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“IMANA is committed to providing CME activities that are fair, balanced, and free of bias. Full and specific disclosure information is provided in your handouts.”

I have no relevant financial relationship(s) with any commercial interests.

Increasing a Comprehensive Awareness of Maternal Mortality

Adrienne Strong, M.A.

Washington University in St. Louis, Department of Anthropology

Universiteit van Amsterdam

Outline of the presentation Overview of maternal mortality globally Past successes Current challenges Maternal mortality in Tanzania Research on non-clinical causes of maternal death in

the health facility setting Directions for improvement and further research Conclusions

Maternal Mortality: A Global Problem

Graphic from worldmapper.org

Definition of Maternal Death

WHO definition of maternal death: “Maternal death is the death of a woman while pregnant or

within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. To facilitate the identification of maternal deaths in circumstances in which cause of death attribution is inadequate, a new category has been introduce: pregancy-related death is defined as the death of a woman while pregnant or within 42 days of the termination of pregnancy, irrespective of the cause of death.”

Direct and Indirect Causes

Direct causes: "direct complication from pregnancy, birth, or postpartum

related to things that were done or should have been done" major causes include--> hemorrhage, infection, eclampsia and hypertensive disorders, unsafe abortion, obstructed labor (leading to ruptured uterus), embolism, and anesthetic complications

Indirect causes: "due to a disease or condition that is exacerbated or

caused by the pregnancy" i.e. heart conditions, renal disease, HIV, malaria

Past Successes

Progress has been made since the 1985 launch of the Safe Motherhood Initiative but there is much work still to be done and we must still consider the effects of severe morbidity sustained during pregnancy, birth, and the post-partum

Safe Motherhood Timeline

Safe motherhood Initiative Launched• 1985

Millennium Development Goals Adopted• 2000

Endpoint of MDGs• 2015

Changing Strategies

Shifting policy focus since 1985 Emphasis on training local birth attendants Encouraging access to prenatal care Incorporating a rights-based approach Emphasis on skilled attendance at birth Emphasizing access to Basic Emergency Obstetric Care

(BEmOC) and Comprehensive Emergency Obstetric Care (CEmOC)

Evidence based interventions and policies (including capacity building for BEmOC and CEmOC)

BEmOC and CEmOC Requirements BEmOC

Parenteral antibiotics Oxytocic drugs Anti-convulsants Manual removal of

placenta Assisted vaginal

delivery

CEmOC All of the above plus

safe blood transfusions and ability to perform surgery

WHO Notes General Successes Leadership and partnership

Evidence and innovation

Dual long- and short-term strategies

Adaptation to change for sustained progress

Improvements in strategies related to gender, neonatal health, nutrition, and safer motherhood

Improved efforts to conduct death reviews

Continuing Challenges

Continuing Challenges

In Communities Data collection

Distribution of supplies and funds

On-going presence of traditional/indigenous birth attendants

In Health Facilities Data collection

Communication

Continuing education

Connection between all levels of the health care system

Continuing Challenges

In Communities Male involvement

Transportation

Skilled providers and support for them

Sensitization

In Health Facilities Blood supplies

Improving provider skill levels

Management and leadership

Consistent and reliable supply of equipment and medications

Data Collection Lack of documentation

Incomplete civil registery systems Lack of death certificates Misunderstanding of how to document or code deaths Misdiagnosis or incorrect attribution of cause of death

Estimates from different organizations all different Biases and purposeful withholding of data

Approaching MDGs endpoint in 2015 Desire for projects to look like they are working Desire to avoid litigation Desire or need to cover-up pregnancy state, cases of unwanted

pregnancies or abortions

Estimates

Estimating Maternal Mortality Rates As per the WHO document “Trends in Maternal

Mortality: 1990-2013”

Overall Challenges

Political will Funds and budgeting for maternal and child health

care Reaching people in less densely populated areas Corruption and bureaucratic procedures Quality of prenatal care and regular attendance “Cultural” barriers

Maternal Death

Delay in deciding to seek care

Delay in reaching

careDelay in receiving

care

The 3 Delays Model

Thaddeus and Maine, 1994

Pregnancy

Desire for Care

Seek transportatio

nReach

Hospital

Care

Doesn’t seek care

Bad experience, decides not to return

Denied permission, no place to go

Unable to find transport

Does not receive care

Barrier

BarrierBarrierBa

rrier

Barrier

The Poverty Factor

Poverty sets women up for many pregnancy-related complications and puts her at risk for all three delays

The Status of Women

What

social resources can she mobilize if she develops a co

mplication or emergency?

Unwanted pregnancy

Adolescent pregnancy

Unstabl

e relationship with partner or

family

Lack of male

involvement in

reproductive

and women’s health

Other Clinical Conditions

Classified as indirect causes of maternal death, may be exacerbated by the pregnancy but not directly caused by it

Particularly HIV/AIDS Malaria Anemia Renal conditions Cardiovascular conditions

Maternal Mortality in Tanzania

White Ribbon Alliance Tanzania

Wajibika Mama Aishi

Political Commitment Advocating for political commitment to the promise that

50% of government health centers (secondary level of care) will provide CEmOC services

Increasing per capita spending on health care Building dispensaries and health centers in every village

throughout Tanzania Increasing number of health professionals who graduate

from training programs each year

Social and Institutional Environments of Health Facilities

An Institutional Environment is Comprised of…

Formally stated goals and mission of an organization Organization of staff, bureaucratic procedures Hierarchy Leadership Communication Involvement of staff in larger, organization-level decision making Opportunities for education and career advancement Supplies/equipment- quality and availability Budget Connection to outside organizations, the government

How Does This Affect Care? Level of provider training Supportive supervision Budget for staff, supplies, and maintenance of infrastructure Poor leadership and communication can lead to conflict

between staff members Routines are hard to change Lack of creative problem solving No consistent recognition of jobs well done Difficult disciplinary procedures with few immediate effects

Examples Small but important problems

Illegible handwriting, especially clinicians leads to delays, repeat tests, communication issues

No lab tests done when ordered or answers not retrieved ANC clinics and inpatient

Opportunities for leadership and problem solving Interactions and communication with patients

Should keep in mind disempowered populations i.e. very young, older grand multiparous women, women from villages, uneducated, etc.

Patient education Basic physiological explanations of how the body works and

what to expect during pregnancy and birth (i.e. what does “bado sana” mean while in labor)

Examples cont. Timely, honest, and comprehensive reviews of deaths, near

misses, and cases of mismanagement What went wrong? What can we do better next time? What

kinds of systems do we have to implement to make our work more efficient and effective? Follow up at all levels, including districts, to find this information

Routes for asking for and addressing patient complaints Is there a transparent and easily accessible way for patients

and their family members to express concerns or ask questions about the care they received? How are their concerns used to improve care?

From the Data

Focus Group Discussion (n=19) What can cause a pregnant woman to die during,

pregnancy, birth, or in the post-partum period? Other questions: What are the biggest difficulties at the

hospital? What problems do women have when seeking care at the maternal child health clinic and during labor and birth?

Interpersonal Interactions

Conflicts between providers Poor leadership skills

Not collaborative; accusatory style Lack of initiative to generate new ideas and solutions Unable to effectively get genuine input from subordinates

Lack of cohesive vision for the care and services provided As generated by staff members themselves, not imposed

from outside or a higher level

Results of Interpersonal Relations Care Suffers!- lack of rigor and lack of communication

leads to bad outcomes Ward or clinic staff unable to work effectively as a team New ideas are not encouraged and implemented Worker burnout and decrease in motivation Decreases in staff morale Women unhappy with services and do not return or come

late

In the Village Setting Different problems

Severe shortage of workers Low-levels of training Lack of supplies Lack of support from

district health administration

LACK OF KNOWLEDGE Long distances to referral

centers Low levels of supervision

The Way Forward Improving integration of health

systems at all levels

Improving communication within and between facilities

Being mindful of the influence of social interactions on patients’ likelihood to return for care

Continuing capacity building for medical interventions

Improved documentation and death surveillance

Continuing efforts at improving health knowledge and community participation in maternal health

Future and Continuing Research

Need more information on the functioning of local health care administration and the challenges they face from a qualitative perspective

Integrating clinical and non-clinical causes within facilities in order to increase our understanding of the confluence of events leading to maternal death

References Bazzano, A. N., Kirkwood, B., Tawaih-Agyemang, C., Owusu-Agyei, S., & Adongo, P. (2008). Social costs of skilled attendance at birth in rural

Ghana. International Journal of Gynecology and Obstetrics (102), 91-94. doi: 10.1016/j.ijgo.2008.02.004

Campbell, O. M., & Graham, W. J. (2006). Maternal Survival 2: Strategies for reducing maternal mortality: getting on with what works. The Lancet (368), 1284-99. doi: 10.1016/S0140-6736(06)69381-2

Donnay, F. (2000). Maternal survival in developing countries: what has been done, what can be achieved in the next decade. International Journal of Gynecology & Obstetrics (70), 89-97.

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Griffiths, P., & Stephenson, R. (2001). Understanding users' perspectives of barriers to maternal health care use in Maharashtra, India. Journal of Biosocial Science , 33, 339-359.

Koblinsky, M., Matthews, Z., Hussein, J., Mavalankar, D., Mridha, M. K., Anwar, I., et al. (2006). Maternal survival 3: going to scale with professional skilled care. The Lancet (368), 1377-86. doi: 10.1016/S0140-6736(06)69382-3

Kruk, M. E., Mbaruku, G., Rockers, P. C., & Galea, S. (2008). User fee exemptions are not enough: out-of-pocket payments for "free" delivery services in rural Tanzania. Tropical Medicine and International Health , 13 (12), 1442-1451.

Kyomuhendo, G. B. (2003). Low use of rural maternity services in Uganda: impact on women's status, traditional beliefs and limited resources. Reproductive Health Matters , 11 (21), 16-26.

Lubbock, L. A., & Stephenson, R. B. (2008). Utilization of maternal health care services in the department of Matagalpa, Nicaragua. Pan American Journal of Public Health , 24 (2), 75-84.

Ronsmans, C., & Graham, W. J. (2006). Maternal Survival 1: Maternal mortality: who, when, where, and why. The Lancet (368), 1189-200. doi: 10.1016/S0140-6736(06)69380-X

Thaddeus and Maine (1994) “Too far to walk: maternal mortality in context.” Social Science & Medicine 38 (8): 1091-110.

White Ribbon Alliance Tanzania [WRATZ] (2014). www.whiteribbonalliance.org/national-alliances/tanzania/

World Health Organization [WHO] (2014) “Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank, and the United Nations Population Division.” WHO: Geneva, Switzerland.

Disclosure

“IMANA is committed to providing CME activities that are fair, balanced, and free of bias. Full and specific disclosure information is provided in your handouts.”

I have no relevant financial relationship(s) with any commercial interests.