Barbara Deller, CNM, MPH Mary Ellen Stanton, CNM. MSN,
FACNM
October 27, 2006
Saving Mothers: Evidence and Issues
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Purpose of this Session
Take a look at….
• Progress towards maternal survival
• New Evidence
• Issue & Discussion
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The Lifetime Risk of Maternal Death in some places in the world it is staggering
1:94
1:16
1:2,800
1:160
Source: WHO, UNICEF and UNFPA. Maternal Mortality in 2000; Lancet Neonatal Survival Series, 2005
The chance of a woman dying as a result of pregnancy is 150 x greater in sub-Saharan Africa than it is in the United States
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Have we made progress?
MDG 5 Target
Reducing Maternal Mortality: Getting on with What Works,
US Launch of The Lancet Maternal Survival Series, Ronsmans and Koblinsky, Oct 5, 2006
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Recent Successes in Maternal Mortality Reduction
0
100
200
300
400
500
600
700
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
Ma
tern
al M
ort
alit
y R
ati
o
(Ma
tern
al D
ea
ths
pe
r 1
00
,00
0 L
ive
Bir
ths
)
Morocco36% decline
Egypt52% decline
Bangladesh34% decline
Sources: Morocco: DHS 1992; Bangladesh: National Institute of Population Research and Training 2002; Bolivia DHS 1994, DHS 2003. Egypt: DHS 2000. Egypt Ministry of Health and Population; Indonesia: DHS 1994, DHS 2002; Guatemala: Duarte et al. 2003; Kenya DHS 1998, DHS 2003; Senegal DHS 1992, DHS 2005.
Data point plotted is midpoint of date range.
Indonesia21% decline
Bolivia45% decline
Guatemala30% decline
Kenya30% decline
Senegal28% decline
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Progress in reducing maternal mortality
• Globally1
– essentially no change via estimates since 1990– > 500,000 deaths annually– MMR 400/100,000 live births (US 17)– 2005 estimates not yet available
• In specific countries2 – Wide variability– Other surveys show good progress in some
countries– Overall lack of progress in sub-Saharan Africa
Source: 1 WHO Maternal Mortality in 200: Estimates Developed by WHO, UNICEF, UNFPA 2 Demographic and Health Surveys, Macro Int.
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The Poor Are Hardest Hit
Source: C Ronsmans and Koblinsky, presentation at US Launch of The Lancet’s Maternal Survival Series, 5 Oct 06, Washington, DC
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100
200
300
400
500
600
700
800
900
Tanzania 1996 Indonesia 2002 Peru 2000
Mate
rnal m
ort
alit
y r
atio
Poorest 20% Richest 20%
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Leading Causes of Maternal Death
Cause of death Developed countries
Africa Asia Latin America/ Caribbean
Hemorrhage 13% 34% 31% 21%
Hypertensive disorders
16% 9% 9% 26%
Sepsis/infections
2% 10% 12% 8%
Abortion 8% 4% 8% 12%
Obstructed labor
0% 4% 9% 13%
Anemia 0% 4% 13% 0%
HIV/AIDS 0% 6% 0% 0%Source: Khan et al, WHO analysis of causes of maternal death: a systematic review, The Lancet, March 28, 2006 -- % rounded; not included on this table: ectopic pregnancy, embolism, other direct causes, other indirect causes, unclassified deaths
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Because Maternal Mortality is “relatively rare,”
Severe acute maternal morbidity (SAMM)
may be important in measuring progress• SAMM—”near miss”--“A very ill pregnant or
recently delivered woman who would have died had it not been that luck and good care was on her side” — differs from complications
• Systematic review -- 30 reports --prevalence– Disease-specific (e.g. eclampsia) 0.80% - 8.23%– Management specific (e.g. hysterectomy) 0.01%-2.99%– Organ system dysfunction/failure—0.38%-1.09%
• Inverse trend in prevalence with development status of the country
• Need better definitions before uptakeSource: reported in Say, WHO systematic review of maternal morbidity and mortality, Reproductive Health, 2004
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WHO Global Survey, 2005 -- Latin America
Caesarean Rates and Pregnancy Outcomes
• Median C/S rate 33%, 51% in private hospitals• C/S rate was positively associated with
– Increase in a severe maternal morbidity and mortality (index)
– Postnatal tx with antibiotics– Fetal death and neonatal mortality and morbidity– C/S did not improve perinatal outcomes
• Preterm delivery rates and neonatal mortality rose at rates of C/S between 10 and 20%
• Limitations included: – 3 of 11 countries (Haiti, USA, Paraguay) and 3 selected
institutions originally selected did not participate– Limited standardization of diagnoses
Source: Villar, et al. Caesarean delivery rates and pregnancy outcomes: 2005 Global Survey…in Latin America, 2006.
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CHALLENGE
We do know a lot about what interventions
workbut. . . we still face
manyissues in programmingto bring life-savinginterventions tochildbearing women toreduce maternalmortality
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In the developing world where 50% of births occur in home. . .
. . . what strategy should we invest in for maximum reduction in maternal mortality?
• Bring skilled care to mothers at home• Bring misoprostol (and other
evidence-based home care) to homes where there is no skilled care
• Bring mothers to skilled care
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Skilled care at home
• Women’s choice
• Success in UK, Denmark, Malaysia
• Inefficient
• Requires links to EmOC
• Quality uncertain/supervision difficult
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Effective interventions at home without SBA
• Evidence of some effective interventions related to significant maternal complications that don’t require SBA (Lancet does not agree)– Oral misoprostol– Iron supplementation
• TBA meta analysis did not show effectiveness in reducing maternal mortality
• If trained de novo—huge investment
• Supervision and logistics difficult
Lancet advocates pragmatism
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Oral misoprostolRural India, 2006
• 1620 women, placebo-controlled trial• Misoprostol: oral, stable, positive safety
profile—can be used in the absence of a skilled birth attendant
• Misoprostol associated with– Reduction in PPH (12% to 6.4%; p<0.0001)– Reduction in acute severe PPH (1.2% to 0.2%;
p<0.0001)– Decrease in mean PP blood loss (262.3 to 214.3ml;
p<0.0001)– Transitory chills and fever
Source: Derman, et al, Oral misoprostol in preventing postpartum hemorrhage in resource-poor communities: A randomized controlled trial, The Lancet, Oct. 7, 2006.
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SBA at the facility(includes EmOC or link)
• Can maintain normality (vs hospital)
• Can provide robust interventions
• Promotes 24/7• Scale-up team
model can be 10x solo practitioners
• No RCTs• Does not ensure
quality—studies document– Negligence– Iatrogenic
complications– Abuse
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Strategy Proposed in The Lancet:Team of skilled birth attendants in health
center
• Care during delivery is the priority
• All women should be able to deliver in health centres, with midwives working in teams
• Target the women in greatest need: poor and rural women in sub-Saharan Africa and South Asia
Reducing Maternal Mortality: Getting on with What Works, US Launch of The Lancet Maternal Survival Series, Ronsmans and Koblinsky, Oct 5, 2006
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Considerations• Design programming approach based upon MMR, cause of
death, current availability and cadres of providers
• Can chose more than one approach—keeping in mind that everything costs
• Plan for scale to achieve public health impact
• Phasing strategies
• Different approaches with massive deprivation and marginal exclusion
• Lancet: Need a new era of strategic thinking to address stagnation:
Vision Funds Human resources Track progress
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Our Pearls
• The chance of a woman dying as a result of pregnancy is 150 times greater in Sub-Saharan Africa than in the U.S. This is the health indicator with the greatest disparity between the developed and the developing work.
• Postpartum hemorrhage (PPH) is, by far, the biggest maternal killed, responsible for greater than 30% of maternal deaths in Asia and Africa. PPH is preventable.