Intro maternal mortality

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“Every Pregnancy Is at Risk:” Current Approach to Reduction of Maternal Mortality: 

“Every Pregnancy Is at Risk:” Current Approach to Reduction of Maternal Mortality Advances in Maternal and Neonatal Health

Session Objectives: 

Session Objectives To review: Magnitude of maternal and neonatal mortality Causes of maternal mortality Interventions to reduce maternal mortality Traditional birth attendant Antenatal care Risk screening Skilled attendant at childbirth

What Is Safe Motherhood?: 

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

Maternal Health: Scope of Problem: 

Maternal Health: Scope of Problem 180–200 million pregnancies per year 75 million unwanted pregnancies 50 million induced abortions 20 million unsafe abortions (same as above) 600,000 maternal deaths (1 per minute) 1 maternal death = 30 maternal morbidities

Neonatal Health: Scope of Problem: 

Neonatal Health: Scope of Problem 3 million neonatal deaths (first week of life) 3 million stillbirths

Maternal Mortality: A Global Tragedy: 

Maternal Mortality: A Global Tragedy Annually, 585,000 women die of pregnancy related complications 99% in developing world ~ 1% in developed countries

Maternal Death Watch: 

Every Minute... Maternal Death Watch 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 from a pregnancy-related complication

Global Causes of Maternal Mortality: 

Global Causes of Maternal Mortality

But WHY Do These Women Die?: 

But WHY Do These Women Die? 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 Delay in reaching care Mountains, islands, rivers — poor organization Delay in receiving care Supplies, personnel Poorly trained personnel with punitive attitude Finances Three Delays Model

Maternal Health Services: 

Maternal Health Services Good quality maternal health services are not universally available and accessible > 35% receive no antenatal care ~ 50% of deliveries unattended by skilled provider ~ 70% receive no postpartum care during 1st 6 weeks following delivery

Interventions to Reduce Maternal Mortality: 

Interventions to Reduce Maternal Mortality Historical Review Traditional birth attendants Antenatal care Risk screening Current Approach Skilled attendant at delivery

Historical Review of Interventions: 

Historical Review of Interventions The flawed assumption: Most life-threatening obstetric complications can be predicted or prevented

Interventions: Traditional Birth Attendants: 

Interventions: Traditional Birth Attendants Advantages Community-based Sought out by women Low tech Teaches clean delivery Disadvantages Technical skills limited May keep women away from life-saving interventions due to false reassurance

Maternal Mortality Reduction Sri Lanka 1940–1985: 

Maternal Mortality Reduction Sri Lanka 1940–1985 Health system improvements: Introduction of system of health facilities Expansion of midwifery skills Decreased use of home delivery and delivery by untrained birth attendants Spread of family planning

Maternal Mortality Reduction Sri Lanka 1940–1985: 

Maternal Mortality Reduction Sri Lanka 1940–1985 85% births attended by trained personnel

Interventions: Traditional Birth Attendants: 

Interventions: Traditional Birth Attendants Conclusion: TBAs are useful in the maternal health network, but there will not be a substantial reduction in maternal mortality by TBAs delivering clinical services alone

Interventions: Antenatal Care: 

Interventions: Antenatal Care Antenatal care clinics started in US, Australia, Scotland between 1910–1915 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 However, widely used as a maternal mortality reduction strategy in 1980’s and early 1990’s Is ANC important? YES!! Early detection of problems and birth preparation

Maternal Mortality: UK 1840–1960: 

Maternal Mortality: UK 1840–1960 Improvements in nutrition, sanitation Antibiotics, banked blood, surgical improvements Antenatal care Maine 1999.

Interventions: Risk Screening : 

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

Interventions: Skilled Attendant at Childbirth: 

Interventions: Skilled Attendant at Childbirth Proper training, range of skills Assess risk factors Recognize onset of complications Observe woman, monitor fetus/infant Perform essential basic interventions Refer mother/baby to higher level of care if complications arise requiring interventions outside realm of competence Have patience and empathy WHO 1999.

Interventions: Skilled Attendant at Childbirth: 

Interventions: Skilled Attendant at Childbirth Proven effective Malaysia: basic maternity services 320  157 Cuba: national priority 118  31 China: facility based childbirth 1500  50 Malaysia vs. Indonesia: Trained community midwives (2 years) vs. untrained midwives (4 years)


The higher the proportion of deliveries attended by skilled attendant in a country, the lower the country’s maternal mortality ratio % skilled attendant at delivery Maternal deaths per 1000000 live births


Summary Skilled attendant at childbirth is the most effective intervention WHO 1999.


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. World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: Geneva.

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