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The WHO MultiCountry Survey on Maternal and Newborn Health

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1 The WHO MultiCountry Survey on Maternal and Newborn Health - 2010-11
Prof. Dr. Syeda Batool Mazhar FRCOG (U.K), FCPS (PK) Head of Department, MCH Centre, PIMS, Islamabad

2 Background The world has seen two important changes in maternal health: Substantial reduction in global maternal mortality Increase in proportion of childbirths in health facilities. Progress though remarkable is insufficient to meet the MDG’s Estimated 287,000 women died in 2010 of causes related to pregnancy and childbirth A substantial proportion of childbirths are still taking place in communities without skilled birth assistance In 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 Background Quality of care is a multidimensional concept resulting in patient and provider satisfaction and improved health outcomes that includes Appropriate use of effective clinical and non-clinical interventions Strengthened health infrastructure Health 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 Objective To 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 Objectives To 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 mortality To 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 2011 14 WHO sub-regions selected based on levels of child and adult mortality Worldwide network of 357 health facilities in 29 countries from Africa, Asia, Latin America and the Middle East 314,623 observations

7 29 countries, 357 health facilities
Americas - 8 countries Africa - 7 countries Asia - 14 countries 314,623 deliveries

Group I Low MMR Group II Moderate MMR Group III High MMR Group IV Very High MMR (MMR<20) (MMR 20-99) (MMR ) (MMR 300+) Japan Qatar Argentina Brazil China Jordan Lebanon Sri Lanka Mexico Mongolia Nicaragua Occupied Palestinian T Peru Philippines Paraguay Thailand Viet Nam Ecuador India Cambodia Nepal Pakistan Afghanistan Angola Democratic Republic of the Congo Kenya Niger Nigeria Uganda

9 Materials and methods Medical records of all eligible women were reviewed Average data collection period = 92 days The health facilities were eligible if they conducted ≥1,000 deliveries annually and had the capacity to provide caesarean section Countries, 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 College Nishtar Hospital Multan Bahawalpur Victoria Hospital DHQ Hospital Toba Tek Singh THQ Hospital Muridke Sheikh Zayed Hospital Lahore Services Hospital Lahore. Federal Capital: PIMS, Islamabad Civil Hospital Karachi Sobhraj Hospital Karachi Korangi Hospital Karachi Qatar Hospital Karachi Taluka Hospital Rohri Civil Hospital Jakobabad Civil Hospital Badin & FGSH, Islamabad

11 Materials and methods Study Population
All women giving birth in selected study hospitals 11

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 status 13

14 Most of eligible women are giving birth
Eligibility Criteria The Study Population Most of eligible women are giving birth 14

15 But, few eligible women are not giving birth
Eligibility Criteria The Study Population But, few eligible women are not giving birth 15

16 Eligibility Criteria The Study Population
All delivering women+ all near miss cases and deaths of non delivering women 16

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 management But 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 ICD10 05_XXX_MM18

19 Why maternal near miss Mortality ?
Near miss/SAMM cases share many characteristics with maternal deaths Can 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_MM20 A set of organ dysfunction markers including Basic laboratory tests & Management-related markers Clinical criteria based on the clinical assessment where laboratory and other techniques are not available

21 Results We Report the main findings of the WHO Multi country Survey on Maternal and Newborn Health which evaluated The burden of pregnancy-related complications, The coverage of key maternal health interventions

22 Summary of Global MCSurvey Results
Countries Total Women ,623 Maternal near miss Maternal deaths Severe 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=53 Delivery in participating facility (women with or without organ dysfunction) n=13122 Abortive outcome n=11 Antepartum n=8 Postpartum n=34 Near miss n=10 Maternal death n=1 Near miss n=4 Maternal death n=4 Near miss n=28 Maternal death n=6 No near miss with out complication n=12017 No near miss with complication n=1026 Near miss n=52 Maternal death n=27

25 Frequency And Severity Of Pregnancy-related Complications
Pakistan EMRO WORLD WOMEN 13175 49484 308985 Women with complications 1158 (8.7%) 3088 (6.2 %) (7.4%) Women with SMO 132 (1 %) (0.84 %) (0.98 %) Maternal near miss cases 94 555 2529 Maternal deaths 38 59 514 Maternal mortality ratio 299 123 170 Maternal nearmiss : maternal mortality ratio 3:1 10:1 5:1

26 Maternal mortality ratio(WHO MCS 2011)

27 Coverage Of Key Interventions
Pakistan(%) EMRO(%) World(%) prophylactic oxytocin 97.9 96.7 90.1 therapeutic oxytocin 93.6 85.7 86.4 magnesium sulphate for eclampsia 93.3 91.8 86.8 prophylactic antibiotic for c section 80.9 77.9 87.7 parentral antibiotic for sepsis 88.5 82.0 77.0 Corticosteroids for preterm birth 57.7 40.6 37.1

28 Coverage of key interventions by country group
Low- MMR countries Moderate-MMR countries High MMR countries Very-High MMR countries Prophylactic oxytocin 82% 91% 88% 92% Therapeutic oxytocin 84% 86% MgSO4 for eclapmsia 75% 89% 80% 87% Prophylactic antibiotic for c sec 36% 83% Parentral antibiotics for sepsis 69% 63%

29 Interventions related to postpartum hemorrhage prevention of PPH n=13175
% Use of oxytocin 12875 96.4% Misoprostol 7227 54.9% Ergotamine 2893 22% Other uterotonics 213 1.6%

30 Interventions related to postpartum hemorrhage treatment of PPH n=187
% Oxytocin 175 93.6 Misoprostol 158 84.5 Ergometrine 107 57.2 Other uterotonics 34 18.3 Any uterotonics 177 94.6 Artery ligation 19 1 Balloon or condom tamponade 6 3.2 Hysterectomy 10.2 Severe maternal outcomes 38 20.3 Deaths 13 6.9

31 Interventions related to preterm labour N=1449
Yes% Use of corticosteroids 47.9 Betamimetics 1.5 NSAIDS 0.6 Ca channel blockers 6.6 Oxytocin antagonist 0.4 MgSO4 0.5 Bed rest 34.2 Hydration 36.1 No treatment for PTL 42

32 Pregnancy Complications and Severe Maternal Outcome
Statistically sig diff b/w SMO and non-SMO group for maternal education p= 0.000 Statistically 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%
spinal 3690 89%

38 Maternal intensive care use
Pakistan EMRO World ICU admission rate 0.5% 1% 0.6% ICU admission rate among women with SMO 32.6% 48.5% 31.7% SMO rate among women admitted to ICU 61.4% 49.6% Proportion of maternal deaths assisted without ICU admission 44.7% 42.4% 69.6%

39 Facilities in study hospitals in Pakistan
Yes No NICU 63.4% 36% Appropriate adult ICU 57.7% 42.3% Appropriate neonatal ICU 60% 39% Ambulance 100% Blood bank 94.6% 3.6%

40 Medical staff availability in study hospitals (Pakistan)
24/7 Inside facility % 24/7 Outside facility Partially available Peadiatrician 41 39 19 Obstetrician 73 26.6 Anesthetist 70 16.9 12.4

41 Women with SMO Pakistan
Perinatal outcome Variables All women Pakistan Women with SMO Pakistan Preterm births 11.2 53.2 Fetal deaths 3.2 39.2 Early neonatal deaths (intra-hospital) 2.1 14.9 Neonatal intensive care unit admission 7.4 33.3 Birth weight distribution among live births <1750g 18.7 g 5.5 25.0 g 3.3 6.2 g 86.6 47.9 >4000g 2.6

42 Relation Of Birth Weight With Neonatal Outcome
Outcome of newborns p-value Discharged (n = 12590) Died (n = 293) Birth weight Low birth weight 1304 (10.4%) 186 (63.5%) <0.001 Normal birth weight 11286 (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 facilities Mismatch 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 Discussion Other elements of care and quality may be playing a strong role in severe maternal morbidity survival as in Postpartum 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 Discussion Assessment 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 & nutrition Poor maternal education Lack of birth spacing Poor antenatal care (ANC) Unskilled deliveries Lack of clean delivery practices Improper neonatal resuscitation Poor post natal care Poor 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 Conclusions Implementing 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 health Policy making and advocacy Publication of study related papers in reputed medical journals

52 References World 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: /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 ACKNOWLEDGEMENT The 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 ACKNOWLEDGEMENT Pakistan Country Coordinator: Prof. Dr Syeda Batool Mazhar Punjab Province Coordinator: Prof. Dr Arif Tajjammul Assistant Coordinator: Dr Alia Bashir Sind Province Coordinator: Prof. Dr Shereen Bhutta Assistant Coordinator: Dr Haleema Yasmin HOSPITAL COORDINATORS: SELECTED HOSPITALS Prof. Dr Ghazala Mahmud & Dr Nasira Tasnim Unit I, MCH Centre, PIMS, Islamabad Prof. Dr Syeda Batool Mazhar & Dr Shagufta Yasmin Unit II, MCH Centre, PIMS, Islamabad Dr Riffat Shaheen & Dr Fariha Rahim Federal government Services Hospital, Islamabad Prof. Dr Asma Usmani Benazir Bhutto Hospital, Rawalpindi, RMC Prof. Dr Rizwana Chaudary & Dr Naheed Unit I, Holy Family Hospital, Rawalpindi ,RMC Prof. Dr Fehmida Shaheen Unit II, Holy Family Hospital, Rawalpindi, RMC Prof. Dr Shagufta Sayyal District Headquarter Hospital, Rawalpindi, RMC Prof. Dr M. Saeed & Dr M.Ikram Shiekh Zayed hospital, Lahore Prof. Dr Naheed Fatima Unit I, Bahawalpur Victoria Hospital. Dr Tasneem Akhter Unit II, Bahawalpur Victoria Hospital, Prof. Dr Samee & Dr Hajra Masood Nishtar Hospital Multan Prof. Dr Saqib Siddiq, Dr Rubina Services Hospital Lahore Dr. Shamama, District Headquarter Hosp, Toba Tek Singh Dr Nuzhat Alam THQ Hospital, Muridke Prof. Dr Nargis soomro Unit I, Civil Hospital Karachi, DMC Prof. Dr Subhana Tayyab Unit II, Civil Hospital Karachi, DMC Prof. Dr Ayesha Khan Unit III, Civil Hospital Karachi, DMC Dr Syed Hasan Ala Qatar Hospital, Karachi Dr Tahira Jabeen Korangi Hospital, Karachi Dr Sonia Sobhraj Hospital, Karachi Dr Naheed Soomro Civil Hospital, Jacobabad Dr Shabana Solangi Taluka Hospital, Rohri Dr Hakimzadi Civil Hospital, Badin


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