Non-medical factors related to maternal mortality Birgitta Essén, MD, associate professor Senior...
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Transcript of Non-medical factors related to maternal mortality Birgitta Essén, MD, associate professor Senior...
Non-medical factors related to maternal mortality
Birgitta Essén, MD, associate professorSenior Lecturer in International Maternal Health Care
Department of Women’s and Children’s HealthIMCH, Uppsala University
outline
• RH history (SRHR)
• MM: medical factors, classification
• MM: non medical factors
• UN, WHO policy
How did it start?
Biafra 1967-1970Biafra 1967-1970
Main PH focus:
• Population !
• => FP
• ”Maternal and child health”
”ReproductiveHealth”
”ReproductiveHealth”
Maternalhealth
Maternalhealth
FPFP
Reproductive health -International focus/attention
• Bucharest 1974 – UN Population Conf.• Mexico City 1984 – same focus: population
• Cairo 1994 – International Conference on Population and Development (=>”RH”)
• Beijing – UN Conference on Women• WHO strategy approved 2004 Safe
Mootherhood • UN MDG 5• WHO Continum of Care 2010
Sexual &reproductive
health& rights
Sexual &reproductive
health& rights
FPFPViolence against women
Violence against women
Child-lessnessChild-
lessness
Cxcancer
Cxcancer
HIV/AIDSHIV/AIDS
STDSTD AbortionAbortion
AdolescentSRHR
AdolescentSRHR
Maternalnewbornhealth
Maternalnewbornhealth
”ReproductiveHealth”
”ReproductiveHealth”
Maternalhealth
Maternalhealth
FPFP
MGD 5MGD 5
1990 to 20151990 to 2015
Reduce maternal mortality with 3/4
Maternal mortality
• MDG 5• Hill K, et al. Estimates of maternal mortality worldwide between 1990 and
2005: an assessment of available data. Lancet. 2007;370.
• Disparities poor-rich • Graham WJ, et al. The familial technique for linking maternal death with
poverty. Lancet. 2004;363
• Lifetime risk (WHO 2007)
• Ethiopa:1 in 10
• Norway: 1 in 15,000
Trends in strategies to reduce maternal mortality
• Safe Motherhood Initiative, Nairobi 1987• AbouZahr C. Safe motherhood: a brief history of the global movement
1947–2002. Br Med Bull. 2003.
• Other MDGs: 1 eradicating powerty2 primary education3 gender equity
• …however, most strategies have been vertical programs focusing on single interventions !
• Starrs AM. Safe motherhood initiative: 20 years and counting. Lancet. 2006.
Maternal mortality ratio Maternal mortality ratio per 100 000 livebirths, 2008per 100 000 livebirths, 2008
Hogan et al., Lancet 2010
Norge: 8/100 000
Afghanistan: 1575/100 000
Etiopia: 590/100 000Dem rep Kongo
Nigeria
Pakistan
India
Yearly reduction MM (%), 1990-2008 Yearly reduction MM (%), 1990-2008
Hogan et al., Lancet 2010
“Big five”
• Haemorrhage
• Sepsis
• Preeclampsia/eclampsia
• Obstructed labour
• Unsafe abortions
Why?
Socioeconomic factors contributing
• No power to decide• Inequality• Low education/illiteracy• Poverty• Early marriages• Harmful practices• No access to delivery care• No access to family planning and antenatal care• Infrastructure
Halving MMR
0
500
1000
1500
2000
2500
3000
1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995
Year
MMR
per 1
00,00
0 live
birt
hs
8 years
4 years
11 years10 years 8 years
13 years
Sri Lanka
0
100
200
300
400
500
600
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
Year
MM
R
8 years
13 years
7 years
9 years 6 years
Malaysia
www.worldbank.org ”Investing effectively in maternal health”
History: 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
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
Maternal mortalityMaternal mortality, time trend, time trend (100 (100 000/deliveries)000/deliveries)
ÅrÅr
Death Death womenwomen
Maternal mortality where?
Shifting from
Unskilled Care
To Skilled Care
4 models of delivery careKoblinsky, Bull WHO
• Traditional birth attendants (TBA)
• Skilled birth attendants –at home
• Skilled birth attendants –at health center
• Hospital
Trends in strategies to reduce maternal mortality – health care seeking
behaviour
“Consequently, increased attention with regard to the utilization of obstetric care has been directed toward understanding the motivations and behaviours of pregnant women and their social network”
Rööst et al 2009.
WHO 4. august 2010
Contiuum of care
Interventions at home/community levelInterventions at first level health facilities Interventions at referral facilities
WHO Policy, 2010
• Family planning (Safe abortion, STI prevention) ”Reduce MM with 30%”
• ANC ”Reduce MM with 50 % and NM 15%”
• Emergency Obsteric Care, Skilled BA
”Reduce MM 95%”
Countdown report to 2015Countdown report to 2015AfghanistanAfghanistan
EtiopiaEtiopia
IndiaIndia
Interventions in 68 “Countdown Countries”
Bhutta ZA et al., Lancet 2010
Conclusions Maternal newborn health
• Maternal & newborn survival extra dependent on functioning health care (less on general living conditions)
• Public awareness through reporting is fundamental
• Infrastructure and Education• Skilled birth attendance is key – midwives!• As well as backup for obstetric emergencies
Thanks for listening!
Any questions? Give me a break…