maternal mortality in jordan

7/29/2019 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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http://en.wikipedia.org/wiki/File:The_United_Nations_Building.jpg


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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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MMR

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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

maternal mortality in jordan

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