averting maternal death and disability (amdd) developed for use in amdd-partnered projects february...
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Averting Maternal Death and Disability
(AMDD)
Averting Maternal Death and Disability
(AMDD)
Developed for use in AMDD-partnered projectsFebruary 2002
By
Nadia Hijab & Czikus Carriere
Developed for use in AMDD-partnered projectsFebruary 2002
By
Nadia Hijab & Czikus Carriere
Program OrientationA Tool for Self-Learning
Program OrientationA Tool for Self-Learning
This Presentation Covers:This Presentation Covers:
• Causes of Maternal Death and Disability• Evolution of Understanding of the Problem• Central Role of Emergency Obstetric Care • UN Process Indicators • The AMDD Program
What Is Maternal Death?What Is Maternal Death?
The death of a woman while she is pregnant
The death of a woman while she is pregnant
…From any cause related to
or aggravated by the pregnancyWorld Health Organization (WHO)
within 42 days of the
termination of the pregnancy…
within 42 days of the
termination of the pregnancy…
…or…
WHO Estimates 515 000 Maternal Deaths Each YearWHO Estimates 515 000 Maternal Deaths Each Year
MORE THAN ONE WOMAN
DIES EVERY MINUTE from pregnancy-related causes
MORE THAN ONE WOMAN
DIES EVERY MINUTE from pregnancy-related causes
What Is Maternal Disability?What Is Maternal Disability?
Short- or Long-term Illness
Caused by
Obstetric Complications
Short- or Long-term Illness
Caused by
Obstetric Complications
The Most Serious Is Obstetric Fistula (An Abnormal Passage Between Vagina and Bladder or Rectum Often Caused by Obstructed Labor when it is Not Treated with
Cesarean Section)
The Most Serious Is Obstetric Fistula (An Abnormal Passage Between Vagina and Bladder or Rectum Often Caused by Obstructed Labor when it is Not Treated with
Cesarean Section)
What Do Women Die Of?What Do Women Die Of?
They Die Of Obstetric Complications
That Need Not Be Fatal
They Die Of Obstetric Complications
That Need Not Be Fatal
OBSTETRIC COMPLICATIONSOBSTETRIC COMPLICATIONS
• Hemorrhage 21%• Unsafe Abortion 14%• Eclampsia 13%• Obstructed Labor 8%• Infection 8%• Other 11%
• Hemorrhage 21%• Unsafe Abortion 14%• Eclampsia 13%• Obstructed Labor 8%• Infection 8%• Other 11%
Account for about 3/4 of Maternal DeathsAccount for about 3/4 of Maternal Deaths
DIRECT DIRECT
OBSTETRIC COMPLICATIONSOBSTETRIC COMPLICATIONS
• Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis
• And Increasingly HIV / AIDS
• Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis
• And Increasingly HIV / AIDS
Account for about 1/4 of Maternal DeathsAccount for about 1/4 of Maternal Deaths
INDIRECT INDIRECT
Most Obstetric Complications Occur Suddenly
Most Obstetric Complications Occur Suddenly
If women do not receive medical treatment on time,
they will probably suffer disability…
If women do not receive medical treatment on time,
they will probably suffer disability…
Or DieOr Die
Without WarningWithout Warning
WHERE DO WOMEN DIE TODAY?WHERE DO WOMEN DIE TODAY?
99% of Maternal Deaths Today
Occur in
Africa, Asia and Latin America
99% of Maternal Deaths Today
Occur in
Africa, Asia and Latin America
WHAT ABOUT THE REST OF THE WORLD?
WHAT ABOUT THE REST OF THE WORLD?
Maternal Mortality Used to be Very High in Europe and the U.S.
So was Infant Mortality.
Maternal Mortality Used to be Very High in Europe and the U.S.
So was Infant Mortality.
In 1915,
Maternal and Infant Mortality Rates
Were as High in the U.S.
As They Are in Africa Today
WHAT HAPPENED NEXT?WHAT HAPPENED NEXT?
Better Living Conditions
Reduced Infant Mortality in the U.S.
By over 40%
Between 1915 and 1933
Better Living Conditions
Reduced Infant Mortality in the U.S.
By over 40%
Between 1915 and 1933
BUT MATERNAL MORTALITY
BUT MATERNAL MORTALITY
“The well known triad
of fever, haemorrhage and toxaemia predominated…”
(Irvine Loudon)
“The well known triad
of fever, haemorrhage and toxaemia predominated…”
(Irvine Loudon)
REMAINED THE SAMEREMAINED THE SAME
…Until the late 1930s…Until the late 1930s
There was then a
“steep and sustained decline
which has continued in most Western countries
at much the same rate
for over fifty years” (Irvine Loudon)
There was then a
“steep and sustained decline
which has continued in most Western countries
at much the same rate
for over fifty years” (Irvine Loudon)
What Happened To Reduce Maternal Mortality
In The West?
What Happened To Reduce Maternal Mortality
In The West?
Effective treatment for obstetric complications
was developed and used,
e.g., antibiotics for infection,
blood transfusions for hemorrhage
Effective treatment for obstetric complications
was developed and used,
e.g., antibiotics for infection,
blood transfusions for hemorrhage
Most Obstetric ComplicationsMost Obstetric Complications
Can Neither
Be Predicted
Nor Prevented…
Can Neither
Be Predicted
Nor Prevented… But If Women Receive Effective Treatment
In Time,
But If Women Receive Effective Treatment
In Time,
…Almost All Can Be Saved…Almost All Can Be Saved
How Much Time Do We Have?
How Much Time Do We Have?
It is estimated that, if untreated, death occurs on average in:
It is estimated that, if untreated, death occurs on average in:
2 hours from Postpartum Hemorrhage
12 hours from Antepartum Hemorrhage
2 days from Obstructed Labor
6 days from Infection
2 hours from Postpartum Hemorrhage
12 hours from Antepartum Hemorrhage
2 days from Obstructed Labor
6 days from Infection
To Avert Death and Disability…
To Avert Death and Disability…
…We Need To EnsureThat Women have Access To…
…We Need To EnsureThat Women have Access To…
Emergency Obstetric CareEmergency Obstetric Care
(EmOC)(EmOC)
How Can We Improve Access
To EmOC?
How Can We Improve Access
To EmOC?
By making sure health facilities provide the
services needed to save women’s lives.
By making sure health facilities provide the
services needed to save women’s lives.
Eight key functions “signal” a facility’sability to provide EmOC
Eight key functions “signal” a facility’sability to provide EmOC
EmOC Key FunctionsCover These Services:
EmOC Key FunctionsCover These Services:
• Antibiotics (intravenous or by injection)
• Oxytocic Drugs
(ditto)
• Anticonvulsants
(ditto)
• Manual Removal of Placenta
• Removal of Retained Products
• Assisted Vaginal Delivery
• Surgery (Cesarean Section)
• Blood Transfusion
Basic and Comprehensive EmOC FacilitiesBasic and Comprehensive EmOC Facilities
Antibiotics (intravenous or by injection)• Oxytocic Drugs (ditto)• Anticonvulsants (ditto)• Manual Removal of Placenta• Removal of Retained Products• Assisted Vaginal Delivery
Antibiotics (intravenous or by injection)• Oxytocic Drugs (ditto)• Anticonvulsants (ditto)• Manual Removal of Placenta• Removal of Retained Products• Assisted Vaginal Delivery
BASICBASICEmOC Facilities Provide The First Six Services
• Antibiotics (intravenous or by injection)
• Oxytocic Drugs (ditto)• Anticonvulsants (ditto)• Manual Removal of Placenta• Removal of Retained Products• Assisted Vaginal Delivery
COMPREHENSIVECOMPREHENSIVE
Basic and Comprehensive EmOC FacilitiesBasic and Comprehensive EmOC Facilities
EmOC Facilities Provide All Eight Services
• Surgery (Cesarean Section)• Blood Transfusion
THE GOOD NEWSTHE GOOD NEWS
Not all these functions need hospitals and doctors
Well-trained nurses and midwives can perform most functions at Basic EmOC Facilities
An Important Point
For Resource Poor Areas
An Important Point
For Resource Poor Areas
How Can We Tell We Are Making a Difference?
How Can We Tell We Are Making a Difference?
If we know we have provided enough EmOC…
If we know we have provided enough EmOC…
…and if we know that these services are being used by women suffering obstetric complications…
…and if we know that these services are being used by women suffering obstetric complications…
WE CAN BE CONFIDENT
THAT WE ARE SAVING WOMEN’S LIVES
WE CAN BE CONFIDENT
THAT WE ARE SAVING WOMEN’S LIVES
How Do We Know Which Women
Will Experience Complications?
How Do We Know Which Women
Will Experience Complications?
WE DON’TWE DON’T
…But we do know that of any population of pregnant women at least 15% will experience an obstetric complication
…This is as true of pregnant women in the US and Europe as of women in Africa, Asia and Latin America
Nobody Knows Why This Happens.It Is a Fact of Life
Nobody Knows Why This Happens.It Is a Fact of Life
Can We Really TellIf Services Are Functioning?
Can We Really TellIf Services Are Functioning?
In 1991,
UNICEF and Columbia University developed
6 Process Indicators to do just that
In 1991,
UNICEF and Columbia University developed
6 Process Indicators to do just that
These were issued by UNICEF/WHO/UNFPA in 1997:
Guidelines for Monitoring Availability
and Use of Obstetric Services
These were issued by UNICEF/WHO/UNFPA in 1997:
Guidelines for Monitoring Availability
and Use of Obstetric Services
…And Are Being Used?…And Are Being Used?
In general, process indicators show you the changes in the
conditions
that lead to an outcome(such as death or disability)
In general, process indicators show you the changes in the
conditions
that lead to an outcome(such as death or disability)
Process IndicatorsProcess Indicators
Access to…Access to…
THE 6 PROCESS INDICATORSTHE 6 PROCESS INDICATORS
tell us about changes in:tell us about changes in:
Utilization of…Utilization of… and Quality of…and Quality of…
EmOC ServicesEmOC Services
INDICATOR # 1INDICATOR # 1
For every 500,000 population,there should be at least:
For every 500,000 population,there should be at least:
1 Comprehensive EmOC Facility
4 Basic EmOC Facilities
1 Comprehensive EmOC Facility
4 Basic EmOC Facilities
INDICATOR # 2INDICATOR # 2Geographical Distribution
of EmOC FacilitiesGeographical Distribution
of EmOC Facilities
EmOC Facilities should be well-distributed to serve 500,000 people
EmOC Facilities should be well-distributed to serve 500,000 people
Minimum: 1 Comprehensive and 4 Basic EmOC FacilitiesMinimum: 1 Comprehensive and 4 Basic EmOC Facilities
INDICATOR # 3INDICATOR # 3
Proportion of All Births in EmOC Facilities
Proportion of All Births in EmOC Facilities
At Least 15%
of All Births in the Community
Should Take Place in EmOC Facilities
At Least 15%
of All Births in the Community
Should Take Place in EmOC Facilities
INDICATOR # 4INDICATOR # 4
Met Need for EmOC ServicesMet Need for EmOC Services
At Least 100% of Women Estimated to Have Obstetric
Complications Should Be Treated in EmOC Facilities
At Least 100% of Women Estimated to Have Obstetric
Complications Should Be Treated in EmOC Facilities
INDICATOR # 5INDICATOR # 5
Cesarean Sections As a Percentage of All Births
Cesarean Sections As a Percentage of All Births
Minimum: 5%
Maximum: 15%
Minimum: 5%
Maximum: 15%
INDICATOR # 6INDICATOR # 6
Case Fatality RateCase Fatality Rate
Proportion of Women
With Obstetric Complications
Admitted to a Facility
Who Die:
Proportion of Women
With Obstetric Complications
Admitted to a Facility
Who Die:
Maximum Acceptable Level:
1%
CALCULATING ALL 6 INDICATORSCALCULATING ALL 6 INDICATORS
• Gives you an indication of where the problems lie and where action is needed.
• Also, these indicators are sensitive to change: within months, you can know if your project is making a difference
• Gives you an indication of where the problems lie and where action is needed.
• Also, these indicators are sensitive to change: within months, you can know if your project is making a difference
ACCESS TO EmOCACCESS TO EmOC
Problems:• Does Indicator # 1
show you need more EmOC facilities?
• Does Indicator # 2 show you need better distributed EmOC facilities?
Problems:• Does Indicator # 1
show you need more EmOC facilities?
• Does Indicator # 2 show you need better distributed EmOC facilities?
Action:• Most countries
already have enough facilities; they may just need to upgrade services to ensure 1 Comprehensive and 4 Basic EmOC facilities per 500,000 population
Action:• Most countries
already have enough facilities; they may just need to upgrade services to ensure 1 Comprehensive and 4 Basic EmOC facilities per 500,000 population
UTILIZATION OF EmOCUTILIZATION OF EmOC
• Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population?
• Does Indicator # 4 show that “Met Need” is less than 100%? (I.e. that not all women who experience obstetric complications are using EmOC facilities)
• Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section?
• Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population?
• Does Indicator # 4 show that “Met Need” is less than 100%? (I.e. that not all women who experience obstetric complications are using EmOC facilities)
• Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section?
ProblemsProblems
UTILIZATION OF EmOCUTILIZATION OF EmOC
• Do you have enough qualified staff?• Do you need to train staff on management of
emergency obstetric complications?• Does hospital management need improvement?• What’s the supply situation like?• What’s the equipment situation like?
• Do you have enough qualified staff?• Do you need to train staff on management of
emergency obstetric complications?• Does hospital management need improvement?• What’s the supply situation like?• What’s the equipment situation like?
If all the above is in place, conduct focus groups in the community to find out why
women are not coming for care
If all the above is in place, conduct focus groups in the community to find out why
women are not coming for care
Action: Collect More Info First
Action: Collect More Info First
QUALITY OF EmOCQUALITY OF EmOC
Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities?
Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities?
Problem:Problem:
QUALITY OF EmOCQUALITY OF EmOC
• Find out if your EmOC facilities are really functioning
• Check staff numbers, skills, management capacity, supplies and equipment
• Lobby your health ministry for more support – and get the community to lobby with you
• Find out if your EmOC facilities are really functioning
• Check staff numbers, skills, management capacity, supplies and equipment
• Lobby your health ministry for more support – and get the community to lobby with you
Action:Get More Info
Action:Get More Info
Any Country Can Avert
Maternal Death And Disability
If It Makes Good EmOC
Any Country Can Avert
Maternal Death And Disability
If It Makes Good EmOC
Available And Accessibleon Time
Available And Accessibleon Time
The AMDD ProgramThe AMDD Program
• The AMDD Program Was Established in 1999 at Columbia University’s School of Public Health, Heilbrunn Department of Population and Family Health
• The AMDD Program Is Dedicated to Improving the Availability, Quality and Utilization of Life-saving Obstetric Services in Developing Countries
• AMDD Partners Projects in Close to 50 Countries, Within a Framework That Links Technical Know-How With Management Capacity and Human Rights
• AMDD Is Funded by a Generous Grant From the Bill and Melinda Gates Foundation
AMDD PartnersAMDD PartnersProject Partners:• United Nations Children’s Fund (UNICEF): projects in Bangladesh, Bhutan,
India, Nepal, Pakistan and Sri Lanka• United Nations Fund for Population Activities (UNFPA): projects in India,
Morocco, Mozambique and Nicaragua• Regional Prevention of Maternal Mortality (RPMM) Network: teams and
projects in19 sub-Saharan African countries• CARE: projects in Ethiopia, Rwanda, Tanzania, Peru and Tajikistan• Save the Children: projects in Mali and Vietnam• Reproductive Health for Refugees (RHR) Consortium: projects in 12 countries
Project Partners:• United Nations Children’s Fund (UNICEF): projects in Bangladesh, Bhutan,
India, Nepal, Pakistan and Sri Lanka• United Nations Fund for Population Activities (UNFPA): projects in India,
Morocco, Mozambique and Nicaragua• Regional Prevention of Maternal Mortality (RPMM) Network: teams and
projects in19 sub-Saharan African countries• CARE: projects in Ethiopia, Rwanda, Tanzania, Peru and Tajikistan• Save the Children: projects in Mali and Vietnam• Reproductive Health for Refugees (RHR) Consortium: projects in 12 countries
AMDD PartnersAMDD Partners
Technical Partners:• Family Health International• John Snow International• Indian Institute of Management
at Ahmedabad (IIMA)• JHPIEGO• Engender Health
(formerly AVSC International)
RESOURCESRESOURCESUNICEF/WHO/UNFPA, Guidelines for Monitoring the Availability and Use of Obstetric Services, UNICEF, New York, October 1997
Maine, Deborah, Safe Motherhood Programs: Options and Issues, Columbia University, New York, 1991
UNFPA and AMDD, Reducing Maternal Deaths: Selecting Priorities, Tracking Progress, Distance Learning Courses on Population Issues, Turin, UN System Staff College, 2002
Loudon, Irvine, “On Maternal and Infant Mortality 1900-1960”, Social History of Medicine, April 1991, Vol. 4, No.1, pp 29-73
Created byNadia Hijab & Czikus Carriere
Created byNadia Hijab & Czikus Carriere