The talk is about maternal and perinatal mortality.

1. MATERNAL AND PERINATAL
MORTALITY
Meshack Gaolathe Lehelepa
201601436
MBBS V
OBGY Seminar 4

2. PRESENTATION
OUTLINE
 INTRODUCTION
 DEFINITIONS
 BOTSWANA PROFILE
 MATERNAL MORTALITY AUDIT
 MAJOR CAUSES OF MATERNAL MORTALITY
 MAJOR CAUSES OF PERINATAL MORTALITY
 INTERVENTIONS AND PREVENTION

3. INTRODUCTION
 Maternal death is a tragedy for an individual woman, for her family
and the community
 Worldwide nearly 600,000 women between the age of 15 and 49 die
every year due to complications arising from pregnancy and childbirth
 This means, almost every minute of every year, there is a maternal
death. 99% of which occur in the developing countries
 Majority (80%) of these deaths are preventable.

4.  Maternal mortality is higher in women living in rural areas and
among poorer communities
Between 1990 and 2015, maternal mortality worldwide dropped by
about 44%
 Between 2016 and 2030, as part of the sustainable Development
goals, the target is to reduce the global maternal mortality ratio to
less than 70 per 100,000 live births

5. DEFINITIONS
 Maternal Mortality- Death of a woman while pregnant or within 42
days of the termination of pregnancy irrespective of the duration and
the site of pregnancy, from any cause related to or aggravated by the
pregnancy or its management but not from accidental or incidental
causes
 Late maternal death- The death of a woman from direct or indirect
obstetrical causes more than 42days, but less than one year, after
termination of pregnancy.

6.  Maternal mortality ratio- Maternal Mortality Ratio is defined as the
number of maternal deaths per 100,000 live births. This indicator
estimates the proportion of pregnant women or mothers who die
from causes related or aggravated by pregnancy or its management.
 Maternal mortality rate- number of maternal deaths in a given
period per 100, 000 women of reproductive age( 15 to 49) during the
same time period.

7.  Perinatal mortality- defined as deaths among fetuses weighing
1000 g or more at birth (28 weeks gestation) who die before or
during delivery or within the first 7 days of delivery.
 Neonatal death- infant death before 28days of age
 Neonatal mortality rate- is the number of neonatal deaths during a
year, divided by the number of live births during the same year,
expressed per 1000 live births.

8. MDG 5
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

10. BOTSWANA PROFILE
The following Stats brief presents the Maternal Mortality Ratio for
the years 2014 to 2019
 Data used for this brief is provided by the Ministry of Health and
wellness through reporting from the health facilities
 The brief showed that 87 maternal deaths were reported in 2019
from 52,304 live births .Maternal Mortality Ratio declined steadily
from 156.6 in 2016 to 133.7 in 2018 and was estimated at 166.3
deaths per 100,000 live births in 2019

12. MATERNAL DEATH AUDITS
 The Safe Motherhood Conference of 1987 in Nairobi recommended that
countries adopt strategies to reduce maternal mortality by at least 50% by
the year 2000
 The Botswana government accepted these recommendations and
launched its national Safe Motherhood Initiative in 1990
 The initial objective of the programme at the time of establishment was to
reduce the maternal mortality ratio to 150 by 2011

13.  Botswana has also endorsed the Millennium Development Goal of reducing the 1990
maternal mortality ratio by 75% by the year 2015
 In order to measure the impact of Safe Motherhood programme interventions, a system of
continuous evaluation and assessment of progress in relation to maternity care was
developed
 Thus, a national maternal morbidity and mortality monitoring system, with two main
monitoring levels, was developed in 1998
 The system is designed to provide an opportunity for all those involved in the health system
to participate

18. CLASSIFICATION
 Causes of maternal deaths can be classified into three categories,
namely ;
 Direct
 Indirect
Non- obstetric

19.  Direct obstetric deaths (75%) - A death resulting from complications
of pregnancy, labour or delivery or their management.
 Indirect deaths (25%) - A death in which pregnancy exacerbated a
pre-existing health problem
 Non-Maternal Death - A death that occurred during pregnancy or
within 42 days of termination of pregnancy, but was considered
unrelated to pregnancy (e.g. due to injury, homicide, or suicide)

20. CAUSES OF MATERNAL DEATHS AND
INTERVENTIONS
Causes Percentag
e
Proven Interventions
Hemorrhage: Mostly due to postpartum
hemorrhage. Other causes are : (i) Antepartum
hemorrhage (abruptio placenta, placenta
previa) (ii) Retained placenta (iii) Abortion
complications and ectopic pregnancy.
Hemorrhage is more dangerous when the
woman is anemic.
20–25 • Treat anemia in pregnancy
• Skilled attendant at birth
• Prevent/treat hemorrhage
• Use oxytocics in time
• Replace Fluid loss
• Transfusion of blood, if severe
hemorrhage
Infection is associated with labor and
puerperium. Infections from premature rupture
of membranes, prolonged and obstructed
labor are still frequent in the developing world.
15–20 • Skilled attendant at birth
• Clean practices during delivery
• Antibiotics — if infection is evident
Unsafe abortion 10–13 • Skilled attendant
• Access to family planning and safe abortion
services
• Antibiotics after evacuation

21. Hypertension during pregnancy
preeclampsia, eclampsia
12–15 • Early detection
• Appropriate referral
• Antiseizure
prophylaxis/treatment with
MgSO4
Obstructed labor—due to
cephalopelvic disproportion,
abnormal lie or malpresentation.
8 • Use of partograph
• Detection in time
• Refer for operative delivery
Anemia is an indirect cause of
death. About 50% of pregnant
women worldwide suffer from
anemia. Anemia is commonly due
to dietary deficiency (nutrition,
iron, folic acid, iodine and other
micronutrients) or infections
15–20 • Routine Iron-folic acid
supplementation
• Treat hookworm, malaria, HIV,
etc.
• Admit when Hb ≤ 7 g/d
Other indirect causes: Viral
hepatitis is endemic in India with
high mortality. Death is mostly in
the last trimester due to hepatic
coma and coagulation failure and
5–10 • Safe drinking water
• Immunization
• Appropriate referral and
supportive care

22. STEPS TO REDUCE MATERNAL MORTALITY
(ACTIONS FOR SAFE MOTHERHOOD)
 Health Sector Actions
 A skilled attendant should be present at every birth. Functioning referral system is
essential for integration of domiciliary and institutional services.
 Emergency obstetric care (EmOC) is to be provided either by a field staff at the
door step of a pregnant woman or preferably at the first referral unit (FRU).
 Good quality obstetric services at the referral centers are to be ensured. Facilities
for blood transfusion, laparotomy and cesarean section must be available
Prevention of unwanted pregnancy and unsafe abortion. All couples and individuals
should have access to effective, client oriented and confidential family planning
services.
Frequent joint consultation among specialists in the management of medical
disorders in pregnancy particularly anemia, diabetes, cardiac disease, viral
hepatitis, and hypertension

23.  Community, Society and Family Actions
 Wide range of groups (women’s groups), health care professionals, religious
leaders and safe motherhood committees (regional, district) can help the woman to
obtain the essential obstetric care.
 Health Planners/Policy Makers’ Actions
To organize community education, motivation and formation of safe motherhood
committee at the local level.
To strengthen the referral system for obstetric emergencies.
To develop written management protocols for obstetric emergencies in the
hospitals

24. PERINATAL
MORTALITY

26. BOTSWANA PROFILE
 In 2019, neonatal mortality rate for Botswana was 17.9 deaths per 1,000
live births. Neonatal mortality rate of Botswana fell gradually from 35.2
deaths per 1,000 live births in 1970 to 17.9 deaths per 1,000 live births in
2019.
 The fall in statistics can be attributed to the interventions that are currently
being implemented in order to curb perinatal mortality

27. CAUSES
 Epidemiological: Age over 35 years, teenagers, parity above 5, low
socioeconomic condition, poor maternal nutritional status—all
adversely affect the pregnancy outcome
 Medical disorders:
Anemia (Hb < 8 g/dL),
hypertensive disorders of pregnancy,
diabetes mellitus,
syphilis,
acute fever (malaria)
 infection (HIV)

28.  Obstetric complications:
Antepartum hemorrhage
Preeclampsia-eclampsia
Rh isoimmunization
Cervical incompetence
 Complications of labor:
Dystocia from disproportion, malpresentation, abnormal uterine action, premature
rupture of membranes may result in asphyxia, amnionitis and birth injuries
contributing to perinatal deaths

29.  Fetoplacental factors
 Multiple pregnancy
 Congenital malformation and chromosomal abnormalities
 Intrauterine growth restriction and low-birth-weight babies
 Preterm labor and preterm rupture of the membranes

30. INTERVENTIONS
 Genetic counselling
 Regular antenatal care,
 Detection and management of medical disorders in pregnancy
 Screening of high-risk patients
 Careful monitoring in labor
 Skilled birth attendant
 Provision of referral neonatal service
 Health care education of the mother about the care of the newborn

31. REFERENCES
 Konar, H., 2014. DC Dutta's textbook of obstetrics. London: JP Brothers Medical.
https://www.who.int/maternal_child_adolescent/events/2008/mdg5
/countries/final_cp_botswana_18_09_08.pdf
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6794541/
statsbots.org.bw/sites/default/files/publications/Botswana%20Mater
nal%20Mortality%20Ratio%20%202019.pdf
 https://pdf.usaid.gov/pdf_docs/PA00TCKG.pdf