Lecture 3 maternal mortality

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Lecture 3 maternal mortality

  1. 1. 06/09/1406/09/14 11 Maternal MortalityMaternal Mortality March, 2012March, 2012 Addis Ababa UniversityAddis Ababa University
  2. 2. 06/09/1406/09/14 22 Learning objectivesLearning objectives  At the end of this class the students will beAt the end of this class the students will be able to:able to:  Define maternal mortality  Identify the major causes of maternal mortality  Describe the global experiences of maternal mortality  Describe current issues, strategies and approaches in maternal mortality prevention
  3. 3. 06/09/1406/09/14 33 Maternal Mortality (MM)Maternal Mortality (MM)  What is MM?What is MM?  What are Major causes?What are Major causes?  What are contributing factors?What are contributing factors?  What can be done?What can be done?
  4. 4. 06/09/1406/09/14 44 MM….MM…. Maternal mortalityMaternal mortality::  The death of a woman whileThe death of a woman while pregnantpregnant or withinor within 42 days42 days after termination of pregnancy,after termination of pregnancy, irrespective of the site & duration ofirrespective of the site & duration of pregnancy, from any cause related to orpregnancy, from any cause related to or aggravated by the pregnancy or itsaggravated by the pregnancy or its management, but not from accidental ormanagement, but not from accidental or incidental causesincidental causes (WHO, 10(WHO, 10thth revision ofrevision of ICD, 1992)ICD, 1992)
  5. 5. 06/09/1406/09/14 55 MM…MM… Pregnancy-related deathPregnancy-related death  The death of a woman while pregnant or within 42The death of a woman while pregnant or within 42 days of termination of pregnancy,days of termination of pregnancy, irrespectiveirrespective of theof the cause of the death.cause of the death.  Like maternal deaths, pregnancy-related deaths canLike maternal deaths, pregnancy-related deaths can be associated with any pregnancy outcome, andbe associated with any pregnancy outcome, and can occur at any gestational age.can occur at any gestational age.  The difference is that pregnancy-related deathsThe difference is that pregnancy-related deaths include deaths frominclude deaths from allall including accidental andincluding accidental and incidental causes.incidental causes.
  6. 6. 06/09/1406/09/14 66 MM…MM… Late maternal deathLate maternal death  The death of a woman from direct or indirectThe death of a woman from direct or indirect obstetric causes more than 42 days but less than oneobstetric causes more than 42 days but less than one year after the termination of pregnancy.year after the termination of pregnancy.  Identifying late maternal deaths makes it possibleIdentifying late maternal deaths makes it possible to count deaths in which a woman had problemsto count deaths in which a woman had problems that began during pregnancy, even if she survivedthat began during pregnancy, even if she survived for more than 42 days after its termination.for more than 42 days after its termination.
  7. 7. 06/09/1406/09/14 77 MM…MM…  Maternal mortality is series problem globally,Maternal mortality is series problem globally, particularly in developing countries.particularly in developing countries.  However it is theHowever it is the TIP OF THE ICEBERG  For every maternal death 16 – 100 maternalFor every maternal death 16 – 100 maternal morbiditymorbidity  ¼ of all adult women in the developing world –¼ of all adult women in the developing world – suffer short/ long-term problemssuffer short/ long-term problems  Women’s lifetime risk of dying from pregnancyWomen’s lifetime risk of dying from pregnancy  1 in 16 – 20 pregnancies - in Africa1 in 16 – 20 pregnancies - in Africa  1 in 1400 pregnancies - in Europe1 in 1400 pregnancies - in Europe  1 in 3700 pregnancies - in North America1 in 3700 pregnancies - in North America
  8. 8. 06/09/1406/09/14 88
  9. 9. 06/09/1406/09/14 99 Determinants of MMDeterminants of MM  Proximal Factors (Medical causes)Proximal Factors (Medical causes)  Direct causesDirect causes  Indirect causesIndirect causes  Intermediate Factors- contributingIntermediate Factors- contributing  Poor access, poor quality of healthPoor access, poor quality of health servicesservices  Age at delivery, gravidity/parity (tooAge at delivery, gravidity/parity (too many, early and close preg.)many, early and close preg.)  General health statusGeneral health status  Underlying Factors- basicUnderlying Factors- basic  Poverty, poor infrastructure, women’s statusPoverty, poor infrastructure, women’s status (decision making), poor educational status,(decision making), poor educational status, Culture, ValuesCulture, Values
  10. 10. 06/09/1406/09/14 1010 Causes of MMCauses of MM Maternal mortality could result fromMaternal mortality could result from Direct or indirect causesDirect or indirect causes  DIRECT CAUSES (80%):DIRECT CAUSES (80%):  Those resulting from:Those resulting from:  obstetric complications (pregnancy, labor, &obstetric complications (pregnancy, labor, & puerperium)puerperium)  interventions, omissions, incorrect treatment,interventions, omissions, incorrect treatment, oror  a chain of events resulting from any of thea chain of events resulting from any of the above.above.
  11. 11. 06/09/1406/09/14 1111 Direct causesDirect causes  Hemorrhage (APH, PPH) -25%Hemorrhage (APH, PPH) -25%  Sepsis- 15%Sepsis- 15%  Unsafe abortion – 13%Unsafe abortion – 13%  Hypertensive disorders of pregnancyHypertensive disorders of pregnancy (Preeclampsia, eclampsia) – 12%(Preeclampsia, eclampsia) – 12%  Obstructed labour –Obstructed labour – 77%%  Other direct – 8%Other direct – 8%
  12. 12. 06/09/1406/09/14 1212 Indirect causesIndirect causes  INDIRECT CAUSES (20%):INDIRECT CAUSES (20%):  Those resulting from previous existing diseasesThose resulting from previous existing diseases or diseases that developed during pregnancyor diseases that developed during pregnancy and which is not due to direct obstetric causesand which is not due to direct obstetric causes but aggravated bybut aggravated by physiologic effectsphysiologic effects ofof pregnancy.pregnancy.  Existing cardiovascular diseases,Existing cardiovascular diseases, malaria, anemia etcmalaria, anemia etc
  13. 13. 06/09/1406/09/14 1313 Causes of MM EthiopiaCauses of MM Ethiopia Sepsis 12% Hypertention 9% Obstructed labor 22% Abortion 32% Others 15% Haemorrhage 10% Source: MOH 2003
  14. 14. Millennium Development GoalsMillennium Development Goals (MDGs, 2000)(MDGs, 2000)  Commitments made at ICPD and FWCWCommitments made at ICPD and FWCW  Goal 1Goal 1: Eradicate extreme poverty and hunger;: Eradicate extreme poverty and hunger;  Goal 2Goal 2; Achieve universal primary education;; Achieve universal primary education;  Goal 3Goal 3: Promote gender equality and empower women;: Promote gender equality and empower women;  Goal 4Goal 4: Reduce infant and child mortality rates by two-: Reduce infant and child mortality rates by two- thirds by 2015;thirds by 2015;  Goal 5:Goal 5: Improve maternal health – reduce MMR by 75%Improve maternal health – reduce MMR by 75% by 2015by 2015;;  Goal 6Goal 6: Combat HIV/AIDS and malaria;: Combat HIV/AIDS and malaria;  Goal 7Goal 7: Ensuring Environmental sustainability: Ensuring Environmental sustainability  Goal 8Goal 8: Develop a global partnership for development: Develop a global partnership for development
  15. 15. Causes of MMCauses of MM The median time period between the onset ofThe median time period between the onset of complication to death of a mother iscomplication to death of a mother is too shorttoo short forfor some complicationssome complications  PPH = 2HrsPPH = 2Hrs  Ruptured uterus = 1 dayRuptured uterus = 1 day  Eclampsia = 2 daysEclampsia = 2 days  Obstructed labor = 3 daysObstructed labor = 3 days  Puerperal sepsis = 6 daysPuerperal sepsis = 6 days  Complicated abortion = 7 daysComplicated abortion = 7 days 06/09/1406/09/14 1515
  16. 16. 06/09/1406/09/14 1616 Roads to MMRoads to MM  THE THREE DELAYS MODELTHE THREE DELAYS MODEL  Maternal death results as a result of theMaternal death results as a result of the three delays.three delays.  Once the pregnancy occurred womenOnce the pregnancy occurred women experience theexperience the classic three delaysclassic three delays
  17. 17. 06/09/1406/09/14 1717 Three delaysThree delays  First delay:First delay: delay indelay in deciding to seek caredeciding to seek care for anfor an obstetric complication.obstetric complication.  The second delayThe second delay : d: delay toelay to go to healthgo to health facilityfacility after the decision has been made toafter the decision has been made to seek care.seek care.  The third delayThe third delay :: delay indelay in obtaining careobtaining care onceonce present at the facility.present at the facility.
  18. 18. What causes The first delay?What causes The first delay?  Lack of information andLack of information and inadequate knowledgeinadequate knowledge about danger signalsabout danger signals during pregnancy andduring pregnancy and laborlabor  Cultural /traditionalCultural /traditional practices that restrictpractices that restrict women from seekingwomen from seeking health carehealth care  Lack of moneyLack of money 06/09/1406/09/14 1818 Male Involvement is Key
  19. 19. What causes The second delay?What causes The second delay? This is a delay in physicallyThis is a delay in physically reaching the carereaching the care facility/facility/inability to accessinability to access health facilities:health facilities:  Out of reach of health facilitiesOut of reach of health facilities  Poor roads and communicationPoor roads and communication networknetwork  Poor community supportPoor community support mechanismsmechanisms 06/09/1406/09/14 1919
  20. 20. What causesWhat causes The third delay?The third delay?  Is the delay inIs the delay in obtainingobtaining carecare once present at theonce present at the facility.facility.  women wait for many hourswomen wait for many hours at the referral centre becauseat the referral centre because ofof  poor staffing,poor staffing,  prepayment policies, orprepayment policies, or  difficulties in obtainingdifficulties in obtaining blood supplies, equipment orblood supplies, equipment or an operating theatre.an operating theatre. 06/09/1406/09/14 2020
  21. 21. 06/09/1406/09/14 2121 How to avoid/reduce the threeHow to avoid/reduce the three delaysdelays  To avoid the first two delaysTo avoid the first two delays educate and encourage communities to:educate and encourage communities to:  recognise complicationsrecognise complications  Know when and where to seek appropriateKnow when and where to seek appropriate carecare  develop birth preparedness plan , includingdevelop birth preparedness plan , including emergency transportationemergency transportation  improve transportation to a facility offeringimprove transportation to a facility offering a highera higher level of carelevel of care
  22. 22. 06/09/1406/09/14 2222 Avoid three delays…Avoid three delays…  To avoid the third delayTo avoid the third delay  Improving quality of serviceImproving quality of service  Training and deployment of skilled healthTraining and deployment of skilled health professional to the health facilitiesprofessional to the health facilities
  23. 23. 06/09/1406/09/14 2323 Global situation in MMGlobal situation in MM  According to (WHO, UNICEF 2010).According to (WHO, UNICEF 2010).  MDG5 target: to reduce byMDG5 target: to reduce by ¾¾ between 1990 & 2015between 1990 & 2015  That isThat is 5.5%5.5% annual decline.annual decline.  7 years progress only7 years progress only 34%34% decline between 1990 anddecline between 1990 and 2008 was achieved2008 was achieved  2.3%2.3% average annual declineaverage annual decline  As a result, an estimated 358,000 maternal deaths inAs a result, an estimated 358,000 maternal deaths in 20082008  MMR ofMMR of 260260 per 100000 live births in 2008 asper 100000 live births in 2008 as compared tocompared to 400400 per 100000 live births in 1990per 100000 live births in 1990
  24. 24. 06/09/1406/09/14 2424 Situations…Situations…  99% of these deaths occurred in developing99% of these deaths occurred in developing countriescountries  SSA & South Asia accounted forSSA & South Asia accounted for 87%87%  SSA:SSA:  Highest MMR atHighest MMR at 640640 per 100000 live birthsper 100000 live births  Annual decline ofAnnual decline of 1.7%1.7% (WHO, UNICEF 2010).(WHO, UNICEF 2010).
  25. 25. 06/09/1406/09/14 2525Source: (WHO, UNICEF, 2010)Source: (WHO, UNICEF, 2010)
  26. 26. 06/09/1406/09/14 2626 MM & MDGs in EthiopiaMM & MDGs in Ethiopia  MDG5: 3/4 reductionMDG5: 3/4 reduction  EDHSEDHS  In 2000 aroundIn 2000 around 871871 maternal deaths/100,000LBsmaternal deaths/100,000LBs  In 2005 aroundIn 2005 around 673673 maternal deaths/100,000LBsmaternal deaths/100,000LBs  In 2011 aroundIn 2011 around 676676 maternal deaths/100,000LBsmaternal deaths/100,000LBs  With this progress difficult to achieve MDG5.With this progress difficult to achieve MDG5.
  27. 27. 06/09/1406/09/14 2727 MDG – Reducing MMR by 75% by 2015MDG – Reducing MMR by 75% by 2015 0 250 500 750 10002001 2003 2005 2007 2009 2011 2013 2015 Year Maternaldeathsper100,000live births No change in maternal care Improved maternal care
  28. 28. 06/09/1406/09/14 2828 Reducing MM, past and presentReducing MM, past and present  For many years, maternal mortality reductionFor many years, maternal mortality reduction programmes focused on two main components:programmes focused on two main components:  ANC risk detection andANC risk detection and  Training of TBAs to attend low risk deliveryTraining of TBAs to attend low risk delivery  The intent of these programmes wasThe intent of these programmes was  Complications are predictable andComplications are predictable and  Low risk = TBAs/TTBAsLow risk = TBAs/TTBAs  women with life-threatening complications wouldwomen with life-threatening complications would be transferred to a higher level of care in a timelybe transferred to a higher level of care in a timely fashion.fashion.
  29. 29. 06/09/1406/09/14 2929 Reducing MM, past and present…Reducing MM, past and present…  Weakness of the past approachWeakness of the past approach  Countries with high rates of maternal mortality nearlyCountries with high rates of maternal mortality nearly always have a shortage of facilities offering EmOC/lifealways have a shortage of facilities offering EmOC/life saving care.saving care.  TBAs simply do not have the skills to recognizeTBAs simply do not have the skills to recognize complications, even when trainedcomplications, even when trained  Early detection of complication needs skilled attendantEarly detection of complication needs skilled attendant  Complications are not predictableComplications are not predictable
  30. 30. 06/09/1406/09/14 3030 Reducing MM, past andReducing MM, past and presentpresent…… Present thinkingPresent thinking  Maternal deaths /Major obstetricMaternal deaths /Major obstetric complications are not predictable (mostcomplications are not predictable (most complications occurcomplications occur ++ 24 hrs of labor)24 hrs of labor)  Risk assessment has not worked –Risk assessment has not worked –  Every pregnancy faces risk (20-30% of high riskEvery pregnancy faces risk (20-30% of high risk develop complication and as well many of the lowdevelop complication and as well many of the low risk develop complication)risk develop complication)  Some obstetric complications are notSome obstetric complications are not predictable & preventablepredictable & preventable
  31. 31. 06/09/1406/09/14 3131 Present thinking…Present thinking…  The vast majority of maternal deaths areThe vast majority of maternal deaths are preventable by treatment (accesses EOC)preventable by treatment (accesses EOC)  Early detection of complication possible butEarly detection of complication possible but needs skilled attendantneeds skilled attendant  Ensure a medically skilled attendant at everyEnsure a medically skilled attendant at every birthbirth  Doubt on effectiveness of TBAS?Doubt on effectiveness of TBAS?  Goal directed ANC- put every pregnancyGoal directed ANC- put every pregnancy under riskunder risk Reducing MM, past and present…Reducing MM, past and present…
  32. 32. 06/09/1406/09/14 3232  Much of the current thinking about maternal mortalityMuch of the current thinking about maternal mortality came fromcame from A.A. Global experience:Global experience:  observing countries that have been successfulobserving countries that have been successful in dramatically reducing maternal mortalityin dramatically reducing maternal mortality B.B. Program evaluation and Research findings :Program evaluation and Research findings :  the safe motherhood initiative 10 yeasthe safe motherhood initiative 10 yeas experience & othersexperience & others Reducing MM, past and present…Reducing MM, past and present…
  33. 33. 06/09/1406/09/14 3333 Global experience…Global experience…  In Sweden, MMR declined from 567 to 227/100,000 LBIn Sweden, MMR declined from 567 to 227/100,000 LB over three decades(1861 to 1894).over three decades(1861 to 1894).  Due to:Due to:  Increased midwifery-assisted home birthsIncreased midwifery-assisted home births (from 30% to 70%) and(from 30% to 70%) and  Promotion of aseptic technique in hospital andPromotion of aseptic technique in hospital and midwife-assisted homebirths.midwife-assisted homebirths.
  34. 34. 06/09/1406/09/14 3434  There was a drop of MM after World War IIThere was a drop of MM after World War II  MMR reached between 250 - 400 in the lateMMR reached between 250 - 400 in the late 19th century19th century  This was a direct result ofThis was a direct result of  the introduction of antibiotics,the introduction of antibiotics,  blood transfusions andblood transfusions and  readily available Caesarean sectionsreadily available Caesarean sections..  These interventions are effective in preventingThese interventions are effective in preventing most causes of maternal deaths: sepsis,most causes of maternal deaths: sepsis, haemorrhage, and obstructed labour.haemorrhage, and obstructed labour. Global experience..Global experience..
  35. 35. 06/09/1406/09/14 3535 Global experience..Global experience..  Currently the issue of MM is becoming evidentCurrently the issue of MM is becoming evident because of the following reasonsbecause of the following reasons 1.1. Establishment of national birth andEstablishment of national birth and death registers that include the causesdeath registers that include the causes of deathof death  enabled monitoring of maternal mortalityenabled monitoring of maternal mortality trends and revealed the high toll of maternaltrends and revealed the high toll of maternal deathsdeaths  brought awareness of the problem andbrought awareness of the problem and  increased political will and a swift legislativeincreased political will and a swift legislative effort to improve access to skilled care at birth.effort to improve access to skilled care at birth.
  36. 36. 06/09/1406/09/14 3636 Global experience..Global experience.. 2. Sustained Political Commitment2. Sustained Political Commitment  improvingimproving accessaccess to the services &to the services & acceptabilityacceptability 3. Investments in primary education and3. Investments in primary education and primary health careprimary health care (accesses to maternal health care)(accesses to maternal health care) 4. Steady evolution in the health sector4. Steady evolution in the health sector  midwivesmidwives (skilled attendant)(skilled attendant) replacing TBAsreplacing TBAs 5. Every maternal death was reviewed5. Every maternal death was reviewed  District MCH committees use adverse obstetrics eventsDistrict MCH committees use adverse obstetrics events to mobilize and educate communitiesto mobilize and educate communities  Care systems placed joint responsibility on the districtCare systems placed joint responsibility on the district hospital and rural health service to prevent maternalhospital and rural health service to prevent maternal deathdeath
  37. 37. 06/09/1406/09/14 3737 Program evaluation and researchesProgram evaluation and researches SAFE MOTHERHOOD INTIATIVE (NAIROBI 1987)SAFE MOTHERHOOD INTIATIVE (NAIROBI 1987)  Gave greater visibility to the hidden inequity ofGave greater visibility to the hidden inequity of maternal ill-health.maternal ill-health.  Comprehensive understanding of the roots andComprehensive understanding of the roots and causes of the unacceptable toll of maternalcauses of the unacceptable toll of maternal mortality in developing countries.mortality in developing countries.  Put maternal mortality at the forefront ofPut maternal mortality at the forefront of international public health.international public health.
  38. 38. 06/09/1406/09/14 3838 Programs & approaches to reducePrograms & approaches to reduce maternal mortalitymaternal mortality 1.1. SAFE MOTHERHOOD INTIATIVE (SMI) 1987SAFE MOTHERHOOD INTIATIVE (SMI) 1987 Strategies of SMIStrategies of SMI  Risk assessment during pregnancy by a trainedRisk assessment during pregnancy by a trained non-physiciannon-physician  Promote use of TBAs for low risk womenPromote use of TBAs for low risk women  FP to avoid unwanted pregnancies and unsafeFP to avoid unwanted pregnancies and unsafe abortionabortion  Availability and access to first referral levelAvailability and access to first referral level treatment for obstetric complicationstreatment for obstetric complications  Improving the status of womenImproving the status of women  Changing laws, attitudes, practices eg: earlyChanging laws, attitudes, practices eg: early marriage, female genital mutilationmarriage, female genital mutilation  Local data on maternal mortality neededLocal data on maternal mortality needed
  39. 39. 06/09/1406/09/14 3939 Programs & approaches…Programs & approaches…  Lessons learned from SMI (first 10 yrs evaluation 1997)  Maternal deaths /Major obstetric complications areMaternal deaths /Major obstetric complications are not predictablenot predictable  Risk assessment has not workedRisk assessment has not worked  Some obstetric complications are not preventableSome obstetric complications are not preventable  Early detection of complication possible but needsEarly detection of complication possible but needs skilled attendantskilled attendant  Ensure a medically skilled attendant at every birthEnsure a medically skilled attendant at every birth  The vast majority of maternal deaths are preventableThe vast majority of maternal deaths are preventable by treatment (accesses EOC)by treatment (accesses EOC)  Measurement limitations for maternal mortality (usingMeasurement limitations for maternal mortality (using MMR etc) was recognized – The use of processMMR etc) was recognized – The use of process indicators emphasized.indicators emphasized.
  40. 40. 06/09/1406/09/14 4040  Improve access to quality RH services (FP, goalImprove access to quality RH services (FP, goal oriented ANC, Essential obstetric care-EOC, etc )oriented ANC, Essential obstetric care-EOC, etc )  Every pregnancy faces risk-Ensure skilledEvery pregnancy faces risk-Ensure skilled attendance at deliveryattendance at delivery  Prevent unwanted pregnancy and unsafe abortionPrevent unwanted pregnancy and unsafe abortion  Delay marriage and first birthDelay marriage and first birth Action messagesAction messages
  41. 41. 06/09/1406/09/14 4141  Empower women, ensure choicesEmpower women, ensure choices  Advance safe motherhood through human rightsAdvance safe motherhood through human rights  Safe motherhood is a vital economic and social investmentSafe motherhood is a vital economic and social investment advocacy and gov’t commitmentadvocacy and gov’t commitment  Measure progress with process indicators (MMR?)Measure progress with process indicators (MMR?)  Ensure the power of the relationship at national, international,Ensure the power of the relationship at national, international, & the community level& the community level Action messages…Action messages…
  42. 42. 06/09/1406/09/14 4242  reallocating investment in health care to support the most cost-reallocating investment in health care to support the most cost- effective interventionseffective interventions  investing in maternal health care services and making theminvesting in maternal health care services and making them available, especially in poor and rural areasavailable, especially in poor and rural areas  strengthening the capacity of community health centers andstrengthening the capacity of community health centers and district hospitals to provide needed care, especially fordistrict hospitals to provide needed care, especially for obstetric complications, through staff training and provision ofobstetric complications, through staff training and provision of equipmentequipment Action messages…Action messages…
  43. 43. 06/09/1406/09/14 4343  working with private providers to expand and improve safeworking with private providers to expand and improve safe motherhood servicesmotherhood services  encouraging for-profit providers to provide free or low costencouraging for-profit providers to provide free or low cost care to those who can't afford to paycare to those who can't afford to pay  supporting NGOs and voluntary organizations that may be ablesupporting NGOs and voluntary organizations that may be able to mobilize private and community support for deliveringto mobilize private and community support for delivering services to underserved or disadvantaged women.services to underserved or disadvantaged women. Action messages…Action messages…
  44. 44. 06/09/1406/09/14 4444 2. WHO mother baby package2. WHO mother baby package  PregnancyPregnancy  DeliveryDelivery  After deliveryAfter delivery  MothersMothers  NewbornNewborn 3. UNFPA three pronged intervention3. UNFPA three pronged intervention  Accesses Quality FPAccesses Quality FP  Accesses EOCAccesses EOC  Skilled attendant at every birthSkilled attendant at every birth 4. Millennium summit task force4. Millennium summit task force  Every birth attended by aEvery birth attended by a skilled health care professionalskilled health care professional  Every woman has access toEvery woman has access to Emergency Obstetric CareEmergency Obstetric Care (EmOC)(EmOC)  Referral systemReferral system ensures women who need emergency care reach it inensures women who need emergency care reach it in timetime Other Program approaches to reduce MM inOther Program approaches to reduce MM in addition to SMIaddition to SMI
  45. 45. 06/09/1406/09/14 4545 Summary- Causes of Maternal deaths andSummary- Causes of Maternal deaths and proven interventionsproven interventions Cause of maternalCause of maternal deathdeath %% Proven interventionsProven interventions Bleeding after deliveryBleeding after delivery 2525 Treat anemia in pregnancy.Treat anemia in pregnancy. Skilled attendant at birth: prevent or treat bleeding withSkilled attendant at birth: prevent or treat bleeding with correct drugs, replace fluid loss by intravenous drip orcorrect drugs, replace fluid loss by intravenous drip or transfusion if severe.transfusion if severe. Infection after deliveryInfection after delivery 1515 Skilled attendant at birth: clean practices.Skilled attendant at birth: clean practices. Treat with antibiotics if infection arises.Treat with antibiotics if infection arises. Unsafe abortionUnsafe abortion 1313 Skilled attendant: give antibiotics, empty uterus, replaceSkilled attendant: give antibiotics, empty uterus, replace fluids if needed, counsel and provide family planning.fluids if needed, counsel and provide family planning. High blood pressure duringHigh blood pressure during pregnancy, eclampsiapregnancy, eclampsia 1212 Detect, refer; Treat ecalmpsia with appropriateDetect, refer; Treat ecalmpsia with appropriate anticonvulsant (MgSo4) ; refer unconscious woman foranticonvulsant (MgSo4) ; refer unconscious woman for expert urgent deliveryexpert urgent delivery Obstructed laborObstructed labor 77 Detect, refer urgently for operative deliveryDetect, refer urgently for operative delivery Other causesOther causes 88 Refer ectopic pregnancy for operationRefer ectopic pregnancy for operation
  46. 46. 06/09/1406/09/14 4646 ReferencesReferences  WHO/UNICEF/UNFPA& the world bank (2010). TrWHO/UNICEF/UNFPA& the world bank (2010). Tr Trends in Maternal Mortality: 1990 to 2008 Estimates developed by WHO, UNICEF, UNFPA and The World Bank  WHO/UNICEF/UNFPA& the world bank. Maternal mortality in 2000, EstimatesWHO/UNICEF/UNFPA& the world bank. Maternal mortality in 2000, Estimates developed by WHO, UNICEF and UNFPA, 2007.developed by WHO, UNICEF and UNFPA, 2007.  WHO/UNICEF/UNFPA. Maternal mortality in 2000, Estimates developed by WHO,WHO/UNICEF/UNFPA. Maternal mortality in 2000, Estimates developed by WHO, UNICEF and UNFPA. Available at:UNICEF and UNFPA. Available at: http://www.alianzaipss.org/reproductive-health/publications/maternal_mortality_2000/challenghttp://www.alianzaipss.org/reproductive-health/publications/maternal_mortality_2000/challeng  World Health Organization.World Health Organization. International Statistical Classification of Diseases and RelatedInternational Statistical Classification of Diseases and Related Health Problems. Tenth RevisionHealth Problems. Tenth Revision. Geneva, World Health Organization, 1992.. Geneva, World Health Organization, 1992.  UNDG.UNDG. Indicators for monitoring the Millennium Development Goals: Definitions, Rationale,Indicators for monitoring the Millennium Development Goals: Definitions, Rationale, Concepts and sourcesConcepts and sources, United Nations: New York, 2003., United Nations: New York, 2003.
  47. 47. 06/09/1406/09/14 4747 Thank you!Thank you!

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