To reduce MM … l Need to understand the epidemiology of maternal mortality [MM] l A counterintuitive phenomenon l Many “obvious” approaches don’t work, e.g. risk screening, training TBAs
Maternal Mortality RegionMM RatioLifetime Risk 1 in … Africa83020 Asia33094 Latin America190160 North America172,500 World40074
Causes of Direct Obstetric Deaths The “Big 5” l Hemorrhage l Infection l Hypertensive diseases l Obstructed labor l Unsafe induced abortion
The Way Programs Should Work Evidence Interventions Indicators Strategy
Interventions Indicators Strategy Assumptions The way it often works
Assumption If we just take very good care of pregnant women, few will develop serious obstetric complications.
History: Prenatal Care l 1910-15 first clinics in UK (and US) l By 1930, 80% pregnant women in UK have prenatal care l But maternal mortality did not decline
TBAs & “Clean Delivery” In Matlab, Bangladesh, TBAs were trained to use clean delivery practices. The did use these practices, but maternal deaths due to infection did not decline.
Assumption Through prenatal screening, We can identify the women who will need medical care
The Math of Prediction It works for groups but not for individuals.
Example: Matlab, Bangladesh 1968-70 Maternal Age 10-1420-29 MM Ratio 1770450 Relative Risk 3.91 # Births 50911,286 # Deaths 951
Example: United Kingdom 1985-87 Maternal Age20-2445+ MM Ratio37188 Relative Risk1 5.1 # Deaths242
Risk and Prediction (cont.) A big risk in a small population = few deaths A small risk in a big population = many deaths
In Short... Once a woman is pregnant most serious obstetric complications cannot be predicted or prevented, but they can be treated.
So All pregnant women need access to emergency obstetric care (EmOC)
Sri Lanka & Malaysia How did they do it ? l Expanding access to effective maternity care by midwives and doctors l Improving utilization and quality of care with emphasis on making life-saving care free. The World Bank, 2003
Signal Functions of Basic EmOC : l Parenteral antibiotics, oxytocics, anticonvulsants l Manual removal of placenta l Removal of retained products l Assisted vaginal delivery l Neonatal resuscitation (new) Should be at health centers
Signal Functions of Comprehensive EmOC: l All Basic EmOC functions l Blood transfusion l Surgery (c-section) Should be at District Hospitals
EmOC is not “Hi Tech” It is mostly 1950s medicine !
EmOC is the foundation Emergency Obstetric Care Skilled Attendant Referral Risk Screening Social Mobilization Waiting Homes TBA Training Antenatal Care
Assumption EmOC is too expensive Community-based workers are more affordable
A cost-effectiveness exercise: unit cost Dollars $350 $10,000 $30,000
Cost (cont.) Suppose, per district, there are: l 100 MCHW s l 4 health centers l 1 district hospital
Estimated program cost (in $000s) Dollars 30 40 35
In Reducing Maternal Deaths There are really only 3 issues: l COVERAGE OF SERVICES l QUALITY OF CARE l UTILIZATION OF SERVICES
The Road toMaternal Mortality Reduction: Shortcuts or Detours ?
Pseudo-Interventions l “Safe Birth Kits”: No evidence of effectiveness in reducing maternal deaths, but consume effort, attention and funds. l Advocacy for Advocacy: If not linked to programs, advocacy can be a detour.
1-Complication MM Programs Example: Home-based prevention of post-partum hemorrhage (PPH) Hemorrhage = 25% of maternal deaths Perhaps ½ preventable = 12.5%
Semi-Skilled Attendants If you leave the skills out of Skilled Birth Attendant what do you get?
Institutional Delivery Targets Easy to measure, but no indication of quality of care You can reach the target But miss the goal !
“In the Meantime …” If we don’t get started now fixing health systems in 20 years we will still be in the meantime.
General Lesson: We must build health systems l Need a strong evidence base l Training and equipment are never enough l Management systems are crucial l Even skilled personnel need support l Learn from expensive failures