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Maternal MortalityMaternal Mortality

March, 2012 March, 2012

Addis Ababa UniversityAddis Ababa University

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Learning objectivesLearning objectives

At the end of this class the students will be At the end of this class the students will be able to:able to: Define maternal mortality Identify the major causes of maternal mortality Describe the global experiences of maternal

mortality Describe current issues, strategies and approaches

in maternal mortality prevention

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Maternal Mortality (MM)Maternal Mortality (MM)

What is MM?What is MM? What are Major causes?What are Major causes? What are contributing factors?What are contributing factors? What can be done?What can be done?

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MM….MM….

Maternal mortalityMaternal mortality:: The death of a woman while The death of a woman while pregnantpregnant or or

within within 42 days42 days after termination of after termination of pregnancy, irrespective of the site & duration pregnancy, irrespective of the site & duration of pregnancy, from any cause related to or of pregnancy, from any cause related to or aggravated by the pregnancy or its aggravated by the pregnancy or its management, but not from accidental or management, but not from accidental or

incidental causesincidental causes (WHO, 10 (WHO, 10thth revision of revision of ICD, 1992)ICD, 1992)

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MM…MM…

Pregnancy-related deathPregnancy-related death The death of a woman while pregnant or within 42 The death of a woman while pregnant or within 42

days of termination of pregnancy, days of termination of pregnancy, irrespective irrespective of the of the cause of the death. cause of the death. Like maternal deaths, pregnancy-related deaths can Like maternal deaths, pregnancy-related deaths can

be associated with any pregnancy outcome, and be associated with any pregnancy outcome, and can occur at any gestational age.can occur at any gestational age.

The difference is that pregnancy-related deaths The difference is that pregnancy-related deaths include deaths from include deaths from all all including accidental and including accidental and incidental causes.incidental causes.

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MM…MM…

Late maternal deathLate maternal death The death of a woman from direct or indirect The death of a woman from direct or indirect

obstetric causes more than 42 days but less than one obstetric causes more than 42 days but less than one year after the termination of pregnancy. year after the termination of pregnancy.

Identifying late maternal deaths makes it possible Identifying late maternal deaths makes it possible to count deaths in which a woman had problems to count deaths in which a woman had problems that began during pregnancy, even if she survived that began during pregnancy, even if she survived for more than 42 days after its termination.for more than 42 days after its termination.

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MM…MM… Maternal mortality is series problem globally, Maternal mortality is series problem globally,

particularly in developing countries.particularly in developing countries. However it is the However it is the TIP OF THE ICEBERG

For every maternal death 16 – 100 maternal For every maternal death 16 – 100 maternal morbidity morbidity

¼ of all adult women in the developing world –¼ of all adult women in the developing world –suffer short/ long-term problemssuffer short/ long-term problems

Women’s lifetime risk of dying from pregnancyWomen’s lifetime risk of dying from pregnancy 1 in 16 – 20 pregnancies - in Africa1 in 16 – 20 pregnancies - in Africa 1 in 1400 pregnancies - in Europe1 in 1400 pregnancies - in Europe 1 in 3700 pregnancies - in North America1 in 3700 pregnancies - in North America

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Determinants of MMDeterminants of MM Proximal Factors (Medical causes)Proximal Factors (Medical causes)

Direct causesDirect causes Indirect causes Indirect causes

Intermediate Factors- contributingIntermediate Factors- contributing Poor access, poor quality of health Poor access, poor quality of health

services services Age at delivery, gravidity/parity (too Age at delivery, gravidity/parity (too

many, early and close preg.) many, early and close preg.) General health statusGeneral health status

Underlying Factors- basicUnderlying Factors- basic Poverty, poor infrastructure, women’s Poverty, poor infrastructure, women’s

status (decision making), poor educational status (decision making), poor educational status, Culture, Valuesstatus, Culture, Values

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Causes of MMCauses of MMMaternal mortality could result from Maternal mortality could result from

Direct or indirect causesDirect or indirect causes

DIRECT CAUSES (80%):DIRECT CAUSES (80%): Those resulting from:Those resulting from:

obstetric complications (pregnancy, labor, & obstetric complications (pregnancy, labor, & puerperium) puerperium)

interventions, omissions, incorrect interventions, omissions, incorrect treatment, ortreatment, or

a chain of events resulting from any of the a chain of events resulting from any of the above.above.

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Direct causesDirect causes

Hemorrhage (APH, PPH) -25%Hemorrhage (APH, PPH) -25% Sepsis- 15%Sepsis- 15% Unsafe abortion – 13%Unsafe abortion – 13% Hypertensive disorders of pregnancy Hypertensive disorders of pregnancy

(Preeclampsia, eclampsia) – 12%(Preeclampsia, eclampsia) – 12% Obstructed labour – Obstructed labour – 77%% Other direct – 8%Other direct – 8%

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Indirect causesIndirect causes

INDIRECT CAUSES (20%): INDIRECT CAUSES (20%): Those resulting from previous existing diseases Those resulting from previous existing diseases

or diseases that developed during pregnancy or diseases that developed during pregnancy and which is not due to direct obstetric causes and which is not due to direct obstetric causes but aggravated by but aggravated by physiologic effects physiologic effects of of pregnancy.pregnancy.

Existing cardiovascular diseases, Existing cardiovascular diseases, malaria, anemia etcmalaria, anemia etc

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Causes of MM EthiopiaCauses of MM Ethiopia

Sepsis12%

Hypertention9%

Obstructed labor22%

Abortion32%

Others15%

Haemorrhage10%

Source: MOH 2003

Millennium Development Goals Millennium Development Goals (MDGs, 2000)(MDGs, 2000)

Commitments made at ICPD and FWCWCommitments made at ICPD and FWCW Goal 1Goal 1: Eradicate extreme poverty and hunger;: Eradicate extreme poverty and hunger; Goal 2Goal 2; Achieve universal primary education;; Achieve universal primary education; Goal 3Goal 3: Promote gender equality and empower women;: Promote gender equality and empower women; Goal 4Goal 4: Reduce infant and child mortality rates by two-: Reduce infant and child mortality rates by two-

thirds by 2015;thirds by 2015; Goal 5: Goal 5: Improve maternal health – reduce MMR by 75% Improve maternal health – reduce MMR by 75%

by 2015by 2015;; Goal 6Goal 6: Combat HIV/AIDS and malaria;: Combat HIV/AIDS and malaria; Goal 7Goal 7: Ensuring Environmental sustainability: Ensuring Environmental sustainability Goal 8Goal 8: Develop a global partnership for development: Develop a global partnership for development

Causes of MMCauses of MM

The median time period between the onset of The median time period between the onset of complication to death of a mother is complication to death of a mother is too short too short for for some complicationssome complications

PPH = 2Hrs PPH = 2Hrs Ruptured uterus = 1 day Ruptured uterus = 1 day Eclampsia = 2 days Eclampsia = 2 days Obstructed labor = 3 daysObstructed labor = 3 days Puerperal sepsis = 6 daysPuerperal sepsis = 6 days Complicated abortion = 7 daysComplicated abortion = 7 days

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Roads to MMRoads to MM

THE THREE DELAYS MODELTHE THREE DELAYS MODEL

Maternal death results as a result of the Maternal death results as a result of the three delays.three delays.

Once the pregnancy occurred women Once the pregnancy occurred women experience the experience the classic three delaysclassic three delays

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Three delaysThree delays

First delay:First delay: delay in delay in deciding to seek caredeciding to seek care for an for an obstetric complication. obstetric complication.

The second delayThe second delay : d : delay to elay to go to health go to health facilityfacility after the decision has been made after the decision has been made to seek care.to seek care.

The third delayThe third delay : : delay in delay in obtaining careobtaining care once once present at the facility.present at the facility.

What causes The first delay?What causes The first delay? Lack of information and Lack of information and

inadequate knowledge inadequate knowledge about danger signals about danger signals during pregnancy and during pregnancy and laborlabor

Cultural /traditional Cultural /traditional practices that restrict practices that restrict women from seeking women from seeking health carehealth care

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Male Involvement is Key

What causes The second delay?What causes The second delay? This is a delay in This is a delay in

physically reaching the physically reaching the care facility/care facility/inability to inability to access health facilities:access health facilities:

Out of reach of health facilities Out of reach of health facilities Poor roads and communication Poor roads and communication

networknetwork Poor community support Poor community support

mechanismsmechanisms

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What causes What causes The third The third delay?delay? Is the delay in Is the delay in obtaining obtaining

carecare once present at the once present at the facility. facility.

women wait for many hours women wait for many hours at the referral centre because at the referral centre because ofof poor staffing, poor staffing, prepayment policies, or prepayment policies, or difficulties in obtaining difficulties in obtaining

blood supplies, equipment or blood supplies, equipment or an operating theatre.an operating theatre.

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How to avoid/reduce the three How to avoid/reduce the three delaysdelays

To avoid the first two delaysTo avoid the first two delayseducate and encourage communities to: educate and encourage communities to:

recognise complications recognise complications Know when and where to seek appropriate Know when and where to seek appropriate

carecare develop birth preparedness plan , develop birth preparedness plan ,

including emergency transportation including emergency transportation

improve transportation to a facility improve transportation to a facility offering a higheroffering a higher level of carelevel of care

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Avoid three delays…Avoid three delays…

To avoid the third delayTo avoid the third delay Improving quality of serviceImproving quality of service

Training and deployment of skilled Training and deployment of skilled

health professional to the health health professional to the health facilitiesfacilities

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Global situation in MMGlobal situation in MM According to (WHO, UNICEF 2010).According to (WHO, UNICEF 2010).

MDG5 target: to reduce by MDG5 target: to reduce by ¾ ¾ between 1990 & 2015 between 1990 & 2015 That is That is 5.5%5.5% annual decline. annual decline. 7 years progress only 7 years progress only 34%34% decline between 1990 and decline between 1990 and

2008 was achieved2008 was achieved 2.3%2.3% average annual decline average annual decline As a result, an estimated 358,000 maternal deaths in As a result, an estimated 358,000 maternal deaths in

2008 2008 MMR of MMR of 260260 per 100000 live births in 2008 as per 100000 live births in 2008 as

compared to compared to 400 400 per 100000 live births in 1990per 100000 live births in 1990

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Situations…Situations…

99% of these deaths occurred in developing 99% of these deaths occurred in developing countries countries

SSA & South Asia accounted for SSA & South Asia accounted for 87%87%

SSA:SSA: Highest MMR at Highest MMR at 640640 per 100000 live births per 100000 live births Annual decline of Annual decline of 1.7%1.7%

(WHO, UNICEF 2010).(WHO, UNICEF 2010).

04/10/2304/10/23 2525Source: (WHO, UNICEF, 2010)Source: (WHO, UNICEF, 2010)

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MM & MDGs in EthiopiaMM & MDGs in Ethiopia

MDG5: 3/4 reductionMDG5: 3/4 reduction EDHSEDHS

In 2000 around In 2000 around 871871 maternal deaths/100,000LBs maternal deaths/100,000LBs In 2005 around In 2005 around 673 673 maternal deaths/100,000LBsmaternal deaths/100,000LBs In 2011 around In 2011 around 676 676 maternal deaths/100,000LBsmaternal deaths/100,000LBs With this progress difficult to achieve MDG5.With this progress difficult to achieve MDG5.

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MDG – Reducing MMR by 75% by 2015MDG – Reducing MMR by 75% by 2015

0

250

500

750

1000

Year

Mat

erna

l dea

ths

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0,00

0 liv

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births

No change in maternal careImproved maternal care

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Reducing MM, past and presentReducing MM, past and present For many years, maternal mortality reduction For many years, maternal mortality reduction

programmes focused on two main components:programmes focused on two main components: ANC risk detection and ANC risk detection and Training of TBAs to attend low risk deliveryTraining of TBAs to attend low risk delivery

The intent of these programmes wasThe intent of these programmes was Complications are predictable andComplications are predictable and Low risk = TBAs/TTBAsLow risk = TBAs/TTBAs women with life-threatening complications women with life-threatening complications

would be transferred to a higher level of care in would be transferred to a higher level of care in a timely fashion. a timely fashion.

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Reducing MM, past and present…Reducing MM, past and present… Weakness of the past approach Weakness of the past approach

Countries with high rates of maternal mortality nearly always have a shortage Countries with high rates of maternal mortality nearly always have a shortage

of facilities offering EmOC/life saving care. of facilities offering EmOC/life saving care.

TBAs simply do not have the skills to recognize complications, even when TBAs simply do not have the skills to recognize complications, even when

trainedtrained

Early detection of complication needs skilled attendantEarly detection of complication needs skilled attendant

Complications are not predictableComplications are not predictable

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Reducing MM, past and Reducing MM, past and presentpresent……Present thinking Present thinking Maternal deaths /Major obstetric complications are not predictable (most Maternal deaths /Major obstetric complications are not predictable (most

complications occur complications occur ++ 24 hrs of labor) 24 hrs of labor)

Risk assessment has not worked –Risk assessment has not worked – Every pregnancy faces risk (20-30% of high risk develop complication and as well Every pregnancy faces risk (20-30% of high risk develop complication and as well

many of the low risk develop complication) many of the low risk develop complication)

Some obstetric complications are not predictable & preventableSome obstetric complications are not predictable & preventable

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Present thinking…Present thinking… The vast majority of maternal deaths are The vast majority of maternal deaths are

preventable by treatment (accesses EOC)preventable by treatment (accesses EOC)

Early detection of complication possible but Early detection of complication possible but needs skilled attendantneeds skilled attendant

Ensure a medically skilled attendant at every Ensure a medically skilled attendant at every birthbirth

Doubt on effectiveness of TBAS?Doubt on effectiveness of TBAS?

Goal directed ANC- put every pregnancy Goal directed ANC- put every pregnancy under riskunder risk

Reducing MM, past and present…Reducing MM, past and present…

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Much of the current thinking about maternal mortality Much of the current thinking about maternal mortality came fromcame from

A.A. Global experience:Global experience: observing countries that have been observing countries that have been

successful in dramatically reducing maternal successful in dramatically reducing maternal mortality mortality

B.B. Program evaluation and Research findings : Program evaluation and Research findings : the safe motherhood initiative 10 yeas the safe motherhood initiative 10 yeas

experience & othersexperience & others

Reducing MM, past and present…Reducing MM, past and present…

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Global experience…Global experience…

In Sweden, MMR declined from 567 to 227/100,000 LB In Sweden, MMR declined from 567 to 227/100,000 LB over three decades(1861 to 1894).over three decades(1861 to 1894). Due to:Due to:

Increased midwifery-assisted home birthsIncreased midwifery-assisted home births

(from 30% to 70%) and(from 30% to 70%) and Promotion of aseptic technique in hospital and Promotion of aseptic technique in hospital and

midwife-assisted homebirths.midwife-assisted homebirths.

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There was a drop of MM after World War II There was a drop of MM after World War II MMR reached between 250 - 400 in the MMR reached between 250 - 400 in the

late 19th centurylate 19th century This was a direct result of This was a direct result of

the introduction of antibiotics, the introduction of antibiotics, blood transfusions and blood transfusions and readily available Caesarean sectionsreadily available Caesarean sections. .

These interventions are effective in These interventions are effective in preventing most causes of maternal deaths: preventing most causes of maternal deaths: sepsis, haemorrhage, and obstructed labour.sepsis, haemorrhage, and obstructed labour.

Global experience..Global experience..

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Global experience..Global experience..

Currently the issue of MM is becoming evident Currently the issue of MM is becoming evident because of the following reasonsbecause of the following reasons

1.1. Establishment of national birth and Establishment of national birth and death registers that include the causes death registers that include the causes of death of death enabled monitoring of maternal mortality enabled monitoring of maternal mortality

trends and revealed the high toll of maternal trends and revealed the high toll of maternal deaths deaths

brought awareness of the problem andbrought awareness of the problem and increased political will and a swift legislative increased political will and a swift legislative

effort to improve access to skilled care at effort to improve access to skilled care at birth. birth.

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Global experience..Global experience..

2. Sustained Political Commitment2. Sustained Political Commitment improving improving accessaccess to the services & to the services & acceptability acceptability

3. Investments in primary education and 3. Investments in primary education and primary health careprimary health care

(accesses to maternal health care)(accesses to maternal health care)

4. Steady evolution in the health sector4. Steady evolution in the health sector midwives midwives (skilled attendant)(skilled attendant) replacing TBAs replacing TBAs

5. Every maternal death was reviewed5. Every maternal death was reviewed District MCH committees use adverse obstetrics events District MCH committees use adverse obstetrics events

to mobilize and educate communitiesto mobilize and educate communities Care systems placed joint responsibility on the district Care systems placed joint responsibility on the district

hospital and rural health service to prevent maternal hospital and rural health service to prevent maternal deathdeath

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Program evaluation and researchesProgram evaluation and researches

SAFE MOTHERHOOD INTIATIVE (NAIROBI 1987)SAFE MOTHERHOOD INTIATIVE (NAIROBI 1987)

Gave greater visibility to the hidden inequity of Gave greater visibility to the hidden inequity of maternal ill-health.maternal ill-health.

Comprehensive understanding of the roots and Comprehensive understanding of the roots and causes of the unacceptable toll of maternal causes of the unacceptable toll of maternal mortality in developing countries. mortality in developing countries.

Put maternal mortality at the forefront of Put maternal mortality at the forefront of international public health.international public health.

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Programs & approaches to reduce Programs & approaches to reduce maternal mortalitymaternal mortality

1.1. SAFE MOTHERHOOD INTIATIVE (SMI) 1987SAFE MOTHERHOOD INTIATIVE (SMI) 1987Strategies of SMIStrategies of SMI Risk assessment during pregnancy by a trained Risk assessment during pregnancy by a trained

non-physician non-physician Promote use of TBAs for low risk womenPromote use of TBAs for low risk women FP to avoid unwanted pregnancies and unsafe FP to avoid unwanted pregnancies and unsafe

abortionabortion Availability and access to first referral level Availability and access to first referral level

treatment for obstetric complicationstreatment for obstetric complications Improving the status of womenImproving the status of women Changing laws, attitudes, practices eg: early Changing laws, attitudes, practices eg: early

marriage, female genital mutilationmarriage, female genital mutilation Local data on maternal mortality neededLocal data on maternal mortality needed

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Programs & approaches…Programs & approaches… Lessons learned from SMI (first 10 yrs evaluation 1997)

Maternal deaths /Major obstetric complications are Maternal deaths /Major obstetric complications are not predictable not predictable

Risk assessment has not worked Risk assessment has not worked Some obstetric complications are not preventableSome obstetric complications are not preventable Early detection of complication possible but needs Early detection of complication possible but needs

skilled attendantskilled attendant Ensure a medically skilled attendant at every birthEnsure a medically skilled attendant at every birth The vast majority of maternal deaths are preventable The vast majority of maternal deaths are preventable

by treatment (accesses EOC)by treatment (accesses EOC) Measurement limitations for maternal mortality Measurement limitations for maternal mortality

(using MMR etc) was recognized – The use of process (using MMR etc) was recognized – The use of process indicators emphasized.indicators emphasized.

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Improve access to quality RH services (FP, goal Improve access to quality RH services (FP, goal oriented ANC, Essential obstetric care-EOC, etc )oriented ANC, Essential obstetric care-EOC, etc )

Every pregnancy faces risk-Ensure skilled Every pregnancy faces risk-Ensure skilled attendance at deliveryattendance at delivery

Prevent unwanted pregnancy and unsafe abortion Prevent unwanted pregnancy and unsafe abortion

Delay marriage and first birth Delay marriage and first birth

Action messagesAction messages

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Empower women, ensure choicesEmpower women, ensure choices

Advance safe motherhood through human rightsAdvance safe motherhood through human rights

Safe motherhood is a vital economic and social investment Safe motherhood is a vital economic and social investment advocacy and gov’t commitmentadvocacy and gov’t commitment

Measure progress with process indicators (MMR?)Measure progress with process indicators (MMR?)

Ensure the power of the relationship at national, international, Ensure the power of the relationship at national, international, & the community level& the community level

Action messages…Action messages…

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reallocating investment in health care to support the most cost-reallocating investment in health care to support the most cost-effective interventionseffective interventions

investing in maternal health care services and making them investing in maternal health care services and making them available, especially in poor and rural areasavailable, especially in poor and rural areas

strengthening the capacity of community health centers and strengthening the capacity of community health centers and district hospitals to provide needed care, especially for district hospitals to provide needed care, especially for obstetric complications, through staff training and provision of obstetric complications, through staff training and provision of equipmentequipment

Action messages…Action messages…

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working with private providers to expand and improve safe working with private providers to expand and improve safe motherhood servicesmotherhood services

encouraging for-profit providers to provide free or low cost encouraging for-profit providers to provide free or low cost care to those who can't afford to paycare to those who can't afford to pay

supporting NGOs and voluntary organizations that may be able supporting NGOs and voluntary organizations that may be able to mobilize private and community support for delivering to mobilize private and community support for delivering services to underserved or disadvantaged women.services to underserved or disadvantaged women.

Action messages…Action messages…

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2. WHO mother baby package2. WHO mother baby package PregnancyPregnancy DeliveryDelivery After deliveryAfter delivery

MothersMothers NewbornNewborn

3. UNFPA three pronged intervention3. UNFPA three pronged intervention Accesses Quality FPAccesses Quality FP Accesses EOCAccesses EOC Skilled attendant at every birthSkilled attendant at every birth

4. Millennium summit task force4. Millennium summit task force Every birth attended by a Every birth attended by a skilled health care professional skilled health care professional Every woman has access to Every woman has access to Emergency Obstetric Care Emergency Obstetric Care (EmOC)(EmOC) Referral system Referral system ensures women who need emergency care reach it in ensures women who need emergency care reach it in

timetime

Other Program approaches to reduce MM in Other Program approaches to reduce MM in addition to SMI addition to SMI

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Summary- Causes of Maternal deaths and Summary- Causes of Maternal deaths and proven interventionsproven interventions

Cause of maternal Cause of maternal deathdeath

%% Proven interventionsProven interventions

Bleeding after deliveryBleeding after delivery 2525 Treat anemia in pregnancy.Treat anemia in pregnancy.

Skilled attendant at birth: prevent or treat bleeding with Skilled attendant at birth: prevent or treat bleeding with correct drugs, replace fluid loss by intravenous drip or correct drugs, replace fluid loss by intravenous drip or transfusion if severe.transfusion if severe.

Infection after deliveryInfection after delivery 1515 Skilled attendant at birth: clean practices.Skilled attendant at birth: clean practices.

Treat with antibiotics if infection arises.Treat with antibiotics if infection arises.

Unsafe abortionUnsafe abortion 1313 Skilled attendant: give antibiotics, empty uterus, replace Skilled attendant: give antibiotics, empty uterus, replace fluids if needed, counsel and provide family planning.fluids if needed, counsel and provide family planning.

High blood pressure during High blood pressure during pregnancy, eclampsiapregnancy, eclampsia

1212 Detect, refer; Treat ecalmpsia with appropriate Detect, refer; Treat ecalmpsia with appropriate anticonvulsant (MgSo4) ; refer unconscious woman for anticonvulsant (MgSo4) ; refer unconscious woman for expert urgent deliveryexpert urgent delivery

Obstructed laborObstructed labor 77 Detect, refer urgently for operative deliveryDetect, refer urgently for operative delivery

Other causesOther causes 88 Refer ectopic pregnancy for operationRefer ectopic pregnancy for operation

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References References

WHO/UNICEF/UNFPA& the world bank (2010). Tr WHO/UNICEF/UNFPA& the world bank (2010). Tr Trends in Maternal Mortality: 1990 to 2008 Estimates developed by WHO, UNICEF, UNFPA and The World Bank

WHO/UNICEF/UNFPA& the world bank. Maternal mortality in 2000, Estimates WHO/UNICEF/UNFPA& the world bank. Maternal mortality in 2000, Estimates developed by WHO, UNICEF and UNFPA, 2007.developed by WHO, UNICEF and UNFPA, 2007.

WHO/UNICEF/UNFPA. Maternal mortality in 2000, Estimates developed by WHO, WHO/UNICEF/UNFPA. Maternal mortality in 2000, Estimates developed by WHO, UNICEF and UNFPA. Available at: UNICEF and UNFPA. Available at: http://www.alianzaipss.org/reproductive-health/publications/maternal_mortality_2000/challenge.pdf

World Health Organization. World Health Organization. International Statistical Classification of Diseases and Related International Statistical Classification of Diseases and Related Health Problems. Tenth RevisionHealth Problems. Tenth Revision. Geneva, World Health Organization, 1992.. Geneva, World Health Organization, 1992.

UNDG. UNDG. Indicators for monitoring the Millennium Development Goals: Definitions, Rationale, Indicators for monitoring the Millennium Development Goals: Definitions, Rationale, Concepts and sourcesConcepts and sources, United Nations: New York, 2003., United Nations: New York, 2003.

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Thank you!Thank you!