DEADLY DELAYS Dr . Sujnanendra Mishra MD(O&G)
E very year……. <ul><li>500 000  + women die of complications of pregnancy and childbirth </li></ul><ul><li>7 million women...
Skilled Attendance at Birth upgrading of midwifery skills can respond to this situation by strengthening maternal and newb...
NO DELAY,   ANY MORE………
Delay means death
Why did She die? Ante partum hemorrhage due to placenta praevia, which means that the placenta, or what we call the “after...
Delay in Blood Transfusion Delay in initiating Proper care
Delay in reaching Hospital It took Padmini four hours to reach hospital from the time she started bleeding severely, becau...
This was not the first time….. she suffered bleeding. In fact she had two minor episodes of bleeding during the same month...
Delay in Antenatal Care She was not a very healthy woman. Even before pregnancy, she suffered from chronic iron deficiency...
She is 39 years old Five of her children are still living, three off them are males. TOO OLD TOO MANY She should not have ...
TOO far from PROVIDERS
HOUSEWIFE TO A POOR AGRICULTURAL LABOUR
She was an illiterate woman  and she lived with her husband in a remote village.
A woman of Padmini’s socioeconomic position has a relative risk of maternal mortality: <ul><li>5 times more than the avera...
POVERTY ILLETERACY LACK OF KNOWLEDGE SOCIAL INJUSTICE She dies Non-availability of blood and care
SHE COULD HAVE BEEN SAVED . CAN PREVENT SUCH DEATH …………… A care provider,
The Road to Maternal Death.
Traditional Antenatal Care  What it looks like <ul><li>Originated from models developed in Europe in early decades of the ...
Problems with the Risk Approach <ul><ul><li>Poor predictive value  – Does not distinguish those who will develop  complica...
Problems with the Risk Approach  continued <ul><ul><li>False security  –  Many women categorized as “low risk” do develop ...
Lessons from Risk Approach <ul><li>Every pregnant woman is at risk of complications and must have access to quality matern...
Antenatal Care: Best Practices <ul><li>Not recommended </li></ul><ul><li>Numerous routine visits </li></ul><ul><li>High-ri...
Recommended <ul><li>Prevention </li></ul><ul><li>For all women </li></ul><ul><ul><li>Tetanus toxoid </li></ul></ul><ul><ul...
Causes of maternal death <ul><li>What are the main causes of maternal death & how do you avert them? </li></ul>
Reduction of maternal death through ANC: <ul><li>Haemorrhage </li></ul><ul><ul><li>Iron/folate supplementation, measuremen...
Reduction of maternal death through ANC: <ul><li>Puerperal sepsis  </li></ul><ul><ul><li>Treatment of STIs, plan for safe/...
birth preparedness and complication readiness
Birth preparedness plan <ul><li>What do you mean by birth preparedness plan? </li></ul><ul><li>Birth preparedness is advan...
Birth Preparedness Plan <ul><li>Discussion of safest place for delivery with a skilled attendant and complication readines...
<ul><li>What birth preparedness plan are specific to HIV positive pregnant women? </li></ul>
Recommended Birth Preparedness, including  Complication Readiness <ul><li>Preparing for Normal birth </li></ul><ul><ul><ul...
Recommended Birth Preparedness, including  Complication Readiness <ul><li>Preparing for Normal birth </li></ul><ul><ul><ul...
If home birth is the only option for an HIV+ woman, the health worker should:   <ul><li>Be certain ARV drugs are available...
What are the key steps in preparing for birth? <ul><li>Preparing for birth entails saving money to pay for service charges...
What are the major points that should be covered during antenatal counselling? <ul><li>Antenatal counselling should includ...
What are some barriers to birth preparedness? <ul><li>Gaps in knowledge concerning preparing for birth and the risks </li>...
What are some starting points for counselling women on birth preparedness and motivating them to prepare for delivery? <ul...
What realistic solutions can counsellors can provide women during antenatal counselling to overcome barriers to birth prep...
 
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Deadly delay

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Delay in decision to seek care, Delay in reaching care, Delay in receiving care,these three phases of delay rarely operate in isolation, and delay leading to maternal death is often multifactorial. Indeed the factors are likely to be interactive and multiplicative. Thus barriers and poor care encountered at Phase 2 and 3 feed back into subsequent decision-making at Phase 1. Interventions to reduce maternal mortality must address each of the Three Delays in order to have the greatest effect.

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  • 24- Slides 2-17 Interactive presentation (20 to 25 minutes) The core of these early European models has developed or changed very little despite the increase in medical and midwifery knowledge. To a large extent, developing countries have adopted the antenatal (ANC) model of developed countries with little or no adjustment for endemic diseases or epidemiological considerations. Visits are often irregular, with long waiting time, little feedback to (or real communication with) mothers and little or no communication with obstetrical or labor units. Source : Villar J and P Bergsjo. 1997. Scientific basis for the content of routine antenatal care. Acta Obstetricia et Gynecologica Scandinavica 76(1): 1-14.
  • 24-
  • 24- See optional slides 21-23 for additional information about problems with the risk approach in predicting complications (e.g., postpartum hemorrhage, pregnancy-induced hypertension).
  • 24- Every woman needs access to quality maternity care; every woman needs to be cared for by a skilled attendant.
  • 24-
  • 24- See the following optional slides for details: Optional slide 41, tetanus toxoid Optional slide 42, iron deficiency Optional slide 43, iron folate supplements Optional slide 44, malaria in pregnancy Optional slides 45 and 46, treatment of malaria during pregnancy Optional slide 47, hookworms in pregnant women Optional slide 48, iodine deficiency and supplementation Optional slides 49 and 50, vitamin A supplementation
  • 24- Planning and preparation for mother, family, community and skilled care provider Individual birth plans will be shaped by the culture, socioeconomic, and geographical situation of the family as well as by the needs and condition of the individual client. See optional slides 24-25 for details about the need for birth preparedness based on a study in Nepal.
  • 24- Planning and preparation for mother, family, community and skilled care provider Individual birth plans will be shaped by the culture, socioeconomic, and geographical situation of the family as well as by the needs and condition of the individual client. See optional slides 24-25 for details about the need for birth preparedness based on a study in Nepal.
  • Deadly delay

    1. 1. DEADLY DELAYS Dr . Sujnanendra Mishra MD(O&G)
    2. 2. E very year……. <ul><li>500 000 + women die of complications of pregnancy and childbirth </li></ul><ul><li>7 million women who survive childbirth suffer serious health problems </li></ul><ul><li>50 million women suffer adverse health consequences after childbirth. </li></ul>The overwhelming majority of these deaths and complications occur in developing countries
    3. 3. Skilled Attendance at Birth upgrading of midwifery skills can respond to this situation by strengthening maternal and newborn health services and Reduce MMR &IMR . IMPOSSIBLE can be I M POSSIBLE
    4. 4. NO DELAY, ANY MORE………
    5. 5. Delay means death
    6. 6. Why did She die? Ante partum hemorrhage due to placenta praevia, which means that the placenta, or what we call the “afterbirth”, was situated too low down in the uterus. A woman with this condition will inevitably develop bleeding in the latter part of pregnancy or before delivery
    7. 7. Delay in Blood Transfusion Delay in initiating Proper care
    8. 8. Delay in reaching Hospital It took Padmini four hours to reach hospital from the time she started bleeding severely, because transport was not readily available to take her to the hospital. Doctor had left hospital when she reached. The sisters started infusion and informed doctor staying few km away and asked the relatives to arrange BLOOD,
    9. 9. This was not the first time….. she suffered bleeding. In fact she had two minor episodes of bleeding during the same month and on both occasions the bleeding stopped spontaneously. This is a very dangerous signal in late pregnancy. It always indicates that a severe attack of bleeding is imminent, yet Padmini was never warned about this and no action was taken. <ul><ul><ul><li>Delay in Early detection </li></ul></ul></ul>
    10. 10. Delay in Antenatal Care She was not a very healthy woman. Even before pregnancy, she suffered from chronic iron deficiency anaemia caused by malnutrition and parasitic infestations. That severe anaemia must have contributed to the fact that she could not endure the additional severe blood loss. Her reserves of blood were already at a very low level.
    11. 11. She is 39 years old Five of her children are still living, three off them are males. TOO OLD TOO MANY She should not have opted for another child.
    12. 12. TOO far from PROVIDERS
    13. 13. HOUSEWIFE TO A POOR AGRICULTURAL LABOUR
    14. 14. She was an illiterate woman and she lived with her husband in a remote village.
    15. 15. A woman of Padmini’s socioeconomic position has a relative risk of maternal mortality: <ul><li>5 times more than the average in the whole country. </li></ul><ul><li>10 times more than a woman in a higher socioeconomic position in the country in which she is living. </li></ul><ul><li>100 times more than a woman living in a developed country. </li></ul>
    16. 16. POVERTY ILLETERACY LACK OF KNOWLEDGE SOCIAL INJUSTICE She dies Non-availability of blood and care
    17. 17. SHE COULD HAVE BEEN SAVED . CAN PREVENT SUCH DEATH …………… A care provider,
    18. 18. The Road to Maternal Death.
    19. 19. Traditional Antenatal Care What it looks like <ul><li>Originated from models developed in Europe in early decades of the century </li></ul><ul><li>Ritualistic rather than rational </li></ul><ul><li>Emphasis of visits is on frequency and numbers, rather than on essential goal-directed elements </li></ul>24- Source : Villar and Bergsjo 1997.
    20. 20. Problems with the Risk Approach <ul><ul><li>Poor predictive value – Does not distinguish those who will develop complications from those who will not. </li></ul></ul><ul><ul><li>Consumes scarce resources – Many women categorized as “high risk” never develop complications but consume scarce resources. </li></ul></ul>24-
    21. 21. Problems with the Risk Approach continued <ul><ul><li>False security – Many women categorized as “low risk” do develop complications but are never told how to recognize or respond to them. </li></ul></ul><ul><ul><li>Diverted resources – Away from the improvement of services for all women </li></ul></ul>24-
    22. 22. Lessons from Risk Approach <ul><li>Every pregnant woman is at risk of complications and must have access to quality maternity care. </li></ul><ul><li>Even low-risk women may develop complications. </li></ul><ul><li>No amount of screening will separate out those women who will need emergency care from those who will not need such care. </li></ul>24-
    23. 23. Antenatal Care: Best Practices <ul><li>Not recommended </li></ul><ul><li>Numerous routine visits </li></ul><ul><li>High-risk approach </li></ul><ul><li>Routine measurement: </li></ul><ul><ul><li>Height </li></ul></ul><ul><ul><li>Fetal position before 36 weeks </li></ul></ul><ul><ul><li>Ankle edema </li></ul></ul><ul><li>Recommended </li></ul><ul><li>Focused antenatal visits by skilled provider </li></ul><ul><li>Birth preparedness and complication readiness planning </li></ul><ul><li>Counseling for family planning, breastfeeding, danger signs, HIV/STIs and nutrition </li></ul><ul><li>Detection and management of co-existing conditions and complications </li></ul><ul><li>Tetanus toxoid </li></ul><ul><li>Iron and folate </li></ul><ul><li>In selected populations </li></ul><ul><ul><li>Malaria preventive treatment </li></ul></ul><ul><ul><li>Helminth presumptive treatment </li></ul></ul><ul><ul><li>Iodine </li></ul></ul><ul><ul><li>Vitamin A </li></ul></ul>24-
    24. 24. Recommended <ul><li>Prevention </li></ul><ul><li>For all women </li></ul><ul><ul><li>Tetanus toxoid </li></ul></ul><ul><ul><li>Iron and folate supplementation </li></ul></ul><ul><li>In select populations </li></ul><ul><ul><li>Malaria - intermittent preventive treatment </li></ul></ul><ul><ul><li>Routine hookworm treatment </li></ul></ul><ul><ul><li>Iodine supplementation </li></ul></ul><ul><ul><li>Vitamin A supplementation </li></ul></ul>24-
    25. 25. Causes of maternal death <ul><li>What are the main causes of maternal death & how do you avert them? </li></ul>
    26. 26. Reduction of maternal death through ANC: <ul><li>Haemorrhage </li></ul><ul><ul><li>Iron/folate supplementation, measurement of HCT and Blood typing, malaria prevention, availability of blood for transfusion </li></ul></ul><ul><li>Preeclampsia /eclampsia </li></ul><ul><ul><li>BP measurement, warning signs, urine for protein, rapid referral and treatment with Mag sulphate </li></ul></ul><ul><li>Obstructed labour </li></ul><ul><ul><li>Fundal height measurement, fetal lie after 36 weeks, use of partograph in labor and rapid referral for prolonged labor </li></ul></ul>
    27. 27. Reduction of maternal death through ANC: <ul><li>Puerperal sepsis </li></ul><ul><ul><li>Treatment of STIs, plan for safe/clean delivery, two doses of tetanus toxoid, PMTCT and ARV if indicated </li></ul></ul><ul><li>Complications of unsafe abortion </li></ul><ul><ul><li>Post abortion care, family planning </li></ul></ul>
    28. 28. birth preparedness and complication readiness
    29. 29. Birth preparedness plan <ul><li>What do you mean by birth preparedness plan? </li></ul><ul><li>Birth preparedness is advance planning and preparation for delivery. </li></ul><ul><li>Birth preparedness helps ensure that women can reach professional delivery care when labour begins and can also </li></ul><ul><li>help reduce the delays that occur when women experience obstetric complications </li></ul>
    30. 30. Birth Preparedness Plan <ul><li>Discussion of safest place for delivery with a skilled attendant and complication readiness </li></ul><ul><li>HIV+ women should be advised to deliver in a health facility, and to go to the facility whenever labor starts or her water breaks </li></ul><ul><ul><li>The HIV+ woman must remember to bring her ARV drugs to the facility. </li></ul></ul>
    31. 31. <ul><li>What birth preparedness plan are specific to HIV positive pregnant women? </li></ul>
    32. 32. Recommended Birth Preparedness, including Complication Readiness <ul><li>Preparing for Normal birth </li></ul><ul><ul><ul><li>Skilled attendant </li></ul></ul></ul><ul><ul><ul><li>Place of delivery </li></ul></ul></ul><ul><ul><ul><li>Finance </li></ul></ul></ul><ul><ul><ul><li>Nutrition </li></ul></ul></ul><ul><ul><ul><li>Essential items </li></ul></ul></ul><ul><li>Readiness for Complications </li></ul><ul><ul><ul><li>Early detection </li></ul></ul></ul><ul><ul><ul><li>Designated decision maker(s) </li></ul></ul></ul><ul><ul><ul><li>Emergency funds </li></ul></ul></ul><ul><ul><ul><li>Communication </li></ul></ul></ul><ul><ul><ul><li>Transport </li></ul></ul></ul><ul><ul><ul><li>Blood donors </li></ul></ul></ul>24-
    33. 33. Recommended Birth Preparedness, including Complication Readiness <ul><li>Preparing for Normal birth </li></ul><ul><ul><ul><li>Skilled attendant </li></ul></ul></ul><ul><ul><ul><li>Place of delivery </li></ul></ul></ul><ul><ul><ul><li>Finance </li></ul></ul></ul><ul><ul><ul><li>Nutrition </li></ul></ul></ul><ul><ul><ul><li>Essential items </li></ul></ul></ul><ul><li>Readiness for Complications </li></ul><ul><ul><ul><li>Early detection </li></ul></ul></ul><ul><ul><ul><li>Designated decision maker(s) </li></ul></ul></ul><ul><ul><ul><li>Emergency funds </li></ul></ul></ul><ul><ul><ul><li>Communication </li></ul></ul></ul><ul><ul><ul><li>Transport </li></ul></ul></ul><ul><ul><ul><li>Blood donors </li></ul></ul></ul>24-
    34. 34. If home birth is the only option for an HIV+ woman, the health worker should: <ul><li>Be certain ARV drugs are available for the woman and her newborn </li></ul><ul><li>Provide careful instructions on how to take the ARV drugs. </li></ul><ul><li>Arrange for a treatment supporter,TBA or CHW of her choice to help with ART or ARV prophylaxis at home. </li></ul>
    35. 35. What are the key steps in preparing for birth? <ul><li>Preparing for birth entails saving money to pay for service charges/fees, medical supplies and transport to a facility as well as saving additional money in case of an emergency. </li></ul><ul><li>Other elements of birth preparedness include </li></ul><ul><li>deciding on a delivery location, </li></ul><ul><li>discussing delivery preferences with family members, </li></ul><ul><li>identifying means of transport to a facility, </li></ul><ul><li>identifying potential blood donors and </li></ul><ul><li>Knowing the danger signs associated with obstetric complications. </li></ul>
    36. 36. What are the major points that should be covered during antenatal counselling? <ul><li>Antenatal counselling should include advice on: attending antenatal care each month throughout pregnancy; </li></ul><ul><li>preparing for delivery and possible emergencies; steps involved in preparing for birth; </li></ul><ul><li>risks associated with pregnancy, delivery and the postpartum period; danger signs of obstetric complications; and the importance of early postpartum care and when to attend postpartum check ups. </li></ul><ul><li>Antenatal counselling should also address HIV/AIDS to ensure that women are informed of the increased risks of HIV/AIDS during pregnancy, how to protect themselves against HIV/AIDS and where to go for voluntary counselling and testing (VCT) services. </li></ul>
    37. 37. What are some barriers to birth preparedness? <ul><li>Gaps in knowledge concerning preparing for birth and the risks </li></ul><ul><li>associated with pregnancy and delivery; </li></ul><ul><li>financial and geographical barriers that make saving money and reaching a facility challenging and cultural beliefs, attitudes and taboos surrounding preparation for birth, pregnancy, delivery and the postpartum period. </li></ul><ul><li>Many communities believe that planning for birth will bring bad luck or is unwise since the baby may not live. </li></ul><ul><li>ANC counsellors can help women explore these beliefs and prepare for other future events (e.g. how they can save in advance to pay for school fees or for the next planting season, etc.) </li></ul>
    38. 38. What are some starting points for counselling women on birth preparedness and motivating them to prepare for delivery? <ul><li>Communities are generally concerned about maternal death and recognise the risks associated with pregnancy and delivery; thus, they may be motivated to learn about how they can make childbirth Safer. </li></ul><ul><li>Women may be motivated to seek antenatal care to determine their due date, knowing the foetal presentation and detecting complications, which can serve as a starting point for counselling them on birth preparedness. </li></ul><ul><li>Some women and families are motivated to prepare for birth by saving money and buying essential medical supplies, but they lack feasible solutions to economic and geographical challenges. </li></ul>
    39. 39. What realistic solutions can counsellors can provide women during antenatal counselling to overcome barriers to birth preparation? <ul><li>Counsellors can help women see how saving a very small amount of money each week adds up to a significant amount after nine months of pregnancy. </li></ul><ul><li>Similarly, ANC providers can help women explore traditional taboos or beliefs that discourage birth preparedness and see how they do prepare for unforeseen or unpredictable events in other aspects of their lives. </li></ul><ul><li>To help women overcome transport or geographic barriers, providers can help women explore available transport options or the possibility of temporarily moving closer to the facility close to the anticipated date of delivery </li></ul>

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