Vincent De Brouwere: New Approaches to Maternal Mortality In Africa
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Vincent De Brouwere: New Approaches to Maternal Mortality In Africa

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Vincent De Brouwere (Professor of Public Health at the Institute of Tropical Medicine, Antwerp, Belgium):

Vincent De Brouwere (Professor of Public Health at the Institute of Tropical Medicine, Antwerp, Belgium):
Why and when did maternal mortality decline in modern societies?

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Vincent De Brouwere: New Approaches to Maternal Mortality In Africa Vincent De Brouwere: New Approaches to Maternal Mortality In Africa Presentation Transcript

  • Why and when did maternalmortality decline in modern societies? Vincent De Brouwere Vincent De Brouwere Maternal & Reproductive Health Unit Woman & Child Health Research Centre 1 Institute of Tropical Medicine, Antwerp
  • Decline of maternal mortality in Westernmodern societies• Midwifery development: 17th century – Textbooks of obstetrics and illustrated manuals (initiated by French men-midwives)• Midwifery schools: 18th century in Europe• Professionalization of childbirth: 19th century Success however depended on social integration of techniques and political willingness to scale-up the professionalisation of childbirth 2
  • Childbirth before Man-Midwifery Source: Loudon, 1997 3
  • Levels of maternal mortality • Before the 18th century – England, Somerset parishes 16th-18th: 2,440-2,940West Sussex parish maternal deaths/100,000register,1561 baptisms (Wilmott-Dobbie 1982) – 1,300 on average in Europe before the mid-17th century 4https://www.westsussex.gov.uk/leisure/explore_west_sussex/record_office_and_archives/family_history/parish_registers_on_microfiche.aspx
  • Levels of maternal mortality 1887, Britain • Variations – Famines and chronic nutrition deficiencies – Puerperal fever epidemics (Leipzig 1652, Germany then Paris 1664, London 1760, Dublin 1770, the rest of Europe)Mid-17th century – Competence of birth attendants and iatrogenesis Consequence of rickets 5
  • Guilds and regulations• Internal regulations through the guilds (professional oath)• External regulations from City Council – Paris: 1560 – The Netherlands (early 17th century): town midwives – Germany, England & Wales (18th century)• Countryside: no real regulation but religion and social pressure 6
  • Training midwives: the 17th French school Textbooks first Louise Bourgeois (1609) François Mauriceau (1668) Cosme Viardel (1671) Jane Sharpe (Britain) (1671) Paul Portal (1685) Hendrik van Deventer, Holland (1685) Philippe Peu (1694) 7
  • A special caseIn Sweden:• Johan von Hoorne (1697) 8
  • Creation of MidwiferySchools in 18th Europe 9
  • Field training (outside schools) • 10,000 midwives trained by Angélique du Coudray in France between 1760 and 1783Mme du Coudray’s teaching travel map The ‘Mme du Coudray’s machine’ Source: Gelbart 1998 10
  • Maternal mortality ratios in England & Wales, USA, and Sweden Sulfonamides 1st transfusion of human blood 1000 Blood bank Blood transfusion Maternal deaths per 100,000 births 900 safer Asepsis / antisepsis 800 USA 700 C-section rate E&W riseSources: 600Howard C-section lethality1921; 500 Sweden decreasedHögberg etal. 1986; 400Högberg 300and Wall1986a; 200Loudon1992a; 100WHO & 0Unicef1996 1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000 England & Wales Sweden U.S.A. 11
  • SwedenTechnical elements Political conditions Information: Awareness &Magnitude & ‘avoidability’ political pressure Number and causes Health Commission: of maternal deaths Skilled birth attendants 1751 required to decrease Maternal mortality Early reduction of maternal mortality 12
  • Professionalization of midwifery in Sweden1708: midwifery school1723: J. von Hoorn 1st paid state employed teacher of midwifery1751: decision to increase the number of midwives1829: training in the use of forceps and sharp instruments1881: asepsis and antisepsis 1847 / 1795 1861 1855 1860 1865 13
  • Sweden Technical elements Political conditions Information: Awareness & Magnitude & ‘avoidability’ political pressure Policy: Involvement & accountabilityProfessional obstetric care of professionals Early reduction of maternal mortality 14
  • Sweden rural areas, 1861-95. The correlation between the % ofdeliveries by trained midwives and the MMR due to maternalcauses OTHER than sepsis 15
  • Sweden Technical elements Political conditions Information: Awareness & Magnitude & ‘avoidability’ political pressure Policy: Involvement & accountabilityProfessional obstetric care of professionals Strategy: Public commitment: Access to professional regulations, norms obstetric care & investment Early reduction of maternal mortality 16
  • 1800-2000: maternal mortality ratios 1000 Maternal deaths per 100,000 births 900 USA 800 700 E&W 600 500 Sweden 400 300 200 100 0 1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000 England & Wales Sweden U.S.A. 17
  • USA Technical elements Political conditions Information: Late information Awareness & Magnitude & avoidability No pressure political pressure until 1930 Policy: Involvement & accountability Focus on gynaecologistsProfessional obstetric care of professionals Abuse of technology Strategy: Public commitment: Focus on hospitals Access to professional regulations, norms obstetric care Barriers to access & investment No regulation Stagnation 18
  • 1918-20: Maternal mortality according to policies Maternal Mortality RatioMainly 799 USdoctors 648 New Zealand 615 Scotland “it was not so much the place of delivery France 664 as the type of birth attendant which was Ireland 553Mixdoctors crucial” 501 Australiamidwives “in Britain between 1850 and 1950 the 433 E&W midwife was the safer birth attendant for 297 Norway normal deliveries” Sweden 258Mainlymidwives 242 Loudon,Netherlands The 1992 235 Denmark 19
  • Getting all of it right• Combined ingredients: • Missing ingredients – Significant reduction, even – Reduction delayed until modern without hospitalisation hospital technologies become – Less medicalisation in next accessible phase – More medicalisation in next phaseJapan, Denmark, Norway, USA, Belgium, Sweden, The Great-Britain, France, Italy Netherlands 20
  • Maternal deaths/ 1935-1980 MMR 100,000 births 1000 Maternal mortality decline Green: Europe 900 Purple: Asia• Achieves stable historical 800 Blue: Latin America lows, but only in the 700 industrialized world• Professional assistance 600 becomes the norm: Sri Lanka 500 – purely hospital based deliveries – mixed hospital / home 400• Technology matures 300• Quality of care and evidence Ecuador based medicine 200 Japan Costa Rica & Cuba• Access generalized (universal 100 coverage) 0 1935 1945 1955 1965 1975 1985 21
  • Lessons from European history• Knowledge of maternal mortality levels and concept of avoidable death• Professionalisation of childbirth – Education leading to competence – Non interventionism and patience – Recognized status by the government – Accountability• Scaling up of skilled attendance at delivery – Midwives in numbers – Financial barrier removed – Backup from hospitals 22
  • Messages from historical Europe to Africa• The key to reduction of MM is professionalisation of obstetric care backed-up by a network of accessible hospitals (C-EmOC)• The key to successful professionalisation is the production of adequate numbers of competent midwives with a recognized status and local accountability• Human resource is the key… and the biggest challenge 23