Measurement of Maternal Mortality in Maldives

1. Measurement of Maternal Mortality in Maldives Ms. Mariyam Nazviya Ministry of Health & Family Republic of Maldives ESA/STAT/AC.219/21

2. Contents • Background Information on Maldives • Definitions • MMR Trends • Measurement of MMR • Sources • Methodology • Maternal Death Review process • Progress towards achieving MDG Goal 5 • Issues & Challenges

3. Background Information on Maldives • Consist of 1190 tiny coral Islands • Spread over 90,000sq km of the Indian ocean. • Inhabited 200 islands • Islands grouped to 20 atolls • The total population of the country is 31,4542 • Small dispersed populations with difficult and expensive transport system cause delays in timely exchange of information. However development in telecommunication has brought about positive changes

4. Definitions • WHO standard definitions are followed in the country: • Maternal Death: The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. • Direct Obstetric cause: Those resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium) from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above • Indirect Obstetric cause: Those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy

5. Maternal Mortality Trends 1997-2009

6. Maternal Mortality Trends 1997-2009

7. Measurement of MMR Methods Central level (MOHF) investigation Institutional level (Facility) investigation Coverage National - All maternal deaths are reviewed Started Maternal Death Review committee 1999 1997

8. Maternal Death Review Process Death Reporting Reporting through death forms - VRS Notification of death mandatory within 24 hrs of occurrence Detailed information (within 7-14 days) Analysis of case Case Review (MOHF) Maternal and Perinatal Morbidity and Mortality Committee Institutional (facility) level

9. Maternal Death Review Process Maternal Death Review Committee Reviews forms/ questionnaires / Patient Medical Record / Past Records Analysis of case Directs to additional investigation /information Confirms cause of death / identifies faults/ factors Recommends preventive actions

10. Maternal Death Review Process Medical records Nursing care records ANC/PNC records Prescription records Interviews with attending staff ANC records Other health care records Interviews - health workers Interviews - family members Source of information Maternal Death Review Committee Review & analyze the information Information analysis & reporting Ministry of Health, Health Information and Research Section Prepares a case report of each death; Compiles an annual report Every Five Years, a Synthesis Report is compiled

11. 2009 81/ 100000lb 2015 125/ 100000lb 2000 75/ 100000lb 1990 500/ 100000lb Progress towards achieving MDG Goal 5 Reduce maternal mortality ratio by three quarters, between 1990 and 2015 FLUCTUATING TREND … On Track

12. Progress towards achieving MDG Goal 5 Improvement in health care services With the decline in mortality, direct causes are declining Expansion of obstetric/gynecological services Improved antenatal care services High proportion of institutional deliveries High proportion of skilled attendance at birth

13. Strategies adopted to improve maternal and neonatal care • Strengthening and expansion of Maternal and Child health services • Strengthening of essential obstetric care • Ensure quality of care • Proper supervision and monitoring of services • Implementation of target oriented awareness programmes

14. Issues & Challenges • Population size very small • Statistically brings a large variation to MMR with just one or two deaths • Over 90 Percent of Institutional deliveries • However, not all hospitals in atolls are equipped with Emergency Obstetric / Neonatal care • Service Delivery and timely referral a challenge due to geographical dispersed nature of islands • Establishing a public transport mechanism – one of the priorities of the current government • Quality of Care needs to be improved • Limitation of capacity (institutional / HR)

15. Conclusion • Maldives has made significant achievements in reduction of Maternal Mortality since 1990 and currently the country's MMR stands at 81 / 100,000 live births in the year 2009. • Maternal death reviews are conducted for all Maternal deaths • More than one source of reporting (through VRS as well as Maternal Death Review Process) • Due to the small population, an increase or decrease in just one maternal death brings a significant change to the MMR. As such, the trends over the past few years is seen to fluctuate, although generally it can be said that country is on track to achieving MDG Goal 5.

16. Thank you!