Mmr 2016

MATERNAL MORTALITY

One woman dies every minute somewhere in the world because of a complication related to pregnancy or childbirth - and 80% of these deaths

could be prevented.

THE REALITY

MATERNAL DEATH

The death of a woman while pregnant or within 42 days of termination of pregnancy: irrespective of the duration and site of pregnancy from any cause related to or aggravated by the

pregnancy or its management From other causes not related or caused by the

pregnancy Termination of pregnancy:

Normal delivery Miscarriage Ectopic/Molar

CLASSIFICATION Direct

Deaths resulting from obstetric complications in pregnancy, labour and puerperium

Indirect Deaths resulting from previous existing disease or diseases that developed during pregnancy and which was aggravated during pregnancy

Fortuitous Deaths from other causes not related to or influenced by pregnancy

Late Death after 6 weeks until 1 year after delivery

Classifiction ExamplesDirect Thromboembolism

HaemorrhageEctopicsHypertensive disease of pregnancySepsisAmniotic fluid embolism

Indirect Cardiac diseaseSuicideEpilepsy/CNS haemorrhageInfectionsRespiratory/gastrointestinal diseases

CLASSIFICATION

MMR(MATERNAL MORTALITY RATIO)

(MATERNAL MORTALITY RATIO)

Maternal mortality ratio (MMR) is the number of women who die from pregnancy related causes during pregnancy and within 42 days of childbirth, per 100,000 live births.

Excluding accidental or incidental causes

No of women dies 100,000 live births

MDG 5 (MILLENNIUM DEVELOPMENTAL GOALS)MDG 5: improve maternal health Target 5.A. Reduce by three quarters, between

1990 and 2015, the maternal mortality ratio

Target 5.B. Achieve, by 2015, universal access to reproductive health

National MMR have reached a plateau between 28-30/100,000 LB the last 10 years

State MMR showing a decreasing trend the last 4 years….

MMR for 2010 (21.3) & 2011 (19.9) – reaching a plateau?

MDG 5 target for state by 2015 – 11.08/100,000 LB

OUR STATE…. There is marked reduction in MMR in our state

YEAR MMR ( per 100,000 live births)

2008 30.82009 262010 21.32011 21.72012 26.62013 9.3 (*** achieve MDG 5

target)

CEMD(CONFIDENTIAL ENQUIRIES INTO MATERNAL DEATH)

SUMMARY FROM CEMD REPORT 2006-2008

772 pregnancy related deaths were reported from 2006-2008 MMR in 2008 was 27.3 per 100,000 live births Principal cause of maternal deaths are obstetric embolism,

medical disorders in pregnancy, PPH & hypertensive disorder >60% of the maternal death occurred during postnatal period The risk of maternal death was higher in woman aged >40

years & in mothers who had >6 childrens Maternal death tagged with the green code increased from

26.6% in 2006 to 32.3% in 2008

TABLE: NUMBER OF PREGNANCY RELATED DEATH FROM 2001-2008

YEAR 2001 2003 2005 2006 2007 2008

No of deaths

316 236 255 247 258 267

TABLE: MMR ACCORDING TO STATESTATES 2006 2007 2008

Death MMR Death MMR Death MMRPerlis 0 0 2 50.9 1 24.1Kedah 8 23.7 10 29.7 9 25.6P.Pinang 4 18.4 8 36 8 35.1Perak 7 19.3 6 16.7 11 30.1Selangor 24 26.4 22 23.6 22 22.7K.Lumpur 5 20.2 2 8.0 5 19.7Putrajaya 0 0 0 0 0 0N.Sembilan 4 24.3 4 23.7 7 40.9Melaka 5 39.1 5 37.7 6 44.6Johor 21 37.6 24 42.2 11 19.3Pahang 9 36.5 6 24.3 9 35.3Terengganu 7 32.1 5 22.5 1 4.3Kelantan 7 20.8 8 23.8 13 37.5Sabah 15 34.1 21 45.7 15 30.3Labuan 0 0 0 0 0 0Sarawak 11 26.1 13 31.1 15 35.0Malaysia 127 27.3 136 28.8 133 27.3

TABLE: CAUSES OF MATERNAL DEATHS

CAUSES 2006 2007 2008

PPH 24 (18.9%) 23 (16.9%) 26 (19.5%)HPT DISORDER 22 (17.4%) 25 (18.4%) 14 (10.5%)OBSTETRIC EMBOLISM

18 (14.2%) 24 (17.7%) 40 (30%)

MEDICAL ILLNESS 24 (18.9%) 20 (14.7%) 24 (18%)

APH 5 (3.9%) 2 (1.5%) 2 (1.5%)PUERPERAL SEPSIS

2 (1.6%) 3 (2.2%) 4 (3.1%)

ABORTION 3 (2.3%) 6 (4.4%) 3 (2.3%)ECTOPIC 9 (7.1%) 7 (5.1%) 3 (2.3%)UNSPECIFIED COMPLICATION OF PREGNANCY & PUERPERIUM

5 (3.9%) 8 (5.9%) 2 (1.5%)

ASSOCIATED WITH ANAESTHESIA

0 1 (0.7%) 1 (0.8%)

OTHERS 9 (7.1%) 11 (8.1%) 9 (6.7%)TOTAL 127 136 133

PPHHPT

EMBOLIS

M

MEDIC

AL APH

SEPSIS

ABORTION

ECTO

PIC

UNSPEC

IFIED

ANAESTH

ESIA C

X

OTHER

S0

5

10

15

20

25

30

35

200620072008

TABLE: DEATH BY CITIZENSHIP STATUS

CLASSIFICATION

2006 2007 2008

Malaysian citizens

186 (76.1%) 202 (78.2%) 197 (73.8%)

Non citizens with legal documents

24 (9.7%) 28 (10.9%) 31 (11.6%)

Non citizens without legal documents

35 (14.2%) 28 (10.9%) 39 (14.6%)

TABLE: CLASSIFICATION OF PREGNANCY RELATED DEATHS

CLASSIFICATION 2006 2007 2008Direct 100 (47.2%) 115 (50%) 110 (48.2%)Indirect 27 (12.7%) 21 (9.1%) 23 (10.1%)Subtotal 127 136 133MMR 27.3 28.8 27.3Fortuituos 85 (40.1%) 94 (40.9%) 95 (41.7%)Grand total 212 230 228

TABLE : MATERNAL DEATH BY AGE SPECIFIC GROUP

AGE 2006 2007 2008< 19 32 18.5 16.920-24 26.6 19.4 17.625-29 12.5 20.5 17.930-34 27.2 30.8 26.735-39 44.4 48.3 44.840-44 81.8 67.8 81.3>45 56.1 112.5 114.6

TABLE : MATERNAL DEATH BY PARITY SPECIFIC

PARITY 2006 2007 2008

Primigravida 8.4 17.1 11.5

Multiparity 32 30.5 32.6

Grandmultipara 80.3 70 64.5

TABLE: MATERNAL DEATH BY FAMILY PLANNING PRACTICE

FAMILY PLANNING

2006 2007 2008

Ever user 30 (23.6%) 25 (18.4%) 24 (18.3%)

None user 68 (53.5%) 86 (63.2%) 82 (62.6%)

Don’t know 29 (22.9%) 25 (18.4%) 27 (19.1%)

TOTAL 127 136 133

TABLE: MATERNAL DEATH BY STAGE OF PREGNANCY

STAGE OF PREGNANCY

2006 2007 2008

Antenatal 27 (21.3%) 26 (19.1%) 32 (24%)Intrapartum 19 (15%) 13 (9.6%) 11 (8.3%)Post partum 69 (54.3%) 84 (61.8%) 83 (62.4%)Early pregnancy deaths

12 (9.4%) 13 (9.5%) 7 (5.3%)

TOTAL 127 136 133

TABLE: MATERNAL DEATHS BY COLOUR CODING

COLOUR CODING

2006 2007 2008

Red 15 (11.8%) 18 (13.2%) 13 (9.8%)Yellow 17 (13.4%) 24 (17.7%) 17 (12.8%)Green 34 (26.7%) 45 (33.1%) 43 (32.3%)White 12 (9.5%) 7 (5.1%) 12 (9%)No information 49 (38.6%) 42 (30.9%) 48 (36.1%)

TOTAL 127 136 133

KEY RECOMMENDATIONS Ectopic pregnancy should be ruled out in any woman in the

reproductive age who complains of abdominal pain. Pre-conception care should be provided for women with

pre-existing medical conditions. Combined care to the women with current or previous

medical conditions Awareness on thromboprophylaxis & postnatal depression

among Health professional To follow Obstetric protocols and guidelines and to

organise regular obstetric drills

STEPS TO REDUCE MMR Greater effort should be made to provide family planning

services to high risk women Existing referral system should be strengthened through

supervision and communication Regular obstetric drills should be organised for health

staff managing obstetric patients All home deliveries must be conducted by trained

personnel Home visits and defaulter tracing must be done by

health staff Hospital staffs must inform the health clinic once patient

discharged

Why mothers

continue to die ???

DELAYS CAUSES DEATH Delays in deciding to seek care

Delays in reaching appropriate care

Delays in receiving care at the health / hospital facility

PATIENT FACTORS

These are factors attributable to the attitude of women and/or their relatives, which prevented appropriate care being

received by the patient

PERSONNEL OR FACILITY FACTORS

These are factors related to inadequacies in the number, types or availability of personnel or

facilities

REMEDIABLE CLINICAL FACTORS

These are specific interventions or approaches to management that would have reduced the

likelihood of death of the mother.

REMEDIABLE CLINICAL FACTORS1.Failure to diagnose2.Failure to appreciate severity.3.Inadequate, inappropriate or delayed therapy.4.Failure of adherence to protocols5.Inappropriate delegation of duties.6.Failure to inform seniors.7.Failure to inform other specialists.8.Failure of combined care.9.Failure of communication.10. Delay / failure of referral.11. Failure of home visits / defaulter tracing.

More than 50% of patients who died had

some degree of unsatisfactory management

‘Substandard care’‘Remediable clinical factors’

SAY NO TO HOME BIRTH !!

** INCREASE MATERNAL MORTALITY** INCREASE PERINATAL MORTALITY

QUESTIONS??