Presentation on theme: "The WHO MultiCountry Survey on Maternal and Newborn Health"— Presentation transcript:
1 The WHO MultiCountry Survey on Maternal and Newborn Health - 2010-11 Prof. Dr. Syeda Batool MazharFRCOG (U.K), FCPS (PK)Head of Department, MCH Centre, PIMS, Islamabad
2 BackgroundThe world has seen two important changes in maternal health:Substantial reduction in global maternal mortalityIncrease in proportion of childbirths in health facilities.Progress though remarkable is insufficient to meet the MDG’sEstimated 287,000 women died in 2010 of causes related to pregnancy and childbirthA substantial proportion of childbirths are still taking place in communities without skilled birth assistanceIn many settings, women prefer to deliver in the community due to concerns about perceived quality of care in health facilities.Thus quality of care is increasingly critical to accelerate reduction in maternal mortality & stimulate demand for institutional births..
3 BackgroundQuality of care is a multidimensional concept resulting in patient and provider satisfaction and improved health outcomes that includesAppropriate use of effective clinical and non-clinical interventionsStrengthened health infrastructureHealth providers’ attitude“As part of strategies to improve maternal health care, great emphasis has been placed on maximizing coverage that can be objectively monitored and evaluated, however other dimensions of quality are more challenging”
4 The WHO Multi Country Survey on Maternal and Newborn Health 2010-11 Primary ObjectiveTo study the incidence and the management of maternal and neonatal conditions highly associated with maternal and neonatal mortality in a worldwide network of health facilities.4
5 The WHO Multicountry Survey on Maternal & Newborn Health 2010-11 Secondary ObjectivesTo assess the quality of care by the maternal near miss indicators and the use of effective preventive and therapeutic interventions.To examine the relationship of the use of effective preventive and therapeutic interventions with severe perinatal morbidity and mortalityTo consolidate the WHO Multicountry, Maternal and Perinatal Health network and strengthen research capacity of health facilities worldwide.
6 Materials and methods Large cross-sectional survey May 2010 to December 201114 WHO sub-regions selected based on levels of child and adult mortalityWorldwide network of 357 health facilitiesin 29 countries from Africa, Asia, Latin America and the Middle East314,623 observations
8 SELECTED COUNTRIES IN WHO MULTICOUNTRY SURVEY Group ILow MMRGroup IIModerate MMRGroup IIIHigh MMRGroup IVVery High MMR(MMR<20)(MMR 20-99)(MMR )(MMR 300+)JapanQatarArgentinaBrazilChinaJordanLebanonSri LankaMexicoMongoliaNicaraguaOccupied Palestinian TPeruPhilippinesParaguayThailandViet NamEcuadorIndiaCambodiaNepalPakistanAfghanistanAngolaDemocratic Republic of the CongoKenyaNigerNigeriaUganda
9 Materials and methodsMedical records of all eligible women were reviewedAverage data collection period = 92 daysThe health facilities were eligible if they conducted ≥1,000 deliveries annually and had the capacity to provide caesarean sectionCountries, provinces and health facilities were randomly selected through a stratified, multistage cluster sampling strategy.Health facilities were located in urban or peri-urban areas and 37% of them were tertiary hospitals (11% were primary and 46% were secondary health facilities)
10 The WHO MultiCountry Survey on Maternal and Newborn Health 2010-11 16 health facilities with annual delivery rates > 1000, randomly selected in Sind, Punjab and Islamabad.Punjab:Sindh:Rawalpindi Medical CollegeNishtar Hospital MultanBahawalpur Victoria HospitalDHQ Hospital Toba Tek SinghTHQ Hospital MuridkeSheikh Zayed Hospital LahoreServices Hospital Lahore.Federal Capital: PIMS, IslamabadCivil Hospital KarachiSobhraj Hospital KarachiKorangi Hospital KarachiQatar Hospital KarachiTaluka Hospital RohriCivil Hospital JakobabadCivil Hospital Badin& FGSH, Islamabad
11 Materials and methods Study Population All women giving birthin selected study hospitals11
12 Materials and methods Study Population All deaths of women during pregnancy, childbirth or within seven days of termination of pregnancy(regardless of the gestational age and the delivery status)12
13 Materials and methods Study Population All maternal near miss cases, regardless of the gestational age and the delivery status13
14 Most of eligible women are giving birth Eligibility CriteriaThe Study PopulationMost of eligible women are giving birth14
15 But, few eligible women are not giving birth Eligibility CriteriaThe Study PopulationBut, few eligible women are not giving birth15
16 Eligibility Criteria The Study Population All delivering women+ all near miss cases and deaths of non delivering women16
17 Maternal Mortality Definition: Maternal death (MD)is the death of a woman while pregnant or within 42 days of termination of pregnancy,Irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its managementBut not from accidental or incidental causes.World Health Organization
18 Maternal Near Miss Mortality Definition:"A woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy"This definition by WHO reconciles previous maternal near miss definitions and is aligned with "maternal death" definition of ICD1005_XXX_MM18
19 Why maternal near miss Mortality ? Near miss/SAMM cases share many characteristics with maternal deathsCan directly inform on obstacles that had to be overcome after the onset of an acute complication.Corrective actions for identified problems can be taken to reduce related mortality and long-term morbidity
20 WHO Maternal Near Miss identification criteria 05_XXX_MM20A set of organ dysfunction markers including Basic laboratory tests & Management-related markersClinical criteria based on the clinical assessment where laboratory and other techniques are not available
21 ResultsWe Report the main findings of the WHO Multi country Survey on Maternal and Newborn Health which evaluatedThe burden of pregnancy-related complications,The coverage of key maternal health interventions
22 Summary of Global MCSurvey Results CountriesTotal Women ,623Maternal near missMaternal deathsSevere maternal outcome (MNM+MM) 1%Potential life-threatening conditions 7%
23 Summary of Global MCSurvey Results Most frequent complications in women with severe maternal outcomes:Postpartum hemorrhage (26 %).Pre-eclampsia /eclampsia (26 %).The observed mortality in high mortality countries including Pakistan, was 2-3 times higher than expected for the assessed severity despite a high coverage of essential interventions.
24 Total no of patients STUDY FLOW CHART: PAKISTAN n.= 13175 No delivery in participating facility (women with organ dysfunction)n=53Delivery in participating facility (women with or without organ dysfunction) n=13122Abortive outcome n=11Antepartum n=8Postpartum n=34Near miss n=10Maternal death n=1Near miss n=4Maternal death n=4Near miss n=28Maternal death n=6No near miss with out complication n=12017No near miss with complication n=1026Near miss n=52Maternal death n=27
25 Frequency And Severity Of Pregnancy-related Complications PakistanEMROWORLDWOMEN1317549484308985Women with complications1158 (8.7%)3088 (6.2 %)(7.4%)Women with SMO132 (1 %)(0.84 %)(0.98 %)Maternal near miss cases945552529Maternal deaths3859514Maternal mortality ratio299123170Maternal nearmiss : maternal mortality ratio3:110:15:1
27 Coverage Of Key Interventions Pakistan(%)EMRO(%)World(%)prophylactic oxytocin97.996.790.1therapeutic oxytocin93.685.786.4magnesium sulphate for eclampsia93.391.886.8prophylactic antibiotic forc section80.977.987.7parentral antibiotic for sepsis88.582.077.0Corticosteroids for preterm birth57.740.637.1
28 Coverage of key interventions by country group Low- MMR countriesModerate-MMR countriesHigh MMR countriesVery-High MMR countriesProphylactic oxytocin82%91%88%92%Therapeutic oxytocin84%86%MgSO4 for eclapmsia75%89%80%87%Prophylactic antibiotic for c sec36%83%Parentral antibiotics for sepsis69%63%
29 Interventions related to postpartum hemorrhage prevention of PPH n=13175 %Use of oxytocin1287596.4%Misoprostol722754.9%Ergotamine289322%Other uterotonics2131.6%
30 Interventions related to postpartum hemorrhage treatment of PPH n=187 %Oxytocin17593.6Misoprostol15884.5Ergometrine10757.2Other uterotonics3418.3Any uterotonics17794.6Artery ligation191Balloon or condom tamponade63.2Hysterectomy10.2Severe maternal outcomes3820.3Deaths136.9
31 Interventions related to preterm labour N=1449 Yes%Use of corticosteroids47.9Betamimetics1.5NSAIDS0.6Ca channel blockers6.6Oxytocin antagonist0.4MgSO40.5Bed rest34.2Hydration36.1No treatment for PTL42
32 Pregnancy Complications and Severe Maternal Outcome Statistically sig diff b/w SMO and non-SMO group for maternal education p= 0.000Statistically sig diff b/w SMO and non-SMO group for no of previous c section P=0.027
33 Maternal complications Hemorrhage related severe maternal outcome
34 Maternal complications Infection related severe maternal outcome SMO n=132
35 Maternal Complications In Severe Maternal Outcome Hypertensive Disorders
36 Maternal complications other complications related severe maternal outcome
37 Anesthesia for LSCS N= 4202 % Gen anesthesia 464 11% Epidural 48 1% spinal369089%
38 Maternal intensive care use PakistanEMROWorldICU admission rate0.5%1%0.6%ICU admission rate among women with SMO32.6%48.5%31.7%SMO rate among women admitted to ICU61.4%49.6%Proportion of maternal deaths assisted without ICU admission44.7%42.4%69.6%
39 Facilities in study hospitals in Pakistan YesNoNICU63.4%36%Appropriate adult ICU57.7%42.3%Appropriate neonatal ICU60%39%Ambulance100%Blood bank94.6%3.6%
40 Medical staff availability in study hospitals (Pakistan) 24/7 Inside facility%24/7 Outside facilityPartially availablePeadiatrician413919Obstetrician7326.6Anesthetist7016.912.4
41 Women with SMO Pakistan Perinatal outcomeVariablesAll womenPakistanWomen with SMO PakistanPreterm births11.253.2Fetal deaths3.239.2Early neonatal deaths (intra-hospital)2.114.9Neonatal intensive care unit admission7.433.3Birth weight distribution among live births<1750g18.7g5.525.0g3.36.2g86.647.9>4000g2.6
42 Relation Of Birth Weight With Neonatal Outcome Outcome of newbornsp-valueDischarged(n = 12590)Died(n = 293)Birth weightLow birth weight1304 (10.4%)186 (63.5%)<0.001Normal birth weight11286 (89.6%)107 (36.5%)
43 Discussion“Beyond the coverage of essential interventions – the next challenge for reducing global maternal mortality “The high coverage of essential interventions suggests that these interventions are available & used in majority of studied health facilitiesMismatch between high coverage of essential interventions and the substantial variations in health outcomes implies that there are other factors driving these outcomes.Delays in implementing these interventions or interventions poorly implemented could explain part of the excessive mortality and morbidity observed in some settings.Verticalization of care (i.e. few effective interventions implemented in disconnection of comprehensive care) could be an issue
44 DiscussionOther elements of care and quality may be playing a strong role in severe maternal morbidity survival as inPostpartum haemorrhage, prophylactic and therapeutic uterotonics are essential but shock management and prompt surgical care are also critical.Magnesium sulphate is fundamental to the management of eclampsia, but other aspects of care (such as pre-delivery stabilization, severe hypertension management or airway management for adequate oxygenation and prevention of aspiration pneumonia) are also essential.The prevalence of infection increased as case severity increased.The prevalence of sepsis and other systemic infections is more than four times the prevalence of puerperal endometritis. This may indicate that the prevention, early identification and appropriate management of secondary infections (e.g. postoperative infection, aspiration pneumonia) and other non-obstetric infections should be regarded as a high priority
45 DiscussionAssessment of severity is often incomplete: there is an apparent underestimation of severity due to paucity of information related to organ dysfunction.In settings where important constraints in the assessment of severity exist, poor assessments of severity may contribute to delays in the implementation of effective interventions and poor clinical management.Health systems issues (such as referral processes), underlying undernutrition, pre-existing moderate to severe anaemia and other factors could also have played a role.
46 Discussion It is the MOM… Neonatal Outcome Poor maternal health & nutritionPoor maternal educationLack of birth spacingPoor antenatal care (ANC)Unskilled deliveriesLack of clean delivery practicesImproper neonatal resuscitationPoor post natal carePoor infant feeding practices
47 Strengths of WHO MC Survey It is one of the largest studies exploring the management of severe complications and the prevalence of maternal near miss using standardized definitions across several countries. This study captured approximately 0.7% of the maternal deaths during a 3-month period in the world.Several procedures were adopted to ensure appropriate implementation and high quality data (such as training, pre-data entry visual check of the data collection forms, automated queries, double-checking selected medical records, and thorough audit of unclear cases, particularly maternal deaths)Ensuring standardization of processes is a challenging task by minimizing methodological heterogeneity and maximized data quality .
48 Limitations of WHO MC Survey The magnitude and the no’s of personnel involved (> 1500 )The data source-Routine hospital records, could be suboptimal.Only short-term ( 7 days) intra-hospital data collected. A small no of survivors may have died in the remaining puerperal and NN period.In settings where basic laboratory tests are not available there is a possibility of under-identification of near miss cases and under-estimation of severity. In such settings, a large proportion of women with unrecognized organ dysfunctions may die in absence of appropriate life support, worsening the ratio of MD to MNM.The study design did not assess labor duration, hence no data available on the prevalence of obstructed labor.As the WHOMCS conducted in secondary and tertiary facilities it may not represent maternal outcomes and coverage of essential interventions in smaller facilities or in the community.
49 Generalisability and Applicability of WHO MC Survey In view of study characteristics, the present findings should not be regarded as representative of countries, but indicative of the situation in a large sample of health facilities.The situation in lower-level facilities is likely to be different, particularly in terms of coverage of essential interventions.The coverage of facility-based care in a given geographical area may influence the frequency of complications observed at the facility level.
50 ConclusionsImplementing the systematic identification of near miss case, mapping the use of critical interventions and analysing the corresponding indicators are the initial steps for using the maternal near miss concept as a tool to improve MN health.These findings are a good starter for a more comprehensive dialogue with governments, professional and civil societies, health systems or facilities for promoting best practices, improving quality of care and achieving better MCH.
51 THE WAY FORWARD “Translating Research Into Experience” Identification of priorities in maternal and newborn healthPolicy making and advocacyPublication of study related papers in reputed medical journals
52 ReferencesWorld Health Organization, UNICEF, UNFPA and the World Bank. Trends in maternal mortality: 1990 to Geneva: World Health Organization, 2012 (World Health Organization website. Available: _eng.pdf. Accessed 2012 April 8).United Nations. Global Strategy for Women's and Children's Health. New York: United Nations, 2010 (World Health Organization website)Souza JP, Gülmezoglu AM, Carroli G, Lumbiganon P, Qureshi Z; WHOMCS Research Group. The World Health Organization multicountry survey on maternal and newborn health: study protocol. BMC Health Serv Res Oct 26;11: 286.World Health Organization: Evaluating the quality of care for severe pregnancy complications: The WHO near-miss approach for maternal health. Geneva: World Health Organization, 2011 (World Health Organization website. Available: who.int/publications /2011/ _eng.pdf. Accessed 2012 Nov 12)Beyond the coverage of essential interventions – the next challenge for reducing global maternal mortality: findings of the World Health Organization Multi-country Survey on Maternal and Newborn Health. Souza JP, Gülmezoglu AM, Joshua Vogel, Carroli G, Lumbiganon P et al. Lancet, May Accepted. Awaiting publication.
53 ACKNOWLEDGEMENTThe Multicountry Survey on Maternal and Newborn Health acknowledges the extensive network of institutions and individuals who contributed to the project design and implementation, including researchers, study coordinators, data collectors, data clerks and other partners including the staff from the Ministries of Health and WHO offices.Members of the WHO MCS Research Group include: João Paulo Souza (WHO – Global Study Coordinator), Ahmet Metin Gülmezoglu (WHO – Global Study Coordinator), Guillermo Carroli (Centro Rosarino de Estudios Perinatales - CREP, Argentina – Coordinator for Latin America), Pisake Lumbiganon (Khon Kaen University, Thailand – Coordinator for Asia), Zahida Qureshi (University of Nairobi, Kenya – Coordinator for Africa) and the country coordinators from 29 selected countries.For Pakistan, support of WHO Country Office led by Dr K Bille, Dr Nima Abid, Dr Shadoul, Dr Iqbal Kahut and Dr Zareef is appreciated. The federal MNCH cell staff, Islamabad, in particular Dr Salim assisted in the selection of facilities as well as in coordination. The office of Federal Director General Health, Dr Rashid Juma and Executive Director, PIMS, provided excellent administrative guidance as necessary. The central office in PIMS, Islamabad and its staff as well as residents who assisted the central office are acknowledged for their contribution.
54 ACKNOWLEDGEMENTPakistan Country Coordinator: Prof. Dr Syeda Batool MazharPunjab Province Coordinator: Prof. Dr Arif Tajjammul Assistant Coordinator: Dr Alia BashirSind Province Coordinator: Prof. Dr Shereen Bhutta Assistant Coordinator: Dr Haleema YasminHOSPITAL COORDINATORS: SELECTED HOSPITALSProf. Dr Ghazala Mahmud & Dr Nasira Tasnim Unit I, MCH Centre, PIMS, IslamabadProf. Dr Syeda Batool Mazhar & Dr Shagufta Yasmin Unit II, MCH Centre, PIMS, IslamabadDr Riffat Shaheen & Dr Fariha Rahim Federal government Services Hospital, IslamabadProf. Dr Asma Usmani Benazir Bhutto Hospital, Rawalpindi, RMCProf. Dr Rizwana Chaudary & Dr Naheed Unit I, Holy Family Hospital, Rawalpindi ,RMCProf. Dr Fehmida Shaheen Unit II, Holy Family Hospital, Rawalpindi, RMCProf. Dr Shagufta Sayyal District Headquarter Hospital, Rawalpindi, RMCProf. Dr M. Saeed & Dr M.Ikram Shiekh Zayed hospital, LahoreProf. Dr Naheed Fatima Unit I, Bahawalpur Victoria Hospital.Dr Tasneem Akhter Unit II, Bahawalpur Victoria Hospital,Prof. Dr Samee & Dr Hajra Masood Nishtar Hospital MultanProf. Dr Saqib Siddiq, Dr Rubina Services Hospital LahoreDr. Shamama, District Headquarter Hosp, Toba Tek SinghDr Nuzhat Alam THQ Hospital, MuridkeProf. Dr Nargis soomro Unit I, Civil Hospital Karachi, DMCProf. Dr Subhana Tayyab Unit II, Civil Hospital Karachi, DMCProf. Dr Ayesha Khan Unit III, Civil Hospital Karachi, DMCDr Syed Hasan Ala Qatar Hospital, KarachiDr Tahira Jabeen Korangi Hospital, KarachiDr Sonia Sobhraj Hospital, KarachiDr Naheed Soomro Civil Hospital, JacobabadDr Shabana Solangi Taluka Hospital, RohriDr Hakimzadi Civil Hospital, Badin