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??