Maternal and newborn mortality and morbidities€¦ · Dr Monir Islam Director, Department of...
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Department of Making Pregnancy Safer, WHO, Geneva Maternal and newborn mortality and morbidities The silent Tsunamis Dr Monir Islam Director, Department of Making Pregnancy safer, WHO, Geneva
Transcript of Maternal and newborn mortality and morbidities€¦ · Dr Monir Islam Director, Department of...
Department of Making Pregnancy Safer, WHO, Geneva
Maternal and newborn mortality and morbidities
The silent Tsunamis
Dr Monir Islam
Director,
Department of Making Pregnancy safer, WHO, Geneva
Department of Making Pregnancy Safer, WHO, Geneva
Our Goals for Safe Motherhood
Reduction of maternal and newborn mortality and morbidity - the silent tragedies
Department of Making Pregnancy Safer, WHO, Geneva
Pregnancy and ChildbirthGlobal Situation
Pregnancy and ChildbirthPregnancy and ChildbirthGlobal SituationGlobal Situation
••180180--200 million pregnancies every year200 million pregnancies every year••75 million unwanted pregnancies75 million unwanted pregnancies••50 million induced abortions50 million induced abortions••20 million unsafe abortions20 million unsafe abortions••20 million women suffer from maternal morbidity20 million women suffer from maternal morbidity••600,000 die from complications600,000 die from complications••3 million newborns die within the first week of life3 million newborns die within the first week of life••3 million babies are born dead3 million babies are born dead
Department of Making Pregnancy Safer, WHO, Geneva
Causes of maternal mortalityCauses of maternal mortality
Sepsis15%
Obstructed labour
8%
Haemorrhage24%
Hypertensive disorders
12%
Unsafe abortion
13%
Other direct causes
8%
Indirect causes20%
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Department of Making Pregnancy Safer, WHO, Geneva
Causes of neonatal deathsCauses of neonatal deathsCauses of neonatal deaths
All other (5.1%)Diarrhoea (1.5%)Congenital anomalies 11.1%))Sepsis, meningitis (7.2%)Prematurity (10.3%)Birth Injuries (10.6%)Neonatal Tetanus (14.1%)Pneumonia (19%)Birth asphyxia (21.1%)
Most of these deaths are preventable or treatable
Department of Making Pregnancy Safer, WHO, Geneva
Let us look at evidence
Department of Making Pregnancy Safer, WHO, Geneva
The health of the mother and newborn are The health of the mother and newborn are inseparableinseparable
0
20
40
60
80
100
120
Africa Asia Latin America & theCaribbean
More developed regions
Stillbirt
hs and
neo
natal d
eaths pe
r 100
0 birth
s
0
40
80
120
Materna
l dea
ths pe
r 10'00
0* live
births
Neonatal deaths per 1000 live birthsStillbirths per 1000 birthsMaternal deaths per 10'000* live births
Source: WHO estimates 2000
Department of Making Pregnancy Safer, WHO, Geneva
When a parent diesWhen a parent dies
0
2
4
6
8
10
12
No parents die Father dies Mother dies
% of c
hildren dy
ing
Sons die (%)
Daughters die (%)
Data from Data from MatlabMatlab 19831983--8989
Source: Strong, M. Source: Strong, M. Health Transition ReviewHealth Transition Review 2(2), 19922(2), 1992
Department of Making Pregnancy Safer, WHO, Geneva
0
100
200
300
400
500
600
700
800
900
1000
1850 1860 1870 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990
USA
E&W
SW
Median Poor Countries '93
T
Department of Making Pregnancy Safer, WHO, Geneva
Maternal Mortality since the 1960s in Malaysia, Sri Maternal Mortality since the 1960s in Malaysia, Sri Lanka and ThailandLanka and Thailand
050
100150200250300350400450
1960 1964 1968 1972 1976 1980 1984 1988 1992
Mat
erna
l Mor
talit
y
Thailand Sri Lanka Malaysia
7200 new midwives registrations
18,314 new midwives
From 2,5040 beds to 10,800 in small community hospitals
Department of Making Pregnancy Safer, WHO, Geneva
R2 = 0.74
0
200
400
600
800
1000
1200
1400
1600
1800
2000
0 10 20 30 40 50 60 70 80 90 100
Y Log. (Y)
The higher the proportion of deliveries attended by skilled atteThe higher the proportion of deliveries attended by skilled attendant in ndant in a country, the lower the countrya country, the lower the country’’s maternal mortality ratios maternal mortality ratio
% skilled attendant at delivery% skilled attendant at delivery
Mat
erna
l dea
ths
per 1
0000
00 li
ve b
irths
Mat
erna
l dea
ths
per 1
0000
00 li
ve b
irths
Department of Making Pregnancy Safer, WHO, Geneva
% Deliveries attended by a Doctor
100806040200% D
eliv
erie
s A
ttend
ed b
y a
Mid
wife
/Nur
se
100
80
60
40
20
0
MMR(1990)
1000+
500-999
250-499
100-249
< 100
Senegal
Nigeria
BangladeshNepal
Uganda
Sri Lanka
Burkina
Partnership Ratio: % Deliveries with Doctor by Partnership Ratio: % Deliveries with Doctor by % Deliveries with Midwife/Nurse% Deliveries with Midwife/Nurse
Mozambique
THE DUGALD BAIRD CENTREfor research on women's health
Department of Making Pregnancy Safer, WHO, Geneva
1
10
100
1000
10000
0.0 0.2 0.4 0.6 0.8 1.0WHO Overall Health Systems Performance IndexM
MR
(dea
ths
per 1
00 0
00 li
ve b
irths
)[lo
g sc
ale]
Maternal Mortality Ratio and HealthMaternal Mortality Ratio and HealthSystem PerformanceSystem Performance
Department of Making Pregnancy Safer, WHO, Geneva
Deliveries conducted by different providersDeliveries conducted by different providers
0
20
40
60
80
100
% of all deliveries
Bangladesh India Nepal Indonesia
SA TTBA Others
Department of Making Pregnancy Safer, WHO, Geneva
Maternal Mortality Ratio in SAT Hospital, Kerala, 1966-1997
0100200300400500600700800
1966-69 '73-75 '82-85 '86-87 '89-91 '92-93 '93-97
Kerala
AssamUP
Orissa
Source: Challenges in Safe Motherhood Initiative in KeralaUNFPA
Department of Making Pregnancy Safer, WHO, Geneva
Home,assisted by doctor
2%Home, assisted by ANM/Nurse
4%
Home,assisted by TBA
8%
Private institution
17%
Public institution
17%Home, assisted
by others52%
Distribution of deliveries by place of delivery and assistance in case of home delivery India,
1998-99
Source: RCH-RHS, 1998-99
Department of Making Pregnancy Safer, WHO, Geneva
Parents' Home
1%
NGO/Trust Hospital
3% Own Home5%
Other1%
Private Institution
54%
Public Institution
36%
Doctor91%
Mssing1%
Dai3%
Other2%
ANM/Nurse/Midwife/LHV
3%
Place of Delivery and Assistance During Delivery Kerala, 1998-99
Source: NFHS-2 1998-99
Department of Making Pregnancy Safer, WHO, Geneva
0102030405060708090
Kerala Goa TamilNadu
Assam UP Bihar
D.Comp Care PD Comp Care
Delivery and Post Delivery Complications and Health Care Seeking Behaviour India, 19988-99
Department of Making Pregnancy Safer, WHO, Geneva
% of Total Public Expenditure
10
20
30
40
50
1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999
% ag
e
State adminstration (UP) Education and Health (UP)
State Administration (Kerala) Education and Health (Kerala)Source: Reserve Bank of India Bulletins, 1955-1998
Department of Making Pregnancy Safer, WHO, Geneva
MMRMMR inin ThailandThailand byby regionsregions inin 19971997--20012001M
MR
Year1997 1998 1999 2000 2001
10
15
20
25
30
35
40
45
50
55
NorthSouthCountryCentralNortheast
Health promotion, MOPH 2003
Department of Making Pregnancy Safer, WHO, Geneva
Rich Poor Divide
And
Investment
Department of Making Pregnancy Safer, WHO, Geneva
Rich Poor Divide: Rich Poor Divide: Who should programme targetWho should programme target
0102030405060708090
% of w
omen
Malnurishedwomen
15-18 yrs givingbirth
Women usingcontraceptives
3 ANC visits Birth AttendedSBA
Poorest fifth Middle fifth Richest fifthSource: Population Reference Bureau 2004
Department of Making Pregnancy Safer, WHO, Geneva
POORPOOR--RICH INEQUALITIES IN ACCESS TO DIFFERENT RICH INEQUALITIES IN ACCESS TO DIFFERENT TYPES OF HEALTH CARETYPES OF HEALTH CARE
0
10
20
30
40
50
60
70
80
90
1st Quintile(Poorest)
2nd Quintile 3rd Quintile 4th Quintile 5th Quintile(Richest)
Attended DeliveriesDiarrhoea Treatment (in Health Facility)ARI Treatment (in Health Facility)
% O
F C
ASE
S
(unweighted average of 10 developing countries)
Source: World Bank (1999) Safe Motherhood and The World Bank.
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Department of Making Pregnancy Safer, WHO, Geneva
Ground Reality
Department of Making Pregnancy Safer, WHO, Geneva
Percentage of women age 15Percentage of women age 15--19 who are mother 19 who are mother or currently pregnant, by single years of ageor currently pregnant, by single years of age
15.9
5.52.21.5
26
10.5
3.7
9.3
36.5
19
10.7
17.5
45
29.1
18.9
34
57.3
41
29.7
40
0
10
20
30
40
50
60
15 16 17 18 19
Bangladesh India Indonesia Nepal
Department of Making Pregnancy Safer, WHO, Geneva
Recognition
Department of Making Pregnancy Safer, WHO, Geneva
Recognition Referral
Department of Making Pregnancy Safer, WHO, Geneva
ReferralRecognition Responsiveness
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Department of Making Pregnancy Safer, WHO, Geneva
Where Care for Pregnancy and Childbirth Is Provided?
Where Care for Pregnancy and Childbirth Is Where Care for Pregnancy and Childbirth Is Provided?Provided?
Home/Community 1st level facility Hospital
No of pregnant women seen
Equipment, supplies, case management skills
Specialised care
Department of Making Pregnancy Safer, WHO, Geneva
Interventions forInterventions forsafe motherhoodsafe motherhood
Department of Making Pregnancy Safer, WHO, Geneva
Skilled Care at Every BirthSkilled Care at Every Birth
SuppliesSupplies
Health professionals with midwifery skills (promoting utilisation, pregnancy care and providing care for normal deliveries and Obstetric First Aid, newborn care)
Health professionals with skills to provide Basic Essential Obstetric and newborn care
Health professionals with skills to provide Comprehensive Essential Obstetric Care
Referral
TransportTransport DrugsDrugs
EquipmentEquipment
THE DUGALD BAIRD CENTREfor research on women's health
PolicyPolicy
Management and supervisionManagement and supervision
We need a functioning system
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Department of Making Pregnancy Safer, WHO, Geneva
Integrated Management of Pregnancy and Childbirth
Integrated Management of Pregnancy and Integrated Management of Pregnancy and ChildbirthChildbirth
Management guidelines for
pregnancy and child birth and
post partum careat different levels
Health educationand promotion andcommunity support
activities
Supplies, equipments and transport
District level management of health services/skilled human resources
Monitoring and surveillance
Integrated casemanagement
guidelines, trainingand follow-up
Interventions toimprove family and
communitypractices
Hea
lth
wor
ker s
kills
Fam
ily a
nd
com
mun
ityH
ealth
sys
tem
IMPACmay bring
it alltogether
Department of Making Pregnancy Safer, WHO, Geneva
Investment/implementation decisionsInvestment/implementation decisions
•• Where to investWhere to invest–– Poorly performing state/province/district with high Poorly performing state/province/district with high
mortalitymortality–– Middle performing with moderate/low mortalityMiddle performing with moderate/low mortality–– Well performing with lowest mortalityWell performing with lowest mortality
•• Which groupWhich group–– PoorestPoorest–– Middle incomeMiddle income–– RichestRichest
•• Step wise (districts/states) or country wideStep wise (districts/states) or country wide
Department of Making Pregnancy Safer, WHO, Geneva
To achieve our goals weTo achieve our goals we needneed
• Political CommitmentPolitical Commitment
•• Appropriate investmentAppropriate investment
•• Right strategyRight strategy
•• Policy and legislationsPolicy and legislations
•• Public/Private/NGO mix Public/Private/NGO mix
•• TimeTime
Department of Making Pregnancy Safer, WHO, Geneva
No more poor options for poor peopleNo more poor options for poor people
Developing countries are not rich enough to Developing countries are not rich enough to invest on cheap ideas and strategiesinvest on cheap ideas and strategies
