Evidence Based

Approaches for Reduction

of Maternal Mortality

Hemant Dwivedi
 Session Objectives
To review:
Magnitude of Maternal mortality
Causes of Maternal mortality
Interventions to reduce maternal mortality
Traditional birth attendant
Antenatal care
Risk screening
Reduce Unwanted Fertility
Skilled attendant at childbirth
Emergency obstetrics Care
Current Program Strategies
What we can do?
Current Approach to Reduction of Maternal Mortality 2
Maternal Mortality: A Global Tragedy

Annually, 536,000 women

die of pregnancy related
complications
99% in developing
world
~ 1% in developed
countries
25% global burden by
India
Every minute one
Maternal Death occur

Current Approach to Reduction of Maternal Mortality 3

Maternal and Infant Mortality are two
critical indicators that measure not only
health conditions, but overall
development level of a country.

Both are key goals in the National Rural

Health Mission (NRHM) and the
Millennium Development Goals (MDG#
4 and 5).
 Maternal Mortality Ratio
Year MMR(INDIA) ORISSA
1998-99 : 407 367
2001 03 : 301 358
2004 06 : 254 303

XI Plan Goal (2012) : 100 119

MDG Target (2015) : 136
 Recent Trends MMR India
(SRS-04-06)
States of India MMR
Kerala 95
Tamil Nadu 111
West Bengal 141
Andhra Pradesh 154
Bihar/Jharkhand 312
Madhya Pradesh/ Chhattisgarh 335
Orissa 303
Assam 480
India 254

Current Approach to Reduction of Maternal Mortality 6

Causes of Maternal Mortality in India
(SRS-2003)

Current Approach to Reduction of Maternal Mortality 7

But WHY Do These Women Die?
Three Delays Model
Delay in Decision to Seek Care
Lack of understanding of complications
Acceptance of maternal death
Low status of women
Socio-cultural barriers to seeking care
Delay in Reaching Care
Mountains, islands, rivers poor organization
Delay in Receiving Care
Supplies, personnel
Poorly trained personnel with punitive attitude
Finances
Current Approach to Reduction of Maternal Mortality 8
 Interventions to Reduce
Maternal Mortality
Historical Review

Traditional Birth Attendants

Antenatal Care

Risk Screening

Current Approach

Reduce Unwanted Fertility

Skilled Attendant at Delivery

Emergency Obst. Care

Current Approach to Reduction of Maternal Mortality 9

Historical Review of Interventions

The flawed assumption:

Most life-threatening obstetric

complications can be predicted or
prevented

Current Approach to Reduction of Maternal Mortality 10

 Interventions:
Traditional Birth Attendants

Advantages Disadvantages
Community-based Technical skills
limited
Sought out by women
May keep women
Low tech
away from life-saving
Can perform clean interventions due to
delivery false reassurance

Current Approach to Reduction of Maternal Mortality 11

 Interventions:
Traditional Birth Attendants
Conclusion: TBAs are useful in the
maternal health network, but there will not
be a substantial reduction in maternal
mortality by deliveries conducted through
TBAs.

Maternal Deaths prevented-3 percent

Current Approach to Reduction of Maternal Mortality 12

 Interventions: Antenatal Care
Antenatal care clinics started in USA, Australia, Scotland
between 19101915
Concept - Screening healthy women for signs of
risk/disease
No substantial reduction in maternal mortality
However, widely used as a maternal mortality reduction
strategy in 1980s and early 1990s

Is ANC important? YES!!

Early detection of problems and Birth Preparation

Maternal Deaths prevented-11 percent

Current Approach to Reduction of Maternal Mortality 13
Maternal Mortality: UK 18401960

Improvements in Antenatal Antibiotics, banked blood,

nutrition, sanitation care surgical improvements

Maine 1999. Current Approach to Reduction of Maternal Mortality 14

Interventions: Risk Screening

Disadvantages
Very-poorly predictive
Costly: Early and longer stay in health facilities
If risk-negative, gives false security

Conclusion: Cannot identify those at risk of

maternal mortality Every pregnancy is at risk, if
not proved, otherwise.

Current Approach to Reduction of Maternal Mortality

15
Historical decline in Maternal
mortality in the West
Not much decline till 1930
Rapid decline after 1940s
While infant mortality declined since 1800s
gradually as socio-economic conditions
improved.(Community based interventions)
Factors affecting maternal mortality decline-
Increased availability of blood, antibiotics, safe
surgery.

Current Approach to Reduction of Maternal Mortality 16

Are there populations who are rich,
well nourished and educated but
have high maternal mortality?
Yes in USA there are such populations eg.
Faith Assembly of God who are rich, well
nourished, and educated : their MMR was 872 in
1982 while in that year MMR in US general
population was only 8 per 100,000 live births.
What is the key difference between these two
groups? Use of modern obstetric care.

Current Approach to Reduction of Maternal Mortality 17

MM: What the Evidence Shows

Once a woman is pregnant usually most

serious obstetric complications cannot be
predicted or prevented ,but they can be
treated.
About 15 %
do develop obstetric complications.

Current Approach to Reduction of Maternal Mortality 18

 Do women die immediately after
developing complications in delivery?
Average Complications to death interval
Hemorrhage PPH: 2 Hours ( 5.7 hrs*)
APH: 12 Hours(11.5 hrs)
Ruptured uterus 1 Day
Eclampsia 2 Day (1.7 Days)
Obstructed Labour 3 Days
Infection 6 Days (2.4 Days)
(* Study in Maharashtra Ganatra et al. WHO bulletin 1998, 76(6):591-598.

Current Approach to Reduction of Maternal Mortality 19

Current Approach to Reduction of Maternal Mortality 20
 So
All pregnant women
need Access to*
Emergency Obstetric Care
(EmOC)

* Not the same as Institutional Delivery [ID]

Current Approach to Reduction of Maternal Mortality 21

 Interventions: Skilled
Attendant at Childbirth
SBA- An accredited health professional- such as Midwife,
Doctor, Nurse-Who have been educated and trained to
proficiency in the skills needed to manage normal
pregnancy, child birth and the immediate post- natal
period, and the identification, management and referral of
complication in women and newborn.
Proper training for range of skills
Assess danger signs and Recognize onset of complications
Observe woman, monitor fetus/infant
Perform essential basic interventions
Refer mother/baby to higher level of care if complications arise
requiring interventions outside realm of competence

Current Approach to Reduction of Maternal Mortality 22

Maternal Mortality Reduction
Sri Lanka 19401985

Health system improvements:

Introduction of system of health facilities
Expansion of midwifery skills
Decreased use of home delivery and delivery
by untrained birth attendants
Spread of family planning

Current Approach to Reduction of Maternal Mortality 23

Maternal Mortality Reduction
Sri Lanka 19401985

by trained personnel
85% births attended
Current Approach to Reduction of Maternal Mortality 24
 Interventions:
Skilled Attendant at Childbirth
Proven effective
Malaysia: basic maternity services 320 157
Cuba: national priority 118 31
China: facility based childbirth 1500 50
Malaysia (41)vs. Indonesia (230):
Trained community midwives (2 years) vs.
untrained midwives (4 years)

Current Approach to Reduction of Maternal Mortality 25

 The higher the proportion of deliveries attended by skilled attendant
in a country, the lower the countrys maternal mortality ratio
2000
Maternal deaths per 1000000 live births

1800
2
R = 0.74
1600 Y Log. (Y)

1400

1200

1000

800

600

400

200

0
0 10 20 30 40 50 60 70 80 90 100

% skilled attendant at delivery

Current Approach to Reduction of Maternal Mortality 26
 MMR & SBA
Countries MMR SBA %
Afghanistan 1800 14
Nepal 830 11
Bangladesh 570 13
Bhutan 440 37
Pakistan 320 31
India 254 43*
Sri Lanka 58 96
South Asia 500 37
Global 400 63

Current Approach to Reduction of Maternal Mortality 27

 Interventions:
Emergency Obst care
Vast Majority of deaths (75%) due to Direct Obstetric
complications
These complications occur even in well nourished and well
educated women
Can not usually be predicted
Can not be prevented : some exceptions such as AMTSL
for preventing PPH, IP for Post partum infections and
provision of safe and early abortion services
Overlap with SAB
Emoc facilities provide a critical back up for SAB

Current Approach to Reduction of Maternal Mortality 28

Current Approach to Reduction of Maternal Mortality 29
 Interventions: Reduce
Unwanted fertility
Huge unmet demand for spacing and
permanent methods
Significant proportion of maternal deaths
attributable to unsafe abortions
Nearly One third of fertility: unwanted
Access to quality contraceptive services will
help in reducing unwanted fertility which in
turn will reduce numbers of maternal deaths

Current Approach to Reduction of Maternal Mortality 30

What proportion of maternal deaths
these strategies can prevent?
TBA training 03 %
ANC 11 %
Family Planning 26 %
Health Centers (BEmOC) 25 %
HC & Urban Hospitals (C) 60 %
HC & rural Hospitals 67 %

Current Approach to Reduction of Maternal Mortality 31

Programmatic Interventions
Reduce Maternal Mortality
1. Access to Information and Services for
Contraception Too early and too frequent,
too many
2. Access to skill Birth attendance SBA &
BEmOC (obs. First aid)
3. Access to Emergency Obstetric Care
4. Access to safe abortion services
5. Access to ANC and PNC Services

Current Approach to Reduction of Maternal Mortality 32

Organizing Maternal Health Services
with active Referral Linkages

CEmOC SDH/DH

CEmOC Services CHC / Block PHC

BEmOC Services PHC (New)

Midwifery Services Sub Centre

Current Approach to Reduction of Maternal Mortality 33

 Maternal Health Services
Good quality maternal health
services are not universally
available and accessible
> 39% receive no antenatal
care
~ 40% of deliveries
unattended by skilled
provider
~ 60% receive no
postpartum care during 1st
6 weeks following delivery
15% unmet need of FP

Current Approach to Reduction of Maternal Mortality 34

What was planned and what happened?
(Time, Resource &Energy)
5%
TBA Training
TBA

10% ANC ANC Coverage

Coverage

30%
SBA
EmOC

55% EmOC & Safe

Abortion Services

Planned SBA ? Safe Abortion?

Current Approach to Reduction of Maternal Mortality 35
Program Design: The Causal Chain

This is what links actions to outcomes

and impact.
Must be evidence-based, not faith-based
Links must be tested and monitored
If one link breaks, the chain is broken

Current Approach to Reduction of Maternal Mortality 36

JSY JSY Plans
Causal Chain
Instit.
Deliv.
Better
Ob.
Care EmOC
for
Complic.
Deliv.

Lives
Saved
Current Approach to Reduction of Maternal Mortality 37
JSY JSY Plans
Evidence Chain
Instit.
Deliv.
Better
Ob.
Care EmOC
for
Complic.
Evidence
Deliv.
Needs more evidence Lives
Saved
Current Approach to Reduction of Maternal Mortality 38
 Orissa Scenario

250

190

Current Approach to Reduction of Maternal Mortality 39

 What we can Do
ACCESS TO -
Skilled attendance at birth,
Emergency obstetric care
Family planning
Pre-natal and post-natal care
- ARE ABSOLUTELY ESSENTIAL
But reduction of MMR to Western levels goes beyond health
it requires better nutrition, better hygiene, better
education of mothers and better gender equality, in other
words, better overall development of people.

Current Approach to Reduction of Maternal Mortality 40

Current Approach to Reduction of Maternal Mortality 41
Estimation of mortality from the main obstetric complications worldwide and impact of possibly preventable deaths.-WHO-19

Sl. Cause of Death Number % of Possible

No. of Death Deaths preventable
% Number

01. Hemorrhage 127 000 25% 55% 70 000

02. Sepsis 76 000 15% 75% 57 000
03. Preeclampsia/eclamps 64 000 12% 65% 42 000
ia
04. Obstructed labour 38 000 8% 80% 30 000
05. Unsafe abortion 67 000 13% 75% 50 000
06. Other direct causes 39 000 8% --- ---
07. Indirect cause 100 000 20% 20% 20 000
TOTAL 510 000 100% 269 000

Current Approach to Reduction of Maternal Mortality 42

UN Signal Functions of EmOC
Basic
Parenteral antibiotics, oxytocics,
anti-convulsants
Manual removal of the placenta
Removal of retained products (e.g., MVA)
Assisted vaginal delivery

Neonatal resuscitation (new)
Comprehensive = Basic +
Surgery
Blood transfusion

Current Approach to Reduction of Maternal Mortality 43

Figure: 4.9.
To provide skilled care at and after child birth and to deal with

50

400 Maternal Mortality ratio per 100000

live births

8-9 years
Malaysia 1951-61
Sri Lanka 1956-1965
Bolvia Late 1990s
200
6-7 years
Sri Lanka 1974-1981
Thailand 1974-1981
Egypt 1993-2000
Chile 1971-1977 4-6 years
Colombia 1970-1975 Honduras 1975-81
Thailand 1981-1985
Nicaragua 1973-1979
100

Current Approach to Reduction of Maternal Mortality 44