maternal health in emergencies and beyond deepti thomas-paulose md, mph global health division st....

Maternal health in Maternal health in Emergencies and BeyondEmergencies and Beyond

Deepti Thomas-Paulose MD, MPHDeepti Thomas-Paulose MD, MPH

Global Health Division Global Health Division

St. Luke’s Roosevelt Hospital CenterSt. Luke’s Roosevelt Hospital Center

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OutlineOutline

DefinitionsDefinitionsSome sobering numbersSome sobering numbersDirect and Indirect CausesDirect and Indirect CausesEmOCEmOCCrisisCrisisPost-Emergency PhasePost-Emergency PhaseReferencesReferences

DefinitionsDefinitions

Maternal Mortality Maternal Mortality – – death death of a woman of a woman while she is pregnant, or within 42 days of while she is pregnant, or within 42 days of termination of pregnancy regardless of the termination of pregnancy regardless of the site or duration of the pregnancy. site or duration of the pregnancy.


Maternal Mortality Ratio Maternal Mortality Ratio – the number of – the number of maternal deaths per 100,000 live births maternal deaths per 100,000 live births per year. The numerator includes deaths per year. The numerator includes deaths to women during their pregnancy or in the to women during their pregnancy or in the first six weeks after delivery. first six weeks after delivery.


Maternal Mortality Rate Maternal Mortality Rate – the number of – the number of maternal deaths per 100,000 women of maternal deaths per 100,000 women of reproductive age (15-49). This measures reproductive age (15-49). This measures the impact of maternal deaths on the the impact of maternal deaths on the population of women as a whole but is population of women as a whole but is generally not used in public health since generally not used in public health since not all women are at risk for maternal not all women are at risk for maternal mortality—only those that are pregnant. mortality—only those that are pregnant.


Lifetime Risk of Maternal Death Lifetime Risk of Maternal Death – the – the probability of dying as a result of probability of dying as a result of pregnancy cumulative across pregnancies pregnancy cumulative across pregnancies in a woman's life in a woman's life

Obtaining accurate maternal death data is Obtaining accurate maternal death data is challenging in the developing world because challenging in the developing world because accurate vital statistics are not available in many accurate vital statistics are not available in many areas (particularly rural areas), and because the areas (particularly rural areas), and because the majority of births take place outside of health majority of births take place outside of health facilities. Instead of using vital statistics to track facilities. Instead of using vital statistics to track pregnancy related deaths, survey data is used pregnancy related deaths, survey data is used instead. Thus, these data significantly instead. Thus, these data significantly underestimate the actual number of pregnancy-underestimate the actual number of pregnancy-associated deaths.associated deaths.

Recent 2008 data estimated 342,900 maternal deaths worldwide in 2008

down from 536,000 in 2005.

They estimate that more than 50% of all They estimate that more than 50% of all maternal deaths in 2008 occurred in six maternal deaths in 2008 occurred in six

countries: India, Nigeria, Pakistan, countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Afghanistan, Ethiopia, and the Democratic

Republic of the Congo Republic of the Congo

Sobering factsSobering facts

Based on 2005 data, theaverage lifetime risk of a woman in aleast developed country dying fromcomplications related to pregnancyor childbirth is more than 300 timesgreater than for a woman living inan industrialized country. No other

mortality rate is so unequal.

Beyond Pregnancy and Beyond Pregnancy and ChildbirthChildbirth

For everywoman who dies from causes related

to pregnancy or childbirth, it is estimatedthat there are 20 others who

suffer pregnancy-related illness orexperience other severe consequences.

An estimated10 million women annually who survive

their pregnancies experiencesuch adverse outcomes.


Almost 40 per cent of under-five deaths – or 3.7million in 2004, according to thelatest World Health Organizationestimates – occur in the first 28days of life. Three quarters of

neonatal deaths take place in thefirst seven days, the early neonatal

period; most of these are alsopreventable.


Lowering a mother’s risk ofmortality and morbidity directlyimproves a child’s prospects for

survival. In a studyconducted in Afghanistan, 74

per cent of infants born alive tomothers who died of maternal

causes also subsequently died.

Quality of Health SystemsQuality of Health Systems

Maternal mortality ratios stronglyreflect the overall effectiveness of

health systems, which in many low incomedeveloping countries suffer

from weak administrative, technicaland logistical capacity, inadequatefinancial investment and a lack of

skilled health personnel.

Top Ten Failed States 2010*Top Ten Failed States 2010*

1.1. SomaliaSomalia

2.2. ChadChad

3.3. SudanSudan

4.4. ZimbabweZimbabwe

5.5. Dem. Rep. of the Dem. Rep. of the CongoCongo

6. Afghanistan6. Afghanistan

7. Iraq7. Iraq

8. Central African 8. Central African RepublicRepublic

9. Guinea9. Guinea

10. Pakistan10. Pakistan

*http://www.foreignpolicy.com/articles/2009/06/22/2009_failed_states_index_interactive_map_and_rankings

Source-UNFPA

Maternal health – as epitomized

by the risk of death or disability

from causes related to pregnancy and

childbirth – has scarcely advanced in

decades is the result of multiple underlying

causes.

The root cause may lie

in women’s disadvantaged position

in many countries and cultures, and in

the lack of attention to, and accountability

for women’s rights.

A human rights-based approach toimproving maternal and neonatal

health focuses on enhancing healthcareprovision, addressing gender discrimination

and inequities in societythrough cultural, social and behavioral

changes, among other means,and targeting those countries and

communities most at risk.

MDG 5MDG 5

The reduction of maternal mortality is a The reduction of maternal mortality is a leading Millennium Development Goal leading Millennium Development Goal (MDG), which calls for a 75% reduction in (MDG), which calls for a 75% reduction in maternal mortality by the year 2015. maternal mortality by the year 2015.

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Causes of Maternal MortalityCauses of Maternal Mortality

Direct Causes Direct Causes are those related to are those related to obstetric complications of pregnancy, labor obstetric complications of pregnancy, labor and delivery, and the post-partum periods. and delivery, and the post-partum periods. Direct causes account for 80% of maternal Direct causes account for 80% of maternal death. death.

Indirect causes Indirect causes are those relating to pre-are those relating to pre-existing medical conditions that may be existing medical conditions that may be aggravated by the physiologic demands of aggravated by the physiologic demands of pregnancy. pregnancy.

Direct CausesDirect Causes

HemorrhageHemorrhage Accounts for approximately 25% of maternal Accounts for approximately 25% of maternal

deaths and is the single most serious risk to deaths and is the single most serious risk to maternal health. maternal health.

Blood loss during pregnancy, labor, or post-Blood loss during pregnancy, labor, or post-partum. partum.

Can rapidly lead to death without medical Can rapidly lead to death without medical intervention. intervention.

Can be treated with blood transfusions, Can be treated with blood transfusions, oxytocics oxytocics and/or manual removal of the and/or manual removal of the placenta. placenta.


SepsisSepsis Accounts for approximately 15% of maternal Accounts for approximately 15% of maternal

deaths. deaths. Related to poor hygiene and infection control Related to poor hygiene and infection control

during delivery or to the presence of untreated during delivery or to the presence of untreated sexually transmitted infections during pregnancy. sexually transmitted infections during pregnancy.

Can be prevented or managed with high Can be prevented or managed with high standards for infection control, appropriate standards for infection control, appropriate prenatal testing and treatment of maternal prenatal testing and treatment of maternal infection, and appropriate use of intravenous or infection, and appropriate use of intravenous or intramuscular antibiotics during labor and post-intramuscular antibiotics during labor and post-partum period. partum period.


Hypertensive Disorders Hypertensive Disorders Accounts for approximately 12% of maternal deaths Accounts for approximately 12% of maternal deaths Pre-eclampsia Pre-eclampsia is characterized by is characterized by hypertension, hypertension,

proteinurea proteinurea general general edema, edema, and sudden weight gain. If and sudden weight gain. If left untreated, can lead to left untreated, can lead to eclampsia. eclampsia.

Eclampsia Eclampsia is characterized by kidney failure, seizures, is characterized by kidney failure, seizures, and coma during pregnancy or post-partum. Can lead to and coma during pregnancy or post-partum. Can lead to maternal and/or infant death. maternal and/or infant death.

Pre-eclampsia can be identified in the prenatal period by Pre-eclampsia can be identified in the prenatal period by monitoring blood pressure, screening urine for protein, monitoring blood pressure, screening urine for protein, and through physical assessment. and through physical assessment.

Treatment available during childbirth includes the use of Treatment available during childbirth includes the use of sedative or anti-convulsant drugs. sedative or anti-convulsant drugs.

Treatment of Hypertension in Treatment of Hypertension in PregnancyPregnancy

Unclear benefit in mild to moderate HTNUnclear benefit in mild to moderate HTN In severe HTN, use any anti-HTN drug In severe HTN, use any anti-HTN drug

availableavailableLoad with 4 grams of IV magnesium then Load with 4 grams of IV magnesium then

1-2 grams per hour to prevent eclampsia 1-2 grams per hour to prevent eclampsia and also to treat seizuresand also to treat seizures

Magnesium overdoseMagnesium overdose Cardiac arrestCardiac arrest

Pulmonary edema (lungs Pulmonary edema (lungs fill with fluid; can be fatal) fill with fluid; can be fatal)

Chest painChest pain

Cardiac conduction Cardiac conduction defectsdefects

Low blood pressureLow blood pressureLow calciumLow calcium

Increased urinary calciumIncreased urinary calcium

Visual disturbancesVisual disturbances

Decreased bone densityDecreased bone density

Respiratory depression Respiratory depression (difficulty breathing) (difficulty breathing)

Muscular hyperexcitability Muscular hyperexcitability


Prolonged or Obstructed Labor Prolonged or Obstructed Labor Accounts for 8% of maternal deaths. Accounts for 8% of maternal deaths. Caused by Caused by cephalopelvic disproportion (CPD)cephalopelvic disproportion (CPD), a , a

disproportion between the size of the fetal head and the disproportion between the size of the fetal head and the maternal pelvis; or by the position of the fetus at the time maternal pelvis; or by the position of the fetus at the time of delivery. of delivery.

Increased incidence among women with poor nutritional Increased incidence among women with poor nutritional status status

Use of assisted vaginal delivery methods such as Use of assisted vaginal delivery methods such as forceps, vacuum extractor, or performing a Caesarean forceps, vacuum extractor, or performing a Caesarean Section can prevent adverse outcomes. Section can prevent adverse outcomes.

CPD is the leading cause of obstetrical fistula CPD is the leading cause of obstetrical fistula


Unsafe Abortion Unsafe Abortion Accounts for approximately 13% of maternal Accounts for approximately 13% of maternal

deaths. deaths. In some parts of the world unsafe abortion In some parts of the world unsafe abortion

accounts for 1/3 of maternal deaths. accounts for 1/3 of maternal deaths. Approximately 67,000 cases of abortion related Approximately 67,000 cases of abortion related

deaths occur each year. deaths occur each year. Can be prevented by providing safe abortion, Can be prevented by providing safe abortion,

quality family planning services, and competent quality family planning services, and competent post-abortion care. post-abortion care.

Indirect CausesIndirect Causes

Accounts for approximately 20% of maternal Accounts for approximately 20% of maternal deaths. deaths.

Pre-existing medical conditions such as anemia, Pre-existing medical conditions such as anemia, malaria, hepatitis, heart disease, and HIV/AIDS malaria, hepatitis, heart disease, and HIV/AIDS can increase the risk of maternal death. can increase the risk of maternal death.

Risk of adverse outcomes can be reduced Risk of adverse outcomes can be reduced through prenatal identification and treatment as through prenatal identification and treatment as well as the availability of appropriate basic well as the availability of appropriate basic emergency obstetric care (emergency obstetric care (EmOCEmOC) at the time of ) at the time of delivery. delivery.

EmOCEmOC

Reproductive Health in CrisisReproductive Health in Crisis

There are multiple competing health There are multiple competing health priorities in an emergency, such as priorities in an emergency, such as addressing diarrhea, measles, acute addressing diarrhea, measles, acute respiratory infections, malaria and respiratory infections, malaria and malnutritionmalnutrition

Reproductive health needs should not be Reproductive health needs should not be ignoredignored

Reproductive Health in CrisisReproductive Health in Crisis

In any displaced population, approximately In any displaced population, approximately 4 percent of the total population will be 4 percent of the total population will be pregnant at a given time.*pregnant at a given time.*

Of these pregnant women, 15 percent will Of these pregnant women, 15 percent will experience an unpredictable obstetric experience an unpredictable obstetric complication, such as obstructed or complication, such as obstructed or prolonged labor, pre-eclampsia or prolonged labor, pre-eclampsia or eclampsia, sepsis, ruptured uterus, ectopic eclampsia, sepsis, ruptured uterus, ectopic pregnancy or complications of abortion.*pregnancy or complications of abortion.*

*UNFPA, UNICEF, WHO

What causes women to die from What causes women to die from obstetric complications?obstetric complications?

delay in deciding to seek care; delay in deciding to seek care; delay in reaching care due to delay in reaching care due to

transportation difficulties; and transportation difficulties; and delay in having appropriate care available delay in having appropriate care available

at the facility once reached.at the facility once reached.

The Minimum Initial Service Package (MISP)

A series of actions needed to respond to the reproductive health needs of populations in the early phase of a refugee situation (which may or may not be an emergency). The MISP is not just kits of equipment and supplies; it is a set of activities that must be implemented in a coordinated manner by appropriately trained staff. It can be implemented without any new needs assessment since documented evidence already justifies its use.

MISPMISP

Prevents excess neonatal and maternal morbidity and mortality, reduces HIV transmission, prevents and manages the consequences of sexual violence, and includes planning for the provision of comprehensive reproductive health services integrated into the primary health program in place.

MISP objectives and activitiesMISP objectives and activities

1.1. Identify an organization(s) and Identify an organization(s) and individual(s) to facilitate the individual(s) to facilitate the coordinationcoordination and and implementationimplementation of the MISP by: of the MISP by: ensuring the overall RH Coordinator is in ensuring the overall RH Coordinator is in place and functioning under the health place and functioning under the health coordination team; ensuring RH focal coordination team; ensuring RH focal points in camps and implementing points in camps and implementing agencies are in place; making available agencies are in place; making available material for implementing the MISP and material for implementing the MISP and ensuring its use.ensuring its use.


2.2. Prevent sexual violencePrevent sexual violence and provide and provide appropriate assistance to survivors by: appropriate assistance to survivors by: ensuring systems are in place to protect ensuring systems are in place to protect displaced populations, particularly women displaced populations, particularly women and girls, from sexual violence; ensuring and girls, from sexual violence; ensuring medical services, including psychosocial medical services, including psychosocial support, are available for survivors of support, are available for survivors of sexual violence.sexual violence.


3.3. Reduce the transmission of HIVReduce the transmission of HIV by: by: enforcing respect for universal enforcing respect for universal precautions; guaranteeing the availability precautions; guaranteeing the availability of free condoms; ensuring that blood for of free condoms; ensuring that blood for transfusion is safe.transfusion is safe.


4.4. Prevent excess maternal and Prevent excess maternal and neonatal mortality and morbidityneonatal mortality and morbidity by: by: providing clean delivery kits to all visibly providing clean delivery kits to all visibly pregnant women and birth attendants to pregnant women and birth attendants to promote clean home deliveries; providing promote clean home deliveries; providing midwife delivery kits (UNICEF or midwife delivery kits (UNICEF or equivalent) to facilitate clean and safe equivalent) to facilitate clean and safe deliveries at the health facility; initiating deliveries at the health facility; initiating the establishment of a referral system to the establishment of a referral system to manage obstetric emergencies.manage obstetric emergencies.

The New Emergency Health Kit

The kit provides the drugs and medical supplies for 10,000 people for approximately 3 months. It is designed to meet the primary health care needs of a displaced population without medical facilities, or a population with disrupted medical facilities in the immediate aftermath of a disaster.

The kit includes supplies for professional midwifery care and emergency contraception.

Clean Delivery Kits

Clean Delivery Kits consist of a square meter of plastic sheet, a bar of soap, a razor blade, a length of string, and a pictorial instruction sheet


5.5. Plan for the Plan for the provision of provision of comprehensive reproductive health comprehensive reproductive health servicesservices, integrated into primary health , integrated into primary health care (PHC), as the situation permits by: care (PHC), as the situation permits by: collecting basic background information collecting basic background information identifying sites for future delivery of identifying sites for future delivery of comprehensive RH services; assessing comprehensive RH services; assessing staff and identifying training protocols; staff and identifying training protocols; identifying procurement channels and identifying procurement channels and assessing monthly drug consumption.assessing monthly drug consumption.

Post-Emergency PhasePost-Emergency Phase

The main methods of reducing maternal and newborn mortality and morbidity are

well established and understood.


Quality antenatal care providing a

comprehensive package of health

and nutrition services.Preventing mother-to-child transmission

of HIV and offering antiretroviral

treatment for women in need.


Basic preventive and curative interventions, including immunization

against neonatal tetanus for pregnant

women, routine immunization, distribution of insecticide treated mosquito nets and oral rehydration salts, among others.


Access to improved water and sanitation,

and adoption of improved hygiene practices, especially at delivery. Clean water for hygiene and drinking is essential for safe delivery


Access to skilled health personnel –a doctor, nurse or midwife – at

delivery.

A strong referral system, skilled health workers and well equipped facilities are pivotal to reducing maternal and newborn deaths resulting

from complications during childbirth.

Health workers treat babies in the Sick Newborn Care Unit, India.


Basic emergency obstetric care at

a minimum of four facilities per 500,000 population – adapted to each country’s circumstances – for women who experience some complication.

Comprehensive emergency obstetric care at a minimum of one facility in every district or

one per 500,000 population.


A post-natal visit for every mother and newborn as soon as possible after delivery, ideally within 24 hours, with additional visits towards the end of the first week and at four to six weeks.


Knowledge and life skills for pregnant women and families on the danger signs of maternal and newborn health and about referral systems.

Maternal nutrition counseling and supplementation as needed as part of routine antenatal, post-natal and neonatal care.


Essential care for all newborns, including initiation of breastfeeding within the first hour of birth, exclusive breastfeeding, infection control, warmth provision and avoidance of bathing during the first 24 hours.

Household to Hospital Continuum Household to Hospital Continuum of Careof Care

Closely linking the household with Closely linking the household with community health workers, peripheral community health workers, peripheral health facilities and hospitals to health facilities and hospitals to promote essential maternal and promote essential maternal and newborn care (EMNC)newborn care (EMNC)

Accredited Social Health Activist Accredited Social Health Activist (ASHA) program in India(ASHA) program in India

SummarySummary

Maternal mortality reflective of quality of Maternal mortality reflective of quality of health systemshealth systems

Key interventions save livesKey interventions save livesAccess to skilled care of utmost Access to skilled care of utmost

importanceimportance

Mumtaz MahalMumtaz Mahal

ReferencesReferences

UNICEF State of the World’s Children 2009UNICEF State of the World’s Children 2009 http://misp.rhrc.org/content/view/22/36/lang,englihttp://misp.rhrc.org/content/view/22/36/lang,engli

sh/sh/ http://whqlibdoc.who.int/hq/2001/WHO_RHR_00http://whqlibdoc.who.int/hq/2001/WHO_RHR_00

.13.pdf.13.pdf http://www.who.int/whosis/whostat/http://www.who.int/whosis/whostat/

EN_WHS09_Table2.pdfEN_WHS09_Table2.pdf Refugee Health- An approach to emergency Refugee Health- An approach to emergency

situationssituations Averting Maternal Death and DisabilityAverting Maternal Death and Disability

maternal health in emergencies and beyond deepti thomas-paulose md, mph global health division st....

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