PRESENTATION - 2

Every Pregnancy Is at Risk: Current Approach to Reduction of Maternal and Neonatal Mortality By;Mignot Anley (DMRHospital)
Federal Democratic Republic of Ethiopia Ministry of Health

BEmONC LRP ETHIOPIA

Best Practices in Maternal and Newborn Care

Session Objectives

By the end of this session participants will be able to:

Recognize the situation of maternal and neonatal mortality & morbidity globally and in our country specifically. Describe factors affecting maternal and perinatal mortality and morbidity. Review historical and current interventions to reduce maternal and neonatal mortality

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

What Is Safe Motherhood?

A womans ability to have a SAFE and healthy pregnancy and childbirth.

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn
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Current Approach to Reduction of Maternal and Neonatal Mortality

Definitions

Maternal Mortality = is defined as 'the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Can be Direct or Indirect Maternal Deaths
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BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Definitions; contd..

Define:

Maternal Mortality Ratio:

Perinatal Mortality

Perinatal mortality Rate

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Maternal Mortality: A Global Tragedy

Annually, 287,000 women die of pregnancy related complications*

99% in developing world ~ 1% in developed countries Many millions more suffer complications e.g. obstetric fistulae, secondary infertility
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* World HealthBEmONC Statistics 2010, LRP: Ethiopia

(WHO-2012 . Best Practicesreport) in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Maternal Mortality trends

Globally, the total number of maternal deaths decreased from 543 000 in 1990 to 287 000 in 2010. Likewise, the global maternal mortality ratio (MMR) declined from 400 maternal deaths per 100 000 live births in 1990 to 210 in 2010

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Maternal Death Watch (Global)

Every Minute...

Of every day...

380 women become pregnant 190 women face unplanned or unwanted pregnancy 110 women experience a pregnancy related complication 40 women have an unsafe abortion 1 woman dies every two minutes from a pregnancyrelated complication
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BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Ask group: What are the major causes of maternal mortality?

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Causes of maternal deaths, global

*Nearly all (99%) abortion deaths are due to unsafe abortion. **This category includes deaths due to obstructed labor or anaemia. Other direct causes include embolism, ectopic pregnancy, anesthesia-related. Indirect causes include: malaria, heart disease.
Source: WHO 2010. BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn
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Current Approach to Reduction of Maternal and Neonatal Mortality

Maternal Mortality in Ethiopia

Out of estimated 2,924,225 pregnancies in 2003E.C, only 16.6% attended by a skilled health provider. (Health and Health Related Indicators
EFY,2003)

Maternal mortality ratio decreased from 871/100 000 live births in 2011 to 676/100 000 live births in 2011 (DHS-2011), Our country is one of the six countries in 2008 which contribute more than 50% of all maternal deaths. (THE LANCET on 12 April 2010)
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BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Maternal Mortality in Ethiopia; contd

EDHS EDHS EDHS 2000 EDHS2005 2011, TT2+ 2011, ANC, ,PW/PAB, TT2+ EDHS2005 EDHS 34 EDHS2005 PW/PAB, 48 2000, ANC, EDHS 2011 EDHS EDHS 28 , ANC, 28 2000, TT2+ 27 EDHS 2011, PW/PAB, Delivery at 2000, EDHS2005 17 health , Delivery Delivery at facility , 10 health at health facility facility ,5 ,5

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

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Current Approach to Reduction of Maternal and Neonatal Mortality

Maternal Mortality in Ethiopia; contd

Causes of maternal mortality in Ethiopia; (Facility based study)

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

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Current Approach to Reduction of Maternal and Neonatal Mortality

Neonatal Health: Scope of Problem

Newborn health and survival are closely linked to care the mother receives before and during pregnancy, childbirth, and the postnatal period.

Every year:
4 million neonatal deaths (first month of life) 4 million stillbirths Eight neonatal deaths every minute

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

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Current Approach to Reduction of Maternal and Neonatal Mortality

Two-thirds Rule Global Infant Mortality Rates

More than 7 million infants die annually between birth and 12 months of age Of those who die in the first year

Nearly 2/3 die in the first month

2/3 die in the first week 2/3 die in the first 24 hours
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Of those who die in the first month

Of those who die in the first week

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Ask group: What are major causes of neonatal mortality?

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

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Current Approach to Reduction of Maternal and Neonatal Mortality

Causes of Newborn Death

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Current Approach to Reduction of Maternal and Neonatal Mortality

Ethiopias Neonatal Health status

Neonatal mortality is 37 per1,000 live births (DHS 2011). 50 percent of infant deaths in Ethiopia occur during the first month of life. One in every 17 Ethiopian children dies before reaching age one,

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

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Current Approach to Reduction of Maternal and Neonatal Mortality

Child Mortality Rate trends in Ethiopia: NMR, IMR and U5MR

EDHS 2000, EDHS2005, underfive underfive moratlity rate, moratlity rate, EDHS 2000, 166 EDHS 2011, EDHS 123 Infant EDHS2005, 2000 underfive Mortality rate, moratlity rate, EDHS2005 97 Infant EDHS 2011, Mortality rate, 88 EDHS 2000, Infant 77 EDHS2005, EDHS EDHS 2011, Neonatal Mortality rate, 2011 Neonatal Neonatal Mortality rate, 59 Mortality rate, rate, 49 Mortality 39 37

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

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Current Approach to Reduction of Maternal and Neonatal Mortality

But WHY Do These Women and Newborns Die?

Three Delays Model

Delay in decision to seek care

Lack of understanding of complications Acceptance of maternal and newborn death Low status of women Socio-cultural barriers to seeking care
Mountains, islands, rivers poor organization Lack of transport Lack of triage system Lack of supplies, personnel Poorly trained personnel; poor attitudes
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Delay in reaching care

Delay in receiving care

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Ask group: What are some interventions that have not proved successful in reducing mortality?

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

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Current Approach to Reduction of Maternal and Neonatal Mortality

Interventions to Reduce Maternal and Newborn Mortality

Historical Review

Traditional birth attendants Antenatal care

Risk screening

Current Approach

Skilled attendant at delivery

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

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Current Approach to Reduction of Maternal and Neonatal Mortality

Historical Review of Interventions The flawed assumption:

Most life-threatening obstetric

and newborn complications

can be predicted or prevented

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Current Approach to Reduction of Maternal and Neonatal Mortality

The Crucial Facts

Major obstetric complications are not predictable

EVERY woman and newborn faces risk Maternal deaths are not predictable

Most maternal deaths occur during labour, delivery or the first 24 hours postpartum When problems are managed in a timely and effective manner, mothers and babies lives are saved
Providers and the facility must be prepared to address emergencies at all times 80% of maternal deaths are preventable by BEmONC LRP: Ethiopia Current Approach to Reduction of appropriate treatment 25

Maternal and Neonatal Mortality

Best Practices in Maternal and Newborn

Interventions: Antenatal Care

Antenatal care clinics started in US, Australia, Scotland between 19101915 New concept - screening healthy women for signs of disease By 1930s large number (1200) ANC clinics opened in UK No reduction in maternal mortality Is ANC important? YES!! Focused, individualized care leads to early detection of problems and birth preparation
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BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Interventions: Risk Screening

Disadvantages Very-poorly predictive Costly: Removes woman to maternity waiting homes If risk-negative, gives false security Conclusion: Cannot identify those at risk of maternal mortality

Every pregnancy is at risk

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn
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Current Approach to Reduction of Maternal and Neonatal Mortality

What are the key interventions to reduce maternal and neonatal mortality?

Access to family planning, Skilled attendants during pregnancy and childbirth Access to emergency obstetric and newborn care (EmONC),
Effective referral system Fully functioning health services 24/7

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Current Approach to Reduction of Maternal and Neonatal Mortality

Most important intervention: Skilled Attendant at Childbirth

A skilled health provider is: an accredited health professional midwife, doctor or nurse who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postpartum period and in the identification, management and referral of complications in women and newborns (WHO, ICM & FIGO 2004)
BEmONC LRP: Ethiopia WHO 1999. Best Practices in Maternal and Newborn
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Current Approach to Reduction of Maternal and Neonatal Mortality

EmONC Signal Functions (2009)

Basic EmONC
1) Administer parenteral antibiotics 2) Administer uterotonic drugs (e.g. parenteral oxytocin, misoprostol)

Comprehensive EmONC
Perform EmOC Signal functions 1-7, plus: 8) Perform surgery (e.g. cesarean delivery)

3) Administer parenteral anticonvulsants (e.g. magnesium sulfate)

9) Perform blood transfusion

4) Perform manual removal of placenta 10) Provision of emergency obstetric anaesthesia 5) Perform removal of retained products (e.g. MVA) 6) Perform assisted vaginal delivery (e.g. vacuum extraction) 7) Perform neonatal resuscitation (e.g. with bag and mask)
BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn
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Current Approach to Reduction of Maternal and Neonatal Mortality

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Interventions: Skilled Attendant at Childbirth

Interventions proven effective resulting in decreased maternal mortality rates (MMR):

Malaysia: basic maternity services; MMR decreased from 320 to 157 Cuba: national priority; MMR decreased from 118 to 31 China: facility based childbirth; MMR decreased from 1500 to 50

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Current Approach to Reduction of Maternal and Neonatal Mortality

Maternal Mortality Reduction Sri Lanka 19401985

Maternal Deaths per 100 000 livebirths

85% births attended by trained personnel

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of 32 Maternal and Neonatal Mortality

Maternal Mortality: UK 18401960

1840 1850 1860 1870

Improvements in nutrition, sanitation

Antenatal care
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Antibiotics, banked blood, surgical improvements

Maine 1999. Current Approach to Reduction of Maternal and Neonatal Mortality

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

The higher the proportion of deliveries attended by skilled provider, the lower the countrys maternal mortality ratio
Maternal deaths per 1000000 live births
y = -578.45ln(x) + 2761.10 R = 0.74
Y Log. (Y)

% skilled attendant at delivery

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Current Approach to Reduction of Maternal and Neonatal Mortality

Evidence based care

For years, much of basic and emergency obstetric and newborn care was provided according to tradition and routine practice rather than according to evidence. To be effective, care should be evidence-based. We have better understanding of emergency obstetric care (EmOC) and best practices in labour and delivery and Enhanced appreciation of the role that community mobilization, birth preparedness, and a continuum of care make
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BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Proven Interventions for Maternal Survival

Magnesium Sulfate Calcium

Hypertensive disorder 9% Anemia 4%

Partogram Cesarean Section

Nutrition Counseling Iron Folate IPTp, Malaria Control

Clean Delivery Antibiotics Tetanus Toxoid

Obstructed Labor 4%

Hemorrhage 34%

Sepsis 16% Unsafe Abortion 4%

Other Causes 30%

Family Planning Postabortion Care

Source: WHO Analysis of causes of maternal deaths: A systematic review. The Lancet, Vol 367, April 1, 2006.

Active Management of the Third Stage of Labor Misoprostol

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

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Current Approach to Reduction of Maternal and Neonatal Mortality

What do women want?

Clean facilities Women friendly care kindness, respect, information Availability of drugs and medical equipment Culturally appropriate services
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BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn

Current Approach to Reduction of Maternal and Neonatal Mortality

Summary
Skilled attendant at childbirth is one of the most effective interventions to prevent maternal and perinatal mortality and morbidity
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Current Approach to Reduction of Maternal and Neonatal Mortality

References
Maine D. 1999. What's So Special about Maternal Mortality?, in Safe Motherhood Initiatives: Critical Issues. Berer M et al (eds). Blackwell Science Limited: London. Lancet Maternal Survival Series, September 28, 2006 at www.thelancet.com World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: Geneva. WHO Analysis of causes of maternal deaths: A systematic review. The Lancet, vol 367, April 1, 2006.

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