Overview: Maternal and Child Health in Underdeveloped

Countries

or: The World is Not Flat

HSERV/GH 544Winter Term 2011

Objectives of session

• Provide an overview of main health problems of women, newborns, and children in underdeveloped countries, including the underlying inequalities

• Present the main interventions that address those problems

• Present some challenges in promoting maternal and newborn health in resource-poor settings, with examples from Nepal

Terms used in global MCHDefinitions:IMR= Infant mortality rate (deaths 0-11 months/1000 live births)

MMR= Maternal mortality ratio (pregnancy-related deaths per 100,000 births)

LTR=Lifetime risk of dying of a pregnancy-related cause (expressed as a ratio of 1:x women of childbearing age)

TFR=Total fertility rate (expected pregnancies per woman CBA)

CPR=Contraceptive prevalence rate (proportion of couples in union using a modern contraceptive method)

ANC=Antenatal care (variously defined)

SBA=Skilled Birth Attendant (doctor, nurse or midwife)

PC/GNI=Per capita gross national product

Some inequalities in global health:

MMR LTR PC/GNIItaly 3 26,600 32,020United States 11 4800 44,970 Thailand 44 900 2990Ecuador 210 170 2840India 450 70 820Mozambique 520 45 290Timor-Leste 380 35 840 Nepal 830 31 260

Source: State of the World’s Children 2008, UNICEF

Why such economic inequities?

• Post-colonial legacy

• Current economic system -- e.g. national debt, international bank policies (“conditionalities”), terms of trade, etc.

• “Aid” focus on technological solutions, specific diseases

Maternal Health Problems

• ~200 million pregnancies per year

• ~75 million unwanted pregnancies

• ~20 million unsafe abortions• ~350,000 maternal deaths (1-2

per minute)• 1 maternal death = 30

maternal morbidities

*other direct causes include ectopic pregnancy, embolism, anaesthesia-related** indirect causes include: anaemia, malaria, heart disease, HIV/AIDS.

What are the medical causes of maternal deaths?

Where do the maternal deaths occur?

http://www.gapminder.org/(50% of all deaths in 2008 were in only 6 countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo).

Skilled Care at Delivery and Maternal Deaths:

66

39

35

67

84

92

190

220

560

940

110

64Percent of births assisted by skilled attendants, 1995-2000

Number of maternal deaths per 100,000 live births, 2000

Sub-Saharan Africa

South Asia

East Asiaand Pacific

Middle East andNorth Africa

Latin America/Caribbean

Central, EasternEurope/ Baltics/ CIS*

* Commonwealth of Independent States (former Soviet Union). Source: UNICEF End of Decade Databases—Delivery Care and Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF, and UNFPA, 2004.

Remember equity….?

From: A global picture of poor-rich differences in the utilisation of delivery care, Anton Kunst and Tanja Houweling, Health Services Organization and Policy, 17, 2001

Why do so many women lack skilled birth care?

1. 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

2. Delay in reaching care– Geography (mountains, islands, rivers) – no realistic access– Poor transport & organization

3. Delay in receiving quality care– Shortages of supplies, personnel, transport to higher facility– Poorly trained personnel with punitive attitude– Finances

Current approaches to reducing maternal mortality

• Antenatal care

• Improving skills of birth attendants– Traditional birth attendants (TBAs)– Skilled professional attendant at delivery

(SBAs)

• Emergency Obstetric Care (EmOC)

• Postpartum care

• Family planning

Child Health Problems

Status of child health today

• ~8 million children under 5 die every year

• ~22,000 will die today – equivalent to a tsunami every week– Over one-third of these deaths are to newborns

• More than half of these deaths are preventable and/or treatable with relatively simple measures

Causes of Mortality among Preschool Children

23%

18%

15%

10%

5%

25%

4%

23%

18%

15%

10%

5%

25%

4%

Deaths associated with malnutrition ~50%

Other

HIV/AIDS

Measles

Malaria

Diarrhea

Acute Respiratory

Infection

Perinatal

Source: WHO (2003)

How effective are global child health programs?

• At least a quarter of children are not routinely immunized

• Almost half do not have access to antibiotics to treat pneumonia

• Nearly two-thirds do not receive oral rehydration solution to treat diarrhea

• 90% do not sleep under insecticide-treated nets to prevent malaria

Fall in the standardized death rate per 100,000 population for nine common

infectious diseases in relation to specific medical measures for the United States, 1900-1973 (Source: McKinlay , J. B., & McKinlay, S. M. (1977). The questionable contribution of medical measures to the decline of mortality in the United States in the twentieth century. Milbank Memorial Fund Quarterly. Health and Society, 55 (3), 405-428.)

But remember -- technology is not the only answer….

Source: www.childinfo.org

Health of Newborns

Health risks in the newborn:

Where are newborns dying?

http://www.gapminder.org

Causes of newborn deaths

SEPSIS (septicemia, pneumonia, meningitis, diarrhea)

52%ASPHYXIA

20%

PREMATURITY

15%

Other13%

(Bang AT, Lancet 1999;354:1955-61))

In summary:

• Maternal health problems are often not predictable, may require relatively sophisticated medical interventions

• Most common child health problems can be dealt with at the community level

• Newborn health problems require a mixture of the two approaches