MATERNAL HEALTH 12-Jul-05 Photo credit: Media for Development International.

MATERNAL HEALTH12-Jul-05

Photo credit: Media for Development International

Learning Objectives

At the end of this session, participants will be able to:

• Describe a conceptual framework for maternal health

• Identify the main interventions/approaches to improve maternal health

• Discuss core output and outcome indicators; recognize their strengths and limitations

Every Minute...

Maternal Health: Problem

• 380 women become pregnant

• 190 women face unplanned or unwanted pregnancy

• 110 women experience a pregnancy-related complication

• 40 women have an unsafe abortion

• 1 woman dies from a pregnancy-related complication

Source: JHPIEGO

Annually, 585,000 women die of pregnancy related complications

Global Causes of Maternal Mortality

24.8

14.9

12.96.912.9

7.9

19.8

Hemorrhage 24.8%

Infection 14.9%

Eclampsia 12.9%

Obstructed Labor6.9%Unsafe Abortion12.9%Other Direct Causes7.9%Indirect Causes19.8%

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

Three Delays Model

Global Targets

Target 6 of the MDGs

To reduce the maternal mortality ratio by three-quarters between 1990 and

2015.

Interventions to Reduce Maternal Mortality

HISTORICAL REVIEW

• Antenatal care

• Traditional birth attendants

• Risk screening

CURRENT APPROACH

• Skilled attendance at delivery

RecommendedBirth Preparedness, Including Complication Readiness

• Preparing for Normal Birth– Skilled attendant– Place of delivery– Finance– Nutrition– Essential items

• Readiness for Complications– Early detection– Designated decision

maker(s)– Emergency funds– Communication– Transport– Blood donors

ANC Recommendations (I)

• Goal-directed visits by skilled provider

• Four visits for normal pregnancy

• Counseling – Nutrition, FP, danger signs, breastfeeding,

HIV/STIs

• Detection/management of existing diseases & conditions

ANC Recommendations (II)

• Detection/management of complications• Prevention

– All women: • Tetanus toxoid vaccination• Iron folate supplementation

– Select populations:• Malaria intermittent preventive treatment• Routine hookworm treatment• Iodine supplementation• Vitamin A supplementation

ImpactOutcome

•Skilled attend-ance at birth

•Increas-ed know-ledge of danger signs

Output

•Community availability of emergency transport

•Trained providers in EmOC

•Increased access to mat. health services

•Increased competence of skilled birth attendants

Process Input

I. Behavior ChangeBirth Preparedness•Attendant at birthComplication Readiness•Collaboration•Transport•Finances•Blood (walking donor)

Maternal and newborn Survival

II. Policy/Advocacy•Policy & environment for quality, access

III. Essential Ob. Care•In-service & pre-service training in EmOC

Logic Model

•Finance

•Equipment

•Supplies

•Transport

•Staff

M&E Challenges (I)

• Establishing causality

• Maternal health is multifactorial

• Improvements in overall health status are not necessarily followed by concomitant changes in mortality

• Considerable time lag to measure mortality change

M&E Challenges (II)

• Rarity of maternal deaths– Data collection costs– Confidence intervals

• Identifying deaths related to early pregnancy and induced abortion

• Establishing trends in maternal mortality

• Reliable cause-of-death data are difficult to obtain

M&E Challenges (III)

• Evaluation study design

• Incomplete vital registration systems

• Selectivity bias with health services data

• Estimating denominators for facility-based maternal mortality rates

• Rural-urban differences in maternal mortality may reflect differences in fertility patterns

Defining Maternal DeathAccording to the Tenth Revision of the ICD:

Maternal Death:A maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of theduration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental causes (WHO 1993).

NOTE: 2 criteria•Temporal relationship to the pregnant state•Causal relationship to the pregnant state

Pregnancy-related death: “time of death” definition; Irrespective of cause.

Maternal Mortality Indicators

• Maternal mortality ratio

• Maternal mortality rate

• Life-time risk of maternal morality

• Proportion maternal

Maternal Mortality Ratio

MMRatio:

N of maternal deaths in a specified period *100,000 N of live births in same period

Interpretation:

MMRatio = 50-250 per 100,000 live birthsProblems with quality of care

MMRatio > 250 per 100,000 live birthsProblems with quality of care & access

Maternal Mortality Rate

MMRate:

N of maternal deaths in a specified period *1000N of women of reproductive age

Relation Between Rate and Ratio

• MM Rate = MM ratio * GFR• MM Ratio = MMRate / GFR

• Example: the maternal mortality rate is 2 per 1,000 women 15-49 years and the general fertility rate is 200 per 1,000 women 15-49, what is the maternal mortality ratio?– Ratio = .002/.2 * 100,000 = 1,000 per 100,000 live births

General fertility rate = 1000*(N of live births in a period) / (N of women of reproductive age in a period)

Other Maternal Mortality Indicators

• Life time risk of maternal mortality = (N of maternal deaths over the reproductive life span) / (women entering the reproductive period)

• Proportion maternal = proportion of all female deaths due to maternal causes = (N of maternal deaths in a period/Number of all female deaths in same period) * 100

Where Do Maternal Mortality Data Come From?

• Vital registration data - MM Rate and MM Ratio• Health service data – maternity registers - MM

Ratio• Special studies

– Hospital studies – tracing deaths, interviews– Ramos studies– Longitudinal studies, verbal autopsy

• Surveys & censuses– Direct estimation - Rate and Ratio– Sisterhood method (indirect) – Rate and Ratio

Sisterhood (Indirect) Method to Estimate Maternal Mortality

• Questions are asked to female respondents 15-49 about the number of sisters and how many have died during pregnancy, childbirth and puerperium (no questions about age of sisters)

• Gives life time risk and proportion of adult female deaths due to maternal causes

• Gives deaths covering 40 year-period, centering on 12 years before the survey

Direct Maternal Sibling Method to Estimate Maternal Mortality

• Questions are asked to female (and male) respondents 15-49 about the sisters born to the same mother– age of surviving siblings– age at death of siblings who died– number of years ago the sibling died– whether the sister died during pregnancy, childbirth and

puerperium (no questions about age of sisters)• Gives maternal mortality rate for 7-year period prior

to the survey; gives age-specific mortality rates• Gives maternal mortality ratio, using the general

fertility rate

Maternal Mortality: Not Easy to Measure

• Estimates not precise • Estimates refer to periods several years before survey• Surveys are expensive• Difficult to assess change due to wide confidence

intervals on estimates• Maternal mortality should be measured once every 7-10

years

Maternal mortality ratios with 95 % confidence intervals

0

200

400

600

800

1000

1200

0-6 years 7-13 years 0-6 years 7-13 years

Malawi 1992 Senegal 1992-3

Measuring Utilization of MH Services

• Percent of births attended by skilled health personnel

N of live births attended by skilled health personnel

Total no. of live births

• Percent of women 15-49 attended at least once during pregnancy by skilled health personnel

UNICEF, WHO, UNFPA “Process Indicators”:

• Availability of Emergency Obstetric Care (EmOC)

• Geographical distribution of EmOC facilities

• % of births attended in an Emergency Obstetric Care facility

• Cesarean section rates

• Met Need for Obstetric Care

• Case Fatality Rate (from hospitals)

UNICEF, WHO, UNFPA, 1997

Indicators of Services Availability• Facilities

– Basic Emergency Obstetric Care facilities per 500,000 population (4)

– Comprehensive Emergency Obstetric Care facilities per 500,000 population (1)

• Distributions– Geographic distribution

UNICEF, WHO, UNFPA, 1997

Basic and Comprehensive EmOC FacilitiesBasic and Comprehensive EmOC Facilities

BASICBASICEmOC Facilities Provide the first 6 Services

• Antibiotics (intravenous or by injection)• Oxytocic Drugs (ditto)• Anticonvulsants (ditto)• Manual Removal of Placenta• Removal of Retained Products• Assisted Vaginal Delivery

• Surgery (Cesarean Section)

• Blood Transfusion

% of births attended in an Emergency Obstetric Care facility

• (Number of live births attended in an EmOC facility)/(All live births*) (> 15%)

* The numerator is the sum of births taking place in EmOC facilities. The denominator is restricted to live births simply due to the fact that data on pregnancies are not available (often estimated from census or other pop-based data).

Experience with % births in EmOC facilities

• Requires collecting and summing information across facilities in a geographic area

• Questions as to how important/feasible it is to ask health facility staff to adjust population totals

• Requires knowledge as to the state of services being offered at multiple health facilities (ie, reaching criteria for Basic, Comprehensive obstetric care)

Population-based C-section Rates

• (N of caesarian section operations in geographic area per time period)/(N of live births) (5-15%)*

NOTE: must be interpreted entirely differently than hospital-based caesarian section rates. In Referral Hospitals, one may see C-Section Rates of 25-35% and that may be appropriate because of its referral status.

Case Fatality Rate• Percent of women with obstetric complications in

a specific facility who die (1%)

• Strengths & limitations– Definition of a “fatality” is straight forward– Easy to understand/interpret– Is best used in hospitals with a large volume of

births/deaths– Follow up requires more in-depth investigation

(maternal death audits or other qualitative methods)

Met Need for EmOC

Percent of women with major obstetric complications who are treated (in a given geographic area and time period) (100%)*

(N of women w/ ob.complications in facilities)/(15% of estimated live births in catchment area*)

Experience With “Met Need”

• Assumes that the recorded complication was treated• Requires data on complications (RE: standardization of

definitions, is it necessary?)• Will often require changing the delivery room register

(adding a column)• Changing the register should be viewed as an

intervention in and of itself• Whose responsibility is it to act on the results?

Utilization of “UN Process Indicators”

Utilization of “UN Process Indicators”

CALCULATING ALL 6 INDICATORS• Gives you an indication of where the

problems lie and where action is needed.

• Also, these indicators are sensitive to change: within months, you can know if your project is making a difference

CALCULATING ALL 6 INDICATORS• Gives you an indication of where the

problems lie and where action is needed.

• Also, these indicators are sensitive to change: within months, you can know if your project is making a difference

Availability of EmOCAvailability of EmOC

Problems:

• Does Indicator # 1 show you need more EmOC facilities?

• Does Indicator # 2 show you need better distributed EmOC facilities?

Problems:

• Does Indicator # 1 show you need more EmOC facilities?

• Does Indicator # 2 show you need better distributed EmOC facilities?

Action:• Most countries

already have enough facilities; they may just need to upgrade services to ensure 1 Comprehensive and 4 Basic EmOC facilities per 500,000 population

Action:• Most countries

already have enough facilities; they may just need to upgrade services to ensure 1 Comprehensive and 4 Basic EmOC facilities per 500,000 population

Utilization of EmOCUtilization of EmOCProblemsProblems

• Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population?

• Does Indicator # 4 show that “Met Need” is less than 100%? (I.e. that not all women who experience obstetric complications are using EmOC facilities)

• Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section?

• Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population?

• Does Indicator # 4 show that “Met Need” is less than 100%? (I.e. that not all women who experience obstetric complications are using EmOC facilities)

• Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section?

Utilization of EmOCUtilization of EmOCAction:

Collect More Information FirstAction:

Collect More Information First

• Do you have enough qualified staff?• Do you need to train staff on management of

emergency obstetric complications?• Does hospital management need improvement?• What’s the supply situation like?• What’s the equipment situation like?

• Do you have enough qualified staff?• Do you need to train staff on management of

emergency obstetric complications?• Does hospital management need improvement?• What’s the supply situation like?• What’s the equipment situation like?

If all the above is in place, conduct focus groups in the community to find out why

women are not coming for care

If all the above is in place, conduct focus groups in the community to find out why

women are not coming for care

Quality of EmOCQuality of EmOC

Problem:Problem:

• Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities?

• Find out if your EmOC facilities are really functioning

• Check staff numbers, skills, management capacity, supplies and equipment

• Lobby the health ministry for more support; get community to lobby with you

Action:Action:

Summary on “Process Indicators”

• UN process indicators only part of picture

• Maternity record keeping important– Non-standard format– Incomplete, illegible, missing records– Non standard definitions of obstetric complications– Misclassification or non-recording of maternal death

• In maternal health, no indicator of service provision or use is unequivocally linked to a reduction in maternal mortality

• Maternal mortality unsuitable for documenting change at programme level

• Attributing changes to the programme per se may be difficult, and providing ‘scientific’ proof of programme effectiveness may be not be achievable.

Source: Ronsmans, 2001, HSOP #17, p 337 Continued

Conclusions re Evaluation

References

• Campbell, O., Filippi, V., Koblinsky, M., Marshall, T., Mortimer, J., Pittrof, R., Ronsmans, C., and Williams, L. 1997. Lessons Learnt: A decade of measuring the impact of safe motherhood programmes.  London: London School of Hygiene and Tropical Medicine.

• Stanton, C., Abderrahim, N., and Hill, K. 2000. “An assessment of DHS maternal mortality indicators.” Studies in Family Planning 31(2): 111-123.

• Thaddeus, S. and Maine, D. 1994. Too far to walk: maternal mortality in context. Social Science and Medicine 38(8): 1091-1110.

• UNICEF, WHO, and UNFPA. 1997. Guidelines for Monitoring the Availability and Use of Obstetric Services. New York: UNICEF

Supplemental Slides I Measuring Service Utilization by Women With Complications • Count number of women with specific complications

in the health facilities• Derive expected number of complications in a year

– standard guesstimate: 15% of all deliveries have complications

– estimate from self-reported data by women on the occurrence of complications in a survey (OVER METHOD)

– Specific prevalence of complications based on literature

Supplemental Slides (II)OVER METHOD

• Prevalence of specific complications, known from other studies (Pitroff, 1997):

• breech at delivery: 31.7 per 1,000 deliveries

• twin pregnancy: 28.4 per 1,000 deliveries

• placental abruption:10 per 1,000 deliveries

• placenta praevia: 3 per 1,000 deliveries

• Example - In a district with an estimated 10,000 deliveries in a year, 40 breech deliveries were reported by the health facilities. What is the coverage of breech deliveries by health facilities?

Supplemental Slides (III)OVER METHOD

Problem:• Example - In a district with an estimated 10,000 deliveries

in a year, 40 breech deliveries were reported by the health facilities. What is the coverage of breech deliveries by health facilities?

• Prevalence of breech at delivery: 31.7 per 1,000 deliveries (Pitroff, 1997)

Answer:• 10,000 * 31.7/1000 = 317 breech deliveries are

expected; coverage is 40/317 = 13%