maternal mortality in jordan
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Maternal Mortality in Jordan
2007-2008
Professor Zouhair Amarin
Jordan University of Science and Technology
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Worldwide, childbearing carries a major
risk to the life of women
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http://images.google.jo/imgres?imgurl=http://www.marefa.org/images/thumb/2/2f/Small_Flag_of_the_United_Nations_ZP.svg/488px-Small_Flag_of_the_United_Nations_ZP.svg.png&imgrefurl=http://www.marefa.org/index.php/%25D8%25B5%25D9%2588%25D8%25B1%25D8%25A9:Small_Flag_of_the_United_Nations_ZP.svg&usg=__LXQ_woFmXQp2TeUEoOTNhD-rkT8=&h=488&w=488&sz=91&hl=ar&start=3&tbnid=YSDhti4CK7KEJM:&tbnh=130&tbnw=130&prev=/images%3Fq%3Dunited%2Bnations%26gbv%3D2%26hl%3Dar%26safe%3Dactive -
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Measures of maternal mortality
rateMaternal mortality
ratioMaternal mortality
Lifetime risk of maternal death
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are often used interchangeablyRate and Ratio
useddenominatorIt is essential to specify the
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rateMaternal mortality
Is the number of maternal deaths in a given period
women of reproductive age100 000per
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ratioMaternal mortality
Is the number of maternal deaths during a
duringlive births100 000given year per
the same period
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The Millennium Development Goals (MDGs
are eight international development goals
192 United Nations member states and 23
international organizations have agreed to
achieve those goals by the year 2015
http://en.wikipedia.org/wiki/International_developmenthttp://en.wikipedia.org/wiki/United_Nationshttp://en.wikipedia.org/wiki/United_Nations_member_stateshttp://en.wikipedia.org/wiki/International_organizationshttp://en.wikipedia.org/wiki/International_organizationshttp://en.wikipedia.org/wiki/United_Nations_member_stateshttp://en.wikipedia.org/wiki/United_Nationshttp://en.wikipedia.org/wiki/International_development -
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Reducing maternal mortality by three quarters
between 1990 and 2015 is a specific part of Goal 5
(Improving Maternal Health) of the eight MDGs
http://en.wikipedia.org/wiki/Millenium_Development_Goalshttp://en.wikipedia.org/wiki/Millenium_Development_Goals -
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At global level, maternal mortality
has decreased less than 1% annually
between 1990 and 2005
This is far below the 5.5% annual
decline, which is necessary to achievethe fifth MDG
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WHO UNICEF and UNFPA 2003 MMR
The world average 400
Developed regions 20
Developing regions 440
http://en.wikipedia.org/wiki/World_Health_Organizationhttp://en.wikipedia.org/wiki/UNICEFhttp://en.wikipedia.org/wiki/UNFPAhttp://en.wikipedia.org/wiki/UNFPAhttp://en.wikipedia.org/wiki/UNICEFhttp://en.wikipedia.org/wiki/World_Health_Organization -
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Approaches for measuring maternal mortality
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Civil Registration Systems
Routine recording of deaths is not complete
The womans pregnancy status may not beknown and the death would not be reported
as a maternal death
Medical certification of death is deficient,
accurate attribution of deaths as maternal
death is difficult
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In the UK, the Confidential Enquiry into
Maternal Deaths (20002002) identified 44%
more maternal deaths than was reported in the
routine Civil Registration System
Studies have shown that the true number ofmaternal deaths could be almost 200% higher
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In the absence of complete and accurate civil
registration systems, MMRs are based upon:
Household surveys
Sisterhood methods
Reproductive-age mortality studies (RAMOS)
Verbal autopsies
Censuses
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2007 - 2008
Study
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Objectives
1. Determine maternal mortality ratio among Jordanian women
2. Identify the direct and indirectcauses of maternal mortality
3. Determine the extent to which maternal deaths arepreventable
4. Assess hospital medical and vital records for completeness
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Step 1
Civil Registry, 1164 names were obtainedfor dead married women, 15-49 years of
age
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Step 2
From the MOH, 848 names were obtained
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Step 3
Both lists were pooled to contain only marriedwomen in the age group 15-49 years
1177names
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Step 4
229 names from hospital registries
1177 + 229 = 1406 dead women of
reproductive age
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All hospitals and forensic departments werevisited to search for maternal deaths
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112
pregnancy related maternal deaths
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Number of maternal deaths, number of live births, total fertility
rate, and measures of maternal mortality in 2007-2008
76 deaths (60-95)
Number of maternal deaths in 2007-
2008 (95% CI)
397588 live birthsNumber of live births
3.6Total fertility rate in 2007
19.1 (14.3-26.5)Maternal Mortality Ratio (95% CI)
2.0Maternal Mortality Rate
0.0007 (1 in 1428)
Lifetime risk of maternal death (The
probability that a 15-year-old female
will die from a maternal cause)
Sociodemographic and health characteristics of study population
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Sociodemographic and health characteristics of study population
(N=76)
%nAge
40.83115-29
35.52730-39
23.71840-49
Region
59.245Middle (62.3% of population)
2519Northern (28.1% of population)
15.812Southern (9.3% of population)
Family size
29.3172-3
41.4244-6
29.3177 (average family size 5.75)
Income in Jordanian Dinar
80.441350
19.610>350
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%nGravidity
43.1281-332.3214-6
24.6167
Parity
34.8230-1
39.4262-4
25.8175
Gestational age24.01827
22.71728-36
53.34037
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%nCauses of maternal deaths
73.756Direct Causes
25.019HaemorrhageUterine rupture (n=5)
Uterine atony (n=5)
Placental abruption (n=3)
DIC (n=4)
Ruptured ectopic pregnancy (n=2)
23.718Thrombosis and thromboembolism
7.96Sepsis
6.65Hypertensive disorders of pregnancy5.34Amniotic fluid embolism
3.93Anesthesia
1.31Hyperemesis gravidarum
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%nCauses of maternal deaths
26.320Indirect Causes
10.58Cardiac disease
7.96Diseases of the CNS
CVA (n=4)Epilepsy (n=2)
5.24Infectious diseases
Hepatobiliary peritonitis (n=2)
Pancreatic perotonitis (n=1)
Pulmonary infection (n=1)
1.31Chronic anemia
1.31Renal failure
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75% of cardiac deaths were associated with some degree of substandard care
Avoidable deaths
%nVariable
5441Avoidable deaths
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Antenatal care (N = 54*)
%nAntenatal attendance
83.345Received antenatal care
16.79No antenatal care
10054Total
*22 women had no details of ANC
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Antenatal care (N = 45)
%nBooking and # visits
91
9100
41
445
1st trimester booking visit
2nd or 3rd trimester bookingTotal
33.3
66.7100
15
3045
Number of visits
1-3
4Total
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Frequency distribution of maternal deaths by period of pregnancy, type of
hospital and autopsy status (N=76)
%nPeriod of pregnancy
36.8
6.6
56.6
28
5
43
During pregnancy
Intrapartum
Postpartum
Type of hospital
17.113Dead on arrival2.62Maternity
46.135Peripheral
34.226Referral
Autopsy status17.113Dead on arrival - Autopsy
11.89Hospital death - Autopsy
3.93Brought-in dead - No Autopsy
67.151Hospital death - No Autopsy
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Frequency distribution of maternal deaths by delivery (N=76)
TotalType of delivery
24 (31.5 %)No delivery5 (6.5 %)Abortion
15 (19.7 %)Spontaneous vaginal
1 (1.3 %)Induced vaginal
1 (1.3 %)Ventouse
3 (3.9 %)Forceps
0 (0.0 %)Vaginal breech
27 (35.5 %)Caesarean section
20 (26.3 %)Emergency
5 (6.5 %)Elective
1 (1.3 %)Perimortem
1 ( 1.3 %)Postmortem
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Frequency distribution by contraceptive practices
%nEver use of contraception
29.415Yes
70.636No
Planned pregnancy
51.339Yes
Of all 76 maternal deaths, the details of family
planning were not available for 25 (32.9%) women
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Delays
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Delays and standards of care
%n
4.03Transport delay
55.342Delay in seeking care
48.737Lack of prompt care
52.640Substandard management
5.34Suboptimal facilities
F di ib i f id l d i id l d h b
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Frequency distribution of accidental and incidental deaths by cause
nCause of death
11Road traffic accident
4CO poisoning3Lymphoma or Leukemia
2Homicide
1Burn
2Electric shock
1Meningitis
1Pancreatic cancer
1Breast cancer
1Ruptured aneurism
1Colon cancer
2Bowel obstruction
3Cardio-vascular accident
1Dog bite
1Fall
1Drowning
36Total
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Out of 72 files on maternal deaths (4 files could not be
located), only 12 (16.6%) were well structured and had
complete details about events in their respective hospitals
Substandard quality was evident in all other medical case
notes that were reviewed
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2007-20081995/6
19.141.4MMR
HaemorrhageHypertensionDirect 1
Thrombotic eventsHaemorrhageDirect 2
SepsisThrombotic eventsDirect 3
CardiacCardiacIndirect 1
CNS eventsMalignancyIndirect 2
Infectious diseasesDiabetesIndirect 3
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This report should reassure the public that maternal deaths in
Jordan are rare and declining. Overall, 76 women had a
maternal death out of the 397588 mothers who gave live birthduring 2007-2008
The MMR for both direct and indirect causes of death showed a
remarkable decrease as compared with the last Report of 1995-
1996
A reduction of 53.9% achieved in 12 years (4.5% annual
reduction) goes well with the 75% reduction as recommended
by the MDG 5
At global level, maternal mortality had decreased at an average
of < 1% annually between 1990 and 2005. This is far below the
5.5% annual decline recommended by the MDG 5
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0 2 15 19 19 2327 32 35 37
58 5984
180227
365 380
546
750
1044
1107
329
0
200
400
600
800
1000
1200
UAE
KUW
SA
JOR
BAH
OMA
LIB
QAT
PAL
TUN
SYR
EGY
IRQ
ALG
MOR
YEM
COM
DJI
MAU
SOM
SUD
AVR08
Country
MMR
(Per10
0,0
00livebirths)
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RECOMMENDATIONS
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General
Recognition of maternal health as a priority issue
Reallocation of human and financial resources to the
relevant interventions
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Scale up the implementation of the strategies and plans ofaction related to Making Pregnancy Safer
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Upgrade recording and reporting systems
Develop national surveillance systems to identify
epidemiological patterns and maternal mortality trends
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Implementation of community-based interventions related to
maternal health
Early recognition of the danger signs of sickness and also on
preventive measures to promote maternal health
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Introduce maternal health guidelines into the teachingcurricula of medical and paramedical schools
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Haemorrhage
A forum of experts at a national level is recommended to
develop a multidisciplinary massive haemorrhage protocol
that should be updated and rehearsed regularly in conjunction
with blood banks
All grades of staff should participate in drills on site and
consultant haematologists should be involved
Women at high risk of bleeding should be delivered in centres
with facilities for blood transfusion and ICU
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Thromboembolism
Acute symptoms suggestive of thromboembolism in known
high-risk women are an emergency and anticoagulation may be
indicated before the diagnosis is clear
Attention should be paid to the up-to-date guidance on dosages
A thrombophilic risk profile protocol should be developed and
implemented in all maternity hospitals
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Sepsis
Hospitals should have an antibiotic policy for cases of sepsis
to control infection and prevent the development of DIC and
organ failure
Advice from a microbiologist must be sought early to ensure
appropriate antibiotic therapy
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Cardiac disease
Women with known cardiac disease should receive pre-
pregnancy counseling
All medical and nursing staff should be trained in basic,
intermediate and advanced life support
Emergency drills for maternal resuscitation should be
regularly practiced, and should include the identification ofthe equipment required
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Preconception counseling and antenatal care
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Health Education
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Communication and collaboration
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Continuous professional development
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Policies and protocols
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Accreditation
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Multidisciplinary support
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Documentation
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Death notification
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Finally
the act of getting pregnant should not be a death
sentence
BBC reporter on maternal mortality in Malawi, where 1in 10 dies during childbirth
26th October 2009
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Thank you
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