1. Maternal Mortality Assistant Professor Dr. Batool A. Gh. Yassin Depart. Of Community & family Medicine Baghdad College of Medicine 2014

2. Objectives By the end of this lecture you should be able to: Define & classify maternal deaths & disability. Define & classify maternal deaths & disability. List the most common causes of maternal mortality. List the most common causes of maternal mortality. Value the time factor in providing emergency obstetrical care. Value the time factor in providing emergency obstetrical care. Identify the important steps for reducing maternal death. Identify the important steps for reducing maternal death. Enumerate the key functions of emergency obstetric care. Enumerate the key functions of emergency obstetric care.

3. What Is Maternal Death? The death of a woman while she is pregnant … From any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. World Health Organization (WHO) … or … within 42 days of the termination of the pregnancy … … or … within 42 days of the termination of the pregnancy …

4. WHO Estimates 515 000 Maternal Deaths Each Year MORE THAN ONE WOMAN DIE EVERY MINUTE from pregnancy-related causes

5. Direct MD: Deaths resulting from obstetrical complications of the pregnancy, labour, or puerperium, and from interventions, omissions, incorrect treatment, or a chain of events resulting from the above. Indirect MD: Deaths resulting from previous existing disease or a disease that developed during pregnancy, labour or puerperium and aggravated by the maternal physiological adaptation to pregnancy. Deaths resulting from previous existing disease or a disease that developed during pregnancy, labour or puerperium and aggravated by the maternal physiological adaptation to pregnancy. Maternal Death; Definitions

6. What Is Maternal Disability? Short- or Long-term Illness Caused by Obstetric Complications Obstetric Complications Short- or Long-term Illness Caused by Obstetric Complications Obstetric Complications The Most Serious Maternal Disability Is Fistula (An Abnormal Passage Between Vagina and Bladder or Rectum often caused by obstructed labor when it is not treated with Cesarean Section) The Most Serious Maternal Disability Is Fistula (An Abnormal Passage Between Vagina and Bladder or Rectum often caused by obstructed labor when it is not treated with Cesarean Section)

7. What Do Women Die Of? They Die Of Obstetric Complications That Need Not Be Fatal They Die Of Obstetric Complications That Need Not Be Fatal

8. OBSTETRIC COMPLICATIONS DIRECT OBSTETRIC COMPLICATIONS Hemorrhage21% Hemorrhage21% Unsafe Abortion14% Unsafe Abortion14% Eclampsia13% Eclampsia13% Obstructed Labor 8% Obstructed Labor 8% Infection 8% Infection 8% Other11% Other11% Hemorrhage21% Hemorrhage21% Unsafe Abortion14% Unsafe Abortion14% Eclampsia13% Eclampsia13% Obstructed Labor 8% Obstructed Labor 8% Infection 8% Infection 8% Other11% Other11% Account for 75% of Maternal Deaths

9. OBSTETRIC COMPLICATIONS INDIRECT OBSTETRIC COMPLICATIONS Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis And Increasingly HIV / AIDS Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis And Increasingly HIV / AIDS Account for 25% of Maternal Deaths

10. Most Obstetric Complications Occur Suddenly If women do not receive medical treatment on time, they will probably suffer disability … If women do not receive medical treatment on time, they will probably suffer disability … Or Die Without Warning

11. WHERE DO WOMEN DIE TODAY? 99% of Maternal Deaths Today Occur in Occur in Africa, Asia and Latin America 99% of Maternal Deaths Today Occur in Occur in Africa, Asia and Latin America

12. WHAT ABOUT THE REST OF THE WORLD? Maternal Deaths Used to be Very High in Europe and the U.S. So was Infant Mortality. Maternal Deaths Used to be Very High in Europe and the U.S. So was Infant Mortality. In 1915, Maternal and Infant Mortality Rates Were As High in the U.S. As They Are in Africa Today

13. WHAT HAPPENED NEXT? Better Living Conditions Reduced Infant Mortality in the U.S. by over 40% between 1915 and 1933 Better Living Conditions Reduced Infant Mortality in the U.S. by over 40% between 1915 and 1933

14. BUT MATERNAL MORTALITY “The well known triad of fever, hemorrhage and toxemia predominated…” “The well known triad of fever, hemorrhage and toxemia predominated…” REMAINED THE SAME

15. …Until the late 1930s There was a “steep and sustained decline which has continued in most Western countries at much the same rate for over fifty years” There was a “steep and sustained decline which has continued in most Western countries at much the same rate for over fifty years”

16. What Happened To Reduce Maternal Mortality In The West? Effective treatment for obstetric complications was developed and used, e.g., antibiotics for infection, blood transfusions for hemorrhage Effective treatment for obstetric complications was developed and used, e.g., antibiotics for infection, blood transfusions for hemorrhage

17. Most Obstetric Complications Can Neither Be Predicted Nor Prevented… Can Neither Be Predicted Nor Prevented… But If Women Receive Effective Treatment in Time, But If Women Receive Effective Treatment in Time, … Almost All Can Be Saved

18. How Much Time Do We Have? If untreated, death occurs on average in 2 hours from Postpartum Hemorrhage 2 hours from Postpartum Hemorrhage 12 hours from Antepartum Hemorrhage 2 daysfrom Obstructed Labor 2 daysfrom Obstructed Labor 6 daysfrom Infection 6 daysfrom Infection 2 hours from Postpartum Hemorrhage 2 hours from Postpartum Hemorrhage 12 hours from Antepartum Hemorrhage 2 daysfrom Obstructed Labor 2 daysfrom Obstructed Labor 6 daysfrom Infection 6 daysfrom Infection

19. Prevention of Maternal Deaths: –Establish maternal mortality committees –Improve standards of health facilities (hospitals and PHC centres) –Proper training of health professionals (obstetricians, GPs, midwives and TBAs) –Community education to encourage mothers to have ANC –Identification and management of high risk groups –Research

20. To Avert Death and Disability… … We Need To Ensure That Women have Access To … … We Need To Ensure That Women have Access To … Emergency Obstetric Care (EmOC)

21. How Can We Improve Access To EmOC? By making sure health facilities provide services needed to save women ’ s lives. By making sure health facilities provide services needed to save women ’ s lives. Eight key functions “ signal ” a facility ’ s ability to provide EmOC Eight key functions “ signal ” a facility ’ s ability to provide EmOC

22. EmOC Key Functions Cover These Services  Antibiotics (IV or IM)  Oxytocic Drugs  Anticonvulsants  Manual Removal of Placenta  Antibiotics (IV or IM)  Oxytocic Drugs  Anticonvulsants  Manual Removal of Placenta  Removal of Retained Products  Assisted Vaginal Delivery  Surgery (Cesarean Section)  Blood Transfusion  Removal of Retained Products  Assisted Vaginal Delivery  Surgery (Cesarean Section)  Blood Transfusion All these services should be provided at the Comprehensive EmOC level, whereas the first six services should be provided at the level of basic EmOC

23. THE GOOD NEWS Not all these functions need hospitals and doctors Well-trained nurses and midwives can perform most at Basic EmOC Facilities An Important Point For Resource Poor Areas An Important Point For Resource Poor Areas

24. How Can We Tell We Are Making a Difference? If we know we have provided enough EmOC… …and if we know that these services are being used by women suffering obstetric complications… WE CAN BE CONFIDENT THAT WE ARE SAVING WOMEN ’ S LIVES WE CAN BE CONFIDENT THAT WE ARE SAVING WOMEN ’ S LIVES

25. How Do We Know Which Women Will E xperience Complications? WE DON ’ T

26. … But we do know that of any population of pregnant women 15% will experience an obstetric complication … This is as true of pregnant women in the US and Europe as of women in Africa, Asia and Latin America Nobody Knows Why This Happens. It Is a Fact of Life Nobody Knows Why This Happens. It Is a Fact of Life

27. Any Country Can Avert Maternal Death And Disability If It Makes Good EmOC Any Country Can Avert Maternal Death And Disability If It Makes Good EmOC Available And Accessible