Maternal mortality and morbidity: A global perspective

1. Maternal mortality and morbidity: A global perspective Julia Hussein Julia Hussein

2. Definitions Maternal health: health of women during pregnancy, childbirth and the postpartum period. (World Health Organization 2009) Safe motherhood: a woman's ability to have a safe and healthy pregnancy and delivery (Interagency Group for Safe Motherhood 2002) Maternal mortality : Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to, or aggravated by the pregnancy or its management but not from accidental or incidental causes (International Classification of Disease ICD-10 2007) Maternal morbidity: Illness or disability occurring as a result of or in relation to pregnancy and childbirth (White Ribbon Alliance 2004).

3. How big is the problem? Every year: • 536 000 women die • 300 million women experience short or long term morbidity • 8 million stillbirths and early neonatal deaths When a woman dies: • Her children’s lives are threatened • Families lose her contribution to the household • Productivity in the community and the economy is reduced Every minute, one woman dies from a pregnancy related problem

4. Estimates Of Maternal Mortality ~2005

5. Maternal deaths per 100,000 live births (estimates for year 2005) <100 100-299 300-499 500-999 1000+

6. CAUSES OF MATERNAL DEATH Indirect causes Bleeding Other direct causes Obstructed labour Infection Eclampsia Unsafe abortion

7. MDG 5 Target Is Millennium Development Goal-5 on track?

8. Progress has been achieved in some countries

9. The evidence

10. Timing of death is critical Most deaths cluster around labour or within 24 hours after delivery

11. The causes of death should drive the interventions Most problems can be prevented or treated during delivery or immediate postpartum Most problems can not be predicted or prevented antenatally Excessive bleeding is the main cause of death Source of data: WHO systematic review 2006.

12. Core interventions In recent years, technical experts have come together around four core strategies for maternal mortality reduction: • family planning and other reproductive health services • skilled care during pregnancy and childbirth, • emergency care when life-threatening complications develop• immediate post-natal care for mothers and newborns

13. Half the world’s women currently give birth with a health professional: Most urban women A third of rural women The proportion of deliveries with a professional has stagnated in sub-Saharan Africa Where women deliver and who attends them is paramount Proportion of births with a professional Urban Rural 1992 2001 1992 2001 Sub-Saharan Africa South Asia

14. Coverage of deliveries by skilled health personnel shows two main barriers Europe and central Asia Sub-Saharan Africa South Asia Marginal Exclusion: Barriers include cost, quality of care, & reluctance to use Proportion delivering with health professional Massive Deprivation: Professional care is barely available

15. The poorest women face the highest risk of maternal death

16. Rich-poor gap in skilled care

17. Low uptake is clustered in the poor % distribution of health facility delivery by wealth quintiles Ghana sub-national levels Penfold et al 2007

18. Emergency care is not available to the poor Indonesia sub-national: Poor-rich gap in caesarean sections

19. Demand Education Knowledge and awareness of health care services Preferences Cultural factors Distance Costs etc Supply Staff availability Availability of equipment, drugs Distribution of facilities Management Staff knowledge Technology etc Supply and demand barriers

20. Demand Costs and distance matters

21. How much do women pay for delivery? Average cost of care to mothers in US$ In Burkina Faso, normal delivery costs constitute 43% of per capita income in the poorest and 138% for Caesarean

22. Costs of access are significant • Distance costs often negatively impact service utilisation and cause delays • Transport can take up over 25% of total patient costs • Poorer households are subject to inferior transport • Direct costs • Fees for service • Payments for drugs, equipment etc Ensor & Cooper 2004

23. Distance to facilities matters • Burkina Faso: • 77% of births in households living within 1 km of the health centre took place in a facility • 18% in homes more than 10 km from the health centre • Senegal exemption scheme (free normal deliveries and caesareans since 2005) • increased utilisation, but household costs remained high • favours urban poor over rural poor • geographic exclusion for those living far from facilities.

24. How are the poor affected? Indonesia sub national: % distribution of catastrophic payments* for care in obstetric complications by wealth quintiles *40% or more of a household’s disposable income + Social tensions from catastrophic payments

25. Payments for health care have lasting adverse consequences Burkina Faso: • Poorest women had highest level of asset sales • Poorest women spent least on care in absolute terms, but largest proportion of household income • All women with near-miss complications reported frequent spending of savings, borrowing, & sale of assets • 8% of women with normal deliveries reported borrowing to meet the cost of care

26. Quality is key • Too few • Too unskilled • Too late

27. Too few: Indonesia “A midwife in every village”

28. Too unskilled: Indonesian village midwives performance Clinical skills • Diagnostic skills sufficient to identify urgent referral needs • Incorrect manoeuvres • Lack of confidence in obstetric first aid Contraindicated and unnecessary vaginal examinations were performed and basic assessments of vital signs and contractions were missed. “…although [the midwife] knew the patient [was] bleeding, she did the internal examination.” Panel assessment case 1 (near-miss, haemorrhage)

29. Too unskilled: Does quality of care change with increasing case load in Ghana? Mean quality of care assessment scores for before and after fee exemption (health centres) n = 1,268 deliveries Maximum score 44 Volta region Central, Volta, public, private Central region

30. Too unskilled: provider attitude “….because of the pushing I had soiled my pad and so she (nurse midwife) ordered that I should go and dispose of it myself….this was difficult, but I had to crawl to the disposal bin” “When she (nurse midwife) came and realised the baby was out she asked me why I had not told her….How could I have known that the baby was about to come out?”

31. Few partographs Inappropriate and ineffective drugs Doctor rarely present when woman in critical condition Acute resuscitation efforts were poor Completed audit forms seldom found Too late: substandard care in Ghana

32. Too late: Delays in the health system, Indonesia “the woman needed a blood transfusion when she was admitted to hospital at 9.00am with retained placenta and haemorrhage, but the hospital had no blood supplies. The patient’s father travelled to another hospital to obtain blood. More delay was experienced when he found out he had to pay for the blood. He returned to his daughter’s hospital at 5.00pm. By this time, the patient had become so weak that blood could not be given. She passed away at 5.30pm with the placenta undelivered. This death was probably directly preventable, had blood been immediately available”. (case 8, maternal death, haemorrhage),

33. Political commitment is critical a consistent and significant effort >10 years Governments, donors, professionals and civil society need to work in concert More health professionals for delivery strategic human resource decisions for 100% coverage Training, deployment, retention, skills Huge shortage of human resources Double the supply by 2015 Over 300,000 more to achieve a coverage of 75% 24,000 health centres Greater financial resources Protect poorest from catastrophic payments More investment Translating strategy to programmes

34. DR ALEXANDER GORDON (1752-1799) A Treatise on the Epidemic Puerperal Fever of Aberdeen: 1795 A moment in distant history………… “… provided irrefutable evidence that puerperal fever could be carried by the birth-attendant from one lying-in woman to another.” Loudon (1992) Death in Childbirth

35. Sir Dugald Baird Regius Professor of Midwifery University of Aberdeen 1937-1965 700 600 500 Maternal deaths per 400 100,000 live 300 births 200 100 0 1926 1946 1966 1986 TRENDS IN MATERNAL MORTALITY IN SCOTLAND 2006

36. Trends in maternal mortality: Malaysia“REPORT” 1955: ORGANISATION Legislation of midwifery care 1970s: PROVIDERS Midwives investigate female deaths in the community Maternal mortality ratio per 100 000 live births 1990s: RESOURCES &TRENDS Maintenance and improvement of reporting systems 1950s: RIGHTS Birth and death registration 1970: EQUITY Policy changes to address poverty Year Graham and Hussein 2006

37. Immpact is…. ….the global research initiative for maternal mortality programme assessment

38. Immpact activities Burkina Faso Ghana India Indonesia Nepal Nicaragua Pakistan Senegal South Asia Tajikistan Uganda Vietnam Zimbabwe • Develop measurement methods and tools • Generate evidence and undertake evaluations • Build capacity in partner institutions

39. Useful websites • http://www.un.org/millenniumgoals/ • http://www.unmillenniumproject.org/goals/index.htm • http://www.maternal-mortality-measurement.org/ • http://www.who.int/pmnch/en/ • http://www.who.int/making_pregnancy_safer/en/ • http://www.who.int/reproductive-health/ • http://www.whiteribbonalliance.org/ • http://www.amddprogram.org/ • http://www.familycareintl.org/en/home • http://www.immpact-international.org/