Reducing Maternal Mortality: examples of health technologies in Asia and Africa Fifth Annual Meeting of the African Science Academy Development Initiative.

Reducing Maternal Mortality: examples of health technologies in Asia and AfricaFifth Annual Meeting of the African Science Academy Development Initiative (ASADI)

Ayo Ajayi,November 10, 2009

What we know…

Africa

9.1%

9.7%

3.9%

4.1%

0.5%

2.0%

4.9%

6.2%

3.7%

16.7%

5.4%

33.9%

Asia

9.1%

11.6%5.7%

9.4%

0.1%

0.4%

1.6%

0.0%

12.8%

12.5%

6.1%

30.8%

Haemorrhage Hypertensive disorders

Sepsis/Infections Abortion

Obstructed labour Ectopic pregnancy

Embolism Other direct causes of death

HIV/AIDS Anaemia

Other indirect causes of death Unclassified deaths

Country Rankings for Neonatal and Maternal Deaths

Ranking for numbers Ranking for numbers of neonatal deaths of maternal deaths

1 India 1

2 China 9

3 Pakistan 3

4 Nigeria 2

5 Bangladesh 8

6 Ethiopia 4

7 Dem. Rep. Congo 4

8 Indonesia 11

9 Afghanistan 7

10 Tanzania 6

WHO/UNICEF/UNFPA estimates of maternal mortality for 2000

2.5 million

neonatal

deaths

Approximatel

y

66% of

global

total

325,000

maternal

deaths

Approximatel

y

61% of

global

total

Causes of Maternal Mortality in Asia

Hemorrhage is the leading cause of maternal mortality in Asia.

Other causes include embolism, ectopic pregnancy, anesthesia-related, include: malaria, heart disease.Source:" WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, vol 367, April 1, 2006.

Postpartum Hemorrhage

14 million cases of postpartum hemorrhage (PPH) per year

PPH causes up to 60% of all maternal deaths in developing countries

PPH often needs a quick response, which is especially difficult if delivery is at home, or in high volume, low resource facilities

Case Study: Pakistan

Verbal Autopsy of Maternal Deaths in 2 Districts

Findings

Most of the deaths were:

in the lower socio-economic group

in the postpartum period (71%)

within 24 hours 40 %, mostly of PPH

in health facilities (Govt. 37, Pvt.

34) (Sukkur & Malir districts 2004-

2006)

Simple steps… a balanced approach to PPH prevention

An evidence-based intervention for skilled birth attendants (SBAs), combined with a community-based strategy, can prevent 50-60 % of PPH

Active management of the third stage of labor for SBAs

Community-based distribution of misoprostol

Evidence Supporting Use of Oxytocin in the Active Management of the 3rd Stage of Labor (ATMSL)

Reduces incidence of PPH by 60% Reduces the quantity of blood loss—thereby

decreasing incidence and severity of anemia Reduce emergencies and related cost, transport Reduces the use of blood transfusion Routine use of 10 IU of oxytocin can reduce the

incidence of PPH, but it is difficult to ensure safe injection

Active Management Physiologic Management OR and 95% CIBristol Trial ‘88 50/846 (5.9%) 152/849 (17.9%) 3.13 (2.3-4.2)Hinchingbrooke Trial ‘98 51/748 (6.8%) 126/764 (16.5%)

2.42 (1.78-3.3)

For Births That Occur Without Skilled Care

Community-based distribution of misoprostol is an effective strategy

Why?

We cannot predict PPH on the basis of risk factors.

In many countries very few deliveries are attended by a skilled attendant.

Once severe PPH occurs, death follows very rapidly

Timely referral and transport to facilities is not always available or affordable

Availability of EOC services is grossly limited.

Eclampsia and pre-eclampsia in Kano State In Kano state, eclampsia was the

commonest cause of maternal deaths and contributed 46.3% of all the deaths in one study[i] and 31.3% in another[ii].

[i] Society of Gynaecology and Obstetrics of Nigeria (SOGON). Status of emergency obstetric service in six states of Nigeria- A needs assessment report. June 2004

[ii] Adamu YM, Salihu HM, Sathiakumar N and Alexander R. Maternal mortality in Northern Nigeria: a population based study. Eur J Obs Gynae Rep Biol 2003; 109(2): 153-159

Patient DataPatient Data

Biichi General Hospital 95 5%

Danbatta General Hospital 152 8%

Doguwa General Hospital 58 3%

Gwarzo General Hospital 91 5%

Minjibir General Hospital 79 4%

Murtala Mohammed specialist Hospital

799 43%

Rano General Hospital 153 8%

Rogo General Hospital 115 6%

Tudun Wada general Hospital 110 6%

Wudil General Hospital 194 11%

Total 1846 100%

On the basis of the available evidence, The World Health Organisation (WHO) has recommended MgSO4 as the most effective, safe and low cost drug for the treatment of severe pre-eclampsia and eclampsia

Provider acceptabilityProvider acceptability

Whereas 77.5% of the participants have heard of MgSO4, only 28.4% have ever administered it

83.4% knew the drug was used for treatment of severe preeclampsia/eclampsia

10.7% have heard of Magpie trial Common sources of information:

colleagues, journals and clinical instructors

Age distribution among patients treated

Highest formal education attained by the patients treated

Case Outcomes

MaternalAlive 1643 89%Dead 77 4.2%Missing 126 6.8%Total 1846 100

%

Peri-Natal1472 79.7

%239 12.9

%135 7.3%

1846 100%

MMR and attributable deaths from eclampsia comparison

Facility based MMR pre intervention (2007) was 3195/ 100 000 live births while post intervention (2008) was 2146/ 100 000 live births

This demonstrated a reduction in MMR of 32.8% over the one year period of the intervention

Maternal attributable deaths from eclampsia fell by 66% across the 10 health facilities

ImpactProduct development

Regulatoryprocesses

Effectiveuse

Introduction strategies

Research Product development

Regulatoryprocesses

Scaled up effective

use

Introduction strategies

Research

Financial commitment and political leadership

Engagement of affected communities

Value Chain for Public Health Impact

Conclusion – What does this all mean? If public health impact is our goal, we must keep

the entire value chain in mind as we identify and introduce new interventions

Even in the world’s most remote regions, simple and appropriate health technologies can be used to save the lives of mothers and children

Innovation plays an important role in meeting the needs of the most vulnerable, not just innovation in technology, but processes and behavior change.

Acknowlegements

1. Deborah Ambruster, PATH - POPPHI Project, DC2. Jamil Tukur & Andrew Karlyn, Population Council, Abuja

Ayo Ajayi, MD, MPHVice president – Field [email protected]