2. LEARNING OBJECTIVES By the end of the module, the participants will be able to:  Identify major causes of maternal and neonatal mortality  Determine the role of radiology in maternal and neonatal health  Illustrate the impact of ultrasonography and interventional radiology  Identify items necessary for a successful program  Identify strategies to advocate for radiology 1

3. KEY FACTS  The estimated risk of a woman dying from causes associated with the pregnancy postpartum cycle in high-income countries is 1 in 3 400, compared to 1 in 52 in lower-income countries. In 2013, the recorded estimated maternal death was 289 000.  Every day, approximately 800 women die from preventable causes related to pregnancy and childbirth.  99% of all maternal deaths occur in developing countries.  Maternal mortality is higher in women living in rural areas and among poorer communities. 2

4. CAUSES OF DEATH The major complications that account for nearly 75% of all maternal deaths include:  Severe bleeding (mostly bleeding after childbirth)  High blood pressure during pregnancy (pre-eclampsia and eclampsia)  Complications from delivery and unsafe abortion. 3

5. 4 MATERNAL MORTALITY

6. LATIN AMERICA AND THE CARIBBEAN (LAC) MATERNAL AND NEONATAL HEALTH

7. KEY FACTS IN LAC 6 In Latin America and the Caribbean, approximately 16 women die every day from complications of pregnancy or childbirth. In 2013, 9,300 women died from maternal causes

8. KEY FACTS IN LAC In LAC, 250 babies die each day before having reached 28 days of age. Neonatal deaths occur during the first week of life, and the main causes include prematurity, congenital anomalies, asphyxia, sepsis and other infections. 7

9. TRENDS IN LAC  Hemorrhage is one of the leading causes of these deaths. One in five maternal deaths in the region results from hemorrhage during the third trimester of pregnancy or immediately following childbirth 8 Haiti Training zero maternal death by hemorrhage

10. HYPERTENSION  25% of maternal deaths are related to complications from high blood pressure.  Babies of mothers with hypertension have a greater risk of fetal and neonatal mortality, as well as being small for gestational age, premature birth, neonatal depression and respiratory problems. 9

11. UNSAFE ABORTION  Worldwide 1 in 10 pregnancies end in an unsafe abortion.  There were 14 unsafe abortions per 1000 women aged 15–44 years worldwide and Almost all unsafe abortions take place in developing countries.  The highest [regional] unsafe abortion rate (31) is in the Latin America and the Caribbean Region  The rate of unsafe abortion in Latin America and the Caribbean is 31 per 1,000 women ages 15 to 44, in contrast to 22 per 1,000 in the rest of the world. 10

12. THE ROLE OF RADIOLOGY 11

13. ROLE OF RADIOLOGY Radiology plays a major role in maternal and neonatal’s health through the proper use of obstetric ultrasonography and interventional radiology. Ultrasonography plays a diagnostic role and interventional radiology is more therapeutic 12

14. ULTRASONOGRAPHY Ultrasonography can address potential life threatening complications such as fetal malpresentation, multiple gestations, ectopic pregnancy and placenta previa. Also, it is useful in the assessment of the cervix in women at risk for premature birth, developmental defects before birth and other pathologies. 13

15. ADVANTAGES OF ULTRASONOGRAPHY The use of Ultrasound is very beneficial and is an asset in both high and low income countries.  It is an economically sound solution as it could be a portable unit, low cost and requires limited personnel.  Ultrasonography does not emit ionizing radiation; it does not require room shielding or staff monitoring, but a small contingency of consumable such as gel and print medium or data storage 14

16. INTERVENTIONAL RADIOLOGY Interventional Radiology is making childbirth safer for some women by reducing bleeding during delivery. Interventional radiology is an advanced branch of medicine that uses minimally invasive procedures to treat a variety of conditions. One of the best known applications of interventional radiology is to control or stop excessive bleeding through a procedure called embolization. Unlike ultrasonography, interventional radiology requires a specific and complex infrastructure as well as resources to support the services 15

17. QUALITY SERVICES Radiology requires well trained professionals with extensive knowledge in the acquisition and interpretation of images. Also, the implementation of quality control and assurance programs will ensure a reliable and accurate diagnosis 16

18. CHALLENGES Even where diagnostic imaging is available, both the quality and safety of the procedures may be questionable. Latin America and the Caribbean face a lack of:  Access and quality of imaging services  Availability of qualified human resources and continuing education  Quality control and assurance programs  National regulatory programs 17

19. ACCESS TO IMAGING SERVICES IN LAC An estimated 3.6 billion diagnostic x–rays are performed worldwide each year, but this figure masks the wide disparity in radiological diagnosis rates between the developing and industrialized countries. 18

20. ACCESS TO IMAGING SERVICES In Latin America and the Caribbean, countries at an intermediate level of health care development perform some 400 radiological studies per 1,000 population annually, while the numbers for those with low levels of health care development remain unchanged at 30 per 1,000 population. In the industrialized countries the figure is 1,700 studies per 1,000 population. 19

21. QUALIFIED HUMAN RESOURCES PAHO studies have shown that there is a direct relationship between the accuracy of radiological interpretation and the quality of images. In turn, the quality of the images was directly related to the training of radiological technologists 20

22. QUALTIY ASSURANCE AND CONTROL Quality assurance programs designed to obtain accurate diagnoses improve the quality of the image and reduce the dose of radiation to both patient and health worker. A 2008 study conducted in sentinel hospitals showed that the quality of the pediatric chest x–rays was not good and there were major differences in the doses of radiation and the quality of the images 21

23. NATIONAL REGULATORY PROGRAM Almost two thirds of all low-income countries do not have a national health technology policy in the national health programs to guide the planning, assessment, acquisition and management of medical equipment. Although 21 Latin American and Caribbean countries have regulatory authorities in radiation safety, the technical capacity and resources are insufficient to perform the required function 22

24. RECOMMENDATIONS  Placement of Accreditation Committees for the Implementation of Accreditation Programs o Each facility seeking accreditation of ultrasound services should submit clinical images and physicians’ reports to the accreditation committee for evaluation and ultimately approval  Personnel Qualification o Formally trained professional able to apply protocols and maintain basic standard of care  Implementation of Quality Assurance and Control Programs o Routine quality control (QC) testing of the ultrasound equipment must occur regularly; a minimum requirement is annually Jiménez P, Borrás C, Fleitas I. Accreditation of diagnostic imaging services in developing countries. Rev Panam Salud Publica. 2006; 20(2/3):104–12. 23

25. WORLD RADIOLOGY DAY WORLD RADIOLOGY DAY IS CELEBRATED ON NOVEMBER 8 AROUND THE WORLD.  The PAHO’s Radiological Health Program celebrates to bring awareness of the role of imaging in many public health concerns including maternal and neonatal health.  The event allows to discuss strategies to make the programs more effective and successful 24

26. WORLD RADIOLOGY DAY 2013 25

27. WORLD RADIOLOGY DAY 2014 26

28. WORLD RADIOLOGY DAY 2015 27

29. YOUR ROLE ON WORLD RADIOLOGY DAY Health Authorities will play a critical role in World Radiology Day:  Ensure the implementation of policies to guide the planning, assessment, acquisition and management of medical equipment  Developing policies for standard of care  Ensure that the health workers are properly trained in the technology and have access to continuing education 28

30. REFERENCES 1.World Health Organization (May 2014). Maternal Mortality. Fact sheet N°348. http://www.who.int/mediacentre/factsheets/fs348/en/ http://www.who.int/mediacentre/factsheets/fs348/en/ 2.Pan American Health Organization (April 2015). New PAHO/WHO Network Will Monitor The Health Of Women And New Born In Latin America And The Caribbean http://www.paho.org/hq/index.php?option=com_content&view=article&id=10725%3A2015-pahowho- network-will-monitor-the-health-of-women-and-newborns&catid=740%3Anews-press- releases&Itemid=1926&lang=en http://www.paho.org/hq/index.php?option=com_content&view=article&id=10725%3A2015-pahowho- network-will-monitor-the-health-of-women-and-newborns&catid=740%3Anews-press- releases&Itemid=1926&lang=en 3.Pan American Health Organization (May 2014). 11 countries in Latin America and the Caribbean have reduced maternal mortality New UN data show 4.http://www.paho.org/hq/index.php?option=com_content&view=article&id=9552%3A2014-11-countries- latin-america-caribbean-reduced-maternal-mortality-new-data-show&catid=740%3Anews-press- releases&Itemid=1926&lang=enhttp://www.paho.org/hq/index.php?option=com_content&view=article&id=9552%3A2014-11-countries- latin-america-caribbean-reduced-maternal-mortality-new-data-show&catid=740%3Anews-press- releases&Itemid=1926&lang=en 5.Pan American Health Organization (2013) Fact Sheets On Hypertension And Pregnancy. http://www.paho.org/hipertension/wp-content/uploads/2013/04/WHD2013-factsheet-eng.pdf http://www.paho.org/hipertension/wp-content/uploads/2013/04/WHD2013-factsheet-eng.pdf 6.Pan American Health Organization: Training in Haiti for Zero maternal deaths by hemorrhage. http://www.paho.org/HQ/index.php?option=com_content&view=article&id=11001%3A2015-training-haiti- zero-maternal-deaths-hemorrhage&catid=4717%3Afgl-news&Itemid=39620&lang=en http://www.paho.org/HQ/index.php?option=com_content&view=article&id=11001%3A2015-training-haiti- zero-maternal-deaths-hemorrhage&catid=4717%3Afgl-news&Itemid=39620&lang=en 29

31. 30 THANK YOU