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

1
Every Pregnancy Is at RiskCurrent Approach to
Reduction of Maternal Mortality

• Advances in Maternal and Neonatal Health

2
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

3
What Is Safe Motherhood?
A womans ability to have a SAFE and healthy
pregnancy and childbirth.
4
Maternal Health Scope of Problem

• 180200 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

5
Neonatal Health Scope of Problem

• 3 million neonatal deaths (first week of life)
• 3 million stillbirths

6
Maternal Mortality A Global Tragedy

• Annually, 585,000 women die of pregnancy related
  complications
• 99 in developing world
• 1 in developed countries

7
Maternal Death Watch
Every Minute...

• 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

8
Global Causes of Maternal Mortality
9
But WHY Do These Women Die?
Three Delays Model

• 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

10
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

11
Interventions to Reduce Maternal Mortality

• Historical Review
• Traditional birth attendants
• Antenatal care
• Risk screening
• Current Approach
• Skilled attendant at delivery

12
Historical Review of Interventions

• The flawed assumption
• Most life-threatening obstetric complications can
  be predicted or prevented

13
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

14
Maternal Mortality ReductionSri Lanka 19401985

• 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

15
Maternal Mortality ReductionSri Lanka 19401985
85 births attended by trained personnel
16
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

17
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
• However, widely used as a maternal mortality
  reduction strategy in 1980s and early 1990s
• Is ANC important? YES!!
• Early detection of problems and birth preparation

18
Maternal Mortality UK 18401960
Improvements in nutrition, sanitation
Antibiotics, banked blood, surgical improvements
Antenatal care
Maine 1999.
19
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

20
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.
21
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)

22
The higher the proportion of deliveries attended
by skilled attendant in a country, the lower the
countrys maternal mortality ratio
Maternal deaths per 1000000 live births
skilled attendant at delivery
23
Summary

• Skilled attendant at childbirth is the most
  effective intervention

WHO 1999.
24
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.