p -2- current aproaches -2013

Federal Democratic Republic of Ethiopia Ministry of Health

BEmONC – LRPETHIOPIA Best Practices in Maternal and Newborn Care

“Every Pregnancy Is at Risk:”Current Approach to

Reduction of Maternal and Neonatal Mortality By;Mignot

Anley (DMRHospital)

PRESENTATION - 2

BEmONC – LRP: EthiopiaBest Practices in Maternal and

Newborn Care

Current Approach to Reduction of Maternal and Neonatal Mortality

Session Objectives

By the end of this session participants will be able to: Recognize the situation of maternal and

neonatal mortality & morbidity globally and in our country specifically.

Describe factors affecting maternal and perinatal mortality and morbidity.

Review historical and current interventions to reduce maternal and neonatal mortality

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Newborn Care


What Is Safe Motherhood?

3

“ A woman’s ability to have a SAFE and healthy pregnancy and childbirth. ”


Newborn Care


Definitions

Maternal Mortality = is defined as 'the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

Can be Direct or Indirect Maternal Deaths

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Definitions; contd..

Define:

Maternal Mortality Ratio:

Perinatal Mortality

Perinatal mortality Rate

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Maternal Mortality: A Global Tragedy

Annually, 287,000 women die of pregnancy related complications* 99% in developing

world ~ 1% in developed

countries Many millions more

suffer complications e.g. obstetric fistulae, secondary infertility

* World Health Statistics 2010, (WHO-2012 report).

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Maternal Mortality trends

Globally, the total number of maternal deaths decreased from 543 000 in 1990 to 287 000 in 2010.

Likewise, the global maternal mortality ratio (MMR) declined from 400 maternal deaths per 100 000 live births in 1990 to 210 in 2010

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Maternal Death Watch(Global)

380 women become pregnant

190 women face unplanned or unwanted pregnancy

110 women experience a pregnancy related complication

40 women have an unsafe abortion

1 woman dies every two minutes from a pregnancy-related complication8

Every Minute...

Of every day...


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Ask group: What are the major causes of maternal mortality?

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*Nearly all (99%) abortion deaths are due to unsafe abortion. **This category includes deaths due to obstructed labor or anaemia.Other direct causes include embolism, ectopic pregnancy, anesthesia-related. Indirect causes include: malaria, heart disease. Source: WHO 2010.

Causes of maternal deaths, global


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Maternal Mortality in Ethiopia

Out of estimated 2,924,225 pregnancies in 2003E.C, only 16.6% attended by a skilled health provider. (Health and Health Related Indicators EFY,2003)

Maternal mortality ratio decreased from 871/100 000 live births in 2011 to 676/100 000 live births in 2011 (DHS-2011),

Our country is one of the six countries in 2008 which contribute more than 50% of all maternal deaths. (THE LANCET on 12 April 2010)

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Maternal Mortality in Ethiopia; contd…

Delivery at health facility

ANC TT2+ PW/PAB0

5

10

15

20

25

30

35

40

45

50

5

27

17

5

28 28

10

34

48EDHS 2000

EDHS2005

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Maternal Mortality in Ethiopia; contd…

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Causes of maternal mortality in Ethiopia; (Facility based study)


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Neonatal Health: Scope of Problem

Newborn health and survival are closely linked to care the mother receives before and during pregnancy, childbirth, and the postnatal period.

Every year: 4 million neonatal deaths (first month of

life) 4 million stillbirths Eight neonatal deaths every minute

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Two-thirds RuleGlobal Infant Mortality Rates

More than 7 million infants die annually between birth and 12 months of age

Of those who die in the first year Nearly 2/3 die in the first month

Of those who die in the first month 2/3 die in the first week

Of those who die in the first week 2/3 die in the first 24 hours

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Ask group: What are major causes of neonatal mortality?

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Causes of Newborn Death

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Ethiopia’s Neonatal Health status

Neonatal mortality is 37 per1,000 live births (DHS 2011).

50 percent of infant deaths in Ethiopia occur during the first month of life.

One in every 17 Ethiopian children dies before reaching age one,

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Child Mortality Rate trends in Ethiopia:

NMR, IMR and U5MR

Neonatal Mortality

rate

Infant Mortality

rate

underfive moratlity

rate

0

20

40

60

80

100

120

140

160

180

49

97

166

39

77

123

37

59

88EDHS 2000

EDHS2005

EDHS 2011

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But WHY Do These Women and Newborns Die?

Delay in decision to seek care Lack of understanding of complications Acceptance of maternal and newborn death Low status of women Socio-cultural barriers to seeking care

Delay in reaching care Mountains, islands, rivers — poor organization Lack of transport

Delay in receiving care Lack of triage system Lack of supplies, personnel Poorly trained personnel; poor attitudes

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Three Delays Model


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Ask group: What are some interventions that have not proved successful in reducing

mortality?

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Interventions to Reduce Maternal and Newborn Mortality

Historical Review Traditional birth

attendants

Antenatal care

Risk screening

Current Approach Skilled attendant at

delivery23


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Historical Review of Interventions

The flawed assumption:

Most life-threatening

obstetric and newborn

complications can be

predicted or prevented

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The Crucial Facts

Major obstetric complications are not predictable EVERY woman and newborn faces risk Maternal deaths are not predictable

Most maternal deaths occur during labour, delivery or the first 24 hours postpartum

When problems are managed in a timely and effective manner, mothers and babies lives are saved Providers and the facility must be prepared

to address emergencies at all times 80% of maternal deaths are preventable by

appropriate treatment25


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Interventions: Antenatal Care

Antenatal care clinics started in US, Australia, Scotland between 1910–1915

New concept - screening healthy women for signs of disease

By 1930’s large number (1200) ANC clinics opened in UK

No reduction in maternal mortality Is ANC important? YES!!

Focused, individualized care leads to early detection of problems and birth preparation

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Interventions: Risk Screening

Disadvantages Very-poorly predictive Costly: Removes woman to maternity

waiting homes If risk-negative, gives false security Conclusion: Cannot identify those at risk

of maternal mortality

Every pregnancy is at risk

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What are the key interventions to reduce maternal and neonatal

mortality? Access to family planning, Skilled attendants during pregnancy and

childbirth Access to emergency obstetric and

newborn care (EmONC), Effective referral system Fully functioning health services 24/7

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Most important intervention: Skilled Attendant at Childbirth

A skilled health provider is: an accredited health professional –

midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postpartum period and in the identification, management and referral of complications in women and newborns

(WHO, ICM & FIGO 2004)

29WHO 1999.


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EmONC Signal Functions (2009)

Basic EmONC Comprehensive EmONC

1) Administer parenteral antibiotics

Perform EmOC Signal functions 1-7, plus:

2) Administer uterotonic drugs (e.g. parenteral oxytocin, misoprostol)

8) Perform surgery (e.g. cesarean delivery)

3) Administer parenteral anticonvulsants (e.g. magnesium sulfate)

9) Perform blood transfusion

4) Perform manual removal of placenta

10) Provision of emergency obstetric anaesthesia

5) Perform removal of retained products (e.g. MVA)

6) Perform assisted vaginal delivery (e.g. vacuum extraction)

7) Perform neonatal resuscitation (e.g. with bag and mask) 3030


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Interventions: Skilled Attendant at Childbirth

Interventions proven effective resulting in decreased maternal mortality rates (MMR): Malaysia: basic maternity services; MMR

decreased from 320 to 157 Cuba: national priority; MMR decreased

from 118 to 31 China: facility based childbirth; MMR

decreased from 1500 to 50

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Maternal Mortality ReductionSri Lanka 1940–1985

1940–45 1950–55 1960–65 1970–75 1980–850

200

400

600

800

1000

1200

1400

1600

1800M

ate

rna

l D

ea

ths

pe

r 1

00

00

0

liv

eb

irth

s

32

85% births attended by trained personnel


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Maternal Mortality: UK 1840–1960

1840

1850

1860

1870

1880

1890

1900

1910

1920

1930

1940

1950

1960

050

100150200250300350400450500

Maternal Deaths

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Improvements in nutrition, sanitation Antibiotics, banked blood,

surgical improvementsAntenatal care

Maine 1999.


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The higher the proportion of deliveries attended by skilled provider, the lower the country’s maternal mortality ratio

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0 10 20 30 40 50 60 70 80 90 1000

200

400

600

800

1000

1200

1400

1600

1800

2000R² = 0.73598151462267

Y Logarithmic (Y)

% skilled attendant at delivery

Mat

erna

l dea

ths

per

1000

000

live

birt

hs


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Evidence based care

For years, much of basic and emergency obstetric and newborn care was provided according to “tradition” and “routine” practice rather than according to evidence.

To be effective, care should be evidence-based.

We have better understanding of emergency obstetric care (EmOC) and ‘best practices’ in labour and delivery and

Enhanced appreciation of the role that community mobilization, birth preparedness, and a continuum of care make35


Newborn Care


Proven Interventions for Maternal Survival

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Source: WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, Vol 367, April 1, 2006.

Anemia4%

Hemorrhage 34%

Other Causes30%

Unsafe Abortion

4%

Sepsis 16%

Obstructed Labor

4%

Hypertensive disorder

9%

Active Management of the Third

Stage of Labor

Misoprostol

Magnesium Sulfate

Calcium

Clean Delivery

Antibiotics Tetanus

Toxoid

Nutrition Counseling

Iron Folate IPTp, Malaria

Control

Partogram Cesarean

Section

Family Planning

Postabortion Care


Newborn Care


What do women want?

Clean facilities Women friendly

care – kindness, respect, information

Availability of drugs and medical equipment

Culturally appropriate services 37


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Summary

Skilled attendant at childbirth is

one of the most effective

interventions to prevent maternal

and perinatal mortality and

morbidity

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References

Maine D. 1999. What's So Special about Maternal Mortality?, in Safe Motherhood Initiatives: Critical Issues. Berer M et al (eds). Blackwell Science Limited: London.Lancet Maternal Survival Series, September 28, 2006 at www.thelancet.comWorld Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: Geneva.WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, vol 367, April 1, 2006.

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THANK YOU!

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