It deals with: Introduction International Perspectives National Status Complication during Pregnancy, Childbirth, Postpartum period including Neonatal Problems Causes of Maternal and neonatal mortality Framework of determinants of maternal mortality Three delay model

1. Maternal and Neonatal
Morbidity and Mortality
Presentation By:
Bikram Adhikari (136)
MPH-2018
School of Public Health and Community Medicine
1

2. Overview
• Introduction
• International Perspectives
• National Status
• Complication during Pregnancy, Childbirth, Postpartum period
including Neonatal Problems
• Causes of Maternal and neonatal mortality
• Framework of determinants of maternal mortality
• Three delay model
2

3. Maternal Morbidity
• Maternal Morbidity: Maternal morbidity can be conceptualized as a
spectrum ranging, at its most severe, from a “maternal near miss” –
defined by the World Health Organization (WHO) as the near death of
a woman who has survived a complication occurring during
pregnancy or childbirth or within 42 days of the termination of
pregnancy – to non-life-threatening morbidity, which is more
common by far.
3

4. Maternal Morbidity
• It refers any physical or mental illness or disability directly related to
pregnancy and/or child birth.
• Acute maternal morbidities.
• Postpartum maternal morbidities and disabilities.
• Chronic morbidities.
4

5. Acute Maternal Morbidities
• It include various terms
• Obstetric complications
• Maternal complications
• Absolute maternal indications’ (AMIs)
• Severe acute maternal morbidities’ (SAMMs)
• Near-miss’
• Other acute problems
5

6. Obstetric complications
• Obstetric or maternal complications are acute conditions that may
directly cause maternal deaths.
• It includes complicated cases’ like
• Antepartum or postpartum haemorrhage
• Prolonged or obstructed labour
• Postpartum sepsis
• Complications of abortion
• Pre-eclampsia/eclampsia
• Ectopic pregnancy
• Ruptured uterus
6

7. Absolute maternal indications (AMIs)
• Are life-threatening or severe obstetric complications requiring a
specific major obstetric intervention which can be verified through
records of health services. AMIs reflect conditions that, without
intervention, have a high probability of causing maternal death during
childbirth or sequelae including the following :
• Severe antepartum haemorrhage
• Placenta praevia and abruptio placentae
• Severe postpartum haemorrhage requiring surgical intervention
• Foetopelvic disproportion (pre-rupture and uterine rupture)
• Shoulder or transverse lie
7

8. Severe acute maternal morbidities
(SAMMs) and Near -Miss
• SAMMs Include complications that are ‘absolutely’ life-threatening
that women who experiences these problems are unlikely to survive if
they do not receive care in a hospital.
• Near-miss is defined by the WHO as:
“a woman who nearly died but survived a complication that occurred
during pregnancy, childbirth or within 42 days of termination of
pregnancy”, or to put more simply,
8

9. Postpartum maternal morbidities and
disabilities
• Postpartum maternal morbidities and disabilities are the long-term
physical or mental consequences resulting from pregnancy, childbirth,
acute maternal morbidities, or the management thereof, and most
often referred to as long-term chronic morbidities and other
problems experienced postpartum (23).
9

10. Chronic morbidities
• Chronic morbidities are conditions caused by the birthing process and
are not life-threatening but greatly impair the quality of life, such as
fistula, uterine prolapse, and dyspareunia.
10

11. Maternal Mortality
• Maternal Mortality: A maternal death is the death of a woman while
pregnant or within 42 days of termination of pregnancy, irrespective
of the duration and the site of the pregnancy, and can stem from any
cause related to or aggravated by the pregnancy or its management,
but not from accidental or incidental causes (WHO).
• Maternal deaths fall into two groups
• Direct obstetric deaths
• Indirect obstetric deaths
11

12. Causes of maternal Mortality
• In most developing countries, the major medical causes of maternal
mortality:
• Hemorrhage
• Hemorrhage (heavy bleeding) cause can be categorized as:
• Antepartum (before delivery)
• Premature placental separation (placental abruption)
• Postpartum (after delivery):
• Failure of the uterus to contract after delivery (uterine atony)
12

13. Causes of Maternal Mortality
• Hypertensive diseases of pregnancy
• Various types of maternal infections, among other things
13

14. Neonatal Mortality
• Neonatal Mortality:
• Defined as the death of a live-born baby within 28 days of life.
• Sub-divided into two:
• Early neonatal deaths (deaths between 0 and 7 completed days of
birth)
• Late neonatal deaths (deaths after 7 days to 28 completed days of
birth)
14

15. Neonatal Morbidity
• Neonatal Morbidity
• “A diseased condition or state during first 28 days of life”
15

16. Causes of Neonatal Mortality
• Neonatal mortality in low-income countries is typically attributed to :
• Infection
• Asphyxia
• Prematurity
16

17. Framework of Determinants of Maternal
Mortality
17

18. 18

19. International status-Maternal Mortality
• Every day, approximately 830 women die from preventable causes
related to pregnancy and childbirth.
• 99% of all maternal deaths occur in developing countries.
• More than half of these deaths occur in sub-Saharan Africa and
almost one third occur in South Asia.
• More than half of maternal deaths occur in fragile and humanitarian
settings.
19

20. International status-Maternal Mortality
• The maternal mortality ratio in developing countries in 2015 is 239
per 100 000 live births versus 12 per 100 000 live births in developed
countries.
• 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.
20

21. 21

22. International status-Neonatal
• In 2016, 2.6 million deaths, or roughly 46% of all under-five deaths,
occur during neonatal period.
• 7000 newborn deaths every day.
• 1 million dying on the first day of birth and close to 1 million dying
within the next six days.
• On current trends, more than 60 countries will miss the SDG target of
reducing neonatal mortality to at least as low as 12 deaths per 1000
live births by 2030.
• About half of them will not reach the target by 2050. These countries
carry about 80 per cent of the burden of neonatal deaths in 2016.
22

23. International status-Neonatal
http://apps.who.int/gho/data/node.sdg.3-2-viz-3?lang=en
23

24. • Nepal-20.7 per 1000
http://apps.who.int/gho/data/node.sdg.3-2-viz-3?lang=en 24

25. National status-Maternal Mortality
• The maternal mortality ratio (MMR) in Nepal decreased from 539
maternal deaths per 100,000 live births to 239 maternal deaths per
100,000 live births between 1996 and 2016.
• In 2016, roughly 12% of deaths among women of reproductive age
were classified as maternal deaths.
25

26. National status-Neonatal Mortality
26

27. Complication during Pregnancy, Childbirth,
Postpartum period including Neonatal
Problems
27

28. Complication
During
Pregnancy
Problems Symptoms Treatment
Anemia
Lower than normal
number of healthy
red blood cells
• Feel tired or weak
• Look pale
• Feel faint
• Shortness of breath
• Treating the underlying
cause of the anemia
• Iron and folic acid
supplements
• Monitoring iron levels
throughout pregnancy
Depression
Extreme sadness
during pregnancy
• Intense sadness
• Helplessness and
irritability
• Appetite changes
• Thoughts of
harming self or
baby
One or a combination of
treatment options, including:
Therapy, Support groups and
Medicines
Getting treatment is
important for both mother
and baby since a mother's
depression can affect her
baby's development
28

29. 29
Complication
During
Pregnancy

30. 30
Complication
During
Pregnancy

31. 31
Complication
During
Pregnancy

32. 32
Complication
During
Pregnancy

33. 33
Complication
During
Pregnancy

34. 34
Complication
During
Pregnancy

35. Delivery and Postpartum Complications
• Abnormal Presentation
• Amniotic Fluid Embolism
• Haemorrhage
• Incontinence (Urinal and Faecal)
• Obstructed and Prolonged Labor
• Perineal tearing
• Postpartum depression
• Post Traumatic Stress Disorder
• Sepsis
35

36. 36
Delivery and
Postpartum
Complications

37. 37
Delivery and
Postpartum
Complications

38. 38
Delivery and
Postpartum
Complications

39. Problem Symptom Treatment/Management
Postpartum Depression
• Severe mood swings
• Excessive crying
• Difficulty bonding with the
baby
• Loss of appetite or eating
much more than usual
• Inability to sleep
(insomnia) or sleeping too
much
• Overwhelming fatigue or
loss of energy
• Psychotherapy
• Antidepressants
39
Delivery and
Postpartum
Complications

40. 40
Delivery and
Postpartum
Complications

41. Neonatal Problems
41

42. 42

43. 43

44. 44

45. 45

46. Three Delays Model
• The three delays model (Thaddeus and Maine 1994), attractive
because of its simplicity and action-oriented presentation, is based on
the following premises:
• Maternal complications are mostly emergencies.
• Maternal complications cannot be predicted with sufficient accuracy.
• Maternal deaths are largely preventable through tertiary prevention
(preventing deaths among women who have been diagnosed with a
complication).
46

47. Three Delays Model
• At the 1987 launch of the Safe Motherhood Initiative, maternal health
experts discussed how long a woman would have to have a particular
complication before she would die, if untreated.
• They agreed that
• Postpartum hemorrhage  < 2 hours before death;
• Antepartum hemorrhage 12 hours;
• Eclampsia 2 days; Obstructed labor 3 days; Sepsis 6 days,
47

48. Three Delays Model
• The model has three levels of delay:
• The first delay is the elapsed time between the onset of a
complication and the recognition of the need to transport the patient
to a facility.
• The second delay is the elapsed time between leaving the home and
reaching the facility.
• The third delay is the elapsed time from presentation at the facility to
the provision of appropriate treatment.
48

49. Three Delays Model-Determinants
• The first delay:
• Related to
• The low status of women
• Poor understanding of complications and risk factors in pregnancy
and when to seek medical help
• Previous poor experience of health care
• Acceptance of maternal death
• Financial implications
49

50. Three Delays Model-Determinants
• The second delay:
• Reated to:
• Distance to health centers and hospitals.
• Availability of and cost of transportation.
• Poor roads and infrastructure.
• Geography e.g. mountainous terrain, rivers.
• Type of transport and the quality of the roads
• Performance of the referral system between facilities.
50

51. Three Delays Model-Determinants
• The third delay:
• Related to:
• Quality of care, such as the number and training of staff members
• Availability of blood supplies and essential equipment
• Poor facilities and lack of medical supplies (little to no antibiotic
availability)
• Poorly motivated medical staff
• Inadequate sanitation
51

52. Three Delays Model-Weakness
• Doesn’t include the concept of primary prevention (avoid pregnancy)
and sec. prevention (avoid complications once pregnant).
• Ignores family planning, non-communicable chronic diseases, antenatal
care, and postpartum care.
• Implicitly, it also assumes that complications arise at home, where
women intend to give birth, whereas increasing numbers of women
deliver in facilities.
• It does not consider the newly identified “fourth delay,” which arises
when women are discharged unwell or chronically ill from facilities and
die at home during the post pregnancy period or in the next pregnancy
52

53. References
• Goldenberg, Robert L., Elizabeth M. McClure, Zulfiqar A. Bhutta, José M.
Belizán, Uma M. Reddy, Craig E. Rubens, Hillary Mabeya, Vicki Flenady, and
Gary L. Darmstadt. 2011. Stillbirths: The vision for 2020.” Lancet
377(9779):1798-1805.
• https://data.unicef.org/topic/maternal-health/maternal-mortality/
• https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
• https://www.healthynewbornnetwork.org/resource/nepal-demographic-
health-survey-2016-key-indicators/
• NDHS report-2017
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3397324/
53

54. 4/26/2019 54
Thank you