Epidemiology of Maternal and Neonatal Mortality in Malawi

1. Epidemiology of Maternal and Neonatal Mortality in Malawi Dr. Chisale Mhango FRCOG NPC Training in MNH

2. MATERNAL MORTALITY IN LOW RESOURCE COUNTRIES: How to accelerated reduction Objectives: • Understand the issues relating to MMR • Review Global and Local Progress on Reduction of MMR • Key article from The Lancet • Discuss effective strategies

3. Outline of presentation • Definitions of terms • Global and Local Trends in MMR and NNM • Causes of maternal and neonatal mortality • Current data on place of delivery in Malawi • Coverage for Skilled Birth Attendants in Malawi • Rationale for new roles for TBAs NPC Training in MNH

4. Definitions Statistical measurements.. Alternative definition of MD in ICD-10 (1992)

5. Definitions cont… Definitions and Statistical measurements..

6. Methods of defining Maternal Mortality

7. Millennium Development Goal 5: Improve Maternal Health • Target 5.A: • Reduce by 3/4, between 1990 and 2015, the maternal mortality ratio • Indicators: • Maternal mortality ratio • Proportion of births attended by skilled health personnel • Target 5.B: • Achieve, by 2015, universal access to reproductive health • Indicators: • Contraceptive prevalence rate • Adolescent birth rate • Antenatal care coverage • Unmet need for family planning

8. Millennium Development Goal 4: Reduce Child Mortality • Target 4: • Reduce by 2/3, between 1990 and 2015, the child mortality rate • Indicators: • Under-five mortality rate • Infant mortality rate • Proportion of 1 year-old children immunized against measles

9. The Lancet Article Maternal mortality for 181 countries, 1980–2008:a systematic analysis of progress towards Millennium Development Goal 5 Margaret C Hogan, Kyle J Foreman, Mohsen Naghavi, Stephanie Y Ahn, Mengru Wang, Susanna M Makela, Alan D Lopez, Rafael Lozano, Christopher J L Murray Volume 375 May 8, 2010, pp. 1609-1623.

11. Map of Priority Countries

12. Global Situation 180-210 million pregnancies annually 80 million unwanted pregnancies 50 million induced abortions 20 million unsafe abortions 68,000 deaths from unsafe abortion 20 million women suffer from maternal morbidity Estimated 350,000 to 450,000 maternal deaths 3million babies are born dead Almost 10 million children under age of 5 die Of which 3 million newborns die within the first week 500,000 infants are infected with HIV

13. Every Single minute… …1 woman dies …380 women become pregnant …190 women face an unplanned or unwanted pregnancy …110 women experience pregnancy-related complications …40 women have an unsafe abortion

14. MM WHO estimates

15. MM WHO… Estimates

16. Maternal Mortality: The latest data “These numbers should now act as a catalyst, not a brake, for accelerated action on MDG-5, including scaled-up resource commitments. Investment incontrovertibly saves the lives of women during pregnancy.” Richard Horton Source: Hogan MC et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet 2010: published online April 12. doi:10.1016/S0140-6736(10)60518-1. For the first time, new data indicate that we are seeing real progress in reducing maternal mortality worldwide. A new study published in The Lancet in May 2010 revealed that the number of women dying from pregnancy-related causes has declined from 526,300 in 1980 to 342,900 in 2008. The finding contradict previous research which showed very little change in reducing maternal mortality, and represent a powerful opportunity to show that investments to reduce maternal mortality actually work.

17. Current Situation 6 Countries Account for 50% of Maternal Mortality - India - Afghanistan - Nigeria - Ethiopia - Pakistan - Democratic Republic of the Congo

18. Countdown to 2015 NPC Training in MNH

19. Trends in Maternal Mortality in Malawi: UN Estimates with extrapolation to 2015 NPC Training in MNH

20. Trends in Under-5 Mortality Rate (top line) and Infant Mortality Rate (lower line) in Malawi

21. Neonatal Mortality Rate in Malawi NPC Training in MNH

22. Causes of Maternal Mortality

23. Main direct causes of maternal deaths in Malawi • Haemorrhage after childbirth (27%) • Sepsis after childbirth (23%) • Hypertension of Pregnancy (17%) • Complications of unsafe abortion (16%) ALL THESE CONDITIONS ARE COMMONEST WITH CHILDBIRTH OR ABORTION OUTSIDE HEALTH FACILITIES Source: MDHS2010 NPC Training in MNH

24. Main causes of neonatal deaths • Birth asphyxia • lack of resuscitation skills at birth • Low birth weight • Prematurity leading to • Cold injury • RDS • HIV • Severe infections • Home births NPC Training in MNH

25. Time of Death

26. Key strategies to reduce maternal mortality

27. What factors are driving maternal mortality in Malawi? Not only medical issues, but also a social, economic, political and human rights issues • Poverty • No food security • Low female literacy rates • Cultural factors • High fertility rate • Poor functioning health infrastructure • Contraceptive services • Insufficient focus on quality of care • Inadequate number of skilled health workers. • Physical infrastructure • Basic tools of the trade • Slow adoption of evidence based policy “I am going to fetch a baby. The journey is dangerous and I may not return …”

28. Maternal Mortality: The Link to Family Planning 3.70 3.26 2.56 The Lancet study data indicate that the global decline in fertilityis a key contributing factor to the decline in maternal mortality. Societies in which the total fertility rate has decreased are also those in which maternal mortality has decreased. Global decline in total fertility rate (TFR) I__________________I_________________I 19801990 2008

30. Skilled attendance at birth saves mothers and babies Skilled attendance at childbirth is the most effective intervention

31. Access to skilled birth attendants About 35 % of pregnant women in developing countries have no access to, or contact with, health personnel before delivery, and only 57 % give birth with a skilled attendant present.

32. Access to emergency obstetric care EmOC • 42 % of all pregnancies everywhere experience a complication. In 15 % of all pregnancies, the complications arelife-threatening. • 61 % of maternal deaths occur just before, during, or just after delivery, often from complications that cannot be predicted and are difficult to prevent • Therefore… it is critical that every woman have access to emergency obstetric care

33. Why Women Do Not Access Health Services? • Distance from health services • Lack of transportation • Cost • Multiple demands on women’s time • Lack of decision-making power within the family • Attitude of health care providers • Limited access to education • Inadequate health care services • Discriminatory or inadequate laws or health care policies • Culture • Community

34. Reasons for decrease of maternal mortality Global decrease in Total Fertility Rate (TFR) Increase of income in low-income countries Increase in maternal education Increase in skilled birth attendants from approximately 25% to 45–55%

35. 1. What Interventions Work?

36. 2. What Interventions Work?

37. 3. What Interventions Work? • Access to quality care for pregnancy and childbirth • - Antenatal care • - Skilled attendance at birth, including emergency obstetric and neonatal care • - Immediate postnatal care for mothers and newborns • Access to family planning • - Counseling • - Services • - Modern contraception • Access to safe abortion (when legal) childbirth • - Antenatal care • - Skilled attendance at birth, including emergency obstetric and neonatal care • - Immediate postnatal care for mothers and newborns • Access to family planning • - Counseling • - Services • - Modern contraception • Access to safe abortion (when legal) • Strong health systems • - Scaling-up critical health interventions • - Training health care professionals • - Training of mid-wives • Accelerated access to life-saving, interventions, medicines and vaccines • - Vaccines to target pneumonia, tetanus, and diarrhea • - Prevention, screening and treatment of HIV and STIs • - Treatment and prevention of malaria, pneumonia and diarrhea

38. Coverage failures across the continuum of care GLOBALLY • For some interventions: • Family planning • Exclusive breastfeeding • Clinical care for newborn and child illnesses • In some • countries: • Wide gaps in coverage across countries Coverage estimates for interventions across the continuum of care in the 68 priority countries (2000-2006). Vertical bars indicate the range in coverage across countries.

39. Place of Delivery in Malawi URBAN RURAL 71% in health facilities 70% had skilled attendance at birth For all Malawi, 73% women had skilled attendance at childbirth • 84% in health facilities • 85% had skilled attendance at birth • For all Malawi 72% delivered in health facilities • 98% women with tertiary education had skilled attendance at childbirth compared to 63% women without education. NPC Training in MNH Source: MDHS 2010

40. Which women and newborns were dying the most in Malawi? Mothers Neonates Babies born without skilled attendant present at birth. Suffered the most from birth asphyxia, cold injury and infection, especially if they were under weight or premature • Women who delivered or procured abortion outside the health facilities, especially when they developed, PPH, PIH and sepsis • Women who developed these complications while in health facility, had treatment initiated earlier and were less likely to die. NPC Training in MNH

41. Rationale for Change of TBA roles • International WHO and local studies revealed that investment in TBAs did not contribute significantly to reduction of maternal and neonatal deaths • The option of TBA births prevented the scale up of skilled attendance at child births • As soon as the TBA option was removed in Malawi, health facility births soared, distance of health facility had been overestimated NPC Training in MNH

42. Trends in Skilled Attendance at Birth in Malawi NPC Training in MNH

43. There is no better time to reduce maternal and child death in Malawi - Commited leadership critical

44. References/reading B-Lynch C, Keith LG, Lalonde AB, Karoshi M. A Textbook of Post Partum Hemorrhage: A comprehensive guide to evaluation, management and surgical intervention. Sapiens Publishing, 2006. Chowdhury ME, Botlero R, Koblinsky M, Saha SK, Dieltiens G, Ronsmans C. Determinants of reduction in maternal mortality in Matlab, Bangladesh: a 30-year cohort study. Lancet 2007; 370: 1320–28. Countdown Coverage Writing Group, on behalf of the Countdown to 2015 Core Group. Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions. Lancet 2008; 371: 1247–58 Deneux-Tharaux C, Berg C, Bouvier-Colle MH, et al. Underreporting of pregnancy-related mortality in the United States and Europe. ObstetGynecol2005; 106: 684–92. Fortney JA, Leong M. Saving Mother’s Lives: Programs that work. ClinObstetGynecol2009; 52: 224. Graham WJ, Ahmed S, Stanton C, Abou-Zahr CL, Campbell OM. Measuring maternal mortality: an overview of opportunities and options for developing countries. BMC Med 2008; 6: 12. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Landagan OZ, Barrios EB. An estimation procedure for a spatial-temporal model. Stat ProbabLett2007; 77: 401–06. The Millennium Development Goals Report 2008. New York: United Nations, 2008. Murray CJL, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010,375: 1609-1623 Ronsmans C, Graham WJ, on behalf of The Lancet Maternal Survival Series steering group. Maternal mortality: who, when,where, and why. Lancet 2006; 368: 1189–200. WHO. International statistical classification of diseases and related health problems, tenth revision instruction manual (2 edn). Geneva: World Health Organization, 2004. WHO, PMNCH. Joint Action Plan for Women’s and Children’s health. Geneva: World Health Organization, Partnership for Maternal, Newborn and Child Health, 2010 Draft. WHO, UNICEF. Countdown to 2015 Decade Report (2000-2010): Taking stock of maternal, newborn and child survival. Geneva: World Health Organization and UNICEF, 2010. WHO, UNICEF, UNFPA, World Bank. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva: World Health Organization. 2007. WHO. WHO Mortality Database. Geneva: World Health Organization, 2010. http://www.who.int/whosis/mort/download/en/index.html (accessed March 23, 2010).