Download - P -2- Current Aproaches -2013
Federal Democratic Republic of Ethiopia Ministry of Health
BEmONC – LRPETHIOPIA Best Practices in Maternal and Newborn Care
“Every Pregnancy Is at Risk:”Current Approach to
Reduction of Maternal and Neonatal Mortality By;Mignot
Anley (DMRHospital)
PRESENTATION - 2
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
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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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
What Is Safe Motherhood?
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“ A woman’s ability to have a SAFE and healthy pregnancy and childbirth. ”
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Definitions; contd..
Define:
Maternal Mortality Ratio:
Perinatal Mortality
Perinatal mortality Rate
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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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
* World Health Statistics 2010, (WHO-2012 report).
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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Maternal Death Watch(Global)
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 complication8
Every Minute...
Of every day...
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Ask group: What are the major causes of maternal mortality?
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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
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*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.
Causes of maternal deaths, global
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Maternal Mortality in Ethiopia; contd…
Delivery at health facility
ANC TT2+ PW/PAB0
5
10
15
20
25
30
35
40
45
50
5
27
17
5
28 28
10
34
48EDHS 2000
EDHS2005
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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Maternal Mortality in Ethiopia; contd…
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Causes of maternal mortality in Ethiopia; (Facility based study)
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Two-thirds RuleGlobal 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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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Ask group: What are major causes of neonatal mortality?
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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Causes of Newborn Death
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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Child Mortality Rate trends in Ethiopia:
NMR, IMR and U5MR
Neonatal Mortality
rate
Infant Mortality
rate
underfive moratlity
rate
0
20
40
60
80
100
120
140
160
180
49
97
166
39
77
123
37
59
88EDHS 2000
EDHS2005
EDHS 2011
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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
But WHY Do These Women and Newborns Die?
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
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Three Delays Model
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Ask group: What are some interventions that have not proved successful in reducing
mortality?
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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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
delivery23
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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 treatment25
BEmONC – LRP: EthiopiaBest 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 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 Is ANC important? YES!!
Focused, individualized care leads to early detection of problems and birth preparation
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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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)
29WHO 1999.
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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 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) 3030
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
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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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Maternal Mortality ReductionSri Lanka 1940–1985
1940–45 1950–55 1960–65 1970–75 1980–850
200
400
600
800
1000
1200
1400
1600
1800M
ate
rna
l D
ea
ths
pe
r 1
00
00
0
liv
eb
irth
s
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85% births attended by trained personnel
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Maternal Mortality: UK 1840–1960
1840
1850
1860
1870
1880
1890
1900
1910
1920
1930
1940
1950
1960
050
100150200250300350400450500
Maternal Deaths
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Improvements in nutrition, sanitation Antibiotics, banked blood,
surgical improvementsAntenatal care
Maine 1999.
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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
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0 10 20 30 40 50 60 70 80 90 1000
200
400
600
800
1000
1200
1400
1600
1800
2000R² = 0.73598151462267
Y Logarithmic (Y)
% skilled attendant at delivery
Mat
erna
l dea
ths
per
1000
000
live
birt
hs
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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 make35
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
Current Approach to Reduction of Maternal and Neonatal Mortality
Proven Interventions for Maternal Survival
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Source: WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, Vol 367, April 1, 2006.
Anemia4%
Hemorrhage 34%
Other Causes30%
Unsafe Abortion
4%
Sepsis 16%
Obstructed Labor
4%
Hypertensive disorder
9%
Active Management of the Third
Stage of Labor
Misoprostol
Magnesium Sulfate
Calcium
Clean Delivery
Antibiotics Tetanus
Toxoid
Nutrition Counseling
Iron Folate IPTp, Malaria
Control
Partogram Cesarean
Section
Family Planning
Postabortion Care
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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 37
BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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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BEmONC – LRP: EthiopiaBest Practices in Maternal and
Newborn Care
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.comWorld 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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