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Maternal and Child Health

Global scenario

Prof. Tahera AhmedFormer Asstt. RepresentativeUNFPA

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Definition of Health-WHO

A state of complete physical, mental and social well being and not merely the absence of disease or infirmity.

The defn. has been amplified to include the ability to lead a socially and economically productive life.

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MCH. Maternal and Child Health

therefore implies that

Mothers and (would be mothers) have access to promotive, preventive , curative and rehabilitative health care for themselves and their children.

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MCH includes:

Reduction of maternal, perinatal, infant and childhood mortality and morbidity

Promotion of Reproductive Health Promotion of physical and psychological

development of children and adolescents Life long health of mothers and children

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Major Global Maternal and Child Health Issues1. Maternal and newborn survival2. Respiratory Infections3. Diarrhoeal Diseases4. Malaria5. HIV/AIDS, Tuberculosis6. Vaccine preventable Diseases7. Accidents8. Nutrition and Environment9. VAW and Child Abuse

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Maternal Health-Global concerns

Five main killers cause more than 70% of maternal deaths worldwide:

1. severe bleeding,2. infections, 3. unsafe abortion 4. hypertensive disorders (pre-eclampsia and

eclampsia) and 5. obstructed labour.

Postpartum bleeding can kill even a healthy woman, if unattended, within two hours.

Most of these deaths are preventable. 

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Maternal mortalityMaternal mortality is defined by the World Health

Organization as the death of a woman –  Either while pregnant Or within 42 days after termination of pregnancy from any

cause related to or aggravated by the pregnancy or its management

This includes death as a complication of abortion or miscarriage at any stage of pregnancy.

On an average, worldwide, nearly 600,000 maternal deaths occur each year; 99% occur in the developing world.  The majority of maternal deaths are preventable. 

Despite target of the Millennium Development Goals (MDGs) to reduce the maternal mortality ratio, by 2005 the global maternal mortality ratio declined by only 5%, from 430 to 400 maternal deaths per 100 000 live births.

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Maternal morbidities More than 136 million women give birth a

year. About 20 million of them experience: pregnancy-related illness after childbirth.

The list of morbidities includes fever, anaemia, fistula, incontinence, infertility and depression.

Very often, ill women are stigmatized and ostracized by their husbands, families and communities.  

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Adolescent mothers

About 14 million girls aged between 15 and 19 give birth each year, accounting for more than 10% of all births.

In the developing world, about 90% of the births to adolescents occur in marriage.

In many countries, the risk of maternal death is twice as high for an adolescent mother as for other pregnant women.

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Adolescent Mother

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Rich-Poor Differentials

The state of maternal health mirrors the gap between the rich and the poor. Only 1% of maternal deaths occur in high-income countries.

A woman's lifetime risk of dying from complications in childbirth or pregnancy is about one in 7in Niger and one in 48,000 in Ireland.

Maternal mortality is higher in rural areas and among poorer and less educated communities.  

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Unsafe Abortions

About 18 million unsafe abortions are carried out in developing countries every year, resulting in 70, 000 maternal deaths. Many of these deaths could be prevented if information and services on family planning and contraceptives were available and put into practice.

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The Maternal Health situation globallyRegion MMR

World 400

Developed region 9

Countries of CIS 51

Developing region 450

Africa 820

Northern Africa 160

Sub-Saharan 900

Asia 330

Eastern Asia 50

South Asia 490

South Eastern Asia 300

Western Asia 160

Latin America and and Caribbean 130

Oceania 430

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Human and Reproductive Rights Maternal mortality is not just a health issue; it is a

human rights issue. “It is time to recognize that avoidable maternal mortality is

a human rights problem on a massive scale.” Paul Hunt, former UN Special Rapporteur on the Right to the Highest Attainable Standard of Health.

International conventions like the Commission for the Elimination of All Forms of Discrimination against Women (CEDAW), the International Conference on Population and Development (ICPD), and the Beijing conference on women (FWCW) have emphasized women’s rights to a healthy and safe pregnancy and childbirth.

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Incidence of major complications of childbirth, worldwide

Complication

Incidence(% of

Live births)

Number of cases per year

Case-fatality rate

Maternal deaths in 2000 (%)

Main sequelae for survivors

DALYs lost (000)

Post partum

haemorrhage

10.5 13,795,000 1 132,000 Severe anaemia

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Sepsis 4.4 5,768,000 1.3 79,000 Infertility 6901

Pre-eclampsia and eclampsia

3.2 4,152,000 1.7 63,000 Not well

evaluated

2 231

Obstructed Labour

4.6 6,038,000 0.7 42,000 Fistula, incontinence

2 951

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Success : building health systems

Industrialized countries halved their maternal mortality in the early 20th century by providing professional midwifery care at childbirth;

They further reduced it to current historical lows by improving access to hospitals after the Second World War .

A number of developing countries have gone the same way over the last few decades.

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Sri Lanka One of the earliest and best-documented examples is Sri

Lanka, where maternal mortality levels, compounded by malaria, had remained well above 1500 per 100 ,000 births in the first half of the 20th century – despite 20 years of antenatal care. In this period midwifery was professionalized, but access remained limited.

From around1947 mortality ratios started to drop, due to improved access and the development of health care facilities in the country . This brought mortality ratios down to between 80 and 100 per 100, 000 births by 1975.

Improved management and quality then further lowered them to below 30 in the 1990s, according to Ministry of Health time series.

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Malaysia Malaysia also has a long-standing tradition of professional

midwifery – since 1923. Maternal mortality was reduced from more than 500 per

100 000 births in the early1950s to around 250 in 1960. The country then gradually improved survival of mothers

and newborns further by introducing a maternal and child health programme.

A district health care system was introduced and midwifery care was stepped up through a network of “low-risk delivery centres”, backed up by high-quality referral care, all with close and intensive quality assurance and on the initiative of the public sector authorities.

This brought maternal mortality to below 100 per 100 000 by around 1975,and then to below 50 per 100 000 by the 1980s

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Thailand Until the 1960s Thailand had maternal mortality levels

above 400 per 100 000births, the equivalent to UK in 1900 or USA in 1939.

During the 1960s traditional birth attendants were gradually substituted by certified village midwives, mortality came down to 200 - 250 per 100 000 births.

The number of midwives increased to 18 314. Midwives became key figures in villages, proud of their professional and social status.

Mortality dropped steadily and caught up with Sri Lanka by 1980. Within 10 years, from 1977 to1987, the number of beds in small community hospitals quadrupled, to 10,800, and the number of doctors in districts rose from a few hundred to 1,339.

The main effort then went into strengthening and equipping district hospitals.

By1990 the maternal mortality ratio was below 50 per 100 000 births

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Egypt

Egypt reduced its maternal mortality by more than 50% in eight years, from 174 in 1993 to 84 per 100 000 live births in 2000:

major efforts to promote safer motherhood doubled the proportion of births attended by a doctor or nurse and improved access to emergency obstetric care

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Breakdowns of access to skilled care These examples illustrate that long-term initiatives and

efforts to provide skilled professional care at birth produce results; unfortunately, the converse is true as well.

In Tajikistan , economic upheaval following the break-up of the Soviet Union and newly won independence in 1991, compounded by civil war, led to erosion of the capacity of the health care system to provide accessible care and a dramatic tenfold increase in the proportion of women giving birth at home with no skilled assistance. Maternal mortality ratios rose as a result.

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Breakdowns of access to skilled care In Iraq, sanctions during the 1990s severely

disrupted previously well-functioning health care services, and maternal mortality ratios increased from 50 per 100 000 in 1989 to 117 per 100 000 in 1997, and were as high as 294 per 100 000 in central and southern parts of the country .

Iraq also experienced a massive increase in neonatal mortality during this period: from 25 to 59 per 1000 between 1995 and 2000.

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Skilled care: Factors for Success

The countries that have successfully managed to make motherhood safer have three things in common:

First, policy-makers and managers were informed: they were aware that they had a problem, knew that it could be tackled, and decided to act upon that information.

Second, they chose a common-sense strategy that proved to be the right one: not just antenatal care, but also professional care at and after childbirth for all mothers, by skilled midwives, nurse-midwives or doctors, backed up by hospital care.

Third, they made sure that access to these services – financial and geographical – would be guaranteed for the entire population .

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Skilled care: Factors for Delays in Success

1. Where information is lacking and commitment is hesitant 2. Where strategies other than that of professionalization of

delivery care are chosen 3. Where universal access is not achieved, This explains why the USA lagged so far behind a number

of northern European countries in the 1930s, and why many developing countries today still have high levels

of maternal mortality . To provide skilled care at and after childbirth and to deal

with complications is a matter of common sense and the challenge we have to face

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Care that is close to women – and safe All mothers and newborns, need skilled maternal and

neonatal care provided by professionals at and after birth.

There is a need and demand for care that is close to where people live, but at the same time safe, with a skilled professional able to act immediately when largely unpredictable complications occur.

The Critical features of the type of care is required is: responsive, accessible in all ways, and a midwife, or a

person with equivalent skills, is there to provide it competently to all mothers, with the necessary means and in the right environment.

This level of care is appropriately referred to as “first-level” care. the attendant should have the skill-base required to attend to situations that can suddenly and unexpectedly become life-threatening.

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Recommended packages: the result of an international consensus

Most interventions, such as surveillance of the progress of labour, psychological support, initiation of breastfeeding and others, have to be implemented for all mothers and newborns in all circumstances.

Other elements in the package – such as manual removal of the placenta or resuscitation of the newborn – are only needed when the situation demands it. It is crucial that the whole package be available and on offer to all, immediately, at every childbirth

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“skilled attendants”.

These interventions can only be provided by trained professionals with skills and competences called “skilled attendants”.

A skilled attendant has the level of skills and competence required to deliver a baby normally and recognize a complication, a situation which is difficult to predict and decide on the right action .

Choosing the wrong intervention or hesitating for too long to intervene or to refer the woman a t the right time and in the right way can have disastrous consequences.

The prototype for a skilled attendant is the licensed midwife including nurse-midwives

Gynaecologists-obstetricians are more appropriate for back-up referral care.

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3 functions for Care that is close to women – and safe

1. The first is to make sure that the birth takes place in the best of circumstances, by building a personal relationship between the pregnant woman and the professional.

2. The second function is to resolve complications as they arise, making sure that they do not degenerate into life-threatening emergencies.

3. The third is to respond to life-threatening emergencies when they do occur, either directly or by calling on referral-level care that has to be available as a back-up.

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A back-up in case of complications

Back-up is ideally provided in a hospital where doctors – specialists, skilled general practitioners or mid-level technicians with the appropriate skills – can deal with mothers whose problems are too complex for first-level providers.

To make the difference between life and death, the required staff and equipment must be available 24 hours a day, and the links between the two levels of care should be strong.

Transportation should be available

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Postpartum care is important For many women, poverty combines with

cultural constraints to construct a “social curtain” around them . In places where the majority of births take place at home, postpartum care may be unavailable or women may not know that services exist.

Many service providers and families focus on the well-being of the new baby and may not know the importance of complications such as postpartum bleeding .

The need is for a pragmatic approach to PNC in resource-poor settings to ensure continuity of care

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Training practitioners for safe delivery: two formulas

There are two formulas for which satisfactory results have been documented

1. The first is the training of nurse-midwives, with an entry level of more than 10 years’ education, three years of nursing training and one to two years of midwifery. Australia, Botswana, Kenya, Senegal, Sweden and the United Kingdom.

2. The second formula is direct-entry midwife training: three years’ combined theoretical and practical specialist midwifery training after more than 10 years of general education. Successful in Canada, Indonesia and the United Kingdom.

3. The conclusion is that reaching the skills threshold where a midwife or nurse-midwife can work autonomously requires a considerable investment in high-level basic training.

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Key features of first-level and back-up maternal and newborn care

First-level maternal and newborn care

Back-up maternal and newborn care

Defining feature Close to client: demedicalized, but professional care

Referral level technical platform

For whom? For all mothers and new borns For mothers and newborns who present problems that cannot be solved by first-level care

By whom? Best by midwives; alternatively, by doctors or by doctors or nurses if correctly trained and skilled

. Best by a team that includes gynaecologists-obstetricians and paediatricians; alternatively,appropriately trained doctors or mid-level technicians

Where? preferably in midwife-led facilities; also in all hospitals with maternity wards

In all hospitals

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First-level care save lives .First-level care does save lives and manage emergencies. It does

so by controlling conditions before they become life threatening (by treating anaemia, or by avoiding complications (through active management of the third stage of labour,).

A midwife or other professional with midwifery skills can deal with a range of emergencies on the spot, such as by administering vacuum extraction in case of fetal distress or by arranging emergency referral for caesarean section or other back-up care.

First-level care takes place in an environment where a woman is comfortable with her surroundings, and where the fear and pain that go with giving birth are managed positively.

Maternal and newborn care at first level provides a whole package of care that improves maternal and newborn outcomes.

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Antenatal care is important

ANC with TT and other check ups important However “no amount of screening will separate those women

who will from those who will not need emergency medical care” .

most women who eventually experience complications have few or no risk factors, and most of the women with risk factors go on to have uneventful pregnancies and deliveries .Antenatal care is important to further maternal and newborn health – but not as a stand-alone strategy and not as a screening instrument.

To ensure safe childbirth, on the other hand, skilled professional care needs to be available for all births, even the ones not at risk.

Referral Centers are critical to save mothers

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Maternal Nutrition In Southeast Asia, 450 million adult women suffer from

protein energy malnutrition.

In nations like Pakistan and Bangladesh, 70 percent of women present with chronic energy deficiency.

In Africa, 20 to 40 percent of women are malnourished.

In Southeast Asia and Africa, 19.2 million women live with AIDS, according to a 2003 World Health Organization report.

More than 60 percent of women in Southeast Asian nations and 80 percent of pregnant women in India suffer from iron deficiency anemia. 2.5 million women suffer from iodine and vitamin A deficiency, and the maximum number of reported cases is in the Asian countries.

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Global prevalence of nutritional anemia

Region Pregnant Women Nonpregnant Women All Women

World 51% 35% 36%

Developing countries

55% 42% 44%

Developed countries

17% 12% 12%

Asia 59% 44% 45%

India 87.5% 80% 60%

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Maternal Nutrition

80% of the world's undernourished children live in just 20 countries. Intensified nutrition action in these countries can lead to achievement of the first Millennium Development Goal (MDG) and greatly increase the chances of achieving goals for child and maternal mortality (MDGs 4 and 5)

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Maternal Nutrition

The period in the life cycle from the mother’s pregnancy to the child’s second birthday provides a critical window of opportunity in which interventions to improve maternal and child undernutrition can have a positive impact on young children’s prospects for survival, growth andd evelopment, especially in developing countries.

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A package of effective nutrition interventions has widely been agreed upon by experts. It includes interventions in key areas:

Maternal nutrition during pregnancy and lactation. # Initiation of breastfeeding within the first hour

after birth, exclusive breastfeeding for the first 6 months,

continued breastfeeding up to at least24 months of age.

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# Adequate complementary feeding from 6 months onward, and micronutrient interventions as needed.

Successful programming in these areas will lead tomarked reductions in the levels of chronic undernutrition

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Maternal depression affects both mothers and children

Depression in women during pregnancy and in the year after birth has been reported in all cultures.

Average about 10–15% in industrialized countries. Even higher rates are reported from developing

countries. This contributes substantially to maternal mortality and morbidity.

Parasuicide– thoughts of suicide or actual self-harm –occurs in up to 20% of mothers in developing countries. Suicide is a leading cause of maternal mortality in countries as diverse as the United Kingdom and Vietnam.

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Maternal depression has serious physical and psychological consequences for

children. The infants and children of mothers who are

depressed, especially those experiencing social disadvantage, have

lower birth weight, underweight at age six months, short for age at six months, poor cognitive development, higher rates of antisocial behaviour, hyperactivity and

attention difficulties, experience emotional problems.

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Maternal depression

It is important that maternal, newborn and child health programmes recognize the importance of these problems and provide support and training to health workers for recognizing, assessing and treating mothers with depression.

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LET US ALL WORK FOR IMPROVED MCH STATUS

A HEALTHY MOTHER AND A HEALTHY CHILD

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