courses on Population Issues, Turin, UN System Staff College, 2002 Loudon, Irvine, “On Maternal and Infant Mortality 1900-1960”, Social History of Medicine, April 1991, Vol. 4, No.1, pp 29-73

  47. Created byNadia Hijab & Czikus Carriere

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