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Maternal mortality and morbidity: A global perspective. Julia Hussein . Julia Hussein. Definitions. Maternal health: health of women during pregnancy, childbirth and the postpartum period. (World Health Organization 2009)

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definitions
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).

how big is the problem
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

causes of maternal death
CAUSES OF MATERNAL DEATH

Indirect causes

Bleeding

Other direct causes

Obstructed labour

Infection

Eclampsia

Unsafe abortion

slide10

Timing of death is critical

Most deaths cluster

around labour or

within 24 hours after

delivery

slide11

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.

slide12

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

slide13
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

coverage of deliveries by skilled health personnel shows two main barriers
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

low uptake is clustered in the poor
Low uptake is clustered in the poor

% distribution of health facility delivery by wealth quintiles

Ghana sub-national levels

Penfold et al 2007

emergency care is not available to the poor
Emergency care is not available to the poor

Indonesia sub-national: Poor-rich gap in caesarean sections

supply and demand barriers
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
demand
Demand

Costs and distance matters

how much do women pay for delivery
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

costs of access are significant
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

distance to facilities matters
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.
how are the poor affected
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

payments for health care have lasting adverse consequences
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
quality is key
Quality is key
  • Too few
  • Too unskilled
  • Too late
too unskilled indonesian village midwives performance
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)

too unskilled does quality of care change with increasing case load in ghana
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

too unskilled provider attitude
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?”

slide31
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

too late delays in the health system indonesia
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),

translating strategy to programmes
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
slide34

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

slide35

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

trends in maternal mortality malaysia report
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

slide37

Immpact is….

….the global research initiative

for maternal mortality programme assessment

slide38

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
useful websites
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/
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