plenary 2-reducing maternal mortality lessons learnt
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Reducing Maternal Mortality;Lessons Learnt
Baizury BashahKlinik Kesihatan Putrajaya Presint 9
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Contents Definition Millennium Development Goal #5
Malaysian achievement
How Malaysia fares compared to othercountries
WHO recommendations
Malaysian initiatives
Summary
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Definition
Maternal death
The death of a woman while pregnant orwithin 42 days of termination of pregnancy,
irrespective of the duration and site of thepregnancy, from any cause related to or
aggravated by the pregnancy or its
management,
but not from accidental or incidental causes
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Maternal mortality ratio
Number of maternal deaths during given time period_______________________________________ X 100,000
Number of Life birth during same period of time
This measure captures the probability of dying once a womanis pregnant, and so is also referred to as the obstetric risk
Maternal mortality rate:
Number of maternal deaths in a population X100,000
Number of women aged 1549 years (reproductive age)
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Prerequisite for good measurement
an established system for registration of births,deaths and causes of death
well-functioning health information systems that combinedata from facilities, administrative sources and surveys
Countries must have:
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Table 1. Sources of maternal mortality data used in
generating the 2010 maternal mortality ratio estimates
Group Source of maternal mortality data Number of
countries/
territories
% of countries/
territories in each
category
% of births in
181 countries/
territories
covered
A Civil registration
characterized as complete,
with good attribution of causeof death
65 35.9 15.7
B Countries lacking good
complete registration data but
where other types of data are
available
89 49.2 80.3
C No national data on maternal
mortality27 14.9 4.0
Total 181 100.0 100.0
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Definitions of misclassification,incompleteness and underreporting
Misclassification
Refers to incorrect coding in civil registration, due either to error in
the medical certification of cause of death or error in applying the
correct code
Incompleteness
Refers to incomplete death registration. Includes both the identification of
individual deaths in each country and the national coverage of the register
Underreporting
Is a combination of misclassification and incompleteness
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Guess which group Malaysiabelongs to??
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Estimates of maternal mortality ratio(MMR, maternal deaths per 100 000 live births),
number of maternal deaths, lifetime risk , 2010
Country MMR Range of MMR
uncertainty
Number of
maternal
deaths
Lifetime risk
of maternal
death, 1:
PM
(%)*
Gp
Lower
estimate
Upper
estimate
Malaysia 29 12 64 170 1300 2.4 CThailand 48 33 70 400 1400 1 B
Singapore 3 2 7 2 25,300 0.3 A
Philippines 99 66 140 2300 300 6.3 B
Indonesia 220 130 350 9600 210 5.0 B
*Proportion of maternal deaths among deaths of women of reproductive age (PM)
Source: , WHO 2012 . Trends in Maternal Mortality 1990 to 2010
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Contents Definition Millennium Development Goal #5
Malaysian achievement
How Malaysia fares compared to othercountries
WHO recommendations
Malaysian initiatives
Summary
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MDG #5
TARGET 5A :
Reduce by three-quarters (75%) between 1990and 2015, the maternal mortality ratio
Target 5B:
Achieve, by 2015, universal access toreproductive health
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MDG 5 to improve maternal healthTargets MDG indicators Baseline Target
(2015)
Latest
achievement
5.1 MMR 44/100,000 LB
(1991)
11/100,000 LB 26.1 (2010)
5.2 Proportion of birth
attended by skilled
health professionals
74.2%
(1990)
95.0% 98.6% (2011)
5.3 Contraceptive
prevalence rate
54.6% (1994) To increase 51.8% ( 2004)
5.4 Adolescent birth rate 28 births per
1000adolescent
To decrease 14 births per
1000
adolescent
(2010)5.5 Antenatal care
coverage (1 visit)
78% (1990) 90.0% 94% (2011)
5.6 Unmet need for
family planning
24.5 % (2004) To decrease
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Contents Definition Millennium Development Goal #5
Malaysian achievement
How Malaysia fares compared to othercountries
WHO recommendations
Malaysian initiatives Summary
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MDG 5a: Maternal Mortality Ratio (MMR) Achievementagainst Set Target MDG 5
Source: Department of Statistics Malaysia
(131) (137) (134) (128) (126)
(no. of deaths)
(110p) (50)
Target
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MMR by ethnicity ( 1997-2007)
Ethnic Grp 1997 1999 2001 2003 2006 2007 2009 2011p
Malay 33.6 (100) 34.0 (104) 33.5 (100) 28.8 (80) 25 ( 68) 28.4 ( 78) 30 (88) 26.1(79)
Chinese 18.6 ( 20) 12.4 (14) 15.3 (15) 16.4 (15) 16.5 ( 14) 12.9 (10) 16( 20) 6.7(5)
Indians 36.7 ( 13) 31.1 (11) 40.7 (14) 18.6 (6) 13 ( 44) 23.6 (7) 37 (11) 15.6(4)
Otherbumi
27.4 ( 17) 39.2 (20) 49.4 (31) 33.4 (19) 26.2 (15 40.8 (24) 50.1 (32) 44.8(29)
Target :11/100,000LBby 2015
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Only the Chinese has achieved the
targeted MMR of 6.7/100,000 LB
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At what point during pregnancyand
childbirth do women die?
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60%-75% : During Postpartum
15 -25% : Antenatal
Source: Reports on the Confidential Enquiries into Maternal Deaths in Malaysia
MATERNAL DEATHS by PHASE OF PREGNANCY :
MALAYSIA 1991-2008
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Maternal deaths by phase of pregnancy/delivery :
Malaysia 2011-2012
Source : BPKK, KKM
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Post partum 48hrs 42 days
Health personnel from Klinik Kesihatan &Klinik Desa can contribute more by
doing quality , regular post natal care
Identify red flag signs & symptoms
Timely referral to M&HO / FMS or hospital
Causes of maternal death (direct/indirect)
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Causes of maternal death (direct/indirect)
Malaysia 2011-2012
Direct cause Indirect cause
Obstetric
embolism
Hemorrhage
Medical
conditions
HDP
Source : BPKK
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MMR PLACE OF DELIVERY
Home deliveries associated with high MMR 50-80 per 100,000 deliveries
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Home deliveries on the rise;
causing sepsis??
/
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Maternal deaths; preventable / non preventable
Malaysia 2011-2012
Source : BPKK, KKM
Contributory factors Clinical factors
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Contributory factors Clinical factors
(analysis based on preventable deaths 2012)
Percentage
C t ib t f t N li i l f t
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Contributory factors Non-clinical factors
(analysis based on preventable deaths 2012)
Percentage
C t ib t f t P ti t F t
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Contributory factors Patient Factors
(analysis based on preventable deaths 2012)
Percentage
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Contents
Definition Millennium Development Goal #5
Malaysian achievement
How Malaysia fares compared to othercountries
WHO recommendations
Malaysian initiatives Summary
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How does Malaysia fare?
(1980 2010)
Maternal Mortality Ratio per 100,000 LB
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Source - WHO World Health statistics 2012
by Region and Country
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Contents
Definition Millennium Development Goal #5
Malaysian achievement
How Malaysia fares compared to othercountries
WHO recommendations
Malaysian initiatives Summary
6 k f WHO h
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6 key messages from WHO research-informed viewpoint
Maternal health has many valued outcomes, butmaintaining focus on maternal death is crucial inareas where the mortality burden is high
Many single interventions are available, but none
alone can reduce the rate of maternal mortality in apopulation
Strategies will work if the component packages areeffective and the means used for their distribution
achieve high coverage of the intended target group
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6 key messages from WHO research-informed viewpoint
The epidemiology of maternal mortality requiresprioritisation of the intrapartum period
A health centre intrapartum-care strategy can be
justified as the best bet to bring down high rates ofmaternal mortality
There are further opportunities to alter the risks ofmaternal death outside the intrapartum period
antenatal care, postpartum care, family planning,and safe abortion
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WHO recommendationsWHO recommendations Malaysia
Non-pregnant women of reproductive age: all (4) All
Periconceptual folic acid supplementation (women planning
Pregnancy)
Iron supplementation (in areas of high iron deficiency anaemia)
Access to care to screen/diagnose health problems (e.g. worm
infestation, severe anaemia, heart disease, HIV, asthma,diabetes)
Salt iodisation
Non-pregnant women of reproductive age: ill (6) All
Non-pregnant women of reproductive age: not wanting child
Female condom x
Emergency contraception
Male sterilisation
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WHO recommendationsWHO recommendations Malaysia
Pregnant women not wanting child, Prevent unsafe inducedabortion (2) Where legally, politically, and culturally acceptable(medical abortions could potentially be delivered at the household level, and attain high
coverage, thereby averting a substantial proportion of maternal deaths)
Mifepristone / misoprostol (medical abortion)
Vacuum aspiration
All pregnant women (26)
Calcium (reduce risk of PE)
Intrapartum women (delivery and immediate postpartum) (17) All
All postpartum women (13)
Insecticide treated bednets (malaria vs dengue) x
Pregnant, intrapartum, postpartum women with complications (45)
Calcium supplementation (in women at high risk of PE)
Post induced-abortion contraceptive advice
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WHO recommendationsWHO recommendations Malaysia
*Stimulate nipples post term to induce labour x*Intraumbilical vein injection with saline solution
and oxytocin to reduce need for manual removal
of placenta (Prevent need for manual removal of
placenta; retained placenta; postpartum
haemorrhage)
x
* WHO. Reproductive Health Library, version 9. World Health Organization.http://www.rhlibrary.com/default.asp (accessed Sept 5, 2006).
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Contents
Definition Millennium Development Goal #5
Malaysian achievement
How Malaysia fares compared to othercountries
WHO recommendations
Malaysian initiatives Summary
C fid ti l i i i t t l
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Confidential enquiries into maternaldeaths (CEMD)
Previously:
at clinic, district, state level attended by allinvolved, national level by a committee
Presently:
all the above +
national level every 3 months, attended byrepresentatives from the states, by zones
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Problems identified
Social difficulties on the rise
Need to involve other agencies since MedicalSocial worker in health facilities is scarce
Certification of death by non medical personnel
Police not to issue burial permits without knowingthe cause of death
Post mortem for unsure cause of death
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Problems identified
Geographical difficulties still exist especially in EMalaysia
Making trained personnel more accessible byrotation
Upgrade facilities
Restrictions on management
E.g Need to have 2 specialists signatures for X-ray examination in pregnant ladies
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Strategies Pre pregnancy care optimise health, for men
too
Guidelines primary & secondary care
Personalised care
Continuation of thrombolytic Rx in primarycare
Setting up of EPAU / PAC in secondary care
Notification of high risk admissions &discharges
Combined clinic
S i
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Strategies Family planning service in secondary care
Setting up of low risk birthing centre
Higher risk can be given more attention Revival of ABC
Alternative to home deliveries
Private wing for full paying patients moreoptions for patients
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Others
Malaysia towards health transformation,integration between public & private
?Delivery can either be in public or privatehealth facilities
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Contents
Definition Millennium Development Goal #5
Malaysian achievement
How Malaysia fares compared to othercountries
WHO recommendations
Malaysian initiatives Summary
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Summary
WHO does not recognise Malaysias data (MOH,Pendaftaran)
Malaysias MMR is still NOT on target
Only the Chinese population has achieved thetargeted MMR of , 11/100,000LB (6.7/100,000 LB)
Up to 75% of maternal death occur during postpartum period
S
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Summary
Around 50% of death is preventable, half dueto cardiac diseases
Haemorrhage, embolism, HDP, Sepsis arethe major direct causes of death
Home delivery is associated with high MMR
Summary
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Summary
Malaysia complies to many of WHO relevantrecommendation
Malaysia need to look outside of the box, e.g: delivery can be at public or private health facilities
Personalised care add in patients in fb for easyaccess to advice
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Thank you
baizuryfms@yahoo.com
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