Global Maternal Health: Status and Emerging Strategies

Martha C. Carlough, MD, MPH

UNC/Chapel Hill Department of Family Medicine IntraHealth International, Inc.

Objectives

•  Review the current understanding of global maternal deaths (measurement and statistics) –  WHY, WHEN, WHERE AND WHO?

•  Discuss international evidence based strategies and guidelines directed towards understanding and reducing maternal deaths

•  Share some new ideas on the horizon – innovations and appropriate technologies

•  I have nothing to disclose

What is the definition of a maternal death?

•  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 due to accidental or incidental causes

•  LATE maternal death is defined as death of a

women from direct or indirect obstetric causes more than 42 days but less than one year after the termination of a pregnancy.

WHO. ICD-10. 2012

Measuring maternal mortality is not simple….

•  Maternal Mortality Ratio (MMR): – The number of maternal deaths per 100,000 live

births in the same time period

•  Maternal Mortality Rate: – The number of maternal deaths per 100,000

women of reproductive age in the same time period

•  Lifetime Risk of Maternal Death: – The probability of a woman dying from a maternal

cause during the course of her lifetime (includes risk of death x # of pregnancies or TFR)

Direct obstetric death

Death resulting from: •  obstetric complications of the pregnant

state (pregnancy, birth or postpartum) or •  interventions, omissions, and/or incorrect

treatment for complications

Common causes of direct obstetric death

•  Obstetric Hemorrhage •  Pregnancy-related Infection •  Hypertensive disorders in pregnancy •  Obstructed labor •  Pregnancy with abortive outcome (abortion,

miscarriage, ectopic) •  Complications of anesthesia or surgery related

to pregnancy •  Other obstetric complications – coagulation

disorders, pulmonary embolism, stroke

Indirect obstetric death

Death of a pregnant woman or woman within 42 days of termination of pregnancy resulting from: •  pre-existing disease or •  disease/injury exacerbated by pregnancy

Common causes of indirect obstetric death

•  Exacerbation of cardiac or renal disease •  Severe anemia •  Malaria •  Tuberculosis •  Violence related to pregnancy state

– domestic violence, homicide, suicide •  HIV disease

Global Causes of Maternal Mortality

Ronsmans and Graham, 2006, Khan et.al. 2006

Global maternal morbidity •  For every ONE maternal death, 40-60

women experience an illness or injury related to pregnancy

•  Affects family life, productivity – estimated societal cost of $ 6.8 billion

•  Important causes: –  obstetric fistula and other birth related trauma (genital prolapse) –  Perinatal depression – (up to 20% of women) –  severe anemia (42% of pregnancies worldwide) –  Infertility, pelvic pain –  Anemia and other micronutrient deficiencies

WHEN do maternal deaths occur?

•  MOST deaths occur between 28 weeks gestation (third trimester) and one week after delivery

•  Time of maternal death clusters around labor, delivery and first 24-48 hours postpartum >80% of deaths

•  Pregnancies ending in abortion or stillbirth have higher rates of late maternal deaths than pregnancies ending in term, live infants

Mortality risk vs. time since pregnancy ended:

•  Study in Matlab, Bangladesh (ICDDRB) •  Risk on Day #1 is 100x higher and on Day

3# 30x higher than one year after pregnancy

•  Women who have a pregnancy which does not end in a live birth are 2-3X more likely to have a late maternal death

•  Importance of promoting at least 24 hour postpartum care in facilities.

Hurt and Ronsmans, 2002

WHERE do maternal deaths occur?

•  This varies significantly based on national rates of facility births and skilled attendance at birth, but up to 40% of all registered maternal deaths occur in health facilities (and where investigated, 30% of these deaths are associated with poor quality of care)

•  5-10% of deaths occur in transit •  Remainder of deaths at home (>50% or up to 80%

in countries with low facility based births)

Ronsmans and Graham. 2006

WHO/UNFPA/UNICEF/World Bank update published in 2010:

•  After years of little progress, FINALLY, some good news. Since 1990, there has been overall a 34% decline in global maternal mortality

•  Now estimated at 358,000 maternal deaths per year

•  Sub Saharan Africa and South Asia account for 87% of these deaths (313,000)

Hogan, 2010

Global MMR update:

•  147 countries experienced SOME decline in maternal mortality from 1990-2008

•  23 countries had an increase, most of these are in Sub Saharan Africa – In addition - Afghanistan, Laos,

Bangladesh, Haiti and Cambodia – And of developing countries: USA, Canada

and Norway L

Hogan, 2010

Highest Maternal Mortality Ratio’s overall:

•  Chad (1100) •  Somalia (1000) •  Sierra Leone and Central African Republic

(890) •  Burundi (800) •  All with MMR still >500:

– Liberia, Sudan, Cameroon, Nigeria, Mauritania, Lesotho, Guinea, Niger, Zimbabwe, DRC, Mali

11 countries account for 65% of maternal deaths:

Afghanistan India Indonesia Kenya Nigeria Sudan Pakistan Bangladesh Tanzania Ethiopia DRC

Millenium Development Goal #5: •  2000 - Millenium Declaration

–  MDG#5: Reduce the MM ratio by 85% by 2015 –  Target – increase skilled attendance at birth to 60% by 2015

•  Commonly acknowledged that this is the MDG towards which the least progress has been made. Global annual decline about 2% - would need to be closer to 5% to reach the goal.

•  Global obstetric risk in 1990 à 532:100,000 live births in 2010 à 358 :100,000 live births

•  MMR remains the highest BY FAR in Sub Saharan Africa (SSA) at 640:100,000 live births - 2x higher than South Asia, 4x higher than Latin America (LA), 50X higher than most industrial countries

•  Global Lifetime risk of maternal death is 1:74 –  1:11 women in Afghanistan die

WHO is more likely to die?

•  EVERY woman is at risk •  Those who lack skilled attendance at birth •  Those who do not have access to quality

emergency care, and do not attend antenatal care

•  Women who are poor, lack education, and live in rural isolated situations

The majority of maternal mortality worldwide is experienced by women who could have been designated “low risk”, and many women who are “high risk” and are given extra attention go on to deliver without a problem.

The single

most important, evidence based

obstetric care decision for most women in the

world and reduces maternal mortality by an estimated 13-33%

Skilled Attendance at Birth:

Graham et.al. 2001

Definition of a Skilled Birth Attendant

•  “Trained health provider who has completed a set course of study in handling obstetric emergencies and is registered or legally licensed to practice.”

•  Includes doctors, nurses, midwives and other health workers who can diagnose and manage complications during pregnancy and childbirth, assist in normal deliveries, and who are linked to a referral system for further care when necessary.

Safe Motherhood IAG. 2000 and WHO 2000.

Skilled Attendance variation:

•  In countries where untrained individuals carry out most deliveries, MMR’s are the highest (500-1000/100,000 live births) –  (e.g. Somalia, Chad, Afghanistan)

•  In countries where skilled attendants linked with a referral system carry out most deliveries, irrespective of whether birth is at home, in a maternity home or hospital, MMR can be significantly reduced –  (e.g. Sri Lanka, Malaysia, Nepal!)

Skilled Attendance – WHO 2010 update •  Globally, skilled attendance has increased to 68%

of births (vs. 45% in 1990) but HUGE geographic variation

•  SS Africa has “stalled out” with little change in skilled attendance at birth through 2010 (still <50% in most countries)

•  World Bank in 2005 estimated that 3x the number of current skilled attendants (or 700,000 more) would be needed to achieve universal skilled care by 2015.

•  WHO Skilled Attendance Global Update (2010)

Skilled attendance is influenced by:

•  Attendance at antenatal care •  Parity •  Education •  Socioeconomic status

What is the purpose of antenatal care?

•  Modest benefits for infant – increased birth weight and infant survival, decreased risk of infection

•  Opportunity to evidence based interventions:

–  intermittent preventive treatment (IPT) and bed nets for malaria prevention, ARVs for HIV, tetanus vaccination, nutrition and micronutrient interventions

•  Connection with health system – birth preparedness and complication readiness

•  Women who attend antenatal care are more likely to have a skilled attendant at birth: –  No antenatal care (13%), 1 visit (28%), >3 visits (78%)

Stanton, 2008

Birth Preparedness

Preparing for normal birth

– Skilled attendant – Deciding on place of

delivery – Availability of essential

clean items for birth

Complication Readiness

•  Early detection of problems •  Designated decision maker(s) •  Emergency funds •  Rapid referral •  Transport •  Blood donors

Addressing Major Causes of Maternal Mortality and Morbidity:

•  Postpartum Hemorrhage •  Hypertensive Disorders •  Pregnancy-related Infection •  Pregnancy with abortive outcome •  Obstructed Labor, Induction of Labor,

Reduction of unnecessary CS and surgical complications

•  Indirect – malaria, HIV, anemia, violence

Postpartum Hemorrhage •  Leading cause of mortality in low income

countries, >25% of all deaths •  Atony is leading cause of PPH

–  Other causes: trauma, retained placenta, uterine rupture, coagulation disorders

•  In MOST cases, no identifiable risk •  Although definition is >500cc of blood loss, in

reality many women lose much more and PPH not recognized

•  In women with pre-existing anemia a smaller volume of blood loss could result in severe complications

Active Management of the Third Stage of Labor (AMTSL):

•  Associated with decreased risk of PPH (RR=0.38) with a number needed to treat (NNT) of 18

1. Administration of a uterotonic after delivery of baby at every birth –  Although oxytocin remains the FIRST choice,

misoprostol (Cytotec®) has been approved for use in situations where oxytocin, which requires an injection, is not available

2. Controlled cord traction 3. Uterine massage after delivery of placenta

ICM/FIGO Joint statement, 2005

Cochrane Reviews. 2003, 2006

Re-evaluation of each AMSTL component: •  Administration of uterotonic is THE MOST

IMPORTANT STEP – oxytocin alone remains 1st choice

•  Cord cutting at 2-3 minutes recommended, while simultaneously initiating essential newborn care unless neonatal resuscitation needed

•  Controlled cord traction is now optional (except at CS, where preferred over manual removal) where SBA present and NOT recommended without SBA

•  Where uterotonics are used, uterine massage after placenta delivery not recommended

•  Frequent postpartum abdominal uterine tone for identification of atony is recommended for all women

Postpartum Hemorrhage Treatment

•  Early and aggressive crystalloid fluid replacement, and standard massive transfusion protocols along with uterotonic medications

•  Refractory bleeding or trauma – tranexamic acid •  Intrauterine balloon tamponade recommended for

persistent bleeding or if uterotonics not available •  Other temporizing measures supported only if

uterotonics or surgery not possible or for referral/transport •  Bimanual uterine compression, aortic compression, non-pneumatic

anti-shock garments

WHO, 2012

Community Based PPH prevention:

Uniject – 10 U oxytocin in single use, disposable bubble pack

The “Birth Safety Pill” – 600 mcg of misoprostol packaged for self-administration after delivery

Hypertensive Disorders of Pregnancy (HDP)

•  Account for approximately 10% of global maternal deaths

•  Unfortunately, unlike AMSTL for PPH there is no “magic bullet” for hypertensive disease

•  Only definitive treatment is pregnancy termination or delivery, though highest risk of stroke due to HDP is postpartum

•  High risk: previous HDP, chronic HTN, renal disease, obesity/DM, auto-immune disease, twins

WHO, 2011

Prevention of Pre-Eclampsia

•  Calcium supplementation – 13 RCTs, >15K women, dose of 1.5-2g of

Calcium associated with RR=0.45 (greater in women with low Calcium intake of <600mg/day)

•  Aspirin – 60 RCTs, >37K women, low dose ASA (75mg)

in women at high risk associated with RR=0.75, improved (RR=0.82) if started prior to 20 weeks gestation

Villar, Cochrane, 2006

Treatment of Severe Pre-Eclampsia •  Antihypertensive drug choice and route for Rx for severe

HTN based on clinician experience and availability of med – no clear BEST choice

•  Magnesium sulphate reduces risk of seizures – RR=0.41. Magpie Trial of >10K women. Superior to placebo and any other anti-seizure medication – diazepam, phenobarbital, lorazepam…. –  In situations where full IV regimen is not possible,

initiating IM loading dose followed by immediate transfer is recommended.

•  Induction is recommended for women with severe pre-E at any gestational age when fetus is not viable or unlikely to achieve viability within 1-2 weeks

Lack of availability of critical medications impacts quality of care:

•  Although oxytocin, misoprostol and magnesium sulphate are on the WHO essential drug list and MOST national formularies, they are often not available when and where needed

•  Recent survey of 37 countries supported by USAID projects demonstrated: – Magnesium sulphate available 75% of the

time, oxytocin 70% of the time and misoprostol (where legally available) 35% of the time.

MCHIP 2012 Global Status Report

Pregnancy-Related Infection

•  Prophylactic antibiotic for CS, manual removal of placenta

•  Antibiotics and induction of labor for premature ROM (reduces chorioamniotis by RR=0.57)

•  Screening for asymptomatic bacteruria in pregnancy and aggressive treatment of urinary tract and reproductive tract infections in pregnancy

•  Initiating broad spectrum antibiotics within one hour of diagnosis of sepsis significantly reduces mortality (Surviving Sepsis Guidelines, 2008)

Hofmeyer, 2009

Abortion and Post-abortion (PAC)

Care •  41% of pregnancies globally are unwanted; 22%

result in induced abortion •  There is one unsafe abortion for every seven

births •  Approximately 40% of induced abortions

worldwide are carried out under unsafe conditions (rates highest in LA and East Africa)

•  Between 10-50% of all women who undergo unsafe abortion need medical care for complications

WHO and IPAS. 2010

Family Planning •  Without pregnancy there would be no maternal

death •  Globally, average fertility rate has decreased from

4.9 in 1960s to 2.7 today •  Unmet need for contraception is still as high as

33% in SSA and parts of South Asia •  At least 25% of maternal deaths could be

prevented if unplanned and unwanted pregnancies were prevented

•  Continual access to FP commodities remains one of the most important challenges worldwide

UNFPA Press Release 2009

Unmet need for FP of 201 million women in developing countries translates to:

•  23 million unplanned births •  22 million abortions •  2 million miscarriages •  1.4 million infant deaths •  142,000 pregnancy-related deaths

– 53,000 from unsafe abortion – 89,000 from other causes

Guttmacher Policy Review,. Spring 2010

Obstructed/Prolonged Labor:

•  The partograph….”There is no evidence that use of a partograph alone results in reduced CS, instrumented vaginal delivery, or poor neonatal outcomes. Routine use cannot be strongly supported, though it appears reasonable to continue use based on local standards until stronger evidence as a critical intervention is possible.”

•  Identify malpresentation early, external cephalic version for breech (otherwise CS delivery)

•  Keep labor normal – maternal position, continuous support, ambulation

Lavender, Cochrane, 2012

Anatomy of obstetric fistula

An obstetric fistula MOST often develops during labor and birth when the infant’s head descends into the maternal pelvis and cannot pass through. • Woman’s pelvis is too small or poorly developed • Infant is too big or is poorly positioned (malpresentation or malposition) • Labor is obstructed • Results in urinary and/or fecal incontinence

Obstetric fistula

•  The most common type is between bladder and vagina (VVF), and the woman has resulting in urinary incontinence.

•  Most of the time, VVF can be diagnosed

1-2 weeks postpartum, but it may be obvious as soon as 24-48 hours after delivery.

An extrapolation from the WHO Global Burden of Disease study:

•  6.5 million in least developed countries experience obstructed labor each year –  5% of women with labor ending in live birth had obstructed labor –  8% of maternal mortality due to obstructed labor

•  Somewhere between 2-5% of these women PROBABLY develop fistula

•  This amounts to 130,000 new cases per year •  Many women live for years with fistulas out of

contact with the health care system and without opportunities for repair

WHO, 2006

Early detection and treatment •  If a woman has recently survived a prolonged or

obstructed labor, prevent development of an obstetric fistula OR promote spontaneous closing of a small fistula Indwelling urinary foley catheterization for at least 2 weeks (and as long as 4-6 weeks for larger fistula)

•  IF there is an experienced clinician available, explore the vagina and gently excise any necrotic tissue. Surgical repair when necrotic edges clean.

•  No benefit of traditional delay of surgery until 3 months

Prevention

•  Educate and empower women and communities about fistula

•  Delay early childbearing •  STOP female genital mutilation •  Recognize and prevent prolonged/

obstructed labor

Obstetric Fistula largely represents a failure of emergency obstetric care

A substantial portion of maternal deaths occur in hospital:

•  Women who arrive too late to benefit from care

•  Women who arrive in time with complications who do not receive timely, quality care

•  Women who develop complications in the course of normal labor in hospital who are not cared for well

•  Up to a third of in hospital deaths have some MAY be due to poor quality care.

WHO recommendations for Induction of Labor (IOL) – High points:

•  Up to 10% of all deliveries globally involve IOL and it is not necessarily risk free

•  IOL not recommended for uncomplicated pregnancy <41 weeks (or where gestational age cannot be reliably confirmed)

•  IOL recommended for premature ROM, and pregnancy >41 weeks

•  Agents supported: misoprostol (25 mcg oral q 2 hrs, 25 mcg vaginal q 6 hrs), balloon catheter, sweeping (moderate evidence only) and oxytocin

•  IOL only in facilities with CS capability and never in outpatient facilities

WHO. 2011

2004-2008 WHO global caesarian survey:

•  Staged survey of CS delivery –  24 countries, >400 facilities, >300,000 deliveries

•  ↑ Rate of C/S associated with: –  ↑ rate of use of postpartum antibiotics –  ↑ rate of PPH and blood transfusion –  ↑ length of hospital stay for mother (beyond 7 days) –  ↑ rate of prematurity, neonatal unit admissions and

neonatal deaths –clearly evident as C/S rates exceed 20% •  Risk of short term adverse outcome 6x higher

(OR=5.93) for CS without indication vs. vaginal delivery

Villar. Lancet. 2006 Souza, 2010

Caesarean section rate: •  A marker for quality of EmOC •  WHO recommends that 5-15% of deliveries

by C/S for the health of mother and/or infant; higher or lower rates associated with increased mortality

•  12% overall for developing countries – <1% in some rural areas of SSA and South Asia – 60-75% in some LA countries (Brazil, Mexico)

Reducing Hospital-based maternal deaths:

•  Established and available protocols, case management and emergency drills

•  Safe surgical care •  Monitoring and evaluation

– Maternal death audits – Verbal autopsies of maternal deaths – Recognizing unreported maternal deaths – Examining “near miss” maternal deaths

Rapid Ascertainment Process for Institutional Deaths (RAPID)

•  Review of all institutional records of death to women of reproductive age (15-49) to identify unreported maternal deaths – all wards (trauma, surgical, GYN, pediatric…)

•  Classify: direct or indirect maternal death, or unrelated

•  Often uncovers up to 1/3rd more maternal deaths than initially reported

Immpact Toolkit. 2007

WHO uniform definition of maternal “near miss”

•  Severe life threatening obstetric complication necessitating urgent medical intervention to prevent the likely death of the mother

•  Clinical criteria: cyanosis, gasping, tachypnea (RR>40) shock, oliguria, clotting failure, loss of consciousness, jaundice with pre-eclampsia

•  Laboratory criteria: O2 sat <90%, Creatinine >3.5, pH <7.1, platelets <50K, bilirubin >100

•  Management based criteria: use of vasoactive drugs, hysterectomy following hemorrhage, transfusion of >5 u of RBCs, intubation not related to anesthesia for surgery, dialysis, need for CPR

WHO, 2011

Indirect causes of maternal mortality

•  Malaria •  HIV/AIDS •  Anemia •  Violence

Malaria in Pregnancy

•  Pregnant women 2x as likely to become infected than non-pregnant women.

•  Most at risk: 1st and 2nd pregnancies, co-infection with HIV and women who move from low à high transmission area

•  400,000 pregnant women get malaria each year, 10,000 maternal deaths/year in Africa or 11% of global maternal mortality

•  The risk of a pregnant woman dying with cerebral malaria approaches 50% if not treated appropriately in the first 24 hours

Guyatt, 2001

Low Transmission Areas

•  In areas of low or unstable transmission (<10% population prevalence) , all women are at increased risk of acute infection, including cerebral malaria.

•  In areas with high or stable malaria transmission (population prevalence > 10%) women may not as commonly have acute illness in pregnancy, but the associated morbidities (e.g. anemia, LBW and prematurity) are still present

•  Focus interventions accordingly

Choosing interventions:

•  High Transmission areas –  IPTp and iron/folate

supplementation for all pregnant women

–  Long lasting nets for pregnant women; particularly vulnerable groups (adolescents, HIV/AIDS, those moving from low transmission à high transmission area)

–  Presumptive treatment with severe anemia and fever >24 hours without other cause

•  Low Transmission areas –  IPTp relatively less

effective –  iron/folate supplementation

for pregnant women –  Seasonal long lasting nets

for pregnant women and consider indoor residual spraying

–  PROMPT treatment of symptomatic malaria which may quickly progress in non-immune women

Treating complicated malaria •  Remember there are other reasons for

seiziures in the pregnant woman •  Risk of death is greatest in first 24 hours –

DON’T delay treatment. •  First trimester

–  Quinine is drug of choice but arteminsin combination therapies (ACT) also now a supported option

•  2nd and 3rd trimesters –  IM or IV artesunate is the first and artemether the 2nd

option (can be given rectally if injection not possible)

WHO. 2010

Maternal Deaths and HIV •  Not all deaths of HIV+ women in

pregnancy are classified as a maternal death, but many now are…

•  Proportion of global maternal deaths in SSA was 23% in 1980 vs. 52% in 2008

•  9% of all maternal deaths or an estimated 42,000 deaths per year due to HIV/AIDS

•  Anti-retrovirals (HAART) reduce maternal to child transmission of HIV, but also save maternal lives

Anemia and maternal health •  Iron deficiency anemia is THE most common micronutrient

deficiency globally. •  Formal WHO recommendation is 6 months of Fe/folate

during pregnancy and 2 months postpartum for women with moderate to severe anemia

•  Blanket iron supplementation programs to pregnant women have largely not been effective

•  Most hopeful approaches are with population based food supplementation and targeted weekly supplementation with multi-micronutrient mixes –  Vitamin C, Vitamin A (appropriate dose for pregnancy,

7000 IU/day or 25,000 IU/week) Zinc, Folate and B vitamins.

Berger, et.al. 2011

• Pregnant girls 2-3x more likely to die from violent causes than non-pregnant girls in same age range.

• Violence against women is common in crisis situations (e.g. refugee camps) and reproductive health needs are often overlooked in complex humanitarian emergencies

• More than half of deaths due to homicide in pregnancy are related to intimate partner violence

Ronsmans and Khlat, 1999.

The high cost for women of violence, civil unrest and war:

Access to emergency obstetric care is often disrupted in emergencies:

Birth at the Ramallah checkpoint, West Bank. Palestine

Appropriate technology for saving lives

•  Delivery training models – Partopants TM

– Mama Natalie TM

•  Other devices – Maternova – PATH

– WHO 10 best new technologies – Gates Grant Challenge Grants

In summary… •  There is reason to hopeful, but lots of work

remaining – and A LOT that fits FM physician skills nicely

•  The road forward must include: – Reduction of unplanned and unwanted

pregnancies –  Increased access to skilled attendance and safe

emergency OB care for ALL women – Systematic change to improve quality of care in

facilities

Questions and comments?

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