mmr2

1. Maternal mortality
as a public health problem

2. Outline
 Introduction
– Burden of maternal mortality
– Causes and preventive measures
 Where are we now?
– Situation
 Where do we want to go?
– Sustainable Development Goals
 Why maternal mortality is of public health importance?
 What do we need to do to get there?
– Strategies/Approaches
 Conclusion

3. Introduction
Maternal mortality is defined as "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. (WHO)
 More than 90% of maternal deaths are preventable and occurs in
low resource settings (Sub Saharan Africa, Southern Asia etc.)
 Varying maternal mortalities among high income and low income
countries reflects inequalities in accessing quality health services
 Maternal mortality ratio represents the status of
healthcare services and social wellbeing of a country

4. Burden of maternal mortality
Region MMR # Maternal Deaths
Northern Africa 70 3,100
Sub Saharan Africa (SSA) 546 201,000
Eastern Asia 27 4,800
Southern Asia 176 66,000
South Eastern Asia 110 13,000
Western Asia 91 4,700
Caucasus & Central Asia 33 610
Latin America & Caribbean 67 7,300
Oceania 187 500
World 216 303,000
Source: WHO and others, trends in maternal mortality 1990 to 2015. p18
Estimates of maternal mortality ratio (MMR) and
maternal deaths in 2015 From 1990 – 2015
globally:
 MMR decreased
trend by 43.9%
 10.7 million women
died from maternal
causes
 Despite decline in
MMR, the ratio is 15
times higher in low
income than high
income countries.

5. Where are we now?

6. Situation of maternal mortality
 The MMR in SSA stands at 546 per 100,000 live births
– It accounts for about two third (66%) of the global maternal
deaths
 Tanzania is among the countries in SSA with highest MMR.
– The most recent population-based surveys indicate that the mean
MMR in Tanzania is 556 per 100,000 live births.
 For almost three decades (1990–2016) MMR in Tanzania have
remained high, with no sign of a significant reduction despite several
efforts.
Source: TDHS 2015/2016

7. Challenges with MMR
Reliable information about the rates and trends in maternal mortality is
essential for resource mobilization, planning and assessment of
progress
 Challenge to identify maternal deaths precisely, particularly in
settings where routine recording of deaths is not complete within
civil registration systems.
 The woman’s pregnancy status may not have been known and the
death would, therefore, not have been reported as a maternal death.
 In most low income country settings where medical certification of
cause of death does not exist, accurate attribution of female deaths
as maternal death is difficult.
 Inadequate skilled attendant at birth.
 Still women opt or forced to deliver at home by traditional birth
attendants.

8. Where do we want to go?

9. Sustainable Development Goal
 Assessment of progress towards MDG 5, the target for
which was a 75% reduction in the maternal mortality
ratio by 2015 was attained by only 10 countries globally
 SDG target 3.1: Maternal Mortality Ratio reduction.
 By the year 2030:
 Reduce the average global maternal mortality ratio to less than
70 per 100,000 live births.
 No country should have maternal mortality ratio twice the global
average, that is no more than 140 per 100,000 live births
Source: One Plan III

10. Causes of maternal mortalities
Source: The global maternal mortality rate,2017

11. Causes of maternal mortality (Tanzania)
Comparison of proportion of all major causes of maternal related deaths between the
2006-2010 and 2011-2015 periods in Tanzania.
(Source: Veneranda M et al, 2019)

12. Causes of maternal mortalities ..
Underlying causes:
 Social: Early marriage, Early pregnancies, Gender discrimination,
Ignorance, Desire for selective sex of the child and Gender-based
Violence
 Economic: Poverty, Lack of timely transport and communication,
Delay in taking decisions (3 delays - delay to seek care, delay
transport to appropriate health facility and delay in provision of
adequate care) and Improper dietary habits.
 Medical: Lack of antenatal care, Lack of emergency obstetric care,
Inadequate essential drugs, Inadequate number of competent
health workers leading to wrong diagnosis and delay in making
decisions and Pre existing chronic diseases like HIV/AIDS

13. Maternal mortality as a public health problem
The maternal mortality is a public health issue due the fact that it affects
all people from the family to the nation level.
 It affects many people and threatened communities, prevalence of
maternal mortality is high, causes economic burden and most of its
causes are preventable.
 Family level: Children may miss immunizations, breastfeeding and
prone to malnutrition, Older sibling is likely to drop out of school to
take care of the young one, increased risk of child abuse, HIV/AIDS
acquisition, stress, alcohol abuse among men and poverty
escalation.

14. Maternal mortality as a public health problem..
 Community level: Loss of productivity (breadwinner) in the
community, child and other siblings will be burden to community.
 National level: Drain of resources due to malnutrition and loss of
productivity, More children in streets due to loss of a caretaker,
prone to early pregnancies, sexual abuse, drug abuse, high
number of youth with HIV, child labour, many children and youth
with lack of education and a vicious circle of poverty

15. Maternal mortality as a public health problem…
• Greater disparity in levels of maternal mortality than in any other
public health indicator between developed and developing countries.
• In developed and developing countries, not all maternal deaths are
reported and, thus, national mortality ratios obtained by analysis of
death registrations are often under-estimated
• Very little scientifically based information is available on cause-
specific mortality rates for many developing countries.

16. Maternal mortality as a public health problem….
• Most of the information comes from the verbal autopsy, used to
obtain causes of death by interviewing lay respondents on the signs
and symptoms experienced by the deceased before death.
• To obtain reliable information on the individual medical causes of
maternal mortality is however extremely difficult, especially for deaths
that occur at home.

17. Who do we get there?

18. Six Pillars of Safe Motherhood
Safe Motherhood
FP ANC
OBS
Care
PNC PAC
STI/HIV
Control
Communication for Behaviour Change
Primary Health Care
Equity and Education for women
Source: Wikipedia
 Safe Motherhood (SM) means ensuring that all women have access to the
information and services they need to go safely through pregnancy and childbirth.
 The goal of SM programs is to have prenatal care, trained birth attendants, and
postpartum follow-up focus less on preventing complications than on recognizing
them and preventing them from producing fatalities.

19. Strategies
Prevention of maternal mortality at Family level:
– Health education,
– Age at marriage,
– Utilization of RCH services,
– Awareness of ANC services,
– Importance of immunization,
– Nutritional education and
– Spacing or limitation of births.

20. Strategies ..
Prevention of maternal mortality at Community level:
– Community should take maternal mortality as a major problem,
– Proactive community initiatives like:
• Seeking medical advise/care,
• Poverty eradication,
• Women's empowerment measures,
• Improvement of literacy and
• Improved communication.

21. Strategies …
Prevention of maternal mortality at National level:
– Improvement Health Delivery Infrastructure,
– Provision of RCH services at remote areas,
– Improve qualified number of Human Resource for Health,
– Provision of Essential/Emergency Obstetric Care,
– Training of traditional birth attendants,
– Emergency management of eclampsia and third stage of labor,
– Improved transport facilities.

22. Address The Three Delays Approach
First delay - Individual decision making
 Delay is on the part of the mother, family or community not
recognizing a life threatening condition
 Most deaths occur during labor or in the first 24 hours postpartum,
recognizing an emergency is not easy
 Most births occur at home with unskilled attendants, and it takes skill
to predict or prevent bad outcomes and medical knowledge to
diagnose and immediately act on complications.
 Therefore, by the time the lay midwife or family realizes that there is
a problem, it is too late

23. Address The Three Delays Approach..
Second delay - Access to affordable services
• Delay is in reaching a health facility due to poor road conditions,
lack of transportation, or too remote area.
• Many villages do not have access to paved roads and many families
do not have access to vehicles.
• Public transportation may be the main transportation method.
• It take hours or days to reach a health facility.
• Therefore, women with life-threatening conditions often do not make
it to the facility in time

24. Address The Three Delays Approach…
Third delay - Service provision by skilled personnel
• Delay occurs at the healthcare facility.
• Upon arrival, women receive inadequate care or inefficient
treatment.
• Resource poor countries with fragile health facilities do not have
technology or services necessary to provide critical care to
hemorrhaging, infected or convulsive patients.
• Omissions in treatment, incorrect treatment, and a lack of supplies
contribute to maternal mortality

25. Conclusion
Effective and integrated healthcare system is crucial to prevent maternal deaths
 Poorer marginalized women are at higher risk of maternal mortality and
morbidity that can be prevented through:
 Increase number of skilled attendant at birth;
 Improve access of adolescents to Sexual Reproductive Health;
 Expanding use of contraceptive method mix including condoms;
 Minimize levels of unsafe abortion;
 Eliminating all forms of violence against women and girls;
 Ending child marriage and teenage pregnancies; and
 Eradicating harmful traditional practices including FGM
“No woman should die while bringing life”

26. References
• National Plan III for Reproductive, Maternal, Newborn, Child and Adolescent Health &
Nutrition (2021/2022 - 2025/2026)
• https://www.ohchr.org/sites/default/files/Documents/Issues/Women/WRGS/SexualHealth/INF
O_MMM_WEB.pdf
• Shirin, Sonia & Nahar, Shamsun. (2013). Maternal Mortality - A Public Health Problem.
Ibrahim Medical College Journal. 6. 10.3329/imcj.v6i2.14735.
• World Health Organization, Maternal Mortality, Key Facts (2018); World Health Organization,
Preventing Unsafe Abortion, Key Facts (2018); Every Woman Every Child, The Global
Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030).
• Patterns and causes of Hospital maternal mortality in Tanzania: A 10-year retrospective
analysis. Bwana VM, Rumanisha SF, Mremi IR, Lyimo EP, Mboera LEG (2019).
• Shoo RS, Mboera LEG, Ndeki S, Munishi G. Stagnating maternal mortality in Tanzania: what
went wrong and what can be done. Tanzania J Health Res 2017; 19
(2): http://dx.doi.org/10.4314/thrb.v19i2.6

27. Thanks