2. Introduction
World wide, pregnancy and childbirth claim the lives of
an estimated 514,000 women each year.
This translates to one woman dying every minute.
Maternal mortality is one of the measures of the
QUALITY of health care system.
In Malaysia, significant reduction in MMR over the last
50 yrs:
540/100,000 LB in 1950
139/100,000LB in 1970
44/100,000 LB in 1991
28.1/100,000 LB in 2000
National objective - to reduce MMR to <20/100,000 LB.
3. Successes in Maternal Mortality Reduction
-
200
400
600
800
1,000
1,200
1,400
1,600
1840 1860 1880 1900 1920 1940 1960 1980 2000
Maternal
Mortality
Ratio
Maternal
Deaths
per
100,000
Live
Births
China
Malaysia
USA
England
& Wales
Sweden
Source: England, Wales, Sweden, USA: VanLerberghe and DeBrouwere,
Safe Motherhood Strategies, A Review of the Evidence, 2001
Malaysia, China: Koblinsky, Et al., Issues in Programming for Safe Motherhood, 2000
4. Maternal Death
The death of a woman while pregnant or within 42 days
of termination of pregnancy,
irrespective of the duration and site of pregnancy,
from any cause related to or aggravated by the pregnancy or its
management,
but not from accidental or incidental causes
5. Classification
Direct
Deaths resulting from obstetric complications in
pregnancy, labour and puerperium
Indirect
Deaths resulting from previous existing disease or
diseases that developed during pregnancy and which was
aggravated during pregnancy
Fortuitous
Deaths from other causes not related to or influenced by
pregnancy
Only direct and indirect deaths are included in MMR
calculation.
6. Principles of CEMD System
Confidentially concerning patient and care given.
Non-punitive in action.
Comprehensive - every maternal death must be
investigated.
Seamless-intersectoral collaboration (between public
health, hospital and private sectors).
7. Flow Chart On The Organization Of Investigation
Of Maternal Mortality
DEATH IDENTIFIED BY COORDINATOR
INVESTIGATED BY INVESTIGATOR
MCHO NOTIFIED
FORMS FILLED BY INVESTIGATOR
AND OTHERS AT DISTRICT LEVEL &
SUBMITTED TO MCHO
MCHO OBTAINS CODES FROM
SECRETARIAT,WRITES COMBINED SUMMARY
& SUBMITS TO NATIONAL ETHICAL
COMMITTEE
REVIEW BY NTC
REPORTS
ACTION
10. Causes of Maternal Deaths Malaysia
1991-1996
0%
5%
10%
15%
20%
25%
30%
35%
40%
PPH HDP Embolism Medical Ob trauma Others
1991
1992
1993
1994
1995
1996
11. Maternal Deaths Malaysia
PPH leading cause of maternal death (about 25%),
commonly due to retained placenta and uterine atony
HDP next common cause, most deaths occuring
postpartum. Associated with eclampsia,
cardiopulmonary complications, cerebral haemorrhage,
severe preeclampsia and DIVC
Thromboembolism
12. Maternal Deaths Malaysia
Associated medical conditions e. g. rheumatic heart
disease especially mitral stenosis
Obstetric trauma include uterine rupture, uterine
inversion and cervical, vaginal and uterine tears
Others include antepartum haemorrhage, sepsis,
miscarriage, ectopic, associated with anaesthsia and
unknown
14. Maternal Deaths Sarawak
Postpartum haemorrhage is the leading cause of
maternal mortality (about 35%)
Medical conditions next most common (25%)
Sepsis is third (11%)
Hypertensive disorders of pregnancy (8%)
Relatively large proportion unspecified
Others include ectopic, miscarriage, APH,
amniotic fluid embolism and cancers
15. General summary
Patients profile:
Age - majority between 20-39
Parity - over 60% multip
Education - 60% primary/secondary schooling
Occupation - 60% housewifes
Marital status - 3% unmarried
Family Planning - >55% no FP
Citizenship - 160 non-citizens
17. - The areas with the most potential for preventing
maternal deaths are direct deaths
- More emphasis are needed on family planning
- Continuous training for health care providers
involved to be familiar with manuals and protocols
by MOH
18. Post Partum Haemorrhage
Contributes about 20%
Uterine atony & retained or adherent placenta -
main cause
Risk factors - >40yrs , multiparity
Home delivery - 19-37% of deaths
Risk of dying from PPH for mothers delivering at
home is 3-5x higher than govt. facility. Additional
risks - untrained attendants and no adequate ANC
19. Contributing factors -
-recurring problem of delayed or unavailable emergency
transportation to hospital
-geographical remoteness
-inaccessabilty to health care facilities
20. Recommendations :
- family planning
- Adequate ANC counselling and accurate risk
assessment
- Availability facilities for adequate resuscitation-blood
and blood products
- Emergency transport arrangements to higher level of
care
- Early admission for patients living far from health
centres
21. Obsteric trauma
Most frequent causes - uterine rupture , pelvic
haematoma, cervical lacerations, uterine inversion
Risk factors - high parity - injudicious use of
oxytocics
Remediable clinical factors-
- inappropriate utilisation of oxytocics
- Failure to diagnose
- Failure to appreciate severity of clinical problem
- Late referral
- Delayed involvement of senior staff
22. Recommendations
- Need for proper protocol & guidelines on
augmentation & induction of labour
- increase awareness of problems especially uterine
rupture, difficult deliveries, grand multips and scarred
uterus
- Need for birth attendants to be able to recognise
inversion and able to institute appropriate treatment
- Train birth attendants on management of third stage
23. Hypertensive disorders of
pregnancy
1/3 were primigravida
The immediate association with death were
eclampsia,cardiopulmonary complications,cerebral
h’age,severe PE & DIVC.
Deaths could have been prevented if health care
providers were more aggressive and vigilant in their
management.
Proteinuria in pregnant women should be carefully
investigated and monitored.
24hr urine protein - gold standard but not always
practical. Dipstick commonly used- protein 2+ cut off
for abnormal
24. Magnesium sulphate
- not widely used in management of eclampsia
- Prevention and treatment for eclampsia
- Consider prophylactic MgSO4 in cases of severe PE
- Drug availability to nurses/midwifes who could
administer it IM
25. Obstetric embolism
Amniotic fluid & blood clot embolism.
Only 11/91 had post mortem confirmation.
Subjective clinical assessment unreliable
Any women with signs and symptoms of VTE
should have objective tests performed
expeditiously to avoid risks, inconvenience and
costs of inappropriate anti coagualtion
AFE - previously high mortality rate , now 16-30%
due to better intensive care and recognition of the
fact that milder cases do occur
26. Recommendations
- awareness of the need for thromboprophylaxis for at risk cases.
- quality assurance checklists to evaluate the number of at risk
mothers who actually receive thromboprophylaxis.
- objective tests should be performed to evaluate all cases of
suspected DVT and PTE
- D-dimer assays can be used as a quick test to help decide on
cases which may requre objective testing
- Amniotic fluid registry could help improve our understanding
on this condition
- MO’s need to be aware of a possible AFE if the baby is born in
a sudden unexpectedly poor condition
- A multidisciplinary approach to resuscition of the collapsed
patient provides best results
27. Home delivery
Cause - majority were PPH due to retained placenta and
uterine atony. There were also death due to uterine rupture
<20% conducted by trained staff
28. Recommendations
- Should be discouraged
- All delivered by trained staff
- ABC - alternative for those who refuse hosp.
delivery, only low risk
- Those from remote areas brought out and housed
near ABC/health centres
- Flying squad in remote areas to retrieve mothers
29. Heart Diseases in Pregnancy
Majority of deaths in post partum period
Commonest pathology - RHD with MS
Health care provider must understand changes in
pregnancy
-proper history taken and examination done
-once diagnosed -investigate-ECG,Echo,CXR
Most cases
- patient or spouse does not volunteer the relevant history at
antenatal visits
- Doctors fail to examine heart or misses findings
- Pathological murmurs mistaken for physiological ones
30. Ideally
- seen in preconception clinic
- Contraceptive advice - permanent contraception in those
with Eisenmenger’s syndrome, pulmonary hypertension
and cardiomyopathy
- manage in combined clinic
31. HIV/AIDS
Increasing trend in many Asian countries
12 deaths ‘97-’00
They were in an advanced stage of their disease at the
time of presentation for antenatal care or for delivery
Oral thrush/respiratory symptoms were primary
presentation
Diagnosis was delayed in 50% of cases
In those known HIV cases management was inadequate
Majority had no knowledge of their seropositivity prior
to pregnancy and also they were from lower socio-
economic stratum and had lower education level
32. Utilisation of point-of-care HIV testing during
labour should be seriously considered for those who
present with no prior HIV testing prenatally, so that
not to deny the unborn child of the benefit of
antiretroviral therapy intrapartum to reduce
maternal to child transmission.
33. Benefits of CEMD
1.Improvement in the reporting system of maternal
deaths.Since the CEMD was established in’91, it
has succeeded in enhancing data capture on
maternal deaths.
2. Changing trends in maternal deaths.Direct
maternal death:81%(’91) to 63%(’94), 58.1%
(’96) and 56.4(‘00). Indirect: 8%(’91) to 15%
(’96), 10.5%(‘00)
34. Cont…
3. Impact on policies and practices.
Specific financial allocation for purchase of equipments &
improvement of the Ix system have been made after the
CEMD was started.
Various policies,strategies & specific were developed such
as:
35. Cont…
A. Infrastructure strengthening:
Alternative birthing centre.
Improvement of communication.
Equipment.
Training –national/state level, training curriculum,
educational materials/training modules.
36. Cont…
B. Improvement of work process.
Use of partogram for home deliveries.
Home based maternal health records.
Development of mx protocols.
Establishment of combined clinics.
Identification of areas for further research.
