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PRESENTATION - 2

“Every Pregnancy Is at Risk:”

Current Approach to Reduction of Maternal and Neonatal Mortality By;Mignot Anley (DMRHospital)

PRESENTATION - 2 “Every Pregnancy Is at Risk:” Current Approach to Reduction of Maternal and Neonatal

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

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Current Approach to Reduction of Maternal and Neonatal Mortality

What Is Safe Motherhood?

What Is Safe Motherhood? “ A woman’s ability to have a SAFE and healthy pregnancy and

“ A woman’s ability to have a SAFE and healthy pregnancy and childbirth. ”

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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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Current Approach to Reduction of Maternal and Neonatal Mortality

Definitions; contd ..

  • Define:

    • Maternal Mortality Ratio:

    • Perinatal Mortality

    • Perinatal mortality Rate

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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

Maternal Mortality: A Global Tragedy  Annually, 287,000 women die of pregnancy related complications*  99%

* World Health Statistics 2010,

BEmONC LRP: Ethiopia

(WHO-2012 report).

Best Practices in Maternal and Newborn

Care

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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

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Current Approach to Reduction of Maternal and Neonatal Mortality

Maternal Death Watch (Global)

Every Minute ...

Of every day ...
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 pregnancy- related complication

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Current Approach to Reduction of Maternal and Neonatal Mortality

Ask group: What are the major

causes

mortality?

of maternal

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Current Approach to Reduction of Maternal and Neonatal Mortality

Causes of maternal deaths, global

Causes of maternal deaths, global *Nearly all (99%) abortion deaths are due to unsafe abortion. **This

*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.

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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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Current Approach to Reduction of Maternal and Neonatal Mortality

Maternal Mortality in Ethiopia; contd…

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

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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)

Maternal Mortality in Ethiopia; contd… Causes of maternal mortality in Ethiopia; ( Facility based study) BEmONC

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn Care

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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

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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

  • Of those who die in the first month

    • 2/3 die in the first week

  • Of those who die in the first week

    • 2/3 die in the first 24 hours

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Current Approach to Reduction of Maternal and Neonatal Mortality

Ask group: What are major causes of neonatal mortality?

Ask group: What are major causes of neonatal mortality? BEmONC – LRP: Ethiopia Best Practices in

BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn Care

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Current Approach to Reduction of Maternal and Neonatal Mortality

Causes of Newborn Death

Causes of Newborn Death BEmONC – LRP: Ethiopia Best Practices in Maternal and Newborn Care 17

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Current Approach to Reduction of Maternal and Neonatal Mortality

Ethiopia‘s 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,

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

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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

  • Delay in reaching care

    • Mountains, islands, rivers poor organization

    • Lack of transport

  • Delay in receiving care

    • Lack of triage system

    • Lack of supplies, personnel

    • Poorly trained personnel; poor attitudes

  • BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn Care

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    Current Approach to Reduction of Maternal and Neonatal Mortality

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

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

    BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn Care

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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

    Interventions to Reduce Maternal and Newborn Mortality Historical Review  Traditional birth attendants  Antenatal care

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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 appropriate treatment 25

    BEmONC LRP: Ethiopia

    The Crucial Facts  Major obstetric complications are not predictable  EVERY woman and newborn faces

    Best Practices in Maternal and Newborn Care

    Current Approach to Reduction of Maternal and Neonatal Mortality

    Interventions: Antenatal Care

    • Antenatal care clinics started in US, Australia, Scotland between 19101915

    • New concept - screening healthy women for signs of disease

    • By 1930‘s 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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    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

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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)

    WHO 1999.

    BEmONC LRP: Ethiopia

    Best Practices in Maternal and Newborn

    Care

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    Current Approach to Reduction of Maternal and Neonatal Mortality

    EmONC Signal Functions (2009)

    Basic EmONC

    Comprehensive EmONC

    1) Administer parenteral antibiotics

    Perform EmOC Signal functions 1-7, plus:

    2) Administer uterotonic drugs (e.g. parenteral oxytocin, misoprostol)

    8) Perform surgery (e.g. cesarean delivery)

    3) Administer parenteral

    9) Perform blood transfusion

    anticonvulsants (e.g. magnesium sulfate)

    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)

     

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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

    85% births attended by trained personnel Maternal Deaths per 100 000 livebirths
    85% births attended
    by trained personnel
    Maternal Deaths per 100 000
    livebirths

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    Current Approach to Reduction of

    Maternal and Neonatal Mortality

    Maternal Mortality: UK 18401960

    1840 1850 1860 1870
    1840
    1850
    1860
    1870
    Maternal Mortality: UK 1840 – 1960 1840 1850 1860 1870 Improvements in nutrition, sanitation BEmONC –

    Improvements in nutrition, sanitation

    BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn Care

    Antenatal care 33
    Antenatal
    care
    33

    Antibiotics, banked blood, surgical improvements

    Maine 1999.

    Current Approach to Reduction of Maternal and Neonatal Mortality

    The higher the proportion of deliveries attended by skilled

    provider, the lower the country’s maternal mortality ratio

    y = -578.45ln(x) + 2761.10 R² = 0.74 Y Log. (Y) % skilled attendant at delivery
    y = -578.45ln(x) + 2761.10
    R² = 0.74
    Y
    Log. (Y)
    % skilled attendant at delivery
    Maternal deaths per 1000000 live births

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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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    Current Approach to Reduction of Maternal and Neonatal Mortality

    Proven Interventions for Maternal Survival

    • Magnesium Sulfate

    • Nutrition

      • Calcium

    Proven Interventions for Maternal Survival  Magnesium Sulfate  Nutrition  Calcium Hypertensive Counseling  Iron

    Hypertensive

    Counseling

    • Iron Folate

    IPTp, Malaria Control

    Proven Interventions for Maternal Survival  Magnesium Sulfate  Nutrition  Calcium Hypertensive Counseling  Iron
    • Partogram

      • Cesarean

    Section

    Proven Interventions for Maternal Survival  Magnesium Sulfate  Nutrition  Calcium Hypertensive Counseling  Iron
    Proven Interventions for Maternal Survival  Magnesium Sulfate  Nutrition  Calcium Hypertensive Counseling  Iron

    Obstructed

    Anemia disorder  4% 9% 34% Other Causes 30%
    Anemia
    disorder
    4%
    9%
    34%
    Other Causes
    30%

    Labor

    4%

    • Clean Delivery

      • Antibiotics

        • Tetanus Toxoid

    Hemorrhage

    Proven Interventions for Maternal Survival  Magnesium Sulfate  Nutrition  Calcium Hypertensive Counseling  Iron
    Proven Interventions for Maternal Survival  Magnesium Sulfate  Nutrition  Calcium Hypertensive Counseling  Iron

    Sepsis

    16%

    Proven Interventions for Maternal Survival  Magnesium Sulfate  Nutrition  Calcium Hypertensive Counseling  Iron

    Unsafe

    Abortion

    4%

    • Active Management of the Third Stage of Labor

    • Misoprostol

    Proven Interventions for Maternal Survival  Magnesium Sulfate  Nutrition  Calcium Hypertensive Counseling  Iron
    • Family Planning

      • Postabortion Care

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

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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

    BEmONC LRP: Ethiopia Best Practices in Maternal and Newborn Care

    What do women want?  Clean facilities  Women friendly care – kindness, respect, information 
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    Current Approach to Reduction of Maternal and Neonatal Mortality

    Summary

    Summary Skilled attendant at childbirth is one of the most effective interventions to prevent maternal and

    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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    Current Approach to Reduction of Maternal and Neonatal Mortality