plenary 2-reducing maternal mortality lessons learnt

7/27/2019 Plenary 2-Reducing Maternal Mortality Lessons Learnt

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Reducing Maternal Mortality;Lessons Learnt

Baizury BashahKlinik Kesihatan Putrajaya Presint 9


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Contents Definition Millennium Development Goal #5

Malaysian achievement

How Malaysia fares compared to othercountries

WHO recommendations

Malaysian initiatives

Summary


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Definition

Maternal death

The death of a woman while pregnant orwithin 42 days of termination of pregnancy,

irrespective of the duration and site of thepregnancy, from any cause related to or

aggravated by the pregnancy or its

management,

but not from accidental or incidental causes


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Maternal mortality ratio

Number of maternal deaths during given time period_______________________________________ X 100,000

Number of Life birth during same period of time

This measure captures the probability of dying once a womanis pregnant, and so is also referred to as the obstetric risk

Maternal mortality rate:

Number of maternal deaths in a population X100,000

Number of women aged 1549 years (reproductive age)


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Prerequisite for good measurement

an established system for registration of births,deaths and causes of death

well-functioning health information systems that combinedata from facilities, administrative sources and surveys

Countries must have:


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Table 1. Sources of maternal mortality data used in

generating the 2010 maternal mortality ratio estimates

Group Source of maternal mortality data Number of

countries/

territories

% of countries/

territories in each

category

% of births in

181 countries/

territories

covered

A Civil registration

characterized as complete,

with good attribution of causeof death

65 35.9 15.7

B Countries lacking good

complete registration data but

where other types of data are

available

89 49.2 80.3

C No national data on maternal

mortality27 14.9 4.0

Total 181 100.0 100.0


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Definitions of misclassification,incompleteness and underreporting

Misclassification

Refers to incorrect coding in civil registration, due either to error in

the medical certification of cause of death or error in applying the

correct code

Incompleteness

Refers to incomplete death registration. Includes both the identification of

individual deaths in each country and the national coverage of the register

Underreporting

Is a combination of misclassification and incompleteness


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Guess which group Malaysiabelongs to??


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Estimates of maternal mortality ratio(MMR, maternal deaths per 100 000 live births),

number of maternal deaths, lifetime risk , 2010

Country MMR Range of MMR

uncertainty

Number of

maternal

deaths

Lifetime risk

of maternal

death, 1:

PM

(%)*

Gp

Lower

estimate

Upper

estimate

Malaysia 29 12 64 170 1300 2.4 CThailand 48 33 70 400 1400 1 B

Singapore 3 2 7 2 25,300 0.3 A

Philippines 99 66 140 2300 300 6.3 B

Indonesia 220 130 350 9600 210 5.0 B

*Proportion of maternal deaths among deaths of women of reproductive age (PM)

Source: , WHO 2012 . Trends in Maternal Mortality 1990 to 2010


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WHO recommendations

Malaysian initiatives

Summary


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MDG #5

TARGET 5A :

Reduce by three-quarters (75%) between 1990and 2015, the maternal mortality ratio

Target 5B:

Achieve, by 2015, universal access toreproductive health


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MDG 5 to improve maternal healthTargets MDG indicators Baseline Target

(2015)

Latest

achievement

5.1 MMR 44/100,000 LB

(1991)

11/100,000 LB 26.1 (2010)

5.2 Proportion of birth

attended by skilled

health professionals

74.2%

(1990)

95.0% 98.6% (2011)

5.3 Contraceptive

prevalence rate

54.6% (1994) To increase 51.8% ( 2004)

5.4 Adolescent birth rate 28 births per

1000adolescent

To decrease 14 births per

1000

adolescent

(2010)5.5 Antenatal care

coverage (1 visit)

78% (1990) 90.0% 94% (2011)

5.6 Unmet need for

family planning

24.5 % (2004) To decrease


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WHO recommendations

Malaysian initiatives Summary


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MDG 5a: Maternal Mortality Ratio (MMR) Achievementagainst Set Target MDG 5

Source: Department of Statistics Malaysia

(131) (137) (134) (128) (126)

(no. of deaths)

(110p) (50)

Target


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MMR by ethnicity ( 1997-2007)

Ethnic Grp 1997 1999 2001 2003 2006 2007 2009 2011p

Malay 33.6 (100) 34.0 (104) 33.5 (100) 28.8 (80) 25 ( 68) 28.4 ( 78) 30 (88) 26.1(79)

Chinese 18.6 ( 20) 12.4 (14) 15.3 (15) 16.4 (15) 16.5 ( 14) 12.9 (10) 16( 20) 6.7(5)

Indians 36.7 ( 13) 31.1 (11) 40.7 (14) 18.6 (6) 13 ( 44) 23.6 (7) 37 (11) 15.6(4)

Otherbumi

27.4 ( 17) 39.2 (20) 49.4 (31) 33.4 (19) 26.2 (15 40.8 (24) 50.1 (32) 44.8(29)

Target :11/100,000LBby 2015


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Only the Chinese has achieved the

targeted MMR of 6.7/100,000 LB


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At what point during pregnancyand

childbirth do women die?


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60%-75% : During Postpartum

15 -25% : Antenatal

Source: Reports on the Confidential Enquiries into Maternal Deaths in Malaysia

MATERNAL DEATHS by PHASE OF PREGNANCY :

MALAYSIA 1991-2008


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Maternal deaths by phase of pregnancy/delivery :

Malaysia 2011-2012

Source : BPKK, KKM


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Post partum 48hrs 42 days

Health personnel from Klinik Kesihatan &Klinik Desa can contribute more by

doing quality , regular post natal care

Identify red flag signs & symptoms

Timely referral to M&HO / FMS or hospital

Causes of maternal death (direct/indirect)


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Causes of maternal death (direct/indirect)

Malaysia 2011-2012

Direct cause Indirect cause

Obstetric

embolism

Hemorrhage

Medical

conditions

HDP

Source : BPKK


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MMR PLACE OF DELIVERY

Home deliveries associated with high MMR 50-80 per 100,000 deliveries


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Home deliveries on the rise;

causing sepsis??

/


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Maternal deaths; preventable / non preventable

Malaysia 2011-2012

Source : BPKK, KKM

Contributory factors Clinical factors


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Contributory factors Clinical factors

(analysis based on preventable deaths 2012)

Percentage

C t ib t f t N li i l f t


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Contributory factors Non-clinical factors


Percentage

C t ib t f t P ti t F t


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Contributory factors Patient Factors


Percentage


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Contents

Definition Millennium Development Goal #5



WHO recommendations



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How does Malaysia fare?

(1980 2010)

Maternal Mortality Ratio per 100,000 LB


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Source - WHO World Health statistics 2012

by Region and Country


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Contents




WHO recommendations


6 k f WHO h


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6 key messages from WHO research-informed viewpoint

Maternal health has many valued outcomes, butmaintaining focus on maternal death is crucial inareas where the mortality burden is high

Many single interventions are available, but none

alone can reduce the rate of maternal mortality in apopulation

Strategies will work if the component packages areeffective and the means used for their distribution

achieve high coverage of the intended target group


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6 key messages from WHO research-informed viewpoint

The epidemiology of maternal mortality requiresprioritisation of the intrapartum period

A health centre intrapartum-care strategy can be

justified as the best bet to bring down high rates ofmaternal mortality

There are further opportunities to alter the risks ofmaternal death outside the intrapartum period

antenatal care, postpartum care, family planning,and safe abortion


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WHO recommendationsWHO recommendations Malaysia

Non-pregnant women of reproductive age: all (4) All

Periconceptual folic acid supplementation (women planning

Pregnancy)

Iron supplementation (in areas of high iron deficiency anaemia)

Access to care to screen/diagnose health problems (e.g. worm

infestation, severe anaemia, heart disease, HIV, asthma,diabetes)

Salt iodisation

Non-pregnant women of reproductive age: ill (6) All

Non-pregnant women of reproductive age: not wanting child

Female condom x

Emergency contraception

Male sterilisation


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Pregnant women not wanting child, Prevent unsafe inducedabortion (2) Where legally, politically, and culturally acceptable(medical abortions could potentially be delivered at the household level, and attain high

coverage, thereby averting a substantial proportion of maternal deaths)

Mifepristone / misoprostol (medical abortion)

Vacuum aspiration

All pregnant women (26)

Calcium (reduce risk of PE)

Intrapartum women (delivery and immediate postpartum) (17) All

All postpartum women (13)

Insecticide treated bednets (malaria vs dengue) x

Pregnant, intrapartum, postpartum women with complications (45)

Calcium supplementation (in women at high risk of PE)

Post induced-abortion contraceptive advice


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*Stimulate nipples post term to induce labour x*Intraumbilical vein injection with saline solution

and oxytocin to reduce need for manual removal

of placenta (Prevent need for manual removal of

placenta; retained placenta; postpartum

haemorrhage)

x

* WHO. Reproductive Health Library, version 9. World Health Organization.http://www.rhlibrary.com/default.asp (accessed Sept 5, 2006).


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Contents




WHO recommendations


C fid ti l i i i t t l


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Confidential enquiries into maternaldeaths (CEMD)

Previously:

at clinic, district, state level attended by allinvolved, national level by a committee

Presently:

all the above +

national level every 3 months, attended byrepresentatives from the states, by zones


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Problems identified

Social difficulties on the rise

Need to involve other agencies since MedicalSocial worker in health facilities is scarce

Certification of death by non medical personnel

Police not to issue burial permits without knowingthe cause of death

Post mortem for unsure cause of death


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Problems identified

Geographical difficulties still exist especially in EMalaysia

Making trained personnel more accessible byrotation

Upgrade facilities

Restrictions on management

E.g Need to have 2 specialists signatures for X-ray examination in pregnant ladies


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Strategies Pre pregnancy care optimise health, for men

too

Guidelines primary & secondary care

Personalised care

Continuation of thrombolytic Rx in primarycare

Setting up of EPAU / PAC in secondary care

Notification of high risk admissions &discharges

Combined clinic

S i


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Strategies Family planning service in secondary care

Setting up of low risk birthing centre

Higher risk can be given more attention Revival of ABC

Alternative to home deliveries

Private wing for full paying patients moreoptions for patients


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Others

Malaysia towards health transformation,integration between public & private

?Delivery can either be in public or privatehealth facilities


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Contents




WHO recommendations



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Summary

WHO does not recognise Malaysias data (MOH,Pendaftaran)

Malaysias MMR is still NOT on target

Only the Chinese population has achieved thetargeted MMR of , 11/100,000LB (6.7/100,000 LB)

Up to 75% of maternal death occur during postpartum period

S


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Summary

Around 50% of death is preventable, half dueto cardiac diseases

Haemorrhage, embolism, HDP, Sepsis arethe major direct causes of death

Home delivery is associated with high MMR

Summary


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Summary

Malaysia complies to many of WHO relevantrecommendation

Malaysia need to look outside of the box, e.g: delivery can be at public or private health facilities

Personalised care add in patients in fb for easyaccess to advice


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Thank you

[email protected]

plenary 2-reducing maternal mortality lessons learnt

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