1. Evidence Based Approaches for Reduction of Maternal Mortality Hemant Dwivedi

2. Session Objectives To review: Magnitude of Maternal mortality Causes of Maternal mortality Interventions to reduce maternal mortality –Traditional birth attendant –Antenatal care –Risk screening –Reduce Unwanted Fertility –Skilled attendant at childbirth –Emergency obstetrics Care Current Program Strategies What we can do? 2Current Approach to Reduction of Maternal Mortality

3. Maternal Mortality: A Global Tragedy Annually, 536,000 women die of pregnancy related complications 99% in developing world ~ 1% in developed countries 25% global burden by India Every minute one Maternal Death occur 3Current Approach to Reduction of Maternal Mortality

4. Maternal and Infant Mortality are two critical indicators that measure not only health conditions, but overall development level of a country. Both are key goals in the National Rural Health Mission (NRHM) and the Millennium Development Goals (MDG# 4 and 5).

5. Maternal Mortality Ratio YearMMR(INDIA) ORISSA 1998-99 : 407 367 2001 – 03 : 301 358 2004 – 06 : 254 303 XI Plan Goal (2012) : 100 119 MDG Target (2015) : 136

6. Recent Trends MMR – India (SRS-04-06) 6Current Approach to Reduction of Maternal Mortality States of IndiaMMR Kerala95 Tamil Nadu111 West Bengal141 Andhra Pradesh154 Bihar/Jharkhand312 Madhya Pradesh/ Chhattisgarh335 Orissa303 Assam480 India254

7. Causes of Maternal Mortality in India (SRS-2003) 7Current Approach to Reduction of Maternal Mortality

8. But WHY Do These Women Die? Delay in Decision to Seek Care Lack of understanding of complications Acceptance of maternal death Low status of women Socio-cultural barriers to seeking care Delay in Reaching Care Mountains, islands, rivers — poor organization Delay in Receiving Care Supplies, personnel Poorly trained personnel with punitive attitude Finances 8Current Approach to Reduction of Maternal Mortality Three Delays Model

9. Interventions to Reduce Maternal Mortality Historical Review Traditional Birth Attendants Antenatal Care Risk Screening Current Approach Reduce Unwanted Fertility Skilled Attendant at Delivery Emergency Obst. Care 9Current Approach to Reduction of Maternal Mortality

10. Historical Review of Interventions The flawed assumption: Most life-threatening obstetric complications can be predicted or prevented 10Current Approach to Reduction of Maternal Mortality

11. Interventions: Traditional Birth Attendants Advantages Community-based Sought out by women Low tech Can perform clean delivery Disadvantages Technical skills limited May keep women away from life-saving interventions due to false reassurance 11Current Approach to Reduction of Maternal Mortality

12. Interventions: Traditional Birth Attendants Conclusion: TBAs are useful in the maternal health network, but there will not be a substantial reduction in maternal mortality by deliveries conducted through TBAs. Maternal Deaths prevented-3 percent 12Current Approach to Reduction of Maternal Mortality

13. Interventions: Antenatal Care Antenatal care clinics started in USA, Australia, Scotland between 1910–1915 Concept - Screening healthy women for signs of risk/disease No substantial reduction in maternal mortality However, widely used as a maternal mortality reduction strategy in 1980’s and early 1990’s Is ANC important? YES!! Early detection of problems and Birth Preparation Maternal Deaths prevented-11 percent 13Current Approach to Reduction of Maternal Mortality

14. Maternal Mortality: UK 1840–1960 14Current Approach to Reduction of Maternal Mortality Improvements in nutrition, sanitation Antibiotics, banked blood, surgical improvements Antenatal care Maine 1999.

15. Interventions: Risk Screening Disadvantages Very-poorly predictive Costly: Early and longer stay in health facilities If risk-negative, gives false security Conclusion: Cannot identify those at risk of maternal mortality — Every pregnancy is at risk, if not proved, otherwise. 15 Current Approach to Reduction of Maternal Mortality

16. Historical decline in Maternal mortality in the West Not much decline till 1930 Rapid decline after 1940s While infant mortality declined since 1800s gradually as socio-economic conditions improved.(Community based interventions) Factors affecting maternal mortality decline- Increased availability of blood, antibiotics, safe surgery. 16Current Approach to Reduction of Maternal Mortality

17. Are there populations who are rich, well nourished and educated but have high maternal mortality? Yes in USA there are such populations – eg. Faith Assembly of God who are rich, well nourished, and educated : their MMR was 872 in 1982 while in that year MMR in US general population was only 8 per 100,000 live births. What is the key difference between these two groups? Use of modern obstetric care. 17Current Approach to Reduction of Maternal Mortality

18. MM: What the Evidence Shows Once a woman is pregnant usually most serious obstetric complications cannot be predicted or prevented, but they can be treated. About 15 % do develop obstetric complications. 18Current Approach to Reduction of Maternal Mortality

19. Do women die immediately after developing complications in delivery? Average Complications to death interval Hemorrhage PPH: 2 Hours ( 5.7 hrs*) APH: 12 Hours(11.5 hrs) Ruptured uterus 1 Day Eclampsia 2 Day(1.7 Days) Obstructed Labour 3 Days Infection 6 Days(2.4 Days) (* Study in Maharashtra – Ganatra et al. WHO bulletin 1998, 76(6):591-598. 19Current Approach to Reduction of Maternal Mortality

20. 20Current Approach to Reduction of Maternal Mortality

21. So All pregnant women need Access to* Emergency Obstetric Care (EmOC) * Not the same as Institutional Delivery [ID] 21Current Approach to Reduction of Maternal Mortality

22. Interventions: Skilled Attendant at Childbirth SBA- An accredited health professional- such as Midwife, Doctor, Nurse-Who have been educated and trained to proficiency in the skills needed to manage normal pregnancy, child birth and the immediate post- natal period, and the identification, management and referral of complication in women and newborn. Proper training for range of skills Assess danger signs and Recognize onset of complications Observe woman, monitor fetus/infant Perform essential basic interventions Refer mother/baby to higher level of care if complications arise requiring interventions outside realm of competence 22Current Approach to Reduction of Maternal Mortality

23. Maternal Mortality Reduction Sri Lanka 1940–1985 Health system improvements: Introduction of system of health facilities Expansion of midwifery skills Decreased use of home delivery and delivery by untrained birth attendants Spread of family planning 23Current Approach to Reduction of Maternal Mortality

24. Maternal Mortality Reduction Sri Lanka 1940–1985 24Current Approach to Reduction of Maternal Mortality 85% births attended by trained personnel

25. Interventions: Skilled Attendant at Childbirth Proven effective Malaysia: basic maternity services 320  157 Cuba: national priority 118  31 China: facility based childbirth 1500  50 Malaysia (41)vs. Indonesia (230): Trained community midwives (2 years) vs. untrained midwives (4 years) 25Current Approach to Reduction of Maternal Mortality

26. 26Current Approach to Reduction of Maternal Mortality The higher the proportion of deliveries attended by skilled attendant in a country, the lower the country’s maternal mortality ratio % skilled attendant at delivery Maternal deaths per 1000000 live births

27. 27Current Approach to Reduction of Maternal Mortality Countries MMR SBA % Afghanistan 1800 14 Nepal 830 11 Bangladesh 570 13 Bhutan 440 37 Pakistan 320 31 India 254 43* Sri Lanka 58 96 South Asia 500 37 Global 400 63 MMR & SBA

28. Interventions: Emergency Obst care Vast Majority of deaths (75%) due to Direct Obstetric complications These complications occur even in well nourished and well educated women Can not usually be predicted Can not be prevented : some exceptions such as AMTSL for preventing PPH, IP for Post partum infections and provision of safe and early abortion services Overlap with SAB Emoc facilities provide a critical back up for SAB 28Current Approach to Reduction of Maternal Mortality

29. 29Current Approach to Reduction of Maternal Mortality

30. Interventions: Reduce Unwanted fertility Huge unmet demand for spacing and permanent methods Significant proportion of maternal deaths attributable to unsafe abortions Nearly One third of fertility: unwanted Access to quality contraceptive services will help in reducing unwanted fertility which in turn will reduce numbers of maternal deaths 30Current Approach to Reduction of Maternal Mortality

31. What proportion of maternal deaths these strategies can prevent? TBA training03 % ANC11 % Family Planning26 % Health Centers (BEmOC)25 % HC & Urban Hospitals (C)60 % HC & rural Hospitals67 % 31Current Approach to Reduction of Maternal Mortality

32. Programmatic Interventions– Reduce Maternal Mortality 1. Access to Information and Services for Contraception – Too early and too frequent, too many 2. Access to skill Birth attendance – SBA & BEmOC (obs. First aid) 3. Access to Emergency Obstetric Care 4. Access to safe abortion services 5. Access to ANC and PNC Services 32Current Approach to Reduction of Maternal Mortality

33. Organizing Maternal Health Services with active Referral Linkages 33Current Approach to Reduction of Maternal Mortality Midwifery Services BEmOC Services CEmOC Services CEmOC SDH/DH CHC / Block PHC PHC (New) Sub Centre

34. Maternal Health Services Good quality maternal health services are not universally available and accessible > 39% receive no antenatal care ~ 40% of deliveries unattended by skilled provider ~ 60% receive no postpartum care during 1st 6 weeks following delivery 15% unmet need of FP 34Current Approach to Reduction of Maternal Mortality

35. What was planned and what happened? (Time, Resource &Energy) 35Current Approach to Reduction of Maternal Mortality TBA ANC Coverage SBA EmOC & Safe Abortion Services TBA Training ANC Coverage EmOC 5% 10% 30% 55% Planned SBA ? Safe Abortion?

36. Program Design: The Causal Chain This is what links actions to outcomes and impact. Must be evidence-based, not faith-based Links must be tested and monitored If one link breaks, the chain is broken 36Current Approach to Reduction of Maternal Mortality

37. JSY Plan’s Causal Chain 37Current Approach to Reduction of Maternal Mortality JSY Better Ob. Care EmOC for Complic. Deliv. Instit. Deliv. Lives Saved

38. JSY Plan’s Evidence Chain 38Current Approach to Reduction of Maternal Mortality JSY Better Ob. Care EmOC for Complic. Deliv. Instit. Deliv. Lives Saved Evidence Needs more evidence

39. Orissa Scenario 39Current Approach to Reduction of Maternal Mortality 250 190

40. What we can Do ACCESS TO - Skilled attendance at birth, Emergency obstetric care Family planning Pre-natal and post-natal care - ARE ABSOLUTELY ESSENTIAL But reduction of MMR to Western levels goes beyond health – it requires better nutrition, better hygiene, better education of mothers and better gender equality, in other words, better overall development of people. 40Current Approach to Reduction of Maternal Mortality

41. 41Current Approach to Reduction of Maternal Mortality

42. 42Current Approach to Reduction of Maternal Mortality Sl. No. Cause of DeathNumber of Death % of Deaths Possible preventable %Number 01.Hemorrhage127 00025%55%70 000 02.Sepsis76 00015%75%57 000 03.Preeclampsia/eclamps ia 64 00012%65%42 000 04.Obstructed labour38 0008%80%30 000 05.Unsafe abortion67 00013%75%50 000 06.Other direct causes39 0008%--- 07.Indirect cause100 00020% 20 000 TOTAL510 000100%269 000 Estimation of mortality from the main obstetric complications worldwide and impact of possibly preventable deaths.-WHO-1994

43. UN “Signal Functions” of EmOC Basic Parenteral antibiotics, oxytocics, anti-convulsants Manual removal of the placenta Removal of retained products (e.g., MVA) Assisted vaginal delivery Neonatal resuscitation (new) Comprehensive = Basic + Surgery Blood transfusion 43Current Approach to Reduction of Maternal Mortality

44. 44Current Approach to Reduction of Maternal Mortality Maternal Mortality ratio per 100000 live births 400 200 100 8-9 years Malaysia 1951-61 Sri Lanka 1956-1965 Bolvia Late – 1990s 6-7 years Sri Lanka 1974-1981 Thailand 1974-1981 Egypt 1993-2000 Chile 1971-1977 Colombia 1970-1975 4-6 years Honduras 1975-81 Thailand 1981-1985 Nicaragua 1973-1979 50 Figure: 4.9. To provide skilled care at and after child birth and to deal with