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…