1. Ms. Mariyam Nazviya Ministry of Health & Family Republic of Maldives ESA/STAT/AC.219/21

2. Background Information on Maldives Definitions MMR Trends Measurement of MMR Sources SourcesMethodology Maternal Death Review process Progress towards achieving MDG Goal 5 Issues & Challenges

3. Consist of 1190 tiny coral Islands Spread over 90,000sq km of the Indian ocean. Inhabited 200 islands Islands grouped to 20 atolls The total population of the country is 31,4542 Small dispersed populations with difficult and expensive transport system cause delays in timely exchange of information. However development in telecommunication has brought about positive changes

4. WHO standard definitions are followed in the country: Maternal Death: The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Direct Obstetric cause: Those resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium) from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above Indirect Obstetric cause: Those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy

7. Institutional level (Facility) investigation Central level (MOHF) investigation Methods Coverage National - All maternal deaths are reviewed 1997 Started Maternal Death Review committee 1999

8. Death Reporting Notification of death mandatory within 24 hrs of occurrence Reporting through death forms - VRS Institutional (facility) level Case Review (MOHF) Maternal and Perinatal Morbidity and Mortality Committee Analysis of case Detailed information (within 7-14 days)

9. Reviews forms/ questionnaires / Patient Medical Record / Past Records Maternal Death Review Committee Analysis of case Confirms cause of death / identifies faults/ factors Directs to additional investigation /information Recommends preventive actions

10. Source of information Medical records Nursing care records ANC/PNC records Prescription records Interviews with attending staff ANC records Other health care records Interviews - health workers Interviews - family members Information analysis & reporting Maternal Death Review Committee Ministry of Health, Health Information and Research Section Review & analyze the information Prepares a case report of each death; Compiles an annual report Every Five Years, a Synthesis Report is compiled

11. 2000 75/ 100000lb 2009 81/ 100000lb 2015 125/ 100000lb Reduce maternal mortality ratio by three quarters, between 1990 and 2015 1990 500/ 100000lb FLUCTUATING TREND … On Track

12. Improvement in health care services Expansion of obstetric/gynecological services Improved antenatal care services High proportion of institutional deliveries High proportion of skilled attendance at birth With the decline in mortality, direct causes are declining

13.  Strengthening and expansion of Maternal and Child health services  Strengthening of essential obstetric care  Ensure quality of care  Proper supervision and monitoring of services  Implementation of target oriented awareness programmes

14. Population size very small Population size very small Statistically brings a large variation to MMR with just one or two deaths Over 90 Percent of Institutional deliveries However, not all hospitals in atolls are equipped with Emergency Obstetric / Neonatal care Service Delivery and timely referral a challenge due to geographical dispersed nature of islands Establishing a public transport mechanism – one of the priorities of the current government Quality of Care needs to be improved Limitation of capacity (institutional / HR)

15. Maldives has made significant achievements in reduction of Maternal Mortality since 1990 and currently the country's MMR stands at 81 / 100,000 live births in the year 2009. Maldives has made significant achievements in reduction of Maternal Mortality since 1990 and currently the country's MMR stands at 81 / 100,000 live births in the year 2009. Maternal death reviews are conducted for all Maternal deaths More than one source of reporting (through VRS as well as Maternal Death Review Process) Due to the small population, an increase or decrease in just one maternal death brings a significant change to the MMR. As such, the trends over the past few years is seen to fluctuate, although generally it can be said that country is on track to achieving MDG Goal 5.