Maternal health challenges

& successes: an overview

focussing on low-income

settings

Oona Campbell

9 March 2012

Improving health worldwide

www.lshtm.ac.uk

High maternal mortality historically, for

UK & rich

Year Population

MMR

1500-1750

European

nobility ~2000

1930-32

E&W Social

Class I&II 444

E&W Social

Class IV 389

2008

Afghanistan 1400

Swaziland 420

UK 12

Pictures of Monument to Princess Charlotte died 1817 St.

George’s Chapel, Windsor Castle and portrait of a wealthy pregnant woman painted to leave a memento in case she died

Dramatic declines in high-income

populations

0

100

200

300

400

500

600

700

Maternal mortality ratios, England & Wales, 1850-2005

Declines coincide with: •Antibiotics

•Blood transfusions

•Management of

hypertensive diseases of

pregnancy

Maternal deaths in rich countries “eliminated” Deaths by cause & sex England & Wales 2009:

•63 maternal deaths •66 breast cancer deaths in men

Background

• MDG 5 – improve maternal health; an important global health challenge

• Ensuring women give birth with a skilled birth attendant, and can access emergency obstetric care, is crucial

A woman dying each minute: day in, day out

Photo of pregnant women with lifetime risk of death painted on their bodies

Global Commitment

0

100

200

300

400

500

600

700

Maternal mortality ratios, England & Wales, 1850-2005 and Global Targets 1990-2015

UK Global

19

90

20

15

Epidemiology of Maternal Death

<100 100-299 300-499 500-999 1000+

Maternal deaths per 100,000 live births, 2008

What are the causes of

death?

• Haemorrhage

• Hypertensive diseases of pregnancy

• Sepsis

• Obstructed labour

• Unsafe abortion

• As well as other underlying conditions (indirect causes)

0

100

200

300

400

500

600

700

800

900

1000

Sub-Saharan Africa

Ma

tern

al m

ort

alit

y r

atio

Haemorrhage Hypertensive diseases

Sepsis/Infection Obstructed labour

Other direct Abortion

Indirect causes Unclassified

Dire

ct

ca

use

s

Epidemiology of Maternal Death

•Complications difficult to predict or prevent •Treatment needs some skill

1. Renewed focus on delivery & emergency obstetric care, & family planning and abortion

Combined with: 2. More health professionals 3. Greater financial resources 4. Robust tracking of progress & accountability 5. Greater political commitment

What needs to be

done?

Global Strategy for Women’s and

Children’s Health (United Nations, 2010)

•Every Woman Every Child: 3 strategic areas • Reducing financial barriers • Creating stronger policy environment towards

women’s and children’s health • Strengthening and improving delivery of health

services

Photo of Ban Ki Moon at world economic summit

Challenges &

successes

Categorisation of all Zambian health facilities according

to their EmOC functions (n=1370)

30

24

42

39

155

375

466

239

0 100 200 300 400 500

CEmOC

CEmOC-1

BEmOC

BEmOC-1

BEmOC-2

BEmOC-4

Substandard delivery service

No delivery service

Number of facilities

Services availability: Emergency

Obstetric Capability, Zambia health

facilities (n=1370) Gabrysch 2010

0 20 40 60 80 100

Rural

Urban

% of Population within 15km of any delivery service

Distance from services: Access to obstetric

care in Zambia (Gabrysch et al 2011)

14/17

Urban population: 3,460,000

Rural population: 7,057,000

% of Population within 15km of BEmOC

3 20 40 60 80 100 120 140.

Lusaka

Copperbelt

ZAMBIA

Northwestern

Southern

Western

Eastern

Luapula

Central

Northern

Zambia - Doctors per 3600 births by province

Staffing: doctor density in Zambia

compared to Sri Lank a (Gabrysch et al 2011)

3 20 40 60 80 100 120 140.

Western

Central

SRI LANKA

North-Western

Sabaragamuwa

East

Uva

Southern

North-Central

North

Sri Lanka - Doctors per 3600 births by province

Poor Quality of Care in Facilities:

time to treatment (Ivory Coast): near misses

16

0 2 4 6 8 10 12

UterineRupture

UterineRupture

UterineRupture

UterineRupture

UterineRupture

UterineRupture

call doctor obtain kit kit complete kit other

Gohou et al 2004

Economic costs: catastrophic consequences of

unaffordable emergency care (Borghi et al 2006)

Country/year % GDP/capita for normal

delivery in hospital

% GDP/capita for

caesarean section

Ghana, 2002 5-6 16-35

Burkina Faso

2006

43 138

Dzakpasu (2010)

National policies to remove user fees for delivery

care

Ghana: skilled attendance increasing; inequality decreasing

40 44 44

47

57

0

10

20

30

40

50

60

70

80

Pe

rce

nt

of

de

live

rie

s

, Ghana Demographic and Health Survey 2008; Dzakpasu et al 2012

Quality of care: can be poor: (Khayat & Campbell 2000)

Perineal shaving for all 92%

All women tied during delivery 59%

Adopts any position likes during labour 38%

All mothers helped breastfeed 23%

Evidence based practices in Lebanese hospitals: 1997

Increase in facility use following adoption of culturally sensitive practices in Ayacucho,

Peru: 6% (1999) to 83% (2007)

Can be improved Gabrysch et al

2009)

Global financial resources have not been

adequate but are improving (Pitt et al 2011)

• Maternal & newborn health not given financial priority despite a burden of disease larger than for HIV, TB, or Malaria

• Global development assistance to maternal & neonatal health was $563million (2003) & $1227million (2008)

0

1

2

3

4

5

6

7

8

9

Perc

ent

of

DA

LYs

Unmet need for Contraception, 1990-1995 &

2000-2005: appalling but improving Sedgh et al 2007

& UNFPA 2010

23% in least developed vs. 9% in developing countries 137 million women worldwide

Abortion Policies/Provision improving in

some places

Conclusions

Achievable Target? 75% in 25 years

0

100

200

300

400

500

600

700

Maternal mortality ratios, England & Wales, 1850-2005 and Global Targets 1990-2015

(and transposed to 1925-1950)

Progress

0

100

200

300

400

500

600

700

Maternal mortality ratios, England & Wales, 1850-2005 and Global MMR 1990-2008; Target 2015

19

90

20

15

20

08

0

100

200

300

400

500

600

700

Mate

rn

al d

eath

s p

er 1

00000 li

ve b

irth

s

Sri Lanka Thailand Malaysia

Honduras Egypt Matlab, Bangladesh

Bangladesh MM Survey 2001 China India

Progress in LMICs

A topic for

women’s

day??

Bhavna Bahri Gregory John Smith

Child birth and maternal mortality pose many challenges: Women in need of care…. Women in their traditional role…burdened, and weak But also… Women as skilled birth attendants providing care that prevents death…Women as survivors …strong, resilient and creators of the future

• Photo of woman burdened by carrying a child

Photo of woman uplifted by child

8th of March is the day of the rebellion of the working women against the kitchen slavery

March 8th

is

the day we

ensure other

women don’t

lose their lives

giving life

• Too many women are still dying in their prime years

• Maternal mortality is an MDG that 189 countries have signed up to

• We need to get on with what works

Copyright ICDDR,B/06-1109/Bitu/Map

Thank you