maternal mortality & the mdgs deborah maine professor, international health boston university,...
TRANSCRIPT
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Maternal Mortality& the MDGs
Deborah MaineProfessor, International Health
Boston University, School of Public Health
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MDG Goal: Improve maternal health
Target: Reduce the MM Ratio by 3/4 by 2015
Indicators: Maternal mortality ratio Proportion of births attended by skilled
health personnel
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The MDG for MM
Is it realistic ?
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History
MMRs
Sri Lanka: 1947 -- 1500
1960 -- 250
1980 -- 100
Malaysia: 1950 > 500
1975 < 100
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To reduce MM …
Need to understand the epidemiology of maternal mortality [MM]
A counterintuitive phenomenon Many “obvious” approaches don’t work,
e.g. risk screening, training TBAs
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Maternal Mortality
Region MM Ratio Lifetime Risk
1 in …
Africa 830 20
Asia 330 94
Latin America 190 160
North America 17 2,500
World 400 74
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Causes of Direct Obstetric Deaths
The “Big 5” Hemorrhage Infection Hypertensive diseases Obstructed labor Unsafe induced abortion
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The Way Programs Should WorkEvidence
Interventions
Indicators
Strategy
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Interventions
IndicatorsStrategy
Assumptions
The way it often works
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Assumption
If we just take very good care
of pregnant women,
few will develop serious
obstetric complications.
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History: Prenatal Care
1910-15 first clinics in UK (and US) By 1930, 80% pregnant women in UK
have prenatal care But maternal mortality did not decline
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TBAs & “Clean Delivery”
In Matlab, Bangladesh, TBAs were trained to use clean delivery practices.
The did use these practices, but maternal deaths due to infection
did not decline.
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Assumption
Through prenatal screening,
We can identify the women
who will need medical care
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The Math of Prediction
It works for groups
but not for individuals.
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Example: Matlab, Bangladesh1968-70
Maternal Age 10-14 20-29
MM Ratio 1770 450
Relative Risk 3.9 1
# Births 509 11,286
# Deaths 9 51
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Example: United Kingdom1985-87
Maternal Age 20-24 45+
MM Ratio 37 188
Relative Risk 1 5.1
# Deaths 24 2
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Risk and Prediction (cont.)
A big risk in a small population =
few deaths
A small risk in a big population =
many deaths
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In Short ...
Once a woman is pregnant
most serious obstetric complications
cannot be predicted or prevented,
but they can be treated.
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So
All pregnant women
need access to
emergency obstetric care
(EmOC)
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Sri Lanka & Malaysia
How did they do it ? Expanding access to effective
maternity care by midwives and doctors Improving utilization and quality of care
with emphasis on making life-saving care free.
The World Bank, 2003
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Assumption
EmOC is
“Hi-Tech”
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Signal Functions of Basic EmOC :
Parenteral antibiotics, oxytocics, anticonvulsants
Manual removal of placenta Removal of retained products Assisted vaginal delivery Neonatal resuscitation (new)
Should be at health centers
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Signal Functions of Comprehensive EmOC:
All Basic EmOC functions Blood transfusion Surgery (c-section)
Should be at District Hospitals
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EmOC is not “Hi Tech”
It is mostly 1950s medicine !
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EmOC is the foundation
Emergency Obstetric Care
SkilledAttendant Referral
Risk Screening
Social Mobilization
Waiting Homes
TBA Training
AntenatalCare
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Assumption
EmOC is too expensive
Community-based workers
are more affordable
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A cost-effectiveness exercise: unit cost
0 5000 10000 15000 20000 25000 30000 35000
Upgrading 1District Hospital
Upgrading 1Health Center
Training etc, 1MCHW
PROGRAM
Dollars
$350
$10,000
$30,000
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Cost (cont.)
Suppose, per district, there are:
100 MCHW s 4 health centers 1 district hospital
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Estimated program cost (in $000s)
0 10 20 30 40 50
Upgrading 1District Hospital
Upgrading 4Health Centers
Training etc, 100MCHWs
PROGRAM
Dollars
30
40
35
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Estimated obstetric deaths prevented (%)
0 10 20 30 40 50 60
District hospital
Health centers
MCHW training
PROGRAM
50
Percent
25
15
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Estimated cost per death averted ($000)
0 200 400 600 800 1000
Upgrading 1District Hospital
Upgrading 4Health Centers
Training etc, 100MCHWs
PROGRAM
$580
$845
$217
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In short …
Something that is not effective
can never be cost-effective.
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Measuring Progress:
Are we measuring the right things?
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The Way It Should WorkEvidence
Interventions
Indicators
Strategy
But sometimes …
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MDG Goal: Improve maternal health
Target: Reduce the MM Ratio by 3/4 by 2015
Indicators: Maternal mortality ratio Proportion of births attended by skilled
health personnel
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Promoting SBAs
What is the evidence base
for this policy?
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SBAs and MMR, 170 countries
R2 = 0.6124
0
500
1000
1500
2000
2500
0 20 40 60 80 100% Skilled Attendant at Delivery
Mat
ern
al M
ort
ality
Rat
io
(per
100
,000
live
bir
ths)
Country n=170
Source: Safe Motherhood Initiative website and Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA (2001)
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SBAs and MMR, 50 Countries with MMR>400
R2 = 0.0818
0
500
1000
1500
2000
2500
0 20 40 60 80 100
% Skilled Attendant at Delivery
Ma
tern
al M
ort
alit
y R
ati
o
(pe
r 1
00
,00
0 li
ve
bir
ths
)
Country n=50
Source: Safe Motherhood Initiative website and Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA (2001)
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This shows:
the relationship between
delivery by SBAs
and MMR
is not strong
for high-mortality countries
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Source: Saving Lives: Skilled Attendance at Childbirth, W. Graham, 2000.
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Source: Saving Lives: Skilled Attendance at Childbirth, W. Graham, 2000.
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This shows:
the relationship between
delivery by midwives
and reduced MMR
is not clearcut –
probably due to regional variation in what midwives are trained and permitted to do.
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Skilled Attendants need to be part of
a functioning health system
To Be Effective
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Sri Lanka, 1970s >
HealthFacilities
SBAs
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Many Proposed Programs
HealthFacilities
SBAs
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In Reducing Maternal Deaths
There are really only 3 issues: COVERAGE OF SERVICES QUALITY OF CARE UTILIZATION OF SERVICES
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The Road toMaternal Mortality Reduction:
Shortcuts or Detours ?
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Pseudo-Interventions
“Safe Birth Kits”: No evidence of effectiveness in reducing maternal deaths, but consume effort, attention and funds.
Advocacy for Advocacy: If not linked to programs, advocacy can be a detour.
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1-Complication MM Programs
Example: Home-based prevention of post-partum hemorrhage (PPH)
Hemorrhage = 25% of maternal deaths
Perhaps ½ preventable = 12.5%
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Semi-Skilled Attendants
If you leave the skills out of
Skilled Birth Attendant
what do you get?
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Institutional Delivery Targets
Easy to measure, but
no indication of quality of care
You can reach the target
But miss the goal !
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“In the Meantime …”
If we don’t get started now
fixing health systems
in 20 years we will still be
in the meantime.
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General Lesson:We must build health systems Need a strong evidence base Training and equipment are never
enough Management systems are crucial Even skilled personnel need support Learn from expensive failures