The WHO MultiCountry Survey on Maternal and Newborn Health - 2010-11

1. The WHO MultiCountry Survey on Maternal and Newborn Health - 2010-11 Prof. Dr. SyedaBatoolMazhar FRCOG (U.K), FCPS (PK) Head of Department, MCH Centre, PIMS, Islamabad

2. Background The world has seen two important changes in maternal health: • Substantial reduction in global maternal mortality • Increase in proportion of childbirths in health facilities. Progress though remarkable is insufficient to meet the MDG’s • Estimated 287,000 women died in 2010 of causes related to pregnancy and childbirth • A substantial proportion of childbirths are still taking place in communities without skilled birth assistance • In many settings, women prefer to deliver in the community due to concerns about perceived quality of care in health facilities. • Thus quality of care is increasingly critical to accelerate reduction in maternal mortality & stimulate demand for institutional births. .

3. Background Quality of care is a multidimensional concept resulting in patient and provider satisfaction and improved health outcomes that includes • Appropriate use of effective clinical and non-clinical interventions • Strengthened health infrastructure • Health providers’ attitude “As part of strategies to improve maternal health care, great emphasis has been placed on maximizing coverage that can be objectively monitored and evaluated, however other dimensions of quality are more challenging”

4. The WHO Multi Country Survey on Maternal and Newborn Health 2010-11 Primary Objective To study the incidence and the management of maternal and neonatal conditions highly associated with maternal and neonatal mortality in a worldwide network of health facilities.

5. The WHO Multicountry Survey on Maternal & Newborn Health 2010-11 Secondary Objectives • To assess the quality of care by the maternal near miss indicators and the use of effective preventive and therapeutic interventions. • To examine the relationship of the use of effective preventive and therapeutic interventions with severe perinatal morbidity and mortality • To consolidate the WHO Multicountry, Maternal and Perinatal Health network and strengthen research capacity of health facilities worldwide.

6. Materials and methods

7. 29 countries, 357 health facilities • Americas - 8 countries • Africa - 7 countries • Asia - 14 countries • 314,623 deliveries

8. SELECTED COUNTRIES IN WHO MULTICOUNTRY SURVEY

9. Materials and methods

10. The WHO MultiCountry Survey on Maternal and Newborn Health 2010-11 16 health facilities with annual delivery rates > 1000, randomly selected in Sind, Punjab and Islamabad. Punjab: Sindh: Civil Hospital Karachi Sobhraj Hospital Karachi Korangi Hospital Karachi Qatar Hospital Karachi Taluka Hospital Rohri Civil Hospital Jakobabad Civil Hospital Badin & FGSH, Islamabad • Rawalpindi Medical College • Nishtar Hospital Multan • Bahawalpur Victoria Hospital • DHQ Hospital Toba Tek Singh • THQ Hospital Muridke • Sheikh Zayed Hospital Lahore • Services Hospital Lahore. Federal Capital: PIMS, Islamabad

11. Materials and methodsStudy Population All women giving birth in selected study hospitals

12. Materials and methodsStudy Population All deaths of women during pregnancy, childbirth or within seven days of termination of pregnancy (regardless of the gestational age and the delivery status)

13. Materials and methodsStudy Population All maternal near miss cases, regardless of the gestational age and the delivery status

14. Eligibility Criteria The Study Population Most of eligible women are giving birth

15. Eligibility Criteria The Study Population But, few eligible women are not giving birth

16. Eligibility Criteria The Study Population All delivering women+ all near miss cases and deaths of non delivering women

17. Maternal Mortality Definition: • Maternal death (MD)is the 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. World Health Organization

18. Maternal Near Miss Mortality Definition: "A woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy" This definition by WHO reconciles previous maternal near miss definitions and is aligned with "maternal death" definition of ICD10 05_XXX_MM18

19. Why maternal near miss Mortality ? • Near miss/SAMM cases share many characteristics with maternal deaths • Can directly inform on obstacles that had to be overcome after the onset of an acute complication. • Corrective actions for identified problems can be taken to reduce related mortality and long-term morbidity

20. WHO Maternal Near Miss identification criteria 05_XXX_MM20 • A set of organ dysfunction markers including Basic laboratory tests & Management-related markers • Clinical criteria based on the clinical assessment where laboratory and other techniques are not available

21. Results We Report the main findings of the WHO Multi country Survey on Maternal and Newborn Health which evaluated • The burden of pregnancy-related complications, • The coverage of key maternal health interventions

22. Summary of Global MCSurvey Results • Countries 29 • Total Women 314,623 • Maternal near miss 2529 • Maternal deaths 514 • Severe maternal outcome (MNM+MM) 1% • Potential life-threatening conditions 7%

23. Summary of Global MCSurvey Results • Most frequent complications in women with severe maternal outcomes: Postpartum hemorrhage (26 %). Pre-eclampsia /eclampsia (26 %). • The observed mortality in high mortality countries including Pakistan, was 2-3 times higher than expected for the assessed severity despite a high coverage of essential interventions.

24. STUDY FLOW CHART: PAKISTAN Total no of patients n.= 13175 No delivery in participating facility (women with organ dysfunction)n=53 Delivery in participating facility (women with or without organ dysfunction) n=13122 Abortive outcome n=11 Antepartum n=8 Postpartum n=34 Near miss n=10 Maternal death n=1 Near miss n=4 Maternal death n=4 Near miss n=28 Maternal death n=6 No near miss with out complication n=12017 No near miss with complication n=1026 Near miss n=52 Maternal death n=27

25. Frequency And Severity Of Pregnancy-related Complications

26. Maternal mortality ratio(WHO MCS 2011)

27. Coverage Of Key Interventions

28. Coverage of key interventions by country group

29. Interventions related to postpartum hemorrhageprevention of PPHn=13175

30. Interventions related to postpartum hemorrhagetreatment of PPHn=187

31. Interventions related to preterm labourN=1449

32. Pregnancy Complications and Severe Maternal Outcome Statistically sig diff b/w SMO and non-SMO group for maternal education p= 0.000 Statistically sig diff b/w SMO and non-SMO group for no of previous c section P=0.027

33. Maternal complications Hemorrhage related severe maternal outcome

34. Maternal complications Infection related severe maternal outcome SMO n=132

35. Maternal Complications In Severe Maternal Outcome Hypertensive Disorders

36. Maternal complications other complications related severe maternal outcome

37. Anesthesia for LSCS

38. Maternal intensive care use

39. Facilities in study hospitals in Pakistan

40. Medical staff availability in study hospitals (Pakistan)

41. Perinatal outcome

42. Relation Of Birth Weight With Neonatal Outcome

43. Discussion “Beyond the coverage of essential interventions – the next challenge for reducing global maternal mortality “ • The high coverage of essential interventions suggests that these interventions are available & used in majority of studied health facilities • Mismatch between high coverage of essential interventions and the substantial variations in health outcomes implies that there are other factors driving these outcomes. • Delays in implementing these interventions or interventions poorly implemented could explain part of the excessive mortality and morbidity observed in some settings. • Verticalization of care (i.e. few effective interventions implemented in disconnection of comprehensive care) could be an issue

44. Discussion Other elements of care and quality may be playing a strong role in severe maternal morbidity survival as in • Postpartum haemorrhage, prophylactic and therapeutic uterotonics are essential but shock management and prompt surgical care are also critical. • Magnesium sulphate is fundamental to the management of eclampsia, but other aspects of care (such as pre-delivery stabilization, severe hypertension management or airway management for adequate oxygenation and prevention of aspiration pneumonia) are also essential. • The prevalence of infection increased as case severity increased. • The prevalence of sepsis and other systemic infections is more than four times the prevalence of puerperal endometritis. This may indicate that the prevention, early identification and appropriate management of secondary infections (e.g. postoperative infection, aspiration pneumonia) and other non-obstetric infections should be regarded as a high priority

45. Discussion • Assessment of severity is often incomplete: there is an apparent underestimation of severity due to paucity of information related to organ dysfunction. • In settings where important constraints in the assessment of severity exist, poor assessments of severity may contribute to delays in the implementation of effective interventions and poor clinical management. • Health systems issues (such as referral processes), underlying undernutrition, pre-existing moderate to severe anaemia and other factors could also have played a role.

46. Discussion Neonatal Outcome It is the MOM… Poor maternal health & nutrition Poor maternal education Lack of birth spacing Poor antenatal care (ANC) Unskilled deliveries Lack of clean delivery practices Improper neonatal resuscitation Poor post natal care Poor infant feeding practices

47. Strengths of WHO MC Survey • It is one of the largest studies exploring the management of severe complications and the prevalence of maternal near miss using standardized definitions across several countries. This study captured approximately 0.7% of the maternal deaths during a 3-month period in the world. • Several procedures were adopted to ensure appropriate implementation and high quality data (such as training, pre-data entry visual check of the data collection forms, automated queries, double-checking selected medical records, and thorough audit of unclear cases, particularly maternal deaths) • Ensuring standardization of processes is a challenging task by minimizing methodological heterogeneity and maximized data quality .

48. Limitations of WHO MC Survey • The magnitude and the no’s of personnel involved (> 1500 ) • The data source-Routine hospital records, could be suboptimal. • Only short-term ( 7 days) intra-hospital data collected. A small no of survivors may have died in the remaining puerperal and NN period. • In settings where basic laboratory tests are not available there is a possibility of under-identification of near miss cases and under-estimation of severity. In such settings, a large proportion of women with unrecognized organ dysfunctions may die in absence of appropriate life support, worsening the ratio of MD to MNM. • The study design did not assess labor duration, hence no data available on the prevalence of obstructed labor. • As the WHOMCS conducted in secondary and tertiary facilities it may not represent maternal outcomes and coverage of essential interventions in smaller facilities or in the community.

49. Generalisability and Applicabilityof WHO MC Survey • In view of study characteristics, the present findings should not be regarded as representative of countries, but indicative of the situation in a large sample of health facilities. • The situation in lower-level facilities is likely to be different, particularly in terms of coverage of essential interventions. • The coverage of facility-based care in a given geographical area may influence the frequency of complications observed at the facility level.

50. Conclusions • Implementing the systematic identification of near miss case, mapping the use of critical interventions and analysing the corresponding indicators are the initial steps for using the maternal near miss concept as a tool to improve MN health. • These findings are a good starter for a more comprehensive dialogue with governments, professional and civil societies, health systems or facilities for promoting best practices, improving quality of care and achieving better MCH.