Epidemiology of Maternal and Neonatal Mortality in Malawi Dr. Chisale Mhango FRCOG 1 NPC Training in MNH
Jan 24, 2016
Epidemiology of Maternal and Neonatal Mortality in Malawi
Dr. Chisale Mhango FRCOG
1NPC Training in MNH
MATERNAL MORTALITY IN LOW RESOURCE COUNTRIES: How to accelerated reduction
Objectives:• Understand the issues relating to
MMR
• Review Global and Local Progress on Reduction of MMR– Key article from The Lancet
• Discuss effective strategies
Outline of presentation
1. Definitions of terms2. Global and Local Trends in MMR and NNM3. Causes of maternal and neonatal mortality4. Current data on place of delivery in
Malawi5. Coverage for Skilled Birth Attendants in
Malawi6. Rationale for new roles for TBAs
3NPC Training in MNH
DefinitionsStatistical measurements..
Maternal Mortality Ratio
Number of maternal deaths during a given period per 100,000 live births during the same time-period
Maternal Mortality Rate
Number of maternal deaths in a given period per 100,000 women of reproductive age during the same time-period
Adult life time risk of maternal death
The probability of dying from a maternal cause during a woman’s reproductive lifespan.
Alternative definition of MD in ICD-10 (1992)
Pregnancy-related death
The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.
Late maternal death The death of a woman from direct or indirect obstetric causes, more than 42 days but less than one year after termination of pregnancy.
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Definitions cont…
Neonatal mortality The probability of dying within the first month of life
Infant mortality The probability of dying before the first birthday
Post-neonatal mortality
The difference between infant and neonatal mortality
Under-5 mortality The probability of dying between birth and the fifth birthday
Child mortality The probability of dying between the first and fifth birthday
Neonatal mortalityrate
Number of deaths within 28 days of life per 1,000 live births
Early neonatal mortality rate
Number of deaths within 7 days of life per 1,000 live births
Infant mortality rate Number of deaths within the first 12 months of life per 1,000 live births
Under-5 mortality rate Number of deaths within the first five years of life per 1,000 live births
Child mortality rate Number of deaths within the first five years of life per 1,000 children surviving to 12 months of age.
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Definitions and Statistical measurements..
Methods of defining Maternal Mortality
Millennium Development Goal 5: Improve Maternal Health
Target 5.A:Reduce by 3/4, between
1990 and 2015, the maternal mortality ratio
Indicators:Maternal mortality ratioProportion of births
attended by skilled health personnel
Target 5.B:Achieve, by 2015, universal
access to reproductive health
Indicators:Contraceptive prevalence
rateAdolescent birth rateAntenatal care coverageUnmet need for family
planning
Millennium Development Goal 4: Reduce Child Mortality
Target 4:Reduce by 2/3, between 1990 and 2015, the child mortality rate
Indicators:Under-five mortality rateInfant mortality rateProportion of 1 year-old children immunized against
measles
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The Lancet ArticleMaternal mortality for 181 countries, 1980–2008:a systematic analysis of progress towards Millennium Development Goal 5
Margaret C Hogan, Kyle J Foreman, Mohsen Naghavi, Stephanie Y Ahn, Mengru Wang, Susanna M Makela, Alan D Lopez, Rafael Lozano, Christopher J L Murray
Volume 375 May 8, 2010, pp. 1609-1623.
Map of Priority Countries
Global SituationGlobal Situation• 180-210 million pregnancies annually
• 80 million unwanted pregnancies
• 50 million induced abortions
• 20 million unsafe abortions
• 68,000 deaths from unsafe abortion
• 20 million women suffer from maternal morbidity
• Estimated 350,000 to 450,000 maternal deaths
• 3million babies are born dead
• Almost 10 million children under age of 5 die
• Of which 3 million newborns die within the first week
• 500,000 infants are infected with HIV
Every Single minute……380 women become pregnant…190 women face an unplanned or unwanted pregnancy…110 women experience pregnancy-related complications …40 women have an unsafe abortion
…1 woman dies
MM WHO estimates
MM WHO… Estimates
Maternal Mortality: The latest data
• For the first time, new data indicate that we are seeing real progress in reducing maternal mortality worldwide.
• A new study published in The Lancet in May 2010 revealed that the number of women dying from pregnancy-related causes has declined from 526,300 in 1980 to 342,900 in 2008.
• The finding contradict previous research which showed very little change in reducing maternal mortality, and represent a powerful opportunity to show that investments to reduce maternal mortality actually work.
“These numbers should now act as a catalyst, not a brake, for accelerated action on MDG-5, including scaled-up resource
commitments. Investment incontrovertibly saves the lives of women during pregnancy.” Richard Horton
Source: Hogan MC et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet 2010: published online April 12. doi:10.1016/S0140-6736(10)60518-1.
Current Situation
6 Countries Account for 50%
of Maternal Mortality
- India - Afghanistan
- Nigeria - Ethiopia
- Pakistan - Democratic Republic of the Congo
Countdown to 2015
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Trends in Maternal Mortality in Malawi: UN Estimates with extrapolation to 2015
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Trends in Under-5 Mortality Rate (top line) and Infant Mortality Rate (lower line) in Malawi
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Neonatal Mortality Rate in Malawi
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Causes of Maternal Mortality
Main direct causes of maternal deaths in Malawi
1. Haemorrhage after childbirth (27%)2. Sepsis after childbirth (23%)3. Hypertension of Pregnancy (17%)4. Complications of unsafe abortion (16%)
ALL THESE CONDITIONS ARE COMMONEST WITH CHILDBIRTH OR ABORTION OUTSIDE HEALTH
FACILITIES
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NPC Training in MNHSource: MDHS2010
Main causes of neonatal deaths
1. Birth asphyxia– lack of resuscitation skills at birth
2. Low birth weight–Prematurity leading to
• Cold injury• RDS
–HIV 3. Severe infections
–Home births 24NPC Training in MNH
Time of Death
Key strategies to reduce maternal mortality
What factors are driving maternal mortality in Malawi?
Not only medical issues, but also a social, economic, political and human rights issues•Poverty
– No food security
•Low female literacy rates– Cultural factors
•High fertility rate
•Poor functioning health infrastructure– Contraceptive services
– Insufficient focus on quality of care – Inadequate number of skilled health workers.– Physical infrastructure– Basic tools of the trade
• Slow adoption of evidence based policy
“I am going to fetch a baby. The journey is dangerous and I may not return …”
Maternal Mortality: The Link to Family Planning
• The Lancet study data indicate that the global decline in fertility is a key contributing factor to the decline in maternal mortality.
• Societies in which the total fertility rate has decreased are also those in which maternal mortality has decreased.
Global decline in total fertility rate (TFR)
I__________________I_________________I
1980 1990 2008
3.70 3.26 2.56
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Skilled attendance at birth saves mothers and babies
WHOApril 2005
Skilled attendance at childbirth is the most effective intervention
Access to skilled birth attendants
About 35 % of pregnant women in developing countries have no access to, or contact with, health personnel before delivery, and only 57 % give birth with a skilled attendant present.
Access to emergency obstetric care
42 % of all pregnancies everywhere experience a complication.
In 15 % of all pregnancies, the complications are life-threatening.
61 % of maternal deaths occur just before, during, or just after
delivery, often from complications that cannot be predicted and are difficult to prevent
Therefore… it is critical that every woman have access to emergency obstetric care
Why Women Do Not Access Health Services?
Distance from health servicesLack of transportationCostMultiple demands on women’s timeLack of decision-making power within the familyAttitude of health care providersLimited access to educationInadequate health care servicesDiscriminatory or inadequate laws or
health care policiesCultureCommunity
Reasons for decrease of maternal mortality
• Global decrease in Total Fertility Rate (TFR)• Increase of income in low-income countries• Increase in maternal education• Increase in skilled birth attendants from approximately
25% to 45–55%
Cause of Death % of Deaths Known Successful Interventions
Haemorrhage 24-35% of maternal deaths
- Oxytocin and Misoprostol are medications that can prevent or stop bleeding during and immediately following delivery. - Controlled cord traction and uterine massage are known techniques to stop postpartum bleeding.- Skilled attendants are necessary to administer medication or perform techniques.
Unsafe Abortion 9-13% of maternal deaths
- Family planning information and access to contraception and reproductive health supplies are needed to prevent unintended and unplanned pregnancies. - Where legal, effective reproductive services include the availability of safe abortions conducted by trained healthcare providers using proper techniques under sanitary conditions.- Post-abortion care including emergency treatment for complications from spontaneous or induced abortion, follow-up and referral to other reproductive health services.
Infections (e.g. Sepsis, pneumonia, tetnus)
8-15% of maternal deaths, 29-36% of newborn deaths, 46% of child deaths
- Antibiotics and immunizations are critical to treat infections in women and children.- Hygienic delivery and postpartum care in a health facility can prevent infections in mothers and newborns.- Treatment by a skilled health care provider near children’s homes.
Eclampsia & Hypertensive Disorders
12% of maternal deaths
- Magnesium Sulphate can be administered by skilled attendants as an effective, safe and inexpensive medication that reduces the risk of eclampsia and maternal death caused by pregnancy-related hypertensive disorders.
1. What Interventions Work?
Cause of Death % of Death Known Successful Interventions
Obstructed Labour
8% of maternal deaths
- Caesarean section by trained, skilled attendants can perform this surgical procedure to ensure safe childbirth when obstructed labour or other complications make vaginal birth impossible or unsafe for the mother and baby.- Access to proper nutrition can help prevent obstructed labour by ensuring proper growth and development in women.
Asphyxia 23% of newborn deaths
- Increasing maternal nutrition reduces the likelihood of low birth weight, a significant factor in causing birth asphyxia.- Presence of a skilled attendant to provide immediate care after delivery.
Diarrhoea 24% of child deaths, 2.4% of newborn deaths
- Treatment by a skilled health.- Oral rehydration therapy using oral rehydration salts, home fluid and food intake guidelines.- Increased sanitation and access to clean water.
Malaria and HIV/AIDS
15% of child deaths19% of women’s deaths (AIDS)
- Treatment by a skilled health care provider.- Use of insecticide-treated nets and region-specific antimalarial medicines.- Preventing Maternal to Child Transmission (PMTCT) counseling and ARVs-Treatment with ARVs for women
Nutrition-related disorders
35% of child deaths
- Access to proper, age appropriate nutrition sources.- Encouraging breastfeeding from 1-hr after birth through 6 months of age.- Vitamin A supplements.
2. What Interventions Work?
3. What Interventions Work? childbirth
– - Antenatal care– - Skilled attendance at birth, including
emergency obstetric and neonatal care– - Immediate postnatal care for mothers
and newborns
Access to family planning– - Counseling– - Services– - Modern contraception
Access to safe abortion (when legal)
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Access to quality care for pregnancy and childbirth
- Antenatal care- Skilled attendance at birth, including emergency obstetric and neonatal care- Immediate postnatal care for mothers and newborns
Access to family planning- Counseling- Services- Modern contraception
Access to safe abortion (when legal)
Strong health systems– - Scaling-up critical health
interventions– - Training health care
professionals– - Training of mid-wives
Accelerated access to life-saving, interventions, medicines and vaccines
– - Vaccines to target pneumonia, tetanus, and diarrhea
– - Prevention, screening and treatment of HIV and STIs
– - Treatment and prevention of malaria, pneumonia and diarrhea
COVERAGE FAILURES ACROSS THE CONTINUUM OF CARE GLOBALLY
Coverage estimates for interventions across the continuum of care in the 68 priority countries (2000-2006). Vertical bars indicate the range in coverage across countries.
For some interventions:•Family planning•Exclusive breastfeeding•Clinical care for newborn and child illnesses
In some countries:• Wide gaps in coverage across countries
Place of Delivery in Malawi
URBAN1. 84% in health facilities
a. 85% had skilled attendance at birth
2. For all Malawi 72% delivered in health facilities
3. 98% women with tertiary education had skilled attendance at childbirth compared to 63% women without education.
RURAL1. 71% in health facilities
a. 70% had skilled attendance at birth
2. For all Malawi, 73% women had skilled attendance at childbirth
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NPC Training in MNH Source: MDHS 2010
Which women and newborns were dying the most in Malawi?
Mothers• Women who delivered or
procured abortion outside the health facilities, especially when they developed, PPH, PIH and sepsis– Women who developed these
complications while in health facility, had treatment initiated earlier and were less likely to die.
Neonates• Babies born without skilled
attendant present at birth.– Suffered the most from birth
asphyxia, cold injury and infection, especially if they were under weight or premature
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Rationale for Change of TBA roles
1. International WHO and local studies revealed that investment in TBAs did not contribute significantly to reduction of maternal and neonatal deaths
2. The option of TBA births prevented the scale up of skilled attendance at child births
– As soon as the TBA option was removed in Malawi, health facility births soared, distance of health facility had been overestimated
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Trends in Skilled Attendance at Birth in Malawi
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NPC Training in MNH
There is no better time to reduce maternal and child death in Malawi - Commited leadership critical
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surgical intervention. Sapiens Publishing, 2006. • Chowdhury ME, Botlero R, Koblinsky M, Saha SK, Dieltiens G, Ronsmans C. Determinants of reduction in maternal mortality in Matlab,
Bangladesh: a 30-year cohort study. Lancet 2007; 370: 1320–28.• Countdown Coverage Writing Group, on behalf of the Countdown to 2015 Core Group. Countdown to 2015 for maternal, newborn, and child
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developing countries. BMC Med 2008; 6: 12.• Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R,• Landagan OZ, Barrios EB. An estimation procedure for a spatial-temporal model. Stat Probab Lett 2007; 77: 401–06.• The Millennium Development Goals Report 2008. New York: United Nations, 2008.• Murray CJL, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5.
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World Health Organization. 2007.• WHO. WHO Mortality Database. Geneva: World Health Organization, 2010. http://www.who.int/whosis/mort/download/en/index.html
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