Maternal Mortality
Understanding the Biological and
Social Contexts
Jeromeo Jose
11382333
Biological and Social Foundation...
The great divide of Maternal Mortality
Everyday, 800 women die
from pregnancy and
childbirth
Developing countries
Develope...
The Philippine Context
162
221
0
50
100
150
200
250
'08 '09 '10 '11
Philippines Maternal Mortality
RP MDG
Source: Departme...
What do we mean by maternal death?
• a maternal death is the death of a woman
while pregnant or within 42 days of
terminat...
Medical causes of death and
treatment (WHO, 2011)
• Post partum hemorrhage
– World’s leading cause of maternal mortality
–...
Medical causes of death and
treatment (WHO, 2011)
• Severe Pre-eclampsia and Eclampsia
– Major health problems in developi...
Medical causes of death and
treatment (WHO, 2011)
• Maternal sepsis
– Infection can follow an abortion or childbirth and i...
Medical causes of death and
treatment (WHO, 2011)
• Sexually transmitted infections
– Nearly a million people acquire a se...
Maternal Death Review
18 deaths in 82 LGUs (9 audited cases)
Top causes of
maternal
deaths
Placenta Previa/PPH
Eclampsia
S...
Systems Approach to addressing
Maternal Mortality
• 6 Building Blocks (Technical)
– Governance, Human
Resource, Financing,...
Road Map
• A way to analyze the health situation in
municipalities including gaps and challenges
• A road map to weigh opt...
Progress of LGUs vis-a-vis building blocks
Leadership &
Governance
Majority have reactivated and expanded membership of th...
Medicines
Procurement and inventory systems have been fixed at
the RHU but availability of medicines in barangay health
st...
Health Outcomes (SLAM, Cohort 3)
207
73
153
106
70
212
0
50
100
150
200
250
'08 '09 '10 '11 '12 '13
SLAM and Cohort 3 MMR
...
Working on Health Seeking Behavior
2.47
5.30 5.94 16.96 22.12
16.52 14.91 33.62
2.47
5.30
12.99
15.59
29.44
0
5
10
15
20
2...
Conclusions
• Medical and social factors are important to be
understood.
• There is a technical solution that can be
imple...
No mother should die giving life...
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Maternal mortality

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Understanding Maternal Mortality using the medical and social contexts. In explaining the social contexts, the presentation will present a case of the Zuellig Family Foundation on Maternal Death Reviews.

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  • Everyday: Approximately 800 women die from preventable causes related to pregnancy and childbirth.99% of all maternal deaths occur in developing countries. (half of these deaths occur in sub-Saharan Africa and almost one third occur in South Asia). 792 a day in developing countries. 396, Sub Saharan Africa, 264 in South Asia. This means one maternal death in every two minutes in a developing country. Every four minutes, a mother dies in Sub-Saharan Africa.Maternal mortality is higher in women living in rural areas and among poorer communities.Young adolescents face a higher risk of complications and death as a result of pregnancy than older women.Skilled care before, during and after childbirth can save the lives of women and newborn babies.Between 1990 and 2010, maternal mortality worldwide dropped by almost 50%
  • International Classification of Diseases (ICD-10)
  • 1. WHO recommendations for the prevention of postpartum haemorrhage. Geneva, World Health Organization, 2007.2. WHO guidelines for the management of postpartum haemorrhage and retained placenta. Geneva, World Health Organization, 2009.3. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PFA. WHO analysis of causes of maternal death: a systematic review. Lancet,2006, 367:1066-1074
  • 4. Managing complications in pregnancy and childbirth: a guide for midwives and doctors. Geneva, World Health Organization, 2007(Integrated management of pregnancy and childbirth).5. Duley L. Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean. British Journal of Obstetrics and Gynaecology, 1992, 99:547-553.
  • 3. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PFA. WHO analysis of causes of maternal death: a systematic review. Lancet,2006, 367:1066-1074.4. Managing complications in pregnancy and childbirth: a guide for midwives and doctors. Geneva, World Health Organization, 2007(Integrated management of pregnancy and childbirth).6. Kulier R, Gülmezoglu AM, Hofmeyr GJ, Cheng LN, Campana A. Medical methods for first trimester abortion. Cochrane Databaseof Systematic Reviews, 2007, Issue 4. Art. No.: CD002855. DOI: 10.1002/14651858.CD002855.pub3.7. Unsafe abortion. Global and regional estimates of incidence of unsafe abortion and associated mortality in 2003. Fifth edition.Geneva, World Health Organization, 2007.
  • 8. Global strategy for the prevention and control of sexually transmitted infections: 2006–2015: breaking the chain of transmission. Geneva, World Health Organization 2007.9. Glasier A, Gülmezoglu AM, Schmid GP, Moreno CG, Van look PF. Sexual and reproductive health: a matter of life and death. Lancet, 2006, 367: 1595-607.10. Guidelines for the management of sexually transmitted infections. Geneva, World Health Organization, 2003.11. Delport SD, Pattinson RC. Congenital and perinatal infections: prevention, diagnosis and treatment. Syphilis: prevention, diagnosis and management during pregnancy and infancy. In: Newell M-L, McIntyre J. Eds. Cambridge, UK, Cambridge UniversityPress 2000;258-275
  • 3 delayshttp://www.jica.go.jp/project/philippines/0600894/04/pdf/ppt_03.pdf
  • Next time, use the colored scorecard
  • Maternal mortality

    1. 1. Maternal Mortality Understanding the Biological and Social Contexts Jeromeo Jose 11382333 Biological and Social Foundations of Health MAHESOS
    2. 2. The great divide of Maternal Mortality Everyday, 800 women die from pregnancy and childbirth Developing countries Developed Countries 99% • Who are the most susceptible? – Women living in rural areas and poor communities – Young adolescents – Women who do not receive care (pre, during and post)
    3. 3. The Philippine Context 162 221 0 50 100 150 200 250 '08 '09 '10 '11 Philippines Maternal Mortality RP MDG Source: Department of Health
    4. 4. What do we mean by maternal death? • a maternal death is 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 (ICD-10)
    5. 5. Medical causes of death and treatment (WHO, 2011) • Post partum hemorrhage – World’s leading cause of maternal mortality – 127,000 maternal deaths annually – may cause up to 50% percent of all maternal deaths in developing countries – Medicines • Oxytocin: 10 IU in 1-ml ampoule • Sodium chloride: injectable solution 0.9% isotonic or Sodium lactate compound solution – injectable (Ringer’s lactate)
    6. 6. Medical causes of death and treatment (WHO, 2011) • Severe Pre-eclampsia and Eclampsia – Major health problems in developing countries. – Every year, eclampsia is associated with an estimated 50 000 maternal deaths worldwide. – Medicines • Calcium gluconate injection (for treatment of magnesium toxicity): 100 mg/ml in a 10-ml ampoule • Magnesium sulfate: injection 500 mg/ml in a 2-ml ampoule, 500 mg/ml in a 10-ml ampoule
    7. 7. Medical causes of death and treatment (WHO, 2011) • Maternal sepsis – Infection can follow an abortion or childbirth and is a major cause of death. – Sepsis not related to unsafe abortion accounts for up to 15% of maternal deaths in developing countries. – Medicines • Ampicillin: powder for injection 500 mg; 1 g (as a sodium salt) in vial • Gentamicin: injection 10 mg; 40 mg /ml in a 2-ml vial • Metronidazole: injection 500 mg in a 100-ml vial • Misoprostol: tablet 200 μg
    8. 8. Medical causes of death and treatment (WHO, 2011) • Sexually transmitted infections – Nearly a million people acquire a sexually transmitted infection, including HIV, every day. – The results of infection include acute symptoms, chronic infection, and serious delayed consequences such as infertility, ectopic pregnancy, cervical cancer, and the untimely deaths of infants and adults. – Medicines • Uncomplicated genital chlamydial infections: Azithromycin: capsule 250 mg; 500 mg or oral liquid 200 mg/5 ml • Gonococcal infection – uncomplicated anogenital infection: Cefixime: capsule 400 mg • Syphilis: Benzathine benzylpenicillin: powder for injection 900 mg benzylpenicillin in a 5-ml vial; 1.44 g benzylpenicillin in a 5-ml vial
    9. 9. Maternal Death Review 18 deaths in 82 LGUs (9 audited cases) Top causes of maternal deaths Placenta Previa/PPH Eclampsia Sepsis others 56% 22% 11% 11% Gravida Status Gravida Percentage Prima Gravida 11% 2 – 4 33% Multi Gravida 53% Interventions: Preventive measures: 1. Map catchment areas 2. Augment human resources (competency & number) / health facilities /equipment 3. Implement well-coordinated referral and return referral systems, including transportation to and from home to facility 4. Improve access to medicines for obstetric emergencies like anti-hypertensive meds 1. Pregnancy Tracking System, early detection of high-risk patients 2. Birthing plans for high-risk patients 3. Skills Training (BEMONC, Life-saving Skills) for birth attendants 4. FP counselling and access to FP commodities Referral Hospital 44% RHU/ BHS 12% Home 44% SBA=67% vs Hilot=33% Hilots now referring pregnant women albeit usually late Maternal Deaths
    10. 10. Systems Approach to addressing Maternal Mortality • 6 Building Blocks (Technical) – Governance, Human Resource, Financing, Medicines, Health Info, Service Delivery. (WHO) • Local leadership is the key to changing systems and innovating programs that lead to better health outcomes (ZFF, 2012) – Focused on Mayors and MHOs who decide to change the health system, through meaningful engagements and new arrangements with other stakeholders.
    11. 11. Road Map • A way to analyze the health situation in municipalities including gaps and challenges • A road map to weigh options and set priorities • A scorecard to measure accomplishment. Intervention on Health Systems Transformation: Municipal Basic Health System’s Technical Roadmap Leadership & Governance Health Financing Health Human Resource Access to Medicine & Technology Health information System Health Service Delivery MunicipalHealthGovernance Municipal Health Action Plan HealthResourceGenerationand Management LGU Budget for Health (15% IRA) RHUandBHSResourcemanagement Health Human Resource Adequacy at the RHU (MD 1:20,000) (Nurse 1:20,000) DrugManagementSystem Presence of Essential Medicine at the RHU (Stock Basis) DataCollection,UtilizationandInformationDissemination Accomplished Baseline Data Collection BarangayHealth Infrastructure Presence of Barangay Health Stations (1 BHS:1 Braangay or 1 BHS per Catchment) Maintenance and Operations Utilization Actual budget Utilization (95% Utilization) RHU HHR Competency Available Transportation for Emergency Regular Data Gathering and Recording MaternalandChildCare Sustainable Maternal Health Care Initiatives Pre-Natal Services (at least 80%) Full Implementation of Magna Carta for Public Health WorkersExpanded and Functional Local Health Board Facility-Based Devleiries (85%) BLGU Health Budget (5% of Barangay IRA) Skilled Birth Attendants (85%) Installed Performance Management System Sustainable Breastfeedi ng Initiatives Exclusive Breastfeeding for Infants (70%) RHU Medicine Tracking and Inventory System Maternal/Infant Death Review Newborns Initiated Breastfeeding (85%) BarangayHealthGovernance Functional Barangay Health Governance Body (with functional CHT) LocalPhilhealthAdministration 4-in-1 Accreditation Sustainable Essential Intrapartum and Newborn Care Initiatives Health Human Resource Adequacy in BHS (1 Midwife: 1 Brgy; with consideration to GIDA) (BHW to HH 1:20HH) Sustainable Infant and Child Care Initiatives Fully Immunized Child (95%) Regular IEC for Enrolled Indigent (for Q1 and Q2) Monthly Updated Health Data Board Under-5 Malnutrition Prevalence Rate (Below 17.3%) BHS HHR Competency (Basic BHW Training Course and CHT Training) Accomplishment, Utilization and Dissemination of the DILG, DOH LGU Scorecards ReproductiveHealth Sustainable Adolescent Reproductive Health Initiatives Reimbursement Filing (PCB, MCP, TB- DOTS) Sustainable Family Planning Initiatives Provision of FP Commodities and Services (RHU) Implemented and Integrated Barangay Health Plan Contraceptive Prevalence Rate (63%) System for BHW Recruitment and Retention Mechanisms Creation of Citizen’s Chrater Ordinance and System for Claims Disposition and Utilization Monitoring Ratio of Community- Based Pharmaccy (1 BNB/CBP catchment or 1 BNB per barangay) Unmet Needs (50% under NHTS) WaSH Sanitary Toilets (86%) Ordnance and Timely Provision of BHW Honorarium Access to Safe Water (87% of HH)
    12. 12. Progress of LGUs vis-a-vis building blocks Leadership & Governance Majority have reactivated and expanded membership of their local health boards Activating barangay health boards a work in progress in most LGUs Human Resources Most have hired additional personnel but ideal ratios have yet to be met Financing 33 of 82 (40%) LGUs have 4-in-1 Philhealth accreditation Non-ARMM LGUs have increased health budgets to 10% or above Still working on having barangays raise their health budgets to 5% Continuous & close coordination with DOH-ARMM & Philhealth led to release of much-needed reimbursements to LGUs in the region
    13. 13. Medicines Procurement and inventory systems have been fixed at the RHU but availability of medicines in barangay health stations needs to improve in cohorts that have ended the 2-year partnership Accessibility, procurement & inventory systems are being improved in other LGUs Service Delivery LGUs have created their own innovative programs to address issues Information systems Systems of reporting & recording have improved Need to improve ability to analyze data Need to strengthen mortality audit system Progress of LGUs vis-a-vis building blocks
    14. 14. Health Outcomes (SLAM, Cohort 3) 207 73 153 106 70 212 0 50 100 150 200 250 '08 '09 '10 '11 '12 '13 SLAM and Cohort 3 MMR Cohort 3 SLAM 141 68 41 0 Cohort 3 Sources: FHSIS for ZFF ARMM municipalities
    15. 15. Working on Health Seeking Behavior 2.47 5.30 5.94 16.96 22.12 16.52 14.91 33.62 2.47 5.30 12.99 15.59 29.44 0 5 10 15 20 25 30 35 40 '08 '09 '10 '11 '12 Facility Based Deliveries Trend (ARMM) Cohort 1 Cohort 3 ARMM Cohort 51.44 49.12 39.74 41.88 34.21 73.41 69.53 72.41 51.44 49.12 62.18 60.31 59.68 0 10 20 30 40 50 60 70 80 '08 '09 '10 '11 '12 Deliveries Attended by Skilled Birth Attendants (ARMM) Cohort 1 Cohort 3 ARMM Cohort Sources: FHSIS for ZFF ARMM municipalities
    16. 16. Conclusions • Medical and social factors are important to be understood. • There is a technical solution that can be implemented – medical response, strengthening the health system (6BB) • Leadership will ensure that more stakeholders gain ownership of the issue.
    17. 17. No mother should die giving life...

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