1. Maternal death in Africa: How Wales can help Alison Fiander

2. Overview Background to problem What could Wales do? Emergency obstetric surgical skills programme in The Gambia Mulago Hospital, Kampala, Uganda

3. Childbirth: a joyful occasion or one of grief? Every minute somewhere in the world a woman dies in childbirth

4. Maternal Death in Developing Countries 2007 - 20th anniversary of Safe Motherhood Initiative launched in Nairobi  Very slow progress in reducing maternal mortality Millennium Development Goal  Reduce maternal mortality by 75% by 2015 75% of maternal deaths are preventable

5. Size of the problem Over 500,000 deaths per year  95% in Africa and Asia  Equivalent to one jumbo jet crashing every 4 hours day in and day out, killing entire passenger load of young women  Or one death a minute Life time risk of dying from childbirth  1 in 10 developing countries  1 in 5,100 UK

6. Maternal deaths in Africa Sub-Saharan Africa  Highest maternal mortality in world: >1000 deaths per 100,000 live births  Adolescent childbearing contributes to risk  Neonatal mortality highest in world: >45 deaths per 1000 live births  When a mother dies, her baby dies and often her other children  Community productivity declines

7. ‘To be pregnant in Africa is as dangerous as swimming in a river full of crocodiles’ Tanzania ‘Maternal deaths happen everywhere on earth but it is the degree which is scaring Africa’ Malawi

8. Causes of maternal deaths 5 big killers: Haemorrhage Sepsis Hypertensive disorders Abortion Obstructed labour Other direct causes Indirect  malaria, anaemia, HIV

9. Consequences of poor maternal health Survivors of childbirth are at risk of morbidity For each death 30 more suffer short or long term disabilities 49 million in WHO African region will suffer over next 10 years:  Obstetric fistulae  Chronic anaemia  Infertility  Depression  Stress incontinence  Fatigue

10. Obstacles to safe motherhood 3 major delays: Delay in deciding to seek care  Non recognition of danger signs  Lack of preparation by family & community Delay in reaching health care facility  Poor roads, lack of transport, poor communication Delay in appropriate care after reaching facility  Inadequate skilled staff  lack of drugs, equipment, supplies  Poor referral system

11. ‘ In Zambezia central province, Mozambique, women must cross the Zambezi river in search of medical care. The crossing takes 3 days and the pregnant may either give birth on the slow sailing boats or find death before reaching the other side of the river.’

12. Community Interventions Training of community health care workers:  Recognition of life-threatening complications  When and where to seek help  Birth preparedness plans including emergency transport

13. ‘To be pregnant in Africa is to be haunted by the ghost of death - either before childbirth, during labour or soon after birth’ Malawi ‘My mother died at childbirth when I was 12 years old. Medicine women massaged her stomach and spat gnawed leaves over her body. After two days of suffering she died.‘ West Africa

14. Health Care Interventions Skilled health worker during pregnancy and delivery Access to emergency obstetric services when complications arise

15. Health Care Interventions Emergency Obstetric Care: At primary health care level  Normal delivery, MROP, IV oxytocin, antibiotics, MgSO4 At referral level  Operative intervention: ventouse, forceps, CS, safe blood transfusion

16. ‘The root cause of maternal deaths is abject poverty and the brain drain that affects most African countries.’ Zambia

17. Maternal death in Africa: What can we do to help? Overseas opportunities : 1 The Gambia - Emergency Obstetric Services project 2 Uganda - Experience in large Teaching Hospital & introduction of audit/risk management

18. The Gambia - Emergency Obstetric Services To avoid deaths and long- term/permanent morbidity, the management of obstetric emergencies must be more effective Management in the first hour or two of the presentation of an emergency is a major determinant of outcome Lack of trained obstetricians

19. Background Until recently: Emergencies poorly managed Doctors and nurses demoralised Essential emergency drugs, medical supplies and basic equipment not available Relatives frequently had to buy drugs or disposables before emergency could be treated

20. Refurbishment of Brikama Health Centre, The Gambia Operating Theatre - before and after

21. Emergency obstetric care Training manual Flying squad Training courses:

22. The Gambia project Based at Brikama Health Centre Accommodation available Trainee for 6-12 months to manage Obstetric Emergencies Teach operative delivery to midwives Teach on management of obstetric emergencies Triage vesico-vaginal fistulae (VVF)

23. Mulago Hospital, Kampala, Uganda Teaching hospital with 33,000 deliveries  30% still adolescent  High maternal mortality rate 12-15 CS/day 250-300 new cases of cervical ca annually Supported by Body Trust Development of audit/risk management Applications (letter & CV) by 10 July 2008 to commence Autumn 2008