Evidence Based Approaches for Reduction of Maternal Mortality Hemant Dwivedi.

Evidence Based Approaches for Reduction

of Maternal Mortality

Hemant Dwivedi

Session Objectives To review:

Magnitude of Maternal mortality Causes of Maternal mortality Interventions to reduce maternal mortality

– Traditional birth attendant– Antenatal care– Risk screening– Reduce Unwanted Fertility– Skilled attendant at childbirth– Emergency obstetrics Care

Current Program Strategies What we can do?

2Current Approach to Reduction of Maternal Mortality

Maternal Mortality: A Global Tragedy

Annually, 536,000 women die of pregnancy related complications

99% in developing world

~ 1% in developed countries

25% global burden by India

Every minute one Maternal Death occur


Maternal and Infant Mortality are two critical indicators that measure not only health conditions, but overall development level of a country.

Both are key goals in the National Rural Health Mission (NRHM) and the Millennium Development Goals (MDG# 4 and 5).

Maternal Mortality RatioMaternal Mortality Ratio

Year MMR(INDIA) ORISSA

1998-99 : 407 367

2001 – 03 : 301 358

2004 – 06 : 254 303

XI Plan Goal (2012) : 100 119

MDG Target (2015) : 136

Recent Trends MMR – India (SRS-04-06)


States of India MMR

Kerala 95

Tamil Nadu 111

West Bengal 141

Andhra Pradesh 154

Bihar/Jharkhand 312

Madhya Pradesh/ Chhattisgarh 335

Orissa 303

Assam 480

India 254

Causes of Maternal Mortality in India (SRS-2003)


But WHY Do These Women Die?

Delay in Decision to Seek Care

Lack of understanding of complications Acceptance of maternal death Low status of women Socio-cultural barriers to seeking care

Delay in Reaching Care

Mountains, islands, rivers — poor organization Delay in Receiving Care

Supplies, personnel Poorly trained personnel with punitive attitude Finances


Three Delays Model

Interventions to Reduce Maternal Mortality

Historical Review

Traditional Birth Attendants

Antenatal Care

Risk Screening

Current Approach

Reduce Unwanted Fertility

Skilled Attendant at Delivery

Emergency Obst. Care


Historical Review of Interventions

The flawed assumption:

Most life-threatening obstetric

complications can be predicted or

prevented


Interventions: Traditional Birth Attendants

Advantages

Community-based

Sought out by women

Low tech

Can perform clean delivery

Disadvantages

Technical skills limited

May keep women away from life-saving interventions due to false reassurance


Interventions: Traditional Birth Attendants

Conclusion: TBAs are useful in the maternal health network, but there will not be a substantial reduction in maternal mortality by deliveries conducted through TBAs.

Maternal Deaths prevented-3 percent


Interventions: Antenatal Care

Antenatal care clinics started in USA, Australia, Scotland between 1910–1915

Concept - Screening healthy women for signs of risk/disease

No substantial reduction in maternal mortality

However, widely used as a maternal mortality reduction strategy in 1980’s and early 1990’s

Is ANC important? YES!!

Early detection of problems and Birth Preparation

Maternal Deaths prevented-11 percent13Current Approach to Reduction of Maternal Mortality

Maternal Mortality: UK 1840–1960

050

100150200250300350400450500

MaternalDeaths


Improvements in nutrition, sanitation

Antibiotics, banked blood, surgical improvements

Antenatal care

Maine 1999.

Interventions: Risk Screening

Disadvantages

Very-poorly predictive

Costly: Early and longer stay in health facilities

If risk-negative, gives false security

Conclusion: Cannot identify those at risk of maternal mortality — Every pregnancy is at risk, if not proved, otherwise.

15

Current Approach to Reduction of Maternal Mortality

Historical decline in Maternal mortality in the West

Not much decline till 1930

Rapid decline after 1940s

While infant mortality declined since 1800s gradually as socio-economic conditions improved.(Community based interventions)

Factors affecting maternal mortality decline- Increased availability of blood, antibiotics, safe surgery.


Are there populations who are rich, well nourished and educated but

have high maternal mortality?

Yes in USA there are such populations – eg. Faith Assembly of God who are rich, well nourished, and educated : their MMR was 872 in 1982 while in that year MMR in US general population was only 8 per 100,000 live births.

What is the key difference between these two groups? Use of modern obstetric care.


MM: What the Evidence Shows

Once a woman is pregnant usually most serious obstetric complications cannot be predicted or prevented ,but they can be

treated.

About 15 %

do develop obstetric complications.


Do women die immediately after developing complications in delivery?

Average Complications to death interval Hemorrhage PPH: 2 Hours ( 5.7 hrs*)

APH: 12 Hours(11.5 hrs)

Ruptured uterus 1 Day

Eclampsia 2 Day (1.7 Days)

Obstructed Labour 3 Days

Infection 6 Days (2.4 Days) (* Study in Maharashtra – Ganatra et al. WHO bulletin 1998, 76(6):591-598.


20Current Approach to Reduction of Maternal MortalityUN

Maternal deaths averted through Maternal deaths averted through access to services access to services (World (World Bank, 2004)Bank, 2004)

SoAll pregnant women

need Access to*

Emergency Obstetric Care

(EmOC)

* Not the same as Institutional Delivery [ID]


Interventions: Skilled Attendant at Childbirth

SBA- An accredited health professional- such as Midwife, Doctor, Nurse-Who have been educated and trained to proficiency in the skills needed to manage normal pregnancy, child birth and the immediate post- natal period, and the identification, management and referral of complication in women and newborn.

Proper training for range of skills

Assess danger signs and Recognize onset of complications

Observe woman, monitor fetus/infant

Perform essential basic interventions

Refer mother/baby to higher level of care if complications arise requiring interventions outside realm of competence


Maternal Mortality ReductionSri Lanka 1940–1985

Health system improvements:

Introduction of system of health facilities

Expansion of midwifery skills

Decreased use of home delivery and delivery by untrained birth attendants

Spread of family planning


Maternal Mortality ReductionSri Lanka 1940–1985

0

200

400

600

800

1000

1200

1400

1600

1800

1940–45 1950–55 1960–65 1970–75 1980–85Mat

ern

al D

eath

s p

er 1

00 0

00 li

veb

irth

s


85%

birt

hs a

ttend

ed

by tr

aine

d pe

rson

nel

Interventions: Skilled Attendant at Childbirth Proven effective

Malaysia: basic maternity services 320 157 Cuba: national priority 118 31 China: facility based childbirth 1500 50

Malaysia (41)vs. Indonesia (230):

Trained community midwives (2 years) vs. untrained midwives (4 years)



R2 = 0.74

0

200

400

600

800

1000

1200

1400

1600

1800

2000

0 10 20 30 40 50 60 70 80 90 100

Y Log. (Y)

The higher the proportion of deliveries attended by skilled attendant in a country, the lower the country’s maternal mortality ratio

% skilled attendant at delivery

Mat

erna

l dea

ths

per

1000

000

live

birt

hs


Countries MMR SBA %

Afghanistan 1800 14

Nepal 830 11

Bangladesh 570 13

Bhutan 440 37

Pakistan 320 31

India 254 43*

Sri Lanka 58 96

South Asia 500 37

Global 400 63

MMR & SBA

Interventions: Emergency Obst care

Vast Majority of deaths (75%) due to Direct Obstetric complications

These complications occur even in well nourished and well educated women

Can not usually be predicted

Can not be prevented : some exceptions such as AMTSL for preventing PPH, IP for Post partum infections and provision of safe and early abortion services

Overlap with SAB

Emoc facilities provide a critical back up for SAB



Interventions: Reduce Unwanted fertility

Huge unmet demand for spacing and permanent methods

Significant proportion of maternal deaths attributable to unsafe abortions

Nearly One third of fertility: unwanted

Access to quality contraceptive services will help in reducing unwanted fertility which in turn will reduce numbers of maternal deaths


What proportion of maternal deaths these strategies can prevent?

TBA training 03 %

ANC 11 %

Family Planning 26 %

Health Centers (BEmOC) 25 %

HC & Urban Hospitals (C) 60 %

HC & rural Hospitals 67 %


Programmatic Interventions– Reduce Maternal Mortality

1. Access to Information and Services for Contraception – Too early and too frequent, too many

2. Access to skill Birth attendance – SBA & BEmOC (obs. First aid)

3. Access to Emergency Obstetric Care

4. Access to safe abortion services

5. Access to ANC and PNC Services


Organizing Maternal Health Services with active Referral Linkages


Midwifery Services

BEmOC Services

CEmOC Services

CEmOC SDH/DH

CHC / Block PHC

PHC (New)

Sub Centre

Maternal Health Services

Good quality maternal health services are not universally available and accessible

> 39% receive no antenatal care

~ 40% of deliveries unattended by skilled provider

~ 60% receive no postpartum care during 1st 6 weeks following delivery

15% unmet need of FP


What was planned and what happened? (Time, Resource &Energy)


TBA

ANC Coverage

SBA

EmOC & Safe Abortion Services

TBA Training

ANC Coverage

EmOC

5%

10%

30%

55%

Planned SBA ? Safe Abortion?

Program Design: The Causal Chain

This is what links actions to outcomes and impact.

Must be evidence-based, not faith-based

Links must be tested and monitored

If one link breaks, the chain is broken


JSY Plan’s Causal Chain


JSY

BetterOb.

Care EmOC for

Complic.Deliv.

Instit.Deliv.

Lives Saved

JSY Plan’s Evidence Chain


JSY

BetterOb.

Care EmOC for

Complic.Deliv.

Instit.Deliv.

Lives Saved

EvidenceNeeds more evidence

Orissa Scenario


250

190

What we can DoACCESS TO -

Skilled attendance at birth,

Emergency obstetric care

Family planning

Pre-natal and post-natal care

- ARE ABSOLUTELY ESSENTIAL

But reduction of MMR to Western levels goes beyond health – it requires better nutrition, better hygiene, better education of mothers and better gender equality, in other words, better overall development of people.




Sl. No.

Cause of Death Number of Death

% of Deaths

Possible preventable

% Number

01. Hemorrhage 127 000 25% 55% 70 000

02. Sepsis 76 000 15% 75% 57 000

03. Preeclampsia/eclampsia

64 000 12% 65% 42 000

04. Obstructed labour 38 000 8% 80% 30 000

05. Unsafe abortion 67 000 13% 75% 50 000

06. Other direct causes 39 000 8% --- ---

07. Indirect cause 100 000 20% 20% 20 000

TOTAL 510 000 100% 269 000

Estimation of mortality from the main obstetric complications worldwide and impact of possibly preventable deaths.-WHO-1994

UN “Signal Functions” of EmOCBasic

Parenteral antibiotics, oxytocics,

anti-convulsants Manual removal of the placenta Removal of retained products (e.g., MVA) Assisted vaginal delivery

Neonatal resuscitation (new)Comprehensive = Basic +

Surgery Blood transfusion



Maternal Mortality ratio per 100000 live births

400

200

100

8-9 yearsMalaysia 1951-61Sri Lanka 1956-1965Bolvia Late – 1990s

6-7 yearsSri Lanka 1974-1981Thailand 1974-1981Egypt 1993-2000Chile 1971-1977Colombia 1970-1975

4-6 yearsHonduras 1975-81Thailand 1981-1985Nicaragua 1973-1979

50

Figure: 4.9.

To provide skilled care at and after child birth and to deal with

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Evidence Based Approaches for Reduction of Maternal Mortality Hemant Dwivedi.

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