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Maternal mortality

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  • 1. MATERNAL MORTALITY Prof. M.C.Bansal. MBBS.MS. MICOG.FICOG. Meenakhi Baitule DNB (st)
  • 2. DEFINATION  Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management ,but not from accidental or incidental causes. .Direct maternal death that is the result of a complication of the pregnancy, delivery, or management of the two. Haemorrhage , Infection and PIH are responsible for 75-80% of Direct maternal Deaths. Indirect maternal death that is a pregnancy-related death in a patient with a preexisting or newly developed health problem unrelated to pregnancy. e.g. Anemia,Malaria,Diabetes and maternal cardio pulmonary diseases etc. cause 20-25% maternal deaths due to indirect reasons. Fatalities during but unrelated to a pregnancy are termed accidental, incidental, or non obstetrical maternal deaths.
  • 3. INTRODDUCTION • Over 68% of India's total population lives in rural, underdeveloped localities, Half of India‟s population is living below poverty line; struggling for better and easy access to health care and services. • As per Census 2011, the population of India is 1210.19 million comprising 586.47 million (48.5%) females and 623.72 million (51.5%) males. • A study conducted in 2009, found that 43.9% of mothers reported to have experienced postpartum morbidities six weeks after delivery.
  • 4. Maternal Mortality: A Global Tragedy • Annually, 536,000 women die of pregnancy related complications • 99% in developing world • ~ 1% in developed countries • 25% global burden by India.(with 16% of world’s population). Indan National---MMRatio :--254/100,000 live births. • MMRate :-- 120. (USA:-0.5) Every minute one Maternal Death occur 4 Indian maternal mortality rates* in rural areas are highest amongst the world.
  • 5. Maternal mortality In India A mother dies every 1o minutes in India. Target--- MGD target to bring down MMR below 150 maternal deaths / 1 lac live birth –by 2015 . A letter to WHO from central Ministery of health & family welfare dated12th July , 2012 ---- “ In fact a reduction of MGD 388points(86%) has all ready been a chieved by 2008aginst required reduction of MGD 450 pints by 2015.”
  • 6. MMR wise from Rank Highest to lower Name Of Country MMR= Mat. Deaths / 1 lac / live births 1 Chad 1100 43 Pakistan 260 45 Bangala Desh 240 51 Indonesia 220 52 Myanmar(Burma) 220 54 India 200 60 Nepal 170 99 Mauritius 63 110 Thiland 48 116 China 37 117 Shri Lanka 35 136 USA 21 146 UK 12 150 Canada 12 173 Japan 05 Year of reporting Data by All countries --- -2010. Source--- The world facts Book Publication
  • 7. Maternal conditions most frequently reported in studies included in the WHO/HRP systematic review(2005) • Hypertensive disorders of pregnancy (14.9)(%) • Stillbirth (13.9) • Preterm delivery (8.2) • Induced abortion (6.7) • Haemorrhage (antepartum, intrapartum, postpartum, unspecified) (6.2) • Anaemia (4.5) • Placenta anomalies (praevia, abruptio, etc.) (4.1) • Spontaneous abortion (4.0)
  • 8. • Gestational diabetes (3.8) • Ectopic pregnancy (2.5) • Premature rupture of membranes (2.4) • Perineal laceration (2.3) • Uterine rupture (2.0) • Obstructed labour (1.7) • Depression (postpartum, during pregnancy) (1.6) • Puerperal infection (1.5) • Violence during pregnancy (1.3) • Urinary tract infection (1.1) • Malaria (0.9) • Other conditions (16.4)
  • 9. Causes of maternal death in Asia • Morbidity Percentage • Haemorrhage 30.8 • Anaemia 12.8 • Other indirect causes of deaths 12.5 • Sepsis/infection 11.6 • Obstructed labour 9.4 • Hypertensive disorders 9.1 • Unclassified deaths 6.1 • Abortion 5.7 • Other direct causes of deaths 1.6 • Embolism 0.4 • Ectopic pregnancy 0.1 • HIV/AIDS 0 The results of the review, which was published in The Lancet,(Khan KS et al. WHO analysis of causes of maternal death: a systematic review. Lancet, 2006, 367:1066–1074.)
  • 10. Pie Chart showing Most common Causes of MMR
  • 11. • About 10% of maternal deaths may occur late, that is after 42 days after a termination or delivery, thus, some definitions* extend the time period of observation to one year after the end of the gestation. • Forty-five percent of postpartum deaths occur within 24 hours. • . pregnancy-associated homicide accounts for 2 to 10 deaths per 100,000 live births, possibly substantially higher due to underreporting
  • 12. • Unintended pregnancy is a major cause of maternal deaths. Worldwide, unintended pregnancy resulted in almost 700,000 maternal deaths from 1995 to 2000 (approximately one-fifth of the maternal deaths during that period). • The majority (64%) resulted from complications from unsafe or unsanitary abortion. Unattended pregnancies
  • 13. Worldwide ,every year approximately about 8 million women suffer from pregnancy related complications. Over half a million of them die. For 1 maternal death ; at least 16 more suffer from severe maternal morbidities. In developing countries the* lifetime risk of maternal death is 1 in 11, for developed nations it is only 1 in 5000. In India it is * There is no single cause of death and disability for men between the ages of 15 and 44 that is close to the magnitude of maternal death and disability**
  • 14. PREVENTION• Maternal mortality can greatly be reduced by ensuring prompt & quality obstetric care services supported with an equally effective family planning services. • It requires action to break down political, economic, social & cultural barriers that women face in accessing the facilites that can prevent maternal mortality. • Majority of these deaths (80%) are preventable. • Good obstetric care:---reduces mortality & morbidity arising from complications during pregnancy & childbirth. • Family planning services:--reduces mortality through reduction in proportion in high risk , unwanted, untimed , too early and to many pregnancies. • As many of these complications are unpredictable , may occur at any time during pregnancy , childbirth & post partum period. Therefore EVERY WOMAN , irrespective of her risk status , MAY REQUIRE EMERGENCY OBSTETRIC CARE SERVICES, SO AVAILABILITY & ACCESSIBILITY OF EmOC becomes one of the most imp. Part of the program me. EmOC=Emergency obstetric Care
  • 15. EmOC:--Emergency obstetric Care. Fatal obstetrical emergency can arise all of a sudden and at any moment ( in Ante natal , Intra natal and or in post natal period ) A critical moment, a woman needs : • Immediate access to quality emergency obstetric care as nearer to her premises. • Skilled medical workers who can take prompt action, identify complications, Facilities for Blood Transfusion , drugs & required equipments are necessary to save her life and the life of her baby.
  • 16. The causes of maternal death World Health Organization, World Health Report 2005 • Sepsis (Infection) 15% • As many as 5.2 million new cases of maternal sepsis occur annually and an estimated 62,000 maternal deaths will result from this complication.1 In order to prevent infections, it is essential that women deliver in a hygienic environment using all majors of universal aseptic precautions and if infection does occur, be treated with antibiotics. In addition to the threat to women’s lives, the condition is also associated with more than one million neonatal deaths and can also lead to long term consequences for the woman such as infertility. 1 Hussein et al (2011), A review of health system infection control measures in developing countries: what can be learned to reduce maternal mortality, Globalization and Health,
  • 17. • Unsafe Abortion 13% • Worldwide, nearly half of all induced abortions are performed under unsafe circumstances. • 98 percent of these unsafe abortions occur in developing countries. • Reducing the number of women dying as a result of an unsafe abortion requires a multi-faceted approach. Appropriate care must be available at nearby health centre to all women who present with the complications due to incomplete abortion, sepsis and hemorrhage; following an unsafe abortion. • In order to prevent unsafe abortions: • women need access to family planning and emergency contraceptives to reduce the number of unwanted pregnancies. • Got . Should pass flexible legislation for conducting Abortions --- Indian Govt. passed MTP law in 1972. • To promote safe abortion, wide publicity should be done regarding law , availability of facility, care performed by skilled medical workers in safe and hygienic conditions.. Necessary standard infra structure and training of skilled medical persons also need to be developed.
  • 18. • Hemorrhage (severe bleeding) accounts for approximately a quarter of all maternal deaths and can kill even a healthy woman within two hours. • The majority of hemorrhage cases occur immediately after delivery (PPH) and can be prevented and treated with simple measures. For example, an injection of oxytocin/methergine/prostodine given immediately after childbirth is extremely effective in reducing the risk of atonic postpartum haemorrhage. In some cases, the urgent manual removal of the placenta is required, and some women need a blood transfusion and/or a surgical intervention. • Haemorrhage can result in anaemic pregnant women can increase maternal moratality by many folds . Correction of anaemia during pregnancy (Hb >10gm%) will go long way to reduce MMR Haemorrhage 24%
  • 19. • Obstructed labour can be the result of a woman‟s pelvis being too narrow for the baby‟s head to pass through during birth, the baby being in the wrong position/Presentaton , big baby or by inadequate incordinated uterine contractions. • Without an appropriate medical intervention, a woman may spend a number of days in labour and eventually dies of complications of a ruptured uterus/exhaustion, sepsis and dry labour. • Commonly, the baby is stillborn or dies soon after birth. Skilled medical workers can manage many of these problems before labour becomes obstructed or recognize slow and prolong progress of labour By PARTOGRAM and refer a woman for an instrumental delivery or caesarean section. • If a woman survives prolonged obstructed labour, she may be left with an obstetric fistula( Urinary / Rectovaginal Fistula) . Obstructed Labour 8%
  • 20. (Pre-Eclampsia/Eclampsia) 12% • Pre-eclampsia is a pregnancy-induced hypertensive disorder occurring during late pregnancy, labour, or after childbirth. • The life threatening stage – eclampsia – is characterized by seizures & or Coma. • Mild pre-eclampsia can be monitored during pregnancy but severe pre-eclampsia or eclampsia requires urgent care in a hospital. • Blood pressure can be lowered by the use of specific antihypertensive drugs( methyl dopa , nifedipine, labitalol . Seizures can be prevented with magnesium sulphate therapy. The only „cure‟ for the condition is the delivery of the baby, which must be done as quickly as possible, either by vaginal delivery or caesarean section. Hypertensive Disorders ----PIH
  • 21. SAFE MOTHERHOOD • Considering the high maternal deaths in developing countries WHO in 1987 introduced the idea of “SAFE MOTHERHOOD INITIATIVE” at a conference in Nairobi, Kenya. • It is a global effort to reduce maternal deaths by at least half by 2000,(254)now it is extended up to 2015.(MMR <100). • Objectives are to enhance the quality & safety of girl‟s & women‟s lives through adaption of combination of health & non health strategies. • It is designed to operate through partners:--- 1) Government agencies 2)Non-government agencies 3) Other groups & individuals. • It aims to improve women‟s health through social, community & economic interventions. • Maternal & child health promotion is one of the key commitments in WHO constitution.
  • 22. Is the Poverty of any Country ---Only Responsible? • Experts from WHO, UNFPA, UNICEF, IPPFF World Bank ,the population council , other national & international agencies concerned with safe motherhood concluded that ,country‟s overall economic wealth is not the only important determinant.*India vs any poor country. • “It is possible to reduce maternal mortality significantly with limited investment & effective policy interventions”. • According to national & international human rights treaties (1948) safe motherhood is a human rights issue. • It is the reflection of SOCIAL DISADVANTAGE not merely a health disadvantage.
  • 23. BASIC FACTS UNDERLYING CLINICAL CAUSES OF MATERNAL DEATHS • Women living in poverty and in rural areas, & women belonging to ethnic minorities are among those particularly at risk. • Complications from Teenage pregnancy and childbirth are the leading cause of death for 15-19 years old women & adolescent girls in developing countries. • These deeply shocking statistics and facts reveal chronic and entrenched health inequalities. • Low social status of girls & women (Gender inequality):-it‟s a fundamental determinant. • 1)Less opportunity for basic education, 2)Excess physical work,
  • 24. 3)Poor diet:-poor maternal health that results in poor pregnancy outcome.4) Less ability to make decisions,5)Less access to economic resources. 6) Unplanned child birth that are too early, too frequently , too many or too late. 7) Less utilization of essential obstetric services. • Inadequate antenatal care. • Lack of skilled attendant during the time of delivery • Lack of appropriate referral services, EmOC , sex education , family planning & safe abortion services. • Lack of political commitment , lack of information regardings availability of safe mother hood services at no cost or at minimal expenditure by the family..
  • 25. THREE DELAY MODEL It is often said that maternal mortality is due to a number of interrelated delays which ultimately prevent a pregnant women accessing the health care she needs. Each delay is closely related to services, goods, facilities and conditions which are important elements of the right to health (1) Delay in seeking appropriate medical help for an obstetric emergency for • reasons of cost, • lack of recognition of an emergency, • poor education, lack of access to information and • gender inequality. (2)
  • 26. (2) Delay in reaching an appropriate facility • for reasons of distance , Under developed transportation and Medical & Health infrastructure. (3) Delay in receiving adequate care when a facility is reached, because there are • shortages in staff / electricity and water. • Medical supplies are not available/ inadequate.
  • 27. • In developing countries < 50% women are delivered by skilled birth attendant, • only 10% deliver in a hospital or health centre. • About 15% face life threatening complications.
  • 28. RCH:-REPRODUCTIVE & CHILD HEALTH CARE • RCH CARE is an integrated & composite approach to improve the status of women & children in India. • It incorporates the inputs of the Govt. of India (NRHM-2005,NPP-2000) & supports of donor agencies like world bank, WHO, European Commission &others. • AIMS:--1) safe motherhood. • 2)child survival. • 3)Adolescent health • 4)Family planning • 5)prevention & management of infection (STI & RTI)
  • 29. • NRHM 2005 was introduced to improve RCH care. • Partnership for PMNCH was imitated to reach the Millennium Development Goals 4 & 5. • Main objective:-To reduce maternal mortality by 3/4th & child mortality by 2/3 rd by 2015. • New initiatives:-1)To provide basic & comprehensive EmOC & essential new born care. • To strengthen and to make all PHCs , CHCs and FRUs operational as 24 hrs delivery center.
  • 30. ANTENATAL CARE INTRANATAL CARE ESSENT IAL NEWBORN CARE ESSENTIAL OBSTETRIC CARE- 1) Early registration of pregnancy-12-14 weeks 2) A minimum of 4 antenatal visits(WHO) and 3 (GOI). 16 , 24-28 , 32, 36 3) To identify high risk cases during pregnancy , labour and peurperium 4) To strengthen the referral system 5) Routine immunization with Tetanus Toxoid 6) Iron and folic acid therapy(100mg/day for100 days) 1) Institutional deliveries in 80% cases and 100% by skilled birth attendant. 2) Three cleans- hands , perineal area ,cutting of umbilical cord and clean labour room must be maintained. POST NATAL CARE 1) Support to restore the health of mother and newborn. 2) Family planning services 3) Safe abortion services. 4) Breast feeding- early and exclusive. 5) Universal immunization program. 1) Clean delivery 2) Resuscitation at birth 3) Prevention of hypothermia 4) Prevention of infection 5) Baby friendly hospital initiatives 6) Referral of sick newborn
  • 31. RCH - II 1) Community need assessment approach (CNAA) 2) Up gradation of facilities at FRU for emergency obstetrics and newborn care at sub-district level. 3) Training of SBA( skilled Birth Attendant) & permission to administer certain life saving drugs and to perform life saving procedures under specific situations. Drugs-Tab. mesoprost, inj. oxytocin , inj. MgSo4, antibiotics, inj.prostodin etc. Procedures – manual removal of placenta , removal of RPOCs(incomplete abortion with bleeding ), active management of III stage of labour and maintaning a partograph.