Barbara Deller, CNM, MPH Mary Ellen Stanton, CNM. MSN,

FACNM

October 27, 2006

Saving Mothers: Evidence and Issues

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Purpose of this Session

Take a look at….

• Progress towards maternal survival

• New Evidence

• Issue & Discussion

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“A woman who is pregnant has one foot in the grave”

. . . Local Proverb, Chad

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The Lifetime Risk of Maternal Death in some places in the world it is staggering

1:94

1:16

1:2,800

1:160

Source: WHO, UNICEF and UNFPA. Maternal Mortality in 2000; Lancet Neonatal Survival Series, 2005

The chance of a woman dying as a result of pregnancy is 150 x greater in sub-Saharan Africa than it is in the United States

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Have we made progress?

MDG 5 Target

Reducing Maternal Mortality: Getting on with What Works,

US Launch of The Lancet Maternal Survival Series, Ronsmans and Koblinsky, Oct 5, 2006

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Recent Successes in Maternal Mortality Reduction

0

100

200

300

400

500

600

700

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Ma

tern

al M

ort

alit

y R

ati

o

(Ma

tern

al D

ea

ths

pe

r 1

00

,00

0 L

ive

Bir

ths

)

Morocco36% decline

Egypt52% decline

Bangladesh34% decline

Sources: Morocco: DHS 1992; Bangladesh: National Institute of Population Research and Training 2002; Bolivia DHS 1994, DHS 2003. Egypt: DHS 2000. Egypt Ministry of Health and Population; Indonesia: DHS 1994, DHS 2002; Guatemala: Duarte et al. 2003; Kenya DHS 1998, DHS 2003; Senegal DHS 1992, DHS 2005.

Data point plotted is midpoint of date range.

Indonesia21% decline

Bolivia45% decline

Guatemala30% decline

Kenya30% decline

Senegal28% decline

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Progress in reducing maternal mortality

• Globally1

– essentially no change via estimates since 1990– > 500,000 deaths annually– MMR 400/100,000 live births (US 17)– 2005 estimates not yet available

• In specific countries2 – Wide variability– Other surveys show good progress in some

countries– Overall lack of progress in sub-Saharan Africa

Source: 1 WHO Maternal Mortality in 200: Estimates Developed by WHO, UNICEF, UNFPA 2 Demographic and Health Surveys, Macro Int.

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The Poor Are Hardest Hit

Source: C Ronsmans and Koblinsky, presentation at US Launch of The Lancet’s Maternal Survival Series, 5 Oct 06, Washington, DC

0

100

200

300

400

500

600

700

800

900

Tanzania 1996 Indonesia 2002 Peru 2000

Mate

rnal m

ort

alit

y r

atio

Poorest 20% Richest 20%

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Geographical variation in the distribution ofcauses of maternal deaths

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Leading Causes of Maternal Death

Cause of death Developed countries

Africa Asia Latin America/ Caribbean

Hemorrhage 13% 34% 31% 21%

Hypertensive disorders

16% 9% 9% 26%

Sepsis/infections

2% 10% 12% 8%

Abortion 8% 4% 8% 12%

Obstructed labor

0% 4% 9% 13%

Anemia 0% 4% 13% 0%

HIV/AIDS 0% 6% 0% 0%Source: Khan et al, WHO analysis of causes of maternal death: a systematic review, The Lancet, March 28, 2006 -- % rounded; not included on this table: ectopic pregnancy, embolism, other direct causes, other indirect causes, unclassified deaths

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Because Maternal Mortality is “relatively rare,”

Severe acute maternal morbidity (SAMM)

may be important in measuring progress• SAMM—”near miss”--“A very ill pregnant or

recently delivered woman who would have died had it not been that luck and good care was on her side” — differs from complications

• Systematic review -- 30 reports --prevalence– Disease-specific (e.g. eclampsia) 0.80% - 8.23%– Management specific (e.g. hysterectomy) 0.01%-2.99%– Organ system dysfunction/failure—0.38%-1.09%

• Inverse trend in prevalence with development status of the country

• Need better definitions before uptakeSource: reported in Say, WHO systematic review of maternal morbidity and mortality, Reproductive Health, 2004

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Caesarean sections by type and facility

WHO global survey, 2005

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WHO Global Survey, 2005 -- Latin America

Caesarean Rates and Pregnancy Outcomes

• Median C/S rate 33%, 51% in private hospitals• C/S rate was positively associated with

– Increase in a severe maternal morbidity and mortality (index)

– Postnatal tx with antibiotics– Fetal death and neonatal mortality and morbidity– C/S did not improve perinatal outcomes

• Preterm delivery rates and neonatal mortality rose at rates of C/S between 10 and 20%

• Limitations included: – 3 of 11 countries (Haiti, USA, Paraguay) and 3 selected

institutions originally selected did not participate– Limited standardization of diagnoses

Source: Villar, et al. Caesarean delivery rates and pregnancy outcomes: 2005 Global Survey…in Latin America, 2006.

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CHALLENGE

We do know a lot about what interventions

workbut. . . we still face

manyissues in programmingto bring life-savinginterventions tochildbearing women toreduce maternalmortality

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In the developing world where 50% of births occur in home. . .

. . . what strategy should we invest in for maximum reduction in maternal mortality?

• Bring skilled care to mothers at home• Bring misoprostol (and other

evidence-based home care) to homes where there is no skilled care

• Bring mothers to skilled care

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Skilled care at home

• Women’s choice

• Success in UK, Denmark, Malaysia

• Inefficient

• Requires links to EmOC

• Quality uncertain/supervision difficult

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Effective interventions at home without SBA

• Evidence of some effective interventions related to significant maternal complications that don’t require SBA (Lancet does not agree)– Oral misoprostol– Iron supplementation

• TBA meta analysis did not show effectiveness in reducing maternal mortality

• If trained de novo—huge investment

• Supervision and logistics difficult

Lancet advocates pragmatism

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Oral misoprostolRural India, 2006

• 1620 women, placebo-controlled trial• Misoprostol: oral, stable, positive safety

profile—can be used in the absence of a skilled birth attendant

• Misoprostol associated with– Reduction in PPH (12% to 6.4%; p<0.0001)– Reduction in acute severe PPH (1.2% to 0.2%;

p<0.0001)– Decrease in mean PP blood loss (262.3 to 214.3ml;

p<0.0001)– Transitory chills and fever

Source: Derman, et al, Oral misoprostol in preventing postpartum hemorrhage in resource-poor communities: A randomized controlled trial, The Lancet, Oct. 7, 2006.

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SBA at the facility(includes EmOC or link)

• Can maintain normality (vs hospital)

• Can provide robust interventions

• Promotes 24/7• Scale-up team

model can be 10x solo practitioners

• No RCTs• Does not ensure

quality—studies document– Negligence– Iatrogenic

complications– Abuse

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Strategy Proposed in The Lancet:Team of skilled birth attendants in health

center

• Care during delivery is the priority

• All women should be able to deliver in health centres, with midwives working in teams

• Target the women in greatest need: poor and rural women in sub-Saharan Africa and South Asia

Reducing Maternal Mortality: Getting on with What Works, US Launch of The Lancet Maternal Survival Series, Ronsmans and Koblinsky, Oct 5, 2006

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Considerations• Design programming approach based upon MMR, cause of

death, current availability and cadres of providers

• Can chose more than one approach—keeping in mind that everything costs

• Plan for scale to achieve public health impact

• Phasing strategies

• Different approaches with massive deprivation and marginal exclusion

• Lancet: Need a new era of strategic thinking to address stagnation:

Vision Funds Human resources Track progress

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Our Pearls

• The chance of a woman dying as a result of pregnancy is 150 times greater in Sub-Saharan Africa than in the U.S. This is the health indicator with the greatest disparity between the developed and the developing work.

• Postpartum hemorrhage (PPH) is, by far, the biggest maternal killed, responsible for greater than 30% of maternal deaths in Asia and Africa. PPH is preventable.

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“ Women are not dying because of diseases we cannot treat . . .

. . . they are dying because societies have yet to make the decision that their lives are worth saving ”

. . . . Mahmoud Fathalla