1. ALSO Korogwe 2009 Causes of Maternal and Neonatal Deaths Why mothers and newborns die

2. The aim of maternal health care to prevent death and disability of women, related to pregnancy and birth

3. The decades of irresponsible commitments

4. ”Maternal mortality will be reduced by 50% by the year 2000” World Summit for children, New York, 1990

5. The decades of irresponsible commitments ”Maternal mortality will be reduced by 50% by the year 2000” ICPD, Cairo, 1994

6. The decades of irresponsible commitments ”Maternal mortality will be reduced by 50% by the year 2000” Women’s Conference, Beijing, 1995

7. The decades of irresponsible commitments ”Maternal mortality will be reduced by 50% by the year 2000” World Summit for Social Development, Copenhagen, 1995

8. So, what happened by the year 2000?

9. Maternal mortality 1995 Maternal deaths MMR (Maternal deaths per 100.000 live births) WORLDWIDE WESTEN LOWINCOME Africa Asia Latin America 515.000 2.800 512.000 273.000 217.000 22.000 400 21 440 1.000 280 190

10. Maternal mortality 19952000 Maternal deaths MMR (Maternal deaths per 100.000 live births) Materna l deaths MMR Maternal deaths per 100.000 live births) WORLDWIDE WESTEN LOWINCOME Africa Asia Latin America 515.000 2.800 512.000 273.000 217.000 22.000 400 21 440 1.000 280 190 529.000 2.500 527.000 251.000 253.000 22.000 400 20 440 830 330 190

12. UN Millenium Development Goal 5 by 2015 75% reduction of maternal deaths 90% skilled delivery attendance Tanzania: MMR 950/100,000 live births increased from 1996 to 2004 46% deliveries in health facilities

13. The cause of maternal deaths Poverty More than ½ million women die every year in relation to pregnancy and delivery. That is one every minute. In Denmark one out of 17.000 women die in relation to childbearing. In Subsaharan Africa one out of 15. In Afghanistan one out of six. Ninety nine percent of all maternal deaths occur in low income countries reflecting the greatest disparity between rich and poor countries of any health indicator

15. Developing countries that reduced MMR

16. Kigoma Region, Tanzania

17. Clinical causes of maternal deaths Direct obstetric causes: 75% Haemorrhage21% Abortion14% Eclampsia13% Obstructed labor 8% Infection 8% Indirect obstetric causes 25% Malaria, anemia, hepatitis, HIV/AIDS Causes vary from place to place

18. Components of Maternal health care Ante natal care Post partum care Traditional birth attendants Skilled delivery attendance Emergency obstetric care

19. Ante natal care Screening for mother and child morbidity and risc, f.ex: Obstetric history Hypertension Anemia Number, position and growth of fetus(es) Preventive administering of drugs, f.ex: Iron, folic acid, antimalaria-drugs, tetanus-immunization Treatment or referral of certain complications, f.ex: Malposition Preeclampsia Infection (including malaria) Ante partum bleeding Planning of delivery Ante natal care has not been able to reduce maternal morbidity and mortality significantly as most complications occur unexpected during or after birth

20. Post partum care A significant share of maternal deaths happen in the postpartum period (the 6 weeks after birth) – bleeding, infection, eclampsia The majority of delivered women don’t get postpartum care.

21. Training of traditional birth attendants Training of Traditional birth attendants in safe delivery and referral at complications has been tried It has proven difficult to align western and traditional health concepts; results have been disappointing and the strategy has largely been abandoned Training of TBAs has been criticized for not respecting the skills of traditional birth attendants and not considering that most TBAs are illiterate Women’s satisfaction of maternal care by TBAs is higher than by modern health services

22. Skilled delivery attendants The main strategy for the last ten years to reduce maternal mortality: 90% of all births by skilled delivery attendants A skilled attendant is trained in midwifery skills (2 yrs.+) Problems: Human and economical ressources - Brain drain Skilled attendants are not necessarily able to treat obstetric complications due to lack of training or supplies Many women don’t recognize the importance of skilled attendants and prefer to deliver at home

23. Skilled delivery attendants

24. Skilled delivery attendants – doctors

25. Skilled delivery attendants - midwives

26. Emergency obstetric care 1 Most complications occur unexpected and sudden in low risk pregnant women 75% of complications occur around the time of birth Skilled delivery attendants must be able to perform adequate life saving emergency obstetric care at all deliveries

27. Emergency obstetric care 2 UN signal functions Basic emergency obstetric care (2 hrs) 1. Administration of parenteral antibioticsInfection, abortion 2. Administration of parenteral oxytocic drugsBleeding 3. Administration of anticonvulsant drugsEclampsia 4. Manual removal of placenta Bleeding, infection, abortion 5. Removal of retained products Bleeding, infection, abortion 6. Assisted vaginal delivery Obstructed labour Comprehensive emergency obstetric care (12 hrs) 7.Cesarean sectionObstructed labour 8.Blood transfusionBleeding

28. Emergency obstetric care 3 Delays in receiving life saving treatment 1st Delay: Delay in deciding to seek medical assistance 2nd Delay: Delay in reaching health facility 3rd Delay: Delay in receiving adequate treatment once at the health facility

29. Emergency obstetric care 3 Delays in receiving life saving treatment 1st Delay: Delay in deciding to seek medical assistance 2nd Delay: Delay in reaching health facility 3rd Delay: Delay in receiving adequate treatment once at the health facility

30. The National Road Map Strategic Plan To Accelerate The Reduction of Maternal and Newborn Deaths In Tanzania (2006 -2010) Tanzanian Ministry of Health By 2010 Reduce MMR from 578 to 265 Increase deliveries by skilled attendants from 46% in 2004 to 80% The road map EmOC objective Basic EmOC at all Health Facilities by 2010 Comprehensive EmOC at half Health Centres and all Hospitals

31. Newborns

32. Under five mortality Each year 11 million children under the age of 5 years die 4 million die within the first month 3 million within the first week 1 million within the first day The UN MDG 4 is to reduce under five mortality by 2/3 by 2015

33. Neonatal mortality World AfricaE. AfricaTanzania Live births133 mio. 30.3 mio.10.6 mio. 1423000 Stillbirths 3.3 mio. 1.0 mio. 0.3 mio. 56000 Neonatal deaths 4.0 mio. 1.24 mio 0.44 mio. 113000 NMR (/1000 LB) 30 41 42 62

34. Neonatal mortality

36. A home-based study on neonatal mortality in Gadchiroli, India NMR was reduced 70% by Asphyxia management Supportive care in LBW Sepsis management

37. ALSO in Kagera Impact on neonatal mortality

38. Before: No=577After: No=565 Stillborn 15 2,5% 15 2,7% Assisted ventilation 17 3,0% 13 2,4% Cardio-Pulmonary Resuscitation 7 1,2% 6 1,1% With mother <10 minutes: 32 5,8%39472,0% Born alive Apgar 4-10 but died before discharge 6/528 1,1% 0/521 0,0%