1. Maternal & Reproductive Health
Odessa Hamidi
Dr. Casanova

2. Objectives
Understand measures of maternal health and major causes of maternal mortality
With focus on Malaria, Obstetric Fistula, HIV/AIDS
Understand and describe the perception of women and gender inequalities
Understand areas that have an impact in decreasing maternal mortality 

3. What issues do you think of?

4. What issues do you think of?
Lack of access to health services
Cost, transportation, societal norms
Lack of facilities, education
Antenatal care & post-partum care
Contraception & Family Planning
Gender Inequality issues
Female Genital Mutilation/Cutting
Child Marriage

5. Current Picture
350,000+ women die each year from complications due to pregnancy or childbirth
Higher lifetime risk of death for women in high-fertility settings
1 in 76 in developing world
1 in 8,000 in the developed world
2000 births occur each year at UMC meaning there is a maternal death once every 4 years compared to if UMC was part of the developing world then 26 women would die each year just for giving birth.

6. Measures of Reproductive Health
Life expectancy
Fertility
Perinatal mortality
Low birth weight
Maternal mortality
How do we quantify these measures? Your powerpoint has statistics and definitions listed in the notes section, which you can refer to on your own later if you’re interested
Life expectancy – expected # of years of life
USA – 77.8 years
Haiti – 49.2 years
Afghanistan – 43.3 years
Swaziland – 32.6 years
Fertility – average # of births per woman
Population must have fertility of 2.1 children/woman to replace itself
UN predicts population will exceed 10 billion by the year 2100
Perinatal mortality – stillbirths and infant deaths within 1st week of life
Function of mother’s health, nutritional status, access to health care
6.3 million deaths/year with 3.3 million stillbirths
Rate of perinatal mortality
62 per 1,000 in Africa
7 per 1,000 in North America Low birth weight – less than 5 lb 8 oz or 2500 grams at birth
96% in developing countries
20 times more likely to die
Maternal mortality – death related to the reproductive process
Inequalities in access to services between wealthy and the poor
Leading cause of death and disability among women of reproductive age
Source: World Factbook, 2006

7. Reproductive Health Disparities
99% of maternal deaths occur in the developing world
65% occur in 11 countries – Afghanistan, Bangladesh, Ethiopia, Democratic Republic of Congo, Kenya, India, Indonesia, Nigeria, Pakistan, Sudan, Tanzania
For every woman who dies in pregnancy/childbirth, 20 endure injury, infection, disease, and disabilities

8. Maternal Mortality Ratio
65% occur in 11 countries – Afghanistan, Bangladesh, Ethiopia, Democratic Republic of Congo, Kenya, India, Indonesia, Nigeria, Pakistan, Sudan, Tanzania
--It goes without saying that this is a social issue when the disparities between the developed and developing world are so extreme
--It is important to remember that those who survive with disabilities such as fistula, they endure lifelong suffering in the form of social ostracizing by their own husbands, families, and communities (We’ll talk more about this in a few mins).
Per 100,000 births, 2008

9. "That women in some regions of the world, primarily sub- Saharan Africa and South Asia, are still facing such high risks of dying during pregnancy and childbirth is an infringement of their rights."
Globally, more than 500,000 women die each year because of complications related to pregnancy and childbirth. Almost half of these women are in sub-Saharan Africa. But the 0.1 per cent annual rate of reduction in this region, where the problem is most acute, is slower than in any other region.

10. Maternal Mortality
“Indirect causes” = from diseases or physical traumas unrelated to but aggravated by pregnancy: Anemia, malaria, hepatitis, diabetes, HIV/AIDS, physical & sexual abuse
“There is no mystery about why most of these women are dying. They are dying because they have no access or limited access to health care, or because the quality of care is poor. They die due to haemorrhage, sepsis, hypertensive disorders, unsafe abortion and prolonged or obstructed labour – complications that can often be effectively treated in a health system that provides skilled personnel facilities to handle emergencies when they occur and post-partum care. A woman’s health and nutritional status, including HIV and anaemia, underlie these causes, along with societal factors such as poverty, inequity, women’s low status and attitudes towards women and their needs.”

11. Anemia & Malaria
Risk of stillbirths, spontaneous abortions, low birth weight infants, neonatal death
Maternal death due to anemia
Intermittent preventative treatment in pregnancy (IPTp) and insecticide-treated bed nets (ITN)
Anemia can be compounded by malaria or intestinal parasites and low quality diet.
Anemia coupled with malaria greatly increases the risk of death in cases of intrapartum or postpartum haemorrhage and can increase the chance of death from cardiac failure in women.
P. falciparum infection during pregnancy is estimated to cause as many as maternal deaths each year, 8% to 14% of all low birth weight babies, and 3% to 8% of all infant deaths.
South of the Sahara = where 90% of the global malaria burden occurs
Use of insecticide-treated mosquito nets is crucial:
IPTp (intermittent preventative treatment) involves providing all pregnant women with at least two preventive treatment doses of an effective antimalarial drug during routine antenatal clinic visits. This approach has been shown to be safe, inexpensive and effective. A study in Malawi evaluating IPT showed a decline in placental infection (32% to 23%) and in the number of low birth weight babies (23% to 10%).
It also found that 75% of all pregnant women took advantage of IPT when offered (Presidents Malaria Initiative, PMI)
WHAT DOES IT TAKE TO IMPLEMENT THIS (other than awareness, etc):
integration of malaria control tools with other health programs targeted to pregnant women/newborns
RBM's vision is of a world free from the burden of malaria.
By 2015, the malaria-specific Millennium Development Goal (MDG) is achieved, and malaria is no longer a major cause of mortality and no longer a barrier to social and economic development and growth anywhere in the world.
In Africa, malaria deaths have been cut by one third within the last decade; outside of Africa, 35 out of the 53 countries, affected by malaria, have reduced cases by 50% in the same time period. In countries where access to malaria control interventions has improved most significantly, overall child mortality rates have fallen by approximately 20%. (

12. Obstetric Fistula
Picture:
Prolonged childbirth causes compression of internal tissue in the mother. This compromises the blood supply and eventually leads to loss of tissue which creates an abnormal opening between the reproductive system and the excretory system
Traumatic fistulas can also develop due to sexual violence
This results in uncontrollable leakage into the vagina from the bladder or the rectum, leaving the woman incontinent. (Usually vesicovaginal)

13. Obstetric Fistula
Her baby is unlikely to survive. If she survives, a woman with fistula is likely to be rejected by her husband because of her inability to bear more children and her foul smell. She will be shunned by her community and forced to live an isolated existence. These women suffer profound psychological trauma resulting from their utter loss of status and dignity, in addition to suffering constantly from their physical internal injury (such as skin infections, kidney disorders and even death)
The WHO estimates that there are 2 million woman are currently living with an untreated obstetric fistula and 50, ,000 women are affected each year

14. Obstetric Fistula
Occurs to young women in rural areas without access to medical care
Most frequently during first birth
Uncomplicated fistula can be repaired by a simple surgery that has cure rates of 90%
Preventable with family planning to delay age of first pregnancy and timely access to obstetric care
"Every Mother Counts" Video
OBSTETRIC FISTULA VIDEO:
MULTIFACTORIAL PROBLEM (like most things we have discussed)
-lack of self importance/place in society with this debilitation
-Staying at home. don't have money to go to hospital
-Lack of trained medical personnel.
How to prevent fistula & early childbirth?

15. HIV/AIDS
Two-thirds of all people infected with HIV live in sub- Saharan Africa
Access to antiretroviral medication
370,000 children were born with HIV in 2009
Sub-Saharan Africa, India
These women may be at higher risk than others of haemorrhage, sepsis and complications of Caesarean section, all causes of maternal death.
MVP:
Mother to child transmission programs in 80 villages in 10 African countries
Provides antiretroviral
prophylaxis for HIV
positive pregnant
women as well as family
planning services to prevent
unintended pregnancies

16. Preventing Mother to Child Transmission (PMTCT)
WHO no longer recommends one-time single dose prophylaxis with nevirapine due to development of drug resistance. Still in practice in some areas and does have significant benefit (reduces transmission of HIV from mother to child by 50%). Infants with HIV+ mothers may still contract HIV despite nevirapine and some will contract HIV through breast milk. If these infants were exposed to single dose nevirapine, 50% will develop drug resistance to nevirapine by 6-8 weeks of age

17. Preventing Mother to Child Transmission (PMTCT)
HIV/AIDS transmission can occur during pregnancy, labour and delivery, or breastfeeding.
15-30% during labour/delivery
5-20% during breastfeeding
Mother to child transmission programs in 80 villages in 10 African countries
Even where PMTCT services are available, not all women receive the full benefit

18. “No child should be born with HIV; no child should be an orphan because of HIV; no child should die due to lack of access to treatment.”
-Ebube Sylvia Taylor, an 11-year-old Nigerian, born free of HIV, speaking to world leaders who gathered in New York in to share progress made towards achieving the Millennium Development Goals by 2015.
Even where PMTCT services are available, not all women receive the full benefit: Why is this?
Not being offered an HIV test
Refusing to take an HIV test
Not returning for follow up visits
Not adhering to self-administered drugs
Why might women refuse to be tested?
“Some women refuse to be tested because they fear learning that they have a life-threatening condition; because they distrust HIV tests; or because they do not expect their results to remain confidential, and fear stigma and discrimination following a positive result. In many cases these fears are very justified and have been worsened in cases where health-care workers are under a lot of pressure to test women, and therefore make testing compulsory. It is imperative that global or national efforts to ensure testing coverage of pregnant women do not result in health-care workers at a community level denying a woman healthcare on the basis of her refusing to take an HIV test”

19. -Woman from Cote D’Ivoire
“My husband might see me with the medicines, and he will want to know what they are for. That way he will find out about my [HIV positive test] result. Even the location bothers me, because everyone who comes to the clinic knows what goes on [at the programme]. As soon as a pregnant woman is seen coming here, it's known right away that she is seropositive.”
-Woman from Cote D’Ivoire
“To achieve a high success rate, PMTCT programmes must have well-trained, supportive staff who take great care to ensure confidentiality. They must be backed up by effective HIV testing and counselling programmes and by good quality HIV/AIDS education, which is essential to eliminate myths and misunderstandings among pregnant women, and to counter stigma and discrimination in the wider community. Under these conditions, antiretroviral drugs have the potential to save many thousands of babies’ lives.”

20. Prevention & Progress
Family planning services, contraceptives, and abortion services
Avoidance of unintended pregnancies
Skilled attendants
Emergency care for complications
HOW TO IMPROVE
-Midwives & incentive programs (to refer to hospitals)
-Contraceptives
-Genital cutting? Look up in 'half the sky'
-Open discussions within the societies
-remember not to antagonize the males.
-HIV education

21. “Better health and education, and freedom to plan their family's future, will widen women's economic choices; but it will also liberate their minds and spirits.”
- Nafis Sadik, Secretary-General of the ICPD (International Conference on Population and Development)

22. Millennium Development Goals
8 international development goals to reduce poverty and improve lives by 2015 decided upon by the members of the United Nations and international organizations
Goal 3 – Promote gender equality and empower women
Goal 4 – Reduce child mortality by 66% by 2015
Goal 5 – Improve maternal health
Goal 6 – Combat HIV/AIDS, malaria and other diseases
“There are clear linkages between improvements in maternal health and other MDGs. The costs associated with poor maternal health are often a cause of impoverishment; improved maternal health can reduce poverty (MDG 1) by saving families from the often devastating economic consequences of a mother’s death or disability. Skilled care for mothers during birth and immediately following will improve child survival (MDG 4), both by protecting infants in the vulnerable neonatal period and by allowing more mothers to survive to care for their children. Access to reproductive health – the focus of MDG target 5.B – is also associated with poverty reduction and child survival. And effective maternity care services will make it possible to prevent and treat malaria in mothers and babies, as well as to prevent mother-to-child transmission of HIV (MDG 6).”

23. Millennium Development Goals
MDG 5: Reduce maternal mortality by ¾ between
1990: 850 maternal deaths/100,000 live births
2000: 400 maternal deaths/100,000 live births
2015 goal: 213 maternal deaths/100,000 live births
Maternal deaths have dropped by almost 50 percent worldwide
Success stories: :
Goal 5:
Widening access to maternal health services in Egypt: The Ministry of Health and Population significantly increased access to obstetric and neonatal care, in particular to vulnerable populations in Upper Egypt. About 32 maternity homes were constructed in rural areas. The number of births attended by trained healthcare workers in rural areas has since doubled to 50 per cent.
Fighting fistula in sub-Saharan Africa, South Asia and the Arab States: In 2003, the UN Population Fund (UNFPA), together with government and private partners, launched the Campaign to End Fistula, a childbirth injury that leaves women incontinent, isolated and ashamed. The campaign is now active in 49 countries across sub-Saharan Africa, South Asia and the Arab States. More than 28 countries have integrated the issue into relevant national policies and more than 16,000 women have received fistula treatment and care.
Investing in mobile maternal health units in Pakistan: UNFPA-supported mobile clinics were set up in Pakistan in 2005 and had received nearly 850,000 patients by Women can use them for antenatal consultations, deliveries, post-miscarriage complications and referrals for Caesarean section. The mobile units managed to provide skilled birth attendance to 43 per cent of pregnant women in remote areas, 12 per cent higher than the national average.

24. Access to family planning, contraceptives, abortive services
“122 million women around the world want contraception and can’t get it” –Half the Sky
Also from HTS:
40% of all pregnancies globally are unplanned or unwanted and almost HALF result in induced abortions.

25. Family Planning Benefits Reduction in maternal and newborn mortality
Reduction in transmission of HIV/AIDS
Reduction in # of abortions
Reduction in unplanned pregnancies in young women leading to improvements in education and employment opportunities

26. Contraceptive Use
Contraceptive use continues to increase although there is still an unmet need for contraception and family planning services
Female sterilization and IUDs are the main methods of contraception in developing countries
ICPD goal to achieve universal access to reproductive health by 2015
Important because
-- Unwanted pregnancies less likely to receive early antenatal care or give birth under supervision & prevents seeking unsafe abortions
spacing pregnancies by at least two years increases chance of child survival.
-- Up to 100,000 maternal deaths per year could be avoided with available contraceptives
Some 215 million women who would prefer to delay or avoid pregnancy still lack access to safe and effective contraception. It is estimated that satisfying the unmet need for family planning alone could cut the number of maternal deaths by almost a third. (

27. Abortions
Significant decline in the number of women dying from unsafe abortions worldwide (56,000 in 2003 to 47,000 in 2008)
Unintended pregnancies are the root of unsafe abortions
~13% of maternal deaths
The UK established the Safe Abortion Action Fund to provide resources to NGOs that focus on safe abortions
Unsafe Abortion: The Missing Link in Global Efforts to Improve Maternal Health
Addressing the role of unsafe abortion is 3-Fold:
Access to family planning services
Provision of safe abortion care
Promotion of emergency or post-abortion care to treat complications of incomplete or unsafe abortions
ABORTION LAWS:
-Decline is partly due to: “Between 1997 and 2008, the grounds on which abortion may be legally performed were broadened in 17 countries: Benin, Bhutan, Cambodia, Chad, Colombia, Ethiopia, Guinea, Iran, Mali, Nepal, Niger, Portugal, Saint Lucia, Swaziland, Switzerland, Thailand and Togo. Mexico City and parts of Australia (Capital Territory, Victoria, Tasmania and Western Australia) also liberalized their abortion laws.
-In 2008, more than 97% of abortions in Africa were unsafe. Southern Africa is the subregion with the lowest proportion of unsafe abortions (58%). Close to 90% of women in the subregion live in South Africa, where abortion was liberalized in 1997.
-In Nepal, where abortion was made legal on broad grounds in 2002, it appears that abortion-related complications are on the decline: A recent study in eight districts found that abortion-related complications accounted for 54% of all facility-treated maternal illnesses in 1998, but for only 28% in 2008–2009
Side note/interesting:
“On the front end, the United States is the world's leading donor in supporting family planning programs. On the back end, USAID's family planning and reproductive health program also supports access to postabortion care, although only partially. However, the United States does not work at all on the controversial middle prong of provision of safe abortion services.”
“European donors have increasingly become forthright and dedicated defenders of the full spectrum of sexual and reproductive health and rights. Countries that have supported foreign assistance specifically for abortion include Denmark, Finland, the Netherlands, Norway, Sweden and the United Kingdom.”

28. Skilled Attendance at Birth
Midwives, nurses, physicians and others who have been trained in proficiency in midwifery skills.
Provides safe, cost-effective, and timely emergency obstetric care
A skilled attendant includes: midwife, but is broader and more generic. It also includes nurses, physicians and others who have been trained in proficiency in midwifery skills. (does not include Traditional birth attendants who lack formal professional training)
When they are properly trained, empowered and supported, midwives in the community offer the most cost-effective and high-quality path to universal access to maternal health care.
Skilled attendants are trained to recognize complications of pregnancy early and manage problem or stabilize patient and refer to higher level of care
Community-based midwives help provide services to women in impoverished and rural areas
International Confederation of Midwives has expanded midwifery training to countries with the highest levels of maternal deaths
State of World’s Midwifery 2011 report states that 112,000 additional health personnel with midwifery skills are needed in the 38 countries surveyed

29. Giving Midwives More Responsibility
Increasing responsibility and protection to midwives makes emergency obstetric care more widely available in rural areas
Reduces costs
Increases access to care.
In Mozambique, senior nurses trained to perform Caesarean sections have achieved outcomes as good as those performed by specialist obstetricians. The training was part of an effort to make emergency obstetric care available at the lowest levels of the health system possible, particularly in rural areas where distance may be a significant barrier.
Unfortunately, this is occurring in very few places, even though experienced midwives often have the required skill set and are willing to take on greater responsibility if they were authorized.
An example of a country that is making progress in this area:
Until recently, Bangladesh had only community midwives. A cadre of certified midwives did not exist.
Bangladesh has been aided (Through UNFPA and ICM) to establish its first three midwifery training institutions, and the first-ever midwifery class graduated in A new midwife association has been launched and a country midwifery adviser posted. Bangladesh also has begun implementing a three-year, direct-entry midwifery programme., a two-year community midwifery education programme and post-basic midwifery training for nurses. Bangladesh has committed to double the percentage of births attended by a skilled health professional by 2015 and seeks to train an additional 3,000 midwives in total.

30. Proportion of Births Attended by Health Personnel

31. Edna Adan Hospital: Hargeisa, Somaliland
First licensed nurse-midwife in her country
Treats women and trains the next generation of midwives
Trained > 700 students
Rate of maternal mortality in Somaliland has decreased from 16 deaths per 1,000 live births (1997) to 10 per 1,000 (2006)
Trains students in nursing, midwifery, lab and pharm techs.
Delivered >12,000 babies & treated > 14,000 patients
Woman of the country providing this work especially in a country that has not received official international recognitino (hard to get support logistically from international aid groups)

32. Hamlin Fistula Hospital – Addis Abbaba, Ethiopia
Established in 1974
Provides free fistula repair surgery and healthcare for women
Interview with Dr Hamlin
Only 42% of Ethiopian women receive prenatal care
Less than 13% give birth with the help of a skilled birth attendant/midwife
Campaign to End Fistula
Strategies:
Provide access to adequate medical care for all pregnant women and emergency obstetric care for all who develop complications.
Increase access to education and family planning services for women and men.
Postpone pregnancy for young girls until they are physically mature.
Improve girls' nutrition to prevent stunted growth (which can leave the mother's pelvis small in relation to the baby's head) and to minimize the risk of complications during childbirth.
Repair physical damage through medical intervention and emotional damage through counselling. 

33. Gender Inequality
“Globally, women between the age 15 and 44 are more likely to be injured or die as a result of violence against women than through cancer, traffic accidents, malaria and war combined.”
– UN, Office for the Coordinator of Humanitarian Affairs. 9 December 2005.
Reproductive rights are key to fulfilling several of the Millenium Developmental goals – ending gender inequality, maternal mortality, improving the health of children. Affording reproductive rights to women is empowering, give them control of their own future and can help lift them out of poverty.
At the 1994 International Conference on Population and Development (ICPD), 179 governments pledged to make reproductive health care universally available "as soon as possible and no later than 2015".(3) From that conference emerged the global consensus that reproductive rights are central to human rights, sustainable development, gender equality and women's empowerment.

34. Discrimination Throughout a Lifetime
Infancy – infanticide, sex-selective abortion
Childhood – educational disadvantages, decreased change of completing primary and secondary education
Adolescence – abuse, exploitation, violence, child marriage, trafficking, lack of knowledge of reproductive health
Motherhood – pregnancy complications, maternal mortality, lack of power to control reproduction
Old age – discrimination from inheritance, property laws
Sex-selective abortion
Mothers under the age of 15 are at greater risk for death during childbirth

35. Female Genital Mutilation
Female genital mutilation (FGM) – procedures that intentionally alter or injure female genital organs for non-medical reasons
Reasons vary by region and include:
To reduce female sexuality (premarital sex, libido, etc)
Rite of passage to womanhood
Enhance fertility and child survival
Religious beliefs
In all cases female genital mutilation/cutting is a violation of humans rights as it offers no health benefits and leads to permanent damage or death
4 types of FGM
Type 1 – removal of clitoris
Type 2 – removal of clitoris and labia minora
Type 3 – infibulation – narrowing of the vaginal opening by creation of a seal using the labia majora
Type 4 – all other procedures that cause damage/harm to female genitalia
Sources:
Female genital mutilation = female circumcision, female genital cutting
Affect 100 to 140 million girls and women worldwide
Often done in unsanitary setting without anesthetics
Occurs between infancy and age 15 – most often on young girls
Practiced as a ritual in many African countries as a rite of passage and protection against promiscuity
Practiced in western, eastern & north-eastern Africa, some countries in Asia, the Middle East, immigrant populations in North America & Europe
Consequences – hemorrhage, sepsis, abscess/cyst formation, problems urinating, urinary tract infections, infertility, childbirth complications & newborn deaths
Feb 6 – International Day Against Female Genital Mutilation

36. “If you think education is expensive, try ignorance.”
“There is no tool for development more effective than the empowerment of women.”
Kofi Annan (U.N. Secretary-General '97-'07)
“If you think education is expensive, try ignorance.”
-Derek Bok
UNICEF’s report on the state of the world’s children states that gender equality and the well-being of children go hand in hand (2007)
Women do two-thirds of the world’s work, receive 10 percent of the world’s income and own 1 percent of the means of production

37. Empowerment & Education
“For each additional year of education achieved by 1,000 women, two maternal deaths will be prevented”
Better knowledge about health care practices
Expanded use of health services
Improved nutrition
Increased spacing between births
“Research has shown that mothers are more likely to use cash for the children’s benefits, and because the payments elevate the status of the mothers within the household” –HTS p173 “Opportunidades”
Ideas: how to incentivize taking care of your women.
Lack of value in the women causes problems in getting them to these forms of care
“Participatory, community-led decision-making”
Statistics indicate that for each additional year of education achieved by 1,000 women, two maternal deaths will be prevented.24 Research shows that maternal mortality is also reduced by better knowledge about health-care practices, expanded use of health services during pregnancy and birth, improved nutrition and increased spacing between births – all factors that are fostered by girls’ education.25 Women and girls are empowered when they have adequate knowledge about reproductive health, sexuality and HIV and AIDS, and can make decisions regarding these issues.

38. http://www.youtube.com/watch?v=N4ok_5D27BY&fe ature=relmfu
“UNICEF: Girls around the world talk about their lives and their rights”‬ I